Follow-up studies of the classical landmark studies in Glaucoma.

PURPOSE OF REVIEW: It was not until the nineteen nineties that there was scientific evidence for the primary treatment concept of glaucoma, lowering intraocular pressure. The treatment concept of lowering intraocular pressure is now proven by randomized controlled clinical trials (landmark studies). This review provides an overview of the follow-up studies to these landmark studies from the last 18 months. RECENT FINDINGS: The 20-year data of the ocular hypertension treatment study showed a 49% incidence of primary open-angle glaucoma. The data of this landmark study was used for developing different machine learning algorithms. Bilateral disease, disc hemorrhages, and higher intraocular pressure (IOP) were risk factors for visual field deterioration in the United Kingdom Glaucoma Treatment Study. The Advanced Glaucoma Intervention Trial and the Collaborative Initial Glaucoma Treatment Study identified demographic factors, comorbidity, and clinical variables associated with visual field damage. Analysis was performed on Chinese subsets from the Laser in Glaucoma and Ocular Hypertension Study (LiGHT). Looking at all the follow-up studies to the tube shunt landmark studies, preoperative IOP, neovascular glaucoma, Ahmed implantation, and younger age were predictors of failure. A follow-up study to the Effectiveness in Angle-Closure Glaucoma in Lens Extraction Study showed that patients were ten times more likely to maintain a drop-free target IOP after lens extraction than after laser iridotomy. A superior location for iridotomy results in significantly more significant angle widening than temporal or nasal locations, as shown by a follow-up study to the Zhongshan Angle Closure Prevention Trial using OCT and gonioscopy. SUMMARY: The number of published follow-up studies to the landmark studies in glaucoma show the ongoing development of clinical questions in management of glaucoma.

Selective laser trabeculoplasty following failed combined phacoemulsification cataract extraction and excimer laser trabeculotomy can control intraocular pressure for a limited time.

PURPOSE: To assess the efficacy of selective laser trabeculoplasty (SLT) following failed phacoemulsification cataract extraction combined with excimer laser trabeculotomy (phaco-ELT). METHODS: Retrospectively, the medical records of patients with primary or secondary open-angle glaucoma or ocular hypertension who underwent SLT between January 2001 and February 2015 by one surgeon at a single center after a failed phaco-ELT were evaluated. Exclusion criteria were: angle-closure glaucoma, optic nerve atrophy due to disease other than glaucoma, and additional glaucoma procedures between phaco-ELT and SLT. The main outcome measures were time to failure and Kaplan-Meier survival. Complete success was defined as a reduction of intraocular pressure (IOP) of > 3 mmHg and > 20% compared to baseline, and the number of AGM ≤ baseline. RESULTS: A total of 23 eyes of 21 subjects were included. Baseline IOP was 19.7 (range, 19.1-22.7) mmHg, and the number of AGM at baseline was 2.5 (range, 1.9-2.9). Median time to failure after SLT was 7.2 (range, 6.6-7.8) months. The number of antiglaucoma medications did not change during that time. CONCLUSIONS: In eyes in which the IOP is no longer controlled following phaco-ELT, SLT could be an option to slow disease progression or prolong time until incisional filtration surgery. However, time to failure after SLT is limited. Thus, close follow-up visits are necessary in order to not delay an incisional surgery.

Is laser trabeculoplasty the new star in glaucoma treatment?

PURPOSE OF REVIEW: For decades, laser trabeculoplasty has been a well-proven therapeutic option in glaucoma management, and more recently, it has only gained in popularity. One reason for such popularity is that selective laser trabeculoplasty (SLT) is a therapy independent of patient adherence, which is typically low among glaucoma patients. Consequently, the number of studies on SLT has multiplied throughout the past years. This review provides an overview of studies on SLT from the last 12 months. RECENT FINDINGS: The studies on treatment outcome show a wide range of success rates of SLT reaching between 18 and 88%; however, study designs differ and many studies are not directly comparable. The prospective laser trabeculoplasty for open-angle glaucoma and ocular hypertension (LiGHT) trial has demonstrated good efficacy of SLT - 75% of the eyes achieved their target pressure without drops and 58% after a single SLT. SUMMARY: SLT has proven to be effective in lowering IOP with satisfactory success rates even after single SLT. SLT is repeatable independent of patient's adherence.

Influence of new treatment modalities on adherence in glaucoma.

PURPOSE OF REVIEW: It is well known that glaucoma patients are not adherent to their therapeutic regimens. The issue of nonadherence is multifactorial and includes inadequate communication between doctors and patients, resulting in significant costs associated with enhanced disease progression. Therapeutic regimens are risk factors which often influences adherence rates. Thus, alternative treatment modalities, especially those risk factors that do not rely on patients' cooperation, may enable improvements in long-term outcomes of glaucoma in patient. RECENT FINDINGS: The studies selected for this review were divided into new medications, especially advancements in pharmaceutical approaches to treat glaucoma and new ways of delivering the medication, new surgical methods, especially minimally invasive surgery methods for glaucoma, and new studies about adherence in glaucoma. SUMMARY: Surprisingly, a very few studies on glaucoma medication or surgery addressed the concept of adherence. However, adherence is discussed in studies which consider psychological aspects of patients or communication issues between doctors and patients. Although these studies were performed in clinical settings, the issue of adherence is not addressed; despite it has significant effect on long-term outpatient care. A combination of both aspects, adherence and miscommunication, should be considered in studies.

Twenty-four hour intraocular pressure measurements and home tonometry.

PURPOSE OF REVIEW: IOP is the only treatable risk factor contributing to glaucoma and most management and treatment of glaucoma is based on IOP. However, current IOP measurements are limited to office hours and control of glaucoma in many patients would benefit from the ability to monitor IOP diurnally so as not to miss abnormal pressures, which occur outside of office hours Consequently, to improve patient care, the ability to enable accurate and minimally disruptive diurnal IOP monitoring would improve caring for these patients. RECENT FINDINGS: The studies we selected for this review can be divided into three categories: self-/home-tonometry, continuous invasive intraocular pressure measurements, and continuous noninvasive ocular measurements. SUMMARY: The desire to obtain better insight in our patients' true diurnal IOP has led to the development of home-tonometers, in addition to extraocular and intraocular continuous pressure measurement devices. All of the devices have respective advantages and disadvantages, but none to date completely fulfills the goal of providing a true diurnal IOP profile.Video abstracthttp://links.lww.com/COOP/A27.

Increasing healthcare costs: can we influence the costs of glaucoma care?

PURPOSE OF REVIEW: Despite a decrease in real average growth rates per capita since 2009, healthcare costs continue to rise worldwide. Numerous patient-related and doctor-related factors have contributed to this rise. Glaucoma is the leading cause of irreversible blindness and requires chronic, usually lifelong treatment. As with other chronic diseases, the adherence to prescribed treatment is often low and maybe influenced by the cost of the therapy. The purpose of this review is to seek potential solutions to best control the escalating costs of glaucoma care. RECENT FINDINGS: The studies we selected for this review can be divided into four different categories: costs of diagnostic tests; costs of direct comparisons between drugs or laser and conventional surgery; patient-related factors (such as adherence); and general aspects regarding costs: theoretical models and calculations. SUMMARY: It is challenging to find reliable studies concerning this subject matter. As patients are under the umbrellas of variously organized healthcare systems which span different cultures, the costs between countries are difficult to compare. However, one common aspect to lower costs in glaucoma care is to improve patient adherence. Theoretical models with actual patient studies could enable cost reductions by comparing multiple diagnostic and therapeutic scenarios. VIDEO ABSTRACT: http://links.lww.com/COOP/A22.

[Early recognition and management of the disease]. / Glaukom - Früherkennung und Management.

Glaucoma is a progressive disease of the optic nerve potentially leading to a destruction of the nerve and therefore to blindness. It is a multifactorial disease and patients of all age groups can be affected. Different risk factors influence the course of the disease. The quality of life of the patients is already reduced when the patients show moderate changes of their visual field. The patients experience more falls and may be forced to stop driving. With an early and adequate treatment the progression of the disease can be slowed down. The early recognition of the disease is important and belongs into the hands of ophthalmologists. The treatment for glaucoma is a difficult task and needs an intense collaboration of the ophthalmologist with the patient and the treating primary care physician.

European Glaucoma Society research priorities for glaucoma care.

BACKGROUND/AIMS: The goal of health research is to improve patients care and outcomes. Thus, it is essential that research addresses questions that are important to patients and clinicians. The aim of this study was to develop a list of priorities for glaucoma research involving stakeholders from different countries in Europe. METHODS: We used a three-phase method, including a two-round electronic Delphi survey and a workshop. The clinician and patient electronic surveys were conducted in parallel and independently. For phase I, the survey was distributed to patients from 27 European countries in 6 different languages, and to European Glaucoma Society members, ophthalmologists with expertise in glaucoma care, asking to name up to five research priorities. During phase II, participants were asked to rank the questions identified in phase I using a Likert scale. Phase III was a 1 day workshop with patients and clinicians. The purpose was to make decisions about the 10 most important research priorities using the top 20 priorities identified by patients and clinicians. RESULTS: In phase I, 308 patients and 150 clinicians were involved. In phase II, the highest-ranking priority for both patients and clinicians was 'treatments to restore vision'. In phase III, eight patients and four clinicians were involved. The top three priorities were 'treatments to stop sight loss', 'treatments to restore vision' and 'improved detection of worsening glaucoma'. CONCLUSION: We have developed a list of priorities for glaucoma research involving clinicians and patients from different European countries that will help guide research efforts and investment.

Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges.

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

[Structure/function/treatment in glaucoma: progress over the last 10 years]. / Struktur/Funktion/Behandlung beim Glaukom: Fortschritt in den letzten 10 Jahren.

Since the 1990s several so-called landmark studies were carried out, which played an important role in the management of glaucoma patients due to their multicenter, randomized and masked structure. The Ocular Hypertension Treatment Study (OHTS) and the Collaborative Initial Treatment Glaucoma Study (CIGTS) and their follow-up studies are especially important in the conservative glaucoma management and in the evaluation of structure and function. The OHTS examined if lowering of the intraocular pressure (IOP) treatment reduces the progression from ocular hypertension to primary open angle glaucoma and what risk factors influence the progression. The CIGTS examined the progression of glaucoma in patients treated either with pharmacotherapy or with surgery. The recent studies, the United Kingdom Glaucoma Treatment Study (UKGTS) and Glaucoma Automated Test Evaluation (GATE) investigated the influence of treatment with latanoprost on the development of visual field defects and examination of different screening tests in glaucoma, respectively. The OHTS provided results that justify prophylactic treatment as well as watchful waiting. The results of CIGTS showed that under certain conditions surgical treatment of a newly discovered glaucoma can be recommended for moderate to advanced glaucoma. In the UKGTS treatment with latanoprost reduced the intraocular pressure and also the progression of visual field defects in beginning and moderate glaucoma damage. The GATE study found no clear-cut advantage of screening examinations, with cost effectiveness and without a substantial proportion of diagnoses being missed.

The treatment of glaucoma using topical preservative-free agents: an evaluation of safety and tolerability.

Introduction: Preservative-free (PF) medications represent a valuable treatment strategy in the lifelong management of glaucoma. By removing preservative toxicity, PF formulations provide tangible clinical benefits to glaucoma patients worldwide. They improve tolerability and adherence, leading to a positive impact in long-term intraocular pressure (IOP) control.Areas covered: A critical review of the subject is provided, including selected evidence on the safety and tolerability of currently available topical PF formulations. Cumulative evidence confirms that topical PF medications are at least equally efficacious to their preserved equivalents. There is convincing short-term evidence for superior tolerability and safety of PF formulations compared to preserved medications. The long-term benefits and success of PF therapy requires further elucidation.Expert opinion: Successful stepwise administration of medical therapy for glaucoma remains elusive. There is a greater risk for ocular toxicity and therapy failure with preserved topical glaucoma therapy. Currently available and emerging PF therapy options potentially optimize lifelong stepwise glaucoma therapy and may enhance outcome. To avert complications from preservatives leading to poor adherence, ideally, future antiglaucoma therapy should become 100% PF. There are still key aspects of PF therapy that warrant further investigation.

Influence of Cost of Care and Adherence in Glaucoma Management: An Update.

The costs for glaucoma care are rising worldwide. The main reason is the increase of life expectancy and the increasing variety of diagnostic tests and therapeutically options by implants and devices. How can we influence the increase in costs? Does a relationship exist between the rising costs and the behavior of patients especially in regard to adherence of patients to the prescribed therapy? Are there ways to improve adherence? The costs of a disease can be estimated by adding the direct costs and the indirect costs deriving from the disease. Many studies have been looking at the direct costs, for example, the costs of diagnostic tests and treatment modalities. Unfortunately, not many studies investigated the indirect costs, i.e., costs related to the need of a person to accompany the patient during his or her outpatient visits or the costs deriving from loss of work capacity because of the disease itself or the outpatient visits. Adherence or the synonym compliance has been discussed since many years, and it seems that it remains a major problem in the management of many chronic diseases. Despite all efforts to improve adherence, the adherence rate in chronic diseases such as glaucoma or arterial hypertension remains considerably low. One of the main factors in improving adherence is raising patient's awareness of the disease by providing general understanding of their disease. Other important factors are simplified therapeutic regimens, e.g., fixed combination drops, sustained drug release techniques, or new glaucoma surgical procedures with a more favorable risk profile.

Awareness about glaucoma and related eye health attitudes in Switzerland: a survey of the general public.

OBJECTIVE: To assess the level of awareness about glaucoma and its consequences and to evaluate associated eye health attitudes in a randomly selected general urban and rural population in Switzerland. METHODS: A cluster random sample of the Swiss population was interviewed. Five-hundred and two telephone interviews with subjects who were representative of the 35- to 70-year-old population of the German- and French-speaking parts of Switzerland were conducted. Data were collected about their gender, age, educational status and professional situation. STUDY TYPE: Cross-sectional survey. RESULTS: In total, 76% (n = 383) of respondents did not have any (or any correct) association with the term 'glaucoma'. Only 24.7% (n = 123) of the interviewees could describe glaucoma as an eye condition. Awareness of glaucoma was independent of age, gender, educational status, and household income. Associated therapeutic measures were surgery (75%) and medical treatment (57%). Seventy-one percent of all respondents wear eyeglasses, 74% of all females and 67% of males. CONCLUSION: Awareness and knowledge about glaucoma are relatively low in the average Swiss population across all segments of society. The lack of awareness on this insidious disease has important implications for the uptake of ophthalmic care and may result in avoidable blindness. These data also show that the ophthalmologist is considered by the majority of people to be the primary contact for eye health-related information and sight corrections.