Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial.

BACKGROUND: Treatments for open-angle glaucoma aim to prevent vision loss through lowering of intraocular pressure, but to our knowledge no placebo-controlled trials have assessed visual function preservation, and the observation periods of previous (unmasked) trials have typically been at least 5 years. We assessed vision preservation in patients given latanoprost compared with those given placebo. METHODS: In this randomised, triple-masked, placebo-controlled trial, we enrolled patients with newly diagnosed open-angle glaucoma at ten UK centres (tertiary referral centres, teaching hospitals, and district general hospitals). Eligible patients were randomly allocated (1:1) with a website-generated randomisation schedule, stratified by centre and with a permuted block design, to receive either latanoprost 0·005% (intervention group) or placebo (control group) eye drops. Drops were administered from identical bottles, once a day, to both eyes. The primary outcome was time to visual field deterioration within 24 months. Analyses were done in all individuals with follow-up data. The Data and Safety Monitoring Committee (DSMC) recommended stopping the trial on Jan 6, 2011 (last patient visit July, 2011), after an interim analysis, and suggested a change in primary outcome from the difference in proportions of patients with incident progression between groups to time to visual field deterioration within 24 months. This trial is registered, number ISRCTN96423140. FINDINGS: We enrolled 516 individuals between Dec 1, 2006, and March 16, 2010. Baseline mean intraocular pressure was 19·6 mm Hg (SD 4·6) in 258 patients in the latanoprost group and 20·1 mm Hg (4·8) in 258 controls. At 24 months, mean reduction in intraocular pressure was 3·8 mm Hg (4·0) in 231 patients assessed in the latanoprost group and 0·9 mm Hg (3·8) in 230 patients assessed in the placebo group. Visual field preservation was significantly longer in the latanoprost group than in the placebo group: adjusted hazard ratio (HR) 0·44 (95% CI 0·28-0·69; p=0·0003). We noted 18 serious adverse events, none attributable to the study drug. INTERPRETATION: This is the first randomised placebo-controlled trial to show preservation of the visual field with an intraocular-pressure-lowering drug in patients with open-angle glaucoma. The study design enabled significant differences in vision to be assessed in a relatively short observation period. FUNDING: Pfizer, UK National Institute for Health Research Biomedical Research Centre.

Combined conjunctival relieving incisions and advancement for the repair of late-onset leaking trabeculectomy blebs.

PURPOSE: To describe a surgical technique for the repair of late-onset leaking blebs. METHODS: A surgical technique is described followed by a retrospective review of 5 clinical cases. All patients had a minimum of 12 months follow up. RESULTS: In all cases the leaks were successfully closed and bleb function was maintained. Of 5 patients, 3 required subsequent topical glaucoma medication though none required further drainage surgery. The mean intraocular pressure at last follow up was 16 mm Hg (range 10 to 27 mm Hg). CONCLUSIONS: This technique can be considered as an option for patients who require surgical revision for a leaking trabeculectomy bleb.

Service innovation in glaucoma management: using a Web-based electronic patient record to facilitate virtual specialist supervision of a shared care glaucoma programme.

AIM: To assess the importance of specialist supervision in a new model of glaucoma service delivery. METHODS: An optometrist supported by three technicians managed each glaucoma clinic. Patients underwent testing and clinical examination before the optometrist triaged them into one of five groups: 'normal', 'stable', 'low risk', 'unstable' and 'high risk'. Patient data were uploaded to an electronic medical record to facilitate virtual review by a glaucoma specialist. RESULTS: 24 257 glaucoma reviews at three glaucoma clinics during a 31-month period were analysed. The clinic optometrists and glaucoma specialists had substantial agreement (κ 0.69). 13 patients were identified to be high risk by the glaucoma specialist that had not been identified as such by the optometrist. Glaucoma specialists amended 13% of the optometrists' interim decisions resulting in an overall reduction in review appointments by 2.4%. CONCLUSIONS: Employing technicians and optometrists to triage glaucoma patients into groups defined by risk of blindness allows higher risk patients to be directed to a glaucoma specialist. Virtual review allows the glaucoma specialist to remain in overall control while reducing the risk that patients are treated or followed-up unnecessarily. Demand for glaucoma appointments can be reduced allowing scarce medical resources to be directed to patients most in need.

Analysis of the diurnal intraocular pressure profile pre and post trabeculectomy using 24-hour monitoring of intraocular pressure.

PURPOSE: To compare the diurnal intraocular pressure (IOP) profile pre and post trabeculectomy with a control group of medically controlled patients. We compared the change in mean, peak, and diurnal IOP fluctuation. METHODS: This was an observational study of patients at the Bristol Eye Hospital, United Kingdom. All patients underwent initial and subsequent phasing, with surgery between for cases. The unpaired Student t test compared the changes (initial-subsequent) in mean, peak, and fluctuation between cases and controls. RESULTS: Fifteen eyes underwent trabeculectomy surgery while the control group contained 17 eyes controlled on topical medical treatment. There was a statistically significant reduction in both mean IOP of 3.7 mmHg (p=0.002) and peak IOP of 4.4 mmHg (p=0.025) in the surgical group compared to the medical group. There was no statistically significant change in the IOP fluctuation between the 2 study groups (p=0.296). CONCLUSIONS: There is a significant reduction in mean IOP and peak IOP following trabeculectomy. We showed no statistically significant change in the diurnal fluctuation of IOP following trabeculectomy.