Long-term efficacy of selective laser trabeculoplasty in patients on prostaglandin therapy.

BACKGROUND: The aim of the study was to analyse the efficacy of selective laser trabeculoplasty in patients on medical therapy and to evaluate a possible influence of prostaglandin therapy on intraocular pressure reduction. PATIENTS AND METHODS: A retrospective chart review was undertaken of patients with ocular hypertension or open angle glaucoma who underwent selective laser trabeculoplasty between 3/2008 and 12/2010. Data were collected preoperatively, on the day of intervention, 1 day, 1 month and then every 3 months post selective laser trabeculoplasty. The main outcome measure was mean intraocular pressure reduction. RESULTS: 109 eyes (76 on prostaglandins) were included. Mean preoperative intraocular pressure was 22.3 ± 4.5 mmHg (prostaglandin naïve) and 19.2 ± 4.8 mmHg (on prostaglandin) (p=0.003). Up to 1 year follow-up, intraocular pressure was statistically significantly reduced in both groups (p ≤ 0.019). Eyes with a higher preoperative intraocular pressure had a greater pressure reduction (Spearman rho=0.387, p=0.002). Eyes naïve to prostaglandins initially had a greater reduction in intraocular pressure, although after 1 year of follow-up the difference was no longer statistically significant. CONCLUSIONS: Selective laser trabeculoplasty significantly reduces intraocular pressure in patients already on medical therapy. A sustained influence of prostaglandin therapy on the efficacy of selective laser trabeculoplasty was not found.

Long-term efficacy of selective laser trabeculoplasty in pseudophakic patients - a "real-life" analysis.

BACKGROUND: The aim of this study was to report on the course and long-term effect of selective laser trabeculoplasty on intraocular pressure of pseudophakic patients suffering from open angle glaucoma or ocular hypertension with insufficient intraocular pressure lowering despite maximally tolerated topical and systemic intraocular pressure lowering medication. PATIENTS AND METHODS: A retrospective chart review of patients who underwent selective laser trabeculoplasty (360°) between 2008 and 2010 at the University hospital Zurich was undertaken. Intraocular pressure values before intervention, on the day of the intervention, 1 day, 1 month, 3 months and every 3 months up to 43 months after the intervention were analysed with respect to lens status. RESULTS: Out of 153 treated eyes of 111 patients (mean age 70.6 years ± 11.13 SD) 40 were pseudophakic. Mean baseline intraocular pressures were 19.00 mmHg ± 4.61 in the pseudophakic group and 20.12 mmHg ± 4.89 in the phakic group. One month after selective laser trabeculoplasty intraocular pressure reduction measured between -0.33 and -4.10 mmHg (CI 95%) in the pseudophakic group and between -3.64 and -5.58 mmHg (CI 95%) in the phakic group, the difference at this time point was significant (p=0.01). Beyond one month after selective laser trabeculoplasty there was no statistically significant difference in intraocular pressure reduction between pseudophakic and phakic patients. The mean decrease in intraocular pressure from baseline to the last follow-up of 43 months was 0.67 mmHg in the pseudophakic group and 0.25 mmHg in the phakic group (p=0.72). CONCLUSIONS: One month after selective laser trabeculoplasty pseudophakic patients showed a statistically significant diminished reduction of intraocular pressure compared to phakic patients. Later on there was no statistically significant difference in intraocular pressure reduction between pseudophakic and phakic patients. Therefore we conclude that there was no clinically relevant influence of pseudophakia on the long-term effect of selective laser trabeculoplasty.

Investigating the transfer rate of waterpipe additives to smoke as an integral part of toxicological risk assessments.

Waterpipe, also known as hookah, narghile or narghila, shisha or hubbly bubbly, is a tobacco-smoking device. Waterpipe tobacco is heated and consumed by a process of inhaling tobacco smoke, that bubbles through water before being inhaled. To date, limited studies have examined the transfer of waterpipe additives from tobacco to smoke. This study was designed to investigate the filtration ability of water in the waterpipe's bowl to define exposure to additives in waterpipe smoke, which is an essential requirement to perform toxicological risk assessments of waterpipe additives. Within this study, a standard smoking protocol (ISO 22486) was used to evaluate the transfer of > 40 additives from experimental and commercially available samples. These results are the first to provide such an extensive dataset of information showing transfer rates varying between 6% and 61% depending on the additive. Various physicochemical parameters of the additives including water solubility, partition coefficient, molecular weight, boiling point, and vapor pressure were also evaluated to seek to identify any correlation to transfer rate that may be later used to predict transfer. The amount of additive transfer from waterpipe tobacco to the smoke was found to be moderately correlated to vapor pressure (Pearson correlation coefficient = 0.33) with subsequent multivariate analysis using step-wise selection indicating 39% of the transfer rate variance can be explained collectively by the additive boiling point, molecular weight, vapor pressure and water solubility. These findings underscore the complexity of additive transfer and highlight the necessity of exposure assessment for meaningful waterpipe additive risk assessments.

[The role of Stratus OCT in anti-VEGF therapy. Qualitative and quantitative assessment of neovascular AMD]. / Die Rolle des Stratus-OCT bei der Anti-VEGF-Therapie : Qualitative und quantitative Beurteilung bei neovaskulärer AMD.

BACKGROUND: The evaluation of OCT3 during anti-VEGF therapy. METHODS: A total of 29 patients with choroidal neovascularization secondary to AMD received 3 intravitreal injections of ranibizumab. OCT examination and visual acuity testing (ETDRS) were performed before therapy onset, after 1 week and after 1, 2 and 3 months. RESULTS: The central retinal thickness (CRT) was assessed correctly by OCT in 128 out of 145 measurements. There was a distinct (84%) but not significant correlation between decrease in central retinal thickness and increase in visual acuity. Incorrect retinal layer segmentation and inadequate CRT measurements were a significant technical limitation. CONCLUSION: During anti-VEGF therapy, OCT allows documentation and quantification of morphologic retinal changes and in most cases also for an estimation of functional improvement.

Medical interventions for primary open angle glaucoma and ocular hypertension.

BACKGROUND: Primary open angle glaucoma (POAG) is a progressive optic neuropathy with an elevated intraocular pressure (IOP), where the optic nerve head becomes pathologically excavated and the visual field (VF) is characteristically altered. Ocular hypertension (OHT) is a condition with elevated IOP but without discernible pathology of the optic nerve head or the VF. It is a major risk factor for development of POAG. OBJECTIVES: To assess and compare the effectiveness of topical pharmacological treatment for POAG or OHT to prevent progression or onset of glaucomatous optic neuropathy. SEARCH STRATEGY: We searched CENTRAL, MEDLINE and EMBASE in May 2007. We searched the bibliographies of identified articles and contacted experts, investigators and pharmaceutical companies for additional published and unpublished studies. SELECTION CRITERIA: Randomised controlled trials comparing topical pharmacological treatment to placebo, no treatment or other treatment for specified endpoints which included people with POAG or OHT, and with duration of treatment of at least one year. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. Where appropriate, we summarised data using Peto odds ratio and mean difference after testing for heterogeneity between studies. MAIN RESULTS: We included 26 trials, which randomised 4979 participants, in this review. Meta-analysis of 10 trials clearly demonstrated reduction of onset of VF defects in treated OHT (OR 0.62, 95% CI 0.47 to 0.81). No single drug showed a significant VF protection compared to placebo or untreated controls. We did identify some border line evidence for a positive influence of treatment on VF prognosis (OR 0.67, 95% CI 0.45 to 1.00) for the beta-blockers . AUTHORS' CONCLUSIONS: The results of this review support the current practice of IOP lowering treatment of OHT. A visual field protective effect has been clearly demonstrated for medical IOP lowering treatment. Positive but weak evidence for a beneficial effect of the class of beta-blockers has been shown. Direct comparisons of prostaglandins or brimonidine to placebo are not available and the comparison of dorzolamide to placebo failed to demonstrate a protective effect. However, absence of data or failure to prove effectiveness should not be interpreted as proof of absence of any effect. The decision to treat a patient or not, as well as the decision regarding the drug with which to start treatment, should remain individualised, taking in to account the amount of damage, the level of IOP, age and other patient characteristics.

[Effectiveness of selective laser trabeculoplasty in patients with insufficient control of intraocular pressure despite maximum tolerated medical therapy]. / Wirksamkeit der selektiven Lasertrabekuloplastik bei Patienten mit unzureichender Augendrucksenkung unter maximaler Therapie.

BACKGROUND: Reduction of intraocular pressure (IOP) is still the primary goal of glaucoma treatment. The aim of this prospective study was to examine the IOP lowering effect of selective laser trabeculoplasty (SLT) in patients on maximum tolerated medical therapy (MTMT), especially with regard to a potential influence of pseudophakia and topical prostaglandin analogues (PGA) on IOP reduction. MATERIAL AND METHODS: A total of 30 patients with a diagnosis of primary open angle glaucoma, normal tension glaucoma and pseudoexfoliative glaucoma with uncontrolled IOP despite MTMT underwent SLT treatment circumferentially over 360°. Follow-up visits were conducted 1 day after SLT and then 1, 3, 6, 9, and 12 months post-treatment. The initial medication was continued unchanged for 3 months. RESULTS: Median follow-up was 11.97 ± 3.1 months, mean IOP at baseline was 19.60 ± 4.69 mmHg, mean IOP reduction was -19.95 ± 17.14% 1 month after and -14.07 ± 23.57% 12 months after SLT (p < 0.001 and p = 0.003, respectively). Patients with higher baseline IOP had greater reduction of IOP after SLT (R(2) = 0.482, p < 0.001). Phakic patients had a significantly greater IOP reduction compared to pseudophakic patients (- 4.55 ± 4.45 mmHg and + 2.75 ± 6.75 mmHg, respectively, p = 0.010). Patients without PGA had a statistically insignificant greater IOP reduction compared to patients with PGA (- 7.40 ± 4.72 mmHg and -2.48 ± 5.22 mmHg, respectively, p = 0.066) and four patients needed additional surgery to lower IOP. CONCLUSION: Even in patients already on maximum IOP lowering medication, SLT has the potential to significantly reduce IOP up to 1 year after treatment. The IOP reduction is most pronounced in phakic eyes with high preoperative IOP.

[Recommendations for follow-up examinations in patients with ocular hypertension]. / Empfehlungen notwendiger Kontrolluntersuchungen bei okulärer Hypertension.

Ocular hypertension (OHT) describes a condition with elevated intraocular pressure (IOP) above the norm ( > 21 mmHg). By definition the anterior chamber angle is open and there are neither signs of glaucomatous optic nerve damage nor visual field defects. Thus, for the diagnosis of OHT an extensive baseline examination is mandatory in order to rule out pre-existing glaucomatous damage. Patients with ocular hypertension are at a higher risk of developing glaucoma. Therefore, periodical routine examinations with a standardized protocol for specific follow-up examinations are highly recommended.

[One-year results after combined cataract surgery and excimer laser trabeculotomy for elevated intraocular pressure]. / 1-Jahres-Ergebnisse nach kombinierter Kataraktoperation und Excimer-Laser-Trabekulotomie bei erhöhtem Intraokulardruck.

BACKGROUND: Glaucoma is one of the most common reasons for blindness. Usually an elevated resistance to aqueous outflow is the reason, while aqueous humor production is still normal. Medical reduction of intraocular pressure (IOP) is the first-line therapy in most cases. The gold standard of surgical treatment is trabeculectomy (TE). But TE has a lot of postoperative complications. Therefore we prefer the combined procedure of cataract extraction plus excimer laser trabeculotomy (phaco-ELT) for a selected group of glaucoma patients. Indications are cataract together with moderately elevated IOP without medical therapy or a moderate cataract together with elevated IOP under medical therapy. PATIENTS AND METHODS: During ELT, 10 pores were created over 90° of the anterior chamber angle; 28 eyes of 28 patients (10 men and 18 women) were reexamined 12 months ± 2 weeks after combined phaco-ELT. Four patients were excluded because of IOP-lowering surgery during the follow-up. IOP, best corrected visual acuity, slit lamp biomicroscopy as well as glaucoma medication history (antiglaucoma drugs, AGD) were recorded. RESULTS: The mean age was 74.33±11.81 years. The diagnosis was primary open-angle glaucoma in 9 eyes, pseudoexfoliative glaucoma in 15 eyes, ocular hypertension in 3 eyes, and 1 post-traumatic secondary glaucoma. On average, phaco-ELT could reduce the IOP by 8.79±5.28 mmHg (-34.70%, p<0.001). AGD could be reduced by 0.79±1.50 (-62.70%, p=0.017) at the same time. CONCLUSION: The ELT is easy to perform at the end of cataract surgery. Duration of surgery is only prolonged by 2 to 3 minutes. We found an average IOP reduction of 8.79 mmHg (-34.70%) and an average reduction of 0.79 AGD. It is known that the effect of IOP reduction is constant over time unlike argon or selective laser trabeculoplasty. If needed later on, filtering surgery is not compromised because there is no conjunctival touch during ELT and therefore no scarring of the conjunctiva. For a selected collective of glaucoma patients this procedure could be a good way to avoid trabeculectomy.

Retinal nerve fiber layer birefringence evaluated with polarization sensitive spectral domain OCT and scanning laser polarimetry: a comparison.

A polarization-sensitive spectral domain optical coherence tomography (PS-SD-OCT) system is used to measure phase retardation and birefringence of the human retinal nerve fiber layer (RNFL) in vivo. The instrument records three parameters simultaneously: intensity, phase retardation and optic-axis orientation. 3D data sets are recorded in the optic nerve-head area of a healthy and a glaucomatous eye, and the results are presented in various ways: En-face phase-retardation maps of the RNFL are generated from the recorded 3D data and results are compared with scanning laser polarimetry (SLP). The depth information provided by OCT is used to segment the RNFL in the intensity image and measure the RNFL thickness. From the retardation and thickness data, 2D birefringence maps of the RNFL are derived. Circumpapillary plots of RNFL retardation and thickness obtained by PS-SD-OCT are quantitatively compared with those obtained by SLP.