Management Of Primary Open-angle Glaucoma Research Articles

A COMPARATIVE STUDY OF TOPICAL BETAXALOL AND TIMOLOL FOR THEIR EFFICACY AND SIDE EFFECTS

Purpose: Primary open angle glaucoma (POAG) is one such field in Ophthalmology where ophthalmologists have failed to stop blindness due to it. All the available treatment modalities are directed towards the reduction of intraocular pressure (IOP) but without interfering the basic aetiopathogenesis. In this study we propose to study efficacy, potency and adverse effects of topical Timolol and Betaxalol in primary open angle glaucoma. Methodology: A comparative study of topical Betaxalol 0.5% and Timolol 0.5% in the management of POAG was conducted at Tertiary care hospital. Fifty patients of newly diagnosed POAG of different age, sex, religion from both urban and rural population attending eye OPD were included in this study. 25 patients were treated with topical Timolol maleate 0.5% ophthalmic solution BD and 25 patients were treated with topical 0.5% Betaxalol hydrochloride phthalmic solution BD. At 20 weeks follow up IOP levels n both the groups measured by applanation tonometer were compare to each other. Results: In this study a total of 50 patients with POAG were studied. 25 patients were treated with Timolol maleate 0.5% ophthalmic solution and 25 patients were treated with 0.5% Betaxalol hydrochloride ophthalmic solution. Out of 50 patients, 29 (58%) were male and 21(42%) were female patients. POAG was most common in the age group of 51-60 years with average age 51.50 (S.D. 9.8) years. Average age in males was 54.50 years, while in female it was 49.31 years. Conclusion: both Timolol and Betaxalol are effective in decreasing IOP in POAG patients. The magnitude of Timolol in decreasing IOP is more as compared to Betaxalol. The selective beta 1 adrenergic inhibition of Betaxalol provides an added benefit for those patients in whom beta 2 blockade could be harmful.

Prescribing pattern and adverse events of drugs used in patients with primary open-angle glaucoma (POAG) attending a tertiary care hospital: Retrospective study

Background: Primary open-angle glaucoma (POAG) is the most prevalent type of glaucoma leading to progressive loss of visual function in adults. Aims and Objectives: This study was conducted to determine the prescribing pattern and to assess the associated adverse reactions of drugs used in the treatment of POAG in a tertiary care teaching hospital. Materials and Methods: This was a retrospective, case-record-based study conducted on patients attending the department of ophthalmology for treatment of POAG at Srinivas Hospital, Mukka, from October 2014 to December 2015. The study was initiated after obtaining approval from the Institutional Ethics Committee. Data were analyzed using statistical package for social sciences version 17 and presented as percentages and frequency. Results: Out of 74 prescriptions analyzed, 48 (64.86%) patients were treated with monotherapy and 26 patients with combination therapy of drugs. The majority of patients were on timolol as monotherapy with prescription rate of 29.16% followed by bimatoprost 20.83%. Combination therapy was prescribed to 35.14% of the patients; the commonly used regimen was timolol + brimonidine (30.76% patients). 16 patients reported adverse effects such as blurred vision, ocular irritation, and foreign body sensation; however, the most of the patients tolerated the prescribed drugs well. Conclusion: The present study results help to know the different treatment strategies employed in the management of POAG, and reasons for the preference of prescribed drugs. Most of the patients tolerated the antiglaucoma medications well and had a few side effects which did not warrant discontinuation of treatment.

A comparative study on safety and efficacy of travoprost and brimonidine/timolol fixed combination in patients of primary open angle glaucoma

Background: The purpose of this study was to compare and evaluate the clinical efficacy of topically applied travoprost 0.004% eye drops versus brimonidine/timolol fixed combination eye drops in the management of primary open-angle glaucoma. Methods: In this prospective, randomized study, 65 patients received either travoprost eye drops once daily in the morning (n=33) or brimonidine/timolol fixed combination eye drops twice daily (n=32). Intra ocular pressure (IOP) was assessed at 2, 4, 8, and 12 weeks. The primary outcome measure was mean reduction in IOP. Results: Thebaseline mean IOP values were similar between two groups. Mean reduction of IOP in the right eye for brimonidine/timolol fixed combination group was 9±2.9 mmHg, whereas in the left eye it was 10.9±2.8 mmHg. In the travoprost group, the reduction in IOP of the right eye was 7.8±2.9 mmHg (p=0.0002) and 7.5±3.4 mmHg (p=0.0001) in the left eye. The mean reduction of IOP for the brimonidine/timolol group was 9.95 mmHg and for the travoprost group it was 7.6 mmHg (p<0.0001) in both the eyes. Conclusions: The fixed combination brimonidine/timolol twice daily demonstrated superior mean IOP lowering efficacy compared to travoprost 0.004% in patients with open-angle glaucoma.

The impact of postgraduate training on UK optometrists' clinical decision-making in glaucoma.

To investigate the impact of a postgraduate training module on optometrists' clinical decision-making in relation to the diagnosis and management of primary open-angle glaucoma. A group of United Kingdom community optometrists (n=53) were assessed immediately before and again 3months after completing a 3-day didactic postgraduate university module on the diagnosis and management of glaucoma. A smaller control cohort (n=20), who did not receive the intervention, was recruited and completed the same assessments on two occasions, separated by approximately 3months. The assessments comprised: knowledge of five key features of the optic disc in glaucoma, performance on a computer program (Discus) that assessed the ability to differentiate normal from glaucomatous discs and a clinical decision-making exercise using case-based scenarios. The scores for the knowledge of important disc features for the intervention cohort significantly increased from a median of 2/5 to 5/5 post-intervention (p<0.001). For the control cohort, the difference in median scores between the two tests was not significant. Analysing the performance of the intervention cohort using the Discus program showed no significant improvement in ability to diagnose a glaucomatous disc following the intervention [mean area under the receiver operating characteristic curve pre-intervention=0.85 (95% CI: 0.76-0.91), post-intervention=0.84 (95% CI: 0.76-0.91)]. Similarly, there were no statistically significant differences in mean areas under the receiver operating characteristic curve between tests for the control cohort, although both cohorts compared favourably with a previously published Discus data set from a panel of experts in disc analysis (mean area=0.87). For the clinical decision-making exercise the median test score for the intervention cohort was unchanged pre- and post-intervention. The results of the present study suggest that a traditional didactic approach, in isolation, is unlikely to be suited to training optometrists to achieve or develop the clinical competencies required for glaucoma detection and management. Consideration should be given to the development of specialist postgraduate training that is more practice-based, provides opportunities for active learning and includes strategies for feedback and reinforcement.

A comparative study of sutureless scleral tunnel trabeculectomy versus conventional trabeculectomy in the management of primary open-angle glaucoma

The aim of this study was to compare the outcome and complications of sutureless trabeculectomy with conventional trabeculectomy. A total of 52 eyes were randomly assigned to two groups. One group received standard conventional trabeculectomy and the other group received sutureless trabeculectomy. The patients were evaluated at 1, 3, 6 and 12 months after surgery. Patient data such as sex, age, intraocular pressure (IOP), logMAR visual acuity, antiglaucoma medications, and intraoperative and postoperative complications were collected and statistically analyzed. The mean age of the conventional and sutureless groups was 48.5 ± 15.4 and 57.3 ± 13.9 years, respectively. All patients achieved IOP levels <21 mmHg with a mean IOP of 13.4 ± 5.3 mmHg in the conventional group and 12.8 ± 2.6 mmHg in the sutureless group at 6 months and 11.00 ± 1.3 and 12.4 ± 3.2 mmHg at 12 months post surgery, respectively. These results showed a significant decrease compared to preoperative measures but did not show a significant difference between the two groups (p = 0.659). The number of antigalucoma medications used postoperatively showed a significant decline from preoperative status of 0.7 ± 0.58 in the conventional group and 0.4 ± 0.4 in the sutureless trabeculectomy group after 6 months and 0.68 ± 0.8 and 0.78 ± 0.9 after 12 months, respectively; however, there was no significant difference between the two groups (p = 0.112). No intraoperative complications were encountered in any of the groups. One patient in the sutureless trabeculectomy group developed mild hyphema which was managed medically. In the conventional group, two patients had failed trabeculectomy which was successfully revised, two patients showed hypotony 2 days after surgery which was managed medically and normal pressure was achieved within 5 days. Sutureless trabeculectomy appears to be a safe and easy method with results comparable to conventional trabeculectomy.

Long-term Medical Management of Primary Open-Angle Glaucoma and Ocular Hypertension in the UK

The objective was to assess the long-term economic consequences of the medical management of glaucoma in the UK. The economic evaluation was conducted using the results from a 10-year Markov model based around 3 key triggers for a switch in medical therapy for glaucoma, namely: lack of tolerance (using hyperemia as a proxy); intraocular pressure (IOP) not meeting treatment benchmark; and glaucoma progression. Clinical data from a comprehensive systematic literature review and meta-analysis were used. Direct costs associated with glaucoma treatment are considered (at 2008/9 prices) from the perspective of the UK NHS as payer (outpatient/secondary care setting). Using this model, the economic consequences of 3 prostaglandin-based treatment sequences were compared. Drug acquisition costs account for around 8% to 13% of the total cost of glaucoma and, if ophthalmologist visits are included, amount to approximately £0.80 to £0.90 per day of medical therapy. The total long-term costs of all prostaglandin strategies are similar because of a shift in resources: increased drug costs are offset by fewer clinic visits to instigate treatment switches, and by avoiding surgery or costs associated with managing low vision. Under the latanoprost-based strategy, patients would have longer intervals between the need to switch therapies, which is largely due to a reduction in hyperemia, seen as a proxy for tolerance. This leads to a delay in glaucoma progression of 12 to 13 months. For every 1000 clinic appointments, 719 patients can be managed for 1 year with a latanoprost-based strategy compared with 586 or 568 with a bimatoprost or travoprost-based strategy. Drug acquisition costs are not a key driver of the total cost of glaucoma management and the cost of medical therapy is offset by avoiding the cost of managing low vision. Economic models of glaucoma should include the long-term consequences of treatment as these will affect cost-effectiveness. This analysis supports the hypothesis that the economic and clinical benefits can be optimized by minimizing therapy switches.

Combined analysis of five observational studies evaluating the efficacy and tolerability of bimatoprost/timolol fixed combination in patients with primary open‐angle glaucoma or ocular hypertension

AbstractPurpose To evaluate the efficacy and tolerability of a fixed combination (FC) of bimatoprost 0.3 mg/ml and timolol 5.0 mg/ml (BTFC; Ganfort®) in patients with primary open‐angle glaucoma (POAG) or ocular hypertension (OHT).Methods This was a combined analysis of five prospective, observational studies involving 5556 patients from 830 centres in Germany, Switzerland, Netherlands, Austria and France. All treatment decisions were at the physician’s discretion.Results In the study population, 78% had POAG and the remainder had OHT. Patients were monitored for a median of 14 weeks. Overall, 93% (n = 5164) had received prior therapy; 47% receiving timolol. The most frequent reason for switching to BTFC (in 81% of patients with prior therapy) was insufficient intraocular pressure (IOP) control. Over the treatment period, mean IOP decreased from 21.5 to 16.1 mmHg with BTFC (25% reduction). BTFC reduced IOP in patients previously receiving prostaglandin monotherapy, β‐blocker, carbonic anhydrase inhibitor (CAI) and FCs containing a prostaglandin or CAI plus β‐blocker. In categorical analyses, physicians rated BTFC efficacy as ‘very good’ or ‘good’ in 86% of patients. BTFC tolerability was rated ‘very good’ or ‘good’ by 70% of physicians and 65% of patients. Adverse events were recorded for 9.7% (n = 541) of patients: the most common were eye irritation (2.8%) and ocular hyperaemia (2.2%).Conclusion When used in a real‐life clinical setting, BTFC was well tolerated and effective in the management of POAG and OHT. Commercial interest

RAND-like Appropriateness Methodology Consensus for Primary Open-Angle Glaucoma in Latin America

To report the results of a Latin American consensus panel regarding the diagnosis and management of primary open-angle glaucoma and to compare these results with those from a similar panel in the United States. A RAND-like (Research and Development) appropriateness methodology was used to assess glaucoma practice in Latin America. The 148 polling statements created for the RAND- like analysis in the United States and 10 additional statements specific to glaucoma care in Latin America were presented to a panel of Latin American glaucoma experts. Panelists were polled in private using the RAND- like methodology before and after the panel meeting. Consensus agreement or disagreement among Latin American experts was reached for 51.3% of statements before the meeting and increased to 66.5% in the private, anonymous meeting after polling (79.0% agreement, 21.0% disagreement). Although there was a high degree of concordance (111 of 148 statements; 75%) between the results of this Latin American panel and the United States panel, there were some notable exceptions relating to diagnostic and therapeutic decision making. This RAND-like consensus methodology provides a perspective of how Latin American glaucoma practitioners view many aspects of glaucoma and compares these results with those obtained using a similar methodology from practitioners in the United States. These findings may be helpful to ophthalmologists providing glaucoma care in Latin America and in other regions of the world.

What Comparative Effectiveness Research Is Needed? A Framework for Using Guidelines and Systematic Reviews to Identify Evidence Gaps and Research Priorities

The authors developed and tested a framework for identifying evidence gaps and prioritizing comparative effectiveness research by using a combination of clinical practice guidelines and systematic reviews. In phase 1 of the project, reported elsewhere, 45 clinical questions on the management of primary open-angle glaucoma were derived from practice guidelines and prioritized by using a 2-round Delphi survey of clinicians. On the basis of the clinicians' responses, 9 questions were classified as high-priority. In phase 2, reported here, systematic reviews that addressed the 45 clinical questions were identified. The reviews were classified as at low, high, or unclear risk of bias, and evidence gaps (in which no systematic review was at low risk of bias) were identified. The following comparative effectiveness research agenda is proposed: Two of the 9 high-priority questions require new primary research (such as a randomized, controlled trial) and 4 require a new systematic review. The utility and limitations of the framework and future adaptations are discussed.

Genetic Complexity of Primary Open-angle Glaucoma

Glaucoma is a complex genetic optic disease characterized by a range of optic neuropathies. There are many subtypes of glaucoma but primary open-angle glaucoma (POAG) associated with elevated intraocular pressure (IOP) is the most prevalent form. Based on the age of diagnosis, POAG is categorized as early-onset POAG or juvenile open-angle glaucoma (JOAG) diagnosed between 10 and 35 years and adult-onset POAG (APOAG) diagnosed in the fifth or sixth decade of life. Employing genetic tools like genome wide linkage analysis, association studies, mutation analysis, microarray expression analysis and serial analysis of gene expression at least 26 genetic loci have been identified for POAG but only three causative genes (Myocilin, Optineurin and WDR36) have been discovered till date. Sequence alterations in these genes result in or increase the likelihood of getting this disease than normal subjects. Although currently 5% of the POAG cases are linked to mutations in these three genes, more than 32 genes are identified to be associated with POAG. Like many other complex diseases gene environment interaction plays a pivotal role in the pathogenesis of POAG also. Lifestyle modifications, quality of diet, level of exercise and oxidative stress are the major risk factors influencing the severity and likelihood of POAG. Intense studies are required to find new genes and genetic defects related to POAG and the role of environment on the POAG pathogenesis. These initiatives can give new horizons to the diagnosis and clinical management of POAG.

A Canadian glaucoma strategy.

To develop Canadian guidelines for the management of primary open-angle glaucoma and provide a quick and practical reference for physicians in the office setting. A Canadian Glaucoma Strategy began with a review of the literature and existing guidelines, as well as consultation with glaucoma specialists and general ophthalmologists across Canada. The resulting information was assessed by a panel of glaucoma experts and general ophthalmologists at the Canadian Glaucoma Strategy Forum to distill what was learned and construct the algorithms of care. A Canadian Glaucoma Strategy was developed in 4 algorithms. First, patients are diagnosed on the basis of risk assessment and clinical findings. The staging algorithm is designed to determine the disease stage, while the treatment and follow-up algorithms focus on control of intraocular pressure and continuing patient follow-up. A Canadian Glaucoma Strategy is a practical series of algorithms that can be at hand in the office setting, providing the general ophthalmologist with an up-to-date guide for the management of patients with glaucoma concerns.

A Critical Appraisal and Comparison of the Quality and Recommendations of Glaucoma Clinical Practice Guidelines

To appraise primary open-angle glaucoma (POAG) practice guidelines critically and to compare these guidelines' major recommendations. Evaluation of clinical practice guidelines and their development process. Glaucoma fellowship-trained ophthalmologists. The POAG clinical practice guidelines published by the American Academy of Ophthalmology (AAO), European Glaucoma Society (EGS), and South East Asia Glaucoma Interest Group (SEAGIG) were evaluated by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Domain scores using the AGREE instrument. Critical appraisal using the AGREE instrument demonstrated that the AAO guidelines scored favorably (>60%) in the domains of scope and purpose, rigor of development, and clarity and presentation, while scoring unfavorably (<60%) in the domains of stakeholder involvement, applicability, and editorial independence. The Terminology and Guidelines for Glaucoma and the Asia Pacific Glaucoma Guidelines respectively developed by EGS and SEAGIG scored favorably in the domains of scope and purpose and clarity and presentation, but scored unfavorably in the domains of stakeholder involvement, applicability, and editorial independence. The major recommendations regarding diagnosis and management of POAG were similar among the 3 guidelines, although the level of detail varied considerably. Although the clinical practice guidelines from the AAO, SEAGIG, and EGS have contributed to developing evidence-based guidelines for glaucoma management, there is variability in the quality of the guideline development process and how it is reported as evaluated by a standardized instrument. The adoption of common standards in developing clinical practice guidelines in ophthalmology should improve their consistency and quality. Proprietary or commercial disclosure may be found after the references.

Setting Priorities for Comparative Effectiveness Research: A Case Study Using Primary Open-Angle Glaucoma

To test the feasibility of a framework for prioritizing new comparative effectiveness research (CER) questions related to management of primary open-angle glaucoma (POAG) using practice guidelines and a survey of clinicians. Cross-sectional survey. Members of the American Glaucoma Society (AGS). We restated as an answerable clinical question each recommendation in the 2005 American Academy of Ophthalmology Preferred Practice Patterns (PPPs) regarding the management of POAG. We asked members of the AGS to rank the importance of each clinical question, on a scale of 0 (not important at all) to 10 (very important), using a 2-round Delphi survey conducted online between April and September 2008. Respondents had the option of selecting "no judgment" or "research has already answered this question" to each question in lieu of the 0 to 10 rating. We used the ratings assigned by the Delphi respondents to determine the importance of each clinical question. Ranking of importance of each clinical question. We derived 45 clinical questions from the POAG PPPs. Of the 620 AGS members invited to participate in the survey, 169 completed the Round 1 survey; 105 of 169 also completed Round 2. We observed 4 response patterns to the individual questions. Nine clinical questions were ranked as the most important: 4 questions on medical intervention, 4 questions on filtering surgery, and 1 question on adjustment of therapy. Our theoretical model for priority setting for CER questions is a feasible and pragmatic approach that merits testing in other medical settings.

Suppression of Corticosteroid-Induced Ocular Hypertension in Sheep by Anecortave

To confirm the ocular hypotensive effects of anecortave acetate on an ovine model for steroid-induced ocular hypertension. Eyes of normal sheep exhibit a robust steroid-induced ocular hypertensive response. Recent observations in an uncontrolled, interventional case series indicated that anecortave elicited hypotensive effects when administered as a sub-Tenon depot in the eyes of a small sample of patients with glaucoma. Intraocular pressure (IOP) was monitored by Perkins applanation tonometry in 16 normal sheep receiving topically administered prednisolone acetate, 0.5%, in both eyes, 3 times daily, a protocol that doubled IOP within 12 days. Half of the sheep had received a unilateral sub-Tenon injection of anecortave in 1 eye prior to the initiation of the bilateral prednisolone instillations, while the 8 remaining sheep received the unilateral anecortave sub-Tenon depot after the IOP was maximally elevated by the prednisolone instillations. In these 2 sets of experiments, the presence of the anecortave depot suppressed the steroid-induced IOP elevation and reverted the elevated IOP to baseline levels. Measurements of aqueous outflow facility indicated that eyes treated with prednisolone plus anecortave exhibited a 5.8-fold higher outflow facility than the fellow eyes solely exposed to prednisolone, indicating that anecortave prevented the increase in outflow resistance produced by the corticosteroid. Elucidation of the mechanisms of action of anecortave in animal models may prove relevant to the design of novel interventions for the management of primary open-angle glaucoma.

Surgical management of primary open-angle glaucoma in Africans

Trabeculectomy and its various modifications have been the ‘gold standard’ in the management of glaucoma. However, the risk of sight-threatening complications has remained unacceptably high and some have questioned the belief that trabeculectomy is the best form of treatment for glaucoma. In black Africans, there is the additional problem of a higher tendency for trabeculectomy failure. Compliance with medical therapy is poor. Lasers are expensive and not readily available. Nonpenetrating glaucoma surgeries have been reported to be less effective than trabeculectomy but with a better safety profile. However, the skill for these procedures is not yet readily available in Africa. Tube shunt and cyclodestructive procedures are available for refractory or complicated cases. Newer techniques such as canalostomy are being developed. Further research to find a new surgical procedure that is inexpensive, effective, long lasting or permanent, as well as rapid and simple to perform, is required to tackle the problem in sub-Saharan Africa.

Medical management of primary open-angle glaucoma: Best practices associated with enhanced patient compliance and persistency.

Primary open angle glaucoma is a chronic optic neuropathy often requiring lifelong treatment. Patient compliance, adherence and persistence with therapy play a vital role in improved outcomes by reducing morbidity and the economic consequences that are associated with disease progression. A literature review including searches of The Cochrane Library, MEDLINE, PubMed, conference proceedings, and bibliographies of identified articles reveals the enormous public health burden in various populations due to the impact of glaucoma associated visual impairment on the overall quality of life eg, fear of blindness, inability to work in certain occupations, driving restrictions, motor vehicle accidents, falls, and general health status. Providing specific definitions for the frequently misunderstood terms "compliance, persistence and adherence" with reference to medication use is central not only for monitoring patients' drug dosing histories and clinical outcomes but also for subsequent research. In this review article, a summary of the advantages/disadvantages including cost-effectiveness of various medical approaches to glaucoma treatment, techniques employed for measuring patient compliance and actual patient preferences for therapy are outlined. We conclude by identifying the key barriers to ongoing treatment and suggest some best practices to enhance compliance and persistence.

A Canadian glaucoma strategy

Background: To develop Canadian guidelines for the management of primary open-angle glaucoma and provide a quick and practical reference for physicians in the office setting.Methods: A Canadian Glaucoma Strategy began with a review of the literature and existing guidelines, as well as consultation with glaucoma specialists and general ophthalmologists across Canada. The resulting information was assessed by a panel of glaucoma experts and general ophthalmologists at the Canadian Glaucoma Strategy Forum to distill what was learned and construct the algorithms of care.Results: A Canadian Glaucoma Strategy was developed in 4 algorithms. First, patients are diagnosed on the basis of risk assessment and clinical findings. The staging algorithm is designed to determine the disease stage, while the treatment and follow-up algorithms focus on control of intraocular pressure and continuing patient follow-up.Interpretation: A Canadian Glaucoma Strategy is a practical series of algorithms that can be at hand in the office setting, providing the general ophthalmologist with an up-to-date guide for the management of patients with glaucoma concerns.

Trabectome®—Forging a New Frontier in Primary Open Angle Glaucoma Management An Advanced Medical Device which Greatly Reduces Glaucoma Surgery Time and Improves Outcome

Trabectome®—Forging a New Frontier in Primary Open Angle Glaucoma Management An Advanced Medical Device which Greatly Reduces Glaucoma Surgery Time and Improves Outcome

ReGAE 1: using the Shah–Cross model as an orientating framework in African-Caribbean glaucoma research

The inter-relationship between health-care research, policy and service development is convoluted and difficult to articulate. This paper describes a framework for planning research into a range of ophthalmic conditions differentially associated with specific ethnic groups. It discusses the utility of the 'Shah-Cross Model' in mapping development of a glaucoma research project, and communicating its implications for local eye-care policy and ophthalmic services directed towards detection and management of primary open-angle glaucoma in the African-Caribbean population in the UK.

PEE7: A COST COMPARISON STUDY OF COMMON PRACTICE AND BEST PRACTICE TREATMENT FOR PRIMARY OPEN-ANGLE GLAUCOMA IN THE UNITED STATES

OBJECTIVE: To compare the total, drug, and medical care costs of common practice and best practice management of primary open-angle glaucoma (POAG). METHODS: A Delphi panel of ophthalmologists specialized in glaucoma management was convened in order to delineate practice patterns representative of community physicians (common practice), and to characterize the ideal or optimal standards of care (best practice). A decision analytic approach was used to depict and economically quantify the clinical sequelae under each scenario for POAG patients initiated on medical therapy. Common and best practice decision trees were developed for prototypic agents of the most commonly used first-line classes of medications. Percentage likelihood of drug usage was determined based upon physician consensus whereas drug and surgical efficacy rates were determined based upon a composite of published data. Typical drug dosing regimens and number of medical visits, as determined by physician consensus, were used to estimate the cost of treatment. RESULTS: The total average annual cost of treatment per eye was estimated at $733.85 for common practice and $732.09 for best practice. Drug costs were estimated at $358.66 for common practice and $341.38 for best practice. Costs of medical care were estimated at $375.19 for common practice and $390.71 for best practice. Surgical costs comprised a larger proportion of medical care costs in best practice as compared to common practice (17.84% vs. 14.29%). In comparing best practice and common practice decision analyses, non-selective beta-blockers were used less often whereas alpha-2 agonists were used more often as first-line medical therapy. The probability of first-line success has been estimated at 71.2% for common practice and 72.3% for best practice. CONCLUSION: Despite higher surgical costs and improved outcomes associated with best practice management of POAG as compared with common practice, total, drug, and medical care costs of best practice were comparable to those of common practice.