Prevalence of glaucoma in Germany: results from the Gutenberg Health Study

Systematic Review of Instruments for the Assessment of Patient-Reported Outcomes and Quality of Life in Patients with Childhood Glaucoma

TOPIC

To identify patient-reported outcome measures (PROMs) that have been used in children and adolescents with glaucoma and to evaluate their methodologic quality.

CLINICAL RELEVANCE

Childhood glaucoma impairs vision and quality of life (QoL) throughout all stages of life. Thus, a PROM needs to cover many different age groups and topics. Various instruments have been used to evaluate patient-reported outcomes (PROs) in patients with childhood glaucoma, however, it is unclear which PROM has the highest methodologic quality and complies best with the needs of patients with childhood glaucoma.

METHODS

A systematic literature review was performed searching MEDLINE (PubMed), the Cochrane Library, Web of Science, and PsycINFO (EBSCO). We included peer-reviewed full-text articles of the past 10 years in English, German, or Spanish language that reported PROMs in children with glaucoma. The study selection and methodologic quality assessment of the identified PROMs was performed by 2 independent reviewers using a 7-point checklist. The content was mapped onto the World Health Organization International Classification of Functioning, Disability and Health. The systematic review was prospectively registered in PROSPERO (ID CRD42022353936).

RESULTS

The search strategy retrieved 3295 matches. A total of 2901 studies were screened, and 11 relevant articles were identified using 10 different instruments. The instruments addressed functional visual ability, vision-related QoL, health-related QoL, and life satisfaction. Six instruments were applicable for the use in children. Seven of the questionnaires received the highest number of positive ratings (5/7). None of the instruments considered the views of patients with childhood glaucoma during their development.

CONCLUSION

This systematic review provides a descriptive catalog of vision-specific and generic health PRO instruments that have been used in childhood glaucoma cohorts. An instrument specifically developed for childhood glaucoma is lacking which might result in missing important factors, such as permanent treatment with eye drops, repeated surgeries, and heritability of the disease, when investigating the QoL in children with glaucoma.

FINANCIAL DISCLOSURE(S)

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

How latanoprost changed glaucoma management

Glaucoma is currently considered one of the leading causes of severe visual impairment and blindness worldwide. Topical medical therapy represents the treatment of choice for many glaucoma patients. Introduction of latanoprost, 25 years ago, with an entirely new mechanism of action from that of the antiglaucoma drugs used up to that time was a very important milestone. Since then, due mainly to their efficacy, limited systemic side effects and once daily dosing, prostaglandin analogues (PGAs) have become as the first-choice treatment for primary open-angle glaucoma. PGAs are in general terms well tolerated, although they are associated with several mild to moderate ocular and periocular adverse events. Among them, conjunctival hyperemia, eyelash changes, eyelid pigmentation, iris pigmentation and hypertrichosis around the eyes are the most prevalent. The objective of this paper is to review the role of PGAs in the treatment of glaucoma over the 25 years since the launch of Latanoprost and their impact on clinical practice outcomes.

[Use of antiglaucomatous drugs in the urban adult population : New Insights into the prevalence of glaucoma from the Hamburg City Health Study]

BACKGROUND

Glaucoma is a widespread ophthalmological disease. Knowledge about the spread of the disease in the population is necessary with respect to further questions on comorbidities, risk factors and the provision of care.

OBJECTIVE

An analysis of the use of glaucoma medications and the prevalence of glaucoma in an urban adult population was carried out.

MATERIAL AND METHODS

The Hamburg City Health Study (HCHS) is a prospective, long-term, population-based cohort study that includes a random sample of 45,000 participants aged between 45 and 79 years from the general population of Hamburg, Germany. Apart from various medical parameters, data include premedication and the medical history of the participants. The use of antiglaucomatous medication among the first 10,000 study participants was analyzed and the prevalence of glaucoma was estimated according to the use of medications as well as by the self-reported history of glaucoma. Descriptive analysis and logistic regression analysis were performed to analyze the data and to calculate correlations by age and gender.

RESULTS

In the study population 319 persons were on medication to lower the intraocular pressure (IOP, mean age 67.1 years, SD = 7.57 years), which is equivalent to an estimated prevalence of 3.35% (95% confidence interval, CI 3.00-3.70%). A positive correlation was observed between age and the use of IOP-lowering medication, which is statistically highly significant (p = < 0.001). The analysis by gender showed a slightly higher prevalence among women, which was not statistically significant. The estimated prevalence according to glaucoma medication and history were only partly congruent.

DISCUSSION

This estimated prevalence of glaucoma is comparable to other epidemiological studies. The study results cover not only patients with manifest glaucoma but also persons who were treated for ocular hypertension. The inconsistency between the prevalence of glaucoma medication and the diagnosis of glaucoma can be explained by different treatment strategies and also by information deficits.

A generalizable deep learning regression model for automated glaucoma screening from fundus images

A plethora of classification models for the detection of glaucoma from fundus images have been proposed in recent years. Often trained with data from a single glaucoma clinic, they report impressive performance on internal test sets, but tend to struggle in generalizing to external sets. This performance drop can be attributed to data shifts in glaucoma prevalence, fundus camera, and the definition of glaucoma ground truth. In this study, we confirm that a previously described regression network for glaucoma referral (G-RISK) obtains excellent results in a variety of challenging settings. Thirteen different data sources of labeled fundus images were utilized. The data sources include two large population cohorts (Australian Blue Mountains Eye Study, BMES and German Gutenberg Health Study, GHS) and 11 publicly available datasets (AIROGS, ORIGA, REFUGE1, LAG, ODIR, REFUGE2, GAMMA, RIM-ONEr3, RIM-ONE DL, ACRIMA, PAPILA). To minimize data shifts in input data, a standardized image processing strategy was developed to obtain 30° disc-centered images from the original data. A total of 149,455 images were included for model testing. Area under the receiver operating characteristic curve (AUC) for BMES and GHS population cohorts were at 0.976 [95% CI: 0.967-0.986] and 0.984 [95% CI: 0.980-0.991] on participant level, respectively. At a fixed specificity of 95%, sensitivities were at 87.3% and 90.3%, respectively, surpassing the minimum criteria of 85% sensitivity recommended by Prevent Blindness America. AUC values on the eleven publicly available data sets ranged from 0.854 to 0.988. These results confirm the excellent generalizability of a glaucoma risk regression model trained with homogeneous data from a single tertiary referral center. Further validation using prospective cohort studies is warranted.

Comparison between Intraocular Pressure Profiles over 24 and 48 h in the Management of Glaucoma

(1) Background: Due to significant variation, sporadic IOP measurements often fail to correctly assess the IOP situation in glaucoma patients. Thus, diurnal-nocturnal IOP profiles can be used as a diagnostic tool. The purpose of this study is to determine the additional diagnostic value of prolonged IOP profiles. (2) Methods: All diagnostic 48 h IOP profiles from a large university hospital, between 2017 and 2019, were reviewed. Elevated IOP > 21 mmHg, IOP variation > 6 mmHg and nocturnal IOP peaks were defined as IOP events of interest and counted. The analysis was repeated for the first 24 h of every IOP profile only. The Chi2 test was used for statistical analysis. (3) Results: 661 IOP profiles were included. Specifically, 59% of the 48 h IOP profiles revealed IOP values above 21 mmHg, and 87% showed IOP fluctuation greater than 6 mmHg. Nocturnal peaks in the supine position could be observed in 51% of the patients. In the profiles censored for the first 24 h, the fractions were 50%, 71% and 48%, (p < 0.01, p < 0.01 and p = 0.12) respectively. (4) Conclusions: the 48 h IOP profiles identified more patients with IOP events of interest than the 24 h IOP profiles. The additional diagnostic value must be weighed against the higher costs.

[Glaucoma in infancy and childhood]

Glaucoma in infancy and childhood is a rare disease. An immediate diagnosis and treatment are absolutely necessary to prevent blindness of affected children. Childhood glaucoma is characterized by a heterogeneous phenotype: besides primary congenital glaucoma, secondary types often exist and the individualized treatment requires an experienced interdisciplinary team. The pathogenesis is not always discernible and genetic alterations sometimes cause the disease. A surgical procedure is usually necessary to lower the intraocular pressure. Refractive and orthoptic care are equally important to avoid amblyopia. This article gives an overview of childhood glaucoma and outlines the most important diagnostic and therapeutic aspects.

Kindliche Glaukomerkrankungen

Glaukomerkrankungen im Kindesalter sind selten. Da ohne Behandlung in der Regel die Erblindung eintritt, ist eine umgehende Diagnosestellung und Therapie von höchster Bedeutung. Die Heterogenität der Erkrankung erfordert eine genaue Kenntnis der möglichen Ursachen und deren individuelle Behandlung. Dieser Artikel soll einen Überblick über die kindlichen Glaukome vermitteln und die wichtigsten Aspekte der Therapie aufzeigen.

[Childhood Glaucoma]

Childhood glaucoma is a rare disease. Since a lacking therapy normally leads to blindness an immediate diagnosis and appropriate treatment are crucial. The heterogeneity of childhood glaucoma requires a comprehensive knowledge of possible underlying pathomechanisms of primary and secondary childhood glaucoma types. Several types of childhood glaucoma are accompanied with ocular or systemic syndromes and hereditary causes are frequent. Thus, an interdisciplinary team of ophthalmologists, orthoptists, pediatricians, human geneticists, and anesthesiologists is vital for a successful supply. Most cases rely on a dysgenesis of trabecular meshwork with impaired outflow. Thus, usually a surgical approach is indicated. To handle a surgery in a buphthalmic eye an experienced hand is required. Special attention should be paid on the correct prescription of topical antiglaucomatous therapy in children since they are more prone to develop side effects. This article aims to provide an overview about the different childhood glaucoma types and to point out the most important aspects of their individual treatment strategies.

Effects of femtosecond laser-assisted trephination on donor tissue in liquid interface as compared to applanated interface

Purpose

To evaluate the effects of femtosecond laser‐assisted keratoplasty using a liquid patient interface (L‐PI) as opposed to an applanated interface (A‐PI) on graft quality and functionality markers.

Methods

Pressure measurements during femtosecond laser‐assisted trephination were performed using two groups of 10 porcine eyes. Trephination was performed either in an L‐PI or in an A‐PI setting. Pressure sensor needles placed intravitreally continuously recorded intraocular pressure during trephination. Twenty paired human donor eyes were used to test the morphological quality of donor tissue after trephination in L‐PI and A‐PI settings. Optical coherence tomography (OCT) scans were performed before and after trephination. Images were processed using ImageJ and pixel².

Results

During trephination, pressure measurements with an L‐PI were significantly lower than with an A‐PI (p = 0.0121). Mean pressure during trephination was 78.1 mmHg ± 37.6 mmHg with L‐PI and 188.6 mmHg ± 17.7 mmHg with A‐PI. Trephination in A‐PI produced a significantly larger increase (p < 0.00001) in donor pachymetry than trephination in L‐PI. Significantly lower areas of Descemet folds were achieved in L‐PI trephination than in A‐PI trephination (p < 0.01). There was no significant difference in circularity between A‐PI and L‐PI (p = 0.27). Total time required for trephination was comparable between L‐PI and A‐PI (p = 0.45). Time taken to reach working vacuum was achieved significantly more quickly in L‐PI (p < 0.05).

Conclusion

Femtosecond laser‐assisted L‐PI keratoplasty appears to be a promising method to decrease stress to donor and recipient tissue during femtosecond laser‐assisted trephination. Results showed favourable donor tissue morphology markers after L‐PI trephination.

MicroPulse Transscleral Laser Therapy Demonstrates Similar Efficacy with a Superior and More Favorable Safety Profile Compared to Continuous-Wave Transscleral Cyclophotocoagulation

Purpose. The aim of this study was to compare effectiveness and safety of MicroPulse transscleral laser therapy (MP-TLT) using the original MicroPulse P3® device and continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) using the G-Probe® device in glaucoma. Methods. Spherical equivalent, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and number of topical or oral ophthalmic pressure-reducing medications were registered at every time point, up to the last follow-up at 12 months. A complete slit-lamp examination was conducted to record the following complications: corneal edema, persistent ocular hypotony (IOP ≤5 mmHg) on two consecutive follow-up visits, choroidal detachment, phthisis bulbi, sympathetic ophthalmia, cystoid macular edema, or other abnormal ocular findings. Success was defined as IOP between 6 and 21 mmHg and >20% reduction in IOP with or without antiglaucoma medications. Results. 47 eyes underwent MP-TLT and 150 CW-TSCPC. At 12 months, success was achieved in 88.6% in the CW-TSCPC group and 87.5% in the MP-TLT group ( $p$  = 0.883). In the CW-TSCPC group, eyes achieved a 42.4% IOP reduction (from 28.3 ± 12.3 mmHg to 15.3 ± 6.0 mmHg) and a 31.1% reduction (from 22.0 ± 7.2 mmHg to 15.7 ± 4.8 mmHg) in the MP-TLT group. Visual acuity remained primarily unaltered in both groups. Conclusion. MP-TLT was as effective in lowering IOP as CW-TSCPC and achieved comparable success. Additionally, MP-TLT demonstrated consistent and effective outcomes at every time point. The improved safety profile of MP-TLT allows the therapeutic spectrum to be broadened, granting ophthalmologists’ treatment of glaucoma in earlier stages of glaucoma than those typically treated with CW-TSCPC, i.e., early to moderate and to patients with good central-vision.

First and second transscleral cyclophotocoagulation treatments provide similar intraocular pressure-lowering efficacy in patients with refractory glaucoma

Purpose

The aim of this study is to address the safety and effectiveness of a second continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) treatment by comparing its outcome against a first CW-TSCPC treatment in the same patients with refractory glaucoma.

Methods

Twenty-one eyes with either primary or secondary glaucoma received a second CW-TSCPC laser session ≥ 3 months after the first treatment. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), and number of topical or oral ophthalmic pressure-reducing medications were registered at every time point up to the last follow-up at 3 months. A complete slit-lamp examination was conducted to record for complications or other abnormal ocular findings. Success was defined as IOP between 6 and 21 mmHg and > 20% reduction in IOP with or without anti-glaucoma medications.

Results

At 3 months follow-up of the first CW-TSCPC treatment, a 24.8% decrease in IOP was observed, whereas a 45.6% IOP decrease was observed 3 months post the second CW-TSCPC treatment. Visual acuity did not decrease, and no major complications were observed post either treatment within the follow-up period. Time to failure was 79.5 ± 24.6 and 77.1 ± 29.4, respectively (P = 0.955). No serious complications were observed.

Conclusion

A second CW-TSCPC treatment proved to be a safe and effective treatment option when the first CW-TSCPC treatment was insufficient in maintaining the desired IOP level for a prolonged time (mean time between both sessions 6.4 ± 8.0 months).

Time trends, associations and prevalence of blindness and vision loss due to glaucoma: an analysis of observational data from the Global Burden of Disease Study 2017

OBJECTIVE

To estimate global prevalence of blindness and vision loss caused by glaucoma, and to evaluate the impact of socioeconomic factors on it.

DESIGN

A population-based observational study.

SETTING

The prevalence of blindness and vision loss due to glaucoma were obtained from the Global Burden of Disease Study 2017 database. The Human Development Index (HDI), inequality-adjusted HDI and other socioeconomic data were acquired from international open databases.

MAIN OUTCOME MEASURES

The prevalence of blindness and vision loss due to glaucoma by age, gender, subregion and Socio-Demographic Index (SDI) levels. Multiple linear regression analysis was performed to explore the associations between the prevalence and socioeconomic indicators.

RESULTS

The overall age-standardised prevalence of blindness and vision loss due to glaucoma worldwide was 81.5 per 100 000 in 1990 and 75.6 per 100 000 in 2017. In 2017, men had a higher age-standardised prevalence than women (6.07% vs 5.42%), and the worldwide prevalence increased with age, from 0.5 per 100 000 in the 45-49 year age group to 112.9 per 100 000 among those 70+. Eastern Mediterranean and African regions had the highest prevalence during the whole period, while the Americas region had the lowest prevalence. The prevalence was highest in low-SDI and low-income regions while lowest in high-SDI and high-income regions over the past 27 years. Multiple linear regression showed cataract surgery rate (β=-0.01, p=0.009), refractive error prevalence (β=-0.03, p=0.024) and expected years of schooling (β= -8.33, p=0.035) were associated with lower prevalence, while gross national income per capita (β=0.002, p<0.001) was associated with higher prevalence.

CONCLUSIONS

Lower socioeconomic levels and worse access to eyecare services are associated with higher prevalence of glaucoma-related blindness and vision loss. These findings provide evidence for policy-makers that investments in these areas may reduce the burden of the leading cause of irreversible blindness.

Peripheral corneal thickness and associated factors - results from the population-based German Gutenberg Health Study

PURPOSE

Changes in peripheral corneal thickness are described in various corneal diseases such as corneal ectasia. However, few data exist describing the increase in corneal thickness from central to peripheral and reporting the normal distribution of corneal thickness in rings around the corneal centre. The aim of this study was to report these cornea characteristics and investigate associated factors in a population-based setting.

METHODS

The Gutenberg Health Study is a prospective, population-based study examining participants in a 5-year follow-up (age range 40-80 years) using Scheimpflug imaging. Corneal thickness was assessed in each participant at the apex, as well as in the corneal centre (thinnest corneal thickness) and in rings with 2, 4, 6, 8 and 10 mm diameter around the corneal centre, and the increase in corneal thickness towards the periphery. The relationship between corneal thickness at these locations and possible associated factors was determined using linear regression models. For this purpose, general and ocular parameters were included.

RESULTS

A total of 9729 participants were included in the present analysis (4874 women, age 59.2 ± 10.8 years). Multivariable analysis showed a correlation between the increase in corneal thickness in the circles from 0 to 10 mm (diameter) and the following parameters: age (B = -0.24 µm per year, p < 0.001); body height (B = -0.04 µm, p = 0.005); smoking (B = -0.72 µm, p < 0.001); spherical equivalent (B = -0.70 µm per dioptre, p < 0.001); white-to-white distance (B = -0.75 µm/mm, p < 0.001); mean corneal radius (B = -3.61 µm/mm, p < 0.001); intraocular pressure (B = -0.12 µm/mmHg, p < 0.001); glaucoma (B = -1.94 µm, p < 0.001); and pseudophakia (B = 0.89 µm, p < 0.001).

CONCLUSION

The results of the present study suggest that several general and ocular parameters are associated with peripheral corneal thickness. In the context of diagnosing glaucoma, a smaller increase in corneal thickness towards the periphery might be a new additional marker.

A Simple Subjective Evaluation of Enface OCT Reflectance Images Distinguishes Glaucoma From Healthy Eyes

Purpose

We present a subjective approach to detecting glaucomatous defects in enface images and assess its diagnostic performance. We also test the hypothesis that if reflectivity changes precede thickness changes in glaucoma there should be reduced correlation between the modalities in glaucoma compared to controls.

Methods

Twenty glaucoma participants and 20 age-matched controls underwent high-resolution OCT scans of one eye. 4 µm-thick enface slabs were constructed through the retina. Enface indices were depths of first gap in visible retinal nerve fiber bundles (RNFBs) and last visible bundle, subjectively evaluated in six sectors of a 3.5 mm circle around the optic disc. Retinal nerve fiber layer thickness (RNFLT) along the same circle was extracted at angles corresponding to enface indices. Between-group differences were tested by linear mixed models. Diagnostic performance was measured by partial receiver operating characteristic area (pAUC).

Results

First gap and last visible bundle were closer to the inner limiting membrane in glaucoma eyes (both P < 0.0001). Enface indices showed excellent diagnostic performance (pAUCs 0.63-1.00), similar to RNFLT (pAUCs 0.63-0.95). Correlation between enface and RNFLT parameters was strong in healthy (r = 0.81-0.92) and glaucoma eyes (r = 0.73-0.80).

Conclusions

This simple subjective method reliably identifies glaucomatous defects in enface images with diagnostic performance at least as good as existing thickness indices. Thickness and reflectivity were similarly related in healthy and glaucoma eyes, providing no strong evidence of reflectivity loss preceding thinning. Objective analyses may realize further potential of enface OCT images in glaucoma.

Translational Relevance

Novel enface OCT indices may aid glaucoma diagnosis.

Risk factors for open-angle glaucoma and recommendations for glaucoma screening

Open-angle glaucomas are a group of chronic progressive optic nerve neuropathies with a gonioscopic open anterior chamber angle. They are one of the main causes of visual impairment and blindness in industrialized countries. The aim of this article is to discuss and evaluate the epidemiology and risk factors for the development of open-angle glaucoma and to present the screening procedure for open-angle glaucoma according to the recently published S2e guidelines of the Association of the Scientific Medical Societies in Germany (AWMF).

[Glaucoma care in Germany-Results of a survey among German ophthalmologists-Part 1: diagnostics]

Hintergrund

Die Möglichkeiten in der Glaukomversorgung sind in den letzten Jahren immer vielfältiger geworden. Unter den Mitgliedern der Deutschen Ophthalmologischen Gesellschaft (DOG) und des Berufsverbands der Augenärzte Deutschlands (BVA) wurde eine anonymisierte Befragung durchgeführt, um zu erfassen, welche Behandlungswege in der Versorgung von Glaukompatienten gewählt werden, welche diagnostischen Parameter den Augenärztinnen und Augenärzten wichtig sind und welche Rolle Behandlungsleitlinien in der Alltagspraxis zukommt.

Ziel der Arbeit

Meinungsbild unter der deutschen Augenärzteschaft über die aktuelle Glaukomversorgung, zentrale diagnostische Parameter und ihre Anwendung in der Alltagspraxis.

Material und Methoden

Die Befragung wurde durch einen Online-Fragebogen mit insgesamt 26 Fragen (107 Items) zur Versorgungspraxis in der Glaukomdiagnostik und der Glaukomtherapie durchgeführt. Vollständig ausgefüllte Fragebögen lagen von 1361 Personen vor.

Ergebnisse

Die Papillenbeurteilung an der Spaltlampe hat für Augenärzte weiterhin den höchsten diagnostischen Stellenwert. Auch der Rolle der optischen Kohärenztomographie (OCT) kommt eine sehr hohe diagnostische Bewertung zu. Bei der Interpretation verschiedener diagnostischer Parameter ergibt sich eine höhere Sicherheit für papillennahe Parameter unter den Befragten. Eine leitliniengemäße Versorgung wird nach Selbstauskunft der Augenärzte weitgehend betrieben. Etwa zwei Drittel der Befragten führen im ersten Behandlungsjahr zwei oder mehr Gesichtsfelduntersuchungen durch und ebenso eine strukturelle Papillendarstellung einmal im Jahr. Die Rolle der Gonioskopie wird kontrovers gesehen und nicht einheitlich intensiv praktiziert.

Diskussion

Die Diagnosestellung beim Glaukom ist eine große klinische Herausforderung. Die verschiedenen diagnostischen Parameter haben einen unterschiedlich hohen Wert für Augenärzte. Morphometrische Verfahren haben eine sehr hohe Bedeutung gewonnen und ermöglichen eine assistierte, jedoch keine automatisierte Diagnostik. Mehr Behandlungsleitlinien und Standards bei der Glaukomversorgung werden gewünscht und sollten in Aus- und Weiterbildung und in den Behandlungsalltag implementiert sein.

The prevalence and incidence of glaucoma in Norway 2004-2018: A nationwide population-based study

PURPOSE

To describe prevalence, life-time prevalence and incidence of glaucoma in Norway over a 15-year period.

MATERIALS AND METHODS

Data from The Norwegian Prescription Database was used to identify all prescriptions for glaucoma medication during the period 2004 to 2018. Population figures and lifespan data were obtained from The National Bureau of Statistics.

RESULTS

Of a population of 5.3 million, a total of 75733 patients using glaucoma eye drops were identified in 2018. The national prevalence was thus 1.4%, whilst in those over 70 years of age, 8.0%. When divided into counties, the prevalence varied between 1.1 and 1.9%. Overall, the prevalence was stable in the period 2004-2018. Life time prevalence was found to be 9.4% for men and 10.2% for women. National one-year incidence proportion per 10000 was 17.0 for the total population and a peak incidence of 93.8/10000 in the 80-89 year age group was identified.

CONCLUSIONS

Glaucoma prevalence remained stable during the period 2004-2018, while incidence decreased slightly in the elderly population.

Treatment Complexity in Primary Open-Angle Glaucoma (POAG): Perspectives on Patient Selection in Micro-Invasive Glaucoma Surgery (MIGS) Using Stents

BACKGROUND

Primary open-angle glaucoma (POAG) is still one of the most common causes of impaired vision worldwide, despite the further development of therapy options, and can lead to blindness. Micro-invasive glaucoma surgery (MIGS) using stents aims at reducing intraocular pressure (IOP), as it is the main risk factor. With regard to adherence and adverse drug reactions it also aims at reducing the drug burden on patients. The study investigates under everyday conditions the criteria according to which ophthalmologists in Germany select patients for MIGS using stents. In addition, it will be investigated which patients (could) benefit most from the therapy.

MATERIAL AND METHODS

In this qualitative study, 11 narrative interviews were conducted between May 2017 and July 2018 with ophthalmologists working in the hospital or in a private practice. They were interviewed on their experiences in the treatment of POAG with microstents. The interviews were analysed by an interdisciplinary team using the qualitative content analysis.

RESULTS

The stages of therapy escalation form the frame of reference for patient selection in MIGS using stents. Only if the IOP cannot be sufficiently reduced by drop therapy or when this causes drug-related side effects that are intolerable for the patients, stents are apparently used as the next higher escalation stage. The intensive post-operative medication and the frequent check-up appointments are perceived as barriers by the interviewees, especially for people with or without disabilities, who are dependent on external help and/or those living in rural areas. The active cooperation of the patients in the demanding aftercare seems to be indispensable for the ophthalmologists. In addition, necessary revisions are sometimes stressful for patients (physical/psychological) and doctors (work organisation/therapy). Against the background of the organisational and economic challenges in the outpatient spectrum of tasks, especially physicians in private practice seem to weigh up carefully for which patients microstent therapy would be reasonable.

CONCLUSION

In view of the therapeutic requirements, the current microstent therapy seems to be used in a selected, adherent patient group. Further qualitative and quantitative studies (in other health care regions and structures) are necessary to verify and extend the available results.

[Risk factors for open-angle glaucoma and recommendations for glaucoma screening]

Open-angle glaucomas are a group of chronic progressive optic nerve neuropathies with a gonioscopic open anterior chamber angle. They are one of the main causes of visual impairment and blindness in industrialized countries. The aim of this article is to discuss and evaluate the epidemiology and risk factors for the development of open-angle glaucoma and to present the screening procedure for open-angle glaucoma according to the recently published S2e guidelines of the Association of the Scientific Medical Societies in Germany (AWMF).

The Diagnosis and Treatment of Glaucoma

BACKGROUND

Glaucoma is a group of chronically progressive disorders of the optic nerve. In this article, we present the epidemiology of and risk factors for glaucoma, as well as the diagnostic work-up and treatment options.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and the Cochrane Library, supplemented by further articles chosen by the authors.

RESULTS

In Europe, the prevalence of glaucoma is 2.93% among persons aged 40 to 80 years. The prevalence rises with age, reaching 10% in persons over 90 years old. The available diagnostic methods include ophthalmoscopy, tonometry, perimetry, and imaging techniques. The treatment of glaucoma is focused on lowering the intraocular pressure with topical drugs, laser therapy, and glaucoma surgery. In patients with manifest glaucoma, lowering the intraocular pressure prevents the progression of visual field defects, with a number needed to treat of 7.

CONCLUSION

The diagnostic evaluation of glaucoma rests on multiple pillars, all of which must be considered for establishing the diagnosis and defining the desired target pressure: these are, among others, the intraocular pressure and ocular function and morphology. Individually tailored pressure-lowering treatment should be evaluated in regularly scheduled follow-up visits for assessment of function and morphology and adjusted as necessary to minimize the risk of progression.

[Prevalence of ophthalmic diseases in the population older than 50 years]

The ageing of population is accompanied by an increase in the frequency of chronic diseases, including ophthalmic. The progression of ophthalmologic disturbances has population specificity and its analysis in Russian population is relevant.

PURPOSE

To study the prevalence and age- and gender-related gradient of ophthalmic diseases (cataract, glaucoma, age-related macular degeneration, diabetic and hypertensive retinopathy) in the Russian population older than 50 years.

MATERIAL AND METHODS

A random population cohort (9360, aged 45-69 years) was examined in Novosibirsk in 2003/05 and re-examined in 2015/17 (the HAPIEE project). Ophthalmological parameters were studied in a random subsample (324 m/f, aged 55-84, 2015/17). Clinical and instrumental methods were applied to assess eye diseases: cataract, glaucoma, age-related macular degeneration (AMD), diabetic retinopathy (DR), hypertensive retinopathy (HR) and other ophthalmic diseases.

RESULTS

In the studied sample of men and women aged 55-84 years, the prevalence of cataract was 72.8%, AMD - 25.7%, glaucoma - 6.2%, DR - 2.1%, HR - 79.6%. The prevalence of other ophthalmic diseases (myopia, hyperopia, astigmatism, pterygium, pinguecula, dystrophy of cornea and retina, tumors and inflammatory diseases) was 13.5%. The frequency of cataract (p<0.001) and AMD (p=0.003) significantly increased with age. The frequency of glaucoma did not change substantially in the studied age range with insignificant increase in those older than 80 years (14.3%). The frequency of DR and HR were not consistently related to age.

CONCLUSIONS

In the studied population sample of men and women aged 55-84 years (Novosibirsk), the prevalence of cataract and HR is high; the prevalence of AMD is similar to populations with moderate frequency of diseases; the frequency of glaucoma is close to populations with high prevalence of this disease. The frequency of cataract and AMD increased with age. There was no consistent age gradient of the frequency of glaucoma, DR and HR in the age range of 55-84 years.

Association of Birth Weight with Peripapillary Retinal Nerve Fiber Layer Thickness in Adulthood—Results from a Population-Based Study

Purpose

Low birth weight is associated with altered retinal development in childhood, including reduced peripapillary retinal nerve fiber layer (pRNFL) thickness. However, to the best of our knowledge, no population-based study has analyzed the relationship of low birth weight to pRNFL thickness in adulthood. The purpose of this study was to investigate whether birth weight has a long-term effect on pRNFL thickness in adulthood.

Methods

In the German population-based Gutenberg Health Study (GHS), participants were examined with spectral-domain optical coherence tomography using a peripapillary scan and automated measurement of pRNFL thickness as a global parameter and in six sectors. The association between self-reported birth weight and the different pRNFL sectors were analyzed with multivariable linear regression, adjusted for potential confounders including sex, age, axial length, self-reported age-related macular degeneration, and glaucoma.

Results

In 3,028 participants, self-reported birth weight was documented and pRNFL measurements were successfully performed (1632 females, ages 54.9 ± 10.0 years). After adjustment for several confounders in the multivariable model, a positive association was observed between birth weight and pRNFL thickness in the global sector (β = 0.13 µm/100 g; 95% CI, 0.08–0.18; P < 0.001; R² = 0.007) and especially in the inferotemporal sector (β = 0.22 µm/100 g; 95% CI, 0.15–0.29; P < 0.001; R² = 0.008) and inferonasal sector (β = 0.28 µm/100 g; 95% CI, 0.17–0.39; P < 0.001; R² = 0.005).

Conclusions

Our data show that there is a weak relationship between birth weight and pRNFL thickness in adulthood. This weak association is particularly present in the inferior part of the optic nerve head. Therefore, low birth weight may have an impact on optic nerve head development and potentially on ocular disease development.

[Seroprevalence and SARS-CoV-2 testing in healthcare occupations]

The SARS-CoV‑2 causes a disease spectrum that includes asymptomatic and mildly symptomatic infections with subclinical manifestations but which can nevertheless still be potentially contagious. Evidence from SARS-CoV‑2 infected macaque monkeys and from studies with seasonal coronaviruses suggests that the infection is likely to produce an immunity that is protective for a certain period of time. Available test methods enable a high degree of reliability, e.g. if high-quality serological methods are combined. Although individual test results have to be interpreted with caution, serosurveillance in a tertiary eye care center and large eye research institute can reduce anxiety and provide clarity regarding the actual number of (unreported) SARS-CoV‑2 infections.

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.

[Treatment success of canaloplasty and trabeculectomy by the same surgeon with the same level of experience in the long-term course]

BACKGROUND

Trabeculectomy (TE) with the use of antimetabolites is the standard procedure in glaucoma surgery, whereas canaloplasty (CP) is a nonpenetrating and potentially less invasive alternative.

OBJECTIVE

The aim of this retrospective case series was to compare the long-term success of CP and TE under the same conditions and with the same levels of experience of the surgeon as well as to investigate whether preoperative intraocular pressure (IOP) and postoperative IOP correlate with eachother.

METHODS

The study included 57 eyes that underwent either CP or TE (CP n = 27; male = 50.0% age 60.7 ± 13.2 years; TE n = 30; male = 55.6% age 68.0 ± 9.1 years). Each of the procedures was performed by the same surgeon with comparable levels of experience. The comparison included preoperative and postoperative visual field damage, preoperative and postoperative IOP (mm Hg) after 1 and 6 weeks, 6 and 12 months as well as in the long-term course (1-3 years) and the necessary local treatment at the corresponding times.

RESULTS

With both methods no worsening of the visual field could be detected and the patient groups showed comparable preoperative and postoperative mean deviations (MD). The CP showed a positive correlation between preoperative and postoperative 1‑year IOP (r = 0.4; p = 0.022), whereas TE showed no significant correlation between preoperative and postoperative IOP. The count of local antiglaucoma medication in long-term comparison (1-3 years after surgery) was higher after CP than after TE (1.5 ± 1.6 vs. 0.5 ± 0.8; p = 0.003). In both groups there were no severe postoperative complications. The overall success rates (without treatment) were higher at all time points after TE.

DISCUSSION

With both methods conducted by the same surgeon with the same levels of experience, an effective reduction of the IOP was achieved. It seems that the higher the preoperative IOP before CP, the higher the achievable pressure after 1 year and in the long term. In contrast, after TE the IOP was effectively reduced in the long term regardless of the initial IOP. The CP seems to be inferior to TE under the same conditions with respect to complete surgical success (without local treatment).

Potentially inappropriate prescriptions of anticholinergic medications in patients with closed-angle glaucoma

PURPOSE

Glaucoma is the leading cause for blindness after cataracts worldwide. The aim was to identify anticholinergic drugs prescribed to patients diagnosed with closed-angle glaucoma in Colombia.

METHODS

This cross-sectional study identified the prescribing patterns of cholinergic antagonists related to the increased intraocular pressure in patients diagnosed with closed-angle glaucoma from a Colombian database. The Anticholinergic Drug Scale was used to quantify the anticholinergic burden.

RESULTS

We identified 1958 patients with closed-angle glaucoma, with a mean age of 70.5 ± 10.3 years, 72.9% of whom were women. Cholinergic antagonists were prescribed in at least 32.4% of cases. An age range between 75 and 84 years (odds ratio (OR) 2.35, 95% confidence interval (CI) 1.366-4.059) and being aged 85 years or older (OR 3.40, 95% CI 1.809-6.425) were associated with a greater probability of receiving an anticholinergic burden between 1 and 2 points. Females (OR 1.54, 95% CI 1.096-2.181) had a higher probability of receiving an anticholinergic burden ≥ 3 points. Interactions between antiglaucoma medications and anticholinergic treatments were identified in 32.1% of the patients.

CONCLUSIONS

Most patients were prescribed multiple antiglaucoma medications, reflecting a large number of potentially inappropriate prescriptions, with anticholinergic drugs, related to the increased intraocular pressure.

Posterior segment eye lesions: prevalence and associations with ocular and systemic parameters: results from the Gutenberg Health Study

BACKGROUND

To estimate the prevalence of posterior segment eye lesions and to identify their ocular and systemic associations within the Gutenberg Health Study (GHS) in Germany.

METHODS

Assessment and grading of fundus images as well as physical examination and history taking were performed in the cross-sectional analysis of 15,010 subjects (aged 35-74 years) using standardised procedures to determine the prevalence and associations of various posterior segment eye lesions.

RESULTS

Fundus photographs of both eyes were available for 12,782 (85.2%; 50% female) subjects. The prevalence weighted to the region of Mainz and Mainz-Bingen in Germany was for choroidal nevi 2.4%, drusen of the optic nerve head 0.2%, tilted discs 1.5%, chorioretinal scars suggestive of toxoplasmosis 0.2%, retinitis pigmentosa 0.04% and persistent hyaloid artery 0.02%. Choroidal nevi were positively associated with a history of myocardial infarction (OR = 2.7, 95% confidence interval 1.2-6.2, p value = 0.017). Tilted discs were positively associated with increased intraocular pressure (OR = 1.09 per mm Hg (1.02-1.16), p = 0.011) and negatively associated with smoking (OR 0.4 (0.3-0.7), p = 0.0022). Participants with tilted discs had a mean spherical equivalent of - 3.6 dioptres (standard deviation 4.0) compared with - 0.4 dioptres (2.4) to those without.

CONCLUSION

Our study is-to the best of our knowledge-the first to determine the prevalence of drusen of optic nerve head among Caucasians, to show a positive association between tilted discs and increased intraocular pressure and questions a possible link between choroidal nevi and myocardial infarction. It also showed that participants with tilted discs had a lower mean spherical equivalent than those without.