Recent trends in glaucoma surgery: a nationwide database study in Japan, 2011-2019

Evaluation of machine learning approach for surgical results of Ahmed valve implantation in patients with glaucoma

BACKGROUND

Ahmed valve implantation demonstrated an increasing proportion in glaucoma surgery, but predicting the successful maintenance of target intraocular pressure remains a challenging task. This study aimed to evaluate the performance of machine learning (ML) in predicting surgical outcomes after Ahmed valve implantation and to assess potential risk factors associated with surgical failure to contribute to improving the success rate.

METHODS

This study used preoperative data of patients who underwent Ahmed valve implantation from 2017 to 2021 at Ajou University Hospital. These datasets included demographic and ophthalmic parameters (dataset A), systemic medical records excluding psychiatric records (dataset B), and psychiatric medications (dataset C). Logistic regression, extreme gradient boosting (XGBoost), and support vector machines were first evaluated using only dataset A. The algorithm with the best performance was selected based on the area under the receiver operating characteristics curve (AUROC). Finally, three additional prediction models were developed using the best performance algorithm, incorporating combinations of multiple datasets to predict surgical outcomes at 1 year.

RESULTS

Among 153 eyes of 133 patients, 131 (85.6%) and 22 (14.4%) eyes were categorized as the success and failure groups, respectively. The XGBoost was shown as the best-performance model with an AUROC value of 0.684, using only dataset A. The final three further prediction models were developed based on the combination of multiple datasets using the XGBoost model. All datasets combinations demonstrated the best performances in terms of AUROC (dataset A + B: 0.782; A + C: 0.773; A + B + C: 0.801). Furthermore, advancing age was a risk factor associated with a higher surgical failure incidence.

CONCLUSIONS

ML provides some predictive value in predicting the outcomes of Ahmed valve implantation at 1 year. ML evaluation revealed advancing age as a common risk factor for surgical failure.

Comparing corneal biomechanic changes among solo cataract surgery, microhook ab interno trabeculotomy and iStent implantation

Minimally invasive glaucoma surgery has expanded the surgical treatment options in glaucoma, particularly when combined with cataract surgery. It is clinically relevant to understand the associated postoperative changes in biomechanical properties because they are influential on the measurement of intraocular pressure (IOP) and play an important role in the pathogenesis of open-angle glaucoma (OAG). This retrospective case-control study included OAG patients who underwent cataract surgery combined with microhook ab interno trabeculotomy (µLOT group: 53 eyes of 36 patients) or iStent implantation (iStent group: 59 eyes of 37 patients) and 62 eyes of 42 solo cataract patients without glaucoma as a control group. Changes in ten biomechanical parameters measured with the Ocular Response Analyzer and Corneal Visualization Scheimpflug Technology (Corvis ST) at 3 and 6 months postoperatively relative to baseline were compared among the 3 groups. In all the groups, IOP significantly decreased postoperatively. In the µLOT and control groups, significant changes in Corvis ST-related parameters, including stiffness parameter A1 and stress‒strain index, indicated that the cornea became softer postoperatively. In contrast, these parameters were unchanged in the iStent group. Apart from IOP reduction, the results show variations in corneal biomechanical changes from minimally invasive glaucoma surgery combined with cataract surgery.

Effects of Brimonidine, Omidenepag Isopropyl, and Ripasudil Ophthalmic Solutions to Protect against H2O2-Induced Oxidative Stress in Human Trabecular Meshwork Cells

PURPOSE

We investigated whether hydrogen peroxide (H2O2)-induced oxidative stress causes human trabecular meshwork (HTM) cell dysfunction observed in open angle glaucoma (OAG) in vitro, and the effects of topical glaucoma medications on oxidative stress in HTM cells.

METHODS

We used commercially available ophthalmic solutions of brimonidine, omidenepag isopropyl, and ripasudil in the study. HTM cells were exposed to H2O2 for 1 h, with or without glaucoma medications. We assessed cell viability and senescence via WST-1 and senescence-associated-β-galactosidase (SA-β-Gal) activity assays. After exposure to H2O2 and glaucoma medications, we evaluated changes in markers of fibrosis and stress by using real-time quantitative polymerase chain reaction (qPCR) to measure the mRNA levels of collagen type I alpha 1 chain (COL1A1), fibronectin, alpha-smooth muscle actin (α-SMA), matrix metalloproteinase-2 (MMP-2), endoplasmic reticulum stress markers of C/EBP homologous protein (CHOP), 78-kDa glucose-regulated protein (GRP78), and splicing X-box binding protein-1 (sXBP-1).

RESULTS

HTM cell viability decreased and SA-β-Gal activity increased significantly after exposure to H2O2. Treatment with three ophthalmic solutions attenuated these changes. Real-time qPCR revealed that H2O2 upregulated the mRNA levels of COL1A1, fibronectin, α-SMA, CHOP, GRP78, and sXBP-1, whereas it downregulated MMP-2 mRNA expression significantly. Brimonidine suppressed the upregulation of stress markers CHOP and GRP78. Additionally, omidenepag isopropyl and ripasudil decreased the upregulation of COL1A1 and sXBP-1. Furthermore, ripasudil significantly suppressed fibrotic markers fibronectin and α-SMA, compared with the other two medications.

CONCLUSION

In vitro, H2O2 treatment of HTM cells induced characteristic changes of OAG, such as fibrosis changes and the upregulation of stress markers. These glaucomatous changes were attenuated by additional treatments with brimonidine, omidenepag isopropyl, and ripasudil ophthalmic solutions.

Practice patterns and costs of glaucoma treatment in Japan

PURPOSE

Understanding the practice patterns and costs of glaucoma care in real-world clinical settings is important for optimizing medical expenses. However, glaucoma treatment trends and associated costs in Japan are unknown. We aimed to unveil glaucoma treatment trends and costs using a large administrative claims database in Japan.

STUDY DESIGN

Retrospective cohort study.

METHODS

We included patients diagnosed with glaucoma between April 2014 and March 2021 using the DeSC database. We calculated the frequencies and costs of antiglaucoma eyedrops, incisional or laser procedures, and ophthalmic examinations stratified by fiscal year and age. In the year-by-year analyses, the age distribution was standardized based on the 2020 distribution.

RESULTS

A total of 841,747 patient-years (429,051 patients) were included. The number of prescribed eyedrops significantly increased and the fixed-combination eyedrops proportion decreased with age. Trabeculectomy frequency decreased, and that of laser trabeculoplasty increased during the observation period. The frequencies of both incisional and laser procedures peaked in the 75-79 age group. In 2020, 16.1 bottles of eyedrops per patient-year were prescribed, and 15.9 incisional surgeries and 11.3 laser therapies were performed per 1000 patient-years. Intraocular pressure measurement and visual field testing were performed 6.5 times and 2.0 times per patient-year, respectively. The total direct cost of glaucoma treatment was 55,139 yen (US $399.5) per patient-year, of which medications accounted for 44.2%, ophthalmic examinations for 47.4%, and incisional or laser procedures for 8.4%.

CONCLUSION

These results may be useful for understanding glaucoma treatment trends and costs in Japan.

Nationwide Analysis of Glaucoma Surgeries in Fiscal Years of 2014 and 2020 in Japan

Nationwide trends in glaucoma surgical procedures were assessed by using the NDB Open Data 2014 and 2020. In Japan, 33,340 non-laser, 54,569 laser, and 88,019 total glaucoma surgeries were performed in 2014. In 2020, 60,108 non-laser, 60,547 laser, and 120,655 total glaucoma surgeries were performed. The rates from 2014 to 2020 were 180%, 111%, and 137%, respectively. In each procedure, angle surgery (326%), tube shunt surgery (383%), ciliary coagulation (489%), and gonio-laser (225%) were remarkably increased, while iridectomy (75%) and iris laser (77%) decreased during the same period. An increase in laser surgery was seen in young age groups, namely, 55-59 years old and younger, while non-laser surgery was increased in old age groups, namely, 45-49 years old and older. In 2020, 47.6 non-laser, 48.0 laser, and 95.6 total glaucoma surgeries were performed per 100,000 persons. None of the vital statistics, including prefectural population, mean age, and rate of ≥65-year-old people, were significantly associated with the number of glaucoma surgeries. Glaucoma practice patterns changed each time a new device or procedure was introduced. The results of the current study reflected the use of new procedures, such as minimally invasive glaucoma surgery, tube shunt, selective laser trabeculoplasty, and micropulse cyclophotocoagulation.

Recent Trends in Treatment and Associated Costs of Primary Angle-Closure Glaucoma: A Retrospective Cohort Study

PURPOSE

To describe recent trends in the treatment for primary angle-closure glaucoma (PACG) and its associated costs in a clinical setting.

DESIGN

A retrospective cohort study.

SUBJECTS

We included patients with PACG from 2011 to 2020 using a large-scale administrative claims database in Japan.

METHODS

We calculated the frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries, stratified by fiscal years and age groups.

MAIN OUTCOME MEASURES

Frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries.

RESULTS

We identified 5654 patients with PACG (15 338 patient-years). Prostanoid FP receptor agonist, nonselective β-blocker, and topical carbonic anhydrase inhibitor use decreased, whereas prostanoid EP2 receptor agonist, α-2 adrenergic agonist, Rho-associated protein kinase inhibitor, and fixed-combination eyedrops use increased. The total amount of drug per patient-year significantly decreased. In recent years, the frequency of cataract surgery increased, whereas that of laser peripheral iridotomy decreased. Visual field testing, slit-lamp examination, intraocular pressure measurement, and funduscopy were performed 0.83, 6.65, 5.15, and 4.61 times/patient-year, respectively. The total cost of drugs, examinations, and surgeries was 60 338 yen per patient-year. Patients with PACG spent more than twice the money on surgeries and examinations than they did on antiglaucoma drugs.

CONCLUSION

The amount of antiglaucoma drugs dispensed decreased, and the proportion of fixed-combination and newly introduced eyedrops increased. Frequency of cataract surgery increased whereas that of laser peripheral iridotomy decreased in recent years. Surgeries and examinations were the major cost drivers for PACG treatment. The current results would be valuable information for future economic analyses and policy making.

FINANCIAL DISCLOSURE(S)

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

Validity of Algorithms to Identify Patients With Glaucoma Using the Japanese Claims Data

PRCIS

Diagnostic or antiglaucoma drug records in the Japanese claims data showed a high validity in identifying glaucoma patients. Specific subtypes were identified with high specificity and negative predictive values but low sensitivity and positive predictive values.

PURPOSE

Despite the widespread use of administrative claims data in epidemiological research on glaucoma, only a few studies have investigated the validity of the methods in defining patients with glaucoma using diagnoses and drug records. We aimed to evaluate the validity of these algorithms in identifying patients with glaucoma using the Japanese claims data.

METHODS

Two ophthalmologists independently reviewed the medical charts and administrative claims data of 500 randomly selected patients who visited the Department of Ophthalmology of an academic hospital in 2019. We constructed 12 algorithms to identify patients with any type and specific subtypes of glaucoma using the claims records of diagnosis, antiglaucoma drugs, and visual field tests. We regarded the diagnosis of glaucoma based on the medical charts as the reference standard and calculated the sensitivity, specificity, and positive and negative predictive values of each algorithm based on the claims data.

RESULTS

The algorithms of ≥1 diagnostic record per year and ≥1 antiglaucoma drug record per year exhibited sensitivities of 94.6% and 89.2%, respectively, and specificities of 88.9% and 98.3%, respectively. An increase in the frequency of records resulted in a decreased sensitivity and slightly increased specificity. The addition of visual field tests did not improve the validity. The algorithms for specific subtypes of glaucoma exhibited high specificity and relatively low sensitivity.

CONCLUSION

Diagnostic or antiglaucoma drug records in the Japanese claims data were useful for identifying patients with glaucoma. Researchers should select identification algorithms based on the study design.

One-year costs of incisional glaucoma surgery and laser therapy

BACKGROUND

This study aimed to calculate one-year total costs of incisional glaucoma surgery and laser therapy in a real-world clinical setting.

METHODS

We conducted a retrospective cohort study from July 2010 to March 2021 using the Diagnosis Procedure Combination database. We included patients hospitalized for incisional glaucoma surgery (trabeculectomy, trabeculotomy, tube shunt surgery, Ex-PRESS surgery, or iStent implantation) or laser therapy (laser peripheral iridotomy, surgical iridectomy, laser trabeculoplasty, cyclocryotherapy, or cyclophotocoagulation). The outcomes were total costs, including costs of hospitalization, re-admissions, antiglaucoma drugs, ophthalmic examinations, and outpatient visits for incisional glaucoma surgery and laser therapy within one year.

RESULTS

We identified 49,202 eligible hospitalizations. The one-year median total cost was 707,497 yen [interquartile range: 546,887-944,664 yen]. The median total cost was the highest in patients undergoing tube shunt surgery, followed by Ex-PRESS surgery, iStent implantation, and trabeculectomy. The number and cost of postoperative outpatient visits and length of hospital stay were higher in patients who underwent trabeculectomy and Ex-PRESS surgery than in those after tube shunt surgery. The total costs of laser therapies were lower than those of incisional glaucoma surgeries. The total cost was the highest in the 0-19 age group (856,398 [649,419-1,258,844] yen).

CONCLUSIONS

Tube shunt surgery was the costliest in terms of total one-year costs. Trabeculectomy and Ex-PRESS surgery were associated with long hospital stays and incurred high postoperative costs. The costs of laser therapies were relatively low. However, cost-effectiveness of laser therapies compared with incisional surgeries needs to be analyzed in future research.

Minimally Invasive Glaucoma Surgery in Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is responsible for half of the glaucoma-related blindness worldwide. Cataract surgery with or without trabeculectomy has been considered to be the first-line treatment in eyes with medically uncontrolled PACG. While minimally invasive glaucoma surgery has become an important surgical approach for primary open-angle glaucoma, its indications and benefits in PACG are less clear. This review summarizes the efficacy and safety profile of minimally invasive glaucoma surgery in PACG to unfold new insights into the surgical management of PACG.

CO2 Laser-Assisted Sclerectomy Surgery Alone or Combined with Phacoemulsification in Primary Open-Angle Glaucoma: Comparison of 1-Year Outcomes

Introduction

To compare 1-year outcomes of CO₂ laser-assisted sclerectomy surgery (CLASS) alone or combined with phacoemulsification (CLASS + Phaco) in eyes with primary open-angle glaucoma (POAG).

Methods

This was a prospective, comparative, case series study. A total of 46 eyes with POAG underwent CLASS or CLASS + Phaco were followed up for 1 year. The primary outcomes included changes in intraocular pressure (IOP), medication and best corrected visual acuity (BCVA). The secondary outcomes were success rate, functional bleb, postoperative laser intervention and complications.

Results

CLASS alone resulted in a greater IOP reduction compared with CLASS + Phaco. BCVA improved remarkably in CLASS + Phaco group, but there was no difference in BCVA before and after CLASS. The number of antiglaucoma medications significantly decreased at 12 months postoperatively in both groups. Functional blebs were more commonly seen in the CLASS than combination group. The overall success rate was higher in the CLASS than CLASS + Phaco group at 1 year after surgery. The incidence of peripheral anterior synechiae (PAS) in CLASS + Phaco group was significantly lower than that of CLASS alone.

Conclusion

CLASS alone achieved a greater IOP reduction, more common functional bleb formation and a higher success rate compared to CLASS combined with Phaco, while combination surgery yielded a better BCVA improvement and a lower PAS incidence than CLASS alone. Both surgical strategies have favorable safety and efficacy among POAG patients. Combined surgery could be a viable option for patients with co-existing POAG and cataract.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00539-2.