24-Hour Evaluation of the Effectiveness and Tolerability of Preservative-Free Tafluprost-Timolol Fixed Combination in Open-Angle Glaucoma or Ocular Hypertensive Patients Previously Treated with Preserved Latanoprost

Purpose

The effectiveness, safety and tolerability of the preservative-free fixed combination of tafluprost and timolol (PF-TTFC) were evaluated over the 24-h in patients with open-angle glaucoma or ocular hypertension showing signs and symptoms of Ocular Surface Disease (OSD) and uncontrolled intraocular pressure (IOP) on prior benzalkonium chloride (BAK) - Latanoprost monotherapy.

Methods

In this multi-center, prospective, interventional, non-comparative clinical trial, patients treated with BAK-Latanoprost underwent 24-h IOP measurements (8 am, 11 am, 2 pm, 5 pm, 8 pm, 11 pm, 2 am, 5 am) at baseline and after 3 months from switch to PF-TTFC. Mean 24-h IOP and daytime (8 am-8 pm) vs nighttime (11 pm - 5 am) IOP were compared. Changes in OSD signs and symptoms, quality of life (QoL) and in-vivo corneal confocal microscopy (IVCM) were also evaluated.

Results

Thirty-eight patients were analyzed. The mean 24-h IOP significantly decreased after 3 months from 17.8 mmHg (95% CI: 17.1-18.6) to 15.3 mmHg (95% CI: 14.6-16.1, p < 0.001). IOP was significantly reduced both at daytime (p < 0.001) and nighttime (p < 0.001), with better IOP control at night [-2.9 (95% CI: -3.5 to -2.1) mmHg vs -2.3 (95% CI: -2.9 to -1.6) mmHg]. In 20 patients (52.6%), corneal fluorescein staining improved, whereas in 4 patients (10.5%) it worsened. Hyperemia has improved in 24 (63.3%) patients and worsened in 2 (5.3%). Breakup time, Schirmer test and QoL scores showed no changes. At IVCM, the mean corneal wing-cell size was found significantly decreased (p < 0.005).

Conclusion

The switch from BAK-Latanoprost to PF-TTFC significantly reduced IOP over the 24-h and improved OSD signs and symptoms.

Micropulse Transscleral Cyclophotocoagulation in Non-Incisional Eyes with Ocular Hypertension and Primary Open-Angle Glaucoma

Purpose

To investigate the safety and effectiveness of micropulse transscleral cyclophotocoagulation (MPTSCPC) in non-incisional eyes with ocular hypertension (OHT) and early, moderate, and severe primary open-angle glaucoma (POAG).

Methods

Retrospective cohort study of eyes that underwent MPTSCPC from 2016 to 2019 at an outpatient clinic in Canada. Eyes were excluded if any incisional procedures, except cataract surgery, were performed prior to MPTSCPC treatment. Laser power ranged from 900 to 2500mW.

Results

A total of 153 eyes from 93 patients were included (OHT n=22; early POAG n=46; moderate POAG n=35; severe POAG n=50). The baseline IOP was 18.37 ± 4.76mmHg in the total cohort. All cohorts experienced a significant mean IOP reduction by final follow-up (total p<0.001; OHT p=0.003; early POAG p<0.001; moderate POAG p=0.022; severe POAG p=0.015). Overall, 52.9% of eyes achieved an IOP reduction of ≥20% from baseline to final follow-up (OHT 59.1%; early POAG 58.7%; moderate POAG 45.7%; severe POAG 50.0%). There was worsening in best-corrected visual acuity in the total cohort (mean difference=0.11 ± 0.36 logMAR, p=0.11), mostly attributable to cataract progression (34.1% of phakic eyes) and ocular surface disease (7.2%). The number of topical medications and drug classes remained unchanged in the total cohort (p=0.425 and p=0.791, respectively). Twenty-two eyes (14.4%) required retreatment, which provided an additional IOP reduction of 1.26mmHg (p=0.344). By final follow-up, 8 eyes (5.2%) required escalation to incisional procedures.

Conclusion

MPTSCPC is a safe and effective adjunct IOP-lowering treatment in non-incisional eyes with OHT and POAG.

Vision-Related Quality of Life and Associated Factors Among an Adult Population with Glaucoma Attending a Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Glaucoma is a group of ocular conditions that leads to irreversible blindness. It can affect the vision-related quality of life in many ways. In Ethiopia, limited information is available on how and to what extent the vision-related quality of life of the glaucoma population has been affected.

Objective

This study attempted to assess the vision-related quality of life and associated factors among an adult population with glaucoma attending Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia.

Methods

The cross-sectional study was conducted on the adult population with glaucoma attending Felege Hiwot Comprehensive Specialized Hospital. Systematic random sampling was employed to select 319 study participants. Descriptive and summary statistics were calculated. Simple and multiple linear regressions were performed to determine factors associated with vision-related quality of life. A p-value of <0.05 in multivariable regression was considered statistically significant at a 95% confidence level.

Results

The mean glaucoma quality of life-15 score in this study was 47.85 ± 15.41. Below primary education, primary education, visual acuity of the better eye, visual acuity of the worse eye, and severe glaucoma were significantly associated with the glaucoma quality of life-15 score.

Conclusion and Recommendation

The study observed poorer vision-related quality of life in the glaucoma population than previously reported in Ethiopia and around the globe. The vision-related quality of life was significantly associated with educational status, visual acuity of the better and worse eye, and stage of glaucoma in the better eye. Educating the glaucoma population on the nature of the disease, advice on early presentation, and better-coping strategies for the condition are warranted.

Evaluation of the Efficacy Duration of Topical Therapies in Eyes with Primary Open-Angle Glaucoma

Background: To investigate the efficacy interval of the topical therapies available for primary open-angle glaucoma (POAG) and the ocular and systemic features potentially associated. Methods: This retrospective study included 190 patients with POAG undergoing first topical therapy, throughout a follow-up of 15 years. The patients started one topical intraocular pressure (IOP)-lowering drug within single molecules such betablockers, prostaglandin or dorzolamide, or fixed combinations such as betablockers + prostaglandin, betablockers + dorzolamide, or betablockers + brimonidine. Efficacy duration was measured as the time between the start of the therapy and the change due to IOP increase or visual field worsening. For each patient, ocular and systemic features and comorbidities were analysed to detect any significant correlation with the length of effectiveness of every drug used. Results: The molecules explored showed some discrepancies in terms of mean duration of efficacy; however, no significant differences were demonstrated (p > 0.05). Furthermore, when evaluating the overall cohort, no systemic or ocular features correlated significantly with the effectiveness of the molecules explored. However, the same analysis carried out upon stratifying the different groups according to the IOP-lowering drops they received, demonstrated that the drug efficacy could be influenced by several ocular and systemic features. Conclusion: Data observed in this study suggest that there is no difference in using one of the medications evaluated as first choice of treatment of POAG if the patients are accurately evaluated and the most recent guidelines are adopted.

Ab Interno XEN Gel Stent Implantation in Eyes with Previous Tube Shunt Surgery

Purpose

After tube shunt surgery, many factors may contribute to insufficient filtration over time, prompting further intervention to achieve optimal intraocular pressure (IOP) control. This study explores whether ab interno XEN gel stent implantation could be a viable approach in eyes that need further IOP reduction after tube shunt surgery.

Methods

This is a retrospective, single-surgeon case series on ab interno XEN45 gel stent implantation in eyes that had previous tube shunt surgery. Main outcome measures were IOP and number of glaucoma medications at the pre-operative visit, post-operative week (POW) 1, and post-operative month (POM) 1, 3, 6, and 12. Adverse events and further interventions were noted. Surgery outcome was qualified as absolute success (IOP ≤ 18mmHg or ≥ 20% IOP reduction without glaucoma medications), qualified success (IOP ≤ 18mmHg or ≥ 20% IOP reduction with glaucoma medications), or failure (IOP > 18mmHg and < 20% IOP reduction with maximum tolerated glaucoma medications).

Results

7 eyes from 6 patients were included in this study. IOP was reduced from 23.9 ± 5.3 mmHg (mean ± standard deviation) pre-operatively to 14.0 ± 5.3 mmHg at POM12 (p < 0.05). Number of glaucoma medications was reduced from 4.3 ± 1.3 pre-operatively to 1.6 ± 1.6 at POM12 (p < 0.05). Hypotony and choroidal effusion were noted in one case which resolved before POM1. Bleb needling was required in 3 of the 7 eyes (43%), with one eye requiring needling twice. By POM12, 2 of 7 eyes (29%) achieved absolute success, 4 eyes (57%) qualified success, and 1 eye (14%) was qualified as failure.

Conclusion

Ab interno XEN gel stent can effectively reduce IOP and number of glaucoma medications after failed tube shunt surgery. Nonetheless, further interventions such as bleb needling may still be required to optimize IOP control.

Rates of Visual Field Change in Patients With Glaucoma and Healthy Individuals: Findings From a Median 25-Year Follow-up

Importance

Estimating the rate of glaucomatous visual field change provides practical assessment of disease progression and has implications for management decisions.

Objective

To assess the rates of visual field change in patients receiving treatment for glaucoma compared with healthy individuals over an extensive follow-up period and to quantify the impact of important covariates for these rates.

Design, Setting, and Participants

This prospective longitudinal cohort study was conducted in a hospital-based setting from January 1991 to February 2020. The study included 40 patients receiving treatment for open-angle glaucoma and 29 healthy participants. One eye of each participant was randomly selected as the study eye.

Exposures

Patients with glaucoma and healthy participants received testing with standard automated perimetry every 6 months. Individual rates of mean sensitivity change were computed using ordinary least-squares regression analysis, and linear mixed-effects modeling was used to estimate the mean rates of mean sensitivity change in the 2 groups and the impact of baseline mean sensitivity, baseline age, and follow-up intraocular pressure for rate estimates.

Main Outcomes and Measures

Rate of mean sensitivity change in patients with glaucoma and healthy participants.

Results

A total of 40 patients with glaucoma (median age, 53.07 years [IQR, 48.34-57.97 years]; 21 men [52%]) and 29 healthy participants (median age, 48.80 years [IQR, 40.40-59.07 years], 17 women [59%]) were followed up for a median of 25.65 years (IQR, 22.49-27.02 years) and 19.56 years (IQR, 16.19-26.21 years), respectively. Most participants (65 individuals [94%]) self-identified as White, with the exception of 2 patients with glaucoma (1 self-identified as Black and 1 as South Asian) and 2 healthy participants (both self-identified as South Asian). The mean follow-up intraocular pressure of patients with glaucoma (median, 15.83 mm Hg [IQR, 13.05-17.33 mm Hg]) was similar to that of healthy participants (median, 14.94 mm Hg [IQR, 13.28-16.01 mm Hg]; P = .25). In an ordinary least-squares regression analysis, 31 patients (78%) with glaucoma had rates of mean sensitivity change within the range of healthy participants (ie, between -0.20 dB/y and 0.15 dB/y). Linear mixed-effects modeling revealed that the mean (SE) rate of mean sensitivity change in healthy participants was 0.003 (0.033) dB/y (95% CI, -0.062 to 0.068; P = .93). In comparison, patients with glaucoma had a mean (SE) rate of mean sensitivity change that was -0.032 (0.052) dB/y faster, but this difference was not statistically significant (95% CI, -0.134 to 0.070; P = .53). Among covariates, only baseline mean sensitivity was associated with the rate of mean sensitivity change (mean [SE], 0.021 [0.010] dB/y/dB; 95% CI, 0.002-0.041; P = .03).

Conclusions and Relevance

The results of this cohort study suggest that over a median follow-up of more than 25 years, the rate of visual field change in patients receiving treatment for glaucoma was comparable to that of healthy individuals. These findings could guide practitioners in making management decisions.

Differences in visual field loss pattern when transitioning from SITA standard to SITA faster

Swedish Interactive Threshold Algorithm (SITA) Faster is the most recent and fastest testing algorithm for the evaluation of Humphrey visual fields (VF). However, existing evidence suggests that there are some differences in global measures of VF loss in eyes transitioning from SITA Standard to the newer SITA Faster. These differences may be relevant, especially in glaucoma, where VF changes over time influence clinical decisions around treatment. Furthermore, characterization of differences in localizable VF loss patterns between algorithms, rather than global summary measures, can be important for clinician interpretation when transitioning testing strategies. In this study, we determined the effect of transitioning from SITA Standard to SITA Faster on VF loss patterns in glaucomatous eyes undergoing longitudinal VF testing in a real-world clinical setting. Archetypal analysis was used to derive composition weights of 16 clinically relevant VF patterns (i.e., archetypes (AT)) from patient VFs. We found switching from SITA Standard to SITA Faster was associated with less preservation of VF loss (i.e., abnormal AT 2-4, 6-9, 11, 13, 14) relative to successive SITA Standard exams (P value < 0.01) and was associated with relatively greater preservation of AT 1, the normal VF (P value < 0.01). Eyes that transition from SITA Standard to SITA Faster in a real-world clinical setting have an increased likelihood of preserving patterns reflecting a normal VF and lower tendency to preserve patterns reflecting abnormal VF as compared to consecutive SITA Standard exams in the same eye.

Anterior Segment Optical Coherence Tomography Angiography Following Trabecular Bypass Minimally Invasive Glaucoma Surgery

Objective

To assess anterior segment optical coherence tomography angiography (AS-OCTA) imaging of the episcleral vessels before and after trabecular bypass minimally invasive glaucoma surgery (MIGS).

Design

A prospective, clinical, single-centre, single-arm pilot feasibility study conducted at National University Hospital, Singapore.

Subjects

Patients with primary glaucomatous optic neuropathy undergoing Hydrus Microstent (Ivantis Inc., Irvine, CA, USA) implantation, who require at least one intra-ocular pressure-lowering medication. One or two eyes per patient may be enrolled.

Methods

We performed AS-OCTA (Nidek RS-3000 Advance 2, Gamagori, Japan) pre- and up to 6 months post-MIGS implantation using a standard protocol in all cornealimbal quadrants, to derive episcleral vessel densities (VD) using a previously described technique.

Main Outcome Measures

Episcleral VD pre- and post-surgery, in sectors with and without the implant.

Results

We obtained serial AS-OCTA images in 25 eyes undergoing MIGS implantation (23 subjects, mean age 70.3 ± 1.5, 61% female) with mean preoperative intraocular pressure (IOP) of 15.5 mmHg ± 4.0. We observed reductions in postoperative episcleral VD compared to preoperative VD at month 1 (mean difference −3.2, p = 0.001), month 3 (mean difference −2.94, p = 0.004) and month 6 (mean difference −2.19, p = 0.039) in sectors with implants (overall 6 month follow-up, p = 0.011). No significant changes were detected in episcleral VD in the sectors without implants (p = 0.910).

Conclusion

In our pilot study, AS-OCTA was able to detect changes in the episcleral VD following trabecular bypass MIGS, which may be a useful modality to evaluate surgical outcomes if validated in future studies.

The appropriateness of and barriers to glaucoma care delivery by Australian optometrists

CLINICAL RELEVANCE

Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery.

BACKGROUND

To determine the appropriateness of and barriers to glaucoma care by optometrists.

METHODS

A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31 optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care.

RESULTS

Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14 (38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms.

CONCLUSION

Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

Shared Care and Virtual Clinics for Glaucoma in a Hospital Setting

Glaucoma patients require lifelong management, and the prevalence of glaucoma is expected to increase, resulting in capacity problems in many hospital eye departments. New models of care delivery are needed to offer requisite capacity. This review evaluates two alternative schemes for glaucoma care within a hospital, i.e., shared care (SC) and virtual clinics (VCs), whereby non-medical staff are entrusted with more responsibilities, and compares these schemes with the “traditional” ophthalmologist-led outpatient service (standard care). A literature search was conducted in three large bibliographic databases (PubMed, Embase, and Trip), and the abstracts from the prior five annual meetings of the Association for Research in Vision and Ophthalmology were consulted. Twenty-nine were included in the review (14 on SC and 15 on VCs). Patients with low risk of vision loss were considered suitable for these approaches. Among the non-medical staff, optometrists were the most frequently involved. The quality of both schemes was good and improved with the non-medical staff being trained in glaucoma care. No evidence was found on patients feeling disadvantaged by the lack of a doctor visit. Both schemes increased the hospital’s efficiency. Both SC and VCs are promising approaches to tackle the upcoming capacity problems of hospital-based glaucoma care.

The Effect of Achieving Target Intraocular Pressure on Visual Field Worsening

PURPOSE

To estimate the effect of achieving target intraocular pressure (IOP) values on visual field (VF) worsening in a treated clinical population.

DESIGN

Retrospective analysis of longitudinal data.

PARTICIPANTS

A total of 2852 eyes of 1688 patients with glaucoma-related diagnoses treated in a tertiary care practice. All included eyes had at least 5 reliable VF tests and 5 IOP measures on separate visits along with at least 1 target IOP defined by a clinician on the first or second visit.

METHODS

The primary dependent variable was the slope of the mean deviation (MD) over time (decibels [dB]/year). The primary independent variable was mean target difference (measured IOP - target IOP). We created simple linear regression models and mixed-effects linear models to study the relationship between MD slope and mean target difference for individual eyes. In the mixed-effects models, we included an interaction term to account for disease severity (mild/suspect, moderate, or advanced) and a spline term to account for the differing effects of achieving target IOP (target difference ≤0) and failing to achieve target IOP (target difference >0).

MAIN OUTCOME MEASURES

Rate of change in MD slope (changes in dB/year) per 1 mmHg change in target difference at different stages of glaucoma severity.

RESULTS

Across all eyes, a simple linear regression model demonstrated that a 1 mmHg increase in target difference had a -0.018 dB/year (confidence interval [CI], -0.026 to -0.011; P < 0.05) effect on MD slope. The mixed-effects model shows that eyes with moderate disease that fail to achieve their target IOP experience the largest effects, with a 1 mmHg increase in target difference resulting in a -0.119 dB/year (CI, -0.168 to -0.070; P < 0.05) worse MD slope. The effects of missing target IOP on VF worsening were more pronounced than the effect of absolute level of IOP on VF worsening, where a 1 mmHg increase in IOP had a -0.004 dB/year (CI, -0.011 to 0.003; P > 0.05) effect on the MD slope.

CONCLUSIONS

In treated patients, failing to achieve target IOP was associated with more rapid VF worsening. Eyes with moderate glaucoma experienced the greatest VF worsening from failing to achieve target IOP.

Cost Analysis and Rational Use of Anti-Glaucoma Therapy in a Tertiary Hospital in Ghana

Introduction

Glaucoma is the leading cause of irreversible blindness worldwide. In Ghana, 19.4% of all blindness recorded is due to glaucoma. Reducing intraocular pressure medically (using eye drops) is the evidence-based therapeutic option.

Objective

To determine the rational use and undertake cost analysis of anti-glaucoma drugs among patients attending clinic at the Lions International Eye Centre (LIEC), Korle-Bu Teaching Hospital.

Methods

In this cross-sectional study, we reviewed all prescriptions presented to the pharmacy unit from 01/12/2015 to 31/03/2016. The dispensed drops were classified, and all anti-glaucoma drugs were identified. This was followed by cost analysis.

Results

A total of 588 prescriptions were captured, 27.3% (161/588) contained an anti-glaucoma medication. The mean number of anti-glaucoma medications was 1.71 of which 52.7% was prescribed to females. Prostaglandin analogs (PGA) were the most prescribed (37% (102/276)), followed by beta blockers (25.4% (70/276)), carbonic anhydrase group of medicines (16.3% (45/276)), combined beta blockers (11.2% (31/276)), alpha agonists (8.7% (24/276)) and miotics (1.4% (4/276)). The median (IQR) cost of anti-glaucoma therapy per prescription per month was GHC 65.00 (GHC38.5-GHC140) about [US$16.25 (US$ 9.6–US$35)]. Azopt (Brimonidine) was the most expensive with daily treatment cost of GHC 5.8 (about US$ 1.45), whilst the least expensive drug with a daily treatment cost of GHC 0.14 (about US$ 0.035) was timolol eye drops.

Conclusion

Prostaglandin analogs though expensive remain the most preferred treatment for managing glaucoma at the Korle-Bu Eye Centre in Ghana. This may adversely affect treatment among the poor since prostaglandins analogs are currently not covered by insurance.

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.

Knowledge translation for the everyday optometrist

A gap exists between best evidence and actual clinical care provided to patients. The advent of evidence-based practice was meant to address this gap by providing practitioners with a method to search, evaluate and incorporate evidence into practice. However, the gap continues to exist. The health research fields of knowledge translation and implementation science have evolved over the last few decades to assist practitioners in embedding research findings and best evidence into routine practice. Knowledge translation seeks to improve public health outcomes by facilitating the movement of best evidence from the bench to clinical practice. Implementation science is the study of methods to integrate research findings and evidence-based practice into routine practice. This literature review aims to revisit the concepts of evidence-based practice and to introduce knowledge translation and implementation science by exploring their roles and influences in the delivery of appropriate glaucoma care by optometrists.

Phacoemulsification Combined With Endoscopic Versus Transscleral Cyclophotocoagulation in Poorly Controlled Glaucoma: A Comparative Case Series

OBJECTIVE

The objective of this study was to report medium-term outcomes of a novel combination of phacoemulsification with transscleral cyclophotocoagulation (phaco-TCP) compared with combined phacoemulsification and endoscopic cyclophotocoagulation (phaco-ECP) in patients with uncontrolled or suboptimally controlled glaucoma and coexisting cataract.

MATERIALS AND METHODS

Retrospective case series of 80 consecutive patients with a minimum of 12 months of follow-up. In total, 46 eyes underwent phaco-ECP and 34 phaco-TCP. Success was defined as intraocular pressure (IOP) between 6 and 21 mm Hg with ≥20% reduction from preoperative IOP (with no increase in ocular hypotensive medications or further glaucoma surgery). Secondary outcomes were change in IOP, number of ocular hypotensive medications and safety.

RESULTS

The mean follow-up was 32.6 ±10.3 months. Preoperative clinical characteristics were similar in both groups. At latest follow-up, success rate was greater with phaco-TCP than phaco-ECP (67.6% and 47.8%, P=0.037). IOP was also significantly lower after phaco-TCP (14.88±5.57 mm Hg, from 22.62±6.52 mm Hg) than phaco-ECP (18.07±6.72 mm Hg, from 22.83±7.88, P=0.0273). Ocular hypotensive medications required reduced similarly after phaco-TCP (from 3.38±0.88 to 2.65±1.04 medications, P=0.0012) and phaco-ECP (from 3.07±0.929 to 2.63±1.42 medications, P=0.0108). There were no cases of hypotony or reduction in vision related to glaucoma with either surgical intervention and a similar proportion required further glaucoma surgery (phaco-ECP 15.2%, phako-TCP 5.9%, P=0.2884).

CONCLUSIONS

Phaco-TCP appears more successful in controlling IOP than phaco-ECP with similar safety. Further investigation is warranted of this newly proposed combination which may be particularly useful where access or experience with ECP or other minimally invasive glaucoma surgery is limited.

Glaucoma referrals from primary care and subsequent hospital management in an urban Australian hospital

BACKGROUND

Public hospital ophthalmology services are in high demand and patients requiring medical or surgical intervention for glaucoma may worsen while awaiting care. In Australia, tertiary hospital care requires a referral from primary care providers. This study investigates the quality of glaucoma referrals received at a tertiary public hospital in Australia, and describes the types of glaucoma cases referred for hospital management.

METHODS

An investigation of 200 sequential glaucoma referrals received at a major Australian public hospital from 2013-2016, and the subsequent hospital management. A clinical file audit was made of patient medical records, including referral letters to extract the referral content, and the hospital glaucoma diagnostic outcomes and patient management.

RESULTS

Most referrals came from optometrists (72 per cent) and general practitioners (22 per cent) with the remainder from other specialists. The majority of the referrals contained less than 50 per cent of the key clinical and demographic parameters. Referrals from optometrists provided more ophthalmic information (visual acuity, visual field, intraocular pressure, ocular history). Referrals from general practitioners contained more medical information (systemic co-morbidities medication and allergies). The median wait-time from referral to hospital appointment was 400 days. Of patients attending a hospital appointment, 59 per cent required surgical or medical management, and 16 per cent did not have glaucoma. Overall 18 per cent were discharged, with no differences noted by referral content or referring practitioner.

CONCLUSION

Most referrals did not include useful diagnostic information on ocular, medical and social risks for glaucoma. There is an opportunity to improve targeting of primary care referrals for glaucoma, since patients who were discharged immediately after their hospital appointment are exacerbating the long hospital wait-time. Better information transfer may help to identify patients requiring more urgent intervention. A standardised referral template and guidelines would support collaborative care and streamline access to hospital services.

Optical Coherence Tomography May Help Distinguish Glaucoma from Suprasellar Tumor-Associated Optic Disc

PURPOSE

This study aimed to differentiate patients with bilateral disc cupping associated with suprasellar tumor from patients with open-angle glaucoma by analyzing differences in optical coherence tomography (OCT) of the optic nerve.

METHODS

In this retrospective cross-sectional study, we collected data from the eyes of 25 patients with suprasellar craniopharyngioma or pituitary macroadenomas (group 1) and 35 patients with primary open-angle glaucoma (POAG) (group 2), seen between 2001 and 2015, all with a visual acuity of ≥20/40, for whom Stratus Time-Domain (TD) optic nerve OCT scans were available. The main outcome measures were the retinal nerve fiber layer (RNFL) thickness, disc area, cup volume, cup/disc ratio, and rim area.

RESULTS

A total of 31 patients met the inclusion criteria and were included in the study: 16 with suprasellar tumors and 15 with POAG. Both groups were similar in terms of gender and age (P > 0.05). The glaucoma group had a borderline greater total RNFL thickness (74.2 μm versus 62.8 μm, P=0.07), disc area (2.70 mm2 versus 2.16 mm2, P=0.004), and cup volume (0.20 mm3 versus 0.08 mm3, P=0.02). In multivariate, glaucoma was associated with increased total RNFL thickness (OR = 1.116 per μm, P=0.008), increased disc area (OR = 2.402 per 100 μm2, P=0.002), and decreased rim area (OR = 0.272 per 100 μm2, P=0.011). Of these, the parameter with the greatest AUC was the disc area (AUC = 0.79). Using the Youden index, the optimal cut-off point identified for stratification was a disc area greater than 2.33 μm2.

CONCLUSIONS

In patients with bilateral disc cupping, a decreased total RNFL thickness and smaller disc area seem to be associated with suprasellar tumors (when compared with open-angle glaucoma). These findings may aid in early diagnosis of cupping from suprasellar tumors, before compressive visual loss occurs.

Assessing the Methodological Quality of Glaucoma Clinical Practice Guidelines and Their Recommendations on Microinvasive Glaucoma Surgery: A Systematic Review

INTRODUCTION

Clinical practice guidelines (CPG) are regarded by many as critical communications providing guidance within specific medical fields. Over a decade ago, the first microinvasive glaucoma surgical (MIGS) procedures were introduced. Since then, a number of these novel intraocular pressure controlling surgical options have been approved worldwide. Governing bodies and health care administration often utilize CPGs when considering funding for newer technologies. This highlights the importance of well-written, accurate, and up-to-date CPGs in the rapidly evolving field of MIGS. If CPGs are unable to fill this role, their use in treatment decision-making is doing a disservice to patients, who will be denied currently available and potentially superior care. To determine the overall value of a CPG, the methodological quality with which it was developed, in addition to the current relevance and appropriateness of its recommendations, should be evaluated. The objective of the present study was to assess the methodological quality of currently available international glaucoma CPGs, as well as their coverage of MIGS as a surrogate marker of relevance and appropriateness to policy-makers and ophthalmologists alike.

MATERIALS AND METHODS

To identify potentially relevant CPGs, a predefined search strategy was used to search the following databases: Medline, EMBASE, BIOSIS, and Web of Science. All CPGs related to adult glaucoma and published in English were included. CPG methodological quality was assessed by 3 individuals using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Studies were then assessed for coverage of MIGS devices and procedures.

RESULTS

Search strategy and subsequent screening identified 11 CPGs for analysis. Eight were of high quality according to the AGREE II criteria. Three included basic information on MIGS, but none provided specific recommendations regarding their indications or which patient populations would benefit most.

CONCLUSIONS

Many international glaucoma CPGs are of high methodological quality. However, coverage of MIGS is sparse, nonspecific and in many instances, absent. This causes CPGs to be a suboptimal source in guiding physicians and health policy-makers in areas characterized by novel and/or rapidly evolving technologies. Mechanisms to incorporate updated evidence in CPGs would have to be considered before they can be used as a source of contemporary clinical decision-making.

Cost-effectiveness analysis of standalone trabecular micro-bypass stents in patients with mild-to-moderate open-angle glaucoma in Canada

OBJECTIVES

To estimate the cost-utility of two trabecular micro-bypass stents (TBS) implantation vs standard of care (SOC) in patients with mild-to-moderate open-angle glaucoma (OAG) in the Canadian healthcare setting.

METHODS

The deterioration in visual field (VF) defect over a 15-year time horizon was tracked using a Markov model with Hodapp-Parrish-Anderson stages of glaucoma (mild, moderate, advanced, severe/blind) and death as health states. Meta-analyses of randomized clinical trials were conducted to estimate the pooled reduction in intraocular pressure (IOP) and medication use due to TBS and SOC. The rate of decline in VF loss was adjusted by the extent of IOP reduction to estimate transition probabilities. Healthcare resource utilization, unit costs (2017 CAD), and progression-related utility scores were obtained by literature review, and medication costs with wastage were obtained from IMS Brogan PharmaStat. The impact of parameter and methodological uncertainty on costs and quality-adjusted life years (QALYs) was examined using probabilistic and 1-way sensitivity analyses.

RESULTS

The meta-analysis showed an additional reduction of 1.13 medications/patient and an additional decrease in IOP of -1.10 mmHg at 36 months favoring TBS. TBS strongly dominated medication alone, due to higher improvement in quality-of-life (0.068 QALYs), fewer blind eyes (-0.0031), and a decrease in total healthcare costs of C$2,908.3 per patient over the time horizon (C$9,394.1 TBS vs C$12,302.4 medication alone). Sensitivity analyses showed that results were robust to the uncertainties in model inputs and assumptions. Time-to-dominance was 44 months (3.7 years).

CONCLUSIONS

The TBS procedure was cost-effective over SOC in a 15-year time horizon, with quality-of-life gains.

Case Series of Combined iStent Implantation and Phacoemulsification in Eyes with Primary Angle Closure Disease: One-Year Outcomes

PURPOSE

To evaluate the safety and efficacy of combined iStent® trabecular micro-bypass device (Glaukos, Laguna Hills, CA) and phacoemulsification in eyes with primary angle closure disease.

METHODS

A two-center prospective interventional case series of consecutive patients with primary angle closure (PAC) or primary angle closure glaucoma (PACG) on at least one glaucoma medication, who underwent iStent implantation with cataract surgery. Postoperatively, patients were assessed on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, visual acuity, and the presence of complications were assessed at each visit. Complete success was defined as IOP reduction of at least 20% without the use of glaucoma medications.

RESULTS

Thirty-seven eyes with angle closure disease were included in this study. At 1-year, postoperative mean IOP (14.8 ± 3.94 mmHg) was significantly decreased compared with preoperative medicated (17.5 ± 3.82 mmHg, p = 0.008) and unmedicated (24.6 ± 3.41 mmHg, p < 0.001) IOP. Complete success was achieved in 89.2% of the eyes. The number of glaucoma medications decreased from 1.49 ± 0.77 to 0.14 ± 0.48 (p < 0.001). Preoperative medicated IOP was a risk factor for failure (hazard ratio 3.45, 95% confidence interval 1.52-7.85, p = 0.003), after adjustment for age, gender, and race. The most common postoperative complications were iStent occlusion with iris (27.0%) and hyphema (18.9%). There were no sight-threatening intraoperative or postoperative complications.

CONCLUSION

Combined iStent implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications for at least 12 months, with a favorable safety profile.

FUNDING

Glaukos Corporation; NMRC Science Translational and Applied Research (STAR) award.

Can the appropriateness of eye care be measured through cross-sectional retrospective patient record review in eye care practices in Australia? The iCareTrack feasibility study

OBJECTIVES

The CareTrack study found that a wide range of appropriateness of care (ie, care in line with evidence-based or consensus-based guidelines) was delivered across many health conditions in Australia. This study therefore aimed to demonstrate the feasibility of using the CareTrack method (a retrospective onsite record review) to measure the appropriateness of eye care delivery.

DESIGN

Cross-sectional feasibility study.

SETTING AND PARTICIPANTS

Two hundred and thirteen patient records randomly selected from eight optometry and ophthalmology practices in Australia, selected through a combination of convenience and maximum variation sampling.

METHODS

Retrospective record review designed to assess the alignment between eye care delivered and 93 clinical indicators (Delphi method involving 11 experts) extracted from evidence-based clinical practice guidelines.

PRIMARY OUTCOME MEASURE

Number of eligible patient records, sampling rates and data collection time. This feasibility study also tested the ability of 93 clinical indicators to measure percentage appropriate eye care for preventative, glaucoma and diabetic eye care. A secondary outcome was the percentage of practitioner-patient encounters at which appropriate eye care was received.

RESULTS

A median of 20 records (range 9 to 63) per practice were reviewed. Data collection time ranged from 3 to 5.5 hours (median 3.5). The most effective sampling strategy involved random letter generation followed by sequential sampling. The appropriateness of care was 69% (95% CI 67% to 70%) for preventative eye care, 60% (95% CI 56% to 58%) for glaucoma and 63% (95% CI 57% to 69%) for diabetic eye care.

CONCLUSIONS

Appropriateness of eye care can be measured effectively using retrospective record review of eye care practices and consensus-based care indicators.

Traumatic hyphaema in children: a retrospective and prospective study of outcomes at an Australian paediatric centre

Objective

This study aims to evaluate the presenting characteristics, management, outcomes and complications for paediatric traumatic hyphaema in Western Australia.

Methods and Analysis

A retrospective review of medical records was conducted for consecutive patients ≤16 years of age admitted for traumatic hyphaema to Princess Margaret Hospital for Children (Perth, Australia) between January 2002 and December 2013 (n=82). From this sample, a cohort whose injury occurred ≥5 years prior attended a prospective ocular examination (n=16). Hospital records were reviewed for patient demographics, injury details, management, visual outcomes and complications. The prospective cohort underwent examination for visual and structural outcomes.

Results

Most injuries (72%) resulted from projectile objects. Angle recession was present in 53% and was associated with projectiles (p=0.002). Most eyes (81%) achieved a final visual acuity of 0.3 logarithm of the minimum angle of resolution (logMAR) (20/40) or better. Age ≤5 years and posterior segment injury were significant predictors of final visual acuity poorer than 0.3 logMAR. At ≥5 years post-trauma, injured eyes had greater intraocular pressure (IOP) (p=0.024) and anterior chamber depth (ACD) (p=0.022) compared with sound eyes. IOP asymmetry was associated with angle recession (p=0.008) and ACD asymmetry (p=0.012).

Conclusion

Poorer visual outcomes are associated with younger age at injury and posterior segment injury. Angle recession and ACD asymmetry are associated with IOP asymmetry 5-12 years after injury.

Washout Duration of Prostaglandin Analogues: A Systematic Review and Meta-analysis

TOPIC

Prostaglandin analogues (PGAs) are first-line medical therapy for primary open angle glaucoma (POAG) and ocular hypertension (OHT). Intraocular pressure (IOP) lowering effects in full responders are known to be 25-33% for this class; however, partial responders and nonresponders do exist. In clinical trials or prospective series, discontinuation and washout of PGAs is necessary to evaluate true change in IOP from novel surgeries and medical therapies.

CLINICAL RELEVANCE

To identify all relevant papers with pertinent data on washout of PGAs and quantify the duration and long-term effect of reported PGA washout periods in glaucoma and OHT patients.

METHODS

A systematic review and meta-analysis was conducted to investigate the long-term effects on IOP after discontinuation of topical PGAs POAG and OHT patients. The main search was conducted in MEDLINE/PubMed, EMBASE, Cochrane Library, CINAHL, Web of Science, and BIOSIS Previews and conference proceedings.

RESULTS

1055 papers were identified, 548 were independently screened by two physicians., and 56 papers were analyzed for washout durations. The mean washout was found to be 4.56 weeks (±1.25), with the mode and median being 5 weeks. Five studies were analyzed as randomized control trials in which latanoprost was discontinued for 4 weeks prior to restarting another intraocular pressure-lowering drug. Meta-analysis revealed a 4-week discontinuation of latanoprost, on average, subjects returned to their baseline IOP.

CONCLUSION

A significant IOP-lowering effect of latanoprost was not observed beyond 4 weeks, suggesting this may be an appropriate washout period for latanoprost. We could not identify appropriate washout periods for either travoprost or bimatoprost, although a majority of articles had 4-week washout durations for the two drugs. Despite the widespread use of this class of medication, there is a paucity of literature on the effects of PGA washout in patients that are treatment naïve to other topical medications.

The Effects of Phacoemulsification on Intraocular Pressure and Topical Medication Use in Patients With Glaucoma: A Systematic Review and Meta-analysis of 3-Year Data

PURPOSE

For patients with comorbid cataract and primary open-angle glaucoma (POAG), guidance is lacking as to whether cataract extraction and traditional filtering surgery should be performed as a staged or combined procedure. Achieving this guidance requires an evidence-based understanding of the effects of phacoemulsification alone on intraocular pressure (IOP) in patients with POAG. For this reason, a systematic review and meta-analysis was undertaken to synthesize evidence quantifying the effect of phacoemulsification on IOP and the required number of topical glaucoma medications in patients with cataract and POAG.

MATERIALS AND METHODS

Database searches were last run on August 15, 2016 to identify potentially relevant studies. Identified articles were screened for relevance and meta-analysis was used to compute postoperative mean and percentage reduction in IOP (IOPR%) as well as mean difference in topical glaucoma medications.

RESULTS

The search strategy identified 1613 records. Thirty-two studies (1826 subjects) were included in quantitative synthesis. A 12%, 14%, 15%, and 9% reduction in IOP from baseline occurred 6, 12, 24, and 36 months after phacoemulsification. A mean reduction of 0.57, 0.47, 0.38, and 0.16 medications per patient of glaucoma medication occurred 6, 12, 24, and 36 months after phacoemulsification.

CONCLUSIONS

Phacoemulsification as a solo procedure does lower IOP in patients with POAG, and reduces dependency on topical glaucoma medications. These effects appear to last at least 36 months with gradual loss of the initial effect noted after 2 years. Certain populations appear to experience much greater reductions in IOP than others and future work to identify these high responding patients is needed.

Undetected angle closure in patients with a diagnosis of open-angle glaucoma

OBJECTIVE

The aim of this study was to identify the proportion of patients referred to a tertiary glaucoma centre with a diagnosis of open-angle glaucoma (OAG) who were found to have angle closure glaucoma.

DESIGN

Retrospective chart review.

METHODS

Consecutive new patients referred for glaucoma management to a tertiary centre between July 2010 and December 2011 were reviewed. Patients whose referrals for glaucoma assessment specified angle status as "open" were included. The data collected included glaucoma specialist's angle assessment, diagnosis, and glaucoma severity. The status of those with 180 degrees or more Shaffer angle grading of 0 was classified as "closed."

RESULTS

From 1234 glaucoma referrals, 179 cases were specified to have a diagnosis of OAG or when angles were known to be open. Of these, 16 (8.9%) were found on examination by the glaucoma specialist to have angle closure. Pseudoexfoliation was present in 4 of 16 patients (25%) in the missed angle-closure glaucoma (ACG) group and 22 of 108 patients (13.5%) in the remaining OAG group. There was no difference found in demographic or ocular biometric parameters between those with confirmed OAG versus those with missed ACG.

CONCLUSIONS

Almost 1 in 11 patients referred by ophthalmologists to a tertiary glaucoma centre with a diagnosis of OAG were in fact found to have angle closure. Given the different treatment approaches for ACG versus OAG, this study suggests a need to strengthen angle evaluations.

Frequency of unplanned interventions in patients attending for a presumed routine glaucoma follow-up appointment

OBJECTIVE

To determine the frequency of patient visits in which an unplanned treatment modification was required in chronic patients attending a glaucoma clinic for routine follow-up and to identify the treatment interventions most commonly employed.

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

A total of 630 previously stable patients attending a glaucoma clinic for routine follow-up.

METHODS

This was a single-centre survey of all eligible patients returning to an academic glaucoma clinic. Data regarding whether patients' visit remained routine or required intervention, which clinical parameter had changed, and any alterations in treatment regimens were studied.

RESULTS

The percentage of patients found to require a change in management was 20.79% (131 of 630 patients); 16.9% were found to have a cause for change because of glaucoma, and the remaining 4% required intervention because of a nonglaucomatous condition. The most common parameter that changed treatment was intraocular pressure (43.87%), followed by visual fields (21.29%). The frequency of abnormal parameters varied within each subtype of glaucoma. The frequency of treatment changes among those with primary open-angle glaucoma was 22.58% compared with 16.5% of glaucoma suspects, 14% of ocular hypertensives, 32% of pseudoexfoliative glaucoma, and 50% of normal tension glaucoma patients. The most common intervention (32.84%) was a change in antiglaucoma medications. The next most frequent interventions were laser procedures (21.90%) and surgery (16.06%).

CONCLUSIONS

This study suggests that a significant minority of patients attending a glaucoma clinic for a routine appointment require treatment modification.

Medical Management of Glaucoma in the 21st Century from a Canadian Perspective

Glaucoma is a medical term describing a group of progressive optic neuropathies characterized by degeneration of retinal ganglion cells and retinal nerve fibre layer and resulting in changes in the optic nerve head. Glaucoma is a leading cause of irreversible vision loss worldwide. With the aging population it is expected that the prevalence of glaucoma will continue to increase. Despite recent advances in imaging and visual field testing techniques that allow establishment of earlier diagnosis and treatment initiation, significant numbers of glaucoma patients are undiagnosed and present late in the course of their disease. This can lead to irreversible vision loss, reduced quality of life, and a higher socioeconomic burden. Selection of therapeutic approaches for glaucoma should be based on careful ocular examination, patient medical history, presence of comorbidities, and awareness of concomitant systemic therapies. Therapy should also be individualized to patients' needs and preferences. Recent developments in this therapeutic field require revisiting treatment algorithms and integration of traditional and novel approaches in order to ensure optimal visual outcomes. This article provides an overview of recent developments and practice trends in the medical management of glaucoma in Canada. A discussion of the surgical management is beyond the scope of this paper.

Vision-related Quality of Life Outcomes of Cataract Surgery in Advanced Glaucoma Patients

PURPOSE

To demonstrate longitudinal postoperative vision-related quality of life and visual acuity changes after cataract surgery in advanced glaucoma patients.

MATERIALS AND METHODS

In total, 93 patients who underwent cataract surgeries were collected from June 2010 through June 2013 in Shanghai First People's Hospital, Shanghai Jiao Tong University, and were followed up for at least 3 months. Patients with advanced glaucoma, here defined as near total cupping of the optic nerve with severe visual field loss within 10 degrees of fixation, were enrolled. A standard phacoemulsification technique with the insertion of an intraocular lens was used. No complications occurred intraoperatively or postoperatively. Preoperative and 3-month postoperative vision-related quality of life were assessed in face-to-face interviews. The Chinese-version of the Low Vision Quality of Life Questionnaire (CLVQOL) was used. Wilcoxon signed-rank test was used to compare the differences in the best-corrected visual acuity (BCVA), weighted average LogMAR (WMAR), and CLVQOL scores. A binary logistic regression analysis was conducted to explore the potential factors associated with the change in CLVQOL scores.

RESULTS

The overall changes in the CLVQOL composite scores ranged between 4 and 42 (median=19). Statistically significant increases occurred in the composite scores of all of the subscales, the total CLVQOL, the BCVA in the surgery eye, and the WMAR (all P<0.001). Greater increases in the CLVQOL composite scores was associated with superior preoperative WMAR (odds ratio: 9.920, P<0.05), and age below 60 years (odds ratio: 9.905, P<0.05).

CONCLUSIONS

Cataract surgery should be recommended for advanced glaucoma patients with stable intraocular pressure.

Update on the Medical Treatment of Primary Open-Angle Glaucoma

Glaucoma comprises a group of progressive, neurodegenerative disorders characterized by retinal ganglion cell death and nerve fiber layer atrophy. Several randomized controlled trials have consistently demonstrated the efficacy of intraocular pressure lowering to slow or halt the measurable progression of the disease. Medical therapy, in places where it is easily accessible, is often the primary method to lower intraocular pressure. We review the medical options currently available and possible future options currently in development. The 5 contemporary classes of topical agents in use include prostaglandin analogs, beta blockers, carbonic anhydrase inhibitors, alpha agonists, and cholinergics. In addition, several fixed combination agents are commercially available. Agents from each of these classes have unique mechanisms of action, adverse effects, and other characteristics that impact how they are used in clinical practice. Despite the plethora of medical options available, there are limitations to topical ophthalmic therapy such as the high rate of noncompliance and local and systemic adverse effects. Alternate and sustained drug delivery models, such as injectable agents and punctal plug delivery systems, may in the future alleviate some such concerns and lead to increased efficacy of treatment while minimizing adverse effects.

Glaucoma Suspect: Diagnosis and Management

Glaucoma suspect is a diagnosis reserved for individuals who do not definitively have glaucoma at the present time but have characteristics suggesting that they are at high risk of developing the disease in the future based on a variety of factors. This review provides a practical approach to individuals classified as glaucoma suspects caused by one or more of the following risk factors or indicators of disease: ocular hypertension, optic nerve features suggestive of glaucoma, visual field abnormalities, and other characteristics placing them at greater risk than the average population. In addition to diagnostic considerations, this overview provides information on therapeutic approaches to the glaucoma suspect.

Diagnostic accuracy of the iCare rebound tonometer compared to the Perkins applanation tonometer in assessing intraocular pressure in rural patients

Background: Vision health is recognized as a critical unmet need in North America. The ocular morbidity associated with glaucoma results from increased intraocular pressure (IOP) and early detection is crucial for the management of glaucoma. Our objective was to find a diagnostically accurate screening tool for intraocular hypertension that can be used in rural communities. We sought to validate the diagnostic accuracy of the iCare rebound tonometer against the gold standard Perkins applanation tonometer (PAT) in measuring IOP.

Methods: Patients from two rural communities in Ontario, Canada visiting their optometrists for routine appointments had their IOP measured by a non-contact tonometer (NCT), an iCare rebound tonometer, and a Perkins applanation tonometer (PAT). Values of sensitivity, specificity, and likelihood ratios for a positive and negative result were calculated for the iCare and the NCT.

Results: Complete data was collected from 209 patients. Overall, the iCare tonometer had high levels of validity, as compared to the gold standard PAT. The iCare tonometer displayed excellent sensitivity of 98.3% (90–99%, 95% CI) and excellent negative likelihood ratio of 0.024 (0.0088–0.066, 95% CI) which is useful for ruling out intraocular hypertension.

Conclusions: The iCare tonometer is a reasonably valid tool for detecting elevated IOP. Its ease of use, simplicity, and accessibility makes it a good screening tool to improve eye health in rural areas.

Short-Term Intraocular Pressure Elevations after Combined Phacoemulsification and Implantation of Two Trabecular Micro-Bypass Stents: Prednisolone versus Loteprednol

Objective. To compare the effects of prednisolone and of loteprednol after combined phacoemulsification and trabecular micro-bypass stent implantation (phaco-iStent). Methods. Patients who underwent phaco-iStent between April 2013 and November 2014 were identified by retrospective chart review. Postoperatively, they received either prednisolone (n = 38) or loteprednol (n = 58). Baseline data was compared. Primary outcomes including intraocular pressure (IOP) and number of glaucoma medications (NGM) were analyzed at preoperative visit, postoperative day 1, weeks 1-2, weeks 3-4, and months 2-3. Results. Both groups had similar preoperative parameters (p > 0.05). The mean IOP spike occurred at postoperative weeks 1-2 with an increase of 2.21 ± 7.30 mmHg in the loteprednol group and 2.54 ± 9.28 mmHg in the prednisolone group. It decreased by weeks 3-4 in both groups and continued to improve at months 2-3. NGM showed significant reduction (p < 0.0001) after the surgery and remained stable in both groups. No significant group effect or time-group interaction in IOP and NGM evolution was detected (p > 0.05). The proportions of patients needing paracentesis were similar between the two groups. Conclusion. Similar early IOP elevations after combined phaco-iStent occurred with both prednisolone and loteprednol. Facilitated glucocorticoid infusion, altered aqueous humor outflow, and local inflammation may be contributing factors.

Implantation of 2 trabecular microbypass stents in a patient with primary open-angle glaucoma refractory to previous glaucoma-filtering surgeries

A 77-year-old woman with primary open-angle glaucoma was referred for surgical evaluation after failing to achieve target intraocular pressure (IOP) despite previous combined phacotrabeculectomy and Ahmed valve implantations. The IOP prior to surgery was 28 mm Hg on topical dorzolamide-timolol, latanoprost, and brimonidine. Trabecular bypass surgery with implantation of 2 iStents was performed. The IOP decreased by 11 mm Hg to 17 mm Hg after surgery and has remained stable for 2 years. This is the first published case reporting this magnitude of IOP reduction sustained for more than 2 years following insertion of 2 trabecular microbypass stents in a patient who had previous glaucoma-filtering surgeries. Further prospective studies are needed to establish expanded surgical indications for implantation of trabecular microbypass stents.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Frequency of visual field testing when monitoring patients newly diagnosed with glaucoma: mixed methods and modelling

Background

Visual field (VF) tests are the benchmark for detecting and monitoring the eye disease glaucoma. Measurements from VF tests are variable, which means that frequent monitoring, perhaps over a long period of time, is required to accurately detect true glaucomatous progression. In 2009, guidelines for the diagnosis and management of glaucoma issued by the National Institute for Health and Care Excellence revealed an absence of research evidence about the clinical effectiveness and cost-effectiveness of using different monitoring intervals to detect disease progression. However, the European Glaucoma Society (EGS) guidelines on patient examination recommend that newly diagnosed glaucoma patients should undergo VF testing three times per year in the first 2 years after initial diagnosis.

Objectives

The primary objective of this project was to explore the clinical effectiveness and cost-effectiveness of using different monitoring intervals to detect VF progression in newly diagnosed glaucoma patients. Other objectives sought to (1) explore glaucoma patients’ views and experiences of monitoring using focus groups; and (2) establish glaucoma subspecialists’ attitudes regarding frequency of VF testing using a five-item questionnaire.

Design

These questions were investigated using a multicentre audit of current practice and existing NHS data (VF records from almost 90,000 patients). New research knowledge was provided through statistical and health economic modelling of these and additional published data.

Results

The multicentre audit showed that VF monitoring is, on average, carried out annually. Patient focus groups indicated that, although patients do not like VF testing, they accept it as a critical part of their care. Patients raised concerns regarding distracting testing environments, quality of instructions, explanation of results and excessive waiting times. Questionnaires revealed that clinicians’ attitudes towards the frequency of VF testing varied considerably, and many glaucoma specialists believed that current recommendations are impractical. Statistical modelling suggested that EGS recommendations could be clinically effective as progression can be identified sooner than is possible with annual testing. Health economic modelling suggested that increased VF monitoring may also be cost-effective [incremental cost-effectiveness ratio (ICER) was equal to £21,679].

Conclusions

Statistical modelling of VF data suggests there is strong rationale for following EGS recommendations with the primary benefit of providing better information about fast-progressing patients. Our health economic model suggested that increasing VF testingmaybe cost-effective (ICER was equal to £21,679), especially when accounting for gains to society. Nevertheless, many clinicians consider increased VF testing of patients impossible with current resources. In addition, patient focus groups raised concerns about the practicalities of delivery of VF tests.

Future work

Results from this study could inform the design of a prospective randomised comparative trial of different VF monitoring intervals in glaucoma linked to stratifying patients according to risk factors for progression. The statistical model for VF data can be further developed to be used as a practical tool for optimising individualised follow-up. The views of clinicians and patients indicate that service delivery of VF testing is an important issue and worthy of further investigation. Ensuring the confidence and co-operation of the patient should be at the centre of future research into the most efficient strategies for glaucoma monitoring.

Funding

This work was funded by the National Institute for Health Research Health Services and Delivery Research programme.

Bimatoprost-loaded ocular inserts as sustained release drug delivery systems for glaucoma treatment: in vitro and in vivo evaluation

The purpose of the present study was to develop and assess a novel sustained-release drug delivery system of Bimatoprost (BIM). Chitosan polymeric inserts were prepared using the solvent casting method and characterized by swelling studies, infrared spectroscopy, differential scanning calorimetry, drug content, scanning electron microscopy and in vitro drug release. Biodistribution of ^99mTc-BIM eye drops and ^99mTc-BIM-loaded inserts, after ocular administration in Wistar rats, was accessed by ex vivo radiation counting. The inserts were evaluated for their therapeutic efficacy in glaucomatous Wistar rats. Glaucoma was induced by weekly intracameral injection of hyaluronic acid. BIM-loaded inserts (equivalent to 9.0 µg BIM) were administered once into conjunctival sac, after ocular hypertension confirmation. BIM eye drop was topically instilled in a second group of glaucomatous rats for 15 days days, while placebo inserts were administered once in a third group. An untreated glaucomatous group was used as control. Intraocular pressure (IOP) was monitored for four consecutive weeks after treatment began. At the end of the experiment, retinal ganglion cells and optic nerve head cupping were evaluated in the histological eye sections. Characterization results revealed that the drug physically interacted, but did not chemically react with the polymeric matrix. Inserts sustainedly released BIM in vitro during 8 hours. Biodistribution studies showed that the amount of ^99mTc-BIM that remained in the eye was significantly lower after eye drop instillation than after chitosan insert implantation. BIM-loaded inserts lowered IOP for 4 weeks, after one application, while IOP values remained significantly high for the placebo and untreated groups. Eye drops were only effective during the daily treatment period. IOP results were reflected in RGC counting and optic nerve head cupping damage. BIM-loaded inserts provided sustained release of BIM and seem to be a promising system for glaucoma management.

Socioeconomic status as a risk factor for late presentation of glaucoma in Canada

OBJECTIVE

To evaluate the effect of socioeconomic status on late presentation of glaucoma.

DESIGN

Prospective, multicentre, cross-sectional study.

PARTICIPANTS

Newly diagnosed open-angle glaucoma.

METHODS

Eligible subjects with newly diagnosed open-angle glaucoma underwent a comprehensive ocular examination and were classified as mild, moderate, or advanced according to the Canadian Ophthalmological Society glaucoma guidelines. Socioeconomic status was estimated by linking the subjects' postal code to the median household income in the 2006 Canadian population census at the level of dissemination areas. Five equal income groups ranging from the lowest to the highest income quintile were considered and compared regarding the frequency and proportion of moderate or advanced glaucoma.

RESULTS

A total of 290 subjects were included in the analysis; 151 (52.1%) had mild, 79 (26.9%) moderate, and 60 (21.0%) advanced disease at initial diagnosis. Patients with newly diagnosed glaucoma were less likely to come from the poorest neighborhood areas (16.21%) when compared with an expected one fifth (20%) of patients presented in each of the 5 social economic groups (P = 0.56). Compared with people from the poorest neighborhood areas, people from the richest neighborhood areas had a marginally lower risk for having moderate or advanced glaucoma at first presentation (prevalence ratio 0.66, 95% confidence interval: 0.43-1.02, P = 0.06). This association was stronger among those ≥65 years old (P = 0.006).

CONCLUSIONS

To the best of our knowledge, this is the first study in Canada to provide evidence that socioeconomic deprivation is associated with greater severity of glaucoma at presentation, specifically for those ≥65 years old. Consideration should be given to targeting poor neighborhood areas for glaucoma education, screening, or both.

The use of teleglaucoma at the University of Alberta

The aim of the teleglaucoma service at the University of Alberta is to improve access for people in northern Alberta who have early-stage glaucoma or who are at risk for glaucoma. Two types of teleglaucoma service are offered: remote and in-house. A standardized approach is used to capture patient information (structured histories, examinations and fundus photographs) which is then sent to a tertiary care centre for grading and recommendations. Only one grader reads and makes management recommendations for each case. Reports are sent electronically. A total of 195 cases have been graded through the remote service since 2008. A total of 62 cases have been graded through the in-house service since 2011. The average reporting time for consultations in the in-house service was 7 days, and it was also 7 days for the remote service. We believe that the use of teleglaucoma can improve the way that patients are diagnosed and managed, both in industrialized and developing countries. Teleglaucoma is currently being used as a screening tool at the Aga Khan University Hospital in Nairobi with mobile units equipped with a fundus camera and a visual field machine.

Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity

BACKGROUND

Clinical guidelines have been the subject of much criticism in primary care literature partly due to potential conflicts in their implementation among patients with multiple chronic conditions. We assessed the relevance of selected Canadian clinical guidelines on chronic diseases for patients with comorbidity and examined their quality.

METHODS

We selected 16 chronic medical conditions according to their frequency of occurrence, complexity of treatment, and pertinence to primary care. Recent Canadian clinical guidelines (2004 - 2009) on these conditions, published in English or French, were retrieved. We assessed guideline relevance to the care of patients with comorbidity with a tool developed by Boyd and colleagues. Quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.

RESULTS

Regarding relevance, 56.2% of guidelines addressed treatment for patients with multiple chronic conditions and 18.8% addressed the issue for older patients. Fifteen guidelines (93.8%) included specific recommendations for patients with one concurrent condition; only three guidelines (18.8%) addressed specific recommendations for patients with two comorbid conditions and one for more than two concurrent comorbid conditions. Quality of the evaluated guidelines was good to very good in four out of the six domains measured using the AGREE instrument. The domains with lower mean scores were Stakeholder Involvement and Applicability.

CONCLUSIONS

The quality of the Canadian guidelines examined is generally good, yet their relevance for patients with two or more chronic conditions is very limited and there is room for improvement in this respect.