Primary Open-Angle Glaucoma Preferred Practice Pattern®

Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US

BACKGROUND

Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions.

METHODS

A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing.

RESULTS

Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases.

CONCLUSIONS

We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Genetics and Glaucoma: the state of the art

Glaucoma is the second leading cause of irreversible blindness worldwide. Although genetic background contributes differently to rare early-onset glaucoma (before age 40) or common adult-onset glaucoma, it is now considered an important factor in all major forms of the disease. Genetic and genomic studies, including GWAS, are contributing to identifying novel loci associated with glaucoma or to endophenotypes across ancestries to enrich the knowledge about glaucoma genetic susceptibility. Moreover, new high-throughput functional genomics contributes to defining the relevance of genetic results in the biological pathways and processes involved in glaucoma pathogenesis. Such studies are expected to advance significantly our understanding of glaucoma's genetic basis and provide new druggable targets to treat glaucoma. This review gives an overview of the role of genetics in the pathogenesis or risk of glaucoma.

Five-Year Outcomes of Single Trabecular Microbypass Stent (iStent®) Implantation with Phacoemulsification in Korean Patients

INTRODUCTION

This study reports the long-term intraocular pressure (IOP)-lowering efficacy and safety of a single trabecular microbypass stent (iStent®; Glaukos Corp., San Clemente, CA, USA) for medically controlled open-angle glaucoma in Korean patients.

METHODS

This retrospective observational study included 42 eyes of 35 patients with primary open-angle glaucoma (POAG). All subjects underwent single first-generation iStent® implantation with phacoemulsification by a single surgeon with 5 years follow-up. The primary outcomes were changes in IOP and the number of antiglaucoma medications compared to the preoperative values. The secondary outcome was the proportion of eyes with IOP ≤ 18 mmHg without medication, ≤ 15 mmHg without medication, and ≤ 18 mmHg with or without medication. Adverse events and need for secondary glaucoma surgery were also recorded.

RESULTS

The mean IOP decreased from 15.8 ± 2.8 to 13.8 ± 1.7 mmHg and the mean number of medications was reduced from 2.24 ± 1.18 to 0.83 ± 1.12, respectively, at year 5. At 3 and 5 years, 80.6% and 78.6% of eyes, respectively, were receiving fewer medications than preoperative numbers. In contrast, only 50% of eyes on four preoperative medications showed medication reductions at 5 years. At years 3 and 5, 61.3% and 53.5% of eyes achieved IOP ≤ 18 mmHg without medication, whereas 90.3% and 89.3% of eyes achieved ≤ 18 mmHg regardless of medication use, respectively. Four eyes required additional glaucoma surgery (two Ahmed glaucoma valve implantations, one trabeculectomy, and one XEN 45 Gel Stent implantation), and all were receiving four preoperative antiglaucoma medications. Transient IOP elevation (14.3%) was the most common complication, followed by five hyphema, one stent obstruction, one stent malposition, and one severe anterior chamber reaction.

CONCLUSION

This study demonstrated a good safety profile and sustained IOP reduction after the implantation of a single trabecular microbypass stent (iStent®) with phacoemulsification in Korean patients. The majority of subjects with POAG showed a relatively good response; however, eyes receiving a higher number of medications preoperatively (especially four medications) had difficulty achieving a low target IOP.

Evaluation of Publications from the American Academy of Ophthalmology: A 5-Year Analysis of Ophthalmology Literature

Objective

To analyze recent publications in Ophthalmology, the journal of the American Academy of Ophthalmology.

Design

Retrospective review of published articles.

Participants

No human participants were involved in the study.

Methods

Articles published in Ophthalmology from January 2018 to December 2022 were reviewed and analyzed.

Main Outcome Measures

Research and review articles were included and analyzed per the following: total number of published articles based on related subspecialty area, level of evidence using the modified Oxford level of evidence, number of citations, number of listed authors, gender of the corresponding author, country of affiliation of the corresponding and contributing author(s), and involvement of consortium(s), group(s), or committee(s).

Results

A total of 965 articles were included. The mean (standard deviation) number of authors per article was 8.6 (5.7) and the majority of corresponding authors were male (665, 70.7%). The greatest number of published articles were related to retina (296, 30.7%) followed by glaucoma (172, 17.8%). The greatest number of Preferred Practice Pattern guidelines were also related to retina (7/24, 29.1%), followed by cornea/dry eye syndrome/external disease (6/24, 25%). Retina (77) had the most level 1 evidence, glaucoma (30) for level 2 evidence, and retina for levels 3 (69) and 4 (65). There were 223 articles contributed by consortia/groups/committees, with most from retina (73, 32.7%) followed by glaucoma (40, 17.9%). The mean number of citations per subspecialty article was highest in retina (45.8/article), followed by uveitis (31.7/article). The United States had the greatest number of affiliated corresponding authors (544, 56.4%), followed by the United Kingdom (68, 7.0%). There were 357 (37.0%) articles with coauthors affiliated outside the corresponding author's country of affiliation, although with a downward trend over the most recent 5-year period. There has been an increasing trend in the number of authors and consortia/group/committee involvement in publications.

Conclusions

Although team science and collaborations have increased recently, ongoing efforts to diversify individuals, groups, and subspecialties may be needed.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical Efficacy of Omidenepag Isopropyl for Primary Open-Angle Glaucoma, Normal Tension Glaucoma, or Ocular Hypertension: A Meta-Analysis

Purpose: To investigate the clinical efficacy of omidenepag isopropyl (OMDI) among glaucoma patients in terms of increased intraocular pressure (IOP) changes through a meta-analysis. Methods: Studies investigating the clinical efficacy of OMDI toward glaucoma patients were systemically searched. Inclusion criteria include recruiting studies that consisted of glaucoma or normal tension glaucoma patients who received OMDI treatment at least 4 weeks in duration. The primary outcome was to compare changes in IOP levels at baseline before OMDI treatment and after OMDI treatment. Results: Six studies were included with a total of 358 eyes. Our results showed OMDI monotherapy resulted in significant decreased IOP among patients with ocular hypertension, with weighted mean difference post-OMDI treatment being -4.684 (95% confidence interval: -6.010 to -3.358) and I2 of 91.092%. Separate subgroup analyses also showed initial IOP greater than 21 mmHg and those within the age group greater than 65 years old to be correlated with significant reduction in IOP post-OMDI. Randomized control trial (RCTs) design was also found to be superior compared with non-RCT in terms of investigating IOP changes after OMDI. The country of origin of the recruited studies and OMDI dosage frequencies were also found to have no effect on overall IOP changes after OMDI treatment. Conclusions: The current meta-analysis indicates OMDI to be a clinically effective treatment for glaucoma patients in terms of lowering IOP levels.

High Myopia Normative Database of Peripapillary Retinal Nerve Fiber Layer Thickness to Detect Myopic Glaucoma in a Chinese Population

PURPOSE

To develop and validate the performance of a high myopia (HM)-specific normative database of peripapillary retinal nerve fiber layer (pRNFL) thickness in differentiating HM from highly myopic glaucoma (HMG).

DESIGN

Cross-sectional multicenter study.

PARTICIPANTS

A total of 1367 Chinese participants (2325 eyes) with nonpathologic HM or HMG were included from 4 centers. After quality control, 1108 eyes from 694 participants with HM were included in the normative database; 459 eyes from 408 participants (323 eyes with HM and 136 eyes with HMG) and 322 eyes from 197 participants (131 eyes with HM and 191 eyes with HMG) were included in the internal and external validation sets, respectively. Only HMG eyes with an intraocular pressure > 21 mmHg were included.

METHODS

The pRNFL thickness was measured with swept-source (SS) OCT. Four strategies of pRNFL-specified values were examined, including global and quadrantic pRNFL thickness below the lowest fifth or the lowest first percentile of the normative database.

MAIN OUTCOMES MEASURES

The accuracy, sensitivity, and specificity of the HM-specific normative database for detecting HMG.

RESULTS

Setting the fifth percentile of the global pRNFL thickness as the threshold, using the HM-specific normative database, we achieved an accuracy of 0.93 (95% confidence interval [CI], 0.90-0.95) and 0.85 (95% CI, 0.81-0.89), and, using the first percentile as the threshold, we acheived an accuracy of 0.85 (95% CI, 0.81-0.88) and 0.70 (95% CI, 0.65-0.75) in detecting HMG in the internal and external validation sets, respectively. The fifth percentile of the global pRNFL thickness achieved high sensitivities of 0.75 (95% CI, 0.67-0.82) and 0.75 (95% CI, 0.68-0.81) and specificities of 1.00 (95% CI, 0.99-1.00) and 1.00 (95% CI, 0.97-1.00) in the internal and external validation datasets, respectively. Compared with the built-in database of the OCT device, the HM-specific normative database showed a higher sensitivity and specificity than the corresponding pRNFL thickness below the fifth or first percentile (P < 0.001 for all).

CONCLUSIONS

The HM-specific normative database is more capable of detecting HMG eyes than the SS OCT built-in database, which may be an effective tool for differential diagnosis between HMG and HM.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Influence of Goniotomy Size on Treatment Safety and Efficacy for Primary Open-Angle Glaucoma: A Multicenter Study

PURPOSE

To compare the efficacy and safety of 120-, 240-, and 360-degree goniotomy (GT) with or without phacoemulsification with intraocular lens implantation (PEI) for patients with primary open-angle glaucoma (POAG).

DESIGN

Multicenter, retrospective, comparative, nonrandomized interventional study.

METHODS

Patients diagnosed with POAG who underwent GT with or without PEI were included, and divided into 6 groups: 1) standalone 120-degree GT (120GT); 2) standalone 240-degree GT (240GT); 3) standalone 360-degree GT (360GT); 4) PEI + 120GT; 5) PEI + 240GT; and 6) PEI + 360GT. Data on intraocular pressure (IOP), the number of ocular hypotensive medications, and complications were collected and compared. Success was defined as a postoperative IOP within the range of 6 to 18 mm Hg and a 20% reduction from baseline without further glaucoma surgery. Complete success and qualified success were defined as the above without and with ocular hypotensive medications, respectively.

RESULTS

Three hundred eight eyes of 231 patients were included with a mean follow-up of 14.4 ± 8.6 months (6.0-48.0 months). There were no significant differences in the reductions in IOP and number of medications and cumulative survival probability for complete and qualified success rates among the 3 groups of standalone GT and PEI + GT. The 360GT group had the highest proportion of hyphema with or without PEI.

CONCLUSIONS

120GT, 240GT, and 360GT with or without PEI showed similar efficacy in reducing IOP and medications used in POAG. 360GT with or without PEI was more likely to cause hyphema compared with 120GT or 240GT. 120GT with or without PEI was sufficient for treating POAG with or without cataract..

Additive effects of brimonidine tartrate 0.1%/brinzolamide 1% fixed-dose combination in prostaglandin analog-treated Japanese glaucoma patients

PURPOSE

A brimonidine tartrate 0.1%/brinzolamide 1% fixed-dose combination (BBFC) was recently approved for glaucoma and ocular hypertension treatment in Japan. We investigated the efficacy and safety of BBFC used concomitantly with prostaglandin analogs (PG) or a PG/beta-blocker fixed-dose combination (PG/beta FC).

STUDY DESIGN

This was a prospective, open-label, multicenter study.

PATIENTS AND METHODS

We enrolled Japanese patients with open-angle glaucoma. BBFC (Ailamide) was concomitantly administered to either the PG or the PG/beta FC group, and intraocular pressure (IOP) and safety were evaluated at 4 and 12 weeks. The groups were stratified into low and high IOP baseline groups based on the median baseline IOP.

RESULTS

We enrolled 100 patients, 91 of whom completed the 12-week follow-up. The mean ages were 67.1 and 65.7 years in the PG group (n = 45, baseline IOP of 15.7 ± 2.3 mmHg) and the PG/beta FC group (n = 46, baseline IOP of 16.3 ± 2.3 mmHg), respectively. After BBFC administration, IOPs at 4 and 12 weeks were 13.0 ± 2.0 and 13.0 ± 2.6 mmHg (P < 0.0001) in the PG group, respectively, and 13.7 ± 2.4 and 13.7 ± 2.2 mmHg (P < 0.0001) in the PG/beta FC group, respectively. IOP decreased by - 2.0 ± 1.8 mmHg (P < 0.0001) and -1.9 ± 1.4 mmHg (P < 0.0001) in the low baseline PG group (14.1 mmHg) and low baseline PG/beta FC group (14.8 mmHg) at 12 weeks, respectively. Sixteen adverse events were identified, all of which were common and did not affect visual acuity.

CONCLUSIONS

BBFC can be used concomitantly with PG or PG/beta FC to reduce IOP without serious complications.

Participant Experience Using Novel Perimetry Tests to Monitor Glaucoma Progression

PRCIS

Participant surveys taken after using tablet-based and smart visual function analyzer (SVFA) perimetry tests suggest that patients may prefer novel perimetry tests over traditional visual field machines.

PURPOSE

Compare patient experience using the IMOvifa SVFA and the tablet-based Melbourne Rapid Fields visual field (VF) tests to the Humphrey Field 24-2 Swedish Interactive Threshold Algorithm Standard.

PATIENTS AND METHODS

Prospective observational cohort study on adult participants with diagnoses of glaucoma suspect, ocular hypertension, or glaucoma. Participants attended 2 study visits ~3 months apart. During the first visit, participants were trained to use the 2 novel perimeters, took 1 test on both new devices and the Humphrey Field Analyzer, then were surveyed. Participants received tablets and performed weekly tablet VF tests at home between study visits. At the final study visit, participants re-took the VF tests and completed the same surveys.

RESULTS

Eighty-one participants were surveyed twice. At the baseline survey, participants preferred the SVFA (71.7%) and tablet tests (69.2%) over the Humphrey VF. Most were willing to perform weekly monitoring at home on the SVFA (69.1%) and tablet (75.4%). Participants generally had a "very good" overall experience when testing on the SVFA (71.6%) and tablet (90.1%). At the final visit, fewer participants were willing to test on the tablet daily (23.5% to 9.9%; P = 0.02 for change) and more were willing to test monthly (18.5% to 33.3%; P = 0.03 for change).

CONCLUSION

Users reported a preference for novel VF devices. Overall participant experience using these devices was positive, supporting the feasibility of home monitoring of VFs from an experience perspective.

XEN 45 Gel Stent Implantation in Open Angle Glaucoma: 5-Year Results of a Prospective Study

PRCIS

XEN 45 Gel Stent is safe and effective for 3 years. The study results provide useful insight into the outcome of XEN 45 Gel Stent surgery over 5 years in daily clinical practice.

PURPOSE

To evaluate 5-year outcomes of XEN 45 gel stent implantation (XEN) in patients with open angle glaucoma.

METHODS

This is a prospective, single-center, interventional study. XEN implantation either alone (XEN) or combined with phacoemulsification (Phaco + XEN) was performed on 170 consecutive eyes (126 patients) with uncontrolled intraocular pressure (IOP) or disease progression despite medical treatment. "Complete" surgical success at 60 months was defined as unmedicated IOP ≤15 mm Hg and a relative IOP reduction ≥20% from medicated baseline, while "qualified" success allowed fewer ocular hypotensive medications than at baseline. Other definitions of success with various IOP targets were also analyzed. Secondary outcomes included mean IOP and IOP-lowering medication changes and rates of reoperations.

RESULTS

Mean age was 78.1±9.2 years, and 70.3% were female. Mean medicated IOP decreased from 19.8±7.7 mm Hg [19.6±7.1 (XEN) vs. 19.8±7.0 mm Hg (Phaco+XEN)] at baseline to 12.6±3.1 mm Hg [12.5± 3.1 (XEN) vs. 12.6±3.1 (Phaco+XEN)] at 5 years (-37.0%; P < 0.001). Medications decreased from 2.0±1.3 [2.0±1.3 (XEN) vs. 2.0±1.3 (Phaco+XEN)] to 0.8±1.1 [0.8±1.1 (XEN) vs. 0.8±1.1 (Phaco + XEN)] (-60%; P <0.001). Needling was performed in 84 eyes (49%), and 19.4% underwent a secondary surgical intervention. Complete success at 3 years was a strong predictor of success at 5 years (odds ratio: 3.06, P <0.01), while needling was associated with higher rates of failure (odds ratio: 3.6, P <0.01).

CONCLUSIONS

At 5 years, XEN gel stent implantation was a safe procedure and achieved clinically meaningful IOP and medication reduction. Success at 3 years is a predictor of success at 5 years. Needling correlates with higher failure rates.

Factors Associated with Topical Medication Instillation Failure in Glaucoma: VRAMS-QPiG Study

INTRODUCTION

To report eyedrop instillation techniques and factors associated with instillation failure among glaucoma subjects in the Video-Recorded Assessment of Medication Skill and Questionnaire-based evaluation of Perception in Glaucoma Study.

METHODS

In this cross-sectional observational study, subjects were 60 patients with glaucoma (mean ± standard deviation age, 68.4 ± 11.3 years; 30 men) who required ocular hypotensive medication(s). Subjects completed ophthalmologic examinations and the Mini-Cog cognitive function test; their typical eyedrop instillation technique was video-recorded. Subjects rated their technique as successes/failures by questionnaire and two examiners rated the successes/failures based on video assessment. Discrepancy between self-reported and video-assessed success/failure rates of instillation was the main outcome measures. Multivariate logistic regression identified factors in instillation failure.

RESULTS

Of 48/56 (86%) self-reported successes, 27/48 (56%) failed based on video assessment; as a result, 32/56 (57%) were inconsistent between subjective and objective assessments. Overall, 30/56 (54%) failed based on video assessment. In the subject-based data model, older age [odds ratio (OR) 0.93/year, P = 0.025] and lower cognitive function score (OR 2.7/score, P = 0.025) were factors in failed instillations. In the eye-based data model, less myopic objective refractive error (OR 0.77/diopter, P = 0.016) and lower visual field foveal threshold (OR 1.1/decibel, P = 0.041) were factors in failures.

CONCLUSION

In addition to older age, decreased cognitive function, hyperopia, and decreased foveal sensitivity are risks for failed eyedrop instillation. Treating physicians can screen patients who require guidance by checking the risk factors of instillation failure rather than by relying on patient reports.

Safety and Efficacy of Goniotomy following Failed Surgery for Glaucoma

PRCIS

Goniotomy (GT) is an alternative surgery for patients with prior failed surgery for glaucoma.

PURPOSE

To evaluate the efficacy and safety of GT in patients with prior failed surgery for glaucoma.

MATERIALS AND METHODS

A prospective, observational multicentered study was performed for patients who underwent GT with prior single or multiple surgery for glaucoma. Outcome measures included intraocular pressure (IOP) change, best-corrected visual acuity change, ocular hypotensive medication use, and occurrence of adverse events through 12 months. Complete success was defined as a postoperative IOP within 6-18 mmHg and a 20% reduction from baseline without ocular hypotensive medications. Qualified success was the same as the definition of complete success, except for postoperative use of medication. Logistic regression models were used to investigate the potential factors for surgical success.

RESULTS

A total of 38 eyes of 34 patients were included. Twenty-three eyes had only 1 prior surgery, 13 eyes had 2 prior surgeries, 1 eye had 3 prior surgeries, and 1 eye had 4 prior surgeries. At month 12, there was complete success in 42.1% of the eyes and qualified success in 78.9% of the eyes. Preoperatively, the mean IOP was 29.4±6.9 mmHg and the median number of glaucoma medications used was 3.0 (2.0, 4.0); this decreased to 16.7±3.6 mmHg (43.2% reduction; P <0.001) and 2.0 (0.0, 3.0) ( P <0.001) at month 12, respectively. The most common complications included hyphema (13.2%), IOP spike (7.9%), and corneal edema (5.2%). Older age significantly contributed to surgical success.

CONCLUSIONS

GT seems to be a safe and effective procedure for patients with prior failed surgery for glaucoma.

Treatment of Diabetic Macular Edema or Macular Edema Following Retinal Vein Occlusion Based on Repeated Injection of the Dexamethasone Intravitreal Implant: A Retrospective Real-World Analysis

Purpose

To assess the "real world" utility of repeated injection with the dexamethasone intravitreal implant (DEX) in routine practice.

Methods

This was a retrospective, single-center analysis of consecutive patients with diabetic macular edema, or macular edema following retinal vein occlusion, treated with DEX. None had received prior intravitreal steroid treatment. DEX was implanted as per the manufacturer's instructions.

Results

Seventy-eight individuals (95 eyes) were included (50.0% female; mean age: 68.1 ± 12.4 years; mean duration of macular edema: 13.2 ± 12.9 months). Thirty-three eyes (34.7%) had received previous treatment with an anti-vascular endothelial growth factor (anti-VEGF) and/or laser. Thirty eyes (31.6%) underwent one round of DEX implantation; the remainder received 2-5 cycles (total: 225 cycles). Initial DEX treatment led to significant increases in visual acuity (VA) at 6 weeks (mean change: 4.6 letters; P=0.004). Greater VA improvements during the first treatment cycle were associated with inferior baseline VA (P=0.02), borderline associated with baseline central macular thickness (CMT; P=0.06), and independent of prior anti-VEGF treatment (P=0.39). In an analysis of all DEX injections, VA improvements were robust across cycles 1 and 2 but reduced in cycle 3 (P=0.03). CMT improvements did not differ based on injection number (P=0.20). Increases in intraocular pressure (IOP) were largest over the first 6 weeks (but rebounded towards baseline more rapidly) in cycle 1 versus cycles 2 and 3 (P<0.001). IOP rises were typically manageable with topical medications.

Conclusion

This analysis confirms the broad utility of DEX and may inform decision-making in routine practice.

Phase 3, Randomized Study Comparing Intracameral Bimatoprost Implant 15 µg and Selective Laser Trabeculectomy in Patients with Open-Angle Glaucoma or Ocular Hypertension

Purpose

We evaluate the safety and intraocular pressure (IOP)-lowering effect of 15-µg bimatoprost implant (higher dose than the currently approved product) compared with selective laser trabeculoplasty (SLT) in patients with open-angle glaucoma or ocular hypertension.

Methods

Randomized, phase 3, 12-month, multicenter, paired-eye, patient- and efficacy evaluator-masked noninferiority study. Patients with inadequate IOP control were randomized to receive 360° SLT (day 1) or up to 3 administrations of 15-µg bimatoprost implant (day 4, weeks 16 and 32) in the primary eye and the alternative treatment in the contralateral eye. The primary endpoint was IOP change from baseline at weeks 4, 12, and 24.

Results

At weeks 4, 12, and 24, mean IOP change from baseline ranged from -7.01 to -6.65 mm Hg in implant-treated eyes (N=138) and -6.45 to -6.26 mm Hg in SLT-treated eyes (N=138). Differences in IOP change from baseline ranged from -0.70 to -0.25 mm Hg favoring implant; the upper limit of the 95% confidence interval of the difference (implant minus SLT) was <1.0 mm Hg at all 3 visits. The probability of requiring no additional (rescue) IOP-lowering treatment in implant-treated versus SLT-treated eyes was 93.6% versus 86.5% at day 180 and 74.6% versus 77.1% at day 360. Corneal endothelial cell loss was more common in implant-treated eyes and typically occurred after repeated implant administration.

Conclusion

Bimatoprost implant 15 µg met prespecified criteria for statistical and clinical noninferiority to SLT in lowering IOP, and after 1, 2, or 3 administrations, demonstrated a duration of IOP lowering similar to SLT. Bimatoprost implant 15 µg was associated with corneal adverse events in some patients, especially after repeated administrations at a fixed interval, and has been discontinued from development. A lower dose strength of implant (bimatoprost implant 10 µg, Durysta) is US Food and Drug Administration-approved for single administration.

Adherence to visual field examination in glaucoma patients during the Coronavirus disease 2019 outbreak

We described the proportion of adherence to the scheduled visual field (VF) examination and the associated factors in glaucoma patients in a tertiary referral center during the Coronavirus disease 2019 (COVID-19) outbreak in Taiwan. Patients with scheduled VF examinations during May 25th to July 12th, 2021, were retrospectively evaluated. Clinical characteristics including type of glaucoma, intraocular pressure (IOP) at the day of arranging VF examinations, prescriptions of anti-glaucoma medications, non-medical glaucoma treatment, length of glaucoma history, mean deviation (MD) of VF defect, and announcement of glaucoma progression were recorded. The associations between the adherence and the clinical factors were analyzed by univariate and multivariate logistic regression. There were 204 patients included, of which 37 patients (18.14%) adhered to VF examinations. A total of 161 patients (78.9%) were diagnosed with open-angle glaucoma (OAG), 27 patients (13.2%) with angle closure glaucoma, and 16 patients (7.8%) with glaucoma suspect. Most of the participants (41.2%) had mild VF defect and had been prescribed with no more than 1 bottle of anti-glaucoma medication. In the multivariate analysis, diagnosis of glaucoma suspect (P = .02) and history of SLT (P = .04) were significantly associated with better adherence. Glaucoma severity and the announcement of glaucoma progression were not significantly associated with adherence to VF examination. The COVID-19 pandemic had greatly influenced the adherence to VF examination in glaucoma patients. This study demonstrated that patients with the diagnosis of glaucoma suspect and history of SLT were more likely to adhere to VF examinations even during the COVID-19 pandemic.

Comparing Outcomes of Phacoemulsification and Endocyclophotocoagulation with Either Dual Blade Goniotomy (PEcK) or Two Trabecular Stents (ICE2)

Purpose

To compare outcomes of phacoemulsification and endocyclophotocoagulation with either dual blade goniotomy (PEcK) or two trabecular stents (ICE2).

Setting

Retrospective, nonrandomized comparative study from a level 3 triage center.

Methods

One hundred and seventy charts and a total of 1294 visits were reviewed following either PEcK or ICE2 from 2018 to 2022. One hundred and twenty-eight patients had PEcK and 42 underwent ICE2. Patients with less than 30 days of follow-up were excluded. The mean follow-up time was 505 ± 308 days. Two Kaplan-Meier curves (KM) assessed survival with ≤ baseline medications while maintaining (1) [GIC - Goal IOP Criteria] IOP ≤ goal IOP or (2) [PRC - Percent Reduction Criteria] IOP reduction ≥ 20% with 5 mmHg ≤ IOP ≤ 21 mmHg for at least two consecutive visits. IOP and medication burden reduction were compared using a paired t-test.

Results

Most patients were Caucasian (65%) and had mild-stage glaucoma (43%). The most common glaucoma type was primary open-angle glaucoma (58%). Average age was 72.2 years at the time of surgery. Mean preoperative IOP was 17.58 ± 4.98 mmHg on 3.00 ± 1.41 medications in PEcK and 15.36 ± 3.58 mmHg on 1.81 ± 1.11 medications in ICE2 (p = 0.015 for IOP; p < 0.001 for medications). Under GIC, the success rate was significantly higher in PEcK at POM6 (69% vs 46%, p < 0.001) and POY1 (63% vs 36%, p < 0.001). Under PRC, the success rate was significantly higher in PEcK at POM6 (73% vs 61%, p = 0.031) and POY1 (67% vs 50%, p = 0.028). Mean reductions at POY1 were 5.00 ± 4.31 mmHg on 1.35 ± 1.08 less medications after PEcK and 3.14 ± 2.83 mmHg on 1.01 ± 0.94 less medications after ICE2 (p < 0.001 at POY1 for IOP; p < 0.05 after POW6 for medications).

Conclusion

Both PEcK and ICE2 reduce medication and IOP from baseline, with PEcK having more favorable GIC and PRC success rates and greater IOP and medication reduction at 1 year.

Quality of life in glaucoma

BACKGROUND

An essential goal of glaucoma management is to prevent a patient's visual impairment that compromises their health-related quality of life (QOL). The disease itself, in addition to the medical or surgical treatment, can have a large impact on one's life. We aim to briefly review and evaluate aspects of QOL in glaucoma.

METHODS

The PubMed database was utilized for the literature examination of this review. Keywords that were searched included glaucoma, quality of life, vision-related QOL (VRQOL), quality of life questionnaire, and glaucoma therapy.

RESULTS

The main topics identified and analyzed during the literature review stages include factors affecting VRQOL, the assessment of VRQOL using questionnaires, QOL in early and severe glaucoma, glaucoma and activities of daily living, glaucoma treatments, and new advances in clinically assessing QOL. The study findings indicate a relationship between the deterioration of visual field and the quality of life. The investigation shows that visual loss can result in a range of daily life challenges, which include compromised mental health status and difficulties with driving, reading, and recognizing people.

CONCLUSION

Glaucoma-induced visual field loss can significantly impact different aspects of patients' life, and several methods exist for evaluating changes in quality of life. Quality of life assessments have their limitations as they are subjective. As potential future steps, we suggest exploring technological advancements such as virtual reality to improve patient care and outcomes.

Technological Advances in a Therapy of Primary Open-Angle Glaucoma: Insights into Current Nanotechnologies

Glaucoma is a leading cause of irreversible blindness and is characterized by increased intraocular pressure (IOP) and progressive optic nerve damage. The current therapeutic approaches for glaucoma management, such as eye drops and oral medications, face challenges including poor bioavailability, low patient compliance, and limited efficacy. In recent years, nanotechnology has emerged as a promising approach to overcome these limitations and revolutionize glaucoma treatment. In this narrative review, we present an overview of the novel nanotechnologies employed in the treatment of primary open-angle glaucoma. Various nanosystems, including liposomes, niosomes, nanoparticles, and other nanostructured carriers, have been developed to enhance the delivery and bioavailability of antiglaucoma drugs. They offer advantages such as a high drug loading capacity, sustained release, improved corneal permeability, and targeted drug delivery to the ocular tissues. The application of nanotechnologies in glaucoma treatment represents a transformative approach that addresses the limitations of conventional therapies. However, further research is needed to optimize the formulations, evaluate long-term safety, and implement these nanotechnologies into clinical practice. With continued advancements in nanotechnology, the future holds great potential for improving the management and outcomes of glaucoma, ultimately preserving vision and improving the lives of millions affected by this debilitating disease.

Preservative-Free versus Benzalkonium Chloride-Preserved Latanoprost Ophthalmic Solution in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension: A Phase 3 US Clinical Trial

Purpose

To evaluate the safety and efficacy of a preservative-free latanoprost 0.005% formulation (T2345) in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) compared to benzalkonium chloride-preserved latanoprost 0.005% (BPL) formulation in the United States (US).

Patients and Methods

A prospective, randomized, multicenter, observer-masked, parallel-group study enrolled 335 patients diagnosed with POAG or OHT from 31 US sites who had adequately controlled intraocular pressure (IOP; ≤18 mm Hg) with latanoprost monotherapy. After a ≥72-hour washout period, patients were randomized to T2345 (n=165) or BPL (n=170) groups. Study drugs were dosed once-daily from Day 0 to Day 84 in one or both eyes. The study eye was the eye with lower IOP at baseline. The primary efficacy measure was the between-group comparison of the mean IOP values in the study eye at each time point (8 AM, 10 AM, and 4 PM on Days 15, 42, and 84). Safety measurements included ocular and systemic treatment-emergent adverse events (TEAEs).

Results

Both T2345 and BPL adequately controlled IOP with 95% CIs within 1.5 mm Hg in the study eye at all assessed time points. The percentages of patients with diurnal IOP <18 mm Hg at Day 84 were 73.1% vs 78.7% for the T2345 and BPL groups, respectively. Adverse events were generally mild-to-moderate and primarily ocular. Fewer patients in the T2345 group experienced ocular TEAEs (13.9% vs 22.5%, respectively) and TEAEs with a suspected relationship to the study medication compared with the BPL group (5.5% vs 11.8%, respectively). The most common ocular TEAEs were instillation site pain and conjunctival hyperemia.

Conclusion

In patients with POAG or OHT, both T2345 and BPL maintained IOP at or below clinically meaningful values for the duration of the study. T2345 showed a favorable safety profile, with numerically lower incidences of ocular TEAEs than BPL.

Frontloading SITA-Faster Can Increase Frequency and Reliability of Visual Field Testing at Minimal Time Cost

PURPOSE

To report the outcomes of frontloaded visual field (VF) testing (2 tests per eye on the same visit) over 2 longitudinal, consecutive visits using SITA-Faster (SFR) in terms of global indices, reliability metrics, and test duration.

DESIGN

Prospective longitudinal study.

SUBJECTS

A total of 902 eyes of 463 subjects with normal, suspect, or manifest glaucoma.

METHODS

Two intravisit SFR VF tests (T1 and T2) per eye at an initial (Ti) and follow-up (Tf) visit.

MAIN OUTCOME MEASURES

Intra- and intervisit global indices, reliability metrics, and test durations.

RESULTS

The mean age of the subjects was 63.6 years, and 58.3% were male. Seven hundred ninety eyes (87.4%) had a diagnosis of glaucoma or glaucoma suspicion. The mean duration between visits was 265.0 (standard deviation 98.8) days. In total, 3608 VF tests were analyzed, with the correlation of mean deviation (MD) values of the frontloaded tests at each visit high (T1/T2 MD correlation at initial visit r = 0.83, root mean squared error [RMSE] = 1.26, follow-up visit r = 0.83, RMSE = 1.25, P < 0.0001) and greater than the correlation of MD between visits (Ti1/Tf1 MD correlation r = 0.72, RMSE = 1.31). There was a significant intra-visit decrease in rates of abnormally high sensitivity in the glaucoma hemifield test (3.2% vs. 1.6%, P = 0.0023) and rates of unreliable test results (15.4% vs. 9.2%, P = 0.002) from T1 to T2 in both visits, with a corresponding significant decrease in MD (-1.28 dB vs. -1.68 dB, P < 0.0001) and VF index (P = 0.03). The mean duration of each SFR test was 132.6 (SD 27.2) seconds.

CONCLUSIONS

Frontloading VFs using SFR produced sets of repeatable perimetric data with significant improvement of reliability indices from the first to second test. This may help increase testing frequency at minimal time cost to meet recommended guidelines and for evaluating patients prone to high variability.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Multiple (frontloaded) visual field tests increase identification of very slow mean deviation progression in glaucoma

OBJECTIVE

To determine the effect of frontloading (multiple) visual field (VF) tests at the same visit for detecting mean deviation (MD) change in slowly progressive glaucoma.

METHODS

This was a computer simulation study. Baseline MD (range, 0 to -12 dB) and progression rate (range, 0 to -0.4 dB/year, non-inclusive) were generated for 10,000 patients. Each patient had 6 simulated "stable" baseline VF tests. Then follow-up VFs (up to 10 years) were generated by incorporating progression rate and within-visit and between-visit variability. The independent variables were number of VF tests per visit (one non-frontloaded or two frontloaded), VF reliability (100%, 85%, or 70%), repeat testing because of unreliable results (yes or no), and follow-up interval (6-monthly or yearly). The outcomes were detection of progression (MD slope that was negative and significant at p < 0.05), MD at detection, and number of years to detection.

RESULTS

Frontloading identified more progressors (62.7%-79.2%) compared with non-frontloading (31.0%-36.7%) at 10 years (p < 0.0001). Six-monthly follow-ups led to greater detection than yearly intervals. Progressors detected by both methods were detected by the non-frontloaded method sooner (up to 0.26 years), but this was small and not clinically significant (MD difference, 0.06 dB). An increase (less severe) in MD, an increase (slower) in progression rate, and an increase in SD of baseline VFs decreased the likelihood of detecting progression.

CONCLUSIONS

Frontloading VF tests at 6-monthly intervals improve detection rates of MD progression in slowly progressive glaucoma patients compared with performing 1 test per visit at yearly intervals.

Pharmaceutical Approaches to Normal Tension Glaucoma

Normal tension glaucoma (NTG) is defined as a subtype of primary open-angle glaucoma (POAG) in which the intraocular pressure (IOP) values are constantly within the statistically normal range without treatment and represents approximately the 30-40% of all glaucomatous cases. The pathophysiology of this condition is multifactorial and is still not completely well known. Several theories have been proposed to explain the onset and progression of this disease, which can be divided into IOP-dependent and IOP-independent factors, suggesting different therapeutic strategies. The current literature strongly supports the fundamental role of IOP in NTG. The gold standard treatment for NTG tends to be based on the lowering IOP even if "statistically normal". Numerous studies have shown, however, that the IOP reduction alone is not enough to slow down or stop the disease progression in all cases, suggesting that other IOP-independent risk factors may contribute to the NTG pathogenesis. In addition to IOP-lowering strategies, several different therapeutic approaches for NTG have been proposed, based on vaso-active, antioxidant, anti-inflammatory and/or neuroprotective substances. To date, unfortunately, there are no standardized or proven treatment alternatives for NTG when compared to traditional IOP reduction treatment regimes. The efficacy of the IOP-independent strategies in decreasing the risk or treating NTG still remains inconclusive. The aim of this review is to highlight strategies reported in the current literature to treat NTG. The paper also describes the challenges in finding appropriate and pertinent treatments for this potentially vision-threatening disease. Further comprehension of NTG pathophysiology can help clinicians determine when to use IOP-lowering treatments alone and when to consider additional or alternatively individualized therapies focused on particular risk factors, on a case-by-case basis.

Factors Associated with Follow-Up Adherence After Teleophthalmology for Diabetic Eye Screening Before and During the COVID-19 Pandemic

Abstract Background: Follow-up adherence with in-person care is critical for achieving improved clinical outcomes in telemedicine screening programs. We sought to quantify the impact of the COVID-19 pandemic upon follow-up adherence and factors associated with follow-up adherence after teleophthalmology for diabetic eye screening. Methods: We retrospectively reviewed medical records of adults screened in a clinical teleophthalmology program at urban and rural primary care clinics between May 2015 and December 2020. We defined follow-up adherence as medical record documentation of an in-person eye exam within 1 year among patients referred for further care. Regression models were used to identify factors associated with follow-up adherence. Results: Among 948 patients, 925 (97.6%) had health insurance and 170 (17.9%) were referred for follow-up. Follow-up adherence declined from 62.7% (n = 52) prepandemic to 46.0% (n = 40) during the pandemic (p = 0.04). There was a significant decline in follow-up adherence among patients from rural (p < 0.001), but not urban (p = 0.72) primary care clinics. Higher median household income (odds ratio [OR] 1.68, 95% confidence interval [CI]: 1.19-2.36) and obtaining care from an urban clinic (OR 5.29, 95% CI: 2.09-13.43) were associated with greater likelihood of follow-up during the pandemic. Discussion: Follow-up adherence remains limited after teleophthalmology screening even in a highly insured patient population, with a further decline observed during the COVID-19 pandemic. Our results suggest that rural patients and those with lower socioeconomic status experienced greater barriers to follow-up eye care during the COVID-19 pandemic. Conclusions: Addressing barriers to in-person follow-up care is needed to effectively improve clinical outcomes after teleophthalmology screening.

Gel Stent Versus Trabeculectomy: The Randomized, Multicenter, Gold-Standard Pathway Study (GPS) of Effectiveness and Safety at 12 Months

PURPOSE

To compare effectiveness and safety of the gel stent to trabeculectomy in open-angle glaucoma (OAG).

DESIGN

Prospective, randomized, multicenter, noninferiority study.

METHODS

Patients with OAG and intraocular pressure (IOP) 15 to 44 mm Hg on topical IOP-lowering medication were randomized 2:1 to gel stent implantation or trabeculectomy. Primary end point (surgical success): percentage of patients at month 12 achieving ≥20% IOP reduction from baseline without medication increase, clinical hypotony, vision loss to counting fingers, or secondary surgical intervention (SSI) in a noninferiority test with 24% margins. Secondary end points (month 12) included mean IOP and medication count, postoperative intervention rate, visual recovery, and patient-reported outcomes (PROs). Safety end points included adverse events (AEs).

RESULTS

At month 12, the gel stent was statistically noninferior to trabeculectomy (between-treatment difference [Δ], -6.1%; 95% CI, -22.9%, 10.8%); 62.1% and 68.2% achieved the primary end point, respectively (P=.487); mean IOP and medication count reductions from baseline were significant (P<.001); and the IOP change-related Δ (2.8 mm Hg) favored trabeculectomy (P=.024). The gel stent resulted in fewer eyes requiring in-office postoperative interventions (P=.024 after excluding laser suture lysis), faster visual recovery (P≤.048), and greater 6-month improvements in visual function problems (ie, PROs; P≤.022). The most common AEs were reduced visual acuity at any time (gel stent, 38.9%; trabeculectomy, 54.5%) and hypotony (IOP <6 mm Hg at any time) (gel stent, 23.2%; trabeculectomy, 50.0%).

CONCLUSIONS

At month 12, the gel stent was statistically noninferior to trabeculectomy, per the percentage of patients achieving ≥20% IOP reduction from baseline without medication increase, clinical hypotony, vision loss to counting fingers, or SSI. Trabeculectomy achieved a statistically lower mean IOP, numerically lower failure rate, and numerically lower need for supplemental medications. The gel stent resulted in fewer postoperative interventions, better visual recovery, and fewer AEs.

Crossover Randomized Study of Pharmacologic Effects of Ripasudil-Brimonidine Fixed-Dose Combination Versus Ripasudil or Brimonidine

INTRODUCTION

Multidrug regimens for glaucoma treatment often result in adherence issues due to inconvenience; these issues may be improved with fixed-dose combination drugs. The ophthalmic solution of ripasudil-brimonidine fixed-dose combination (RBFC; K-232) is the first treatment combining a Rho kinase inhibitor and an α2-adrenoceptor agonist, and has demonstrated ability to lower intraocular pressure (IOP) and have various effects on conjunctival hyperemia and corneal endothelial cell morphology. This study evaluates the pharmacologic effects of RBFC treatment versus its separate components-ripasudil or brimonidine.

METHODS

This single-center, prospective, randomized, open-label, blinded endpoint study with 3 × 3 crossover design randomly assigned healthy adult men to three groups (1:1:1) to undergo consecutive 8-day administration phases (with drug-free intervals of at least 5 days). Subjects received twice-daily instillation of RBFC → ripasudil → brimonidine (group A), ripasudil → brimonidine → RBFC (group B), or brimonidine → RBFC → ripasudil (group C). Endpoints included change in IOP, severity of conjunctival hyperemia, corneal endothelial cell morphology, pupil diameter, and pharmacokinetics.

RESULTS

Eighteen subjects were assigned in total (six to each group). RBFC significantly reduced IOP from baseline at 1 h post-instillation on days 1 and 8 (12.7 vs. 9.1 and 9.0 mmHg, respectively; both P < 0.001), and provided significantly greater IOP reductions than ripasudil or brimonidine at several time points. The most common adverse drug reaction with all three treatments was mild conjunctival hyperemia, which transiently increased in severity with RBFC or ripasudil, peaking at 15 min post-instillation. In post hoc analyses, conjunctival hyperemia scores were lower with RBFC than with ripasudil at several time points. Transient morphologic changes in corneal endothelial cells occurred for up to several hours with RBFC or ripasudil, but not with brimonidine. Pupil diameter did not change with RBFC.

CONCLUSION

RBFC significantly reduced IOP compared with each agent alone. A combination of each agent's pharmacologic profile was observed in that of RBFC.

TRIAL REGISTRATION

Japan Registry of Clinical Trials; Registration No. jRCT2080225220.

Will the PRESERFLO™ MicroShunt impact the future of trabeculectomy practice? A UK and Éire Glaucoma Society National Survey

BACKGROUND/OBJECTIVES

To explore the attitudes of UK glaucoma specialists regarding the current and future practice of trabeculectomy and the novel PRESERFLO™ MicroShunt (PF-MS) device, and intentions to adopt the PF-MS into routine glaucoma surgical practice.

METHODS

Online survey of UK and Éire Glaucoma Society members.

RESULTS

43 glaucoma consultants completed the survey. All surgeons performed trabeculectomies (median of 40 annually) and 51% undertook PF-MS procedures (median of 22.5 annually). The mean duration of surgery was reported as 48.9 (SD 13.3) and 31.2 (SD 9.9) min for trabeculectomy and PF-MS respectively (p < 0.0001). For surgeons not currently using the PF-MS, 65% planned to do so. Respondents judged completion of 35 trabeculectomies and 10 PF-MS were required to achieve basic competence. 91% of participants predicted their trabeculectomy volume would decrease and 73% expected PF-MS usage to increase. Respondents reported a median of six and four follow-ups within 3 months post surgery for trabeculectomy and PF-MS respectively (p < 0.0001). Respondents reported trabeculectomy required more post-operative interventions than the PF-MS and 81.8% judged the patient experience to be better with the PF-MS. The PF-MS was deemed suitable for early visual field loss by 72% of respondents, severe visual field loss by 35% and normal tension glaucoma by 21%.

CONCLUSION

The PF-MS has seen rapid adoption in the UK. Respondents predict its usage will significantly increase whilst trabeculectomies will decrease. They report the PF-MS is quicker to learn and perform, and requires less post-operative follow-ups and interventions which may facilitate a more efficient service delivery for patients requiring glaucoma surgery.

Case report: Medical treatment for limbal epithelial stem cell deficiency in patients treated for glaucoma

Limbal epithelial stem cell deficiency (LSCD) is an abnormal corneal epithelial lesion with several causes. The patient was diagnosed using fluorescein staining. Bullous keratopathy, multiple surgeries, and drug-related damage can cause LSCD in glaucoma patients. We evaluated the medical treatment course for LSCD in patients with glaucoma. We retrospectively reviewed the electronic medical records of patients diagnosed with LSCD and investigated their background, course of treatment, and classification stages of LSCD before and after treatment. The global consensus classification system (stages IA-C, IIA-B, and III) proposed by Deng et al. (Cornea 2020) was used. Seven patients (two males) and eight eyes were studied. The median age of the patients was 82 years, and the mean duration of glaucoma treatment was 8 years. The patients had open-angle glaucoma (four eyes), exfoliation glaucoma (one eye), neovascular glaucoma (one eye), normal tension glaucoma (one eye), and uveitic glaucoma (one eye). Stage classifications at diagnosis were stage IA in four eyes and stages IC, IIA, IIB, and III in one eye each. All treatments were carried out with dry eye drops, steroid eye drops, and antibiotics. The mean duration of treatment was 1.4 years. The classifications at the time of the final visit were normal corneal epithelium (three eyes), stage IA (two eyes), IIA (one eye), and III (two eyes). Three eyes (37%) improved by more than one stage and one eye deteriorated by more than one stage. LSCD is long-lasting and difficult to treat in a short period; thus, it requires careful medical attention.

A Retrospective Cohort Study on the Difficulties of Diagnosing and Managing Glaucoma in Patients with Coexistent Neurodegenerative Disease

Aim

To investigate the limitations of diagnosing glaucoma in patients with coexistent neurodegenerative disease (NDD) by collecting information on demographics, examination findings, optical coherence tomography (OCT), and visual field (VF) tests.

Materials and methods

Retrospective cohort study of patients with primary open-angle glaucoma and coexistent dementia, multiple sclerosis (MS), Parkinson's disease (PD), or cerebrovascular accident (CVA) from 2014 to 2020. We included patients with a minimum of 3 years of follow-up. Demographics, ophthalmic exam, OCT, and VF findings were reported and compared across NDD groups using the Chi-squared and analysis of variance tests.

Results

We included 199 patients with glaucoma and coexistent NDD, including dementia (51.3%), CVA (11.2%), PD (18.1%), and MS (19.6%). Cupping, neuroretinal rim thinning, pallor, and peripapillary atrophy of the optic nerve were most frequently observed. There was a high number of missing values from OCT to VF tests, and zero patients had a complete OCT or VF test. Additionally, 67.8 and 77.4% of patients received <1 OCT and VF/year, respectively. Retinal nerve fiber layer (RNFL) thinning was observed most frequently in the superior (33.2% OD and 30.7% OS) and inferior (25.6% OD and 30.2% OS) quadrants, with the most significant thinning seen in CVA patients compared to other NDDs (p < 0.05). Glaucoma hemifield tests (GHTs) were abnormal in 23.1% OD and 22.6% OS, and the average mean deviation was -7.43 [standard deviation (SD) 8.23] OD and -8.79 (SD 7.99) OS.

Conclusion

The OCT and VF tests are frequently unavailable and may be confounded in patients with coexistent glaucoma and NDDs, complicating glaucoma diagnosis and management.

Clinical significance

Diagnosing and managing glaucoma in patients with coexistent NDD is difficult, given the lack of available and reliable OCT and VF testing data. Providers may be forced to rely on intraocular pressure (IOP) and other imperfect measures.

How to cite this article

Ciociola EC, Patel K, Blahnik T, et al. A Retrospective Cohort Study on the Difficulties of Diagnosing and Managing Glaucoma in Patients with Coexistent Neurodegenerative Disease. J Curr Glaucoma Pract 2023;17(3):126-133.

The budget impact of introducing the OMNI® surgical system to a United States health plan for managing mild-to-moderate primary open-angle glaucoma

OBJECTIVES

Minimally invasive glaucoma surgery devices fill an unmet need in the treatment paradigm between topical intraocular pressure medicines and more invasive filtration procedures. This study evaluated the adoption of The OMNI® Surgical System with or without cataract surgery in primary open-angle glaucoma patients.

METHODS

A budget impact analysis estimated costs before and after adoption of OMNI® to a hypothetical US health plan with 1 million Medicare-covered lives over two years. Model input data were derived from published sources and development of the model included primary research with key opinion leaders and payers. The model compared total annual direct costs for OMNI® versus other treatment options (medications, other minimally invasive surgical procedures, selective laser trabeculoplasty) to calculate budget impact. A one-way sensitivity analysis was conducted to assess parameter uncertainty.

RESULTS

Increased adoption of OMNI® resulted in budget neutrality over the two years with a decrease in total costs of $35,362. Per member per month incremental costs were $0.00 when used without cataract surgery and yielded cost savings of -$0.01 when used with cataract surgery. Sensitivity analysis confirmed model robustness and identified surgical center fee variability as a key driver of costs.

CONCLUSION

OMNI® is budgetary efficient from a US payer perspective.

Visualising structural and functional characteristics distinguishing between newly diagnosed high-tension and low-tension glaucoma patients

PURPOSE

To determine whether there are quantifiable structural or functional differences that can distinguish between high-tension glaucoma (HTG; intraocular pressure [IOP] > 21 mm Hg) and low-tension glaucoma (LTG; IOP ≤ 21 mm Hg) at diagnosis.

METHOD

This was a retrospective, cross-sectional study. Clinical results of one eye from 90 newly diagnosed HTG and 319 newly diagnosed LTG patients (117 with very-low-tension glaucoma [vLTG; ≤15 mm Hg] and 202 with middling LTG [mLTG; >15 mm Hg, ≤21 mm Hg]) were extracted, which included relevant demographic covariates of glaucoma, quantitative optical coherence tomography (including the optic nerve head, retinal nerve fibre layer and ganglion cell-inner plexiform layer) measurements and standard automated perimetry global metrics. We used binary logistic regression analysis to identify statistically significant clinical parameters distinguishing between phenotypic groups for inclusion in principal component (PC) (factor) analysis (PCA). The separability between each centroid for each cohort was calculated using the Euclidean distance (d(x,y)).

RESULTS

The binary logistic regression comparing HTG and all LTG identified eight statistically significant clinical parameters. Subsequent PCA results included three PCs with an eigenvalue >1. PCs 1 and 2 accounted for 21.2% and 20.2% of the model, respectively, with a d(x,y) = 0.468, indicating low separability between HTG and LTG. The analysis comparing vLTG, mLTG and HTG identified 15 significant clinical parameters, which were subsequently grouped into five PCs. PCs 1 and 2 accounted for 24.1% and 17.8%, respectively. The largest separation was observed between vLTG and HTG (d(x,y) = 0.581), followed by vLTG and mLTG (d(x,y) = 0.435) and lastly mLTG and HTG (d(x,y) = 0.210).

CONCLUSION

Conventional quantitative structural or functional parameters could not distinguish between pressure-defined glaucoma phenotypes at the point of diagnosis and are therefore not contributory to separating cohorts. The overlap in findings highlights the heterogeneity of the primary open-angle glaucoma clinical presentations among pressure-defined groups at the cohort level.

Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma

OBJECTIVE

To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective.

DESIGN

Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial.

SUBJECTS

Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence.

METHODS

Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER).

RESULTS

Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY.

CONCLUSIONS

From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found after the references.

Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center

Aims and background

Practice guidelines assert that high-risk glaucoma suspects should be treated. Yet, there is ambiguity regarding what constitutes a high enough risk for treatment. The purpose of this study was to determine which factors contribute to the decision to treat glaucoma suspects and ocular hypertensive patients in an academic ophthalmology practice.

Materials and methods

Retrospective cohort study of glaucoma suspects or ocular hypertensives at an academic ophthalmology practice from 2014 to 2020. Demographics, comorbidities, intraocular pressure (IOP), optical coherence tomography (OCT) findings, and visual field measurements were compared between treated and untreated patients. A multivariable logistic regression model assessed predictors of glaucoma suspected treatment.

Results

Of the 388 patients included, 311 (80%) were untreated, and 77 (20%) were treated. There was no statistical difference in age, race/ethnicity, family history of glaucoma, central corneal thickness (CCT), or any visual field parameters between the two groups. Treated glaucoma suspects had higher IOP, thinner retinal nerve fiber layers (RNFL), more RNFL asymmetry, thinner ganglion cell-inner plexiform layers (GCIPL), and a higher prevalence of optic disc drusen, disc hemorrhage, ocular trauma, and proliferative diabetic retinopathy (PDR) (p < 0.05 for all). In the multivariable model, elevated IOP {odds ratio [OR] 1.16 [95% confidence interval (CI) 1.04-1.30], p = 0.008}, yellow temporal [5.76 (1.80-18.40), p = 0.003] and superior [3.18 (1.01-10.0), p = 0.05] RNFL quadrants, and a history of optic disc drusen [8.77 (1.96-39.34), p = 0.005] were significant predictors of glaucoma suspect treatment.

Conclusion

Higher IOP, RNFL thinning, and optic disc drusen were the strongest factors in the decision to treat a glaucoma suspect or ocular hypertensive patient. RNFL asymmetry, GCIPL thinning, and ocular comorbidities may also factor into treatment decisions.

Clinical significance

Understanding the clinical characteristics that prompt glaucoma suspect treatment helps further define glaucoma suspect disease status and inform when treatment should be initiated.

How to cite this article

Ciociola EC, Anderson A, Jiang H, et al. Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center. J Curr Glaucoma Pract 2023;17(3):157-165.

Combined MIGS: Comparing Additive Effects of Phacoemulsification, Endocyclophotocoagulation, and Kahook Dual Blade

Purpose

Combining two or more MIGS (cMIGS) promises to be more efficacious than single MIGS (sMIGS). This study compared the efficacy of PEcK, which combines Phacoemulsification (Phaco), Endocyclophotocoagulation (ECP), and Kahook dual blade (KDB), relative to both of its constituent sMIGS, Phaco/ECP (Endo Optiks, NJ) and Phaco/KDB (New World Medical, CA) for the first time.

Patients and methods

Data was collected retrospectively from 1833 visits of 271 patients who underwent PEcK, Phaco/ECP, or Phaco/KDB from 2016-2021 at Massachusetts Eye and Ear. Primary outcomes included Generalized Estimating Equations (GEE) of intraocular pressure (IOP) and medication burden, as well as survival models.

Results

Mean preoperative IOP was 17.6 ± 5.0 (SD) mmHg on 3.0 ± 1.4 medications in the PEcK group (n = 128), 17.9 ± 5.1 mmHg on 2.2 ± 1.5 medications in the Phaco/ECP group (n = 78), and 16.1 ± 4.3 mmHg on 0.4 ± 1.0 medications in the Phaco/KDB group (n = 65). For more than 36 months, all procedures resulted in significant patterns of IOP and medication reduction (all p < 0.001), before and after statistical adjustment. The reduction pattern in IOP was significantly different when comparing all groups over time and favored PEcK (p = 0.04), but the reduction pattern in medications was not significantly different (p = 0.11). Procedures did not differ in procedural time (p = 0.18) or in survival to maintain ≥20% IOP reduction (p = 0.43) without additional medication or procedure. There was a trend toward significant difference in maintaining IOP ≤ goal IOP that favored PEcK over Phaco/ECP after adjustment (p = 0.09).

Conclusion

PEcK may confer greater IOP reduction without added procedural time compared to Phaco/ECP and Phaco/KDB in predominantly mild or moderate glaucoma. Further research on cMIGS may benefit from adopting this comparative analysis to constituent MIGS.

Provider use of a participatory decision-making style with African American patients with glaucoma

OBJECTIVE

To examine whether non-adherent African American patients with glaucoma who received a question prompt list and video intervention were more likely to be given treatment options, have their input included into treatment regimens, and rate their providers as using more of a participatory decision-making style.

METHODS

African American patients with glaucoma taking one or more glaucoma medications and reported being non-adherent were randomized to a pre-visit video and glaucoma question prompt list intervention or usual care.

RESULTS

189 African American patients with glaucoma participated. Providers gave patients treatment choices during 5.3% of visits and included patient input into treatment regimen decisions during 2.1% of visits. Male patients and patients with more years of education were significantly more likely to rate their providers as using more of a participatory decision-making style.

CONCLUSION

African American patients with glaucoma rated their providers high on using a participatory decision-making style. Yet, providers infrequently presented non-adherent patients with medication treatment options, and it was rare for providers to include patient input into treatment decisions.

PRACTICE IMPLICATIONS

Providers should provide non-adherent patients with different glaucoma treatment options. Non-adherent African American patients with glaucoma should be encouraged to ask their providers for different medication treatment options.

Use Pattern of Ophthalmic Antiglaucoma Agents with and without Preservatives: A Cross-Sectional Study

BACKGROUND

Different drugs have been approved to reduce the intraocular pressure. However, most of them contain preservatives to maintain sterility and these can be toxic to the ocular surface. The aim was to determine the patterns of use of antiglaucoma agents and ophthalmic preservatives in a group of patients from Colombia.

METHODS

A cross-sectional study that identified ophthalmic antiglaucoma agents from a population database of 9.2 million. Sociodemographic and pharmacological variables were considered. Descriptive and bivariate analyses were performed.

RESULTS

A total of 38,262 patients were identified, with a mean age of 69.2 ± 13.3 years, and 58.6% were women. A total of 98.8% were prescribed antiglaucoma drugs in multidose containers. The most widely used were prostaglandin analogs (59.9%), especially latanoprost (51.6%) and β-blockers (59.2%). A total of 54.7% of patients received combined management, especially with fixed-dose combination (FDC) drugs (41.3%). A total of 94.1% used antiglaucoma drugs with preservatives (benzalkonium chloride, 68.4%).

CONCLUSIONS

The pharmacological treatment of glaucoma was very heterogeneous, but the most commonly used therapeutic groups were in accordance with the recommendations of clinical practice guidelines but with differences by sex and age. Most of the patients were exposed to preservatives, especially benzalkonium chloride, but the wide use of FDC drugs can minimize toxicity on the ocular surface.

Validation of Rates of Mean Deviation Change as Clinically Relevant End Points for Glaucoma Progression

PURPOSE

To investigate whether rates of standard automated perimetry (SAP) mean deviation (MD) over an initial 2-year follow-up period were predictive of events of visual field progression over an extended follow-up.

DESIGN

Longitudinal, prospective, observational study.

PARTICIPANTS

Two hundred forty-six eyes of 168 patients with glaucoma followed up every 6 months for up to 5 years.

METHODS

Patients were required to have a minimum of 5 reliable SAP tests during the first 2 years of follow-up. Events of progression were evaluated using 2 methods: Guided Progression Analysis (GPA; Carl Zeiss Meditec, Inc) and a United States Food and Drug Administration (FDA)-suggested end point. The date of the first test showing progression after the first 2 years was considered to be the event date. Rates of change in SAP MD were calculated for the first 2 years of follow-up, and joint longitudinal survival models were used to assess the risk of faster initial MD loss for subsequent progression based on each event analysis.

MAIN OUTCOME MEASURE

Risk of having an event of progression based on initial rates of SAP MD change.

RESULTS

Fifty-six eye (22.8%) showed an event of progression by the GPA and 51 eyes (20.7%) did so by the FDA end point. Each 0.1-dB/year faster rate of SAP MD loss in the first 2 years was associated with a 26% increase in risk of a GPA progression end point developing (R2 = 76%) and 32% risk of an FDA-based end point developing (R2 = 83%). A reduction of 30% in the rate of MD change in the first 2 years was associated with a 20% reduction in the cumulative probability of a progression event developing over 5 years of follow-up.

CONCLUSIONS

Rates of SAP MD change for eyes with glaucoma calculated over the initial 2 years of follow-up were strongly predictive of events of progression over subsequent follow-up. Our findings give support for the use of slopes of MD change as suitable end points of progression in clinical trials.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Prostaglandin analogs in ophthalmology

Glaucoma is a major cause of irreversible blindness worldwide. Reducing intraocular pressure (IOP) is currently the only approach to prevent further optic nerve head damage. Pharmacotherapy is the mainstay of treatment for glaucoma patients. In recent years, a significant milestone in glaucoma treatment has been a transition to prostaglandin analogs (PGAs) as the first line of drugs. The rapid shift from traditional β-blockers to PGAs is primarily due to their excellent efficacy, convenient once-a-day usage, better diurnal control of IOP, and systemic safety profiles. This review article aims to provide information regarding the various PGAs in practice and also the newer promising drugs.

From bench to behaviour: The role of lifestyle factors on intraocular pressure, neuroprotection, and disease progression in glaucoma

Current glaucoma management centres on intraocular pressure (IOP) reduction through pharmacological and surgical therapy. Despite broad interest in active management of glaucoma through lifestyle modifications, such recommendations have yet to be incorporated into standards of treatment. In this review, noteworthy preclinical studies and their translations in clinical populations are discussed to evaluate the roles of lifestyle factors in lowering IOP, offering neuroprotection, and/or slowing disease progression in those with open-angle glaucoma. Current literature suggests that aerobic exercise may be associated with neuroprotection and decreased disease progression. Mindfulness is associated with IOP reductions and neuroprotection. Caffeine is associated with mild, transient IOP elevations of uncertain significance. Nicotinamide supplementation is associated with neuroprotection and short-term visual function improvement. This review also highlights knowledge gaps regarding these factors and opportunities to strengthen our understanding of their role in glaucoma, including future preclinical studies that elucidate underlying mechanisms and clinical studies with additional functional endpoints and longer follow-up.

Mendelian Randomization and Transcriptome-Wide Association Analysis Identified Genes That Were Pleiotropically Associated with Intraocular Pressure

BACKGROUND

Intraocular pressure (IOP) is a major modifiable risk factor for glaucoma. However, the mechanisms underlying the controlling of IOP remain to be elucidated.

OBJECTIVE

To prioritize genes that are pleiotropically associated with IOP.

METHODS

We adopted a two-sample Mendelian randomization method, named summary-based Mendelian randomization (SMR), to examine the pleiotropic effect of gene expression on IOP. The SMR analyses were based on summarized data from a genome-wide association study (GWAS) on IOP. We conducted separate SMR analyses using Genotype-Tissue Expression (GTEx) and Consortium for the Architecture of Gene Expression (CAGE) expression quantitative trait loci (eQTL) data. Additionally, we performed a transcriptome-wide association study (TWAS) to identify genes whose cis-regulated expression levels were associated with IOP.

RESULTS

We identified 19 and 25 genes showing pleiotropic association with IOP using the GTEx and CAGE eQTL data, respectively. RP11-259G18.3 (P_SMR = 2.66 × 10^-6), KANSL1-AS1 (P_SMR = 2.78 × 10^-6), and RP11-259G18.2 (P_SMR = 2.91 × 10^-6) were the top three genes using the GTEx eQTL data. LRRC37A4 (P_SMR = 1.19 × 10^-5), MGC57346 (P_SMR = 1.19 × 10^-5), and RNF167 (P_SMR = 1.53 × 10^-5) were the top three genes using the CAGE eQTL data. Most of the identified genes were found in or near the 17q21.31 genomic region. Additionally, our TWAS analysis identified 18 significant genes whose expression was associated with IOP. Of these, 12 and 4 were also identified by the SMR analysis using the GTEx and CAGE eQTL data, respectively.

CONCLUSIONS

Our findings suggest that the 17q21.31 genomic region may play a critical role in the regulation of IOP.

High Polygenic Risk is Associated with Earlier Initiation and Escalation of Treatment in Early Primary Open Angle Glaucoma

PURPOSE

To assess whether a glaucoma polygenic risk score (PRS) was associated with treatment commencement or escalation in early primary open angle glaucoma.

DESIGN

Prospective longitudinal observational cohort study.

PARTICIPANTS

Participants from the PROGRESSA study (Progression Risk of Glaucoma: RElevant SNPs with Significant Association) were divided into a cohort of glaucoma suspects who were treatment naive at enrolment, and early manifest and suspect glaucoma cases on treatment at enrolment.

METHODS

A per-allele weighted glaucoma PRS was calculated for 1,107 participants. Multivariable mixed effects Cox proportional regression analysis assessed the association between PRS and time to commencement of intraocular pressure (IOP) lowering therapy in 416 glaucoma suspects who were treatment naive at study enrolment. Secondary analysis evaluated the association between PRS and escalation of IOP lowering therapy amongst 691 suspect and early manifest glaucoma cases who were on IOP lowering therapy at enrolment.

MAIN OUTCOME MEASURES

Commencement or escalation of IOP lowering therapy.

RESULTS

A higher glaucoma PRS was associated with a greater risk of commencing IOP-lowering therapy within 5 years (HR: 1.45/Standard Deviation (SD) 95% Confidence Interval (CI) [1.27, 1.62] P<0.001). This finding persisted after adjustment for relevant demographic and clinical parameters (adjusted HR: 1.23/SD 95%CI [1.07, 1.43] P=0.005). Participants in the upper population-based quintile had a 3.3 times greater risk of commencing therapy by 5 years than the lowest quintile (HR: 3.30 95%CI [1.63, 6,70] P<0.001), and a 5.4 greater risk of commencing IOP lowering therapy by 2 years than the lowest quintile (HR: 5.45 95%CI [2.08, 14.25] P<0.001). A higher glaucoma PRS was associated with a greater risk of treatment escalation amongst cases on treatment at enrolment (HR: 1.19/SD 95%CI [1.09, 1.31] P<0.001). In combined analysis of treatment naive suspects and treated cases, participants in the top population-based quintile were at 2.3 times greater risk of requiring initiation or escalation of IOP lowering therapy than the lowest quintile (HR: 2.33 95%CI [1.75, 3.01] P<0.001).

CONCLUSIONS

This study demonstrates novel associations between glaucoma polygenic risk and risk of commencement or escalation of IOP lowering therapy, building upon previous work highlighting the potential clinical utility of genetic risk stratification in glaucoma.

Aqueous humor cytokine levels are associated with the severity of visual field defects in patients with primary open-angle glaucoma

BACKGROUND

To evaluate the aqueous humor (AH) levels of cytokines in primary open-angle glaucoma (POAG) patients and cataract patients.

METHODS

Thirty-eight POAG patients and 26 cataract patients were recruited. Peripheral blood (PB) was collected from each subject. The POAG group was divided into 2 subgroups according to the severity of visual field defects. The cutoff point of the mean deviation (MD) of the visual field was -12 dB. AH was obtained at the time of anterior chamber puncture during cataract or glaucoma surgery by using a 27-gauge needle attached to a microsyringe. AH and PB levels of interleukin-2 (IL-2), tumor necrosis factor-alpha (TNF-α), transforming growth factor-beta2 (TGF-β2) and IL-4 were assayed by enzyme-linked immunosorbent assay. Postoperative intraocular pressures (IOPs) of POAG patients were recorded during the follow-up period.

RESULTS

TNF-α and TGF-β2 showed significantly higher AH levels in the POAG group than in the cataract group (P < 0.001 and P = 0.001, respectively). For the POAG group, preoperative IOPs were significantly positively correlated with AH levels of TNF-α (r² = 0.129, P = 0.027) and TGF-β2 (r² = 0.273, P = 0.001). AH levels of TGF-β2 were significantly different among cataract patients, POAG patients with MD> -12 dB and POAG patients with MD≤ -12 dB (P = 0.001). AH levels of TNF-α were significantly positively associated with IOP reduction after trabeculectomy (P = 0.025). AH and PB levels of cytokines were not related to the long-term success of trabeculectomy.

CONCLUSION

The levels of TNF-α and TGF-β2 showed different profiles in POAG patients and cataract patients. AH levels of TGF-β2 were correlated with the severity of glaucomatous neuropathy in POAG patients. The findings suggest possible roles for cytokines in the pathogenesis and development of POAG.

Refractive Error and Anterior Chamber Depth as Risk Factors in Primary Angle Closure Disease: The Chinese American Eye Study

PRCIS

The risk of primary angle closure disease (PACD) rises rapidly with greater hyperopia while remaining relatively low for all degrees of myopia. Refractive error (RE) is useful for angle closure risk stratification in the absence of biometric data.

PURPOSE

To assess the role of RE and anterior chamber depth (ACD) as risk factors in PACD.

METHODS

Chinese American Eye Study participants received complete eye examinations including refraction, gonioscopy, amplitude-scan biometry, and anterior segment ocular coherence tomography imaging. PACD included primary angle closure suspect (≥3 quadrants of angle closure on gonioscopy) and primary angle closure/primary angle closure glaucoma (peripheral anterior synechiae or intraocular pressure >21 mm Hg). Logistic regression models were developed to assess associations between PACD and RE and/or ACD adjusted for sex and age. Locally weighted scatterplot smoothing curves were plotted to assess continuous relationships between variables.

RESULTS

Three thousand nine hundred seventy eyes (3403 open angle and 567 PACD) were included. The risk of PACD increased with greater hyperopia [odds ratio (OR) = 1.41 per diopter (D); P < 0.001] and shallower ACD (OR = 1.75 per 0.1 mm; P < 0.001). Hyperopia (≥ + 0.5 D; OR = 5.03) and emmetropia (-0.5 D to +0.5 D; OR = 2.78) conferred a significantly higher risk of PACD compared with myopia (≤0.5 D). ACD (standardized regression coefficient = -0.54) was a 2.5-fold stronger predictor of PACD risk compared with RE (standardized regression coefficient = 0.22) when both variables were included in one multivariable model. The sensitivity and specificity of a 2.6 mm ACD cutoff for PACD were 77.5% and 83.2% and of a +2.0 D RE cutoff were 22.3% and 89.1%.

CONCLUSION

The risk of PACD rises rapidly with greater hyperopia while remaining relatively low for all degrees of myopia. Although RE is a weaker predictor of PACD than ACD, it remains a useful metric to identify patients who would benefit from gonioscopy in the absence of biometric data.

FP and EP2 prostanoid receptor agonist drugs and aqueous humor outflow devices for treating ocular hypertension and glaucoma

Prostaglandin (PG) receptors represent important druggable targets due to the many diverse actions of PGs in the body. From an ocular perspective, the discovery, development, and health agency approvals of prostaglandin F (FP) receptor agonists (FPAs) have revolutionized the medical treatment of ocular hypertension (OHT) and glaucoma. FPAs, such as latanoprost, travoprost, bimatoprost, and tafluprost, powerfully lower and control intraocular pressure (IOP), and became first-line therapeutics to treat this leading cause of blindness in the late 1990s to early 2000s. More recently, a latanoprost-nitric oxide (NO) donor conjugate, latanoprostene bunod, and a novel FP/EP3 receptor dual agonist, sepetaprost (ONO-9054 or DE-126), have also demonstrated robust IOP-reducing activity. Moreover, a selective non-PG prostanoid EP2 receptor agonist, omidenepag isopropyl (OMDI), was discovered, characterized, and has been approved in the United States, Japan and several other Asian countries for treating OHT/glaucoma. FPAs primarily enhance uveoscleral (UVSC) outflow of aqueous humor (AQH) to reduce IOP, but cause darkening of the iris and periorbital skin, uneven thickening and elongation of eyelashes, and deepening of the upper eyelid sulcus during chronic treatment. In contrast, OMDI lowers and controls IOP by activation of both the UVSC and trabecular meshwork outflow pathways, and it has a lower propensity to induce the aforementioned FPA-induced ocular side effects. Another means to address OHT is to physically promote the drainage of the AQH from the anterior chamber of the eye of patients with OHT/glaucoma. This has successfully been achieved by the recent approval and introduction of miniature devices into the anterior chamber by minimally invasive glaucoma surgeries. This review covers the three major aspects mentioned above to highlight the etiology of OHT/glaucoma, and the pharmacotherapeutics and devices that can be used to combat this blinding ocular disease.

Home Monitoring of Glaucoma Using a Home Tonometer and a Novel Virtual Reality Visual Field Device: Acceptability and Feasibility

OBJECTIVE

Our aim was to assess the acceptability and feasibility of iCare HOME tonometer (HT) and Virtual Field (VF) devices in the home monitoring of glaucoma.

DESIGN

Prospective feasibility and acceptability study.

SUBJECTS

Twenty patients (39 eyes) with primary open-angle glaucoma, open-angle glaucoma, ocular hypertension, or suspected glaucoma.

METHODS

Patients were trained and instructed to bring 2 devices home for 1 week and use the HT 4 times/day for 4 days and the VF 3 times total.

MAIN OUTCOME MEASURES

For acceptability, we conducted satisfaction surveys and semistructured, qualitative interviews with a thematic analysis. Feasibility was assessed by device usage and quality of tests.

RESULTS

Most patients (73.7%) felt that the HT was easy to use, and 100% of them found the HT useful. All patients (100%) felt that VF was easy to use, and 94.4% of them found the VF useful. All patients (100%) obtained acceptable intraocular pressure and completed a VF test at home. We identified 4 key themes, with 33 subthemes. The key themes include the following: (1) advantages of home monitoring; (2) difficulties with home monitoring; (3) future considerations in home monitoring; and (4) the experience of patients with glaucoma.

CONCLUSIONS

The HT and VF were acceptable and feasible in a small cohort of motivated subjects. Patients were able to perform these tests proficiently at home, and they were generally enthused to obtain more data about their intraocular health, as it allowed them a heightened sense of security and insight about their chronic disease, as well as a reduction in foreseeable barriers to care. Home monitoring may also improve upon glaucoma care by enhancing patient empowerment and fostering community bonds. The VF should be further evaluated to ensure validity.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Association of an Objective Structural and Functional Reference Standard for Glaucoma with Quality of Life Outcomes

PURPOSE

To compare self-reported quality-of-life (QoL) outcomes of patients diagnosed as normal, glaucoma suspect, and glaucoma based on an objective reference standard for glaucomatous optic neuropathy (GON).

DESIGN

Cross-sectional study.

PARTICIPANTS

1884 eyes of 1019 patients were included in the study.

METHODS

The data was sourced from the Duke Glaucoma Registry. Eyes were classified according to the presence and topographic correspondence of functional and structural damage, as assessed by parameters from standard automated perimetry (SAP) and spectral-domain OCT (SD-OCT). The objective diagnosis of the worse eye was used to define patient-level diagnosis. To assess QoL in the diagnostic groups, 14 unidimensional vision-related items of the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) were used to assess QoL in the diagnostic groups. Association between NEI VFQ-25 Rasch-calibrated scores and diagnostic groups was assessed through multivariable regression that controlled for confounding demographic and socioeconomic variables such as age, sex, race, income, marriage status, insurance status, and highest education level.

MAIN OUTCOME MEASURES

NEI VFQ-25 Rasch scores compared with objective criteria diagnosis based on SAP mean deviation (MD) and SD-OCT retinal nerve fiber layer (RNFL) thickness.

RESULTS

Overall, eyes classified as normal, glaucoma suspect, and glaucoma had decreasing mean scores in SAP MD (0.2 ± 1.0 dB, -0.9 ± 2.4 dB, -6.2 ± 7.0 dB, respectively; P < 0.001) and SD-OCT RNFL thickness (97.8 ± 9.5 μm, 89.0 ± 13.1 μm, 64.5 ± 12.8 μm, respectively; P < 0.001). The mean Rasch-calibrated NEI VFQ-25 score was significantly different among normal, suspect, and glaucoma groups (82.9 ± 13.0, 78.2 ± 14.8, and 72.6 ± 16.2, respectively; P < 0.001). When adjusted for confounding socioeconomic variables, glaucoma patients had significantly worse QoL than those classified as normal (β = -6.8 Rasch score units; P < 0.001).

CONCLUSION

A glaucoma diagnosis, based on an objective reference standard for GON, was significantly associated with worse Rasch-adjusted scores of QoL. Utilization of such objective criteria may provide clinically relevant metrics with potential to improve comparability of research findings and validation of newly proposed diagnostic tools.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Comparison of 10-2 and 24-2 Perimetry to Diagnose Glaucoma Using OCT as an Independent Reference Standard

PURPOSE

To compare the performance of the 10-2 test versus 24-2 standard automated perimetry (SAP) test for the diagnosis of glaucoma using OCT as an independent standard for glaucomatous damage.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 1375 pairs of 10-2 and 24-2 SAP tests from 569 eyes of 339 subjects were used for the analysis. A total of 440 (77%) eyes had a diagnosis of glaucoma, and 129 (23%) eyes were normal. All participants underwent 10-2 and 24-2 SAP tests within 30 days.

METHODS

Glaucomatous severity was quantified based on OCT macula ganglion cell layer (mGCL) and circumpapillary retinal nerve fiber layer. The area under the receiver operating characteristic (ROC) curve (AUC) was used to compare 10-2 and 24-2 metrics for discriminating healthy eyes from those of glaucoma, at different levels of disease severity.

MAIN OUTCOME MEASURES

Areas under the ROC curves and sensitivities at fixed specificities of 80% and 95%.

RESULTS

The overall AUC for mean deviation (MD) for the 24-2 test (0.808) was significantly higher than that of the 10-2 test (0.742; P < 0.001). When compared at different stages of the disease, the 24-2 test performed generally better than the 10-2 test, notably in the earlier stages of the disease. For early damage (first quartile), the 24-2 MD had an AUC of 0.658 versus 0.590 for 10-2 MD (P = 0.018). For advanced damage (fourth quartile), corresponding values were 0.954 vs. 0.903 (P = 0.013). Similar trends were observed when glaucoma severity was defined based on structural macular damage with mGCL thickness.

CONCLUSIONS

The 24-2 SAP test had better diagnostic accuracy compared with that of the 10-2 test for detecting equivalent levels of glaucomatous damage, as measured by quantitative assessment of retinal nerve fiber layer and macula by OCT.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Comparative outcomes of phacoemulsification combined with micro-invasive glaucoma surgery plus: Schlemm canal microstent versus Ab interno trabecular excision

PURPOSE

To report the relative efficacy of combining phacoemulsification with a Schlemm's canal microstent (Phaco/Hydrus) or dual blade trabecular excision (Phaco/KDB).

DESIGN

Retrospective study.

METHODS

One hundred and thirty-one eyes of 131 patients who underwent Phaco/Hydrus or Phaco/KDB procedures from January 2016 to July 2021 at a tertiary care center were included and assessed for up to 36months postoperatively. Primary outcomes were intraocular pressure (IOP) and number of glaucoma medications, evaluated by generalized estimating equations (GEE). Two Kaplan-Meier estimates (KM) assessed survival without additional intervention or pressure lowering medication while maintaining: (1) IOP≤21mmHg and≥20% IOP reduction or (2) IOP≤preoperatively designated goal.

RESULTS

Mean preoperative IOP was 17.70±4.91 (SD) mmHg on 0.28±0.86 medications in the Phaco/Hydrus cohort (n=69) and 15.92±4.34mmHg on 0.19±0.70 medications in the Phaco/KDB cohort (n=62). At 12months, mean IOP was reduced to 14.98±2.77mmHg on 0.12±0.60 medications after Phaco/Hydrus and 13.52±4.13mmHg on 0.04±0.19 medications after Phaco/KDB. GEE models of IOP (P<0.001) and medication burden (P<0.05) showed significant patterns of reduction across all timepoints in both cohorts. There were no differences in IOP reduction (P=0.94), number of medications (P=0.95) or survival (P=0.72 by KM1, P=0.11 by KM2) between procedures.

CONCLUSIONS

Both Phaco/Hydrus and Phaco/KDB resulted in significantly reduced IOP and medication burden for over 12months. Phaco/Hydrus and Phaco/KDB confer similar outcomes in terms of IOP, medication burden, survival, and procedural time in a population with predominantly mild and moderate open-angle glaucoma.

Heterogeneity of Ocular Hemodynamic Biomarkers among Open Angle Glaucoma Patients of African and European Descent

This study investigated the heterogeneity of ocular hemodynamic biomarkers in early open angle glaucoma (OAG) patients and healthy controls of African (AD) and European descent (ED). Sixty OAG patients (38 ED, 22 AD) and 65 healthy controls (47 ED, 18 AD) participated in a prospective, cross-sectional study assessing: intraocular pressure (IOP), blood pressure (BP), ocular perfusion pressure (OPP), visual field (VF) and vascular densities (VD) via optical coherence tomography angiography (OCTA). Comparisons between outcomes were adjusted for age, diabetes status and BP. VF, IOP, BP and OPP were not significantly different between OAG subgroups or controls. Multiple VD biomarkers were significantly lower in OAG patients of ED (p < 0.05) while central macular VD was lower in OAG patients of AD vs. OAG patients of ED (p = 0.024). Macular and parafoveal thickness were significantly lower in AD OAG patients compared to those of ED (p = 0.006-0.049). OAG patients of AD had a negative correlation between IOP and VF index (r = -0.86) while ED patients had a slightly positive relationship (r = 0.26); difference between groups (p < 0.001). Age-adjusted OCTA biomarkers exhibit significant variation in early OAG patients of AD and ED.