Lifetime visual prognosis for patients with primary open-angle glaucoma

Clinical risk stratification in glaucoma

Glaucoma is the leading cause of preventable sight loss in the United Kingdom and the provision of timely glaucoma care has been highlighted as a significant challenge in recent years. Following a recent high-profile investigation, The Healthcare Safety Investigation Branch recommended the validation of risk stratification models to safeguard the vision-related quality of life of glaucoma patients. There continues to be no nationally agreed evidence-based risk stratification model for glaucoma care across the United Kingdom. Some models have used simple measures of disease staging such as visual field mean deviation as surrogates for risk, but more refined, individualised risk stratification models should include factors related to both visual impairment and visual disability. Candidate tools should also incorporate both ocular and systemic co-morbidities, rate of disease progression, visual needs and driving status and undergo clinical refinement and validation to justify implementation. The disruption to routine glaucoma care caused by the COVID-19 pandemic has only highlighted the importance of such risk stratification models and has accelerated their development, application and evaluation. This review aims to critically appraise the available evidence underpinning current approaches for glaucoma risk stratification and to discuss how these may be applied to contemporary glaucoma care within the United Kingdom. Further research will be essential to justify and validate the utility of glaucoma risk stratification models in everyday clinical practice.

Measuring glaucoma quality of life in an Asian population using item banking: psychometric evaluation and computerized adaptive testing simulations

PURPOSE

To assess the psychometric properties of glaucoma-specific health-related quality of life (HRQoL) item banks (IBs), and explore their efficiency using computerized adaptive testing (CAT) simulations.

METHODS

In this cross-sectional, clinical study, 300 Asian glaucoma patients answered 221 items within seven IBs: Ocular Comfort Symptoms (OS); Activity Limitation (AL); Lighting (LT); Mobility (MB); Glaucoma Management (GM); Psychosocial (PSY); and Work (WK). Rasch analysis was conducted to assess each IB's psychometric properties (e.g., item "fit" to the construct; unidimensionality) and a set of analytic performance criteria guiding decision making relating to retaining or dropping domains and items was employed. CAT simulations determined the mean number of items for 'high' and 'moderate' measurement precision (stopping rule: SEM 0.3 and 0.387, respectively).

RESULTS

Participants' mean age was 67.2 ± 9.2 years (62% male; 87% Chinese). LT, MB, and GM displayed good psychometric properties overall. To optimize AL's psychometric properties, 16 items were deleted due to poor "fit", high missing data, item bias, low discrimination and/or a low clinical/patient importance rating. To resolve multidimensionality in PSY, we rehomed 16 items into a "Concern (CN)" domain. PSY and CN required further amendment, including collapsing of response categories, and removal of poorly functioning items (N = 7). Due to poor measurement precision, low applicability and high ceiling effect, low test information indices, and low item separation index the WK IB was not considered further. In CAT simulations on the final seven IBs (n = 182 items total), an average of 12.1 and 15.7 items per IB were required for moderate and high precision measurement, respectively.

CONCLUSIONS

After reengineering our seven IBs, they displayed robust psychometric properties and good efficiency in CAT simulations. Once finalized, GlauCAT™-Asian may enable comprehensive assessment of the HRQoL impact of glaucoma and associated treatments.

Immunomodulatory and Antioxidant Drugs in Glaucoma Treatment

Glaucoma, a group of diseases characterized by progressive retinal ganglion cell loss, cupping of the optic disc, and a typical pattern of visual field defects, is a leading cause of severe visual impairment and blindness worldwide. Elevated intraocular pressure (IOP) is the leading risk factor for glaucoma development. However, glaucoma can also develop at normal pressure levels. An increased susceptibility of retinal ganglion cells to IOP, systemic vascular dysregulation, endothelial dysfunction, and autoimmune imbalances have been suggested as playing a role in the pathophysiology of normal-tension glaucoma. Since inflammation and oxidative stress play a role in all forms of glaucoma, the goal of this review article is to present an overview of the inflammatory and pro-oxidant mechanisms in the pathophysiology of glaucoma and to discuss immunomodulatory and antioxidant treatment approaches.

Characteristics of a large, labeled dataset for the training of artificial intelligence for glaucoma screening with fundus photographs

Purpose

Significant visual impairment due to glaucoma is largely caused by the disease being detected too late.

Objective

To build a labeled data set for training artificial intelligence (AI) algorithms for glaucoma screening by fundus photography, to assess the accuracy of the graders, and to characterize the features of all eyes with referable glaucoma (RG).

Design

Cross-sectional study.

Subjects

Color fundus photographs (CFPs) of 113 893 eyes of 60 357 individuals were obtained from EyePACS, California, United States, from a population screening program for diabetic retinopathy.

Methods

Carefully selected graders (ophthalmologists and optometrists) graded the images. To qualify, they had to pass the European Optic Disc Assessment Trial optic disc assessment with ≥ 85% accuracy and 92% specificity. Of 90 candidates, 30 passed. Each image of the EyePACS set was then scored by varying random pairs of graders as "RG," "no referable glaucoma (NRG)," or "ungradable (UG)." In case of disagreement, a glaucoma specialist made the final grading. Referable glaucoma was scored if visual field damage was expected. In case of RG, graders were instructed to mark up to 10 relevant glaucomatous features.

Main Outcome Measures

Qualitative features in eyes with RG.

Results

The performance of each grader was monitored; if the sensitivity and specificity dropped below 80% and 95%, respectively (the final grade served as reference), they exited the study and their gradings were redone by other graders. In all, 20 graders qualified; their mean sensitivity and specificity (standard deviation [SD]) were 85.6% (5.7) and 96.1% (2.8), respectively. The 2 graders agreed in 92.45% of the images (Gwet's AC2, expressing the inter-rater reliability, was 0.917). Of all gradings, the sensitivity and specificity (95% confidence interval) were 86.0 (85.2-86.7)% and 96.4 (96.3-96.5)%, respectively. Of all gradable eyes (n = 111 183; 97.62%) the prevalence of RG was 4.38%. The most common features of RG were the appearance of the neuroretinal rim (NRR) inferiorly and superiorly.

Conclusions

A large data set of CFPs was put together of sufficient quality to develop AI screening solutions for glaucoma. The most common features of RG were the appearance of the NRR inferiorly and superiorly. Disc hemorrhages were a rare feature of RG.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Estimating the Length of the Preclinical Detectable Phase for Open-Angle Glaucoma

Importance

A 50% reduction of glaucoma-related blindness has previously been demonstrated in a population that was screened for open-angle glaucoma. Ongoing screening trials of high-risk populations and forthcoming low-cost screening methods suggest that such screening may become more common in the future. One would then need to estimate a key component of the natural history of chronic disease, the mean preclinical detectable phase (PCDP). Knowledge of the PCDP is essential for the planning and early evaluation of screening programs and has been estimated for several types of cancer that are screened for.

Objective

To estimate the mean PCDP for open-angle glaucoma.

Design, Setting, and Participants

A large population-based screening for open-angle glaucoma was conducted from October 1992 to January 1997 in Malmö, Sweden, including 32 918 participants aged 57 to 77 years. A retrospective medical record review was conducted to assess the prevalence of newly detected cases at the screening, incidence of new cases after the screening, and the expected clinical incidence, ie, the number of new glaucoma cases expected to be detected without a screening. The latter was derived from incident cases in the screened age cohorts before the screening started and from older cohorts not invited to the screening. A total of 2029 patients were included in the current study. Data were analyzed from March 2020 to October 2021.

Main Outcomes and Measures

The length of the mean PCDP was calculated by 2 different methods: first, by dividing the prevalence of screen-detected glaucoma with the clinical incidence, assuming that the screening sensitivity was 100% and second, by using a Markov chain Monte Carlo (MCMC) model simulation that simultaneously derived both the length of the mean PCDP and the sensitivity of the screening.

Results

Of 2029 included patients, 1352 (66.6%) were female. Of 1420 screened patients, the mean age at screening was 67.4 years (95% CI, 67.2-67.7). The mean length of the PCDP of the whole study population was 10.7 years (95% CI, 8.7-13.0) by the prevalence/incidence method and 10.1 years (95% credible interval, 8.9-11.2) by the MCMC method.

Conclusions and Relevance

The mean PCDP was similar for both methods of analysis, approximately 10 years. A mean PCDP of 10 years found in the current study allows for screening with reasonably long intervals, eg, 5 years.

Psychometric Evaluation of Glaucoma Quality of Life Item Banks (GlauCAT) and Initial Assessment Using Computerized Adaptive Testing

Purpose

To evaluate the psychometric properties of glaucoma-specific quality of life (QoL) item banks (GlauCAT) and assess their performance using computerized adaptive testing (CAT) simulations.

Methods

In this cross-sectional study, 293 participants with glaucoma (mean age ± SD, 70.7 ± 13.2 years; 45% female) answered 342 items in 12 QoL item banks (IBs): Activity Limitation (AL); Driving (DV); Convenience (CV); Economic (EC); Emotional (EM); General Symptoms (GS); Health Concerns (HC); Lighting (LT); Mobility (MB); Ocular Surface Symptoms (OS); Social (SC); and Visual Symptoms (VS). These IBs were assessed using Rasch analysis, and CAT simulations with 1000 simulated respondents were utilized to determine the average number of items to be administered to achieve moderate and high precision levels.

Results

The AL, DV, EM, HC, LT, MB, EC, OS, SC, and VS IBs required relatively minor amendments to achieve satisfactory psychometric fit. To resolve multidimensionality, we split CV into Treatment Convenience (TCV) and General Convenience (GCV). Due to poor measurement precision, the GS IB was not pursued further. This resulted in 12 total IBs. In CAT simulations, an average of 3.7 and 7.3 items per IB were required to attain measurement at moderate and high precision, respectively.

Conclusions

Following rigorous psychometric assessment, we developed 12 valid glaucoma-specific QoL domains that can obtain highly precise person measure estimates using a small number of items.

Translational Relevance

GlauCAT will enable researchers and clinicians to quickly and comprehensively assess the impact of glaucoma and its associated interventions across a range of QoL domains.

Predictors of Early Onset Glaucoma

Purpose/Relevance

To determine the influence of hypertension (HTN), type 2 diabetes (DM2), migraine, and obstructive sleep apnea (OSA) on the onset of primary open-angle glaucoma (POAG) to enhance predictive accuracy.

Methods

In this cross-sectional study, data for 389 eligible patients with POAG were collected through medical records review and phone surveys. All data were assessed collectively using stepwise multiple regression analysis to determine the relative contribution to age at POAG diagnosis. We used the following groups, based on age at diagnosis, HTN for patients with or without DM2 (model 1), HTN for patients with DM2 (model 2), DM2 for patients with or without HTN (model 3), and DM2 for patients with HTN (model 4).

Results

In model 1, age at HTN diagnosis was associated with age at POAG diagnosis (β = 0.14; 95% CI, 0.01–0.26, p = 0.04). In model 2, age at HTN diagnosis was not associated with age at POAG diagnosis (p > 0.05). In model 3, age at DM2 diagnosis was associated with age at POAG diagnosis (β = 0.37; 95% CI 0.16–0.58, p = 0.001). In model 4, age at DM2 diagnosis was associated with age at POAG diagnosis (β = 0.40; 95% CI 0.00–0.15, p = 0.003). Asian race/ethnicity was associated with early onset of POAG in model 3 (β = −6.44; 95% CI −12.34–0.54, p = 0.033). OSA and migraine did not influence the onset of POAG.

Conclusion

Our study found that the diagnosis of DM2 and HTN at an earlier age is associated with the early onset of POAG.

Screening for Open-Angle Glaucoma and Its Effect on Blindness

PURPOSE

To evaluate the effect of population screening on low vision and blindness from open-angle glaucoma.

DESIGN

Retrospective cohort study.

METHODS

A large population-based screening for glaucoma was conducted in Malmö, Sweden, from 1992 to 1997. A total of 42,497 subjects were invited, of which 32,918 were screened, and 9,579 were non-responders (ie, did not participate). The records of glaucoma patients who had visited the Department of Ophthalmology at Malmö University Hospital from January 1, 1987, to December 31, 2017, were reviewed. Patients diagnosed at or after the screening were assessed for moderate or severe vision impairment, here called low vision, or blindness by the World Health Organization definition. Selection bias was corrected by creating a group of potential screening participants from a comparison group of clinical patients. Main outcome measures were the risk ratios of the cumulative incidence for bilateral low vision or blindness caused by glaucoma in screened patients compared with the potential participants.

RESULTS

The cumulative incidence of blindness was 0.17% in the screened population versus 0.32% among the potential participants; and for low vision 0.25% versus 0.53%. The risk ratio (95% confidence interval) between the two was 0.52 (0.32-0.84) for blindness and 0.46 (0.31-0.68) for low vision. There were no differences between the proportions of potential confounders in the comparison group and those in the non-responders.

CONCLUSIONS

The results suggest that population screening may reduce bilateral low vision and blindness caused by glaucoma by approximately 50%.

Breaking bad news about glaucoma: a SPIKES strategy primer

PURPOSE

Most ophthalmic physicians are not formally trained for breaking the news of having sight threatening diseases, requiring lifelong therapy. This study aims to ascertain physician practices and patients' experiences regarding delivery of bad news.

METHODS

An online, anonymous questionnaire was sent to 400 ophthalmologists practising glaucoma to gather information as to how they deliver bad news to their patients. A parallel survey was also conducted amongst 100 established glaucoma patients to know whether how their doctor had delivered the diagnosis of glaucoma to them. After this, resident doctors were trained in SPIKES strategy and the patient survey was repeated in 100 new patients.

RESULTS

Two hundred and eighteen out of 400 ophthalmologists responded to our survey resulting in a survey yield of 54.5%. About 56.5% ophthalmologists dealt with disclosing the diagnosis >20 times a month; 70% of responders always discussed about the true severity of disease up-front. Only 8.70% respondents had formal training for breaking the bad news. Results of first phase of patient survey revealed that nearly one-third of patients (27%), felt that their doctor used incomprehensible medical terminology and 42% patients said that their doctor downplayed their diagnosis. Only 12% provided information to their patients about reliable sources to gather additional information. After the resident doctors were trained in SPIKES strategy, the second phase of patient survey had marked positive change in the way information was delivered.

CONCLUSION

The current study shows that despite years of clinical experience, many ophthalmologists face difficulty in delivering bad news for a sight threatening disease such as glaucoma. Therefore, SPIKES strategy or a similar protocol must be taught to practising ophthalmologists at all levels, to alleviate worries of patients suffering from chronic, visually debilitating diseases.

Lifetime visual outcomes of patients undergoing trabeculectomy

BACKGROUND

The most important outcome for patients undergoing trabeculectomy is to maintain the quality of life in their remaining years. This study quantifies end of life vision in terms of visual acuity (VA) and visual field status.

METHODS

A prospective service evaluation of patients undergoing trabeculectomy (from 2000 to 2012) who died prior to the study evaluation point (November 2018). Demographic data including socioeconomic status were collected and change in clinical measurement for the cohort between time of surgery and death was measured.

RESULTS

160 of 659 patients had died (24.3%), 4 were excluded due to insufficient data, leaving 156 patients (196 eyes) for evaluation. Male-to-female ratio was 3:2, 86% of patients were Caucasian. Mean age at surgery on first eye was 76.5 years (SD 9.0). Life expectancy post-trabeculectomy was 7.5 years (0.1-17.2). Mean change in VA was logarithm of the mean angle of resolution (LogMAR) 0.32 (SD 0.59) and visual field mean deviation progressed at a median of -0.44 dB/year (from -5.98 to 3.9) for eyes with at least a year of follow-up. Severe vision loss (loss of ≥10 letters on LogMAR) occurred in 78 eyes (40%) of which 18 (9%) were due to glaucoma, 69 patients (44%) required glaucoma drops at end of life.

CONCLUSION

Trabeculectomy is successful in slowing or preventing further glaucoma progression and thus maintaining visual function in the majority of eyes for the remainder of life. For those with severe vision loss at the end of life, only one in four was due to further progression of their glaucoma.

Contributing ocular comorbidity to end-of-life visual acuity in medically treated glaucoma patients, ocular hypertension and glaucoma suspect patients

AIM

To assess the visual acuity at the end of life in glaucoma suspect patients, ocular hypertension, and patients treated for glaucoma and to find factors contributing to a reduced visual acuity in this cohort of deceased patients.

METHODS

In a cohort of 3883 medically treated glaucoma patients, glaucoma suspect, or patients with ocular hypertension assembled in 2001-2004, 1639 were deceased. Patient data were collected from electronic and paper patient files. The files of 1378 patients were studied and the last measured visual acuity and ocular comorbidities influencing the visual acuity were extracted.

RESULTS

Our results show that only 37.2% of patients had no visual impairment in either eye, 30.5% was visually impaired or blind in both eyes and 4.1% was blind in both eyes, all based on VA. The most common contributing factors for severe visual impairment or blindness (prevalence ≥ 1%) were: glaucoma, retinal vein occlusion, dry and exudative age-related macular degeneration, past retinal detachment, amblyopia, diabetic retinopathy, anterior ischemic optic neuropathy, trauma, decompensated cornea, past keratitis, enucleation, corneal transplantation, and macular hole.

CONCLUSIONS

Despite the current advanced treatment modalities for glaucoma, 30.5% of patients had a VA < 0.5 in both eyes and 4.1% was blind in both eyes. However, this disability cannot be confidently attributed only to glaucoma. Besides glaucoma, most common contributing factors were among others retinal and macular diseases. Patient management in glaucoma should be based on more than lowering the intraocular pressure to prevent blindness at the end of life.

Advanced glaucoma at diagnosis: current perspectives

Presentation with advanced glaucoma is a significant risk factor for lifetime blindness. The asymptomatic nature of glaucoma, particularly in early disease, means that substantial vision loss in one eye does not always translate into a perceptible loss of visual function. This, along with the lack of an effective screening strategy, contributes to late presentation. Those most at risk of presenting with advanced glaucoma have asymptomatic high intraocular pressure (IOP), no family history of glaucoma, are socially disadvantaged, and do not attend sight testing. Patients with glaucoma may have impaired functionality for daily activities, such as reading, walking and driving. Quality of life measures have shown this to be significantly worse in patients with more severe visual field loss, particularly if bilateral. In addition, quality of life decreases faster with further bilateral visual field loss when advanced visual field damage is present. Management of these patients requires disproportionally more resources than those with earlier disease. Both medical and surgical options are used as the initial approach to treat patients presenting with advanced glaucoma. The most recently published National Institute for Health and Care Excellence (NICE) guidelines suggest that patients presenting with advanced disease should be offered trabeculectomy as a primary intervention. However, more evidence is required to determine the best initial management. The Treatment of Advanced Glaucoma Study (TAGS) is being conducted, comparing primary medical management with primary mitomycin C-augmented trabeculectomy for people presenting with advanced open-angle glaucoma. The results of TAGS will provide robust evidence for the most appropriate initial intervention.

Twenty-year outcomes in patients with newly diagnosed glaucoma: mortality and visual function

Background/aims

To determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years.

Methods

Twenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates. Probability of death was calculated using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. Visual outcome was analysed at the 20-year follow-up visit.

Results

From 68, 14 (21%) were lost to follow-up. In the remaining 54, 20 (37%) were alive 20 years after diagnosis. Of 63% who died, mean age of death was 84 years, most commonly due to vascular disease. Mean age at presentation of those who died was 73.7 years versus 63.2 years for survivors (P=0.001). The median time to death was 16 years. On visual field analysis, nearly half (48.9%) of eyes did not deteriorate, but 28.3% eyes deteriorated by more than two stages. Those who died had worse final visual acuity than survivors (P<0.001). Three who died were registered severely visually impaired mainly from macular disease, but no survivors were registered (P<0.001).

Conclusion

In this cohort, approximately two-thirds of patients with glaucoma died within 20 years of diagnosis. In most older patients with glaucoma, the overall goal of preventing visual handicap and blindness is achievable 20 years after diagnosis.

Treatment of Advanced Glaucoma Study: a multicentre randomised controlled trial comparing primary medical treatment with primary trabeculectomy for people with newly diagnosed advanced glaucoma-study protocol

BACKGROUND

Presentation with advanced glaucoma is the major risk factor for lifetime blindness. Effective intervention at diagnosis is expected to minimise risk of further visual loss in this group of patients.

AIM

To compare clinical and cost-effectiveness of primary medical management compared with primary surgery for people presenting with advanced open-angle glaucoma (OAG).

METHODS

Design: A prospective, pragmatic multicentre randomised controlled trial (RCT).

SETTING

Twenty-seven UK hospital eye services.

PARTICIPANTS

Four hundred and forty patients presenting with advanced OAG, according to the Hodapp-Parish-Anderson classification of visual field loss.

INTERVENTION

Participants will be randomised to medical treatment or augmented trabeculectomy (1:1 allocation minimised by centre and presence of advanced disease in both eyes).

MAIN OUTCOME MEASURES

The primary outcome is vision-related quality of life measured by the National Eye Institute-Visual Function Questionnaire-25 at 24 months. Secondary outcomes include generic EQ-5D-5L, Health Utility Index-3 and glaucoma-related health status (Glaucoma Utility Index), patient experience, visual field measured by mean deviation value, logarithm of the mean angle of resolution visual acuity, intraocular pressure, adverse events, standards for driving and eligibility for blind certification. Incremental cost per quality-adjusted life-year (QALY) based on EQ-5D-5L and glaucoma profile instrument will be estimated.

RESULTS

The study will report the comparative effectiveness and cost-effectiveness of medical treatment against augmented trabeculectomy in patients presenting with advanced glaucoma in terms of patient-reported health and visual function, clinical outcomes and incremental cost per QALY at 2 years.

CONCLUSIONS

Treatment of Advanced Glaucoma Study will be the first RCT reporting outcomes from the perspective of those with advanced glaucoma.

TRIAL REGISTRATION NUMBER

ISRCTN56878850, Pre-results.

A Systematic Review of End-of-Life Visual Impairment in Open-Angle Glaucoma: An Epidemiological Autopsy

PURPOSE

Glaucoma patients are still at risk of becoming blind. It is of clinical significance to determine the risk of blindness and its causes to prevent its occurrence. This systematic review estimates the number of treated glaucoma patients with end-of-life visual impairment (VI) and blindness and the factors that are associated with this.

METHODS

A systematic literature search in relevant databases was conducted in August 2014 on end-of-life VI. A total of 2574 articles were identified, of which 5 on end-of-life VI. Several data items were extracted from the reports and presented in tables.

RESULTS

All studies had a retrospective design. A considerable number of glaucoma patients were found to be blind at the end of their life; with up to 24% unilateral and 10% bilateral blindness. The following factors were associated with blindness: (1) baseline severity of visual field loss: advanced stage of glaucoma or substantial visual field loss at the initial visit; (2) factors influencing progression: fluctuation of intraocular pressure (IOP) during treatment, presence of pseudoexfoliation, poor patient compliance, higher IOP; (3) longer time period: longer duration of disease and older age at death because of a longer life expectancy; and (4) coexistence of other ocular pathology.

CONCLUSIONS

Further prevention of blindness in glaucoma patients is needed. To reach this goal, it is important to address the risk factors for blindness identified in this review, especially those that can be modified, such as advanced disease at diagnosis, high and fluctuating IOP, and poor compliance.

Ethnicity and Deprivation are Associated With Blindness Among Adults With Primary Glaucoma in Nigeria: Results From the Nigeria National Blindness and Visual Impairment Survey

PURPOSE

We explored the risk factors for glaucoma blindness among adults aged 40 years and above with primary glaucoma in Nigeria.

PARTICIPANTS AND METHODS

A total of 13,591 participants aged 40 years and above were examined in the Nigeria Blindness Survey; 682 (5.02%; 95 CI, 4.60%-5.47%) had glaucoma by ISGEO's criteria. This was a case-control study (n=890 eyes of 629 persons): glaucoma blind persons were cases and glaucoma not-blind were controls. Education and occupation were used to determine socioeconomic status scores, which were divided into 3 tertiles (affluent, medium, deprived). We assessed sociodemographic, biophysical, and ocular factors by logistic regression analysis for association with glaucoma blindness. Multinomial regression analysis was also performed with nonglaucoma as the reference category.

RESULTS

A total of 119/629 (18.9%; 95% CI, 15.9%-22.4%) persons were blind in both eyes; 510 were controls. There was interethnic variation in odds of blindness; age, male sex, socioeconomic status, prior diagnosis of glaucoma, hypertension, intraocular pressure, and lens opacity were associated with glaucoma blindness. Axial length, mean ocular perfusion pressure, and angle-closure glaucoma were associated with blind glaucoma eyes. In multivariate analysis, Igbo ethnicity (OR=2.79; 95% CI, 1.03-7.57) had higher risk as was being male (OR=4.59; 95% CI, 1.73-12.16) and unmarried (OR=2.50; 95% CI, 1.03-6.07). Deprivation (OR=3.57; 95% CI, 1.46-8.72), prior glaucoma diagnosis (OR=5.89; 95% CI, 1.79-19.40), and intraocular pressure (OR=1.07; 95% CI, 1.04-1.09) were also independent risk factors for glaucoma blindness.

CONCLUSION

Approximately 1 in 5 people with primary glaucoma were blind. Male sex, ethnicity and deprivation were strongly associated with blindness. Services for glaucoma need to improve in Nigeria, focusing on poor communities and men.

Factors associated with lifetime risk of open-angle glaucoma blindness

PURPOSE

To investigate factors associated with bilateral glaucoma blindness, particularly factors available at the time of diagnosis.

METHODS

Retrospective chart review of all patients with primary open-angle glaucoma (POAG) or pseudoexfoliative glaucoma (PEXG) followed at the Department of Ophthalmology or Low Vision Center of Skåne University Hospital, Malmö, Sweden, who died between January 2006 and June 2010. Disease stage at diagnosis was defined by a simplified version of Mills' glaucoma staging system using perimetric mean deviation (MD) to define six stages of severity. Blindness was defined according to WHO criteria. We used logistic regression analysis to examine the association between risk factors and glaucoma blindness.

RESULTS

Four hundred and 23 patients were included; 60% POAG and 40% PEXG. Sixty-four patients (15%) became blind from glaucoma. Blind patients had significantly longer mean duration with diagnosed disease than patients who did not go blind (14.8 years ± 5.8 versus 10.6 years ± 6.5, p < 0.001). The risk of blindness increased with higher intraocular pressure (IOP) (OR 1.08, 95% CI 1.03-1.13) and with each stage of more advanced field loss at time of diagnosis (OR 1.80 95% CI 1.34-2.41). Older age at death was also associated with an increased risk of blindness (OR 1.09 95% CI 1.03-1.14), while age at diagnosis was unimportant. PEXG was not an independent risk factor for blindness.

CONCLUSIONS

Higher IOP and worse visual field status at baseline were important risk factors, as was older age at death.

The risk of newly developed visual impairment in treated normal-tension glaucoma: 10-year follow-up

PURPOSE

To investigate the risk and risk factors for newly developed visual impairment in treated patients with normal-tension glaucoma (NTG) followed up on for 10 years.

METHODS

Patients with NTG, who did not have visual impairment at the initial diagnosis and had undergone intraocular pressure (IOP)-lowering treatment for more than 7 years, were included on the basis of a retrospective chart review. Visual impairment was defined as either low vision (0.05 [20/400] ≤ visual acuity (VA) <0.3 [20/60] and/or 10 degrees ≤ central visual field (VF) <20 degrees) or blindness (VA <0.05 [20/400] and/or central VF <10 degrees) by World Health Organization (WHO) criteria. To investigate the risk and risk factors for newly developed visual impairment, Kaplan-Meier survival analysis and generalized linear mixed effects models were utilized.

RESULTS

During the 10.8 years mean follow-up period, 20 eyes of 16 patients were diagnosed as visual impairment (12 eyes as low vision, 8 as blindness) among 623 eyes of 411 patients. The cumulative risk of visual impairment in at least one eye was 2.8% at 10 years and 8.7% at 15 years. The risk factors for visual impairment from treated NTG were worse VF mean deviation (MD) at diagnosis and longer follow-up period.

CONCLUSION

The risk of newly developed visual impairment in the treated patients with NTG was relatively low. Worse VF MD at diagnosis and longer follow-up period were associated with development of visual impairment.

Prevalence of end-of-life visual impairment in patients followed for glaucoma

PURPOSE

To assess the prevalence of end-of-life visual impairment in patients followed for glaucoma.

METHODS

Data of 122 patients followed for glaucoma who had died between July 2008 and July 2010 and who had visited the ophthalmology outpatient department of a large non-academic Dutch hospital were collected from the medical files. Sixty-one patients had open-angle glaucoma (OAG), and 61 patients were suspect for glaucoma or had ocular hypertension (OHT). Visual impairment was defined as a mean deviation value <-15 dB or a Snellen visual acuity <0.3 (20/60) of the better eye. We determined the number of patients with visual impairment on the last patient visit before death and investigated its main explanations.

RESULTS

Overall, the mean age at death was 81.8 years after a mean follow-up period of 9.2 years. Seventy-three per cent of all patients had their last visit in the year preceding death. In OAG, 16 patients (26%) had an end-of-life visual impairment. In nine patients (15%), this was caused by glaucoma. Eight of them had substantial visual loss at the initial visit. Six (10%) impaired OAG cases were mainly explained by ocular comorbidity, and there was an equal contribution of comorbidity and glaucoma in one case. Five glaucoma suspects or patients with OHT (8%) were visually impaired at death and these were all caused by ocular comorbidity.

CONCLUSION

The prevalence of end-of-life visual impairment is considerable in patients with OAG. Substantial visual loss at baseline is an important contributing factor. In glaucoma suspects or patients with OHT, the prevalence is lower and can be attributed to ocular comorbidity.

Lifetime risk of blindness in open-angle glaucoma

PURPOSE

To determine the lifetime risk and duration of blindness in patients with manifest open-angle glaucoma (OAG).

DESIGN

Retrospective chart review.

METHODS

We studied glaucoma patients who died between January 2006 and June 2010. Most glaucoma patients living in the catchment area (city of Malmö; n = 305 000) are managed at the Department of Ophthalmology at Skåne University Hospital in Malmö. From the patient records we extracted visual field status, visual acuity, and low vision or blindness as defined by the World Health Organization (WHO) criteria and caused by glaucoma at the time of diagnosis and during follow-up. We also noted age at diagnosis and death and when low vision or blindness occurred.

RESULTS

Five hundred and ninety-two patients were included. At the time of the last visit 250 patients (42.2%) had at least 1 blind eye because of glaucoma, while 97 patients (16.4%) were bilaterally blind, and 12 patients (0.5%) had low vision. Median time with a glaucoma diagnosis was 12 years (<1-29), median age when developing bilateral blindness was 86 years, and median duration of bilateral blindness was 2 years (<1-13). The cumulative incidences of blindness in at least 1 eye and bilateral blindness from glaucoma were 26.5% and 5.5%, respectively, after 10 years, and 38.1% and 13.5% at 20 years.

CONCLUSIONS

Approximately 1 out of 6 glaucoma patients was bilaterally blind from glaucoma at the last visit. Median duration of bilateral blindness was 2 years.

Direct healthcare costs of glaucoma treatment

AIMS

To report the complete lifetime direct healthcare costs of glaucoma treatment in a database of 1136 patients attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK.

METHOD

The database was interrogated to identify all patients who had initiated treatment at the Glaucoma Clinic at Glasgow Royal Infirmary, and who had subsequently died of natural causes. The healthcare resource use based cost assessment was based on two aspects of the direct National Health Service cost: drug costs (prescribed medications) and non-drug costs (inpatient or outpatient/and surgical or procedure costs).

RESULTS

106 patients (53 men, 53 women) were identified for whom there were lifetime treatment data. The mean lifespan of the patients was 80.5 years, and the mean number of years attending the glaucoma clinic was 7.05 years (range 1-22 years). The mean cost of glaucoma treatment over the lifetime of the patients was £3001, with an annual mean cost per patient of £475. Non-drug and drug costs made up 66% and 34% respectively, of the lifetime costs.

CONCLUSIONS

This is the only study to directly assess the lifetime treatment costs of glaucoma. Awareness of the costs of glaucoma treatment may be of increased importance in these financially challenging times.

Current status of unoprostone for the management of glaucoma and the future of its use in the treatment of retinal disease

INTRODUCTION

Optic nerve and retinal diseases such as glaucoma, age-related macular degeneration (AMD) and retinitis pigmentosa (RP) are significant public health concerns and have a momentous impact on patients' functional status and quality of life. These diseases are among the most common causes of visual impairment worldwide and account for billions of dollars in healthcare expenditures and lost productivity. The importance of adequate treatment of these conditions and the need for efficacious therapeutic drugs cannot be overstated. Unoprostone continues to be developed as a potential treatment for these debilitating diseases.

AREAS COVERED

This review provides background information on unoprostone isopropyl (unoprostone), a prostanoid and synthetic docosanoid approved for the treatment of open-angle glaucoma and ocular hypertension, and recapitulates safety and efficacy data as it relates to this indication. Additionally, this review describes potential new uses of unoprostone as therapy for dry AMD and RP. A literature search of peer-reviewed publications was performed utilizing PubMed. Searches were last updated on 10 September 2012.

EXPERT OPINION

Current data indicate that unoprostone does significantly lower intraocular pressure (IOP) and has a favorable safety and tolerability profile. However, the IOP-lowering effects of unoprostone do not compare with other commercially available prostanoids and it has the disadvantage of a twice-daily rather than once-daily dosing regimen. Nonetheless, recent data suggest that unoprostone may improve neuronal survival and increase ocular blood flow, indicating that it may have some value as a therapy for glaucoma, RP and dry AMD. Further studies are needed to confirm whether unoprostone provides any clinically significant advantage over the other commercially available prostanoids.

Incorporating life expectancy in glaucoma care

AIM

To calculate for which combinations of age and perimetric disease stage glaucoma patients are unlikely to become visually impaired during their lifetime.

METHODS

We used residual life expectancy data (life expectancy adjusted for the age already reached) as provided by Statistics Netherlands and rates of progression as derived from published studies. We calculated the baseline mean deviation (MD) for which an individual would reach a MD of -20 dB at the end of life as a function of age and rate of progression. For situations in which the individual rate of progression is unknown, we used the 90th percentiles of rate of progression and residual life expectancy. For situations in which the individual rate of progression is known, we used the 95th percentile of the residual life expectancy.

RESULTS

An easily applicable graphical tool was developed that enables an accurate estimate of the probability of becoming visually impaired during lifetime, given age, current glaucomatous damage, and--if available--the individual rate of progression.

CONCLUSIONS

This novel tool enables the clinician to incorporate life expectancy in glaucoma care in a well-founded manner and may serve as a starting point for personalized decision making.

The impact of change in visual field on health-related quality of life the los angeles latino eye study

PURPOSE

To assess the impact of change in visual field (VF) on change in health-related quality of life (HRQoL) at the population level.

DESIGN

Prospective cohort study.

PARTICIPANTS

Three thousand one hundred seventy-five Los Angles Latino Eye Study participants.

METHODS

Objective measures of VF and visual acuity and self-reported HRQoL were collected at baseline and at the 4-year follow-up. Analysis of covariance was used to evaluate mean differences in change of HRQoL across severity levels of change in VF and to test for effect modification by covariates.

MAIN OUTCOME MEASURES

General and vision-specific HRQoL.

RESULTS

Of 3175 participants, 1430 (45%) showed a change in VF (≥1 decibel [dB]) and 1715 (54%) reported a clinically important change (≥5 points) in vision-specific HRQoL. Progressive worsening and improvement in the VF were associated with increasing losses and gains in vision-specific HRQoL for the composite score and 10 of its 11 subscales (all P(trend)<0.05). Losses in VF of more than 5 dB and gains of more than 3 dB were associated with clinically meaningful losses and gains in vision-specific HRQoL, respectively. Areas of vision-specific HRQoL most affected by greater losses in VF were driving, dependency, role-functioning, and mental health. The effect of change in VF (loss or gain) on mean change in vision-specific HRQoL varied by level of baseline vision loss (in VF, visual acuity, or both) and by change in visual acuity (all P(interaction)<0.05). Those with moderate or severe VF loss at baseline and with a more than 5 dB loss in VF during the study period had a mean loss of vision-specific HRQoL of 11.3 points, whereas those with no VF loss at baseline had a mean loss of 0.97 points. Similarly, with a more than 5 dB loss in VF and baseline visual acuity impairment (mild or severe), there was a loss in vision-specific HRQoL of 10.5 points, whereas with no visual acuity impairment at baseline, there was a loss of vision-specific HRQoL of 3.7 points.

CONCLUSIONS

Both losses and gains in VF produce clinically meaningful changes in vision-specific HRQoL. In the presence of pre-existing vision loss (VF and visual acuity), similar levels of VF change produce greater losses in QOL.

Exploring eye movements in patients with glaucoma when viewing a driving scene

Background

Glaucoma is a progressive eye disease and a leading cause of visual disability. Automated assessment of the visual field determines the different stages in the disease process: it would be desirable to link these measurements taken in the clinic with patient's actual function, or establish if patients compensate for their restricted field of view when performing everyday tasks. Hence, this study investigated eye movements in glaucomatous patients when viewing driving scenes in a hazard perception test (HPT).

Methodology/Principal Findings

The HPT is a component of the UK driving licence test consisting of a series of short film clips of various traffic scenes viewed from the driver's perspective each containing hazardous situations that require the camera car to change direction or slow down. Data from nine glaucomatous patients with binocular visual field defects and ten age-matched control subjects were considered (all experienced drivers). Each subject viewed 26 different films with eye movements simultaneously monitored by an eye tracker. Computer software was purpose written to pre-process the data, co-register it to the film clips and to quantify eye movements and point-of-regard (using a dynamic bivariate contour ellipse analysis). On average, and across all HPT films, patients exhibited different eye movement characteristics to controls making, for example, significantly more saccades (P<0.001; 95% confidence interval for mean increase: 9.2 to 22.4%). Whilst the average region of ‘point-of-regard’ of the patients did not differ significantly from the controls, there were revealing cases where patients failed to see a hazard in relation to their binocular visual field defect.

Conclusions/Significance

Characteristics of eye movement patterns in patients with bilateral glaucoma can differ significantly from age-matched controls when viewing a traffic scene. Further studies of eye movements made by glaucomatous patients could provide useful information about the definition of the visual field component required for fitness to drive.

Evaluating clinical change and visual function concerns in drivers and nondrivers with glaucoma

PURPOSE

To compare drivers and nondrivers, and to describe the specific concerns of drivers, among individuals with glaucoma.

METHODS

Six hundred seven patients with newly diagnosed glaucoma treated at 14 clinical centers of the Collaborative Initial Glaucoma Treatment Study were randomly assigned to initial medicine or surgery and were followed up every 6 months. Driving status (drivers versus nondrivers) and patient-reported visual function were determined by the Visual Activities Questionnaire and the National Eye Institute Visual Function Questionnaire. Clinical evaluation included visual field mean deviation (MD) and visual acuity. Statistical comparisons were made using t, chi(2), and exact tests and regression and Rasch analyses.

RESULTS

Drivers were more likely than nondrivers to be male, white, married, employed, and more educated and to have higher incomes and fewer comorbidities. More than 50% of drivers reported at least "some" difficulty performing tasks involving glare, whereas 22% reported at least "some" difficulty with tasks requiring peripheral vision. At 54 months, drivers with moderate/severe bilateral visual field loss (VFL) reported greater difficulty with night driving and tasks involving visual search and visual processing speed than drivers with less bilateral VFL (all P<0.05). Although those who remained drivers over follow-up had better MD in both eyes than those who became nondrivers because of eyesight, a number of drivers had marked VFL.

CONCLUSIONS

Inquiring about specific difficulties with tasks related to glare, visual processing speed, visual search, and peripheral vision in driving, especially among patients with substantial bilateral visual field damage, will enable physicians to more effectively counsel patients regarding driving.

The socioeconomic impact among Egyptian glaucoma patients

BACKGROUND/AIM

To evaluate the economic burden of intraocular pressure (IOP)-lowering medications on Egyptian patients with glaucoma, in addition to studying the social grounds of glaucoma education.

METHODS

In a cross-sectional observational study, the clinical and socioeconomic data were collected from 68 glaucomatous patients who were attending the outpatient clinics of Cairo University Hospital, through interviews, questionnaires, and clinical examinations.

RESULTS

Patients had a mean IOP of 22.9 mm Hg (SD 11.5). Just under half the patients had an IOP of over 30 mmHg although 88% were on medical treatment; average of 2.1 medications (SD 0.8). Patients had been spending 79.5 LE (SD 95.3) on glaucoma medications a month, which equals 30.1% of their monthly income. Forty per cent of patients did not know that glaucoma causes blindness. The primary source of knowledge about glaucoma for 79.4% of patients was the ophthalmologist.

CONCLUSION

The lack of control of IOP is probably related to the economic burden associated with glaucoma medications. 'Glaucoma education' is an important issue to both the treating ophthalmologist and the patient.