Systematic review of clinical practice guidelines for the diagnosis and management of open angle glaucoma

doi:10.21203/rs.3.rs-4843576/v1

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Systematic Review

Systematic review of clinical practice guidelines for the diagnosis and management of open angle glaucoma

https://doi.org/10.21203/rs.3.rs-4843576/v1

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Précis:

Clinical Practice Guidelines(CPGs) for Open Angle Glaucoma(OAG) have evolved through the years and differ in their methodological quality. NICE, IETSI and SNSG have a high methodological quality, appraised with AGREE-II.

Topic:

To assess the methodological quality of Clinical Practice Guidelines (CPG) for the diagnosis and management of open angle glaucoma (OAG).

Clinical relevance:

An assessment of the methodological quality of Clinical Practice Guidelines (CPG) for the diagnosis and management of open angle glaucoma (OAG) is reported.

Methods:

A systematic review of CPGs for the diagnosis and management of OAG, published between January-2017 and November-2023, was carried out with a search in databases, metasearch engines, CPG development institutions, ophthalmology associations and CPG repositories. A search update was run in January 2024. Protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO: CRD42024510656. Nine CPGs published in English/Spanish, between 2017 and 2024 were selected, and 5 authors evaluated them independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument. An individual assessment by domain (AGREE-II), an overall assessment of the guide, and its use with or without modifications was performed. Additionally, a meta-synthesis of the recommendations for the most relevant outcomes of each CPG was performed.

Results:

The lowest scores were in applicability and rigour of development (mean 47.9% and 48% respectively). The highest score (mean 72.1%) was for domain 4 ‘clarity of presentation’. NICE (92.1%), IETSI (77.5%) and SNSG (75.8%) presented the best score in domain 3 ‘Rigour of development’. When evaluating the overall quality of the CPGs analysed, only NICE, EGS-5-TGG, SNS and MaHTAS could be recommended with modifications. All the CPGs used GRADE approach for making recommendations. In the meta-synthesis, recommendations are similar between CPG, however variability was found in selective laser trabeculoplasty and minimally invasive glaucoma surgery indications (MIGS).

Conclusions:

NICE, IETSI and SNSG CPGs for the diagnosis and management of OAG, have a high methodological quality, appraised with AGREE-II. NICE, EGS-5-TGG, IETSI and SNSG have high scores in applicability.

Ophthalmology

Epidemiology

Glaucoma

Open-Angle

Practice guideline

Minimally Invasive Surgical Procedures

Antiglaucoma Agents

Glaucoma is a chronic disease characterized by an abnormal drainage of aqueous humor and can be classified in several types of glaucoma, such as primary or secondary glaucoma. Open angle glaucoma (OAG) is a “chronic, progressive, potentially blinding, irreversible eye disease causing optic nerve rim and retinal nerve fiber layer loss with related visual field defects”; characterized by a normal angle, associated with several risk factors as older age, higher intraocular pressure (IOP), race, family history of glaucoma, myopia, and thinner corneal central thickness ¹. OAG prevalence in Europe is 2.60%², with no statistically significant sex-related difference in the prevalence between men (3.05%) and women (2.22%)². A timely diagnosis and treatment are relevant to avoid a progression leading to irreversible blindness as it enlightens in several clinical practice guidelines.

Clinical practice guidelines (CPG) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” ³. CPG for the diagnosis and management of glaucoma have evolved through the years, with different editions developed by organizations like American Academy of Ophthalmology (Preferred Practice Pattern − 2016⁴ and 2020⁵) or European Glaucoma Society (Terminology and Guidelines 4th ⁶ and 5th edition¹).

The most applied method to assess CPG methodological quality is the “Appraisal of Guidelines for Research & Evaluation” (AGREE) Instrument⁷. Several studies have assessed the quality of CPG in primary open angle glaucoma (OAG) ^8–10, minimally invasive glaucoma surgery (MIGS) ^11,12 and childhood glaucoma¹³. The aim of this paper was to assess the methodological quality of Clinical Practice Guidelines (CPG) for the diagnosis and management of open angle glaucoma (OAG).

A systematic review of CPGs was conducted in compliance with methodology reports^14–16, as well as previous studies carried out by our team^12,17. Protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO: CRD42024510656. No human subjects were included in this study. No Institutional Review Board approval was required. All research adhered to the tenets of the Declaration of Helsinki. The requirement for informed consent was waived because of the retrospective nature of the study.

Eligibility Criteria

This systematic review focused on clinical practice guidelines for open angle glaucoma CPGs were selected if they were written in English or Spanish, published within the last 7 years, and full text was available.

Systematic Literature search

Two authors (JGO and ISO) conducted a systematic literature search for OAG CPGs in November 2023, with no limitations by language or year of publication. A search update was run in January 2024. Academic databases (Pubmed/Medline, Scopus, Web of Science, Embase), metasearch engines (Tripdatabase, Epistemonikos), CPG developer organizations, ophthalmology associations and CPG repositories/databases were searched (Supplement 1). Search strategy can be found in Supplement 2.

CPG screening

Two authors (JGO and ISO), independently screened the titles and abstracts of identified records. Records retrieved through databases were screened using Rayyan.ai software, and records from organizations websites were screened manually. Disagreements were resolved through discussion and reviewed by a third author (TGO). If a consensus document was retrieved, it was included for the next phase, to assess its content.

Guideline selection and data extraction

CPG details were extracted (Title, year of publication, organization, language, developing status, funding, development group details, objective, scope, target users, population, external review, search strategy, update details, conflict of interest, monitoring/auditing, evidence/grading of recommendations and clinical questions). CPGs were not excluded based on overall quality. In the case of updated CPG, previous CPG (1 or 2 previous editions), supplements and additional files were searched, and data extracted.

Guideline quality critical appraisal

Five authors (JGO, SBU, RBE, RMB, CBM) critically appraised the quality of the guidelines using the AGREE II instrument^7,18.

The AGREE II checklist comprises 23 items (each with specific reporting criteria) in six domains to assess the methodological quality of CPGs. The rating of AGREE II items follows a 7-point scale, with 1 representing strongly disagree and 7 representing strongly agree. The domains assessed by the AGREE II instrument are: (1) scope and purpose; (2) stakeholder involvement; (3) rigor of development; (4) clarity of presentation; (5) applicability; and (6) editorial independence. Upon completing the 23 items, overall Guideline Assessment was performed, defining its use with or without recommendation.

Guideline clinical recommendation meta-synthesis:

A meta-synthesis of most clinically relevant recommendations was performed. Two authors with experience in glaucoma (SBU and RMB) extracted independently the key recommendations and built a recommendations matrix, reviewed by a third author (CBM). Selected recommendations items were reviewed additionally by an author with experience in glaucoma (TGO).

Guideline selection

Literature search through databases and meta-search engines retrieved 5601 records, and we deleted 2,314 of those using the duplicate detection tool of Rayyan web application. 3287 records were screened by tittle and abstract using Rayyan web application, and 13 records were selected for full text review. Six articles were excluded because of the following reasons: wrong topic (n = 4) and old version of included guidelines (n = 2). 61 records were retrieved through GPGs developers or Ophthalmology organizations webpages. One CPG was retrieved from the “GuíaSalud del Sistema Nacional de Salud de España” (SNSG) and other from “Instituto de Evaluación de Tecnologías en Salud e Investigación – EsSalud, Perú” (IETSI) webpage. Other CPG were excluded because of the following reasons: language not English/Spanish (n = 1), wrong topic (n = 52), already included (n = 5), and out-of-date (n = 1). Manual search identified no additional study. (Figure N° 1).

Finally, nine CPG were selected. The selected guidelines were developed by: the Finnish Association of Ophthalmologists and the Finnish Glaucoma Society¹⁹ published in English in January 2024 and in Finnish in March 2023²⁰, Swedish Ophthalmological Society²¹ published in English in January 2024 and in Swedish in September 2022²², Japanese Glaucoma Society²³ published in English in February 2023 and in Japanese in February 2022²⁴, National Institute for Health and Care Excellence (NICE)²⁵ first version published in 2017 with an update published in 2022, European Glaucoma Society¹, Instituto de Evaluación de Tecnologías en Salud e Investigación – EsSalud (IETSI)²⁶, American academy of Ophthalmology⁵, Ministerio de Sanidad, Servicios Sociales e Igualdad de España and Agència de Qualitat i Avaluació Sanitàries de Catalunya²⁷, and Malaysian Health Technology Assessment Section - Medical Development Division - Ministry of Health Malaysia²⁸ (Tables 1 and 2).

Guideline quality

Regarding quality of evidence, all CPG used GRADE system for rating quality of evidence and grading recommendation (Table 2).

Of the six domains from AGREE II (Table 3), the lowest score was in domain 6 “Editorial independence” (EGS-5-TGG and NSG), and the highest score was in domain 4 “clarity of presentation” (NICE). NICE Guideline presented the best score in domain 3 “Rigour of development” (92.1%) (Table 3 and Table 4).

Guideline clinical recommendation meta-synthesis:

A meta-synthesis of most clinically relevant recommendations is presented in Table N° 5. Selected recommendations included; general features (risk factors, screening, target intraocular pressure (IOP), corneal central thickness (CCT) correction, gonioscopy, standard automated perimetry (SAP), optical coherence tomography (OCT) for follow-up), management (laser trabeculoplasty as first line treatment, prostaglandin analogues (PGA) as first drug, other considerations, surgery/laser trabeculoplasty indication,), surgery (trabeculectomy, combined trabeculectomy with cataract surgery, minimally invasive glaucoma surgery (MIGS), glaucoma drainage devices (GDD), Non-penetrating deep sclerectomy (NPDS), lens extraction, cyclodestructive procedures and other issues (patient education and adherence, pregnancy and breastfeeding).

Table N° 1: Selected CPG for the diagnosis and management of open angle glaucoma.

Denomination	Title	Year of Publication	Organization	Language
FCCG¹⁹	Finnish Current Care Guideline for diagnostics, treatment and follow-up of primary open-angle glaucoma, normal-tension glaucoma and pseudoexfoliative glaucoma	2024 (2023****)	Finnish Medical Society Duodecim, the Finnish Association of Ophthalmologists and the Finnish Glaucoma Society - Finland	English/Finnish
NSG²¹	Nordic and Swedish guidelines for the management of open-angle glaucoma	2024 (2022***)	Swedish ophthalmological society – Sweden	English/Swedish
JGSG²³	The Japan Glaucoma Society guidelines for glaucoma − 5th edition	2023 (2022**)	Japan Glaucoma Society – Japan	Japanese/English
NICE²⁵	Glaucoma: diagnosis and management	2022 (2017*)	National Institute for Health and Care Excellence (NICE) – United Kingdom	English
EGS-5-TGG¹	Terminology and Guidelines for Glaucoma (5th edition)	2021	European Glaucoma Society-Europe	English/Spanish
IETSI²⁶	Guía de Práctica Clínica para el manejo de Glaucoma de Ángulo Abierto	2021	Instituto de Evaluación de Tecnologías en Salud e Investigación - EsSalud – Perú	Spanish
POAG-PPP-2020⁵	Primary Open-Angle Glaucoma Preferred Practice Pattern®	2020	American Academy of Ophthalmology – United States of America	English
SNSG²⁷	Guía de Práctica Clínica sobre Glaucoma de Ángulo Abierto	2017	Ministerio de Sanidad, Servicios Sociales e Igualdad de España and Agència de Qualitat i Avaluació Sanitàries de Catalunya - Spain	Spanish
MaHTAS²⁸	Management of Glaucoma	2017	Malaysian Health Technology Assessment Section Medical Development Division, Ministry of Health - Malaysia	English
** Published in Finnish in March 2023 * Published in Swedish in September 2022 **Published in Japanese in February 2022
** Last updated: 26 January 2022

FCCG: Finnish Current Care Guideline NSG: Nordic and Swedish guidelines JGSG: Japan Glaucoma Society Guideline

NICE: National Institute for Health and Care Excellence EGS: European Glaucoma Society IETSI: Instituto de Evaluación de Tecnologías en Salud e Investigación PPP: Preferred Practice Pattern SNSG: Sistema Nacional de Salud Guideline MaHTAS: Malaysian Health Technology Assessment Section

Table N° 2: Characteristics of CPG for the diagnosis and management of open angle glaucoma.

Characteristic	Subcharacteristic	FCCG	NSG	JGSG	NICE	EGS-5-TGG	IETSI	POAG-PPP-2020	SNSG	MaHTAS
Guideline status		Update	Update	Update	Update	Update	New	Update	New	Update
Developer organization		Society and PO	PO	Society	PO	Society	PO	Society	PO	PO
Funding		Yes	NR	Yes	NR	NR	Yes	Yes	Yes	Yes
Development group	Number	10	8	25	9(25*)	54	14	9	16	16
	Affiliation details	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes
	Specialty/sub-specialty details	No	No	No	Yes	No	Yes	No	Yes	Yes
	Non-physician specialist	NR	NR	No	Yes	NR	Yes	NR	Yes	Yes
	Population representative	NR****	No	No	Yes	NR	No	NR	Yes	No
	Methodologist	NR	NR	NR	Yes	Yes	Yes	Yes	Yes	Yes
External review		NR	NR	NR	Yes	Yes	Yes	Yes	Yes	Yes
General features	Objective	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
	Scope	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
	Target users	No	No	No	Yes	Yes	Yes	Yes	Yes	Yes
	Population	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes
Evidence searches	Search strategy	No	No	No	Yes	No	Yes	Yes	Yes	Yes
	Number of referenced citations	173	3	302	170	NA	27	243	147	123
Update	Previous guide	2014	2012	2017	2009	2014	NA	2015	NA	2008
Update	Next update	NR	NR	NR	NR	NR	2024***	2025	NR	2021
Detailed declaration of conflict of interest		Yes	NR	Yes	Yes	No	Yes	Yes	Yes	No
Monitoring and/or auditing criteria		Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Evidence and grading of recommendations		GRADE	NR	GRADE±	GRADE	GRADE	GRADE	GRADE	GRADE	GRADE
Clinical questions in the CPG		9	0	14	1*****	16	8	0	38	16

NR: Not reported NA: Not applicable. PO: Public Organization

*2021 Guideline Update Committee **2017 Guideline Committee members and NGC technical team members ***3-year update plan

****Not reported in the Guideline Development Group (GDG), but considered in during the development.

*****1 question for the updated version.

Table 3

Domain scores (%)
Domain	FCCG	NSG	JGSG	NICE	EGS-5-TGG	IETSI	POAG-PPP-2020	SNSG	MaHTAS	MEAN
1: Scope and Purpose	83.3%	31.1%	37.8%	92.2%	82.2%	72.2%	37.8%	96.7%	77.8%	67.9%
2: Stakeholder Involvement	41.1%	15.6%	18.90%	80%	66.7%	53.3%	43.3%	88.9%	64.4%	52.5%
3: Rigour of Development	41.3%	5.8%	25.80%	92.1%	30.4%	77.5%	39.2%	75.8%	44.2%	48.0%
4: Clarity of Presentation	60%	47.8%	65.60%	97.8%	88.9%	78.9%	42.2%	94.4%	73.3%	72.1%
5: Applicability	40%	29.2%	21.70%	80%	36.7%	56.7%	41.7%	61.7%	63.3%	47.9%
6: Editorial Independence	55%	0%	35.00%	90%	0%	58.3%	86.7%	80%	38.3%	49.3%
Overall Guideline Assessment	3	2	3	6	4	3	3	5	4	3,7
Recommendation	No	No	No	Yes, without modifications	Yes, with modifications	No	No	Yes, with modifications	Yes, with modifications	-

Table 4: Summary of Appraisers’ Comments on the Open Angle Glaucoma Clinical Practice Guidelines assessed, organized by AGREE II Domains

AGREE II domain

Strength

Weaknesses

1. Scope and Purpose

• The objective is well defined (NICE, EGS-5-TGG, IETSI, SNSG, MaHTAS, FCCG partially in JGSG, NSG).

• The health questions are covered (NICE, EGS-5-TGG, IETSI, SNSG, MaHTAS, FCCG, partially in JGSG).

• Population to whom the guideline is meant to apply is described (NICE, IETSI, POAG-PPP-2020, SNSG, MaHTAS partially in EGS-5-TGG, FCCG).

• Health questions are not specifically described (POAG-PPP-2020, JGSG, NSG).

• No description of excluded populations is available (IETSI, POAG-PPP-2020, JGSG, NSG).

• Population to whom the guideline is meant to apply is not described (JGSG, NSG).

2. Stakeholder Involvement

• Guideline development group included individuals from relevant professional groups: clinical and methodological (NICE, POAG-PPP-2020, SNSG, MaHTAS, JGSG, partially in NSG, FCCG).

• Views and preferences of the target population were addressed (NICE, SNSG, FCCG, partially in EGS-5-TGG).

• Target users were reported (NICE, EGS-5-TGG, IETSI, POAG-PPP-2020, SNSG, MaHTAS).

• Guideline development group partially describe the expertise, institution, geographical location, or member’s role (EGS-5-TGG).

• Does not include patient representatives (IETSI, NSG, JGSG).

• The views and preferences of the target population have not been sought (IETSI, POAG-PPP-2020, MaHTAS, NSG, JGSG).

• No description about discipline/content expertise, institution, or geographical location was reported (POAG-PPP-2020).

• No report of target users (FCCG, NSG)

3. Rigor of development

• Details of the strategy used were reported (NICE, IETSI, POAG-PPP-2020, SNSG, MaHTAS, FCCG, partially in NSG).

• The criteria for selecting the evidence are clearly described (NICE, IETSI, partially in POAG-PPP-2020, SNSG, MaHTAS, JGSG, FCCG).

• Strengths and limitations of the body of evidence are clearly described (NICE, IETSI, SNSG, MaHTAS, partially in JGSG).

• Methods for formulating the recommendations are described (IETSI, partially in SNSG, MaHTAS, JGSG and FCCG).

• The health benefits, side effects, and risks have been considered in formulating the recommendations (NICE, IETSI, SNSG, JGSG).

• There is an explicit link between the recommendations and the supporting evidence (NICE, IETSI, SNSG, FCCG, partially in JGSG).

• The guideline has been externally reviewed by experts prior to its publication (NICE, IETSI, POAG-PPP-2020, SNSG, MaHTAS, FCCG).

• A procedure for updating the guideline was provided (IETSI, POAG-PPP-2020, SNSG, MaHTAS, partially in NICE).

• No details of the strategy used were reported (JGSG).

• Did not carry out systematic searches for costs, outcomes assessment by patients, feasibility, or implementation (IETSI, JGSG).

• The methods for formulating the recommendations are partially described (NICE, FCCG).

• Strengths and limitations of the body of evidence, methods for formulating recommendations, are not clearly described (POAG-PPP-2020, JGSG, FCCG).

• Health benefits, side effects, and risks in formulating recommendations, have not been reported (MaHTAS).

• There is no explicit link between the recommendations and the supporting evidence (MaHTAS and POAG-PPP-2020).

• A procedure for updating the guideline is not provided (EGS-5-TGG, JGSG).

• Guideline wasn’t externally reviewed (JGSG).

• Most of the domain items were not reported or free available (EGS-5-TGG, NSG).

• Guideline was externally reviewed, but external reviewers’ comments are not available (EGS-5-TGG).

4. Clarity of presentation

• Recommendations are specific and unambiguous (NICE, EGS-5-TGG, IETSI, POAG-PPP-2020, SNSG, MaHTAS, JGSG, NSG, FCCG).

• The different options for management of the condition or health issue are clearly presented (NICE, EGS-5-TGG, IETSI, POAG-PPP-2020, SNSG, MaHTAS, JGSG, NSG, FCCG).

• Key recommendations are easily identifiable (NICE, EGS-5-TGG, IETSI, POAG-PPP-2020, SNSG, MaHTAS, NSG, partially FCCG).

• Does not include several clinical issues relevant to glaucoma (IETSI).

5. Applicability

• Describes facilitators and barriers to its application (IETSI, MaHTAS, NICE, partially in SNSG, POAG-PPP-2020, NSG).

• Provides advice and/or tools on how the recommendations can be put into practice (NICE, IETSI. POAG-PPP-2020, SNSG, MaHTAS, FCCG).

• Potential resource implications of applying the recommendations have been considered (NICE, EGS-5-TGG, POAG-PPP-2020, SNSG, FCCG).

• Presents clinical monitoring criteria (NICE, IETSI, MaHTAS, SNSG, partially reported (only clinical criteria) in EGS-5-TGG, POAG-PPP-2020, JGSG, NSG and FCCG).

• No description of how the information influenced the guideline development process and/or formation of the recommendations (NICE, JGSG, NSG).

• Does not describe facilitators and barriers to its application (EGS-5-TGG, JGSG, FCCG).

• Potential resource implications have not been considered (IETSI, MaHTAS, JGSG, NSG).

6. Editorial independence

• Competing interests of guideline development group members have been recorded and addressed (NICE, IETSI, POAG-PPP-2020, SNSG, JGSG, FCCG).

• Guideline report details about funding body (MaHTAS).

• No description about funding body or competing interests of guideline development group is available (EGS-5-TGG, NSG)

• There’s no statement that the views of the funding body have not influenced the content of the guideline (all guidelines).

• Competing interest of guideline development group are not described (MaHTAS, NSG).

7. Overall Guideline Assessment

• FCCG: 3, No.

• NSG: 2, No.

• JGSG: 3, No

• NICE: 6, yes, without modifications.

• EGS-5-TGG: 4, yes, with modifications.

• IETSI: 3, No.

• POAG-PPP-2020: 3, No.

• SNSG: 5, Yes, with modifications.

• MaHTAS: 4, yes, with modifications.

*Comments specific to certain CPGs are indicated in parentheses; comments lacking denotations pertain to all nine CPGs.

Table Nº 5: Recommendations Matrix of clinical practice guidelines for the diagnosis and management of OAG.

	FCCG (2024)	NSG (2024)	JGSG (2023)	NICE (2022)	EGS-5-TGG (2021)	IETSI (2021)	POAG-PPP-2020 (2020)	SNSG (2017)	MaTHAS (2017)
Risk factors /predictors
Ocular	Age, IOP, pseudo exfoliation with Ocular Hypertension (OHT), optic nerve head hemorrhage, myopia	Elevated IOP, exfoliation syndrome, moderate to high myopia, optic disc hemorrhages, pigment dispersion syndrome, thin CCT	Elevated IOP, thin CCT, large C/D ratio, small optic nerve rim area, disc hemorrhage, large β-zone of peripapillary chorioretinal atrophy, low corneal hysteresis, low ocular perfusion pressure	Level of IOP, CCT	Elevated IOP, disc hemorrhage, myopia	Elevated IOP, myopia	Elevated IOP, thin CCT, myopia, low ocular perfusion pressure	Elevated IOP, myopia	Elevated and/or asymmetry of IOP, thinner CCT, myopia, corneal hysteresis
Other	Family history of glaucoma, African ancestry, reduced perfusion pressure	Older age, family history, non-Caucasian ethnicity (mainly African), low diastolic blood pressure	Age, family history of glaucoma, low diastolic and systolic blood pressure, type 2 diabetes, exfoliation syndrome, poor drug adherence	Family history, life expectancy	Older age, non-White ethnicity (particularly Black), family history of glaucoma, pseudo exfoliation, low diastolic blood pressure	Older age, black and/or hispanic ethnicity, family history of glaucoma, diabetes	Older age, family history of glaucoma, African race or Latino/Hispanic ethnicity, type 2 diabetes	Age, ethnicity (predominantly black), diabetes, family history of glaucoma	Older age; West African, Afro-Caribbean or Hispanic/Latino ethnicity; positive family history, Obstructive Sleep Apnea Syndrome, diabetes mellitus
Screening	Not Recommended	NC	NC	NC	Not Recommended	NC	Screening is more useful and cost-effective when it is targeted at populations at high risk of glaucoma	It is suggested to perform glaucoma screening in patients with risk factors for developing the disease	Should be considered for patients with risk factors, especially: age > 40 years, family history of glaucoma, diabetes mellitus
Target IOP	Adjusted at each follow-up	Continuously evaluated and adjusted	Set according to the stage of glaucoma	Prefer ‘clinically acceptable control of IOP’	Updated at each monitoring	Target IOP will be determined and adjusted individually for each patient based on the treating physician´s criteria and periodic reevaluation	Individualized and adjusted further down or even up during the disease	It is reasonable to aim for a 25 to 50% reduction in baseline IOP without treatment, depending on the level of PIO, stages, age, presence of risk factors, rate of progression	Individualized and adjusted during the disease
Central corneal thickness (CCT) correction	No	No	No	No	No	NC	No	NC	No
Gonioscopy	Cannot be replaced by automated imaging	Yes	Yes, static and dynamic	If not available, use OCT or Van Herick.	Yes	Yes. Use UBM exceptionally	Yes	If impossible, choose Van Herick	Yes, static and dynamic
Standard Automated Perimetry (SAP)	Use the same instrument and protocol for follow-up. 2–6 VF are needed to confirm progression. In advanced glaucoma monitor progression with central 10-degree VF	5–6 Visual Field (VF) during the first 2 years, except patients with newly discovered OHT. Adapt the stimulus intensity and size according to the stage of glaucoma.	Minimum of 5 VF to determine progression. Newly diagnosed glaucoma: measure as frequently as possible during the first 2 years.	Establish a baseline and severity of impairment at diagnosis	3 times per year during the first 2 years in newly diagnosed patients	Yes	Repeat the same strategy that showed a new glaucomatous defect to confirm VF damage progression.	Minimum of 6 VF in the first 2 years of diagnosis to calculate rate and progression	Change stimulus size and strategy in advanced disease
OCT for diagnosis and follow-up	Do not diagnose or assess progression based on OCT alone. Examinations with different devices are not comparable.	Repeated examinations may show false positive progression. Floor effect in advanced glaucoma complicates assessment.	Suitable for early stages. Not recommended in advanced glaucoma (floor effect)	Useful for baseline documentation	Don't diagnose solely on OCT	Yes	Yes	Yes	Yes
Management
Laser trabeculoplasty as first line treatment	Yes	Yes	No: It is used as an alternative treatment for patients who cannot achieve target IOP using drug therapy	Yes	Yes	No: If bad adherence to pharmacological treatment is expected	Yes	No: If bad pharmacological treatment adherence is expected. Don't associated with pharmacological treatment in patients with uncontrolled glaucoma.	Yes
Prostaglandin analogues (PGA) as first-line drug	Yes.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Other considerations	Beta blocker can be chosen as first line treatment. Fixed combination of PGA and beta blocker reduce IOP more than other combinations.	For good adherence, a fixed combination is usually chosen	Drug therapy is the first -line treatment for primary open-angle glaucoma.	Do not offer treatment to people with suspected chronic open angle glaucoma (COAG) and IOP less than 24 mmHg unless they are at risk of visual impairment within their lifetime. Advise people to continue regular visits to their primary eye care professional.	Fixed combination is preferable to multiple drugs	Start treatment with two drugs in patients with high initial IOP	Fixed combinations are not recommended for initial treatment	In people with open-angle glaucoma, initial treatment with beta-blockers is recommended if prostaglandin analogues cannot be used	Fixed combinations provide improved long-term adherence compared with non-fixed components
Laser trabeculoplasty or Surgery indication	If insufficient response, intolerance to treatment or progression, despite lowered IOP	If more than 3 drugs are required to achieve target IOP	When multiple medications are required	After treatment with medicines from 2 therapeutic classes	When insufficiently controlled with two or three agents	NC	NC	Consider if there is no response to medical treatment, or if there is progression	If more than two medications are required to achieve target IOP
Surgery
Trabeculectomy	Complication’s area more frequent than in non-penetrating surgeries	Gold standard	Initial treatment for patients with inadequate control of IOP by drug therapy or laser therapy or for severe cases	Offer people with advanced chronic open angle glaucoma (COAG), glaucoma surgery with pharmacological augmentation (Mitomycin C - MMC) as indicated	When other forms of therapy have failed to control the disease or are not suitable; and target pressure is unlikely to be achievable with topical medications and/or laser.	Adults with primary open angle glaucoma (POAG) that do not meet target IOP despite maximum tolerated pharmacological/laser treatment, are not suitable for pharmacological/laser treatment, or present advanced glaucoma damage at diagnosis.	Indicated when medications and appropriate laser therapy are insufficient to control disease; can be considered as initial therapy in selected cases.	In severe glaucoma and in cases with a high risk of progression despite optimal medical treatment	Primary surgery of choice in primary open angle glaucoma (POAG)
Combined trabeculectomy with cataract surgery	NC	Better IOP lowering than cataract surgery alone, but lower success rate than filtering surgery alone	Weakly recommended	NC	IOP reduction is more than phacoemulsification alone. Success rate is less than filtration surgery alone	NC	Not as effective as glaucoma surgery alone in lowering IOP	NC	Significantly lower mean IOP than phacoemulsification alone
MIGS	Brief comment about MIGS. No evidence of the efficacy compared to traditional glaucoma surgery	General information about characteristics, classification, and indications. Suitable in early or moderate glaucoma. Not sufficient information on long-term effects and safety	Procedure should be performed by a surgeon with sufficient experience in anterior chamber angle surgery. Mentions: EX-PRESS, ab interno trabeculotomy (with metal hook, nylon thread or, trabectome) and iStent.	NC	A list of available techniques. Mild to moderate glaucoma. It is possible to combine it with phacoemulsification. Doesn't precise specific techniques.	NC	Description list of techniques. Some are only FDA approved to be performed concurrently with phacoemulsification. Less effective in lowering IOP than trabeculectomy and GDD. More favorable safety profile in the short term. Mentions: Trabectome, KDB, GATT with iTrack or suture, ABiC, iStent and iStent inject, Hydrus microstent, Xen gel stent.	Lack of descriptions and recommendations	Not recommended
Non-penetrating deep sclerectomy (NPDS)	Brief comment	NC	Brief comment	NC	Brief comment	NC	Description of technique and brief comment about Deep sclerectomy	Description of technique and offers recommendations (1 general and 4 specific)	Brief comment
Glaucoma drainage devices (GDD)	Higher success rate than trabeculectomy in eyes with previous intraocular surgery	First-line surgical procedure in some cases	Patients with unsuccessful trabeculectomy with concomitant use of antimetabolites, severe conjunctival scarring because of previous surgery, those who are unlikely to achieve successful trabeculectomy or technically cannot undergo other filtration procedures. Less effective in lowering IOP than trabeculectomy	NC	Patients with risk factors for a poor result of trabeculectomy with antifibrotics. Potential role as a primary surgical procedure in selected cases.	Patients who do not meet target IOP or evidence a progression in visual field damage despite maximum tolerated pharmacological treatment and trabeculectomy, or when trabeculectomy has a high failure rate.	Indicated when trabeculectomy has failed to control IOP or is deemed unlikely to succeed. Use patch allografts of sclera, cornea, or pericardium to prevent tube erosion.	Patients that have not controlled IOP despite pharmacological treatment, or when filtering surgery has failed. GDDs are not the first choice of surgical treatment in naïve patients.	Patients with high risk of failure from augmented trabeculectomy
Lens extraction	Might impair the filtration of a previous glaucoma surgery. The risk is lower if there is a time gap of over 12 months between surgeries.	Consider early cataract surgery in patients with glaucoma.	NC	NC	Cataract surgery alone as an intervention to control glaucoma is not recommended. Performed after trabeculectomy can affect the IOP control.	NC	Multifocal intraocular lenses may have adverse effects on contrast sensitivity and visual field performance in patients with glaucoma.	NC	The risk of bleb failure is reduced if lens extraction is performed > 6 months post-trabeculectomy.
Cyclodestructive procedures	Effective and safe in difficult-to-treat glaucoma. Repeated treatments are often required.	When filtering surgery has not worked/is not effective enough or not feasible and in painful blind eyes	Refractory cases in which other treatments are ineffective because it can cause vision threatening complications	Offer cyclodiode laser treatment to people with chronic open angle glaucoma (COAG) (including advanced COAG) who prefer not to have glaucoma surgery or whom glaucoma surgery is not suitable	Indicated when filtration surgery or GDD are likely to fail/have failed/are not feasible; and in refractory glaucoma	Adults with primary open angle glaucoma (POAG) that don't meet target IOP despite treatment, patients that cannot have glaucoma drainage devices (GDD) implanted, and in painful blind eye	Eyes with limited visual potential or that are otherwise poor candidates for incisional ocular surgery	NC	Indicated in painful blind eyes or eyes with poor vision, failed multiple filtering surgeries. May be performed in sighted eyes when the benefits outweigh the risks for incisional surgery.
Other issues
Patient education and adherence	It is unclear whether patient education improves compliance	Recommended. Glaucoma schools create affinity and exchange of experience between patients	Recommended	Recommended	Recommended	NC	Recommended. Peer-support groups or counseling are helpful to some patients.	Recommended	Recommended
Pregnancy and breastfeeding	Discuss with the doctor that is treating the pregnancy whether to star treatment or to monitor without treatment	NC	Drug therapy for glaucoma should be discontinued during pregnancy, childbirth, and lactation. Laser therapy or surgery should be considered if IOP control worsens upon discontinuation of the drug. There are no glaucoma medications for which safety has been established in pregnant women, fetuses, or nursing mothers.	Specific consideration in terms of discussions about management and pharmacological treatment.	Temporary treatment discontinuation can be considered. No IOP-lowering medications have been labeled for use during pregnancy and/or breastfeeding. Systemic absorption should be reduced by punctal occlusion and eyelid closure. During breastfeeding, PGAs, carbonic anhydrase inhibitors and beta-blockers may be acceptable.	NC	The American Academy of Pediatrics has approved the use of carbonic anhydrase inhibitors during lactation. Brimonidine can cause apnea in infants, toddlers, and children; therefore, is not recommended to be used in mothers who are breastfeeding.	Vaginal delivery is not contraindicated and must only be evaluated in cases of severe or advanced glaucoma. The ideal for newborn child, who is breastfed, is that de mother can control herself without medical treatment because all drugs can pass through the milk	Topical beta-blockers can be the first-line medications when considering medical treatment of glaucoma in pregnancy.
NC: Not covered

Methodological Quality

Glaucoma CPG has evolved with high quality CPG, unlike other diseases like retinal vein occlusion^17,29. Three CPG (NICE, IETSI and SNSG) reached the minimum suggested for a high-quality CPG (at least 3/6 domains > 60% including domain 3), and 2 (EGS-5-TGG and MaHTAS) for moderate-quality CPG (≥ 3 domains score > 60%, except Domain 3). EGS-5-TGG is the most used CPG in Europe, with a high score in clarity of presentation (88.9%), however it had a low score for “Rigour of development”. “The inclusion of a diverse representation of clinical, scientific, and methodological experts”³⁰ leads to a well-developed CPG. EGS-5-TGG and MaHTAS had low scores for “Rigour of development” despite including methodological experts, due to the absence of reporting the development process or make it available online, as other CPGs have done. However, they received high scores for the “Clarity of Presentation” domain. IETSI had the support of methodological experts, achieving high methodological scores with an adequate reporting, but its clinical recommendations are lowly valid.

In guideline development group (GDG), clinical experts should “contextualize evidence, extrapolate evidence from indirect sources and interpret low-quality evidence”³¹, strengthening the credibility of the CPG “by acknowledging that the final document is based on both an exhaustive evaluation of the published literature (“evidence”) and the wealth of experience possessed by expert members”³², an issue not achieved by IETSI CPG.

Additionally, a CPG ought to provide “a clear explanation of how the experts were chosen, how they reached a consensus, and which issues the experts were tasked with addressing”³¹.

Ou et al.(2011)⁸ appraised 3 CPG using AGREE (first version): Preferred Practice Pattern in Primary Open-Angle Glaucoma (2005), SEAGIG’s Asia Pacific Glaucoma Guidelines (2003–2004), and EGS’s Terminology and Guidelines for Glaucoma, 2nd edition (2003). They reported that on domain 3 “Rigour of development”, scores were close to 60% (American Academy of Ophthalmology (AAO) 67%, EGS 63%, and SEAGIG 58%), with high scores in domain 4 Clarity of presentation (AAO 85%, EGS 79%, and SEAGIG 88%). The AGREE I (first version), did not include “strengths and limitations of the body of evidence” (Item 9 in AGREE-II), an important issue in CPG development that could decrease the scores for domain 3. Several CPG assessed in our study failed to properly report the body of evidence, including Evidence to Decision frameworks³³ or reporting GRADE tables³⁴, like NICE and IETSI did.

Wu et al.(2015)⁹ evaluated the methodological quality of 3 CPG for OAG using AGREE II: American Academy of Ophthalmology (AAO) 2010, Canadian Ophthalmological Society (COS) 2009, and National Institute for Health and Care Excellence (NICE) 2009. They reported that in domain 3 “Rigour of development”, scores were different (AAO 63%, COS 72% and NICE 92%). Also, clarity of presentation scored high (AAO 78%, COS 96%, NICE 97%), with NICE having the best scores over the other CPG evaluated, but all “failed to describe specific roles of panel members and/or delineate the involvement of patient representatives”, and “external review processes were unclear”. The description of roles of GDG and including patient representatives is important, considering that glaucoma is a chronic disease with several patient’s organizations.

To improve CPG, GDG should include patients or patient representatives in CPG development; and “ensure that patients, patient organizations, and interested members of the public have an opportunity to review the CPG and describe how their comments were addressed”³⁰. Only 3 CPG assessed in our study (FCCG, NICE and SNSG) considered patient representatives or included the views and preferences of the target population. Most CPG include patients in two steps “identifying the question” and “reviewing the draft guideline”, usually using a single method (e.g., group or individual contributions, surveys or Delphi)³⁵.

Urrego and Ñustes (2019)¹⁰ assessed 4 CPG for OAG in Colombia (Sociedad Colombiana de Oftalmología 2010), México (Centro Nacional de Excelencia Tecnológica en Salud 2016), Chile (Ministerio de Salud 2013) and Spain (Ministerio de Sanidad, Servicios Sociales e Igualdad 2017- SNSG). They reported that 2 CPG scored high in domain 3 “rigour of development” (Mexico 83.3% and SNSG 85.4%) and all CPG scored high in domain 4 “Clarity of presentation” (mean 90.27%). SNSG scored high scores in our assessment (scores > 60% in all domains), with the lowest score in applicability and rigour of the development, because of its publication date and search details.

An update of the SNSG CPG is available (https://portal.guiasalud.es/egpc/glaucoma-presentacion/) and introduce a note for readers: “More than 5 years have passed since the publication and its update is pending. The recommendations it contains must be considered with caution considering that their validity is pending evaluation”). CPG become outdated after 3 years³⁶, considering that they search strategy was updated before the publication of the CPG (using Re-run search or database alerts³⁷), process not performed by most of the CPG assessed in our study. Not include a pre-publication update is frequent in CPG for OAG or MIGS procedures¹².

Wu et al.³⁸ appraised the quality of clinical practice guidelines for glaucoma suspects, and its definition, including CPG like EGS-5-TGG, NICE, and MaHTAS. They reported that NICE and MaHTAS scored high in domain 3 “rigour of development” (NICE 91%, MaHTAS 84%, and EGS-5-TGG 50%); and they scored high in domain 4 “Clarity of presentation” (NICE 92%, MaHTAS 89%, and EGS-5-TGG 89%). EGS-5-TGG was the only with 0% in “Editorial Independence”, similar to our scores for EGS-5-TGG and NSG. It is crucial to consider the importance of reporting Conflict of Interest (COI) in CPG since they are often not disclosed³⁹, or inadequately reported (payments not reported)⁴⁰. In critical appraisal, a complete assessment should be done⁴¹, especially when assessing CPG, where available tools for report of quality (RIGHT checklist, iCAHE Guideline Quality Checklist), adherence to Trustworthy Standards (NEATS), or development of quality (AGREE-II), recommends the reporting of COI⁴².

Our scores are similar to what reported Wu et al. for these guidelines, however, Wu et al. scored higher for MaHTAS and EGS-5-TGG, and assessed by 2 authors. In our study, 5 appraisers (3 ophthalmologist and 2 ophthalmologists with experience in glaucoma) appraissed all the CPG, and 5 authors had previous experience in CPG appraisal^12,17,43,44. Agree II recommends at least 2 appraisers and preferably 4, because a higher number of appraisers increase the reliability^7,18. High quality CPG may not necessarily have recommendations highly valid, implementable or clinical applicable, so a CPG should be evaluated for its methodology, content, and the use of its recommendations in clinical practice⁴⁵. For the most comprehensive evaluation of the ophthalmology CPG, it is ideal to have an ophthalmologist with expertise in evidence-based medicine, critical appraisal and guideline methodology, as they can appraise both the methodological process and the relevance of the content. EGS-5-TGG had a low score in domain 3, however they included easy-to-apply flowcharts, check lists, algorithms and summaries, becoming one of the most useful CPG for its use in daily clinical practice (recommended with modifications). IETSI CPG had a high score in domain 3 but with recommendations were lowly valid.

Qureshi et al.(2021)⁴⁶ identified systematic reviews of interventions for glaucoma and assessed their reliability. They reported that only 49/129 Systematic Reviews are reliable, and the majority of reviews addressed OAG and OHT. Only 17 were reliable for medical interventions and 16 for surgical and postoperative interventions, however, there was an uncertainty of the effectiveness of combined cataract surgery. Only 11 reviews were reliable for laser and perioperative interventions, concluding that SLT is effective as the first line for POAG and selective ALT have similar efficacy to reduce IOP. Regarding surgical devices 5 reviews were reliable, however there was uncertainty about MIGS effectiveness, and its use in combined surgery with cataract or MIGS alone. This SR included studies until August 7, 2019, so it did not include results from LIGHT (Laser in Glaucoma and Ocular Hypertension) or SALT (Steroids after Laser Trabeculoplasty) trials.

In the last years, the total number of recommendations in PPP has decreased, especially in glaucoma, however high level of evidence recommendations have increased⁴⁷. When making recommendations, GDG should include the impact on equity of recommendations, and promote equitable practices in older people, with limited economic resources, living in rural contexts, with poor access to health services, from racial and ethnic minorities, or in cases of cognitive or physical disability. Only NICE, IETSI and POAG-PPP-2020 addressed these issues.

Guideline clinical recommendation meta-synthesis

Several studies have reported several risk factors associated with glaucoma, however, recent evidence has reported obstructive sleep apnea as a risk factor (Odds Ratio 3.66)⁴⁸. Other factors like smoking (moderate to heavy smoking) have been associated with glaucoma progression (vessel density loss)^49,50, or alcohol (implicated in OAG risk, however mediating or confounding factors can be present)⁵¹.

Most of the CPG do not recommend or addresses screening, however, PPP, SNSG and MATHAS recommend the screening in patients at high risk. The United States Preventives Services Task Force, The United Kingdom’s National Screening Committee, the Pan-American Association of Ophthalmology, and The International Council of Ophthalmology’s 2015 Glaucoma Eye Care Task Force neither recommend screening⁵². An evidence report published in 2022 by the US Preventive Services Task Force regarding Screening for Glaucoma in Adults reported limited direct evidence on glaucoma screening, showing no association with benefits⁵³.

Actually, there is controversy regarding the role of lens extraction (early cataract surgery recommended by NSG or not recommended as a surgery alone by EGS-5-TGG). Armstrong et al. reported that in patients with POAG, cataract surgery alone decreased IOP and the number of antiglaucoma medication (NAM)⁵⁴. IOP reduction was 11.9%, 14.4% and 15.4%, for 1 month, 1 and 2 years postoperatively, respectively⁵⁴. A systematic review of randomized controlled trials reported that cataract surgery in patients with OAG had a decrease on IOP following surgery and a reduced dependency on glaucoma medications⁵⁵. On a recent Meta-Analysis (January 2024), Pasquali et al. reported a significant IOP reduction in patients with OAG after cataract surgery (6, 12 and 24 months)⁵⁶.

The CPG evaluated the effectiveness of combined cataract and glaucoma surgery, and found that combined surgery with trabeculectomy may lead to a greater decrease in IOP but a lower success rate. A Cochrane review assessed the relative effectiveness and safety of combined surgery versus cataract surgery, and reported that there is low-quality evidence that combined surgery has better IOP control compared with cataract surgery alone⁵⁷. Also, there was uncertainty regarding the complications of the surgery, and the quality of the evidence was very low (several types of glaucoma surgery) and poor (reporting of the outcomes)⁵⁷.

Most of the CPG recommended SLT, except JGSG, IETSI an SNSG, however the last was the only CPG published before the first report of LIGHT trial results. LIGHT trial changed the paradigm of the primary treatment for glaucoma and positioned the SLT as the primary treatment in patients with OAG. Zhou et al. reported on a Meta-Analysis published in 2021, that several types of lasers trabeculoplasty are equally effective for decreasing IOP compared with medical therapy⁵⁸. 180-degree SLT was slightly more effective than ALT reducing NAM, however there was no significant difference between 180° and 360° SLT at six months⁵⁸.

Rolim-de-Moura et al. reported on a Cochrane systematic review published in 2022, that Laser trabeculoplasty is better than antiglaucoma medication(AM) in terms of progression of open-angle glaucoma (visual field loss) and may be like modern eye drops in controlling eye pressure at a lower cost, with no serious unwanted effects⁵⁹. Gazzard et al. published in 2023 the 6-years results of LIGHT trial, and reported that SLT provides long-term control in patients with OAG vs antiglaucoma medications (AM), with a reduced need for incisional glaucoma and cataract surgery⁶⁰.

SLT is an effective long-term option to treat OAG, equivalent to ALT based on level I evidence, according to an HTA performed by the AAO in January 2024⁶¹. SLT can be used either as primary treatment, as a replacement for AM, or as an additional intervention in patients with AM⁶¹. Recently published Meta-Analysis (May 2024), reported a greater IOP reduction at one month and at one year with 360° SLT compared with 180°, however, there was not a significant difference at 2 years⁶².

Regarding MIGS, Michaelov et al.(2018)¹¹ assessed the methodological quality of 14 CPGs and recommendations for MIGS procedures. They reported that several CPG scored high for rigour of development (POAG-PPP 2016 94.4%, EGS 2014 68%, NICE 2009 99.3%). Also, only 3/11 CPGs mentioned MIGS as an option for surgical management of glaucoma (The Asia Pacific Glaucoma Guideline (APGG) 2016, the POAG-PPP 2016, and the EGS 2014).

On a recently published scoping review performed by our team, we assessed recommendations addressing MIGS in 13 OAG CPG or MIGS procedures CPG like the NICE Interventional Procedure Guideline and the EGS-SI (European Glaucoma Society - A guide on surgical innovation for glaucoma). We found that the assessed CPGs have not adequately addressed MIGS recommendations in terms of updated evidence, available procedures, and recommendations¹².

Most of CPG recommend trabeculectomy as gold standard, however this statement will change in future years. Since introducing MIGS, trabeculectomy became less used or is indicated when MIGS fails. Zaifar et al. reported that when comparing cataract + MIGS vs cataract + trabeculectomy, both combined surgeries have similar outcomes, but the first has less severe complications (e.g. hypotony, maculopathy, and choroidal effusion)⁶³.

CPG recommends Glaucoma drainage devices (GDD) in eyes with risk factors for a poor result of trabeculectomy or in cases with previous intraocular surgery. The Primary Tube Versus Trabeculectomy study was a multicenter randomized clinical trial comparing the safety and efficacy of tube shunt surgery and trabeculectomy with mitomycin C (MMC) in eyes without previous ocular surgery. They reported similar IOP reduction for both procedures after 5 years, however, the NAM was lower for trabeculectomy⁶⁴. A recently published Health Technology Assessment (HTA) from the AAO (February 2024) assessed the “efficacy and safety of the use of aqueous shunts with extraocular reservoir for the management of adult OAG”, and reported that valved/non-valved devices are effective to lower IOP in eyes with and without prior incisional surgery, supported by strong evidence⁶⁵. Also, they reported that evidence to show superiority of tubes over trabeculectomy as a primary glaucoma surgery, is lacking⁶⁵.

Few CPG addressed non-penetrating deep sclerectomy (NPDS). NPDS is a worldwide procedure that prevents the sudden hypotony related with penetrating surgery, and lets the filtration of aqueous humour through trabeculo-Descemet membrane. NPDS reports showed a marginally lower effect over IOP compared with trabeculectomy, but same efficacy, and lower risks of complication⁶⁶. One issue with NPDS is that a peak emerges some months after the surgery, requiring a goniopuncture to be performed. Slagle et al. reported that a “3 month cut-off was associated with better IOP control and less adverse events than early laser goniopuncture”⁶⁷.

NPDS can be performed alone or in combination with cataract surgery; with no devices or using a Nonabsorbable Uveoscleral Implant (Esnoper-Clip)⁶⁸. When comparing NPDS alone or in combination with cataract surgery, efficacy is similar, and the last achieves excellent IOP control^69,70. When comparing penetrating and NPDS, the last had better safety profile (BCVA recovery, complication rates and post-operative interventions)⁷¹.

Patients’ adherence to glaucoma medications is a relevant issue. Most of the CPG recommend patient education and adherence, which includes benefits in side effects of treatment, proper instillation technique of eye drop and compliance and continuity to treatment; however, FGCC reports an unclear effect of education over compliance. EGS assessed the interventions that can improve adherence to medical treatment, and reported that “simplified regime, education, effective communication, and alarms/messages” have very low level of evidence, with weak strength of recommendation.

CPG makes recommendations for future research, addressing epidemiological, clinical, diagnostic, or treatment issues. Only NICE, JGSG, IETSI, and SNSG guidelines suggest topics with insufficient evidence that researchers can address nearby as clinical questions for better decision-making.

Azuara et al. reported EGS research priorities for glaucoma care and includes: stop sight loss/stopping progression of glaucoma, improved detection of worsening glaucoma/better tools to detect progression, better surgical or laser treatments including improved MIGS or better evidence for MIGS, and treatments with fewer side effects⁷².

Finally, glaucoma is an ophthalmological condition, continuously evolving with recent developments, most of them with the goal of achieve relevant outcomes. Results do not show which CPG is better, but we can report that NICE, IETSI and SNSG CPGs for the diagnosis and management of OAG have a high methodological quality, appraised with AGREE-II. NICE, EGS-5-TGG, IETSI and SNSG have high scores in applicability.

NICE, IETSI and SNSG CPGs for the diagnosis and management of OAG have a high methodological quality, appraised with AGREE-II. NICE, EGS-5-TGG, IETSI and SNSG have high scores in applicability. In the meta-synthesis, recommendations are similar between CPG, however variability was found in selective laser trabeculoplasty and minimally invasive glaucoma surgery (MIGS) indications.

Conflict of interest:

JGO has received speaker fees of Esteve, Novelty Technology Care and Angelini. JGO has received Travel and meeting support from Esteve, Bausch and Lomb, Thea, Equipsa, Alcon, Zeiss, Angelini, Brudylab, and Salvat.

RBE has received Travel and meeting support from Bayer, Salvat, Zeiss, Angelini, Thea, Roche, Alcon, Esteve and AbbVie.

CBM has received Travel and meeting support from Bausch and Lomb.

SBU, RMB, ISO and TGO have nothing to disclose.

Funding:

Self-funded.

Author Contribution Statement

JGO: Conceptualization, Validation, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Writing - Review & Editing.

SBU: Validation, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Writing - Review & Editing.

RBE: Validation, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Writing - Review & Editing.

RMB: Validation, Formal analysis, Investigation, Data Curation, Writing - Review & Editing.

ISO: Validation, Formal analysis, Investigation, Data Curation, Writing - Review & Editing.

CBM: Validation, Investigation, Data Curation, Writing - Review & Editing.

TGO: Conceptualization, Investigation, Writing - Review & Editing.

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The authors declare no competing interests.

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Systematic review of clinical practice guidelines for the diagnosis and management of open angle glaucoma

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I. INTRODUCTION

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