Follow-up studies of the classical landmark studies in Glaucoma.

PURPOSE OF REVIEW: It was not until the nineteen nineties that there was scientific evidence for the primary treatment concept of glaucoma, lowering intraocular pressure. The treatment concept of lowering intraocular pressure is now proven by randomized controlled clinical trials (landmark studies). This review provides an overview of the follow-up studies to these landmark studies from the last 18 months. RECENT FINDINGS: The 20-year data of the ocular hypertension treatment study showed a 49% incidence of primary open-angle glaucoma. The data of this landmark study was used for developing different machine learning algorithms. Bilateral disease, disc hemorrhages, and higher intraocular pressure (IOP) were risk factors for visual field deterioration in the United Kingdom Glaucoma Treatment Study. The Advanced Glaucoma Intervention Trial and the Collaborative Initial Glaucoma Treatment Study identified demographic factors, comorbidity, and clinical variables associated with visual field damage. Analysis was performed on Chinese subsets from the Laser in Glaucoma and Ocular Hypertension Study (LiGHT). Looking at all the follow-up studies to the tube shunt landmark studies, preoperative IOP, neovascular glaucoma, Ahmed implantation, and younger age were predictors of failure. A follow-up study to the Effectiveness in Angle-Closure Glaucoma in Lens Extraction Study showed that patients were ten times more likely to maintain a drop-free target IOP after lens extraction than after laser iridotomy. A superior location for iridotomy results in significantly more significant angle widening than temporal or nasal locations, as shown by a follow-up study to the Zhongshan Angle Closure Prevention Trial using OCT and gonioscopy. SUMMARY: The number of published follow-up studies to the landmark studies in glaucoma show the ongoing development of clinical questions in management of glaucoma.

Long-term treatment success and safety of combined phacoemulsification plus excimer laser trabeculostomy: an 8-year follow-up study.

PURPOSE: Combined phacoemulsification plus excimer laser trabeculostomy (phaco-ELT) is a minimally invasive surgery that effectively reduces intraocular pressure (IOP) in patients with glaucoma and a concomitant diagnosis of cataract. The aim of this study was to evaluate the long-term treatment success as well as safety of phaco-ELT over an 8-year follow-up period. METHODS: Patients with a diagnosis of primary or secondary glaucoma or ocular hypertension and a visually significant cataract who underwent a combined phaco-ELT between January 1, 2008, and December 31, 2010, were included. Data for IOP, the number of IOP-lowering medications (meds), best-corrected visual acuity, complications, and subsequent surgeries to lower IOP were collected preoperatively (baseline) and intraoperatively as well as at 1 day, 1 week, 1 month, 3 months, 6 months, 9 months, 1 year, and every 6 months thereafter to 8 years postoperatively. RESULTS: One hundred sixty-one eyes of 128 patients were included. After 8 years of follow-up, the long-term treatment success rate with IOP ≤ 21 mmHg was 50.2%. No serious intra- or postoperative complications occurred. The mean IOP decreased significantly from 19.3 (±4.8) mmHg at baseline to 15.4 (±3.2, p =0.0040) mmHg at 8 years. Additionally, meds remained below baseline after 8 years of follow-up and were reduced significantly for up to 4 years. Only 25.5% of the eyes required a subsequent surgery to lower IOP during the follow-up period. CONCLUSION: Combined phaco-ELT is a safe procedure without serious intra- or postoperative complications, which has a positive long-term effect regarding IOP and meds. Remarkably, the mean IOP-lowering effect remained stable and was reduced ≥ 20% from baseline after 3 months for the remainder of the follow-up duration, whereas the number of meds was reduced significantly for up to 4 years. Furthermore, only 25.5% of the eyes required a subsequent surgery to control IOP throughout the whole follow-up of 8 years.

First and second transscleral cyclophotocoagulation treatments provide similar intraocular pressure-lowering efficacy in patients with refractory glaucoma.

PURPOSE: The aim of this study is to address the safety and effectiveness of a second continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) treatment by comparing its outcome against a first CW-TSCPC treatment in the same patients with refractory glaucoma. METHODS: Twenty-one eyes with either primary or secondary glaucoma received a second CW-TSCPC laser session ≥ 3 months after the first treatment. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), and number of topical or oral ophthalmic pressure-reducing medications were registered at every time point up to the last follow-up at 3 months. A complete slit-lamp examination was conducted to record for complications or other abnormal ocular findings. Success was defined as IOP between 6 and 21 mmHg and > 20% reduction in IOP with or without anti-glaucoma medications. RESULTS: At 3 months follow-up of the first CW-TSCPC treatment, a 24.8% decrease in IOP was observed, whereas a 45.6% IOP decrease was observed 3 months post the second CW-TSCPC treatment. Visual acuity did not decrease, and no major complications were observed post either treatment within the follow-up period. Time to failure was 79.5 ± 24.6 and 77.1 ± 29.4, respectively (P = 0.955). No serious complications were observed. CONCLUSION: A second CW-TSCPC treatment proved to be a safe and effective treatment option when the first CW-TSCPC treatment was insufficient in maintaining the desired IOP level for a prolonged time (mean time between both sessions 6.4 ± 8.0 months).

The AIDA and the extra laser systems for excimer laser trabeculotomy proved comparable IOP lowering efficacy-12-month results.

PURPOSE: Cataract surgery combined with excimer laser trabeculotomy (phaco-ELT) leads to a significant reduction in intraocular pressure by enhancing trabecular outflow. The aim of this study is to compare two laser systems for ELT (AIDA vs. ExTra). METHODS: In this retrospective chart review, inclusion criteria were a diagnosis of glaucoma and phaco-ELT between 07/17/2010 and 07/17/2018. Data were collected preoperatively and postoperatively up to 1 year. Success was defined as IOP reduction of ≥ 20% compared to baseline plus an IOP of < 21 mmHg with no hypotony, no loss of light perception vision, and no subsequent glaucoma surgery. RESULTS: Three hundred and fourteen eyes (mean age 75.9 ± 8.6 years) were included. Baseline intraocular pressure (IOP) for the ExTra group (94 eyes) was 20.3 ± 5.9 mmHg on 2.0 ± 1.3 anti-glaucoma drugs (AGD) and a best-corrected visual acuity (BCVA, logMar) of 0.5 ± 0.4. For The AIDA group (220 eyes), baseline IOP was 18.7 ± 6.3 mmHg on 2.0 ± 1.3 AGD and a BCVA of 0.3 ± 0.3. In the ExTra group, IOP was reduced to 12.8 ± 2.5 mmHg (-37%) and in the AIDA group to 14.7 ± 3.9 (-21%, p = 0.14) at 1 year. AGD reduction in the ExTra group was 1.3 ± 1.5 and 1.8 ± 1.4 in the AIDA group (p = 0.14). Success rates were 80% (ExTra) and 70% (AIDA), respectively (p = 0.552). Thirty-one eyes (10.0%) required a subsequent glaucoma surgery during the follow-up. CONCLUSION: Both laser platforms, the ExTra and the AIDA laser, used for Phaco-ELT lead to a significant reduction in intraocular pressure and anti-glaucoma drugs with no statistically significant difference in success rates during the follow-up of 12 months. TRIAL REGISTRATION SWISSETHICS: 2018-01,791.

Selective laser trabeculoplasty following failed combined phacoemulsification cataract extraction and excimer laser trabeculotomy can control intraocular pressure for a limited time.

PURPOSE: To assess the efficacy of selective laser trabeculoplasty (SLT) following failed phacoemulsification cataract extraction combined with excimer laser trabeculotomy (phaco-ELT). METHODS: Retrospectively, the medical records of patients with primary or secondary open-angle glaucoma or ocular hypertension who underwent SLT between January 2001 and February 2015 by one surgeon at a single center after a failed phaco-ELT were evaluated. Exclusion criteria were: angle-closure glaucoma, optic nerve atrophy due to disease other than glaucoma, and additional glaucoma procedures between phaco-ELT and SLT. The main outcome measures were time to failure and Kaplan-Meier survival. Complete success was defined as a reduction of intraocular pressure (IOP) of > 3 mmHg and > 20% compared to baseline, and the number of AGM ≤ baseline. RESULTS: A total of 23 eyes of 21 subjects were included. Baseline IOP was 19.7 (range, 19.1-22.7) mmHg, and the number of AGM at baseline was 2.5 (range, 1.9-2.9). Median time to failure after SLT was 7.2 (range, 6.6-7.8) months. The number of antiglaucoma medications did not change during that time. CONCLUSIONS: In eyes in which the IOP is no longer controlled following phaco-ELT, SLT could be an option to slow disease progression or prolong time until incisional filtration surgery. However, time to failure after SLT is limited. Thus, close follow-up visits are necessary in order to not delay an incisional surgery.

Is laser trabeculoplasty the new star in glaucoma treatment?

PURPOSE OF REVIEW: For decades, laser trabeculoplasty has been a well-proven therapeutic option in glaucoma management, and more recently, it has only gained in popularity. One reason for such popularity is that selective laser trabeculoplasty (SLT) is a therapy independent of patient adherence, which is typically low among glaucoma patients. Consequently, the number of studies on SLT has multiplied throughout the past years. This review provides an overview of studies on SLT from the last 12 months. RECENT FINDINGS: The studies on treatment outcome show a wide range of success rates of SLT reaching between 18 and 88%; however, study designs differ and many studies are not directly comparable. The prospective laser trabeculoplasty for open-angle glaucoma and ocular hypertension (LiGHT) trial has demonstrated good efficacy of SLT - 75% of the eyes achieved their target pressure without drops and 58% after a single SLT. SUMMARY: SLT has proven to be effective in lowering IOP with satisfactory success rates even after single SLT. SLT is repeatable independent of patient's adherence.

Correction to: Incidence of dyschromatopsy in glaucoma.

In the original publication, the family and given name of authors were swapped incorrectly in the author group.

Incidence of dyschromatopsy in glaucoma.

PURPOSE: As proven in studies dating back to the eighteenth century, color vision changes may occur early in the course of glaucoma. Our aim was to reevaluate the incidence of acquired color vision deficiency in glaucoma patients of the University hospital Zürich by using the Panel D-15 test. METHODS: Inclusion criteria of the study involved a diagnosis of glaucoma, age equal or greater than 18 years with no upper limit and a best-corrected visual acuity (BCVA) smaller than ≤ 0.7 logMAR. All volunteers were tested twice monocularly for color vision with (1) the Ishihara color plate test and (2) the Farnsworth and Lanthony Panel D-15 test by one examiner (L.B.). Using the Moment of Inertia Method of Vingrys and King-Smith (Investig Ophthalmol Vis Sci 29(1):50-63, 1988), we measured the color defect type (blue-yellow, red-green or non-selective). RESULTS: One hundred and fifty-one eyes of 87 glaucoma patients were included in this study. Nine eyes showed a deficient result in the Ishihara test, which proves a congenital red-green weakness. Fifty-one (33.8%) eyes showed color vision anomalies in the desaturated test and 24 (15.9%) eyes in the saturated Panel D-15 test. A total of 25.2% and 8.6% of eyes in the desaturated and saturated test were diffuse dyschromatopsia, respectively. The second most prevalent deficiencies were blue-yellow defects with 4.0% and 4.6% of saturated and desaturated results. Just the covariate visual acuity had a significant influence on the Panel D-15 result, whereas other variables like age, sex or intraocular pressure did not show any impact. CONCLUSION: This study ascertains that the long-known theory of color vision defects in patients with glaucoma is also relevant in our sample of 151 eyes, providing continuity to claims firstly reported many years ago. Despite our results highlighting more diffuse dyschromatopsia than other similar experiments, we have also proven that the tritanomalous defects occur more frequently than other color defects.

Correction to: Success of combined cataract extraction plus excimer laser trabeculotomy exceeds that of combined ab interno trabeculectomy with the trabectome or cataract extraction alone.

In the original publication, the corresponding author name was spelt incorrectly.

Success of combined cataract extraction plus excimer laser trabeculotomy exceeds that of combined ab interno trabeculectomy with the trabectome or cataract extraction alone.

PURPOSE: To determine the efficacy of cataract surgery alone and combined with two minimally invasive glaucoma surgery (MIGS) procedures (phaco-ELT and phaco-aiT). METHODS: Data was collected from 12/2007 to 02/2012 in this retrospective, non-randomized, comparative single surgery center study. Reduction in IOP and hypotensive medication (AGD), change in visual acuity, success rates, and complications were computed by comparing preoperative data with data at 1 year postoperatively. RESULTS: A total of 245 eyes of 245 subjects were included. Study eyes underwent phaco alone (38 eye) or combined phaco-ELT (105 eye) and phaco-aiT (102 eye). Phaco alone, combined phaco-ELT, and combined phaco-aiT lowered IOP by 1.5 ± 4.0 mmHg, 4.3 ± 5.6, and 5.3 ± 4.5 mmHg, respectively (P < 0.01). Survival time of phaco-ELT outreached survival time of phaco alone and combined phaco-aiT (20.6 ± 1.0 vs. 13.2 ± 0.4 and 12.9 ± 0.6 month, respectively). No serious complications or adverse events occurred. None of the cases required a subsequent procedure within the first year to lower IOP further. CONCLUSIONS: All three surgical procedures lowered IOP and reduced medication. However, the IOP-lowering efficacy of the two combined MIGS procedures exceeded the effect of phaco alone. A combined phaco and MIGS procedures seem reasonable to consider whenever a cataract surgery in an eye with glaucoma or ocular hypertension is considered. In addition, the combined MIGS procedure effectively lowers IOP whenever a target IOP in the mid-teens is sufficient. In this study, the nonthermal phaco-ELT procedure showed superior efficacy at 1 year over phaco alone and phaco-aiT in the Kaplan-Meier statistics.

Influence of new treatment modalities on adherence in glaucoma.

PURPOSE OF REVIEW: It is well known that glaucoma patients are not adherent to their therapeutic regimens. The issue of nonadherence is multifactorial and includes inadequate communication between doctors and patients, resulting in significant costs associated with enhanced disease progression. Therapeutic regimens are risk factors which often influences adherence rates. Thus, alternative treatment modalities, especially those risk factors that do not rely on patients' cooperation, may enable improvements in long-term outcomes of glaucoma in patient. RECENT FINDINGS: The studies selected for this review were divided into new medications, especially advancements in pharmaceutical approaches to treat glaucoma and new ways of delivering the medication, new surgical methods, especially minimally invasive surgery methods for glaucoma, and new studies about adherence in glaucoma. SUMMARY: Surprisingly, a very few studies on glaucoma medication or surgery addressed the concept of adherence. However, adherence is discussed in studies which consider psychological aspects of patients or communication issues between doctors and patients. Although these studies were performed in clinical settings, the issue of adherence is not addressed; despite it has significant effect on long-term outpatient care. A combination of both aspects, adherence and miscommunication, should be considered in studies.

[Cyclodestructive Procedures to Lower Intraocular Pressure - A Review]. / Zyklodestruktive Verfahren zur Senkung des Augeninnendrucks ­ eine Übersicht.

The only therapy for glaucoma, for which there is sufficient evidence, is the lowering of intraocular pressure. Intraocular pressure reduction can be achieved by an improvement in outflow or a reduction of aqueous humor production. Surgically, a reduction of aqueous humor production can be achieved by cyclodestructive procedures. This article provides a brief summary of the different cyclodestructive procedures. The efficacy of cyclophotocoagulation is well documented. The risk profile has been reduced by changes in the laser protocols. Serious complications described in early studies (e.g., visual loss) rarely occur nowadays. The indication spectrum of cyclophotocoagulation has expanded from end-stage glaucoma to glaucoma with good visual acuity. Even the use of cyclodestructive procedures in pediatric glaucoma has gained acceptance. A promising next generation of micropulsed diode lasers could further reduce the risk profile with the same effectiveness. The non-inferiority of micropulse cyclophotocoagulation versus the established procedures has been proven in early studies. However, studies with long-term follow-up and on side-effects are still lacking. Furthermore, a standardized laser protocol must be established.

Twenty-four hour intraocular pressure measurements and home tonometry.

PURPOSE OF REVIEW: IOP is the only treatable risk factor contributing to glaucoma and most management and treatment of glaucoma is based on IOP. However, current IOP measurements are limited to office hours and control of glaucoma in many patients would benefit from the ability to monitor IOP diurnally so as not to miss abnormal pressures, which occur outside of office hours Consequently, to improve patient care, the ability to enable accurate and minimally disruptive diurnal IOP monitoring would improve caring for these patients. RECENT FINDINGS: The studies we selected for this review can be divided into three categories: self-/home-tonometry, continuous invasive intraocular pressure measurements, and continuous noninvasive ocular measurements. SUMMARY: The desire to obtain better insight in our patients' true diurnal IOP has led to the development of home-tonometers, in addition to extraocular and intraocular continuous pressure measurement devices. All of the devices have respective advantages and disadvantages, but none to date completely fulfills the goal of providing a true diurnal IOP profile.Video abstracthttp://links.lww.com/COOP/A27.

Increasing healthcare costs: can we influence the costs of glaucoma care?

PURPOSE OF REVIEW: Despite a decrease in real average growth rates per capita since 2009, healthcare costs continue to rise worldwide. Numerous patient-related and doctor-related factors have contributed to this rise. Glaucoma is the leading cause of irreversible blindness and requires chronic, usually lifelong treatment. As with other chronic diseases, the adherence to prescribed treatment is often low and maybe influenced by the cost of the therapy. The purpose of this review is to seek potential solutions to best control the escalating costs of glaucoma care. RECENT FINDINGS: The studies we selected for this review can be divided into four different categories: costs of diagnostic tests; costs of direct comparisons between drugs or laser and conventional surgery; patient-related factors (such as adherence); and general aspects regarding costs: theoretical models and calculations. SUMMARY: It is challenging to find reliable studies concerning this subject matter. As patients are under the umbrellas of variously organized healthcare systems which span different cultures, the costs between countries are difficult to compare. However, one common aspect to lower costs in glaucoma care is to improve patient adherence. Theoretical models with actual patient studies could enable cost reductions by comparing multiple diagnostic and therapeutic scenarios. VIDEO ABSTRACT: http://links.lww.com/COOP/A22.

Comparative analysis of human tear fluid and aqueous humor proteomes.

PURPOSE: Technological advancements allowing for the analysis of low-volume samples have led to the investigation of human tear fluid and aqueous humor (AH) as potential biomarker sources. However, acquiring AH samples poses significant challenges, making human tear fluid a more accessible alternative. This study aims to compare the protein compositions of these two biofluids to evaluate their suitability for biomarker discovery. METHODS: Paired tear and AH samples were collected from 20 patients undergoing cataract surgery. Tear samples were collected using Schirmer strips prior to surgery, and AH samples were collected from the anterior chamber immediately after corneal incision. Proteins were extracted and analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS: A total of 481 proteins were identified in greater than 50% of the tear samples, and 191 proteins were detected in greater than 50% of the AH samples. Of these proteins, 82 were found to be common between the two biofluids, with ALB, LTF, TF, LCN1, and IGKC being the most abundant. CONCLUSION: Although tear fluid and the AH are functionally independent and physically separated, many of the proteins detected in AH were also detected in tears. This direct comparison of the proteomic content of tear fluid and AH may aid in further investigation of tear fluid as a source of readily accessible biomarkers for various human diseases.

AHP DB: a reference database of proteins in the human aqueous humor.

The aqueous humor (AH) is a low-viscosity biofluid that continuously circulates from the posterior chamber to the anterior chamber of the eye. Recent advances in high-resolution mass-spectrometry workflows have facilitated the study of proteomic content in small-volume biofluids like AH, highlighting the potential clinical implications of the AH proteome. Nevertheless, in-depth investigations into the role of AH proteins in ocular diseases have encountered challenges due to limited accessibility to these workflows, difficulties in large-scale AH sample collection and the absence of a reference AH proteomic database. In response to these obstacles, and to promote further research on the involvement of AH proteins in ocular physiology and pathology, we have developed the web-based Aqueous Humor Proteomics Database (AHP DB). The current version of AHP DB contains proteomic data from 307 human AH samples, which were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The database offers comprehensive information on 1683 proteins identified in the AH samples. Furthermore, relevant clinical data are provided for each analyzed sample. Researchers also have the option to download these datasets individually for offline use, rendering it a valuable resource for the scientific community. Database URL: https://ahp.augusta.edu/.

Swiss Multicenter Ab Interno XEN45 Gel Stent Study: 2-Year Real-World Data.

INTRODUCTION: The aim of this study was to investigate the 2-year postoperative efficacy of the XEN45 Gel Stent by evaluating the reduction of intraocular pressure (IOP) and the need for eye pressure-lowering medications in a multicenter setting in Switzerland. METHODS: Patients with various types of glaucoma who received a XEN45 Gel Stent with or without combined phacoemulsification cataract surgery at five hospitals in Switzerland were retrospectively enrolled. Pre- and postoperative IOP, the number of antiglaucoma medications, and the need of subsequent interventions to control IOP were assessed. The success rate was defined as a ≥ 20% reduction of IOP 2 years postoperatively without the need for subsequent glaucoma surgery. RESULTS: A total of 345 eyes were included: 44.3% with primary open-angle, 42.0% pseudoexfoliation, and 13.7% with other types of glaucoma. Of these, 206 patients were followed for 2 years. Preoperatively, the mean IOP was 26.3 ± 8.9 mmHg and the mean number of antiglaucoma medications administered was 3.0 ± 1.3. Two years postoperatively, the success rate was 66.0% (95% confidence interval 59.3-72.1%), the IOP had dropped by 43.8% to 14.8 ± 5.7 mmHg, and the number of medications was reduced by a mean of 2.0 ± 1.7 per day. Postoperative complications and the need for interventions remained low. CONCLUSION: The XEN45 Gel Stent successfully reduced IOP and the number of antiglaucoma drugs in most patients at 2 years postoperatively.