Preservative-free versus preserved glaucoma eye drops and occurrence of glaucoma surgery. A retrospective study based on the French national health insurance information system, 2008-2016.

PURPOSE: Preservatives contained in glaucoma eye drops have been shown to have a deleterious impact on the ocular surface. We aimed to assess the association between preservative exposure and the occurrence of further glaucoma surgery among patients with glaucoma or ocular hypertension in France. METHODS: The study concerned all patients who first received glaucoma eye drop treatments in a French medical-administrative database (EGB) between 2008 and 2015. Three groups were created according to the level of preservative exposure during the whole follow-up: '0% preservatives', 'mixed' and '100% preservatives'. The occurrence of glaucoma surgery was estimated according to preservative exposure indicators in Cox multivariate models adjusted on age, sex, number of glaucoma eye drops simultaneously used, systemic antihypertensive treatment and duration of treatment. RESULTS: The sample consisted of 12 454 patients. The median (interquartile range) follow-up was 4.1 (1.7-6.1) years. A total of 231 (1.9%) patients underwent glaucoma surgery during follow-up. On multivariable analysis, the risk of glaucoma surgery was increased for the 'mixed' group (hazard ratio [HR] = 3.94 [95% CI, 1.54-10.05]) and for the '100% preservative' group (HR = 7.97 [95% CI, 3.07-20.67]) when compared with the 0% preservative group. CONCLUSION: We found an association between exposure to glaucoma eye drop preservatives and the prevalence of further glaucoma surgery. While these data might be used to support the consideration of routine use of preservative-free drops, in the absence of a randomized clinical trial, they cannot prove a direct cause-and-effect relationship between preservative-free glaucoma eye drops and further glaucoma surgery.

Secondary surgical intervention after primary glaucoma filtration surgery: an Ontario population-based study.

OBJECTIVE: To identify factors associated with secondary surgical intervention after glaucoma filtration surgery. DESIGN: Population-based retrospective cohort. METHODS: Patient records with billing claims for a primary glaucoma filtration surgery occurring between April 2003 and March 2015 were identified. Each identified record was examined for instances of secondary glaucoma surgeries within the patient's first postoperative year. Baseline characteristics of patients who required secondary surgical intervention were compared with those who did not. A multivariable Cox proportional hazards model was used to calculate hazard ratios. RESULTS: Within a cohort of 10,097 patients, 349 (3.46%) underwent a secondary surgical intervention within the first postoperative year. Interventions were less frequent after surgeries that included an indwelling drainage device (HR=0.58 95% CI, 0.37-0.89), phacoemulsification (HR=0.33, 0.21-0.52), or both (HR=0.09, 0.03-0.31). Patients with preoperative aminoglycoside and mydriatic exposure had significantly increased risk of secondary surgical intervention (HR=3.19, 1.89-5.36) and (HR=2.32, 1.49-3.61). Patients who underwent surgery on their contralateral eye experienced secondary surgical interventions more frequently: 7.44 per 10,000 person-days (versus 1.18 per 10,000 person-days, p < 0.0001). No significant differences in the rates of secondary surgical intervention were observed for patients taking different classes of glaucoma medications or those exposed to higher amounts of benzalkonium chloride. CONCLUSIONS: In Ontario, the overall rates of secondary surgical interventions in the first postoperative year are low but significantly higher in certain patient populations. Further work is required to address the higher rate of secondary surgical intervention in patients with a history of certain perioperative eye drop medications and those who require sequential-bilateral procedures.

Changes in Australian practice patterns for glaucoma management.

IMPORTANCE: The demand for glaucoma care is projected to increase significantly with the ageing population. BACKGROUND: To characterize trends in Australian practice patterns for glaucoma management over the 15-y period between 2003 and 2017. DESIGN: Retrospective audit. SAMPLES: The Medicare eligible population. METHODS: Audit of Medicare Benefits Schedule item number reimbursements in the private healthcare sector, and dispensed Pharmaceutical Benefits Scheme (PBS) prescriptions. MAIN OUTCOME MEASURES: Number, unadjusted cost and services per capita in the enrolled population. RESULTS: The number of medication prescriptions peaked in 2015, but then declined by 14.9%. PBS expenditure on glaucoma medications has been falling since 2012. There was a 9.2-fold increase in fixed-combination prescriptions and 281-fold increase in unpreserved medication prescriptions. In 2017, optometrists generated 1.86% of glaucoma prescriptions. Reimbursements for computerized perimetry increased dramatically for optometrists, and in 2017 optometrist-initiated perimetry exceeded ophthalmologist-initiated perimetry by 35.3%. There were significant increases in laser procedure rates, including laser trabeculoplasty (4.61-fold), laser iridotomy (2.55-fold) and cyclodestructive procedures (2.33-fold). There was a 3.83-fold increase in glaucoma drainage device insertions. Ab interno trabecular microbypass procedures increased 715% from 2014 to 2017. Adjusted for Medicare population, trabecular microbypass is performed at more than twice the rate of primary filtering operations. CONCLUSIONS AND RELEVANCE: This is the first time that glaucoma medication use and expenditure have declined since auditing began in 1992. Glaucoma laser procedures, drainage device implantation and trabecular microbypass increased substantially over the study period. In contrast, the rate of primary filtering operations increased in proportion to population growth. The increase in overall cost of glaucoma care has primarily been driven by computerized perimetry; however, this has been partially offset by a decline in medication expenditure.

Risk of Glaucoma Surgery After Corneal Transplant Surgery in Medicare Patients.

PURPOSE: Glaucoma is a well-documented complication of corneal transplants, contributing significantly to ultimate visual loss. Reported incidence of glaucoma following corneal transplants is highly variable, and definitions of posttransplant glaucoma are inconsistent. Here we use glaucoma surgery as a more rigid and specific endpoint to compare rates following different corneal transplant surgeries. DESIGN: Retrospective cohort study. METHODS: A 5% random sample of Medicare beneficiaries from 2010-2013 was obtained and patients were identified with Current Procedural Terminology (CPT) codes for penetrating keratoplasty (PK), endothelial keratoplasty (EK), anterior lamellar keratoplasty (ALK), and keratoprosthesis (KPro). Rates of glaucoma surgery within the same year following the abovementioned corneal transplants were analyzed. Subgroup analyses included patients who carried preexisting glaucoma diagnoses prior to corneal transplant surgery. RESULTS: There were 3098 patients who underwent corneal transplants during the study period, including 1919 EK, 1012 PK, 46 ALK, 32 KPro, and 89 both PK and EK. Rates of glaucoma surgery ranged from 6.1% to 9.4% in the corneal transplant groups, without statistically significant differences among groups. However, 10.0% of patients with preexisting glaucoma required glaucoma surgery following any transplant surgery, compared with 5.3% of patients without preexisting glaucoma. This included 12.4% of PK patients with preexisting glaucoma compared with 2.8% of PK patients without preexisting glaucoma (P < .01). CONCLUSIONS: Despite literature suggesting that more angle-altering cornea surgeries confer higher risk, we found no statistically significant differences among various transplant groups. Patients with preexisting glaucoma, however, had higher risk of glaucoma surgery within the same year following corneal transplant surgery, which was especially pronounced in the PK group. These patients require special care when considering long-term effects of corneal transplants.

Estudio prospectivo de las ampollas de filtración poscirugía de implante XEN45 / Prospective study of filtering blebs after XEN45 surgery

Objetivo: Analizar cualitativamente la evolución de las ampollas de filtración mediante tomografía de coherencia óptica de segmento anterior (OCT-SA) en pacientes con implante XEN45. Métodos: Estudio prospectivo de las ampollas de filtración de 30 ojos operados de catarata y glaucoma mediante facoemulsificación e implantación XEN45 (FACO-XEN). Se realizó OCT-SA analizando la morfología y la reflectividad de la ampolla al mes 3, 6 y 12 postoperatorio. La funcionalidad se estudió considerando una presión intraocular (PIO) ≤ 18mm Hg sin medicación hipotensora. Resultados: La PIO permitió clasificar las ampollas en no funcionales: planas (6,67%) y encapsuladas (3,33%) y funcionales (90%), las cuales dividimos según su morfología en quísticas (5/27), difusas (2/27) y laminar o en capas (20/27). Las quísticas presentaron una PIO media de 12,8, 12,6 y 14,0 mm Hg a los 3, 6 y 12 meses respectivamente. En las difusas la PIO media fue 13,0, 11,5 y 13,0 mm Hg a los 3, 6 y 12 meses respectivamente. En las de patrón en capas la PIO media fue 14,45, 14,55 y 14,8 mm Hg a los 3, 6 y 12 meses respectivamente. El porcentaje de ampollas con alta reflectividad fue de 48,15%, 62,96% y 77,78% a los 3, 6 y 12 meses, con una PIO media de 14,23, 14,59 y 15,14mmHg en cada período, respectivamente. Conclusión: El análisis de OCT-SA podría ser un buen predictor de la funcionalidad de la ampollas en la cirugía FACO-XEN. Aquellas quísticas o con menor reflectividad parecen tener mejor éxito postoperatorio. Pese a ello, se requieren estudios a mayor largo plazo (AU)

Objective: To qualitatively analyse the evolution of filtering blebs after XEN surgery, by using anterior segment optical coherence tomography (AS-OCT). Methods: A prospective study was performed on filtering blebs of 30 eyes with cataracts and glaucoma, surgically operated on using phacoemulsification and XEN45 implantation (PHACO-XEN). AS-OCT was used to analyse bleb morphology and reflectivity at 3, 6, and 12 months after surgery. Functionality was studied considering an intraocular pressure (IOP) ≤ 18 mm Hg without antihypertensive medication. Results: The IOP enabled the blebs to be classified into non-functional: flat (6.67%) and encapsulated (3.33%); and functional (90%), which were then divide by their morphology into cystic (5/27), diffuse (2/27), and layered (20/27). Cystic types had a mean IOP of 12.8, 12.6, and 14.0 mm Hg at 3, 6 and 12 months, respectively. In the diffuse type, the mean IOP was 13.0, 11.5 and 13.0 mm Hg at 3, 6 and 12 months, respectively. In the layers pattern the mean IOP was 14.45, 14.55 and 14.8 mm Hg at 3, 6 and 12 months respectively. The percentage of blebs with high reflectivity was 48.15%, 62.96%, and 77.78%, at 3, 6 and 12 months, with a mean IOP of 14.23, 14.59, and 15.14mmHg in each time period, respectively. Conclusion: AS-OCT could be a good predictor of bleb functionality in PHACO-XEN surgery. Those with a cystic pattern or low reflectivity seem to have better post-operative success. Nevertheless, more long-term studies are required (AU)

Eficacia del SENSIMED Triggerfish (R) para el seguimiento postoperatorio de la cirugía combinada FACO-ExPRESS / Efficacy of the SENSIMED Triggerfish(R) in the postoperative follow-up of PHACO-ExPRESS combined surgery

Objetivo: Estudiar la utilidad del sistema SENSIMED Triggerfish(R) en el control postoperatorio de la cirugía combinada de facoemulsificación e implante ExPRESS (FACO-ExPRESS) en pacientes con catarata y glaucoma primario de ángulo abierto (GPAA) con un seguimiento de 2 meses: Métodos Estudio prospectivo de 15 ojos intervenidos de cirugía combinada FACO-ExPRESS. Utilizando el sistema SENSIMED Triggerfish (R) (Sensimed AG, Lausanne, Suiza) se realizaron 2 registros de los patrones circadianos de la presión intraocular (PIO), uno previa y otro posterior a la cirugía. Se registró la agudeza visual mejor corregida, comorbilidades, PIO previa y de los días 7-30-60 poscirugía, medicamentos hipotensores y complicaciones. Resultados: La muestra final fue de 12 ojos. La agudeza visual mejor corregida (escala Log MAR) media preoperatoria fue 0,5 ± 0,2 y poscirugía 0,4 ± 0,1 (p = 0,02). La PIO media previa fue de 18,7 ± 3,8 mm Hg con 2,9 ± 0,7 fármacos. La PIO media en los días 7, 30 y 60 descendió a 13 ± 4,1mmHg (p = 0,002), 13,5 ± 2 mm Hg (p=0,001) y 13,9 ± 2,5 mm Hg (p=0,001) respectivamente. Las amplitudes de las curvas circadianas cambiaron significativamente entre antes y después de la cirugía (p = 0,007). Los valores medios de los periodos diurno y nocturno disminuyeron significativamente de 146,8 ± 80,9mVeq y 61,2 ± 92mVeq precirugía a 36,4 ± 36mVeq (p=0,000) y -23,2 ± 47,6mVeq (p = 0,014) poscirugía, respectivamente. Un paciente presentó complicaciones. Conclusiones: El sistema de monitorización SENSIMED Triggerfish(R) mostró cambios en los patrones circadianos, así como disminución de las amplitudes medias de las curvas tras la técnica combinada FACO-ExPRESS, lo que sugiere que este sistema puede convertirse en una herramienta útil para el seguimiento postoperatorio del GPAA (AU)

Objective: To determine the usefulness of the SENSIMED Triggerfish(R) system in the postoperative control of combined phacoemulsification and ExPRESS implant (PHACO-ExPRESS) surgery in patients with cataract and chronic open angle glaucoma (COAG) during a 2 months follow-up. Methods: A prospective study conducted on 15 eyes that were subjected to PHACO-ExPRESS combined surgery. Using the SENSIMED Triggerfish (R) system, two records of the circadian patterns of intraocular pressure (IOP) were performed, one before and one after surgery. A record was made of the best corrected visual acuity (BCVA), comorbidities, previous IOP, and 7-30-60 days after surgery, as well as any hypotensive drugs and complications. Results: The final sample was 12 eyes. The mean pre-operative BCVA (log MAR chart) before surgery was 0.5 ± 0.2, and after surgery 0.14 ± 0.1 (P = .02). The previous IOP was 18.7 ± 3.8mmHg with 2.9 ± 0.7 drugs. The mean IOP at 7, 30, and 60 days after surgery decreased to 13±4.1mmHg (P =.002), 13.5 ± 2mmHg (P =.001), and 13.9 ± 2.5mmHg (P =.001), respectively. The amplitudes of the circadian curves changed significantly after surgery (P =.007). The mean values between daytime and night-time periods decreased significantly from 146.8 ± 80.9 mVeq and 61.2±92.mVeq before surgery to 36.4 ± 36 mVeq (P =.000), and -23,2 ± 47.6mVeq (P =.014) after surgery, respectively. There were complications in one patient. Conclusions: The SENSIMED Triggerfish® monitoring system showed changes in the curves of the circadian patterns, as well as decreased mean amplitudes after the combined PHACO-ExPRESS technique, suggesting that it may become a useful tool for postoperative follow-up of COAG (AU)

Glaucoma laser and surgical procedure rates in Australia.

AIM: To determine trends in the number of glaucoma laser and surgical procedures performed in Australia between 1994 and 2014. METHODS: Medicare claims were analysed to determine the number of glaucoma-related procedures reimbursed in Australia between 1994 and 2014. Glaucoma procedures were identified by Medicare Benefits Schedule item number and analysed by age range, gender, state, month and year. RESULTS: Laser trabeculoplasty rates declined 60% between 1994 and 2003 before increasing a dramatic 353% between 2003 and 2014. Laser iridotomies increased 281% over the study period while cyclodestructive procedures increased 207%. The number of primary filtering operations for glaucoma fell 68% from a peak in 1996 to a low in 2006 and then remained stable. However, the number of filtering operations in eyes where a previous filtering operation had been performed increased 27%. There was a marked increase in glaucoma drainage device insertion, increasing 234% over the study period. CONCLUSIONS: There has been a substantial increase in laser trabeculoplasty procedures in Australia, following a decline between 1994 and 2003. Primary filtering operations for glaucoma have declined in number while glaucoma drainage devices are playing an increasingly prominent role in the surgical management of glaucoma.

Seasonal Variation in the Incidence of Late-onset Bleb-related Infection After Filtering Surgery in Japan: The Japan Glaucoma Society Survey of Bleb-related Infection Report 3.

PURPOSE: To investigate seasonal variations in the incidence of late-onset bleb-related infection after filtering surgery in Japan and the relationship between season and other factors. PATIENTS AND METHODS: This multicenter, prospective study is part of a 5-year-long Japan Glaucoma Society survey of bleb-related infection. We analyzed 156 cases of first-time infections (106 men, 50 women) encountered over 5 years to determine the seasonal variation using the Roger test and the relationships between season, sex, and age by logistic regression analysis. RESULTS: We noted significant monthly seasonal variation in the incidence of infection, which was the highest in January and February (23 and 18 infections, respectively; P=0.018) and lowest from August to November (9, 9, 11, and 8 infections, in that order). Multiple logistic regression analysis revealed that infections were most frequent among women in spring (odds ratio, 8.43; P=0.005). Staphylococcus aureus and Streptococcus spp. infections were more frequent in warmer seasons than in winter. Less virulent species, namely, coagulase-negative Staphylococcus spp., Corynebacterium spp., and Enterococcus spp., were frequently detected in winter. Coagulase-negative Staphylococcus spp. and Haemophilus influenzae were more frequent in women and men, respectively. CONCLUSIONS: The incidence of late-onset bleb-related infection showed significant seasonal variation and sex differences. The climate in Japan may influence the incidence of bleb-related infection. Moreover, besides climate, physical activity level and lifestyle may contribute to the seasonal variation in the incidence and sex differences in the involved bacterial agents of bleb-related infections in Japan.

A Quantitative Analysis of the Relationship between Medicare Payment and Service Volume for Glaucoma Procedures from 2005 through 2009.

PURPOSE: To calculate the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures. DESIGN: Retrospective, longitudinal database study. SUBJECTS: A 100% dataset of all glaucoma procedures performed on Medicare Part B beneficiaries within the United States from 2005 to 2009. METHODS: Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in glaucoma service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. MAIN OUTCOME MEASURES: Payment-volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for laser trabeculoplasty (Current Procedural Terminology [CPT] code 65855), trabeculectomy without previous surgery (CPT code 66170), trabeculectomy with previous surgery (CPT code 66172), aqueous shunt to reservoir (CPT code 66180), laser iridotomy (CPT code 66761), and scleral reinforcement with graft (CPT code 67255). RESULTS: The payment-volume elasticity was nonsignificant for 4 of 6 procedures studied: laser trabeculoplasty (elasticity, -0.27; 95% confidence interval [CI], -1.31 to 0.77; P = 0.61), trabeculectomy without previous surgery (elasticity, -0.42; 95% CI, -0.85 to 0.01; P = 0.053), trabeculectomy with previous surgery (elasticity, -0.28; 95% CI, -0.83 to 0.28; P = 0.32), and aqueous shunt to reservoir (elasticity, -0.47; 95% CI, -3.32 to 2.37; P = 0.74). Two procedures yielded significant associations between Medicare payment and service volume. For laser iridotomy, the payment-volume elasticity was -1.06 (95% CI, -1.39 to -0.72; P < 0.001): for every 1% decrease in CPT code 66761 payment, laser iridotomy service volume increased by 1.06%. For scleral reinforcement with graft, the payment-volume elasticity was -2.92 (95% CI, -5.72 to -0.12; P = 0.041): for every 1% decrease in CPT code 67255 payment, scleral reinforcement with graft service volume increased by 2.92%. CONCLUSIONS: This study calculated the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures and found varying magnitudes of payment-volume elasticities, suggesting that the volume response to changes in Medicare payments, if present, is not uniform across all Medicare procedures.

Surgical output and clinic burden of glaucoma in lagos, Nigeria.

PURPOSE: To estimate the outpatient clinic burden and surgical workload related to glaucoma in Lagos, Nigeria. METHODS: A multicentre study involving the 2 tertiary eye institutions, 7 secondary eye centers with eye care facilities, and the largest private eye hospital in Lagos state, Nigeria. Data on outpatient department (OPD) visits were collected over a 4-week period, using a specially designed tally sheet. Theater records were examined in each hospital over a 1-year period (2009) for the number and types of glaucoma surgeries performed. RESULTS: A total of 6240 patients visited the OPD over the 4-week period, out of which 1577 (25.3%) were glaucoma patients. OPD visit per ophthalmologist were 274, 323, and 61, whereas glaucoma visits per ophthalmologist were 75, 70, and 23 in the tertiary, secondary, and private centers, respectively. Glaucoma surgeries constituted 8.6% of total surgeries (n=4050). Trabeculectomy with intraoperative 5-fluorouracil was the most common procedure (81.0%). Number of glaucoma surgeries per ophthalmologist per month in the tertiary, secondary, and private centers were 0.5, 0.9, and 1.4, respectively. Overall number of glaucoma surgery per ophthalmologist per month was 1. CONCLUSIONS: Glaucoma visits constitute a significant proportion of eye clinic visits in Lagos state, Nigeria, and therefore, necessary manpower, infrastructure, and equipments should be mobilized for its optimal management. Also, there is a relatively low output of glaucoma surgeries that needs to be further investigated and appropriate measures taken to manage it.

Global rates of glaucoma surgery.

PURPOSE: To estimate global rates of glaucoma surgery. METHODS: National glaucoma and national ophthalmology societies were contacted to obtain rates of glaucoma surgery for the preceding 5 years. In countries without a professional society, leading ophthalmologists or non-governmental organizations (NGO) were approached. When available, published literature was used for the estimates. Three levels of evidence were assigned: published data from central government or insurance registries (level I), estimates provided by a national professional society based on survey of members (level II), and estimates based on data from individual glaucoma surgeons (level III). Glaucoma surgical rate (GSR) was defined as the annual number of total glaucoma surgeries performed per million population. Linear regression analysis was performed between GSR and the following parameters: population per ophthalmologist, per capita gross domestic product (GDP), and per capita health expenditures. RESULTS: Seventy-three glaucoma societies, 35 ophthalmology societies, as well as six NGOs and 37 leading ophthalmologists (11 other countries) were contacted. Data were obtained from 38 countries (10 level I, 23 level II, and 5 lev el III) with a total population of 1.723 billion. The average GSR was 139.2 ± 113.1 (range, 2.9-500.0). There was a positive correlation between GSR and GDP (r(2) = 0.309, P = 0.0004) and GSR and the number of ophthalmologists (r(2) = 0.476, P < 0.0001). CONCLUSION: There is a paucity of data on rates of glaucoma surgery, particularly from developing countries. The new metric GSR may be useful for the allocation of healthcare resources, as well as for planning and monitoring public health interventions in glaucoma.

Patient refusal of glaucoma surgery and associated factors in Lagos, Nigeria.

PURPOSE: To determine the prevalence of patient refusal of glaucoma surgery (GSR) and the associated factors in Lagos, Nigeria. MATERIALS AND METHODS: A multicenter cross-sectional survey was conducted in Lagos state, Nigeria. Twelve centres were invited to participate, but data collection was completed in 10. Newly diagnosed glaucoma patients were recruited and interviewed from these sites over a four week period on prior awareness of glaucoma, surgery refusal, and reason(s) for the refusal. Presenting visual acuity was recorded from the patient files. The odds ratio and 95% confidence intervals (CI) were calculated. RESULTS: A total of 208 newly diagnosed glaucoma patients were recruited. Sixty-five (31.2%) patients refused surgery. Fear of surgery (31 (47.7%) patients), and fear of going blind (19 (29.2%) patients) were the most common reasons. The odds ratio of surgery refusal were marital status - not married versus married (2.0; 95% CI, 1.02-3.94), use of traditional medication - users versus non users (2.4; 95% CI, 1.1-5.2), perception of glaucoma causing blindness - no versus yes (3.7; 95% CI, 1.3-10.5), type of institution - government versus private (5.7; 95% CI, 1.3-25.1), and visual acuity in the better eye - normal vision versus visual impairment (2.3; 95% CI, 1.1-4.9). Age, gender, level of education, family history of glaucoma, and prior awareness of the diagnosis of glaucoma, were not significantly associated with surgery refusal. Perception of patients concerning glaucoma blindness was the strongest factor on multivariate analysis. CONCLUSION: GSR was relatively low in this study. Unmarried status, use of traditional medications, perception that glaucoma cannot cause blindness, government hospital patients, and good vision in the better eye were associated with GSR. These factors might help in the clinical setting in identifying appropriate individuals for targeted counseling, as well as the need for increased public awareness about glaucoma.

Impact of age, diagnosis, and history of glaucoma surgery on outcomes in pediatric patients treated with latanoprost.

PURPOSE: To evaluate the impact of age, glaucoma-specific diagnosis, and history of prior glaucoma surgery on outcomes in pediatric patients treated with latanoprost monotherapy. PATIENTS AND METHODS: Prospective, randomized, double-masked 12-week, multicenter study included individuals 18 years or younger with glaucoma. Subjects stratified by age (0 to <3, 3 to <12, 12 to 18 y), diagnosis [primary congenital glaucoma (PCG) vs. non-PCG], and baseline intraocular pressure (IOP; 22 to <27, 27 to 31, >31 mm Hg), and randomized (1:1) to latanoprost vehicle (8 AM) and latanoprost 0.005% (8 PM) or timolol 0.5% (or 0.25% for those less than 3 y old; 8 AM/8 PM). IOP and safety assessments performed and adverse events recorded at baseline, weeks 1, 4, 12. Post hoc analyses in age-specific and diagnosis-specific groups of latanoprost-treated subjects were conducted (intent-to-treat population). RESULTS: Sixty-eight subjects were treated with latanoprost (0 to <3, n=17; 3 to <12, n=26; 12 to 18, n=25); 82%, 42%, and 24%, respectively, had a primary diagnosis of PCG. Among Non-PCG subjects, 0% (0/3), 47% (7/15), and 63% (12/19) had a primary diagnosis of juvenile open-angle glaucoma in the 0 to <3, 3 to <12, and 12 to 18 year cohorts, respectively. Mean percent IOP reductions from baseline at week 12 were 22%, 24%, and 30% in the youngest through oldest age groups, respectively (P=0.3600). At week 12, a higher responder rate (≥15% IOP reduction) was observed in the non-PCG than in the PCG group (70% vs. 45%, respectively; P=0.0361). Latanoprost was well tolerated. CONCLUSION: All age and diagnosis subgroups showed clinically relevant (>20%) mean IOP reduction at week 12 with latanoprost monotherapy.

The impact of available anti-glaucoma therapy on the volume and age profile of patients undergoing glaucoma filtration surgery.

PURPOSE: To investigate whether new classes of glaucoma medication have influenced glaucoma filtration surgery over a 20-year period in the southeast region of Ireland. METHODS: All patients undergoing glaucoma filtration surgery between January 1986 and December 2005 in Waterford Regional Hospital were identified. The following data were recorded for each patient: age; sex; and type of filtration procedure. RESULTS: Over the 20-year study period two consultant ophthalmic surgeons performed a total of 760 glaucoma filtration procedures on patients aged over 20 years. The annual average number of glaucoma surgeries declined steadily, defined by availability of different topical anti-glaucoma medications, from an average of 23.75 surgeries per surgeon per year in the subperiod 1986-1995, to 21 in 1996, 20 in 1997, and 12.69 surgeries per surgeon per year in 1998-2005, these differences being statistically significant (general linear model, P<0.001). The age profile of patients did not change significantly over the course of the study period. CONCLUSIONS: The volume of patients requiring glaucoma filtration surgery under the care of two consultant ophthalmic surgeons decreased over the 20-year study period, an era in which three classes of anti-glaucoma medications were made available. However, an increase in the age profile of patients undergoing glaucoma filtration surgery during the same period was not observed. Further study is required to resolve whether introduction of the new topical anti-glaucoma medications has led to a real reduction in the demand for glaucoma filtration surgery, or has just led to the deferral of such a demand.

Escalation of glaucoma therapy after penetrating keratoplasty.

PURPOSE: To determine the prevalence and risk factors for escalation of glaucoma therapy after penetrating keratoplasty (PK) and its impact on graft survival and visual outcome. DESIGN: Retrospective case series. PARTICIPANTS: Seven hundred fifteen consecutive eyes of 678 patients undergoing PK. METHODS: Retrospective review of every case of PK performed at King Khaled Eye Specialist Hospital between January 1, 2001 and December 31, 2002. MAIN OUTCOME MEASURES: Escalation of glaucoma therapy, graft survival, and visual outcome. RESULTS: Escalation of glaucoma therapy occurred in 89 (12.4%) eyes of 715 PK procedures during a mean follow-up of 32.2 months. Medical escalation accounted for 73 (82.0%) cases, whereas surgical escalation occurred in 16 (18.0%) eyes. The following were significantly associated with an increased risk of escalation of glaucoma therapy: surgical indication for PK (P<0.001), increasing patient age (P<0.001), preexisting glaucoma (P<0.001), recipient trephination < 7.0 mm (P = 0.02), and pseudophakia or aphakia (P<0.001). Eyes with escalation of glaucoma therapy had significant reduction in graft survival compared with eyes in which this did not occur (52.8% vs. 82.9%, P<0.001). Escalation of glaucoma therapy was associated with a significant reduction in the percentage of eyes achieving visual acuity of 20/40 or better (9.0% vs. 42.1%, P<0.001) and a significant increase in those obtaining 20/200 or worse (70.8% vs. 26.7%, P<0.001). CONCLUSIONS: Escalation of glaucoma therapy is a serious sequela of PK that is significantly associated with an increased risk of graft failure and poor visual outcome.

Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004.

OBJECTIVE: To observe how the treatment of glaucoma has changed over the last decade. DESIGN: Retrospective, observational, population-based analysis. PARTICIPANTS: Medicare beneficiaries between 1995 and 2004. METHODS: Medicare fee-for-service data claims between 1995 and 2004 were analyzed to determine the number of penetrating surgeries and laser procedures performed for glaucoma in the decade spanning 1995 and 2004. MAIN OUTCOME MEASURE: Number of Medicare beneficiaries receiving glaucoma-related laser procedures or surgery. RESULTS: Trabeculectomies in eyes without previous surgery or trauma decreased 53% over the study period, from 51,690 in 1995 to 24,178 in 2004, although trabeculectomy in eyes with scarring increased 9%. The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. Cyclophotocoagulation procedures rose 248% over the study period, from 3264 procedures in 1995 to 11,356 procedures in 2004. Between 1995 and 2001, the number of laser trabeculoplasties decreased 57%, from a high of 151,244 in 1995 to a low of 75,647 in 2001. From 2001 to 2004, the number of trabeculoplasties more than doubled, with 157,490 performed in 2004. The number of laser iridotomies showed little fluctuation, increasing 18% over the study period and ranging from 63,773 to 85,286 every year. Over the study period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. CONCLUSIONS: Medicare recipients with glaucoma are more likely to be treated with aqueous shunting procedures or cyclophotocoagulation and less likely to be treated with trabeculectomy, compared with past years. After a decline in use between 1995 and 2001, laser trabeculoplasty increased substantially from 2001 to 2004. Fistulization procedures other than trabeculectomy and surgical iridectomy have become very uncommon.

Topical ocular hypotensive medication and lens opacification: evidence from the ocular hypertension treatment study.

PURPOSE: To determine whether topical ocular hypotensive medication is associated with refractive changes, visual symptoms, decreased visual function, or increased lens opacification. DESIGN: Multi-center clinical trial. METHODS: We compared the medication and observation groups of the Ocular Hypertension Treatment Study (OHTS) during 6.3 years of follow-up with regard to the rate of cataract and combined cataract/filtering surgery, and change from baseline in visual function, refraction, and visual symptoms. A one-time assessment of lens opacification was done using the Lens Opacities Classification System III (LOCS III) grading system. RESULTS: An increased rate of cataract extraction and cataract/filtering surgery was found in the medication group (7.6%) compared with the observation group (5.6%) (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.05 to 2.29). The medication and observation groups did not differ with regard to changes from baseline to June 2002 in Humphrey visual field mean deviation, Humphrey visual field foveal sensitivity, Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity, refraction, and visual symptoms. For the medication and observation groups, LOCS III readings were similar for nuclear color, nuclear opalescence, and cortical opacification. There was a borderline higher mean grade for posterior subcapsular opacity in the medication group (0.43 +/- 0.6 SD) compared with the observation group (0.36 +/- 0.6 SD) (P = .07). CONCLUSIONS: We noted an increased rate of cataract extraction and cataract/filtering surgery in the medication group as well as a borderline higher grade of posterior subcapsular opacification in the medication group on LOCS III readings. We found no evidence for a general effect of topical ocular hypotensive medication on lens opacification or visual function.

Comparative safety profile between "modern" trabeculectomy and non-penetrationg deep sclerectomy.

PURPOSE: To compare the incidence and the severity of short-and medium-term complications following "modern" trabeculectomy (mTRAB) with non-penetrating deep sclerectomy (NPDS). MATERIALS AND METHODS: Comparative retrospective nonrandomized study including 65 eyes (55 patients) (mean age: 68.6 years) with medically uncontrolled glaucoma. mTRAB was performed in 43 eyes, NPDS in 22 eyes. mTRAB was performed according to a slightly modified P.T. Khaw protocol. NPDS procedures were done according to Kozlov's and Mermoud's technique with SKGEL implant in 18/22 eyes. Intraoperative antimetabolites (AMETAB) were given in 25 eyes (58%) in the mTRAB and 17 (77%) in the NPDS (p>0.05). RESULTS: Mean follow-up was longer in NPDS (10.7+/-5.5 months) than in mTRAB (8.5+/-3.4 months) (p<0.05). Preoperatively, the two groups were comparable in respect of age, type of glaucoma, mean IOP, severity of VF defects and bleb failure risk factors (p>0.05). Peroperatively, mTRAB were uneventful in 86% vs 90% of NPDS. 1st month postop complications occurred in 60.4% in mTRAB and 77.2% in NPDS (P>0.05). Most of them were minor and transient in both surgeries. Postop early anterior chamber inflammation was mild to moderate in all cases. The incidence of wound leaks (21% in the mTRAB group and 18% in the NPDS group) and hyperfiltration related complications (14% and 13.6% respectively in the mTRAB and NPDS group) were comparable between the two procedures (p > 0.05). Intraoperative antimetabolite application was not associated with an increased rate of postoperative hyperfiltration related complications. Scarring of filtration blebs had concerned a lower percentage of mTRAB eyes (19%) than the NPDS (36%). The number for 5-FU injections was less - although not significantly - in the mTRAB than in the other group (18.6% in mTRAB versus 41% in NPDS (p=0.05). Late complications were not observed in the mTRAB group. Iris prolapse associated with increased IOP occurred in 3 of the 22 NPDS procedures (13.6%). Final mean visual acuity was unchanged compared with preop value and was similar between the 2 groups (p>0.05). Diffuse, mildly vascularized filtration blebs were observed in 84% in mTRAB and 64% in DS (p>0.05). Mean IOP significantly decreased from 24.8+/-8.3 mm Hg to 13.4+/-4,3 mm Hg in mTRAB and from 25.1+/-6.5 mm Hg to 14.7+/-4.6 mm Hg in DS (p> 0.05). It was not different between the 2 groups with and without AMETAB augmentation. 70% of the mTRAB achieved a final IOP < or = 15 mmHg vs 41% in NPDS (p<0.05). The mean number of postop medications was 0.49 in mTRAB and 0.96 in NPDS (p<0.05). Complete (target IOP reached without meds) and qualified (target IOP reached with and without meds) final success rates were 60% and 88% in mTRAB and 36.4% and 68.2% in NPDS (p>0.05). CONCLUSIONS: Whether surgery was augmented with intraoperative antimetabolite or not, mTRAB revealed as a priority to be associated with comparable and even less complications than deep sclerectomy. Owing to the limitations of our study and until further confirmation, our results have suggested that mTRAB was associated with a slightly more important IOP reduction as well as higher success rates than NPDS.