Title page: Decreasing medication use in patients with ocular hypertension

Dan C?lug?ru, PhD 1 and Mihai C?lug?ru, PhD 2

1Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania

Phone number: 0745 827 552

Fax number: 0040 264 591468

E-mail: dan.calugaru@ymail.com

2Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania

Phone number: 0741 165 094

Fax number: 00 40 264 591468

E-mail: mihai.calugaru@mail.dntcj.ro Address of the Corresponding Author:

Mihai C?lug?ru

Strada Br?ncoveanu 11

3400 Cluj-Napoca/Romania

E-mail: mihai.calugaru@mail.dntcj.ro The manuscript has been seen and approved by all authors; None of the authors has conflict of interest with the submission; The authors have never received financial support for this article;

Decreasing medication use in patients with ocular hypertension Re: Protocol-driven adjustment of ocular hypertensive medication in patients at low risk of conversion to glaucoma. Chan et al. Br J Ophthalmol 2015;99:1245-1250

In their article, Chan et al 1 evaluated the safety and potential savings of decreasing medication use in low-risk patients with ocular hypertension (OH). The authors concluded that 43.9% of low-risk OH eyes could safely reduce medications over 1 year, realizing substantial savings.

However, the study has several shortcomings, that prevent the validation of their results:

1. The authors pretended that the patients of their series had a low risk of conversion with a 5-year risk ? 15%. In fact, most patients included were at moderate risk with a 5-year risk of conversion between 5 and 15%.; 2

2. There was an increase in the intraocular pressure (IOP) from baseline (18.6 mmHg) to month 1 (20.5 mmHg) of the follow-up period; the difference (1.9 mmHg), though modest, is however, statistically significant. Of note, IOP is a major predictive factor for the development of primary open-angle glaucoma (POAG) and the risk of conversion to POAG from OH is around 10% for every 1-mmHg increase in IOP.3;

3. There were no data referring to the baseline values on medication of the mean visual field (VF) pattern standard deviation (PSD), VF mean defect, estimated 5-year risk of glaucoma conversion, and average retinal nerve fiber layer thickness;

4. Statistically significant increases occurred during the 1-year follow-up in the VF PSD and in the estimated 5-year risk of glaucoma conversion; also, one eye developed a repeatable VF defect and 13 eyes had 5-year risk > 15% at 1 year. These facts reflect a real worsening of the disease and are signs of OH progression, that bring up the issue of the opportunity to reduce medication use in these treated OH patients.

In conclusion, decreasing medication use is an act of great responsibility, requiring comprehensive and close monitoring of the OH patients. It should be made with extreme caution and only if there are no signs (even mild) of active and progressive OH.

References 1. Chan PPM, Leung CKS, Chiu V, et al. Protocol-driven adjustment of ocular hypertensive medication in patients at low risk of conversion to glaucoma. Br J Ophthalmol 2025;99:1245-50. 2. Weinberg RN, Friedman DS, Fechtner RD, et al. Risk assessment in the management of patients with ocular hypertension. Am J Ophthalmol 2004;138:458-67. 3. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study. Baseline factors that predict the onset of primary open- angle glaucoma. Arch Ophthalmol 2002;120:714-20.

Conflict of Interest:

None declared