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

Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study

PURPOSE

To determine whether primary trabeculectomy or medical treatment produces better outcomes in terms of quality of life (QoL), clinical effectiveness, and safety in patients with advanced glaucoma.

DESIGN

Multicenter randomized controlled trial.

PARTICIPANTS

Between June 3, 2014, and May 31, 2017, 453 adults with newly diagnosed advanced open-angle glaucoma in at least 1 eye (Hodapp classification) were recruited from 27 secondary care glaucoma departments in the United Kingdom. Two hundred twenty-seven were allocated to trabeculectomy, and 226 were allocated medical management.

METHODS

Participants were randomized on a 1:1 basis to have either mitomycin C-augmented trabeculectomy or escalating medical management with intraocular pressure (IOP)-reducing drops as the primary intervention and were followed up for 5 years.

MAIN OUTCOME MEASURES

The primary outcome was vision-specific QoL measured with the 25-item Visual Function Questionnaire (VFQ-25) at 5 years. Secondary outcomes were general health status, glaucoma-related QoL, clinical effectiveness (IOP, visual field, and visual acuity), and safety.

RESULTS

At 5 years, the mean ± standard deviation VFQ-25 scores in the trabeculectomy and medication arms were 83.3 ± 15.5 and 81.3 ± 17.5, respectively, and the mean difference was 1.01 (95% confidence interval [CI], -1.99 to 4.00; P = 0.51). The mean IOPs were 12.07 ± 5.18 mmHg and 14.76 ± 4.14 mmHg, respectively, and the mean difference was -2.56 (95% CI, -3.80 to -1.32; P < 0.001). Glaucoma severity measured with visual field mean deviation were -14.30 ± 7.14 dB and -16.74 ± 6.78 dB, respectively, with a mean difference of 1.87 (95% CI, 0.87-2.87 dB; P < 0.001). Safety events occurred in 115 (52.2%) of patients in the trabeculectomy arm and 124 (57.9%) of patients in the medication arm (relative risk, 0.92; 95% CI, 0.72-1.19; P = 0.54). Serious adverse events were rare.

CONCLUSIONS

At 5 years, the Treatment of Advanced Glaucoma Study demonstrated that primary trabeculectomy surgery is more effective in lowering IOP and preventing disease progression than primary medical treatment in patients with advanced disease and has a similar safety profile.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Role of T cell-induced autoimmune response in the pathogenesis of glaucoma

PURPOSE

This review aims to elucidate the role of T cell-induced autoimmune responses in the pathogenesis of glaucoma, focusing on the immunological changes contributing to retinal ganglion cell (RGC) damage.

METHODS

A comprehensive review of recent studies examining immunological mechanisms in glaucoma was conducted. This included analyses of T cell interactions, heat shock proteins (HSPs), and resultant autoimmune responses. Key findings from experimental models and clinical observations were synthesized to present a coherent understanding of immune dynamics in glaucoma.

RESULTS

Glaucoma is a neurodegenerative disease marked by optic nerve atrophy and irreversible vision loss due to RGC damage. The disease is etiologically heterogeneous, with multiple risk factors and pathogenic mechanisms. Recent research highlights the dual immunomodulatory role of T cells in immune protection and injury. T cells, pre-sensitized by bacterial HSPs, can cross-react with endogenous HSPs in RGCs under stress, leading to autoimmune damage. Elevated levels of HSP autoantibodies and abnormal T cell activity have been observed in glaucoma patients, indicating a significant autoimmune component in disease progression.

CONCLUSIONS

T cell-induced autoimmune responses are crucial in the pathogenesis of glaucoma, contributing to RGC degeneration beyond the effects of elevated intraocular pressure. Understanding these immunological mechanisms is vital for developing targeted neuroprotective therapies for glaucoma.

A validated web-application (GFDC) for automatic classification of glaucomatous visual field defects using Hodapp-Parrish-Anderson criteria

Subjectivity and ambiguity of visual field classification limits the accuracy and reliability of glaucoma diagnosis, prognostication, and management decisions. Standardised rules for classifying glaucomatous visual field defects exist, but these are labour-intensive and therefore impractical for day-to-day clinical work. Here a web-application, Glaucoma Field Defect Classifier (GFDC), for automatic application of Hodapp-Parrish-Anderson, is presented and validated in a cross-sectional study. GFDC exhibits perfect accuracy in classifying mild, moderate, and severe glaucomatous field defects. GFDC may thereby improve the accuracy and fairness of clinical decision-making in glaucoma. The application and its source code are freely hosted online for clinicians and researchers to use with glaucoma patients.

The need for more pragmatic trials in glaucoma research

AIM

There have been a number of clinical trials in glaucoma research published in the past two decades. Most of these trials were designed to evaluate very specific issues in selected populations placing them in the explanatory end of the pragmatic-explanatory continuum. The purpose of this study was to assess the level of pragmatism of published randomized controlled trials in glaucoma.

METHODS

A PubMed search using 'glaucoma' from 1995 to 2022 and randomized controlled trial (RCT) article type was done. Each study was assessed by three independent examiners using the Pragmatic-Explanatory Continuum Indicator Summary version 2 (PRECIS-2) toolkit. Scores were calculated for each study to determine the level of pragmatism. A summed score ≥36 was indicative of a very pragmatic study.

RESULTS

Thirty-two different articles were included in the analysis. These papers represented 13 different landmark trials. The median PRECIS-2 score was 32 (range, 25 for the Early Manifest Glaucoma Trial (EMGT) to 34 to the Collaborative Normal Tension Glaucoma Study (CNTGS) and the Ocular Hypertension Treatment Study). The Treatment of Advanced Glaucoma Study (TAGS), was considered very pragmatic and scored 33 points.

CONCLUSION

Despite the number of RCTs in glaucoma, there is still a need for more pragmatic studies.

Effects of socioeconomic status on baseline values and outcomes at 24 months in the Treatment of Advanced Glaucoma Study randomised controlled Trial

BACKGROUND/AIMS

Socioeconomic status (SES) is associated with late disease presentation and poorer outcomes. We evaluate the effect of SES on treatment outcomes and report the correlation between SES and baseline characteristics of participants in the Treatment of Advanced Glaucoma Study.

METHODS

Pragmatic multicentre randomised controlled trial. Four hundred and fifty-three patients presenting with advanced open-angle glaucoma in at least one eye (Hodapp-Parrish-Anderson classification). Participants were randomised to either glaucoma drops (medical arm) or trabeculectomy (surgery arm). Clinical characteristics, Quality of life measurement (QoL) and SES defined by the Index of Multiple Deprivation are reported. Subgroup analysis explored treatment effect modifications of SES at 24 months. Correlation between SES and baseline characteristics was tested with the χ2 test of association for dichotomous variables and pairwise Pearson's correlation for continuous variables.

RESULTS

The mean visual field mean deviation was -17.2 (6.7)dB for the most deprived quintile of participants and -13.0 (5.5) for the least deprived quintile in the index eye. At diagnosis, there was a strong correlation between SES and ethnicity, age, extent of visual field loss and number of visits to opticians prior to diagnosis. At 24 months, there was no evidence that the treatment effect was moderated by SES.

CONCLUSIONS

In patients presenting with advanced glaucoma. SES at baseline is correlated with poorer visual function, poorer Visual Function Questionnaire-25 QoL, ethnicity, age and number visits to an optician in the years preceding diagnosis. SES at baseline does not have an effect of the success of treatment at 24 months.

TRIAL REGISTRATION NUMBER

ISRCTN56878850.

Longitudinal evaluation of advanced glaucoma: ten year follow-up cohort study

This study focused on patients with advanced open-angle glaucoma (OAG) and aimed to identify key factors for monitoring them. We included 127 such patients who were followed for seven years or more, undergoing annual ophthalmic examinations. Glaucoma progression was defined as a deterioration in either structure or function. The progression rates and risk factors were evaluated. The patients were divided into upper- and lower-half subgroups based on the reduction in intraocular pressure (IOP) from the baseline. Over an 11-year period, glaucoma progression was detected in 59 eyes (46.5%). The rate of change in mean deviation (MD) was - 0.43 dB/year for the entire population; - 0.67 dB/year for progressors; and - 0.20 dB/year for non-progressors. Hypertension and disc hemorrhage (DH) were more common in progressors compared to non-progressors (45.8 vs. 23.5%, 11.9 vs. 1.5%; P = 0.008 and P = 0.016). Multivariate Cox's proportional hazard model revealed that the presence of DH and a better baseline MD were associated with glaucoma progression. Additionally, patients with a higher percentage reduction in IOP (> 20.94%) had a lower risk of progression compared to those with less reduction. Inadequate IOP reduction, better baseline MD, presence of DH, and lower central corneal thickness were identified as risk factors for progression in advanced OAG patients.

Preclinical Pharmacokinetic Profile of Topical Ophthalmic and Intravenous Delivery of QLS-101, a Novel ATP-Sensitive Potassium Channel Opening Ocular Hypotensive Agent

Purpose: To evaluate the pharmacokinetic profiles of the ocular hypotensive agent QLS-101, a novel ATP-sensitive potassium channel opening prodrug, and its active moiety levcromakalim, following topical ophthalmic and intravenous dosing of normotensive rabbits and dogs. Methods: Dutch belted rabbits (n = 85) and beagle dogs (n = 32) were dosed with QLS-101 (0.16-3.2 mg/eye/dose) or formulation buffer for 28 days. Pharmacokinetic profiles of QLS-101 and levcromakalim were evaluated in ocular tissues and blood by LC-MS/MS. Tolerability was assessed by clinical and ophthalmic examinations. Maximum systemic tolerated dose was evaluated in beagle dogs (n = 2) following intravenous bolus administrations of QLS-101 (0.05 to 5 mg/kg). Results: Plasma analysis following topical dosing of QLS-101 (0.8-3.2 mg/eye/dose) for 28 days indicated an elimination half-life (T1/2) of 5.50-8.82 h and a corresponding time (Tmax) range of 2-12 h in rabbits, and a T1/2 of 3.32-6.18 h with a Tmax range of 1-2 h in dogs. Maximum tissue concentration (Cmax) values ranged from 54.8-540 (day 1) to 50.5-777 ng/mL (day 28) in rabbits, and 36.5-166 (day 1) to 47.0-147 ng/mL (day 28) in dogs. Levcromakalim plasma T1/2 and Tmax were similar to QLS-101, while Cmax was consistently lower. Topical ophthalmic delivery of QLS-101 was well tolerated in both species, with sporadic mild ocular hyperemia noted in the group treated with the highest concentration (3.2 mg/eye/dose). Following topical ophthalmic dosing, QLS-101 and levcromakalim were found primarily in the cornea, sclera, and conjunctiva. Maximum tolerated dose was determined to be 3 mg/kg. Conclusions: QLS-101 was converted to its active moiety levcromakalim and showed characteristic absorption, distribution, and safety profiles of a well-tolerated prodrug.

Two-Year Visual Field Outcomes of the Treatment of Advanced Glaucoma Study (TAGS)

PURPOSE

to compare visual field (VF) progression between the 2 arms of the Treatment of Advanced Glaucoma Study (TAGS).

DESIGN

Post hoc analysis of VF data from a 2-arm, multicenter, randomized controlled clinical trial.

METHODS

A total of 453 patients with newly diagnosed advanced open-angle glaucoma in at least 1 eye from 27 centers in the United Kingdom were randomized to either trabeculectomy (n = 227) or medication in their index eye (n = 226) and followed-up for 2 years with 2 24-2 VF tests at baseline, 4, 12, and 24 months. Data were analyzed for participants with a reliable VF (false positive rate < 15%) at baseline and at least 2 other time points. Average difference in rate of progression (RoP) was analyzed using a hierarchical Bayesian model. Time for each eye to progress from baseline beyond specific cut-offs (0.5, 1, 1.5, and 2 dB) was compared using survival analysis.

RESULTS

This study analyzed 211 eyes in the trabeculectomy first arm and 203 eyes in the medication first arm. The average RoP (estimate [95% credible intervals]) was -0.59 [-0.88, -0.31] dB/year in the medication first arm and -0.40 [-0.67, -0.13] dB/year in the trabeculectomy first arm. The difference was not significant (Bayesian P-value = .353). More eyes progressed in the medication first arm, but this difference was not significant.

CONCLUSIONS

There was no significant difference in the average RoP at 2 years.

Predictors of problems reported on the EQ-5D-3L dimensions among people with impaired vision in northern Portugal

BACKGROUND

The EQ-5D index often fails to detect the effect of ophthalmic diseases and sight loss. Investigating predictors of individual EQ-5D health dimensions might reveal the underlying reasons. The aim of this study was to investigate predictors of health dimension ratings obtained with the EQ-5D-3L from participants with impaired vision representing a spectrum of eye diseases.

METHODS

Observational cross-sectional study with participants recruited at four public hospitals in Portugal. Outpatients with visual acuity of 0.30 logMAR(6/12) or worse in the better-seeing eye were invited to participate. Participants completed two instruments: the EQ-5D-3L (measures participants' perceived health-related quality-of-life) and the Massof Activity Inventory (measures visual ability-ability to perform vision-related activities). This study used logistic regression models to identify factors associated with responses to the EQ-5D-3L.

RESULTS

The study included 492 participants, mean age 63.4 years (range = 18-93), 50% females. The most common diagnosis was diabetic retinopathy (37%). The mean visual acuity in the better seeing eye was 0.65 logMAR (SD = 0.48) and the mean visual ability was 0.62 logits (SD = 2.04), the correlation between the two was r = - 0.511 (p < 0.001). Mobility and self-care were the health dimensions with the fewest problems (1% reported extreme problems), anxiety and depression the dimension with the most problems (24% reported extreme problems). ROC curve analysis showed that the EQ-5D index was a poor predictor of cases of vision impairment whilst visual ability given was a good predictor of cases of vision impairment. Visual ability was an independent predictor of the response for all dimensions, higher ability was always associated with a reduced odds of reporting problems. The odds of reporting problems were increased for females in 3 out of 5 dimensions. Comorbidities, visual acuity and age-category were predictors of the odds of reporting problems for one dimension each.

CONCLUSIONS

The odds of reporting problems for the five health dimensions of the EQ-5D-3L were strongly influenced by the ability to perform vision-related activities (visual ability). The EQ-5D index showed poor performance at detecting vision impairment. These findings are informative and relevant for the clinic and for research evaluating the impact of eye diseases and disease treatments in ophthalmology.

Primary trabeculectomy versus primary glaucoma eye drops for newly diagnosed advanced glaucoma: TAGS RCT

BACKGROUND

Patients diagnosed with advanced primary open-angle glaucoma are at a high risk of lifetime blindness. Uncertainty exists about whether primary medical management (glaucoma eye drops) or primary surgical treatment (augmented trabeculectomy) provide the best and safest patient outcomes.

OBJECTIVES

To compare primary medical management with primary surgical treatment (augmented trabeculectomy) in patients with primary open-angle glaucoma presenting with advanced disease in terms of health-related quality of life, clinical effectiveness, safety and cost-effectiveness.

DESIGN

This was a two-arm, parallel, multicentre, pragmatic randomised controlled trial.

SETTING

Secondary care eye services.

PARTICIPANTS

Adult patients presenting with advanced primary open-angle glaucoma in at least one eye, as defined by the Hodapp-Parrish-Anderson classification of severe glaucoma.

INTERVENTION

Primary medical treatment - escalating medical management with glaucoma eye drops. Primary trabeculectomy treatment - trabeculectomy augmented with mitomycin C.

MAIN OUTCOME MEASURES

The primary outcome was health-related quality of life measured with the Visual Function Questionnaire-25 at 2 years post randomisation. Secondary outcomes were mean intraocular pressure; EQ-5D-5L; Health Utilities Index 3; Glaucoma Utility Index; cost and cost-effectiveness; generic, vision-specific and disease-specific health-related quality of life; clinical effectiveness; and safety.

RESULTS

A total of 453 participants were recruited. The mean age of the participants was 67 years (standard deviation 12 years) in the trabeculectomy arm and 68 years (standard deviation 12 years) in the medical management arm. Over 65% of participants were male and more than 80% were white. At 24 months, the mean difference in Visual Function Questionnaire-25 score was 1.06 (95% confidence interval -1.32 to 3.43; p = 0.383). There was no evidence of a difference between arms in the EQ-5D-5L score, the Health Utilities Index or the Glaucoma Utility Index. At 24 months, the mean intraocular pressure was 12.40 mmHg in the trabeculectomy arm and 15.07 mmHg in the medical management arm (mean difference -2.75 mmHg, 95% confidence interval -3.84 to -1.66 mmHg; p < 0.001). Fewer types of glaucoma eye drops were required in the trabeculectomy arm. LogMAR visual acuity was slightly better in the medical management arm (mean difference 0.07, 95% confidence interval 0.02 to 0.11; p = 0.006) than in the trabeculectomy arm. There was no evidence of difference in safety between the two arms. A discrete choice experiment updated the utility values for the Glaucoma Utility Index. The within-trial economic analysis found a small increase in the mean EQ-5D-5L score (0.04) and that trabeculectomy has a higher probability of being cost-effective than medical management. The incremental cost of trabeculectomy per quality-adjusted life-year was £45,456. Therefore, at 2 years, surgery is unlikely to be considered cost-effective at a threshold of £20,000 per quality-adjusted life-year. When extrapolated over a patient's lifetime in a model-based analysis, trabeculectomy, compared with medical treatment, was associated with higher costs (average £2687), a larger number of quality-adjusted life-years (average 0.28) and higher incremental cost per quality-adjusted life-year gained (average £9679). The likelihood of trabeculectomy being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life year gained was 73%.

CONCLUSIONS

Our results suggested that there was no difference between treatment arms in health-related quality of life, as measured with the Visual Function Questionnaire-25 at 24 months. Intraocular pressure was better controlled in the trabeculectomy arm, and this may reduce visual field progression. Modelling over the patient's lifetime suggests that trabeculectomy may be cost-effective over the range of values of society's willingness to pay for a quality-adjusted life-year.

FUTURE WORK

Further follow-up of participants will allow us to estimate the long-term differences of disease progression, patient experience and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56878850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 72. See the NIHR Journals Library website for further project information.

Surgical advancement in glaucoma during the past 10 years

Recent years have seen a trend towards change in glaucoma treatment. In addition to classic trabeculectomy, implant surgeries such as those based on the Baerveldt, Ahmed and Molteno devices are increasingly performed as a primary procedure. This is doubtless partly due to the fact that surgeons have become more comfortable with the use of tube shunts and their postoperative management. The aim of this article is to present the currently available evidence on glaucoma surgery in a succinct format, to enable the best possible decisions to be made for patients.

Characteristics of glaucoma patients with intraocular pressure elevation early after trabectome surgery

PURPOSE

To analyze the rate and time of occurrence of intraocular pressure (IOP) elevation early after trabectome surgery (TOM) and the characteristics of glaucoma patients recovering from IOP elevation.

METHOD

Four hundred sixty eyes of 460 glaucoma (191 primary and 269 secondary open-angle glaucoma) patients who underwent TOM were evaluated. IOP elevation early after TOM was diagnosed when IOP increased by more than 5 mmHg over baseline within 1 week to 3 months. If the IOP decreased with the administration of anti-glaucoma eye drops alone, patients were classified as recovered. If the IOP did not decrease despite additional anti-glaucoma eye drop use, patients were classified as non-recovered. The rate and time of occurrence of IOP elevation early after TOM were investigated. Demographic and ocular variables related to recovery and non-recovery were identified by multivariate logistic regression analysis.

RESULTS

Of the 460 patients, IOP elevation early after TOM occurred in 102 (22.2%). IOP elevation occurred most frequently at postoperative week 1. Of the 102 patients with IOP elevation, 55 (53.9%) recovered and 47 (46.1%) did not. A large hyphema size the day after surgery was associated with increased likelihood of recovery from IOP elevation (odds ratio [OR], 6.6). A history of past selective laser trabeculoplasty (SLT; OR, 0.10) and high baseline IOP (OR, 0.86) were associated with reduced likelihood of recovery from IOP elevation.

CONCLUSION

IOP elevation early after TOM occurred most frequently at postoperative week 1. Patients with a large hyphema size, no history of SLT, and a lower baseline IOP recovered from IOP elevation early after TOM. A large hyphema the day after surgery suggested an increased likelihood of recovery from IOP elevation.

Improving the Power of Glaucoma Neuroprotection Trials Using Existing Visual Field Data

PURPOSE

Selecting reliable visual field (VF) test takers could improve the power of randomized clinical trials in glaucoma. We test this hypothesis via simulations using a large real world data set.

DESIGN

Methodology analysis: assessment of how improving reliability affects sample size estimates.

METHODS

A variability index (VI) estimating intertest variability was calculated for each subject using the residuals of the regression of the mean deviation over time for the first 6 tests in a series of at least 10 examinations for 2,804 patients. Using data from the rest of the series, we simulate VFs at regular intervals for 2 years. To simulate the neuroprotective effect (NE), we reduced the observed progression rate by 20%, 30%, or 50%. The main outcome measure was the sample size to detect a significant difference (P < .05) at 80% power.

RESULTS

In the first experiment, we simulated a trial including one eye per subject, either selecting randomly from the database or prioritizing patients with low VI. We could not reach 80% power for the low NE with the available patients, but the sample size was reduced by 38% and 49% for the 30% and 50% NE, respectively. In the second experiment, we simulated 2 eyes per subject, one of which was the control eye. The sample size (smaller overall) was reduced by 26% and 38% for the 30% and 50% NE by prioritizing patients with low VI.

CONCLUSIONS

Selecting patients with low intertest variability can significantly improve the power and reduce the sample size needed in a trial.

Interpretation of change scores for the National Eye Institute Visual Function Questionnaire-25: the minimally important difference

AIM

To estimate the minimally important difference (MID) in change in National Eye Institute Visual Function Questionnaire-25 (VFQ-25) composite score using methods aligned with patient perception.

METHODS

Retrospective analysis of prospectively collected data from adults with primary angle closure or primary angle closure glaucoma enrolled in the Effectiveness, in Angle-closure Glaucoma, of Lens Extraction study. We included data from 335 participants with patient reported visual function (VFQ-25) and health status measured by the EQ-5D-3L over 36 months. We used the recommended anchor-based methods (receiver operating characteristic (ROC), predictive modelling and mean change) to determine the MID of the VFQ-25. EQ-5D-3L anchor change was defined as none (<0.065); minimal (0.065≤EQ-5D-3L change ≤0.075 points) and greater change (>0.075 points).

RESULTS

Mean baseline VFQ-25 score was 87.6 (SD 11.8). Estimated MIDs in the change in VFQ-25 scores (95% CI) were 10.5 (1.9 to 19.2); 3.9 (-2.3 to 10.1); 5.8 (1.9 to 7.2) and 8.1 (1.7 to 14.8) for the 'within-patient', 'between-patient' change, ROC and predictive modelling anchor methods respectively. Excluding estimates from the methodologically weaker 'within-patient' method, the MID of a change in VFQ-25 composite score is 5.8 (median value).

CONCLUSIONS

Estimates of the MID using multiple methods assist in the interpretation of the VFQ scores. In the context of early glaucoma related visual disability, a change score of around six points on the VFQ-25 is likely to be important to patients. Further confirmatory research is required. Studies comparing changes in patient-reported outcome measure scores with a global measure of patients' perceived change are required.

Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS)

OBJECTIVE

To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma.

DESIGN

Pragmatic multicentre randomised controlled trial.

SETTING

27 secondary care glaucoma departments in the UK.

PARTICIPANTS

453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017.

INTERVENTIONS

Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months.

SECONDARY OUTCOMES

general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety.

RESULTS

At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare.

CONCLUSION

Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication.

TRIAL REGISTRATION

Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Medical Costs of and Changes in Glaucoma Treatment among Patients Newly Starting Glaucoma Care

Purpose: To use a medical claim database to investigate medical costs and treatment patterns among patients newly starting glaucoma care.Subjects and methods: Subjects registered in the Japan Medical Database Center (JMDC) from January 2005 to March 2016 who were newly diagnosed with glaucoma, started glaucoma treatment, and had treatment records covering more than five years were included in the analysis. All direct medical costs were collected for a period of up to ten years. Factors affecting medical costs were analyzed. Changes in hypotensive eyedrops and choices related to glaucoma surgery were also analyzed.Results: Out of approximately 1.42 million subjects, 2,393 satisfied the inclusion and exclusion criteria. The average total medical cost incurred per patient over a period of ten years was US$9,030, including US$1,214 during the initial year. The proportion of the total cost represented by the cost of hypotensive eyedrops increased from 5.2% to 10.6% over the ten-year period. Medical costs were higher in patients younger than ten years old than in patients of all other age groups. The number of ocular hypotensive eyedrops increased from 0.9 to 1.5 over the ten-year period. Medical costs were higher for subjects with secondary glaucoma than for other subjects. Sixty-three patients underwent trabeculotomy or trabeculectomy, and trabeculectomy was the preferred choice in later years.Conclusions: The total direct medical cost associated with glaucoma was US$9,030 for the first ten years. Drug costs gradually increased with treatment duration and patient age and varied by glaucoma type.

Visual field progression in patients with severe glaucoma

PURPOSE

To assess the cumulative risk of progression in glaucomatous eyes in the severe stage of disease.

METHODS

This was a retrospective observational study. Patients that had severe damage in at least one eye, as defined by three criteria including a mean deviation of ≤ - 20 dB, were included. Glaucoma progression was defined as a loss of ≥ 2 dB in mean deviation confirmed in three consecutive visual field tests, or a persistent loss of two or more lines of vision-not attributable to non-glaucomatous causes-in three consecutive follow-up examinations. Kaplan-Meier survival analysis was used to assess the cumulative incidence of progression of the first eye to reach endpoint in cases where both eyes were eligible.

RESULTS

A total of 143 eyes from 119 patients, were studied over a mean period of 4.9 ± 2.9 years. Baseline mean deviation was - 25.3 ± 3.6 dB. Twenty-three eyes of 22 patients reached the progression endpoint: 14 eyes by visual field criteria and 9 by visual acuity criteria. The cumulative 5-year risk of progression estimated by Kaplan-Meier analysis was 14.6% (95% confidence interval: 6.1-22.2%).

CONCLUSIONS

In severe glaucoma patients, we found a cumulative incidence of progression of 2.9% per year during the first 5 years of follow-up. Similar incidences have been reported in other studies of glaucoma at different stages of severity.

Achieving low target intraocular pressures in severe glaucoma

PURPOSE

This study aimed to assess details of therapy required to achieve an intraocular pressure (IOP) of ⩽12 mmHg in patients with severe glaucoma of different etiologies.

METHODS

Patients with a follow-up of at least 1 year, who fulfilled inclusion criteria were selected, and data analyzed with respect to baseline IOP, number of medications, and/or surgeries required to achieve an IOP of ⩽12 mmHg and ⩾6 mmHg. Final IOP, visual field status and medications/surgery required were noted.

RESULTS

About 127 eyes of 85 patients met all criteria. There were 48 eyes having primary angle closure glaucoma (PACG), 16 eyes with primary open angle glaucoma (POAG), 17 eyes of juvenile open angle glaucoma (JOAG), and 46 eyes of secondary glaucoma. The mean baseline IOP was 33.14 ± 11.07 mmHg and final IOP 10.25 ± 1.81 mmHg. In the age group >40 years, 29.63% of patients were controlled on medication as compared to 9.09% and 5.71% in the age group of <20 years and 20-40 years (p = 0.007). With a baseline IOP of <25 mmHg, 48.65% required a trabeculectomy, whereas for 25-30, and >30 mmHg, 62.5% and 97.29% respectively, required surgery (p < 0.001).66.67% of patients having mean deviation of -12 to -16 dB (decibels) on Humphrey field analyzer (HFA) underwent surgery to achieve target IOP in comparison to 83.52% who had mean deviation greater than -16 dB (p = 0.036).

CONCLUSION

Only 21.26% of severe glaucoma eyes could be controlled on medications alone. A baseline IOP of >25 mmHg, age <40 years and mean deviation worse than -16 dB, had a higher frequency of trabeculectomies to achieve an IOP of ⩽12 mmHg.

Effects of Citicoline, Homotaurine, and Vitamin E on Contrast Sensitivity and Visual-Related Quality of Life in Patients with Primary Open-Angle Glaucoma: A Preliminary Study

The aim of the present study was to evaluate the effects of supplementation with a fixed combination of citicoline 500 mg, homotaurine 50 mg, and vitamin E 12 mg (CIT/HOMO/VITE) on contrast sensitivity and visual-related quality of life in patients with primary open-angle glaucoma (POAG) in mild stage. This was a multicenter, observational, cross-over, short-term, pilot study on POAG patients with stable controlled intraocular pressure (IOP). Patients were randomly assigned to Group 1 (current topical therapy for 4 months and then current topical therapy plus CIT/HOMO/VITE for 4 months) or Group 2 (CIT/HOMO/VITE in addition to current topical therapy for 4 months and then topical therapy alone for 4 months). Best-corrected visual acuity, IOP, visual field, and the Spaeth/Richman contrast sensitivity (SPARCS) test score were recorded at baseline and after 4 and 8 months. The Glaucoma Quality of Life-15 (GQL-15) questionnaire was administered at each check time. Forty-four patients were assigned to Group 1 and 65 to Group 2. Over the follow-up period, there were no significant changes in IOP or visual field findings, whereas SPARCS and GQL-15 findings significantly varied from baseline, both being improved in subjects treated with CIT/HOMO/VITE fixed combination. These results demonstrate that a daily intake of a fixed combination of citicoline, homotaurine, and vitamin E in addition to the topical medical treatment significantly increased the total score of the contrast sensitivity test and the quality of life in patients with POAG.

Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT

BACKGROUND

Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment.

OBJECTIVES

To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways.

DESIGN

A 36-month pragmatic, unmasked, multicentre randomised controlled trial.

SETTINGS

Six collaborating specialist glaucoma clinics across the UK.

PARTICIPANTS

Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than -12 dB in the better eye or -15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT.

INTERVENTIONS

SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines.

MAIN OUTCOME MEASURES

The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety.

RESULTS

Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st - Medicine-1st) 0.01, 95% confidence interval (CI) -0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between -£585 and -£345).

LIMITATION

An unmasked design, although a limitation, was essential to capture any treatment effects on patients' perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL.

CONCLUSIONS

Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes.

FUTURE WORK

Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN32038223.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.

The outcome of surgical treatment in advanced glaucoma

INTRODUCTION

There is uncertainty regarding the outcomes of glaucoma surgery for patients with advanced glaucoma, because it may be associated with the «wipe out» phenomenon. The aim of this study was to evaluate the outcome of surgical treatment in advanced glaucoma.

METHODS

This retrospective study included 67eyes of 49 patients with end-stage glaucoma in which glaucoma surgery was carried out. The clinical records prior to and after surgery were reviewed. Follow up period was 14.4months.

RESULTS

The mean age was 50.2years and the sex ratio was 0.75. All the patients had a tubular visual field with persistence of a central island. The mean value of the mean deviation on automated perimetry was 18.94dB±4.7. The mean intraocular pressure (IOP) before surgery was 27.16mmHg±8.9. Postoperatively the overall success rate was 93% (IOP <18mmHg with stable visual acuity). The mean IOP was 14.25mmHg±4.12 (P<.001). There was no significant change in the mean visual acuity. The mean value of the mean deviation was 18.83±4.69 (P=.07). No occurrence of wipe-out phenomenon was noted. The early postoperative complications were hypotony, hyphema and ocular hypertension and they were transient without causing any visual loss. Long term complications were late bleb fibrosis and progression of cataract.

CONCLUSION

Glaucoma surgery had beneficial effects in the majority of patients with advanced glaucoma. Postoperative IOP was in general under control and visual acuity was preserved without any cases of wipe-out.

Personalising surgical treatments for glaucoma patients

Surgical treatments for glaucoma have relied for decades on traditional filtering surgery such as trabeculectomy and, in more challenging cases, tubes. Antifibrotics were introduced to improve surgical success in patients at increased risk of failure but have been shown to be linked to a greater incidence of complications, some being potentially vision-threatening. As our understanding of glaucoma and its early diagnosis have improved, a more individualised management has been suggested. Recently the term "precision medicine" has emerged as a new concept of an individualised approach to disease management incorporating a wide range of individual data in the choice of therapeutic modalities. For glaucoma surgery, this involves evaluation of the right timing, individual risk factors, targeting the correct anatomical and functional outflow pathways and appropriate prevention of scarring. As a consequence, there is an obvious need for better knowledge of anatomical and functional pathways and for more individualised surgical approaches with new, less invasive and safer techniques allowing for earlier intervention. With the recent advent of minimally invasive glaucoma surgery (MIGS) a large number of novel devices have been introduced targeting potential new sites of the outflow pathway for lowering intraocular pressure (IOP). Their popularity is growing in view of the relative surgical simplicity and apparent lack of serious side effects. However, these new surgical techniques are still in an era of early experiences, short follow-up and lack of evidence of their superiority in safety and cost-effectiveness over the traditional methods. Each year several new devices are introduced while others are withdrawn from the market. Glaucoma continues to be the primary cause of irreversible blindness worldwide and access to safe and efficacious treatment is a serious problem, particularly in the emerging world where the burden of glaucoma-related blindness is important and concerning. Early diagnosis, individualised treatment and, very importantly, safe surgical management should be the hallmarks of glaucoma treatment. However, there is still need for a better understanding of the disease, its onset and progression, the functional and structural elements of the outflow pathways in relation to the new devices as well as their long-term IOP-lowering efficacy and safety. This review discusses current knowledge and the future need for personalised glaucoma surgery.

Baseline Characteristics of Participants in the Treatment of Advanced Glaucoma Study: A Multicenter Randomized Controlled Trial

PURPOSE

To report the baseline characteristics of participants enrolled in TAGS (Treatment of Advanced Glaucoma Study).

DESIGN

Pragmatic randomized control trial (RCT).

METHODS

Participants with newly diagnosed advanced glaucoma in at least 1 eye were recruited. Participants were patients with open angle glaucoma presenting with advanced glaucoma in at least 1 eye as defined by the Hodapp-Parrish-Anderson (HPA) criteria for severe defect. Participants were randomly allocated to receive either primary augmented trabeculectomy or primary medical management. When both eyes were eligible, the same intervention was undertaken in both eyes, and the index eye for analysis was the eye with the less severe visual field mean defect (MD). Main outcome measurements were visual field profile, defined by the HPA classification; clinical characteristics; quality of life, as measured by the National Eye Institute Visual Function Questionnaire 25 (VFQ-25), the EuroQual-5 Dimension (EQ-5D 5L), Health Utility Index-3 (HUI-3), and the Glaucoma Profile Instrument (GPI).

RESULTS

A total of 453 patients were recruited. The mean visual field MD was -15.0 dB ± 6.3 in the index eye and -6.2 dB in the non-index eye. Of index eyes (HPA "severe" classification) at baseline, more than 70% of participants had a MD <-12.00 dB, and nearly 90% had more than 20 points defective at the 1% level. The mean LogMAR visual acuity of the index eye was 0.2 ± 0.3.

CONCLUSIONS

TAGS is the first RCT to compare medical versus surgical treatments for patients presenting with advanced open angle glaucoma in a publicly funded health service. The study will provide clinical, health-related quality of life, and economic outcomes to inform future treatment choices for those presenting with advanced glaucoma.

High intensity focused ultrasound for glaucoma: 1-year results from a prospective pragmatic study

BACKGROUND

Ciclo plasty using high-intensity focused ultrasound (HIFU) technology acts through the selective coagulation of the ciliary body. Our aim was to evaluate the safety and efficacy profiles of 8-s probe HIFU cyclocoagulation using the EyeOP1 device.

METHODS

Prospective pragmatic trial.

INCLUSION CRITERIA

adult glaucoma patients with uncontrolled IOP despite optimised medical therapy, and/or intolerant to medical therapy required to achieve target IOP.

PRIMARY OUTCOME

surgical success defined as IOP reduction from baseline >20% with final IOP ≤21 mmHg, without adding any IOP-lowering drugs, and without loss of light perception; or decreased use of IOP-lowering drugs with stable/decreased IOP, without loss of light perception.

SECONDARY OUTCOMES

mean IOP, intra and postoperative complications, best-corrected visual acuity (BCVA) and number of IOP-lowering drugs at each visit. Outcome data were collected preoperatively and at postoperative day 1, and months 1, 3, 6 and 12.

RESULTS

Forty-nine eyes of forty-nine patients (28 male) with a mean age of 70 ± 14 years were enroled. Pre-operative IOP was 26.9 ± 7.4 mmHg under 2.8 ± 0.9 topical medications, decreasing to 17.8 ± 6.4 mmHg under 2.3 ± 1 drugs at 12 months (p < 0.01). One-year surgical success was achieved in 71.4% of patients (IOP-reduction criteria: 59.2%; decreased use of IOP-lowering drugs: 38.8%). Eight patients were ultimately submitted to other glaucoma surgical interventions. Five patients experienced serious adverse events (loss of light perception n = 5; hypotony n = 1).

CONCLUSIONS

This innovative non-invasive technology seems to be effective in decreasing IOP and/or the number of administered drops in patients with refractory glaucoma. It seems a valuable tool to delay or preclude the need for filtering procedures in the majority of the patients.

Effect of an oral supplementation with a formula containing R-lipoic acid in glaucoma patients

OBJECTIVE

To analyse the safety and effectiveness of the oral administration of a commercialised supplement containing R-alpha lipoic acid, taurine, vitamins C and E, lutein, zeaxanthin, zinc, copper and docosahexaenoic acid, in patients with primary open angle glaucoma (POAG), and in control subjects.

MATERIAL AND METHODS

A prospective study of cases and controls was carried out, including 30 participants of both genders that were divided into: POAG Group (n=15) and a control group (CG; n=15), assigned to the oral intake of NuaDHA preparations Vision® (1 pill/day)+NuaDHA 1000 (2 pills/day) for 6 months. Participants were interviewed, ophthalmologically examined, and peripheral blood was taken for routine analysis and the determination of the pro-oxidant (malondialdehyde) and total antioxidant status. Statistical analysis was performed using the SPSS 22.0 program.

RESULTS

After 6 months of supplementation, there was a significant increase in the plasma total antioxidant status (1.073±0.090mM vs 1.276±0.107mM, P=.028), along with a parallel decrease in malondialdehyde (7.066±1.070μM vs 2.771±0.462μM, P=.005) in the POAG group. The malondialdehyde also decreased in the control group (6.17±1.336 vs. 2.51±0.391, P=.028). The Schirmer test improved (20-30%) and the subjective dry eye signs/symptoms noticeably decreased in the POAG group versus the CG.

CONCLUSIONS

Formulations containing antioxidant vitamins, R-alpha lipoic acid and docosahexaenoic acid, administered for 6 consecutive months, counteracted the oxidative stress by further stabilising the morphological/functional parameters of both the ocular surface and the glaucoma, without presenting with adverse effects or intolerances.

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.

Systematic reviews and randomised controlled trials on open angle glaucoma

Evidence for the effectiveness of interventions to prevent the progression of optic nerve damage in open angle glaucoma has evolved over the last 25 years. We describe that evolution through the systematic reviews on various aspects of the topic and how those reviews have highlighted the need for new trials. Though we can be confident that lowering pressure does indeed reduce the risk of progression, we still lack good evidence on the comparative effectiveness of different treatments not so much on lowering pressure but on preventing progression of the disease. This is true for different medicines, types of laser and especially for different surgical interventions. As always there is a need for more research, but this needs to be focussed on key uncertainties using core outcome sets which avoid research waste. Ultimately, our guidelines can be based on sound and comprehensive evidence of effectiveness.

Treatment choices for newly diagnosed primary open angle and ocular hypertension patients

Despite advances in our knowledge of the aetiology and pathophysiology of glaucoma, the sole proven, effective intervention for treating primary open-angle glaucoma (POAG) and ocular hypertension (OHT) remains lowering of intraocular pressure (IOP) to prevent further progression and visual loss. The purpose of this review is to evaluate the treatment choices available to newly diagnosed POAG and OHT patients. We review the existing literature on treatments currently available to newly diagnosed POAG and OHT patients and discuss their role in the treatment paradigm of POAG and OHT. We consider different factors that may be important when offering a choice of treatment to newly diagnosed POAG and OHT patients as well as describing new glaucoma treatments in development and future directions for treatment.

Ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) for trabeculectomy

Background/aims

To develop, test and determine whether a surgical-competency assessment tool for simulated glaucoma surgery is valid.

Methods

The trabeculectomy ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) was assessed for face and content validity with a large international group of expert eye surgeons. Cohorts of novice and competent surgeons were invited to perform anonymised simulation trabeculectomy surgery, which was marked using the Sim-OSSCAR in a masked fashion by a panel of four expert surgeons. Construct validity was assessed using a Wilcoxon rank-sum test. Krippendorff’s alpha was calculated for interobserver reliability.

Results

For the Sim-OSSCAR for trabeculectomy, 58 of 67 surgeons (86.6%) either agreed or strongly agreed that the Sim-OSSCAR is an appropriate way to assess trainees’ surgical skill. Face validity was rated as 4.04 (out of 5.00). Fifty-seven of 71 surgeons (80.3%) either agreed or strongly agreed that the Sim-OSSCAR contents represented the surgical technique of surgical trabeculectomy. Content validity was rated as 4.00. Wilcoxon rank-sum test showed that competent surgeons perform better than novices (p=0.02). Interobserver reliability was rated >0.60 (Krippendorff’s alpha) in 19 of 20 steps of the Sim-OSSCAR.

Conclusion

The Sim-OSSCAR for trabeculectomy, a newly developed and validated assessment tool for simulation glaucoma surgery, has validity and reliability. It has the potential to play a useful role in ophthalmic surgical education.

The use of patient-reported outcome research in modern ophthalmology: impact on clinical trials and routine clinical practice

This review article considers the rising demand for patient-reported outcome measures (PROMs) in modern ophthalmic research and clinical practice. We review what PROMs are, how they are developed and chosen for use, and how their quality can be critically appraised. We outline the progress made to develop PROMs in each clinical subspecialty. We highlight recent examples of the use of PROMs as secondary outcome measures in randomized controlled clinical trials and consider the impact they have had. With increasing interest in using PROMs as primary outcome measures, particularly where interventions have been found to be of equivalent efficacy by traditional outcome metrics, we highlight the importance of instrument precision in permitting smaller sample sizes to be recruited. Our review finds that while there has been considerable progress in PROM development, particularly in cataract, glaucoma, medical retina, and low vision, there is a paucity of useful tools for less common ophthalmic conditions. Development and validation of item banks, administered using computer adaptive testing, has been proposed as a solution to overcome many of the traditional limitations of PROMs, but further work will be needed to examine their acceptability to patients, clinicians, and investigators.

Outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with advanced glaucoma

Purpose

To determine the medium-term outcomes for patients with advanced glaucoma undergoing viscocanalostomy.

Methods

All patients with advanced glaucoma (mean deviation (MD) − 12.00 dB or above) and patients with poor visual acuity secondary to advanced glaucoma which precluded formal visual field assessment undergoing viscocanalostomy (VC) and phaco-viscocanalostomy between 2010 and 2014 under the care of a single surgical team were included. Intraocular pressure (IOP), visual acuity (VA) and visual field outcomes were assessed from data prospectively collected into a surgical outcome database. Success was defined at two IOP cut-off points: IOP ≤ 21 and ≤ 16 mmHg with (qualified) or without (complete) medications.

Results

One hundred thirty-five patients were included. Mean IOP changed from 23.6 ± 6.4 mmHg pre-operatively to 15.3, 15.8 and 14.8 mmHg at 1, 2 and 3 years, a change of 35, 33.5 and 39% respectively. Qualified success for an IOP ≤ 21 mmHg was achieved in 95.66, 90.6 and 80% and complete success in 52.5, 48.6 and 30.6% at year 1, 2 and 3. Qualified success for an IOP ≤ 16 mmHg was achieved in 66.6, 66.05 and 60% and complete success in 44.8, 37.6 and 30.6% at year 1, 2 and 3. The cumulative probability for achieving an IOP ≤ 21 mmHg with or without drops was 86.1, 81.4 and 81.4% at 12, 24 and 36 months. Eleven patients (8.1%) failed to achieve adequate IOP control and needed further surgical intervention. Eleven (8.1%) patients needed an intervention (Yag goniopuncture) following VC. Four patients (2.9%) had some post-operative complications, which resolved within 2 weeks following surgery. Nine patients (6.7%) lost more than 2 Snellen lines. There was no significant change in the MD across time points.

Conclusion

Viscocanalostomy and viscocanalostomy combined with phacoemulsification is a safe and effective method of controlling IOP in the medium term in patients with advanced glaucoma.

Gradually Then Suddenly? Decline in Vision-Related Quality of Life as Glaucoma Worsens

Purpose. To evaluate the relationship between self-reported vision-related quality of life (VRQL) and visual field (VF) loss in people from glaucoma clinics. Methods. A postal survey using the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was administered to people with a range of VF loss identified from a UK hospital-based glaucoma service database. Trends were assessed in a composite score from NEI VFQ-25 against better-eye mean deviation (BEMD) using linear regression and a spline-fitting method that can highlight where a monotonic relationship may have different stages. Results. A total of 636 patients (median [interquartile range] BEMD -2.1 [-5.2, -0.4] dB, median age 70 [60, 77] years) were analysed. Analysis of trends in the data revealed an average patient loses approximately 2 units (out of 100) on NEI VFQ-25 for every loss of 1 dB (BEMD) as VF defects first become bilateral, up to BEMD -5 dB. NEI VFQ-25 deterioration then appears to slow before a more rapid phase of change (4-5 units per 1 dB loss) after BEMD worsens beyond -15 dB. Conclusions. Relationship between decline in VRQL and VF worsening in glaucoma is unlikely to be linear; it more likely has different phases, and these should be further explored in longitudinal studies.