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January 1993

Randomized Clinical Trials on Medical Treatment of GlaucomaAre They Appropriate to Guide Clinical Practice?

Author Affiliations

From the Eye Clinic, University of Milan, Institute of Biomedial Science, S. Pãolo Hospital (Drs Rossetti, Marchetti, and Orzalesi) and the Laboratory of Clinical Epidemiology (Centro "Catullo e Daniela Borgomainerio"), Mario Negri Institute (Drs Rossetti, Torri, and Liberati), Milan, Italy; and the Laboratory of Pharmacology and Clinical Epidemiology, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy (Dr Scorpiglione).

Arch Ophthalmol. 1993;111(1):96-103. doi:10.1001/archopht.1993.01090010100034

• A systematic quantitative and qualitative overview of published randomized clinical trials was undertaken to assess the yield of medical treatment on the outcome of patients with primary open angle glaucoma. Reports of 102 randomized clinical trials were published between 1975 and 1991, totaling about 5000 patients. Only 16% (16/102) of the trials were, however, properly designed (ie, comparing an active treatment with a placebo-treated or untreated control group) to answer the question of whether any medical treatment can effectively cure patients with primary open angle glaucoma. Pooled analysis showed a moderate yet statistically significant reduction in mean intraocular pressure (−4.9 mm Hg; 95% confidence interval [Cl], −7.3 to −2.5 mm Hg); however, data on long-term visual field changes were available in only three randomized clinical trials, and their statistical combination failed to show a significant protective effect of active treatment (odds ratio, 0.75; 95% CI, 0.42 to 1.35). All of the remaining 86 randomized clinical trials looked at the effectiveness of one drug vs another in lowering intraocular pressure and were thus of no use in the overview. Practicing ophthalmologists should be aware that the effectiveness of pressure-lowering agents in the treatment of primary open angle glaucoma is still to be determined and that the vast majority of published trials are not appropriate to guide clinical practice. It is urgent to plan trials with end-point and follow-up duration that is fully relevant for the health of patients.