M. Roy Wilson

National Survey of the Prevalence and Risk Factors of Glaucoma in St. Lucia, West Indies: Part I. Prevalence Findings+++

Although blacks appear to be at higher risk for blindness from glaucoma, there is little information available on the epidemiology of this disease in this population. Using a cluster sampling technique with systematic allocation of clusters, the authors conducted a national survey of black individuals 30 years of age and older, in St. Lucia. A total of 1679 individuals underwent a screening examination that included visual acuity, intraocular pressure (IOP) measurement, and cup/disc (C/D) evaluation. Every third person had a screening field on the Humphrey field analyzer. Individuals with either elevated IOP, abnormal C/D ratio, or an abnormal screening visual field were referred for a definitive examination and threshold visual fields. A total of 520 people were referred. Identified by stringent criteria for the diagnosis of glaucoma, which required reliable threshold visual fields abnormal by the mirror image method, 147 individuals had glaucoma for a prevalence of 8.8% in the 30 years of age and older population.

Initial Clinical Experience With the Ahmed Glaucoma Valve Implant

PURPOSE We studied the Ahmed Glaucoma Valve implant, an aqueous shunting device that has a unidirectional valve mechanism designed to prevent postoperative hypotony in eyes with intractable glaucoma. METHODS In this multicenter, prospective clinical trial, we studied 60 eyes (60 patients) with increased intraocular pressure or glaucoma that had not responded to medical treatment, laser photocoagulation, or previous glaucoma surgery, in which the Ahmed Glaucoma Valve implant was placed to decrease intraocular pressure. RESULTS Success was defined as intraocular pressure less than 22 mm Hg and greater than 4 mm Hg for two months or longer, intraocular pressure that was lowered by at least 20% from preoperative values (in eyes with preoperative intraocular pressures less than 22 mm Hg), and no additional glaucoma surgery or visually devastating complications. Cumulative probability of success at 12 months was 78%. Eight (13%) of 60 eyes had intraocular pressure less than 5 mm Hg the first postoperative day. Two other eyes had shallow anterior chambers, which required anterior chamber reformation. The major complications associated with the use of the valve were serous choroidal detachments in 13 eyes (22%), blockage of the tube in six eyes (10%), malposition of the tube in four eyes (7%), a suprachoroidal hemorrhage in one eye (2%), and corneal graft rejections in three (19%) of 16 eyes with corneal grafts. CONCLUSIONS Although the 12-month success with the Ahmed Glaucoma Valve implant is similar to that reported for other drainage devices, the complications associated with overfiltration in the immediate postoperative period appear to be less frequent than with other valved drainage devices. Randomized, prospective studies to compare the Ahmed Glaucoma Valve implant with other drainage devices are needed to make clinical comparisons of the different devices.

Follow-up of the original cohort with the Ahmed glaucoma valve implant

PURPOSE To study the long-term results of the Ahmed glaucoma valve implant in patients with complicated glaucoma in whom short-term results have been reported. METHODS In this multicenter study, we analyzed the long-term outcome of a cohort of 60 eyes from 60 patients in whom the Ahmed glaucoma valve was implanted. Failure was characterized by at least one of the following: intraocular pressure greater than 21 mm Hg at both of the last two visits less than 6 mm Hg at both of the last two visits, loss of light perception, additional glaucoma surgery, devastating complications, and removal or replacement of the Ahmed glaucoma valve implant. Devastating complications included chronic hypotony, retinal detachment, malignant glaucoma, endophthalmitis, and phthisis bulbi; we also report results that add corneal complications (corneal decompensation or edema, corneal graft failure) as defining a devastating complication. RESULTS The mean follow-up time for the 60 eyes was 30.5 months (range, 2.1 to 63.5). When corneal complications were included in the definition of failure, 26 eyes (43%) were considered failures. Cumulative probabilities of success at 1, 2, 3, and 4 years were 76%, 68%, 54%, and 45%, respectively. When corneal complications were excluded from the definition of failure, 13 eyes (21.5%) were considered failures. Cumulative probabilities of success at 1, 2, 3, and 4 years were 87%, 82%, 76%, and 76%, respectively. Most of the failures after 12 months of postoperative follow-up were because of corneal complications. CONCLUSIONS The long-term performance of the Ahmed glaucoma valve implant is comparable to other drainage devices. More than 12 months after the implantation of the Ahmed glaucoma valve implant, the most frequent adverse outcome was corneal decompensation or corneal graft failure. These corneal problems may be secondary to the type of eyes that have drainage devices or to the drainage device itself. Further investigation is needed to identify the reasons that corneal problems follow drainage device implantation.

Primary Open-Angle Glaucoma in Blacks: A Review

Glaucoma is one of the leading causes of blindness worldwide. Primary open-angle glaucoma (POAG) is the most prevalent form of glaucoma and has a particularly devastating impact in blacks. In the black American population, POAG prevalence is estimated to be six times as high in certain age groups compared to whites. POAG is more likely to result in irreversible blindness, appears approximately 10 years earlier and progresses more rapidly in blacks than in whites. Racial differences in optic disk parameters have been reported and show that blacks have larger optic disks than whites. This finding is robust and may account for the reported differences in other optic disk parameters. The existence of racial differences in intraocular pressure remains to be demonstrated, as conflicting findings are reported in the literature. Intraocular pressure may actually be underestimated in blacks, perhaps because they have thinner corneas. The prevalence of diabetes and hypertension is higher in blacks than in whites, and although no causal relationship has been established between POAG and each of these systemic diseases, some reports suggest that they often occur together, perhaps through an indirect relationship with intraocular pressure. Compounding the problem, there is evidence that blacks are less responsive to both drug and surgical treatment for POAG. Finally, they often have reduced accessibility to treatment and are less aware of the risks of having POAG. This article provides a comprehensive review of the current knowledge pertaining to POAG in blacks.

Long-term follow-up of primary glaucoma surgery with ahmed glaucoma valve implant versus trabeculectomy ☆

PURPOSE To compare the long-term results of trabeculectomy and Ahmed glaucoma valve implant in the initial surgical management of primary open- and closed-angle glaucoma. DESIGN Randomized controlled clinical trial. METHODS One eye each of consecutive patients with primary glaucoma and without prior intraocular surgery was randomized to receive either trabeculectomy or the Ahmed implant. Large university-affiliated eye hospital in Columbo, Sri Lanka. RESULTS Of 123 patients, 64 were randomized to trabeculectomy and 59 to the Ahmed implant. With a mean follow-up of 31 months, the trabeculectomy group had statistically lower intraocular pressures (IOP) during the first postoperative year. After the first year, the IOPs were comparable. No statistically significant differences between groups were noted for postoperative visual acuity, visual field, anterior chamber depth, and short-term or long-term complications. Adjunctive medication requirement was comparable for both groups. The cumulative probabilities of success (IOP <21 mm Hg and at least 15% reduction in IOP from preoperative levels) at the final follow-up period (months, 41-52) were 68.1% for trabeculectomy and 69.8% for Ahmed implant (P =.86). CONCLUSIONS Lower IOPs were noted for the trabeculectomy group during the first year. With longer follow-up, the IOPs and the cumulative probabilities of success were comparable between the two groups.

The African descent and glaucoma evaluation study (ADAGES): Design and baseline data

OBJECTIVE To identify factors accounting for differences in glaucoma onset and rate of progression between individuals of African descent and European descent. DESIGN A prospective, multicenter observational cohort study of 1221 participants of African descent and European descent with no glaucoma (normal), suspected glaucoma, and glaucoma. Six hundred eighty-six patient participants in the African Descent and Glaucoma Evaluation Study will be followed up longitudinally. Four hundred thirty-six participants of European descent from the Diagnostic Innovations in Glaucoma Study (DIGS) were also included. Baseline demographics, visual function (standard automated perimetry, short-wavelength automated perimetry, frequency doubling technology perimetry), optic nerve structure (retina tomography, optical coherence tomography), clinical status, and risk factors were measured. RESULTS Individuals of African descent had (1) thinner corneas (P < .001) across all diagnostic groups, (2) a higher percentage of reported diabetes mellitus (P < .001) and high blood pressure (P < .001) and a lower percentage of reported heart disease (P = .001), and (3) worse pattern standard deviation for standard automated perimetry fields overall (P = .001) and within normal limits (P = .01) than individuals of European descent. No differences were present for mean intraocular pressure (P = .79). CONCLUSIONS Significant baseline differences were found in a number of clinical findings between persons of African descent compared with European descent. Longitudinal data from the African Descent and Glaucoma Evaluation Study will be important for determining which baseline features are important and predictive for accurate diagnosis and follow-up in this high-risk group. Trial Registration clinicaltrials.gov Identifier: NCT00221923.

Original ArticlesFollow-up of the original cohort with the Ahmed glaucoma valve implant1☆

PURPOSE To study the long-term results of the Ahmed glaucoma valve implant in patients with complicated glaucoma in whom short-term results have been reported. METHODS In this multicenter study, we analyzed the long-term outcome of a cohort of 60 eyes from 60 patients in whom the Ahmed glaucoma valve was implanted. Failure was characterized by at least one of the following: intraocular pressure greater than 21 mm Hg at both of the last two visits less than 6 mm Hg at both of the last two visits, loss of light perception, additional glaucoma surgery, devastating complications, and removal or replacement of the Ahmed glaucoma valve implant. Devastating complications included chronic hypotony, retinal detachment, malignant glaucoma, endophthalmitis, and phthisis bulbi; we also report results that add corneal complications (corneal decompensation or edema, corneal graft failure) as defining a devastating complication. RESULTS The mean follow-up time for the 60 eyes was 30.5 months (range, 2.1 to 63.5). When corneal complications were included in the definition of failure, 26 eyes (43%) were considered failures. Cumulative probabilities of success at 1, 2, 3, and 4 years were 76%, 68%, 54%, and 45%, respectively. When corneal complications were excluded from the definition of failure, 13 eyes (21.5%) were considered failures. Cumulative probabilities of success at 1, 2, 3, and 4 years were 87%, 82%, 76%, and 76%, respectively. Most of the failures after 12 months of postoperative follow-up were because of corneal complications. CONCLUSIONS The long-term performance of the Ahmed glaucoma valve implant is comparable to other drainage devices. More than 12 months after the implantation of the Ahmed glaucoma valve implant, the most frequent adverse outcome was corneal decompensation or corneal graft failure. These corneal problems may be secondary to the type of eyes that have drainage devices or to the drainage device itself. Further investigation is needed to identify the reasons that corneal problems follow drainage device implantation.

Functional status and well-being in patients with glaucoma as measured by the Medical Outcomes Study short form-36 questionnaire

PURPOSE This study aimed to determine whether patients with glaucoma have different functional status and well-being than patients without glaucoma. DESIGN Prospective case-control study. PARTICIPANTS The study population was recruited from 2 university-based glaucoma clinical practices and a university-based general ophthalmology clinic and consisted of 121 patients with open-angle glaucoma, 42 with diagnosis of glaucoma suspect, and 135 with no chronic ocular conditions except cataract. INTERVENTION Administration of Medical Outcomes Study 36-item short-form survey (SF-36) was performed. Demographic information, medical history, and responses to the SF-36 questionnaire were elicited by an interviewer. Medical record review was performed to obtain clinical examination data and to substantiate the medical and demographic data obtained by the interviewer. MAIN OUTCOME MEASURES The SF-36 scores by diagnostic group, demographic characteristics, and medical history were examined. Secondary outcome measures were SF-36 scores in patients with glaucoma by visual field impairment and glaucoma medication use. RESULTS Patients with glaucoma consistently had lower scores, control subjects had higher scores, and glaucoma suspects had scores intermediate between the two groups. After adjusting for the possible influence of all the other covariate factors, glaucoma was found to be a strong predictor of lower SF-36 scores. CONCLUSION Patients with glaucoma have lower scores, indicating less-functional status, than patients without glaucoma as tested by the SF-36 survey questionnaire.

Hearing Impairment Associated With Depression in US Adults, National Health and Nutrition Examination Survey 2005-2010

IMPORTANCE Depression among hearing impaired US adults has not been studied previously. OBJECTIVE To estimate the prevalence of and risk factors for depression among adults with hearing loss. DESIGN, SETTING, AND PARTICIPANTS Adults aged 18 years or older (N = 18 318) who participated in the National Health and Nutrition Examination Survey (NHANES), 2005-2010, a nationally representative sample. INTERVENTIONS Multistage probability sampling of US population. MAIN OUTCOMES AND MEASURES Depression, assessed by the 9-item Patient Health Questionnaire (PHQ-9) scale, and hearing impairment (HI), assessed by self-report and audiometric examination for adults aged 70 years or older. RESULTS The prevalence of moderate to severe depression (PHQ-9 score, ≥10) was 4.9% for individuals reporting excellent hearing, 7.1% for those with good hearing, and 11.4% for participants who reported a little trouble or greater HI. Using excellent hearing as the reference, after adjusting for all covariates, multivariate odds ratios (ORs) for depression were 1.4 (95% CI, 1.1-1.8) for good hearing, 1.7 (1.3-2.2) for a little trouble, 2.4 (1.7-3.2) for moderate trouble, 1.5 (0.9-2.6) for a lot of trouble, and 0.6 (0.1-2.6) for deaf. Moderate HI (defined by better ear pure-tone average of hearing thresholds at 0.5, 1, 2, and 4 kHz within the range 35- to 49-dB hearing level) was significantly associated with depression among older women (OR, 3.9; 95% CI, 1.3-11.3), after adjusting for age, sex, race/ethnicity, lifestyle characteristics, and selected health conditions. CONCLUSIONS AND RELEVANCE After accounting for health conditions and other factors, including trouble seeing, self-reported HI and audiometrically determined HI were significantly associated with depression, particularly in women. Health care professionals should be aware of an increased risk for depression among adults with hearing loss.

Ahmed Glaucoma Valve Implant vs trabeculectomy in the surgical treatment of glaucoma: a randomized clinical trial

PURPOSE To compare the short- and intermediate-term results of two commonly used glaucoma surgical procedures, trabeculectomy and Ahmed glaucoma valve implant. METHODS A randomized clinical trial was performed at two international centers. One eye each of consecutive patients requiring glaucoma surgery for intraocular pressure control was randomized to receive either trabeculectomy or the Ahmed implant. RESULTS Of the 117 patients, 62 were randomized to trabeculectomy and 55 to the Ahmed implant. With a mean follow-up of 9.7 months, the trabeculectomy group had statistically lower intraocular pressures at weeks 6 to 15 (12.6 mm Hg vs 16.4 mm Hg) and months 11 to 13 (11.4 mm Hg vs 17.2 mm Hg) than the Ahmed implant group. Compared with preoperative status, no statistically significant differences between groups were noted for visual acuity, visual field, lens status, and final anterior chamber depth. The cumulative probabilities of success (intraocular pressure <21 mm Hg and at least 15% reduction in intraocular pressure from preoperative level) were 83.6% for trabeculectomy and 88.1% for Ahmed implant (P =.43). However, the Ahmed implant group had a greater adjunctive medication requirement. On the last visit, 10 of the trabeculectomy eyes and 19 of the Ahmed implant eyes required at least one topical medication (P =.01). There was no statistically significant difference in the rate of complications between the two groups. CONCLUSIONS Lower mean intraocular pressures were noted for the trabeculectomy group. All other results, including success (as defined in this study) and frequency of complications, were comparable between the two groups.