<jats:sec><jats:title>Foreword</jats:title><jats:p>The only time is now. Every “now” is unique. Responsible persons ask themselves, “How can I act well now?” The answers will differ for every person, because just as every situation is unique, so is every person different from every other person. But surely there must be some algorithm that will assist us in coming to the right answer. Unfortunately, no, for there is no right answer. There is only an answer that is as appropriate as we can conclude at that moment in that situation. No written guidelines can apply appropriately to every unique situation.</jats:p><jats:p>Unfortunately we physicians have been suckled on a fallacy: “What’s good for the goose is good for the gander.” Phrased in medical terms, “normal findings are good, and abnormal findings are bad.” This is too simple, and often wrong.</jats:p><jats:p>Good clinicians know that care must be personalized for it to be optimal. So-called normal findings give rough guidance, sometimes applicable to groups, but frequently wrong for individuals. Consider intraocular pressure (IOP). A normal IOP of 15 mmHg good for some and bad for others, and an abnormal IOP of 30 mmHg is good for some and bad for others. We are so bombarded by the myth of the sanctity of the standard distribution curve that it is hard to think independently and specifically. Also, unfortunately, doctors are prone to decide for patients, often on the basis of normative data that is not relevant or important for the particular patient. That we do this is not surprising, as we want to help, and so we default to what seems to be the easy, safe (non-thinking) way, in which we do not have to hold ourselves accountable for the outcome.</jats:p><jats:p>Somebody HAS to decide, or else we would be living in an anarchical world. Also true. And because none of us knows as much as we need to know to act appropriately, we seek advice from so-called “experts.”</jats:p><jats:p>For us to care for people well it is essential that we consider what others recommend. So we look to experts, as we should. However, experts are sometimes right and sometimes wrong. Remember that von Graefe in 1860 recommended surgical iridectomy for all glaucoma, Elliot recommended mustard plaster between the shoulders for glaucoma, Becker based treatment on tonographic findings, Weve reported 100% success with penetrating cyclodiathermy in glaucoma, Lichter advised against laser trabeculoplasty, many thought Cypass was great, and the investigators in the Advanced Glaucoma Intervention Study indicated that an IOP usually around 12 mmHg was better than one usually around 20 mmHg. All wrong. What the authors of these guidelines have done excellently, is to provide a general framework on which ophthalmologists can hang pieces of evidence, so as to be able to evaluate the validity and the importance of that evidence. In doing this meticulously they have provided a valuable service to all ophthalmologists, none of whom individually have either the time or the skill to be fully informed. In their own practices the authors consider whether valid information is relevant for the particular person being considered. That process of considering relevance is essential, always. And relevance is based on the particular unique patient, unique doctor and unique situation. The only guideline the authors can provide in this regard is to remind us all to consider relevance with all patients in all situations, and from the patient’s perspective. Even more important than the service to ophthalmologists is the benefit to patients that will result from thoughtful use of these guidelines.</jats:p><jats:p>We need, also, to remember that diagnoses are generic, and that within every diagnosis there are differences. For example what does a diagnosis of primary open angle mean? Some of those affected will rapidly go blind despite the most thoughtful treatment and others will keep their sight even without treatment. What does a diagnosis of Chandler’s Syndrome mean? In some, surgery works well, and, in others, poorly. So one never directs diagnosis and treatment at a condition, but rather at the person, the objective being the wellness of that person.</jats:p><jats:p>The previous European Glaucoma Society Guidelines are used internationally. It is good that the EGS is again providing updated, useful information.The Guidelines are a practical, inspirational contribution.</jats:p><jats:p><jats:bold>George L. Spaeth, BA, MD.</jats:bold></jats:p><jats:p>Esposito Research Professor, Wills Eye Hospital/Sidney Kimmel Medical College/Thomas Jefferson University</jats:p></jats:sec><jats:sec><jats:title>www.eugs.org</jats:title><jats:sec><jats:title>The Guidelines writers, authors and contributors<jats:break /></jats:title><jats:p>Augusto Azuara-Blanco (<jats:italic>Editor</jats:italic>)</jats:p><jats:p>Luca Bagnasco</jats:p><jats:p>Alessandro Bagnis</jats:p><jats:p>Joao Barbosa Breda</jats:p><jats:p>Chiara Bonzano</jats:p><jats:p>Andrei Brezhnev</jats:p><jats:p>Alain Bron</jats:p><jats:p>Carlo A. Cutolo</jats:p><jats:p>Barbara Cvenkel</jats:p><jats:p>Stefano Gandolfi</jats:p><jats:p>Ted Garway Heath</jats:p><jats:p>Ilmira Gazizova</jats:p><jats:p>Gus Gazzard</jats:p><jats:p>Franz Grehn</jats:p><jats:p>Anders Heijl</jats:p><jats:p>Cornelia Hirn</jats:p><jats:p>Gábor Holló</jats:p><jats:p>Anton Hommer</jats:p><jats:p>Michele Iester</jats:p><jats:p>Ingrida Januleviciene</jats:p><jats:p>Gauti Jóhannesson</jats:p><jats:p>Miriam Kolko</jats:p><jats:p>Tianjing Li</jats:p><jats:p>José Martínez de la Casa</jats:p><jats:p>Frances Meier-Gibbons</jats:p><jats:p>Maria Musolino</jats:p><jats:p>Marta Pazos</jats:p><jats:p>Norbert Pfeiffer</jats:p><jats:p>Sergey Petrov</jats:p><jats:p>Luis Abegao Pinto</jats:p><jats:p>Riccardo Scotto</jats:p><jats:p>Ingeborg Stalmans</jats:p><jats:p>Gordana Sunaric</jats:p><jats:p>Mégevand</jats:p><jats:p>Ernst Tamm</jats:p><jats:p>John Thygesen</jats:p><jats:p>Fotis Topouzis</jats:p><jats:p>Marc Töteberg-Harms</jats:p><jats:p>Carlo E. Traverso (<jats:italic>Editor</jats:italic>)</jats:p><jats:p>Anja Tuulonen</jats:p><jats:p>Zoya Veselovskaya</jats:p><jats:p>Ananth Viswanathan</jats:p><jats:p>Ilgaz Yalvac</jats:p><jats:p>Thierry Zeyen</jats:p></jats:sec><jats:sec><jats:title>Guidelines Committee<jats:break /></jats:title><jats:p>Augusto Azuara-Blanco (<jats:italic>Chair</jats:italic>)</jats:p><jats:p>Carlo E. Traverso (<jats:italic>Co-chair</jats:italic>)</jats:p><jats:p>Manuele Michelessi (<jats:italic>NGP Co-chair</jats:italic>)</jats:p><jats:p>Luis Abegao Pinto</jats:p><jats:p>Michele Iester</jats:p><jats:p>Joao Breda</jats:p><jats:p>Carlo A. Cutolo</jats:p><jats:p>Panayiota Founti</jats:p><jats:p>Gerhard Garhoefer</jats:p><jats:p>Andreas Katsanos</jats:p><jats:p>Miriam Kolko</jats:p><jats:p>Francesco Oddone</jats:p><jats:p>Marta Pazos</jats:p><jats:p>Verena Prokosch-Willing</jats:p><jats:p>Cedric Schweitzer</jats:p><jats:p>Andrew Tatham</jats:p><jats:p>Marc Toteberg-Harms</jats:p></jats:sec><jats:sec><jats:title>Acknowledgements<jats:break /></jats:title><jats:p>Anja Tuulonen</jats:p><jats:p>Ted Garway Heath</jats:p><jats:p>Richard Wormald</jats:p><jats:p>Tianjing Li</jats:p><jats:p>Manuele Michelessi</jats:p><jats:p>Jenny Burr</jats:p><jats:p>Azuara-Blanco for their methodological oversight.</jats:p><jats:p>Tianjing Li and Riaz Qureshi (US Cochrane Eye and Vision Group) and Manuele Michelessi (EGS) for leading the evidence review.</jats:p><jats:sec><jats:title /><jats:p>Manuele Michelessi</jats:p><jats:p>Gianni Virgili</jats:p><jats:p>Joao Barbosa Breda</jats:p><jats:p>Carlo A. Cutolo</jats:p><jats:p>Marta Pazos</jats:p><jats:p>Andreas Katsanos</jats:p><jats:p>Gerhard Garhofer</jats:p><jats:p>Miriam Kolko</jats:p><jats:p>Verena Prokosch</jats:p><jats:p>Panayota Founti</jats:p><jats:p>Francesco Oddone</jats:p><jats:p>Ali Ahmed Al Rajhi</jats:p><jats:p>Tianjing Li</jats:p><jats:p>Riaz Qureshi and Azuara-Blanco for their contribution to the evidence review.</jats:p></jats:sec><jats:sec><jats:title /><jats:p>Karen Osborn and Joanna Bradley from Glaucoma UK charity for their contribution to the section: ‘What matters to patients’ (<jats:italic><jats:uri>https://glaucoma.uk</jats:uri></jats:italic>)</jats:p></jats:sec></jats:sec><jats:sec><jats:title>Additional contributions were made by the following people on specific topics<jats:break /></jats:title><jats:p>Eleftherios Anastasopoulos</jats:p><jats:p>Panayiota Founti</jats:p><jats:p>Gus Gazzard</jats:p><jats:p>Franz Grehn</jats:p><jats:p>Anders Heijl</jats:p><jats:p>Gábor Holló</jats:p><jats:p>Fotis Topouzis</jats:p><jats:p>Anja Tuulonen</jats:p><jats:p>Ananth Viswanatham</jats:p></jats:sec><jats:sec><jats:title>The team of Clinica Oculistica of the University of Genoa for medical editing and illustrations<jats:break /></jats:title><jats:p>Luca Bagnasco</jats:p><jats:p>Alessandro Bagnis</jats:p><jats:p>Chiara Bonzano</jats:p><jats:p>Carlo A. Cutolo</jats:p><jats:p>Michele Lester</jats:p><jats:p>Maria Musolino</jats:p><jats:p>Roberta Parodi</jats:p><jats:p>Riccardo Scotto</jats:p></jats:sec><jats:sec><jats:title>We would like to thank the following colleagues for their help in reviewing/editing section I.7. Landmark randomised controlled trials for glaucoma<jats:break /></jats:title><jats:p>Joe Caprioli</jats:p><jats:p>Ted Garway Heath </jats:p><jats:p>Gus Gazzard </jats:p><jats:p>Divakar Gupta </jats:p><jats:p>Anders Heijl </jats:p><jats:p>Michael Kass </jats:p><jats:p>Stefano Miglior </jats:p><jats:p>David Musch </jats:p><jats:p>Norbert Pfeiffer </jats:p><jats:p>Thierry Zeyen</jats:p></jats:sec><jats:sec><jats:title>External reviews<jats:break /></jats:title><jats:p>We would like to thank the following societies and experts:</jats:p><jats:p>World Glaucoma Association:</jats:p><jats:p>Parul Ichhpujani</jats:p><jats:p>Monisha Nongpiur</jats:p><jats:p>Tanuj Dada</jats:p><jats:p>Sola Olawoye</jats:p><jats:p>Jayme Vianna</jats:p><jats:p>Min Hee Suh</jats:p><jats:p>Farouk Garba</jats:p><jats:p>Simon Skalicky</jats:p><jats:p>Alex Huang</jats:p><jats:p>Farouk Garba</jats:p><jats:p>Pradeep Ramulu</jats:p><jats:p>Verena Prokosch</jats:p><jats:p>Carolina Gracitelli;</jats:p><jats:p>American Glaucoma Society:</jats:p><jats:p>Josh Stein;</jats:p><jats:p>and Latin-American Glaucoma Society:</jats:p><jats:p>Daniel Grigera</jats:p><jats:sec><jats:title /><jats:p>We would like to thank the external reviewers whose comments are listed on <jats:italic><jats:uri>https://www.eugs.org/eng/guidelines.asp</jats:uri></jats:italic></jats:p></jats:sec></jats:sec><jats:sec><jats:title>The EGS executive committee<jats:break /></jats:title><jats:p>Ted Garway Heath (<jats:italic>President</jats:italic>)</jats:p><jats:p>Fotis Topouzis (<jats:italic>Vice President</jats:italic>)</jats:p><jats:p>Ingeborg Stalmans (<jats:italic>Treasurer</jats:italic>)</jats:p><jats:p>Anja Tuulonen (<jats:italic>Past President</jats:italic>)</jats:p><jats:p>Luis Abegao Pinto</jats:p><jats:p>Andrei Brezhnev</jats:p><jats:p>Alain Bron</jats:p><jats:p>Gauti Jóhannesson</jats:p><jats:p>Norbert Pfeiffer</jats:p></jats:sec><jats:sec><jats:title>The board of the European Glaucoma Society Foundation<jats:break /></jats:title><jats:p>Carlo E. Traverso (<jats:italic>Chair</jats:italic>)</jats:p><jats:p>Fotis Topouzis (<jats:italic>Vice Chair</jats:italic>)</jats:p><jats:p>Franz Grehn</jats:p><jats:p>Anders Heijl</jats:p><jats:p>John Thygesen</jats:p><jats:p>Thierry Zeyen</jats:p></jats:sec></jats:sec><jats:sec><jats:title>Glossary<jats:break /></jats:title><jats:p><jats:bold>5-FU</jats:bold> 5-fluorouracil</jats:p><jats:p><jats:bold>AAC</jats:bold> Acute angle closure</jats:p><jats:p><jats:bold>ACG</jats:bold> Angle closure glaucoma</jats:p><jats:p><jats:bold>AGIS</jats:bold> Advanced glaucoma intervention study</jats:p><jats:p><jats:bold>AH</jats:bold> Aqueous humour</jats:p><jats:p><jats:bold>AI</jats:bold> Artificial intelligence</jats:p><jats:p><jats:bold>ALT</jats:bold> Argon laser trabeculoplasty</jats:p><jats:p><jats:bold>BAC</jats:bold> Benzalkalonium chloride</jats:p><jats:p><jats:bold>CCT</jats:bold> Central corneal thickness</jats:p><jats:p><jats:bold>CDR</jats:bold> Cup to disc ratio</jats:p><jats:p><jats:bold>CIGTS</jats:bold> Initial glaucoma treatment study</jats:p><jats:p><jats:bold>CNTGS</jats:bold> Collaborative normal tension glaucoma study</jats:p><jats:p><jats:bold>DCT</jats:bold> Dynamic contour tonometry</jats:p><jats:p><jats:bold>EAGLE</jats:bold> Effectiveness of early lens extraction for the treatment of primary angle closure glaucoma</jats:p><jats:p><jats:bold>EGPS</jats:bold> European glaucoma prevention study</jats:p><jats:p><jats:bold>EGS</jats:bold> European glaucoma society</jats:p><jats:p><jats:bold>EMA</jats:bold> The european medicines agency</jats:p><jats:p><jats:bold>EMGT</jats:bold> Early manifest glaucoma trial</jats:p><jats:p><jats:bold>FC</jats:bold> Flow chart</jats:p><jats:p><jats:bold>FDT</jats:bold> Frequency doubling technology</jats:p><jats:p><jats:bold>FC</jats:bold> Fixed combination</jats:p><jats:p><jats:bold>FL</jats:bold> Fixation losses</jats:p><jats:p><jats:bold>FN</jats:bold> False negatives</jats:p><jats:p><jats:bold>FP</jats:bold> False positive</jats:p><jats:p><jats:bold>GAT</jats:bold> Goldmann applanation tonometry</jats:p><jats:p><jats:bold>GHT</jats:bold> The glaucoma hemifield test</jats:p><jats:p><jats:bold>GRADE</jats:bold> Grading of recommendations, assessment, development and evaluations</jats:p><jats:p><jats:bold>HRT</jats:bold> Heidelberg retina tomography</jats:p><jats:p><jats:bold>ICE</jats:bold> Irido-corneal endothelial syndrome</jats:p><jats:p><jats:bold>IOL</jats:bold> Intraocular lens</jats:p><jats:p><jats:bold>IOP</jats:bold> Intraocular pressure</jats:p><jats:p><jats:bold>ITC</jats:bold> Iridotrabecular contact</jats:p><jats:p><jats:bold>IV</jats:bold> Intravenous</jats:p><jats:p><jats:bold>LIGHT</jats:bold> Laser in glaucoma and ocular hypertension trial</jats:p><jats:p><jats:bold>LPI</jats:bold> Laser peripheral iridotomy</jats:p><jats:p><jats:bold>LV</jats:bold> Loss variance</jats:p><jats:p><jats:bold>MD</jats:bold> Mean defect or mean deviation</jats:p><jats:p><jats:bold>MMC</jats:bold> Mitomycin C</jats:p><jats:p><jats:bold>NCT</jats:bold> Non-contact tonometry</jats:p><jats:p><jats:bold>Nd:YAG</jats:bold> Neodymium-doped yttrium aluminum garnet</jats:p><jats:p><jats:bold>NTG</jats:bold> Normal tension glaucoma</jats:p><jats:p><jats:bold>OAG</jats:bold> Open angle glaucoma</jats:p><jats:p><jats:bold>OCT</jats:bold> Optical coherence tomography</jats:p><jats:p><jats:bold>OHT</jats:bold> Ocular hypertension</jats:p><jats:p><jats:bold>OHTS</jats:bold> The ocular hypertension treatment study</jats:p><jats:p><jats:bold>ONH</jats:bold> Optic nerve head</jats:p><jats:p><jats:bold>ORA</jats:bold> Ocular response analyser</jats:p><jats:p><jats:bold>OSD</jats:bold> Ocular surface disease</jats:p><jats:p><jats:bold>PAC</jats:bold> Primary angle closure</jats:p><jats:p><jats:bold>PACG</jats:bold> Primary angle closure glaucoma</jats:p><jats:p><jats:bold>PACS</jats:bold> Primary angle closure suspect</jats:p><jats:p><jats:bold>PAS</jats:bold> Peripheral anterior synechiae</jats:p><jats:p><jats:bold>PCG</jats:bold> Primary congenital glaucoma</jats:p><jats:p><jats:bold>PDS</jats:bold> Pigment dispersion syndrome</jats:p><jats:p><jats:bold>PGA</jats:bold> Prostaglandin analogue</jats:p><jats:p><jats:bold>POAG</jats:bold> Primary open angle glaucoma</jats:p><jats:p><jats:bold>PG</jats:bold> Pigmentary glaucoma</jats:p><jats:p><jats:bold>PSD</jats:bold> Pattern standard deviation</jats:p><jats:p><jats:bold>PXF</jats:bold> Pseudoexfoliation syndrome</jats:p><jats:p><jats:bold>PXFG</jats:bold> Pseudoexfoliation glaucoma</jats:p><jats:p><jats:bold>RCT</jats:bold> Randomised controlled trial</jats:p><jats:p><jats:bold>RNFL</jats:bold> Retinal nerve fiber layer</jats:p><jats:p><jats:bold>RoP</jats:bold> Rate of progression</jats:p><jats:p><jats:bold>SAP</jats:bold> Standard automated perimetry</jats:p><jats:p><jats:bold>SITA</jats:bold> Swedish interactive threshold algorithm</jats:p><jats:p><jats:bold>SLT</jats:bold> Selective laser trabeculoplasty</jats:p><jats:p><jats:bold>SWAP</jats:bold> Short-wavelength automated perimetry</jats:p><jats:p><jats:bold>TLPI</jats:bold> Thermal laser peripheral iridoplasty</jats:p><jats:p><jats:bold>TM</jats:bold> Trabecular meshwork</jats:p><jats:p><jats:bold>UBM</jats:bold> Ultrasound biomicroscopy</jats:p><jats:p><jats:bold>UGH</jats:bold> Uveitis-glaucoma-hyphema syndrome</jats:p><jats:p><jats:bold>UKGTS</jats:bold> United Kingdom glaucoma treatment study</jats:p><jats:p><jats:bold>VEGF</jats:bold> Vascular endothelial growth factor</jats:p><jats:p><jats:bold>VF</jats:bold> Visual filed</jats:p><jats:p><jats:bold>VFI</jats:bold> Visual field index</jats:p><jats:p><jats:bold>ZAP</jats:bold> Zhongshan angle closure prevention trial</jats:p></jats:sec>