• Glaucoma

    This article published in December 2011 in the American Journal of Ophthalmology challenges physicians to evaluate their utilization of diagnostic testing modalities in the management of glaucoma. The authors question the value of anterior segment, optic nerve and retinal nerve fiber layer imaging modalities, and express concern about the improper allocation of resources in both resource-poor and relatively resource-abundant settings. They champion the concept that more thoughtful prioritization of our resources could alleviate much suffering from glaucoma.

    They reviewed selected articles from primary and secondary sources, assessing the value of any test used in glaucoma in terms of its contexts, kind of value and implicit or explicit benefits.

    They concluded that tonometry, slit-lamp gonioscopy and optic disc evaluation remain the foundation of clinic-based case finding, whether in areas of more or less abundant resources. In resource-poor areas, the authors say it is urgent to identify patients at risk of severe functional loss of vision; screening strategies have proven ineffective and efforts are hindered by the inadequate allocation of support. In resource-abundant areas, the wider spectrum of glaucoma is addressed, with emphasis on early detection of structural changes of little functional consequence, which are increasingly the focus of new and expensive technologies whose clinical value has not been established in longitudinal and population-based studies.

    The authors say that these contrasting realities in part reflect differences among the value ascribed, often implicitly, to the tests used in glaucoma. They encourage physicians to perform self-evaluations of their motivations and to assess the implications of every medical decision. Clearly, more research needs to be done to help us better provide the most cost-effective glaucoma care to our patients.