For Which Glaucoma Suspects Is It Appropriate to Initiate Treatment?

OBJECTIVE: Because uncertainty exists about which glaucoma suspects should be treated, this study sought to identify the glaucoma suspects who an expert panel could agree would be appropriate or inappropriate to treat. DESIGN: The RAND/UCLA appropriateness method, a well-established procedure to synthesize the scientific literature with expert opinion to resolve uncertainty on a health topic. PARTICIPANTS: Eleven-member panel composed of recognized international leaders in the field of glaucoma. METHODS: Based on a systematic review of the literature on potentially important factors to consider when deciding to initiate treatment, more than 1000 scenarios of glaucoma suspects initially were created. The panel formally rated the appropriateness of initiating treatment for glaucoma suspects through a 2-round modified Delphi method, a technique that preserves the confidentiality of individual panelists'ratings but allows panelists to compare their own ratings with those of the entire panel. MAIN OUTCOME MEASURES: Final ratings for scenarios were categorized as appropriate, uncertain, or inappropriate to treat according to typical prespecified statistical criteria previously used in projects using the RAND/UCLA appropriateness method. Tools were developed to help clinicians to approximate the panel ratings of glaucoma suspects. RESULTS: The panel chose age, life expectancy, intraocular pressure (IOP), central corneal thickness, cup-to-disc ratio, disc size, and family history as the variables to consider when deciding whether to treat glaucoma suspects. Permutations of these variables created 1800 unique scenarios. The panel rated 587 (33%) scenarios as appropriate, 585 (33%) as uncertain, and 628 (35%) as inappropriate for treatment initiation. Analysis of variance determined that IOP had greater impact than any other variable on panel ratings. A point system was created with 96% sensitivity and 93% specificity for predicting panel ratings of appropriateness for a glaucoma suspect. CONCLUSIONS: An expert panel can reach agreement on the appropriateness and inappropriateness of treatment for glaucoma suspects.