Ophthalmology. Glaucoma最新文献

Purpose: Assess the effect of social determinants of health on presentation and outcomes in primary congenital glaucoma (PCG) DESIGN: Retrospective case series SUBJECTS: Patients with PCG presenting between 2011 and 2023 with >3 months follow-up METHODS: The percentage of households with 0, 1-2 or >3 community resilience estimates (CRE) risk factors and median income for the census tract of residence for each patient were collected. Initial details and final outcomes were correlated with race, ethnicity, insurance type and census tract data.

Main outcome measures: Final best corrected visual acuity (BCVA) RESULTS: Of 59 patients (105 eyes, 68% male), the presenting average age was 294 ± 365 days. Black patients (n=16) were younger (p<0.0001) than White (n=31) or Other race patients (n=12). While there was no racial or ethnic differences in initial intraocular pressure (IOP), IOP >30 mmHg was associated with worse final BCVA. Patients with Medicaid (n=31) required more glaucoma surgeries compared to those with commercial insurances (n=28, p=0.0305), respectively. Linear regression analysis demonstrated that census tracts with higher percentage of households with >3 CRE risk factors correlated with worse VA (ß=0.02, p=0.0028, R²=0.2). There were no racial, ethnic, insurance type, tract median income or CRE risk factor differences in IOP, number of glaucoma medications, spherical equivalent, or cup-to-disc ratio at final follow-up.

Conclusions: Type of insurance and census data as markers for social determinants of health demonstrated increased risk factors can be associated with worse visual outcomes in PCG.

Objective: Assess the cost-effectiveness of Hydrus Microstent combined with cataract surgery (CS) versus CS alone, for treating patients with mild to moderate primary open angle glaucoma (POAG).

Design: Cost-utility analysis using efficacy and safety results of a pivotal randomized clinical trial SUBJECTS: Modeled cohort of patients with mild to moderate POAG and visually significant cataract METHODS: A semi-Markov model was developed to model effects and costs over a 15-year time horizon from the Canadian public healthcare payer perspective for patients with mild or moderate POAG receiving Hydrus Microstent during CS versus CS alone. The model utilizes the HORIZON trial patient cohort. Progression was guided using the annualized rate of progression (RoP) derived from a post-hoc analysis of 5-year visual field loss (VFL) data from the HORIZON trial. The amount of VF lost was mapped on a sequential addition of medications used as a proxy for irreversible progression. Costs were derived from various publicly available sources and publications. Utility values were sourced from a published analysis that conducted a mapping exercise based on Health Utilities Index mark 3 using Canadian tariffs. We conducted deterministic and probabilistic sensitivity analyses to examine uncertainty around alternative model input values. Scenario analyses explored structural uncertainty.

Main outcome measures: Total costs per patient, quality-adjusted life years (QALYs), and incremental cost-utility ratio (ICUR).

Results: Compared with CS alone, Hydrus + CS was a dominant strategy (greater benefits and lower costs). Although LYs were equivalent between the two treatments (11.41 years), Hydrus + CS arm was associated with higher benefits (9.351 vs. 9.040 in QALYs). This translated into an additional 0.311 QALYs for Hydrus + CS. Total costs were lower with Hydrus + CS (CAD 26,770 vs CAD 27,145) resulting into saving of -CAD 375. Results of scenario analyses showed robustness of the model. The CEAC shows a probability of 85.3% of Hydrus + CS being cost-effective compared with CS alone at a willingness-to-pay (WTP) threshold of 50,000/QALY.

Conclusions: Hydrus Microstent combined with CS is a cost-effective long-term treatment for patients with POAG.

Purpose: To investigate the impact of blood pressure (BP) on rates of retinal nerve fiber layer (RNFL) thinning in glaucomatous eyes with focal ischemic (FI) versus generalized enlargement (GE) optic disc phenotypes.

Design: Prospective cohort study.

Participants: The study included 122 eyes from 101 patients diagnosed with primary open-angle glaucoma. Eyes were classified as FI (n=31, 25%) or GE (n=91, 75%) based on masked grading of stereophotographs at baseline.

Methods: Subjects underwent comprehensive ophthalmic examinations, including intraocular pressure (IOP) measurement and spectral-domain optical coherence tomography (SD-OCT) scans, every 6 months for an overall mean follow-up of 4.2 years ± 1.5 years. Brachial artery BP was measured concurrently, and mean arterial pressure (MAP), systolic arterial pressure (SAP), and diastolic arterial pressure (DAP) were calculated. Rates of global RNFL thickness change over time were assessed using linear mixed models, evaluating the impact of BP parameters in each optic disc phenotype, adjusting for IOP and other confounders. Interaction terms were used to test for differences in the effects of BP and IOP between the FI and GE phenotypes.

Main outcome measures: Effect of MAP, SAP and DAP on rates of RNFL loss over time in FI and GE optic disc phenotypes.

Results: In the adjusted FI group models, each 10-mmHg decrease in MAP, SAP, and DAP was associated with -0.397 μm/year (p=0.006), -0.211 μm/year (p=0.029), and -0.471 μm/year (p=0.005) faster RNFL thinning, respectively. In contrast, BP parameters were not significantly associated with RNFL loss in the GE group. In the multivariable model with interaction terms, the interaction between DAP and phenotype was statistically significant (p=0.019), indicating the FI phenotype exhibited greater sensitivity to lower diastolic pressure compared to GE eyes. In contrast, interaction terms between IOP and optic disc phenotype were not significant in any of the models, suggesting a similar effect of IOP in both phenotypes.

Conclusion: Lower systemic BP levels were associated with faster RNFL thinning in the FI optic disc phenotype, but not in the GE phenotype. These findings highlight the importance of considering both IOP and systemic BP when managing patients with the FI optic disc phenotype.

Purpose: Investigate the influence of baseline blood pressure (BP) on retinal nerve fiber layer (RNFL) rates of change (RoC) in glaucoma patients with central damage or moderate to severe disease.

Design: Prospective cohort study.

Participants: 110 eyes with ≥4 RNFL optical coherence tomography scans and ≥2 years of follow-up.

Methods: Global RNFL RoC were modeled with a Bayesian hierarchical model with subject- and sector-level random effects. Influence of baseline systolic and diastolic BP measures and their interactions with intraocular pressure (IOP) on global RNFL rates of change was investigated in prognostic models adjusting for relevant baseline demographic and clinical measures.

Main outcomes and measures: Magnitude and direction of coefficients for BP, IOP, and their interaction for prediction of global RNFL RoC. One-sided Bayesian p-values denote posterior probability that a regression coefficient is greater than or less than zero with p <0.025 or >0.975 defining significance.

Results: Average (SD) 24-2 visual field mean deviation (MD) at baseline, follow-up time, and number of OCT scans were -8.8 (6.0) dB, 4.3 (0.5) years, and 8.3 (1.4), respectively. In multivariable analyses, female sex, Hispanic ethnicity (vs. White ethnicity), better baseline 24-2 MD, higher contrast sensitivity at 12 cycles per degree, presence of diabetes, and thicker central corneal predicted faster RNFL thinning. Adjusted for covariates, lower diastolic BP combined with higher IOP predicted faster RNFL rates of change. Parallel multivariable models incorporating systolic BP showed similar effects. Among various BP/IOP combinations, eyes with IOP at the 90^th percentile and diastolic (systolic) BP at 10^th percentile demonstrated the fastest RNFL thinning rates (-0.554 and -0.539 μm/year).

Conclusions: Low BP and higher IOP at baseline predicted faster (worse) RNFL rates of change in glaucoma patients with central damage or moderate to advanced disease. While there may be potential benefits to BP management in glaucoma patients, the therapeutic value of BP manipulation in glaucoma patients is yet to be established given the proven benefits of tight BP control in reducing cardiovascular morbidity and mortality.

Purpose: Liver disease is associated with a range of extrahepatic complications, which have recently been expanded to include ophthalmic conditions. However, evidence is lacking regarding its impact on primary open-angle glaucoma (POAG). This study aimed to investigate whether major liver diseases, including metabolic dysfunction-associated steatotic liver disease (MASLD), alcoholic liver disease (ALD), viral hepatitis, and liver fibrosis and cirrhosis, were associated with POAG.

Design: A prospective study based on the UK Biobank cohort with a two-sample Mendelian randomization (MR) analysis for inferring causality.

Participants: A total of 332,345 UK Biobank participants free of glaucoma recruited between 2006 and 2010.

Methods: The exposure of interest was severe liver diseases defined as hospital admission, including MASLD, ALD, viral hepatitis, and liver fibrosis and cirrhosis. Cox proportional hazards models were used with each liver disease treated as a time-varying exposure. The MR analysis was further conducted based on the genome-wide association studies of a histologically characterized cohort for MASLD (n = 19,264) and Internation Glaucoma Genetics Consortium cohort for POAG (n = 216,257).

Main outcome measures: Risk of POAG estimated by hazard ratio (HR) and 95% confidence interval (CI) in observation analysis, and odds ratio (OR) and 95% CI in MR analysis.

Results: Severe MASLD was associated with a 45% increased risk of POAG (HR 1.45; 95% CI 1.12-1.87; P = 0.005), whereas no association was identified between ALD (P = 0.953), viral hepatitis (P = 0.519), or liver fibrosis and cirrhosis (P = 0.794) and incident POAG. Subgroup analysis showed the risk of POAG in relation to MASLD was higher in individuals having more physical activity (HR 1.53; 95% CI 1.04-2.25 vs. HR 1.39; 95% CI 0.99-1.95, P for interaction = 0.033). MR analysis provided evidence that MASLD was causally associated with greater risk of POAG (inverse-variance weighted model: OR 1.035; 95% CI 1.010-1.061; P = 0.005).

Conclusions: Severe MASLD was longitudinally associated with an increased risk of incident POAG, with MR analyses suggesting a potential causal link. These findings suggest POAG examination should be considered in the holistic management of MASLD, and further underscore the impact of the liver on eye health.

Objective: This study investigates the incidence and causes of diagnostic changes from primary open-angle glaucoma suspect (POAGS) to primary open-angle glaucoma (POAG), and vice versa, in clinical practice.

Design: This is a retrospective, single-site, case-control study.

Participants: It includes patients > 40 years of age diagnosed with either POAG or POAGS between 2013 and 2020. Controls had a minimum of 24 months of follow-up without a diagnostic change, whereas cases underwent a diagnostic change from glaucoma to suspect (POAG to POAGS) or from suspect to glaucoma (POAGS to POAG) within 2 years.

Methods: At initial and follow-up visits, diagnosis, treatment, type of ophthalmic provider, and performance of pachymetry, visual fields (VFs), OCT, disc examination, and gonioscopy were recorded.

Main outcome measures: Data were then analyzed to determine if baseline characteristics, type of provider seen, or ophthalmic testing performed were protective or risk factors in regards to diagnostic change.

Results: Nine hundred twenty-two subjects were included, and the incidence of diagnostic changes was 13.8% (127/922), of which 99 (78%) were upstaged from POAGS to POAG and 28 (22%) changed from POAG to POAGS. Pre-existing nonglaucomatous VF defect (P < 0.001) was significantly higher in cases than controls. Cases were significantly less likely to be seen by a glaucoma specialist at the initial visit compared with controls (P < 0.001), and less cases underwent VF testing (P < 0.001), OCT testing (P = 0.017), or gonioscopy (P = 0.013) at the initial visit. On multivariate analysis, performing VFs or OCT at both visits reduced the odds of short-term diagnostic change, whereas changing providers from a nonglaucoma specialist to a glaucoma specialist between visits increased the odds of diagnostic change. In the POAG-to -POAGS cases, 39% (11/28) were treated with either medications or laser trabeculoplasty, whereas 72% (71/99) of the POAGS-to-POAG cases were left untreated between visits.

Conclusions: It is important to understand risk factors for diagnostic changes in glaucoma, in order to prevent undertreatment of disease and overtreatment of suspects. Here we find specialist type and adherence to American Academy of Ophthalmology (AAO) recommended testing to be important factors in preventing short term diagnostic changes.

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