| Summary: | <strong>Background:</strong>Network meta-analysis compares multiple treatment options for the same condition and may be useful for developing clinical practice guidelines. <strong>Purpose:</strong> To compare treatment recommendations for first‐line medical therapy for primary open angle-glaucoma (POAG) from major updates of American Academy of Ophthalmology’s (AAO) guidelines with the evidence available at the time, using network meta‐analysis. <strong>Data Sources:</strong> We searched MEDLINE, EMBASE, and The Cochrane Library on March 11, 2014 for randomized controlled trials (RCTs) of glaucoma monotherapies compared with placebo/vehicle/no treatment or other monotherapies. We searched the AAO website in August 2014 to identify AAO POAG guidelines. <strong>Study Selection:</strong> Eligible RCTs were selected by two independent reviewers and guidelines were selected by one person. <strong>Data Extraction:</strong> One person abstracted recommendations from guidelines and a second person verified. Two people independently abstracted data from included RCTs. <strong>Data Synthesis:</strong> We grouped guidelines together based on literature search dates, and analyzed RCTs that existed at 1991, 1995, 1999, 2004, and 2009. The outcome of interest is intraocular pressure (IOP) at 3 months. Only the latest guideline made a specific recommendation‐‐prostaglandins. Network meta‐analyses showed that all treatments were superior to placebo in lowering IOP at 3 months. The mean reduction (95% credible interval) for the highest ranking class compared with placebo were as follows: 1991: beta blockers, 4.01 (0.48‐7.43); 1995: alpha‐2 adrenergic agonists, 5.64 (1.739.50); 1999: prostaglandins, 5.43 (3.387.38); 2004: prostaglandins, 4.75 (3.11‐6.44); 2009: prostaglandins, 4.58 (2.94‐6.24). <strong>Limitations:</strong> When comparisons are informed by a small number of studies, the treatment effects and rankings may not be stable. <strong>Conclusions:</strong> For timely recommendations when multiple treatment options are available, guidelines developers should consider network meta‐analysis.
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