New EGS guidelines

The 5th Edition of the European Glaucoma Society (EGS) guidelines, released at the 14th EGS Congress, provides answers to key questions regarding the diagnosis and management of glaucoma based on the most up-to-date evidence, reports guidelines editor Augusto Azuara-Blanco PhD, FRCS(Ed), FRCOphth, Clinical Professor of Ophthalmology, Queen’s University Belfast, UK. The large team involved in the new guidelines included Carlo Traverso (co-Editor) and EGS past-president Ted Garway-Heath, as the ultimate decision makers as well as a guidelines committee, the EGS executive committee, researchers experts in evidence synthesis particularly the collaboration with the US branch of Cochrane Eyes and Vision (CEV-US), as well as a patients representative organisation, Glaucoma UK. The new EGS guidelines consist of two parts. Part I includes a new section that addresses 16 key questions in glaucoma management identified by the guidelines committee, with evidence-based recommendations and discussions. To answer these key questions, the guidelines team performed an overview of 4,451 systematic reviews to identify those evaluating technologies and treatments for glaucoma. From these they derived 49 high-quality and reliable systematic reviews. They graded the level of evidence, e.g., considering risk of bias, inconsistency of results and imprecision. They also graded the strength of recommendations, with “strong” signifying benefits well-proven and highly recommended, and “weak” signifying those where the benefit-risk ratio may be less clear. Part I also includes a new section on ‘Things to avoid (choosing wisely)’ with brief but important messages, and sections on patients’ concerns and communication, epidemiology of glaucoma, overview of landmark studies and a concise section describing cost-effectiveness considerations. Part II is similar to a text book and consists of three chapters: the first is on patient examination, the second on classification and terminology and the third on treatment options. As illustrations of the type of recommendations and qualifying remarks included in the new guidelines, Prof Azuara-Blanco highlighted an example of one the 16 key questions, namely question number 10, which asks, “what is the most effective medical treatment, and what is the first-choice medication for open angle glaucoma?” The guidelines’ response is that prostaglandin analogues are the most effective medication and are usually recommended as the first-line treatment for open angle glaucoma. The guidelines class the evidence as high for IOP reduction but very low for other outcomes. However, they also include the comment that other factors may need to be taken into consideration before prescribing the treatment, such as possible adverse effects, co-morbidities, systemic therapy, adherence, patient preferences, life expectancy, cost and availability. Of note, the new EGS guidelines recommends laser trabeculoplasty as a first option for initial treatment of open angle glaucoma and laser trabeculoplasty, at least as good as initial medical treatment. In the section on “Things to avoid”, Prof Azuara-Blanco, highlighted two recommendations he regards as particularly important. The first is that glaucoma diagnosis should not be based on optical coherence tomography alone. The second is that lowering IOP to just below 21mmHg is inadequate in cases of advanced glaucoma. IOP in the low teens or below is necessary.