Impact of a Brief Educational Intervention on Glaucoma Persistence: A Randomized Controlled Clinical Trial.

PURPOSE: To determine whether two sessions of a glaucoma educational intervention resulted in better persistence to glaucoma eye drop therapy compared to normal care. METHODS: A total of 165 patients newly diagnosed with glaucoma who required eye drop therapy were recruited into a randomized clinical trial from the glaucoma clinic at Maisonneuve-Rosemont Hospital in Montreal, Canada. Patients were randomized to either an immediate intervention or normal care. The intervention consisted of two 60-90 minute sessions of education on glaucoma and its management, given in a small group format by a non-practicing ophthalmologist. Persistence to glaucoma medication was examined for 1 year by the use of Hospital medical records and by pharmacy claims records from the Régie de l'assurance maladie du Québec (Quebec Health Insurance Program). A questionnaire was administered, and medication possession ratio calculated. The primary outcome was persistence, defined as having medication available at least 75% of the time. Secondary outcomes included eye drop instillation technique and perception of the importance of eye drop therapy. RESULTS: The intervention group achieved better persistence to eye drop therapy, as 77% of controls and 89% of people receiving the intervention were persistent (p = 0.049). The intervention also resulted in better eye drop instillation technique (p < 0.001) and greater perception of the importance of eye drop therapy (p < 0.001). CONCLUSIONS: Brief instructional sessions offered to newly diagnosed glaucoma patients can result in better persistence rates over 1-year follow-up. Strategies to permanently offer these types of initiatives should be considered.

The value of intraocular pressure asymmetry in diagnosing glaucoma.

PURPOSE: To investigate the amount of intraocular pressure (IOP) asymmetry in a large group of ethnically diverse patients with and without glaucoma, and to delineate the risk for glaucoma which increasing amounts of IOP asymmetry confer upon the patient. PATIENTS AND METHODS: Collaborative retrospective study of 326 glaucoma patients and 326 controls. Former Wills Eye Institute fellows collected single pre-treatment measurements of IOP on patients diagnosed as having definite glaucoma based on characteristic optic nerve damage and confirmatory visual field damage. Patients with a normal eye examination who had normal-appearing optic discs and no apparent glaucoma, or who had a normal eye examination in association with refractive error or cataract, were used as controls. RESULTS: Intraocular pressure asymmetry is a significant risk factor for having glaucoma (odds ratio, 2.14; 95% confidence interval, 1.86-2.47; P<0.001). Absence of IOP asymmetry between the fellow eyes is associated with a 1% probability of having glaucoma. A difference of 3 mm Hg is associated with a 6% probability of having glaucoma, and a difference of >6 mm Hg with a 57% probability of having glaucoma. The association between IOP asymmetry and glaucoma status is significant for subjects with both elevated IOP (P=0.014) and statistically normal IOP (maximum IOP ≤ 21 mm Hg; P<0.001). CONCLUSIONS: Inter-eye asymmetry of IOP is a common finding in patients with glaucoma. There is a direct relationship between the amount of IOP asymmetry between the fellow eyes and the likelihood of having glaucoma.

The early flat anterior chamber after trabeculectomy: a randomized, prospective study of 3 methods of management.

PURPOSE: To evaluate prospectively 3 different approaches to the management of a flat anterior chamber (FAC) because of overfiltration in the early postoperative period after trabeculectomy. MATERIALS AND METHODS: Thirty-six eyes diagnosed with a FAC with total iridocorneal touch, but no lenticular touch (grade II) because of overfiltration in the first 14 days after trabeculectomy were randomized prospectively into 3 groups: group 1--anterior chamber reformation with viscoelastic substance; group 2--anterior chamber reformation with balanced salt solution and concurrent drainage of choroidal effusion; and group 3--pharmacologic therapy with atropine, phenylephrine, and in select cases oral acetazolamide. Outcome measures were visual acuity, amount of intraocular pressure (IOP) reduction, and achievement of predetermined target IOP. RESULTS: Treatment group 2 had a greater number of eyes with acuity decline of two or more lines relative to group 3 (P=0.04). Group 1 had more eyes with acuity decline of two or more lines relative to group 3, but this was not significant (P>0.05). CONCLUSIONS: For grade II FACs because of overfiltration in the early postoperative period after trabeculectomy, reformation of the anterior chamber with drainage of choroidal effusion may be associated with greater long-term trabeculectomy success, but is associated with greater visual acuity loss relative to medicinal therapy alone. Reformation with viscoelastic resulted in a trend toward lowest final IOP in comparison to medicinal therapy alone.

Progressive optic neuropathy in congenital glaucoma associated with the Sirsasana yoga posture.

The authors describe a case of progressive optic neuropathy in a patient with congenital glaucoma who had routinely practiced the Sirsasana (headstand) yoga posture for several years. Ophthalmic examination included best-corrected visual acuity, anterior segment examination, indirect ophthalmoscopy, ultrasound pachymetry for central corneal thickness, and intraocular pressure before, during, and after maintaining the Sirsasana posture for 5 minutes. Intraocular pressure increased significantly during the Sirsasana posture. Transient elevation in intraocular pressure during yoga exercises may lead to progressive glaucomatous optic neuropathy, especially in susceptible patients with congenital glaucoma.

Oral niacin can increase intraocular pressure.

The intraocular pressure of a 73-year-old man with a history of primary open-angle glaucoma had been approximately 21 and 17 mm Hg in the right and left eyes, respectively, while taking latanoprost 0.005% and dorzolamide hydrochloride 2%. When taking 500 mg of oral niacin (also known as vitamin B3 or nicotinic acid), his intraocular pressure increased to 37 and 27 mm Hg in the right and left eyes, respectively, on one occasion. On reexamination, the intraocular pressure had increased to 28 and 23 mm Hg in the right and left eyes, respectively. Each time the niacin was stopped, the intraocular pressure decreased to the original levels.

Releasable suture technique.

PURPOSE: Releasable scleral flap sutures have been effectively used with trabeculectomy to provide a safer postoperative course. This review will assess the indications for using releasable sutures, with the consideration of their advantages and disadvantages, after trabeculectomy. METHODS: A review of the literature provided the most common releasable suture techniques. RESULTS: Releasable scleral flap sutures reduce the incidence of complications of early postoperative overfiltration after trabeculectomy. As a result, there are fewer cases that might require reformation of the anterior chamber and drainage of suprachoroidal fluid. In contrast to performing laser suture lysis; there is no need for a laser, suture visibility under the conjunctiva is irrelevant, and no contact lens is required. CONCLUSIONS: The use of releasable scleral flap sutures in guarded filtration surgery safely provides an effective and simple way of titrating intraocular pressure postoperatively. It allows the transition from a relatively low flow state to a higher rate of subconjunctival filtration to achieve a satisfactory long-term outcome of glaucoma surgery.

Limitations of the Heidelberg Retina Tomograph.

Glaucoma is a progressive optic neuropathy where damages that occur at the optic nerve head and the retinal never fiber layer are associated with changes in the visual field. The Heidelberg Retina Tomograph (Heidelberg Engineering, Carlsbad, CA), a scanning laser ophthalmoscope, performs a three-dimensional topographic analysis of the optic nerve head and the retinal never fiber layer. The Heidelberg Retina Tomograph has been reported to be a reliable and objective method of identifying structural changes prior to the occurrence of visual field defects. In our series of patients, all had significant visual field defects but normal Heidelberg Retina Tomograph results, including rim area and Moorfield regression analysis. It is important to recognize that interpreting the Heidelberg Retina Tomograph results alone may be misleading; however, when combined with careful clinical evaluation of the optic nerve head and the visual field, the Heidelberg Retina Tomograph may provide valuable information in assisting the clinician with the diagnosis and management of glaucoma.

Post-peripheral iridotomy inflammation in patients with dark pigmentation.

A retrospective chart review of four patients who had Nd:YAG peripheral iridotomy performed for narrow anterior chamber angle and subsequently developed marked inflammation after tapering anti-inflammatory steroids. These cases were possibly predisposed to this reaction by the heavy pigmentation of their irides based on race, their use of latanoprost, or the conjunction of these factors.

Managing refractory glaucoma with a fixed combination of bimatoprost (0.03%) and timolol (0.5%).

Glaucoma is a chronic progressive optic neuropathy characterized by progressive loss of retinal ganglion cells, which manifests clinically with loss of optic disc neuroretinal rim tissue, defects in the retinal nerve fiber layer, and deficits on functional visual field testing. The goal of glaucoma treatment is to reduce the intraocular pressure to a level that prevents or minimizes the progressive loss of vision. The current standard of management for the newly diagnosed primary open angle glaucoma (PAOG) patient is to start topical medication. Available topical medications include: beta-adrenergic antagonists, alpha-adrenergic agonists, carbonic anhydraze inhibitors, prostaglandin analogues and miotics. In some patients, IOP is not adequately controlled by monotherapy. In those refractory patients, where more efficacy is required, shifting to another medication or adding a second medication is indicated. The complimentary action between two drugs serves as the basis for combination medications. One avenue of delivering a second medication is through a fixed combination medication that has the advantage of providing two medicines within one drop. Bimatoprost/timolol represents a new fixed combination which is clinically and statistically more effective than either of its active constituents for patients with refractory glaucoma. As regard the safety of the combination, there were no signs or symptoms of intolerance and the incidence of conjunctival hyperemia was clinically and statistically significantly less than each of the two components separately. Bimatoprost/timolol fixed combination offers cost and time savings, which may enhance compliance; also reducing the amount of preservative applied to the eye, will improve tolerability and may also favorably improve eventual surgical outcomes in patients who might require filtering procedures.

Role of intravitreal bevacizumab in neovascular glaucoma.

We report on the effect of intravitreal bevacizumab (IVB) for the treatment of neovascular glaucoma (NVG). A retrospective chart review of 6 consecutive cases of NVG was performed. The follow-up period was 3-19 months (average, 9.7 months). All patients received 1.25 mg (0.05 cc) of IVB followed by panretinal photocoagulation (PRP) approximately 1 week later. In all cases, there was a complete regression of iris and anterior chamber angle neovascularization. However, 2 eyes showed a recurrence of neovascularization; in 1 case, it recurred after 3 months, and in the second, after 5 months. These patients received another IVB injection followed by additional PRP, which resulted in the resolution of the recurrent neovascularization. Glaucoma was controlled with topical eye drops alone in patients who had iris and angle neovascularization without peripheral anterior synechiae (PAS). However, patients with PAS at the time of presentation needed subsequent glaucoma surgery. Our study suggests that IVB may be a valuable addition in the treatment of NVG by hastening the resolution of anterior segment neovascularization, improving the results of glaucoma surgeries, and appears to give long-term control when used in combination with PRP.

The amount of intraocular pressure rise during pharmacological pupillary dilatation is an indicator of the likelihood of future progression of glaucoma.

AIM: To determine if there is a relationship between the amount of increase in IOP following dilatation with a cycloplegic agent and the future course of glaucoma. METHOD: A retrospective chart review of 100 eyes from 55 subjects with open-angle glaucoma who had had IOP measured before and after pharmacological pupillary dilatation was performed to establish the rate of progression of glaucoma, based on serial evaluation of the visual fields using the glaucoma staging system 2 (GSS 2), and optic discs using the disc damage likelihood scale (DDLS). Progressive visual field loss was defined as an increase of two or more stages with the GSS 2 and progressive deterioration of the disc was defined as an increase of two or more stages with the DDLS. Mean follow-up time was 7.2 years. RESULTS: A total of 26 eyes showed glaucomatous progression. The likelihood of progression of glaucoma was related to the amount of IOP increase after pharmacological pupillary dilatation. For every 1 mmHg increase in IOP, the odds of progression increased 24% (p = 0.008). The likelihood of progression of glaucoma, however, was not related to the baseline IOP, which was 20.63 mmHg (SD = 4.59 mmHg) in those showing deterioration of disc or field and 19.72 mmHg (SD = 5.32 mmHg) in those not worsening according to our definition. CONCLUSION: In patients with open-angle glaucoma, the amount of increase in IOP caused by pharmacological pupillary dilatation is related to the likelihood of future progression of glaucoma.

How effectively does medical care achieve its purposes? Evaluation of peer-reviewed literature in ophthalmology related to wellness.

PURPOSE: To get an idea of whether the issue of what makes people healthier is studied in ophthalmology by determining the proportion of articles dealing with that subject. METHODS: Prospective review of all articles published in 3 consecutive issues of 7 peer-reviewed ophthalmology journals, using a grading system in which A signified an article that clearly dealt with a subject expected to have an impact on health or quality of life, or that considered health or quality of life itself directly; B indicated an article similar to A, but not directly concerned with the issue of health; C signified an article similar to B but more distantly related to health or quality of life; and D was the grade given when there was no relationship at all to health or quality of life. Grading was done independently by 3 graders. A literature review on the subject was also performed. RESULTS: Thirty-three articles received a grade of A, 229 of B, 740 of C, and 81 of D. There were more articles that had no relationship at all to health or quality of life than there were articles dealing directly with those issues. CONCLUSIONS: On the basis of a review of the literature and of over 1000 articles, ophthalmologists do not appear to give much priority to issues of quality of life or health. How validly these conclusions can be generalized to general clinicians is not known.