Paul E. Rafuse

Correlation of capsular pseudoexfoliation material and iridocorneal angle pigment with the severity of pseudoexfoliation glaucoma.

PurposeTo evaluate the correlation between the amount of pseudoexfoliation (PXF) material on the anterior lens capsule, pigment in the iridocorneal angle, presenting intraocular pressure (IOP) and severity of glaucoma in patients with PXF glaucoma/syndrome. Patients and MethodsAnterior lens capsule PXF material and iridocorneal pigment of 98 untreated patients with PXF syndrome/glaucoma were graded from photographs and correlated with untreated IOP and indices of glaucoma severity (cup to disc ratio, and visual field mean deviation, and pattern standard deviation). ResultsThere was a positive statistically significant correlation between the iridocorneal angle pigmentation and IOP (P=0.047, R2=0.2), but not the indices of glaucoma severity (P>0.13). There was no significant correlation between the anterior lens capsule PXF material and IOP or the indices of glaucoma severity (P>0.42). The grade of angle pigmentation, but not lens PXF, in eyes with IOP >21 mm Hg was significantly higher than in eyes with IOP ≤21 mm Hg (P=0.04). ConclusionsIn patients with PXF syndrome/glaucoma, gonioscopically identified iridocorneal angle pigmentation correlates more strongly with presenting IOP than the amount of PXF material on the anterior lens capsule.

Rates of glaucomatous visual field change after trabeculectomy

Background Trabeculectomy is frequently performed in patients with glaucoma who are deteriorating, although its effects on rates of visual field (VF) progression are not fully understood. We studied the rate of VF progression post trabeculectomy comparing with medically treated patients matched for VF loss. Methods Medical records of patients who underwent trabeculectomy alone or combined with cataract extraction were reviewed. Patients with 5 or more 24–2 VF examinations post trabeculectomy were selected. The rate of mean deviation (MD) change after surgery was calculated for each patient. These patients were pairwise matched based on baseline MD with patients with glaucoma who were treated medically and had at least 5 VF tests. Results 180 surgical patients were identified and matched with 180 medically treated patients (baseline MD of −8.72 (5.24) dB and −8.71 (5.22) dB, respectively). Surgically and medically treated patients were followed for 7.4 (2.9) and 6.8 (3.1) years respectively. The MD slopes were −0.22 (0.55) dB/year and −0.08 (1.10) dB/year in the surgically and medically treated patients, respectively, and not statistically different (p=0.13, 95% CI −0.31 to 0.04). More patients in the surgical group had fast progression (rates worse than −1 dB/year) than in the medical group (17 and 7 patients, respectively, p=0.05). Conclusions Our findings suggest that most patients who undergo trabeculectomy demonstrate relatively slow rates of VF progression postoperatively, similar to patients treated medically, although some patients can continue to progress despite adequate surgical control of intraocular pressure.

Neuroretinal Rim Area Change in Glaucoma Patients With Visual Field Progression Endpoints and Intraocular Pressure Reduction. The Canadian Glaucoma Study: 4

PURPOSE To compare rim area rates in patients with and without the visual field (VF) progression endpoint in the Canadian Glaucoma Study and determine whether intraocular pressure (IOP) reduction following the endpoint altered rim area rate. DESIGN Prospective multicenter cohort study. METHODS setting: University hospitals. PATIENT POPULATION Two hundred and six patients with open-angle glaucoma were examined at 4-month intervals with standard automated perimetry and confocal scanning laser tomography. INTERVENTION After the endpoint, IOP was reduced by ≥20%. OUTCOME MEASURES Univariate analysis for change in rim area rate and multivariable analysis to adjust for independent covariates (eg, age, sex, and IOP). RESULTS Patients with an endpoint (n = 59) had a worse rim area rate prior to the endpoint compared to those without (n = 147; median [interquartile range]: -14 [-32, 11] × 10(-3) mm(2)/y and -5 [-14, 5] × 10(-3) mm(2)/y, respectively, P = .02). In univariate analysis, there was no difference in rim area rate before and after the endpoint (median difference [95% CI], 8 (-10, 24) × 10(-3) mm(2)/y), but the muItivariate analysis showed that IOP reduction >2 mm Hg after the endpoint was strongly linked to a reduction in rim area rate decline (8 × 10(-3) mm(2)/y for each additional 1 mm Hg reduction). CONCLUSIONS Patients with a VF endpoint had a median rim area rate that was nearly 3 times worse than those without an endpoint. Lower mean follow-up IOP was independently associated with a slower decline in rim area.

The optimal trabeculectomy: patient and procedure.

Guarded external fistulization procedures remain important surgical options for patients who are experiencing progressive vision loss caused by glaucoma. The progenitor procedure, the trabeculectomy, has undergone continuous modifications over the past 40 or more years, rendering the surgery safer and the outcomes more predictable. Studies are cumulating to show that very low intraocular pressures can both reduce glaucomatous vision loss and positively change the rate of progression. Optimal patient selection and patient preparation, as well as some guiding procedural principles, are described in this review.

Evaluating selective laser trabeculoplasty versus argon laser trabeculoplasty in pseudoexfoliation glaucoma patients

OBJECTIVE Laser trabeculoplasty effectively reduces intraocular pressure (IOP) in primary open angle glaucoma, with argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT) showing equivalent outcomes. However, it is unclear which laser modality is more effective in pseudoexfoliation (PXE) glaucoma. This study aims to compare the effectiveness of ALT and SLT in PXE glaucoma. DESIGN Retrospective cohort study. METHODS A chart review evaluating patients diagnosed with PXE glaucoma and treated with laser trabeculoplasty from 2005-2015. Patients with previous glaucoma surgery, other forms of secondary glaucoma, ocular surgery within six months of initial trabeculoplasty or lacking preoperative IOP measurements were excluded. Post-laser measurements were recorded until 24 months after initial intervention. Follow-up data was censored if the patient underwent a subsequent trabeculoplasty different from initial laser treatment. RESULTS We included 84 patients in the ALT group and 123 in the SLT group. The mean (SD) baseline IOP values were 22.7 (±5.6) and 21.6 (±4.8) respectively (p = 0.11), while number of medications were 2.0 (±1.0) and 1.8 (±1.3) for ALT and SLT groups respectively (p = 0.36). The mean IOP reduction for the ALT group at 6, 12 and 24 months were 5.2 (±6.1), 5.4 (±6.9), and 4.9(±7.7) respectively. The corresponding values for the SLT group were 3.4 (±5.2), 3.8 (±4.6), and 4.6 (±6.5). Comparison of both lasers at each time point revealed no significant differences (p > 0.05) in IOP reduction or reduction of glaucoma medication. CONCLUSIONS Our study showed equivalent efficacy between ALT and SLT in patients with PXE glaucoma.