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Screening for Primary Open-angle Glaucoma - a Systematic Review of the Literature
1Maier P., 1Funk J., 2Antes G., 2Falck-Ytter Y.,
1Albert-Ludwigs-Universität Freiburg, Augenklinik (Freiburg)
2Deutsches Cochrane Zentrum (Freiburg)
Purpose: There is increasing pressure from the public in Germany to have various screening programs (e.g., for chronic glaucoma) paid for by the public health insurance carriers. The available literature was therefore searched systematically to determine whether screening, and thus possible prevention, of primary open-angle glaucoma (POAG) or normal tension glaucoma (NTG) may be effective.
Methods: Medline, Embase and other medical databases were searched using a highly sensitive search strategy. Study quality was assessed by two independent researchers, critically appraised and ranked according to levels of evidence.
Results: Primary glaucoma is one of the most common causes of blindness in industrialized nations. Risk factors associated with higher incidence of POAG or NTG include ocular hypertension (OHT), African ancestry, family history of glaucoma, and advanced age. However, the natural history of the disease is not well understood, as most people with OHT alone will not develop glaucoma. Notably, reliable predictors for the progression of visual field loss in POAG, NTG or OHT are missing. For effective screening, adequate sensitivity and specificity of the screening tool are essential. Tonometry, disc assessment, and visual field alone or in combination could not achieve a satisfactory balance of sensitivity and specificity for screening purposes. At a prevalence rate between 1% to 3% for POAG, the positive predictive values of the screening tools remained unsatisfactory. Trials assessing treatment effectiveness were often limited by poor design, such as sole reliance on inadequate surrogate markers. Only few randomized controlled trials included untreated controls. However, when visual field progression was used as primary endpoint, effectiveness of pressure-lowering strategies could not be consistently demonstrated.
Conclusions: Current data do not support the widespread use of screening programs for average risk patients.