Pregnancy outcomes in the medical management of glaucoma: An international multicenter descriptive survey.

PURPOSE: To determine if glaucoma medications are associated with pregnancy and/or postnatal complications. METHODS: Multicenter descriptive survey. Subjects were female patients 18-45 years who were previously pregnant with a diagnosis of glaucoma or ocular hypertension prior to pregnancy. Chart review queried diagnosis, glaucoma severity, and race. Survey questions were asked for each pregnancy and queried pregnancy age, medications used, and pregnancy outcomes/complications. RESULTS: 114 pregnancies of 56 patients (mean 2.0 pregnancies per patient) were included. Three pregnancies with therapeutic abortion were excluded from further analysis. Mean age during pregnancy was 29.1 ± 5.7 years. Of the 111 pregnancies, 20 (18.0%) used no medications and 91 (82.0%) used at least one medication. Medications were topical carbonic anhydrase inhibitors (n = 45), beta-blockers (n = 55), alpha-agonists (n = 56), and prostaglandin analogues (n = 28). Outcomes were: preterm contractions/labour (6.3%), miscarriage (4.5%), stillbirth (4.5%), induction of labour (11.9%), emergency/unplanned caesarean delivery (13.9%), neonatal intensive care unit (NICU) stay (15.8%), congenital anomalies (8.1%), and low birth weight (10.9%). Fisher exact test assessed outcome associations with individual agents, use of any agent, and different number of agents. Alpha-agonist use was associated with NICU stay: 25.5% rate (p = 0.012) in alpha-agonist use. Most of the alpha-agonist use NICU stays occurred in pregnancies with third trimester use. All other associations were not statistically significant. CONCLUSIONS: The data from this survey suggest an overall favourable safety profile for topical glaucoma medications in pregnancy, but further investigation is needed. Caution should be employed regarding third trimester alpha-agonist use owing to association with NICU stay.

Outcomes of bleb needling in primary glaucoma: A prospective interventional study in a South Indian population.

Purpose: This study was conducted to assess the outcomes of bleb needling for the treatment of failure of filtration surgeries in primary glaucoma with a follow-up of six months. Methods: This prospective interventional study included patients with primary glaucoma who underwent trabeculectomy or combined glaucoma and cataract surgery with failed or failing bleb after six weeks of surgery and less than two years. A comprehensive examination including best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement, gonioscopy, slit-lamp examination, and bleb morphology grading was done. Selected patients underwent a subconjunctival bleb needling with mitomycin C (MMC) (dose 0.2 mg/ml). Postoperatively, patients were followed up on the first, third, and sixth months and were assessed with respect to IOP, need for antiglaucoma medication (AGM), and complications. Results: Sixty eyes of 59 patients were included. Preoperatively, 33.3% of patients were on one AGM, whereas postoperatively at the third month 51.7% and at the sixth month 50% of patients were on no AGM. There was a statistically significant decrease in IOP (P < 0.001) from preoperative (mean: 23.8 ± 7.86 mmHg) to postoperative first month (mean: 19.8 ± 9.08 mmHg), third month (mean: 17.4 ± 5.4 mmHg) and sixth month (mean 16.6 ± 4.39). According to the defined criteria in the current study, we achieved 22 (37.9%) successes, 31 qualified successes (53.4%), and 5 (8.6%) failures. Univariate regression analysis showed a higher failure rate among younger age groups. Gender, laterality, and intraoperative complications were not significant statistically. Conclusion: Bleb needling is a safe and effective procedure for the treatment of failed filtration surgeries.

Long-Term Surgical Outcomes of Primary Congenital Glaucoma in a South Indian Population.

PURPOSE: To evaluate the long-term surgical outcomes of children with primary congenital glaucoma (PCG) in a South Indian population. DESIGN: Retrospective cohort study. PARTICIPANTS: Children with PCG who underwent primary surgery from 1997 through 2000 at a tertiary eye center in India with minimum of 5 years of follow-up. METHODS: This retrospective cohort study included children with PCG who underwent trabeculotomy, trabeculectomy, or combined trabeculotomy and trabeculectomy (CTT) as primary surgery from 1997 through 2000 at a tertiary eye center in India with minimum of 5 years of follow-up. Survival analyses were performed to determine cumulative probability of complete and qualified success. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) control, glaucoma medication use, surgical success rates, and complications. RESULTS: The study included 50 eyes of 31 patients. Mean age at initial surgery was 5 months (range, 5 days-48 months) and 19 patients (61.3%) showed bilateral disease. Mean duration of follow-up was 10.9 ± 3.10 years (range, 6-18 years). Mean IOP was reduced from 28.58 ± 9.78 mmHg (range, 10-59 mmHg) before surgery to 17.13 ± 7.62 mmHg after surgery (range, 5-42 mmHg; P < 0.001) at final follow-up. Survival analysis showed that the probability of surgical success with CTT was 77.8% at 1 year, 66.2% at 2 years, 53.0% at 5 years, and 16.6% at 15 years. Visual acuity at last available follow-up correlated with surgical success (P = 0.042). CONCLUSIONS: Surgical success after long-term follow-up of children with PCG is low. The probability of surgical success declines over time. Children with PCG require life-long follow-up and management, even after initial surgical success, to prevent visual impairment and blindness.

The Effectiveness of Intracameral Moxifloxacin Endophthalmitis Prophylaxis for Trabeculectomy.

PURPOSE: To analyze the effectiveness of intracameral moxifloxacin prophylaxis in reducing acute postoperative endophthalmitis after trabeculectomy and combined trabeculectomy plus cataract extraction. DESIGN: Retrospective clinical registry analysis. PARTICIPANTS: Patients undergoing either trabeculectomy or trabeculectomy plus cataract extraction at Aravind Eye Hospitals (AEH) between 2009 and 2018 (inclusive). METHODS: Electronic health records data were analyzed before and after implementation of routine intracameral moxifloxacin, and acute postoperative endophthalmitis rates were compared. During 2015, routine intracameral moxifloxacin prophylaxis was added in a step-wise fashion throughout AEH. Date of implementation was used to create group 1 (without intracameral moxifloxacin prophylaxis) and group 2 (with intracameral moxifloxacin prophylaxis). MAIN OUTCOME MEASURES: The primary outcome was the difference in acute (≤6 weeks) postoperative endophthalmitis between groups 1 and 2. Review of culture results, visual acuity, and intraocular pressure also was performed for patients with endophthalmitis. RESULTS: Thirty-eight thousand nine hundred eyes (group 1) did not receive intracameral moxifloxacin, whereas 19 086 eyes (group 2) did. Although the rate of noninfectious postoperative complications was not significantly different (0.81% vs. 0.67%; P = 0.07), a significantly lower rate of acute postoperative endophthalmitis was found in group 2 versus group 1 (0.03% vs. 0.08%; P = 0.03). Patients receiving intracameral moxifloxacin showed approximately 2.5-times lower odds of infection (odds ratio, 0.39 for group 2 vs. group 1; 95% confidence interval, 0.16-0.95) and almost 4-times lower odds after adjustment for covariates (odds ratio, 0.26 for group 2 vs. group 1; 95% confidence interval, 0.09-0.74). The rate of early postoperative infection after intracameral moxifloxacin introduction was lower for patients undergoing both trabeculectomy alone (0.09%-0.03%; P = 0.27) and combined trabeculectomy plus cataract extraction (0.08%-0.03%; P = 0.06). Although most cultures yielded no growth, no Staphylococcus or gram-negative growth was found for patients in group 2, who received intracameral moxifloxacin. CONCLUSIONS: Intracameral moxifloxacin prophylaxis was associated with a nearly 4-fold lower rate of early postoperative endophthalmitis in patients undergoing trabeculectomy or combined trabeculectomy plus cataract extraction.

Understanding Barriers to Glaucoma Treatment Adherence among Participants in South India.

Purpose: Data on glaucoma treatment barriers in South India is limited; improved knowledge of barriers could advance disease self-management. We aimed to understand glaucoma treatment barriers in South India.Methods: Glaucoma patients ≥18 taking ≥1 medication at the Aravind Eye Hospital were screened with a validated medication adherence tool. Patients who self-reported poor adherence and/or were >3 months late for follow-up completed semi-structured interviews on treatment barriers. Interviews were audio-recorded, transcribed, translated and back-translated to ensure accuracy. Researchers used grounded theory to code the transcripts and identify themes using NVivo 11.0. Demographic and clinical characteristics were abstracted from the medical record.Results: 70/167 (42%) had poor self-reported adherence to drops. The 45 interviewed were 62 ± 12 years and took 1.6 ± 0.7 drops. Forty-two (93%) were non-adherent to medication and 21 (47%) were late for follow-up. Top barriers to medication adherence were difficulty obtaining drops (20, 44%), being busy (18, 40%), and the expense (17, 38%). Top barriers to appointment follow-up were distance to the hospital (21, 47%), expense (20, 44%), and no escort (15, 33%). Other important barriers included mistrust in the health system, poor knowledge of glaucoma and family needs.Conclusions: Previously, 6% of glaucoma patients in South India self-reported poor medication adherence; the 42% identified in this study is in line with glaucoma medication adherence rates globally. Complex factors caused high rates of non-adherence. Societal-level interventions that address systemic barriers and counselling that supports patients' and families' motivation for behaviour change should be implemented.