1. Introduction Glaucoma starting from the definition, unknown etiology for the primary cases, glaucoma suspect, ocular hypertension, early detection, diagnosis, and details of management are all controversial. But the DDLS7 and this study for early detection and target IOP are milestones in our understanding of many of the controversies keeping in mind that multiplicity means satisaction of none. What is new? The risk factors for getting glaucoma include age, race, sex, heredity, family history, systemic (Diabetes, Obesity, Hypertension, Hypotension, arteriosclerosis and smoking) and socioeconomic factors as well as local factors (myopia, corneal thickness and scleral rigidity) all will channel into disc damage for the systemic factors and level of IOP for the local factors. So calculation of the combined probability of getting glaucoma for these 2 factors alone will include all the above mentioned variables. 8 For the calculation of the combined probability of getting glaucoma the study will analyze the probability of getting glaucoma in relation to IOP alone (X axis in table I) then the probability in relation to cup disc ratio (Y axis in table I). Also the combined probability for every X = IOP and every Y=C/D ratio Figure 1 demonstrates the probability of getting glaucoma (Y1)in relation to the IOP(X) and its derived equationY1=Y0+A1eX/T1 Y1= the probability of the incidence of POAG in the next 5 years when the IOP = x1 ( modified from Davanger M, Ringvold A, Bilka S. The probability of having glaucoma at different IOP levels. Acta Ophthalmol. 1991;69:565-8)9 Figure 2 : demonstrates the probability of getting glaucoma (Y2) in relation to the C/D ratio (X)Y2=Y0+A1eX/T1 Y2= the probability of the incidence of POAG in the next 5 years when the C/D ratio = x2 8 (formulated from the results of Wensor MD, McCarty CA, Stanislavsky YL, Livingston PM, Taylor HR. The prevalence of glaucoma in the Melbourne Visual Impairment Project. Ophthalmology. 1998 Apr;105(4):733-9.)6 The combined probability will take in consideration the IOP (Y1) and the C/D (Y2) ratio as the resultant outcome as shown in table1. 8 Y1+Y2 2 Target IOP The target IOP is still another dilemma. different methods for estimation of the target IOP are well known. the most popular is a percent reduction of 40%, 30% and 20 % according to the maximum base line pressure not including the field changes or the disc damage in the calculations. Other methods which include these 2 factors are still not satisfactory. In our study. cases in whom treatment is necessary we have to achieve the target IOP. Our target IOP is to reduce the pressure to a probability of 0.10 or maximally 0.20 if it is possible taking in consideration that the IOP has to be corrected for any change in the corneal thickness or scleral rigidity. The target pressure in our study is related to the C/D ratio (corrected). table 2)Management Management again is still a dilemma. how? Medical treatment : The first drug to be used in early glaucoma or glaucoma suspect and even a definite case of glaucoma is still controversial. Again the second add is also a dilemma. The alternatives of the combined therapy are at a debate. The clinical trials and guide lines will stop all the controversies and the debate The guide lines in our study are as follows: –Normal: nothing to be done –Possible : observe –Probable: treat and observe –Highly probable: treatment vigorously & observe –Definite: full tolerable treatment, laser or surgery & observe Laser treatment : Argon laser trabeculoplasty (ALT) stood the test of time but other alternatives are in the way the success rate is still relatively low. we are far from perfection. i.e. still there is a dilemma. Surgical treatment: Our golden standard is the trabeculectomy but the non0penetrating glaucoma surgery change the position of the trabeculectomy until the moment there is a dilemma. ConclusionConclusion : Glaucoma starting from the definition, unknown etiology for the primary cases, glaucoma suspect, ocular hypertension, early detection, diagnosis, and details of management are all controversial. But the DDLS7 and this study for early detection and target IOP are milestones in our understanding of many of the controversies ReferencesReferences : 1. Weinreb RN, Kitazawa Y, Krieglstein GK. Glaucoma in the 21st century. Published by Harcourt Health Communications, a division of Mosby International Ltd, 2000 2. Mukesh BN, McCarty CA, Rait JL, Taylor HR. Five-year incidence of open-angle glaucoma: the visual impairment project. Ophthalmology. 2002 Jun;109(6):1047-51 3. Weih LM, Nanjan M, McCarty CA, Taylor HR. Prevalence and predictors of open-angle glaucoma: results from the visual impairment project. Ophthalmology. 2001 Nov;108(11):1966-72 4. Rochtchina E, Mitchell P. Projected number of Australians with glaucoma in 2000 and 2030. Clin Experiment Ophthalmol. 2000 Jun;28(3):146 5. Wensor MD, McCarty CA, Stanislavsky YL, Livingston PM, Taylor HR. The prevalence of glaucoma in the Melbourne Visual Impairment Project. Ophthalmology. 1998 Apr;105(4):733-9. 6. Speath GL, Henderer J, Steinmann W. The disc damage likelihood scale (DDLS), Its use in the diagnosis and management of glaucoma. Highlights of ophthalmology. Vol 31 number 4 ; P 4-19; 2003 7. Saif SSEH, Saif MYS, Saif ATS. Early Detection of Glaucoma, A New Scoring System; Bull. Ophthalmol. Soc. Egypt,2005;vol 98,number 3, 351-358 8 Davanger M, Ringvold A, Bilka S. The probability of having glaucoma at different IOP levels. Acta Ophthalmol. 1991;69:565-8 9. 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 ‑ 720. 10. Kass MA, Heuer UK, Higginbotham I;J, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open ‑ angle glaucoma. Arch Ophthalmol. 2002;120:701 ‑ 713. 11. Preferred Practice Patterns Committee, Glaucoma Panel. Primary Open ‑ Angle Glaucoma Suspect. San Francisco: American Academy of Ophthalmology; 2002. 12..Alvarado J, Murphy C, Juster R. Trabecular meshwork cellularity in primary open angle glaucoma and nonglaucomatous normals. Ophthalmology 1984;91:564. 13..Carlo E Traverso. Identifying the target intraocular pressure and adjusting treatment In Robert N Weinreb, Yoshiaki Kitazawa, Günther K Krieglstein, ; Glaucoma in the 21st Century ; Mosby International Ltd 2000 published by Harcourt Health communication 14.Collaborative Normal ‑ Tension Glaucoma Study Group. Comparison of glaucoma progression between untreated patients with normal tension glaucoma and patients with therapeutically reduced intraocular pressures. Am J Ophthalmol 1998;126:487 ‑ 497. 15.Collaborative Normal ‑ Tension Glaucoma Study Group. The effectiveness of intraocular pressure reduction in the treatment of normal ‑ tension glaucoma. Am j Ophthalmol 1998;126:498 ‑ 505. 16.Traverso CE, Semino E, Morescalchi S, et al. Is the visual field of patients with advanced POAG protected by lowering the IOP? In: Mills RP, Wall M, eds. Perimetry update 1994/1995. Amsterdam: Kugler; 1995:309 ‑ 312. Is it still a dilemma in the 21st century? Prof Dr Sayed S. E. H. Saif, MD Dr M. Yasser S Saif, MD ; Dr Ahmed T.S. Saif, MD*** Professor of Ophthalmology, Cairo University Lecturer of Ophthalmology, Beni Sweif University Lecturer of Ophthalmology, Fayoum University Early diagnosis Accordingly people are classified after calculation of the probability of getting glaucoma into the following: Normal up to 0.10 on the probability scale with normal IOP up to 21 mmHg and C/D ratio up to 0.5: (Nothing to be done) Ocular hypertension in whom the rise of IOP above 21 mmHg is the only sign with normal C/D ratio and their management will follow the general scheme of possible, probable, or definite as will be demonstrated. Possible up to 0.20 on the probability scale with rise of IOP more than 21 mmHg and increase of C/D ratio but the combined probability will not exceed 0.20.(Observation) Probable up to 0.30 on the probability scale (these has to be treated and observed) a monotherapy may be sufficient to achieve the target IOP Highly probable up to 0.40 on the probability scale (treatment vigorously and observe) a bi-therapy may be needed to achieve the target IOP Definite more than 0.40 on the probability scale (full tolerable treatment, laser or surgery and observe to achieve the target IOP) Subject and methods: The following are examples to demonstrate how to manage these problematical cases using table 1 for early detection and diagnosis and table 2 for estimation of the target IOP. A : Glaucoma suspect B: Established Glaucoma The diagnosis is easy but the target IOP is problematical Web Page: www.sayedsaif.com Email: sayedsaif1@yahoo.com, ysaif@gawab.com Tel: +20 10 66 99 288, + 20 12 34 56 757www.sayedsaif.comsayedsaif1@yahoo.comysaif@gawab.com