Glaucoma: diagnosis and management

Increased Risk of Ocular Hypertension in Patients With Cushing's Disease

PRCIS

An increased risk of ocular hypertension was seen in Cushing's disease.

INTRODUCTION

Systemic steroid use is a significant risk factor for increased intraocular pressure (IOP). The incidence of ocular hypertension may rise to 30%-40% of the general population due to topical or systemic glucocorticoid usage. However, the incidence of ocular hypertension in endogenous hypercortisolemia, as well as the ophthalmological outcomes after endocrine remission due to surgical resection, remain unknown.

MATERIALS AND METHODS

The IOP, visual field, and peripapillary retinal nerve fiber layer thickness were documented in all patients with Cushing's disease (CD) admitted to a tertiary pituitary center for surgery from January to July 2019. Patients with acromegaly and patients with nonfunctioning pituitary adenoma (NFPA) during the same study period served as controls. We calculated the odds ratio (OR), identified the risk factors of developing ocular hypertension, and presented postoperative trends of the IOP.

RESULTS

A total of 52 patients (38.4±12.4 y old) with CD were included. The IOP was higher in patients with CD (left 19.4±5.4 mm Hg and right 20.0±7.1 mm Hg) than in patients with acromegaly (left 17.5±2.3 mm Hg and right 18.6±7.0 mm Hg, P =0.033) and patients with NFPA (left 17.8±2.6 mm Hg and right 17.4±2.4 mm Hg, P =0.005). A total of 21 eyes (20.2%) in patients with CD were diagnosed with ocular hypertension compared with 4 eyes (4.7%) in the acromegaly group and 4 eyes (4.5%) in the NFPA group. The OR of developing ocular hypertension in patients with CD was 5.1 [95% confidence interval (CI), 1.3-25.1, P =0.029] and 6.6 (95% CI, 1.8-30.3, P =0.007) when compared with the 2 control groups. Among patients with CD, those with a higher urine-free cortisol were more likely to develop ocular hypertension (OR=19.4, 95% CI, 1.7-72.6). The IOP decreased at 1 month after surgery in patients with CD, and the change was sustained for 3 months after surgery.

CONCLUSIONS

An increased risk of ocular hypertension was seen in CD and suggests that endogenous hypercortisolemia should be considered as part of the glaucoma assessment. This result warrants the discretion of both ophthalmologists and neuroendocrinologists.

A review on the use of telemedicine in glaucoma and possible roles in COVID-19 outbreak

We review the use of telemedicine in glaucoma and its possible roles in the COVID-19 outbreak. We performed a literature search of published human studies on teleglaucoma on May 12, 2020, using search terms including “telemedicine” and “glaucoma” that were in English and published over the prior 10 years. This search strategy yielded a total of 14 relevant articles after manual curation. Of the 14 articles, 4 were from the same randomized control trial, 7 were prospective studies, 2 were retrospective studies, 1 was descriptive analysis, and 1 was cost-effective analysis. Seven discussed the common ophthalmologic measurements used in teleglaucoma. Four demonstrated the cost effectiveness of the use of teleglaucoma, and 3 articles investigated patient satisfaction with the use of teleglaucoma. Three articles investigated the correlation between teleglaucoma and face-to-face clinics. Five articles discussed the current use and opportunities of teleglaucoma.

When compared to in-person care, teleglaucoma is more time and cost-effective, shows high patient satisfaction and fair to good agreement with in-person care; however, there is great variation in the reported sensitivity of glaucoma screening, warranting further studies to establish its efficacy. For glaucoma management, both the sensitivity and specificity must be further improved before it could be put into extensive use. Nevertheless, it is worthwhile to explore the possible extensive application of teleglaucoma in monitoring “glaucoma suspects” and maintaining glaucoma follow-up during a pandemic outbreak to reduce the risk of transmission of infection.

Periodontitis and the subsequent risk of glaucoma: results from the real-world practice

Periodontitis is a multifactorial inflammatory disease that can cause tooth loss and contribute to systemic inflammation. It is suggested that periodontitis may be associated with the development of glaucoma. Based on data from Taiwan’s National Health Insurance Research Database, a retrospective cohort study was conducted to investigate the risk of developing glaucoma in patients with periodontitis. The periodontitis cohort consisted of newly diagnosed adult patients (n = 194,090, minimum age = 20 years) between 2000 and 2012. The comparison group included age-, gender-, and diagnosis date-matched people without periodontitis (n = 194,090, minimum age = 20 years). Incident glaucoma was monitored until the end of 2013. Hazard ratios (HRs) with confidence intervals (CIs) were established based on the Cox proportional hazard models. The risk of developing glaucoma was higher in patients with periodontitis than those without periodontitis (31.2 vs. 23.3 patients per 10,000 person-years, with an adjusted HR of 1.26 [95% CI 1.21–1.32]). A high risk was evident even after stratifying by age (adjusted HRs = 1.34 [1.26–1.44] for ages 20–49, 1.24 [1.13–1.36] for ages ≥ 65, and 1.20 [1.12–1.29] for ages 50–64 years), sex (adjusted HRs = 1.33 [1.24–1.41] and 1.21 [1.14–1.28] for men and women, respectively), presence of comorbidity (adjusted HRs = 1.38 [1.29–1.47] and 1.18 [1.12–1.25] for without and with comorbidity, respectively), and corticosteroid use (adjusted HRs = 1.27 [1.21–1.33] and 1.21 [1.08–1.35] for without and with corticosteroid use, respectively). Specifically, patients with periodontitis exhibited a significantly high risk of primary open-angle glaucoma (adjusted HR = 1.31 [1.21–1.32]) but not for primary closed-angle glaucoma (adjusted HR = 1.05 [0.94–1.17]). People with periodontitis are at a greater risk of glaucoma than individuals without periodontitis. Ocular health should be emphasized for such patients, and the underlying mechanisms need further investigation.

A European Perspective on Costs and Cost Effectiveness of Ophthalmic Combinations in the Treatment of Open-Angle Glaucoma

Purpose

Efficacy, safety, and cost implications are important considerations when choosing an ophthalmic treatment. Fixed-combination glaucoma medications containing brimonidine 0.2% and timolol 0.5%, or dorzolamide 2% and timolol 0.5%, were compared with brimonidine 0.2% and dorzolamide 2% that were used as adjunctive therapy to timolol 0.5%.

Methods

A literature review was conducted to determine the outcome parameters of intraocular pressure reduction and tolerability after 3 months of use of brimonidine or dorzolamide, each together with timolol as a fixed-combination or in concomitant therapy. Modelled cost-minimization and cost-effectiveness analyses were performed to investigate the economic consequences of ophthalmic therapy with brimonidine, dorzolamide, and timolol from a societal perspective.

Results

The literature review found that brimonidine and dorzolamide used as fixed combinations with timolol as well as in adjunctive therapy to timolol were equally effective and safe. Furthermore, in the European countries studied, the fixed combination of brimonidine/timolol represented a less costly option when compared to the fixed combination of dorzolamide/timolol evaluated over both a 3-month and a 12-month horizon.

Conclusions

Brimonidine used as a fixed-combination therapy with timolol provided better cost value than dorzolamide/timolol in all the countries studied. For most countries, the fixed combination of brimonidine and timolol also provided better cost value than adjunctive therapy with brimonidine, which was more cost effective than adjunctive therapy with dorzolamide.

Contact lens sensors in ocular diagnostics

Contact lenses as a minimally invasive platform for diagnostics and drug delivery have emerged in recent years. Contact lens sensors have been developed for analyzing the glucose composition of tears as a surrogate for blood glucose monitoring and for the diagnosis of glaucoma by measuring intraocular pressure. However, the eye offers a wider diagnostic potential as a sensing site and therefore contact lens sensors have the potential to improve the diagnosis and treatment of many diseases and conditions. With advances in polymer synthesis, electronics and micro/nanofabrication, contact lens sensors can be produced to quantify the concentrations of many biomolecules in ocular fluids. Non- or minimally invasive contact lens sensors can be used directly in a clinical or point-of-care setting to monitor a disease state continuously. This article reviews the state-of-the-art in contact lens sensor fabrication, their detection, wireless powering, and readout mechanisms, and integration with mobile devices and smartphones. High-volume manufacturing considerations of contact lenses are also covered and a case study of an intraocular pressure contact lens sensor is provided as an example of a successful product. This Review further analyzes the contact lens market and the FDA regulatory requirements for commercialization of contact lens sensors.

Australian optometric and ophthalmologic referral pathways for people with age-related macular degeneration, diabetic retinopathy and glaucoma

BACKGROUND

This study investigated the referral pathways offered to patients with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) by ophthalmologists and optometrists.

METHODS

Australian ophthalmologists and optometrists were surveyed regarding referral decisions to other eye-care specialists (inter- or intra-professional), general medical practitioners (GPs), low vision rehabilitation (LVR) and support services. Thematic analysis and concept mapping were applied to highlight current and ideal referral pathways.

RESULTS

The survey was completed by 155 optometrists and 50 ophthalmologists and deemed representative of their respective professions in Australia. Not surprisingly, the vast majority of the participating optometrists (97 to 99 per cent) referred to ophthalmologists regardless of the underlying condition. Clear differences (Chi-square: p < 0.05) were observed in the referral patterns of optometrists and ophthalmologists to GPs and support services. General medical practitioner services were almost exclusively used for patients with DR, while AMD triggered a significantly higher referral rate to low vision rehabilitation and support services than the other two disorders.

CONCLUSION

While ophthalmologists predominantly referred patients with AMD, DR or GL to low vision rehabilitation services, optometrists' referrals were highly skewed toward ophthalmology. Referrals to other supporting services by the two groups were not greatly used. The perceived referral pathways by the two eye-care professionals suggested a unidirectional route, potentially highlighting the need for a more collaborative approach that facilitates optimal use of eye health care and allied services.

Review on Hypothetical Implementing TGF-β Family Members in Glaucoma Therapy

For quite some time, glaucoma has been regarded as more than just intraocular pressure [IOP] elevation. Significant contribution to this conceptual improvement has risen from a better understanding of ocular blood flow, vessel wall integrity and certain advanced ideas in neuroophthalmology, for example neuroprotection. Transforming growth factor-β (TGF-β) molecule, its inhibitors and antagonists have been increasingly researched as possible new anti-glaucoma drugs for its many, pleiotropic, effects. Among those effects, enhancing fibrosis is one of the most apparent, but certain members of this cytokine's superfamily act as anti-fibrotics. Recent scientific efforts strongly support pushing back the frontier of conventional medical treatment. Current medical approaches already use effects on blood flow and neuronal quiescence, with significant systemic side-effects. Endeavours on the ophthalmologic exploitation of selected, favourable effects of pleiotropic TGF-βs could promote TGF-β, its inhibitors or specific antibodies as new, ideal drugs in glaucoma therapy.

Prevalence and determinants of glaucoma in citizens of qatar aged 40 years or older: a community-based survey

Background:

We present the prevalence and determinants of glaucoma among subjects 40 years of age and older in Qatar.

Materials and Methods:

This community-based survey was held in 2009 at 49 randomly selected clusters. Demographic details and history of glaucoma was collected by the nurses. Ophthalmologists evaluated the optic disc and retina using a digital camera housed in a mobile van. Visual field was tested with an automated perimeter, the intraocular pressure with an applanation tonometer and the angle of the anterior chamber by gonioscopy. A panel of glaucoma experts diagnosed subjects with glaucoma.

Results:

This survey enrolled 3,149 (97.3%) participants. The age- and sex-adjusted prevalence of glaucoma in the population aged 40 years and older was 1.73% (95% confidence intervals [CI] 1.69-1.77). Accordingly, 5,641 individuals in this age group in Qatar would have glaucoma. Chronological age of 60 years and older (Odds ratio [OR] 11.1) and the presence of myopia (OR 1.78) were predictors of glaucoma. Open-angle glaucoma was diagnosed in 44 (65.7%) individuals with glaucoma. In nine (13.4%) and 15 (20.9%) subjects, angle closure glaucoma and other (post-traumatic, pseudoexfoliation) glaucoma were present. Bilateral blindness (vision <3/60) and severe visual impairment (<6/60) were found in four (6%) and three (4.5%) subjects with glaucoma, respectively. Glaucoma was treated in 36 (54%) subjects.

Conclusions:

The prevalence of glaucoma among citizens of Qatar aged 40 years and older was 1.71%. Glaucoma was associated with the age of 60 years and older and the presence of myopia.

Reduction of intra-ocular pressure by ocular compression before combined peri- and retrobulbar block

The intra-ocular pressure immediately before glaucoma surgery can be raised. We wished to investigate if ocular compression for 20 min before a combined peri- and retrobulbar injection would result in a lower pressure after the block. Sixty consecutive patients scheduled for filtration surgery were randomly assigned to receive ocular compression using an external pressure device for 20 min before combined peri- and retrobulbar injection (intervention group, who also received compression after the block) or to a control group in whom pressure was applied only after the block was completed. The intra-ocular pressure was measured at baseline, after the 20-min pre-injection compression (intervention group), after injecting the block, and after the 10-min post-injection compression. The pressure did not differ between groups at baseline, after the block or after the post-injection compression. In the intervention group, the compression before the block reduced the median (IQR [range]) pressure from 21.0 (17.0-25.0 [12.0-40.0]) mmHg to 16.8 (12.5-22.5 [7.5-33.5]) mmHg (p<0.001). We conclude that external ocular compression reduces the intra-ocular pressure, but applying an additional compression for 20 min before injecting the block is not beneficial.

Potential of the bioflavonoids in the prevention/treatment of ocular disorders

OBJECTIVES

Flavonoids are a common group of plant polyphenols that give colour and flavour to fruits and vegetables. In recent years, flavonoids have gained importance in the pharmaceutical field through their beneficial effects on human health and are widely available as nutritional supplements. Several pharmacological actions of the bioflavonoids may be useful in the prevention or treatment of ocular diseases responsible for vision loss such as diabetic retinopathy, macular degeneration and cataract. This review aims to summarize the potential therapeutic applications of various bioflavonoids in different ocular diseases and also discusses delivery of these agents to the ocular tissues.

KEY FINDINGS

It is apparent that the flavonoids are capable of acting on various mechanisms or aetiological factors responsible for the development of different sight threatening ocular diseases. From a drug delivery perspective, ocular bioavailability depends on the physicochemical and biopharmaceutical characteristics of the selected flavonoids and very importantly the route of administration.

SUMMARY

The potential therapeutic applications of various bioflavonoids in ocular diseases is reviewed and the delivery of these agents to the ocular tissues is discussed. Whereas oral administration of bioflavonoids may demonstrate some pharmacological activity in the outer sections of the posterior ocular segment, protection of the retinal ganglionic cells in vivo may be limited by this delivery route. Systemic or local administration of these agents may yield much higher and effective concentrations of the parent bioflavonoids in the ocular tissues and at much lower doses.

Depressive symptomatology, medication persistence, and associated healthcare costs in older adults with glaucoma

PURPOSE

Depressive symptoms may impact patients' medication use behavior and utilization of healthcare services. This study examined association between depressive symptoms and Glaucoma medication-related persistence and predictors of associated healthcare charges in older adults with primary open angle Glaucoma.

METHODS

This study used a retrospective cohort of older adults with primary open angle Glaucoma who completed health status assessment, used Glaucoma medications, and were enrolled in a Medicare Health Maintenance Organization. Baseline assessment surveyed patients on demographics, healthcare service utilization in year before enrollment, lifestyle, and quality of life. Demographic, clinical, and utilization-related economic variables were retrieved from administrative claims database of patients' Health Maintenance Organization. Survival techniques were used to measure time to discontinuation (persistence) and Center for Epidemiologic Studies Depression Scale a 20-item self-reporting scale assessed depressive symptomatology on a range of 0 to 60. Associations were examined using mixed-model regression approach. Sensitivity analysis that considered log-transformed and untransformed specifications of cost variable tested model appropriateness.

RESULTS

In total 268 patients were followed for 2 years (N=536). After controlling for potential confounders and temporal effects, depressive symptomatology was associated with decreased Glaucoma medication-related persistence (P<0.005). Patients who lived alone and had cardiovascular disease showed higher odds of experiencing depressive symptoms (P<0.005). Healthcare charges increased with number of comorbidities and prescriptions (P<0.005).

CONCLUSIONS

Presence of depressive symptoms in patients lead to poor Glaucoma medication use behavior. Healthcare expenditures increased for patients with increase in comorbidities. Plan enrollees' risk assessment offers advantage of improving health outcomes and reduces healthcare utilization.

Medication adherence and health care costs with the introduction of latanoprost therapy for glaucoma in a medicare managed care population

BACKGROUND

Latanoprost, a prostaglandin inhibitor, is increasingly being used in the therapeutic management of glaucoma. However, there is scant literature examining the cost and outcome ramifications of latanoprost.

OBJECTIVES

This study examined the medication use behavior (medication-related persistence and adherence rates) and costs associated with the introduction of latanoprost therapy in a treatment-naive older population (aged >or=65 years) enrolled in Medicare.

METHODS

The study employed a retrospective observational cohort design and used administrative claims data from a Medicare health maintenance organization (HMO), which offered complete coverage to enrollees, including prescription benefits. The case group consisted of patients with glaucoma who began latanoprost therapy. The control group consisted of enrollees with glaucoma who started any therapy other than latanoprost. Both groups were followed up for 1 year before and after initiation of therapy. Bivariate and multivariate techniques incorporating health care utilization in the year before the start of new therapy were used to determine the study outcomes.

RESULTS

The case group comprised 101 patients (mean age, 77.60 years), while the control group included 168 patients (mean age, 77.59 years). There were no significant differences across the 2 groups with respect to age, sex, general health scores on the 12 item Short-Form Health Survey, severity of comorbidity, or the proportion of respondents with perception of worsened health. Introduction of latanoprost therapy was associated with higher medication persistence (hazard ratio, 0.90; 95% CI, 0.68-0.98) and adherence rates (mean [SD], 0.51 [0.26] vs 0.40 [0.25]; P < 0.001) compared with patients starting other glaucoma medication. Furthermore, there were no additional increases in total health care costs in the entire population associated with the introduction of latanoprost therapy, after adjusting for group and time effects, as well as other confounders (mean [SD], $4718.24 [$8982.92] vs $4046.55 [$6505.39]).

CONCLUSIONS

Latanoprost therapy offered improved medication use behavior in these older adults enrolled in a Medicare HMO. There were no significant additional increases in overall health care costs as a result of introduction of latanoprost therapy, after adjusting for group and time effects, as well as other baseline confounders in this study cohort.

Categorizing the stage of glaucoma from pre-diagnosis to end-stage disease

PURPOSE

To provide a reliable, comprehensive staging system to assess glaucoma stage in the absence of an universally accepted glaucoma staging system (GSS) on the basis of visual field results.

DESIGN

Literature review and GSS adaptation.

METHODS

After a review of published GSSs was conducted, the Bascom Palmer (Hodapp-Anderson-Parrish) GSS was selected as an appropriate platform for a retrospective GSS on the basis of visual fields. The system was modified by a panel of glaucoma specialists, and additional modifications were made after pilot testing to cover the full range of disease progression, from preglaucoma diagnosis to complete blindness; the ordered stages reflect the typical progression of glaucoma.

RESULTS

The GSS is comprised of six ordered stages and is on the basis of the Humphrey visual field. The completed GSS was validated by reviewing patient charts from 12 US glaucoma centers.

CONCLUSIONS

The GSS allows accurate staging of 100% of glaucoma on the basis of visual fields and other data, enabling evaluation of disease progression and resource utilization at various glaucoma stages. Additionally, treatment costs may be assigned to determine cost-effectiveness of treatment. Research utilizing the GSS has found that cost of care increases with increasing disease severity. The GSS may be used as the basis for creating treatment guidelines, which have the potential to delay glaucoma progression and lower treatment costs.

Acetazolamide: future perspective in topical glaucoma therapeutics

Through this review it is contemplated that acetazolamide (ACZ), an age-old treatment for glaucoma with a myriad of side effects and inadequate topical effectiveness, may be formulated into a topically effective agent by utilizing various newer formulation approaches of ocular drug delivery. Even though it has a poor solubility and penetration power, various studies mentioned in the review indicate that it is possible to successfully formulate topically effective ACZ by using: (i) high concentration of the drug, (ii) surfactant gel preparations of ACZ, (iii) ACZ loaded into liposomes, (iv) cyclodextrins to increase the solubility and hence bioavailability of ACZ, and (v) viscolyzers and other polymers either alone or in combination with cyclodextrins. With the advent of newer topical carbonic anhydrase inhibitors (CAIs) like dorzolamide and brinzolamide, a localized effect with fewer side effects is expected. But whenever absorbed systemically, a similar range of adverse effects (attributable to sulphonamides) may occur upon use. Furthermore, oral ACZ is reported to be more physiologically effective than 2% dorzolamide hydrochloride administered topically, even though in isolated tissues dorzolamide appears to be the most active as it shows the lowest IC(50) values for CA-II and CA-IV [M.F. Surgue, J. Ocular Pharmacol. Ther. 12 (1996) 363-376]. Hence, there exists considerable scope for the development of more/equally effective and inexpensive topically effective formulations of ACZ. The use of various formulation technologies discussed in this review can provide a fresh impetus to research in this area.

Pharmacological and ocular hypotensive properties of topical carbonic anhydrase inhibitors

There was a time gap of over 40 years between the demonstrated oral effectiveness of acetazolamide in lowering the intraocular pressure (IOP) of glaucoma patients and the introduction of a topical carbonic anhydrase (CA) inhibitor. This is due to the fact that CA-II, the isoenzyme which most likely plays an important role in the production of aqueous humor in humans, must be essentially inhibited by 100% to elicit a pharmacological response. The lack of success with earlier attempts to obtain a topical agent stems from an inability to attain and maintain a sufficiently high intraocular concentration of drug to achieve the required inhibition of CA. Dorzolamide and brinzolamide are two topical CA inhibitors which are currently available to treat ocular hypertension and/or glaucoma. Dorzolamide is a very potent inhibitor of CA-II and its site of action is local within the eye. Like oral CA inhibitors, topically applied dorzolamide lowers IOP by decreasing the production of aqueous humor. The drug is used in monotherapy as a 2% solution administered three times daily. Its ocular hypotensive effect is comparable to that of timolol at peak but is somewhat less at trough. The IOP lowering effect of timolol is enhanced by the twice daily administration of 2% dorzolamide either concomitantly or in combination. Topically applied dorzolamide is generally well tolerated and had a low drop-out rate in clinical studies. The most frequent ocular adverse experience is burning and/or stinging. Corneal and lenticular problems have generally not been encountered with long-term therapy with dorzolamide. Topically applied dorzolamide penetrates directly to the posterior segment of the eye and its presence is consistent with the initial report that dorzolamide increases retinal blood flow velocity in patients with normal tension glaucoma. The most frequent systemic adverse experience is a transient bitter taste. Biochemical changes indicative of the systemic inhibition of CA have not been observed in monotherapy studies lasting up to 2 years. This is in harmony with the inability of dorzolamide at steady-state to saturate CA in the red blood cell and the failure to detect its presence in plasma. A 1% suspension of brinzolamide is comparable to 2% dorzolamide in lowering IOP, both drugs being administered three times daily. Although brinzolamide has a lower incidence of burning/ stinging, it elicits more blurred vision.