Is an intensive strategy needed from the outset against open-angle glaucoma?

Is an intensive strategy needed from the outset against open-angle glaucoma?
Is an intensive strategy needed from the outset against open-angle glaucoma?

Traditionally, the management of GAO is based on the prescription of antiglaucoma eye drops. It aims to obtain a target IOP defined according to the patient’s characteristics (initial pressure level, existence of lesions, life expectancy and other risk factors), because there are no rules for formally establishing the IOP threshold to be achieved. The therapeutic objective can therefore be adjusted during the management and the time taken to evaluate therapeutic success can lead to a loss of visual field. The difficulty in determining the speed of progression of this damage can lead to a loss of opportunity. Also, the idea of ​​intensive initial management offers an interesting alternative, even if it can impose higher risks of side effects, poorer adherence or a higher cost. In order to evaluate its relevance, two Swedish centers have set up the GIST study.

242 patients who had pragmatic ophthalmological follow-up for 5 years

The GIST study (The Glaucoma Intensive Treatment Study) included patients with newly diagnosed OAG or exfoliative glaucoma in one or both eyes. Conventional treatment was based on the prescription of eye drops as monotherapy maintained as long as the IOP seemed adequate and without the appearance of visual field damage. The intensive option was based on a combination of three local treatments followed by selective 360-degree trabeculoplasty one week after initiation of local treatment. The follow-up was based on at least 12 consultations spread over the 5 years of follow-up. The therapeutic adaptation was then as consistent as possible with usual clinical practice. The primary endpoint was progression of functional impairment assessed by visual field index (VFI, Visual Field Index).

A total of 242 patients were randomized between the two groups (mean age 68 years, 55% men). At the end of 5 years, 226 patients were still followed up. Seven out of ten patients had OAG and 65% had unilateral involvement. The median IOP at inclusion was 24 mmHg in both groups.

Trend favoring intensive treatment for IOP initially above 24 mmHg

In the conventional treatment group, 81% of patients received prostaglandin therapy and 19% a beta-blocker. Nearly one in two patients underwent treatment intensification during follow-up, of whom 5% ultimately underwent glaucoma surgery. In the intensive treatment group, most treatment combinations were based on bimatoprost-timolol or travoprost-timolol combined with either dorzolamide or brinzolamide. The number of additional visits to those initially planned was comparable in both groups.

At the end of 5 years, the remaining visual field index was 79.3% in the conventional group and 87.1% in the intensive group (p = 0.15). The median visual field loss was 0.65%/year in the conventional group and 0.25%/year in the intensive treatment group. Those who had an IOP at inclusion > 24 mmHg tended to benefit more from intensive care with a median loss which was at the limit of significance (−0.20%/year versus −1.10%/year, p = 0.06) and a 5-year VFI tending to be higher (85.8% versus 74.1% in the conventional treatment group, p = 0.07).

In terms of tolerability, 25% of patients in the conventional group and 36% in the intensive group reported adverse effects, most of them mild.

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