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Ciociola EC, Sekimitsu S, Smith S, Lorch AC, Miller JW, Elze T, Zebardast N. Racial Disparities in Glaucoma Vision Outcomes and Eye Care Utilization: An IRIS Registry Analysis. Am J Ophthalmol 2024; 264:194-204. [PMID: 38548127 DOI: 10.1016/j.ajo.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/09/2024]
Abstract
PURPOSE To evaluate racial disparities in vision outcomes and eye care utilization among glaucoma patients. DESIGN Retrospective cohort study. METHODS In this population-based IRIS Registry (Intelligent Research in Sight) study, we included patients with minimum one diagnosis code for glaucoma at least 6 months prior to January 1, 2015 and at least one eye exam, visual field (VF), optical coherence tomography (OCT), or eye-related inpatient or emergency department (ED) code in 2015. Multivariable logistic and negative binomial regression models were used to assess vision and utilization outcomes, respectively, across race and ethnicity from January 1, 2015 to January 1, 2020. Vision outcomes included cup-to-disc ratio (CDR) progression > 0.80, poor vision (visual acuity 20/200 or worse), low vision codes, and need for glaucoma filtering surgery. Utilization outcomes included outpatient eye exams, OCTs, VFs, inpatient/ED encounters, and lasers/surgeries. RESULTS Among 996,297 patients, 73% were non-Hispanic White, 15% non-Hispanic Black, 9% Hispanic, 3% Asian/Pacific Islander, and 0.3% Native American/Alaska Native. Compared to White eyes, Black and Hispanic eyes had higher adjusted odds of CDR progression (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 1.08-1.17; OR = 1.28, 95% CI = 1.22-1.34), poor vision (OR = 1.26, 95% CI = 1.22-1.29; OR = 1.26, 95% CI = 1.22-1.31), glaucoma filtering surgery (rate ratio (RR) = 1.47, 95% CI = 1.42-1.51; RR = 1.13, 95% CI = 1.09-1.18). Hispanic eyes also had increased odds of low vision diagnoses (Hispanic OR = 1.18, 95% CI = 1.07-1.30). Black and Hispanic patients were less likely to have eye exams (RR = 0.94, 95% CI = 0.94-0.95; RR = 0.99, 95% CI = 0.99-0.99) and OCTs (RR = 0.86, 95% CI = 0.85-0.86; RR = 0.97, 95% CI = 0.96-0.98), yet Black patients had higher odds of inpatient/ED encounters (RR = 1.64, 95% CI = 1.37-1.96) compared to White patients. Native American patients were more likely to have poor vision (OR = 1.17, 95% CI = 1.01-1.36) and less likely to have outpatient visits (RR = 0.89, 95% CI = 0.86-0.91), OCTs (RR = 0.85, 95% CI = 0.82-0.89), visual fields (RR = 0.91, 95% CI = 0.88-0.94) or lasers/surgeries (RR = 0.87, 95% CI = 0.79-0.96) compared to White patients. CONCLUSIONS We found that significant disparities in US eye care exist with Black, Hispanic, and Native American patients having worse vision outcomes and less disease monitoring. Glaucoma may be undertreated in these racial and ethnic minority groups, increasing risk for glaucoma-related vision loss.
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Affiliation(s)
- Elizabeth C Ciociola
- From the Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins (E.C.C.), Baltimore, Maryland, USA
| | - Sayuri Sekimitsu
- Tufts University School of Medicine (S.S., S.S.), Boston, Massachusetts, USA
| | - Sophie Smith
- Tufts University School of Medicine (S.S., S.S.), Boston, Massachusetts, USA
| | - Alice C Lorch
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA (A.C.L., J.W.M., T.E., N.Z., J.W.M., A.L.)
| | - Joan W Miller
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA (A.C.L., J.W.M., T.E., N.Z., J.W.M., A.L.)
| | - Tobias Elze
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA (A.C.L., J.W.M., T.E., N.Z., J.W.M., A.L.)
| | - Nazlee Zebardast
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA (A.C.L., J.W.M., T.E., N.Z., J.W.M., A.L.).
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Pacovska MF, de Amorim-Cabral CLD, Teixeira EGDRM, Kasahara N. The need for more pragmatic trials in glaucoma research. Eur J Ophthalmol 2024:11206721241247428. [PMID: 38602016 DOI: 10.1177/11206721241247428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
AIM There have been a number of clinical trials in glaucoma research published in the past two decades. Most of these trials were designed to evaluate very specific issues in selected populations placing them in the explanatory end of the pragmatic-explanatory continuum. The purpose of this study was to assess the level of pragmatism of published randomized controlled trials in glaucoma. METHODS A PubMed search using 'glaucoma' from 1995 to 2022 and randomized controlled trial (RCT) article type was done. Each study was assessed by three independent examiners using the Pragmatic-Explanatory Continuum Indicator Summary version 2 (PRECIS-2) toolkit. Scores were calculated for each study to determine the level of pragmatism. A summed score ≥36 was indicative of a very pragmatic study. RESULTS Thirty-two different articles were included in the analysis. These papers represented 13 different landmark trials. The median PRECIS-2 score was 32 (range, 25 for the Early Manifest Glaucoma Trial (EMGT) to 34 to the Collaborative Normal Tension Glaucoma Study (CNTGS) and the Ocular Hypertension Treatment Study). The Treatment of Advanced Glaucoma Study (TAGS), was considered very pragmatic and scored 33 points. CONCLUSION Despite the number of RCTs in glaucoma, there is still a need for more pragmatic studies.
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Affiliation(s)
- Mayara Fernanda Pacovska
- Department of Ophthalmology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
| | | | | | - Niro Kasahara
- Department of Ophthalmology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
- Santa Casa de Sao Paulo School of Medical Sciences, Sao Paulo, Brazil
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Barquet-Pizá V, Siegfried CJ. Understanding racial disparities of glaucoma. Curr Opin Ophthalmol 2024; 35:97-103. [PMID: 37922412 DOI: 10.1097/icu.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
PURPOSE OF REVIEW Increased prevalence, earlier onset, and more rapid progression to vision loss from glaucoma has demonstrated racial disparity in numerous studies over decades. Precise etiologies of these important differences among patients of African and Hispanic ancestral background have not been elucidated. This review focuses on currently available epidemiologic/population, genetic, socioeconomic and physiologic studies of racial disparities in this blinding disease. RECENT FINDINGS In depth reviews of several landmark studies of glaucoma prevalence in various racial groups have highlighted potential challenges of lack of recruitment of diverse populations in genetic studies and clinical trials, challenges of racial stratification of subjects, and the impact of socioeconomic variables. SUMMARY Through a more comprehensive analysis of racial disparities of glaucoma, both clinicians and researchers may provide more effective population screening and management with a holistic approach for individualized patient care to provide improved outcomes. Future studies of interventions in sociodemographic factors and genetic/physiologic variables that influence the prevalence, access, and consequential vision loss from glaucoma will be crucial to minimize/eliminate racial disparities and improve outcomes for all.
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Affiliation(s)
- Viviana Barquet-Pizá
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
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Panarelli JF, Moster MR, Garcia-Feijoo J, Flowers BE, Baker ND, Barnebey HS, Grover DS, Khatana AK, Lee B, Nguyen T, Stiles MC, Sadruddin O, Khaw PT. Ab-Externo MicroShunt versus Trabeculectomy in Primary Open-Angle Glaucoma: Two-Year Results from a Randomized, Multicenter Study. Ophthalmology 2024; 131:266-276. [PMID: 37769852 DOI: 10.1016/j.ophtha.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
PURPOSE To compare the effectiveness and safety of the MicroShunt (Santen Inc) versus trabeculectomy in patients with primary open-angle glaucoma (POAG). DESIGN Prospective, randomized, multicenter trial conducted in the United States and Europe. PARTICIPANTS Adult patients (aged 40-85 years) with mild to severe POAG inadequately controlled on maximum tolerated medical therapy and intraocular pressure (IOP) ≥ 15 mmHg and ≤ 40 mmHg. METHODS Patients were randomized 3:1 to stand-alone MicroShunt implantation (n = 395) or trabeculectomy (n = 132), both augmented with mitomycin C (MMC) 0.2 mg/ml for 2 minutes. MAIN OUTCOME MEASURES The primary effectiveness end point was surgical success, defined as ≥ 20% reduction in mean diurnal IOP from baseline with no increase in glaucoma medications. Secondary end points included changes in mean IOP and medication use from baseline and the need for postoperative interventions. RESULTS At 2 years, the rate of surgical success was lower in the MicroShunt group than in the trabeculectomy group (50.6% vs. 64.4%, P = 0.005). Mean diurnal IOP was reduced from 21.1 ± 4.9 mmHg at baseline to 13.9 ± 3.9 mmHg at 24 months in the MicroShunt group and from 21.1 ± 5.0 mmHg at baseline to 10.7 ± 3.7 mmHg at 24 months in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Mean medication use decreased from 3.1 to 0.9 in the MicroShunt group and from 2.9 to 0.4 in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Adverse events at 2 years were generally similar in the 2 groups, except that hypotony was more common in eyes undergoing trabeculectomy (51.1% vs. 30.9%, P < 0.001). Repositioning or explantation of the implant occurred in 6.8% of MicroShunt patients. The majority of these patients had device removal at the time of subsequent glaucoma surgery. Vision-threatening complications were uncommon in both groups. CONCLUSION At 2 years, both the MicroShunt and trabeculectomy provided significant reductions in IOP and medication use, with trabeculectomy continuing to have greater surgical success. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bonny Lee
- New York University, New York, New York
| | | | | | | | - Peng T Khaw
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, England; UCL Institute of Ophthalmology, London, England
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Un Y, Imamoglu S. Clinical outcomes of Ahmed glaucoma valve implantation in primary open-angle glaucoma and pseudoexfoliative glaucoma. Int Ophthalmol 2024; 44:25. [PMID: 38326580 DOI: 10.1007/s10792-024-02918-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/24/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE To investigate the clinical outcomes of Ahmed glaucoma valve (AGV) implantation in primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG). METHODS The patients who underwent AGV implantation for POAG and PEXG between January 2015 and December 2021 in a single tertiary center eye clinic were reviewed retrospectively. Thirty-one eyes with the diagnosis of POAG constituted Group 1 and 40 eyes with the diagnosis of PEXG constituted Group 2. The primary outcome measures were intraocular pressure (IOP) changes after AGV implantation and surgical success at the last visit. We evaluated complete and qualified surgical success using the following three criteria: (1) IOP ≤ 21mmH g, (2) IOP ≤ 18 mmHg, and (3) IOP ≤ 15 mmHg, as well as the absence of any serious complications, such as light perception loss and phthisis bulbi, and additional de novo glaucoma surgery. RESULTS The mean follow-up times were 25.2 (± 21.4) months and 27.6 (± 19.8) months for Groups 1 and 2, respectively (p > 0.05). In Groups 1 and 2, the mean preoperative IOPs were 31.9 ± 9.4 mmHg and 32.3 ± 8.4 mmHg, respectively, which significantly reduced to 14.5 ± 0.7 mmHg and 11.6 ± 0.6 mmHg, respectively at the last postoperative visit (p < 0.001 for both). The mean IOP value at the last visit was statistically significantly lower in Group 2 (p = 0.006). At the last visit, the number of eyes with qualified success according to criteria 1, 2, and 3 was 26 (83.9%), 25 (80.6%), and 18 (58.1%), respectively, in Group 1 and 39 (97.5%), 39 (97.5%), and 32 (80%), respectively, in Group 2. The comparison of the qualified success rates showed statistically significantly higher rates in Group 2 for criterion 2 (p = 0.038). CONCLUSION AGV implantation had high success rates in both POAG and PEXG, but at the final visit, lower IOP levels were reached in the latter.
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Affiliation(s)
- Yasemin Un
- Department of Ophthalmology, Istanbul Haydarpasa Numune Training and Research Hospital, 34668, Uskudar, Istanbul, Turkey.
| | - Serhat Imamoglu
- Department of Ophthalmology, Istanbul Haydarpasa Numune Training and Research Hospital, 34668, Uskudar, Istanbul, Turkey
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Abe RY, Oltramari L, Vessani RM, Schimiti RB, Magacho L, Kanadani FN, Costa VP. Trabeculectomy in Eyes With High Myopia. J Glaucoma 2024; 33:110-115. [PMID: 37671507 DOI: 10.1097/ijg.0000000000002293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023]
Abstract
PRCIS Primary trabeculectomy was safe and effective at lowering intraocular pressure (IOP) in patients with primary open angle glaucoma and high myopia. PURPOSE To investigate the efficacy and safety of trabeculectomy in patients with glaucoma and high myopia. PATIENT AND METHODS Retrospective case-control study. Glaucomatous patients with high myopia undergoing primary trabeculectomy surgery with at least 1 year of follow-up were compared with an age-matched control group without high myopia undergoing the same procedure. Surgical success was defined as: IOP ≤ 15 mm Hg with (qualified) or without (complete) antiglaucoma medications and at least 20% reduction from baseline IOP at the end of 48 months of follow-up. RESULTS We included a total of 90 eyes from 90 patients (45 eyes with high myopia and 45 controls). Within the 90 eyes, 70 eyes underwent trabeculectomy and 20 eyes underwent combined phacoemulsification and trabeculectomy. Although patients with high myopia had higher chances for failure (37% vs. 22%) compared with controls, the difference was not statistically significant ( P =0.067). In the multivariable analysis, patients of African descent ( P =0.043) and those with juvenile glaucoma ( P =0.001) had more chances of failure, even after adjusting for myopia. There was no statistically significant difference between complication rates in both groups. CONCLUSION Trabeculectomy was effective in reducing IOP in patients with high myopia and glaucoma, without the additional risk of complications compared with a control group.
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Affiliation(s)
- Ricardo Y Abe
- Department of Opthalmology, University of Campinas-UNICAMP
- Hospital Oftalmológico de Brasília, Brasília, Distrito Federal
| | - Laura Oltramari
- Hospital Oftalmológico de Brasília, Brasília, Distrito Federal
| | - Roberto M Vessani
- Department of Ophthalmology and Visual Science, Glaucoma Service, Federal University of Sao Paulo, São Paulo
| | - Rui B Schimiti
- Department of Opthalmology, University of Campinas-UNICAMP
| | - Leopoldo Magacho
- Department of Ophthalmology, Federal University of Goiás
- VER Hospital de Olhos, Goiânia, Goiás
| | - Fábio N Kanadani
- Department of Ophthalmology, Glaucoma Institute of Belo Horizonte, Belo Horizonte, Brazil
| | - Vital P Costa
- Department of Opthalmology, University of Campinas-UNICAMP
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Tseng VL, Kitayama K, Yu F, Pan D, Coleman AL. Social Vulnerability, Prevalence of Glaucoma, and Incidence of Glaucoma Surgery in the California Medicare Population. Ophthalmol Glaucoma 2023; 6:616-625. [PMID: 37211091 DOI: 10.1016/j.ogla.2023.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE To examine associations of Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) scores with prevalence of glaucoma and incidence of glaucoma surgery in 2019 California Medicare beneficiaries. DESIGN Retrospective cross-sectional study. PARTICIPANTS 2019 California Medicare beneficiaries ≥ 65 years old with part A and part B coverage. METHODS The exposure of interest was SVI score, which was assessed overall and by themes. Outcomes included prevalence of glaucoma in the study population and incidence of glaucoma surgery in beneficiaries with glaucoma. Logistic regression modeling was performed to assess associations between quartiles of each type of SVI score, prevalence of glaucoma, and incidence of glaucoma surgery, controlling for age, sex, race/ethnicity, Charlson Comorbidity Index score, pseudophakia, and age-related macular degeneration. MAIN OUTCOME MEASURES Prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma in all beneficiaries. Incidence of any glaucoma surgery, trabeculectomy, tube shunt, minimally invasive glaucoma surgery (MIGS), and cyclophotocoagulation (CPC) in beneficiaries with glaucoma. RESULTS Of 5 725 245 beneficiaries in the total study population, there were 215 814 (3.8%) with any glaucoma, and of those with glaucoma, 10 135/215 814 (4.7%) underwent glaucoma surgery. In adjusted analyses for overall SVI score, where higher levels of SVI refer to higher levels of social vulnerability, there were decreased odds of any glaucoma (adjusted odds ratio [aOR] = 0.83; 95% confidence interval [CI] = 0.82, 0.84 for Q4 vs. Q1), POAG (aOR = 0.85; 95% CI = 0.84, 0.87 for Q4 vs. Q1), and SOAG (aOR = 0.59; 95% CI = 0.55, 0.63 for Q4 vs. Q1) in higher (Q4) vs. lower (Q1) SVI quartile. There were increased odds of any glaucoma surgery (aOR = 1.19; 95% CI = 1.12, 1.26 for Q4 vs. Q1), MIGS (aOR = 1.24; 95% CI = 1.15, 1.33 for Q4 vs. Q1), and CPC (aOR = 1.49; 95% CI = 1.29, 1.76 for Q4 vs. Q1) for higher (Q4) vs. lower (Q1) SVI quartile. CONCLUSIONS In the 2019 California Medicare population, there were variable associations between SVI score, prevalence of glaucoma, and incidence of glaucoma surgery. Further investigation is needed to understand the role of social, economic, and demographic factors in glaucoma care on the individual and structural levels. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Victoria L Tseng
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California
| | - Ken Kitayama
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Fei Yu
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Deyu Pan
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California
| | - Anne L Coleman
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.
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Tseng VL, Kitayama K, Yu F, Coleman AL. Disparities in Glaucoma Surgery: A Review of Current Evidence and Future Directions for Improvement. Transl Vis Sci Technol 2023; 12:2. [PMID: 37672254 PMCID: PMC10484012 DOI: 10.1167/tvst.12.9.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/06/2023] [Indexed: 09/07/2023] Open
Abstract
There is a need to understand existing disparities in glaucoma surgery and to create strategies to eliminate these disparities. Disparities can exist in several aspects of glaucoma surgical management, including patient selection and timing of surgery, type of surgery performed, intra-operative and postoperative surgical complications, follow-up surgical care, and long-term surgical outcomes. Additionally, multiple types of disparities can exist within each of these realms, including disparities by race and ethnicity, age, gender, insurance type, people with disabilities, and other social, economic, and demographic factors. Disparities in glaucoma surgery have been examined in large scale datasets, retrospective clinical studies, and clinical trials, and several studies have identified likely racial and ethnic disparities in glaucoma surgical incidence and outcomes. We present existing literature on disparities in glaucoma surgery, analyze the advantages and limitations of various study designs for the investigation of these disparities, and propose directions for future research and interventions to identify and eliminate disparities in surgical glaucoma care.
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Affiliation(s)
- Victoria L. Tseng
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ken Kitayama
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Fei Yu
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anne L. Coleman
- Department of Ophthalmology, Stein and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
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Hung A, Williams AM, Newman-Casey PA, Muir KW, Gatwood J. Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma. Ophthalmol Glaucoma 2023; 6:395-404. [PMID: 36707031 PMCID: PMC10366331 DOI: 10.1016/j.ogla.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/27/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective. DESIGN Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial. SUBJECTS Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence. METHODS Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency. MAIN OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER). RESULTS Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY. CONCLUSIONS From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs. FINANCIAL DISCLOSURES Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Anna Hung
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina; Duke-Margolis Center for Health Policy, Durham, North Carolina.
| | - Andrew M Williams
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina; Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Kelly W Muir
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Justin Gatwood
- College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
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Opazo-Toro V, Fortuna V, Jiménez W, Pazos López M, Royo MJM, Ventura-Abreu N, Brunet M, Milla E. Genotype and Phenotype Influence the Personal Response to Prostaglandin Analogues and Beta-Blockers in Spanish Glaucoma and Ocular Hypertension Patients. Int J Mol Sci 2023; 24:ijms24032093. [PMID: 36768422 PMCID: PMC9916755 DOI: 10.3390/ijms24032093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023] Open
Abstract
Analysis of the genotype that predicts the phenotypic characteristics of a cohort of glaucoma and ocular hypertension patients, and the correlation with their personal pharmacological response to beta-blockers (BB) and prostaglandin analogues (PGA). Prospective study that included 139 eyes from 72 patients under BB and/or PGA treatment, and in some cases other types of ocular hypotensive treatments. Five single-nucleotide polymorphisms were genotyped by real-time PCR assays: prostaglandin-F2α receptor (rs3766355, rs3753380); cytochrome-P450 2D6 (rs16947, rs769258); and beta-2-adrenergic receptor (rs1042714). Other studied variables were mean deviation (MD) of visual field, previous ocular interventions, medical treatment, baseline (bIOP), and treated intraocular pressure (tIOP). From a total of 139 eyes, 71 (51.1%) were left eyes. The main diagnosis was primary open angle glaucoma (66.2%). A total of 57 (41%) eyes were under three or more medications (PGA + BB + other) and, additionally, 57 eyes (41%) had had some kind of glaucoma surgery. The mean bIOP and tIOP were 26.55 ± 8.19 and 21.01 ± 5.54 mmHg, respectively. Significant differences in tIOP were found between heterozygous (HT) (21.07 ± 0.607 mmHg) and homozygous (HM) (20.98 ± 0.639 mmHg) rs3766355 with respect to wildtype individuals (16 ± 1.08 mmHg) (p = 0.031). The MD values presented significant differences between wildtype rs3766355 (-2 ± 2.2 dB), HT (-3.87 ± 4 dB), and HM carriers (-9.37 ± 9.51 dB) (p = 0.009). Significant differences were also observed between the MD in wildtype rs3753380 (-6.1 ± 8.67 dB), HT (-9.02 ± 8.63 dB), and HM carriers (-9.51 ± 7.44 dB) (p = 0.017). Patients carrying the variant rs3766355 in HM or HT presented clinically-significantly higher tIOP than wildtype patients. Additionally, some differences in MD were found in rs3766355 and rs3753380 carriers, and the more alleles that were affected, the worse the MD value, meaning greater severity of the glaucoma. Poor response to treatment and more visual field damage may be associated with being a carrier of these mutated alleles.
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Affiliation(s)
- Valeria Opazo-Toro
- Glaucoma Unit, Instituto Oftalmologico Integral, C/María Auxiliadora 25, 08017 Barcelona, Spain
| | - Virginia Fortuna
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Service, Biomedical Diagnostic Center, Hospital Clinic Barcelona, University of Barcelona, 08007 Barcelona, Spain
| | - Wladimiro Jiménez
- Biochemistry and Molecular Genetics Service, Center for Biomedical Diagnosis, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- August Pí i Sunyer Research Institute (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain
- Correspondence:
| | - Marta Pazos López
- Glaucoma Unit, Institut Clínic d’Oftalmologia, Hospital Clínic, 08036 Barcelona, Spain
| | | | | | - Mercè Brunet
- Biochemistry and Molecular Genetics Service, Center for Biomedical Diagnosis, Hospital Clinic Barcelona, 08036 Barcelona, Spain
- August Pí i Sunyer Research Institute (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain
| | - Elena Milla
- August Pí i Sunyer Research Institute (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain
- Glaucoma Unit, Institut Clínic d’Oftalmologia, Hospital Clínic, 08036 Barcelona, Spain
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11
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Wu AM, Shen LQ. Racial Disparities Affecting Black Patients in Glaucoma Diagnosis and Management. Semin Ophthalmol 2023:1-11. [PMID: 36662128 DOI: 10.1080/08820538.2023.2168489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/01/2023] [Accepted: 04/04/2022] [Indexed: 01/21/2023]
Abstract
Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.
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Affiliation(s)
- Annie M Wu
- Department of Ophthalmology, Glaucoma Service, Massachusetts Eye and Ear, Boston, MA, United States
| | - Lucy Q Shen
- Department of Ophthalmology, Glaucoma Service, Massachusetts Eye and Ear, Boston, MA, United States
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12
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Wu AM, Shen LQ. Racial Disparities Affecting Black Patients In Glaucoma Diagnosis And Management. Semin Ophthalmol 2023; 38:65-75. [PMID: 36453915 DOI: 10.1080/08820538.2022.2152702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.
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Affiliation(s)
- Annie M Wu
- Department of Ophthalmology, Glaucoma Service, Massachusetts Eye and Ear, Boston, MA, United States
| | - Lucy Q Shen
- Department of Ophthalmology, Glaucoma Service, Massachusetts Eye and Ear, Boston, MA, United States
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13
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Elam AR, Tseng VL, Rodriguez TM, Mike EV, Warren AK, Coleman AL. Disparities in Vision Health and Eye Care. Ophthalmology 2022; 129:e89-e113. [PMID: 36058735 PMCID: PMC10109525 DOI: 10.1016/j.ophtha.2022.07.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 10/14/2022] Open
Abstract
Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.
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Affiliation(s)
- Angela R Elam
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Victoria L Tseng
- UCLA Stein and Doheny Eye Institutes, David Geffen School of Medicine, University of California, Los Angeles, California
| | | | - Elise V Mike
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis K Warren
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Anne L Coleman
- UCLA Stein and Doheny Eye Institutes, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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14
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Cabrera MT, Chen A. It's Time We Reform Our Perspectives on Race and Glaucoma. Transl Vis Sci Technol 2022; 11:22. [PMID: 36149645 PMCID: PMC9520514 DOI: 10.1167/tvst.11.9.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Michelle T Cabrera
- Division of Ophthalmology, Seattle Children's Hospital, Seattle, Washington e-mail: .,Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Andrew Chen
- Department of Ophthalmology, University of Washington, Seattle, Washington
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15
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Rolim-de-Moura CR, Paranhos A, Loutfi M, Burton D, Wormald R, Evans JR. Laser trabeculoplasty for open-angle glaucoma and ocular hypertension. Cochrane Database Syst Rev 2022; 8:CD003919. [PMID: 35943114 PMCID: PMC9361429 DOI: 10.1002/14651858.cd003919.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Open-angle glaucoma (OAG) is an important cause of blindness worldwide. Laser trabeculoplasty, a treatment modality, still does not have a clear position in the treatment sequence. OBJECTIVES To assess the effects of laser trabeculoplasty for treating OAG and ocular hypertension (OHT) when compared to medication, glaucoma surgery or no intervention. We also wished to compare the effectiveness of different laser trabeculoplasty technologies for treating OAG and OHT. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; LILACS, ClinicalTrials.gov and the WHO ICTRP. The date of the search was 28 October 2021. We also contacted researchers in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing laser trabeculoplasty with no intervention, with medical treatment, or with surgery in people with OAG or OHT. We also included trials comparing different types of laser trabeculoplasty technologies. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. Two authors screened search results and extracted data independently. We considered the following outcomes at 24 months: failure to control intraocular pressure (IOP), failure to stabilise visual field progression, failure to stabilise optic neuropathy progression, adverse effects, quality of life, and costs. We graded the 'certainty' of the evidence using GRADE. MAIN RESULTS We included 40 studies (5613 eyes of 4028 people) in this review. The majority of the studies were conducted in Europe and in the USA. Most of the studies were at risk of performance and/or detection bias as they were unmasked. None of the studies were judged as having low risk of bias for all domains. We did not identify any studies of laser trabeculoplasty alone versus no intervention. Laser trabeculoplasty versus medication Fourteen studies compared laser trabeculoplasty with medication in either people with primary OAG (7 studies) or primary or secondary OAG (7 studies); five of the 14 studies also included participants with OHT. Six studies used argon laser trabeculoplasty and eight studies used selective laser trabeculoplasty. There was considerable clinical and methodological diversity in these studies leading to statistical heterogeneity in results for the primary outcome "failure to control IOP" at 24 months. Risk ratios (RRs) ranged from 0.43 in favour of laser trabeculoplasty to 1.87 in favour of medication (5 studies, I2 = 89%). Studies of argon laser compared with medication were more likely to show a beneficial effect compared with studies of selective laser (test for interaction P = 0.0001) but the argon laser studies were older and the medication comparator group in those studies may have been less effective. We considered this to be low-certainty evidence because the trials were at risk of bias (they were not masked) and there was unexplained heterogeneity. There was evidence from two studies (624 eyes) that argon laser treatment was associated with less failure to stabilise visual field progression compared with medication (7% versus 11%, RR 0.70, 95% CI 0.42 to 1.16) at 24 months and one further large recent study of selective laser also reported a reduced risk of failure at 48 months (17% versus 26%) RR 0.65, 95% CI 0.52 to 0.81, 1178 eyes). We judged this outcome as moderate-certainty evidence, downgrading for risk of bias. There was only very low-certainty evidence on optic neuropathy progression. Adverse effects were more commonly seen in the laser trabeculoplasty group including peripheral anterior synechiae (PAS) associated with argon laser (32% versus 26%, RR 11.74, 95% CI 5.94 to 23.22; 624 eyes; 2 RCTs; low-certainty evidence); 5% of participants treated with laser in three studies of selective laser group had early IOP spikes (moderate-certainty evidence). One UK-based study provided moderate-certainty evidence that laser trabeculoplasty was more cost-effective. Laser trabeculoplasty versus trabeculectomy Three studies compared laser trabeculoplasty with trabeculectomy. All three studies enrolled participants with OAG (primary or secondary) and used argon laser. People receiving laser trabeculoplasty may have a higher risk of uncontrolled IOP at 24 months compared with people receiving trabeculectomy (16% versus 8%, RR 2.12, 95% CI 1.44 to 3.11; 901 eyes; 2 RCTs). We judged this to be low-certainty evidence because of risk of bias (trials were not masked) and there was inconsistency between the two trials (I2 = 68%). There was limited evidence on visual field progression suggesting a higher risk of failure with laser trabeculoplasty. There was no information on optic neuropathy progression, quality of life or costs. PAS formation and IOP spikes were not reported but in one study trabeculectomy was associated with an increased risk of cataract (RR 1.78, 95% CI 1.46 to 2.16) (very low-certainty evidence). AUTHORS' CONCLUSIONS Laser trabeculoplasty may work better than topical medication in slowing down the progression of open-angle glaucoma (rate of visual field loss) and may be similar to modern eye drops in controlling eye pressure at a lower cost. It is not associated with serious unwanted effects, particularly for the newer types of trabeculoplasty, such as selective laser trabeculoplasty.
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Affiliation(s)
| | - Augusto Paranhos
- Department of Ophthalmology and Visual Science, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mohamed Loutfi
- School of Medicine, University of Liverpool, Liverpool, UK
| | - David Burton
- Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - Richard Wormald
- Cochrane Eyes and Vision, Queen's University Belfast, Belfast, UK
| | - Jennifer R Evans
- Cochrane Eyes and Vision, ICEH, London School of Hygiene & Tropical Medicine, London, UK
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16
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Intracanalicular Dexamethasone Insert or Topical Prednisolone Following iStent and Hydrus Surgery for Glaucoma. J Glaucoma 2022; 31:694-699. [PMID: 35439795 PMCID: PMC9362341 DOI: 10.1097/ijg.0000000000002037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 04/02/2022] [Indexed: 02/04/2023]
Abstract
PRCIS Using an intracanalicular dexamethasone insert or topical prednisolone following iStent and Hydrus surgery provided similar short-term control of postoperative inflammation. PURPOSE The purpose of this study was to compare postoperative inflammation in patients who received an intracanalicular dexamethasone insert or topical prednisolone after iStent or Hydrus insertion during cataract surgery. PATIENTS AND METHODS Patients receiving a dexamethasone insert after iStent or Hydrus insertion were included and compared with age-matched controls who received topical prednisolone. Preoperative data were recorded. Postoperative inflammatory cell and the proportion of patients with zero anterior chamber cells was recorded at month 1. Postoperative intraocular pressure (IOP) and rate of cystoid macular edema were recorded at months 1 and 3. RESULTS Forty eyes receiving topical prednisolone were compared with 35 eyes receiving a dexamethasone insert after iStent or Hydrus insertion. The mean postoperative inflammatory cell for the topical group at month 1 was 0.2±0.3, and the dexamethasone group, 0.3±0.5 ( P =0.816). Overall, 70% of patients in the topical group had zero anterior chamber cell at postoperative month 1 compared with 75.8% in the dexamethasone group ( P =0.583). The mean preoperative IOP for the topical group was 18.8±5.5 and the dexamethasone group was 17.1±4.1 ( P =0.064). Mean postoperative IOP for the topical group at months 1 and 3 was 17.6±6.4 and 15.1±3.1, respectively and the dexamethasone group, 17.5±4.8 and 15.0±3.4, respectively ( P =0.772 and 0.884). One patient developed cystoid macular edema in each group. CONCLUSION There was no statistically significant difference in the proportion of patients who had zero anterior chamber cell at postoperative month 1 between groups receiving intracanalicular dexamethasone insert or topical prednisolone.
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17
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Glaucoma Treatment Outcomes in Open Angle Glaucoma Patients of African Descent. J Glaucoma 2022; 31:479-487. [PMID: 35353787 PMCID: PMC9246921 DOI: 10.1097/ijg.0000000000002027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/19/2022] [Indexed: 01/31/2023]
Abstract
Open angle glaucoma (OAG), characterized by structural changes to the optic nerve head and retinal nerve fiber layer, is a progressive multifactorial optic neuropathy and a leading cause of irreversible blindness globally. Currently, intraocular pressure is the only modifiable risk factor; however, others have been identified, including genetics and race. Importantly, OAG is much more prevalent in persons of African descent (AD) compared with those of European descent (ED). OAG patients of AD are also known to have a more severe course of the disease, a finding potentially explained by structural and/or vascular differences within eye tissues. In addition, disparities in treatment outcomes have been identified in OAG patients of AD. Specifically, prostaglandin analogues have been suggested to be more effective in patients of AD than in those ED, while beta-adrenergic receptors have been suggested to be less effective, although the evidence is inconsistent. AD has also been identified as a risk factor for trabeculectomy failure while laser trabeculoplasty has been conversely found to be very effective in lowering intraocular pressure in patients of AD. Alternative surgical options, including Ex-Press shunt implantation, viscocanalostomy, and canaloplasty are promising in equivalence but require further research to evaluate disparity in outcome properly. In addition to treatment outcomes, social disparities affecting clinical care also exist for AD persons in the form of reduced adherence, access, and choice. Overall, data suggest the need for properly designed prospective trials with AD populations as a primary focus to identify the potential mechanisms driving disparities in treatment and address overall potential bias in glaucoma management.
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18
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Laroche D, Rickford K, Sakkari S. Case report: Cataract extraction/lensectomy, excisional goniotomy and transscleral cyclophotocoagulation: Affordable combination MIGS for plateau iris glaucoma. J Natl Med Assoc 2022; 114:38-41. [PMID: 34998572 DOI: 10.1016/j.jnma.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/10/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Abstract
We report the successful treatment of angle closure glaucoma and plateau iris with combined early cataract surgery/lensectomy, goniotomy, and transscleral cyclophotocoagulation. The underlying mechanism of angle closure and plateau iris was addressed with cataract extraction and goniosynechiolysis. Goniotomy was used to enhance trabecular meshwork outflow and lower intraocular pressure, and the "slow burn" transscleral cyclophotocoagulation was safely performed to reduce the size of the ciliary processes. The unique combinations of these procedures restored the iridocorneal angle anatomy to normalize IOP and prevent vision loss from glaucoma in patients with plateau iris. This is a cost-effective option with longer term efficacy.
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Affiliation(s)
- Daniel Laroche
- New York Eye and Ear Infirmary, Icahn School of Medicine of Mount Sinai, 310 E 14(th) St, New York, NY, USA; Advanced Eyecare of New York, 29 W 127(th) St, New York, NY, USA.
| | - Kara Rickford
- School of Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, New York, USA
| | - Sohail Sakkari
- Advanced Eyecare of New York, 29 W 127(th) St, New York, NY, USA
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19
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Arimura S, Iwasaki K, Orii Y, Takamura Y, Inatani M. Comparison of 5-year outcomes between trabeculectomy combined with phacoemulsification and trabeculectomy followed by phacoemulsification: a retrospective cohort study. BMC Ophthalmol 2021; 21:188. [PMID: 33894759 PMCID: PMC8066976 DOI: 10.1186/s12886-021-01949-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022] Open
Abstract
Background We aimed to compare the outcomes of trabeculectomy combined with phacoemulsification and those of trabeculectomy followed by phacoemulsification. Methods A total of 141 patients with primary open-angle glaucoma, exfoliation glaucoma, and glaucoma secondary to uveitis glaucoma who underwent trabeculectomy followed by (n = 48) or combined with (n = 93) phacoemulsification were included. We analyzed data collected from the Collaborative Bleb-Related Infection Incidence and Treatment Study, a prospective cohort study conducted in 34 clinical centers that included 1249 eyes. The main outcome was the cumulative probability of success based on intraocular pressure (IOP) within 5 years. Surgical failure was defined as a case in which additional glaucoma surgery is required or one of the following criteria are met: preoperative IOP > 21 (A), > 18 (B), or > 15 mmHg (C). The secondary outcomes were cumulative probability of success, risk factors of surgical failure, and Δ visual acuity. However, the data on phacoemulsification during the 5-year follow-up were censored. Results No significant difference was found in the cumulative probability of success as the main outcome. When the data on phacoemulsification during the 5-year follow-up were censored, the probabilities of success of trabeculectomy followed by phacoemulsification were significantly higher for criteria A (p = 0.02), B (p < 0.01), and C (p < 0.01). Lower preoperative IOP, younger age, and trabeculectomy combined with phacoemulsification were associated with poorer outcome. Trabeculectomy followed by phacoemulsification had significantly worse Δ logMAR visual acuity at 6 and 12 months (p < 0.01). Conclusion The cumulative probability of success after trabeculectomy combined with or followed by phacoemulsification remained unchanged. Combining phacoemulsification with trabeculectomy adversely affected the cumulative probability of success after trabeculectomy. The visual acuity improvements observed in the early postoperative period after combining phacoemulsification with trabeculectomy disappeared within 5 years.
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Affiliation(s)
- Shogo Arimura
- Department of Ophthalmology, Faculty of Medical Science, University of Fukui, Yoshida, 23-3 Simoaizuki, Matsuoka, Fukui, Japan
| | - Kentaro Iwasaki
- Department of Ophthalmology, Faculty of Medical Science, University of Fukui, Yoshida, 23-3 Simoaizuki, Matsuoka, Fukui, Japan
| | - Yusuke Orii
- Department of Ophthalmology, Faculty of Medical Science, University of Fukui, Yoshida, 23-3 Simoaizuki, Matsuoka, Fukui, Japan
| | - Yoshihiro Takamura
- Department of Ophthalmology, Faculty of Medical Science, University of Fukui, Yoshida, 23-3 Simoaizuki, Matsuoka, Fukui, Japan
| | - Masaru Inatani
- Department of Ophthalmology, Faculty of Medical Science, University of Fukui, Yoshida, 23-3 Simoaizuki, Matsuoka, Fukui, Japan.
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20
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Liu H, Prokosch V. Energy Metabolism in the Inner Retina in Health and Glaucoma. Int J Mol Sci 2021; 22:ijms22073689. [PMID: 33916246 PMCID: PMC8036449 DOI: 10.3390/ijms22073689] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023] Open
Abstract
Glaucoma, the leading cause of irreversible blindness, is a heterogeneous group of diseases characterized by progressive loss of retinal ganglion cells (RGCs) and their axons and leads to visual loss and blindness. Risk factors for the onset and progression of glaucoma include systemic and ocular factors such as older age, lower ocular perfusion pressure, and intraocular pressure (IOP). Early signs of RGC damage comprise impairment of axonal transport, downregulation of specific genes and metabolic changes. The brain is often cited to be the highest energy-demanding tissue of the human body. The retina is estimated to have equally high demands. RGCs are particularly active in metabolism and vulnerable to energy insufficiency. Understanding the energy metabolism of the inner retina, especially of the RGCs, is pivotal for understanding glaucoma’s pathophysiology. Here we review the key contributors to the high energy demands in the retina and the distinguishing features of energy metabolism of the inner retina. The major features of glaucoma include progressive cell death of retinal ganglions and optic nerve damage. Therefore, this review focuses on the energetic budget of the retinal ganglion cells, optic nerve and the relevant cells that surround them.
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21
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Gedde SJ, Vinod K, Wright MM, Muir KW, Lind JT, Chen PP, Li T, Mansberger SL. Primary Open-Angle Glaucoma Preferred Practice Pattern®. Ophthalmology 2021; 128:P71-P150. [DOI: 10.1016/j.ophtha.2020.10.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022] Open
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Abstract
Lasers have been in use as a treatment modality of glaucoma for more than last four decades. Each passing year has added newer dimensions to the existing laser technologies enhancing their safety and efficacy profile. This has become possible due to continuous research and innovations with proper understanding of the mechanism of action of different variety of lasers as treatment options. Each category of glaucoma has different underlying pathologies. Adequate knowledge and understanding of indications, limitations and hazards of these laser procedures are must before their application for improvising outcome. Recent years have witnessed a revolution this field. A thorough literature search was conducted in PubMed, Medline, the Cochrane Library Database, EMBASE, and Scopus and Google Scholar until May 2020 using the keywords, and all the articles pertaining to the relevant topics were included in this review. Purpose of this review is to summarize the important laser procedures currently in use for managing glaucoma along with updating the readers with recent advances in laser technologies, their extended applications and also analyzing possible future implications.
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23
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Yamada M, Nakano T, Matsuda H, Kim SW, Takagi Y. Cost-effectiveness and budget impact analysis of a patient visit support system for blindness reduction in Japanese patients with glaucoma. J Med Econ 2020; 23:1293-1301. [PMID: 32729756 DOI: 10.1080/13696998.2020.1804392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM To evaluate the cost-effectiveness (CE) and budget impact (BI) of introducing a patient visit support system (ACT Pack) along with standard of care (SoC), in glaucoma treatment in Japan. METHODS A Markov model was designed to estimate the CE and BI of introducing the support system from Japanese payer and governmental perspective, respectively. Inputted data for CE and BI analysis were referred from published literature and based on medical specialists' inputs. Base case scenario for CE considered the support system cost of 30,000 yen per patient per year and a time horizon of 45 years. BI analysis compared the financial impact due to introduction of support system with SoC compared to SoC alone scenario on Japanese healthcare system with a time horizon of 20 years. RESULTS The base case of CE analysis showed the incremental cost per quality-adjusted life years (QALYs) gained with the support system was 3,241,729 yen/QALY (29,470 USD/QALY). The sensitivity analysis showed that the probability of this support system being cost-effective at a threshold of 5 million yen/QALY (45,455 USD/QALY) was 53.26%. Blindness reduction after introduction of this support system was 8.68%. The BI analysis showed that the introduction of support system will lead to a cumulative cost savings of 1,132 billion yen (10 billion US dollars) for Japanese healthcare system over 20 years of time horizon. LIMITATION Due to paucity of similar comparative studies, some assumptions were made based on medical specialists' inputs. Death status was not considered in the analysis. CONCLUSION Introduction of this support system with SoC is cost-effective and will lead to blindness reduction in Japanese patients with glaucoma. Over a 20 year period, it will lead to an overall cost savings of 1,132 billion yen (10 billion US dollars) for the Japanese healthcare system.
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Affiliation(s)
- Masakazu Yamada
- Department of Ophthalmology, Kyorin University School of Medicine, Mitaka, Japan
| | - Tadashi Nakano
- Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Matsuda
- Real World Evidence Solutions, IQVIA solutions Japan, Tokyo, Japan
| | - Seok-Won Kim
- Japan Medical Affairs Group, Santen Pharmaceutical Co., Ltd, Osaka, Japan
| | - Yasutaka Takagi
- Japan Medical Affairs Group, Santen Pharmaceutical Co., Ltd, Osaka, Japan
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24
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Perez CI, Verdaguer S, Khaliliyeh D, Maul EA, Ou Y, Han Y. Subconjunctival Injections of Mitomycin C Are Associated with a Lower Incidence of Hypertensive Phase in Eyes with Ahmed Glaucoma Valve. Ophthalmol Glaucoma 2020; 4:322-329. [PMID: 33059114 DOI: 10.1016/j.ogla.2020.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the association of intraoperative and postoperative subconjunctival injections of mitomycin C (MMC) and rate of the hypertensive phase after implantation of the Ahmed glaucoma valve (AGV). DESIGN Comparative case series. PARTICIPANTS This retrospective comparative study included 37 eyes of 35 patients with uncontrolled glaucoma on maximum tolerated medical therapy who underwent implantation of AGV by a single surgeon. METHODS Consecutive cases operated without the use of MMC from 2015 to 2017 were compared with consecutive cases operated from 2018 to 2019 under a standardized protocol of subconjunctival MMC injections. The MMC group received 0.1 ml of MMC (0.25 mg/ml) injected intraoperatively, at 1 and 4 weeks after the surgery. MAIN OUTCOME MEASURES Incidence of the hypertensive phase (defined as intraocular pressure [IOP] >21 mmHg during the first 3 postoperative months) was compared across groups. Intraocular pressure and glaucoma medications were also compared during the course of the first 6 postoperative months. RESULTS In the MMC and no-MMC groups, 17.6% (3/17) and 55.0% (11/20) of the cases exhibited a hypertensive phase (P = 0.04), respectively. Both groups were comparable in baseline characteristics, including age, preoperative IOP, preoperative glaucoma medications, and previous glaucoma surgeries. At 6 months, mean IOP was 14.0 ± 0.8 mmHg and 14.7 ± 0.9 mmHg for the MMC and no-MMC groups, respectively (P = 0.6). The mean number of glaucoma medications at 6 months was 1.2 ± 0.2 and 2.2 ± 0.3 in the MMC and no-MMC groups, respectively (P = 0.007). CONCLUSIONS Eyes that underwent implantation of AGV experienced a lower incidence of hypertensive phase and required fewer medications when using a standardized protocol of intraoperative and postoperative subconjunctival MMC injections.
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Affiliation(s)
- Claudio I Perez
- Fundación Oftalmológica los Andes, Universidad de los Andes, Santiago, Chile.
| | - Sofia Verdaguer
- Fundación Oftalmológica los Andes, Universidad de los Andes, Santiago, Chile
| | - Daniela Khaliliyeh
- Fundación Oftalmológica los Andes, Universidad de los Andes, Santiago, Chile
| | - Eugenio A Maul
- Fundación Oftalmológica los Andes, Universidad de los Andes, Santiago, Chile
| | - Yvonne Ou
- Department of Ophthalmology, University of California, San Francisco, California
| | - Ying Han
- Department of Ophthalmology, University of California, San Francisco, California
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Morris S, Buszewicz M. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess 2020; 23:1-102. [PMID: 31264958 DOI: 10.3310/hta23310] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment. OBJECTIVES To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways. DESIGN A 36-month pragmatic, unmasked, multicentre randomised controlled trial. SETTINGS Six collaborating specialist glaucoma clinics across the UK. PARTICIPANTS Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than -12 dB in the better eye or -15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT. INTERVENTIONS SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines. MAIN OUTCOME MEASURES The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety. RESULTS Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st - Medicine-1st) 0.01, 95% confidence interval (CI) -0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between -£585 and -£345). LIMITATION An unmasked design, although a limitation, was essential to capture any treatment effects on patients' perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL. CONCLUSIONS Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes. FUTURE WORK Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways. TRIAL REGISTRATION Current Controlled Trials ISRCTN32038223. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gus Gazzard
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Evgenia Konstantakopoulou
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - David Garway-Heath
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Anurag Garg
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Catey Bunce
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard Wormald
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK.,London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Nathwani
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
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Schuster AK, Erb C, Hoffmann EM, Dietlein T, Pfeiffer N. The Diagnosis and Treatment of Glaucoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:225-234. [PMID: 32343668 DOI: 10.3238/arztebl.2020.0225] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/01/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Alexander K Schuster
- Department of Ophthalmology, University Medical Center Mainz; Private Institute of Applied Ophthalmology Berlin; Department of Ophthalmology, University Hospital Cologne
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Evaluation of Long-Term Visual Field Function in Patients Undergoing Glaucoma Drainage Device Implantation. Am J Ophthalmol 2020; 216:44-54. [PMID: 32224104 DOI: 10.1016/j.ajo.2020.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the change in global and regional Humphrey visual fields (VF) after glaucoma drainage device (GDD) implantation over a 3-year follow-up period. DESIGN Retrospective interventional case series. METHODS Patients undergoing GDD placement from between 2010 and 2015 with reliable preoperative and yearly postoperative VF measurements were included. Clinical parameters were compared between preoperative and follow-up visits, including visual acuity, intraocular pressure (IOP), number of glaucoma medications, global VF metrics (mean deviation [MD]), pattern standard deviation (PSD), CIGTS (Collaborative Initial Glaucoma Treatment Study) score of total deviation probability (CIGTS_TDP) and pattern deviation probability (CIGTS_PDP), and regional metrics (regional total deviation (TD), regional pattern deviation (PD), and regional CIGTS_TDP and CIGTS_PDP). Multivariate regression analyses were performed to determine risk factors for VF worsening after GDD surgery. RESULTS A total of 106 eyes from 95 patients were included. Mean IOP ± SD was reduced from 23.1 ± 8.5 mm Hg to 12.7 ± 3.1 mm Hg at 3-year follow-up (P < .001). MD, PSD, and global CIGTS_PDP showed no significant changes in follow-up, whereas global CIGTS_TDP showed mild progression from 10.7 to 12.8 at 3-year follow-up (P = .01). No regional metrics showed worsening at follow-up examinations. Defects in the superior hemifield were more common than in the inferior hemifield at baseline and follow-up examinations for all regional metrics. Pre-operative number of glaucoma medications was associated with worsening on CIGTS_TDP. CONCLUSIONS Overall, GDD surgery is effective at stabilizing VF function over 3 years of follow-up. The superior hemifield is affected more than other regions. The number of pre-operative glaucoma medications is associated with mild VF progression, measured by CIGTS_TDP.
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Grieshaber MC, Pienaar A, Stegmann R. Access to Schlemm's canal for canaloplasty: an intra-individual comparison of two dissection techniques. Acta Ophthalmol 2020; 98:e599-e606. [PMID: 31808611 DOI: 10.1111/aos.14323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/10/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare a modified incision technique with classic scleral flap dissection for canaloplasty with canal expander regarding efficacy and safety. METHODS In a prospective randomized pilot study of 32 eyes of 16 patients with primary open-angle glaucoma, access to Schlemm's canal was created by deep lamellar dissection (scleral flap excision, group 1) or by vertical cut-down incision (group 2). Following canal opening and viscodilation with microcannula and sodium hyaluronate, two Stegmann Canal Expanders were implanted, and the scleral flap or vertical incision, respectively, was closed watertight. RESULTS Mean preoperative intraocular pressure (IOP) was 34.9 mmHg ± 6.7 [standard deviation (SD)] in group 1 and 33.8 mmHg ± 7.7 (SD) in group 2 (p = 0.66); mean postoperative IOP without medications was 14.3 mmHg ± 2.9 (SD) in group 1 and 14.8 mmHg ± 5.2 (SD) in group 2 at 1 month (p = 0.76), and 14.4 mmHg ± 1.9 (SD) in group 1 and 16.8 mmHg ± 3.1 (SD) in group 2 at 12 months (p = 0.01). Overall, there was a significant preoperative-postoperative IOP difference between groups (19.4 mmHg ± 10.1, group 1; 16.6 mmHg ± 8.9, group 2; p = 0.02). Surgery type had a significant effect when adjusted for preoperative IOP, cup-disc ratio, eye side, follow-up number and surgery type (p < 0.01, anova). No filtering bleb was observed in either group. Intra- and postoperative complications were rare and included peripheral Descemet's membrane detachment (3), microhyphema (2) and cannulation into the anterior chamber (1). CONCLUSIONS In this intra-individual comparative study of ab externo canaloplasty with the canal expander, IOP reduction was substantial in both groups and slightly greater in the group with deep scleral flap excision. Additional IOP reduction by transscleral drainage through the Descemet's membrane window and intrascleral lake is suggested.
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Affiliation(s)
- Matthias C Grieshaber
- Department of Ophthalmology, Sefako Makgatho Health Sciences University (formerly Medical University of Southern Africa), Medunsa, Pretoria, South Africa.,Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Ané Pienaar
- Department of Ophthalmology, Sefako Makgatho Health Sciences University (formerly Medical University of Southern Africa), Medunsa, Pretoria, South Africa
| | - Robert Stegmann
- Department of Ophthalmology, Sefako Makgatho Health Sciences University (formerly Medical University of Southern Africa), Medunsa, Pretoria, South Africa
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Lin LT, Chen JT, Lu DW, Tai MC, Liang CM, Chen CL, Pao SI, Hsu CK, Chen YH. Antifibrotic role of low-dose mitomycin-c-induced cellular senescence in trabeculectomy models. PLoS One 2020; 15:e0234706. [PMID: 32574191 PMCID: PMC7310836 DOI: 10.1371/journal.pone.0234706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 05/31/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose We assessed whether mitomycin-C (MMC) has different antifibrotic mechanisms in trabeculectomy wound healing. Methods We identified 2 concentrations of MMC as “low-dose” by using WST-1 assay, Lactic dehydrogenase assay, and fluorescence-activated cell sorting flow cytometry. Senescence-associated β-galactosidase (SA-β-gal) and fibrotic gene expression was examined through immunocytochemistry, flow cytometry, real-time quantitative reverse transcription polymerase chain reaction, Western blotting, zymography, and modified scratch assay in vitro. In vivo, 0.1 mL of MMC or normal saline was injected to Tenon’s capsule before trabeculectomy in a rabbit model. SA-β-gal expression, apoptotic cell death, and collagen deposition in sites treated and not treated with MMC were evaluated using terminal dUTP nick end labeling assay and histochemical staining. Bleb function and intraocular pressure (IOP) levels were examined 3, 7, 14, 21, 28, and 35 days after trabeculectomy. Results In vitro, human Tenon’s fibroblast (HTF) senescence was confirmed by observing cell morphologic change, SA-β-gal accumulation, formation of senescence-associated heterochromatin, increased p16INK4a and p21CIP1/WAF1 expression, lower percentage of Ki-67-positive cells, and decreased COL1A1 release. Increased expression of α-SMA, COL1A1, and Smad2 signaling in TGF-β1-induced stress fibers were passivated in senescent HTFs. In addition, cellular migration enhanced by TGF-β1was inactivated. In vivo, histological examination indicated increased SA-β-gal accumulation, lower apoptosis ratios, and looser collagen deposition in sites treated with 0.2 μM MMC. Low-dose MMC-induced cellular senescence prolonged trabeculectomy bleb survival and reduced IOP levels in a rabbit model. Conclusion Low-dose MMC-induced cellular senescence is involved in the antifibrotic mechanism of trabeculectomy wound healing.
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Affiliation(s)
- Le-Tien Lin
- Department of Ophthalmology, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Jiann-Torng Chen
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Da-Wen Lu
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ming-Cheng Tai
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chang-Min Liang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ching-Long Chen
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shu-I Pao
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chih-Kang Hsu
- Department of Ophthalmology, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yi-Hao Chen
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- * E-mail:
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Intracameral tissue plasminogen activator in trabeculectomy: a 1-year prospective, randomized, controlled study. Int Ophthalmol 2020; 40:1641-1646. [PMID: 32232708 DOI: 10.1007/s10792-020-01331-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the safety and the adjunctive effect of intracameral tissue plasminogen activator (tPA) in trabeculectomy for patients with primary open-angle glaucoma (POAG). METHODS This was a prospective, randomized study consisting of patients with POAG who underwent trabeculectomy in Tel Aviv Medical Center between March 2013 and December 2014. Patients were randomly assigned to two groups: Group 1 underwent mitomycin C (MMC) trabeculectomy and group 2 underwent MMC trabeculectomy with intracameral tPA. Complete and overall success were defined as intraocular pressure (IOP) between 5 and 18 mmHg and at least 30% IOP drop without and with or without anti-glaucoma treatment, respectively. RESULTS A total of 16 patients (seven females and nine males) were recruited, and eight patients were assigned to each group. IOP at presentation was 27 ± 5.3 mmHg and 25.3 ± 5.1 mmHg, compared to 13.7 ± 4.3 mmHg and 10.6 ± 2.0 at 12 months (p < 0.0001) for groups 1 and 2, respectively. Complete success at 12 months was achieved in 62.5% of group 1 compared to 87.5% of group 2 (p = 0.28). Overall success was achieved in 87% compared to 100% of patients at 12 months (p = 0.33). No evidence of complications attributable to tPA was found. CONCLUSIONS Augmentation of tPA during MMC trabeculectomy may have better complete and overall success rates, compared to MMC trabeculectomy. The safety profile was similar for both groups.
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Alaghband P, Galvis EA, Daas A, Nagar A, Beltran-Agulló L, Khawaja AP, Goyal S, Lim KS. Predictors of selective laser trabeculoplasty success in open angle glaucoma or ocular hypertension: does baseline tonography have a predictive role? Br J Ophthalmol 2020; 104:1390-1393. [DOI: 10.1136/bjophthalmol-2019-315489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/03/2022]
Abstract
BackgroundThe determinants of success of selective laser trabeculoplasty (SLT) in treatment-naïve patients with open angle glaucoma (OAG) and ocular hypertension (OHT) have not been understood fully. Therefore, we have conducted this study to explore the predictors of success.MethodsThis is a retrospective review of a pre-existing database of patients who had received primary SLT at St Thomas’ Hospital, London, UK. Patients with OAG and OHT who had received primary 360° SLT treatment and had reliable baseline tonographic outflow facility (TOF) with minimum of 1 year of follow-up were included. Univariate and multivariate analyses were performed to find the determinants of success.ResultsOne hundred and seventy-four patients between August 2006 and February 2010 had received primary 360° SLT treatment and had baseline TOF measurement. Of these, 72 subjects fulfilled the eligibility criteria. In multivariate regression analysis, the only variable associated with success was baseline intraocular pressure (IOP) (R2=0.32, beta=−0.51, p<0.001, 95% CI −2.02 to −0.74).ConclusionTo our knowledge, this is the only study investigating the pretreatment TOF (measured with electronic Shiøtz tonography) and IOP as determinants of success 12 month’s post-360° SLT in treatment-naïve patients with OAG and OHT. This study demonstrated that pretreatment IOP (and not TOF) is the only determinant of success after primary SLT therapy.
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Sihota R, Shakrawal J, Sidhu T, Sharma AK, Dada T, Pandey V. Does TRABECULECTOMY meet the 10-10-10 challenge in PACG, POAG, JOAG and Secondary glaucomas? Int Ophthalmol 2020; 40:1233-1243. [PMID: 31942662 DOI: 10.1007/s10792-020-01289-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Evaluation of the intraocular pressure (IOP) lowering efficacy of trabeculectomies over > 10 years and their ability to stabilize glaucomatous optic neuropathy. METHODS In total, 181 eyes (136 patients), which underwent trabeculectomy (10 min surgery) at least 10 years prior and were on regular follow-up, were evaluated. Qualified/complete success was taken as criteria A: IOP ≤ 12 mmHg, B: IOP ≤ 15 mmHg and C: IOP ≤ 18 mmHg, with all > 5 mmHg, with/without medications. Target IOP in advanced glaucoma is about 10 mmHg, therefore trabeculectomy 10-10-10 challenge! RESULTS The mean age of patients was 46.32 ± 11.50 years. Absolute success was 50.27%, 54.14% and 59.66% according to criteria A, B and C at last follow-up, while qualified success was 70.11%, 81.77% and 96.13%. An IOP of ≤ 12 mmHg was noted in 34, 64.15%, PACG eyes, 14, 73.68%, POAG, 15, 65.22%, JOAG and 64, 74.42%, secondary glaucoma eyes. The reduction in IOP overall was 64.83 ± 16.80% at last review and was 59.47 ± 16.07% in PACG, 62.40 ± 17.72% in POAG, 71.89 ± 8.50% in JOAG and 67.74 ± 18.10% in secondary glaucoma eyes. "Target" IOP was achieved in 97.29% of early glaucoma, 85.71% moderate glaucoma and 70% severe glaucoma eyes. 97.24% of patients were perimetrically stable. 2.21% of eyes post-trabeculectomy had a shallow anterior chamber needing surgical intervention. Visual acuity was maintained or better in 93.92% of patients, with a cataract surgery performed in 6.63% eyes. A repeat trabeculectomy was performed in 3.31% of eyes. CONCLUSION Trabeculectomy 10-10-10 is achievable in the long term, with few complications or repeat surgical interventions in the majority of POAG, PACG, JOAG and secondary glaucomas. Therefore, trabeculectomy should not be relegated to a last resort, but should be undertaken as soon as possible, if medical therapy is inadequate, unaffordable or compliance is an issue.
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Affiliation(s)
- Ramanjit Sihota
- Glaucoma Service, Glaucoma Research and Clinical Facility, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Room No. 475, Fourth Floor, Ansari Nagar, New Delhi, 110029, India
| | - Jyoti Shakrawal
- Glaucoma Service, Glaucoma Research and Clinical Facility, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Room No. 475, Fourth Floor, Ansari Nagar, New Delhi, 110029, India.
| | - Talvir Sidhu
- Glaucoma Service, Glaucoma Research and Clinical Facility, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Room No. 475, Fourth Floor, Ansari Nagar, New Delhi, 110029, India
| | - Ajay K Sharma
- Glaucoma Service, Glaucoma Research and Clinical Facility, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Room No. 475, Fourth Floor, Ansari Nagar, New Delhi, 110029, India
| | - Tanuj Dada
- Glaucoma Service, Glaucoma Research and Clinical Facility, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Room No. 475, Fourth Floor, Ansari Nagar, New Delhi, 110029, India
| | - Veena Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Tachkov K, Vassilev A, Kostova S. Modeling the Pharmacotherapy Cost and Outcomes of Primary Open-Angle Glaucoma With Dry Eye. Front Public Health 2019; 7:363. [PMID: 31921735 PMCID: PMC6934000 DOI: 10.3389/fpubh.2019.00363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Konstantin Tachkov
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Anton Vassilev
- Department of Ophthalmology, Medical University of Sofia, Sofia, Bulgaria
| | - Stanislava Kostova
- Department of Ophthalmology, Medical University of Sofia, Sofia, Bulgaria
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Muñoz M, Anton A, Castany M, Gil A, Martinez A, Muñoz‐Negrete FJ, Urcelay J, Moreno‐Montañes J. The EX-PRESS glaucoma shunt versus nonpenetrating deep sclerectomy with Esnoper implant in combined surgery for open-angle glaucoma: a prospective randomized study. Acta Ophthalmol 2019; 97:e952-e961. [PMID: 30714336 DOI: 10.1111/aos.14023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/29/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To report 1-year treatment outcomes of P50 EX-PRESS implant versus nonpenetrating deep sclerectomy (NPDS) with Esnoper V2000 combined with phacoemulsification. DESIGN Randomized, prospective and multicentre clinical trial. METHODS Settings: Six clinical centres. POPULATION Patients 54-89 years of age without previous filtering surgery with cataract and glaucoma who required lower levels of intraocular pressure (IOP). INTERVENTIONS Phaco-EX-PRESS P50 or Phaco-NPDS with Esnoper V2000, both groups with mitomycin C (0.2 mg/ml for 2 min). MAIN OUTCOME MEASURES IOP, complete success rate (IOP: ≥6 and ≤18 mmHg), visual acuity, use of medical therapy and systematic assessment of complications and postoperative interventions. RESULTS A total of 98 eyes were enrolled, including 50 in the EX-PRESS group and 48 in the NPDS group. At 12 months, IOP (mean ± SD) was 13.9 ± 3.3 mmHg in EX-PRESS group and 13.3 ± 3.6 mmHg in NPDS group (p = 0.38). Success rate was 75% and 80% in EX-PRESS and NPDS groups, respectively (p = 0.53). The number of glaucoma medications (mean ± SD) was 0.2 ± 0.55 in EX-PRESS group and 0.17 ± 0.44 in NPDS group (p = 1.00). The total number of complications was 66 in 35 subjects in EX-PRESS group and 39 in 23 subjects in NPDS group (p = 0.02). The incidence of more than one complication was n = 13 (26%) versus n = 9 (18.8%) in EX-PRESS and NPDS groups, respectively (p = 0.38). The total number of required postoperative interventions was 59 and 26 in EX-PRESS and NPDS groups, respectively (p = 0.01). Visual acuity was similar in both groups at month 12 (p = 0.13). Surgical time (mean ± SD) was 52.6 ± 13.6 min in EX-PRESS group and 63.3 ± 19.4 min in NPDS group (p = 0.01). CONCLUSION Phaco-EX-PRESS surgery had similar success rate compared to Phaco-NPDS during 1 year of follow-up. Both procedures were associated with similar IOP reduction and use of additional medical therapy at 12 months. EX-PRESS surgery required more postoperative interventions and had more complications, but needed less surgical time compared to NPDS.
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Affiliation(s)
- Marcos Muñoz
- Department of Glaucoma Institute Catalan of Retina International University of Catalunya Barcelona Spain
| | - Alfonso Anton
- Department of Glaucoma Institute Catalan of Retina International University of Catalunya Barcelona Spain
- Department of Ophthalmology Esperanza Hospital Barcelona Spain
| | - Marta Castany
- Department of Ophthalmology Vall d'Hebron Hospital Barcelona Spain
| | - Alfonso Gil
- Department of Ophthalmology San Eloy Hospital Barakaldo Spain
| | | | | | - Jose Urcelay
- Department of Ophthalmology Gregorio Marañón Hospital Madrid Spain
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Le JT, Bicket AK, Janssen EM, Grover D, Radhakrishnan S, Vold S, Tarver ME, Eydelman M, Bridges JF, Li T. Prioritizing outcome preferences in patients with ocular hypertension and open-angle glaucoma using best-worst scaling. Ophthalmol Glaucoma 2019; 2:367-373. [PMID: 32355909 PMCID: PMC7192342 DOI: 10.1016/j.ogla.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Purpose To quantify patients' preferences for glaucoma outcomes and use this information to prioritize outcomes that are important to patients. Design A cross-sectional study using best-worst scaling object case (BWS). Participants Two hundred seventy-four participants newly diagnosed with ocular hypertension or mild to moderate open angle glaucoma from three private practices and one academic medical center in the United States. Methods We designed a preference-elicitation survey based on findings from 25 semi-structured, qualitative interviews with patients with glaucoma (reported elsewhere). The survey asked participants to rate the importance of 13 glaucoma outcomes on a Likert scale as a warm-up exercise followed by completion of 13 BWS tasks. For each task, we presented participants a subset of four outcomes from the possible thirteen, and participants chose the most important and least important outcome. Outcomes included in the survey pertain to maintaining ability to perform vision-dependent activities of daily living (e.g., driving), maintaining visual function and perception (e.g., depth perception), minimizing need to take glaucoma drops, not experiencing ocular surface symptoms (e.g., red eyes, teary eyes), and having adequate control of intraocular pressure (IOP). We administered the survey online and analyzed response patterns using conditional logistic regression to determine the relative importance of different outcomes. Main outcome Ordinal ranking of glaucoma outcomes based on preference weights. Results Between September 1, 2017 and February 28, 2018, we invited 1035 patients to complete our survey, among whom 274 (26%) responded. Most participants were older than 65 years of age (146/274, 53%) and currently on IOP-lowering drops (179/274, 65%). Participants identified that outcomes with the largest relative importance weight were having "adequate IOP control" and ability to "drive a car during the day," and the outcomes with the smallest relative importance weights were "maintaining appearance of the eye" and "reducing the number of IOP-lowering drops". Conclusions Determining the relative importance of glaucoma outcomes to patients can help researchers design studies that may better inform clinical and regulatory decision-making. Although IOP is an outcome that researchers often measure in glaucoma clinical trials, patients also prioritized outcomes related to the ability to perform vision-dependent activities such as driving.
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Affiliation(s)
- Jimmy T. Le
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda K. Bicket
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ellen M. Janssen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Sunita Radhakrishnan
- Glaucoma Research and Education Group, Glaucoma Center of San Francisco and, San Francisco, California, USA
| | - Steven Vold
- Vold Vision, PLLC, Fayetteville, Arkansas, USA
| | - Michelle E. Tarver
- Departments of Biomedical Informatics and Surgery, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Malvina Eydelman
- Office of the Center Director, Center for Devices and Radiological Health, United States Food and Drug Administration, White Oak, Maryland, USA
| | - John F.P. Bridges
- Division of Ophthalmic and Ear, Nose and Throat Devices, Center for Devices and Radiological Health, United States Food and Drug Administration, White Oak, Maryland, USA
| | - Tianjing Li
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Newman-Casey PA, Salman M, Lee PP, Gatwood JD. Cost-Utility Analysis of Glaucoma Medication Adherence. Ophthalmology 2019; 127:589-598. [PMID: 31767436 DOI: 10.1016/j.ophtha.2019.09.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/10/2019] [Accepted: 09/27/2019] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The majority of patients with glaucoma do not take their medications as prescribed. Estimates of the cost-utility value of adherence to prescribed glaucoma medication are vital to implement potentially effective interventions. DESIGN Cost-utility analysis using Monte Carlo microsimulations incorporating a series of Markov cycles (10 000 iterations per strategy). PARTICIPANTS Patients with glaucoma aged ≥40 years with a full lifetime horizon (up to 60 years). METHODS The analysis estimated glaucomatous progression on the basis of data from the United Kingdom Glaucoma Treatment Study. Participants with glaucoma entered the model at age 40 years with a mean deviation in the better-seeing eye of -1.4±-1.9 decibels (dB) and -4.3±-3.4 dB in the worse-seeing eye. Participants whose glaucoma worsened each year accumulate -0.8 dB loss compared with -0.1 dB loss for those who remained stable. Data from the Glaucoma Laser Trial and the Tube versus Trabeculectomy Studies were used to assign probabilities of worsening disease among treated patients. Claims data estimating rates of glaucoma medication adherence over 4 years were used to assign probability of adherence. Those with poor adherence were modeled as having outcomes similar to the placebo arm of the clinical trials. As patients' mean deviation deteriorated, they transitioned between health states from mild (≥-6 dB), to moderate (<-6 to ≥-12 dB), to severe glaucoma (<-12 to ≥23 dB), to unilateral (<-20 dB) and bilateral blindness. At each health state, patients incurred the costs of treatment and established health utilities; ultimately, societal costs of low vision and blindness were included. MAIN OUTCOME MEASURES Cost and quality-adjusted life year (QALY) of glaucoma medication adherence. RESULTS Beginning at an initial glaucoma diagnosis at age 40 years, patients proceeded to single-eye blindness as early as 19 years among those who were nonadherent and 23 years for those remaining adherent. Total healthcare costs for adherent patients averaged $62 782 (standard deviation [SD], 34 107), and those for nonadherent patients averaged $52 722 (SD, 38 868). Nonadherent patients had a mean loss of 0.34 QALYs, resulting in a cost-effectiveness ratio of $29 600 per QALY gained. CONCLUSION At a conservative willingness to pay of $50 000/QALY, there is room to expand services to improve patient adherence.
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Affiliation(s)
- Paula Anne Newman-Casey
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.
| | - Mariam Salman
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Paul P Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
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Alkozi HA, Navarro G, Franco R, Pintor J. Melatonin and the control of intraocular pressure. Prog Retin Eye Res 2019; 75:100798. [PMID: 31560946 DOI: 10.1016/j.preteyeres.2019.100798] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 12/15/2022]
Abstract
Melatonin is not only synthesized by the pineal gland but by several ocular structures. This natural indoleamine is of great importance for regulating several eye processes, among which pressure homeostasis is included. Glaucoma, the most prevalent eye disease, also known as the silent thief of vision, is a multifactorial pathology that is associated to age and, often, to intraocular hypertension (IOP). Indeed IOP is the only modifiable risk factor and as such medications are available to control it; however, novel medications are sought to minimize undesirable side effects. Melatonin and analogues decrease IOP in both normotensive and hypertensive eyes. Melatonin activates its cognate membrane receptors, MT1 and MT2, which are present in numerous ocular tissues, including the aqueous-humor-producing ciliary processes. Melatonin receptors belong to the superfamily of G-protein-coupled receptors and their activation would lead to different signalling pathways depending on the tissue. This review describes the molecular mechanisms underlying differential functionalities that are attributed to melatonin receptors. Accordingly, the current work highlights the important role of melatonin and its analogues in the healthy and in the glaucomatous eyes, with special attention to the control of intraocular pressure.
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Affiliation(s)
- Hanan Awad Alkozi
- Department of Biochemistry and Molecular Biology, Faculty of Optics and Optometry, University Complutense of Madrid, Madrid, Spain
| | - Gemma Navarro
- Centro de Investigación en Red, Enfermedades Neurodegeneratives (CiberNed), Instituto de Salud Carlos III, Sinesio Delgado 6, 28029, Madrid, Spain; Department of Biochemistry and Physiology, School of Pharmacy and Food Sciences, Universitat de Barcelona, Avda. Juan XXIII, 27, 08027, Barcelona, Spain
| | - Rafael Franco
- Centro de Investigación en Red, Enfermedades Neurodegeneratives (CiberNed), Instituto de Salud Carlos III, Sinesio Delgado 6, 28029, Madrid, Spain; Department of Biochemistry and Molecular Biomedicine, School of Biology, Universitat de Barcelona, Diagonal 643, 08028, Barcelona, Barcelona, Spain.
| | - Jesus Pintor
- Department of Biochemistry and Molecular Biology, Faculty of Optics and Optometry, University Complutense of Madrid, Madrid, Spain; Real Academia Nacional de Farmacia, Calle Farmacia 11, 28004, Madrid, Spain.
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Rabina G, Barequet D, Mimouni M, Kurtz S, Shemesh G, Rosenblatt A, Rosenfeld E. Intracameral bevacizumab role in trabeculectomy: A 1-year prospective randomized controlled study. Eur J Ophthalmol 2019; 30:1356-1361. [DOI: 10.1177/1120672119874682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the effect of intracameral Bevacizumab on trabeculectomy success rates. Methods: A prospective, randomized, interventional clinical trial. Patients with primary open-angle glaucoma were randomly assigned to two groups: trabeculectomy with mitomycin C and trabeculectomy with mitomycin C and intracameral bevacizumab. Complete success is defined as an intraocular pressure (IOP) reduction of at least 30% from baseline IOP to a measured pressure of between 5 and 18 mm Hg without the use of IOP lowering medications. Qualified success is defined as same achievement of reduced IOP, but with the use of IOP lowering medications. Overall success is defined as same achievement of reduced IOP with or without the use of IOP lowering medications. Results: Thirty-three patients in the mitomycin C group and 36 patients in the mitomycin C and bevacizumab group were included in final analyses. The IOP at presentation was 28.3 ± 8 and 28.4 ± 8.6 mm Hg, compared to 10.8 ± 3.4 and 12.3 ± 3.7 mm Hg at 12 months (p < 0.0001) for the mitomycin C group and the mitomycin C and bevacizumab group, respectively. Complete success at 12 months was achieved in 65% of the mitomycin C group compared to 60% of the mitomycin C and bevacizumab group (p = 0.77). Overall success was achieved in 82% compared to 80% of patients at 12 months (p = 0.78). Both groups showed a statistically significant reduction in IOP after 6 and 12 months (p ⩽ 0.001). There were no statistically significant differences in visual acuity and complications. Conclusion: Intracameral bevacizumab during mitomycin C trabeculectomy in patients with primary open-angle glaucoma apparently does not improve success rates. The adjuvant use of intracameral bevacizumab is therefore not justified.
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Affiliation(s)
- Gilad Rabina
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Barequet
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Mimouni
- Department of Ophthalmology, Rambam Health Care Campus, Affiliated to the Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shimon Kurtz
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabi Shemesh
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Rosenblatt
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldar Rosenfeld
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Denis P, Hirneiß C, Reddy KP, Kamarthy A, Calvo E, Hussain Z, Ahmed IIK. A First-in-Human Study of the Efficacy and Safety of MINIject in Patients with Medically Uncontrolled Open-Angle Glaucoma (STAR-I). Ophthalmol Glaucoma 2019; 2:290-297. [PMID: 32672670 DOI: 10.1016/j.ogla.2019.06.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/27/2019] [Accepted: 06/10/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE To describe the safety and efficacy of a novel, supraciliary, microinvasive glaucoma surgery drainage system, MINIject (iSTAR Medical, Wavre, Belgium), in the study. DESIGN Prospective, multicenter, interventional, single-arm trial. PARTICIPANTS Twenty-six patients with primary open-angle glaucoma uncontrolled with 1 or more intraocular pressure (IOP)-lowering medications. METHODS Using an ab interno approach, 25 eyes were implanted successfully in a stand-alone procedure with a 5-mm long device made of biocompatible STAR material, which is soft and flexible silicone in a microporous, network design. Intraocular pressure, medication use, and other ocular parameters were evaluated before surgery, 1 day, 1 and 2 weeks, and 1, 3, and 6 months after surgery. MAIN OUTCOME MEASURES Intraocular pressure reduction at 6 months compared with baseline analyzed using a paired t test. Safety evaluation entailed tabulation of the nature and frequency of adverse events. RESULTS Mean baseline diurnal IOP was 23.2 mmHg (standard error, 0.6 mmHg) using a mean ± standard deviation of 2.0±1.1 IOP-lowering medication classes. During the 6-month follow-up period, mean IOP ranged from 10.0-16.3 mmHg (mean reductions, 6.9-13.2 mmHg or 31.0%-56.8%). Six months after surgery, mean diurnal IOP was 14.2 mmHg (standard error, 0.9 mmHg), equivalent to a reduction of 9.0 mmHg or 39.1% (P < 0.0001). The mean ± standard deviation number of IOP-lowering medications was 0.3±0.7. Of 24 patients seen at 6-month follow-up, 21 (87.5%) were medication-free and 23 (95.8%) achieved a minimum 20% IOP reduction from baseline. There were no serious adverse events related to the device or procedure, and no additional glaucoma surgery was required. Frequently reported events included anterior chamber inflammation (n = 8), IOP elevation (n = 6), of which 1 event was an IOP spike per protocol, visual acuity reduction (n = 3), and hyphema (n = 3), all of which resolved. There was no change to mean central or peripheral corneal endothelial cell density. No device-related adverse events were reported. CONCLUSIONS The MINIject glaucoma drainage system significantly lowered IOP and eliminated the need for medication in most patients 6 months after surgery when implanted in a standalone procedure. There were no serious ocular adverse events.
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Affiliation(s)
- Philippe Denis
- Department of Ophthalmology, Hôpital de la Croix-Rousse, Lyon, France
| | - Christoph Hirneiß
- Glaucoma Clinic, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Kasu Prasad Reddy
- Ophthalmology, Maxivision Super Speciality Eye Hospital, Hyderabad, India
| | - Anita Kamarthy
- Ophthalmology, Maxivision Super Speciality Eye Hospital, Hyderabad, India
| | - Ernesto Calvo
- Ophthalmology, Clinica de Ojos Orillac-Calvo, Panama City, Panama
| | - Zubair Hussain
- Clinical and Regulatory Affairs, iSTAR Medical, Wavre, Belgium
| | - Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada.
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Samuelson TW, Sarkisian SR, Lubeck DM, Stiles MC, Duh YJ, Romo EA, Giamporcaro JE, Hornbeak DM, Katz LJ, Bartlett W, Buznego C, Johnson S, D'Ambrosio FA, Dehning D, DuBiner H, Goyal R, Hughes B, Marquis RE, Noecker R, Tauber S, Perez BR, Roel L, Sarkisian S, Silverstein S, Day S, Solomon K, Tyson F, Vold S, Samuelson T, Simmons S, Stiles M, Nguyen QH, Bashford KP, Flowers B, Flynn WJ, Gira J, Okeke C, Reiss GR, Tyson SL, Parkhurst G, Linn J, Lubeck D, Solomon J, Singh IP, Johnson RD, Lin C, Kim JW, Crane CJ, Cotter F. Prospective, Randomized, Controlled Pivotal Trial of an Ab Interno Implanted Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract. Ophthalmology 2019; 126:811-821. [DOI: 10.1016/j.ophtha.2019.03.006] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 03/04/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022] Open
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Higashiyama T, Minamikawa T, Kakinoki M, Sawada O, Ohji M. Decreased orbital fat and enophthalmos due to bimatoprost: Quantitative analysis using magnetic resonance imaging. PLoS One 2019; 14:e0214065. [PMID: 30917168 PMCID: PMC6436740 DOI: 10.1371/journal.pone.0214065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/06/2019] [Indexed: 11/25/2022] Open
Abstract
We quantitatively determined the relation between the decrease in orbital fat and enophthalmos due to bimatoprost using magnetic resonance imaging (MRI). Nine orbits in nine patients were treated unilaterally with bimatoprost for glaucoma or ocular hypertension. The contralateral orbits were used as controls. The volumes of the orbital tissues and the enophthalmos were measured using MRI. The mean volumes on the treated and untreated sides were, respectively, 14.6 ± 2.1 and 17.0 ± 4.3 cm3 for orbital fat (P = 0.04) and 3.4 ± 0.5 and 3.3 ± 0.5 cm3 for total extraocular muscles (P = 0.85). The mean enophthalmos values were 14.7 ± 2.5 and 16.0 ± 2.3 mm on the treated and untreated sides, respectively (P = 0.002). The data acquired by quantitatively measuring the volumes of orbital fat and enophthalmos on MRI showed that each might be reduced by bimatoprost administration. The enophthalmos could be caused by the bimatoprost-induced decrease in orbital fat.
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Affiliation(s)
- Tomoaki Higashiyama
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
- * E-mail:
| | - Takayuki Minamikawa
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masashi Kakinoki
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Osamu Sawada
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masahito Ohji
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Kumar H, Mansoori T, Warjri GB, Somarajan BI, Bandil S, Gupta V. Lasers in glaucoma. Indian J Ophthalmol 2018; 66:1539-1553. [PMID: 30355858 PMCID: PMC6213662 DOI: 10.4103/ijo.ijo_555_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/01/2018] [Indexed: 02/06/2023] Open
Abstract
While lasers have been used for many years for the treatment of glaucoma, proper indications and use of the procedures need to be considered before their application. This review summarizes the important laser procedures in Glaucoma.
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Affiliation(s)
- Harsh Kumar
- Centre for Sight, Safdarjung Enclave, New Delhi, India
| | - Tarannum Mansoori
- Anand Eye Institute, Sita Lakshmi Glaucoma Center, Habsiguda, Hyderabad, Telangana, India
| | - Gazella B Warjri
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Bindu I Somarajan
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Suman Bandil
- Centre for Sight, Safdarjung Enclave, New Delhi, India
| | - Viney Gupta
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Palmberg P. Determining If Race Should Be Considered Within the Choice of Glaucoma Surgery. JAMA Ophthalmol 2018; 136:1113-1114. [PMID: 30027273 DOI: 10.1001/jamaophthalmol.2018.2886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul Palmberg
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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Islamaj E, Wubbels RJ, de Waard PW. Primary Baerveldt versus trabeculectomy study after one-year follow-up. Acta Ophthalmol 2018; 96:e740-e746. [PMID: 30022618 DOI: 10.1111/aos.13658] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/05/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE To compare a Baerveldt implant and trabeculectomy with respect to intraocular pressure (IOP) and failure rate at 1 year of follow-up. Secondary outcomes are pharmacological therapy and complications at 1 year of follow-up. METHODS This was a randomized, comparative study. A total of 119 glaucoma patients without previous ocular surgery were included at the Rotterdam Eye Hospital, the Netherlands. One eye of each subject was randomized to either a Baerveldt glaucoma drainage device (BGI) or trabeculectomy (TE). Follow-up visits were conducted at 1 day, 2 weeks, 6 weeks, 3 months, 6 months and 1 year after surgery. RESULTS After one year, the final IOP was equivalent for both treatment groups: 14 ± 4 mmHg (mean ± SD) for the Baerveldt group versus 13 ± 4 mmHg for the trabeculectomy group. Statistically, we found no significant difference in failure rate between the two groups. However, the Baerveldt group needed significantly more medication to decrease IOP. Overall, self-limiting complication rate was similar in both groups. Diplopia, a serious complication, was significantly more present in the BGI group. CONCLUSION One year after surgery, TE shows better results than the BGI. The final IOP, IOP reduction and failure rate are similar, but the need for additional IOP lowering medication in the BGI group is higher as well as the complication rate. The increased risk of developing diplopia after placement of a BGI must be taken into consideration.
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Affiliation(s)
- Esma Islamaj
- Rotterdam Ophthalmic Institute; Rotterdam the Netherlands
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Wubben TJ, Besirli CG, Johnson MW, Zacks DN. Retinal Neuroprotection: Overcoming the Translational Roadblocks. Am J Ophthalmol 2018; 192:xv-xxii. [PMID: 29702074 DOI: 10.1016/j.ajo.2018.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To elucidate the issues that have prevented successful translation of neuroprotective therapeutic modalities for retinal disease from the preclinical to the clinical realm and to suggest strategies to circumvent these barriers in order to develop novel treatments to prevent vision loss. DESIGN Interpretive essay. METHODS Review and synthesis of selected reports of neuroprotective approaches for retinal disease, with interpretation and perspective. RESULTS Retinal neuroprotection is defined as any measure that reduces the death of retinal cells or axonal extensions into the optic nerve, and there is a great unmet need for such therapeutic modalities. Despite encouraging preclinical data, the translation of neuroprotective therapies to the clinic has been fraught with failure. Fundamental issues that have plagued this transition include the animal models used in preclinical studies, the reproducibility of the preclinical data, and the choice of meaningful clinical trial endpoints. Developing animal models that more aptly mimic human disease, defining a set of guidelines for preclinical evaluation of neuroprotective therapies in retinal disease, and identifying and validating biomarkers as surrogate clinical endpoints that shorten and optimize drug development timelines may circumvent some of these barriers to translation. CONCLUSIONS Neuroprotective therapeutic approaches have the potential to prevent vision loss in millions of people affected with eye diseases worldwide. However, a stigma currently accompanies the concept of neuroprotection because of the many past failures to bridge the gap between the preclinical and clinical realms. Understanding and addressing the fundamental reasons for the failure of translatable research provides hope for the future development of neuroprotective therapies.
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Myers JS, Masood I, Hornbeak DM, Belda JI, Auffarth G, Jünemann A, Giamporcaro JE, Martinez-de-la-Casa JM, Ahmed IIK, Voskanyan L, Katz LJ. Prospective Evaluation of Two iStent ® Trabecular Stents, One iStent Supra ® Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes. Adv Ther 2018; 35:395-407. [PMID: 29476443 PMCID: PMC5859115 DOI: 10.1007/s12325-018-0666-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Indexed: 12/01/2022]
Abstract
Introduction This study evaluates long-term outcomes of two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin in eyes with refractory open angle glaucoma (OAG). Methods Prospective ongoing 5-year study of 80 eligible subjects (70 with 4-year follow-up) with OAG and IOP ≥ 18 mmHg after prior trabeculectomy and while taking 1–3 glaucoma medications. Subjects received two iStent® trabecular micro-bypass stents, one iStent Supra® suprachoroidal stent, and postoperative travoprost. Postoperative IOP was measured with medication and annually following medication washouts. Performance was measured by the proportion of eyes with ≥ 20% IOP reduction on one medication (the protocol-specified prostaglandin) versus preoperative medicated IOP (primary outcome); and the proportion of eyes with postoperative IOP ≤ 15 and ≤ 18 mmHg on one medication (secondary outcome). Additional clinical and safety data included medications, visual field, pachymetry, gonioscopy, adverse events, visual acuity, and slit-lamp and fundus examinations. Results Preoperatively, mean medicated IOP was 22.0 ± 3.1 mmHg on 1.2 ± 0.4 medications, and mean unmedicated IOP was 26.4 ± 2.4 mmHg. Postoperatively, among eyes without later cataract surgery, mean medicated IOP at all visits through 48 months was ≤ 13.7 mmHg (≥ 37% reduction), and annual unmedicated IOP was ≤ 18.4 mmHg (reductions of ≥ 30% vs. preoperative unmedicated IOP and ≥ 16% vs. preoperative medicated IOP). At all postoperative visits among eyes without additional surgery or medication, ≥ 91% of eyes had ≥ 20% IOP reduction on one medication versus preoperative medicated IOP. At month 48, 97 and 98% of eyes achieved IOP ≤ 15 and ≤ 18 mmHg, respectively, on one medication. Six eyes required additional medication, no eyes required additional glaucoma surgery, and safety measurements were favorable throughout follow-up. Conclusion IOP control was achieved safely with two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin. This microinvasive, ab interno approach introduces a possible new treatment option for refractory disease. Trial Registration NCT01456390. Funding Glaukos Corporation. Electronic supplementary material The online version of this article (10.1007/s12325-018-0666-4) contains supplementary material, which is available to authorized users.
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Williams AM, Huang W, Muir KW, Stinnett SS, Stone JS, Rosdahl JA. Identifying risk factors for blindness from primary open-angle glaucoma by race: a case-control study. Clin Ophthalmol 2018; 12:377-383. [PMID: 29503525 PMCID: PMC5824746 DOI: 10.2147/opth.s143417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To examine the factors associated with blindness from primary open-angle glaucoma (POAG) among black and white patients at our institution. Patients and methods For this retrospective, case-control study, patients legally blind from POAG ("cases") were matched on age, race, and gender with non-blind POAG patients ("controls"). Thirty-seven black case-control pairs and 19 white case-control pairs were included in this study. Clinical variables were compared at initial presentation and over the course of follow-up. Results Black case-control pairs and white case-control pairs had similar characteristics at presentation, including cup-to-disc ratio and number of glaucoma medications. However, over the course of follow-up, black cases underwent significantly more glaucoma surgeries than matched controls (2.4 versus 1.2, p=0.001), whereas white cases and controls had no significant difference in glaucoma operations (0.9 versus 0.6, p=0.139). Our analysis found that glaucoma surgery is associated with blindness in black patients (odds ratio [OR] 1.6, 95% CI 1.1-2.2) but not in white patients (OR 1.5, 95% CI 0.7-3.2). Conclusion Black and white case-control pairs with POAG shared similar risk factors for blindness at presentation. However, over the follow-up period, black cases required significantly more glaucoma surgeries compared to black controls, whereas there was no significant difference in surgery between white cases and controls. There was no difference in medication changes in either case-control set.
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Affiliation(s)
- Andrew M Williams
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wei Huang
- Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC, USA
| | - Kelly W Muir
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA.,Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sandra S Stinnett
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Jordan S Stone
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jullia A Rosdahl
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
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Katz LJ, Erb C, Carceller Guillamet A, Fea AM, Voskanyan L, Giamporcaro JE, Hornbeak DM. Long-term titrated IOP control with one, two, or three trabecular micro-bypass stents in open-angle glaucoma subjects on topical hypotensive medication: 42-month outcomes. Clin Ophthalmol 2018; 12:255-262. [PMID: 29440867 PMCID: PMC5798569 DOI: 10.2147/opth.s152268] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Evaluate long-term outcomes after one, two, or three trabecular micro-bypass stents implanted in a standalone procedure in eyes with open-angle glaucoma taking ocular hypotensive medication. Patients and methods Prospective randomized ongoing study of 119 subjects (109 with 42-month follow-up) with open-angle glaucoma, preoperative intraocular pressure (IOP) 18-30 mmHg on one to three glaucoma medications, and unmedicated (post-washout) IOP 22-38 mmHg. Subjects were randomized to receive one (n=38), two (n=41), or three (n=40) iStent trabecular micro-bypass stents in a standalone procedure. Postoperatively, IOP was measured with medication and annually following washout. Data included IOP, medications, gonioscopy, pachymetry, visual field, visual acuity, adverse events, and slit-lamp and fundus examinations. Results Preoperative mean medicated IOP was 19.8±1.3 mmHg on 1.71 medications in one-stent eyes, 20.1±1.6 mmHg on 1.76 medications in two-stent eyes, and 20.4±1.8 mmHg on 1.53 medications in three-stent eyes. Post-washout IOP prior to stent implantation was 25.0±1.2, 25.0±1.7, and 25.1±1.9 mmHg in the three groups, respectively. Postoperatively, Month 42 medicated IOP was 15.0±2.8, 15.7±1.0 and 14.8±1.3 mmHg in the three groups, and post-washout IOP (Months 36-37) was 17.4±0.9, 15.8±1.1 and 14.2±1.5 mmHg, respectively. IOP reduction ≥20% without medication was achieved in 89%, 90%, and 92% of one-, two-, and three-stent eyes, respectively, at Month 12; and in 61%, 91%, and 91% of eyes, respectively, at Month 42. The need for additional medication remained consistent at Months 12 and 42 in multi-stent eyes (four two-stent eyes and three three-stent eyes at both time points), whereas it increased in single-stent eyes (four eyes at Month 12 versus 18 eyes at Month 42). Safety parameters were favorable in all groups. Conclusion The standalone implantation of either single or multiple iStent® device(s) produced safe, clinically meaningful IOP and medication reductions through 42 months postoperatively, with incrementally greater and more sustained reductions in multi-stent eyes.
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Affiliation(s)
- L Jay Katz
- Glaucoma Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Carl Erb
- Glaucoma Service, Eye Clinic Wittenbergplatz, Berlin, Germany
| | | | - Antonio M Fea
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Lilit Voskanyan
- Glaucoma Service, S. V. Malayan Ophthalmology Centre, Yerevan, Armenia
| | - Jane Ellen Giamporcaro
- Department of Clinical Research and Medical Affairs, Glaukos Corporation, San Clemente, CA, USA
| | - Dana M Hornbeak
- Department of Clinical Research and Medical Affairs, Glaukos Corporation, San Clemente, CA, USA
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Restrepo NA, Cooke Bailey JN. Primary Open-Angle Glaucoma Genetics in African Americans. CURRENT GENETIC MEDICINE REPORTS 2017; 5:167-174. [PMID: 29276656 PMCID: PMC5739069 DOI: 10.1007/s40142-017-0131-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Individuals of African descent are at highest risk for developing primary open-angle glaucoma (POAG), a devastating disease and major contributor of blindness worldwide. Currently, there is a large dearth of knowledge in this area despite a critical need for better understanding the underlying genetic and environmental factors afflicting this population. Here we highlight the current literature exploring the genetics of POAG in African Americans. RECENT FINDINGS Current studies have yet to replicate European POAG index variants (i.e. CDKN2B-AS1 and SIX1/SIX6) in African Americans or to definitely exclude that these loci contribute to risk in African descent populations. Recent studies have evaluated clinical features that may account for some differences in POAG risk between African Americans and European Americans. SUMMARY In summary, little headway has been made in elucidating the genetics of primary open-angle glaucoma in African Americans and other individuals of African descent.
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Affiliation(s)
- Nicole A. Restrepo
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Jessica N. Cooke Bailey
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
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