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

Retinal Nerve Fibre Layer Thickness Change After CO2 Laser-Assisted Deep Sclerectomy Surgery

Purpose

The goal of our study was to investigate changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA), and retinal nerve fibre layer thickness (RNFLT) after CO2 laser-assisted deep sclerectomy (CLASS).

Methods

We carried out uncomplicated CLASS surgeries and a 12-month follow-up on 22 open-angle glaucomatous (OAG) eyes of 22 patients. IOP, BCVA, and RNFLT with spectral-domain optical coherence tomography (SD OCT) were recorded before and 1, 3, 6, 12 months after surgery.

Results

Mean age of patients was 68.1 years. IOP decreased from preoperative 28.45±5.99 SD mmHg (mean±standard deviation) to 15.09±2.40 mmHg (p=0.00039) at 12 months after surgery. BCVA-change from preoperative 0.34±0.38 SD (LogMAR) to 0.37±0.41 SD (LogMAR) was not significant (p=0.2456). RNFLT-change from preoperative 60.50±18.15µm to 59.63±17.52 µm at 12 months postoperatively was not significant (p=0.056). Qualified success rate of CLASS surgery was 72.7%, whereas complete success rate was 64% at 1 year postoperatively.

Conclusion

Successful CLASS surgery efficiently reduced IOP. At postoperative 12 months, RNFLT and BCVA were not reduced significantly. There was no significant glaucomatous progression after surgery encountered in respect of investigated parameters.

Intraocular pressure-lowering effect of omidenepag isopropyl in latanoprost non-/low-responder patients with primary open-angle glaucoma or ocular hypertension: the FUJI study

PURPOSE

Omidenepag isopropyl (OMDI) is the prodrug of omidenepag, a selective, non-prostaglandin, prostanoid EP2 receptor agonist, which has been shown to lower intraocular pressure (IOP) in patients with glaucoma and ocular hypertension (OHT). This study evaluated the efficacy and safety of OMDI ophthalmic solution 0.002% in patients with primary open-angle glaucoma or OHT who were non-/low responders to latanoprost.

STUDY DESIGN

Open-label, multicenter, Phase 3 study (NCT02822742).

METHODS

Following 1-4-week washout, patients were treated with latanoprost ophthalmic solution 0.005% during an 8-week run-in period. Patients with ≤15% IOP reduction at the end of the run-in (indicating non-/low response) received OMDI 0.002% (one drop once daily for 4 weeks). The primary endpoint was the change from baseline in mean diurnal IOP at Week 4.

RESULTS

In total, 26 patients were treated with OMDI; two withdrew owing to lack of efficacy. The mean diurnal IOP at baseline (end of latanoprost run-in) was 23.1 mmHg (7.6% IOP reduction from end of washout) indicating non-/low response to latanoprost. After 4 weeks of OMDI treatment, mean diurnal IOP was significantly reduced from baseline (-2.99 mmHg; P < 0.0001). No serious adverse events were reported. Adverse events occurred in five patients (19.2%); adverse drug reactions (anterior chamber cell, conjunctival hyperemia, and erythema of eyelid) occurred in two patients (7.7%) and were mild in severity.

CONCLUSIONS

In this study, OMDI 0.002% demonstrated a clinically significant reduction in IOP and was well tolerated in patients with primary open-angle glaucoma and OHT who were non-/low responders to latanoprost.

Impact of Intraocular Pressure Control on Rates of Retinal Nerve Fiber Layer Loss in a Large Clinical Population

PURPOSE

To investigate the impact of intraocular pressure (IOP) control on rates of change of spectral-domain OCT (SD-OCT) retinal nerve fiber layer (RNFL) thickness in a large clinical population.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 85 835 IOP measurements and 60 223 SD-OCT tests from 14 790 eyes of 7844 patients.

METHODS

Data were extracted from the Duke Glaucoma Registry, a large database of electronic medical records of patients with glaucoma and suspected disease followed over time at the Duke Eye Center and satellite clinics. All records from patients with a minimum of 6 months of follow-up and at least 2 good-quality SD-OCT scans and 2 clinical visits with Goldmann applanation tonometry were included. Eyes were categorized according to the frequency of visits with IOP below cutoffs of 21 mmHg, 18 mmHg, and 15 mmHg over time. Rates of change for global RNFL thickness were obtained using linear mixed models and classified as slow if change was slower than -1.0 μm/year; moderate if between -1.0 and -2.0 μm/year; and fast if faster than -2.0 μm/year. Multivariable models were adjusted for age, gender, race, diagnosis, central corneal thickness, follow-up time, and baseline disease severity.

MAIN OUTCOME MEASURES

Rates of change in SD-OCT RNFL thickness according to levels of IOP control.

RESULTS

Eyes had a mean follow-up of 3.5±1.9 years. Average rate of change in RNFL thickness was -0.68±0.59 μm/year. Each 1 mmHg higher mean IOP was associated with 0.05 μm/year faster RNFL loss (P < 0.001) after adjustment for potentially confounding variables. For eyes that had fast progression, 41% of them had IOP <21 mmHg in all visits during follow-up, whereas 20% of them had all visits with IOP <18 mmHg, but only 9% of them had all visits with IOP <15 mmHg.

CONCLUSIONS

Intraocular pressure was significantly associated with rates of progressive RNFL loss in a large clinical population. Eyes with stricter IOP control over follow-up visits had a smaller chance of exhibiting fast deterioration. Our findings may assist clinicians in establishing target pressures in clinical practice.

The Antiglaucoma Agent and EP2 Receptor Agonist Omidenepag Does Not Affect Eyelash Growth in Mice

Purpose: The present study investigated the effects of the antiglaucoma agent and selective E2 receptor agonist omidenepag isopropyl (OMDI) on eyelash growth in comparison with a prostaglandin analog (prostamide receptor agonist) in mice.

Methods: Four-week-old female mice (C57BL/6J) were divided into 3 groups of n = 10 each. The groups were administered 3 μL of 0.003% OMDI solution, the vehicle (negative control), or a 0.03% bimatoprost solution (positive control) on the upper eyelids of the right eyes once daily for 14 days. On the 15th day, all animals were euthanized, and the upper eyelids with eyelashes were fixed with 10% neutral formalin. Eyelashes were evaluated for number, length, and thickness using a stereomicroscope. Specimens were then paraffin-embedded and stained with hematoxylin and eosin, followed by microscopic examination to assess eyelash morphology and growth cycle.

Results: Eyelash number (143.5 ± 6.7/eyelid), thickness, and percentage of dermal papilla in the anagen phase in the OMDI group were similar to those observed in the vehicle group (eyelash number, 144.2 ± 5.7/eyelid). In contrast, eyelash number (166.7 ± 7.0/eyelid), thickness, and the percentage of dermal papilla in the anagen phase were significantly greater in the bimatoprost group compared with those of the vehicle group.

Conclusions: Unlike existing prostaglandin analogs, our findings indicate that OMDI has no effect on eyelash growth in mice, suggesting that it may be a promising antiglaucoma agent with a reduced number of adverse effects.

Comparative efficacy and cost-utility of combined cataract and minimally invasive glaucoma surgery in primary open-angle glaucoma

Purpose

To assess the comparative efficacy and the long-term cost–utility of alternative minimally invasive glaucoma surgeries (MIGSs) when combined with cataract surgery in patients with primary open-angle glaucoma (POAG).

Methods

Treatment effects, as measured by the 1-year reduction in intraocular pressure (IOP), were estimated with an adjusted indirect treatment comparison. Evidence from randomized clinical trials was identified for four different MIGS methods. A disease-transition model was developed by capturing clinically relevant POAG stages and the expected natural disease evolution. Outcomes of the disease-transition model were the comparative utility [quality-adjusted life years (QALYs)], cost and cost–utility of included strategies in a lifetime horizon.

Results

Estimated 1-year IOP reductions were: cataract surgery − 2.05 mmHg (95% CI − 3.38; − 0.72), one trabecular micro-bypass stent − 3.15 mmHg (95% CI − 5.66; − 0.64), two trabecular micro-bypass stents − 4.85 mmHg (95% CI − 7.71; − 1.99) and intracanalicular scaffold − 2.25 mmHg (95% CI − 4.87; 0.37). Discounted outcomes from the disease-transition model appraised the strategy of two trabecular micro-bypass stents with cataract surgery in the moderate POAG stage as the one providing the greatest added value, with 10,955€ per additional QALY. Improved outcomes were seen when assessing MIGS in the moderate POAG stage.

Conclusions

When indirectly comparing alternative MIGS methods combined with cataract surgery, the option of two trabecular micro-bypass stents showed both a superior efficacy and long-term cost–utility from a German perspective. Moreover, outcomes of the disease-transition model suggest POAG patients to beneficiate the most from an earlier intervention in the moderate stage contrary to waiting until an advanced disease is present.

The Hub-and-Spoke Management of Glaucoma

Glaucoma is an extremely significant public health issue, since it is the most common cause of irreversible blindness worldwide, nevertheless it is still widely undiagnosed because of its devious nature. Glaucoma diagnosis criteria are well-defined and have to be strictly observed and recognized: the earlier the disease is diagnosed, the earlier the patient can undergo the most suitable treatment, the better can be the prognosis. The three levels of prevention are essential in the approach to the disease and its pathophysiological features make it eligible for screening. This review provides an overview of the current state of the art in glaucoma management, starting from its prevention and coming to the hub-and-spoke organization. This model applied to glaucoma aims to direct patients toward professional and not professional figures who may guide them in integrated care pathway. This path should be designed in accordance with best practice to coordinate glaucoma prevention, diagnosis, treatment and follow up with the best cost-benefit ratio, protecting both the interests of the patient and of the society.

The Effect of Therapeutic IOP-lowering Interventions on the 24-hour Ocular Dimensional Profile Recorded With a Sensing Contact Lens

PRéCIS:: The 24-hour ocular dimensional profile recorded by a contact lens sensor was affected by intraocular pressure lowering interventions. Among different treatments, incisional surgery had the most significant effect.

PURPOSE

We investigated the effect of different intraocular pressure (IOP)-lowering interventions on contact lens sensor (CLS) parameters and their relationship with Goldmann applanation tonometry (GAT)-measured IOP reduction.

METHODS

Data from reliable CLS recordings performed before and after IOP-lowering interventions were analyzed. Three interventions were evaluated: topical medications, laser trabeculoplasty, and incisional surgery. A set of 115 different CLS parameters were derived from 24-hour curves. We compared before versus after values for each parameter. In addition, linear regression was performed using the percentage change of each CLS parameter as the outcome variable and the type of IOP-lowering procedure as the predictor after adjusting age and race. Finally, we investigated the relationship between changes in CLS parameters and GAT IOP with the Spearman rank correlation coefficient.

RESULTS

A total of 182 eyes of 182 patients were included in the analyses: 60 (33%) topical medications, 69 (38%) laser, and 53 (29%) surgery. The mean GAT IOP change was 3.6±6.5 mm Hg (P<0.001). Overall, more CLS parameters had a significant change after surgery than in the other groups (surgery>laser=drug). Linear regression showed that, for 20 CLS parameters, surgery was the most predictive of greatest percentage change in CLS signals. In all, 11 (9.5%) of the CLS parameters were significantly correlated with GAT changes.

CONCLUSIONS

Incisional glaucoma surgery had a more pronounced effect on GAT and CLS parameters than laser and drugs. The CLS can detect changes in patterns resulting from IOP-lowering interventions beyond daytime GAT IOP. This device could potentially be used to assess treatment efficacy in glaucoma.

Primary Open Angle Glaucoma and Vascular Risk Factors: A Review of Population Based Studies from 1990 to 2019

Glaucoma is one of the leading causes of blindness worldwide, and as the proportion of those over age 40 increases, so will the prevalence of glaucoma. The pathogenesis of primary open angle glaucoma (POAG) is unclear and multiple ocular risk factors have been proposed, including intraocular pressure, ocular perfusion pressure, ocular blood flow, myopia, central corneal thickness, and optic disc hemorrhages. The purpose of this review was to analyze the association between systemic vascular risk factors (including hypertension, diabetes, age, and migraine) and POAG, based on major epidemiological studies. Reports presenting the association between POAG and systemic vascular risk factors included a total of over 50,000 patients. Several epidemiological studies confirmed the importance of vascular risk factors, particularly hypertension and blood pressure dipping, in the pathogenesis and progression of glaucomatous optic neuropathy. We found that diabetes mellitus is associated with elevated intraocular pressure, but has no clear association with POAG. No significant correlation between migraine and POAG was found, however, the definition of migraine varied between studies.

Trends in Glaucoma Filtration Procedures: A Retrospective Administrative Health Records Analysis Over a 13-Year Period in Canada

Background

Glaucoma surgical management has evolved significantly with the introduction of minimally invasive glaucoma surgery. Our aim was to evaluate trends in Canadian glaucoma surgery billing code usage as a surrogate index of the current impact of this new technology in Canada’s publicly funded health-care system.

Methods

Retrospective administrative health records analysis of all patients who underwent a publicly funded glaucoma filtration procedure from January 2003 to December 2016 in the 6 largest Canadian provinces. The frequency of glaucoma-related procedures was adjusted against primary open-angle glaucoma prevalence data. Frequency of all glaucoma filtration procedures with and without implantation of a drainage device in each province per year is reported.

Results

Nationwide, glaucoma filtration procedures per 1000 primary open-angle glaucoma patients per year remained constant, with increased drainage device implantation over time (P<0.0001). Ontario and Nova Scotia mirrored the overall population. British Columbia and Saskatchewan showed increased rates of glaucoma filtration surgery, with increased drainage device implantations. In Quebec, overall filtration surgery decreased, while the rate of device implantation increased (p<0.0001). Alberta showed a decline in filtration surgery and device implantations from 2003 to 2008, and then increased thereafter.

Conclusion

Over the study period, there was a distinct trend towards billing code usage for implanted devices. Challenges encountered during this investigation highlight the need for identifiers in provincial health databases to accommodate the introduction of novel technologies. The absence of specific billing codes for newer technologies prevents accurate analyses of impact, utilization, efficacy and cost implications in contemporary patient management.

Comparison of Two Combinations of Maximum Medical Therapy for Lowering Intraocular Pressure in Primary Open-angle Glaucoma

PURPOSE

We sought to compare the efficacy as well as the safety of two maximum medical therapy combinations applied to lower the intraocular pressure (IOP) in different primary open-angle glaucoma (POAG) age groups.

METHODS

This was a retrospective, consecutive case series study that included 60 eyes of 60 subjects with POAG, specifically 20 subjects aged 40 to 54 years, 21 aged 55 to 69 years, and 19 aged 70 years or older. All had been treated for at least 12 months with triple maximum medical therapy (TMT; dorzolamide/timolol, brimonidine, and latanoprost) to lower their IOP, which subsequently was changed to double maximum medical therapy (DMT, fixed drug combinations of tafluprost/timolol and brinzolamide/brimonidine). The rate of IOP change and adverse drug reactions were compared amongst the three age groups.

RESULTS

The mean IOP change at three months after converting from TMT to DMT was -0.65 ± 1.42 mmHg (-3.84% ± 9.31%) among the overall study group, but this finding was not statistically significant (p = 0.108). In the 40 to 54 years and 55 to 69 years groups, the mean IOP change rates were +0.29 ± 0.96 mmHg (+2.40% ± 6.85%, p = 0.087) and -0.50 ± 0.99 mmHg (-3.05% ± 6.40%, p = 0.084) respectively. In the 70 years or older group, the mean IOP change, interestingly, was -1.80 ± 1.46 mmHg (-11.29% ± 9.31%, p < 0.001) and nine (47.4%) of the 19 subjects showed additional IOP reductions of 10% or more after converting from TMT to DMT. In all three age groups, the incidence rate of dry eye was significantly lower for DMT than for TMT (p = 0.031).

CONCLUSIONS

In POAG patients, DMT was proven to be both effective and safe for lowering the IOP, especially in those 70 years or older group, when compared with the TMT protocol.

Efficacy and safety of ultrasonic circular cyclocoagulation with second-generation probe in glaucoma: A retrospective study

Background

To assess the efficacy and safety of the second-generation probe of ultrasonic circular cyclocoagulation (UC3) in naive or refractory glaucoma, with a 6-month follow-up.

Methods

A retrospective consecutive case-series study included patients having a UC3 procedure with the second-generation probe of the EyeOP1 device, intraocular pressure (IOP) ≥ 21 mmHg and under maximum tolerated medical treatment, with or without previous glaucoma surgery. Surgical success was defined at the 6-month post-operative visit as IOP > 5 and ≤ 21 mmHg with IOP reduction ≥ 20% from baseline, without any reoperation, and visual acuity better than negative light perception.

Results

100 patients were included and 97 (97.0%; 97 eyes) attended the 6-month follow-up. At 6 months, surgical success was obtained in 48 eyes (49.5%). Intraocular pressure was reduced from a mean ± SD preoperative value of 28.0 ± 5.6 mmHg to 19.3 ± 7.1 mmHg at 6 months (p<0.0001). The proportion of eyes requiring oral acetazolamide decreased from 57.0% to 30.0% between baseline and 6 months after surgery (p = 0.0007). We observed 15 (15.0%) cases of postsurgical macular edema, 8 (8.0%) of hypotony, and 20 (20.0%) of visual acuity loss > 2 Snellen lines. Postsurgical macular edema was associated with a history of epiretinal membranes, uveitis or retinal detachment. Risk factors for hypotony were a history of diabetes or trabeculectomy.

Conclusions

The second-generation UC3 probe significantly reduced IOP in eyes with naive and refractory glaucoma but severe post-operative complications were often observed. Further studies are needed to better identify responders and decrease the high risk for complications associated with the procedure.

Treatment choices for newly diagnosed primary open angle and ocular hypertension patients

Despite advances in our knowledge of the aetiology and pathophysiology of glaucoma, the sole proven, effective intervention for treating primary open-angle glaucoma (POAG) and ocular hypertension (OHT) remains lowering of intraocular pressure (IOP) to prevent further progression and visual loss. The purpose of this review is to evaluate the treatment choices available to newly diagnosed POAG and OHT patients. We review the existing literature on treatments currently available to newly diagnosed POAG and OHT patients and discuss their role in the treatment paradigm of POAG and OHT. We consider different factors that may be important when offering a choice of treatment to newly diagnosed POAG and OHT patients as well as describing new glaucoma treatments in development and future directions for treatment.

Modeling the Pharmacotherapy Cost and Outcomes of Primary Open-Angle Glaucoma With Dry Eye

We aimed to analyze and model the cost and results of current outpatient pharmacotherapy practice in patients with primary open-angle glaucoma concomitant with dry-eye disease (POAG+DE). The point of view is that of the health care system and patients, and the time horizon was 1 year. Data were collected through a prospective, observational, real-life study of therapy practice in patients admitted to the specialized ophthalmology clinic at the Alexandrovska University Hospital in Sofia. Pharmacotherapy was recorded and analyzed by therapeutic group and INN. The probability of being prescribed preservative-free or non-free formulations was calculated, as were the cost of yearly therapy, reimbursed cost, and patient co-payment. A decision tree exploring the cost-effectiveness of preservative-free and preservative non-free formulations was built. Outcomes were recorded through three tests measuring tear film stability: TMS, NIBUT Ave, and ST. TMS values below 3, ST above 10 mm, and NIBUT Ave above 14 s were considered as indicators of good disease control. A total of 140 eyes were diagnosed with POAG, of which 64 had concomitant dry-eye disease and were included in the analysis. Monotherapy was prescribed to 34: 14 on preservative-free formulations and 20 on non-free. Meanwhile, 30 eyes received combination therapy: six on preservative-free and 24 on non-free. The monotherapy product was most commonly Prostaglandin Analogs (PG−73.5%), followed by beta-blockers (BB−26.5%). No carbonic anhydrase inhibitors (Ca AA) or alpha-2 adrenergic agonists (alfa 2 AA) were prescribed as monotherapy. The majority of patients showed poor disease control according to all three measures. The incremental cost-effectiveness ratio (ICER) was 744 BGN for TMS and 131 BGN for NUBIT for each successfully controlled eye—far below three times GDP per capita. For ST, the ICER was negative, benefiting non-free formulations. Therapy of POAG+DED with preservative-free formulations is cost-effective according to the WHO threshold of three times GDP. The median costs of the two treatment modalities were similar. Current practice shows that patients experience a higher burden in terms of co-payment than do institutions such as the NHIF.

Maximum Medical Therapy: Brinzolamide/Brimonidine And Travoprost/Timolol Fixed-Dose Combinations In Glaucoma And Ocular Hypertension

Introduction

Maximal medical therapy (MMT) is the use of ≥3 classes of topical anti-glaucoma agents to achieve maximal intraocular pressure (IOP) reduction while minimizing adverse effects and compliance challenges.

Purpose

To evaluate the additive IOP-lowering effect of twice-daily brinzolamide 1%/brimonidine 0.2% fixed-dose combination (BBFC) used adjunctively with once daily travoprost 0.004%/timolol 0.5% fixed-dose combination (TTFC) in patients with open-angle glaucoma (OAG)/ocular hypertension (OHT).

Methods

In this phase IV, double-masked study, patients on TTFC for ≥28 days, aged ≥18 years, with mean IOP ≥19 and ≤28 mmHg in at least 1 eye were randomized to receive BBFC+TTFC (n=67) or vehicle+TTFC (n=67) for 6 weeks. The primary endpoint was mean change in diurnal IOP from baseline (BL, averaged over 09:00 and 11:00) at Week 6.

Results

The study was terminated prematurely due to recruitment challenges. BL mean IOP was similar in both groups (BBFC+TTFC: 21.6±1.78 mmHg; vehicle+TTFC: 21.8±1.90 mmHg). Mean change in diurnal IOP from BL at Week 6 was greater with BBFC+TTFC (−4.25 mmHg, 95% confidence interval [CI]: −4.7, −3.8) than with vehicle+TTFC (−2.11 mmHg, 95% CI: −2.6, −1.6, treatment difference, −2.15 mmHg (95% CI: −2.8, −1.5; P<0.001). Ocular adverse events (AEs) were reported in 11.9% of patients given BBFC+TTFC and 7.5% of patients given vehicle+TTFC. The AE with highest frequency was punctate keratitis (3%) in the BBFC+TTFC group; eye irritation (3%) in the vehicle+TTFC group.

Conclusion

BBFC+TTFC as MMT demonstrated clinically relevant and statistically significant reductions in mean diurnal IOP in patients with OAG/OHT. AEs were consistent with known safety profiles of individual medications.

Retinal thickness as a potential biomarker in patients with amyloid-proven early- and late-onset Alzheimer's disease

Introduction

Retinal thickness measured with optical coherence tomography has been proposed as a noninvasive biomarker for Alzheimer's disease (AD). We therefore measured retinal thickness in well-characterized AD and control participants, considering ophthalmological confounders.

Methods

We included 57 amyloid-proven AD cases and 85 cognitively normal, amyloid-negative controls. All subjects underwent retinal thickness measurements with spectral domain optical coherence tomography and an ophthalmological assessment to exclude ocular disease.

Results

Retinal thickness did not discriminate cases from controls, including stratified analyses for early- versus late-onset AD. We found significant associations between macular thickness and global cortical atrophy [β -0.358; P = .01] and parietal cortical atrophy on magnetic resonance imaging [β -0.371; P < .01] in AD cases.

Discussion

In this study, representing the largest optical coherence tomography cohort with amyloid-proven AD cases, we show that retinal thickness does not discriminate AD from controls, despite evident changes on clinical, neuroimaging, and CSF measures, querying the use of retinal thickness measurements as an AD biomarker.

Corneal Biomechanics and Visual Field Progression in Eyes with Seemingly Well-Controlled Intraocular Pressure

PURPOSE

To investigate the incidence and risk factors for glaucomatous visual field progression in eyes with well-controlled intraocular pressure (IOP).

DESIGN

Prospective cohort.

PARTICIPANTS

A total of 460 eyes of 334 patients with glaucoma under treatment.

METHODS

Study subjects had a mean follow-up of 4.3±0.8 years. Patients were classified as well controlled if all IOP measurements were less than 18 mmHg. Rates of visual field progression were calculated using ordinary least-squares linear regression of standard automated perimetry (SAP) mean deviation (MD) values over time. Progression was defined as a significantly negative MD slope (alpha = 0.05).

MAIN OUTCOME MEASURES

Rates of SAP MD change; mean and peak IOP, and IOP fluctuation; and corneal biomechanics: corneal hysteresis (CH), central corneal thickness (CCT), and corneal index.

RESULTS

Of the 179 eyes with well-controlled IOP, 42 (23.5%) demonstrated visual field progression. There was no significant difference between progressing and stable patients in baseline MD (-6.4±7.1 decibels [dB] vs. -6.0±6.2 dB; P = 0.346), mean IOP (11.7±2.0 mmHg vs. 12.1±2.3 mmHg; P = 0.405), IOP fluctuation (1.6±0.6 mmHg vs. 1.6±0.5 mmHg; P = 0.402), or peak IOP (14.3±1.9 mmHg vs. 14.6±2.1 mmHg; P = 0.926). Progressing eyes had significantly lower CH (8.6±1.3 mmHg vs. 9.4±1.6 mmHg; P = 0.014) and thinner CCT (515.1±33.1 μm vs. 531.1±42.4 μm; P = 0.018, respectively) compared with stable eyes. In the multivariate analysis, a 1 standard deviation lower corneal index, a summation of normalized versions of CH and CCT, resulted in a 68% higher risk of progression (odds ratio, 1.68; 95% confidence interval, 1.08-2.62; P = 0.021).

CONCLUSIONS

Approximately one-quarter of eyes with well-controlled IOP may show visual field progression over time. Thin cornea and low CH are main risk factors.

Effect of Topical Prostaglandin F2α Analogs on Selected Oxidative Stress Parameters in the Tear Film

Background and Objectives: Topically administered antiglaucoma medications, especially those containing benzalkonium chloride (BAC), may cause local adverse effects and compromise ocular surface. The aim of the study was to assess the effect of topical prostaglandin F2α analogs (PGAs): preservative-free latanoprost, BAC-preserved latanoprost, preservative-free tafluprost, and BAC-preserved bimatoprost, on selected oxidative stress parameters in the tear film. Materials and Methods: The patients were divided into five groups: group C (n = 25) control group—subjects who did not use topical antiglaucoma medications, group L (n = 22)—patients using topical preservative-free latanoprost, group L+BAC (n = 25)—patients using topical BAC-preserved latanoprost, group T (n = 19)—patients using topical preservative-free tafluprost, and group B+BAC (n = 17)—patients using topical BAC-preserved bimatoprost. The oxidative stress markers in the tear film samples were evaluated: total protein (TP) concentration, advanced oxidation protein products (AOPP) content, total sulfhydryl (-SH) groups content, the activity of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx), as well as Total Oxidant Status (TOS), Total Antioxidant Response (TAR), and Oxidative Stress Index (OSI). Results: The TP concentrations in the groups L, L+BAC, and B+BAC were statistically significantly higher in comparison with group C. The SOD and CAT activities in the groups L+BAC and B+BAC were statistically significantly higher when compared to group C. As compared to group C, AOPP and TOS were statistically significantly higher in all the study groups. OSI was found to be statistically significantly higher in the groups L+BAC, T, and B+BAC in comparison with group C. Conclusion: Use of topical PGAs by the patients with ocular hypertension or primary open-angle glaucoma is associated with increased oxidative stress in the tear film which is additionally exacerbated by the presence of BAC in the formulation.

Argon Laser Iridoplasty For Plateau Iris Syndrome: Long-Term Outcomes of 48 Eyes

PRECIS

Argon laser peripheral iridoplasty (ALPI) was performed on 48 eyes with plateau iris syndrome (PIS). Indentation gonioscopy was used to monitor the opening of the iridocorneal angle. Mean intraocular pressure (IOP) at 5 years decreased from 15.9 to 14.4 mm Hg. None of the eyes required trabeculectomy.

PURPOSE

The purpose of this article was to report the long-term outcomes of ALPI for PIS.

MATERIALS AND METHODS

A retrospective chart review was performed on all patients with PIS treated with ALPI from 2001 to 2012. The study included 48 eyes from 28 patients with PIS after peripheral iridotomy, with a follow-up of at least 5 years. Patients with advanced glaucoma requiring initial surgical treatment (pathologic discs and IOP above the target IOP despite medical treatment) were excluded. The primary outcomes were the effect on the number of IOP medications, and the need for complementary selective laser trabeculoplasty (SLT) or surgery (trabeculectomy and/or phacoemulsification). Secondary outcomes were optic nerve head changes and adverse events.

RESULTS

The mean IOP statistically decreased after ALPI (15.91±2.62 vs. 14.35±2.18 mm Hg, P>0.001). The mean number of IOP-lowering medications statistically increased after ALPI (0.81±0.94 vs. 1.2±1.04, P>0.001). Mean follow-up was 92.4±26.5 months. At the end of the follow-up, 12 (25%) eyes had no medications, 20 (42%) had 1 medication, 11 (23%) had 2 medications, 3 (6%) had 3 medications, and 2 (4%) had 4. Ten (21%) eyes underwent SLT, 6 (10%) underwent phacoemulsification, and no trabeculectomy was necessary during follow-up. The change in cup to disc ratio from pre-ALPI to latest follow-up was not statistically significant, and no adverse events were reported.

CONCLUSIONS

ALPI is relatively effective and safe to prevent angle-closure glaucoma and avoid trabeculectomy in patients with PIS. This procedure often helps to control IOP, although SLT and additional medical treatments are frequently necessary to maintain the target IOP.

Comparison of head-mounted perimeter (imo®) and Humphrey Field Analyzer

Purpose

The head-mounted automated perimeter imo^® is a new portable perimeter that does not require a dark room and can be used to examine patients in any setting. In this study, imo 24plus (1-2) AIZE examinations were compared with previous Humphrey Field Analyzer (HFA) 30-2 (SITA standard) examinations within the same patient.

Patients and methods

imo examinations (either head-mounted [i-H] or fixed [i-F] type) were performed in patients with glaucoma or suspected glaucoma who had already experienced HFA five or more times. Measurement time and correlations of mean deviation (MD) and visual field index (VFI) values were compared between groups for HFA, i-H, i-F, and imo total (i-T). Fixation loss (FL), false-positive (FP), and false-negative (FN) detection rates were compared. The percentage of binocular random single-eye tests under possible non-occlusion conditions using imo was determined. Mann–Whitney U test was performed, and Spearman’s rank-order correlation coefficient was calculated.

Results

The inclusion period was July to December 2016. Among 273 subjects (543 eyes), 147 (292 eyes) were tested with i-H type and 126 (251 eyes) with i-F type. Mean MD values for HFA and i-T were -6.1±7.8 and -6.2±7.1 dB, respectively. Mean measurement times for HFA, i-H, i-F, and i-T were 15.23±2.07, 10.47±2.11, 11.04±2.31, and 10.54±2.19 minutes, respectively (P<0.01 for HFA vs i-H/i-F). Total mean measurement time was shorter by 30.8% for i-T vs HFA. Correlation coefficients of MD and VFI were R²>0.81 for HFA vs i-H and i-F. FP and FN detection rates were significantly higher with i-T than HFA; there was no significant difference in FL. Binocular random single-eye tests were possible in 85% of cases.

Conclusion

imo reduced measurement time by 30.8%. imo VFI and MD values were highly correlated with HFA. As i-F and i-H types produced similar results, imo can be used in accordance with the patient’s situation.

A New SITA Perimetric Threshold Testing Algorithm: Construction and a Multicenter Clinical Study

PURPOSE

To describe a new time-saving threshold visual field-testing strategy-Swedish Interactive Thresholding Algorithm (SITA) Faster, which is intended to replace SITA Fast-and to report on a clinical evaluation of this new strategy.

DESIGN

Description and validity analysis for modifications applied to SITA Fast.

METHODS

Five centers tested 1 eye of each of 126 glaucoma and glaucoma suspect patients with SITA Faster, SITA Fast, and SITA Standard at each of 2 visits. Outcomes included test time, mean deviation, and the visual field index (VFI), significant test points in probability maps, and intertest threshold variability.

RESULTS

Mean (standard deviation) test times were 171.9 (45.3) seconds for SITA Faster, 247.0 (56.7) for SITA Fast, and 369.5 (64.5) for SITA Standard (P < .001). SITA Faster test times averaged 30.4 % shorter than SITA Fast and 53.5 % shorter than SITA Standard. Mean deviation was similar among all 3 tests.VFI did not differ between SITA Fast and SITA Faster tests, mean difference 0%, but VFI values were 1.2% lower with SITA Standard compared to both SITA Fast (P = .007) and SITA Faster (P = .002). A similar trend was seen with a slightly higher number of significant test points with SITA Standard than with SITA Fast and SITA Faster. All 3 tests had similar test-retest variability over the entire range of threshold values.

CONCLUSIONS

SITA Faster saved considerable test time. SITA Faster and SITA Fast gave almost identical results. There were small differences between SITA Faster and SITA Standard, of the same character as previously shown for SITA Fast vs SITA Standard.

Changes in choroidal thickness and optic nerve head morphology after filtering surgery: nonpenetrating deep sclerectomy versus trabeculectomy

Background

The purpose of this study was to evaluate the changes in choroidal thickness and lamina cribrosa position after nonpenetrating deep sclerectomy (NPDS) and trabeculectomy.

Methods

Twenty-three eyes with glaucoma that required filtering surgery were included (12 NDPS and 11 trabeculectomies) in this prospective observational study. OCT-enhanced depth imaging (OCT-EDI) was used to measure choroidal thickness, prelaminar tissue thickness and lamina cribrosa position before and 7 days and 1 month after surgery. All results are shown as median (interquartile range values).

Results

Intraocular pressure (IOP) was significantly lower 1 week after surgery than at baseline (7 (6/10) mmHg vs. 21 (18/26) mmHg; p < 0.001) with a mean 64% decrease. IOP remained significantly lower at 1 month with a 55% mean decrease as compared to baseline (10 (8/12) mmHg; p < 0.001). One week after surgery, the subfoveolar choroidal thickness (SFCT) significantly increased (372 (306/523) μm vs. 317 (227/413) μm; p = 0.04) and the prelaminar tissue (PLT) was significantly thicker (269 (162/360) μm vs. 138 (87/268) μm; p = 0.02) as compared to preoperative measurements. These changes were not statistically significant at one month. There were no differences concerning these parameters between the NPDS and trabeculectomy groups. During the first week, the SFCT increase was correlated with IOP reduction (r = − 0.41; p = 0.04).

Conclusions

OCT-EDI allowed the visualization of structural changes at the level of the optic nerve and choroidal vascularization during acute IOP changes. No difference was observed between NPDS and trabeculectomy concerning these structural modifications.

Self-measurement with Icare HOME tonometer, patients' feasibility and acceptability

PURPOSE

To evaluate and compare the accuracy of self-measurement of intraocular pressure using Icare Home rebound tonometer with Goldmann applanation tonometer and assess acceptability of self-tonometry in patients with glaucoma and ocular hypertension.

METHODS

In the study, 117 subjects were trained to use Icare Home for self-measurement. Icare Home tonometer readings were compared with Goldmann applanation tonometer, including one eye per patient. Agreement between the two methods of measurement was evaluated by Bland and Altmann analysis. Questionnaire was used to evaluate patients' perception of self-tonometry.

RESULTS

One hundred and three out of 117 patients (88%) were able to measure their own intraocular pressure and 96 (82%) fulfilled the requirements for certification. The mean (SD) difference Goldmann applanation tonometer minus Icare Home was 1.2 (2.4) mmHg (95% limits of agreement, -3.4 to 5.9 mmHg). The magnitude of bias between the two methods depended on central corneal thickness, with greater bias at central corneal thickness <500 µm. In 65 out of 96 subjects (67.7%), Icare Home results were within 2 mmHg of the Goldmann applanation tonometer. Seventy-three out of 93 (78.5%) felt that self-tonometry was easy to use and 75 patients (80.6%) responded that they would use the device at home.

CONCLUSION

Icare Home tonometry tends to slightly underestimate intraocular pressure compared to Goldmann applanation tonometer. Most patients were able to perform self-tonometry and found it acceptable for home use. Measurements using rebound self-tonometry could improve the quality of intraocular pressure data and optimize treatment regimen.

Efficacy and safety of preservative-free timolol 0.1% gel in open-angle glaucoma and ocular hypertension in treatment-naïve patients and patients intolerant to other hypotensive medications

GOALS

To assess the efficacy and safety of preservative-free timolol 0.1% gel in patients with primary open-angle glaucoma (POAG) and ocular hypertension (OHT).

METHODS

In this multicenter, open-label, non-controlled clinical trial in Algeria, treatment-naïve patients with intraocular pressure (IOP)>20mmHg and<31mmHg (treatment-naïve patients, group 1) and patients with IOP controlled by current ocular monotherapy but presenting with local intolerance in at least one eye (intolerant patients; group 2) were eligible. Timolol gel was administered once daily in the morning for 84 days. The primary efficacy criteria were reduction in IOP (group 1) and maintenance of baseline IOP (group 2).

RESULTS

Overall, 93 patients were included (53 in group 1, 40 in group 2). All patients in group 2 had been previously treated with preserved eye drops. In group 1, patients showed a significant reduction in IOP with mean changes in the worse eye of -10.3±3.0mmHg at D28 and -10.8±2.5mmHg at D84 (P<0.0001). In group 2, the maintenance of efficacy on IOP at D84 was satisfactory in 91.7% of patients (worse eye). Preservative-free timolol gel was well tolerated in both groups. In group 2, the overall symptom score was significantly reduced from 8.6±5.1 to 0.9±1.6 at D28 and 0.7±1.2 at D84 (P<0.0001), and the overall ocular sign score from 3.7±2.1 to 0.8±1.0 at D28 and 0.6±0.8 at D84 (P<0.0001).

CONCLUSIONS

This preservative-free timolol 0.1% gel was effective in decreasing IOP in treatment-naïve patients and in controlling IOP and reducing ocular signs and symptoms in patients intolerant to their previous preserved medications.

The Role of Minimally Invasive Glaucoma Surgery Devices in the Management of Glaucoma

SIGNIFICANCE

Noncompliance is a problem affecting glaucoma patients. Approaches to improve adherence include the use of drug-delivery systems and safer forms of surgery. Minimally invasive glaucoma surgery (MIGS) has reduced complications, particularly in combination with cataract surgery, and with its good intraocular pressure (IOP) reduction may reduce or eliminate glaucoma medications.Glaucoma is a progressive disease and a leading cause of irreversible blindness. Elevated IOP is the most important risk factor, but effective medical management is dependent on patient adherence. This review summarizes the adherence problem in glaucoma and the efforts, including MIGS, to provide effective IOP control that is not dependent on patient compliance.The current understanding of patient adherence to pharmacological treatment of glaucoma is discussed including the challenges facing glaucoma patients. Historical approaches to providing IOP control in a sustained and reliable way are presented culminating in a review of the burgeoning use of MIGS devices.It is estimated that, in the United States, 27% of prescriptions written, across all medications, are not filled or are filled but not taken. For ocular hypotensive medications, even when filled, a large percentage (which varies widely by study) are not instilled as prescribed. To address this problem, methods for sustained drug delivery have been and continue to be developed, as well as surgical and laser approaches. Most recently, MIGS devices have gained popularity because of the ease of implantation during cataract surgery, favorable safety profile, and the possibility for effective and long-lasting IOP lowering, as well as the reduction or elimination of need for IOP-lowering medication.Poor adherence to treatment is relatively common among glaucoma patients and is associated with progression of disease. Recommending MIGS implantation during cataract surgery may offer optometrists a valuable treatment option in managing glaucoma patients, particularly where good adherence is in doubt.

In Vivo Scanning Laser Confocal Microscopy of Conjunctival Goblet Cells in Medically-controlled Glaucoma

AIM

The aim of this study was to evaluate the goblet cell density (GCD) of conjunctiva in medically-controlled glaucoma using laser scanning confocal microscopy (LSCM).

MATERIALS AND METHODS

Fifty-five glaucomatous patients were enrolled and divided into two groups: Group 1 (27 eyes), controlled with one medication; and group 2 (28 eyes), controlled with two medications. Seventeen patients with dry eye disease (DED) and 17 healthy individuals served as controls. Patients completed the Ocular Surface Disease Index (OSDI) questionnaire and underwent determination of tear film break-up time (BUT), corneal staining, and Schirmer test I. For the GCD assessment, 12 high-quality images were acquired from the upper conjunctival epithelium (superior nasal, superior central, and superior temporal sectors).

RESULTS

Overall, GCD was significantly reduced in both glaucoma groups and those with DED compared to healthy controls (p<0.001), with values markedly lower in group 2 compared to group 1 (p<0.05). GCD was not significantly different between those with DED and group 2. A significant negative correlation was found of GCD with OSDI and with BUT (p<0.001; R=-0.795 and R=-0.756, respectively).

CONCLUSION

Glaucoma therapy leads to a marked reduction of GCs, especially in the associative regimens. Given the negative correlation with tear film function tests, GCD reduction may play a pivotal role in the pathophysiology of the glaucoma-related disease of the ocular surface.

Optical Coherence Tomography Angiography in Glaucoma: A Review

BACKGROUND

Glaucoma is the leading cause of irreversible blindness worldwide. Several techniques exist for the diagnosis and follow-up of patients. Optical coherence tomography (OCT) angiography (OCTA) is a recently developed technique that provides a quantitative assessment of the microcirculation of the retina and choroid in a fast, noninvasive way. Despite it being a novel technique, several publications have already been done in the glaucoma field. However, a summary of findings is currently lacking.

AIMS

To perform a literature review to assess the role of OCTA in glaucoma diagnosis and follow-up.

METHODS

A database search was carried out using MEDLINE, Embase, and Web of Science, including all original works registered until July 23, 2017.

RESULTS

OCTA (1) has a high repeatability and reproducibility, (2) has good discriminatory power to differentiate normal eyes from glaucoma eyes, (3) is more strongly correlated with visual function than conventional OCT, (4) has good discriminatory power to differentiate early-glaucoma eyes from normal eyes (i.e., at least equal to that of OCT), (5) reaches a floor effect at a more advanced disease stage than OCT, and (6) is able to detect progression in glaucoma eyes.

CONCLUSION

OCTA shows potential to become a part of everyday glaucoma management.

Cyclodestructive procedures for non-refractory glaucoma

BACKGROUND

Glaucoma is a leading cause of blindness worldwide. It results in a progressive loss of peripheral vision and, in late stages, loss of central vision leading to blindness. Early treatment of glaucoma aims to prevent or delay vision loss. Elevated intraocular pressure (IOP) is the main causal modifiable risk factor for glaucoma. Aqueous outflow obstruction is the main cause of IOP elevation, which can be mitigated either by increasing outflow or reducing aqueous humor production. Cyclodestructive procedures use various methods to target and destroy the ciliary body epithelium, the site of aqueous humor production, thereby lowering IOP. The most common approach is laser cyclophotocoagulation.

OBJECTIVES

To assess the effectiveness and safety of cyclodestructive procedures for the management of non-refractory glaucoma (i.e. glaucoma in an eye that has not undergone incisional glaucoma surgery). We also aimed to compare the effect of different routes of administration, laser delivery instruments, and parameters of cyclophotocoagulation with respect to IOP control, visual acuity, pain control, and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 8); Ovid MEDLINE; Embase.com; LILACS; the metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov. The date of the search was 7 August 2017. We also searched the reference lists of reports from included studies.

SELECTION CRITERIA

We included randomized controlled trials of participants who had undergone cyclodestruction as a primary treatment for glaucoma. We included only head-to-head trials that had compared cyclophotocoagulation to other procedural interventions, or compared cyclophotocoagulation using different types of lasers, delivery methods, parameters, or a combination of these factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risks of bias, extracted data, and graded the certainty of the evidence in accordance with Cochrane standards.

MAIN RESULTS

We included one trial (92 eyes of 92 participants) that evaluated the efficacy of diode transscleral cyclophotocoagulation (TSCPC) as primary surgical therapy. We identified no other eligible ongoing or completed trial. The included trial compared low-energy versus high-energy TSCPC in eyes with primary open-angle glaucoma. The trial was conducted in Ghana and had a mean follow-up period of 13.2 months post-treatment. In this trial, low-energy TSCPC was defined as 45.0 J delivered, high-energy as 65.5 J delivered; it is worth noting that other trials have defined high- and low-energy TSCPC differently. We assessed this trial to have had low risk of selection bias and reporting bias, unclear risk of performance bias, and high risk of detection bias and attrition bias. Trial authors excluded 13 participants with missing follow-up data; the analyses therefore included 40 (85%) of 47 participants in the low-energy group and 39 (87%) of 45 participants in the high-energy group.Control of IOP, defined as a decrease in IOP by 20% from baseline value, was achieved in 47% of eyes, at similar rates in the low-energy group and the high-energy groups; the small study size creates uncertainty about the significance of the difference, if any, between energy settings (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.64 to 1.65; 79 participants; low-certainty evidence). The difference in effect between energy settings based on mean decrease in IOP, if any exists, also was uncertain (mean difference (MD) -0.50 mmHg, 95% CI -5.79 to 4.79; 79 participants; low-certainty evidence).Decreased vision was defined as the proportion of participants with a decrease of 2 or more lines on the Snellen chart or one or more categories of visual acuity when unable to read the eye chart. Twenty-three percent of eyes had a decrease in vision. The size of any difference between the low-energy group and the high-energy group was uncertain (RR 1.22, 95% CI 0.54 to 2.76; 79 participants; low-certainty evidence). Data were not available for mean visual acuity and proportion of participants with vision change defined as greater than 1 line on the Snellen chart.The difference in the mean number of glaucoma medications used after cyclophotocoagulation was similar when comparing treatment groups (MD 0.10, 95% CI -0.43 to 0.63; 79 participants; moderate-certainty evidence). Twenty percent of eyes were retreated; the estimated effect of energy settings on the need for retreatment was inconclusive (RR 0.76, 95% CI 0.31 to 1.84; 79 participants; low-certainty evidence). No data for visual field, cost effectiveness, or quality-of-life outcomes were reported by the trial investigators.Adverse events were reported for the total study population, rather than by treatment group. The trial authors stated that most participants reported mild to moderate pain after the procedure, and many had transient conjunctival burns (percentages not reported). Severe iritis occurred in two eyes and hyphema occurred in three eyes. No instances of hypotony or phthisis bulbi were reported. The only adverse outcome that was reported by the treatment group was atonic pupil (RR 0.89 in the low-energy group, 95% CI 0.47 to 1.68; 92 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to evaluate the relative effectiveness and safety of cyclodestructive procedures for the primary procedural management of non-refractory glaucoma. Results from the one included trial did not compare cyclophotocoagulation to other procedural interventions and yielded uncertainty about any difference in outcomes when comparing low-energy versus high-energy diode TSCPC. Overall, the effect of laser treatment on IOP control was modest and the number of eyes experiencing vision loss was limited. More research is needed specific to the management of non-refractory glaucoma.

Switching from concomitant therapy to tafluprost/timolol fixed combination

Purpose

To evaluate the efficacy and safety of tafluprost/timolol fixed combination (TTFC).

Study design

A prospective clinical study.

Methods

Twenty-eight patients (28 eyes) with primary open-angle glaucoma, who had used tafluprost and timolol gel for at least 3 months with good adherence, were enrolled. Concomitant administration of tafluprost and timolol was switched to TTFC without a washout period. The intraocular pressure (IOP), blood pressure, pulse rate, and ocular signs were compared between before switching (baseline), and 4 and 8 weeks after switching. A questionnaire survey was also performed 4 weeks after switching to investigate ocular comfort and patient preferences.

Results

The IOP showed no significant change after switching to TTFC (14.8 ± 2.8, 14.6 ± 3.4, and 14.8 ± 3.7 mmHg at baseline, Week 4, and Week 8, respectively). The pulse rate and systolic blood pressure showed no changes, but diastolic blood pressure was significantly lower at Week 8. At baseline, fluorescein staining revealed corneal abnormalities in 3 patients, which resolved by Week 8 in 1 patient. Hyperemia was noted in 2 patients at baseline, and this also resolved by Week 8 in 1 patient. Three patients discontinued study treatment for the following reasons (1 patient each): blurred vision; ocular irritation, eyelid erythema, and asthenopia; and loss to follow-up from Week 8. The questionnaire survey revealed no significant differences between the 2 treatments, although more patients preferred TTFC.

Conclusion

Among 28 patients enrolled, only 2 patients discontinued the study treatment due to adverse reactions. In patients whose adherence was considered relatively good to concomitant therapy, switching to TTFC achieved similar IOP control with good safety and a high level of patient acceptance.

Systemic Medication Associations with Presumed Advanced or Uncontrolled Primary Open-Angle Glaucoma

PURPOSE

To identify associations between systemic medications and primary open-angle glaucoma (POAG) requiring a procedure using United States insurance claims data in a hypothesis-generating study.

DESIGN

Database study.

PARTICIPANTS

In total, 6130 POAG cases (defined as patients with POAG undergoing a glaucoma procedure) were matched to 30 650 controls (defined as patients undergoing cataract surgery but without a coded glaucoma diagnosis, procedure, or medication) by age, gender, and region of residence.

METHODS

Participant prescription drug use was calculated for the 5-year period before the glaucoma procedure or cataract surgery. Separately for individual generic drugs and drug classes, logistic regression was used to assess the association with POAG status. This was done across all generic drugs and drug classes that were prescribed in at least 1% of cases and controls. Analyses were adjusted for age, sex, region of residence, employment status, insurance plan type, and the total number of drugs prescribed.

MAIN OUTCOME MEASURES

Odds ratio (OR) and 95% confidence intervals (CIs) for the association between each drug or drug class and POAG.

RESULTS

The median age of participants was 72 years, and 52% were women. We tested for associations of POAG with 423 drug classes and 1763 generic drugs, resulting in a total of 2186 statistical tests and a Bonferroni-adjusted significance threshold of P < 2.3 × 10^-5. Selective serotonin reuptake inhibitors (SSRIs) were strongly associated with a reduced risk of POAG (OR, 0.70; 95% CI, 0.64-0.76; P = 1.0 × 10^-15); the most significant drug in this class was citalopram (OR, 0.66; 95% CI, 0.57-0.77; P = 1.2 × 10^-7). Calcium channel blockers were strongly associated with an increased risk of POAG (OR, 1.26; 95% CI, 1.18-1.35; P = 1.8 × 10^-11); the most significant drug in this class was amlodipine (OR, 1.27; 95% CI, 1.18-1.37; P = 5.9 × 10^-10).

CONCLUSIONS

We present data documenting potential associations of SSRIs and calcium channel blockers with POAG requiring a procedure. Further research may be indicated to better evaluate any associates of serotonin metabolism or calcium channels in glaucoma, or establish whether the associations are due to variations in the patterns for prescribing these drugs.