Overuse and Underuse of Visual Field Testing Over 15 Years.

PRéCIS:: A 15-year analysis of 198,843 visual field (VF) tests revealed a growing trend for their performance for nonglaucoma indications. Adherence to glaucoma management guidelines was suboptimal. Guidelines for referral to VF assessments should be established. PURPOSE: The purpose of this study was to identify trends in VF assessments over 15 years among patients with and without suspected or confirmed glaucoma, in a large healthcare maintenance organization. METHODS: This was a population-based retrospective cohort study, conducted by means of electronic medical database analyses. STUDY POPULATION: Maccabi Healthcare Services is an healthcare maintenance organization that insures 2 million members constituting 25% of the population. All members who underwent at least 1 VF test between January 2000 and December 2014 were included. In addition, all members with glaucoma or suspected glaucoma diagnosis or who were prescribed with antiglaucoma medications were evaluated. MAIN OUTCOME MEASURES: VF performance rates. RESULTS: A total of 93,617 Maccabi Healthcare Services members underwent 198,843 VF tests; of whom 47.9% involved patients without any glaucoma-related conditions. There was a growing trend over time toward more of those members to undergo VF tests and, by 2014, non-glaucoma-related members comprised 74.0% of new VF assessments. In contrast, 32.3% of glaucoma-related patients did not perform even 1 VF test throughout the entire study period. Although over 2 years (25.95±6.33 mo) passed between the first glaucoma-related diagnosis and first VF test, once a patient underwent the first VF test, an average once-a-year VF follow-up (0.95±0.37 annual tests) began. CONCLUSION: There is a growing trend for VF tests being apparently overused for indications other than glaucoma. Concurrently, adherence to glaucoma management guidelines on VF tests is suboptimal, leading to discernible underuse. Guidelines for VF assessments in nonglaucoma patients should be established. Adherence to existing glaucoma management guidelines should be improved.

Gold Micro-Shunt Implants Versus Ahmed Glaucoma Valve: Long-term Outcomes of a Prospective Randomized Clinical Trial.

PURPOSE: To compare long-term outcomes of Ahmed glaucoma valve (AGV), 24 µm Gold Micro-Shunt (GMS), and 48 µm GMS implantation for treatment of refractory glaucoma. PATIENTS AND METHODS: This was a 3-armed randomized interventional prospective clinical trial. Within an institutional setting, 29 adults (29 eyes) with refractory glaucoma [mean baseline intraocular pressure (IOP) ≥ 22 mm Hg on maximal medication, status post at least 1 failed trabeculectomy, defined visual field defect, and without recent glaucoma-related surgery] were randomly assigned to AGV, 24 µm GMS, or 48 µm GMS implantation. Exclusion criteria included uveitic, traumatic, or neovascular glaucoma. The 3 groups were comparatively evaluated preoperatively and 1, 2, 3, and 5 years postoperatively for IOP and numbers of glaucoma medications needed. Main outcome measures were implant survival rates. Results of the 24 and 48 µm GMS groups were also compared separately. RESULTS: In all groups the final IOP (in mm Hg) was significantly lower than the preoperative IOP (17.3 ± 2.6 vs. 33.5 ± 6.7, P=0.004; 17.8 ± 2.4 vs. 25.7 ± 0.7, P=0.0001; and 19.6 ± 5.2 vs. 35.6 ± 2.2, P=0.0001 in the AGV, 24 µm GMS, and 48 µm GMS groups, respectively). Differences between initial and final mean numbers of medications were not significant. Cumulative probabilities of success at 5 years were 77.8%, 77.8%, and 72.7%, respectively. CONCLUSIONS: During long-term follow-up, success rates in the 2 GMS groups and the AGV group were similar. Likewise, IOP reduction and the need for continued glaucoma medical therapy remained high and were similar for all devices.

High-intensity focused ultrasound treatment in refractory glaucoma patients: results at 1 year of prospective clinical study.

PURPOSE: To evaluate the safety and efficacy of the ultrasonic circular cyclo-coagulation procedure using high-intensity focused ultrasound by a miniaturized annular device containing 6 piezoceramic transducers in patients with refractory glaucoma. METHODS: This was a prospective interventional noncomparative study of 20 eyes of 20 patients with refractory glaucoma. All eyes were treated with 6 activated transducers operating at 21 MHz. Ultrasound biomicroscopy and a complete ophthalmic examination were performed before the procedure and at 1 day, 1 week, and 1, 3, 6, and 12 months after the procedure. Primary outcomes were surgical success (defined as intraocular pressure (IOP) reduction from baseline ≥20% and IOP >5 mm Hg) at the last follow-up visit. Secondary outcomes were mean IOP at each follow-up visit compared to baseline, medication use, complications, and re-interventions. RESULTS: Intraocular pressure was significantly reduced (p<0.01) from a mean preoperative value of 36.4 ± 5.7 mm Hg to a mean postoperative value of 22.5 ± 10.3 mm Hg at 12 months. Four patients needed to be re-treated. The mean IOP reduction achieved was 38%. Surgical success was achieved in 13 of 20 eyes (65%). No major intraoperative or postoperative complications occurred. CONCLUSIONS: Ultrasonic circular cyclo-coagulation using high-intensity focused ultrasound delivered by a circular miniaturized device containing 6 piezoceramic transducers is an effective and well-tolerated method to reduce IOP in patients with refractory glaucoma.

CO2 laser-assisted deep sclerectomy in glaucoma patients.

PURPOSE: To evaluate the safety and efficacy of CO2 laser-assisted deep sclerectomy surgery (CLASS) in patients with open angle glaucoma. DESIGN: A prospective single-arm, nonrandomized clinical investigation for the evaluation of technology. METHODS: Fifteen eyes of 15 consecutive patients diagnosed with either primary open angle glaucoma or pseudoexfoliation glaucoma who were the candidates for glaucoma filtration surgery were included. Laser-assisted deep sclerectomy using a CO2 laser system was performed in all patients. A half-thickness scleral flap was created, the use of 0.04% mitomycin C for 60 seconds was left at the surgeon's discretion, and a CO2 laser with a beam-manipulating system was used to achieve deep scleral ablation and unroofing of Schlemm's canal zone. Visual acuity, complete ophthalmologic examination, and intraocular pressure (IOP) were measured and documented at baseline, 1, 2, 4, and 6 weeks and at 3, 6, and 12 months, respectively. Complete success was defined as 5≤IOP≤21 mm Hg and 20% IOP reduction with no medication at the 12-month endpoint visit. Qualified success was defined as a similar IOP reduction with medication. RESULTS: The preoperative IOP of 27.3±4.2 mm Hg (mean±SD) dropped to 15.0±3.7 mm Hg at 6 months and 16.6±3.4 mm Hg at 12 months postoperatively, yielding an average IOP reductions at 6 and 12 months of 13.1±4.3 mm Hg (45.1%; 95% CI, 11, 15.3) and 11.5±5.5 mm Hg (39.2%; 95% CI, 8.8, 14.3), respectively (P<0.001). The complete success rate after 12 months was 45.5%, whereas qualified success was 90.9%. Mitomycin C was used in 76.9% of the CLASS subjects.

Postoperative treatment with topical diclofenac versus topical dexamethasone after combined phacotrabeculectomy with mitomycin C.

OBJECTIVE: The objective of the study was to compare the efficacy and safety of topical dexamethasone sodium phosphate 0.1% (Sterodex) to diclofenac sodium 0.1% (Voltaren Ophthalmic) after combined phacotrabeculectomy with mitomycin C. METHODS: This prospective, randomized, double-masked clinical trial includes 42 patients with glaucoma and cataract who underwent a combined phacotrabeculectomy. Patients were randomly assigned to postoperative treatment with topical diclofenac sodium 0.1% or topical dexamethasone phosphate 0.1%. Follow-up duration was 12 months and all examinations were masked. The main outcome measures were intraocular pressure (IOP), number of glaucoma medications, and bleb morphology. RESULTS: Baseline characteristics of the diclofenac (n=21) and dexamethasone (n=21) patients were similar. Phacotrabeculectomy with both postoperative treatments was effective in reducing IOP, lowering the number of glaucoma medications and improving visual acuity at all follow-up points. The average number of medications taken by the dexamethasone group was significantly greater than the diclofenac group at 8 months (1.2 ± 1.4 and 0.3 ± 0.6, respectively, P=0.03). The mean bleb height of the diclofenac group was significantly higher than the dexamethasone group at 3 weeks (P=0.05), and the mean bleb width was significantly wider at 8 months (P=0.04). No significant group differences in IOP were found at any of the follow-up visits, although there was a clinical trend toward lower IOP values in the diclofenac group. Sixteen patients (76%) in the diclofenac group and 17 patients in the dexamethasone group (81%) completed 1 year of follow-up. CONCLUSIONS: In this preliminary study, diclofenac sodium is at least as good as topical dexamethasone phosphate for glaucoma patients undergoing two-site combined phacotrabeculectomy with mitomycin C.

Selective laser trabeculoplasty in uncontrolled pseudoexfoliation glaucoma.

BACKGROUND AND OBJECTIVE: To assess the efficacy and safety of selective laser trabeculoplasty (SLT) in uncontrolled pseudoexfoliation glaucoma (PEXG). PATIENTS AND METHODS: Fifty-seven eyes (57 patients) with uncontrolled PEXG and intra-ocular pressure (IOP) greater than 23 mm Hg underwent SLT. All received ophthalmic evaluation preoperatively and at intervals postoperatively. IOP was measured at 1 hour, 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. During follow-up, patients were treated with topical anti-glaucoma medications as necessary. RESULTS: One year postoperatively, mean IOP in all patients decreased from 26.01 ± 2.5 to 17.8 ± 2.8 mm Hg (31.5%; P < .001). Mean medications per patient decreased from 2.8 to 2.3. Complications included conjunctival redness and infection within 1 day postoperatively in 30 eyes (67%). One hour after SLT treatment, an increase in IOP greater than 5 mm Hg was detected in two eyes (3.5%) and resolved within 24 hours with topical medication. CONCLUSION: SLT is safe and effective in patients with PEXG.

Titanium:sapphire laser trabeculoplasty versus argon laser trabeculoplasty in patients with open-angle glaucoma.

BACKGROUND AND OBJECTIVE: To compare the medium-term outcome of titanium:sapphire laser trabeculoplasty (TLT) (SOLX, Inc., Waltham, MA) to argon laser trabeculoplasty (ALT) in patients with uncontrolled open-angle glaucoma. PATIENTS AND METHODS: Thirty-seven patients with open-angle glaucoma who had uncontrolled intraocular pressure and no previous filtration surgery participated. Eighteen patients were treated with TLT and 19 patients were treated with ALT. All patients underwent comprehensive eye and visual field examinations. RESULTS: The 18 patients in the TLT group had an average (+/- standard deviation) reduction of 8.3 (+/- 2.7) mm Hg, or 32%, from preoperative intraocular pressure (P < .001). The 19 patients in the ALT group had an average reduction of 6.5 (+/- 4.3) mm Hg, or 25%, from preoperative intraocular pressure (P < .001). Patients in both groups achieved a similar decrease in intraocular pressure (P > .05). Two patients (1 in each group) underwent trabeculectomy and were considered failures. Mean follow-up time was 15 months. CONCLUSION: TLT provides similar efficacy to ALT in intraocular pressure reduction in patients with open-angle glaucoma. If confirmed in additional studies, TLT may be used as an alternative to ALT in patients with open-angle glaucoma.

Efficacy and safety of gold micro shunt implantation to the supraciliary space in patients with glaucoma: a pilot study.

PURPOSE: To evaluate the safety and efficacy of Gold Micro Shunt (GMS) implantation to the supraciliary space in patients with glaucoma. METHODS: A total of 38 patients with glaucoma with uncontrolled intraocular pressure (IOP) underwent implantation of the GMS in this prospective 2-center study. MAIN OUTCOME MEASURES: Intraocular pressure and surgical complications. RESULTS: A total of 38 patients with glaucoma participated. The mean follow-up time was 11.7 months. The IOP decreased a mean (SD) of 9 mm Hg from 27.6 (4.7) to 18.2 (4.6) mm Hg (P < .001). Surgical success was achieved in 30 patients (79%) (IOP >5 and <22 mm Hg, with or without antiglaucoma medication). Eight patients had mild to moderate transient hyphema. CONCLUSIONS: Implantation of GMS to the supraciliary space is a safe and effective method of controlling IOP in patients with glaucoma. Use of the GMS resulted in a significant decrease in IOP. APPLICATION TO CLINICAL PRACTICE: The GMS could be an alternative surgical device to standard trabeculectomy.

Intraocular pressure elevation within the first 24 hours after cataract surgery in patients with glaucoma or exfoliation syndrome.

OBJECTIVE: To investigate whether eyes with glaucoma or exfoliation syndrome without glaucoma are prone to exhibit intraocular pressure (IOP) elevation shortly after cataract surgery and, if so, whether timolol maleate 0.5% reduces these spikes. DESIGN: Prospective randomized double-masked clinical trial. PARTICIPANTS: One hundred twenty-two patients with normal eyes, medically well-controlled glaucoma, or exfoliation syndrome who underwent uneventful phacoemulsification cataract extraction. METHODS: Patients were randomly assigned to an immediately postoperative drop of either timolol maleate 0.5% or no treatment. Intraocular pressure was measured preoperatively and 4, 8, and 24 hours and 1 week later. MAIN OUTCOME MEASURES: Intraocular pressure measurements. RESULTS: The changes in postoperative IOP over time differed significantly between glaucoma, exfoliation syndrome, and normal (P = 0.005). Intraocular pressure was significantly lower in the normal group (n = 25) than in both the glaucoma (n = 18) and exfoliation syndrome (n = 19) groups (P<0.001). With 1 drop of prophylactic timolol maleate 0.5% at completion of surgery, the normal group (n = 25) again had IOP significantly lower than those of the glaucoma (n = 15) and exfoliation syndrome (n = 20) groups (P<0.001). Treatment with timolol maleate 0.5% significantly changed postoperative IOP over time in the glaucomatous eyes (P = 0.003), but it made no difference in the exfoliation syndrome (P = 0.4) or normal (P = 0.5) eyes. Intraocular pressure > 25 mmHg did not occur among normal eyes. Intraocular pressure > 25 mmHg and > 30 mmHg occurred in 10 (55%) and 5 (28%) glaucoma patients, respectively, and 5 (27%) and 2 (11%) exfoliation syndrome patients, respectively. Timolol maleate 0.5% eliminated IOP spikes > 30 mmHg and reduced the frequency of IOP > 25 mmHg in both groups to 14% in the glaucoma group and 5% in the exfoliation syndrome group. Most IOP elevation occurred at 4 hours postoperatively. The mean IOP was <20 mmHg in all groups 1 day postoperatively. CONCLUSIONS: Medically well-controlled glaucoma patients and patients with exfoliation syndrome may experience IOP elevation shortly after cataract surgery. Instillation of timolol maleate 0.5% at the end of the procedure in this series eliminated IOP > 30 mmHg, but IOP elevation below that level can still occur.

Donor scleral patch for treating hypotony due to leaking and/or overfiltering blebs.

OBJECTIVE: To report a modified technique of bleb revision with the use of a donor scleral patch in cases in which scleral melting did not allow effective suturing and closure of the aqueous leak. The suturing technique ensures tight adaptation of the scleral patch over the leaky region, and allows better-controlled aqueous flow with loose suturing of the posterior edge of the scleral patch. METHODS: Records of patients who underwent bleb revision with donor scleral graft from 1997 to 2003 were reviewed retrospectively. Chart information including demographic and clinical data was recorded preoperatively and 1 day, 1 week, 1 month, 6 months, and at final follow-up. RESULTS: Fifteen patients underwent this surgical procedure for bleb revision. The mean follow-up time was 22.0 +/- 24.0 months (median = 8.0 months). The mean preoperative visual acuity was 20/50 and the mean intraocular pressure (IOP) was 2.9 +/- 2.3 mm Hg, which improved to 20/30 and 14.1 +/- 3.3 mm Hg respectively, on last follow-up. CONCLUSIONS: The scleral patch with 4-nylon sutures should be proposed in cases in which a macerated scleral bed is revealed during the revision. The loose suturing of the scleral patch at its posterior border was found to prevent intraocular pressure spikes.