Intraocular pressure profile following selective laser trabeculoplasty in pigmentary and primary open-angle glaucoma.

PURPOSE: To compare the intraocular pressure (IOP) profile and the incidence of IOP spikes following selective laser trabeculoplasty (SLT) between pigmentary glaucoma (PG) and primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective comparative study of 65 PG eyes of 51 patients matched with 65 POAG eyes of 65 patients who received SLT. Matching was done based on age, gender, glaucoma severity, pre-laser IOP, and number of medications. Post-SLT IOP spike was defined as IOP elevation ≥5mmHg, 30-45 min after the laser. RESULTS: In PG and POAG groups, the average age was 62.33 ± 9.18 and 62.58 ± 9.19 years (p = 0.95). The glaucoma severity (p = 0.708), baseline IOP (PG = 21.61 ± 1.34mmHg vs. POAG = 21.13 ± 5.09mmHg, p = 0.943), and number of topical glaucoma medications(PG = 2.34 ± 1.34 vs. POAG = 2.1 ± 1.41, p = 0.342) were comparable. More PG patients were on oral acetazolamide (PG = 26.15% vs. POAG = 1.5%, p < 0.001). Average logMAR visual acuity was significantly higher in the POAG group (0.207 ± 0.3 vs. 0.192 ± 0.37, p = 0.012). Eyes with PG received lower laser energy (POAG = 63.65 ± 22.03 mJ vs. PG = 43.71 ± 25.68 mJ, p < 0.001). IOP spikes were recorded in 5 PG eyes (7.6%) and none in the POAG group (p = 0.058). Failure rates were similar (PG = 50.7% and POAG = 43.1%, p = 0.205). In multivariable analysis, only pre-laser IOP (coefficient = 2.154 [CI: 0.765-3.543], p = 0.003) was a significant predictor of IOP change percentage after 12 months. CONCLUSIONS: SLT was comparably effective in both PG and POAG. IOP spikes were observed only in the PG group, though the total laser energy was lower in this group compared with POAG.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

PRCIS: This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. PURPOSE: The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. MATERIALS AND METHODS: Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. RESULTS: There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. CONCLUSION: SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

Predictors of Success in Selective Laser Trabeculoplasty.

PURPOSE: Selective laser trabeculoplasty (SLT) is a common procedure to lower intraocular pressure (IOP) in patients with glaucoma. However, reports are conflicting regarding what factors contribute to SLT success. The purpose of this study was to determine predictors of SLT success. DESIGN: Retrospective case series. PARTICIPANTS: All patients treated with SLT between January 1, 2012, and June 30, 2018. METHODS: Baseline, demographic, procedural, and ophthalmic examination data were recorded at the time of first SLT treatment. Intraocular pressure and medication data were recorded at all follow-up visits. MAIN OUTCOME MEASURES: Selective laser trabeculoplasty success was defined as IOP decrease of 20% or more from baseline at the 3-month, 6-month, and 12-month follow-up visits. Eyes were considered to have failed and were censored when additional SLT or glaucoma surgery was performed. Patients were excluded if they had less than 3 months of follow-up. RESULTS: A total of 997 eyes from 677 patients were included in the study. Mean age was 70.2±11.5 years. Selective laser trabeculoplasty success was achieved in 227 eyes (22.8%), whereas 770 eyes (77.2%) did not meet success criteria. Intraocular pressure before SLT was 21.9±5.2 mmHg while taking 2.0±1.2 medications in eyes with successful SLT, compared with 19.0±5.0 mmHg (P < 0.0001) while taking 2.1±1.3 medications (P = 0.52) in eyes with SLT failure. At the 1-year follow-up, mean IOP in eyes with SLT success was 14.7±3.2 mmHg with 2.0±1.2 medications, compared with 16.3±4.7 mmHg (P = 0.008) with a mean of 1.9±1.3 medications (P = 0.37) in eyes with SLT failure. Eyes with SLT success more often showed greater angle pigment (P = 0.03). Age, glaucoma severity, total SLT power, type of glaucoma, severity of glaucoma, visual field mean defect, and retinal nerve fiber layer thickness were not found to correlate with success. No difference was found between the rate of success based on treatments before SLT, whether surgical or medical. CONCLUSIONS: In this large cohort of eyes undergoing SLT, greater IOP and angle pigment before SLT correlated positively with SLT success. Age, total SLT power, severity of glaucoma, and prior treatments were not associated with SLT success or failure.

Pilot Study Assessing the Use of High-density Polyethylene (Su-Por) for Tube Shunt Patch Grafts.

PURPOSE: To assess the viability of a manufactured high-density polyethylene patch graft material (Su-Por) for prevention of tube shunt exposure. MATERIALS AND METHODS: Retrospective review of the first 11 patients from the Wills Eye Hospital Glaucoma Service to receive the high-density polyethylene patch graft during tube shunt surgery. RESULTS: Four patients (36.3%) experienced an extrusion of the Su-Por patch without a leak within 2.5 months of postoperative follow-up. All 4 patients developed either symptomatic or progressive extrusion. Operative repair was completed with Su-Por removal and replacement with a new human donor patch graft. No patient developed any sign of infection despite the extrusions. The remaining 7 patients had an uneventful postoperative course and continue to have no complications from the Su-Por patch with 9 months of follow-up. CONCLUSIONS: Given the high rate of extrusion of the Su-Por graft, this material seems to be an inadequate alternative for covering tube shunts. Harvested human tissue or other more flexible, manufactured grafts remain the standard of care for covering tube shunts.

The effects of Mozart's music on the performance of glaucoma patients on automated perimetry.

PURPOSE: The purpose of this study was to examine the impact of the Mozart effect on the reliability of the Humphrey visual field (HVF; Carl Zeiss Meditec, Dublin, CA) test in subjects with glaucoma. A previous study showed improved reliability in normal subjects undergoing HVF testing. METHODS: One hundred sixty subjects with glaucoma were randomized to three groups: control, headphones, or music for 10 minutes before HVF testing. The headphone group was provided noise-cancellation headphones but no music. The music group listened to Mozart's Sonata for Two Pianos in D Major. After treatment, subjects took an HVF test in both eyes. The reliability of the test was then compared between the groups and also to prior HVF results with regard to fixation losses, false positives, and false negatives. RESULTS: The rate of fixation losses did not differ significantly between the three groups (P = 0.30 right eye, P = 0.24 left eye). There were also no significant differences in the rate of false positives (P = 0.82 right eye, P = 0.18 left eye) or false negatives (P = 0.91 right eye, P = 0.97 left eye). The reliability of the subject's HVF result was also compared with past field results. No improvements were seen in fixation losses (P = 0.94 right eye, P = 0.17 left eye), false positives (P = 0.85 right eye, P = 0.38 left eye), and false negatives (P = 0.13 right eye, P = 0.50 left eye). CONCLUSIONS: The rate of fixation losses, false positives, and false negatives did not improve in subjects with glaucoma after they listened to Mozart's music. The Mozart effect did not enhance the reliability of the visual field test to a statistically significant degree (ClinicalTrials.gov number, NCT01027039).

Agreement of visual field interpretation among glaucoma specialists and comprehensive ophthalmologists: comparison of time and methods.

AIMS: To evaluate interobserver agreement and interpretation time for three clinically available formats of visual field presentation: serial Humphrey visual field (HVF), STATPAC2 and PROGRESSOR. METHODS: 40 field series from the Advanced Glaucoma Intervention Study were presented to eight glaucoma specialists and eight comprehensive ophthalmologists to determine whether each field series was stable or progressive. Interobserver agreement and agreement with Hodapp-Parrish-Anderson criteria were evaluated using κ statistics, and the interpretation time was compared. RESULTS: For glaucoma specialists, median κ values for interobserver agreement were 0.47, 0.60 and 0.43 for HVF, STATPAC2 and PROGRESSOR, respectively. Respective κ values for comprehensive ophthalmologists were 0.43, 0.43 and 0.35. For glaucoma specialists, median κ values for agreement with Hodapp-Parrish-Anderson criteria were 0.52, 0.67 and 0.52 for HVF, STATPAC2 and PROGRESSOR, respectively. Respective κ values for comprehensive ophthalmologists were 0.41, 0.47 and 0.33. For glaucoma specialists, the mean±SD interpretation time for the series of 40 fields was 63.4±35.9, 57.1±23.1 and 41.1±15.3 min using HVF, STATPAC2 and PROGRESSOR, respectively. Respective interpretation times for comprehensive ophthalmologists were 72.9±38.3, 68.6±30.6 and 51±24.1 min. Interpretation time was decreased when STATPAC2 or PROGRESSOR was used rather than HVF. Time reduction was significant for glaucoma specialists using PROGRESSOR (p=0.02). CONCLUSIONS: For glaucoma specialists, interobserver agreement and agreement with HPA criteria were moderate to substantial. For comprehensive ophthalmologists, interobserver agreement and agreement with HPA criteria were fair to moderate. Field interpretation time may be reduced clinically when using STATPAC2 or PROGRESSOR rather than HVF.

Evaluating a new disc staging scale for glaucomatous damage: the ability to detect change over time.

PURPOSE: To assess the ability of Disc Damage Likelihood Scale (DDLS) in detecting glaucomatous changes in the optic nerve on sequential optic disc stereo-photographs as compared with three other different cup/disc grading systems (C/D). METHODS: Eighty-three pairs of stereo-photographs with a minimum of 5-year follow-up were examined by one group of three observers masked to chronological order by using their clinical expertise. Their conclusions were considered gold standard. Another group of three glaucoma experts examined the same masked pairs to evaluate glaucomatous changes using four different optic nerve grading systems: DDLS, vertical, horizontal, and maximal cup/disc. Ratings of these four methods in the second group were then compared with the gold standard. RESULTS: Baseline and follow-up photographs of 83 eyes were included. Mean follow-up was 6 years. The sensitivities for detecting glaucomatous nerve changes were 71.4%, 63.9%, 66.7%, and 47.2% for DDLS, vertical, horizontal, and maximal cup/disc, respectively. The specificity for finding nerve change was 70.9%, 51.1%, 40.4%, and 48.9%, respectively. The proportion of photographs identified as showing glaucomatous changes differed significantly between the DDLS and vertical C/D (VCD) (X2=7.900, p=0.005), between the DDLS and horizontal C/D (HCD) (X2=13.89, p=0.000), and between DDLS and maximum C/D (MCD) (X2=4.192, p=0.041). The largest area (74.4%) under the receiver operator characteristic curve was obtained by using the DDLS. CONCLUSIONS: DDLS had higher sensitivity and specificity for detecting glaucomatous changes versus the other three C/Ds when considering sequential stereo-photographs.

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg.

PURPOSE: To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt) for patients with IOP over 30 mm Hg. STUDY DESIGN: Prospective interventional case series. METHODS: Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP > 30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test. RESULTS: Mean pretreatment IOP was 37.5 +/- 1.0 mm Hg. Baseline posttreatment IOP was 18.4 +/- 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 +/- 0.9 mm Hg and the peak, 17.6 +/- 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis. CONCLUSIONS: Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.

Patient comfort with combined anterior sub-Tenon's, topical, and intracameral anesthesia versus retrobulbar anesthesia in trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery.

PURPOSE: To assess patient comfort using combined anterior sub-Tenon's, topical, and intracameral ("Blitz") anesthesia versus retrobulbar anesthesia in glaucoma surgery. PATIENTS AND METHODS: In this study, 139 consecutive patients who received retrobulbar anesthesia and 139 consecutive patients who received Blitz anesthesia during glaucoma surgery were evaluated in a prospective fashion. The retrobulbar group included 49 trabeculectomies, 36 aqueous shunts, and 54 phacotrabeculectomies. The Blitz group included 49 trabeculectomies, 30 aqueous shunts, and 60 phacotrabeculectomies. Patients were asked to assess their level of ocular pain operatively and postoperatively on a 10-point visual analog scale. The operative and postoperative pain scores and postoperative sedation of patients receiving retrobulbar anesthesia were compared with those of patients receiving Blitz anesthesia during trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery, separately. RESULTS: No statistically significant difference was found in the mean operative or postoperative pain scores between the two groups during trabeculectomy, phacotrabeculectomy, or aqueous shunt surgery. CONCLUSIONS: Blitz anesthesia offers a reasonable alternative to retrobulbar anesthesia for trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery.

Aqueous shunts for intractable glaucoma in infants.

BACKGROUND AND OBJECTIVE: To evaluate the long-term outcome of aqueous shunts in the treatment of infantile glaucoma refractory to conventional treatment. PATIENTS AND METHODS: The records of all patients up to 3 years of age managed with aqueous shunts for uncontrolled glaucoma between November 1990 and November 1996 were retrospectively reviewed. Ten eyes of 6 patients were included in the study. RESULTS: The mean preoperative intraocular pressure (IOP) was 29.75 +/- 4.15 (mm Hg; SD), with none of the eyes on antiglaucoma medication. Postoperatively, the mean IOP was 18.25 +/- 5.34 (mm Hg; SD) at a mean follow up of 50 +/- 25.6 (SD) months with 7 eyes on topical antiglaucoma medication. At the final follow up, 6 eyes were considered successfully controlled without reintervention, 2 more were controlled after shunt revision, and 2 were considered failures. CONCLUSIONS: Aqueous shunts were relatively effective in this series of infants with recalcitrant glaucoma.

Effectiveness of nonocclusive ligature and fenestration used in Baerveldt aqueous shunts for early postoperative intraocular pressure control.

PURPOSE: The authors determined the effectiveness of two different methods of modification of Baerveldt aqueous shunts in the control of early postoperative intraocular pressure. METHODS: The authors retrospectively reviewed charts of 122 eyes of 113 patients who underwent a Baerveldt 350-mm(2) modified with tube fenestration and charts of 129 eyes of 122 patients who underwent a Baerveldt 350-mm(2) modified with a nonocclusive ligature to examine early postoperative intraocular pressure control. In the fenestration group, the tube was modified with a 4-0 intraluminal suture and an occlusive 6-0 external polyglactin ligature before ocular placement. After ocular placement, the tube was further modified with one to three perforating fenestrations. In the nonocclusive-ligature group, the tube was modified with a 4-0 nylon intraluminal suture with a nonocclusive 6-0 external polyglactin ligature before ocular placement. RESULTS: A total of 94 eyes (77%) achieved adequate intraocular pressure control with or without adjunctive medications and. A total of 28 eyes (23%) had postoperative hypertension or hypotony in the fenestration group versus 81 (62.8%) and 48 (37.2%) eyes in the nonocclusive-ligature group (P = 0.014), respectively. The mean change in intraocular pressure preoperatively and 3 months postoperatively was 18.2 mm Hg versus 21.0 mm Hg (P = 0.11) in the fenestration and nonocclusive-ligature groups, respectively. CONCLUSIONS: Both the nonocclusive ligature and the fenestration methods provide desirable decreases in intraocular pressure in the immediate postoperative period and 3 months postoperatively; however, the fenestration modification may achieve adequate intraocular pressure control more often in the early postoperative period.

O uso intraoperatório de mitomicina C em glaucomas refratários / Topical intraoperative mitomycin C in refractory glaucomas

Foram revistos os prontuários de 42 pacientes portadores de glaucoma refratário submetidos a trabeculectomia associada ao uso intra-operatório de mitomicina C (0.4 mg/ml) entre outubro de 1991 e maio de 1992 no Serviço de Glaucoma do Wills Eye Hospital (Philadelphia, EUA). Dos 42 olhos, 34 puderam ser seguidos por pelo menos 6 meses. Dentre estes 34, 29 (83,5 por cento) apresentaram controle pressórico adequado ao final de um período de seguimento médio de 7,2 +ou- 1,4 meses. As principais complicaçöes pós-operatórias, entre as quais, descolamento da coróide (16,6 por cento), câmara anterior rasa (9,5 por cento) e maculopatia por hipotonia (4,8 por cento) estäo relacionadas ao excesso de filtraçäo observado no pós-operatório. Este estudo sugere que a mitomicina C é um potente inibidor do processo de cicatrizaçäo, altamente eficaz em prevenir a falência da cirurgia filtrante em olhos com glaucomas refratários. A reduçäo da dosagem e do tempo de exposiçäo à mitomicina C podem resultar em um menor número de complicaçöes secundárias ao excesso de filtraçäo. Estudos prospectivos e randomizados estäo sendo realizados para investigar esta possibilidade