European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and options Supported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options

A Pooled Assessment of Ocular Surface Disease After Switching from Preserved Prostaglandins to Tafluprost Across Six Countries in Asia

Background

Preserved prostaglandin analogs (PGAs) have been linked to ocular surface disease (OSD). While the benefits of preservative-low (PL) or -free (PF) Tafluprost (Santen Inc., Japan) were reported in real-world studies in Western countries, this is the first study in Asia to assess the effectiveness and safety of switching from preserved PGA to PL or PF-Tafluprost.

Methods

We conducted a meta-analysis on studies that included adults (>18 years of age) with a Corneal Fluorescein Staining Score (CFS) >1. These individuals had switched to PL or PF-tafluprost after using a preserved PGA therapy for at least 3 months for glaucoma and were identified from Santen’s tafluprost study database. A total of six studies from South Korea, Philippines, Malaysia, Singapore, Thailand, Taiwan were pooled for analysis.

Results

An intraocular pressure (IOP) reduction of 5.9% (0.91 mmHg) was seen in 265 patients. However, this result was not statistically significant (95% CI: −3.64, 1.81; Figure 1). Among 132 patients, a 47.9% reduction in the CFS (95% CI: −3.65, −1.91) was seen. Tear film break-up (n=183) significantly increased by 1.06 seconds (95% CI: 0.65, 1.47). In 88 patients, the bulbar conjunctiva score decreased by −0.46 (95% CI: −0.81, −0.10) and palpebral conjunctiva score decreased by −0.42 (95% CI: −0.67–0.17). One or more new adverse reactions were reported in 3% of the individuals after switching.

Conclusion

Tafluprost IOP reduction is comparable to other PGAs, with significant improvements in the ocular surface and minimal adverse reactions which were already previously reported.

Wound Healing Response After Bleb-Forming Glaucoma Surgery With a SIBS Microshunt in Rabbits

Purpose

The PreserFlo MicroShunt is an innovative implant for the surgical treatment of glaucoma. Although usually effective, surgeries can still fail due to fibrosis. This study was conducted to gain insight into the histological aspects of the fibrotic response and find potential targets to reduce postoperative fibrosis.

Methods

Fifteen New Zealand White rabbits were implanted with a microshunt and followed up for 40 days. Animals were euthanized at postoperative days (PODs) 1, 5, and 40 to collect eyes for histological evaluation. Bleb formation and ocular health were assessed by slit-lamp (SL) biomicroscopy and optical coherence tomography (OCT). Intraocular pressure (IOP) was measured using rebound tonometry.

Results

Blebs failed after approximately 2 weeks based on bleb survival and IOP measurements. No severe complications were observed with OCT and SL. Histology revealed a wide variety of cells, in the bleb and around the microshunt, including polymorphonuclear leucocytes (PMNs), myofibroblasts, and foreign body giant cells, at different PODs.

Conclusions

Implantation of a poly(styrene-b-isobutylene-b-styrene) microshunt in rabbits resulted in the occurrence of a wide variety of cells during the wound-healing response. Future research should further elucidate the potential of these (earlier often overlooked) cells to target the fibrotic response in vivo—for example, by developing novel antifibrotic drugs, methods for sustained delivery of medications, or augmenting material properties.

Translational Relevance

Current antifibrotic therapies aim to inhibit myofibroblasts; however, a wide variety of cells are involved in the fibrotic response. Future research focusing on these cells could offer novel methods for reducing the fibrotic response after glaucoma surgery.

Role of pilocarpine use following laser peripheral iridotomy in eyes with refractory acute angle closure glaucoma: A case report and literature review

RATIONALE

Angle closure glaucoma (ACG) is one of the most emergent types of glaucoma in clinical practice. Laser peripheral iridotomy (LPI) could minimize pupillary block and prevent ACG from an acute attack. However, recurrent increase in intraocular pressure (IOP) may still occur despite successful LPI. The aim of this study is to highlight the importance of postLPI pilocarpine use and larger LPI size as well as to share some experiences of cataract surgery in patients with ACG.

PATIENT CONCERNS

A 63-year-old female was referred to our hospital for headache, and poor control of IOP in the right eye for 3 hours.

DIAGNOSES

The patient was diagnosed ACG in the right eye. Recurrence of ACG in the right eye and new-onset and recurrent ACG in the left eye were noted during follow-up, despite successful LPI. The diagnosis was confirmed through slit lamp and gonioscope examination.

INTERVENTIONS

The LPI size was enlarged and pilocarpine use was maintained at 2% (1 drop 4 times a day) in both the eyes. Finally, cataract surgery was performed in both the eyes.

OUTCOMES

No recurrence of ACG was noted during postLPI pilocarpine use in both the eyes. The postoperative IOP was stable for >6 months after cataract surgery without any surgical intervention or antiglaucoma medication use. No discomfort or major complication was observed.

CONCLUSION

This report highlights the importance of postLPI pilocarpine use and larger LPI size in patients with refractory ACG.

Gonioscopy-Assisted Transluminal Trabeculotomy for Glaucoma: 1-Year Outcomes and Success Predictors

PRCIS

Our results suggest gonioscopy-assisted transluminal trabeculotomy (GATT) as an effective and safe option for the surgical management of open-angle glaucoma (OAG). Older age was the only risk factor for failure in our analysis.

PURPOSE

To report 12-month clinical outcomes, safety profile and success predictors of GATT in patients with OAG.

PATIENTS AND METHODS

A retrospective study of patients (18 y old and above) with medically uncontrolled OAG who underwent GATT as a solo procedure or combined with phacoemulsification (PHACO-GATT) between January 2018 and January 2020. Success at 12 months (primary outcome) was defined as intraocular pressure (IOP) <15 mm Hg, with an IOP reduction of at least 20%, OR a reduction of at least 2 glaucoma medications, compared with baseline. Secondary outcomes were success predictors and safety parameters.

RESULTS

A total of 73 eyes (GATT=38; PHACO-GATT=35) from 58 patients with a mean age of 54.8±11.6 years were included. Overall, after 12 months of follow-up, the mean IOP was reduced from 24.9±8.5 to 12.1±2.1 mm Hg (P<0.001). The mean number of glaucoma medications was reduced from 3.5±0.7 to 1.2±1.2 (P<0.001). The success rate was 87% at 12 months, with no significant differences between GATT (85%) and PHACO-GATT (91%) eyes (P=0.330). Age was the only factor significantly associated with surgical success (hazard ratio=1.35; P=0.012; after adjusting for preoperative IOP and number of glaucoma medications). Patients older than 60 years had a significant greater chance of failure (hazard ratio=10.96; P=0.026) compared with those younger than 60 years. The most common postoperative complication was transient hyphema (39%; median duration, 5 d). No sight-threatening adverse event was documented.

CONCLUSIONS

GATT was effective and safe at lowering IOP with or without cataract extraction in OAG. Patients 60 years or older had a higher risk of failure compared with those younger in age.

The Norwich trabeculectomy study: risk factor analysis for the development of adverse, thin cystic blebs

PURPOSE

To investigate potential risk factors, particularly antimetabolite choice, with regard to the development of adverse bleb morphology in eyes that had undergone trabeculectomy surgery.

METHODS

A single-centre, observational cohort study of 631 consecutive eyes, which had undergone trabeculectomy over an 11-year period. For each case, bleb morphology was recorded at 2 years, and its association with the per-operative antimetabolite as well as potential confounding risk factors was analysed using univariate (unadjusted) and multivariate (adjusted) logistical regression analyses to identify those that could contribute to the development of adverse blebs. A standard protocol for 5-fluorouracil and mitomycin-C utilization was employed in the majority of cases.

RESULTS

When 5-fluorouracil was used (n = 257), 24% of patients formed cystic or partially cystic blebs, whereas with mitomycin-C (n = 299), only 12% formed such adverse blebs, the difference being statistically significant (OR = 3.54, p = 0.002 unadjusted; OR = 7.49, p = 0.00 adjusted). Of the other potential confounding factors, care within the private sector (OR = 0.30 p = 0.02) and a history of previous ocular surgery involving a conjunctival incision were identified as potential risk factors for the formation of adverse cystic blebs (OR = 0.28, p = 0.02).

CONCLUSIONS

Modern use of mitomycin-C appeared to be better than 5-fluorouracil as an adjunctive antimetabolite used at the time of trabeculectomy, with respect to the development of preferable final bleb morphology. The only potential preoperative risk factors found to be significant with respect to adverse cystic bleb development were care in the private health sector and previous ocular surgery involving a conjunctival incision.

Subtenon triamcinolone as an adjuvant in mitomycin-C-enhanced trabeculectomy in non-inflammatory glaucomas: A randomized clinical trial

This unicentric randomized clinical trial was designed to compare the surgical outcomes of mitomycin C-enhanced trabeculectomy (MMC-TRAB) with and without subtenon triamcinolone acetonide (TAAC) injection in patients with non-inflammatory glaucomas. This trial is registered at the Brazilian Registry of Clinical Trials (ReBEC) under the register number RBR-53f8nh. Consecutive non-inflammatory glaucoma patients requiring surgical intervention were randomized into two groups. In the control group, eyes underwent standard MMC-TRAB, while in the intervention group, besides the standard MMC-TRAB, these eyes also received a subtenon TAAC injection (4mg) close to the bleb site at the end of the surgery. The main outcomes of the study were surgical success rates, intraocular pressure (IOP) and number of medications at all timepoints. Success was defined as IOP ≤ 15 mmHg and subdivided in complete or qualified according to the need of medication. A total of 75 eyes of 63 different patients were included (intervention group = 39 eyes; control group = 36 eyes). There was no difference between groups at baseline (p>0.11). Multivariable regression analysis indicated that IOP levels were significantly lower in the intervention group at 18 and 24 months of follow-up when number of medications was considered as a covariate (P<0.001). Complete success rates were higher in the intervention group at 06 (90.9% vs 68.7%; p = 0.03), 12 (87.2% vs 66.7%; p = 0.02) and 18 months (87.2% vs 66.7%; p = 0.02). Additionally, although success rates at 24 months were higher in the intervention group (82.0% vs 66.7%; p = 0.09), this difference did not reach statistical significance. Qualified success rates did not significantly differ between groups at all timepoints. In conclusion, this study found significantly lower IOPs levels at 18 and 24 months of follow-up and higher complete success rates until 18 months of follow-up, with the use of subtenon TAAC as an adjuvant to standard MMC-TRABs in non-inflammatory glaucoma patients.

A Cost-Utility Analysis of Trabecular Bypass Devices Versus Usual Care for Patients With Open-Angle Glaucoma

OBJECTIVE

The aim of this study was to determine whether insertion of a trabecular bypass device (TBD) is a cost-effective intervention for the treatment of open-angle glaucoma (OAG) with mild to moderate vision loss in the Australian setting.

METHODS

We performed a cost-utility analysis of TBD implantation in conjunction with cataract surgery or as a standalone procedure in patients with OAG. The model used a Monte Carlo simulation to follow individual patients through a glaucoma treatment algorithm that included TBD and compared the costs and outcomes with those of patients simulated through an algorithm without TBD (usual care). The model tracked the intraocular pressure (IOP) of individual patients and then, based on this IOP, tracked the progression of the patient's glaucoma. Utility values were assigned dependent on severity of glaucoma. The analysis took the perspective of the Australian health care system. The main outcome was incremental cost per quality-adjusted life-year (QALY) of TBD versus usual care for the treatment of OAG.

RESULTS

In the cataract surgery population, TBD surgery was associated with incremental healthcare costs of A$177 and 0.0726 QALYs per patient, resulting in an incremental cost per QALY gained of A$2430. In the standalone population, the overall incremental cost of TBD surgery versus usual care was A$2234. With QALYs gained of 0.1526 per patient, this equated to an incremental cost per QALY gained ratio of A$14,644.

CONCLUSION

The incremental cost per QALY estimates for TBD were below thresholds generally accepted by Australian healthcare payers, suggesting that TBD is a cost-effective intervention for patients with primary OAG in the Australian setting.

Differences in visual field loss pattern when transitioning from SITA standard to SITA faster

Swedish Interactive Threshold Algorithm (SITA) Faster is the most recent and fastest testing algorithm for the evaluation of Humphrey visual fields (VF). However, existing evidence suggests that there are some differences in global measures of VF loss in eyes transitioning from SITA Standard to the newer SITA Faster. These differences may be relevant, especially in glaucoma, where VF changes over time influence clinical decisions around treatment. Furthermore, characterization of differences in localizable VF loss patterns between algorithms, rather than global summary measures, can be important for clinician interpretation when transitioning testing strategies. In this study, we determined the effect of transitioning from SITA Standard to SITA Faster on VF loss patterns in glaucomatous eyes undergoing longitudinal VF testing in a real-world clinical setting. Archetypal analysis was used to derive composition weights of 16 clinically relevant VF patterns (i.e., archetypes (AT)) from patient VFs. We found switching from SITA Standard to SITA Faster was associated with less preservation of VF loss (i.e., abnormal AT 2-4, 6-9, 11, 13, 14) relative to successive SITA Standard exams (P value < 0.01) and was associated with relatively greater preservation of AT 1, the normal VF (P value < 0.01). Eyes that transition from SITA Standard to SITA Faster in a real-world clinical setting have an increased likelihood of preserving patterns reflecting a normal VF and lower tendency to preserve patterns reflecting abnormal VF as compared to consecutive SITA Standard exams in the same eye.

Reintervention rate in glaucoma filtering surgery: A systematic review and meta-analysis

PURPOSE

Reintervention rate is an important factor impacting on patients, surgeons, and society. To date, only a few studies have focused on this topic. For this reason, a systematic review and meta-analysis was undertaken to assess the reintervention rate after glaucoma filtering surgery.

MATERIALS AND METHODS

Prospective studies reporting the reintervention rate after glaucoma filtering surgery and with at least 12 months of follow-up were systematically searched on PubMed, Medline and Embase databases. The primary outcome was the total reintervention rate following surgery. Secondary outcomes were: the rate of manipulation, in-clinic and in-operating room reintervention; the reintervention rate for intraocular pressure (IOP) control and for complications; demographic, clinical and surgical variables associated with reintervention rate.

RESULTS

Ninety-three studies with a total of 8345 eyes were eligible. The total reintervention rate was 1.84 (95% CI 1.57-2.13), with a lower rate for Baerveldt (0.53, 95% CI 0.29-0.83) and Preserflo (0.60, 95% CI 0.15-1.29), and a higher rate for Xen (4.26, 95% CI 2.59-6.31). The manipulation rate was 0.99 (95% CI 0.77-1.23), the in-clinic reintervention rate was 0.08 (95% CI 0.05-0.12) and the in-operating room reintervention rate was 0.28 (95% CI 0.22-0.35). The reintervention rate for IOP control was 1.26 (95% CI 1.04-1.51) and the reintervention rate for complications was 0.27 (95% CI 0.21-0.35).

CONCLUSIONS

All types of surgery presented a total reintervention rate similar to the overall findings, except studies on Baerveldt and Preserflo Microshunt, with a lower rate, and Xen, with a higher rate. None of the variables evaluated were found to be directly associated with the explored outcomes.

Asynchronous Teleophthalmology for Monitoring Glaucoma Patients in a Rural German Region: A Retrospective Observational Pilot Study

Background: Coronavirus disease 2019 (COVID-19) has created an escalating need for limiting in-person examination and potential viral exposure. Under these circumstances, teleophthalmology allows ophthalmologists to continue providing care to patients while ensuring their safety and that of the medical staff.

Objective: The primary objective of this study was to assess patient satisfaction with an asynchronous teleconsultation for glaucoma patients in a rural German area. Secondary endpoints were patient adherence and the need to change the therapeutic regime.

Methods: This retrospective, observational, and monocentric study included 50 patients diagnosed with primary open-angle glaucoma (n = 49) and ocular hypertension (n = 1) requiring medication to lower intraocular pressure (IOP). Only patients with well-controlled diseases were included, and a brief questionnaire was evaluated, which was completed one year after the baseline visit. Best-corrected visual acuity (BCVA), IOP measurements, visual fields, optical coherence tomography images of the optic nerve head, ultra-widefield photographs of the fundus, and photographs of the anterior segment of the eye were taken at each visit by an experienced optometrist.

Results: Of the 50 patients included, the mean number of follow-up visits in this observation period was 4.4. No patient was lost to follow-up, and there were a total of nine missed follow-up visits (but not lost to follow-up). No patients required a change in their treatment regime during the observational period. Regarding patient-focused assessment, the majority of patients were satisfied or very satisfied with teleconsultation in general.

Conclusion: Asynchronous teleophthalmology is a promising option and effective means to monitor glaucoma patients. The majority of teleophthalmology patients were satisfied with their teleconsultation and adhered to the follow-up schedule. However, prospective trials with a larger number of patients and a more focused examination on specific patient populations are required. Further trials should also focus on the aspect of cost-effectiveness.

Efficacy and Patient Tolerability of Omidenepag Isopropyl in the Treatment of Glaucoma and Ocular Hypertension

Current therapeutic approaches for glaucoma aim to reduce intraocular pressure (IOP), which is the only available and reliable strategy proven to control the risk of disease development and progression. Omidenepag isopropyl (OMDI) is a novel topical ocular hypotensive agent that was launched onto the market for the treatment of glaucoma and ocular hypertension (OHT). After topical instillation and during corneal penetration, OMDI is converted into the active metabolite omidenepag (OMD), which behaves as a non-prostaglandin, selective E-prostanoid subtype 2 (EP2) receptor agonist. The topical administration of 0.002% OMDI once-daily (QD) possesses a 20–35% IOP-lowering effect, comparable to that of prostaglandin analogs targeting F-prostanoid (FP) receptor QD, which are the current first-line for pharmaceutical reduction of IOP. However, the mechanism of action and adverse events (AEs) of OMDI are different from those of FP receptor agonists. OMDI reduces IOP by enhancing both conventional trabecular and uveoscleral outflow facilities without complications of prostaglandin-associated periorbitopathy (PAP) seen with FP receptor agonists. Moreover, OMDI was also effective and well-tolerated in non-/poor responders to latanoprost and showed a stable IOP-lowering effect for one year, and its concomitant use with timolol enhanced the IOP-lowering effect. OMDI demonstrated acceptable safety and tolerability with good adherence and can be used in almost every patient. However, OMDI has some AEs such as conjunctival hyperemia, corneal thickening, macular edema/cystoid macular edema and ocular inflammation. Moreover, OMDI is contraindicated in patients who are allergic to the product, in aphakic or pseudophakic eyes, and in combination with tafluprost eye drops. If used appropriately in the right patients, OMDI could be an effective treatment option for glaucoma and OHT as a first-line alternative to FP agonists. Here, we summarize the results of clinical studies of OMDI and discuss its efficacy and patient tolerability in glaucoma and OHT in this review.

Long-term results of micropulse laser trabeculoplasty with 577-nm yellow wavelength in patients with uncontrolled primary open-angle glaucoma and pseudoexfoliation glaucoma

Our aim was to evaluate the long-term results of micropulse laser trabeculoplasty (MLT) with 577-nm yellow wavelength in the treatment of glaucoma. We reviewed the medical records of 51 patients (51 eyes) with uncontrolled primary open-angle glaucoma or pseudoexfoliation glaucoma who underwent 180° MLT for the first time. The success of MLT was defined as an IOP reduction of ≥ 20% and IOP < 21 mmHg after treatment. If the number of medications was increased or further laser trabeculoplasty or glaucoma surgery was required after treatment, the case was considered unsuccessful. The mean duration of patient follow-up was 18.39 ± 12.17 months (range 3-52 months). Patients included in the study used 2-4 types of antiglaucoma eye drops (mean 3.43 ± 0.7). The mean number of MLT spots was 65.54 ± 6.19, and the mean energy level was 750.98 ± 101.73 mJ. The decrease in intraocular pressure compared to baseline measurements was: 16.72 ± 11.87%, 15.07 ± 13.76%, 12.63 ± 14.29%, 16.66 ± 19.32%, and 16.75 ± 19.78% during follow-up at 3, 6, 12, 24, and 36-48 months. Successful response was achieved in 35.41%, 36.95%, 34.21%, 40%, 41.17%, and 42.85% of patients during 3, 6, 12, 18, 24, and 36-48 months of follow-ups, respectively. Of the 51 eyes studied, 12 patients (23.5%) underwent post-MLT glaucoma surgery, and 7 patients (13.7%) had cataract surgery, whose follow-up data were subsequently censored. The reduction of intraocular pressure showed a significant correlation with baseline intraocular pressure, while age and laser power showed no correlation (p > 0.05). MLT is a novel treatment option for patients with glaucoma with favorable long-term outcomes and a good safety profile.

Comparison of the Drug-Induced Efficacies between Omidenepag Isopropyl, an EP2 Agonist and PGF2α toward TGF-β2-Modulated Human Trabecular Meshwork (HTM) Cells

To compare the drug-induced efficacies between omidenepag (OMD), an EP2 agonist, and prostaglandin F2α (PGF2α) on glaucomatous trabecular meshwork (TM) cells, two- and three-dimensional (2D and 3D) cultures of TGF-β2-modulated human trabecular meshwork (HTM) cells were used. The following analyses were performed: (1) transendothelial electrical resistance (TEER) and FITC-dextran permeability measurements (2D), (2) the size and stiffness of the 3D spheroids, and (3) the expression (both 2D and 3D) by several extracellular matrix (ECM) molecules including collagen (COL) 1, 4 and 6, and fibronectin (FN), and α smooth muscle actin (αSMA), tight junction (TJ)-related molecules, claudin11 (Cldn11) and ZO1, the tissue inhibitor of metalloproteinase (TIMP) 1–4, matrix metalloproteinase (MMP) 2, 9 and 14, connective tissue growth factor (CTGF), and several endoplasmic reticulum (ER) stress-related factors. TGF-β2 significantly increased the TEER values and decreased FITC-dextran permeability, respectively, in the 2D HTM monolayers, and induced the formation of downsized and stiffer 3D HTM spheroids. TGF-β2-induced changes in TEER levels and FITC-dextran permeability were remarkably inhibited by PGF2α. PGF2α induced increases in the sizes and stiffness of the TGF-β2-treated 3D spheroids, but OMD enhanced only spheroid size. Upon exposure to TGF-β2, the expression of most of the molecules that were evaluated were significantly up-regulated, except some of ER stress-related factors were down-regulated. TJ-related molecules or ER stress-related factors were significantly up-regulated (2D) or down-regulated (3D), and down-regulated (2D) by PGF2α and OMD, while both drugs altered the expression of some of the other genes in the 3D spheroids in a different manner. The findings presented herein suggest that PGF2α and OMD differently modulate the permeability of the TGFβ2-modulated 2D monolayers and the physical properties of the 3D HTM spheroids.

Anterior Segment Optical Coherence Tomography Angiography Following Trabecular Bypass Minimally Invasive Glaucoma Surgery

Objective

To assess anterior segment optical coherence tomography angiography (AS-OCTA) imaging of the episcleral vessels before and after trabecular bypass minimally invasive glaucoma surgery (MIGS).

Design

A prospective, clinical, single-centre, single-arm pilot feasibility study conducted at National University Hospital, Singapore.

Subjects

Patients with primary glaucomatous optic neuropathy undergoing Hydrus Microstent (Ivantis Inc., Irvine, CA, USA) implantation, who require at least one intra-ocular pressure-lowering medication. One or two eyes per patient may be enrolled.

Methods

We performed AS-OCTA (Nidek RS-3000 Advance 2, Gamagori, Japan) pre- and up to 6 months post-MIGS implantation using a standard protocol in all cornealimbal quadrants, to derive episcleral vessel densities (VD) using a previously described technique.

Main Outcome Measures

Episcleral VD pre- and post-surgery, in sectors with and without the implant.

Results

We obtained serial AS-OCTA images in 25 eyes undergoing MIGS implantation (23 subjects, mean age 70.3 ± 1.5, 61% female) with mean preoperative intraocular pressure (IOP) of 15.5 mmHg ± 4.0. We observed reductions in postoperative episcleral VD compared to preoperative VD at month 1 (mean difference −3.2, p = 0.001), month 3 (mean difference −2.94, p = 0.004) and month 6 (mean difference −2.19, p = 0.039) in sectors with implants (overall 6 month follow-up, p = 0.011). No significant changes were detected in episcleral VD in the sectors without implants (p = 0.910).

Conclusion

In our pilot study, AS-OCTA was able to detect changes in the episcleral VD following trabecular bypass MIGS, which may be a useful modality to evaluate surgical outcomes if validated in future studies.

Interim Results of Post-Marketing Observational Study of Omidenepag Isopropyl for Glaucoma and Ocular Hypertension in Japan

INTRODUCTION

This post-marketing observational interim analysis evaluated the 12-month effectiveness and safety of omidenepag isopropyl (OMDI) ophthalmic solution in daily clinical settings.

METHODS

This was a multicenter, large-scale, non-interventional, prospective, observational study conducted in Japan. The target enrollment was 3900 patients, and the overall observation period was 12 months. Patients with glaucoma and ocular hypertension (OH) with no previous history of OMDI use were enrolled. The key endpoints were change in intraocular pressure (IOP) from baseline and the incidence of adverse reactions (ADRs).

RESULTS

A total of 1862 patients were evaluated in this 12-month interim analysis. Most patients were diagnosed with normal-tension glaucoma (NTG, 62.0%). The treatment patterns with OMDI were naïve monotherapy (48.4%), switching monotherapy (18.4%), and concomitant therapy (31.1%). The overall incidence of ADRs was 24.3%, which was similar between the monotherapy and concomitant therapy groups. Common ADRs were conjunctival hyperemia, refractive disorder, and myopia. Macular edema was observed in four patients. No ADRs categorized as prostaglandin-associated periorbitopathy were observed. There was a significant reduction in mean IOP at 12 months, with a change of - 1.9 ± 2.9 mmHg from baseline (reduction - 10.4 ± 16.5%). The mean IOP change from baseline was - 2.7 ± 2.6 mmHg in the naïve monotherapy group, - 1.1 ± 2.6 mmHg in the switching monotherapy group, and - 1.6 ± 3.1 mmHg in the concomitant therapy group (all P < 0.05). The mean IOP decreased by - 2.5 ± 3.2 mmHg, - 1.5 ± 2.4 mmHg, and - 2.3 ± 4.5 mmHg in the primary open-angle glaucoma (POAG), NTG, and OH groups, respectively. The treatment persistence with OMDI was 82.4%.

CONCLUSION

This study demonstrated the safety and efficacy of OMDI for glaucoma and OH as monotherapy and concomitant therapy in daily clinical settings. In this interim analysis, OMDI showed a favorable benefit-risk profile, and can be first-line therapy for glaucoma.

Phase 2b, Randomized, 3-Month, Dose-Finding Study of Sepetaprost in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension: The ANGEL Study

Purpose:

This phase 2b, randomized, observer-masked, placebo- and active-controlled, parallel-group, multinational (USA and Japan), multicenter study (NCT03216902) assessed the optimal dose of sepetaprost ophthalmic solution in patients with primary open-angle glaucoma or ocular hypertension.

Methods:

After washout, patients ≥18 years (USA) or ≥20 years of age (Japan) received once-daily sepetaprost for 3 months [0.0005% (n = 43); 0.001% (n = 43); 0.002% (n = 44); and 0.003% (n = 45)], latanoprost 0.005% (n = 44) or placebo until week 6, followed by sepetaprost 0.003% until month 3 (n = 22). Safety assessments included adverse event (AE) occurrence.

Results:

Baseline mean diurnal intraocular pressure (IOP) was 24.3 mmHg for latanoprost and ranged between 24.1 and 24.5 mmHg for the sepetaprost groups. Sepetaprost 0.002% had the lowest IOP at each month 3 time point (9:00 AM; 1:00 PM; 5:00 PM) of all sepetaprost concentrations (mean ± standard error: 17.6 ± 0.5; 17.4 ± 0.4; 16.7 ± 0.4 mmHg); similar values were observed with latanoprost (18.1 ± 0.6; 17.3 ± 0.5; 17.2 ± 0.5 mmHg). A positive dose–response relationship was observed with the 3 lower sepetaprost doses; sepetaprost 0.002% had numerically greater IOP-lowering effects than sepetaprost 0.003%. All sepetaprost doses had statistically significantly greater IOP reductions from baseline versus placebo at week 6 (P < 0.0001). This IOP-lowering effect was consistent between Japan- and USA-based patients. Most AEs were mild and occurred numerically less frequently with sepetaprost 0.002% (34.1%) versus latanoprost (50.0%). The most frequently reported AE was conjunctival hyperemia.

Conclusion:

In this study, sepetaprost 0.002% was the optimal concentration, showing comparable IOP-lowering efficacy and safety with latanoprost 0.005%. Most AEs were mild; occurrence was numerically lower with sepetaprost 0.002% than latanoprost 0.005%.

Effect of Latanoprostene Bunod on Optic Nerve Head Blood Flow

SIGNIFICANCE

Topical latanoprostene bunod increases capillary oxygen saturation and blood volume at the optic nerve head in healthy individuals.

PURPOSE

This study aimed to evaluate the effect of topical latanoprostene bunod on optic nerve blood volume and oxygen saturation in a population of healthy participants.

METHODS

In this prospective double-blind crossover study, 23 healthy participants aged from 21 to 62 years were recruited. Optic nerve head capillary blood volume (ONHvol) and oxygen saturation (ONHSaO2) baselines were measured over a period of 2 hours using multichannel spectroscopic reflectometry and were remeasured after a 7-day once-daily instillation regimen of either latanoprost 0.005% or latanoprostene bunod 0.024%. After a 30-day washout period, participants were crossed over to the alternate product, and measurements were repeated. Participants were used as their own baselines to calculate variation in ONHvol and ONHSaO2 across time and pharmacological agents. The Friedman test was used to establish significant differences in optic nerve head parameters from baseline values, and Conover post hoc analysis was carried for multiple between-group comparisons.

RESULTS

Latanoprostene bunod 0.024% induced a significant increase of 4% in ONHSaO2 compared with latanoprost 0.005% (P < .001). Furthermore, latanoprostene bunod increased ONHvol levels by more than twofold at all time points (P < .001 at T60, T90, and T120). The increase in ONHvol was 66.2% higher than levels achieved with latanoprost at T60 (P = .001), 47% higher at T90 (P < .001), and 45% higher at T120 (P < .01).

CONCLUSIONS

Latanoprostene bunod 0.024% induces a significant increase in optic nerve head blood volume and oxygen saturation in healthy subjects, when compared with latanoprost 0.005%. Future studies are needed to evaluate whether similar responses are elicited in patients suffering from glaucomatous optic neuropathy.

Statin use and the reoperation rates in glaucoma filtration surgery - population-based cohort study

PURPOSE

To examine the association of systemic statin therapy and reoperation rate after glaucoma filtration surgery (GFS).

METHODS

This is a population-based, historic cohort study of 2705 eyes undergoing GFS in Finland between July 2009 and December 2016. GFSs were identified from national administrative healthcare registers. Baseline sociodemographic and health characteristics were documented. Reoperation rates of GFS subgroups were analysed, with statin users compared to non-users. The outcomes were modelled using a Poisson regression model adjusted for age, sex, education, statin use, chronic comorbidities, and cataract surgery with incident rate ratios (IRR) as the main outcome measure.

RESULTS

The cohort contained 2263 subjects with open-angle glaucoma (OAG), 823 men and 1440 women. Surgery was performed on 2705 eyes. First documented procedures: deep sclerectomy (DS) (n = 1601), trabeculectomy (TRE) (799) and glaucoma drainage device (GDD) implantation (305) respectively. In total, 438 secondary operations were performed during the 7.5-year (median 2.25 years) follow-up period. The reoperation rates were 19% after DS, 12% after TRE, and 13% after GDD. Of the surgical procedures, 32% were performed on eyes of patients receiving statin therapy. Statin users showed no difference in reoperation rates (IRR 1.06, CI 0.82-1.37). In subgroups, no difference was observed in the reoperation rates adjusted with statin use after filtration surgery (DS, TRE) (IRR 1.06, CI 0.8-1.40) or GDD implantation (0.57, CI 0.20-1.63).

CONCLUSION

Systemic statin therapy among surgically treated OAG patients had no impact on secondary surgery rates following DS, TRE or GDD implantation.

Animal models and drug candidates for use in glaucoma filtration surgery: A systematic review

Glaucoma, a degenerative disease of the optic nerve, is the leading cause of irreversible blindness worldwide. Currently, there is no curative treatment. The only proven treatment is lowering intraocular pressure (IOP), the most important risk factor. Glaucoma filtration surgery (GFS) can effectively lower IOP. However, approximately 10% of all surgeries fail yearly due to excessive wound healing, leading to fibrosis. GFS animal models are commonly used for the development of novel treatment modalities. The aim of the present review was to provide an overview of available animal models and anti-fibrotic drug candidates. MEDLINE and Embase were systematically searched. Manuscripts until September 1st^, 2021 were included. Studies that used animal models of GFS were included in this review. Additionally, the snowball method was used to identify other publications which had not been identified through the systematic search. Two hundred articles were included in this manuscript. Small rodents (e.g. mice and rats) are often used to study the fibrotic response after GFS and to test drug candidates. Due to their larger eyes, rabbits are better suited to develop medical devices. Novel drugs aim to inhibit specific pathways, e.g. through the use of modulators, monoclonal antibodies, aqueous suppressants or gene therapy. Although most newly studied drugs offer a higher safety profile compared to antimetabolites, their efficacy is in most cases lower when compared to MMC. Current literature on animal models and potential drug candidates for GFS were summarized in this review. Future research should focus on refining current animal models (for example through the induction of glaucoma prior to undertaking GFS) and standardizing animal research to ensure a higher reproducibility and reliability across different research groups. Lastly, novel therapies need to be further optimized, e.g. by conducting more research on the dosage, administration route, application frequency, the option of creating combination therapies, or the development of drug delivery systems for sustained release of anti-fibrotic medication.

Treatment of Glaucoma with Natural Products and Their Mechanism of Action: An Update

Glaucoma is one of the leading causes of irreversible blindness. It is generally caused by increased intraocular pressure, which results in damage of the optic nerve and retinal ganglion cells, ultimately leading to visual field dysfunction. However, even with the use of intraocular pressure-lowering eye drops, the disease still progresses in some patients. In addition to mechanical and vascular dysfunctions of the eye, oxidative stress, neuroinflammation and excitotoxicity have also been implicated in the pathogenesis of glaucoma. Hence, the use of natural products with antioxidant and anti-inflammatory properties may represent an alternative approach for glaucoma treatment. The present review highlights recent preclinical and clinical studies on various natural products shown to possess neuroprotective properties for retinal ganglion cells, which thereby may be effective in the treatment of glaucoma. Intraocular pressure can be reduced by baicalein, forskolin, marijuana, ginsenoside, resveratrol and hesperidin. Alternatively, Ginkgo biloba, Lycium barbarum, Diospyros kaki, Tripterygium wilfordii, saffron, curcumin, caffeine, anthocyanin, coenzyme Q10 and vitamins B3 and D have shown neuroprotective effects on retinal ganglion cells via various mechanisms, especially antioxidant, anti-inflammatory and anti-apoptosis mechanisms. Extensive studies are still required in the future to ensure natural products' efficacy and safety to serve as an alternative therapy for glaucoma.

The cornea and methods for measuring intraocular pressure

Introduction: The study aimed to assert the relationship between central corneal thickness (CCT) and intraocular pressure (IOP) measured by: Goldmann applanation tonometry (GAT) and Dynamic contour tonometry (DCT). Materials and Methods: The study included 150 patients with a mean age of 59.39 ± 13.12 years. Patients were divided into three groups: 50 primary open-angle glaucoma (POAG) patients, 50 ocular hypertension (OHT) patients, and 50 normal tension glaucoma (NTG) patients. IOP was determined using GAT and DCT. CCT was measured by ultrasound pachymetry. Results: IOP measured with DCT was higher than IOP measured with GAT (19.80 ± 3.67 mmHg vs 17.71 ± 3.35 mmHg). A significant positive association between IOP measured with GAT and IOP measured with DCT was found in all patients (r = 0.867, p < 0.01). A significantly positive association between IOP measured with GAT and IOP measured with DCT in POAG (r = 0.855, p <0.01), OHT (r = 0.826, p < 0.01), and NTG patients (r = 0.832, p < 0.01) were found. A significant positive correlation between CCT and IOP measured with GAT (r = 0.198, p < 0.01), as well as a significant positive correlation between CCT and IOP measured with DCT was found (r = 0.198, p < 0.01) in all patients. There was no correlation between CCT and IOP measured neither with GAT nor with DCT separately in three patient groups (p > 0.05). Conclusion: CCT-influenced IOP was measured by both methods, GAT and DCT. DCT can not replace GAT, but it is very useful, especially in cases where errors are in the IOP GAT measurement.

[Efficacy and safety of a fixed combination drug Brinzolol Duo in the treatment of patients with primary open-angle glaucoma]

PURPOSE

To evaluate the efficacy and safety of a new fixed combination of brinzolamide and timolol in patients with stages I and II of primary open-angle glaucoma (POAG).

MATERIAL AND METHODS

Study patients were divided into 2 groups. The patients of the first group were prescribed Brinzolol Duo, the second group received an original drug Azarga. Regimen for both drugs was 1 drop 2 times per day for 84 days. The study included 7 monitoring visits: visit 0 (screening - 124 patients), visit 1 (randomization and treatment initiation - 120 patients), visits 2-4 (therapy), visit 5 (end of therapy - 117 patients), visit 6 (follow-up, study completion).

RESULTS

Out of 120 patients included in the study, 117 subjects had completed all study procedures. It was shown that both compared drugs significantly reduce intraocular pressure (IOP). After 3 months, 46.5% of patients in the Brinzolol Duo group and 46.9% of patients in the Azarga group had IOP lowered by more than 30% compared to baseline, with IOP amounting to ≤18 mm Hg in 36.6% and 30.2% of patients, respectively. Hypotensive efficacy and safety of the drugs were comparable between the groups (p>0.05). The drugs were well tolerated, all adverse events (AEs) were mild or moderate in severity.

CONCLUSION

The new drug Brinzolol Duo (brinzolamide + timolol) significantly reduces IOP in POAG patients with efficacy comparable to Azarga.

Xen45 gel stent ab interno trimming for ostium occlusion: case report

BACKGROUND

Despite the XEN gel stent low-risk profile, various complications following the implant have been described, including internal and external occlusion, with a consequent postoperative rise in intraocular pressure (IOP). In this case report we aimed to present a XEN45 stent internal occlusion successfully treated by trimming in situ its proximal end with a 25 G vitreous scissors using a bimanual technique.

CASE PRESENTATION

A 63-year-old male patient affected by primary open angle glaucoma (IOP = 25 mmHg) and a full thickness macular hole in his right eye, underwent ab-interno Xen gel stent implantation and, 1 month later, a 25 G vitrectomy surgery. Despite a significant IOP reduction after stent implant, 6 days after vitrectomy, IOP increased (25 mmHg) and the conjunctival bleb flattened following occlusion of stent internal ostium by a clot of presumed fibrinous material. The Nd:YAG laser failed to remove the clot, so that we decided to snip a small bit of the proximal end of the Xen tube (about 0,5 mm length) with a 25 G vitreous scissors, using a bimanual technique. In the postoperative day 1 and month 1, the IOP was 8 mmHg and 12 mmHg, respectively. The Anterior Segment OCT confirmed a functional, layered, filtering bleb, and the normal appearance and patency of the XEN proximal segment. No side effects from the intervention were observed.

CONCLUSIONS

Ab interno trimming with vitreous scissors of the occluded proximal end of the XEN stent may represent a safe, rapid and efficient method to restore aqueous humor subconjunctival drainage.

Angle Closure with Patent Laser Peripheral Iridotomy - An Unusual Complication

A 41-year-old female presented with diminished vision in both eyes with recurrent episodes of pain, redness, and watering. With a provisional diagnosis of primary angle-closure glaucoma in the left eye and primary angle closure in the right eye, anti-glaucoma medications were started in the left eye and laser peripheral iridotomy was done in both eyes. Follow-up showed patent iridotomy in both eyes and dilated fundoscopy revealed total cupping in the left eye. Next day, the patient had angle closure in the right eye. On medical management, symptoms subsided but intraocular pressure (IOP) was still raised. Right eye trabeculectomy with cataract surgery was done. Vision was restored to 6/9 with IOP of 12 mmHg after 2 weeks. The event was considered to be precipitated because of plateau iris configuration which is an anatomical variant of angle in angle-closure patients. This proves patent laser iridotomy is not always a ticket to dilatation and one should be aware of all possible complications.

Differential impact of prostaglandin analogues on agreement of intraocular pressure measurements obtained by Goldmann applanation, rebound, and noncontact tonometry

Background

To evaluate the effect of topical prostaglandin analogues on agreement of IOP measurements obtained by Goldmann applanation tonometry (GAT), rebound tonometry (RBT), and noncontact tonometry (NCT) in eyes with primary open- angle glaucoma (POAG).

Methods

Intraocular pressure measurements were obtained using GAT, RBT, and NCT in patients with POAG with or without prostaglandin analogues. The agreement between each tonometry was analysed using Bland-Altman analyses in those with or without prostaglandin analogues. The effect of average IOP on IOP differences was also evaluated.

Results

Among a total of 86 subjects included in the study, 44 patients were using prostaglandin analogues. The difference in IOP measured by GAT and RBT was marginally greater in those with (GAT-RBT: − 0.94 ± 1.63 mmHg) prostaglandin analogues than in those without (− 0.33 ± 1.22 mmHg, P = 0.06). The difference in IOP measured by GAT and NCT was significantly greater in the prostaglandin group (GAT-NCT: 2.40 ± 2.89 mmHg) than in the group without prostaglandin analogues (0.41 ± 1.63 mmHg, P < 0.01). While there was no significant relationship between the average of all tonometries and the difference between tonometries in those without prostaglandin analogues, both RBT and NCT underestimated IOP relative to GAT at higher IOP in those using prostaglandin analogues.

Conclusion

Intraocular pressure measured by RBT and NCT was similar to that measured by GAT in those without prostaglandin analogues. RBT overestimated and NCT underestimated IOP compared to GAT in those using prostaglandin analogues.

Moving beyond the Slit-Lamp Gonioscopy: Challenges and Future Opportunities

After almost a century from its introduction in clinical practice, slit-lamp gonioscopy is still considered the reference standard for evaluating the anterior chamber angle (ACA). Gonioscopy is essential for diagnosing angle closure disease, and ACA features are included in glaucoma's diagnostics and treatments algorithms. However, shortcomings of slit-lamp gonioscopy include a steep learning curve, lack of agreement between examiners and poor documentation. Thanks to advances in miniaturization and computing, new instruments for digital gonioscopy have been developed and marketed. This narrative review focuses on the Gonioscope GS-1, which permits semi-automated circumferential documentation of the ACA in real-colour photographs. Advantages and disadvantages of GS-1 compared with slit-lamp gonioscopy and other ACA imaging technologies such as optical coherence tomography are discussed. Finally, potential opportunities offered by this device for telemedicine, virtual clinics, and automatic classification with deep learning are presented.

Analytical model for managing hypotony after implantation surgery of a glaucoma drainage device

The main aim of glaucoma treatment is to reduce the intraocular pressure (IOP). One of the most common surgical treatments of glaucoma is the implantation of a glaucoma drainage device to drain the aqueous humor from the anterior chamber to a filtration bleb, where the aqueous humor is absorbed. In some cases, the excess of drainage causes ocular hypotony, which constitutes a sight-threatening complication. To prevent hypotony after this intervention, surgeons frequently introduce a suture into the device tube, which increases the hydraulic resistance of the tube and, therefore, the IOP. This study aims to provide an analytical model to correct hypotony following implantation surgery of a glaucoma drainage device, which may help glaucoma surgeons decide on hypotony treatment. The results indicate that the IOP after implanting a cylindrical tube around 300 μm in diameter is essentially the same as that built up in the filtering bleb and can hardly be controlled by introducing a straight suture unless the suture diameter is slightly lower than that of the tube. On the contrary, when the tube diameter is smaller than, for example, 100 μm, significant reductions of the IOP can be obtained by introducing a thin suture into the tube.

Visual Field Progression in Glaucoma: Comparison Between PoPLR and ANSWERS

Purpose

It has been suggested that the detection of visual field progression can be improved by modeling statistical properties of the data such as the increasing retest variability and the spatial correlation among visual field locations. We compared a method that models those properties, Analysis with Non-Stationary Weibull Error Regression and Spatial Enhancement (ANSWERS), against a simpler one that does not, Permutation of Pointwise Linear Regression (PoPLR).

Methods

Visual field series from three independent longitudinal studies in patients with glaucoma were used to compare the positive rate of PoPLR and ANSWERS. To estimate the false-positive rate, the same visual field series were randomly re-ordered in time. The first dataset consisted of series of 7 visual fields from 101 eyes, the second consisted of series of 9 visual fields from 150 eyes, and the third consisted of series of more than 9 visual fields (17.5 on average) from 139 eyes.

Results

For a statistical significance of 0.05, the false-positive rates for ANSWERS were about 3 times greater than expected at 15%, 17%, and 16%, respectively, whereas for PoPLR they were 7%, 3%, and 6%. After equating the specificities at 0.05 for both models, positive rates for ANSWERS were 16%, 25%, and 38%, whereas for PoPLR they were 12%, 33%, and 49%, or about 5% greater on average (95% confidence interval = −1% to 11%).

Conclusions

Despite being simpler and less computationally demanding, PoPLR was at least as sensitive to deterioration as ANSWERS once the specificities were equated.

Translational Relevance

Close control of false-positive rates is key when visual fields of patients are analyzed for change in both clinical practice and clinical trials.

Protein Biomarkers in Glaucoma: A Review

Glaucoma is a multifactorial disease. Early diagnosis of this disease can support treatment and reduce the effects of pathophysiological processes. A significant problem in the diagnosis of glaucoma is limited access to the tested material. Therefore, intensive research is underway to develop biomarkers for fast, noninvasive, and reliable testing. Biomarkers indicated in the formation of glaucoma include chemical compounds from different chemical groups, such as proteins, sugars, and lipids. This review summarizes our knowledge about protein and/or their protein-like derived biomarkers used for glaucoma diagnosis since 2000. The described possibilities resulting from a biomarker search may contribute to identifying a group of compounds strongly correlated with glaucoma development. Such a find would be of great importance in the diagnosis and treatment of this disorder, as current screening techniques have low sensitivity and are unable to diagnose early primary open-angle glaucoma.

Prostaglandin-associated periorbitopathy syndrome (PAPS): Addressing an unmet clinical need

BACKGROUND

Topical prostaglandin analogs (PGAs) are widely approved and preferred first-line options for glaucoma and elevated intraocular pressure (IOP). However, prostaglandin-associated periorbitopathy syndrome (PAPS) is now a well-recognized clinical and cosmetic concern for patients receiving PGAs, especially during long-term and unilateral therapy. PGA-associated periocular changes occur in a substantial proportion of patients, with older patients (>60 years) at greater risk of clinical presentation. PAPS may hinder long-term management of glaucoma, including treatment adherence, ophthalmic surgery outcomes, and reliable IOP measurements.

RECOMMENDATION

New therapeutic approaches may address this unmet clinical need. Omidenepag isopropyl (OMDI) is a novel, non-prostaglandin, selective EP₂ receptor agonist in ongoing development, which provides a unique pharmacological mechanism of action. OMDI appears to provide IOP reductions comparable to PGAs, but without PAPS-related undesirable effects. OMDI may offer a suitable long-term option for patients who demonstrate decreased efficacy, or failure, of PGAs, plus patients with significant PAPS, while fulfilling international guidelines.

The Effect of Intraocular Pressure-Lowering Medication on Metastatic Uveal Melanomas

Simple Summary

The most lethal tumor in the eye is metastatic uveal melanomas, while the most common cause of irreversible blindness is glaucoma. Glaucoma is treated by prescribing intraocular pressure-lowering drugs. Theoretically, these drugs may affect the risk of metastasis of intraocular tumors (uveal melanomas). Using data of a long-running and ongoing study on uveal melanomas, we found that eye drops that lower the intraocular pressure by stimulating outflow of fluid (aqueous humor) may increase the risk of metastasis, and subsequent mortality. Therefore, in patients at risk or suspect for uveal melanoma, we recommend choosing ophthalmic drugs with a working mechanism that is not based on the increase of outflow of aqueous humor from the eye.

Abstract

Background: There has been speculation that IOP-lowering medication, which increases aqueous humor outflow, increases the risk of metastatic uveal melanoma (UM). This hypothesis has not been studied previously but is relevant for UM patients who use IOP-lowering medication. The aim of the current study is to assess the association between the use of intraocular pressure (IOP)-lowering medication and the risk of metastatic UM, and mortality. Methods: A retrospective cohort study, in which patients from the Rotterdam Ocular Melanoma Study were included from 1986 onwards. Medical records were evaluated for use of IOP-lowering medication at baseline (i.e., before diagnosis). For each IOP-lowering medication, we divided patients into two groups for comparison (e.g., patients with alpha2-agonist use and patients without alpha2-agonist use). All patients underwent regular ophthalmic examinations and routine screening for metastasis. Survival analyses were initiated to compare groups in each IOP-lowering medication group. In addition, secondary analyses were performed to examine the association between IOP and the development of metastatic UM, and mortality. Results: A total of 707 patients were included of whom 13 patients used prostaglandin or pilocarpine at baseline. For alpha2-agonist, beta-blocker, carbonic anhydrase inhibitor, and oral IOP-lowering medication these were 4, 14, 11, and 12 patients, respectively. The risk of metastatic UM (choroid and ciliary body melanoma) among the prostaglandin/pilocarpine users was significantly higher than controls (HR [95% CI]: 4.840 [1.452–16.133]). Mortality did not differ significantly among the IOP-lowering medications groups, except for the prostaglandin or pilocarpine group (HR [95% CI]: 7.528 [1.836–30.867]). If we combined all IOP-lowering medication that increase aqueous humor outflow, the risk (HR [95% CI]) of metastatic UM and mortality was 6.344 (1.615–24.918) and 9.743 (2.475–38.353), respectively. There was an association between IOP and mortality, but not for the onset of metastatic UM. Conclusion: The use of topical prostaglandin or pilocarpine may increase the risk of metastatic UM and mortality compared to patients without prostaglandin or pilocarpine use. Therefore, use of IOP-lowering medication which increases aqueous humor outflow, should be avoided in patients with (presumed) UM.

The Frontloading Fields Study (FFS): Detecting Changes in Mean Deviation in Glaucoma Using Multiple Visual Field Tests Per Clinical Visit

Purpose

To determine the impact of different numbers of visual field tests per visit for detecting mean deviation changes over time in patients with early glaucoma or suspected glaucoma and to identify a practical approach to maximize change detection.

Methods

Intrasession (n = 322) and intersession (n = 323) visual field results for patients with glaucoma or suspected glaucoma were used to model mean deviation change in 10,000 progressing and 10,000 non-progressing computer-simulated patients over time. Variables assessed in the model included follow-up intervals (0.5, 1, or 2 years), reliability rates (70%, 85%, or 100%) and number of visual field tests performed at each visit (one to four).

Results

Two visual field tests per session compared with one provided higher case detection rates at 2 years (99%–99.8% vs. 34.7%–76.3%, respectively), reduced time to detection (three or four visits vs. six to 10, respectively), and more positive mean deviation score (−4 dB vs. −10 dB, respectively) at the point of mean deviation change identification, especially in the context of unreliable results. Performing two tests per visit offered similar advantages compared with more tests. False positive change detection rates (<2.5%), were similar across all conditions. Patients followed up 6 monthly had less severe mean deviation loss at follow-up compared to 1-year and 2-year follow-up intervals.

Conclusions

Performing two tests per clinical visit at 6 months is practical using SITA-Faster and provides higher detection rates of mean deviation change in comparison with only one test performed per visit and more spaced-out intervals.

Translational Relevance

This model provides guidance for selecting the number of tests per visit to detect mean deviation change.

Meibomian Gland Changes in Open-angle Glaucoma Users Treated with Topical Medication

SIGNIFICANCE

Glaucoma patients treated with topical hypotensive eye drops often experience changes in the ocular surface, including the lid margin and the meibomian glands. In this study, the clinical parameters of the ocular surface have been analyzed to detect the presence of meibomian gland dysfunction-related dry eye disease.

PURPOSE

This study aimed to evaluate the meibomian gland dysfunction in glaucoma patients secondary to topical antiglaucomatous treatment.

METHODS

A total of 131 eyes from different patients with open-angle glaucoma treated with topical medication and 92 eyes from different patients with untreated ocular hypertension were consecutively and prospectively enrolled. The structure of the meibomian glands was assessed using noncontact meibography (Keratograph 5M; Oculus, Wetzlar, Germany), and their function was evaluated by measurement of meibomian glands expressibility, the duct appearance, and the Marx line location. Moreover, tear osmolarity measurement, corneal staining score (Oxford scale), and ocular symptom assessment (Ocular Surface Disease Index questionnaire) were performed. We also compared these variables in the glaucoma group according to the presence (or not) of preservative in topical treatment.

RESULTS

Meibomian gland depletion was higher in glaucoma patients with topical medication (P < .001). Furthermore, the quantity of meibomian glands and expressibility of meibum in these patients were altered compared with the control group (P < .001 in both cases). In addition, the glaucoma group presented a higher degree of corneal staining as measured with the Oxford scale (P < .001). The Marx line location score was higher (P < .001 in central Marx line and P < .003 in temporal Marx line) in patients using drugs containing preservative than in those having preservative-free treatment. Logistical regression found that Marx line central, Marx line temporal, quantity of meibum expression, and quality of meibum expression have predictive ability to detect meibomian gland dysfunction-related dry eye disease.

CONCLUSIONS

Glaucoma topical treatments produce meibomian gland dysfunction altering their structure and function, and this condition can be worsened using topical treatments containing preservative.

Suppression of Diurnal (9AM-4PM) IOP Fluctuations with Minimally Invasive Glaucoma Surgery: An Analysis of Data from the Prospective, Multicenter, Single-Arm GEMINI Study

PURPOSE

This study analyzes diurnal IOP data (9AM, 12PM, 4PM) from a prospective 12-month trial of the OMNI Surgical System in open-angle glaucoma (OAG) patients with the aim of evaluating effect of MIGS surgery on the amplitude of the diurnal IOP profile pre- and postoperatively.

SETTING

Fifteen ophthalmology practices and surgery centers located in 14 states in the United States.

DESIGN

Prospective, multicenter, IRB approved study. Patients treated with canaloplasty (360°) and trabeculotomy (180°). Patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on zero to four hypotensive medications.

METHODS

Post-hoc analysis of diurnal IOP data from the multicenter GEMINI study. Analysis includes comparison of IOP preoperatively and at month 12 for each of the diurnal time points, 9AM, 12PM, 4PM, change in magnitude of spread between the maximum IOP and minimum IOP for each patient and the proportions of patients preoperatively and at month 12 with IOPs at or below 25, 21, 18, and 15 mmHg, average variability (standard deviation of the 9AM, 12PM, and 4PM IOP) preoperatively and at month 12.

RESULTS

A total of 128 patients included in this analysis. IOP at each diurnal timepoint was significantly lower postoperatively (p<0.0001). The difference between highest and lowest IOP measurement for each patient averaged 2.8 mmHg preoperatively (SD 2.4, MAX 14, MIN 0) and 1.8 mmHg (SD 1.7, MAX 10, MIN 0) month 12 (P<0.00001). The proportion with IOP ≤ to 25, 21, 18, and 15 mmHg increased; 75%-97%, 27%-88%, 1%-79%, and <1%-56%, respectively. The average variability was greater at all time points preoperatively (P<0.0001).

CONCLUSION

This study demonstrates that eyes with OAG can benefit from an overall decreased IOP and degree of IOP fluctuations for as long as 12 months after surgical treatment with canaloplasty and trabeculotomy.

Drugs for the treatment of glaucoma: Targets, structure-activity relationships and clinical research

Glaucoma is the third leading cause of blindness and impairment of vision worldwide, after refractive errors and cataracts. According to the survey, the number of people with glaucoma is more than 76 million, with projections increasing to 112 million by 2040. With the coming of an aging society, the number of people suffering from glaucoma will increase day by day. Glaucoma is a heterogeneous disease characterized by damage to the head of the optic nerve and visual field. High intraocular pressure is a major risk and cause of glaucoma optic neuropathy. Therefore, drug lowering intraocular pressure therapy is still the first-line therapy in clinical practice. Here, the targets, structure-activity relationship, and clinical progress of drugs for the treatment of glaucoma are reviewed.

Twelve-month efficacy and safety of omidenepag isopropyl, a selective EP2 agonist, in open-angle glaucoma and ocular hypertension: the RENGE study

PURPOSE

To assess the long-term safety and efficacy of omidenepag isopropyl (OMDI) 0.002% (a first-in-class, selective, non-prostaglandin, prostanoid EP2 receptor agonist), alone or administered concomitantly with timolol 0.5%, in patients with open-angle glaucoma (OAG, including normal-tension and exfoliation glaucoma) or ocular hypertension (OHT).

STUDY DESIGN

Open-label, multicenter, Phase 3 study (NCT02822729).

METHODS

Patients aged ≥ 20 years, with OAG or OHT, and a baseline diurnal intraocular pressure (IOP) ≥ 16- < 22 mmHg (Group 1) or ≥ 22- ≤ 34 mmHg (Groups 2 and 3) were enrolled. All patients (N = 125) received OMDI 0.002% once daily. Group 3 also received timolol 0.5% twice daily. IOP was measured at baseline and at Weeks 2, 4, 8, 12, 26, 40, and 52.

RESULTS

Significant reductions in mean diurnal IOP from baseline occurred at every visit (P < 0.0001). Mean ± SE diurnal IOP reduction at Week 52 was -3.7 ± 0.3 mmHg (Group 1), -5.6 ± 0.5 mmHg (Group 2), and -8.4 ± 0.6 mmHg (Group 3). Most adverse events (AEs) were mild, and no serious treatment-related AEs were reported. Conjunctival hyperemia (incidence: monotherapy [Groups 1 and 2], 18.8%; concomitant [Group 3], 45.0%) and macular edema (ME)/cystoid macular edema (CME) (incidence: monotherapy, 11.8%; concomitant, 15.0%) occurred most frequently. All treatment-related ME/CME cases occurred in pseudophakic eyes and responded to standard-of-care treatment and study drug discontinuation.

CONCLUSIONS

In this study, OMDI 0.002%, alone or administered concomitantly with timolol 0.5%, resulted in sustained IOP reduction over 52 weeks in patients with OAG or OHT. Concomitant treatment resulted in increased efficacy and increased incidence of conjunctival hyperemia.

Gonioscopy-assisted transluminal trabeculotomy for chronic angle-closure glaucoma: preliminary results

PURPOSE

To report the preliminary results of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with chronic angle-closure glaucoma (CACG).

METHODS

Retrospective, single-center, case series of GATT procedures is performed on patients with CACG. The primary outcome was intraocular pressure (IOP). Success was defined as IOP reduction >30% from baseline at 6 and 12 months with (qualified) or without (complete) glaucoma medication. Secondary outcomes were best-corrected visual acuity (BCVA), visual field (VF), peripheral anterior synechiae (PAS), medications, and complications.

RESULTS

Fifteen eyes (15 patients) with a minimum follow-up of 1 year were included for the analysis. Preoperatively, the mean (±SD) IOP was 30.27 (±4.20) mmHg and 15.20 (±2.08) mmHg at 1 year postoperatively (p<0.001). The mean (±SD) percentage of IOP reduction from baseline was 49% (±9.41). At 6 and 12 months, the success rate complete and qualified was 93% (73% and 20%) and 100% (73% and 27%), respectively. BCVA and VF mean deviation were comparable before and after surgery (p=0.167 and p= 0.710, respectively). The median (range) number of glaucoma drugs decreased from 3 (3-4) before to 0 (0-2) after GATT (p<0.001). The absence of PAS was observed in 80% of patients after surgery. Transient hyphema was a common complication requiring aspiration in one case.

CONCLUSION

At 12 months of follow-up, our preliminary results indicate that GATT in CACG effectively reduces the IOP and the number of medication with a low risk of complications. Following ab interno trabeculotomy, an open-angle without PAS was achieved in the majority of patients.

TRIAL REGISTRATION NUMBER

nr. 2016/0010904.

Assessment of Ocular Surface Disease in Glaucoma Patients in Ghana

PRECIS

Dry eye disease (DED) observed in this study is associated with ocular surface abnormalities as shown by specific dry eye tests. Changes in tear quality may be responsible for dry eye symptoms among the participants.

PURPOSE

This study sought to evaluate DED in glaucoma patients in Ghana.

MATERIALS AND METHODS

This was a hospital-based descriptive cross-sectional study involving glaucoma patients on topical glaucoma treatment for at least 6 months. The medical records of participants were thoroughly reviewed for information on demographics, ocular history, medical history, number of topical antiglaucoma medications used within the last 6 months, and any other ophthalmic medications used by the participants. An Ocular Surface Disease Index (OSDI) questionnaire was administered to each participant, after which Schirmer test and tear break-up time (TBUT) were performed on each participant in a controlled environment.

RESULTS

A total of 100 individuals participated in the study. The mean±SD age of participants was 60.44±14.05 years. The majority (60.0%) of the participants were females and 55.0% of participants used 2 or more topical antiglaucoma medication. Of the participants, 81.0% reported subjective dry eye symptoms. Schirmer test and TBUT showed that 55.0% and 87.0% of the participants had decreased tear production and abnormal tear quality, respectively. Multiple logistic regression showed a significant association between age and abnormal OSDI (P=0.037), Schirmer test (P=0.003), and TBUT (P=0.042); the number of topical glaucoma medications and OSDI (P=0.016) and Schirmer test (P=0.009). The prevalence of DED was 23.0%. Increasing age was associated with an ∼7 times higher odds of having DED (P=0.0019), using >2 glaucoma medications with ∼4.5 times higher odds of having DED (P=0.001), 5 or more years of glaucoma medication use with ∼4 times higher odds of DED (P=0.009), and both benzalkonium chloride and sodium chlorite as preservative was associated with ∼3.5 times higher odds of DED (P=0.047).

CONCLUSION

DED is prevalent among glaucoma patients in Ghana and is associated with age, duration of glaucoma medication, type of preservatives, and number of topical glaucoma medications.

Late-onset Endophthalmitis after XEN45® Implantation: A Retrospective Case Series and Literature Review

AIM AND OBJECTIVE

To report the incidence of late-onset endophthalmitis following XEN45® stent implantation.

BACKGROUND

Long-term safety profile and efficacy in relation to the so-called microinvasive glaucoma surgery (MIGS) techniques are still under evaluation. The XEN45® gel stent entails a bleb formation and often requires postoperative conjunctival management, differing from the current reviewed concept of minimally invasive procedures. Endophthalmitis has been described among the complications, triggered in the majority of cases by tube extrusion.

CASES DESCRIPTION

From our chart of 293 eyes operated on between November 2016 and November 2019, five (1.7%) patients developed endophthalmitis, which took place in the months 3, 4, 5, 11, and 14 after surgery, respectively. Sixty percent had undergone previous needling procedures. All of them showed a previous flat bleb and developed perforation of the conjunctiva caused by the distal portion of the tube. One patient was early eviscerated due to a fateful course. Treatment consisted of intravitreal, oral, and topical antibiotics, as well as topical corticosteroids. Eighty percent underwent device withdrawal, conjunctival gap suturing, anterior chamber washout, aqueous humor (AH) tab extraction (one positive for S. epidermidis and one for Streptococcus agalactiae), and pars plana vitrectomy. A second patient was eviscerated due to phthisis bulbi. Out of three remaining patients, one underwent vitrectomy for retinal detachment, while two patients required glaucoma surgery for intraocular pressure control. The final VA was ≤20/125 in all patients.

CONCLUSION

The XEN45® device appears to trigger endophthalmitis by extruding the stent or unnoticed leakage through conjunctival defects. Special attention should be paid to flat and avascular blebs.

CLINICAL SIGNIFICANCE

This series shows a higher rate of endophthalmitis (1.7%) compared with previous studies with a significant sample size (0.4-1.4%).

HOW TO CITE THIS ARTICLE

Burggraaf-Sánchez de las Matas R, Such-Irusta L, Alfonso-Muñoz EA, et al. Late-onset Endophthalmitis after XEN45® Implantation: A Retrospective Case Series and Literature Review. J Curr Glaucoma Pract 2021;15(3):153-160.

Topical carbonic anhydrase inhibitors and glaucoma in 2021: where do we stand?

Carbonic anhydrase inhibitors (CAIs) have been used for many decades in the treatment of glaucoma. Systemic CAIs were an early treatment option to lower intraocular pressure by reducing aqueous humour production; however, frequent side effects including polyuria and paresthesia contributed to the eventual development of topical CAIs. As topical drug development evolved over time, prostaglandin analogues and beta-blockers have become the gold standard of glaucoma therapies. Although prescribed less often than other classes of topical glaucoma therapies, topical CAIs continue to be used in combination therapies with beta-blockers and alpha agonists. Topical CAIs have also been demonstrated to alter biomarkers of ocular haemodynamics, which have relevance in glaucoma. The purpose of this review is to review and summarise the current state of topical CAI prescribing trends, known efficacy and suggested mechanisms and potential influence on ocular haemodynamics for the future of glaucoma management.

Retinal Vessel Density Changes on Optical Coherence Tomography Angiography and Predictive Factors in Normal-Tension Glaucoma Treated with Topical Beta-Blocker

(1) Background: Topical antiglaucoma medications may alter the microcirculation in the optic nerve head. We aimed to evaluate the changes in retinal vessel density (VD) on optical coherence tomography angiography (OCTA) in patients with newly diagnosed normal-tension glaucoma (NTG) treated with a topical beta-blocker. (2) Methods: This study included 80 patients diagnosed with NTG not using systemic medication, who received topical carteolol treatment between December 2019 and November 2020. We studied the changes in the OCTA VD/signal strength index (SSI) after the 6-month treatment period and determined the predictive factors affecting the changes in VD/SSI. (3) Results: After the 6-month treatment period, the peripapillary VD increased in 40 patients but decreased in the other 40 patients. The univariate and multivariate analyses revealed that old age and hypertension were significant factors associated with a VD/SSI decrease after carteolol treatment. Moreover, high baseline peripapillary, superficial, and deep macular VDs were significantly associated with the VD decrease after carteolol treatment. (4) Conclusions: Carteolol treatment could increase or decrease the VD in patients with NTG. The baseline VD, age, and hypertension could affect these VD changes. Patients with NTG and higher baseline peripapillary or macular VD, older age, and hypertension are more likely to have a decreased VD after carteolol treatment.

Comparison of the SITA Faster-a new visual field strategy with SITA Fast strategy

AIM

To compare visual field defects using the Swedish Interactive Thresholding Algorithm (SITA) Fast strategy with SITA Faster strategy, a newly developed time-saving threshold visual field strategy.

METHODS

Ninety-three participants (60 glaucoma patients and 33 normal controls) were enrolled. One eye from each participant was selected randomly for the study. SITA Fast and SITA Faster were performed using the 24-2 default mode for each test. The differences of visual field defects between the two strategies were compared using the test duration, false-positive response errors, mean deviation (MD), visual field index (VFI) and the numbers of depressed test points at the significant levels of P<5%, <2%, <1%, and <0.5% in probability plots. The correlation between strategies was analyzed. The agreement between strategies was acquired by Bland-Altman analysis.

RESULTS

Mean test durations were 246.0±60.9s for SITA Fast, and 156.3±46.3s for SITA Faster (P<0.001). The test duration of SITA Faster was 36.5% shorter than SITA Fast. The MD, VFI and numbers of depressed points at P<5%, <2%, <1%, and <0.5% in probability plots showed no statistically significant difference between two strategies (P>0.05). Correlation analysis showed a high correlation for MD (r=0.986, P<0.001) and VFI (r=0.986, P<0.001) between the two strategies. Bland-Altman analysis showed great agreement between the two strategies.

CONCLUSION

SITA Faster, which saves considerable test time, has a great test quality comparing to SITA Fast, but may be not directly interchangeable.

24-month outcomes of XEN45 gel implant versus trabeculectomy in primary glaucoma

PURPOSE

To compare the efficacy and safety profiles of XEN implant versus trabeculectomy as a surgical intervention for primary glaucoma.

METHODS

A retrospective cohort study of mild to moderate stage glaucoma patients, who had undergone either XEN implantation or trabeculectomy with adjunctive mitomycin C, was performed in a tertiary eye center.

RESULTS

Fifty-seven eyes for XEN implant and 57 eyes for trabeculectomy with medically uncontrolled glaucoma were included. Preoperative IOP was 16-33 mmHg. Visual field mean deviation was -9.11±6.93 dB in XEN group, and -9.67±5.06 dB in trabeculectomy group (p = 0.195). At the 24-month timepoint, mean IOP was reduced from 21.6±4.0 to 14.6±3.5 mmHg (32.4% reduction) in the XEN group (p<0.001), and from 22.5±5.8 to 12.5±4.1 mmHg (44.4% reduction) in the trabeculectomy group (p<0.001). Final IOP in XEN was significantly higher than trabeculectomy (p = 0.008) with lesser mean IOP percentage reduction at month 24 (p = 0.045). Mean number of medications was reduced from 2.2±1.4 to 0.5±0.7 in XEN group (p<0.001), and from 2.4±0.7 to 0.8±1.3 in trabeculectomy group (p<0.001). Final number of medications was not different between the groups (p = 0.225). Surgical success was comparable between XEN and trabeculectomy group. Overall success was 71.4% vs. 73.3% (p = 0.850), and complete success was 62.9% vs. 62.2% (p = 0.954), respectively. XEN had lower rate of numerical hypotony than trabeculectomy. No serious complication occurred in either procedure group.

CONCLUSION

At 24 months, XEN showed a rate of success comparable to that of trabeculectomy. Although XEN had a higher final IOP than trabeculectomy, XEN achieved 32% IOP reduction, and achieved final IOP in mid-teen level. No serious complication occurred in either group. XEN can be applied for treatment of mild to moderate stages of glaucoma in Southeast Asian patients.

Cost-utility analysis of trabecular micro-bypass stents (TBS) in patients with mild-to-moderate open-angle Glaucoma in Italy

BACKGROUND

Glaucoma is a disease characterized by progressive damage of the optic nerve. Several therapeutic options are available to lower intraocular pressure (IOP). In primary open-angle glaucoma (POAG) patients with inadequate IOP control (or controlled with multiple medical therapies or for whom medical therapy is contraindicated), the implantation of micro-invasive glaucoma surgery devices (MIGS) and concomitant cataract surgery has proved to be more effective in reducing intraocular pressure (IOP), as compared to cataract surgery alone. The objective of this study was to assess the cost-effectiveness of iStent inject® device with concurrent cataract surgery vs. cataract surgery alone, in patients with mild-to-moderate POAG, adopting the Italian National Health Service (NHS) perspective.

METHODS

Simulation of outcomes and costs was undertaken using a Markov model with 4 health states and one-month cycles, that is used to simulate the prognosis of these patients. Efficacy data were obtained from the randomized clinical trial (RCT). A lifetime horizon was adopted in the analysis. A discount rate of 3.5% was applied to both costs and effects. The Italian National Healthcare Service (NHS) perspective was considered, therefore only healthcare direct costs (acquisition of main interventions and subsequent procedures; medications; monitoring and follow-up; adverse events). Model robustness was tested through sensitivity analyses.

RESULTS

Results of the base-case analysis showed that the total lifetime costs were higher in the iStent inject® + concurrent cataract surgery, compared with the cataract surgery alone group (€8368.51 vs. €7134.71 respectively). iStent inject® + concurrent cataract surgery was cost-effective vs. cataract surgery alone, with an incremental cost-effectiveness ratio of €13,037.01 per quality-adjusted life year (QALY) gained. Both one-way deterministic and probabilistic sensitivity analyses confirmed robustness of base-case results. The cost-effectiveness accessibility curve (CEAC) showed that iStent inject® + cataract surgery would have a 98% probability of being cost-effective, compared to cataract surgery alone, when the willingness to pay (WTP) is equal to €50,000 per QALY gained.

CONCLUSIONS

The results of the cost-utility analysis confirm that iStent inject® + cataract surgery is a cost-effective option for the treatment of patients affected by mild-to-moderate POAG, compared with cataract surgery alone, when evaluated from the Italian NHS perspective.

Effects of selective EP2 receptor agonist, omidenepag, on trabecular meshwork cells, Schlemm's canal endothelial cells and ciliary muscle contraction

This study investigated the effects of omidenepag (OMD), a novel selective EP2 receptor agonist, on human trabecular meshwork (HTM) cells, monkey Schlemm’s canal endothelial (SCE) cells, and porcine ciliary muscle (CM) to clarify the mechanism of intraocular pressure (IOP) reduction involving conventional outflow pathway. In HTM and SCE cells, the effects of OMD on transforming growth factor-β2 (TGF-β2)-induced changes were examined. The expression of actin cytoskeleton and extracellular matrix (ECM) proteins, myosin light chain (MLC) phosphorylation in HTM cells were evaluated using real-time quantitative PCR, immunocytochemistry, and western blotting. The expression of barrier-related proteins, ZO-1 and β-catenin, and permeability of SCE cells were evaluated using immunocytochemistry and transendothelial electrical resistance. The CM contraction was determined by contractibility assay. OMD significantly inhibited expression of TGF-β2 induced mRNA, protein, and MLC-phosphorylation on cytoskeletal and ECM remodeling in the HTM dose dependently. In SCE cells, OMD suppressed TGF-β2-induced expression of the barrier-related proteins and decreased SCE monolayer permeability. OMD at 3 µM significantly inhibited CM contraction, however, the effect was not significant at lower concentrations. IOP lowering effect of OMD through conventional outflow pathway is exerted by increasing outflow facilities with the modulation of TM cell fibrosis and SCE cell permeability.

Assessing the Reliability of Intraocular Pressure Measurements Using Rebound Tonometry

PRECIS

In a trio of prospective studies, the iCare rebound tonometer demonstrated significantly lower test-retest variability than Goldmann tonometry with good interoperator and interdevice reproducibility, supporting its value in monitoring intraocular pressure (IOP) changes over time.

PURPOSE

The purpose of this study was to characterize intraoperator and interoperator and interdevice reliability of IOP measurements with rebound tonometry (RT, ic100).

METHODS

Three prospective cross-sectional studies were conducted in distinct sample of adult patients with established glaucoma, suspected glaucoma, or no glaucoma at the West Virginia University Eye Institute. Participants in study 1 underwent 5 RT measurements in one randomly selected eye and 5 Goldmann tonometry measurements in the fellow eye by 1 operator; intraoperator variability was compared using the F test. In study 2, 3 operators each obtained 3 RT measurements in participants in randomized operator order. In study 3, a single operator collected 3 measurements each with 3 RTs in randomized device order. Between-operator and between-device reproducibility were characterized using intraclass correlation coefficients (ICCs).

RESULTS

Overall, 28, 19, and 25 subjects participated in the 3 respective studies. Within-subject variance across subjects was 0.757 in RT measurements and 2.471 in Goldmann measurements (P=0.0035). Interoperator reproducibility of RT measurements was good in both eyes [ICC for right eyes 0.78, 95% confidence interval (CI): 0.60-0.85; ICC for left eyes 0.75, 95% CI: 0.50-0.83]. Interdevice reproducibility of RT measurements was good approaching excellent (ICC for right eyes 0.87, 95% CI: 0.83-0.90; ICC for left eyes 0.89, 95% CI: 0.86-0.91).

CONCLUSIONS

The RT's lower measurement variability and good interoperator and interdevice reproducibility suggest that it can characterize IOP changes over time more robustly than Goldmann tonometry, aiding clinicians in assessing the effectiveness of glaucoma therapy and the consistency of IOP control.

Optical Coherence Tomography Angiography Vessel Density Changes in Normal-tension Glaucoma Treated With Carteolol, Brimonidine, or Dorzolamide

PRECIS

In patients with normal-tension glaucoma (NTG), topical dorzolamide might enhance the vessel density (VD), topical carteolol decreased the VD in the inferior-temporal peripapillary retina, whereas topical brimonidine did not change the VD.

PURPOSE

Topical antiglaucoma medications may improve ocular perfusion pressure or microcirculation in the optic nerve head. The study evaluated responses of retinal VD to topical carteolol, brimonidine, and dorzolamide in NTG using optical coherence tomography angiography.

PATIENTS AND METHODS

This is a retrospective, nonrandomized, comparative study. The study included 131 individuals (77 men, 54 women) diagnosed with NTG, without systemic medication use, who visited the glaucoma clinic of Chang Gung Memorial Hospital, Taiwan, between January 2019 and May 2020. If both eyes were diagnosed with NTG, only the right eye was included. Of these, there were 80 carteolol-treated eyes, 27 brimonidine-treated eyes, and 24 dorzolamide-treated eyes. We studied the response of optical coherence tomography angiography parameters and retinal nerve fiber layer (RNFL) thickness to drugs, 6 months after treatment.

RESULTS

In dorzolamide-treated eyes, increases in the peripapillary superficial retinal VD, especially in the superior-nasal area, were significant; however, no RNFL thickness changes were observed. In contrast, the superficial retinal VD decreased at the inferior-temporal peripapillary area, and RNFL thickness decreased in the inferior-nasal peripapillary area of carteolol-treated eyes. Finally, in brimonidine-treated eyes, changes in either VD parameters or RNFL thickness were not significant.

CONCLUSIONS

Topical dorzolamide possibly enhanced the VD of the peripapillary retina in NTG eyes. On the contrary, topical carteolol possibly decreased VD in the inferior-temporal peripapillary retina. Finally, in cases treated with topical brimonidine, peripapillary microcirculation remained unchanged. The study shows preliminary results and future large-scale studies are needed to confirm findings.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.