Prise en charge de l’hypertonie oculaire et du glaucome chronique à angle ouvert par les ophtalmologistes français : rôle de la pression intra-oculaire cible

Review of glaucoma management in France

PURPOSE

To conduct a review of glaucoma management in France.

METHOD

A 15-question survey was sent to ophthalmologists listed in the journal Réalités Ophtalmologiques and the Syndicat National des Ophtalmologues de France.

RESULTS

459/471 responses were analyzed. Gonioscopy was performed by 64.7% of respondents with a Goldmann three-mirror lens, by 51.4% with a four-mirror lens, and 8.2% preferred to perform the procedure with anterior segment imaging. The visual field was reported to be interpreted without difficulty by 87.8% of the practitioners, and 54.0% utilize a progression software. Ultrasound biomicroscopy was reported to be interpreted without difficulty by 20.0% of practitioners. In cases of severe ocular hypertonia with flat bleb in early postoperative trabeculectomy, 61.7% chose ocular massage as a first-line treatment, 52.9% chose laser suture lysis, 50.5% utilized needling, and 24.8% employed hypotonizing eyedrops. In case of severe ocular hypertonia with flat bleb in early postoperative deep sclerectomy, 53.2% chose goniopuncture as their first treatment, 34.4% employed needling, 31.8% utilized ocular massage, and 23.3% chose hypotonizing eyedrops. The selective laser trabeculoplasty is used as soon as the diagnosis is made by 37.5%, in association with a mono or dual therapy by 93.2%, after trying different combinations of eyedrops by 45.5%, when the visual field deteriorates despite a normalized intraocular pressure by 46.6%, and in cases of hypertonia after filtering surgery by 19.2%. Concerning management for primary angle-closure glaucoma, 80.8% considered peripheral iridotomy, and 18.7% utilized cataract surgery.

CONCLUSION

The diversity of responses concerning glaucoma management should draw attention to the need for standardized practices.

Surgical Outcomes and Quality Assessment of Trabeculectomy: Leveraging Electronic Health Records for Clinical Data Visualization

PRéCIS:: This electronic medical record-based study demonstrates 1 approach to monitor clinical outcomes for individual physicians performing trabeculectomy.

PURPOSE

The purpose of this study was to develop an interactive data visualization platform for evaluating trabeculectomy outcomes and monitoring clinical care quality.

PATIENTS AND METHODS

This is a retrospective electronic health record study in a glaucoma division of an academic medical center. We included 633 patients who underwent trabeculectomy between July 2016 and December 2018. Data were collected for intraocular pressure (IOP), vision loss, number of follow-up visits, and return to the operating room within the initial 3 months. Regression analyses were used to assess factors associated with these study outcomes. Risk of IOP ≤5 mm Hg was assessed using survival analysis. An interactive data visualization platform was created.

RESULTS

A total of 429 trabeculectomy and 204 combined surgeries were analyzed, with preoperative IOP of 21.9±9.4 and 19.4±6.9 mm Hg, respectively. Mean pressure declined by 53% and 41% (P=0.001) by 3 months. Risk of pressure ≤5 mm Hg was higher in white patients and those who underwent trabeculectomy alone. At 3 months, patients on average had 5 clinic visits; 5.5% required additional surgical procedures, and 18% experienced loss of at least 3 lines of best-recorded (not best-corrected) vision. Returning to the operating room was significantly associated with an increased number of clinic visits (coefficient=3.94) and higher odds of vision loss (odds ratio=11.12).

CONCLUSIONS

Over the initial 3 months after trabeculectomy, additional surgeries are rare, while a significant proportion of patients lost vision, and this was strongly associated with a need to return to the operating room. Interactive electronic health record data visualization can be a useful tool for monitoring clinical outcomes.

[Is it possible to combine fixed therapeutic associations?]

The number of fixed associations to treat intraocular pressure has increased over the recent years, to improve patient's treatment adherence. They are generally considered as comparable to the same components administered separately with, in some cases, less side effects. It could thus be appealing to combine fixed associations to reduce these side effects and retain efficacy. However, almost all fixed associations contain timolol, a beta blocker, with a risk of an excessive beta blocking dose and related systemic adverse drug reactions. Several fixed-associations contain a prostaglandin analogue. Their combination would not have a superior efficacy to one fixed combination taken alone. Furthermore, an increased risk or incidence of adverse drug reactions would appear. Specific clinical studies are required before recommending their use in daily clinical practice.