Reproducibility of minimum rim width and retinal nerve fibre layer thickness using the Anatomic Positioning System in glaucoma patients.

OBJECTIVE: To determine the test-retest repeatability of minimum rim width and retinal nerve fibre layer thickness measurements obtained by spectral-domain optical coherence tomography using the Anatomic Positioning System protocol in glaucoma patients and controls. Also, to assess the ability of the minimum rim width and retinal nerve fibre layer thickness to diagnose glaucoma in 2 circular peripapillary locations. METHODS: Spectral domain optical coherence tomography scans of the optic nerve head were obtained twice during the same visit using the Anatomic Positioning System eye-tracking protocol. The minimum rim width and retinal nerve fibre layer thickness were measured at 3 circular diameters (3.5 mm, 4.1 mm, and 4.7 mm). Intraclass correlation coefficients and area under the receiver operating characteristic were calculated for these parameters. RESULTS: A total of 36 glaucomatous eyes and 59 control eyes were included in the analysis. The intraclass correlation coefficients of minimum rim width and retinal nerve fibre layer thickness global measurement for 3.5 mm and 4.1 mm circles ranged between 0.98 and 1.00 and for 4.7 mm circle was between 0.76 and 1.00. The minimum rim width had an area under the receiver operating characteristic of 0.97, while the retinal nerve fibre layer thickness measurements had an area under the receiver operating characteristic of 0.95, 0.95, and 0.96 for the 3.5 mm, 4.1 mm, and 4.7 mm circles, respectively. CONCLUSIONS: The minimum rim width and retinal nerve fibre layer thickness measurements using the Anatomic Positioning System protocol had overall excellent reproducibility and diagnostic performance. Using this protocol and the novel minimum rim width parameter may be useful in more accurate diagnosis and follow-up of patients with glaucoma.

Depression and quality of life in a community-based glaucoma-screening project.

OBJECTIVE: To identify the prevalence and risk factors of depression among individuals given a glaucoma-related diagnosis at a screening program. DESIGN: Cross-sectional community-based in a university hospital. PARTICIPANTS: Volunteers from a community glaucoma-screening program. METHODS: After collecting sociodemographic information, participants were administered the Geriatric Depression Scale-15 (GDS-15) and the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25). RESULTS: Participants were predominantly African American (73.5%), older than 65 years (65.7%), single (75.4%), and female (66.8%). Among 268 participants, 89 were diagnosed with glaucoma and 179 as glaucoma suspects. The frequency of depression among the glaucoma and glaucoma suspect participants was 18% and 16.2%, respectively. The mean GDS-15 score was 2.4 ± 2.7 with no difference between glaucoma and glaucoma suspect groups, p = 0.654. The mean VFQ-25 score was 78.6 ± 15.9 and was lower in glaucoma (74.7 ± 19.7) than glaucoma suspect participants (80.4 ± 13.6), p = 0.003. Risk factors for depression included difficulties with paying expenses (p = 0.017), Asian race (p < 0.001), and poorer scores on the VFQ-25 subscales of "General Health" (p < 0.001), "Distance Activities" (p = 0.024), and "Dependency" (p = 0.001). CONCLUSIONS: Prevalence of depression in those diagnosed with glaucoma or glaucoma suspect was higher than previous estimates of the general population. Glaucoma-screening programs might benefit from including depression-screening protocols along with referral services or low-cost treatments of depression.

Adherence to Follow-up Recommendations Among Individuals in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To evaluate rates of adherence to free follow-up eye exam appointments among participants in the Philadelphia Glaucoma Detection and Treatment Project. PATIENTS AND METHODS: Ophthalmologists and testing equipment were brought directly to participants at risk for glaucoma at 43 community sites in Philadelphia. Those diagnosed with glaucoma-related pathology were recommended to return for follow-up to be reexamined on site. Rates of adherence and clinical and demographic risk factors for adherence were evaluated. RESULTS: Five hundred thirty-one participants were diagnosed with glaucoma-related conditions and recommended to attend community-based follow-up exams. Follow-up adherence rate was 61.2% (n=325/531). Significant factors associated with greater eye exam appointment adherence, based on our univariable analysis, included final diagnosis of glaucoma (risk ratio [RR]=1.33; 95% confidence interval [CI], 1.13-1.57), male sex (RR=1.19; 95% CI, 1.04-1.36), white race (RR=1.26; 95% CI, 1.08-1.48), age (RR=1.17; 95% CI, 1.00-1.37) recommendation for glaucoma medication (RR=1.52; 95% CI, 1.35-1.71), recommendation for laser peripheral iridotomy (RR=1.18; 95% CI, 1.02-1.35), diagnosis of age-related macular degeneration (RR=1.42; 95% CI, 1.13-1.77) and an increased intraocular pressure (>22 mm Hg in the worse eye) (RR=1.23; 95% CI, 1.06-1.42). On the basis of our multivariable model, diagnosis, sex, and recommended glaucoma medications were significantly associated with follow-up adherence. CONCLUSIONS: This study demonstrates that individuals living in underserved urban communities would take advantage of free eye exams in community sites and return for follow-up eye exams in these same settings. Future studies could investigate interventions to improve eye exam appointment adherence in community-based settings to detect glaucoma-eye conditions.

Impossibility to eliminate observer effect in the assessment of adherence in clinical trials.

PURPOSE: To utilize the Travoprost Dosing Aid (DA) in the assessment of patient medication adherence, while also determining whether or not altering the functionality of the DA in three randomized subject groups can reduce observer effect. METHODS: Forty-five subjects were randomized into three groups: two with monitored DAs and one without monitoring. One group of subjects was given a DA that both monitored drop usage and had visual and audible alarms, while the other monitored group included subjects given a DA that had no alarms but continued to monitor drop usage. The third group was given a DA that had no alarm reminders or dose usage monitoring. Subjects were informed that some monitors would not be functional, in an attempt to reduce observer effect, or the effect of being monitored on subject behavior and adherence. A six-item questionnaire was also utilized to assess how the subjects felt about their adherence and DA use. RESULTS: The overall adherence rates were found to be 78% in the fully functional group (95% confidence interval: 70-88) and 76% in the no alarms group (95% confidence interval: 65-89). No association was seen between questionnaire response and medication adherence. The patients in the DA group without alarms had a significantly higher odds ratio of medication adherence if they reported on the questionnaire that using the DA did affect how much they used their drops. CONCLUSION: Though the use of DA was expected to reveal different rates of adherence depending on the functionality of the DA between groups, patients with a nonfunctioning DA did not have a significant difference in medication adherence compared to those given a fully functional DA. This supports that an observer effect was not reduced despite these interventions, and that the subjects adhered to taking their medications as if they had a functioning DA and were being monitored.

Ahmed Versus Baerveldt Glaucoma Drainage Implantation in Patients With Markedly Elevated Intraocular Pressure (≥30 mm Hg).

PURPOSE: Glaucoma patients with markedly elevated intraocular pressure (IOP) are at risk for developing severe hypotony-related complications. The goal of this study was to compare the surgical outcomes of the Ahmed Glaucoma Valve (AGV) and the Baerveldt Glaucoma Implant (BGI) in this patient population. METHODS: Patients with preoperative IOP≥30 mm Hg were included. Outcome measures were: (1) surgical failure (IOP>21 mm Hg or <30% reduction from baseline or IOP≤5 mm Hg on 2 consecutive follow-up visits after 3 mo, or additional glaucoma surgery, or loss of light perception) and (2) surgical complications. RESULTS: A total of 75 patients were included: 37 in the AGV group and 38 in the BGI group. The mean±SD follow-up was 2.3±1.6 years for the AGV group and 2.4±1.7 years for the BGI group (P=0.643). Mean preoperative IOP was 38.7±6.5 mm Hg for the AGV group and 40.8±7.6 mm Hg for the BGI group. At the last follow-up, 10 (27.0%) patients failed in the AGV group compared with 6 (15.8%) patients in the BGI group (P=0.379). The BGI group had higher rate of flat or shallow anterior chamber (n=4, 10%) compared with the AGV group (n=0, 0%) (P=0.043). CONCLUSIONS: Failure rates of AGV and BGI in patients with IOP≥30 mm Hg were comparable. There were more early hypotony-related complications in the BGI group; however, none were vision threatening. Both glaucoma drainage implants were effective in treating patients with uncontrolled glaucoma in an emergency setting.

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

PURPOSE: To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University. MATERIALS AND METHODS: Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App. RESULTS: Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs $3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App. CONCLUSIONS: Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend $3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients' level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.

Bilateral Same-day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To report the outcomes of bilateral, same-day laser peripheral iridotomy (LPI) in the Philadelphia Glaucoma Detection and Treatment Project. METHODS: The Philadelphia Glaucoma Detection and Treatment Project was a community-based initiative aimed to improve detection, management, treatment, and follow-up care of individuals at high risk for glaucoma. This novel project performed LPI, where 2 eyes received laser therapy on the same day. Of the 1649 patients examined between January 1, 2013 and May 31, 2014, patients who underwent bilateral, same-day LPI were included in our analysis. Main outcome measures were visual acuity, intraocular pressure (IOP), and postoperative complication rates. RESULTS: A total of 132 eyes of 66 patients underwent bilateral, same-day LPI. Mean visual acuity remained unchanged following treatment (P=0.85). Eight patients (12.1%) had IOP spikes >5 mm Hg following treatment, and 4 patients (6.1%) spiked >10 mm Hg. IOP returned to normal in all but 1 patient, who was diagnosed with chronic angle-closure glaucoma. Hyphema was reported in 2 patients (3%) and glare in 1 patient (1.5%). Thirteen patients (19.7%) had repeat LPI treatment. All patients successfully tolerated LPI treatment without serious complications. CONCLUSIONS: Performing bilateral, same-day LPI was well tolerated in a large community-based, glaucoma detection and treatment project. Applying this treatment strategy may be considered in similar settings, where patients' access to eye care is limited and it may be a cost-effective strategy.

Evaluation of Nonmydriatic Hand-held Optic Disc Photography Grading in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To determine the reproducibility of optic disc photograph grading obtained by a hand-held fundus camera and to determine the diagnostic value of these photographs in detecting patients with glaucoma in a community-based glaucoma-detection program. MATERIALS AND METHODS: Patients underwent slit-lamp examination by an ophthalmologist who graded each patient's optic discs using 2 methods: cup-to-disc ratio (CDR) and disc damage likelihood scale (DDLS). After a comprehensive glaucoma evaluation, patients were diagnosed as having "glaucoma," "glaucoma suspect," or "no glaucoma." Nonmydriatic, monoscopic optic disc photographs were then taken with a portable digital imaging device. On a different day, the same examiner and a second observer graded the disc photographs in a masked manner and determined a diagnostic impression based only on the disc photographs. RESULTS: Of the 1649 patients examined, 119 subjects were randomly selected according to 3 groups of diagnoses: "glaucoma" (n=36), "glaucoma suspect" (n=50), and "no glaucoma" (n=33). For CDR, the intraobserver agreement was 0.71 and the interobserver agreement was 0.69. For disc DDLS, the intraobserver agreement was 0.65 and the interobserver agreement was 0.67. The area under the receiver-operating characteristic distinguishing between normal and glaucoma was 0.88 and 0.86 for CDR and disc DDLS, respectively. CONCLUSIONS: Nonmydriatic, monoscopic disc photographs obtained by a hand-held camera had only moderate disc grading reproducibility. This could be due to a reduced quality of images, making interpretation more challenging, due to taking photographs through small pupils by a hand-held camera and the high percentage of patients with significant cataracts.

Outcomes of Sequential Glaucoma Drainage Implants in Refractory Glaucoma.

PURPOSE: To describe the outcomes of eyes that have undergone a second glaucoma drainage implant (GDI) surgery. METHODS: A retrospective review of eyes that underwent a second GDI surgery from 2006 to 2013 was conducted. Primary outcome measures included intraocular pressure (IOP) reduction and success rates. Secondary outcome measures included glaucoma medication use, visual acuity, and number of reoperations. Success was defined as 6 ≤ IOP ≤ 21 with at least 20% IOP reduction, and no increase in the number of glaucoma medications from baseline at 3 months of follow-up or more. RESULTS: Sixty-five eyes (63 patients) had a mean follow-up of 22.4 ± 19.9 months. The most frequently placed second GDIs were an Ahmed FP7 (49%) or a Baerveldt 250 (26%) in the inferotemporal (46%) or inferonasal (35%) quadrant. At 3-year follow-up, IOP was reduced from 25.8 ± 7.7 to 17.4 ± 9.9 mm Hg (P = 0.004) and the number of glaucoma medications decreased from 3.6 ± 1.2 to 2.5 ± 1.4 (P = 0.01) compared with baseline. The median time to failure was 24.7 ± 5.8 months. There was no significant difference in failure rates for type of sequential GDI (P = 0.80) or plate location (P = 0.34). There was no significant difference in visual acuity between baseline and 3-year follow-up (P = 1.0). The most common postoperative complication was corneal edema (n = 9, 14%). CONCLUSIONS: Most eyes undergoing a second GDI achieve adequate IOP control with fewer antiglaucoma medications. Failure rates were similar regardless of quadrant selection or GDI type.

Trabeculectomy in Patients With Glaucoma Over 80 Years of Age: Relatively Short-term Outcomes.

PURPOSE: To compare the surgical outcomes of trabeculectomy performed in elderly patients (above 80 y) with those of younger controls. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent trabeculectomy from January 1, 2009 through April 30, 2011 at the Wills Eye Hospital. Patients over 80 years of age were compared with younger controls. Outcome measures included intraocular pressure (IOP), visual acuity, number of glaucoma medications, surgical complications, and surgical failure. Surgical failure was defined as when IOP>21 mm Hg or <20% reduction below baseline or IOP<5 mm Hg or reoperation for glaucoma, or loss of light perception. RESULTS: Eighty-six eyes of patients over 80 years of age (range, 81 to 94 y) were compared with 86 eyes of younger controls (range, 22 to 79 y). Mean follow-up time was 23.9±8.0 and 25.1±8.0 months for each group, respectively. After 1 year, the failure rate was 31.3% in the elderly group, compared with 29.5% in the control group (P=0.98). At last follow-up visit, the rate of failure between the groups was similar (P=0.35). Postoperative complications were similar between the groups (P=0.25). CONCLUSIONS: The surgical outcomes of trabeculectomy in patients older than 80 years were found to be similar to those of younger controls. Taking into consideration elderly glaucoma patients' general health condition and life expectancy, age alone may not be a barrier to performing glaucoma filtration surgery.

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

PURPOSE: To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control. METHODS: Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception. RESULTS: Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively. CONCLUSIONS: The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.

Segmental Analysis of Macular Layers in Patients With Unilateral Primary Open-Angle Glaucoma.

PURPOSE: To measure the thicknesses of the inner layers of the macula in both eyes of patients with unilateral primary open-angle glaucoma (POAG) and compare them with normal control eyes. METHODS: This prospective, cross-sectional pilot study enrolled patients with unilateral POAG, who had visual field defect in only 1 eye, and controls with a normal eye examination. Horizontal and vertical B-scan images centered on the fovea were obtained using spectral domain optical coherence. Semiautomatic delineation and segmentation of the inner layers of the retina were performed to evaluate macular retinal nerve fiber layer (mRNFL), ganglion cell complex (GCC) and ganglion cell-inner plexiform layer (GC-IPL) thicknesses. Mean, superior, inferior, nasal, and temporal inner macular layer thicknesses were compared between affected eyes, fellow eyes without visual field defect, and control eyes. RESULTS: Nineteen patients with unilateral POAG and 14 normal control eyes were enrolled. In the affected POAG eyes, thinning of the mRNFL, GCC, and GC-IPL layers on horizontal and vertical scans were significant when compared with controls (P<0.05), particularly on vertical scans (P<0.001). The mean regional macular GCC and GC-IPL were most severely thinned in the inferior and temporal perifoveal regions. The unaffected eye of patients with unilateral POAG showed significant thinning of the mRNFL only in the vertical scan when compared with normal controls (P<0.05). CONCLUSIONS: Spectral domain optical coherence tomography detected significant thinning of the mRNFL, GCC, and GC-IPL in the affected eyes of patients with unilateral POAG. Fellow eyes showed early structural changes only in the vertical mRNFL scans when compared with normal controls.

Symptoms reported by patients with varying stages of glaucoma: review of 401 cases.

OBJECTIVE: To elucidate the symptoms that patients with glaucoma voluntarily report and to determine the correlation between the symptoms and the stage of glaucoma. DESIGN: Retrospective case series. PARTICIPANTS: A total of 401 patients who presented to the Glaucoma Service from January 2012 through November 2013. METHODS: The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the medical records of patients who visited the Glaucoma Service from January 2012 through November 2013. We recorded any symptom written in the charts at the last eligible visit of each patient. The patients were classified by different stages according to the mean deviation of the Octopus visual field. RESULTS: We analyzed 401 patients, who were graded with mild (n = 170), moderate (n = 106), or severe (n = 125) visual-field loss. The majority of patients did not report any symptoms (56.0%); 24.2% reported ocular surface disease (OSD) symptoms; and 25.8% reported visual complaints. The presence of symptoms positively correlated with the severity of glaucoma (p = 0.01) and the number of surgeries (p = 0.02). Burning/smarting/stinging and blurry vision showed a positive correlation with the severity of glaucoma (p < 0.05). Older patients (> 69 years) showed a significant increase in OSD symptoms (p = 0.001). CONCLUSIONS: About one-fourth of the patients with glaucoma reported visual complaints, and another fourth reported OSD symptoms, both of which correlated with glaucoma severity. The high prevalence of OSD symptoms suggests that patients should be specifically questioned about these symptoms and treated as indicated. This information is of value particularly in the new era of nonpreserved glaucoma medications.