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Ophthalmology Seeks Revised Government Assessment of Glaucoma Screenings and Treatment

11/03/2011   09:00:00 AM

Eye medical doctors assert that recent evaluation could adversely impact high-risk minorities

WASHINGTON AND SAN FRANCISCO – The American Academy of Ophthalmology and the American Glaucoma Society are calling for a new evaluation of glaucoma screening and treatment in response to recent draft reviews prepared by the Agency for Healthcare Research and Quality (AHRQ). The draft reviews assess the effectiveness of glaucoma screenings and treatment, concluding that there is no evidence for or against glaucoma screenings, or a correlation between glaucoma treatment and visual impairment. This is significant as AHRQ shares its reviews with the U.S. Preventive Services Task Force, whose recommendations have implications for Medicare and private-payer coverage decisions, and could hinder access to care for minorities who are at high risk for glaucoma.

Open-angle glaucoma affects an estimated 2.2 million people in the United States, with that number expected to increase to 3.3 million in 2020 as the population ages. Overall, there appears to be a threefold higher prevalence of open-angle glaucoma in African Americans relative to non-Hispanic whites in the United States. Glaucoma is the second-most common cause of blindness in African Americans. Blindness from glaucoma is at least six times more prevalent in African Americans than in non-Hispanic whites. Evidence on Hispanics/Latinos suggests that they have prevalence rates of open-angle glaucoma that are comparable to African Americans.

The Academy and the American Glaucoma Society provided comments to AHRQ noting errors in both how the reviews were conducted, as well as the resulting conclusions. Glaucoma treatment has been demonstrated to reduce visual-field progression and is also linked to preservation of health-related quality of life. Among the 18 specific concerns cited by the Academy and the AGS are: 

  • The AHRQ review focused on the technical aspects of glaucoma screening and overlooked the significant burden that untreated glaucoma and associated blindness has on individuals. This includes economic, social and functional impacts on patients, as well as on society.
  • While glaucoma specialists agree that screening the overall population for glaucoma has limited value, conducting screenings that target high-risk groups will be more effective. The fact that there are identified high-risk populations that are appropriate targets for screening is an essential issue that was not addressed in the review. 
  • There is more evidence on the linkage between quality of life and glaucoma treatment than was presented in the review.
  • The association between visual-field loss with diminished health-related quality of life is not discussed in the review. Glaucoma treatment has been demonstrated to reduce visual-field progression and is also linked to preservation of health-related quality of life.  

"The AHRQ reviews and recommendations for screening and treatment of glaucoma fail to properly weigh the overall effectiveness of proven methods of patient care, and therefore could have significant negative societal impact on the medical community's ability to control the disease," said glaucoma specialist Joseph Caprioli, MD, professor of ophthalmology at UCLA and chairman of the Academy's Practice Improvement Committee. "Glaucoma is largely asymptomatic in its early stages, but will cause significant, irreversible visual impairment without treatment. Preserving a high quality of life for individuals with glaucoma needs to be emphasized – and remain the highest priority – when considering screening and treatment."

Ophthalmologists in their response to AHRQ, noted that it is important to continue screening for open-angle glaucoma because patients are asymptomatic until late in the disease process, when visual loss and functional impairment are irreversible. They referenced the fact that the populations most at-risk for glaucoma and blindness are also the most vulnerable populations in our society, and the least likely to have regular access to "routine" eye care. These factors make intentional outreach strategies for disease detection in these populations necessary. The Academy and AGS assert there is value in identifying or incentivizing high-risk groups to have a comprehensive diagnostic eye examination. If detected early, patients with primary open-angle glaucoma can be treated to either slow or prevent the progression of visual-field loss. Even mild visual-field loss decreases a patient's health-related quality of life.  

Although a randomized controlled trial demonstrating the value of screening with improved quality of life and patient-reported outcomes may not exist, glaucoma specialists believe that there are similarities between findings seen with the early treatment of glaucoma and reduced disease progression with less visual-field loss, and reduction in health-related quality of life that should be considered as part of the overall review of glaucoma screening for at-risk populations.

Read the complete responses by the Academy and the American Glaucoma Society on Comparative Effectiveness of Screening for Glaucoma (PDF 390 KB)and Comparative Effectiveness of Treatment for Glaucoma (PDF 480 KB).

About the American Academy of Ophthalmology
The American Academy of Ophthalmology is the world's largest association of eye physicians and surgeons — Eye M.D.s — with more than 30,000 members worldwide.  Eye health care is provided by the three "O's" – ophthalmologists, optometrists, and opticians. It is the ophthalmologist, or Eye M.D., who can treat it all: eye diseases, infections and injuries, and perform eye surgery. For more information, visit www.aao.org. The Academy's EyeSmart® public education program works to educate the public about the importance of eye health and to empower them to preserve their healthy vision, by providing the most trusted and medically accurate information about eye diseases, conditions and injuries. Visit www.geteyesmart.org to learn more.

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