Meditation enhances brain oxygenation, upregulates BDNF and improves quality of life in patients with primary open angle glaucoma: A randomized controlled trial.

BACKGROUND: Glaucoma (POAG) is a kind of neurodegenerative disease known to be closely associated with stress and adverse quality of life (QOL). Stress has also been shown to be involved in etiopathogenesis of primary open angle glaucoma (POAG). Complementary treatment in form of Meditation has been reported to improve QOL, brain oxygenation and decrease markers of stress. With this premise, a randomized controlled trial was carried out to assess the effect of Meditation on intraocular pressure, subjective QOL and objective markers of stress and brain oxygenation in patients with POAG. METHODS: Sixty patients were randomized into intervention and control groups. Intervention group underwent 45 minutes of Meditation daily for 6 weeks in addition to standard medical treatment while controls received only standard medical treatment. Inclusion criteria were patients with POAG, age >45 years, best corrected visual acuity >6/60. Patients with other ocular co-morbid conditions contributing to vision loss, systemic diseases, patients already practicing meditation in any form were excluded. An assessment of IOP, brain oxygenation using functional near infrared spectroscopy (fNIRS), QOL (WHO-BREF QOL) and stress markers in serum (cortisol, ß-endorphins, interleukin-6, brain derived neurotrophic factor (BDNF), reactive oxygen species) was made at baseline and at 6 weeks. RESULTS: 21 female and 39 male patients were enrolled with a mean age of 57.28±9.37 years. All parameters were comparable between two groups at baseline. At 6 weeks mean level of IOP decreased significantly in intervention group (15.9±1.8 mmHg to 14.4±1.21 mm Hg, p-value 0.0001) as compared to control group (15.7±1.4 mmHg to 15.65±1.41, p-value 0.41). fNIRS showed significant improvement in oxygenated hemoglobin change (ΔHbO) in intervention group in the prefrontal cortex (p-value <  0.0001) as compared to control group (p-value 0.52). WHO-BREF QOL score increased significantly in intervention group (86.6±6.16 to 93.3±5.66, p-value 0.0001) as compared to control (89±7.25 to 89.07±3.24, p-value 0.74).Mean serum cortisol decreased significantly in intervention group (497±46.37 ng/ml to 447±53.78 ng/ml, p-value 0.01) as compared to control group (519.75±24.5 to 522.58±26.63 ng/ml, p-value 0.64). Mean ß-endorphin levels increased significantly (33±5.52pg/ml to 43.27pg/ml, p-value <  0.0001) as compared to control group (34.78±4.1pg/ml to 36.33pg±4.07pg/ml p-value 0.27). Interleukin-6 decreased significantly in intervention group (2.2±0.5 ng/ml to 1.35±0.32 ng/ml, p-value <  0.0001) as compared to control group (2.03±0.37 to 2.17±0.34 ng/ml p-value 0.25). BDNF increased significantly in intervention group (52.24±6.71 to 63.25±13.48 ng/ml p-value 0.004) as compared to control group (53.23±5.82 to 54.42±5.66 ng/ml p-value 0.54). ROS decreased significantly in intervention group (1596.19±179.14 to 1261±244.31 RLU/min/104 neutrophils p-value 0.0001) as compared to control group (1577.5±172.02 to 1662.5±84.75 RLU/min/104 neutrophils p-value 0.16). CONCLUSIONS: A short term course of Meditation was associated with significant improvement in brain oxygenation and QOL along with a reduction in IOP and stress markers. Meditation may be a useful as an adjunct to standard treatment in patients with POAG and potentially decrease the risk of glaucoma progression.

Stent trabecular micro bypass para glaucoma / Micro-bypass trabecular stent for glaucoma

CONTEXTO: El glaucoma es una neuropatía óptica progresiva que en su curso natural conduce a la ceguera. Principalmente se caracteriza, aunque no siempre, por un aumento sostenido de la presión intraocular (PIO) y una alteración estructural y funcional del ojo. El riesgo de ceguera depende del nivel de PIO, cuyos valores normales se encuentran entre 10 y 20 mmHg, la severidad de la enfermedad, la edad de comienzo y otros determinantes, como la historia familiar de glaucoma. El aumento de la PIO es el mayor factor de riesgo de pérdida de la visión, y el único modificable. El glaucoma puede ser de ángulo cerrado o de ángulo abierto (GAA), siendo este último el más frecuente. En el primer caso, ocurre un bloqueo anatómico del ángulo iridocorneal (sitio de drenaje del humor acuoso) de la cámara anterior del iris, lo que puede conducir a un aumento de la PIO; en el segundo caso se produce en general, un aumento de la PIO secundario a un drenaje defectuoso del humor acuoso por el canal de Schlemm. Desde el punto de vista terapéutico, es esencial diferenciar ambas formas de la enfermedad, pues cada una de ellas tiene consideraciones e intervenciones de control específicas. TECNOLOGÍA: El iStent (Glaukos Corporation, Laguna Hills, CA, EE. UU.) es un stent de primera generación, de titânio de 1 mm de longitud, en forma de L, que se inserta en el canal Schlemm (canal de drenaje del humor acuoso) a través de una incisión corneal utilizando un inyector precargado bajo guía gonioscópica, facilitando el drenaje del humor acuoso para el tratamiento del GAA. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso de stents (iStent) trabecular micro by-pass para el glaucoma de ángulo abierto. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: Se incluyeron una RS, dos estudios aleatorizados, un estudio abierto, cuatro GPC y nueve informes de políticas de cobertura de stents trabecular micro bypass para el tratamiento del glaucoma de ángulo abierto. CONCLUSIONES: Evidencia de moderada calidad muestra que el implante de stents trabecular micro bypass em pacientes con glaucoma de ángulo abierto asociado a la facoemulsificación como tratamiento de las cataratas, tiene un beneficio pequeño pero estadísticamente superior a la facoemulsificación aislada en la disminución de la presión intraocular y en el número de fármacos tópicos utilizados para el manejo de la presión intraocular. Evidencia de muy baja calidad no permite estimar la utilidad de los stents trabecular micro by-pass utilizados en forma aislada y no asociados a la facoemulsificación. Algunas de las guías de práctica clínica relevadas consideran su indicación en casos seleccionados, especialmente en pacientes de difícil manejo, y en combinación con facoemulsificación como tratamiento de cataratas presentes en forma concomitante con glaucoma de ángulo abierto. La mayoría de las políticas de cobertura consultadas de financiadores públicos y privados de Estados Unidos y Europa cubren la tecnología en casos de glaucoma de ángulo abierto leve a moderado em los que no se logra un buen control a pesar del tratamiento farmacológico tópico y en combinación con facoemulsificación para el tratamiento de cataratas. Las políticas de cobertura relevadas de Latinoamérica no la mencionan.

Activity Limitation in Glaucoma: Objective Assessment by the Cambridge Glaucoma Visual Function Test.

PURPOSE: We design and evaluate a computer-based objective simulation of activity limitation related to glaucoma. METHODS: A cross-sectional study was performed involving 70 glaucoma patients and 14 controls. Mean age was 69.0 ± 10.2 years; 49 (58.3%) were male. The Cambridge Glaucoma Visual Function Test (CGVFT) was administered to all participants. Rasch analysis and criterion, convergent, and divergent validity tests assessed the psychometric properties of the CGVFT. Regression modeling was used to determine factors predictive of CGVFT person measures. Sociodemographic information, better and worse eye visual field parameters, visual acuity, contrast sensitivity, and the Rasch-analyzed Glaucoma Activity Limitation-9 (GAL-9) and Visual Function Questionnaire Utility Index (VFQUI) questionnaire responses were recorded. RESULTS: From 139 pilot CGVFT items, 59 had acceptable fit to the Rasch model, with acceptable precision (person separation index, 2.13) and targeting. Cambridge Glaucoma Visual Function Test person measure (logit) scores increased between controls (-0.20 ± 0.08) and patients with mild (-0.15 ± 0.08), moderate (-0.13 ± 0.10), and severe (-0.05 ± 0.10) glaucoma (P < 0.001, ANOVA) indicating good criterion validity. Correlation coefficients of 0.455 (P < 0.001) between CGVFT and GAL-9 person measures and 0.399 (P = 0.005) between CGVFT and VFQUI person measures demonstrated convergent validity. Divergent validity was suboptimal. On multivariable analysis, lower better eye mean deviation and greater age were associated with worsening CGVFT person measures (P ≤ 0.001). CONCLUSIONS: The CGVFT is a computerized visual challenge test administered to a cohort of glaucoma patients. It may benefit glaucoma patients, careers, health care providers, and policy makers, providing increased awareness of activity limitation due to glaucoma.

The accuracy of Goldmann applanation tonometry over silicone hydrogel contact lenses in patients with glaucoma.

PURPOSE: To investigate the accuracy of measuring intraocular pressure over a silicone hydrogel contact lens using Goldmann applanation tonometry in eyes with glaucoma. METHODS: This was a prospective, randomized study and enrolled 28 patients (28 right eyes) with primary open angle glaucoma. Intraocular pressure was taken with and without a silicone hydrogel contact lens (-0.50 D), in situ (using Goldmann applanation tonometry), in a randomized order of measurements. Statistical analysis was performed using paired t-test and Bland-Altman plot. RESULTS: The mean difference (± standard deviation) found between intraocular pressure measurement without (mean 16.7 ± 3.2 mmHg) and with (mean 17.3 ± 3.0 mmHg) contact lens was found to be -0.57 ± 2.3 mmHg (95% confidence interval, -1.5 to 0.3). No significant statistical difference was found between the two groups with paired t-test (p=0.19). The Bland Altman plot showed some evidence of increasing variability of differences between two measures of intraocular pressure, with increasing intraocular pressure. The 95% limits of agreement of the Bland Altman plot were unacceptably large (-5 mmHg to 3.9 mmHg). CONCLUSION: Agreement between Goldmann applanation tonometry with and without contact lenses seems to be poor in patients with glaucoma, especially for high intraocular pressure.

[The effectiveness of endonasal electrophoresis of neuroprotective agents used in the rehabilitative treatment of the patients presenting with primary open angle glaucoma].

The objective of the present study was to estimate the effectiveness of the peptide drug cortexin used to treat primary open angle glaucoma. It was shown that endonasal electrophoresis of cortexin resulted in more pronounced positive changes in the dynamics of clinical, functional, perimetric, and electrophysiological characteristics compared with intramuscular administration of the same drug to the patients of the control group. This difference was apparent both immediately after the termination of the treatment and during the long-term follow-up.

Glaucoma and reading: exploring the effects of contrast lowering of text.

PURPOSE: Past research has not fully ascertained the extent to which people with glaucoma have difficulties with reading. This study measures change in reading speed when letter contrast is reduced, to test the hypothesis that patients with glaucoma are more sensitive to letter contrast than age-similar visually healthy people. METHODS: Fifty-three patients with glaucoma [mean age: 66 years (standard deviation: 9)] with bilateral visual field (VF) defects and 40 age-similar visually healthy control subjects [mean age: 69 (standard deviation: 8) years] had reading speeds measured using sets of fixed size, non-scrolling texts on a computer setup that incorporated an eye tracking device. All participants had visual acuity ≥6/9, and they underwent standard tests of visual function including Humphrey 24-2 and 10-2 VFs. Potential non-visual confounders were also tested, including cognitive ability (Middlesex Elderly Assessment of Mental Status Test) and general reading ability. Individual average raw reading speeds were calculated from 8 trials (different passages of text) at both 100% and 20% letter contrast. RESULTS: Patients had an average 24-2 VF MD of -6.5 (range: 0.7 to -17.3) dB in the better eye. The overall median reduction in reading speed due to decreasing the contrast of the text in the patients was 20%, but with considerable between-individual variation (interquartile range, 8%-44%). This reduction was significantly greater (p = 0.01) than the controls [median: 11% (interquartile range, 6%-17%)]. Patients and controls had similar average performance on Middlesex Elderly Assessment of Mental Status Test (p = 0.71), a modified Burt Reading ability test (p = 0.33), and a computer-based lexical decision task (p = 0.53) and had similar self-reported day-to-day reading frequency (p = 0.12). CONCLUSIONS: Average reduction in reading speed caused by a difference in letter contrast between 100% and 20% is significantly more apparent in patients with glaucoma when compared with visually healthy people with a similar age and similar cognitive/reading ability.

Rehabilitation of vision disorder and improved quality of life in patients with primary open angle glaucoma.

BACKGROUND: Primary open angle glaucoma (POAG) is a common cause of irreversible blindness. The variable etiology of POAG poses significant challenges for treatment and rehabilitation. We analyzed a large POAG patient cohort during treatment to reveal possible causes of vision disorder, assess vision-related quality of life (VRQL), and to evaluate the efficacy of rehabilitative treatments. METHODS: We analyzed the visional disturbances in 500 POAG patients (890 eyes) by regular ophthalmic examination and visual field examination using Humphrey 30° perimetry. Appropriate rehabilitative treatments for POAG were prescribed based on results of clinical examination and included correction of ametropia, health education, counseling, and the fitting of typoscopes. VRQL was assessed before and after treatment by a VRQL self-assessment questionnaire. RESULTS: Scores on the VRQL self-assessment were significantly lower compared to healthy controls. The primary cause of the vision disturbances was ametropia (97.99%), and 51.61% of the ametropia eyes had not received appropriate correction. The secondary causes of visual impairment were glaucomatous neurodegeneration (26.29%), complicated cataract, or other accompanying eye diseases. The causes of the clinical low vision (44 patients) were glaucomatous neurodegeneration (32 eyes), fundus diseases (23 eyes), keratopathy (11 eyes), and other eye diseases (10 eyes). The VRQL scores of patients improved significantly after rehabilitation and the correction of ametropia (P < 0.01). Twenty-five patients with low vision were provided with typoscopes, and 21 (84%) experienced significant functional recovery, while the remaining low vision patients could see letter lines two or more levels lower (smaller) on visual charts in a near vision test. CONCLUSIONS: Vision disorders in POAG patients are common and severe. Appropriate rehabilitation, especially the correction of ametropia, can significantly improve VRQL as revealed by the self-assessment of POAG patients.

Lifetime visual prognosis for patients with primary open-angle glaucoma.

AIM: To investigate final visual outcome in primary open angle glaucoma (POAG) including low-tension glaucoma (LTG). METHODS: Retrospective review of case notes for patients who died between 1999 and 2002. All were booked for a follow-up appointment in glaucoma clinic at time of death. RESULTS: A total of 121 case notes were reviewed. In all, 113 patients had POAG and eight had LTG. All were White Caucasians. Mean ages at presentation and death were 74.6 (SD 9.6, range 49-94) and 81.9 (SD 8.3, range 51-98) years, respectively. Mean follow-up duration was 7.4 (SD 6.8, range up to 29) years. Average number of clinic visits was 18 (SD 17, range 1-95). At final visit, 50.4% had cataract operations, and 45.5% had glaucoma operations. At final visit, vision was inadequate for driving in the UK in 47.1%. In 18.2%, this was due to glaucoma alone, while in 28.9%, other ocular pathologies contributed to poor vision. In all, 14% were eligible for partial sight certification, with 6.6% due to glaucoma alone. A total of 3.3% were eligible for blind certification, none due to glaucoma alone. CONCLUSION: This study shows that POAG does affect the quality of life, with regards to glaucoma clinic visits, eye drops, and surgical procedures. Most patients with treated POAG in Norfolk will retain useful vision for their whole life. A significant proportion of patients with POAG do lose vision resulting in driving ineligibility and certification as visually impaired, although actual blindness is uncommon.

Costs and utilization of end-stage glaucoma patients receiving visual rehabilitation care: a US multisite retrospective study.

PURPOSE: Glaucoma is a prevalent ophthalmologic disease and leading cause of blindness. A retrospective analysis was conducted to evaluate resources and costs for end-stage glaucoma patients receiving visual rehabilitation care (VRC). MATERIALS AND METHODS: A chart review was conducted in 3 United States VRC centers. Charts of patients with primary open-angle glaucoma as the primary cause of vision loss (1998 to 2003) were selected, yielding 81 records. Data were collected from patient-level billing and reimbursement records (ophthalmologist/optometrist visits, glaucoma medications, procedures, and specialized low-vision and glaucoma-related services). Visual rehabilitation services included utilization of low-vision devices, assessment of daily functioning, orientation and mobility training, and patient counseling. RESULTS: Mean age at baseline was 72.7 years [standard deviation (SD)=17.2, range: 29 to 95]. Of those with known sex (n=77), 55.8% were women. Medicare was the payer type for most patients (59.3%), whereas 20% had Medicaid. Mean number of visits was 7.1 (SD=6.1) in year 1 and 3.7 (SD=4.2) in year 2, for an annual mean of 5.4 (SD=5.0) visits overall. Total mean cost per patient in year 1 was greater than year 2 [$2170 (SD=$2252) vs. $1202 (SD=$1080), respectively]; of the total 2-year costs, 15% were VRC, 37% ophthalmology care, and 48% pharmacy. Analysis of nonpharmacy costs revealed that VRC accounted for 28% and ophthalmology for 72%. CONCLUSIONS: End-stage glaucoma is associated with appreciable resource utilization and costs, because of both vision rehabilitation and ophthalmology care. Advanced primary open-angle glaucoma has a substantial cost-of-illness, warranting improved management in early stages of disease.

An application of threshold-versus-intensity functions in automated static perimetry.

Increment thresholds were measured over a range of adapting illuminances using a modified automated static perimeter. The data were fitted to a threshold versus intensity model (logT - logT(0) + log((A + A(0))/A(0))n) and the values logT(0) and logA(0) estimated. The effect of eccentricity and age on logT(0) and logA(0) was examined in normal subjects. A small group of patients with ocular disease were then assessed. Macular degeneration appeared to act as disease processes acting near the photoreceptor (d1 model). Glaucoma seemed to act near the site of retinal gain (d3 model). This analysis method may be of value in developing light adaptation strategies in people with ocular disease.

Quality of life in patients with early, moderate and advanced glaucoma.

PURPOSE: To evaluate the quality of life in glaucomatous patients using two different questionnaires: the medical outcomes study 36-item short-form health survey (MOS SF-36) and Viswanathan et al's questionnaire and to compare these two questionnaires. METHODS: Seventy-seven patients with glaucoma were consecutively selected. Two force-choice questionnaires were administered to each patient. Viswanathan et al's questionnaire was related to visual disability and the second was related to the quality of life from the MOS 36-item short-form health survey. Both questionnaires were evaluated among all the considered patients and the results were compared. Then the questionnaire which did the best evaluation was used to test the quality of life in three different subgroups based on the mean deviation of the worse eye. Mann-Whitney non parametric test and Spearman's r coefficient were used and a P value less than 0.05 was considered to be statistically significant. A linear regression model was used. RESULTS: In the entire group (n = 77) the Mean Deviation (MD) was -6.5 +/- 6.8 dB (mean +/- standard deviation) and Corrected Pattern Standard Deviation (CPSD) was 4.7 +/- 4.1 dB. The score of the Viswanathan et al's questionnaire was 8.3 +/- 2.4, while MOS SF-36 score ranged from 60.5% to 100% (mean score %). A significant (P < 0.0001) correlation was found between the score of the Viswanathan et al's questionnaire and MD (r = 0.79), Pattern Standard Deviation (PSD) (r = -0.68) and CPSD (r = -0.61). CONCLUSION: Viswanathan et al's questionnaire was more useful than MOS SF-36, both for the score and for the velocity to use. Furthermore Viswanathan et al's questionnaire was more significantly correlated to visual field MD.

[Relevance of quality of life and treatment compliance measurement in patients with chronic open-angle glaucoma]. / Intérêt de la mesurede la qualité de vie (QDV) et de l'observance thérapeutiquechez les patients atteints de glaucome chronique à angleouvert. Groupe d'étude Glaucome et Qualité de Vie.

Chronic glaucoma is a severe disease that can induce blindness.Early diagnosis and symptomatic treatment reduce the risk of blindness. Treatment that will be started before the onset of clinical signs and will remain lifelong thereafter is troublesome, and therapeutic compliance is usually poor. Thus, quality of life (QOL) measurement in patients with chronic glaucoma has a particular purpose: to measure patients' perception of the disease and treatment in order to maintain good treatment compliance to ensure therapeutic management efficacy and to preserve visual function. No glaucoma-specific instrument is available in the medical and QOL literature. Various generic(SF-36, SF-20 and SIP) and specific(VAQ, VF-14, NEI-VFQ) QOL questionnaires,one glaucoma-specific symptomatic scale (GSS),and one treatment preference scale (COMTol) have been used to measure QOL in glaucoma patients. These instruments do not sufficiently measure the psychosocial dimension of the disease and the QOL impact of treatment. An instrument able to measure all dimensions needs to be developed in order to help ophthalmologists in the therapeutic management of their patients and to measure QOLin patients in the successive stages of the disease.

Estudo comparativo entre o maleato de timolol 0.5 e betaxolol 0.5 na reduçäo da pressäo intra-ocular de pacientes submetidos a trabeculectomia / A comparative study between timolol maleate 0.5// and betaxolol 0.5// in reducing intraocular pressure in patients submited to trabeculectomy

23 pacientes com glaucoma primário de ângulo aberto submetidos a trabeculectomia e com a PIO normalizada foram estudados em relaçäo à resposta hipotensora ao maleato de Timolol 0.5 por cento e Betaxolol 0.5 por cento mostrou reduçäo da PIO significativamente maior que o grupo tratado com Betaxolol (38.5 por cento e 30.0 por cento na 1a. e 4a. semanas com o maleato de Timolol e 26.5 por cento e 17.2 por cento com o Betaxolol)