Success of Primary Trabeculectomy in Advanced Open Angle Glaucoma.

AIM: The study assesed trabeculectomy survival in advanced open angle glaucoma (OAG). METHODS: This is a retrospective longitudinal study in advanced OAG undergoing primary trabeculectomy. Clinical and demographic parameters were recorded. Surgical survival (qualified/complete) was calculated by Kaplan-Meier analysis for multiple upper limits of intraocular pressure (IOP) with/without medication (≤21 mmHg, ≤18 mmHg, ≤15 mmHg, ≤12 mmHg); Cox hazard ratio analysis identified parameters influencing survival. RESULTS: We included 165 eyes from 165 OAG patients: primary forms (POAG) - 86 eyes and secondary (pseudoexfoliative, SOAG) - 79 eyes; mean follow-up interval was 36.21 ± 13.49 months. Clinical parameters were comparable between sub-groups at baseline, except a higher IOP in SOAG vs POAG (36.6 ± 13.2 vs 32.7 ± 11.1 mmHg, p = 0.04); IOP reduction was similar (SOAG vs POAG) 53.93% vs 56.19%, p = 0.45, yet longer hospitalization (8.47 ± 4.39 (SOAG) vs 6.69 ± 3.01 days (POAG), p=0.03) and more medications (0.65 ± 0.24 vs 0.36 ± 0.16, p = 0.05) were needed to achieve comparable final IOP (16.0 ± 9.1 vs 15.1 ± 7.8 mmHg, p = 0.45). Kaplan Meier survival analysis applied for IOP ≤21 mmHg, ≤18 mmHg, ≤15 mmHg and ≤12 mmHg, revealed complete success in 26.2%, 27.3%, 34.5% and 54.6% eyes, respectively; qualified success was found in 45.7%, 48.6%, 77% and 88.6% eyes, respectively. Multiple medications at baseline diminished survival in all tested models (hazard ratio HR > 1, p<0.05), while 5FU+needling improved survival, mostly if combined with lower IOP regime: HR = 0.15, 95% CI = [0.07 -1.12], p = 0.06, if IOP ≤15 mmHg and HR = 0.09, 95% CI = [0.02-1.25], p = 0.06, if IOP ≤12 mmHg. CONCLUSION: Trabeculectomy in advanced OAG reached very good survival rates (77% and 88.6%) at 36 months postoperative, if IOP could be maintained ≤15 mmHg, respectively ≤12 mmHg with medication and additional needling+5FU maneuvers. Specific factors influencing survival were identified for each success definition.

Influence of unilateral intravitreal bevacizumab injection on the incidence of symptomatic choroidal neovascularization in the fellow eye in patients with neovascular age-related macular degeneration (Review).

Neovascular age-related macular degeneration (neovascular ARMD) represents only 10% of ARMD cases but is responsible, if untreated, for quick and severe central vision loss due to major macular changes. The presence of choroidal neovascularization (CNV) in one eye is associated with an approximately 10% risk of CNV development in the fellow eye each year. Intravitreal anti-VEGF therapy has quickly evolved as the standard treatment in neovascular ARMD in the last decade due to significant anatomical and functional improvements, especially in the early stages. In many reports an improvement in the untreated fellow eye was mentioned and systemic exposure was soon confirmed for all anti-VEGF agents after unilateral intravitreal injection. In particular, bevacizumab intravitreal injection is followed by a consistent reduction of serum VEGF levels and the drug was shown to have the longest serum half-life raising important debates about its safety. Once bevacizumab was detected in the fellow eye of an animal model after unilateral injection, the possible influence on fellow eye conversion rate into neovascular ARMD was questioned. Although comparative studies have not found statistically significant differences between drugs regarding the incidence of symptomatic CNV in the fellow eye during treatment, we observed, on a retrospective 36-month evaluation, a reduced incidence of symptomatic CNV in the fellow eye that might be explained by the consistent systemic exposure of bevacizumab.

Inflammatory model in patients with primary open angle glaucoma and diabetes.

AIM: To assess the inflammatory cytokines expression in aqueous humor in diabetic primary open angle glaucoma (POAG) patients. METHODS: A cross-sectional study on 87 eyes, distributed as following: 26 eyes from diabetic patients, 16 eyes with POAG and 21 eyes from diabetic POAG patients; healthy controls (24 eyes) were recruited from patients undergoing conventional cataract surgery. A volume of 100 µL of aqueous humor (AH) was collected during phacoemulsification and 21 inflammatory markers were quantified using a Luminex® cytometric bead assay: IL-1Ra, IL-1α, IL-1ß, IL-5, IL-6, IL-10, IL-17, GM-CSF, IFNγ, CCL2, CCL3, CCL4, CXCL5, CXCL8, bFGF, VEGF, TNFα. Main changes in cytokine profile were analyzed and compared between groups. Data on demographics, duration of glaucoma, intraocular pressure (IOP), number of anti-glaucoma substances were recorded for correlation analysis and prediction models. RESULTS: Significant differences in cytokine expression between groups were detected for CXCL5 (P<0.001), CXCL8 (P=0.004), IL-1α (P<0.001), IL-2 (P<0.001), CCL4 (P=0.003), CCL5 (P<0.001) and TNFα (P=0.05). Post-hoc analysis identified IL-2 (P=0.009) and CXCL5 (P<0.001) as "separation markers" between POAG and diabetic POAG eyes. In POAG patients, the "separation markers" could highly predict the TNFα levels F(1, 16)=14.639, P<0.001, whereas in diabetic patients F(1, 24)=4.844, P=0.006 and diabetic POAG patients F(1, 19)=2.358, P=0.05 the level of prediction was inferior. CONCLUSION: Our results reveal an inflammatory model based on increased TNFα levels in POAG eyes. Simultaneous co-stimulatory molecules and additional inflammatory pathways need to be further explored in diabetic POAG cases, since the prediction model could only partially explain the increased TNFα level in this category of patients.

SHORT TERM EVALUATION OF PERIMETRIC PROGRESSION IN PATIENTS WITH OPEN ANGLE GLAUCOMA AND DIABETES.

AIM OF STUDY: Progression rate in patients with glaucoma and diabetes. MATERIAL AND METHOD: cohort prospective study in Ophthalmology Clinic "Sf. Spiridon" University Hospital Iasi. We recruited patients with positive history for diabetes and of open angle glaucoma (OAG). The control group included subjects with OAG (74 eyes from 74 patients) and the study group (44 eyes, from 44 patients) included subjects with OAG and diabetes. At enrollment all patients had a complete ophthalmologic evaluation along with full metabolic status assessment. There were included only incipient and moderate forms of glaucoma, with mild or no diabetic retinopathy changes. Perimetric progression was assessed at 24 months with automated methods. RESULTS: globally, from 118 investigated eyes, 56.40% cases had primary open angle glaucoma, 41.03% normal tension glaucoma and 2.36% pseudoexfoliative glaucoma. Glaucoma severity classification showed early defects (mean deviation < -6 db) in the study group of 77.27% vs. 83.78% in control group, whereas moderate defects (mean deviation > -6 db) were found in 22.63% in study group vs. 16.21.0% in control group. Mean age of the patients was higher in absolute value in the open angle glaucoma group (64.31 +/- 1.66 years), vs. diabetes + open angle glaucoma (62.69 +/- 1.8 years), with comparable visual acuities (0.91 +/- 0.15 vs. 0.89 +/- 0.16), CID ratios and other clinical pa- rameters (p > 0.05). Mean baseline lOP in the study group was 18.18 +/- 3.55 mrnHg vs. 17.08 +/- 2.4 nimHg in controls (p > 0.05). Analysis of visual field parameters at baseline showed a significant difference (p = 0.48) between groups in MD levels -3.63 +/- 3.35 db (control group) vs. -4.40 +/- 5.78 db (study group), but no difference (p > 0.05) in PSD levels: 3.71 +/- 3.06 db (control group) vs. 4.05 +/- 3.04 dB (study group). Perimetric progression was estimated at 24 months by Glaucoma Progression Analysis software (GPA-Humphrey Visual Field Analyzer II) using 6 reliable visual field (VF) exams. Progression rate was similar between groups--0.19 +/- 0.78 dB/year (OAG) vs. -0.18 +/- 0.05 dB/year (OAG+DM), p > 0.05 and no other risk factor could have been linked to an increased progression rate, except visual field parameters at final and baseline evaluation, in both groups. CONCLUSIONS: On short term, functional deterioration in open angle glaucoma patients having early or moderate stages, occurs similarly in the presence or absence of diabetes.

Risk factors and long term progression in open angle glaucoma patients.

Aim: Investigation of perimetric progression rate and associated risk factors in open angle glaucoma, in clinical practice. Methods: Retrospective study based on clinical charts reviews of patients with primary open angle glaucoma (POAG) being followed for > 5 years with >/ = 5 SITA Standard visual fields. Demographics, visual acuity (VA), central corneal thickness (CCT), intraocular pressure (IOP) and IOP variation, treatment (number of medications), visual fields and associated systemic pathologies were recorded. Patients were followed at every 3-6 months, when identical tests were performed. VF progression rate was calculated as slope of mean deviation (MD) over time by Glaucoma Progression Analysis software. Results: 121 eyes of 121 patients with POAG were included in the study and were followed for a mean period of 68.81 months (SD +/ - 31.7). The mean MD at start was -3.55 dB (SD +/ -5.19)., with a mean number of VF tests of 9.3+/ -2.9. Progression rate reached -0.21 +/ -0.1 db/ year. Mean IOP of all visits decreased over time from 18.20 mmHg to 16.53 mmHg (p<0.05). Systemic factors like positive history of hypertension reached statistical relevance in terms of increased risk for glaucoma progression, but only after age and sex were corrected. MD slope was explained in ANOVA univariate analysis, by the level of MD at baseline, IOP baseline, number of topical medications and CCT in a proportion equal to 71.7% (p=0.004). Conclusion: Rate of visual field changes in POAG was correlated and dependent on the baseline MD level, IOP at baseline, number of topical medications and a thin CCT.

PLATEAU IRIS SYNDROME--CASE SERIES.

Plateau iris is characterized by closing the anterior chamber angle due to a large ciliary body or due to its anterior insertion that alters the position of iris periphery in respect to the trabecular meshwork. There are two aspects that need to be differentiated: plateau iris configuration and plateau iris syndrome. The first describes a situation when the iris root is flat and the anterior chamber is not shallow, the latter refers to a post laser iridotomy condition in which a patent iridotomy has removed the relative pupillary block, but goniscopically confirmed angle closure recurs without central shallowing of the anterior chamber. Isolated plateau iris syndrome is rare compared to plateau iris configuration. We hereby present two case reports of plateau iris syndrome in young patients who came to an ophthalmologic consult by chance.

[Perimetric changes in advanced glaucoma]. / Modificari perimetrice în glaucoamele avansate.

AIM: The evaluation of various perimetric aspects in advanced glaucoma stages correlated to morpho-functional changes. MATHERIAL AND METHOD: Retrospective clinical trial over a 10 months time period that included patients with advanced glaucoma stages, for which there have been recorded several computerised visual field tests (central 24-2 strategy, 10-2 strategy with either III or V--Goldman stimulus spot size) along with other morpho-funtional ocular paramaters: VA, lOP optic disk analysis. RESULTS: We included in our study 56 eyes from 45 patients. In most cases 89% it was an open angle glaucoma (either primary or secondary) Mean visual acuity was 0.45 +/- 0.28. Regarding the perimetric deficit 83% had advanced deficit, 9% moderate and 8% early visual changes. As perimetric type of defect we found a majority with general reduction of sensitivity (33 eyes) + ring shape scotoma. In 6 eyes (10.7%) having left only a central isle of vision we performed the central 10-2 strategy with III or V Goldmann stimulus spot size. Statistic analysis showed scarce correlation between the visual acuity and the quantitative perimetric parameters (MD and PSD), and variance analysis found present a multiple correlation parameter p = 0.07 that proves there is no liniary correspondence between the morpho-functional parameters: VA-MD(PSD) and C/D ratio. CONCLUSIONS: In advanced glaucoma stages, the perimetric changes are mostly severe. Perimetric evaluation is essential in these stages and needs to be individualised.

[Modern assessment of perimetric progression in glaucoma]. / Evaluarea moderna a progresiei perimetrice în glaucom.

OBJECTIVE: Analysis of perimetric deficit progression and accurate evaluation of certain factors that are associated with perimetric progression in glaucomatous patients. MATERIAL AND METHODS: Cohort clinical trial that included a number of 80 eyes in 46 patients having a clear diagnosis of open angle glaucoma or ocular hypertension medically and/or surgically treated in which there have been followed both the dynamics in perimetric deficits and morpho functional parameters related closely and characteristically to the glaucomatous disease. Progression analysis was made using two different methods: manual, testing each spot's sensitivity at a time (EGS criterias were utilized) and automatic (through GPATM--Glaucoma Progression Analysis software). RESULTS: The study group (80 eyes) was evaluated and analyzed over a period of 63.8 months; in 27.5% we detected perimetric progression as it follows: 15 eyes by the GPA analysis and 19 eyes by the manual method. Concurrency rate between the two methods reached 87%. Associated factors with perimetric progression were: pseudoexfoliation, thin cornea, older age and cardiovascular diseases. CONCLUSIONS: Perimetry represents an essential method for the detection of glaucomatous progression. Computerized analysis methods are extremely important and come in clinician's help.