The Effectiveness of a Nurse-led Glaucoma Education on Patient Knowledge and Compliance Motivation Levels: A 1-year Prospective Case Series.

Purpose: To evaluate the impact of a nurse-led glaucoma education program on patient knowledge and compliance levels in an Asian population. Materials and Methods: A 1-year prospective case series involving 69 adult glaucoma patients. Each patient attended a standardized nurse-led glaucoma education session. A questionnaire was administered by a single nurse-clinician and analyzed at three time points (preeducation for baseline, immediately posteducation, and at the 1-year follow-up) to evaluate for associations with patient knowledge and compliance motivation levels. Results: A total of 64 patients were included in the final analysis. Patients with higher educational qualifications or who were employed had better baseline knowledge of glaucoma. Younger patients had higher baseline compliance motivation levels. Immediately posteducation, both median patient knowledge score and compliance motivation levels had a statistically significant increase. Patients on more glaucoma eye drops had greater immediate improvement in confidence in eye drop application. Patients with more positive Humphrey visual field mean deviation values had a greater immediate improvement in confidence in their understanding of glaucoma. A total of 34 patients were readministered the questionnaire at the 1-year time point. Median score for patient knowledge was highest at this point. Employed patients demonstrated better patient knowledge at baseline and at 1-year time point compared to unemployed patients. Unemployed patients experienced a significant improvement in scores from baseline to immediately posteducation, but improvement from immediately posteducation to the 1-year time point was insignificant was insignificant. Conclusion: Our study has examined the effectiveness of a nurse-led glaucoma education program in an Asian population, demonstrating improvement in both patient knowledge and compliance motivation levels up to 1 year after intervention. How to cite this article: Sng JJ, Ang BCH, Soo Hoo WC, et al. The Effectiveness of a Nurse-led Glaucoma Education on Patient Knowledge and Compliance Motivation Levels: A 1-year Prospective Case Series. J Curr Glaucoma Pract 2023;17(3):149-156.

Intraoperative Optical Coherence Tomography for Ab Interno Trabecular Bypass Glaucoma Surgery.

ABSTRACT: The purpose of this study was to demonstrate a case of a novel surgical technique utilizing intraoperative optical coherence tomography (iOCT) to aid implantation and optimal placement of 2 trabecular bypass minimally invasive glaucoma surgery devices-the iStent inject W and the Hydrus microstent. In iStent inject W implantation, where the depth of stent implantation has been correlated to postoperative outcomes. the iOCT allowed real-time appreciation of device implantation depth relative to the trabecular meshwork surface. In Hydrus microstent implantation, the iOCT allowed confirmation of successful stent placement within the Schlemm canal, and may help in cases where intraoperative gonioscopic view of the 3 microstent windows is impeded. This case demonstrated the use of the iOCT as an imaging adjunct to ensure optimal placement of trabecular bypass minimally invasive glaucoma surgery devices such as the iStent inject W and Hydrus microstent.

"Culture-positive exogenous endophthalmitis related to XEN45 gel stent implantation".

PURPOSE: The XEN45 gel stent implant (Allergen, CA, USA) is one of many micro-invasive surgical options available to glaucomatologists. Our case series describes the presentation, treatment, and possible risk factors of XEN45 gel stent related endophthalmitis. OBSERVATIONS: A 71 year old Chinese man and a 88 year old Caucasian woman underwent XEN45 gel stent implantation for primary open angle glaucoma. They presented with endophthalmitis at 7 and 4 months post-surgery respectively. The first patient had stent exposure with blebitis while the second patient did not show any signs of conjunctival defect, stent exposure, bleb leak nor blebitis. Both patients were treated immediately with intravitreal, topical and systemic antibiotics, followed by early vitrectomy. The implant was removed in the first, but not in the second patient. Vitreous cultures grew Streptococcus Viridans in the first patient and Haemophilus influenzae in the other. Unfortunately, the first patient eventually sustained a total retinal detachment requiring surgery and did not recover his vision. The second patient however, recovered with a good Snellen's visual acuity of 6/9 and maintenance of good intraocular pressure and bleb formation. CONCLUSIONS: Exogenous endophthalmitis related to XEN45 gel stent implantation is a rare but devastating complication. The risks factors identified were multiple post-operative procedures, bleb exposure, conjunctival defect, use of antifibrotics, blepharitis and prolonged post-operative antibiotics. XEN45 gel stent implant provides a different challenge to ophthalmologists compared to trabeculectomy as more post-operative procedures are required to prevent subconjunctival scarring. Great care should be taken to individualize the use of antifibrotics in each patient to balance the risk of subconjunctival fibrosis with the risk of infection. In patients with stent exposure we propose early closure of the conjunctiva to close off the portal of entry for pathogens and reduce the need for prophylactic topical antibiotics.

The performance of iPad-based noise-field perimeter versus Humphrey Field Analyser in detecting glaucomatous visual field loss.

BACKGROUND: To conduct a preliminary evaluation of the feasibility of visual field fast (VFF), a free iPad-based noise-field perimeter, in detecting glaucomatous scotomas versus the clinical-standard Humphrey visual field (HVF) test. VFF confronts subjects with a screen of flickering stimulus, allowing the immediate perception of scotomas. METHODS: This was a cross-sectional observational study of 66 glaucoma patients (66 eyes) and 30 healthy controls (30 eyes). All patients had no other visual field disorders. VFF was compared against HVF in terms of whole field and quadrants for the following: (1) correspondence in scotoma detection. (2) Agreement and correlation of the scotoma size (percentage of abnormal visual field area). (3) Test duration. Other domains tested included: (1) correlation of VFF scotoma area with the severity of visual field loss on HVF (mean deviation, MD; visual field index, VFI). (2) Repeatability of VFF. (3) Patient descriptors of scotomas. RESULTS: Using HVF pattern deviation plot as a reference, VFF detected 52/57 (91.2%) of glaucoma subjects with 1 false-positive (control) (kappa = 0.86). 146/184 (79.3%) of abnormal quadrants (visual field defect present) were localized and 23/157 (14.6%) healthy quadrants were falsely identified as abnormal (kappa = 0.61). VFF underestimated scotoma area as compared to HVF (21.0% versus 44.0%, p < 0.01) but correlated positively (r = 0.268, p = 0.044) with HVF area and negatively with VFI (r = -0.340, p = 0.01) and MD (r = -0.398, p < 0.01). Using HVF total deviation plot as reference, VFF's glaucoma detection rate remained unchanged (kappa = 0.86) with similar quadrant detection (kappa = 0.68). However, a greater underestimation of scotoma area was observed (21.0% versus 85.4%, p < 0.01). VFF's quantitative repeatability was excellent for whole field (intraclass correlation coefficient, ICC: 0.96; p < 0.0001) and quadrants (ICC: 0.82-0.96; all p < 0.001). Qualitatively, 35/37 (94.6%) of subjects reported reduced luminance and flicker in scotomas, with similar morphologies on retests. VFF is faster than HVF SITA-Standard in glaucoma (3.60 ± 1.85 min versus 6.92 ± 1.12 min, p < 0.01) and control (1.12 ± 0.486 min versus 5.16 ± 0.727 min, p < 0.01). CONCLUSION: This early model of VFF accurately detected scotomas with high repeatability. However, its accuracy in localizing and quantifying the scotoma can be improved. Considering its portability and cost-effectiveness, VFF demonstrated potential as a general screening tool for moderate-to-severe glaucoma.

12-Month Outcomes of Combined Phacoemulsification and iStent Inject in Asian Eyes with Normal Tension Glaucoma: A Single-Centre Experience.

PURPOSE: To evaluate efficacy and safety of the iStent inject combined with phacoemulsification in Asian eyes with normal-tension glaucoma (NTG) up to 12 months after surgery. STUDY DESIGN: Retrospective case series. METHODS: Retrospective case series of eyes undergoing surgery from April 2017 to August 2019. Outcome measures included intraocular pressure (IOP), number of topical glaucoma medications and adverse outcomes. Data were retrieved from the post-operative day 1 (POD1), week 1 (POW1), month 1 (POM1), month 3 (POM3), month 6 (POM6) and month 12 (POM12) timepoints. Data were analysed at each timepoint for eyes with available clinical data at that visit. Subgroup analysis was performed for a consistent cohort which included only eyes with data at all six follow-up timepoints. RESULTS: Data from 91 eyes in the collective subject group was analysed. Majority of subjects were male (53, 58.2%) and Chinese (79, 86.8%). Mean age was 73.2 ± 7.2 years. Pre-operatively, mean IOP was 14.3 ± 3.0 mmHg and mean number of medications was 1.5 ± 0.8. Significant IOP reduction was observed at all timepoints except POW1 and POM12. The number of medications was reduced at all timepoints (p < 0.001). By POM12, there was reduction of 1.2 ± 1.0 medications (p < 0.001). Both the collective and consistent cohorts demonstrated a trend towards decreasing surgical efficacy with time, in IOP reduction and decrease in medications. None of the eyes experienced sight-threatening complications. CONCLUSIONS: Asian eyes with NTG undergoing combined phacoemulsification and iStent inject surgery demonstrated significant and sustained reduction in number of glaucoma medications up to 12 months post-operatively.

Visual field progression 8 years after trabeculectomy in Asian eyes: results from The Singapore 5-Fluorouracil Study.

BACKGROUND/AIMS: This work aimed to study the effect of long-term intraocular pressure (IOP) fluctuation on visual field (VF) progression 8 years post-trabeculectomy in Asian eyes. METHODS: This was a retrospective analysis of 8-year post-trabeculectomy data from The Singapore 5-Fluorouracil (5-FU) Study. VFs were analysed using Progressor software (Medisoft, Leeds, UK). Outcome measures included mean slope for VF per year, number of progressing points and mean slope for progressing points per year. Multivariate regression analyses were performed adjusting for age, gender, ethnicity, glaucoma type, intraoperative 5-FU, diabetes mellitus, hypertension, best pre-trabeculectomy VF mean deviation, post-trabeculectomy mean IOP, IOP reduction and IOP fluctuation (SD of IOPs at 6-monthly timepoints). RESULTS: 127 (52.3%) subjects completed 8-year follow-up with ≥5 reliable VFs and ≥8 6-monthly IOP measurements. Mean age was 61.8±9.6 years. Post-operatively, mean IOP was 14.2±2.8 mm Hg and mean IOP fluctuation was 2.53±1.20 mm Hg. Higher IOP fluctuation was associated with greater mean slope for field (B=-0.071; p=0.013), number of progressing points (B=0.963; p=0.014) and VF progression as defined by ≥1 progressing point (OR=1.585; p=0.029). There was also a trend towards eyes with higher IOP fluctuation having ≥3 adjacent progressing points in the same hemifield (OR=1.489; p=0.055). Greater mean IOP reduction post-trabeculectomy was associated only with a lower mean slope for progressing points per year (B=-0.026; p=0.028). There was no significant effect of intra-operative 5-FU compared with placebo for all outcome measures. CONCLUSION: In post-trabeculectomy Asian eyes with well-controlled IOP, higher long-term IOP fluctuation may be associated with greater VF progression.

Efficacy of the XEN gel stent on intraocular pressure lowering in East Asian eyes.

PURPOSE: This study aims to evaluate the efficacy and safety of XEN45 gel stent (Allergan plc, Dublin, Ireland) in East Asian patients with glaucoma. METHODS: A retrospective study of consecutive XEN45 gel stent implantation surgeries with or without concurrent cataract surgery from May 2017 to August 2018 was performed in a single institution. The clinical charts of all cases were reviewed to examine the safety and efficacy of the implant. Primary outcome measures were intraocular pressure (IOP), number of topical glaucoma medications required, additional procedures done and adverse outcomes. All patients included were required to fulfil a minimum of three follow-up visits by post-operative month 1. RESULTS: Sixty-three eyes were included in the study. The median duration of follow-up was 6 months [interquartile range (IQR) 2-9]. Median IOP was significantly lowered from 19 mmHg (IQR 16-24) pre-operatively to 15 mmHg (IQR 11-18) at the end-of-follow-up (p < 0.001). The median number of medications was reduced from 3 (IQR 2-4) at baseline to 0 (IQR 0-2) at the end-of-follow-up (p < 0.001). 66.7% of patients were medication-free by the end of follow-up. Post-operative bleb intervention was required for 61.9% of eyes. Adverse events included post-operative hypotony requiring intervention (4.8%) and post-operative gross hyphaema (9.6%). CONCLUSION: The XEN45 gel stent when used as a sole procedure or in combination with cataract surgery in East Asian eyes is effective in the treatment of glaucoma. However, a high rate of post-operative bleb intervention appears to be required to support its efficacy.

Intra-operative optical coherence tomography in glaucoma surgery-a systematic review.

The application of the OCT in clinical ophthalmology has expanded significantly since its introduction more than 20 years ago. There has been recent growing interest in the application of intra-operative optical coherence tomography (iOCT). The iOCT's ability to enhance visualisation and depth appreciation has the potential to be further exploited in glaucoma surgery, especially with the emergence of Minimally Invasive Glaucoma Surgery (MIGS)-to facilitate targeted device placement and fine surgical manoeuvres in the angles, the sub-conjunctival layer and the suprachoroidal space. Hence, this study aims to appraise the current literature on the applications of iOCT in glaucoma surgery. A total of 79 studies were identified following a literature search adhering to PRISMA guidelines. After full text evaluation, 10 studies discussing iOCT use in glaucoma surgery were included. Traditional glaucoma filtering procedures reviewed included trabeculectomy surgery, goniosynechiolysis, bleb needling and glaucoma drainage device implantation. MIGS procedures reviewed included canaloplasty, trabecular aspiration, ab-interno trabectome and the XEN45 gel stent. iOCT use in ophthalmic surgery is becoming increasingly prevalent and has already been applied in various surgeries and procedures in the field of glaucoma. With the greater adoption of MIGS, iOCT may further contribute in facilitating surgical techniques and improving outcomes. While iOCT offers many advantages, there are still limitations to be overcome-iOCT technology continues to evolve to optimise imaging quality and user-experience.

Proteomic Analysis of Aqueous Humor from Primary Open Angle Glaucoma Patients on Drug Treatment Revealed Altered Complement Activation Cascade.

Primary open angle glaucoma (POAG) is a complex disease and a leading cause of irreversible blindness, and its underlying pathophysiology remains poorly understood. Proteomic characterization of the protein composition of aqueous humor (AH) may identify prognostic candidate proteins involved in pathogenesis and progression of the disease. To delineate the possible mechanisms that lead to POAG, this study adopted state-of-art mass spectrometric technique and analyzed AH of POAG and their respective controls. In total, more than 1000 proteins were identified with false discovery rate of less than 1%. Numerous proteins of complement cascade, immunoglobulin, neuronal and amyloidogenic proteins, which were part of processes like acute-phase and inflammatory response, humoral immune and acute inflammatory response, regulation of complement activation and protein processing were identified. Proteins of complement system underwent significant changes, which correlate to pathogenic events characterizing POAG, including altered complement cascade, astrocyte activation, neural degeneration, and apoptosis. Further, protein modification such as deamidation of complement subcomponent was noted, particularly in POAG. Proteomic analysis of AH allows a better understanding of the mechanism involved in the pathogenesis of POAG.

Evaluation of Various Cooling Systems After Exercise-Induced Hyperthermia.

CONTEXT: Rapid diagnosis and expeditious cooling of individuals with exertional heat stroke is paramount for survival. OBJECTIVE: To evaluate the efficacy of various cooling systems after exercise-induced hyperthermia. DESIGN: Crossover study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-two men (age = 24 ± 2 years, height = 1.76 ± 0.07 m, mass = 70.7 ± 9.5 kg) participated. INTERVENTION(S): Each participant completed a treadmill walk until body core temperature reached 39.50°C. The treadmill walk was performed at 5.3 km/h on an 8.5% incline for 50 minutes and then at 5.0 km/h until the end of exercise. Each participant experienced 4 cooling phases in a randomized, repeated-crossover design: (1) no cooling (CON), (2) body-cooling unit (BCU), (3) EMCOOLS Flex.Pad (EC), and (4) ThermoSuit (TS). Cooling continued for 30 minutes or until body core temperature reached 38.00°C, whichever occurred earlier. MAIN OUTCOME MEASURE(S): Body core temperature (obtained via an ingestible telemetric temperature sensor) and heart rate were measured continuously during the exercise and cooling phases. Rating of perceived exertion was monitored every 5 minutes during the exercise phase and thermal sensation every minute during the cooling phase. RESULTS: The absolute cooling rate was greatest with TS (0.16°C/min ± 0.06°C/min) followed by EC (0.12°C/min ± 0.04°C/min), BCU (0.09°C/min ± 0.06°C/min), and CON (0.06°C/min ± 0.02°C/min; P < .001). The TS offered a greater cooling rate than all other cooling modalities in this study, whereas EC offered a greater cooling rate than both CON and BCU (P < .0083 for all). Effect-size calculations, however, showed that EC and BCU were not clinically different. CONCLUSION: These findings provide objective evidence for selecting the most effective cooling system of those we evaluated for cooling individuals with exercise-induced hyperthermia. Nevertheless, factors other than cooling efficacy need to be considered when selecting an appropriate cooling system.

Changes in Japanese eyes after laser peripheral iridotomy: an anterior segment optical coherence tomography study.

BACKGROUND: The aim was to investigate the changes in anterior segment parameters, as assessed by anterior segment optical coherence tomography in Japanese subjects after laser peripheral iridotomy (LPI). DESIGN: This was a prospective observational study. PARTICIPANTS: The participants include 72 subjects with angle closure including primary angle closure suspect (PACS), primary angle closure (PAC), and primary angle closure glaucoma (PACG). METHODS: Anterior segment optical coherence tomography parameters was measured by customized software. Complete data of 51 subjects were available for final analysis. MAIN OUTCOME MEASURES: These were the following parameters: angle opening distance, trabecular-iris space area, anterior chamber depth, width, area and volume (iris thickness, curvature, and area, and lens vault (LV). RESULTS: A total of 25 PACS, 17 PAC and 9 PACG were included. Mean age was 74.7 ± 6.7 years, and majority were women (80.4%). Following LPI, there was a significant increase in mean gonioscopic angle width (1.16 vs. 1.93, P < 0.001) and a corresponding increase in angle opening distance, trabecular-iris space area, and angle recess area (all P < 0.001). The anterior chamber area (P < 0.001), anterior chamber volume (P < 0.001) and anterior chamber depth (P = 0.003) increased significantly; and iris curvature (P < 0.001) was significantly reduced. There were no significant changes in anterior chamber width, LV, iris thickness and area. Age-adjusted and gender-adjusted analysis for predictors of percentage change in angle opening distance 750 showed significant association with greater baseline LV (ß = 0.32, P = 0.03). No significant differences were noted in the mean percentage change in parameters between the PACS and PAC-PACG. CONCLUSIONS: An increase in anterior chamber dimensions, angle widening and iris flattening; with a constant LV, iris thickness and iris area after LPI was demonstrated in Japanese eyes with angle closure.

The Singapore 5-fluorouracil trial: intraocular pressure outcomes at 8 years.

OBJECTIVE: To report the 8-year outcomes of Asian subjects who underwent trabeculectomy augmented by intraoperative 5-fluorouracil (5-FU) or placebo. DESIGN: Retrospective review of a randomized controlled trial. PARTICIPANTS: Subjects with primary open-angle or angle-closure glaucoma. METHODS: Study subjects were prospectively followed up for 3 years. After the last subject recruited had completed 8 years of follow-up, the charts of all subjects were reviewed to capture data from the year 3 visit onward. Kaplan-Meier survival function with Cox regression was performed to identify risk factors associated with trabeculectomy failure at 8 years. MAIN OUTCOME MEASURES: The primary outcome was trabeculectomy failure defined as intraocular pressure (IOP) >21 or <6 mmHg on 2 consecutive occasions after the first 6 weeks after surgery, repeat glaucoma surgery, or loss of light perception. Further end points were defined at IOP levels >17 and >14 mmHg. Secondary outcomes included IOP at 8 years and number of glaucoma medications. Complete success was defined using IOP end points ≤ 21, ≤ 17, or ≤ 14 mmHg at 8 years without medications. RESULTS: Of the 243 enrolled subjects, 170 (70.0%) completed 8 years follow-up, 86 in the 5-FU and 84 in the placebo group. There was no significant difference in failure rates at 8 years for the failure definitions of IOP >21 mmHg (11.6% of the 5-FU group vs. 16.7% of the placebo group; P = 1.00), IOP >17 mmHg (23.3% of the 5-FU group vs. 31% of the placebo group; P = 0.78), and IOP >14 mmHg (46.5% of the 5-FU group vs. 58.3% of the placebo group; P = 0.37). Mean IOP at 8 years was 13.7 mmHg in the 5-FU versus 14.4 mmHg in the placebo group (P = 0.24). Mean number of medications was 0.65 drops in the 5-FU versus 0.93 drops in the placebo group (P = 0.06). Complete success with IOP ≤ 21 mmHg at 8 years was achieved in 48 subjects (55.8%) in the 5-FU and 33 subjects (39.3%) in the placebo group (P = 0.09). Absence of bleb microcysts at 1 year, preoperative IOP, and number of bleb needlings performed within the first year were significantly associated with failure. CONCLUSIONS: There was no significant difference in IOP between the 5-FU and the placebo group at 8 years. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.