Box 1.

Expert panel opinions

Parameters	Expert opinion
Risk and risk assessment	A CCT using either ultrasonic or optic is recommended for risk stratification
	There is no merit in using formulas or nomograms to convert IOP
	In the absence of data on CCT and risk in Indian patients, the panellists did not suggest any range of CCT for risk profiling
Screening for glaucoma	Opportunistic glaucoma screening during cataract camps or a visit to an eye clinic is a possible method of screening glaucoma
	There is a lack of evidence on the cost effectiveness of screening, diagnosing, monitoring, and treating glaucoma in India. Hence, glaucoma screening may be done at the discretion of individual hospitals or ophthalmologists
Diagnosis	Despite a low level of evidence, the panelists agreed to strongly recommend using visual acuity and refractive errors, slit-lamp examination, gonioscopy, tonometry, visual field testing, and clinical assessment of ONH, RNFL, and macula
	The panelists do not recommend CCT adjusted IOP values because CCT-corrected algorithms based on IOP are not validated
	Diagnosis of glaucoma should not be made on the OCT findings alone
	Central corneal thickness can be considered in case of normal tension glaucoma or ocular hypertension
Goldmann applanation tonometry is the gold standard for diagnosing glaucoma, and hence it is recommended over other tonometers
	The accuracy and precision of a tonometer should influence the choice for use in the clinic
	Tonometer must be regularly calibrated. For more details, refer to the APGS guideline
	Anterior chamber angle imaging cannot replace gonioscopy.
	Gonioscopy should be performed in every patient being evaluated for glaucoma
	Some form of photography or imaging of ONH and RNFL features is recommended as sequential photographs help to detect progression
	If photos are unavailable, a disc drawing enumerating the disc is warranted
	Diagnosis of glaucoma should not be made on the OCT findings alone
	Do not rely only on the CDR to describe or document the disc
Setting target IOP	The IOP target must be individualized to the eye and revised at every visit
	Target IOP is the upper limit of IOP judged to be compatible with this treatment goal
	Documentation of target IOP is up to the discretion of the ophthalmologist
	In early glaucoma, an IOP of 18-20 mmHg with a reduction of at least 20% may be sufficient
	In moderate glaucoma, an IOP of 15-17 mmHg with a reduction of at least 30% may be required
	In advanced glaucoma, a reduction of at least 40% may be required
	Glaucoma stages	Target IOP to be achieved
	Mild glaucoma	18.20 mmHg
	Moderate glaucoma	15.17 mmHg
	Advanced glaucoma	10.12 mmHg
Topical glaucoma therapy	Start with monotherapy (except in high IOP and severe disease)
	The order of IOP lowering medications based on their IOP lowering efficacy is as follows:
	Prostaglandin analogues are the most effective medications and are usually recommended as the first choice in OAG, provided the cost is not a limiting factor
Laser iridotomy	Laser iridotomy should be preferred over surgical iridotomy
Laser trabeculoplasty	Selective laser trabeculoplasty is available in India in many ophthalmology departments. It could be tried as a first-line treatment in mild-to-moderate glaucoma, but it is not a universal recommendation
Thermal laser peripheral iridoplasty	Once-daily pilocarpine can be used as an alternative to thermal laser peripheral iridoplasty (TLPI) for plateau iris syndrome and patent peripheral iridotomy
Cyclodestructive procedures	Transcleral cyclophotocoagulation is the most commonly used method in India
Incisional surgery	The commonly preferred surgical technique for penetrating glaucoma surgery is the nonpenetrating glaucoma surgery is not useful in the Indian context
Minimally invasive glaucoma surgery	Minimally invasive glaucoma surgery is not widely available in India and hence no recommendations are made
Antifibrotic agents in glaucoma management	Mitomycin C is the choice of drug in glaucoma surgery
	Antifibrotics should be judiciously used
	Intraoperative mitomycin can be used at 0.1-0.4 mg/mL for 1-3 min, depending on the condition of the disease
	Postoperatively both 5-FU and mitomycin-C can be used
	5-FU concentration: 0.1 mL injection of 50 mg/mL undiluted solution. It has to be administered as subconjunctival injection adjacent to but not into bleb (pH 9), with a small-caliber needle (e.g., 30 G needle on insulin syringe)  Mitomycin C concentration: 0.1 mL injection of 0.1-0.5 mg/mL solution. It must be administered adjacent to but not into bleb, with a small-caliber needle (e.g., 30 G needle on insulin syringe)
Cataract and glaucoma surgery	In patients with cataract and PACG, phacoemulsification alone or combined phacoemulsification+glaucoma surgery is recommended. However, the decision should be made based on the disc and field damage and the status of the angle
Open-angle glaucoma	Trabeculectomy augmented with antifibrotic agents is recommended as initial surgical treatment for OAG, provided the ophthalmologist is familiar with the use of antifibrotics.
	Antifibrotics should be used with caution
	Alternatives like OlogenÒ should not be a preferred option due to a lack of evidence on its equality of superiority over trabeculectomy
Angle-closure disease	Treatment of PACG depends on the spectrum of disease and presence of cataract
	Laser peripheral iridotomy and surgery is combined with medical treatment should be considered in high-risk individuals below the age of 50 years, e.g., high hyperopia, and patients requiring repeated pupil dilation for retinal disease
	Primary angle-closure suspect: LPI in high-risk individuals such as those with very high hyperopia, family history, or those requiring pupil dilatation due to retinal disease
	PAC or PACG: Laser peripheral iridotomy is the first line of treatment
	Visually significant cataract and PAC: Laser peripheral iridotomy to manage PAC or PACG and lens
	extraction should be considered based on level and extent of angle closure and IOP
	There may be a risk of aqueous misdirection or surgical complications if cataract surgery is done without LPI in patients with cataract and PAC or PACG
	Ophthalmologists should be proficient in handling patients with cataract and PAC or PACG
	Prostaglandin analogues are the most effective medications and are usually recommended as the first choice in PACG
	In patients with phakic and PACG, phacoemulsification alone or combined phacoemulsification + glaucoma surgery is recommended. However, the decision should be made based on the disc and field damage and the status of the angle
Monitoring glaucoma progression	Despite a very low level of direct evidence, the panelists endorsed the EGS recommendations
	Keeping in view the goal of preventing vision impairment, the visual acuity, VF testing, clinical assessment of the optic disc and RNFL, tonometry is strongly recommended for monitoring glaucoma progression.
	However, OCT of disc/RNFL/macula and repeat gonioscopy carries a weak recommendation
	In preperimetric glaucoma, OCT is used for monitoring the disease progression. Visual field is mandatory for diagnosing and monitoring the progression of glaucoma
	OCT is always complementary to visual field testing but cannot replace visual field testing in monitoring glaucoma progression

CCT, Central corneal thickness; CDR, cup-to-disc ratio; OAG, open-angle glaucoma; OCT, optical coherence tomography; IOP, intraocular pressure; LPI, laser peripheral iridotomy; ONH, optic nerve head; PGAs, prostaglandin analogues RNFL, retinal nerve fiber layer; PAC, primary angle closure; PACG, primary angle-closure glaucoma.