Prospective, Randomized Controlled Trial of Cataract Surgery vs Combined Cataract Surgery With Insertion of iStent Inject.

PURPOSE: To evaluate the efficacy and safety of combined cataract surgery with insertion of an ab interno trabecular microbypass device (iStent Inject, Glaukos Corporation) compared to cataract surgery alone in patients with mild-to-moderate glaucoma. DESIGN: Prospective, randomized, assessor-masked controlled trial at a single centre. PARTICIPANTS: Eyes with visually-significant cataract and mild-to-moderate glaucoma with preoperative intraocular pressure (IOP) of 12 to 30 mmHg on 0 to 3 ocular hypotensive medications. METHODS: Participants eyes were randomized (2017-2020) 1:1 to combined cataract surgery with iStent Inject (treatment group, n = 56) or cataract surgery alone (control group, n = 48), and followed up for 2 years. MAIN OUTCOME MEASURES: The co-primary effectiveness endpoints were the number of ocular hypotensive medications and IOP at 24-months post-surgery. The secondary effectiveness endpoints were ocular comfort as measured by the Ocular Surface Disease Index (OSDI) and vision-related quality of life as measured by the Glaucoma Activity Limitation Questionnaire (GAL-9) at 24-months. Safety measures included postoperative visual acuity, any unplanned return to the operating theatre, adverse events, and complications. RESULTS: Participants (67.3% male) were aged 53 to 85 years, and treatment groups were similar in terms of mean medicated IOP (treatment group 17.7 mmHg ± 4.0; control group 17.1 mmHg ± 3.1), and number of ocular hypotensive medications (treatment group 1.69 ± 1.05; control group 1.80 ± 1.22) at baseline. At 24 months, the number of ocular hypotensive medications were 0.7 ± 0.9 in the treatment groups compared to 1.5 ± 1.9 in the control group, with an adjusted difference of 0.6 fewer medications per eye in the treatment group (95% CI 0.2-1.1, P = 0.008). In the treatment group, 57% of eyes were on no glaucoma medications compared to 36% in the control group. There was no significant difference in IOP between the 2 groups beyond the 4-weeks. There were no differences in patient-reported outcomes between the 2 groups. The visual outcomes and safety profiles were similar between the 2 groups. CONCLUSIONS: Combined cataract surgery with iStent Inject achieved a clinically- and statistically-significantly greater reduction in ocular hypotensive medication usage at 24-months compared to cataract surgery alone, with no significant difference in IOP. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Online Circular Contrast Perimetry: A Comparison to Standard Automated Perimetry.

PURPOSE: The aim was to validate and compare the diagnostic accuracy of a novel 24-degree, 52-loci online circular contrast perimetry (OCCP) application to standard automated perimetry (SAP). DESIGN: Prospective cohort study. METHODS: Two hundred and twenty participants (125 normal controls, 95 open angle glaucoma patients) were included. Agreement, correlation, sensitivity, specificity, and area under receiver operating curves (AUC) were compared for parameters of OCCP, SAP, and optical coherence tomography (OCT) for the retinal nerve fiber layer and macular ganglion cell complex inner plexiform layer. RESULTS: Pointwise sensitivity for OCCP was greater than SAP by 1.02 log units (95% CI: 0.95-1.08); 95% limits of agreement 0.860 to 1.17. Correlation and agreement for global indices and regional zones between OCCP and SAP were strong. OCCP mean deviation (MD) AUC was 0.885±0.08, similar to other instruments' parameters with the highest AUC: SAP MD (0.851±0.08), OCT retinal nerve fiber layer inferior thickness (0.908±0.07), OCT ganglion cell complex inner plexiform layer inferior thickness (0.849±0.08), P>0.05. At best cutoff, OCCP MD sensitivity/specificity were comparable to SAP MD (90/74 vs 94/65%). CONCLUSIONS: OCCP demonstrates similar perimetric sensitivities to SAP and similar AUC to SAP and OCT in distinguishing glaucoma patients from controls. OCCP holds promise as a glaucoma surveillance and screening tool, with the potential to be utilized for in-clinic and at-home perimetry and expand community testing.

Online circular contrast perimetry via a web-application: optimising parameters and establishing a normative database.

PURPOSE: To establish a normative database and optimise parameters for personal-computer based perimetry via a web-application using circular contrast targets. METHODS: Online 24-degree 52-loci perimetry was delivered through a web-application using circular flickering contrast targets. Embedding contrast differentials within targets allows calculation of relative decibel (rdB) per 256-bit greyscale level differential. Target light-band maximum brightness colour was fixed, while the dark-band varied to achieve the desired rdB level. A staircase system was used with two reversals ranging from 0 to 36 rdB levels. Blind spot localisation at the start of the test was used to optimise viewing distance and subsequently count fixation losses. Gaze was maintained on a spinning golden star which moves mid-test to maximise sampling area. Patients performed the test to each eye separately using a computer in a darkened room at 40-45 cm. RESULTS: 158 eyes of 101 patients completed the Online Circular Contrast Perimetry (OCCP) test. Mean age was 62.9 ± 14.3 years old. Mean sensitivity reduced with age, at 1.0 relative decibel per decade. Mean sensitivity per locus correlated with standard automated perimetry (SAP) in a physiological hill of vision, with an average difference of 4.02 decibels (95% confidence interval (CI) = 3.77-4.27, p < 0.001) and good agreement between tests. CONCLUSIONS: Online circular contract perimetry provides accurate perimetric testing with comparable results to standard automated perimetry.

Daily Meditation Practice for Managing Glaucoma Patients' Attitudes and Acceptance.

PRCIS: Overall, 63% of glaucoma patients agreed to 45-60 minutes of daily meditation. Predictors of accepting meditation included previous meditation practice, a diagnosis of glaucoma <1 year, and having a marital status of "single". PURPOSE: To explore patients' acceptance and barriers towards 45-60 minutes daily meditation for glaucoma management and to identify glaucoma patients with higher perceived stress levels who may benefit more from meditation practice. METHODS: Glaucoma patients attending the Royal Victorian Eye and Ear Hospital, Melbourne, Australia outpatient department were invited to complete a patient survey. This survey explored if patients would agree to 45-60 minutes of daily meditation and included the Determinants of Meditation Practice Inventory and Perceived Stress Scale questionnaires. Questionnaire scores were compared across participants' clinical and demographic characteristics using Student t test, ANOVA, and multiple-linear-regression analysis. RESULTS: Of the 123 eligible patients screened, 100 completed the survey (81.3%). Sixty-three (63%) patients would agree to 45-60 minutes of daily meditation if advised by their doctor. Univariate analysis showed increased acceptance of meditation (lower Determinants of Meditation Practice Inventory scores) to be associated with agreeing to meditate 45-60 minutes daily ( P =0.002), currently or previously practicing meditation ( P =0.006 and P =0.0004 respectively), and having a marital status as "single" ( P =0.02). Multivariate regression analysis showed previous meditation practice and a glaucoma diagnosis of <1 year to be predictive of accepting meditation ( P =0.01 and P =0.03 respectively). There were no predictive factors of Perceived Stress Scale scores. CONCLUSION: Given the high acceptance rate of 45-60 minutes daily meditation (63% of glaucoma patients sampled), this may be recommended for the benefit of patients. Patients who have previously meditated, have a relatively new diagnosis of glaucoma, and are single (marital status) were more accepting of meditation practice.