SUMMARY BENCHMARKS FOR

PREFERRED PRACTICE PATTERN® GUIDELINES

Introduction Cochrane Library for articles in the English language

These are summary benchmarks for the Academy’s is conducted. The results are reviewed by an expert
Preferred Practice Pattern® (PPP) guidelines. The panel and used to prepare the recommendations,
Preferred Practice Pattern series of guidelines has which are then given a rating that shows the strength
been written on the basis of three principles. of evidence when sufficient evidence exists.
• Each Preferred Practice Pattern should be clinically To rate individual studies, a scale based on the
relevant and specific enough to provide useful Scottish Intercollegiate Guideline Network (SIGN) is
information to practitioners. used. The definitions and levels of evidence to rate
• Each recommendation that is made should be given individual studies are as follows:
an explicit rating that shows its importance to the • I++: High-quality meta-analyses, systematic reviews
care process. of randomized controlled trials (RCTs), or RCTs with
• Each recommendation should also be given an a very low risk of bias
explicit rating that shows the strength of evidence • I+: Well-conducted meta-analyses, systematic
that supports the recommendation and reflects the reviews of RCTs, or RCTs with a low risk of bias
best evidence available.
• I–: Meta-analyses, systematic reviews of RCTs, or
Preferred Practice Patterns provide guidance RCTs with a high risk of bias
for the pattern of practice, not for the care of a • II++: High-quality systematic reviews of case-control
particular individual. While they should generally or cohort studies; high-quality case-control or
meet the needs of most patients, they cannot possibly cohort studies with a very low risk of confounding
best meet the needs of all patients. Adherence to or bias and a high probability that the relationship is
these Preferred Practice Patterns will not ensure a causal
successful outcome in every situation. These practice • II+: Well-conducted case-control or cohort studies
patterns should not be deemed inclusive of all proper with a low risk of confounding or bias and a
methods of care or exclusive of other methods of moderate probability that the relationship is causal
care reasonably directed at obtaining the best results.
It may be necessary to approach different patients’ • II–: Case-control or cohort studies with a high risk of
needs in different ways. The physician must make the confounding or bias and a significant risk that the
ultimate judgment about the propriety of the care of relationship is not causal
a particular patient in light of all of the circumstances • III: Nonanalytic studies (e.g., case reports, case
presented by that patient. The American Academy series)
of Ophthalmology is available to assist members in
resolving ethical dilemmas that arise in the course of Recommendations for care are formed based on the
ophthalmic practice. body of the evidence. The body of evidence quality
ratings are defined by Grading of Recommendations
The Preferred Practice Pattern® guidelines are not Assessment, Development and Evaluation (GRADE)
medical standards to be adhered to in all individual as follows:
situations. The Academy specifically disclaims any • Good quality (GQ): Further research is very unlikely
and all liability for injury or other damages of any kind, to change our confidence in the estimate of effect
from negligence or otherwise, for any and all claims
that may arise out of the use of any recommendations • Moderate quality (MQ): Further research is likely to
or other information contained herein. have an important impact on our confidence in the
estimate of effect and may change the estimate
For each major disease condition, recommendations • Insufficient quality (IQ): Further research is
for the process of care, including the history, physical very likely to have an important impact on our
exam and ancillary tests, are summarized, along with confidence in the estimate of effect and is likely to
major recommendations for the care management, change the estimate; any estimate of effect is very
follow-up, and education of the patient. For each uncertain
PPP, a detailed literature search of PubMed and the

© 2018 American Academy of Ophthalmology October 2018 aao.org 1

 SUMMARY BENCHMARKS FOR
PREFERRED PRACTICE PATTERN® GUIDELINES

Introduction (continued) • Level I includes evidence obtained from at least

Key recommendations for care are defined by GRADE one properly conducted, well-designed randomized
as follows: controlled trial. It could include meta-analyses of
randomized controlled trials.
• Strong recommendation (SR): Used when the
desirable effects of an intervention clearly outweigh • Level II includes evidence obtained from the following:
the undesirable effects or clearly do not •W
 ell-designed controlled trials without
• Discretionary recommendation (DR): Used when the randomization
trade-offs are less certain—either because of low- •W
 ell-designed cohort or case-control analytic
quality evidence or because evidence suggests studies, preferably from more than one center
that desirable and undesirable effects are closely •M
 ultiple-time series with or without the
balanced intervention

In PPPs prior to 2011, the panel rated recommendations • Level III includes evidence obtained from one of the
according to its importance to the care process. This following:
“importance to the care process” rating represents • Descriptive studies
care that the panel thought would improve the quality • Case reports
of the patient’s care in a meaningful way. The ratings
•R
 eports of expert committees/organizations (e.g.,
of importance are divided into three levels.
PPP panel consensus with external peer review)
• Level A, defined as most important
• Level B, defined as moderately important This former approach, however, will eventually be
• Level C, defined as relevant but not critical phased out as the AAO adopted the SIGN and
GRADE rating and grading systems.
The panel also rated each recommendation on the
strength of evidence in the available literature to The PPPs are intended to serve as guides in patient
support the recommendation made. The “ratings of care, with greatest emphasis on technical aspects. In
strength of evidence” also are divided into three levels. applying this knowledge, it is essential to recognize
that true medical excellence is achieved only when
skills are applied in a such a manner that the patients’
needs are the foremost consideration. The AAO
is available to assist members in resolving ethical
dilemmas that arise in the course of practice. (AAO
Code of Ethics)

© 2018 American Academy of Ophthalmology October 2018 aao.org 2

 GLAUCOMA
Primary Open-Angle Glaucoma (Initial Evaluation)

Initial Exam History (Key elements) • Laser trabeculoplasty can be considered as initial
• Ocular history therapy in selected patients or an alternative for
• Race/ethnicity patients at high risk for nonadherence to medical
therapy who cannot or will not use medications
• Family history
reliably due to cost, memory problems, difficulty
• Systemic history with instillation, or intolerance to medication (I+, GQ,
• Review of pertinent records DR)
• Current medications • Trabeculectomy is effective in lowering IOP; it is gen­
• Ocular surgery erally indicated when medications and appropriate
laser therapy are insufficient to control disease and
Initial Physical Exam (Key elements) can be considered in selected cases as initial therapy
• Visual acuity measurement (I+, GQ, SR)
• Pupil examination
Surgery and Postoperative Care for Laser
• Slit-lamp biomicroscopy of anterior segment Trabeculoplasty Patients
• Measurement of IOP • The ophthalmologist who performs surgery has the
• Central corneal thickness following responsibilities:
• Gonioscopy - Obtain informed consent
• Evaluation of optic nerve head and retinal nerve fiber - Ensure that the preoperative evaluation confirms
layer using magnified stereoscopic visualization with the need for surgery
slit-lamp biomicroscope and through a dilated pupil - At least one IOP check within 30 minutes to 2
(I+, MQ, SR)
hours of surgery
• Examination of optic nerve head appearance by - Follow-up examination within 6 weeks of surgery
color stereophotography or computer-based image or sooner if concern about IOP-related optic nerve
analysis should be serially documented (I+, MQ, SR) damage
• Evaluation of the fundus (through a dilated pupil
whenever feasible) Surgery and Postoperative Care for Incisional
• Visual field evaluation, preferably by automated Glaucoma Surgery Patients
static threshold perimetry • The ophthalmologist who performs surgery has the
• Evaluation of the optic disc following responsibilities:
• Thinning of the inferior and/or superior neuroretinal - Obtain informed consent
rim - Ensure that the preoperative evaluation accurately
documents findings and indications for surgery
Management Plan for Patients in Whom - Prescribe topical corticosteroids in the
Therapy is Indicated postoperative period
• Set an initial target pressure of at least 25% lower - Follow-up evaluation on the first postoperative day
than pretreatment IOP. Choosing a lower target IOP (12 to 36 hours after surgery) and at least once
can be justified if there is more severe optic nerve during the first 1 to 2 weeks
damage.
- In the absence of complications, perform additional
• Target pressure is an estimate and must be postoperative visits during a 6-week period
individualized and/or adjusted during the course of
- Schedule more frequent visits, as necessary, for
the disease (III, IQ, DR)
patients with postoperative complications
• The goal of treatment is to maintain the IOP in
- Additional treatments as necessary to maximize
a range at which visual field loss is unlikely to
the chances for a successful long-term result
significantly reduce a patient’s health-related quality
of life over his/her lifetime (II+, MQ, DR) Patient Education for Patients with Medical Therapy
• Medical therapy is presently the most common initial • Discuss diagnosis, severity of the disease, prognosis
intervention to lower IOP; consider balance between and management plan, and likelihood of lifelong
side effects and effectiveness in choosing a regimen therapy
of maximal effectiveness and tolerance to achieve • Educate about eyelid closure or nasolacrimal
the desired IOP reduction for each patient occlusion when applying topical medications to
• If progression occurs at the target pressure, reduce systemic absorption
undetected IOP fluctuations and adherence to • Encourage patients to alert their ophthalmologist
therapy should be re-evaluated before adjusting to physical or emotional changes that occur when
target IOP downward taking glaucoma medications
• Assess the patient who is being treated with
glaucoma medication for local ocular and systemic
side effects and toxicity

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 GLAUCOMA
Primary Open-Angle Glaucoma (Follow-up Evaluation)

Exam History • Reassess treatment regimen if target IOP is not

• Interval ocular history achieved and benefits of a change in therapy
outweigh the risk
• Interval systemic medical history
• Adjust target pressure downward if optic disc, retinal
• Side effects of ocular medications nerve fiber layer, or visual field change is progressive
• Frequency and time of last IOP-lowering • Within each of the recommended intervals, factors
medications, and review of medication use that determine frequency of evaluation include the
severity of damage, the rate of progression, the
Physical Exam extent to which the IOP exceeds the target pressure
• Visual acuity measurement and the number and significance of other risk factors
• Slit-lamp biomicroscopy for damage to the optic nerve
• Measurement of IOP Patient Education
• Evaluation of optic nerve head and visual fields • Educate about the disease process, rationale and
(see table below) goals of intervention, status of their condition, and
• Measurement of central corneal thickness should relative benefits and risks of alternative interventions
be repeated after any event that may alter it (e.g., so that patients can participate meaningfully in
refractive surgery) developing an appropriate plan of action
• Refer for or encourage patients with significant
Management Plan For Patients On Medical Therapy visual impairment or blindness to use appropriate
• At each exam, record dosage and frequency of use, vision rehabilitation and social services
discuss adherence to the therapeutic regimen • Patients considering keratorefractive surgery should
and patient’s response to recommendations for be informed about the possible impact laser vision
therapeutic alternatives or diagnostic procedures correction has on reducing contrast sensitivity and
• Perform gonioscopy if there is a suspicion of angle decreasing the accuracy of IOP measurements
closure, anterior-chamber shallowing or anterior-
chamber angle abnormalities or if there is an
unexplained change in IOP. Perform gonioscopy
periodically.

Follow-Up:

Consensus-based Guidelines for Follow-up Glaucoma Status Evaluations with Optic Nerve and Visual Field
Assessment*

Duration of Control Approximate Follow-up Interval

Target IOP Achieved Progression of Damage (months) (months)**
Yes No 6 6
Yes No 6 12
Yes Yes NA 1–2
No Yes NA 1–2
No No NA 3–6
IOP = intraocular pressure; NA = not applicable
**Evaluations consist of clinical examination of the patient, including optic nerve head assessment (with periodic color stereophotography or computerized imaging
of the optic nerve and retinal nerve fiber layer structure) and visual field assessment.
**Patients with more advanced damage or greater lifetime risk from POAG may require more frequent evaluations. These intervals are the maximum recommended
time between evaluations.

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 GLAUCOMA
Primary Open-Angle Glaucoma Suspect (Initial and
Follow-up Evaluation)

Initial Exam History (Key elements) Follow-up Exam History

• Ocular history • Interval ocular history
• Family history • Interval systemic medical history and any change of
• Systemic history systemic medications
• Review of pertinent records • Side effects of ocular medications if patient is being
treated
• Current medications
• Frequency and time of last glaucoma medications,
• Ocular surgery and review of use, if patient is being treated
Initial Physical Exam (Key elements) Follow-up Physical Exam
• Visual acuity measurement • Visual acuity
• Pupil examination • Slit-lamp biomicroscopy
• Slit-lamp biomicroscopy of anterior segment • Measurement of IOP
• Measurement of IOP • Gonioscopy is indicated when there is a suspicion
• Central corneal thickness of an angle-closure component, anterior chamber
• Gonioscopy shallowing or unexplained change in IOP
• Evaluation of optic nerve head and retinal nerve fiber
Follow-up Intervals
layer using magnified stereoscopic visualization with
slit-lamp biomicroscope and through a dilated pupil • Visit intervals depend on the interaction between
patient and disease, which is unique for every patient
• Appearance of the optic nerve head and, if possible,
the RNFL should be documented (II++, GQ, SR) • Frequency of periodic optic nerve head and visual
field evaluation is based on risk assessment. Patients
• Evaluation of the fundus (through a dilated pupil
with thinner corneas, higher IOPs, disc hemorrhage,
whenever feasible)
larger cup-to-disc, larger mean pattern standard
• Visual field evaluation, preferably by automated deviation, or family history of glaucoma may warrant
static threshold perimetry closer follow-up.
• Excavation of the optic cup
Patient Education for Patients with Medical Therapy
• Thinning of the inferior and/or superior neuroretinal
rim • Discuss diagnosis, number and severity of risk
factors, prognosis, management plan and likelihood
Management Plan for Patients in Whom that therapy, once started, will be long term
Therapy is Indicated • Educate about disease process, rationale and goals
• A reasonable initial goal is to set a target pressure of intervention, status of their condition, and relative
20% less than mean of several baseline IOP benefits and risks of alternative interventions
measurements based on criteria from the Ocular • Educate about eyelid closure and nasolacrimal
Hypertension Study (I+, MQ, DR) occlusion when applying topical medications to
• The goal of treatment is to maintain the IOP in reduce systemic absorption
a range at which visual field loss is unlikely to • Encourage patients to alert their ophthalmologist
significantly affect a patient’s health related quality to physical or emotional changes that occur when
of life over his/her lifetime (II+, MQ, DR) taking glaucoma medications
• If visual field glaucomatous damage is newly
detected in a glaucoma suspect patient, it is best to
repeat testing (II++, GQ, SR)
• Clinicians should include all perimetric and other
structural information in addition to digital imaging
technology when formulating patient management
decisions (III, IQ, SR)

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 GLAUCOMA
Primary Angle Closure (Initial Evaluation and Therapy)

Initial Exam History (Key elements) Surgery and Postoperative Care for Iridotomy
• Ocular history (symptoms suggestive of intermittent Patients
angle-closure attacks) • The ophthalmologist who performs surgery has the
• Family history of acute angle-closure glaucoma following responsibilities:
• Systemic history (e.g., use of topical or systemic - Obtain informed consent
medications) - Ensure that preoperative evaluation confirms the
need for surgery
Initial Physical Exam (Key elements) - Perform at least one IOP check immediately prior
• Refractive status to surgery and within 30 minutes to 2 hours
• Pupil following surgery
• Slit-lamp biomicroscopy - Prescribe topical cortico­steroids in the
postoperative period
- Conjunctival hyperemia (in acute cases)
- Ensure that the patient receives adequate
- Central and peripheral anterior chamber depth postoperative care
narrowing
• Follow-up evaluations include:
- Anterior chamber inflammation suggestive of a
recent or current attack - Evaluation of patency of iridotomy by visualizing
the anterior lens capsule
- Corneal swelling. (Microcystic edema and stromal
edema are common in acute cases.) - Measurement of IOP
- Iris abnormalities, including diffuse or focal - Gonioscopy with compression/indentation, if not
atrophy, posterior synechiae, abnormal pupillary performed immediately after iridotomy
function, irregular pupil shape, and a mid-dilated - Pupil dilation to reduce risk of posterior synechiae
pupil (suggestive of a recent or current attack) formation
- Lens changes, including cataract and - Fundus examination as clinically indicated
glaukomflecken • Prescribe medications perioperatively to avert
- Corneal endothelial cell loss sudden IOP elevation, particularly in patients with
• Measurement of IOP severe disease
• Gonioscopy and/or anterior segment imaging of Follow-up of Patients with Iridotomy
both eyes
• After iridotomy, follow patients with glaucomatous
• Evaluation of fundus and optic nerve head using optic neuropathy as specified in the Primary Open-
direct ophthalmoscope or slit-lamp biomicroscope Angle Glaucoma PPP
with an indirect lens
• After iridotomy, patients with a residual open angle
Management Plan for Patients in Whom or a combination of open angle and some PAS with
Iridotomy is Indicated or without glaucomatous optic neuropathy should
be followed at least annually, with special attention
• Iridotomy is indicated for eyes with PAC or primary to repeat gonioscopy
angle-closure glaucoma (I++, GQ, SR)
• Laser iridotomy is the preferred surgical treatment Education For Patients if Iridotomy is Not Performed
for acute angle-closure crisis (AACC) because it has • Patients with primary angle-closure suspect who
a favorable risk-benefit ratio (II+, MQ, SR) have not had an iridotomy should be warned
• In AACC, use medical therapy first to lower the IOP that they are at risk for AACC and that certain
to reduce pain and clear corneal edema. Iridotomy medications cause pupil dilation and include AACC
should then be performed as soon as possible. (III, (III, MQ, DR)
GQ, SR)
• Patients should be informed about the symptoms of
• Perform prophylactic iridotomy in fellow eye if AACC and instructed to notify their ophthalmologist
chamber angle is anatomically narrow, as nearly half immediately if symptoms occur (III, MQ, SR)
of fellow eyes can develop AACC within 5 years (II++,
GQ, SR)

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