Nitin Anand

Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial

BACKGROUND Treatments for open-angle glaucoma aim to prevent vision loss through lowering of intraocular pressure, but to our knowledge no placebo-controlled trials have assessed visual function preservation, and the observation periods of previous (unmasked) trials have typically been at least 5 years. We assessed vision preservation in patients given latanoprost compared with those given placebo. METHODS In this randomised, triple-masked, placebo-controlled trial, we enrolled patients with newly diagnosed open-angle glaucoma at ten UK centres (tertiary referral centres, teaching hospitals, and district general hospitals). Eligible patients were randomly allocated (1:1) with a website-generated randomisation schedule, stratified by centre and with a permuted block design, to receive either latanoprost 0·005% (intervention group) or placebo (control group) eye drops. Drops were administered from identical bottles, once a day, to both eyes. The primary outcome was time to visual field deterioration within 24 months. Analyses were done in all individuals with follow-up data. The Data and Safety Monitoring Committee (DSMC) recommended stopping the trial on Jan 6, 2011 (last patient visit July, 2011), after an interim analysis, and suggested a change in primary outcome from the difference in proportions of patients with incident progression between groups to time to visual field deterioration within 24 months. This trial is registered, number ISRCTN96423140. FINDINGS We enrolled 516 individuals between Dec 1, 2006, and March 16, 2010. Baseline mean intraocular pressure was 19·6 mm Hg (SD 4·6) in 258 patients in the latanoprost group and 20·1 mm Hg (4·8) in 258 controls. At 24 months, mean reduction in intraocular pressure was 3·8 mm Hg (4·0) in 231 patients assessed in the latanoprost group and 0·9 mm Hg (3·8) in 230 patients assessed in the placebo group. Visual field preservation was significantly longer in the latanoprost group than in the placebo group: adjusted hazard ratio (HR) 0·44 (95% CI 0·28-0·69; p=0·0003). We noted 18 serious adverse events, none attributable to the study drug. INTERPRETATION This is the first randomised placebo-controlled trial to show preservation of the visual field with an intraocular-pressure-lowering drug in patients with open-angle glaucoma. The study design enabled significant differences in vision to be assessed in a relatively short observation period. FUNDING Pfizer, UK National Institute for Health Research Biomedical Research Centre.

Long-term outcomes of needle revision of trabeculectomy blebs with mitomycin C and 5-fluorouracil: a comparative safety and efficacy report.

PurposeTo report the long-term comparative outcomes for needle revision with 5-fluorouracil (5-FU) and mitomycin C (MMC) of failed trabeculectomy blebs. Patients and MethodsA retrospective database search was made for all patients who had needle revision with subconjunctival antimetabolite injections on the slit lamp from August 2001 to April 2006. Needle revisions were augmented with MMC instead of 5-FU from December 2003. Ninety-eight eyes of 95 consecutive patients (45 with MMC and 53 with 5-FU) with a minimum follow-up of 1 year were included. 5-FU (5 mg) or MMC (0.02 mg), with 0.1 mL of 2% lignocaine was injected subconjunctivally at least 10 minutes before the revision procedure in the clinic. No patient from the MMC group received subsequent 5-FU injections. ResultsThe 5-FU group had significantly longer mean follow-ups (P<0.001) of 53.0±18.12 months compared with 33.3±9.0 months in the MMC group. The 5-FU group had a significantly higher number of needle revisions than MMC group (1.9±1.0 vs. 1.2±0.5, P=0.001). Twenty-five eyes (47%) of the 5-FU group and 36 eyes (80%) of the MMC group had a single needle revision (P=0.009). The probability of maintaining intraocular pressure between 5 and 16 mm Hg with no glaucoma medication or further surgical procedure was 71% (62%-88%) and 45% (33%-60%) at 1 year and 61% (49%-78%) and 30% (20%-46%) at 2 years in the MMC and 5-FU groups, respectively. MMC use (hazard ratio=2.18, 95% confidence interval, 1.25-3.81, P=0.006) and intraocular pressure drop immediately after needling as a continuous variable (hazard ratio=1.06, 95% confidence interval, 1.00-1.13.8, P=0.03) were significantly associated with success. Twelve eyes (22.6%) with failed 5-FU needling had subsequent MMC needle revisions, 5 of which were successful by the study criterion. Eyes with 5-FU needle revision were more likely to fail within the first 6 months (P=0.02). Serious complications included blebitis in 3 (5.7%) and 1 (2.2%), delayed bleb leaks in 9 (17.0%) and 1 (2.2%) eyes in the 5-FU and MMC groups, respectively. There was no statistical difference in the complication rates between the groups. Aqueous misdirection was observed in 1 (2.2%) eye of MMC group and delayed suprachoroidal hemorrhage in 1 (1.9%) eye of 5-FU group. ConclusionsThis study suggests that MMC is more effective than 5-FU for needle revision of failed trabeculectomy blebs.

Nd:YAG laser goniopuncture after deep sclerectomy: outcomes.

Purpose:  This study aimed to investigate the safety and efficacy of Nd:YAG laser goniopuncture (LGP) in lowering intraocular pressure (IOP) after deep sclerectomy (DS).

Primary Phakic Deep Sclerectomy Augmented With Mitomycin C: Long-term Outcomes

AimTo report the long-term outcomes of deep sclerectomy (DS) with intraoperative mitomycin C in eyes with no previous ocular surgery. MethodsOne hundred ninety-four eyes of 160 consecutive patients who had primary phakic DS between August 2001 and April 2005 were included from a database on all glaucoma surgery in our department. The mean follow-up was 48±15 months (median, 49 mo). ResultsThe probability of a final intraocular pressure (IOP) of less than 19, 16, and 13 mm Hg without medications or needle revisions at 1 year was 85% (80% to 90%, 95% confidence intervals), 83% (78% to 88%), and 68% (62% to 75%). At 3 years was 78% (73% to 85%), 76% (60% to 82%), and 60% (53% to 67%), respectively. The probability of performing Nd:YAG laser goniopuncture (LGP) was 66% (59% to 74%) 3 years after DS. Further glaucoma surgery was undertaken in 16 eyes (8.2%). Intraoperative perforations occurred in 28 eyes (14.4%). Iris synechiae or incarceration in the goniopuncture were observed in 54 (27.8%) during follow-up and were associated with an acute symptomatic rise in IOP in 6 eyes (3.1%). Hypotony with maculopathy was seen after LGP and needling in 3 eyes (1.5%). Blebitis developed in 2 eyes (1%) after LGP and endophthalmitis in 1 eye (0.5%), which had an intraoperative perforation. ConclusionsMitomycin C-enhanced primary DS effectively reduces IOP in primary phakic open-angle glaucoma. Most eyes required LGP to maintain IOP control. However, complications associated with partial-thickness procedures, like bleb-related infections and hypotonic maculopathy were observed.

Surgical revision of failed filtration surgery with mitomycin C augmentation.

AimThe aim of the study was to assess the outcomes of surgical revision with reopening of the scleral flap in eyes with failed glaucoma surgery and adjunctive mitomycin C (MMC). MethodsRetrospective, noncomparative, interventional case series. Fifty-four eyes of 54 consecutive patients with previously failed trabeculectomy or deep sclerectomy who underwent formal surgical revision (23 with concurrent phacoemulsification) were included. MMC, 0.2 mg/mL for 2 to 3 minutes, was applied under a fornix-based conjunctival flap. The preexisting scleral flap was dissected open to reestablish filtration. ResultsMean follow-up was 39.5±10 months. Kaplan-Meier survival analysis showed that the probability (with 95% confidence intervals) of maintaining an intraocular pressure (IOP) between 5 and 18 mm Hg and 20% decrease from preoperative IOP was 64% (47% to 76%) with medications and/or needle revision and 38% (26% to 53%) without, 3 years after surgery. Mean IOP before surgery was 23.6±7.2 mm Hg and 14.4±6.0 three years after surgery (last IOP before further glaucoma procedure carried forward). Needle revision for bleb failure or high IOP was carried out in 23 eyes (42.5%) and further glaucoma surgery in 5 eyes (9.3%). Patients were on an average of 2±1.1 glaucoma medications before surgery. At last follow-up, the number of medications had decreased to 0.8±1.2 (P<0.000), with 23 eyes (42.5%) requiring medications to control IOP. Significant complications included delayed suprachoroidal hemorrhage (3 eyes, 5.6%), delayed bleb leaks (5 eyes, 9.3%), hypotony (2 eyes, 3.7%), and blebitis (2 eyes, 3.7%). ConclusionsThere is a progressive increase in IOP with time after surgical revision of failed glaucoma surgery with adjunctive MMC. A significant proportion of eyes will eventually require a needle revision procedure and/or glaucoma medications to further lower IOP. Also, there is a significant incidence of complications associated with this procedure.

Delayed suprachoroidal hemorrhage after needle revision of trabeculectomy bleb in a patient with hairy cell leukemia

PURPOSE To report a rare complication, delayed suprachoroidal hemorrhage, of needle revision of a nonfunctioning trabeculectomy bleb in a patient with previously undetected hairy cell leukemia. DESIGN Interventional case report. METHODS; An 89-year-old man presented with massive delayed suprachoroidal hemorrhage after needle revision of a trabeculectomy bleb. RESULTS Routine investigations before choriodal drainage showed a low platelet count. Anterior chamber washout and choroidal drainage were done after intravenous platelet infusions. Subsequently, the diagnosis of hairy cell leukemia was made by the hematologist. CONCLUSIONS Delayed suprachoroidal hemorrhage is a rare but devastating complication of needle revision of trabeculectomy blebs and should be borne in mind while performing this seemingly trivial outpatient procedure.

Deep sclerectomy with bevacizumab and mitomycin C: a comparative study.

Purpose:To assess the comparative efficacy and safety of primary deep sclerectomy (DS) augmented with subconjunctival Bevacizumab and intraoperative Mitomycin C (MMC). Methods:Retrospective, comparative case-control series of consecutive primary DS between January 2008 and December 2010. Seventy-five eyes of 73 patients were included, with 32 eyes in the MMC and 43 in the Bevacizumab group. MMC (0.2 mg/mL for 2 min) was applied subconjunctivally before scleral flap dissection. Bevacizumab (2.5 mg in 0.1 mL) was injected subconjunctivally at the end of surgery. Complete success was intraocular pressure (IOP) <19 mm Hg and a 20% decrease from baseline with no postoperative medications. Results:There were no significant baseline differences between the groups. Follow-up after DS was 33.3±6.1 months for the Bevacizumab and 35.0±10.2 months for the MMC group (P=0.34). Complete success rates were 90.7% [95% confidence interval (CI), 82.4%-99.8%] and 87.5% (95% CI, 76.8%-99.7%) at 1 year and 76.5% (95% CI, 64.8%-90.4%) and 74.4% (95% CI, 60.5%-91.4%) at 2 years after DS in the Bevacizumab and MMC groups, respectively (P=0.52). There was no statistical difference in mean IOPs between the groups at all specified time intervals up to 2 years (P=0.28). At last follow-up 2 (6.2%) of the MMC and 2 (4.7%) eyes of Bevacizumab group were on medications to control IOP. Eighteen eyes had complications, 9 (20.9%) in Bevacizumab and 9 (28.1%) in the MMC group (P=0.8). Conclusion:Subconjunctival Bevacizumab with primary DS appears to be as efficacious as MMC augmentation with no additional side effects.

Why do people present late with advanced glaucoma? A qualitative interview study

Objective To explore the presentation behaviours and pathways to detection of adults who first presented to UK hospital eye services with severe glaucoma. Design Semistructured interviews, based on models of diagnostic delay, to obtain a descriptive self-reported account of when and how participants’ glaucoma was detected. Results 11 patients participated (five in Aberdeen, six in Huddersfield). Four participants reported that the optometry appointment at which their glaucoma was detected was their first ever eye test or their first for over 10 years. Seven participants reported attending regular routine optometrist appointments. Their self-reported experiences and pathways to detection describe a variety of missed detection opportunities and delayed referral and treatment. Conclusions The qualitative data suggest that late detection of glaucoma can result from delays at the patient level but, although based on a small sample, delays also occurred at the healthcare provider (system) level both in terms of accuracy of case detection and effective referral. We suggest that current attempts to address the significant burden of over-referral of glaucoma suspects to hospital eye services (a large proportion of which are false positives) must also focus on the issue of false negatives and on reducing missed detection and service delays.

Long-term follow-up of zonulo-hyaloido-vitrectomy for pseudophakic malignant glaucoma

Purpose: To report long-term follow-up of zonulo-hyaloido-vitrectomy (ZHV) via anterior approach for pseudophakic malignant glaucoma refractory to medical treatment. Design: Noncomparative case-series. Materials and Methods: Medical records of 9 patients who sought treatment for aqueous humor misdirection refractory to medical treatment were reviewed. All patients underwent anterior vitrectomy, hyaloido-zonulectomy, and peripheral iridectomy (PI) via an anterior approach. Main outcome measures were preoperative and postoperative visual acuity, intraocular pressure, medications, slit-lamp examination, and fundus findings. Results: 10 eyes of 9 patients (7 female, 2 male) who underwent ZHV for refractory pseudophakic malignant glaucoma between 2003 and 2010 were included in this case-series. The mean age of patients was 77.4 ± 9.0 years, mean follow-up duration 50.2 ± 27.2 months. Recurrence of malignant glaucoma was noted in 40% (four cases) after a successful ZHV on long-term follow-up. Conclusions: An anterior segment surgeon can treat malignant glaucoma refractory to medical treatment successfully by vitrectomy, hyaloido-zonulectomy, and PI. This can be done via an anterior approach and patients require long follow-up to rule out a relapse despite a successful outcome in the short term.