Suspected Glaucoma: Clinical Guidelines

List of Abbreviations

IOP – intraocular pressure

AQH – aqueous humor

ONH – optic nerve head

CI – confidence interval

LI – laser iridotomy/iridectomy

Med – medication

LTP – laser trabeculoplasty

ICD-10 – International Classification of Diseases 10th Revision

INN – International Nonproprietary Name

NRR – neuroretinal rim

OH – ocular hypertension

OCT – optical coherence tomography

SG – suspected glaucoma

VF – visual field

POAG – primary open-angle glaucoma

PERG – pattern electroretinogram

PEX – pseudoexfoliation syndrome

RNFL – retinal nerve fiber layer

ACA – anterior chamber angle

PCC – phacoemulsification of cataract

CCT – central corneal thickness

C/D – ratio of the maximum cup diameter to the OD diameter

ISNT (inferior, superior, nasal, temporal) – rule for ophthalmoscopic assessment of the neuroretinal rim in glaucoma diagnosis

P₀ – true intraocular pressure level

Pt – the tonometry value measured by Maklakov tonometry for intraocular pressure using a 10 g weight.

Terms and Definitions

Ocular biomicroscopy – a method of in vivo visual examination of the optical media and tissues of the eye based on creating contrast between illuminated and non-illuminated areas.

Intraocular pressure – the fluid pressure inside the eye resulting from the balance between aqueous humor production, trabecular and uveoscleral outflow, and episcleral venous pressure, which maintains its shape, ensures a constant supply of circulating nutrients, and supports normal trophism of intraocular tissues.

Gonioscopy – a method of visual examination (inspection) of the anterior chamber angle of the eye performed using a slit lamp and a goniolens (gonioscope).

Optic disc (OD) – the site where retinal ganglion cell axons exit the eyeball.

Neuroretinal rim (NRR) ‒ the area between the optic disc margin and the cup margin where the bulk of retinal ganglion cell axons is projected.

Optical imaging of the optic nerve head and nerve fiber layer using a computer analyzer (hereinafter referred to as optical coherence tomography, OCT) ‒ a non-invasive, contactless in vivo imaging method for qualitative and quantitative analysis of the morphological features of fundus structures, based on the principle of light interferometry.

Ocular hypertension (OH) – an elevated IOP level in the absence of characteristic glaucomatous changes in the OD, RNFL, and VF defects.

Ophthalmoscopy – an instrumental method for examining the ocular fundus and its structures.

Ophthalmotonometry – an instrumental method for measuring the level of IOP, the value of which is determined by analyzing eye deformation data using a tonometer and assessed in millimeters of mercury (mmHg).

Static and automated perimetry– methods for examining the VF.

Visual field (VF) – the set of points in space simultaneously visible to the eye with a fixed gaze.

Scotoma – a VF defect not connected to the peripheral borders.

Retinal nerve fiber layer (RNFL) – the retinal layer consisting of retinal ganglion cell axons.

Anterior chamber angle – the space between the corneoscleral region and the anterior surface of the iris.

MD, mean deviation – a perimetric index determined during static perimetry, representing the average difference between age-corrected normal values of retinal light sensitivity and the measured threshold values at all test points.

PSD, pattern standard deviation – a perimetric index characterizing the severity of focal visual field defects.

GHT, Glaucoma Hemifield Test – a test comparing the upper and lower halves of the VF across 5 (five) corresponding zones.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Suspected glaucoma – a condition characterized by clinical manifestations and/or a combination of risk factors indicating an increased probability of developing POAG [1-7]:

• elevated IOP in the absence of changes in OD, RNFL, and VF parameters – ocular hypertension;

or

• presence of changes in the OD or RNFL suspicious for glaucomatous damage;

or

• presence of changes in the VF suspicious for glaucomatous damage, in the absence of clinical signs of other types of optic neuropathies or retinopathies.

Thus, the term “suspected glaucoma” has a broader meaning than the term “ocular hypertension” (since it includes cohorts of patients with normal IOP levels but structural changes in the OD and/or RNFL and/or visual field). In this context, ocular hypertension can be considered a specific case of “suspected glaucoma”.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

During the examination and follow-up of a patient with suspected glaucoma, special attention is paid to risk factors that increase the likelihood of developing POAG. These include the following local and systemic factors:

• age: POAG predominantly develops in patients over 40 years of age, and its prevalence increases with age (95% CI 2.5–4.0) [8-14].

• race/ethnicity: the prevalence of POAG is several times higher in African Americans than in Caucasians (95% CI 3.83–9.13) [15-18].

• gender: data on the relationship between gender and POAG are contradictory [19-22].

• family history: the prevalence of glaucoma among blood relatives of patients with POAG is 4–9 times higher than in the general population [23-27].

• elevated IOP level: directly correlates with an increase in the prevalence and incidence of POAG. The risk of developing glaucoma increases by 10% for each 1 mmHg increase in IOP above the population norm [28-41].

• pseudoexfoliation syndrome: the presence of pseudoexfoliations increases the risk of POAG by 9–11 times. Within 10 years, glaucoma develops in every third patient with PEX [42-46].

• pigment dispersion syndrome: the risk of developing pigmentary glaucoma in patients with pigment dispersion syndrome was approximately 10% at 5 years and 15% at 15 years [47-50].

• central corneal thickness (CCT): an increased risk of POAG by 30–41% has been established for every 40 µm thinning of CCT below the population norm [31, 51-54].

• myopia: high myopia (≥6 diopters) increases the incidence of suspected glaucoma [55-60].

• ocular perfusion pressure: a low ocular perfusion pressure has been found to be associated with an increased incidence of suspected glaucoma. Since perfusion pressure represents the difference between diastolic blood pressure and IOP, the treatment of arterial hypertension in patients with suspected glaucoma may lead to systemic hypotension and, consequently, impaired blood supply to the OD [61-66].

• optic disc hemorrhages: in the Collaborative Normal Tension Glaucoma Study (CNTGS), the presence of hemorrhages in the OD region significantly correlated with glaucoma progression [67].

• other factors: there are reports of other factors that may be associated with an increased risk of developing POAG (cardiovascular pathology, including systemic arterial hypotension, systemic atherosclerosis; vasospastic syndrome, including Raynaud's disease, migraine, and migraine-like conditions; sleep apnea and syncopal episodes of unclear origin; diabetes mellitus [95% CI 1.20–1.57]). However, literature data remain controversial [68-72].

1.3 Epidemiology of the Disease or Condition

To date, large-scale systemic clinical and epidemiological studies dedicated to detecting individuals with suspected glaucoma and ocular hypertension (OH) have not been conducted in the Russian Federation. In the vast majority of cases, these conditions are diagnosed during population-based glaucoma screenings when elevated IOP is detected [4, 73–77].

According to some domestic and foreign literature sources, the frequency of elevated IOP is 5–15 times higher than the prevalence of glaucoma. Thus, including individuals with ocular hypertension in the group of glaucoma patients would unjustifiably increase the number of the latter tenfold [73, 78–82].

In turn, the prevalence of OH among Caucasians living in the USA aged 40 years and older is 4.5% (ranging from 2.7% in individuals aged 43 to 49 years to 7.7% in individuals aged 75 to 79 years) [83].

The detected prevalence of elevated IOP among Hispanics aged 40 years and older is slightly higher: 3.5% (ranging from 1.7% in individuals aged 40–49 years to 7.4% in individuals aged 80 years and older) [84].

An age-associated increase in the proportion of patients is characteristic of both OH and POAG. However, the growth rate for OH is undoubtedly higher: in the population over 50 years of age, the prevalence of OH reaches 15–20% [31, 85-109].

The true prevalence of OH may be significantly higher, as a considerable number of cases remain undiagnosed. For example, it is estimated that 3 to 6 million people in the USA have elevated IOP levels [28, 110].

1.4 Features of Coding the Disease or Condition

H.40.0 – Suspected glaucoma [111,112].

Comment: according to the International Statistical Classification of Diseases and Related Health Problems, this group also includes other conditions – preglaucoma (H40.00), open anterior chamber angle with borderline changes and low risk of disease progression (H40.01), open anterior chamber angle with borderline changes and high risk of disease progression (H40.02), anatomically narrow anterior chamber angle (H40.03), hormone-(steroid-)induced form (H40.04), ocular hypertension (H40.05), primary angle closure without glaucoma (H40.06) [11,112].

1.5 Classification of the disease or condition

There is no specific classification of OS, but rather conditions characterizing OS are distinguished, which are subdivided into [1, 113, 114]:

1) spurious;

2) essential;

3) symptomatic.

Examples of diagnosis:

Suspected glaucoma in both eyes.

Suspected glaucoma in both eyes. Spurious ocular hypertension in both eyes.

Suspected glaucoma in both eyes. Essential ocular hypertension in both eyes.

Suspected glaucoma in both eyes. Symptomatic ocular hypertension in both eyes.

1.6 Clinical presentation of the disease or condition

Most commonly, in cases of suspected glaucoma, VF and/or ONH and/or RNFL show no deviations from the norm or reveal borderline changes in at least one of the listed functions/structures against the background of periodic or permanent elevation of IOP levels [115].

As a rule, OS, much like primary open-angle glaucoma (POAG), is asymptomatic and in most cases is detected incidentally during the determination of elevated IOP levels, which sometimes manifests as isolated atypical complaints: periodic blurring of vision, seeing colored rings around light sources, eye and head pain, flickering "floaters", rapid fatigue, frequent changes of presbyopic glasses [116-118].

In addition, attention should be paid to elevated IOP levels (>21 mm Hg, Po) without treatment, and asymmetry of ophthalmotonus between fellow eyes [119-122]. Altered appearance of the ONH includes cupping enlargement, neuroretinal rim or RNFL thinning, cup breakthrough to the disc margin, ONH hemorrhage, marked peripapillary atrophy, and asymmetry of morphometric parameters between fellow eyes [1, 122].

Comment: These changes can also be seen in other conditions, such as myopia or ONH anomalies (physiological enlargement of the C/D ratio in a large ONH, tilted abnormal ONH, etc.), where they may be a variant of normal [123, 124]. Up to 40% of retinal nerve fiber layer fibers may be lost before visual field changes and RNFL thickness reduction occur when comparing patients with OS and healthy eyes [125, 126]. In OS, no visual field defects are detected upon testing, or defects appear that are not yet sufficiently conclusive as evidence of glaucoma [122]. If changes are detected and to confirm them, examinations should be repeated taking into account the patient's learning effect [1, 122].

Features of clinical and pathogenetic forms of OS.

OS is characterized by a benign course without ONH damage. However, in some cases (15–25%), progression of OS to glaucoma is possible, therefore this condition should be considered as one of the risk factors [1]. Spurious hypertension is associated with the patient's sustained increased reactivity to tonometry, a high individual IOP level, or technical errors during ophthalmotonus measurement. Essential hypertension is caused by an imbalance of age-related changes in ocular hydrodynamics—impaired outflow of aqueous humor with preserved secretion thereof. In many cases, this imbalance gradually levels out. Symptomatic hypertension represents a short-term or prolonged elevation of IOP levels that is merely a symptom of another disease. If the underlying disease is cured, ophthalmotonus normalizes. Symptomatic hypertension includes glaucomatocyclitic crises, uveitis with hypertension, as well as elevation of ophthalmotonus caused by impaired active regulation of IOP due to intoxication, diencephalic and endocrine disorders, pathological menopausal transition, and long-term therapy with high doses of certain hormones.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the disease or condition:

elevated IOP level in the absence of changes in ONH, RNFL, and VF parameters (ocular hypertension);

or the presence of changes in the ONH or RNFL suspicious for glaucomatous damage;

or the presence of changes in the VF suspicious for glaucomatous damage, in the absence of clinical signs of other types of optic neuropathies or retinopathies.

2.1 Complaints and Anamnesis

Comments: when taking complaints and medical history, attention should be paid to the presence of risk factors for the development of POAG (see section 1.2) [1-7].

2.2 Physical Examination

There are no specific signs of OS that can be detected during a physical examination. General propaedeutic principles of patient examination must be followed.

2.3 Laboratory Diagnostics

There are no diagnostic criteria for OS based on clinical laboratory test data.

2.4 Instrumental Diagnostics

Comments: the study is performed using autorefractometers or retinoscopy, determining the lowest negative or highest positive lens with which maximum visual acuity is achieved. Neutralization of any refractive error is critical for accurate perimetry.

Comment: The baseline method for measuring IOP levels adopted in the Russian Federation is Maklakov tonometry (Pt) using a 10 g weight. The tonography method is used to determine the true IOP level (Po). Applanation tonometry (Goldmann method) (Po) is universally practiced worldwide, the results of which differ from tonometric values. To correlate the two types of tonometry, the Nesterov-Egororov conversion scale for the 10 g Maklakov tonometer can be used. In the Russian Federation, an induction tonometer, a dynamic contour tonometer, and an ocular response analyzer performing measurements via bidirectional corneal applanation (a device that allows, inter alia, interpreting Goldmann tonometry values) and a palpebral tonometer are also registered (the specified measurement method has a number of advantages, in particular, it significantly reduces the risk of contamination due to the absence of direct contact with the eyeball, and can also be used, among other things, in the postoperative period). Non-contact tonometry (pneumotonometry) should be considered as a screening method for determining IOP levels. During follow-up, it is recommended to use a single baseline tonometry method for the correct comparison of obtained results [119-122].

When analyzing tonometry data, absolute IOP values, diurnal fluctuations, the difference in ophthalmotonus between fellow eyes, and the characteristics of orthostatic fluctuations are taken into account [127-130].

The statistical norm for true IOP levels (P₀) in a healthy person ranges from 10 to 21 mm Hg, and for tonometric IOP levels (Pt) from 15 to 25 mm Hg. The average IOP level (Pt) in healthy individuals is 19.9±0.03 mm Hg, and the entire range of the statistical norm can be divided into three zones: the high-normal zone (from 23 to 25 mm Hg, 6.5%), the mid-normal zone (19-22 mm Hg, 72.2%), and the low-normal zone (<18 mm Hg, 20.3%) [131-134].

Diurnal fluctuations in IOP levels, as well as its asymmetry between fellow eyes in healthy individuals, generally remain within 2-3 mm Hg, and only in exceptionally rare cases reach 4-6 mm Hg. The higher the baseline average IOP level, the higher the diurnal fluctuations in ophthalmotonus can be [135, 136].

Orthostatic fluctuations normally rarely exceed 4 mm Hg, while in OS they range from 5 to 13 mm Hg [137-139].

Monitoring IOP levels is also necessary when selecting local hypotensive therapy, taking into account the onset of the drug's action, its peak effect, and the washout period, if treatment is prescribed [30, 144-147].

IOP measurement must be performed prior to gonioscopy and pupillary dilation [1-4].

Comment: Measurement of the depth of the peripheral anterior chamber using the van Herick method is part of biomicroscopy and helps to roughly determine the degree of closure/opening of the iridocorneal angle. Additional criteria to consider during biomicroscopy include: uneven arteriolar narrowing and venular dilation, ampullary vascular dilation, microaneurysm formation, increased capillary permeability, small hemorrhages, and granular blood flow upon conjunctival examination; detection of asymmetry in anterior segment changes, determination of the degree of pigmentation on the endothelium (e.g., Krukenberg spindle, characteristic of pigmentary glaucoma), deposits of pseudoexfoliation along the pupillary margin of the iris and on the anterior lens capsule, presence of iris heterochromia, stromal atrophy and atrophy of its pigment border [148,149].

Comment: Gonioscopy allows for the evaluation of the iridocorneal angle; identification of signs of goniodysgenesis and developmental anomalies of the iridocorneal angle; determination of the feasibility of laser surgery on the structures of the eye iridocorneal angle and performance of these procedures; detection of interocular asymmetry in the gonioscopic picture; and identification of sites of fluid retention.

Gonioscopy is a spatial characteristic of the iridocorneal angle based on the recognition and description of its landmark zones and features, including: biometric parameters (height, profile, and width of the angle—the space between the corneal endothelium and the iris root); level of iris attachment; character and degree of pigmentation of the trabecular meshwork and Schlemm's canal zone; presence of synechiae, pseudoexfoliative material, and other deposits.

To systematize the results of the gonioscopic examination, it is advisable to use the classifications by van Beuningen, G. Spaeth, or R. Shaffer [150, 151].

In addition to gonioscopy, anterior segment OCT can be used to monitor changes in the iridocorneal angle over time (which does not replace gonioscopy) [152].

The examination is not indicated for patients with inflammatory processes of the ocular surface or traumatic injuries of the eyeball, and cannot be performed correctly in patients with significant corneal opacities or hyphema.

Comment: Ophthalmoscopy is performed using various models of ophthalmoscopes, while fundus biomicroscopy under medication-induced mydriasis utilizes non-contact diagnostic ophthalmic lenses (to obtain a stereoscopic image). During ophthalmoscopy, quantitative and qualitative characterization of parameters must be performed.

Qualitative characteristics:

• Neuroretinal rim (NRR): To determine the characteristics of the NRR, it is recommended to use the ISNT rule (Inferior, Superior, Nasalis, Temporalis). In eyes with early or moderately advanced glaucomatous damage, NRR tissue loss is predominantly observed in the inferotemporal and superotemporal sectors of the optic disc. When evaluating the NRR, the ISNT rule can only be used for standard optic disc sizes; in large and small sizes, as well as in myopia with tilted optic discs, NRR evaluation is difficult and requires longitudinal examination to detect disease progression. The sensitivity and specificity of the method do not exceed 80% [153-155].

• Retinal nerve fiber layer (RNFL): Local or diffuse thinning (defects), which are better visualized in red-free light

• optic disc hemorrhage — presence

• peripapillary atrophy — presence and area

Quantitative characteristics:

• Optic disc (size and shape: small, medium, large)

• excavation (size and shape)

• ratio of the maximum excavation size to the optic disc diameter (C/D)

Fundus examination should also focus on: size and shape of the optic disc; size, shape, and degree of pallor (pink or decolorized) of the neuroretinal rim; size of the excavation relative to the optic disc size, configuration (nature of the temporal margin: sloping, steep, undermined) and depth of the excavation (shallow, moderate, deep); C/D ratio; degree of peripapillary chorioretinal atrophy; location of the vascular bundle and associated symptoms of "bayonet" or "kinking" and obliteration of the so-called circumlinear vessel of the optic disc; hemorrhages on the optic disc; retinal arteriole diameter, and RNFL status [156-159].

Characteristic changes of the optic disc and RNFL are presented in section 1.6.

Comment: White-on-white threshold central visual field perimetry (10⁰, 24⁰, and 30⁰) is the preferred method for early detection of visual field defects [160-162]. Various indices, such as mean defect or mean deviation (MD), pattern standard deviation (PSD, LV), as well as various diagnostic tests confirming the results of computer-assisted progression analysis during follow-up, are used to evaluate the results of static and automated perimetry. Automated perimetry is difficult to reproduce in patients with low visual acuity and cognitive impairment. It is advisable to take into account the degree of asymmetry of the above parameters for establishing the diagnosis. The frequency of perimetry in POAG is presented in section 5.

During follow-up, it is recommended to use a single baseline perimetry method for accurate comparison of the obtained results.

2.5 Other Procedures

In the absence of conclusive data to establish a diagnosis or determine disease progression, a number of additional (clarifying) diagnostic methods may be performed in an ophthalmology office (consultative and diagnostic department), ophthalmology department, or Medical Ophthalmology Center [1-7, 122].

Structural and functional methods (tests) are continuously improving, becoming increasingly sensitive to the earliest changes. The gap between observed functional losses and preceding structural changes, in terms of comparing these two monitoring strategies, is steadily narrowing. Structural changes predominate early in the disease, particularly in ocular hypertension (OHT) or early primary open-angle glaucoma (POAG).

Commentary: The normal distribution of central corneal thickness (CCT) in the adult population ranges from 473 to 597 µm (mean, 540±30 µm). Significant deviations from mean CCT values (±50 µm) can affect tonometry results. To date, there is no consensus regarding the use of tonometry correction algorithms based on CCT data. It is advisable to classify corneas into thin (481–520 µm), medium (521–560 µm), and thick (>561 µm), and to take the associated risk into account [121, 163–167].

Commentaries: Data obtained via OCT should not be interpreted as a definitive diagnosis. These are statistical data resulting from a comparison of the patient's metrics with the device's normative database. The obtained results must be correlated with the clinical picture to avoid false conclusions, especially in cases of atypical optic disc variants whose parameters are absent from the database. The initial OCT scan is of critical importance, and high image quality is essential, as subsequent progression assessment relies on comparison with this baseline image. The frequency of OCT in OHT is detailed in Section 5.

The method may also be used for follow-up monitoring in combination with perimetry data [168].

Comments: the decision to prescribe additional diagnostic tests is made by the physician based on the results of the baseline examination. Pattern electroretinography (PERG) has the highest specificity and sensitivity in glaucoma; it reflects the activity of retinal ganglion cells themselves and can serve as a predictor of structural retinal changes. To assess the functional state of the retinal macular area, the PERG P50 component is taken into account, while the PERG N95 component is used to assess the functional state of the optic nerve.

To verify the diagnosis and perform differential diagnosis of ocular hypertension (OH), other additional diagnostic methods may be used: tonography, loading and unloading tests to study the regulation of intraocular pressure [1, 73, 170-171].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Comment: The goal of treating OH-associated ocular hypertension is to maintain IOP at a level where no loss of visual function occurs, and the treatment itself is not associated with side effects affecting the patient's quality of life throughout their lifetime. Treatment is not prescribed in the absence of known risk factors for the development and progression of glaucoma [177].

Most patients with OH do not require treatment, since in more than 90% of untreated patients, OH does not progress to glaucoma during 5 years of follow-up. The risks and benefits of treatment must be weighed against the risk of glaucomatous optic disc damage. Indications for prescribing treatment are relative, decided on an individual basis, and grounded in the assessment and analysis of risk factors [178-182]. Treatment is prescribed upon detecting progressive changes in the optic disc, retinal nerve fiber layer (RNFL), visual fields (VF), or the development of POAG [31].

The benefits and risks of each treatment method should be discussed with the patient. Efforts should be made to have the patient use the minimum number of medications with the possibility of pathogenetic choice of drugs, based primarily on data regarding their clinical efficacy [1-7, 183].

Prolonged use of medications leads to a decrease in their hypotensive effect, which requires timely adjustment of ongoing therapy, for example, when signs of ophthalmotonus subcompensation are detected [173, 183-186].

Before prescribing treatment, the expected "target" pressure level should be determined taking into account baseline ophthalmotonus values and the presence of additional risk factors. The "target" pressure cannot be determined with absolute certainty for a specific patient, and there is no approved algorithm for its establishment, but this does not preclude its use in clinical practice [1-7, 121, 122]. A strategy for determining "target" pressure based on a percentage reduction of ophthalmotonus from baseline is used [1-7]. Based on the results of the Ocular Hypertension Treatment Study (OHTS), one should strive to reduce IOP by at least 20% from the baseline level [30, 31].

3.1 Medical treatment

Comments. Treatment is prescribed when there is progression of changes in the optic disc, RNFL, VF, and also if the patient has additional risk factors [31].

Although laser and surgical treatments can effectively reduce IOP, topical medical treatment using eye drops remains the preferred initial therapy option worldwide due to its favorable risk-benefit profile. When choosing a drug, it is necessary to consider its efficacy, potential side effects, dosing schedule, required percentage of IOP reduction from baseline, potential cost, and availability [1-7, 183].

Comment: prostaglandin analogues, beta-blockers, carbonic anhydrase inhibitors, and antiglaucoma sympathomimetics are used as first-line drugs. Prostaglandin analogues possess the maximum hypotensive activity. Drugs of other pharmacological groups (carbonic anhydrase inhibitors, antiglaucoma sympathomimetics) are used less frequently as initial therapy due to their lower hypotensive efficacy [187-191].

The use of drugs belonging to the group "Antiglaucoma preparations and miotics" is associated with contraindications and side effects that must be taken into account. The main pharmacological groups of drugs used for OH and preglaucoma and their mechanism of action are presented in Table 1.

Table 1 - Main pharmacological groups of drugs belonging to the group "Antiglaucoma preparations and miotics" and their mechanism of action

** belongs to the medications from the Vital and Essential Drugs List for medical use

- poor tolerability of the starting therapy drug;

- provided it is well tolerated, but if the "target" level of intraocular pressure is not achieved [1-7].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment: when using prostaglandin analogues as initial therapy, changing the drug within this group is possible, whereas switching to a drug from another pharmacological group is impractical [1-7, 189, 190, 192, 198].

Comment: it is advisable to combine drugs with different mechanisms of action: those improving outflow and those reducing aqueous humor secretion. To increase the hypotensive efficacy and patient adherence to medical treatment of glaucoma, fixed combination drugs are used containing substances that, having different mechanisms of hypotensive action, exhibit an additive effect when combined (Table 2). It is necessary to avoid prescribing medicinal products belonging to the same pharmacological group (e.g., it is unacceptable to combine two different beta-blockers or two prostaglandin analogues) [1-7,192].

Table 2 - Fixed combinations of drugs from the group "Antiglaucoma preparations and miotics"

Comment: replacement of the components of antiglaucoma combinations is possible if the "target" IOP level is not achieved. The use of more than 3 (three) medicinal products simultaneously is not recommended. Increasing the frequency of eye drop instillation leads to reduced treatment adherence, decreased efficacy, and an increased number of side effects [202].

Discontinuation of treatment in patients with OHT or POAG is possible upon stabilization of the condition during long-term therapy, provided there is an acceptable IOP level and a low risk of visual impairment during the patient's expected lifespan. Upon treatment discontinuation, monitoring of IOP, visual field, and optic nerve status with subsequent re-evaluation is advisable if clinically indicated [203].

Laser interventions used in the treatment of ocular hypertension include laser trabeculoplasty; laser iridotomy in individuals with closed and/or narrow iridocorneal angles (20 degrees or less) (see section 3.2 Laser Treatment)

Comment: none of the drugs from the group "Antiglaucoma preparations and miotics" is classified as safe or completely contraindicated during pregnancy. Drugs for the topical treatment of POAG and OHT are prescribed only if the potential benefit of treatment outweighs the potential risk to the fetus. The main principles of drug administration: use the minimum number of drugs sufficient to achieve the target pressure, discuss treatment with an obstetrician-gynecologist and a pediatrician, and reduce systemic absorption of the drug (by gently pressing the patient's medial canthal area). The most sensitive period is the first trimester of pregnancy due to the potential teratogenic effect of systematically administered drugs on the fetus. Given the possible decrease in IOP during pregnancy in some patients, temporary cessation of topical hypotensive treatment under close supervision may be considered. During pregnancy, beta-blockers, sympathomimetics for glaucoma treatment, and/or topical carbonic anhydrase inhibitors (S01EC Carbonic anhydrase inhibitors) may be prescribed. Prostaglandin analogues should be used with caution due to their effect on uterine tone. Therefore, if signs of uterine hypertonus appear, their discontinuation is necessary. At the 9th month of pregnancy, beta-blockers and sympathomimetics for glaucoma treatment should be discontinued to avoid complications in the newborn [2, 204, 205]. The use of topical carbonic anhydrase inhibitors (S01EC Carbonic anhydrase inhibitors) may be continued. During lactation, it is preferable to prescribe carbonic anhydrase inhibitor drops and prostaglandin analogues [2, 204, 205]. Laser trabeculoplasty can be an initial or adjunctive intervention in pregnant and lactating women [183, 204, 205].

3.2 Laser Treatment

Laser interventions used in the treatment of ocular hypertension aim to restore aqueous humor outflow:

• laser trabeculoplasty (LTP);

• laser iridotomy in individuals with closed and/or narrow iridocorneal angles (20 degrees or less).

The advantages of laser interventions are:

• low invasiveness of procedures;

• absence of serious intra- and postoperative complications;

• ability to perform the intervention on an outpatient basis;

• possibility of repeated laser interventions if the hypotensive effect decreases in the long-term postoperative period.

Comments: The expected average reduction in IOP can be 20-25% (6-9 mmHg). The hypotensive effect of LTP is evaluated 1-2 months after the procedure. Low efficacy of repeated LTP procedures is characteristic. The efficacy of IOP reduction is comparable for different types of laser trabeculoplasty (argon/diode and selective), but the invasiveness of selective LTP and the complication rate for this type of surgery are significantly lower [208]. Repeated LTP is possible after 1 year if the effect of the initial procedure was prolonged and sufficient to reduce IOP [206, 210-212]. Performing selective LTP is advisable in cases of marked trabecular pigmentation (II-IV); repeated procedures show efficacy comparable to the primary surgery [210-212].

IOP monitoring is required 30 minutes and 2 hours after LTP in patients with ocular hypertension to determine the severity of reactive hypertension, the magnitude of which can exceed 10 mmHg [209]. The prescription of local anti-inflammatory therapy for 4-7 days after LTP reduces the likelihood of postoperative complications (reactive hypertension, post-coagulation uveitis, peripheral goniosynechiae) [2].

3.3 Surgical Treatment

3.4 Diet therapy, pain management, and other treatments

There is no special diet for suspected glaucoma. Anesthetic methods (instillations) are used at the stage of laser treatment for suspected glaucoma and are not used as standalone therapy.

To date, no reliable clinical studies have been conducted confirming the efficacy of diet therapy and dietary supplements in suspected glaucoma [214, 215]. Alternative treatment strategies for suspected glaucoma (neuroprotection) are a subject of research and discussion [216-220].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Medical rehabilitation and sanatorium-resort treatment for patients with suspected glaucoma have not been developed.

5. Prevention and Dispensary Observation

There is no specific prevention for suspected glaucoma. The results of studies regarding the medical and economic efficacy of screening, prevention, and dispensary monitoring are contradictory and cannot be of a recommendatory nature [1, 4].

Comments: The first stage of health screening (dispensarization) is performed to detect signs of ocular hypertension and POAG, risk factors, especially with a burdened family history; and to determine medical indications for additional examinations and consultations by an ophthalmologist to clarify the glaucoma diagnosis [1, 221].

Comment: The decision on the frequency of monitoring and the appointment of additional examination methods is made by the physician based on the results of the baseline examination. To date, there is no consensus regarding the intervals and final timelines of monitoring. The frequency of ophthalmological examinations and the scope of examinations and manipulations are determined individually, but at least once a year. The duration of monitoring for patients with suspected glaucoma is determined individually, but if no changes in the morphofunctional parameters of the patient's eye are detected within 3-5 years, additional monitoring should be discontinued and annual examinations by an ophthalmologist recommended in accordance with Order of the Russian Ministry of Health No. 404n dated April 27, 2021 (as amended on September 28, 2023) "On Approval of the Procedure for Conducting Preventive Medical Examination and Dispensarization of Certain Groups of the Adult Population" (Registered with the Russian Ministry of Justice on June 30, 2021, No. 64042).

If signs of glaucomatous optic neuropathy are detected according to OCT and perimetry data during dispensary monitoring of patients with suspected glaucoma, a diagnosis of POAG is established, and further monitoring and management of patients are carried out according to the clinical guidelines "Primary Open-Angle Glaucoma", H40.1.

In patients with suspected glaucoma and ocular hypertension receiving drug therapy, the efficacy and any side effects of treatment are determined; changes and new prescriptions by other specialists for systemic indications that may affect the dynamics of the pathological process and treatment efficacy are identified; and the patient's correct adherence to the hypotensive therapy regimen is monitored.

Each patient visit is accompanied by an assessment of the patient's subjective well-being, visual functions (driving difficulties, dark adaptation, contrast sensitivity issues, reading small print, and distance estimation), quality of life, and treatment adherence. Reassessment of risk factors is carried out at each patient visit.

Regular monitoring of compliance with medical prescriptions makes it possible to increase the effectiveness of the measures taken.

6. Organization of Medical Care

Primary specialized health care for suspected glaucoma is provided by an ophthalmologist in the outpatient department of a medical organization. Treatment (laser interventions, conservative drug therapy, or physiotherapy) is performed in outpatient settings, day-patient settings, or 24-hour inpatient settings.

Indications for hospital admission of patients with suspected glaucoma to a medical organization are:

Planned (elective):

• conducting an in-depth examination, drug and/or laser treatment (if they cannot be performed in outpatient or day-patient settings).

Indications for discharging a patient from a medical organization [1]:

• completion of one of the stages of specialized medical care in a 24-hour or day inpatient setting in the absence of treatment complications requiring drug correction and/or inpatient medical interventions;

• refusal of the patient or their legal representative from specialized medical care in a 24-hour or day inpatient setting established by a medical concilium, in the absence of complications of the underlying disease and/or treatment requiring drug correction and/or inpatient medical interventions;

• the need to transfer the patient to another medical organization according to the relevant medical profile. The conclusion on the feasibility of transferring the patient to a specialized medical organization is made after a preliminary consultation based on the provided medical documents and/or a preliminary examination of the patient by specialist doctors of the medical organization to which the transfer is planned.

7. Additional Information

The risk of disease development and progression is higher in patients with suspected glaucoma who do not adhere to the regimen of hypotensive drop instillations in the presence of ocular hypertension.

According to epidemiological studies, elderly people are characterized by the coexistence of two or more chronic diseases requiring correction of the treatment and diagnostic process carried out for each pathology.

Local factors affecting disease outcome

In the combination of cataract and ocular hypertension, the management tactics may change. It has been established that cataract phacoemulsification in patients with ocular hypertension reduces IOP by 4.1 mmHg, while the hypotensive effect persists for at least 36 months [223, 224].

Keratorefractive surgeries alter the thickness, curvature, and biomechanical properties of the cornea, leading to an inaccurate assessment of IOP [166, 225-226].

High myopia often hinders the early detection of POAG, since glaucomatous changes in the optic disc (OD) may be masked by the features of the optic disc in myopia (myopic conus, tilted OD entry), and visual field defects and thinning of the retinal nerve fiber layer are indistinguishable from those found in glaucoma patients. In this regard, it is advisable to perform repeated diagnostic studies of the state of the OD and retinal nerve fiber layer. It should also be remembered that altered biomechanical properties of the myopic eye cornea lead to inaccurate assessment of IOP by traditional methods [227-230].

Systemic factors affecting disease outcome

POAG and glaucoma are frequently associated with a number of systemic diseases, such as essential hypertension, coronary artery disease, diabetes mellitus, thyroid disorders, asthma, and degenerative diseases of the central nervous system. Comorbidity (the coexistence of two or more diseases in a single patient) leads to a decline in quality of life, health self-assessment, mobility, and functional capabilities, as well as an increase in hospitalizations, healthcare resource utilization, mortality, and treatment costs. The presence of multiple chronic conditions increases the complexity of therapy for both healthcare providers and patients and negatively impacts treatment outcomes. Furthermore, the risk of side effects and harm caused by multiple factors, including drug-drug interactions, increases with the number of medications required to treat each of the pathologies [231, 232].

Comment: Medications used for various underlying conditions can influence the onset and progression of glaucoma. For instance, corticosteroids increase IOP levels regardless of the route of administration in 25-33% of patients, with an IOP increase of ≥32 mm Hg possible in 5% of cases, which undoubtedly increases the risks of glaucoma onset/progression. Conversely, orally administered metformin**, beta-blockers, and HMG-CoA reductase inhibitors (statins) decrease these risks [233, 234]. Concurrent use of topical and systemic beta-blockers (frequently prescribed as monotherapy in patients with glaucoma and concomitant cardiovascular disease, respectively) leads to a significant reduction in the hypotensive effect of topical beta-blockers compared to patients not receiving oral beta-blockers. In addition, this patient population exhibits significantly higher systolic blood pressure values and elevated vascular risks [192].

Criteria for Evaluating the Quality of Medical Care

Quality criteria are used to assess the timeliness of medical care provided, the appropriateness of the choice of prevention, diagnostic, treatment, and rehabilitation methods, and the degree to which the planned outcome is achieved. Quality criteria are applied by disease (condition) groups and by conditions under which medical care is provided.

Table 3.1 - Criteria for assessing the quality of primary health care provided to adults with suspected glaucoma (ICD-10 codes: H40.0), along with levels of evidence certainty and grades of recommendation

Table 3.2 - Criteria for assessing the quality of specialized medical care provided to adults with suspected glaucoma (ICD-10 codes: H40.0), along with levels of evidence certainty and grades of recommendation

References

Appendix A1. Working Group Composition

1. Brezhnev A.Yu., Candidate of Medical Sciences, Associate Professor, Kursk State Medical University of the Russian Ministry of Health, Ophthalmological Clinical Hospital – Ophthalmological Center, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Kursk

2. Gazizova I.R., Doctor of Medical Sciences, Institute of Experimental Medicine Medical Research Center, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Saint Petersburg

3. Dogadova L.P., Candidate of Medical Sciences, Professor at the Department of Ophthalmology, Pacific State Medical University of the Russian Ministry of Health, Chief Ophthalmologist of the Far Eastern Federal District, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Vladivostok

4. Egorov E.A., Doctor of Medical Sciences, Professor at the Academician A.P. Nesterov Department of Ophthalmology, Faculty of General Medicine, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Moscow

5. Erichev V.P., Doctor of Medical Sciences, Professor, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Moscow

6. Kuroedov A.V., Doctor of Medical Sciences, Associate Professor, Head of the Ophthalmological Center, Mandryk Central Military Clinical Hospital of the Russian Ministry of Defense, Head of the Academician A.P. Nesterov Department of Ophthalmology, Faculty of General Medicine, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Moscow

7. Lovpache J.N., Candidate of Medical Sciences, Independent Expert, 3Z-MSK Ophthalmological Clinic, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Moscow

8. Malyugin B.E., Doctor of Medical Sciences, Professor, Deputy Director General for Science, S. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Association of Ophthalmologists of Russia, Moscow

9. Onufriychuk O.N., Candidate of Medical Sciences, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Saint Petersburg

10. Seлезнев А.В., Candidate of Medical Sciences, Associate Professor, Ivanovo State Medical Academy of the Russian Ministry of Health, Russian Society of Glaucoma Specialists, Association of Ophthalmologists of Russia, Ivanovo

11. Simonova S.V., Candidate of Medical Sciences, City Clinical Hospital No. 15 named after O.M. Filatov of the Moscow Healthcare Department, Russian Society of Glaucoma Specialists, Moscow

12. Sokolovskaya T.V., Candidate of Medical Sciences, Leading Researcher at the Department of Surgical Treatment of Glaucoma, S. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Association of Ophthalmologists of Russia, Moscow

13. Sorokoletov G.V., Doctor of Medical Sciences, Head of the Department of Surgical Treatment of Glaucoma, S. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Association of Ophthalmologists of Russia, Moscow

14. Khodzhaev N.S. Doctor of Medical Sciences, Professor, Deputy Director General for Organizational Work and Innovative Development, S. Fyodorov Eye Microsurgery Federal State Institution of the Russian Ministry of Health, Association of Ophthalmologists of Russia, Russian Society of Glaucoma Specialists, Moscow

No conflict of interest is declared.

Appendix A2. Methodology for Developing Clinical Guidelines

Methods used for collecting/selecting evidence: electronic database search, library resources. Description of methods used for collecting/selecting evidence: the evidence base for the guidelines includes publications from the Cochrane Library, EMBASE, and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic and foreign medical journals on the subject with a search depth of at least 10 years.

Levels of evidence certainty are presented in accordance with the methodological recommendations for the development and updating of clinical guidelines. (In Russ.)

Methods used to assess the quality and strength of evidence: expert consensus, significance assessment in accordance with the rating scheme.

A preliminary version of these guidelines was reviewed by independent experts to ensure the accessibility and interpretation of the evidence underlying the recommendations. Comments received from experts were systematized and discussed by members of the working groups of the Russian Society of Glaucoma Specialists and the Association of Ophthalmologists of Russia, and changes made were documented. If no changes were made, the reasons for refusal were recorded.

Comments were received from primary care ophthalmologists regarding the clarity of the presentation of the recommendations and their assessment of the significance of the recommendations as a working tool in daily clinical practice. (In Russ.)

For the final edition and quality control of the implementation of the guidelines, they were re-analyzed by the working group members, who concluded that all expert remarks and comments were taken into account, and the risk of systematic bias in the development of the guidelines was minimized.

Economic analysis

Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Target audience for these clinical guidelines:

1. Ophthalmologists

2. General practitioners (family physicians);

3. Optometrists

4. Residents in Ophthalmology (31.08.59) and scientific and pedagogical personnel (postgraduate students) in the field of Clinical Medicine (31.06.01), profile: Eye Diseases (14.01.07)

5. Students of higher medical educational institutions

Table A1 – Scale for assessing levels of evidence certainty.

Table A2 – Scale for assessing grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic updating – clinical guidelines are reviewed at least once every 3 years, as well as when new data emerge from the perspective of evidence-based medicine regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or if there are justified additions/comments to the previously approved clinical guidelines, but no more than once every 6 months. The decision to update is made by the Russian Ministry of Health based on proposals submitted by medical non-profit professional organizations. The formulated proposals must take into account the results of a comprehensive assessment of medicines, medical devices, and the results of clinical approbation. (In Russ.)

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following documents:

1. International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (adopted by the 43rd World Health Assembly, 1990)

2. "On the transition of health authorities and institutions of the Russian Federation to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision" (as amended by Order of the Russian Ministry of Health No. 3 dated January 12, 1998). Order of the Ministry of Health of the Russian Federation No. 170 dated May 27, 1997.

3. "On forwarding the list of added and deleted ICD-10 categories". Letter of the Ministry of Health of the Russian Federation No. 13-2/166 dated December 5, 2014

4. Federal Law No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (with amendments and additions, effective April 1, 2024).

5. Federal Law No. 489-FZ dated December 25, 2018 (as amended on June 11, 2021) "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation' regarding clinical guidelines"

6. "On approval of the standard of medical care for patients with glaucoma" (standard of medical care for patients with glaucoma in the provision of expensive (high-tech) medical care). Order of the Ministry of Health and Social Development of the Russian Federation No. 549 dated September 6, 2005.

7. "On approval of the standard of medical care for patients with glaucoma" (standard of medical care for patients with glaucoma in the provision of outpatient-polyclinic care in 2007). Order of the Ministry of Health and Social Development of the Russian Federation No. 708 dated October 13, 2006.

8. "On approval of the standard of medical care for patients with glaucoma (in the provision of specialized care)" (standard of medical care for patients with glaucoma (in the provision of specialized care)). Order of the Ministry of Health and Social Development of the Russian Federation No. 350 dated May 21, 2007

9. "On approval of the Procedure for assigning certain functions of the attending physician to a paramedic or midwife by the head of a medical organization when organizing the provision of primary health care and emergency medical care for the direct provision of medical care to a patient during their monitoring and treatment, including the prescription and use of medications, including narcotic and psychotropic medications (as amended on October 31, 2017)". Order of the Ministry of Health of the Russian Federation No. 252n dated March 23, 2012.

10. "On approval of the Procedure for providing medical care to the adult population for diseases of the eye, its adnexa, and orbit". Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012.

11. "On approval of the Regulation on the organization of specialized, including high-tech, medical care (as amended on August 27, 2015)". Order of the Ministry of Health of the Russian Federation No. 796n dated December 2, 2014.

12. "On approval of criteria for assessing the quality of medical care". Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017.

13. "On approval of the professional standard 'Ophthalmologist'". Order of the Ministry of Labor and Social Protection of the Russian Federation No. 470n dated June 5, 2017.

14. Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (as amended on September 24, 2020, with amendments dated October 26, 2022) "On Approval of the Nomenclature of Medical Services" (Registered with the Ministry of Justice of Russia on November 7, 2017, No. 48808)

15. "On Approval of the Criteria for the Formation of the List of Diseases, Conditions (Groups of Diseases, Conditions) for Which Clinical Guidelines Are Developed." Order of the Ministry of Health of the Russian Federation dated February 28, 2019, No. 101n.

16. "On Approval of the Procedure and Deadlines for the Development of Clinical Guidelines, Their Revision, the Standard Form of Clinical Guidelines, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines" (as amended on June 23, 2020). Order of the Ministry of Health of the Russian Federation dated February 28, 2019, No. 103n.

17. "On Approval of the Procedure and Deadlines for the Approval and Adoption of Clinical Guidelines, the Criteria for the Scientific and Practical Council to Make a Decision on Approving, Rejecting, or Sending Clinical Guidelines for Revision, or a Decision on Their Revision." Order of the Ministry of Health of the Russian Federation dated February 28, 2019, No. 104n.

18. Order dated April 27, 2021, No. 404n "On Approval of the Procedure for Conducting Preventive Medical Examinations and Health Checks (Dispensary Profiling) of Specific Groups of the Adult Population" (as amended on September 28, 2023).

19. "On Approval of the List of Vital and Essential Medicines for Medical Use for 2020, the List of Medicines for Medical Use, Including Medicines for Medical Use Prescribed by Decision of Medical Commissions of Medical Organizations, the List of Medicines Intended for Persons with Hemophilia, Cystic Fibrosis, Pituitary Dwarfism, Gaucher Disease, Malignant Neoplasms of Lymphoid, Hematopoietic, and Related Tissues, Multiple Sclerosis, Hemolytic-Uremic Syndrome, Juvenile Arthritis with Systemic Onset, Mucopolysaccharidosis Types I, II, and VI, Persons After Organ and/or Tissue Transplantation, and the Minimum Assortment of Medicines Required for Medical Care" (as amended on November 23, 2020) (edition effective from January 1, 2021). Directive of the Government of the Russian Federation dated October 12, 2019, No. 2406-r.

20. Decree of the Government of the Russian Federation dated December 28, 2023, No. 2353 (as amended on March 23, 2024) "On the Program of State Guarantees of Free Medical Care to Citizens for 2024 and for the Planning Period of 2025 and 2026."

Appendix B. Physician Action Algorithms

Fig. Algorithm for managing patients with suspected POAG (Cited from Prum B.E. Jr., Lim M.C., Mansberger S.L., et al. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern(®) Guidelines [published correction appears in Ophthalmology. 2018;125(6):949]. Ophthalmology. 2016;123(1):138. doi:10.1016/j.ophtha.2015.10.055

Appendix C. Patient Information

Patients with glaucoma suspects should be informed that an accurate diagnosis, as well as the ability to determine and monitor the progression of the disease, will be established using a range of modern examination methods. The benefits and risks of each treatment method must be discussed with the patient.

Below is a patient information leaflet for individuals diagnosed with POAG.

What is GLAUCOMA?

GLAUCOMA is a group of chronic eye diseases occurring predominantly in individuals over 40–50 years of age, the main manifestation of which is an increase in intraocular pressure, leading to gradual damage to the optic nerve and, consequently, the appearance of visual field defects ("side" vision) and decreased visual acuity down to complete blindness.

How does GLAUCOMA manifest? What are the symptoms of the disease?

GLAUCOMA develops gradually, often proceeding without any symptoms, which is precisely what makes it dangerous. Sometimes signs of GLAUCOMA may include: periodic blurring of vision; appearance of rainbow halos around light sources that do not disappear with forceful blinking or rubbing the eye; loss of clear contours when viewing various objects; sensation of "heaviness" or pain in the eye; appearance of a "grid" before the eye; difficulty with close-up work (e.g., reading); need for frequent changes of glasses; difficulty orienting in the dark. Headaches, primarily in the eyebrow and temporal regions, are also possible. In later stages, visual field constriction appears from the nasal side. These symptoms may also be observed in other diseases unrelated to GLAUCOMA, but their occurrence should always serve as a reason to consult an ophthalmologist promptly.

If I see well, does that mean I do not have GLAUCOMA?

GLAUCOMA is an insidious disease that is asymptomatic in its early stages. Therefore, regardless of whether you have complaints or not, you must undergo a routine annual preventive examination by an ophthalmologist as part of medical check-ups (dispensary profiling), with mandatory measurement of IOP and fundus examination. The scope of examinations is determined by the physician.

What are the risk factors that increase the likelihood of developing GLAUCOMA?

Risk factors are not the direct cause of GLAUCOMA, but they increase the likelihood of its occurrence. These include: age: GLAUCOMA usually develops in people after 40 years of age; hereditary predisposition: if family members or close relatives have already been diagnosed with GLAUCOMA; myopia exceeding 6 diopters; diabetes mellitus; migraine.

What treatment will the doctor prescribe for me in case of GLAUCOMA?

The main goal of treatment is to lower the IOP level, which helps stabilize the process or slow down its rate of progression while maintaining an acceptable quality of life. If you are diagnosed with GLAUCOMA, the doctor usually prescribes IOP-lowering eye drops. If medical treatment and adherence to the prescribed regimen do not lower the eye pressure or lower it insufficiently, laser surgery or incisional surgery will be offered. The choice of treatment method for GLAUCOMA is determined individually, depending on the nature of the disease course and other concomitant factors, and falls within the competence of the attending physician.

What is the prognosis for the course of GLAUCOMA?

The primary condition for preserving satisfactory visual functions and the associated quality of life is timely detection of the disease and its adequate treatment. At the same time, GLAUCOMA is a severe, chronic, progressive disease that remains to this day one of the leading causes of irreversible blindness and low vision worldwide.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Glaucoma Risk Calculator

Russian title: Glaucoma Risk Calculator for Individuals with Ocular Hypertension

Original title (if applicable): S.T.A.R II (The Scoring Tool for Assessing Risk) Glaucoma Risk Calculator

Source (official developer website, validation publication): Medeiros F.A., Weinreb R.N., Sample P.A. et al. Validation of a predictive model to estimate the risk of conversion from ocular hypertension to glaucoma. Arch Ophthalmol. 2005;123:1351-1360.

Type (underline): disease risk calculator

Purpose: determining the 5-year risk of developing glaucoma in patients with ocular hypertension

Content (template): parameters used: age, IOP level, CCT, vertical cup-to-disc ratio, visual field PSD index.

Key (interpretation): Based on the results obtained, the 5-year risk of developing glaucoma is estimated as:

A) Low (result below 5%). Recommended strategy: observation without treatment.

B) Moderate (result between 5-15%). Recommended strategy: decision on medical treatment is made individually, taking into account the patient's preference.

C) High (result above 15%). Recommended strategy: treatment aimed at lowering IOP.

Notes. An electronic version of the calculator is available for download on smartphones and tablets (http://www.pocket.md/80/star-ii.html). Currently, this is the most widely used glaucoma risk calculator for patients with ocular hypertension (Ameen S., Javaid F., Cordeiro M.F. Risk calculators in glaucoma // Exp Rev Ophthalmol. 2016; 11(1): 21-27. DOI: 10.1586/17469899.2016.1136213).