Ophthalmology. Glaucoma最新文献

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.

Purpose

To investigate sectoral differences in the relationship between intraocular pressure (IOP) dynamics during dark-room prone testing (DRPT) and visual field (VF) defect progression in primary open-angle glaucoma (POAG) patients.

Design

Retrospective, longitudinal study.

Participants

This retrospective study included 116 eyes of 84 POAG patients who underwent DRPT and had at least 5 reliable VF tests conducted over a more than 2-year follow-up period. We excluded eyes with mean deviation worse than −20 dB or a history of intraocular surgery or laser treatment.

Methods

Average total deviation (TD) was calculated in the superior, central, and inferior sectors of the Humphrey 24-2 or 30-2 program. During DRPT, IOP was measured in the sitting position, and after 60 minutes in the prone position in a dark room, IOP was measured again. The relationship between IOP change during DRPT, IOP after DRPT, and TD slope in each quadrant was analyzed with a linear mixed-effects model, adjusting for other potential confounding factors.

Main Outcome Measures

Total deviation slope in each quadrant, IOP change during DRPT, and IOP after DRPT.

Results

Intraocular pressure after DRPT and IOP change during DRPT were 18.16 ± 3.42 mmHg and 4.92 ± 3.12 mmHg, respectively. Superior TD slope was significantly associated with both IOP after DRPT (β = −0.28, P = 0.003) and IOP change during DRPT (β = −0.21, P = 0.029), while central (β = −0.05, P = 0.595; β = −0.05; P = 0.622) and inferior (β = 0.05, P = 0.611; β = 0.01, P = 0.938) TD slopes were not.

Conclusion

Dark-room prone testing might be a useful test to predict the risk of superior VF defect progression in eyes with POAG.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose

To determine the associations between social vulnerability index (SVI) and baseline severity, worsening, and variability of glaucoma, as assessed by visual field (VF) and OCT.

Design

Retrospective longitudinal cohort study.

Participants

Adults with glaucoma or glaucoma suspect status in 1 or both eyes. Visual fields were derived from 7897 eyes from 4482 patients, while OCTs were derived from 6271 eyes from 3976 patients. All eyes had a minimum of 5 tests over follow-up using either the Humphrey Field Analyzer or the Cirrus HD-OCT.

Methods

Social vulnerability index, which measures neighborhood-level environmental factors, was linked to patients' addresses at the census tract level. Rates of change in mean deviation (MD) and retinal nerve fiber layer (RNFL) thickness were computed using linear regression. The slope of the regression line was used to assess worsening, while the standard deviation of residuals was used as a measure of variability. Multivariable linear mixed-effects models were used to investigate the impact of SVI on baseline, worsening, and variability in both MD and RNFL. We further explored the interaction effect of mean intraocular pressure (IOP) and SVI on worsening in MD and RNFL.

Main Outcome Measures

Glaucoma severity defined based on baseline MD and RNFL thickness. Worsening defined as MD and RNFL slope. Variability defined as the standard deviation of the residuals obtained from MD and RNFL slopes.

Results

Increased (worse) SVI was significantly associated with worse baseline MD (β = −1.07 dB, 95% confidence interval [CI]: [−1.54, −0.60]), thicker baseline RNFL (β = 2.46 μm, 95% CI: [0.75, 4.17]), greater rates of RNFL loss (β = −0.12 μm, 95% CI: [−0.23, −0.02]), and greater VF variability (β = 0.16 dB, 95% CI: [0.07, 0.24]). Having worse SVI was associated with worse RNFL loss with increases in IOP (β_interaction = −0.07, 95% CI: [−0.12, −0.02]).

Conclusions

Increased SVI score is associated with worse functional (VF) loss at baseline, higher rates of structural (OCT) worsening over time, higher VF variability, and a greater effect of IOP on RNFL loss. Further studies are needed to enhance our understanding of these relationships and establish their cause.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective

Angle-based minimally invasive glaucoma surgery (ab-MIGS) has grown substantially, although long-term efficacy is poorly understood. We analyze ab-MIGS effectiveness with and without preceding laser trabeculoplasty (LTP).

Design

Retrospective cohort study.

Subjects

Eyes undergoing ab-MIGS (Canaloplasty, Goniotomy, Trabectome, and iStent) with and without prior laser trabeculoplasty (< 2 years preceding MIGS) were identified in the IRIS® Registry (Intelligent Research in Sight) 2013 to 2018.

Methods

Propensity score matching (PSM) was undertaken to define the following 4 cohorts: (1) standalone ab-MIGS, no prior LTP vs. (2) standalone ab-MIGS, with prior LTP; and (3) ab-MIGS + phacoemulsification, no prior LTP vs. (4) ab-MIGS + phacoemulsification, with prior LTP.

Main Outcome Measures

Failure was defined as subsequent glaucoma reoperation after ab-MIGS (either MIGS or traditional glaucoma surgery). Time-to-event outcome and incidence rates were calculated using survival analysis, and adjusted hazard ratios (aHRs) were generated using multivariate Cox proportional hazards models. Medication data were not available for analysis.

Results

A total of 164 965 unique MIGS procedures were performed, from 2013 to 2018. After PSM, we identified 954 eyes undergoing standalone ab-MIGS and 7522 undergoing ab-MIGS + phacoemulsification. For eyes undergoing standalone ab-MIGS, those with prior LTP (n = 477) were more likely to undergo reoperation vs. those without LTP (n = 477) at 6 and 12 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53; CI, 1.15–2.04; P = 0.004). For eyes undergoing ab-MIGS + phacoemulsification, those with prior LTP (n = 3761) were more likely to undergo reoperation vs. those without LTP (n = 3761) at 12, 24, and 36 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53 CI, 1.15–2.04; P = 0.004).

Conclusions

Prior LTP may be associated with a higher chance of subsequent glaucoma surgery following ab-MIGS, either with or without concurrent phacoemulsification. These findings have important implications for understanding who may benefit most from ab-MIGS, and for guiding patient and surgeon treatment expectations.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose

Glaucoma patients may be considered to have normal vision as long as each point of visual space is perceived by at least 1 eye, that is, with an intact binocular visual field (VF). We aimed to investigate the effect of nonoverlapping VF defects on vision-related quality of life (VR-QoL) in glaucoma.

Design

Cross-sectional study.

Subjects and Controls

Two hundred sixty-nine glaucoma patients and 113 controls.

Methods

We evaluated VR-QoL of glaucoma patients (n = 269) and controls (n = 113) using 4 different questionnaires (National Eye Institute visual function questionnaire [NEI-VFQ-25], NEI-VFQ neuro-ophthalmology supplement, Glaucoma Quality of Life-15, and a luminance-specific questionnaire). We defined “differential VF” (DVF) as a measure of location-specific differences in the VFs of both eyes. Within the group of glaucoma patients, we analyzed the relationship between different aspects of VR-QoL and DVF using ordinal multiple regression analysis. Analyses were adjusted for age, sex, integrated VF (IVF; an estimate of the binocular VF from the monocular VFs), and higher visual acuity of both eyes, and corrected for multiple hypothesis testing.

Main Outcome Measures

Vision-related quality of life.

Results

Glaucoma patients had lower VR-QoL than controls. Among the glaucoma patients, DVF was significantly associated with general vision (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.54–0.89), peripheral vision (OR, 0.68; 95% CI, 0.54–0.86), walking on uneven ground (OR, 0.73; 95% CI, 0.58–0.93), crossing the street (OR, 0.61; 95% CI, 0.46–0.83), seeing other road users coming from the side (OR, 0.67; 95% CI, 0.52–0.85), cycling during the day (OR, 0.64; 95% CI, 0.46–0.89) and seeing outside on a sunny day (OR, 0.73; 95% CI, 0.57–0.94). In general, IVF was a stronger predictor of VR-QoL than DVF.

Conclusions

Nonoverlapping VF defects affect VR-QoL. Although IVF is strongly associated with VR-QoL, basing clinical decisions only on IVF leads to overlooking vision problems that patients may have.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Topic

To identify patient-reported outcome measures (PROMs) that have been used in children and adolescents with glaucoma and to evaluate their methodologic quality.

Clinical relevance

Childhood glaucoma impairs vision and quality of life (QoL) throughout all stages of life. Thus, a PROM needs to cover many different age groups and topics. Various instruments have been used to evaluate patient-reported outcomes (PROs) in patients with childhood glaucoma, however, it is unclear which PROM has the highest methodologic quality and complies best with the needs of patients with childhood glaucoma.

Methods

A systematic literature review was performed searching MEDLINE (PubMed), the Cochrane Library, Web of Science, and PsycINFO (EBSCO). We included peer-reviewed full-text articles of the past 10 years in English, German, or Spanish language that reported PROMs in children with glaucoma. The study selection and methodologic quality assessment of the identified PROMs was performed by 2 independent reviewers using a 7-point checklist. The content was mapped onto the World Health Organization International Classification of Functioning, Disability and Health. The systematic review was prospectively registered in PROSPERO (ID CRD42022353936).

Results

The search strategy retrieved 3295 matches. A total of 2901 studies were screened, and 11 relevant articles were identified using 10 different instruments. The instruments addressed functional visual ability, vision-related QoL, health-related QoL, and life satisfaction. Six instruments were applicable for the use in children. Seven of the questionnaires received the highest number of positive ratings (5/7). None of the instruments considered the views of patients with childhood glaucoma during their development.

Conclusion

This systematic review provides a descriptive catalog of vision-specific and generic health PRO instruments that have been used in childhood glaucoma cohorts. An instrument specifically developed for childhood glaucoma is lacking which might result in missing important factors, such as permanent treatment with eye drops, repeated surgeries, and heritability of the disease, when investigating the QoL in children with glaucoma.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective

To investigate the association of psychosocial factors with health self-management behaviors and beliefs among patients with primary open-angle glaucoma (POAG).

Design

Prospective cross-sectional cohort study.

Participants

Patients (n = 202) with mild, moderate, or advanced bilateral POAG.

Methods

Patients (N = 1164) were identified from electronic medical records at a single academic medical center. Letters soliciting participation were mailed to 591 randomly selected potential participants. Psychometric measures and a social determinants of health questionnaire were administered by phone to 202 study participants.

Main Outcome Measures

The National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ), the Multidimensional Health Locus of Control (MHLC), the Perceived Medical Condition Self-Management Scale-4, the Patient Health Questionnaire-9 (PHQ), the Patient Activation Measure-13 (PAM), a health literacy question, and a social determinants of health questionnaire.

Results

For each increase in level of POAG severity, there was a decrease in mean NEI-VFQ score (P < 0.001). For each unit increase in NEI-VFQ item 1, self-rated vision, mean PAM score increased (R² = 5.3%; P = 0.001; 95% confidence interval [CI], 0.077–0.276). For each unit increase in “Internal” on the MHLC, mean PAM score increased (R² = 19.3%; 95% CI, 0.649–1.166; P < 0.001). For each unit increase in “Doctors” on the MHLC, mean PAM score increased (R² = 11.0%; 95% CI, 1.555–3.606; P < 0.001). For each unit increase in “Chance” on the MHLC, mean PAM score decreased (R² = 2.6%; 95% CI, −0.664 to −0.051; P = 0.023). On multivariate analysis, adjusting for age, sex and race, for each unit increase in PHQ, mean PAM score decreased (95% CI, 0.061–1.35; P = 0.032); for each unit increase in MHLC “Doctors”, mean PAM score increased (95% CI, −1.448 to 3.453; P < 0.001); for each unit increase in MHLC “Internal”, mean PAM score increased (95% CI, 0.639–1.137; P < 0.001); for each unit increase in MHLC “Chance”, mean PAM score decreased (95% CI, −0.685 to −0.098; P = 0.009).

Conclusions

We identified modifiable behavioral factors that could increase patients’ self-perceived ability and confidence to manage their own eye care. Locus of control (MHLC), level of depression (PHQ), and self-rated functional vision (NEI-VFQ) were each associated with patient behaviors, attitudes, and beliefs needed for health self-management (activation, assessed by the PAM) and may be important determinants of adherence behaviors. Targeting change in patients’ care beliefs and behaviors may improve activation and treatment outcomes.

Financial