Sir,

There is currently a wide variety of options available for the treatment of primary open-angle glaucoma (POAG). Guidelines for the management of POAG have been published by the Royal College of Ophthalmologists,1 the European Glaucoma Society (EGS),2 and the American Academy of Ophthalmology (AAO).3 None of these guidelines give specific recommendations in regard to choice of initial treatment. Where there is lack of a consensus opinion and with growing treatment choices, we feel it is important for ophthalmologists, particularly trainees, to know the practice patterns of their colleagues. The aim of this study was to find out first-choice treatment preferences in the United Kingdom.

Methods and results

A questionnaire was sent to all consultant ophthalmologists in the United Kingdom whose names were held by the Royal College of Ophthalmologists. All were sent out by the end of October 2003. In all, 547 (69.2%) responses were received by the end of 2003. A total of 28 respondents indicated that they did not treat glaucoma patients and were excluded from the analysis.

Respondents were asked to select their first choice of initial treatment for three hypothetical patients with either mild, moderate, or severe POAG. They were also asked if they routinely use one-eyed therapeutic trials when instituting therapy for bilateral POAG. Each hypothetical patient was characterized as a 65-year-old white (largest ethnic group in the UK: Office for National Statistics, Census, April 2001) patient with no medical or ocular history, and intraocular pressures of 28 mmHg in both eyes. The differing severities were given as per the AAO guidelines with the mild POAG patient having characteristic optic nerve abnormalities consistent with glaucoma, but with a normal visual field (16 respondents commented that this hypothetical mild POAG patient did not have glaucoma). The moderate POAG patient having visual field abnormalities in one hemifield but not within 5 degrees of fixation. The severe POAG patient was described as having visual field abnormalities in both hemifields and loss within 5 degrees of fixation.

Respondents were also asked to select their first-line surgical technique of choice, even if surgery was not their first choice for any of the hypothetical patients.

Only 31 respondents (6.0%) indicated that they routinely use one-eyed therapeutic trials. This approach has been suggested by EGS and AAO guidelines when initiating treatment. It can give an idea of the drug effect in the face of diurnal variation, but a crossover effect into the nontreated eye must be taken into account. However, it is obviously not widely employed. The preferred treatment choices are summarized in Table 1 (for this study, we have included bimatoprost in the class of prostaglandin analogues rather than group it separately as a prostamide).

Table 1 First choice treatment preferences of ophthalmologists in the United Kingdom for primary open-angle glaucoma
Full size table

The first-choice medical treatment preferences of respondents were similar for each severity category. Prostaglandin analogues being the most popular followed by nonselective beta-blockers. Latanoprost was the prostaglandin analogue chosen by 87.2% of respondents and timolol was the nonselective beta-blocker of choice for 72.7%. No respondents chose surgery as a first choice for mild or moderate POAG. Of those who perform filtration surgery, trabeculectomy was the first-line surgical method chosen by 95.6% with the remainder using nonpenetrating methods and none choosing artificial drainage shunts.

Laser trabeculoplasty was not selected by any respondent as a first-choice option. However, argon laser trabeculoplasty is given by the AAO guidelines as an appropriate alternative to topical medications as initial therapy. With promising pilot studies4, 5 it will be interesting to see if selective laser trabeculoplasty becomes a first-choice treatment in the UK.

Prostaglandin analogues have become a popular first-line choice of treatment, especially given that the hypothetical patient was said to have been healthy and not had any cardiopulmonary disease. This popularity is presumably due to their established efficacy, good systemic side effect profile and convenient once daily dosing. Despite recent studies showing a similar efficacy of the currently available prostaglandin analogues6 latanoprost remains by far the most popular.

It should be remembered that respondents’ treatment choices may have been different had the initial IOP been higher or the hypothetical patient been of a different race. Even so, this study will enable other ophthalmologists, including those in training, to compare their treatment choices with others in their field, allowing for critical appraisal. It may also serve as a baseline for analysing future trends in POAG management and may be of use to clinicans dealing with hospital pharmacies and drug committees.