Current management of glaucoma.

Glaucoma is an irreversible progressive optic neuropathy, for which the major proven treatment is to lower the intraocular pressure (IOP). Five groups of IOP-lowering eye drops have varying mechanisms of action. Some drops, such as ß-blockers and α-2 agonists, have potentially serious systemic side effects. Acetazolamide is the only available oral agent; it is effective at lowering IOP, but significant side effects relegate its use usually to refractory glaucoma. Two new eye drops, netarsudil and latanoprostene bunod, have recently been approved by the United States Food and Drug Administration. Both have novel IOP-lowering mechanisms and target the conventional aqueous outflow system. Selective laser trabeculoplasty is a gentle treatment that enhances conventional aqueous outflow. It may be used as an initial treatment, as a substitute for eye drops, or to delay glaucoma drainage surgery. Recent advancements in glaucoma surgery have seen an influx of minimally invasive glaucoma surgery devices, which are being used more frequently and earlier on in the treatment paradigm. As limited long term data are available, trabeculectomy remains the gold standard IOP-lowering procedure. Improvements in drug delivery are on the horizon. Drug-eluting devices and implants are able to deliver the drug closer to the receptors for an extended period of time. This will improve treatment adherence and efficacy, which are major limitations with current medical therapy.

Patterns of care for glaucoma patients in Korea from 2002 to 2013 using the national health insurance service claims data.

Due to the rapidly increasing life-expectancy, the prevalence of glaucoma has increased steadily in recent years. We aimed to evaluate the patterns of care and primary treatment strategy patterns in Korea according to glaucoma subtypes to assess the quality of care for glaucoma patients.In this serial cross-sectional survey, the claims data from the Korean National Health Insurance Service was used to identify and group glaucoma patients into primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG), other types of glaucoma, and ocular hypertension from 2002 to 2013. Records for outpatient visits, hospitalizations, drug prescriptions, admissions, and surgical interventions were used to determine the patterns of care and identify primary treatment strategies.Both the prevalence (0.11% in 2002 to 0.43% in 2013) and incidence rates (0.06% in 2003 to 0.11% in 2013) for glaucoma increased over time. The mean number of outpatient visits increased (4.9-6.0 visits per year), while the proportion of hospitalized patients (2.3-1.0% of patients) and duration of hospital stay (4.5-3.4 days among hospitalized patients) decreased between 2002 and 2013 for patients with POAG. The proportion of patients not being managed by medication or surgery decreased, with POAG and PACG patients receiving medications increasing from 70.9% and 59.2% in 2002 to 88.4% and 63.3% in 2013, respectively. Finally, while the proportion of trabeculectomy decreased (22.2% to 10.0% of surgical procedures in 2002 and 2013, respectively), more patients with PACG have received iridectomy (59.3% to 86.0% of surgical procedures in 2002 and 2013, respectively).Between 2002 and 2013, the pattern of care for both patients with POAG and PACG has shifted toward management by outpatient visits and intervention with anti-glaucoma medications in Korea.

Selective laser trabeculoplasty: past, present, and future.

Over the past two decades, selective laser trabeculoplasty (SLT) has increasingly become an established laser treatment used to lower intraocular pressure in open-angle glaucoma and ocular hypertensive patients. In this review we trace the origins of SLT from previous argon laser trabeculoplasty and review the current role it has in clinical practice. We outline future directions of SLT research and introduce emerging technologies that are further developing this intervention in the treatment paradigm of glaucoma.

Glaucoma treatment trends: a review.

Glaucoma is one of the most common causes of blindness worldwide, and its prevalence is increasing. The aim of the present review is to describe the current medical and surgical treatment trends in the management of open-angle glaucoma. There has been an increase in the availability of glaucoma medications and the use of laser trabeculoplasty over the past decade, with a subsequent decrease in invasive incisional surgery. In addition, a new class of glaucoma procedures, termed microinvasive glaucoma surgery, has emerged, which aims to fill the gap between conservative medical management and more invasive surgery.

Same-Day Bilateral Glaucoma Laser Treatments in Ontario: 2000 to 2013.

OBJECTIVE: To analyze trends in bilateral, same-day laser iridotomies, and trabeculoplasties in Ontario over the last decade. METHODS: Ontario Health Insurance Plan billing service claims between 2000 and 2013 were analyzed for the yearly number of glaucoma laser procedures. The annual number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS: The volume of same-day bilateral trabeculoplasties increased from 15.3 per 1000 with POAG in 2000 to 74.7 in 2013 (4.9-fold). The proportion that were same-day bilateral procedures increased from 22.7% in 2000 to 40.2% in 2004 (76.9% increase) and remained stable from 2009 to 2013, reaching 38.5% in 2013. The number of same-day bilateral laser iridotomies increased from 3126 in 2000 to 11,716 in 2013 (3.75-fold). The proportion of iridotomies that were bilateral increased from 39% in 2000 to 54.6% in 2006 (40% increase) and remained stable from 2006 to 2013, reaching 56.7% in 2013. CONCLUSIONS: The increase in same-day bilateral trabeculoplasties coincided with the introduction of selective laser trabeculoplasty. The proportion of this practice remained constant for the last 3 years of the study period. In 2013, 56.7% of iridotomies and 38.5% of trabeculoplasties were performed as same-day bilateral procedures. We recommend comparison studies between same-day and sequential laser therapies to assess complication rates and patient satisfaction to provide an evidence-based treatment approach, as there are limited data to support this practice.

Developments in laser trabeculoplasty.

Laser trabeculoplasty has an increasing important role in the management of glaucoma as more emphasis is placed on minimally invasive therapies. In recent years, the following laser trabeculoplasty technologies have been introduced: micropulse laser trabeculoplasty, titanium-sapphire laser trabeculoplasty and pattern scanning trabeculoplasty. These lasers help to reduce the intraocular pressure (IOP) and the burden of glaucoma medical therapy. Literature findings regarding the safety and efficacy of these newer forms of laser trabeculoplasty in the treatment of open-angle glaucoma is summarised. These relatively newer procedures appear to have similar efficacy when compared with the former selective laser trabeculoplasty or argon laser trabeculoplasty. In addition, they potentially offer a more favourable safety profile with fewer complications, including postlaser inflammation and IOP spikes. Further large-scale studies are necessary to evaluate the long-term benefits of these newer forms of laser trabeculoplasty. Their initial promising results offer patients with glaucoma additional treatment alternatives.

Trends in glaucoma surgical procedures in Ontario: 1992-2012.

OBJECTIVE: To analyze trends in the surgical management of glaucoma in Ontario over the past 2 decades. DESIGN: Retrospective analysis of health records. METHODS: Ontario Health Insurance Plan billing service claims between 1992 and 2012 were analyzed for the yearly number of glaucoma laser and incisional surgical procedures. The yearly number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS: Per 1000 people with POAG, laser trabeculoplasty (LT) rates increased nearly 2-fold (185%) from 1992 to 2012, with the rates stabilizing between 2008 and 2012, and total glaucoma filtration procedure (GFP) rates (trabeculectomy, aqueous shunts, and combined GFP and cataract extraction) in 2012 were similar to those in 1992, with a peak rate noted in 1996. Shunts represented 0.9% of GFP in 1992 and 33% in 2012. Data for combination codes billed on the same day for the same patient were available from 2000. From 2000 to 2012 the rates of trabeculectomy alone remained unchanged, the number of aqueous shunts alone increased more than 5-fold, combined trabeculectomy and cataract extraction decreased 81%, whereas combined shunts and cataract extraction increased from 6 in 2000 to 420 in 2012. Combined aqueous shunts and cataract extraction represented 0.4% of combined cataract extractions in 2000 and 26.3% in 2012. CONCLUSIONS: Over the past 2 decades there was an overall increase in the rate of LT, no change in the rate of trabeculectomies, and a significant increase in aqueous shunt surgery.

Recent trends in glaucoma surgery in Scotland, England and Wales.

OBJECTIVE: To evaluate national trends of trabeculectomy, aqueous shunts and cycloablation performed in Scotland, England and Wales from 1993 to 2012. METHODS: The annual numbers of trabeculectomies and aqueous shunts carried out between 1993 and 2012 were obtained from national Scottish, English and Welsh National Health Service databases. The annual rates of trabeculectomy, aqueous shunts and cycloablation were calculated per 100,000 of the population and analysed in the following age groups: 0-14 years, 15-59 years, over 60 years. RESULTS: The highest annual rate of trabecuelctomy was in 1995, this was followed by a sharp decline and subsequent stable rates since 2000. The total annual rates of aqueous shunts have increased more than sixfold from 2003 to 2012. In the 0-14 years age group from 2003 to 2012 the ratio of trabeculectomy to aqueous shunts has reversed; trabeculectomy rates have decreased while rates of aqueous shunts have increased. From 2003 to 2012, rates of cyclocryotherapy have reduced while rates of photocoagulation to the ciliary body have doubled. CONCLUSIONS: Trabeculectomy is the most commonly performed glaucoma operation. Aqueous shunts are rapidly increasing in the surgical management of glaucoma. During the study period, the ratio of trabeculectomy to aqueous shunts has reversed in the younger age group (0-14 years). Rates of cyclocyrotherapy to the ciliary body have dramatically declined while laser photocoagulation to the ciliary body is gaining wider acceptability.

Trends over time and regional variations in the rate of laser trabeculoplasty in the Medicare population.

IMPORTANCE: Laser trabeculoplasty (LTP) is routinely used to treat open-angle glaucoma; hence, understanding variations in its use over time and region is important. OBJECTIVE: To determine trends over time and the regional variation in the performance of LTP. DESIGN, SETTING, AND PARTICIPANTS: Database analysis of a 5% random sample of all Medicare beneficiaries 65 years or older with continuous Part B (medical insurance) coverage and no enrollment in a health maintenance organization for each year from 2002 through 2009. INTERVENTIONS: We counted unique claims with a Current Procedural Terminology code of 65855 (LTP) submitted by ophthalmologists, optometrists, ambulatory surgery centers, or outpatient hospitals by region for each year. We examined trends over time and regional variation in LTP rates in 9 large geographic regions. MAIN OUTCOMES AND MEASURES: Rate of LTP per 10,000 Medicare beneficiary person-years and per 10,000 diagnosed open-angle glaucoma (OAG) person-years. RESULTS: The LTP rates per 10,000 Medicare beneficiary person-years were 36.3, 60.1, and 53.5 for 2002, 2006, and 2009, respectively. The 65.6% increase between 2002 and 2006 and the 11.0% decrease between 2006 and 2009 were statistically significant (tests for linear trend, P = .009 and P < .001, respectively). Similarly, the LTP rate among Medicare beneficiaries with OAG increased from 507.9 per 10,000 person-years in 2002 to 824.3 per 10,000 person-years in 2006 (62.3% increase; P = .009) and then decreased to 741 per 10,000 person-years by 2009 (10.1% decrease; P = .004). The rates per 10,000 OAG person-years differed significantly by region, ranging from 314 in the East South-Central region to 607 in the East North-Central region in 2002 (93.2% higher; P < .001). A similar range of variation was observed in subsequent years. CONCLUSIONS AND RELEVANCE: The rate of LTP for Medicare patients with OAG peaked in 2006 and then decreased through 2009. Nearly twice as many LTP procedures per Medicare beneficiary were performed in some regions compared with others throughout the period.

Trabeculectomy in the 21st century: a multicenter analysis.

OBJECTIVE: To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom. DESIGN: Cross-sectional, multicenter, retrospective follow-up. PARTICIPANTS: A total of 428 eyes of 395 patients. METHODS: Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years. MAIN OUTCOME MEASURES: Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures. RESULTS: Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP <6 mmHg after 6 months). In 3 of these, visual acuity decreased by >2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery. CONCLUSIONS: This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

[Combined cataract and glaucoma surgery. Current options]. / Kombinierte Katarakt-Glaukom-Chirurgie. Aktuelle Optionen.

Trabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.

Subspecialization in glaucoma surgery.

PURPOSE: To evaluate trends in glaucoma surgery subspecialization. DESIGN: Population-based analysis of incisional glaucoma surgery and laser trabeculoplasty practice patterns among all ophthalmologists in Ontario, Canada, from 1995 through 2010. PARTICIPANTS: All ophthalmologists in Ontario, Canada, providing universal health care for the provincial population of approximately 12 million. METHODS: The province of Ontario provides government-funded universal health care insurance to all citizens through the Ontario Health Insurance Plan (OHIP). Anonymized physician services data were obtained from the OHIP database, which has excellent accuracy for procedure performance. MAIN OUTCOME MEASURES: Proportion of ophthalmologists providing incisional glaucoma surgery and laser trabeculoplasty and the distribution of these surgical and laser procedures among ophthalmologists. RESULTS: Between 1995 and 2010, the median number of ophthalmologists in Ontario was 427 (35.1 per 1 million population), ranging from 417 to 453 (32.9-40.3 per 1 million population). The percentage of ophthalmologists providing incisional glaucoma surgery dropped from 35% in 1995 to 19% in 2010, a 47% decline. Over the same period, the mean number of incisional glaucoma surgeries performed per surgeon doubled, and the percentage of incisional glaucoma operations provided by high-volume surgeons rose from 23% to 59%. The percentage of ophthalmologists performing laser trabeculoplasty was relatively stable (48% in 1995 to 50% in 2010). CONCLUSIONS: Over the past 16 years, the proportion of ophthalmologists providing incisional glaucoma surgery has declined significantly. At the same time, the proportion of incisional glaucoma surgery provided by high-volume glaucoma surgeons has more than doubled. These trends will have important implications for stakeholders from policy makers and hospitals to academic departments and residency education programs.

The changing conceptual basis of trabeculectomy: a review of past and current surgical techniques.

The original intent of glaucoma surgery was to allow aqueous humor to exit more easily either through the sclera or into the suprachoroidal space. The former came to be called, generically, a glaucoma filtering procedure. As this surgery evolved, some explored the concept of lowering pressure without producing a hole in the sclera, with its resultant "filtering bleb." For example, Cairns hoped that cutting open the edges of Schlemm's canal would allow aqueous to leave without producing a filtering bleb; however, it became apparent that Cairns's "trabeculectomy" only worked when a filtering bleb developed. The goal of today's trabeculectomy is the creation of a longlasting transscleral fistula. In fact, trabeculectomy is a misnomer as excision of trabecular meshwork is unimportant. Frequently, the tissue excised to create a trans-scleral fistula is sclera, cornea, or both. The current trabeculectomy is really a guarded sclerokeratectomy. Newer techniques hope to increase aqueous outflow through Schlemm's canal to avoid complications associated with subconjunctival filtering blebs. Non-penetrating glaucoma surgeries (deep sclerectomy, viscocanalostomy) and ab interno trabecular surgery attempt to lower intraocular pressure with bleb-less procedures. We describe the recent evolution of glaucoma surgery, particularly the idea that intraocular pressure may be lowered satisfactorily without creating a filtering bleb.

[Effectiveness and relevance of laser trabeculoplasty: treatment of open-angle glaucoma]. / Effektivität und Stellenwert der Lasertrabekuloplastik : Behandlung von Offenwinkelglaukomen.

Laser trabeculoplasty is a common glaucoma therapy that is safe and effective for reducing intraocular pressure. It was developed as a treatment for open-angle glaucoma in the 1970s, and larger studies proved its effectiveness in the years that followed. In recent years, through the implementation of newer processes such as selective laser trabeculoplasty, laser trabeculoplasty has experienced further developments. Because it causes less damage to the trabecular meshwork, it should have fewer adverse effects, making it a repeatable treatment. Studies on the indications, contraindications, and effectiveness of this method in lowering intraocular pressure are reviewed.

[Available laser systems and mechanism of action in laser trabeculoplasty]. / Verfügbare Lasersysteme und Wirkprinzip der Lasertrabekuloplastik.

Intraocular pressure-lowering laser procedures such as argon laser trabeculoplasty and selective laser trabeculoplasty are nowadays an essential part of glaucoma therapy. This article presents the currently most popular laser systems. These various laser procedures are based on the physical structure of the different lasers and on variable generation of laser light. They vary in their effect on the trabecular meshwork on a histopathological level, as well as in the active principles of intraocular pressure reduction. The mechanical, biological, and repopulation theories are currently used to explain the intraocular pressure-lowering effect of the different laser systems; these are discussed in detail.