Visual field progression in patients with severe glaucoma.

PURPOSE: To assess the cumulative risk of progression in glaucomatous eyes in the severe stage of disease. METHODS: This was a retrospective observational study. Patients that had severe damage in at least one eye, as defined by three criteria including a mean deviation of ≤ - 20 dB, were included. Glaucoma progression was defined as a loss of ≥ 2 dB in mean deviation confirmed in three consecutive visual field tests, or a persistent loss of two or more lines of vision-not attributable to non-glaucomatous causes-in three consecutive follow-up examinations. Kaplan-Meier survival analysis was used to assess the cumulative incidence of progression of the first eye to reach endpoint in cases where both eyes were eligible. RESULTS: A total of 143 eyes from 119 patients, were studied over a mean period of 4.9 ± 2.9 years. Baseline mean deviation was - 25.3 ± 3.6 dB. Twenty-three eyes of 22 patients reached the progression endpoint: 14 eyes by visual field criteria and 9 by visual acuity criteria. The cumulative 5-year risk of progression estimated by Kaplan-Meier analysis was 14.6% (95% confidence interval: 6.1-22.2%). CONCLUSIONS: In severe glaucoma patients, we found a cumulative incidence of progression of 2.9% per year during the first 5 years of follow-up. Similar incidences have been reported in other studies of glaucoma at different stages of severity.

Subconjunctival Injections of Mitomycin C Are Associated with a Lower Incidence of Hypertensive Phase in Eyes with Ahmed Glaucoma Valve.

PURPOSE: To evaluate the association of intraoperative and postoperative subconjunctival injections of mitomycin C (MMC) and rate of the hypertensive phase after implantation of the Ahmed glaucoma valve (AGV). DESIGN: Comparative case series. PARTICIPANTS: This retrospective comparative study included 37 eyes of 35 patients with uncontrolled glaucoma on maximum tolerated medical therapy who underwent implantation of AGV by a single surgeon. METHODS: Consecutive cases operated without the use of MMC from 2015 to 2017 were compared with consecutive cases operated from 2018 to 2019 under a standardized protocol of subconjunctival MMC injections. The MMC group received 0.1 ml of MMC (0.25 mg/ml) injected intraoperatively, at 1 and 4 weeks after the surgery. MAIN OUTCOME MEASURES: Incidence of the hypertensive phase (defined as intraocular pressure [IOP] >21 mmHg during the first 3 postoperative months) was compared across groups. Intraocular pressure and glaucoma medications were also compared during the course of the first 6 postoperative months. RESULTS: In the MMC and no-MMC groups, 17.6% (3/17) and 55.0% (11/20) of the cases exhibited a hypertensive phase (P = 0.04), respectively. Both groups were comparable in baseline characteristics, including age, preoperative IOP, preoperative glaucoma medications, and previous glaucoma surgeries. At 6 months, mean IOP was 14.0 ± 0.8 mmHg and 14.7 ± 0.9 mmHg for the MMC and no-MMC groups, respectively (P = 0.6). The mean number of glaucoma medications at 6 months was 1.2 ± 0.2 and 2.2 ± 0.3 in the MMC and no-MMC groups, respectively (P = 0.007). CONCLUSIONS: Eyes that underwent implantation of AGV experienced a lower incidence of hypertensive phase and required fewer medications when using a standardized protocol of intraoperative and postoperative subconjunctival MMC injections.

Glaucomatous visual field loss associated with less travel from home.

PURPOSE: To determine the association between glaucoma and travel away from home. METHODS: Fifty-nine glaucoma suspect controls with normal vision and 80 glaucoma subjects with bilateral visual field (VF) loss wore a cellular tracking device during 1 week of normal activity. Location data were used to evaluate the number of daily excursions away from home as well as daily time spent away from home. RESULTS: Control and glaucoma subjects were similar in age, race, sex, employment, driving support, cognitive ability, mood, and comorbid illness (p > 0.1 for all). Better-eye VF mean deviation (MD) averaged 0.0 decibels (dB) in controls and -11.1 dB in glaucoma subjects. In multivariable models, glaucoma was associated with fewer daily excursions (ß = -0.20; 95% confidence interval [95% CI], -0.38 to -0.02) and a greater likelihood of not leaving home on a given day (odds ratio [OR], 1.82; 95% CI, 1.05 to 3.06). Each 5-dB decrement in the better-eye VF MD was associated with fewer daily excursions (ß = -0.06; 95% CI, -0.11 to -0.01) and a greater chance of not leaving home on a given day (OR, 1.24; 95% CI, 1.04 to 1.47). Time spent away from home did not significantly differ between the glaucoma subjects and suspects (p = 0.18). However, each 5-dB decrement in the better-eye MD was associated with 6% less time away (95% CI, -12 to -1%). CONCLUSIONS: Individuals with glaucoma, particularly those with greater VF loss, are more home bound and travel away from home less than individuals with normal vision. Because being confined to the home environment may have detrimental effects on fitness and health, individuals with glaucoma should be considered for interventions such as orientation and mobility training to encourage safe travel away from home.

The choroid is thicker in angle closure than in open angle and control eyes.

PURPOSE: To study factors associated with choroidal thickness (CT) and to compare CT in angle closure (AC), open angle (OA), and normal eyes. METHODS: Forty controls, 106 OA, and 79 AC subjects underwent measurements of posterior CT by spectral domain-optical coherence tomography, and of intraocular pressure (IOP), blood pressure, axial length (AL), and central corneal thickness (CCT). RESULTS: CT was significantly greater in AC than in OA and normal eyes (HSD test, P ≤ 0.05), but there was no significant difference between OA and normal CT; mean CT was 234, 235, and 318 µm in the normal, OA, and AC groups, respectively. With multivariable analysis among all participants, thinner CT was associated with older age, longer AL, higher IOP, and thicker CCT (all P ≤ 0.03, R(2) = 0.45). Adjusting for other relevant variables, the AC group had a significantly greater CT than either the normal or the OA group (P = 0.003 and 0.03, respectively). In multivariable analysis including only OA and AC patients, neither cup-to-disc ratio nor visual field mean deviation were significantly associated with CT. Multivariable analysis for CT among normal eyes found longer AL to be associated with thinner CT (P = 0.04). CONCLUSIONS: AC eyes had significantly thicker CT than OA and normal eyes, even after adjusting for the shorter AL in AC eyes, supporting hypotheses that choroidal expansion contributes to the development of AC disease. Age, AL, CCT, and IOP were also significantly associated with CT, while severity of glaucoma damage was not.

Choroidal thickness change after water drinking is greater in angle closure than in open angle eyes.

PURPOSE: To study change in choroidal thickness (CT) after water drinking test (WDT), comparing angle closure (AC) to open angle (OA) eyes. METHODS: Before and 30 minutes after drinking 1 L of water, 88 glaucoma subjects underwent measurements of CT by spectral domain-optical coherence tomography, IOP, blood pressure (BP), axial length (AL), and anterior chamber depth (ACD). RESULTS: Baseline CT was significantly greater in AC than in OA eyes (P = 0.002). After WDT, BP, IOP, and AL increased significantly (all P ≤ 0.0001). Mean CT increased significantly in the AC group (5.6 µm, P = 0.04, n = 40) and among 80 subjects whose IOP rose > 2 mm Hg (responders; 3.2 µm, P = 0.048), but not in the OA group or among all subjects (2.5 µm increase overall, <1% of baseline CT, P = 0.10). ACD decreased in AC (-18 µm, P = 0.07), but not in OA eyes (+3 µm, P = 0.74). AC eyes had a significantly greater IOP increase after WDT than OA eyes (P = 0.002, multivariate regression). Among responders, CT increased more in those with larger diastolic perfusion pressure increase and in AC compared to OA eyes (P = 0.04 and P = 0.053, respectively, multivariate regression). CONCLUSIONS: A significant increase in CT and a decrease in ACD after WDT were observed in AC but not in OA eyes, and IOP increased significantly more in AC than in OA eyes, suggesting that the dynamic behavior of the choroid may play a role in the AC process. IOP increase after the WDT was not fully explained by CT increase.

Impact of eyelid closure on the intraocular pressure lowering effect of prostaglandins: a randomised controlled trial.

BACKGROUND/AIMS: To determine if eyelid closure (ELC) after topical prostaglandin instillation provides greater intraocular pressure (IOP) reduction than prostaglandin instillation without ELC. METHODS: Patients receiving chronic bilateral prostaglandin monotherapy were enrolled in this study. The study intervention, ELC, was randomly assigned to one eye, while the fellow eye served as control. ELC was performed for either 1 min or 3 min. After a 1-day washout, the IOP was measured in a masked fashion at baseline, 1 h and 24 h, and at a final visit that took place 7-14 days after enrolment. All visits were scheduled during the morning, and every individual patient's visits occurred at similar times during the day. The main outcome was difference between intervention eye and control eye in IOP-lowering from baseline. RESULTS: 51 patients meeting eligibility criteria were enrolled: 25 were randomised to ELC for 1 min and 26 to ELC for 3 min in the intervention eye. The pooled IOP-lowering difference (95% CI, p value) in intervention versus control eyes was 0.24 mm Hg (-0.5 to 0.9, p=0.50), 0.24 mm Hg (-0.7 to 1.2, p=0.61) and 0.24 mm Hg (-0.7 to 1.2, p=0.61) in the overall group, 1 min ELC subgroup and 3 min ELC subgroup, respectively. The effect of ELC did not change significantly across visits. CONCLUSIONS: ELC did not provide significant additional IOP reduction compared with no ELC in patients using chronic prostaglandin monotherapy. Trial Registration http://clinicaltrials.gov/ct2/show/NCT0083283.

Choroidal thickness measured by spectral domain optical coherence tomography: factors affecting thickness in glaucoma patients.

PURPOSE: To measure choroidal thickness and to determine parameters associated with it. DESIGN: Cross-sectional study. PARTICIPANTS: Seventy-four glaucoma patients and glaucoma suspects. METHODS: Spectral domain optical coherence tomography (SD-OCT) scans were obtained to estimate average choroidal thickness in a group of glaucoma suspects and glaucoma patients. The average thickness was calculated from enhanced depth SD-OCT images and manually analyzed with Image J software. Open-angle glaucoma, open-angle glaucoma suspect, primary angle-closure glaucoma, primary angle closure, and primary angle-closure suspect were defined by published criteria. Glaucoma suspects had normal visual fields bilaterally. Glaucoma was defined by specific criteria for optic disc damage and visual field loss in ≥1 eye. The most affected eye was analyzed for comparisons across individuals, and right/left and upper half/lower half comparisons were made to compare thickness against degree of visual field damage. MAIN OUTCOME MEASURES: Average macular and peripapillary choroidal thickness measured using SD-OCT. RESULTS: The choroidal-scleral interface was visualized in 86% and 96% of the macular and peripapillary scans, respectively. In multivariable linear regression analysis, the macular choroid was significantly thinner in association with 4 features: Longer eyes (22 µm per mm longer [95% confidence interval (CI), -33, -11]), older individuals (31 µm thinner per decade older [95% CI, -44, -17]), lower diastolic ocular perfusion pressure (26 µm thinner per 10 mmHg lower [95% CI, 8, 44]), and thicker central corneas (6 µm per 10 µm thicker cornea [95% CI, -10, 0]). The choroid was not significantly thinner in glaucoma patients than in suspects (14 µm [95% CI, -54, 26]; P = 0.5). Peripapillary choroidal thickness was not significantly different between glaucoma and suspect patients. Thickness was not associated with damage severity as estimated by visual field mean deviation or nerve fiber layer thickness, including comparisons of right with left eye or upper with lower values. CONCLUSIONS: Age, axial length, CCT, and diastolic ocular perfusion pressure are significantly associated with choroidal thickness in glaucoma suspects and glaucoma patients. Degree of glaucoma damage was not consistently associated with choroidal thickness. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.