ABSTRACT
OBJECTIVE: To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN: Pragmatic multicentre randomised controlled trial. SETTING: 27 secondary care glaucoma departments in the UK. PARTICIPANTS: 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS: Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES: general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS: At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION: Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION: Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.
Subject(s)
Glaucoma, Open-Angle/surgery , Quality of Life , Trabeculectomy/statistics & numerical data , Aged , Female , Glaucoma, Open-Angle/psychology , Humans , Intraocular Pressure , Male , Middle Aged , Surveys and Questionnaires , Trabeculectomy/psychology , United Kingdom , Visual AcuityABSTRACT
PURPOSE: Preoperative anxiety is often expressed by patients requiring filtration surgery for their glaucoma. So far, there has been no scale for screening this group of patients for preoperative anxiety. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) is a self-evaluation questionnaire which has been used in specialties other than ophthalmology and which makes it possible to identify the adult patients with a high level of preoperative anxiety over an upcoming surgical procedure. The purpose of this study is to estimate the preoperative anxiety in glaucoma patients requiring filtration surgery. METHODS: We performed a prospective study of 36 adult patients with chronic glaucoma not responding to medical treatment and who were about to undergo filtration surgery (trabeculectomy or deep sclerectomy). The APAIS questionnaire was given to the patients after discussing the indication for surgery. A global anxiety score (ranging from 4 to 20) above 10 defined patients with a high level of preoperative anxiety. We attempted to identify among these patients the factors related to filtration surgery which caused them anxiety (lack of control of intraocular pressure, risk of blindness, presence of the filtering bleb). RESULTS: In our sample of patients, we found that glaucoma was a source of anxiety. That was also true for the surgical procedure, though most patients believe that once the decision had been made, their psychological status was not modified by the upcoming procedure. DISCUSSION: The patient-clinician relationship is important in any chronic disease, all the more so in glaucoma, since this disease remains asymptomatic for a long time. When filtration surgery is necessary, the patients are going to express less preoperative anxiety if they trust their physician and if individualized information has been given to them CONCLUSION: The French version of the APAIS is a quick scale, easily completed, that can be recommended for evaluating anxiety and patients' need for information prior to filtering surgery. It is usually easier for the surgeon to find ways to reduce the patient's anxiety if a relationship of trust has been established between the two.
Subject(s)
Anxiety/epidemiology , Filtering Surgery/psychology , Glaucoma/epidemiology , Glaucoma/surgery , Adult , Aged , Anesthesia/methods , Anesthesia/psychology , Anxiety/etiology , Female , Filtering Surgery/methods , Glaucoma/psychology , Humans , Male , Middle Aged , Patient Education as Topic , Preoperative Period , Trabeculectomy/psychologyABSTRACT
AIM: To explore the experiences of African-Caribbean patients with advanced glaucoma. METHODS: Semi-structured qualitative interviews were used to elicit patients' subjective experiences of becoming a glaucoma patient, receiving treatment, undergoing surgery, and its aftermath. Interview transcripts underwent narrative analysis. RESULTS: The surgeon-patient relationship was central to developing effective coping strategies. Participants described their experiences in terms of what they considered were their responsibilities as patients to the surgeon-patient relationship. They also defined the surgeon's responsibilities and obligations. CONCLUSIONS: The use of patient narratives provides a valuable resource for enhancing communication skills and relationship-centred care in the hospital eye service.
