Glaucoma Drainage Device Technique in a Cohort of Experienced Glaucoma Surgeons in Australia and New Zealand.

PRéCIS:: Glaucoma drainage devices (GDD) by Australian and New Zealand glaucomatologists are implanted superotemporally under a peribulbar anesthesia without the use of mitomycin C. Intraluminal stents and tube fenestration are utilized and covered with a scleral graft. PURPOSE: To evaluate current practice patterns of surgical techniques for GDD among Australia and New Zealand Glaucoma Society members routinely performing GDD surgery. METHODS: Survey of surgeons who performed more than 20 GDD in past 5 years. RESULTS: Surgeon participation rate was 31/32 (96.8%). The most common surgical techniques were Baerveldt GDD (24/32, 77.4%), superotemporal placement (31/31, 100%), and peribulbar anesthesia (21/31, 67.7%). Mitomycin C antimetabolite was used routinely by 9/31 surgeons (29.0%). Most surgeons employed intraluminal stents (23/31, 74.2%) with tube fenestrations (19/31, 61.3%). GDD was placed behind the recti muscles (27/31, 87.1%) and secured with nylon (8/0, 9/0 or 10/0) by 29/31 (93.6%). Most common sclerostomy techniques for tube insertion was a 23-G needle passed ab externo (18/31, 58.1%). Tube placement was in the sulcus (11/31, 35.5%) for pseudophakic patients. The external portion of the tube was most commonly covered with a full-thickness scleral patch graft (21/31, 67.7%). Majority of surgeons (21/31, 67.7%) reviewed patients 3 to 4 times in the first month. CONCLUSIONS: Although a wide range of practice patterns for GDD implantation exists among Australia and New Zealand Glaucoma Society surgeons, there are consistent techniques currently in use to optimize patient outcomes. This report can help surgeons seeking to improve outcomes and minimize complications when trialing the different surgical options.

Clinical practice preferences for glaucoma surgery in Japan: a survey of Japan Glaucoma Society specialists.

PURPOSE: This study evaluated the surgical practice patterns of glaucoma management followed by glaucoma specialists in Japan. METHODS: A survey was administered to 50 glaucoma specialists who were councilors in the Japan Glaucoma Society about surgical preferences and postoperative glaucoma care. RESULTS: All 50 glaucoma specialists participated in the survey. Results show that, in 2019, compared to conventional trabeculotomy (4.6%), the frequency of minimally invasive glaucoma surgery (MIGS), combined with phacoemulsification, remarkably increased (79.0%) for non-operated eyes with mild open-angle glaucoma associated with cataract. Tube-shunt surgery was performed more often for open-angle glaucoma with previously twice failed trabeculectomy (65.8%) and neovascular glaucoma with previously once failed trabeculectomy (63.4%). In addition, during one year post-operatively, MIGS required less frequent follow-up visits compared to filtering surgery. CONCLUSION: Although glaucoma specialists in the Japan Glaucoma Society usually prefer trabeculectomy, in the past decade they have selected tube-shunt surgery more often to treat refractory glaucoma. MIGS is increasing remarkably as the choice primary glaucoma surgery.

Risk Factors for Glaucoma Drainage Device Exposure in a Middle-Eastern Population.

PRéCIS:: In this case-control study, female sex, and older age were risk factors for tube exposure; risk was related to the number of prior ocular surgeries and scleral patch graft (compared with pericardial graft) was found to protect against exposure. PURPOSE: Identification of potential risk factors for glaucoma drainage device (GDD) exposure may help to prevent this potentially blinding complication. The purpose of this study was to evaluate the possible risk factors for GDD exposure in a tertiary eye care center in the Middle-East. METHODS: A retrospective case-control study was undertaken for a 7-year period (2008 to 2015 inclusive). All patients who presented with a GDD incident exposure were identified and were compared with a similar number of controls (without exposure) identified during the same period. Demographic factors, past ocular history, treatment, and surgical technique were recorded for both groups. Bivariate and multivariable analyses were used to identify possible risk factors for tube exposure. RESULTS: A total of 836 patients underwent GDD surgery during this time period and 53 patients were identified with exposure, giving a cumulative incident exposure rate of 6.3% (0.9% per year). Bivariate analysis showed that the median age of cases (51 years) was similar to controls (53 years) (P=0.95), while there was a greater proportion of women with exposure (49%) compared with the control group (28%) with a statistically significant difference (P=0.028). The number of previous surgeries (3.77±2.1) was significantly higher (P=0.018) in the exposure group (4.25±2.0) compared with controls (3.3±2.0). With each unit increase in the number of previous surgeries, the odds of exposure significantly increased by 1.29 (95% confidence interval, 1.05-1.57). In the multivariable regression, female sex (P=0.006) and older age (P=0.025) were significant risk factors and use of a scleral patch (P=0.02) graft potentially protective. CONCLUSIONS: Previous surgery, female sex, and older age are potential risk factors identified in our study. The use of scleral patch graft is potentially protective against GDD extrusion. Further study is needed to elucidate the reasons for these causative and protective factors.

Changes in Australian practice patterns for glaucoma management.

IMPORTANCE: The demand for glaucoma care is projected to increase significantly with the ageing population. BACKGROUND: To characterize trends in Australian practice patterns for glaucoma management over the 15-y period between 2003 and 2017. DESIGN: Retrospective audit. SAMPLES: The Medicare eligible population. METHODS: Audit of Medicare Benefits Schedule item number reimbursements in the private healthcare sector, and dispensed Pharmaceutical Benefits Scheme (PBS) prescriptions. MAIN OUTCOME MEASURES: Number, unadjusted cost and services per capita in the enrolled population. RESULTS: The number of medication prescriptions peaked in 2015, but then declined by 14.9%. PBS expenditure on glaucoma medications has been falling since 2012. There was a 9.2-fold increase in fixed-combination prescriptions and 281-fold increase in unpreserved medication prescriptions. In 2017, optometrists generated 1.86% of glaucoma prescriptions. Reimbursements for computerized perimetry increased dramatically for optometrists, and in 2017 optometrist-initiated perimetry exceeded ophthalmologist-initiated perimetry by 35.3%. There were significant increases in laser procedure rates, including laser trabeculoplasty (4.61-fold), laser iridotomy (2.55-fold) and cyclodestructive procedures (2.33-fold). There was a 3.83-fold increase in glaucoma drainage device insertions. Ab interno trabecular microbypass procedures increased 715% from 2014 to 2017. Adjusted for Medicare population, trabecular microbypass is performed at more than twice the rate of primary filtering operations. CONCLUSIONS AND RELEVANCE: This is the first time that glaucoma medication use and expenditure have declined since auditing began in 1992. Glaucoma laser procedures, drainage device implantation and trabecular microbypass increased substantially over the study period. In contrast, the rate of primary filtering operations increased in proportion to population growth. The increase in overall cost of glaucoma care has primarily been driven by computerized perimetry; however, this has been partially offset by a decline in medication expenditure.

Patient Acceptance of Sustained Glaucoma Treatment Strategies.

PURPOSE: To assess patient acceptance of different methods for delivering sustained-release, intraocular pressure (IOP)-lowering medications. METHODS: Electronic surveys were administered to 150 patients at 2 glaucoma clinics. Participants were questioned on their willingness to accept: (1) drug-eluting contact lenses, (2) ring inserts (3) punctal plugs, and (4) subconjunctival injections as alternatives to IOP-lowering eye drops based on various success levels. Multivariable logistic regression models determined the association between device type and treatment acceptance adjusting for age, sex, study site, cost burden of drops, and previous contact lens use. RESULTS: The majority (69%) of participants were 55 to 74 years of age, and white (65%), and half were female. The majority of participants would accept contacts (59%), rings (51%), plugs (57%), and subconjunctival injections (52%) if they obviated glaucoma surgery; fewer would accept these devices if they reduced (23% to 35%) or eliminated (27% to 42%) drops. Most participants would also accept contacts (56%), plugs (55%), and subconjunctival injections (53%) if they were more effective than eye drops, whereas only 47% would accept a ring; fewer would accept any device if it were equally or less effective than drops. Participants were also 36% (95% confidence interval=0.44-0.92; P=0.02) less likely to accept rings and 32% (95% confidence interval=0.47-0.98; P=0.04) less likely to accept subconjunctival injections as compared with contacts. CONCLUSION: Most glaucoma patients considered sustained drug-delivery modalities acceptable alternatives to IOP-lowering eye drops, but only when they were said to obviate surgery or demonstrate greater efficacy than eye drops.

Glaucoma drainage device surgery after vitreoretinal surgery: incidence and risk factors.

PURPOSE: The initial success of vitreoretinal surgery can be annihilated by an acceleration of preexisting glaucoma or the development of secondary glaucoma. Aim of this study was to determine the incidence of and risk factors for medically uncontrollable glaucoma after vitreoretinal surgery. METHODS: Case-control study amongst patients who underwent vitreoretinal surgery at the University Medical Center Groningen between 1991 and 2011 (in total 14,942 interventions). Cases were all patients who received a glaucoma drainage device after vitreoretinal surgery. Controls were a subset of the patients who underwent vitreoretinal surgery without a subsequent drainage device. Cases and controls were matched (three controls per case) with regard to the year of the (first) vitreoretinal intervention. The incidence rate was calculated from the number of cases and the number of person-years corresponding to all vitreoretinal interventions performed in the study period. Risk factors were analysed with logistic regression. RESULTS: Ninety-five cases were identified after a follow-up of 101,961 person-years (one per 1000 person-years). Cases were younger (p = 0.017), were more often men (p = 0.035), underwent more interventions (p < 0.001) or were treated with silicone oil (p = 0.021), had a higher intra-ocular pressure 1 week after the intervention (p < 0.001) and had more often a history of glaucoma or ocular hypertension (p < 0.001). CONCLUSION: Glaucoma after vitreoretinal surgery that requires a glaucoma drainage device is not very common and patients who need a device differ from those who do not. This gives the opportunity to monitor certain subgroups more closely.

A Quantitative Analysis of the Relationship between Medicare Payment and Service Volume for Glaucoma Procedures from 2005 through 2009.

PURPOSE: To calculate the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures. DESIGN: Retrospective, longitudinal database study. SUBJECTS: A 100% dataset of all glaucoma procedures performed on Medicare Part B beneficiaries within the United States from 2005 to 2009. METHODS: Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in glaucoma service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. MAIN OUTCOME MEASURES: Payment-volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for laser trabeculoplasty (Current Procedural Terminology [CPT] code 65855), trabeculectomy without previous surgery (CPT code 66170), trabeculectomy with previous surgery (CPT code 66172), aqueous shunt to reservoir (CPT code 66180), laser iridotomy (CPT code 66761), and scleral reinforcement with graft (CPT code 67255). RESULTS: The payment-volume elasticity was nonsignificant for 4 of 6 procedures studied: laser trabeculoplasty (elasticity, -0.27; 95% confidence interval [CI], -1.31 to 0.77; P = 0.61), trabeculectomy without previous surgery (elasticity, -0.42; 95% CI, -0.85 to 0.01; P = 0.053), trabeculectomy with previous surgery (elasticity, -0.28; 95% CI, -0.83 to 0.28; P = 0.32), and aqueous shunt to reservoir (elasticity, -0.47; 95% CI, -3.32 to 2.37; P = 0.74). Two procedures yielded significant associations between Medicare payment and service volume. For laser iridotomy, the payment-volume elasticity was -1.06 (95% CI, -1.39 to -0.72; P < 0.001): for every 1% decrease in CPT code 66761 payment, laser iridotomy service volume increased by 1.06%. For scleral reinforcement with graft, the payment-volume elasticity was -2.92 (95% CI, -5.72 to -0.12; P = 0.041): for every 1% decrease in CPT code 67255 payment, scleral reinforcement with graft service volume increased by 2.92%. CONCLUSIONS: This study calculated the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures and found varying magnitudes of payment-volume elasticities, suggesting that the volume response to changes in Medicare payments, if present, is not uniform across all Medicare procedures.

Practice preferences for glaucoma drainage device implantation and cyclodestruction in Australia and New Zealand.

PURPOSE: To evaluate the practice patterns in the use of glaucoma drainage devices (GDD) and cyclodestruction among consultant ophthalmologists in Australia and New Zealand. MATERIALS AND METHODS: A 22-part questionnaire regarding GDD implantation and cyclodestruction practices was sent to all ophthalmologists registered with the Royal Australian and New Zealand College of Ophthalmologists in 2008 by post or e-mail. RESULTS: Sixty-six percent of 872 questionnaires were returned, of these, 14% were from glaucoma subspecialists. Ten percent of all respondents performed GDD implantations. Molteno drains were the most popular device (69%). The most commonly recognized indications for GDD implantation were a history of 2 failed trabeculectomies (85%), neovascular glaucoma (71%), iridocorneal endothelial syndrome (55%), and uveitic glaucoma (52%). Only a minority of surgeons used intraoperative mitomycin C (38%) or 5-fluorouracil (26%) when implanting GDD. Cyclodestruction had been performed by 20% of all respondents. External diode cyclophotocoagulation was the most preferred treatment mode (73%). Sixty-seven percent treated 180 degrees of the ciliary body during initial treatment. Fifty-five percent treated only the earlier untreated area during retreatment. Only 11% of surgeons who performed cyclodestruction agreed that the indications for cyclodestruction are expanding. CONCLUSIONS: A wide range of practice patterns for GDD implantation and cyclodestruction exist among Australian and New Zealand ophthalmologists. This likely reflects a paucity of good evidence to guide practice. The Australasian indications for GDD implantation were moderately different from the reported practice in America. Well-designed clinical trials are needed to better define the indications and best practice for these 2 important glaucoma treatment modalities.

Practice preferences for glaucoma surgery: a survey of the American Glaucoma Society in 2008.

BACKGROUND AND OBJECTIVE: To evaluate glaucoma surgical practice patterns among members of the American Glaucoma Society (AGS). PATIENTS AND METHODS: An anonymous web-based survey was sent to AGS members to determine their preferred surgical approach in ten clinical settings. Survey results were compared with those from 1996 and 2002. RESULTS: A total of 125 (22%) AGS members responded to the survey. Mean glaucoma drainage device (GDD) usage increased from 17.5% (range: 5% to 37%; standard deviation [SD]: 10.9%) in 1996 to 50.8% (range: 15% to 76%; SD: 17.3%) in 2008, and mean trabeculectomy usage decreased from 80.8% (range: 62% to 93%; SD: 11.3%) in 1996 to 45.5% (range: 16% to 80%; SD: 17.9) in 2008. GDD was most popular in none of 8 clinical settings in 1996, and 5 of 8 clinical settings in 2008. Mitomycin C was selected as an adjunctive antifibrotic agent to trabeculectomy in 85% to 99% of cases. CONCLUSION: Glaucoma surgical practice patterns have changed since 1996. The use of a GDD has progressively increased, and the popularity of trabeculectomy decreased between 1996 and 2008. Mitomycin C remains the most frequently selected antifibrotic agent used as an adjunct to trabeculectomy.

Effect of physician remuneration fees on glaucoma procedure rates in Canada.

PURPOSE: Earlier studies have reported wide regional variability in glaucoma procedure rates, suggesting nonclinical factors influencing procedure rates. This study was designed to investigate the possible influence of fees on procedure rates. METHODS: Databases were accessed to obtain yearly provincial population, procedure and ophthalmologist numbers, and physician fees for trabeculoplasties, trabeculectomies, and glaucoma drainage device (GDD) implantations from 1992 to 2007. Regression models using generalized estimating equation methods were used to evaluate the influence of fees on procedure rates after adjusting for temporal trends and the number of ophthalmologists per 1000 persons with glaucoma. RESULTS: Trends in glaucoma procedure rates and fees varied widely among provinces: decrease of 98% to an increase of 380% for trabeculoplasties, decrease of 72% to an increase of 42% for trabeculectomies, and decrease of 32% to an increase of 1292% for GDD. In 2007, provincial remuneration varied from $125 to $553 for trabeculoplasties, $370 to $748 for trabeculectomies, and $426 to $956 for GDD. The regression models found for every 1000 persons with glaucoma, a $100 increase in fee was associated with 0.68 more trabeculoplasties (P=0.94), 1.2 fewer trabeculectomies (P=0.17), and 0.18 more GDD implantations (P=0.18); and for every additional ophthalmologist per 1000 persons with glaucoma, 53.8 more trabeculoplasties (P=0.24), 0.34 more trabeculectomies (P=0.86), and 0.79 more GDD implantations (P=0.0004). A regression model examining procedure substitution effect did not find any association between relative remuneration and procedure rate. CONCLUSION: Our analysis did not show an influence of physician remuneration fee on procedure rates in Canada during the study period.

Glaucoma laser and surgical procedure rates in Canada: a long-term profile.

BACKGROUND: New laser and surgical techniques have had a significant effect on glaucoma therapy. A precise understanding of how these developments are affecting overall glaucoma management is fundamental to health services planning. The objective of this study was to synthesize Canadian national and provincial data regarding glaucoma laser and surgical procedure rates from 1992 to 2004. METHODS: Canadian provincial health insurance databases, which cover virtually all surgical procedures provided domestically to Canadians, were accessed to ascertain yearly total glaucoma procedure numbers. To estimate the number of individuals with glaucoma, an age-stratified glaucoma prevalence model was applied to population census data. RESULTS: Laser trabeculoplasty rates dramatically increased between 2001 and 2004 with the national Canadian rate more than doubling. However, this increase varied widely across regions, ranging from 0% to 530%. Trabeculectomy surgery rates slowly increased from 1992 to 1995, then declined by 29% nationally between 1995 and 2004. Implantation rates of glaucoma drainage devices increased 12-fold nationally between 1992 and 2004; by 2004 this procedure accounted for 10% of incisional glaucoma surgical procedures in Canada. INTERPRETATION: In Canada, laser trabeculoplasty rates have risen significantly over recent years. Trabeculectomy rates have recently declined, and implantation of glaucoma drainage devices is playing an increasingly important role in glaucoma management in this country.

Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004.

OBJECTIVE: To observe how the treatment of glaucoma has changed over the last decade. DESIGN: Retrospective, observational, population-based analysis. PARTICIPANTS: Medicare beneficiaries between 1995 and 2004. METHODS: Medicare fee-for-service data claims between 1995 and 2004 were analyzed to determine the number of penetrating surgeries and laser procedures performed for glaucoma in the decade spanning 1995 and 2004. MAIN OUTCOME MEASURE: Number of Medicare beneficiaries receiving glaucoma-related laser procedures or surgery. RESULTS: Trabeculectomies in eyes without previous surgery or trauma decreased 53% over the study period, from 51,690 in 1995 to 24,178 in 2004, although trabeculectomy in eyes with scarring increased 9%. The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. Cyclophotocoagulation procedures rose 248% over the study period, from 3264 procedures in 1995 to 11,356 procedures in 2004. Between 1995 and 2001, the number of laser trabeculoplasties decreased 57%, from a high of 151,244 in 1995 to a low of 75,647 in 2001. From 2001 to 2004, the number of trabeculoplasties more than doubled, with 157,490 performed in 2004. The number of laser iridotomies showed little fluctuation, increasing 18% over the study period and ranging from 63,773 to 85,286 every year. Over the study period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. CONCLUSIONS: Medicare recipients with glaucoma are more likely to be treated with aqueous shunting procedures or cyclophotocoagulation and less likely to be treated with trabeculectomy, compared with past years. After a decline in use between 1995 and 2001, laser trabeculoplasty increased substantially from 2001 to 2004. Fistulization procedures other than trabeculectomy and surgical iridectomy have become very uncommon.

2002 survey of the American Glaucoma Society: practice preferences for glaucoma surgery and antifibrotic use.

PURPOSE: To determine the preference of members of the American Glaucoma Society for the use of antifibrotic agents (mitomycin C or 5-fluorouracil or both) and glaucoma drainage devices in ten clinical settings. MATERIALS AND METHODS: Voluntary written survey of the American Glaucoma Society. RESULTS: American Glaucoma Society (AGS) members continue to report preference for mitomycin C use in ten clinical settings. The percent usage for glaucoma drainage devices has increased in poor prognosis scenarios including the following: neovascular glaucoma, previous failed trabeculectomy, previous ECCE/ICCE, previous PKP, previous scleral buckling surgery, and uveitic glaucoma. However, trabeculectomy and MMC continue to be more likely employed for surgical management. CONCLUSION: Despite the long-term complications of bleb-related infections, no statistically significant shift in preference away from MMC use or reduction in the concentration of drug delivery was observed since the 1996 survey.