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Glaucoma Treatment Initiation in Glaucoma Suspects Helen L Kornmann, MD, PhD 1 and JoAnn A Giaconi, MD 2 1. Glaucoma Fellow, Bascom Palmer Eye Institute, Miami, Florida, US; 2. Associate Clinical Professor, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, California, US Abstract The decision to initiate treatment in glaucoma suspects is challenging because it requires the clinician to synthesize multiple risk factors for progression and predicting which patients will most likely develop glaucoma. Because clinicians may tend to underestimate risk, clinical tools including the Scoring Tool for Assessing Risk (STAR) and the RAND-UCLA Appropriateness Method (RAM) have been developed to help clinicians integrate the numerous risk factors for glaucoma and stratify a glaucoma suspect into low, intermediate, or high risk. Some glaucoma suspects may lie further along the continuum towards glaucoma than others and, in addition to these tools, nerve imaging is useful in aiding the decision to treat. All of this objective information can help customize a discussion with patients in terms of the advantages of therapy versus observation, but they must be weighed against the costs of treatment in terms of a patient’s quality of life. Keywords Glaucoma suspect, ocular hypertension, glaucoma treatment, quality of life Disclosure: The authors have no conflicts of interest to declare. Received: October 15, 2013 Accepted: November 15, 2013 Citation: US Ophthalmic Review, 2014;7(1):45–9 Correspondence: JoAnn A Giaconi, MD, Jules Stein Eye Institute, David Geffen School of Medicine, 100 Stein Plaza, Los Angeles, CA 90095, US. E: Giaconi@jsei.ucla.edu In patients presenting with obvious signs of glaucoma and vision loss, the decision to start glaucoma treatment is relatively straightforward. The benefit of initiating treatment, in terms of preventing further loss of vision and maintaining quality of life (QoL), generally greatly outweighs the negatives of treatment. Choosing to begin therapy in a glaucoma suspect, on the other hand, is a more difficult decision to make on a patient’s behalf. Even among glaucoma specialists, there can be significant uncertainty regarding the appropriateness of treatment initiation in glaucoma suspects. 1 Within a 10- to 15-year span, one untreated glaucoma suspect may notice changes in visual function and progress to overt glaucoma, while the next suspect may remain stable. Glaucoma suspects bear risk factors, most notably elevated intraocular pressure (IOP) or a suspicious appearing optic disk, which predispose toward glaucoma but without evidence of frank glaucomatous damage. Ocular hypertension affects approximately 8 % of adults over the age of 40 in the US and is a well-studied risk factor defined as an IOP of >21  mmHg at baseline. 2 Another major group of glaucoma suspects are those with clinically suspicious appearing optic disks in the absence of visual field loss that may demonstrate asymmetric cup-to-disk ratio (C/D), focal, or diffuse changes of the neuroretinal rim, disk hemorrhages, or suspicious nerve fiber layer alterations. Examination of the optic nerve head is probably the most important step in the diagnosis of glaucoma and these findings should alert the clinician to the possibility of early glaucoma. One reason for the controversy surrounding treatment initiation is that once started, medical therapy is generally continued indefinitely. The ophthalmologist must constantly balance the risk for possible long- © TO U C H M ED IC A L MED IA 2014 term irreversible visual disability against life expectancy, treatment side effects, financial impact, and negative effects on QoL. Ultimately, the goal of therapy is not to lower IOP but to preserve functional vision as well as QoL. In this article we will review risk factors for progression to glaucoma in glaucoma suspects and how to synthesize this information when deciding to initiate treatment in these patients. Risk Assessment—Whether Or Not To Treat The biggest challenge in deciding on whom to start treatment is the inability to predict with certainty which glaucoma suspect will progress to visual dysfunction and which will remain stable. This decision involves simultaneously taking into account all known risk factors with which a patient may present in order to arrive at an estimate of his or her probability of developing glaucoma. The most important predictors for developing glaucomatous damage are the extent of damage already present and the current rate of disease progression. 3,4 Although progressive change in the optic disk or visual field is the defining feature of glaucoma, generally, it is not possible to assess change on initial patient encounters, since rates of progression can only be observed over time. Therefore, one usually relies on static risk factors to assess risk. However, in patients who are being monitored as glaucoma suspects, subsequent examination and evidence of progression may prompt the clinician to reassess risk and perhaps initiate treatment. Elevated IOP has been shown in almost all population-based studies to be a leading risk factor for the presence or development of glaucoma, 5 and both 45