A three-year prospective, randomized and open comparison between latanoprost and timolol in Japanese normal-tension glaucoma patients

The Impact of Baseline Intraocular Pressure on Initial Treatment Response in the LiGHT Trial: Selective Laser Trabeculoplasty versus Medication

PURPOSE

The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial demonstrated the efficacy and safety of selective laser trabeculoplasty (SLT) compared to topical hypotensive medication as 1st-line therapy for ocular hypertension and open angle glaucoma. This sub-study explores the impact of pre-treatment (baseline) intraocular pressure (IOP) on treatment response for SLT and medication.

DESIGN

Post hoc analysis of randomised control trial data.

PARTICIPANTS

1146 eyes from 662 patients were included in this analysis: 559 eyes in the SLT group and 587 in the medication group.

METHODS

IOP reduction at 8 weeks following treatment with either SLT or prostaglandin analogue (PGA) eye drop initiation was assessed at different levels of baseline IOP, and the groups were compared. Differences in absolute and percentage IOP lowering between SLT and PGA medication were tested with a linear mixed effects model. Differences in the probability of achieving ≥20% IOP lowering between SLT and PGA medication, at different levels of baseline IOP, was estimated using a logistic mixed effects model.

MAIN OUTCOME MEASURE

IOP lowering response to SLT versus PGA eye drops.

RESULTS

Mean IOP was not significantly different between the groups, at baseline or 8 weeks following treatment initiation. Both treatments showed greater IOP lowering at higher baseline IOP and less IOP lowering at lower baseline IOP. SLT tended to achieve more IOP lowering than PGA drops at higher baseline IOP. PGA drops performed better at lower baseline IOP, and the difference compared to SLT, in terms of percentage IOP reduction, was significant at baseline IOP ≤ 17 mmHg. There was a significant difference in the relationship between baseline IOP and probability of ≥20% IOP lowering between the two treatments (p = 0.01), with SLT being more successful than PGA at baseline IOP > 22.51 mmHg.

CONCLUSIONS

These data confirm previous reports of greater IOP lowering with higher baseline IOP for both SLT and topical hypotensive medication. In treatment naïve eyes, at higher baseline IOP, SLT was more successful at achieving ≥20% IOP lowering than PGA drops. At lower baseline IOP, a statistically greater percentage, but not absolute, IOP lowering was seen with PGA drops compared to SLT, although the clinical significance of this is uncertain.

Phase Ⅰ/Ⅱ, Double-Masked, Randomized, Vehicle-Controlled Study of H-1337 Ophthalmic Solution for Glaucoma and Ocular Hypertension

PURPOSE

To perform a phase Ⅰ/Ⅱ evaluation of an H-1337 ophthalmic solution in subjects with primary open-angle glaucoma (POAG) or ocular hypertension (OHT).

DESIGN

This was a phase I/II, randomized, double-masked, vehicle-controlled, dose-response study conducted at 6 private practice sites in the United States. The study was registered with clinicaltrials.gov as NCT03452033.

PARTICIPANTS

Eighty-seven subjects with bilateral POAG or OHT were enrolled.

METHODS

After washout of ocular hypotensive medications as required, the subjects were randomized to receive either the H-1337 ophthalmic solution at 0.06%, 0.2%, and 0.6% or its vehicle twice daily unilaterally in the study eye for the first 3 days and then twice daily in both eyes from day 4 to 28.

MAIN OUTCOME MEASURES

The primary efficacy end point was the mean change in intraocular pressure from baseline (day 0) for each group on day 28 at hour 4 compared with the vehicle.

RESULTS

In the primary efficacy end point, i.e., mean change from the baseline on day 28 at hour 4, the mean change from the baseline was - 4.45 ± 3.801, - 5.16 ± 3.114, - 4.93 ± 3.110, and - 0.39 ± 2.355 in the 0.06%, 0.2%, and 0.6% H-1337 and vehicle groups, respectively. The difference between each active group and the vehicle group was statistically significant (P < 0.0001). Treatment-emergent adverse events (TEAEs) occurred in 49% of subjects who received H-1337 (range, 41% [0.2% arm]-64% [0.6% arm] across the H-1337 arms) and 18% of subjects who received the vehicle. The majority of TEAEs were mild in severity; 3 subjects who received H-1337 had a TEAE of moderate intensity (instillation site erythema, blurred vision, and muscle strain).

CONCLUSIONS

The H-1337 ophthalmic solution showed clinically and statistically significant ocular hypotensive activity and was well tolerated, with a relatively low incidence of hyperemia.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Trabeculectomy With Antimetabolite Agents for Normal Tension Glaucoma: A Systematic Review and Meta-Analysis

Background

Evidence regarding the impact on visual field (VF), intraocular pressure (IOP), and antiglaucoma medications from trabeculectomy with antimetabolites for normal tension glaucoma (NTG) is conflicting because of insufficient study sample sizes. The aim of this study is to systematically assess VF progression rate, IOP control and antiglaucoma medication use after trabeculectomy with antimetabolites for progressing NTG.

Methods

We searched published articles on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception to March 21, 2022. We selected studies that reported VF data before and after trabeculectomy with antimetabolite agents for NTG. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Data were extracted by 2 independent reviewers, and a random-effects model was employed for the meta-analysis. Study outcomes were VF progression rates measured using the pooled mean deviation (MD) slope, changes in antiglaucoma medications, and IOP. Subgroup analyses of the MD slope according to mean age (over or under 65 years), baseline MD (over or under –12 dB), and baseline IOP (over or under 15 mmHg) were performed to determine the results’ robustness.

Results

We included 7 retrospective observational studies (Japan: 6 studies, United States: 1 study) comprising a total of 166 eyes. Mean preoperative VF MD slopes ranged from –0.52 to –1.05 dB/year. The meta-analysis demonstrated significant MD slope improvement after trabeculectomy (pooled mean difference: 0.54 dB/year, 95% CI: 0.40 to 0.67, I² = 9%). Mean age, baseline MD, and baseline IOP subgroup analyses revealed MD slope results were consistent with those of the main analyses. The mean IOP (pooled mean difference: –5.54 mmHg, 95% CI: –6.02 to –5.06, I² = 0%) and mean number of antiglaucoma medications (pooled mean difference: –1.75, 95% CI: –2.97 to –0.53, I² = 98%) significantly decreased after trabeculectomy. The most frequently reported early complications after trabeculectomy were hypotony, hyphema, and shallow anterior chamber.

Conclusion

This systematic review and meta-analysis indicated that trabeculectomy with antimetabolites is beneficial for progressing NTG; it preserves visual function by alleviating the MD slope and reducing antiglaucoma medication use. However, several post-trabeculectomy complications should be monitored.

Prostanoid receptor agonists for glaucoma treatment

Intraocular pressure reduction is the only available and evidence-based medical therapy for glaucoma. Currently, the first-line eye drops are prostaglandin analogues including latanoprost, travoprost, bimatoprost, and tafluprost. These drugs stimulate intraocular prostanoid false positive (FP) receptors and reduce intraocular pressure by increasing mainly uveoscleral aqueous outflow. For 2 decades since latanoprost was launched, no drug has been comparable in its efficacy. In 2018, a prostanoid EP2 agonist, omidenepag, was launched in Japan. Current FP agonists and EP2 agonists indicate comparable intraocular pressure reduction by stimulating prostanoid FP or EP2 receptors. However, their safety profiles are quite different because of the differences between the intracellular signaling pathways through their own receptors. Including these commercially available FP and EP2 receptor agonists, prostanoid receptors have a large potential to control intraocular pressure. In this review I will trace the history and development of FP and EP2 receptor agonists from their original function, and explain their potential as first-line drugs including elucidation of their efficacy and safety.

Central visual field change after fornix-based trabeculectomy in Japanese normal-tension glaucoma patients managed under 15 mmHg

PURPOSE

To investigate how the central visual field would be changed after fornix-based trabeculectomy with mitomycin C in Japanese normal-tension glaucoma (NTG) patients monitored for more than 10 years including before surgery.

METHODS

This is a retrospective cohort study. We identified twenty-eight eyes of 28 NTG cases regularly monitored for more than 5 years and examined static visual field (VF) tests for more than five times before and after fornix-based trabeculectomy (including combined surgery). Based on preoperative data for 6.3 years, we evaluated postoperative changes for 6.0 years in 10-2 VF and 30-2 VF.

RESULTS

Six patients were male and 22 females, the mean age was 57.9 years, and the mean deviation was - 13.7 decibels. After surgery, mean IOP decreased from 13.9 to 9.0 mmHg (P ≤ 0.01), and medication score also did. The rate of 10-2 VF deterioration was significantly suppressed from - 1.0 dB/year preoperatively to - 0.4 dB/year postoperatively (P ≤ 0.01). And when 30-2 VF was divided into six relevant sectors, the rate of deterioration at cecocentral and arcuate areas of the superior hemifield was suppressed postoperatively (P ≤ 0.01 and P = 0.042, respectively).

CONCLUSION

Based on long-term preoperative data, a significant positive change in 10-2 VF was observed after fornix-based trabeculectomy with mitomycin C in Japanese NTG patients with a mean IOP of 13.9 mmHg. Central vision could be expected to be maintained for NTG patients even if its preoperative IOP is low after successful trabeculectomy.

Seasonal Fluctuation in Intraocular Pressure and Retinal Nerve Fiber Layer Thinning in Primary Open-Angle Glaucoma

PURPOSE

To detect seasonal fluctuations in intraocular pressure (IOP) in healthy eyes and eyes with primary open-angle glaucoma (POAG) and to evaluate whether these seasonal fluctuations affect retinal nerve fiber layer (RNFL) thinning in eyes with POAG.

DESIGN

Observational, retrospective cohort study.

PARTICIPANTS

Healthy population who underwent a comprehensive health check-up and patients with POAG using only topical medications were enrolled.

METHODS

Kaplan-Meier survival analysis was used to compare the cumulative incidence probabilities of RNFL thinning between different seasonal IOP fluctuation groups. A Cox proportional hazards model, with adjustments for potential confounding factors, was used to evaluate the association between seasonal fluctuations in IOP and RNFL thinning.

MAIN OUTCOME MEASURES

Intraocular pressure fluctuation rate calculated from winter and summer IOPs and RNFL thinning as determined by event-based analysis with high-definition OCT.

RESULTS

A total of 12 686 healthy eyes and 179 eyes of 179 POAG patients showed a significantly higher IOP in winter than in summer (healthy, 13.2 ± 3.0 mmHg vs. 12.5 ± 2.9 mmHg [P < 0.001]; POAG, 13.1 ± 2.7 mmHg vs. 11.8 ± 2.3 mmHg [P < 0.001]). In POAG patients, the mean age at initial OCT and follow-up duration were 55.1 ± 11.7 years and 98.4 ± 26.4 months, respectively. The mean deviation (MD) at first visit, MD slope, and RNFL thinning rate were -2.2 ± 3.4 dB, -0.07 ± 0.44 dB/year, and -0.44 ± 0.88 μm/year, respectively. During the study period, 85 eyes (47.5%) showed RNFL thinning progression. Kaplan-Meier analysis showed that a high seasonal IOP fluctuation rate significantly suppressed RNFL thinning (P < 0.05, log-rank test). After adjusting for confounders in the Cox analysis, the seasonal IOP fluctuation rate still showed a significantly negative association with RNFL thinning (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99; P = 0.005).

CONCLUSIONS

Winter IOP was higher than summer IOP in both healthy and POAG eyes. The temporary IOP decline in summer, rather than a constant IOP throughout the year, may prevent glaucoma progression.

360-degree suture trabeculotomy ab interno with phacoemulsification in open-angle glaucoma and coexisting cataract: a pilot study

Objective

We performed a pilot trial to evaluate the 24-month safety and efficacy of 360-degree suture trabeculotomy ab interno with phacoemulsification used to treat mild to moderate open-angle glaucoma coexisting with cataract.

Methods and analysis

We randomly assigned 18 eyes with open-angle glaucoma and coexisting cataract to undergo 360-degree suture trabeculotomy ab interno with phacoemulsification (combined) or phacoemulsification alone (control) (1:1 ratio) and followed up patients for 24 months. Main outcome measures were mean postoperative intraocular pressure (IOP) and success probabilities based on Kaplan-Meier life table analyses. Surgical success was defined as follows: criterion A: IOP value ≥6  mm Hg and ≤15  mm Hg, with ≥20 % reduction without medication; criterion B: IOP value ≥6  mm Hg and ≤12  mm Hg, with ≥30% reduction without medication. Secondary outcome measures included the number of medications, complications and best-corrected visual acuity.

Results

Mean IOP values (number of medications), which were 18.4  mm Hg (0.9) and 17.1  mm Hg (1.3) at baseline, showed significant reductions to 11.8  mm Hg (1.0) and 14.6  mm Hg (1.5) at 24 months postoperatively in the combined and control groups, respectively (p=0.0003  and 0.0192, respectively). Success rates for criterion A in the combined and control groups were 77.8% and 11.1%, respectively (p=0.0110) and those for criterion B in the combined and control groups were 46.7% and 0%, respectively (p=0.0036). Both groups had a similar overall occurrence of postoperative complications.

Conclusion

Using 360-degree suture trabeculotomy ab interno with phacoemulsification appeared to be a more beneficial option for mild to moderate open-angle glaucoma with coexisting cataract than phacoemulsification alone.

Trial registration number

UMIN000021170, date of registration: 2016/03/01.

Intraocular Pressure Lowering Effect of Latanoprost as First-line Treatment for Glaucoma

PURPOSE

The purpose of this study was to assess the intraocular pressure (IOP) - reducing effect of latanoprost in treatment-naïve patients with newly detected open-angle glaucoma with no restriction of the level of untreated IOP.

METHODS

Eighty-six patients (105 eyes) with a diagnosis of open-angle glaucoma received IOP-lowering therapy with latanoprost. The IOP reduction 1 and 3 months after initiation of treatment was recorded.

RESULTS

Mean untreated IOP for all eyes was 26.2 mm Hg (ranging from 10 to 51 mm Hg). The mean pressure reduction was 7.9 mm Hg (28%), with equivalent average levels at 1 and 3 months. The reduction in IOP ranged from -2.3 to 25.3 mm Hg after 1 month, and from -1.3 to 33.3 mm Hg after 3 months. The pressure-lowering effect was considerably more pronounced in eyes with higher untreated IOP; the reduction increased by 0.55 mm Hg per mm Hg higher untreated IOP. Four eyes, with untreated IOP within statistically normal limits, had no or negative IOP-reduction. A regression model predicted that IOP reduction ended at untreated IOP≤16 mm Hg. Multiple regression analysis showed that an additional IOP-lowering effect of 1.28 mm Hg was achieved in eyes with pseudoexfoliation glaucoma.

CONCLUSIONS

To the best of our knowledge, this paper is the first to report the IOP-reducing effect of latanoprost treatment at all untreated IOP levels in newly detected glaucoma patients. The effect was proportional to the untreated IOP at all levels above 16 mm Hg and better at higher untreated IOP levels, also in relative terms. Our results further confirm the indication of latanoprost as a first-line therapy for glaucoma.

The clinical effectiveness of tafluprost on Japanese normal-tension glaucoma patients

Purpose

This study evaluates the effect of tafluprost on visual field progression in normal-tension glaucoma (NTG) in a Japanese population under daily clinical practice settings.

Patients and methods

This is a post-marketing, multicenter, non-interventional, observational study. Patients with NTG who initiated tafluprost treatment were registered and prospectively observed for 2–3 years to investigate its effectiveness on visual field progression and intraocular pressure (IOP) and safety in Japan. Visual field progression was evaluated using mean deviation (MD) slopes in a visual field analysis set that comprised patients with reliable Humphrey visual fields taken at 5 or more time points throughout the 2–3 years.

Results

Of the 1,454 patients registered from 160 medical institutions, 1,353 were set for safety analysis and 416 were set for visual field analysis. Due to insufficient effectiveness or safety reasons 194 patients discontinued tafluprost, and 388 patients discontinued tafluprost due to being lost to follow-up or another reason. The MD slopes were −0.09±0.85 dB/year in the entire visual field analysis set, −0.02±0.80 dB/year in naïve monotherapy patients, −0.07±0.68 dB/year in switching monotherapy patients, and −0.32±1.04 dB/year in concomitant therapy patients. In naïve monotherapy, a significant difference in MD slopes was observed between patients with an IOP reduction of 10% or higher (0.11±0.73 dB/year) vs patients with an IOP reduction of <10% (−0.22±0.87 dB/year). Significant differences were also observed in the subset analyses when the patients were divided by both MD and IOP at baseline, and presence of vitreoretinal concomitant disease. The adverse reactions were observed in 9.53% patients without any serious adverse reactions.

Conclusion

An at least 10% IOP reduction with tafluprost monotherapy in 56.7% of the treatment-naïve NTG eyes was sufficient to significantly reduce the MD rate of progression.

Impact of intraocular pressure reduction on visual field progression in normal-tension glaucoma followed up over 15 years

PURPOSE

To investigate the impact of surgical or medical reduction of intraocular pressure (IOP) on progressive normal-tension glaucoma followed up over 15 years.

METHODS

Sixty eyes of 60 patients were divided into 3 intervention groups: group 1 (trabeculectomy, n = 17); group 2 (IOP reduction rate ≥15% with prostaglandin analogs, n = 24); and group 3 (IOP reduction rate <15% with prostaglandin analogs, n = 19). The preintervention and postintervention mean deviation (MD) slopes and IOP were compared. Factors associated with the rate of visual field progression were identified by multiple regression analysis.

RESULTS

The mean follow-up was 19.8 years. In group 1, the preintervention and postintervention IOPs were 14.7 ± 1.3 and 9.1 ± 2.0 mmHg, respectively (P < .001, 38% reduction). The MD slope decreased significantly after trabeculectomy (-0.86 ± 0.51 versus -0.19 ± 0.20 dB/y; P < .001). In group 2, the preintervention and postintervention IOPs were 14.7 ± 1.5 and 11.7 ± 1.2 mmHg, respectively (P < 0.001, 20% reduction), with significant differences in the MD slope (-0.52 ± 0.37 versus -0.31 ± 0.30 dB/y; P = .019). In group 3, the preintervention and postintervention IOPs were 14.4 ± 1.8 and 13.2 ± 1.6 mmHg, respectively (P < 0.001, 8% reduction), with no differences in the MD slope (-0.40 ± 0.27 versus -0.50 ± 0.65 dB/y; P > .05). Multiple regression analysis showed that the average IOP, IOP reduction rate, and preintervention MD slope were related to the extent of the postintervention reduction in the MD slope. The difference in the preintervention and postintervention MD slopes significantly correlated with the rate of IOP reduction (r = 0.559, P < .001).

CONCLUSIONS

A pressure-dependent maintenance effect of the visual field was confirmed in progressive normal-tension glaucoma.

Long-term Safety and Efficacy of Latanoprostene Bunod 0.024% in Japanese Subjects with Open-Angle Glaucoma or Ocular Hypertension: The JUPITER Study

INTRODUCTION

Latanoprostene bunod (LBN) is a novel nitric oxide (NO)-donating prostaglandin F2α analog. We evaluated the long-term safety and intraocular pressure (IOP)-lowering efficacy of LBN ophthalmic solution 0.024% over 1 year in Japanese subjects with open-angle glaucoma (OAG) or ocular hypertension (OHT).

METHODS

This was a single-arm, multicenter, open-label, clinical study. Subjects aged 20 years and older with a diagnosis of OAG or OHT instilled 1 drop of LBN ophthalmic solution 0.024% in the affected eye(s) once daily in the evening for 52 weeks and were evaluated every 4 weeks. Safety assessments included vital signs, comprehensive ophthalmic exams, and treatment-emergent adverse events (AEs). Absolute and percent reductions from baseline in IOP were also determined.

RESULTS

Of 130 subjects enrolled, 121 (93.1%) completed the study. Mean age was 62.5 years, and mean (standard deviation) baseline IOP was 19.6 (2.9) and 18.7 (2.6) mmHg in study eyes and treated fellow eyes, respectively. Overall, 76/130 (58.5%) and 78/126 (61.9%) subjects experienced ≥1 AEs in study eyes and treated fellow eyes, respectively. In both study eyes and treated fellow eyes, the most common AEs were conjunctival hyperemia, growth of eyelashes, eye irritation, and eye pain. At 52 weeks, 9% of treated eyes had an increase in iris pigmentation compared with baseline based on iris photographs. No safety concerns emerged based on vital signs or other ocular assessments. Mean reductions from baseline in IOP of 22.0% and 19.5% were achieved by week 4 in study and treated fellow eyes, respectively. These reductions were maintained through week 52 (P < 0.001 vs. baseline at all visits).

CONCLUSION

Once daily LBN ophthalmic solution 0.024% was safe and well-tolerated in Japanese subjects with OAG or OHT when used for up to 1 year. Long-term treatment with LBN ophthalmic solution 0.024% provided significant and sustained IOP reduction.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01895972.

FUNDING

Bausch & Lomb, Inc. a division of Valeant Pharmaceuticals International Inc.

Progression of primary open angle glaucoma in asymmetrically myopic eyes

PURPOSE

To compare progression of primary open angle glaucoma (POAG) in asymmetrically myopic eyes within the same subject and evaluate whether the degree of myopia is related to glaucoma progression.

METHODS

POAG patients with asymmetric myopia (axial length [AXL] ≥24 mm in both eyes, and the AXL difference between the right and left eyes to be ≥0.5 mm) were included. Glaucoma progression was determined either by optic disc/retinal nerve fiber layer (RNFL) photographs or by serial visual field (VF) data. The progression rates of VF mean deviation (dB/year) and spectral domain optical coherence tomography measured RNFL thickness (μm/year) were compared between the more myopic eye (MME) and the less myopic eye (LME) within the same subject.

RESULTS

A total of 55 patients (mean follow up period; 4.5 ± 1.0 years) were included. The mean AXL demonstrated a significant difference between MME and LME (26.3 ± 1.7 vs. 25.6 ± 1.7 mm; p = 0.036). The mean baseline VF MD (-3.8 ± 5.4 vs. -2.6 ± 4.7 dB; p = 0.21) and average RNFL thickness (77.5 ± 10.6 vs. 79.9 ± 12.3 μm; p = 0.36) did not differ between the MME and LME. Among the 55 patients, optic disc/RNFL photographic progression was noted in the MME in 15 patients, in the LME in 19 patients, and in both eyes in seven patients. VF progression was noted in the MME in seven patients, in the LME in seven patients, and in both eyes in four patients. The VF MD progression rates were -0.25 ± 0.34 dB/year in MME and -0.26 ± 0.34 dB/year in LME cases (p = 0.91). The mean progression rate of the average RNFL thickness also did not differ between the MME and LME (-0.59 ± 0.67 vs. -0.66 ± 0.72 μm/year, p = 0.68).

CONCLUSIONS

The degree of myopia was not associated with glaucoma progression when assessing the same patient using either the VF or optic disc/RNFL criteria in asymmetrically myopic patients.

Nonresponders to Prostaglandin Analogs Among Normal-Tension Glaucoma Patients

PURPOSE

To investigate patients whose intraocular pressure (IOP) did not decrease after treatment using a prostaglandin analog (nonresponders).

METHODS

This was an open-label, retrospective, case series study from a single institution. We retrospectively investigated the mean IOP reduction rates, and the proportions of nonresponders, among normal tension glaucoma (NTG) patients (209 cases, 209 eyes) treated using 1 of 4 prostaglandin analogs: latanoprost (40 patients), travoprost (64 patients), tafluprost (52 patients), or bimatoprost (53 patients). Absolute IOP was compared with pretreatment values for all 4 groups at the first and second visits after commencement of prostaglandin analog monotherapy. The IOP reduction rate was compared between groups. The proportion of nonresponders, defined as patients with IOP reduction rate <10% at both visits, was calculated in each group.

RESULTS

The average IOP had significantly decreased from the pretreatment value at the first visit after treatment; the average IOP reduction rate ranged from 15.3% to 22.6%. The IOP reduction rate in the bimatoprost group was significantly higher than those in the travoprost and tafluprost groups (P < 0.001). We identified 6 nonresponders (15.0%) in the latanoprost group, 9 (14.1%) in the travoprost group, 4 (7.7%) in the tafluprost group, and none (0.0%) in the bimatoprost group; nonresponse rates were significantly lower in the bimatoprost group than in the other groups (P ≤ 0.05).

CONCLUSION

Among NTG patients treated using prostaglandin analogs, from 0% to 15% were classified as nonresponders, depending on the prostaglandin analog used. The proportion of nonresponders was significantly lower in the bimatoprost group.

Relationship between progression of visual field defect and intraocular pressure in primary open-angle glaucoma

Purpose

To analyze the relationship between intraocular pressure (IOP) and the progression of visual field defects in Japanese primary open-angle glaucoma (POAG) and normal-tension glaucoma (NTG) patients.

Patients and methods

The subjects of the study were patients undergoing treatment for POAG or NTG who had performed visual field tests at least ten times with a Humphrey field analyzer (Swedish interactive thresholding algorithm standard, C30-2 program). The progression of visual field defects was defined by a significantly negative value of the mean deviation slope at the final visual field test during the follow-up period. The relationships between the progression of visual field defects and IOP, as well as other clinical factors, were retrospectively analyzed.

Results

A total of 156 eyes of 156 patients were included in the analysis. Significant progression of visual field defects was observed in 70 eyes of 70 patients (44.9%), while no significant progression was evident in 86 eyes of 86 patients (55.1%). The eyes with visual field defect progression had significantly lower baseline IOP (P<0.05), as well as significantly lower IOP reduction rate (P<0.01). The standard deviation of IOP values during follow-up was significantly greater in the eyes with visual field defect progression than in eyes without (P<0.05).

Conclusion

Reducing IOP is thought to be useful for Japanese POAG or NTG patients to suppress the progression of visual field defects. In NTG, IOP management should take into account not only achieving the target IOP, but also minimizing the fluctuation of IOP during follow-up period.

Long Term Results of Visual Field Progression Analysis in Open Angle Glaucoma Patients Under Treatment

Purpose :

To evaluate visual field progression with trend and event analysis in open angle glaucoma patients under treatment.

Materials and Methods :

Fifteen year follow-up results of 408 eyes of 217 glaucoma patients who were followed at Adnan Menderes University, Department of Ophthalmology between 1998 and 2013 were analyzed retrospectively. Visual field data were collected for Mean Deviation (MD), Visual Field Index (VFI), and event occurrence.

Results :

There were 146 primary open-angle glaucoma (POAG), 123 pseudoexfoliative glaucoma (XFG) and 139 normal tension glaucoma (NTG) eyes. MD showed significant change in all diagnostic groups (p<0.001). The difference of VFI between first and last examinations were significantly different in POAG (p<0.001), and XFG (p<0.003) but not in NTG. VFI progression rates were -0.3, -0.43, and -0.2 % loss/year in treated POAG, XFG, and NTG, respectively. The number of empty triangles were statistically different between POAG-NTG (p=0.001), and XFG-NTG (p=0.002) groups. The number of half-filled (p=0.002), and full-filled (p=0.010) triangles were significantly different between XFG-NTG groups.

Conclusion :

Functional long-term follow-up of glaucoma patients can be monitored with visual field indices. We herein report our fifteen year follow-up results in open angle glaucoma.

Effect on intraocular pressure of switching from latanoprost and travoprost monotherapy to timolol fixed combinations in patients with normal-tension glaucoma

Purpose. To evaluate the effect on intraocular pressure (IOP) of switching from latanoprost and travoprost monotherapy to timolol fixed combinations in Japanese patients with normal-tension glaucoma (NTG). Methods. 27 NTG patients (54 eyes) were compared IOP, superficial punctuate keratitis (SPK) scores, and conjunctival injection scores in eyes treated with prostaglandin (PG) or PG analog/beta-blocker (PG/b) fixed-combination 6 months after the change in therapy. Results. The mean baseline intraocular pressure was 17.4 ± 1.59 mmHg in eyes receiving PG therapy only and 17.4 ± 1.69 mmHg in eyes switched to PG/b. Switching to fixed combination therapy from PG monotherapy, the mean IOP was 13.1 ± 1.79 mmHg (P < 0.001)  (-24.71% reduction from baseline) at 6 months. The mean conjunctival injection score was 0.69 for eyes on PG monotherapy and 0.56 for eyes on fixed combination therapy (P = 0.028). The mean SPK scores were 0.46 and 0.53. This difference was not statistically significant (P = 0.463). Conclusions. Switching from PG monotherapy to PG/b fixed combination therapy for NTG resulted in a greater intraocular pressure reduction than PG alone without increasing the number of instillations.

The efficacy and safety of add-on 0.1% brimonidine tartrate preserved with sodium chlorite in on-treatment Japanese normal-tension glaucoma patients

Background

To evaluate the efficacy and safety of newly formulated brimonidine (0.1% brimonidine tartrate preserved with sodium chlorite: brimonidine) as add-on therapy in on-treatment Japanese normal-tension glaucoma (NTG) patients.

Methods

Brimonidine was added to on-treatment NTG patients with intraocular pressures (IOP) of between 13 mmHg and 16 mmHg after three consecutive IOP measurements. The time courses of IOP, conjunctival hyperemia, superficial punctate keratitis, and adverse events were examined at 4, 8, and 12 weeks after brimonidine instillation.

Results

Though 75 of 83 patients (31 males and 52 females; mean age: 63.4±11.6 years) completed the study, six patients discontinued because of side effects and two patients withdrew. The mean IOP after brimonidine addition at week 4 (12.6±1.8 mmHg, P<0.001), week 8 (12.4±1.7 mmHg, P<0.001), and week 12 (12.6±1.8 mmHg, P<0.001) was significantly decreased compared with that before the addition of brimonidine (13.9±1.2 mmHg). No significant changes in superficial punctate keratitis or conjunctival hyperemia scores were observed throughout the study. Dizziness, sleepiness, eye pain, and itching (mild to moderate) were noted in five, four, three, and three patients, respectively.

Conclusions

The addition of newly formulated brimonidine to on-treatment Japanese NTG patients with IOP of 13–16 mmHg further reduced the levels of IOP with minimal side effects and adverse events.

Results of long-term monitoring of normal-tension glaucoma patients receiving medical therapy: results of an 18-year follow-up

PURPOSE

To conduct a ≥15-year follow-up assessment of the visual field (VF) in normal-tension glaucoma (NTG) patients receiving medical therapy and to identify risk factors for VF progression.

DESIGN

A retrospective clinical study.

METHODS

Medical records of 78 eyes of 78 NTG patients monitored for ≥15 years were reviewed. VF progression was defined by a mean deviation (MD) deteriorated twice by 3.00 dB from baseline (MD criterion) and an annual decrease in the MD slope exceeding -0.5 dB/year (MD slope criterion). Logistic regression analysis was employed to identify risk factors for VF progression.

RESULTS

The mean follow-up period was 18.3 years. The average intraocular pressure (IOP) before treatment was 15.1 ±1.9 mmHg and the average treated IOP was 13.5 ±1.5 mmHg with 2.0 medications. Forty-two eyes (53.8%) showed VF progression using the MD criterion and 15 eyes (19.2%) showed a negative MD slope less than -0.5 dB/year. Disc hemorrhage (DH) was observed in 30 eyes (38.5%). The mean VF progression rate was -0.38 ±0.30 dB/year in the DH group and -0.24 ±0.28 dB/year in the non-DH group (P = 0.012). Multiple logistic regression analysis identified DH [relative risk (RR) 4.28; P = 0.028] as a risk factor for VF progression using the MD criterion. DH (RR 8.77; P = 0.007) and IOP fluctuation during follow-up (RR 5.03; P = 0.048) were detected as risk factors using the MD slope criterion.

CONCLUSIONS

DH and IOP fluctuation were associated with VF progression in NTG during long-term therapy.

Travoprost with sofZia® preservative system lowered intraocular pressure of Japanese normal tension glaucoma with minimal side effects

Background

This study aimed to evaluate the effect of travoprost with sofZia® preservative system for lowering the intraocular pressure (IOP) of Japanese normal tension glaucoma (NTG) patients.

Methods

In this prospective, multicenter, open-label study, Japanese NTG patients with baseline IOPs <20 mmHg were enrolled after three consecutive time measurements taken at screening and baseline visits. Travoprost with sofZia® was instilled once daily. Lowering effect on IOP, conjunctival hyperemia, superficial punctate keratopathy, and adverse events were examined at week 4, 8, and 12 after drug instillation.

Results

One-hundred and three of the 107 enrolled patients (baseline IOP =15.2±2.0 mmHg [mean ± standard deviation]) completed the study. The mean IOP value as well as percent reduction was significantly reduced at each visit after travoprost with sofZia® initiation (P<0.0001). The conjunctival hyperemia score was 1 or less throughout the study, though it increased significantly over time. No significant change was observed in superficial punctate keratopathy. The cumulative incidence of side effects such as eyelash changes, eyelid pigmentation, and deepening of the upper lid was 47.6%, 27.2%, and 16.5%, respectively.

Conclusion

Travoprost preserved with sofZia® effectively lowered the IOP of Japanese NTG patients. It was well tolerated with few discontinuations due to adverse events.

Contributing factors for progression of visual field loss in normal-tension glaucoma patients with medical treatment

PURPOSE

To investigate the prognostic factors responsible for the progression of visual field defects (VFDs) in patients with normal-tension glaucoma (NTG) treated with topical antiglaucoma medications.

PATIENTS AND METHODS

A total of 92 eyes in 92 NTG patients treated with only topical antiglaucoma medications for ≥ 5 years were retrospectively analyzed. To identify subfield-based prognostic factors, the central 30-degree visual field (Humphrey Field Analyzer) was divided into 6 subfields: upper and lower arcuate, paracentral, and cecocentral subfields. Factors related to subfield-based progression (age, refraction, mean intraocular pressure (IOP), IOP variability, central corneal thickness, and disc hemorrhage) were evaluated using a linear mixed model.

RESULTS

Ninety-two eyes in 92 NTG patients were included in this study. The mean observation period was 7.7 ± 2.7 (5.0 to 15.5) years, and the estimated rate of change in the mean deviation value was -0.16 ± 0.31 dB/y (P<0.001). A subfield-based linear mixed model analysis of the time course of changes in the mean of total deviation identified a greater extent of myopia as a significant positive prognostic factor for VFD progression in the upper paracentral area (P=0.016). The mean IOP, central corneal thickness, disc hemorrhage, age, and IOP variation showed no significant contribution in any of the subfields.

CONCLUSIONS

The extent of myopia was found to be a significant positive prognostic factor for VFD progression in the upper paracentral subfield for non-high-myopic NTG eyes with an average IOP of 14.2 mm Hg under topical antiglaucoma medication.

A randomized crossover study comparing tafluprost 0.0015% with travoprost 0.004% in patients with normal-tension glaucoma [corrected]

Purpose:

We compared the intraocular pressure (IOP)-lowering effect of tafluprost 0.0015% once daily with travoprost 0.004% once daily in Japanese patients with normal-tension glaucoma (NTG).

Methods:

One hundred sixteen patients with NTG were randomized to use tafluprost 0.0015% or travoprost 0.004% once daily for 12 weeks, followed by a washout period of 4 weeks between switching medications. IOP was measured at baseline and 4, 8, and 12 weeks of each treatment period.

Results:

Ninety patients completed both treatment periods and had IOP data available for evaluation. In both groups, a significant decrease in IOP was observed for all measurement points compared with baseline values (P < 0.0001). There was no significant difference in IOP at each time point between the two groups. Both drugs were effective (defined as more than 10% IOP reduction) in 39 (43%) of 90 patients; only tafluprost was effective in 26 (29%) patients, and only travoprost was effective in 17 (19%) patients. Eight (9%) patients were nonresponders to both drugs.

Conclusions:

Tafluprost and travoprost were equally effective in lowering IOP in patients with normal-tension glaucoma. However, patients with normal-tension glaucoma may vary in response to each medication.

Additive intraocular pressure-lowering effect of dorzolamide 1%/timolol 0.5% fixed combination on prostaglandin monotherapy in patients with normal tension glaucoma

Purpose

To evaluate the intraocular pressure (IOP)-lowering effect of adding dorzolamide 1.0%/timolol 0.5% fixed combination (DTFC) to prostaglandin analogs (PGAs) as monotherapy in patients with normal tension glaucoma.

Methods

A prospective, clinical, case-controlled study of patients with normal tension glaucoma. Patients had been on a once-daily night dose of prostaglandins (PGs) as monotherapy and then received DTFC added to PGs for 8 weeks. The IOP was measured at 9 am, week 0 (baseline), week 4, and week 8.

Results

The baseline IOP of 40 patients who had previously been treated by prostaglandin monotherapy was 15.6 ± 2.0 mmHg at baseline. The IOPs at 4 and 8 weeks after adding DTFC to PGs were 13.5 ± 2.1 mmHg and 13.7 ± 2.2 mmHg, respectively. Significant decrease of the IOP was observed at each time point of measurement as compared with the baseline IOP before adding DTFC (P = 0.01). The percent IOP reduction from the baseline IOP at week 4 and week 8 was 13.5% ± 12.3% and 11.7% ± 13.1%, respectively. The percentage of patients who achieved 10% or more IOP reduction from the baseline IOP at week 8 was 62.5%. The baseline IOP was significantly correlated with the percent IOP reduction at week 8 (P = 0.03, r = 0.34).

Conclusion

DTFC therapy added to PGAs as glaucoma monotherapy is effective in patients with normal tension glaucoma.

Effect of five years of treatment with nipradilol eye drops in patients with normal tension glaucoma

Background

The purpose of this study was to evaluate the effects of topical nipradilol monotherapy for 5 years on intraocular pressure, visual field performance, and optic disk topography.

Methods

Thirty patients with normal tension glaucoma were monitored for intraocular pressure every 1–3 months. A Humphrey visual field test and measurement of optic disk configuration using the Heidelberg retina tomograph II was done after every year of treatment and the results compared with those before treatment. Visual field performance was also evaluated by trend and event analysis.

Results

The mean intraocular pressure ± standard deviation after 3 years of nipradilol treatment (14.1 ± 2.0 mmHg) and after 5 years of nipradilol treatment (13.7 ± 2.1 mmHg) was significantly lower than that before treatment (17.0 ± 1.8 mmHg, P < 0.0001). Heidelberg retina tomograph II parameters, such as mean cup depth and height variation contour after treatment, were significantly increased compared with those before treatment. Visual field performance worsened in eight eyes by trend analysis and eight eyes by event analysis.

Conclusion

Nipradilol monotherapy was effective in reducing intraocular pressure over at least 5 years without worsening of optic disk topography. Furthermore, mean cup depth and height variation contour were also significantly improved. However, visual field performance worsened in 16.0% of patients with normal tension glaucoma.

The impact of intraocular pressure reduction on retinal ganglion cell function measured using pattern electroretinogram in eyes receiving latanoprost 0.005% versus placebo

PURPOSE

To evaluate the impact of intraocular (IOP) reduction on retinal ganglion cell (RGC) function measured using pattern electroretinogram optimized for glaucoma (PERGLA) in glaucoma suspect and glaucomatous eyes receiving latanoprost 0.005% versus placebo.

METHODS

This was a prospective, placebo-controlled, double masked, cross-over clinical trial. One randomly selected eye of each subject meeting eligibility criteria was enrolled. At each visit, subjects underwent five diurnal measurements between 8:00 am and 4:00 pm consisting of Goldmann IOP, and PERGLA measurements. A baseline examination was performed following a 4-week washout period, and repeat examination after randomly receiving latanoprost or placebo for 4-weeks. Subjects were then crossed over to receive the alternative therapy for 4 weeks following a second washout period, and underwent repeat examination. Linear mixed-effect models were used for the analysis.

RESULTS

Sixty-eight eyes (35 glaucoma, 33 glaucoma suspect) of 68 patients (mean age 67.4 ± 10.6 years) were enrolled. The mean IOP (mmHg) after latanoprost 0.005% therapy (14.9 ± 3.8) was significantly lower than baseline (18.8 ± 4.7, p<0.001) or placebo (18.0 ± 4.3), with a mean reduction of -20 ± 13%. Mean PERGLA amplitude (μV) and phase (π-radian) using latanoprost (0.49 ± 0.22 and 1.71 ± 0.22, respectively) were similar (p > 0.05) to baseline (0.49 ± 0.24 and 1.69 ± 0.19) and placebo (0.50 ± 0.24 and 1.72 ± 0.23). No significant (p > 0.05) diurnal variation in PERGLA amplitude was observed at baseline, or using latanoprost or placebo. Treatment with latanoprost, time of day, and IOP were not significantly (p > 0.05) associated with PERGLA amplitude or phase.

CONCLUSION

Twenty percent IOP reduction using latanoprost monotherapy is not associated with improvement in RGC function measured with PERGLA.

Visual field loss in patients with normal-tension glaucoma under topical nipradilol or timolol: subgroup and subfield analyses of the nipradilol-timolol study

PURPOSE

To estimate the deterioration rates of visual field loss in Japanese normal-tension glaucoma (NTG) patients under either topical nipradilol or timolol, and to explore intergroup differences in the treatment results.

METHODS

A total of 146 NTG patients with mild to moderate damage were randomized to either nipradilol or timolol and followed for 3 years with a periodic comprehensive ophthalmological visual field examination (30-2 Humphrey perimeter program) every 6 months (the Nipradilol-Timolol Study). The time course of mean deviation (MD), the average total deviation (TD(mean)) in four subfields, and the corrected pattern standard deviation (CPSD) were compared between the two groups using regression analysis with a linear mixed effect model.

RESULTS

The estimated slope for MD (dB/year) was -0.03 in the nipradilol and -0.05 in the timolol group (P > 0.4). In both groups, TD(mean) in the superior-central subfield and CPSD showed significant changes (-0.3 and 0.2-0.3, P <or= 0.001). In the patients with early visual field loss or those younger than 40 years, deterioration of some visual field parameters tended to be slower in the nipradilol group than in the timolol group.

CONCLUSION

During 3 years of monotherapy with either nipradilol or timolol in NTG patients, only TD(mean) in the superior-central subfield and the CPSD changed significantly without any intergroup differences.

Clinical utility and differential effects of prostaglandin analogs in the management of raised intraocular pressure and ocular hypertension

Prostaglandin analogs (PGA) are powerful topical ocular hypotensive agents available for the treatment of elevated intraocular pressure (IOP). Latanoprost 0.005% and travoprost 0.004% are prodrugs and analogs of prostaglandin F2α. Bimatoprost 0.03% is regarded as a prostamide, and debate continues as to whether it is a prodrug. The free acids of all 3 PGAs reduce IOP by enhancing uveoscleral and trabecular outflow via direct effects on ciliary muscle relaxation and remodeling of extracellular matrix. The vast majority of clinical trials demonstrate IOP-lowering superiority of latanoprost, bimatoprost and travoprost compared with timolol 0.5%, brimonidine 0.2%, or dorzolamide 2% monotherapy. Bimatoprost appears to be more efficacious in IOP-lowering compared with latanoprost, with weighted mean difference in IOP reduction documented in one meta-analysis of 2.59% to 5.60% from 1- to 6-months study duration. PGAs reduce IOP further when used as adjunctive therapy. Fixed combinations of latanoprost, bimatoprost or travoprost formulated with timolol 0.5% and administered once daily are superior to monotherapy of its constituent parts. PGA have near absence of systemic side effects, although do have other commonly encountered ocular adverse effects. The adverse effects of PGA, and also those found more frequently with bimatoprost use include ocular hyperemia, eyelash growth, and peri-ocular pigmentary changes. Iris pigmentary change is unique to PGA treatment. Once daily administration and near absence of systemic side effects enhances tolerance and compliance. PGAs are often prescribed as first-line treatment for ocular hypertension and open-angle glaucoma.

Meta-analysis of medical intervention for normal tension glaucoma

OBJECTIVE

To evaluate the intraocular pressure (IOP) reduction achieved by the most frequently prescribed antiglaucoma drugs in patients with normal tension glaucoma (NTG).

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Fifteen randomized clinical trials reported 25 arms for peak IOP reduction, 16 arms for trough IOP reduction, and 13 arms for diurnal curve IOP reduction.

METHODS

Pertinent publications were identified through systematic searches of PubMed, EMBASE, and the Cochrane Controlled Trials Register. The patients had to be diagnosed as having NTG. Methodological quality was assessed by the Delphi list on a scale from 0 to 18. The pooled 1-month IOP-lowering effects were calculated using the 2-step DerSimonian and Laird estimate method of the random effects model.

MAIN OUTCOME MEASURES

Absolute and relative reductions in IOP from baseline for peak and trough moments.

RESULTS

Quality scores of included studies were generally high, with a mean quality score of 12.7 (range, 9-16). Relative IOP reductions were peak, 15% (12%-18%), and trough, 18% (8%-27%) for timolol; peak, 14% (8%-19%), and trough, 12% (-7% to 31%) for dorzolamide; peak, 24% (17%-31%), and trough, 11% (7%-14%) for brimonidine; peak, 20% (17%-24%), and trough, 20% (18%-23%) for latanoprost; peak, 21% (16%-25%), and trough, 18% (14%-22%) for bimatoprost. The differences in absolute IOP reductions between prostaglandin analogues and timolol varied from 0.9 to 1.0 mmHg at peak and -0.1 to 0.2 mmHg at trough.

CONCLUSIONS

Latanoprost, bimatoprost, and timolol are the most effective IOP-lowering agents in patients with NTG.

Long-term effects of latanoprost monotherapy on intraocular pressure in Japanese glaucoma patients

PURPOSE

To assess the long-term effects of latanoprost monotherapy on intraocular pressure (IOP) reduction in Japanese patients with glaucoma.

METHODS

Those enrolled were patients with glaucoma who had been treated on an outpatient basis for more than 5 years at the Glaucoma Outpatient Clinic of the University of Yamanashi Hospital, with only latanoprost ophthalmic solution as the first drug of choice. Subjects who underwent treatment with a drug other than latanoprost, laser therapy, or surgery were eliminated from the study, and IOP reduction by latanoprost, the dropout rate and causative reasons, and the types of additional therapy were assessed in a retrospective manner.

RESULTS

Seventy-two patients (age: 68.3+/-13.0 y) were enrolled, including 40 men and 32 women for the checking of 72 eyes. There were 47 eyes with normal tension glaucoma (NTG) and 25 with primary open angle glaucoma (POAG). The mean duration of latanoprost monotherapy was 4.1+/-2.0 years (range: 5 mo to 7 y, median: 4.0 y). IOP reduction rates (cumulative dropout rates) relative to the mean IOP before the start of latanoprost monotherapy (17.8+/-3.4 mm Hg) were 11.5% (8.3%), 15.5% (8.3%), 13.0% (9.7%), 13.4% (13.9%), 13.5% (19.4%), and 10.6% (30.6%) at 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after the start of monotherapy, respectively. Although latanoprost demonstrated significant IOP reduction in POAG and NTG, eyes with POAG showed significant IOP reduction than those with NTG. Two eyes presented with local adverse events resulting from the discontinuation of use of latanoprost, and 4 eyes required filtering surgery.

CONCLUSIONS

Latanoprost stably reduced IOP over a long term and maintained visual field in approximately 70% of eyes with glaucoma after treatment for 5 years.

Effect of travoprost on intraocular pressure during 12 months of treatment for normal-tension glaucoma

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering effect of travoprost in normal-tension glaucoma (NTG) over a 12-month follow-up.

METHODS

Forty-five eyes of 45 patients with unilateral NTG were treated with travoprost (0.004%) once a day for 12 months. Mean IOP and the IOP reduction from baseline were assessed at 0.5, 1, 3, 6, 9, and 12 months after the initiation of the treatment. Adverse ocular event frequency and the frequency of discontinuation of treatment due to adverse events were evaluated.

RESULTS

Mean IOP during 12 months of travoprost treatment ranged from 11.17 to 11.82 mmHg, and the mean IOP reduction in relation to baseline IOP from -2.71 to -3.71 mmHg (-18.3% to -25.1%). Mean IOP and IOP changes in the travoprost-treated and control groups were significantly different at every follow-up (P < 0.05 in each case). Both the magnitude (r = 0.6992) and percentage (r = 0.5464) of IOP reductions correlated positively with baseline IOP values. Ocular adverse events were usually mild to moderate and resolved without treatment.

CONCLUSIONS

Travoprost was well tolerated and significantly reduced IOP in NTG patients. In addition, initial IOP reductions were maintained throughout follow-up. Travoprost was found to be more effective in patients with greater baseline IOP.

Reporting of noninferiority and equivalence randomized trials for major prostaglandins: a systematic survey of the ophthalmology literature

BACKGROUND

Standards for reporting clinical trials have improved the transparency of patient-important research. The Consolidated Standards of Reporting Trials (CONSORT) published an extension to address noninferiority and equivalence trials. We aimed to determine the reporting quality of prostaglandin noninferiority and equivalence trials in the treatment of glaucoma.

METHODS

We searched, independently and in duplicate, 6 electronic databases for eligible trials evaluating prostaglandins. We abstracted data on reporting of methodological criteria, including reporting of per-protocol [PP] and intention-to-treat [ITT] analysis, sample size estimation with margins, type of statistical analysis conducted, efficacy summaries, and use of hyperemia measures.

RESULTS

Trials involving the four major prostaglandin groups (latanoprost, travoprost, bimatoprost, unoprostone) were analyzed. We included 36 noninferiority and 11 equivalence trials. Seventeen out of the included 47 trials (36%, 95% Confidence Intervals [CI]: 24-51) were crossover designs. Only 3 studies (6%, 95% CI: 2-17) reported a presented results of both ITT and PP populations. Twelve studies (26%, 95% CI: 15-39) presented only ITT results but mentioned that PP population had similar results. Thirteen trials (28%, 95% CI: 17-42) presented only PP results with no mention of ITT population results while 17 studies (36%, 95% CI: 24-51) presented only ITT results with no mention of PP population results. Thirty-four (72%, 95% CI: 58-83) of studies adequately described their margin of noninferiority/equivalence. Sequence generation was reported in 22/47 trials (47%, 95% CI: 33-61). Allocation concealment was reported in only 10/47 (21%, 95% CI: 12-35) of the trials. Thirty-five studies (74%, 95% CI: 60-85) employed masking of at least two groups, 4/47 (9%, 95% CI: 3-20) masked only patients and 8/47 (17%, 95% CI: 9-30) were open label studies. Eight (17%, 95% CI: 9-30) of the 47 trials employed a combined test of noninferiority and superiority. We also found 6 differing methods of evaluating hyperemia.

CONCLUSION

The quality of reporting noninferiority/equivalency trials in the field of glaucoma is markedly heterogeneous. The adoption of the extended CONSORT statement by journals will potentially improve the transparency of this field.

A systematic review of the characteristics of randomised control trials featuring prostaglandins for the treatment of glaucoma

AIM

To classify the comparative quantity and quality of the RCT evidence of pharmacological treatment for glaucoma.

METHOD

A systematic review of MEDLINE, EMBASE Cochrane CENTRAL and relevant conference proceedings was conducted up to March 2007. RCTs recruiting adults with primary open angle glaucoma (POAG) and/or ocular hypertension (OH) receiving any topical medication or placebo were included. RCTs containing a prostaglandin treatment arm were specifically considered.

RESULTS

A total of 510 publications were identified. Of these, 181 studies had a prostaglandin treatment arm. The median study duration was 12 weeks (IQR 4-13) and 78% of included trials had a duration of 3 months or less. The four studies over 1 year in duration all included a latanoprost and timolol treatment arm. There was a lack of data on younger populations (median of the mean ages of included patients was 63.4 years [IQR: 61-66 years]). Caucasians constituted 79.6% of the studied population. Evidence by ethnicity as well as by co-morbidity, was scarce. The primary outcome for 92% of studies was IOP reduction; little was reported on other indicators. Most trials reported adverse events, with hyperaemia most commonly reported.

CONCLUSION

The RCT evidence base for glaucoma treatment is extensive. This systematic review is the first to consider the characteristics of all RCTs containing a prostaglandin arm. The majority of trials are of short duration and focus on IOP as the efficacy outcome. The limitations of this study are that only trials with a prostaglandin treatment arm are included and due to the large number of included trials only top line data were extracted.

Topical WIN55212-2 alleviates intraocular hypertension in rats through a CB1 receptor mediated mechanism of action

INTRODUCTION

Systemically administered cannabinoids can reduce intraocular pressure (IOP), but produce undesirable cardiovascular and central nervous system effects. In a chronic model of ocular hypertension, we examined the efficacy of acute topical administration of WIN55212-2 (WIN) in a novel commercially available vehicle and in combination with timolol.

METHODS

IOP was chronically elevated by the surgical ligature of vortex veins in Sprague Dawley rats. IOP was measured by using Goldmann applanation tonometry. IOP, blood pressure (BP), and heart rate (HR) were measured at baseline and 30, 60, 90, and 120 min after the topical administration of WIN 1.0%, 0.25%, 0.06%, or 0.015%, the commercially available vehicle, timolol 0.5%, or a combination of WIN and timolol. SR141716 (CB1 antagonist) or SR144528 (CB2 antagonist) was administered topically 30 min before WIN to determine receptor specificity. To determine ocular and systemic penetration, 3H WIN 55212-2 was administered topically and tissues were collected at 60 and 120 min. Ocular irritation was evaluated by slit-lamp examination (SLE) at baseline and 120 min.

RESULTS

WIN significantly decreased IOP in the hypertensive eye, with no BP or HR effects. SR141716 pretreatment significantly inhibited the IOP effects of WIN 1.0% in a dose-dependent manner, while SR 144528 was not as effective. No significant additive effects were observed by combining WIN (0.5% or 1.0%) with timolol 0.5%. WIN was retained in ocular tissue with a t1/2 of 80-100 min. SLE at 120 min revealed no solvent or drug-related toxic effects.

CONCLUSIONS

In a chronic ocular hypertensive rat model, topically applied WIN is an effective, nontoxic ocular hypotensive agent with no hemodynamic side-effects. This effect was predominantly CB1 receptor mediated, but some CB2 contribution could not be ruled out.