WGA Consensus Series 7: Medical Treatment of Glaucoma

Medical Treatment of Glaucoma is the topic of the seventh World Glaucoma Association Consensus. Medical treatment of glaucoma continues to be at the core of glaucoma management. Hence, the results of this report will have broad and significant impact on glaucoma research and clinical practice. The global faculty, consisting of leading authorities on the clinical and scientific aspects of medical management, met in Fort Lauderdale on May 1, 2010 to discuss the reports and refine the consensus statements.

As with prior meetings, it was a daunting task to seek and obtain consensus on such a complicated and nuanced subject. It is unclear how each of us decides how we practice, and evidence to guide us often is sparse. Hence, this consensus, as with the others, is based not only on the published literature, but also on expert opinion. Although consensus does not replace and is not a surrogate for scientific investigation, it does provide considerable value, especially when the desired evidence is lacking. The goal of this consensus is to provide a foundation for medical treatment of glaucoma and how it can be best employed in clinical practice. Identification of those areas for which we have little evidence and, therefore, the need for additional research always is a high priority. We hope that this consensus report will serve as a benchmark of our understanding. However, this consensus report, as with each of the others, is intended to be fluid. It is expected that it will be revised and improved with the emergence of new evidence.

Robert N. Weinreb, Chair

Makoto Araie
Ivan Goldberg
Jeffrey Liebmann
Clive Migdal
Remo Susanna
Co-Chairs

World Glaucoma Association

We mark the seventh consecutive year for the World Glaucoma Association Glaucoma Consensus with Consensus VII. Our topic is the Medical Treatment of Glaucoma.

Global experts were invited and assembled by our international co-Chairs beginning in November 2009, to participate in the Project Forum E-Room, a unique online opportunity to facilitate discussion of each of the consensus meetings. Participants then were engaged in the discussion of ten topical areas to reach consensus on key issues that surround and permeate all aspects of the medical treatment of glaucoma. The results of these thoughtful discussions then were summarized by each of the sections with preliminary consensus statements. The Draft of the Consensus Report, including the preliminary consensus statements, was distributed to the Societies and Partners for review and comments prior to the Consensus Meeting that took place in Fort Lauderdale on Saturday, May 1, 2010. Relevant stakeholders engaged on this day in a stimulating, educational, and thought-provoking session that highlighted the review and revision of the consensus statements. In response to comments during the discussion, sections on medical treatment of glaucoma during pregnancy and childhood glaucoma were added, along with Consensus Statements on these topics. The Consensus Report then was finalized by Consensus co-Chairs and Editors. Consensus statements were reviewed and finalized by the expert Consensus Panel.

Robert N. Weinreb and Jeff Liebmann, Editors

Preface
Introduction

1. Who should be treated?
Felipe A. Medeiros, Remo Susanna, Kuldev Singh

2. Treatment goals. Target IOP
Augusto Azuaro-Blanco and Henry Jampel

3. Drugs

I.Cholingergic agents
Changwon Kee, Takeshi Yoshitomi, Neeru Gupta
II.Beta-blockers
John H.K.
III.Alpha- and Beta-adrenergic antagonists
Atsuo Tomidokoro
Beta-blockers with intrinsic sympathomimetic activity
Allison Ungar, Gadi Wollstein and Joel Schuman
Carbonic anhydrase inhibitors
Gabor Holló, Megumi Honjo, Anthony Realini, Leopold Schmetterer
IV.Alpha-adrenergic agents. Non-selective alpha-adrenergic agonists
Atsuo Tomidokoro, Makoto Araie
Selective alpha-adrenergic agonists
Arthur Sit
Alpha-adrenergic antagonists
Makoto Araie
V.Prostaglandins
Gabor Holló, Makoto Araie, Albert Alm
VI.Fixed combination preparations of IOP-lowering agents in open-angle glaucoma
Philippe Denis, Hagen Thieme, Norbert Pfeiffer
VII.Investigational and future drugs
Carol Toris, Malik Kahook, Paul Kaufman, Hidenobu Tanihara
VIII.Preservatives in topical ophthalmic medications
Malik Y. Kahook
Applying pharmacogenomics to improve open-angle glaucoma treatment outcomes
Stephen G. Schwartz, Tomomi Higashide, Sayoko E. Moroi

4. Selection of drugs

Initial therapy options
Christopher Girkin and Ivan Goldberg
Adjunctive therapy
Fabian Lerner and Ivan Goldberg
Combination therapy – fixed-dose combination (FC)
Carlo E. Traverso, Anton Hommer, Stefano Gandolfi, Francesca Cordeiro, Rajul Parikh, Ivan Goldberg

5. Medical treatments of other types of open-angle glaucoma
Paul Healey, Robert Ritch, Franz Lerner, Daniel Grigera, K. Barton, S. Gandolfi, K. Kashiwagi, Remo Susanna

6. Drug delivery
David Friedman, Jost Jonas, David Greenfield, Ivan Goldberg

Adherence/Perseverance/Dyscompliance
David Friedman, David Greenfield and Ivan Goldberg
Delivery sytems
Jost Jonas, David Greenfield and Ivan Goldberg

7. Health economics
Ronnie George, Anne Coleman, Steven Kymes

8. Non-pharmaceutical medications and approaches

Quercetin and quercetin glycosides
Makoto Araie
Methylcobalamin
Makoto Aihara
Curcumin
Makoto Araie
Ginkgo biloba extract
Robert Ritch
Grape seed extract
Robert Ritch
Resverayrol
Robert Ritch
Pycnogenol
Robert Ritch
Fish oil and omega-3 fatty acids
Sandra Fernando
Alpha-lipoic acid
Sandra Fernando
Soy sauce
Aiko Iwase
Green tea
Aiko Iwase
Non-pharmaceutical approaches to the treatment of glaucoma. Coffee, chocolate and cocoa
Michael S. Kook
N-acetyl cysteine
Robert Nussenblatt
Taurine
Robert Nussenblatt
Citicoline
Vincenzo Parisi
Carnosine
Vincenzo Parisi and Robert Ritch
Carnitine
Vincenzo Parisi and Robert Ritch
Coenzyme Q10
Nathan Radcliffe
Folic acid
Nathan Radcliffe
Glutathione
Nathan Radcliffe
Melatonin
Nathan Radcliffe
Salvia miltiorrhiza
Douglas Rhee
Trifolium pratense (red clover)
Douglas Rhee
Bear bile
Douglas Rhee
Ginseng
Kwok-Fai So and Raymond Chuen-Chung Chang
Wolfberry
Kwok-Fai So and Raymond Chuen-Chung Chang
Bilberry
Kwok-Fai So and Raymond Cheun-Chung Chang
Acupuncture and glaucoma
Simon Law
Exercise
Clement C.Y. Tham
Stress in glaucoma
Lori Ventura

9. Neuroprotection

10. Medical management of glaucoma in infants and children
James D. Brandt and Elizabeth Hodapp

11. Treatment of glaucoma in pregnancy
Elizabeth Hodapp

12. Unmet needs
Christopher Leung

Summary Consensus statements

Index of authors