[Childhood glaucoma associated with Sturge-Weber syndrome --the efficacy of cyclofotocoagulation and other therapeutic methods]

PURPOSE

Sturge-Weber syndrome is a rare congenital neurooculocutaneous disorder. Ocular involvement can include glaucoma and vascular malformations of the conjunctiva, episclera, choroid and retina.

MATERIAL AND METHODS

16 children (16 eyes) with Sturge-Weber syndrome associated with glaucoma (mean age--34 month, mean follow up 8.87 years) treated in our institution, were reviewed. In retrospective analysis were assessed: IOP and postoperative complications after diode laser cyklophotocoagulation (16 eyes), after trabeculectomy (6 eyes) and trabeculectomy with MMC (3 eyes).

RESULTS

In ten eyes (62.5%) good result (IOP 6-22 mmHg) post cyclophotokoagulation--(3x) was recorded, as well as in 3 eyes (50%) post trabeculectomy and in 3 eyes (100%) post trabeculectomy with MMC 0.2/4 min. No postoperative complications occured in cyclophotocoagulation group. Complications after trabeculectomy were the following: 3 cases of hypotony, 4 cases with shallow anterior chamber and 5 with choroidal effusions.

CONCLUSIONS

Diode laser cyclophotocoagulation combined with topical medication is an effective and safe treatment of glaucoma in children with Sturge-Weber syndrome.

Audit of trabeculectomy at a tertiary referral hospital in East Africa

AIM

To audit medium-term results of trabeculectomy at a tertiary referral unit in east Africa.

METHODS

A retrospective review of the files of all patients who underwent trabeculectomy surgery at our hospital during the year 2001.

RESULTS

One hundred fifty-seven patients were included. Mean age was 61 years (SD = 12). Thirty-one patients (20%) were women; 120 of 145 (83%) eyes had cup/disc ratios of 0.8 or greater preoperatively. Intraoperative 5-fluorouracil (5FU) was used in 57 cases (36%). Mean follow-up was 8 months (0-28, SD = 7). Mean intraocular pressures (IOP) was 25 mm Hg (6-70, SD = 10) preoperatively, 11 mm Hg (0-32, SD = 5) at 2 weeks postoperatively, and 13 mm Hg (0-42, SD = 6) at latest follow-up. One hundred fifteen patients (73%) had intraocular pressure of 15 mm Hg or less at latest follow-up and 141 (90%) had intraocular pressure of 21 mm Hg or less. Twenty (13%) had restarted antiglaucoma medication during the follow-up period. Thirty-seven of 148 (25%) lost 2 lines of Snellen acuity or equivalent between preoperative measurement and latest follow-up. Early postoperative complications (usually leaking bleb or shallow anterior chamber with hypotony) occurred in 18 patients (12%) and this was associated with postoperative loss of 2 or more lines of Snellen acuity (OR = 1.11 95% CI 1.02-1.22, P= 0.02). Patients having had 5FU had lower (t = 3.11, P= 0.02) mean intraocular pressure at 2-month follow-up (12 mm Hg, SD = 5) than those who did not receive it (16 mm Hg, SD = 6) but there was no significant difference at later follow-ups. Men (mean 14 mm Hg, SD = 6) had higher (t = 2.71, P= 0.01) intraocular pressures at latest follow-up than women (mean 11 mm Hg, SD = 3).

CONCLUSIONS

The results of surgery compare well with other reported series. 5FU did not demonstrate significant benefit in terms of intraocular pressure lowering beyond 2 months postoperatively. Early postoperative hypotony should be avoided. The gender difference in intraocular pressure results has not previously been reported and deserves further investigation.

Clinical Outcomes of Glaucoma Treatments Over a Patient Lifetime

PURPOSE

To quantify the clinical outcome of glaucoma treatment over a patient's lifetime to identify treatment parameters that would preserve vision across a population.

METHODS

A Markov model was used to reproduce glaucoma treatments and clinical responses over a patient's lifetime. Markov states comprised first-line to fourth-line pharmacological treatments, no treatment, laser therapy, surgery, blindness, and death. All patients began with first-line treatment and passed to the next treatment in line following a failure. After each failure, and always after a fourth-line failure, patients could receive laser therapy or surgery, followed by no treatment or a new first-line treatment. Transitional probabilities came from a cross-sectional study and national statistics. Sensitivity analyses were based on second order Monte-Carlo simulation.

RESULTS

Cohort demographics were average age 59.7 years, life expectancy 22.5 years, females 54.0%. Treatment durations (months) for a patient with ocular hypertension were first-line (89), second-line (49), third-line (41), and no treatment (44); laser interventions numbered 1.251 and surgical 0.882. For a patient with glaucoma the corresponding values were 70, 44, 40, 18, 42, 1.197, and 0.842. First-line or second-line drugs best at controlling intraocular pressure (IOP) reduced laser therapy, surgery, and the prevalence of blindness. The most effective drug should be prescribed first-line. According to our model drugs specifically able to arrest disease progression would be more beneficial than intraocular pressure control.

CONCLUSION

More powerful glaucoma medication (first-line or second-line) would contribute to the preservation of long-term vision.

Transconjunctival Suture Adjustment for Initial Intraocular Pressure Control after Trabeculectomy

PURPOSE

In an experimental human eye model of trabeculectomy, scleral flap suture adjustment allows predictable control of intraocular pressure (IOP). This approach had not previously been described in clinical use; we present a case series with the application of this technique.

METHODS

A prospective, non-comparative interventional case series of consecutive patients undergoing trabeculectomy. Forty trabeculectomies were performed using a 3 mm x 4 mm scleral flap with two apical adjustable 10-0 nylon sutures under a fornix-based conjunctival flap. Intraoperatively the scleral flap sutures were tied tightly to appose the edges of the flap. All trabeculectomies were augmented with antimetabolite intraoperatively. On day one, patients with an IOP greater than 15 mm Hg had their suture tension adjusted to lower their IOP to a target range (10 to 15 mm Hg). Major outcome measures were IOP before and after adjustment and success at last follow-up (IOP < or = 15 mm Hg on no glaucoma medication and no clinically significant complications) without and with adjunctive needling. Other outcomes measured were postoperative complications, bleb needling, final bleb morphology, and visual acuity change from pre-operation to final follow-up.

RESULTS

Average day one IOP was 14.8 mm Hg (standard deviation (SD) 7.8). Fourteen patients had a day one IOP over 15 mm Hg and underwent suture adjustment, lowering IOP to between 10 and 15 mm Hg. (Mean post adjustment IOP was 10.7 mm Hg (SD 3.6)). One patient had a conjunctival tear intraoperatively. Four patients had transient wound leaks. No patients had shallow anterior chambers. All but four had diffuse blebs at last follow-up. Success rate without any further surgical intervention was 75%, and success rate with adjunctive needling was 100%. The mean duration of follow-up was 6.3 months (range 1-12 months).

CONCLUSION

The approach of tying scleral flap sutures tightly with transconjunctival adjustment of sutures if the IOP is greater than 15 mm Hg on day one allows excellent control of early postoperative IOP.

A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma

AIM

To compare 90 degrees , 180 degrees , and 360 degrees selective laser trabeculoplasty (SLT, 532 nm Nd:YAG laser) with latanoprost 0.005% for the control of intraocular pressure (IOP) in ocular hypertension (OHT) and open angle glaucoma (OAG).

METHODS

A prospective, randomised clinical trial in the Department of Ophthalmology, St Thomas's Hospital, London, and Clayton Eye Centre, Wakefield, West Yorkshire. 167 patients (167 eyes) with either OHT or OAG were randomised to receive 90 degrees , 180 degrees , and 360 degrees SLT or latanoprost 0.005% at night and were evaluated at 1 hour, 1 day, 1 week and 1, 3, 6, and 12 months.

RESULTS

The mean follow up was 10.3 months (range 1--12 months). Early, transient, complications such as postoperative ocular pain, uveitis, and 1 hour IOP spike occurred in a number of eyes after SLT, with pain being reported more frequently after 360 degrees than 90 degrees treatments (p>0.001). Success rates defined in terms of both a 20% or more and a 30% or more IOP reduction from baseline measurements with no additional antiglaucomatous interventions were better with latanoprost than 90 degrees (p<0.001) and 180 degrees SLT (p<0.02) treatments. Differences in success rates between latanoprost and 360 degrees SLT did not reach statistical significance (p<0.5). Success rates were greater with 180 degrees and 360 degrees compared to 90 degrees SLT (p<0.05). With 360 degrees SLT, 82% of eyes achieved a >20% IOP reduction and 59% a >30% reduction from baseline. Although success rates were better with 360 degrees than 180 degrees SLT treatments, differences did not reach statistical significance. There were no differences with regard to age, sex, race, pretreatment IOP, OHT versus OAG, laser power settings, and total laser energy delivered between eyes which responded, in terms of a >20% and a >30% IOP reduction, and those that did not respond with 180 degrees and 360 degrees SLT treatments.

CONCLUSIONS

Success rates were higher with latanoprost 0.005% at night than with 90 degrees and 180 degrees SLT treatments. 90 degrees SLT is generally not effective. 360 degrees SLT appears to be an effective treatment with approximately 60% of eyes achieving an IOP reduction of 30% or more. Transient anterior uveitis with associated ocular discomfort is not unusual in the first few days after SLT. Late complications causing ocular morbidity after SLT were not encountered.

[Long-term results after selective laser trabeculoplasty -- a clinical study on 269 eyes]

BACKGROUND

Selective laser trabeculoplasty SLT is a new method to reduce intraocular pressure in eyes with primary open angle glaucoma. With a Q-switched, frequency-doubled Nd:YAG laser it targets the pigmented trabecular meshwork cells without visible damage to the adjacent non-pigmented tissue. SLT acts non-thermally, the intracellular microdisruptions triggered by the laser are confined to the targeted cells, the laser pulses are so short that heat created within the targeted cells does not have time to spread to the surrounding tissue. A clinical prospective study was conducted to evaluate the long-term results, safety and efficacy of SLT in the treatment of open angle glaucoma.

PATIENTS AND METHODS

Since 2002, we have performed a selective laser trabeculoplasty in 269 eyes: in 17 eyes with ocular hypertension, in 239 eyes with primary open angle glaucoma, in 11 eyes with low tension glaucoma, while 2 eyes had a secondary glaucoma due to uveitis. In 22 eyes the primary initial treatment was SLT.

RESULTS

Three months after treatment, the mean IOP reduction from baseline was 3.4 mm Hg, respectively 15 %, after 12 months the mean IOP reduction was 3.0 mm Hg (12.9 %), and after 24 months 2.7 mm Hg or 12.1 %. The response curve of the eyes with ocular hypertension greatly resembled the eyes with primary open angle glaucoma and with low tension glaucoma.

CONCLUSIONS

SLT has shown reasonable efficacy in lowering IOP in eyes with primary open angle glaucoma and ocular hypertension, both as a first-line treatment and as a treatment in medication-refractory eyes. SLT is effective for patients who have had prior treatment with ALT. Long-term follow-up studies are needed to determine whether the IOP lowering effect is sustained over time, and to assess the efficacy of repeated SLT. The exact biological effect induced with the SLT is still not understood.

Long-term results of early trabeculectomy with mitomycin-C and subsequent posterior segment intervention in the treatment of neovascular glaucoma with hazy ocular media

OBJECTIVES

To assess the long-term efficacy and safety of early trabeculectomy with mitomycin-C (TMMC) and subsequent posterior segment intervention in the treatment of neovascular glaucoma (NVG) with hazy ocular media.

MATERIAL AND METHOD

Twenty-three eyes of 21 patients who had NVG with hazy ocular media that precluded posterior segment and had persistent IOP of 30 mm Hg or more despitefully antiglaucoma medications for 48 hours, underwent a modified TMMC (twice application of subconjunctival and subscleral MMC 0.2 mg/ml for 3 and 2 minutes, small internal block excision, laser suturelysis at 2 weeks) and subsequent posterior segment intervention with or without phacoemulsification.

RESULTS

Preoperative IOP ranged from 30-80 mmHg, (mean 38.87 +/- 9.52). Follow-up period ranged from 12-47 months (mean 29 +/- 11.03). At final follow-up, qualified success (an IOP of < or = 21 mm Hg with or without medication) and complete success (an IOP of < or = 15 mm Hg without medication) was achieved in 21 (91.3%) of 23 eyes and in 12 (52.7%) of 23 eyes, respectively. The median successful period of maintaining qualified success was 13 months. Final visual acuity of 20/400 or better was preserved in 12 of 23 eyes (52.7%). None had hypotony maculopathy, leaking blebs or endophthalmitis.

CONCLUSION

Early TMMC and subsequent posterior segment intervention, offerred a safe and prolonged satisfactory result of IOP control in NVG patients with hazy ocular media.

Trabecular meshwork alteration and intraocular pressure change following pulsed near-infrared laser trabeculoplasty in cats

BACKGROUND AND OBJECTIVE

To comparatively assess the safety and variation in intraocular pressure (IOP) of two pulsed near-infrared lasers (titanium:sapphire and alexandrite) for laser trabeculoplasty versus conventional blue-green argon laser trabeculoplasty in an animal model.

MATERIALS AND METHODS

The left eyes of 15 healthy cats received a 180 degree laser trabeculoplasty treatment: 5 with a titanium:sapphire laser, 5 with an alexandrite laser, and 5 with an argon laser. Preoperatively and postoperatively, all animals underwent tonometry, gonioscopy, and slit-lamp examination. The cats were observed up to 12 weeks. Scanning electron microscopy and histologic examination were performed to evaluate potential alterations in the trabecular meshwork structure.

RESULTS

IOP at 1 hour, 1 day, and 1 week following treatment was remarkably lower, irrespective of the laser source used. Following treatment with both near-infrared lasers, gonioscopy showed depigmentation underneath the area of the treated trabecular meshwork and histologic evaluation showed a decrease in pigment density. On scanning electron microscopy, damage to the trabecular meshwork structure could not be detected after treatment with near-infrared lasers.

CONCLUSIONS

Near-infrared laser trabeculoplasty was found to be effective to temporarily lower IOP in cats. The lasers selectively altered pigment-containing cells, avoiding structural damage of the trabecular meshwork anatomy.

[Selective laser trabeculoplasty treatment for medication-refractory open angle glaucoma]

BACKGROUND

Selective laser trabeculoplasty (SLT) is a new method to reduce intraocular pressure in eyes with primary open angle glaucoma. The laser parameters are set to selectively target pigmented trabecular meshwork (TM) cells without damage to the adjacent non-pigmented tissue.

PURPOSE

A clinical retrospective study was conducted to evaluate the 12 months results of SLT in the treatment of medically uncontrolled open angle glaucoma.

PATIENTS AND METHODS

During the period March to September 2004, the authors performed a SLT in 50 patients (50 eyes) with open angle glaucoma uncontrolled on maximally tolerated medical therapy. Treatment was carried out with a frequency-doubled, Q-switched Nd:YAG laser 532 nm.(Selectra 7000 Laser Coherent, Inc., Palo Alto,CA). Approximately 85 to 90 non-overlapping laser spots were placed over 180 degrees of the trabecular meshwork at energy levels ranging from 0.6 to 1.4 mJ per pulse. In patients who required additional SLT therapy, the untreated 180 degrees was treated. During the follow-up period, patients were treated with antiglaucoma medications as required. The success rates were defined as decreases in intraocular pressure (IOP) of 3 mmHg or more with no additional medications, laser, or glaucoma surgery.

RESULTS

The mean IOP reduction from baseline 6 months after treatment was 21% and 20% after 12 months. The success rates were 66% after 6 months and 55% after 12 months. Four eyes (8%) did not respond to SLT. One hour after SLT, an increase in IOP of more than 5 mm Hg was detected in 5 eyes (10%). Seven patients (14%) required additional SLT.

CONCLUSIONS

SLT is efficient in lowering IOP in medication-refractory open angle glaucoma. It should be considered in such patients when surgery is contraindicated or refused.

[Use of physiological reparation regulators in glaucoma surgery: a clinicoimmunological study]

The paper presents the comparative results of clinical and immunological studies dealing with the use of the physiological reparation regulators (the human amniotic membrane and systemic enzyme therapy) and the antimetabolite 5-fluorouracil (5-FU) to prevent excessive ocular tissue scarring. The clinical observations have demonstrated the high efficiency of the proposed methods for the physiological regulation of reparative processes as compared with the use of 5-FU, which manifested as a more marked normalization ofophthalmotonus and fewer numbers of postoperative complications. The investigation of the study of proliferation-activating cytokine (TGF-beta1) and antiprolerative cytokine (IFN-gamma) has demonstrated the immunomodulating properties of the physiological reparation regulators used in the present study.

Excimer laser trabeculotomy: a new, minimally invasive procedure for patients with glaucoma

BACKGROUND

Excimer laser trabeculotomy (ELT) ab interno is a new surgical technique to reduce intraocular pressure (IOP) in patients with glaucoma or ocular hypertension. Our purpose was to examine IOP reduction and the use of antiglaucoma drugs (AGD) in patients treated with ELT and to evaluate the safety of this laser treatment.

METHODS

To increase the outflow of aqueous humor, ten microperforations of the trabecular meshwork were performed by an endoscope-guided photoablative laser probe (Excimer laser, AIDA, TUI-Laser, Munich; pulse energy: 1.2 mJ at fiber tip, pulse duration: 60 ns, repetition rate: 20 Hz). Average operation time usually was about 2 min. In our pilot study, one group of patients without cataract underwent ELT, the other group with cataract underwent phacoemulsification (PHACO) plus ELT. IOP, visual acuity, and AGD were determined preoperatively (T0) and 2-4 months (T1), 5-7 months (T2), 11-13 months (T3), and 22-26 (T4) months after surgery. Treatment was defined to be successful if (1) postoperative IOP was < or =21 mmHg, and (2) IOP reduction was at least 20%.

RESULTS

ELT reduced the IOP from 24.1+/-0.7 (n=69) mmHg preoperatively to 18.8+/-0.4 (T1, n=66), 20.0+/-0.5 (T2, n=51), 18.8+/-0.8 (T3, n= 37), and 16.8+/-1.0 (T4, n=15) mmHg, respectively. However, 28% of the eyes needed repeat surgery due to insufficient IOP reduction. According to Kaplan-Meier statistics, the success rate was 60% (T1), 49% (T2), and 46% (T3), respectively. The number of AGD was 1.9+/-0.1 (T0), 1.2+/-0.2 (T1), 1.3+/-0.2 (T2), 1.8+/-0.2 (T3), and 1.5+/-0.3 (T4). Combined phacoemulsification plus ELT reduced the IOP from 22.4 mmHg+/-0.6 (T0, n=57) to 16.5+/-0.4 (T1, n=52), 16.1+/-0.5 (T2, n= 40), 16.4+/-0.4 (T3, n= 35), and 12.8+/-1.5 (T4, n=4) mmHg, respectively; 7% of the eyes treated with the combined procedure needed repeat surgery due to insufficient IOP reduction. According to Kaplan-Meier statistics, the success rate was 85% (T1), 74% (T2), and 66% (T3), respectively. The number of AGD was 1.1+/-0.2 (T0), 0.9+/-0.2 (T1), 1.1+/-0.2 (T2), 1.2+/-0.2 (T3), and 1.8+/-0.9 (T4).

CONCLUSIONS

ELT, especially in combination with phacoemulsification, is a new, promising, minimally invasive laser treatment to reduce IOP for at least 1-2 years. ELT alone is less effective in IOP reduction.

Fornix vs limbal-based trabeculectomy with mitomycin C

PURPOSE

To compare the effectiveness of limbus- and fornix-based conjunctival flaps in patients undergoing trabeculectomy with mitomycin-C augmentation.

METHODS

A retrospective review of the records of 71 consecutive eyes of 59 patients who underwent trabeculectomy with mitomycin C. All the patients had at least 6 months of follow-up. The first 35 eyes underwent surgery with a limbal-based flap, whereas all subsequent surgeries were by fornix-based procedures.

RESULTS

No significant difference was detected between the groups with regard to patient demographics, preoperative visual field and intraocular pressure parameters, postoperative intraocular pressures at day 1, months 1, 3, and 6 postoperatively, need for intervention, need for supplementary glaucoma medication, and final visual acuity. There were four cases of overdrainage and hypotony in the limbal-based group, whereas none occurred in the fornix-based group. In all 83% percent of eyes in the limbal-based group achieved intraocular pressures off medication of less than 18 mmHg, whereas 94% of the fornix based group obtained such IOP control. One patient in the limbal-based group developed late postoperative endophthalmitis.

CONCLUSION

Trabeculectomy with MMC augmentation is a safe and effective procedure for reduction of IOP and visual rehabilitation whether a fornix- or a limbal-based conjunctival flap is utilised. In this series, there was a greater risk of excessive drainage with subsequent hypotonous complications when surgery was undertaken by a limbal-based procedure.

Baseline IOP predicts selective laser trabeculoplasty success at 1 year post-treatment: results from a randomised clinical trial

BACKGROUND/AIMS

The efficacy and safety of selective laser trabeculoplasty (SLT) has been found to be equivalent to argon laser trabeculoplasty (ALT). Since SLT produces significantly less disturbance to the trabecular meshwork and is theoretically more repeatable than ALT, it has potential to replace ALT as the standard procedure to treat medically uncontrolled open angle glaucoma. This study's objective is to determine factors that predict successful SLT at 1 year post-treatment.

METHODS

As part of a randomised clinical trial comparing the efficacy and safety of SLT to ALT, data on 72 SLT patients were collected, and successful SLT defined as having an SLT induced intraocular pressure (IOP) reduction of >or=20% at 1 year post-treatment follow up.

RESULTS

43 out of the 72 patients who had completed their 1 year follow up visit had an IOP reduction of >or=20% from baseline. No glaucoma risk factors studied predicted successful SLT. The amount of trabecular meshwork pigmentation was not a significant predictor. However, it was discovered that baseline IOP strongly predicted SLT success (odds ratio=1.16; p=0.0001).

CONCLUSION

SLT success was significantly predicted by baseline IOP but not by age, sex, other glaucoma risk factors, type of open angle glaucoma, or by degree of trabecular meshwork pigmentation.

South-East Scotland trabeculectomy survey

AIM

Assessment of trabeculectomy in South-East Scotland (SESTS) with comparison to National Survey of Trabeculectomy (NST) and outcomes of consultant and trainee surgery.

METHOD

A retrospective study of 304 consecutive, primary trabeculectomies, in two Scottish centres (Edinburgh and Dunfermline) with two glaucoma specialists and higher surgical trainees, was performed. The study group had primary open angle glaucoma (65.5%), pseudoexfoliation (6.9%), normal tension glaucoma (7.6%), pigment dispersion syndrome (1.6%), and other complicated glaucoma (18.4%). All patients underwent trabeculectomy by the glaucoma specialist (57.6%) and higher surgical trainee (42.4%) with close scrubbed supervision.

RESULTS

Compared to the NST, the waiting time for surgery (<3 months) was significantly less in the SESTS (P<0.001). There was also significantly more use of intraoperative antimetabolites (P<0.01), bleb intervention (P<0.001), and a higher rate of early complications (P<0.025). There was no significant difference in outcome at intraocular pressure (IOP)<2/3 listing IOP (qualified and unqualified) between the SESTS and the NST. Significantly, more patients achieved an unqualified success of IOP<21 mmHg (P<0.01) and an unqualified success of IOP<16 mmHg in the SESTS than the NST (P<0.05). At 1 year post surgery, visual loss of greater than one Snellen line was more common in the NST (P<0.01) as was the use of anti-glaucoma medication (P<0.001). Trainee cases returned to theatre more frequently (P<0.025) and merited more bleb intervention (P<0.01) than consultant cases, but the long-term outcome was similar.

CONCLUSION

Our study highlights significant changes in the practice and outcome of trabeculectomy compared to the national survey conducted a decade ago.

Comparative evaluation of diode laser trabeculoplasty vs frequency doubled Nd : YAG laser trabeculoplasty in primary open angle glaucoma

AIMS

To evaluate the efficacy of diode laser trabeculoplasty (DLT) and frequency doubled Nd : YAG laser trabeculoplasty (YLT) in primary open angle glaucoma (POAG).

METHODS

A total of 52 eyes of 35 patients with POAG were included. In all, 25 eyes underwent DLT (Group I) and 27 eyes underwent YLT (Group II). IOP, gonioscopy and visual fields were evaluated before and 3, 6, and 9 months and 1 year after the laser. An IOP<21 mmHg without medications or a decrease in the number of glaucoma medications with no progression of disc and field changes was considered a success.

RESULTS

The mean age of patients in Group I was 57.72+/-8.1 years and the patients in Group II had a mean age of 59.85+/-7.76 years. The mean prelaser IOP was 24.93+/-1.49 mmHg and 25.36+/-1.57 mmHg. The mean IOP after DLT at 12 months follow-up was 18.0+/-0.93 mmHg and after YLT was 18.6+/-1.52 mmHg. The reduction of IOP was statistically significant in both the groups at 3, 6, 9, and 12 months (P<0.001), however there was no significant difference between the two groups. Success rates in both groups were similar, 92% in Group I and 92.6% in Group II.

CONCLUSIONS

DLT and Fd YLT are equally effective in controlling IOP in eyes with POAG.

High Failure Rate Associated With 180?? Selective Laser Trabeculoplasty

PURPOSE

To determine the efficacy of selective laser trabeculoplasty (SLT) in a tertiary care referral center.

PATIENTS AND METHODS

In this retrospective study of selective laser trabeculoplasty performed by five physicians, 94 eyes from 94 patients were included. A majority (83/92, 90%) underwent 180 degrees selective laser trabeculoplasty. Selective laser trabeculoplasty failure was defined in two ways: (1) IOP decrease <3 mm Hg (definition one), or (2) IOP decrease <20% (definition two), on two successive visits > or =4 weeks after SLT.

RESULTS

Overall failure rates were 68% (64/94) and 75% (70/94) (by definitions one and two, respectively). By survival/life-table analysis, mean time to failure was 6 months and 5.5 months, by definitions one and two, respectively. By the end of the study (14.5 months), the failure rates were 86% and 92% by definitions one and two, respectively. By each definition, in both univariable and multivariable analysis, only lower baseline IOP was a significant predictor of failure.

CONCLUSIONS

Selective laser trabeculoplasty had an overall low success rate in our tertiary clinic population, with overall failure rates of 68% to 74% in those who underwent 180 degrees selective laser trabeculoplasty.

Intraocular pressure changes in the contralateral eye after trabeculectomy with mitomycin C

AIM

To assess intraocular pressure (IOP) changes of the contralateral eyes of eyes undergoing trabeculectomy with mitomycin C (MMC).

METHODS

Non-comparative retrospective study of 24 consecutive patients who underwent trabeculectomy with MMC that led to more than 45% reduction in IOP. In the contralateral eyes, IOP before surgery was compared with IOP 1 day and 1 month after surgery. 11 fellow eyes were under topical hypotensive therapy while 13 contralateral eyes were not (12 contralateral eyes had previous filtering surgery and one had normal tension glaucoma). No patients had systemic ocular hypotensive therapy.

RESULTS

Mean IOP in all contralateral eyes decreased from 15.5 (SD 5.5) mm Hg to 12.5 (3.8) mm Hg (p<0.01), and 13.0 (4.7) mm Hg (p<0.001) 1 day and 1 month after surgery, respectively. In the 11 fellow eyes under topical ocular hypotensive therapy mean IOP was reduced from 19.5 (4.0) mm Hg to 13.5 (2.2) mm Hg (p<0.01), and 16.5 (2.8) mm Hg (p<0.05) 1 day and 1 month after surgery, respectively. In the 13 fellow eyes not under topical ocular hypotensive therapy mean IOP was reduced from 12.1 (4.2) mm Hg to 11.6 (4.7) mm Hg (p not significant) and 9.8 (3.8) mm Hg (p0.01) 1 day and 1 month after surgery, respectively.

CONCLUSIONS

In the present population, a month after trabeculectomy, mean IOP in the contralateral eyes decreased independently of whether these contralateral eyes were undergoing topical ocular hypotensive therapy or not.

Variations in treatment among adult-onset open-angle glaucoma patients

OBJECTIVE

To determine the predictors of treatment for glaucoma and suspect glaucoma in a nationally representative sample of diagnosed persons.

DESIGN

Retrospective cohort study of persons enrolled in a large managed care organization.

PARTICIPANTS

Thirty-five thousand seven hundred fifty-four diagnosed suspects, 5265 diagnosed glaucoma persons, and 2633 individuals coded as having cupping of the optic disc.

METHODS

Linked pharmacy and patient care information were used to examine the predictors of initiating glaucoma treatment in this cohort of persons insured by a single managed care organization. Predictors entered into logistic regression models included diagnostic group (suspect vs. diagnosed), age group, gender, region of the country, provider type at the initial visit (optometrist or ophthalmologist), diagnosis index date divided into 2 periods (1995-1998 and 1999-2001), and health plan enrollment duration after the initial diagnosis.

MAIN OUTCOME MEASURES

Occurrence of and factors associated with treatment for glaucoma (argon laser trabeculoplasty [ALT], surgery, or topical ocular hypotensives).

RESULTS

A logistic regression model adjusting for glaucoma status, age, region, clinician seen at initial visit, and index date found that women were less likely to undergo treatment (topical ocular hypotensives, ALT, or surgery) than men (odds ratio, 0.76; 95% confidence interval, 0.71-0.80). Factors other than gender that were associated with greater likelihood of treatment were glaucoma diagnosis, older age, region, and longer follow-up.

CONCLUSIONS

We have documented wide variation in treatment among individuals diagnosed as having glaucoma or as glaucoma suspects. Women were 24% less likely to be treated than men, and younger individuals were far less likely to be treated than older ones. Furthermore, treatment varied by region of the country. Understanding the sources of these variations will help in determining how to arrive at better management strategies for individuals with glaucoma and suspect glaucoma.

Treatment and vision-related quality of life in the early manifest glaucoma trial

PURPOSE

To evaluate the effect of treatment, visual function, and other factors on vision-targeted health-related quality of life (HRQOL) of patients with early glaucoma.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Two hundred fifty-five patients with newly detected open-angle glaucoma and repeatable early visual field (VF) defects, 50 to 80 years old (66% female).

METHODS

Patients were randomized to receive either betaxolol plus laser trabeculoplasty in eligible eye(s) or no initial treatment and had ophthalmologic examinations every 3 months. A Swedish translation of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was self-administered at 2 follow-up visits (3 and 6 years after randomization).

MAIN OUTCOME

Multiple linear regression analyses determined the effect of treatment and other factors on (1) VFQ-25 composite scores at the first administration and (2) change in scores between administrations.

RESULTS

Two hundred thirty-three patients had 1 NEI VFQ-25 administration and 167 patients had 2 administrations. Internal consistency reliability was high for the composite VFQ-25 score (Cronbach alpha = 0.88) and satisfactory (alpha> or =0.76) for most subscale scores. At the first administration, the composite score was high (88.8+/-11.7). Mean subscale scores were also generally high (98.0-58.3) and were similar for each study group when analyzed separately. Most lower subscale scores were modestly but significantly related to worse visual acuity (VA) or mean deviation (MD) (better eye, r = 0.15-0.35). Composite scores were similar for treated and untreated patients. Lower composite scores were associated with low VA in the better eye (worse than 0.70) and worse perimetric MD (<4.16 decibels) and nuclear lens opacities (Lens Opacities Classification System II grade > or = 2), but not with age, gender, VF progression, intraocular pressure, cardiovascular disease, or hypertension. Between VFQ-25 administrations, larger decreases in the composite score were associated with larger decreases in VA (P<0.05), female gender (P = 0.001), and older age at first administration (P = 0.006). Treatment (assigned at randomization or later in the study) was not associated with change in HRQOL.

CONCLUSIONS

Results suggest that absence or delay of treatment did not influence vision-targeted HRQOL in these newly diagnosed glaucoma patients. However, visual function affected vision-targeted quality of life up to 6 years after Early Manifest Glaucoma Trial enrollment.

Glaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan

OBJECTIVE

To determine the management patterns for glaucoma and suspect glaucoma in a nationally representative sample of newly treated persons.

DESIGN

Retrospective cohort study of persons enrolled in a large managed care organization.

PARTICIPANTS

One thousand seven hundred twelve diagnosed suspects and 3623 diagnosed glaucoma patients.

METHODS

Linked pharmacy and patient care data were used to examine the glaucoma management and treatment patterns in this cohort of persons insured by a single managed care organization. Rates of monitoring and treatment were calculated for the 3 study groups.

MAIN OUTCOME MEASURES

Probability of monitoring (return visits, visual fields [VFs], and optic nerve head imaging or photography) and treatment (argon laser trabeculoplasty [ALT] and surgery) for newly treated persons with suspect and glaucoma diagnoses.

RESULTS

After a median follow-up of 440 days, 83% of treated diagnosed suspects had had a billed follow-up office visit to either an optometrist or an ophthalmologist at any time during follow-up, 46% had had at least one billed VF, and 13% had had some form of optic nerve head imaging. Rates were slightly higher for those with diagnosed glaucoma (P>0.05). Surgery and ALT were performed rarely in this treated population (1%-6% at 2 years).

CONCLUSIONS

This study suggests that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are falling out of care and are being monitored at rates lower than expected from recommendations of published guidelines. More research is needed to confirm these findings and to determine the reasons for loss to follow-up and low monitoring rates.

Combined clear corneal phacoemulsification and ab interno trabeculectomy: Three-year case series

PURPOSE

To evaluate the efficacy and safety of a novel surgical approach, ab interno trabeculectomy, in a combined procedure (clear corneal phacoemulsification + ab interno trabeculectomy) for the management of concurrent cataract and glaucoma with prognostic factors for filtration failure.

SETTING

Department of Ophthalmology, Palmanova Hospital, Udine, Italy.

METHODS

A prospective noncomparative case series of 11 eyes of 11 consecutive cataract patients with medically uncontrolled primary open-angle glaucoma or pseudoexfoliation glaucoma was performed. Each patient had phacoemulsification + intraocular lens implantation + ab interno trabeculectomy, which consisted of a gonioscopically controlled ab interno removal of a quadrant (3 clock hours) of the trabecular meshwork. The main outcome measures were intraocular pressure (IOP), the number of antiglaucomatous medications used, and complications.

RESULTS

Ten patients completed a 3-year follow-up. One patient had further surgery because of poor IOP control; in this case, the last valid observation was carried forward for IOP calculation. Mean preoperative IOP and IOPs measured 1, 3, 6, 12, 24, and 36 months after surgery were 25.0, 15.8, 15.4, 15.4, 15.2, 15.0, and 15.3 (-38.56%) mm Hg respectively. The number of medications averaged 2.4 before surgery and dropped to 0.8 at the end of follow-up. No major complications occurred during the follow-up period.

CONCLUSIONS

The new surgical procedure combining phacoemulsification with ab interno trabeculectomy can induce a clinically relevant decrease in IOP in eyes with cataract and glaucoma with poor prognosis for filtering surgery. However, a randomized controlled clinical trial with a more extended follow-up and a larger series of patients is needed to ascertain the actual effectiveness and safety of this procedure.