Cheryl S. Sine

Clinical Presentation and Initial Treatment Patterns in Patients With Exfoliation Glaucoma Versus Primary Open-Angle Glaucoma

BACKGROUND AND OBJECTIVE The presentation and initial response to treatment of consecutive patients with exfoliation glaucoma (PXE) and primary open-angle glaucoma (POAG) were evaluated prospectively. PATIENTS AND METHODS Forty-six consecutive newly diagnosed patients with POAG and PXE were included in a prospective study that evaluated the initial clinical course and treatment results. The two groups were age- and race-matched. RESULTS This study found no difference in optic disc parameters at presentation between patients with POAG (n = 22) and those with PXE (n = 24) (P > .05). However, the presenting mean defect was significantly worse in patients with PXE versus those with POAG (P = .0038), although the loss variance was similar (P > .90). The mean presenting intraocular pressure (IOP) for patients with PXE (32.0 +/- 5.2 mm Hg) was greater than that for patients with POAG (27.1 +/- 4.4 mm Hg) (P= .0025). Additionally, patients with PXE required more treatment steps to control IOP (P = .005). Thirteen of 24 patients with PXE versus 3 of 22 patients with POAG (P = .016) required either laser or conventional surgical techniques to reduce IOP. CONCLUSION This study shows that patients with PXE have greater visual field loss and have more difficulty gaining control of IOP on presentation than patients with POAG.

Surgical vs Medical Management of Chronic Open-angle Glaucoma

Purpose We studied patients with chronic open-angle glaucoma who had similar intraocular pressures to determine whether surgical or medical therapy is more effective in preventing progressive, long-term, glaucomatous damage. Methods Included in this study were patients with chronic open-angle glaucoma who were followed for 3 years or longer and were treated, through either medical or surgical therapy, by adjusting intraocular pressure to 18 mm Hg or less as a therapeutic end point. We studied 31 matched pairs of patients in which one member was treated by surgery and one member had medical treatment. In every pair, we matched each patient individually by age, race, and intraocular pressure. Results For the matched pairs of patients in this study, the mean intraocular pressure following initiation of treatment was 13.5 and 13.1 mm Hg for the surgically and medically treated groups, respectively (P = .475). This study found no difference between groups in the incidence of glaucomatous progression following surgical (n = 3) or medical (n = 3) therapy (P > .99, McNemars test) for an average follow-up of 40.0 ± 10.0 and 43.4 ± 8.4 months in the medical and surgical groups, respectively. The glaucoma of three patients progressed on the basis of reduced visual acuity, two by visual field, and one by disk hemorrhage. Although the types of complications from therapy differed between groups, no vision loss or life-threatening events occurred directly from these treatments. Conclusions When intraocular pressure is used as a therapeutic end point, both filtration surgery and medical therapy appear to be equally effective in maintaining long-term visual function and a stable optic disk in chronic open-angle glaucoma.

Total Cholesterol and High-Density Lipoprotein Levels as Risk Factors for Increased Intraocular Pressure

PURPOSE To determine whether high-density lipoprotein and total cholesterol levels were risk factors for increased intraocular pressure in patients with chronic open-angle glaucoma or ocular hypertension. METHODS We measured total cholesterol, high-density lipoprotein, and total cholesterol/high-density lipoprotein ratio in 25 patients with open-angle glaucoma or ocular hypertension who had taken no glaucoma medications for four weeks. We individually matched these patients to 25 control subjects who had no history of open-angle glaucoma or ocular hypertension, on the basis of age, race, gender, and history of vascular disease or diabetes mellitus. RESULTS We found no statistical difference in the high-density lipoprotein (P = .702) or total cholesterol (P = .177) levels or total cholesterol/high-density lipoprotein ratio between groups (P = .178, paired t test). CONCLUSION This study indicates that increased high-density lipoprotein and total cholesterol levels are not risk factors for increased intraocular pressure.

Three-Millimeter Versus 6-mm Incisions in Combined Phacoemulsification and Trabeculectomy

BACKGROUND AND OBJECTIVE To determine the results of phacoemulsification and combined trabeculectomy in subjects receiving either a 3- or a 6-mm scleral incision. PATIENTS AND METHODS The authors evaluated consecutive patients who underwent combined phacoemulsification and trabeculectomy with a 3-mm incision. These patients were individually matched by age, diagnosis, previous surgery, and race to those having a 6-mm incision. RESULTS The study found that 1 year following surgery, results were similar between the 3- and 6-mm incision groups for intraocular pressure (IOP), bleb height, bleb vascularity, number of glaucoma medicines, anterior chamber depth, visual acuity, spherical equivalent, cylinder, and axis (P > .05). No difference was observed between groups with the highest IOP within the first postoperative month (P > .05). Also, no marked differences in number of complications were noted between groups. CONCLUSION This study suggests that 3- and 6-mm incision phacoemulsification combined with trabeculectomy provide similar postoperative IOP control and visual acuity results.

The comparative ocular hypotensive effect of apraclonidine with timolol maleate in exfoliation versus primary open-angle glaucoma patients.

Purpose To compare the effect of adding apraclonidine 0.5% to timolol maleate 0.5% in patients with exfoliation versus primary open-angle glaucoma. Since exfoliation glaucoma is known to demonstrate higher pressures than primary open-angle glaucoma on timolol maleate therapy alone, the authors wished to determine whether apraclonidine equalised the intraocular pressure (IOP) between these two glaucomas when added to timolol maleate.Methods We age-matched 30 consecutive exfoliation and 30 primary open-angle glaucoma patients who had an IOP ≥ 22 mmHg on timolol maleate alone. Patients underwent IOP diurnal curve testing on timolol maleate twice daily alone and, 2 months later, following the addition of apraclonidine 0.5% three times daily. Statistical analysis of the IOP at each time point was by an unpaired t-test between groups. A paired Mest was used to evaluate the reduction in IOP from baseline within groups after the addition of apraclonidine.Results On timolol maleate alone, exfoliation patients had a higher mean IOP at 06:00 and 10:00 hours as well as a higher peak, range and standard deviation of the IOP compared with primary open-angle glaucoma patients (p < 0.05). Following the addition of apraclonidine the mean, peak and range of IOP were statistically similar between groups and only the standard deviations remained higher in the exfoliation glaucoma group (p < 0.001). The mean diurnal IOP after apraclonidine was added was 20.5 ± 7.0 mmHg in the exfoliation glaucoma group and 20.0 ± 3.4 mmHg in the primary open-angle glaucoma group, which was not significantly different between groups (p = 0.73).Conclusions This study suggests that apraclonidine 0.5% used adjunctively with timolol maleate 0.5% solution is associated generally with similar IOP control in exfoliation and primary open-angle glaucoma patients.

Surgical vs Medical Management of Chronic Open-angle Glaucoma: Author Reply

PURPOSE We studied patients with chronic open-angle glaucoma who had similar intraocular pressures to determine whether surgical or medical therapy is more effective in preventing progressive, long-term, glaucomatous damage. METHODS Included in this study were patients with chronic open-angle glaucoma who were followed for 3 years or longer and were treated, through either medical or surgical therapy, by adjusting intraocular pressure to 18 mm Hg or less as a therapeutic end point. We studied 31 matched pairs of patients in which one member was treated by surgery and one member had medical treatment. In every pair, we matched each patient individually by age, race, and intraocular pressure. RESULTS For the matched pairs of patients in this study, the mean intraocular pressure following initiation of treatment was 13.5 and 13.1 mm Hg for the surgically and medically treated groups, respectively (P = .475). This study found no difference between groups in the incidence of glaucomatous progression following surgical (n = 3) or medical (n = 3) therapy (P > .99, McNemars test) for an average follow-up of 40.0 +/- 10.0 and 43.4 +/- 8.4 months in the medical and surgical groups respectively. The glaucoma of three patients progressed on the basis of reduced visual acuity, two by visual field, and one by disk hemorrhage. Although the types of complications from therapy differed between groups, no vision loss or life-threatening events occurred directly from these treatments. CONCLUSIONS When intraocular pressure is used as a therapeutic end point, both filtration surgery and medical therapy appear to be equally effective in maintaining long-term visual function and a stable optic disk in chronic open-angle glaucoma.