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(Review)
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2012, Issue 9
http://www.thecochranelibrary.com
1
School of Medicine, Medical and Biological Sciences Building, University of St Andrews, Fife, UK. 2 Health Services Research Unit,
University of Aberdeen, Aberdeen, UK. 3 Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen,
UK. 4 Eye Centre, Tampere University Hospital, Tampere, Finland
Contact address: Jennifer Burr, School of Medicine, Medical and Biological Sciences Building, University of St Andrews, Fife, KY16
9TF, UK. jmb28@st-andrews.ac.uk.
Citation: Burr J, Azuara-Blanco A, Avenell A, Tuulonen A. Medical versus surgical interventions for open angle glaucoma. Cochrane
Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004399. DOI: 10.1002/14651858.CD004399.pub3.
Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Objectives
To assess the effects of medication compared with initial surgery in adults with OAG.
Search methods
We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7),
Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE
(January 1946 to August 2012), EMBASE (January 1980 to August 2012), Latin American and Caribbean Literature on Health Sciences
(LILACS) (January 1982 to August 2012), Biosciences Information Service (BIOSIS) (January 1969 to August 2012), Cumulative
Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to August 2012), OpenGrey (System for Information on
Grey Literature in Europe) (www.opengrey.eu/), Zetoc, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com)
and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or
language restrictions in the electronic searches for trials. We last searched the electronic databases on 1 August 2012. The National
Research Register (NRR) was last searched in 2007 after which the database was archived. We also checked the reference lists of articles
and contacted researchers in the field.
Selection criteria
We included randomised controlled trials (RCTs) comparing medications with surgery in adults with OAG.
Two authors independently assessed trial quality and extracted data. We contacted study authors for missing information.
Medical versus surgical interventions for open angle glaucoma (Review) 1
Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
Four trials involving 888 participants with previously untreated OAG were included. Surgery was Scheies procedure in one trial and
trabeculectomy in three trials. In three trials, primary medication was usually pilocarpine, in one trial it was a beta-blocker.
The most recent trial included participants with on average mild OAG. At five years, the risk of progressive visual field loss, based on a
three unit change of a composite visual field score, was not significantly different according to initial medication or initial trabeculectomy
(odds ratio (OR) 0.74, 95% confidence interval (CI) 0.54 to 1.01). In an analysis based on mean difference (MD) as a single index
of visual field loss, the between treatment group difference in MD was -0.20 decibel (dB) (95% CI -1.31 to 0.91). For a subgroup
with more severe glaucoma (MD -10 dB), findings from an exploratory analysis suggest that initial trabeculectomy was associated
with marginally less visual field loss at five years than initial medication, (mean difference 0.74 dB (95% CI -0.00 to 1.48). Initial
trabeculectomy was associated with lower average intraocular pressure (IOP) (mean difference 2.20 mmHg (95% CI 1.63 to 2.77) but
more eye symptoms than medication (P = 0.0053). Beyond five years, visual acuity did not differ according to initial treatment (OR
1.48, 95% CI 0.58 to 3.81).
From three trials in more severe OAG, there is some evidence that medication was associated with more progressive visual field loss and
3 to 8 mmHg less IOP lowering than surgery. In the longer-term (two trials) the risk of failure of the randomised treatment was greater
with medication than trabeculectomy (OR 3.90, 95% CI 1.60 to 9.53; hazard ratio (HR) 7.27, 95% CI 2.23 to 25.71). Medications
and surgery have evolved since these trials were undertaken.
In three trials the risk of developing cataract was higher with trabeculectomy (OR 2.69, 95% CI 1.64 to 4.42). Evidence from one trial
suggests that, beyond five years, the risk of needing cataract surgery did not differ according to initial treatment policy (OR 0.63, 95%
CI 0.15 to 2.62).
Methodological weaknesses were identified in all the trials.
Authors conclusions
Primary surgery lowers IOP more than primary medication but is associated with more eye discomfort. One trial suggests that visual
field restriction at five years is not significantly different whether initial treatment is medication or trabeculectomy. There is some
evidence from two small trials in more severe OAG, that initial medication (pilocarpine, now rarely used as first line medication) is
associated with more glaucoma progression than surgery. Beyond five years, there is no evidence of a difference in the need for cataract
surgery according to initial treatment.
The clinical and cost-effectiveness of contemporary medication (prostaglandin analogues, alpha2-agonists and topical carbonic anhy-
drase inhibitors) compared with primary surgery is not known.
Further RCTs of current medical treatments compared with surgery are required, particularly for people with severe glaucoma and
in black ethnic groups. Outcomes should include those reported by patients. Economic evaluations are required to inform treatment
policy.
(d) Other procedures Criteria for considering studies for this review
Alternative microsurgical procedures on the trabecular meshwork
(trabecular aspiration, goniocurettage, laser trabecular ablation,
angle shunting devices and trabeculotomy) have been described as Types of studies
a means of lowering IOP in OAG. These techniques are not widely All randomised controlled trial (RCTs) and quasi-RCTs were eli-
used and their safety and effectiveness is not known (Chihara 1993; gible for inclusion.
Jacobi 2000). Lowering the IOP may also be achieved by reducing
the production of aqueous humour by the ciliary body by laser or
cryo ablation. Types of participants
Participants in the trials were adults with a diagnosis of open an-
gle glaucoma (OAG). We did not include trials with participants
How the intervention might work under 18 years. We did not impose any restrictions according to
Medications lower IOP by either decreasing aqueous production gender or nationality.
or increasing aqueous outflow. Surgery creates an alternative route
for aqueous humour outflow. Lowering IOP reduces the risk of
progressive visual field loss, (AGIS 2000; CNTGSG 1998; Heijl Types of interventions
2002) and the likelihood of progression to visual impairment. We included all trials where medical ocular hypotensive therapy
was compared with:
1. trabeculectomy with or without the use of anti-scarring
Why it is important to do this review agents;
2. non-penetrating trabeculectomy with or without the use of
Early trials in the UK of initial medical treatment versus tra-
anti-scarring agents;
beculectomy suggest that there is less deterioration of visual fields
3. any other anti-glaucomatous surgery, including glaucoma
in the trabeculectomy first group (Jay 1988; Migdal 1994). Re-
drainage devices; or
ports of five-year clinical outcomes of a trial of initial medical ver-
4. laser treatment to the ciliary body, transscleral
sus surgical therapy for OAG show no difference in IOP reduction
cyclophotocoagulation.
or rates of visual field progression between the treatment groups,
We included trials where the medical arm included surgery or laser
but show a higher incidence of cataract and local eye symptoms
in the treatment sequence (if medical treatment was inadequate),
in the surgically-treated group (Lichter 2001). With the develop-
or vice versa for initial surgical treatment as a comparison of initial
ment of newer medications for OAG and the refinement of sur-
medical versus initial surgical treatment.
gical techniques, the relative effectiveness of medical and surgi-
We did not include trials of medical therapy compared to laser
cal treatments on long-term visual outcomes and quality of life is
trabeculoplasty as these are the subject of a separate published
uncertain. It is also unclear whether the treatment choice should
Cochrane review (Rolim de Moura 2007).
be different for individuals identified at higher risk of blindness,
such as people of black ethnicity or people with severe disease at
presentation. Types of outcome measures
Primary outcomes
OBJECTIVES
1. Progressive visual field loss, according to the measures and
1. To study the comparative effectiveness of medical and criteria defined in the study design.
surgical treatment for OAG in terms of measures of glaucoma 2. Health-related quality of life.
progression and patient reported health-related quality of life.
2. To investigate these treatment effects in people of black race Secondary outcomes
and for people with different disease severity.
1. Intraocular pressure (IOP) reduction.
3. To describe any reported costs or economic evaluations of 2. Progression of optic disc damage or nerve fibre layer loss
medical and surgical treatment. according to the criteria defined in the study design.
Allocation
ity of life in one study (CIGTS); the interviewers were masked to
In all four trials the method of randomisation and allocation con- the intervention received although the participants were aware of
cealment was judged to be at low risk of selection bias. The method their randomised intervention. The measure of the primary clini-
of concealment was reported in two trials (CIGTS; Moorfields GT cal outcome for this review (visual fields) was objective, although
1968) and in the other two trials further information supplied by based on subjective responses by the patient, and was well de-
the study authors suggests that the method was adequate (Glasgow scribed in the included studies. The CIGTS used standard auto-
Trial 1988; Moorfields PTT 1994). mated perimetry as the primary outcome measure of visual field
loss and as the reading is automated it was judged as low risk of
Blinding detection bias. In the other three included studies (Glasgow Trial
1988; Moorfields GT 1968; Moorfields PTT 1994), although the
The assessment of outcomes was not masked for any of the trials
scoring system was well described it was unclear as to whether
apart from the telephone interviews recording health-related qual-
REFERENCES
CIGTS
Interventions Medical treatment: sequence of medications, usually beginning with topical beta-blocker
followed by an alternative single topical agent, dual, triple then alternative topical and
or oral medications. If further treatment required, the next treatment step was ALT
followed by trabeculectomy (with or without 5-fluorouracil at the surgeons discretion),
repeat medication, repeat trabeculectomy with anti-fibrotic agents, repeat medication
Surgery: trabeculectomy (with or without 5-fluorouracil at the surgeons discretion)
within 14 days of randomisation, if failure then ALT then sequence of medications, then
repeat trabeculectomy with anti-fibrotic agents, then repeat medications. Criteria for
intervention failure had to be met each time that a further treatment step was initiated
Criteria for intervention failure:
Up to July 1996 - failure to meet a target IOP established at the time of
randomisation and/or evidence of progressive visual field loss on three consecutive tests
performed at separate clinic visits
After July 1996 - the criterion for IOP failure was changed because of concern
that the use of target IOP alone to arbitrate intervention failure might result in overly
aggressive advancement in treatment sequence. If field loss spared the central four
points, i.e. was paracentral then 20% to 25% tolerance above target IOP was allowed
before initiating the next treatment step
Outcomes Progressive visual field loss: Humphrey 24-2 perimetry, with a scoring method designed
for the study*, recorded every three months
HRQOL: measured using disease specific and generic measures = (1) symptom and
health problem check list, (2) Visual Activities Questionnaire, (3) Glaucoma Health
Perceptions Index (4) Sickness Impact Profile, (5) Centre for Epidemiological studies -
Depression Score(CES-D), (6) Health Perceptions Index
IOP: Goldmann applanation tonometry recorded three monthly
Visual acuity: ETDRS
Incidence of cataract surgery
Treatment crossover after intervention failure
Adverse events: mortality (overall deaths but not by intervention group); surgical com-
plications reported but for all eyes (i.e. including the other eye not included in the trial)
Notes Lichter 2001 reports interim outcome data through four years after treatment initiation.
161 participants had not yet achieved 5 years after treatment initiation. Musch 2009
and Musch 2008 report longer-term visual field and IOP outcomes up to 9 years. The
measure of VF used in Musch 2009 was based on mean deviation (MD) as a measure of
VF. The CIGTS investigators moved away from analysing visual field outcomes using
the CIGTS score due to its problematic distributional properties - i.e., floor and ceiling
effects that are not shared by the MD (correspondence with the author). there is potential
for bias due to selective reporting of the primary clinical outcome. Parrish and colleagues
( Parrish 2009) report the optic disc findings, based on follow stereophotographs of
study eyes, obtained from available data in a six month window of the 5-year follow-up
assessment. readers were masked to randomised allocation
Risk of bias
Random sequence generation (selection Low risk Treatment assignment was determined by
bias) the co-ordinating centre.... Minimisation
was used for treatment allocation
Allocation concealment (selection bias) Low risk Method of allocation: remote coordinating
centre
Blinding (performance bias and detection Unclear risk Masking outcome assessment: Examiners of
bias) visual field were not masked according to
Primary Outcome: visual field progression; treatment status, perimetry is automated
HRQoL and therefore considered a low risk of bias
in terms of assessment of a continuous out-
come (MD) and the CIGTS score.The as-
sessment of HRQOL, by trained telephone
interviewers, was masked unless the partic-
ipant revealed his or her treatment status.
The potential for bias is uncertain
Incomplete outcome data (attrition bias) Low risk Long-term VF: 5-year VF data were avail-
Primary outcome: visual field; HRQoL able on 255 (85%) initial surgery group
and 269 (87%) initial medication group.
Higher risk of bias for longer-term VF data:
At 8 years VF data were available on 142
(47%) initial surgery group and 153 (50%)
of initial medication group
Medium-term HRQOL: Patient reported
outcome data at 4 years, were available
on 266 (89%) of participants randomised
to initial surgery and 283 (93%) of par-
ticipants randomised to initial medication
(Janz 2001)
Long-term HRQoL: At five years, data were
available on 195 (65%) of participants ran-
domised to initial surgery and 210 (68%)
of participants randomised to initial medi-
cation (Janz 2001)
Selective reporting (reporting bias) High risk The index of measurement of the visual
field outcome was changed for reporting of
longer-term visual field outcomes (Musch
2009)
Methods Method of allocation: random number tables with concealed allocation in serially
numbered opaque envelopes
Masking of outcome assessment: no
Exclusions after randomisation: 4 patients refused early surgery and were excluded
from the study
Unusual study design: A sub-group analysis, not outlined in the study design, was
performed according to severity of VF loss examining differences in VF outcome
between treatment groups
Duration: Recruitment from 1980 to 1985, maximum follow-up 7 years (mean 4.
6)
Participants Country: UK
Number randomised: 116
Sex: males and females
Ethnicity: white
Disease severity: 66/107 (62%) of participants were classified as severe disease at baseline
with no significant difference between randomised groups. Severe disease was defined
in this study as field stage 2 to 5**. The severity of visual field loss of the 5 participants
who died and 4 exclusions in the first year was not reported
Inclusion criteria: all of the following:
(1) previously undiagnosed case of primary open angle glaucoma, or open angle glaucoma
with pseudoexfoliation
(2) untreated IOP of >26 mmHg(Goldmann) on two occasions
(3) visual field defects characteristic of glaucoma
Exclusion criteria: not stated
Outcomes Progressive visual field loss: visual field measured using Tubingen manual perimetry.
Classified into five stages of loss**. Significant change defined as at least one full stage of
classification from diagnosis
IOP: Goldmann applanation tonometry
Progressive optic disc damage : change in vertical cup to disc ratio of > +/- 0.1
Snellen visual acuity
Intervention failure: short-term outcome data only
Adverse events: mortality; severe irreversible reduction of vision; onset of cataract
analysis.
Figures were not available for optic disc change by randomised group.
Figures were presented for proportion progressing in subgroups defined by early or severe
visual field loss, summary effect measures could not be calculated as the total number of
participants in each subgroup of visual field loss was not reported
Risk of bias
Random sequence generation (selection Low risk Method of allocation: random number ta-
bias) bles
Allocation concealment (selection bias) Low risk Serially numbered opaque envelopes
opened by the investigator. Information re-
ceived from study authors suggests low risk
of bias
Blinding (performance bias and detection Unclear risk Visual fields were undertaken at the trial
bias) centre at yearly intervals and undertaken by
Primary Outcome: visual field progression; trained perimetrists. The change in visual
HRQoL status was assessed by an experienced ob-
server. It is not clear whether the observer
was masked to the treatment status. Ob-
jective measure with well described scoring
system
Incomplete outcome data (attrition bias) High risk Data on 25 (44%) in the group treated
Primary outcome: visual field; HRQoL with medications and 30 (60%) partici-
pants treated by primary trabeculectomy
were available for the final analysis
Selective reporting (reporting bias) Unclear risk Deemed as low risk of bias as visual field
status is recognised as an appropriate pri-
mary outcome. All expected outcomes were
reported
Moorfields GT 1968
Methods Method of allocation: random number tables. The allocation was remote from the
person entering the patient into the study
Masking outcome assessment: not reported
Exclusions after randomisation: 4 in the surgery group
Losses to follow-up: 6 patients in total were lost to follow-up, 5 of these in the
group assigned medical treatment
Duration: 1968 to 1982
Participants Country: UK
Number randomised: 52
Age at entry in years: range 35 to 70
Sex: 37 male and 15 female
Ethnicity: Black race excluded
Inclusion criteria:
(1) IOP > = 23 mmHg on two occasions
(2) visual field loss compatible with glaucoma
(3) glaucomatous cupping
Exclusion criteria:
(1) previous glaucoma surgery
(2) black race
(3) other ophthalmic abnormalities of importance
Interventions Medical: any medical treatment deemed necessary. The most common medication was
pilocarpine 2% and 4%, guanethidine, adrenaline, oral carbonic anhydrase inhibitors.
In 1979 Timoptol was used as a study medication. Participants underwent surgery if the
IOP was deemed not sufficiently well controlled by medical treatment
Surgery: modified Scheies procedure with sector iridectomy. Supplementary medical
treatment was used if the IOP was deemed not sufficiently well controlled
Outcomes Progressive visual field loss: Lister manual perimetry and a visual field score was generated.
Outcome measured as mean score difference between the intervention groups
IOP: Goldmann applanation tonometry. Short and long-term outcome data
Snellen Visual acuity: expressed as a percentage, 6/6 = 100%, 6/9 = 66%, 6/12 = 50%,
6/18 = 33%, 6/24 = 25%, 6/36 = 16%, 6/60 = 10%, CF = 5%, PL acc = 2%, PL inacc
= 1%, NPL = 0%. Long-term outcome measured as score difference
Need for additional medicine or surgery due to intervention failure: only reported for
medical group
Notes It took 7 years to find the required number of suitable patients. The data were analysed
at various times during the trial (1968, 1970 and 1986). Data were analysed according
to interval in trial. This resulted in small numbers available for analysis at these times.
The 1986 data are used in this analysis as this has the most complete follow-up
Risk of bias
Random sequence generation (selection Low risk Method of allocation: random number ta-
bias) bles
Allocation concealment (selection bias) Low risk The allocation was remote from the per-
son entering the patient into the study. In-
formation received from study authors sug-
gests low risk of bias
Blinding (performance bias and detection Unclear risk Masking outcome assessment: not reported
bias) (visual field). Visual fields were assessed by
Primary Outcome: visual field progression; a well described scoring system. The visual
HRQoL field examiner was not reported
Incomplete outcome data (attrition bias) High risk Visual field: Analysis was not by intention
Primary outcome: visual field; HRQoL to treat analysis as four participants who ei-
ther refused or did not receive surgery re-
mained under review but were not included
in the data analysis
Selective reporting (reporting bias) Unclear risk The study was conducted in the 1960s be-
fore it was a requirement to publish the pro-
tocol. Deemed as low risk of bias as visual
field status is recognised as an appropriate
primary outcome. All expected outcomes
were reported
Methods Recruitment started in 1983, and 168 participants were randomised, minimum follow-
up 5-years
Method of allocation: randomly allocated using computer selection and remote
from the ophthalmologist recruiting the participant. In bilateral asymmetric disease the
worse eye was included in the study. In symmetric disease the eye to be included was
randomly allocated
Masking outcome assessment: not stated
Exclusions after randomisation: none
Losses to follow-up: not stated
Unusual study design: the participants were randomly allocated to 3 groups
(medicine, surgery or laser therapy as a primary treatment)
Treatment was considered unsuccessful if IOP was > 22 mmHg on two occasions. In
the event of failure, the alternative therapy from the remaining options was randomly
assigned by computer selection. Failures in each treatment group were excluded from
the calculation of the results from time to failure
Duration: minimum of five years follow-up
Participants Country: UK
Number randomised: 168 patients randomised to primary medical (56), laser (55) or
surgery (57). The participants randomised to initial laser therapy are not included in
this review
Mean age: 62.4 years
Sex: not stated
Ethnicity: 10 participants were black and 10 were Asian
Disease severity: staged according to Friedmann visual field loss at presentation****. 33/
113 (29%) early, 26/113 (23%) middle, 54/113 (48%) late glaucoma
Outcomes (1) Progressive visual field loss: Visual fields(Friedmann) measured at 3 months and then
every 4 months. Humphrey automated perimetry 6 monthly from two years into the
study
(2) IOP reduction: Goldmann applanation tonometry
(3) Visual Acuity: Snellen mean visual acuity score
(4) Intervention failure: Kaplan-Meier survival analysis to point of failure. Failure defined
as IOP > 22 mmHG on two occasions
Notes (1) Friedmann: The mean scores were determined by calculating the mean of the first
three visual field scores after entry into the trial and the mean of the final three visual
field scores
In this study failures, defined as failure to maintain an IOP < 22 mmHg on two occasions,
were excluded from the calculation of results for all outcome assessments except for a
final report measuring visual field progression using automated perimetry
Risk of bias
Random sequence generation (selection Low risk Method of allocation: randomly allocated
bias) using computer selection. In bilateral asym-
metric disease the worse eye was included
in the study. In symmetric disease the eye
to be included was randomly allocated
Allocation concealment (selection bias) Low risk Allocation was remote from the ophthal-
mologist recruiting the participant
Blinding (performance bias and detection Unclear risk Visual field: Masking outcome assessment:
bias) not stated. Objective measure with well de-
Primary Outcome: visual field progression; scribed scoring system. The visual field ex-
HRQoL aminer was not reported
Incomplete outcome data (attrition bias) High risk Losses to follow-up: not stated
Primary outcome: visual field; HRQoL Unusual study design: the participants were
randomly allocated to 3 groups (medicine,
surgery or laser therapy as a primary treat-
ment). Treatment was considered unsuc-
cessful if IOP was > 22 mmHg on two oc-
casions. In the event of failure, the alter-
native therapy from the remaining options
Selective reporting (reporting bias) Unclear risk The study was conducted in the 1980s be-
fore it was a requirement to publish the pro-
tocol. Deemed low risk as visual field sta-
tus is recognised as an appropriate primary
outcome. Visual field measurement using a
different measure are reported in a separate
publication
Anand 2007 This was not a randomised comparison of medical versus surgical treatment. 60 patients were randomised to three
groups: 1. medical treatment; 2. A choice of surgery or medication; and 3. Educational package on glaucoma and an
option to have surgery or medical treatment
Dastur 1994 Not a randomised study. Patients with early open angle glaucoma in both eyes were included in the study. The eyes
with a higher IOP were treated by trabeculectomy and the fellow eye was treated medically
Egbert 2001 This study randomised newly diagnosed OAG to receive TSCPC at one of two energy delivery settings, low energy
versus higher energy. This study was not a study of TSCPC versus medical treatment
Stewart 1996 A retrospective matched pair design. Not a randomised comparative study
Watson 1984 This was a study of patients with severe OAG or patients who had failed medical treatment. The study randomised
participants to receive ALT or Trabeculectomy. ALT as the randomised treatment did not include medical therapy
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Mean change in visual field score 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
from baseline
1.1 Long-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 Mean change in IOP from 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
baseline
2.1 Short-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Long-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Mean change in VA score from 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
baseline
3.1 Long-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Progressive visual field loss 3 Odds Ratio (Fixed, 95% CI) Totals not selected
1.1 Medium-term 1 Odds Ratio (Fixed, 95% CI) 0.0 [0.0, 0.0]
1.2 Long-term (Moorfields 2 Odds Ratio (Fixed, 95% CI) 0.0 [0.0, 0.0]
PTT 1994 baseline at 2 years
into study)
2 Mean change in visual field score 1 Mean Difference (IV, Random, 95% CI) Totals not selected
(Friedmann) from baseline.
Moorfields PTT 1994 not ITT
2.1 Long-term 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
3 Mean difference in visual field 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
score (mean deviation) at five
years (unadjusted)
4 Mean difference in visual 1 Mean Difference (Fixed, 95% CI) Totals not selected
field scores (mean deviation)
according to baseline severity at
five years (adjusted)
4.1 mild severity at baseline 1 Mean Difference (Fixed, 95% CI) 0.0 [0.0, 0.0]
(-2 dB)
4.2 severe severity at baseline 1 Mean Difference (Fixed, 95% CI) 0.0 [0.0, 0.0]
(-10 dB)
5 Mean change in IOP from 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
baseline
5.1 Short-term 2 190 Mean Difference (IV, Fixed, 95% CI) 6.14 [4.25, 8.02]
5.2 Medium-term 1 106 Mean Difference (IV, Fixed, 95% CI) 1.60 [-0.69, 3.89]
Medical versus surgical interventions for open angle glaucoma (Review) 34
Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
5.3 Long-term 1 102 Mean Difference (IV, Fixed, 95% CI) 3.40 [1.04, 5.76]
6 Mean change in IOP from 2 Mean Difference (IV, Fixed, 95% CI) Totals not selected
baseline (exploratory analysis
with assumptions)
6.1 Short-term 2 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.2 Medium-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.3 Long-term 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
7 Mean difference in IOP up to 9 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
years
8 Optic nerve progression at five 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
years
9 Medium to long-term reduction 2 Odds ratio (Fixed, 95% CI) Totals not selected
of VA. CIGTS 2001 adjusted
OR
10 Failure of randomised 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
treatment
10.1 Short-term 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
10.2 Medium-term 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
11 Time to failure of randomised 2 Hazard ratio (Fixed, 95% CI) Totals not selected
treatment
11.1 Long-term 2 Hazard ratio (Fixed, 95% CI) 0.0 [0.0, 0.0]
12 Need for ALT as an additional 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
treatment
12.1 Short-term 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
12.2 Medium-term 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
Analysis 1.1. Comparison 1 Initial medical treatment versus Scheies procedure, Outcome 1 Mean change
in visual field score from baseline.
Review: Medical versus surgical interventions for open angle glaucoma
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Long-term
Moorfields GT 1968 22 25.71 (16.43) 21 11.09 (16.84) 14.62 [ 4.67, 24.57 ]
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Short-term
Moorfields GT 1968 22 -2 (7.1) 21 -10 (4.7) 8.00 [ 4.42, 11.58 ]
2 Long-term
Moorfields GT 1968 22 0 (7.1) 21 -5.6 (4.7) 5.60 [ 2.02, 9.18 ]
Analysis 1.3. Comparison 1 Initial medical treatment versus Scheies procedure, Outcome 3 Mean change
in VA score from baseline.
Review: Medical versus surgical interventions for open angle glaucoma
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Long-term
Moorfields GT 1968 22 -24 (39.2) 21 -29.8 (41.73) 5.80 [ -18.43, 30.03 ]
Study or subgroup Medicine Surgery log [Odds Ratio] Odds Ratio Odds Ratio
N N (SE) IV,Fixed,95% CI IV,Fixed,95% CI
1 Medium-term
Glasgow Trial 1988 57 50 0.94 (0.42) 2.56 [ 1.12, 5.83 ]
0.02 0.1 1 10 50
Favours medicine Favours surgery
Analysis 2.2. Comparison 2 Initial medical treatment versus initial trabeculectomy, Outcome 2 Mean
change in visual field score (Friedmann) from baseline. Moorfields PTT 1994 not ITT.
Outcome: 2 Mean change in visual field score (Friedmann) from baseline. Moorfields PTT 1994 not ITT
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Long-term
Moorfields PTT 1994 46 4.75 (5.62) 56 0.83 (3.74) 3.92 [ 2.02, 5.82 ]
-4 -2 0 2 4
Favours medication Favours surgery
Outcome: 3 Mean difference in visual field score (mean deviation) at five years (unadjusted)
Mean Mean
Study or subgroup Medication Surgery Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
CIGTS 269 -5.5 (6.6) 255 -5.3 (6.4) -0.20 [ -1.31, 0.91 ]
-4 -2 0 2 4
Favours surgery Favours medication
Analysis 2.4. Comparison 2 Initial medical treatment versus initial trabeculectomy, Outcome 4 Mean
difference in visual field scores (mean deviation) according to baseline severity at five years (adjusted).
Outcome: 4 Mean difference in visual field scores (mean deviation) according to baseline severity at five years (adjusted)
Mean Mean
Study or subgroup Mean Difference (SE) Difference Difference
IV,Fixed,95% CI IV,Fixed,95% CI
-2 -1 0 1 2
Favours medication Favours surgery
Mean Mean
Study or subgroup Medicine Surgery Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Short-term
Glasgow Trial 1988 36 -15.1 (6.8) 47 -21.1 (8.8) 31.5 % 6.00 [ 2.64, 9.36 ]
Moorfields PTT 1994 51 -14 (6.8) 56 -20.2 (4.98) 68.5 % 6.20 [ 3.92, 8.48 ]
-10 -5 0 5 10
Favours medicine Favours surgery
Outcome: 6 Mean change in IOP from baseline (exploratory analysis with assumptions)
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Short-term
Glasgow Trial 1988 53 -10.3 (6.8) 46 -21.8 (8.8) 11.50 [ 8.37, 14.63 ]
Moorfields PTT 1994 56 -12.5 (6.8) 57 -19.96 (4.98) 7.46 [ 5.26, 9.66 ]
2 Medium-term
Moorfields PTT 1994 56 -14.3 (6.8) 57 -19.96 (4.98) 5.66 [ 3.46, 7.86 ]
3 Long-term
Moorfields PTT 1994 56 -13.5 (6.8) 57 -19.5 (4.98) 6.00 [ 3.80, 8.20 ]
-20 -10 0 10 20
Favours medicine Favours surgery
Analysis 2.7. Comparison 2 Initial medical treatment versus initial trabeculectomy, Outcome 7 Mean
difference in IOP up to 9 years.
Mean Mean
Study or subgroup Medicine Surgery Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Analysis 2.9. Comparison 2 Initial medical treatment versus initial trabeculectomy, Outcome 9 Medium to
long-term reduction of VA. CIGTS 2001 adjusted OR.
Study or subgroup medicine surgery Odds ratio (SE) Odds ratio Odds ratio
N N IV,Fixed,95% CI IV,Fixed,95% CI
Glasgow Trial 1988 57 50 0.392 (0.482) 0.39 [ -0.55, 1.34 ]
1 Short-term
Glasgow Trial 1988 17/53 7/46 2.63 [ 0.98, 7.08 ]
2 Medium-term
Glasgow Trial 1988 26/50 10/46 3.90 [ 1.60, 9.53 ]
Analysis 2.11. Comparison 2 Initial medical treatment versus initial trabeculectomy, Outcome 11 Time to
failure of randomised treatment.
Review: Medical versus surgical interventions for open angle glaucoma
Study or subgroup medicine surgery log [Hazard ratio] Hazard ratio Hazard ratio
N N (SE) IV,Fixed,95% CI IV,Fixed,95% CI
1 Long-term
Moorfields PTT 1994 56 57 1.984 (0.603) 7.27 [ 2.23, 23.71 ]
1 Short-term
CIGTS 73/307 35/300 2.36 [ 1.52, 3.67 ]
2 Medium-term
CIGTS 86/307 63/300 1.46 [ 1.01, 2.13 ]
APPENDICES
WHATS NEW
Last assessed as up-to-date: 1 August 2012.
8 August 2012 New citation required but conclusions have not changed Issue 9, 2012: Longer term follow-up data from the
CIGTS study included
8 August 2012 New search has been performed Issue 9, 2012: Updated searches yielded no new trials for
inclusion in this update
HISTORY
Protocol first published: Issue 3, 2003
Review first published: Issue 2, 2005
25 April 2007 New search has been performed Issue 1 2008: In this first update to the review, lat-
est search April 2007, one additional potential study
was identified (Anand 2007) which was subsequently
excluded as it was not a randomised comparison of
medicine versus surgery, and three additional reports
associated with CIGTS 2001. These reports did not
provide any additional data on safety or effectiveness to
include in this updated review. The conclusions of the
review are unchanged
27 January 2004 New citation required and conclusions have changed Substantive amendment
DECLARATIONS OF INTEREST
JB has in the past received an educational grant from Pharmacia/Pfizer and support from Pharmacia and Allergan towards the cost of
attendance at international meetings.
AAB has received honoraria for speaking at meetings, support for attending international meetings, educational grants and sponsorship
for research from pharmaceutical companies, including Pharmacia/Pfizer, Allergan, Merck Sharpe & Dohme and Novartis.
AA - none known.
AT has no research or educational grants from health care industry nor advisory board memberships. All international glaucoma
meetings - with very few exceptions - are supported directly or indirectly by companies in health care industry. The major sponsors of
glaucoma meetings are Alcon, Allergan, Heidelberg Engineering, Merck Sharpe & Dohm, Pfizer and Santen. Direct support to AT has
included occasional honoraria for speaking at meetings and reimbursement of travel costs.
Internal sources
Health Services Research Unit, University of Aberdeen, UK.
Department of Ophthalmology, Grampian Universities Hospital NHS Trust, UK.
External sources
Chief Scientist Office of the Scottish Executive Health Department, UK.
INDEX TERMS