Paul Harasymowycz

Determinants of adherence to glaucoma medical therapy in a long-term patient population.

PurposeEstimate patient adherence to glaucoma medications and identify potential determinants of nonadherence. DesignDescriptive study. MethodsTwo hundred patients with open angle glaucoma, ocular hypertension, or glaucoma suspects were interviewed regarding their glaucoma and its treatment and their charts were reviewed. Their ophthalmologist completed a brief assessment form. Drug utilization data were extracted from the provincial drug program database. Patients were defined as adherent if they filled at least 75% of the prescribed medication necessary for their treatment. ResultsData were available for 181 patients. About 62.9% were female and the mean age (±SD) was 75.1±8.8 years. The mean number of years of glaucoma treatment was 10.7±9.3. Self-reported treatment adherence was 88.3%. On the basis of the drug database, the proportion of patients who were adherent to treatment was 71.8%. According to physicians, 74.6% of patients were adherent. Among patients considered by physicians as nonadherent, 71.1% (32/45) were adherent and among patients predicted as adherent, 72.1% (98/136) were adherent. There was no significant difference in adherence according to age, sex, education, and income. However, patients using fewer agents (P=0.041), who were widowed (P=0.041), or who lived alone (P=0.042) were more adherent. Patients using prostaglandins analogs or β-blockers were more adherent than those using carbonic anhydrase inhibitors (P<0.05). ConclusionsFewer medications, use of prostaglandin analogs or β-blockers, living alone, and being widowed were significantly associated with adherence. Physicians were unable to significantly predict which patients are adherent.

Original articleThe Ahmed Versus Baerveldt Study: One-Year Treatment Outcomes

OBJECTIVE To report the 1-year treatment outcomes of the Ahmed Versus Baerveldt (AVB) Study. DESIGN Multicenter randomized clinical trial. PARTICIPANTS A total of 238 patients were enrolled in the study, including 124 in the Ahmed group and 114 in the Baerveldt group. METHODS Patients aged 18 years or older with uncontrolled glaucoma refractory to medicinal, laser, and surgical therapy were randomized to undergo implantation of an Ahmed-FP7 valve (New World Medical, Inc., Rancho Cucamonga, CA) or a Baerveldt-350 implant (Abbott Medical Optics, Inc., Santa Ana, CA), to be followed for 5 years. MAIN OUTCOME MEASURES The primary outcome measure was failure, defined as intraocular pressure (IOP) out of target range (5-18 mmHg with ≥ 20% reduction from baseline) for 2 consecutive visits after 3 months, vision-threatening complications, additional glaucoma procedures, or loss of light perception. Secondary outcome measures included IOP, medication use, visual acuity, complications, and interventions. RESULTS There were no significant differences in baseline ocular or demographic characteristics between the study groups with the exception of sex. Preoperatively, the study group had a mean IOP of 31.4 ± 10.8 mmHg on a mean of 3.1 ± 1.0 glaucoma medications with a median Snellen acuity of 20/100. The cumulative probability of failure a 1-year was 43% in the Ahmed group and 28% in the Baerveldt group (P = 0.02). The mean IOP at 1 year was 16.5 ± 5.3 mmHg in the Ahmed group and 13.6 ± 4.8 mmHg in the Baerveldt group (P < 0.001). The mean number of glaucoma medications required was 1.6 ± 1.3 in the Ahmed group and 1.2 ± 1.3 in the Baerveldt group (P = 0.03). Visual acuity was similar in both groups at all visits in the first year (P = 0.66). In the first year after surgery, there were a similar number of patients who experienced postoperative complications in the 2 groups (45% Ahmed, 54% Baerveldt, P = 0.19), but a greater number of patients in the Baerveldt group required interventions (26% Ahmed vs. 42% Baerveldt, P = 0.009). CONCLUSIONS The Baerveldt-350 group had a higher success rate than the Ahmed-FP7 group after 1 year of follow-up, but required a greater number of interventions. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Phacoemulsification and goniosynechialysis in the management of unresponsive primary angle closure.

Purpose:To evaluate the effectiveness of phacoemulsification and goniosynechialysis (PEGS) in managing acute and subacute primary angle closure unresponsive to conventional therapy. Materials and Methods:Retrospective series of patients of six glaucoma-trained surgeons with primary angle closure that did not respond to medical management, Nd:YAG laser peripheral iridotomy, or argon laser peripheral iridoplasty. Results:A total of twenty-one patients with an average age of 65.6 years were included. Underlying mechanism of angle closure included pupillary block (n = 18) and plateau iris (n = 3). Average intraocular pressure (IOP) immediately prior to PEGS was 40.7 mm Hg, and mean follow-up time after PEGS was 11.7 months. PEGS decreased mean IOP by 25 mm Hg (62%), and mean number of medications from 3.8 pre-surgery to 1.7 post-surgery (55%). Mean LogMar visual acuity improved after PEGS, from 0.64 to 0.44 (Paired t test t = 4.120 P = 0.001). Subsequent trabeculectomy was necessary in one case (5%). Conclusions:Phacoemulsification with goniosynechialysis may be an effective treatment option for primary angle closure unresponsive to conventional therapy.

Relationship between travoprost and central corneal thickness in ocular hypertension and open-angle glaucoma.

Purpose: To evaluate whether treatment with travoprost, an F2a prostaglandin analog, affects central corneal thickness (CCT) and whether intraocular pressure (IOP) response to the medication is related to baseline CCT. Methods: This was a prospective, interventional, nonrandomized, nonconsecutive, clinical trial. In this multicenter study, 379 total patients, 220 with newly or previously diagnosed open-angle glaucoma (OAG), 141 with ocular hypertension (OHT), and 18 unspecified, were recruited from 15 Canadian sites. IOP and CCT assessments were performed at baseline and 6 weeks after treatment with travoprost. Patients on IOP-lowering therapy at the time of enrollment were washed out for 4 weeks before baseline examinations. IOP was measured with Goldmann tonometers and CCT with Accutome IV pachymeters. Statistical analysis was performed with S-PLUS software. Results: Posttherapy mean IOP decreased by 6.31 mm Hg or 24.4% (P < 0.001), and regression analysis indicated relatively greater IOP reduction in patients with higher pretherapy IOP (slope = 0.64; 95% CI, 0.54-0.76). Mean CCT decreased by 6.9 μm (P < 0.001). IOP reduction was not related to CCT reduction (slope = 0.253; 95% CI, −0.232 to 0.739; P = 0.305). Percent IOP decrease was not related to baseline CCT (slope = −0.02; 95% CI, -0.06 to 00.02; P = 0.33) in the total study sample. When OHT and OAG groups were considered separately, the OAG patients had less percent IOP decrease with thicker baseline CCT (slope = −0.067; 95% CI, −0.13 to −0.004; P = 0.037). Conclusions: Treatment with travoprost decreased IOP significantly and was associated with CCT thinning, which had little or no effect on actual IOP decrease. In the OAG group, IOP decrease was found to be statistically smaller in patients with thicker corneas.

SURGICAL TREATMENT OF ADVANCED CHRONIC ANGLE CLOSURE GLAUCOMA IN WEILL-MARCHESANI SYNDROME

PURPOSE To describe the surgical treatment of advanced chronic angle closure glaucoma in Weill-Marchesani syndrome. PATIENTS AND METHODS Two children with Weill-Marchesani syndrome (4 eyes) undergoing lensectomy, anterior vitrectomy, and sutured intraocular lens (IOL) and Molteno tube shunt surgery at Wills Eye Hospital were prospectively studied. Visual acuity and intraocular pressure (IOP) were recorded. RESULTS Both patients presented with increasing myopia and advanced glaucomatous damage. Laser iridotomy was ineffective in deepening the anterior chamber. The first patient developed a flat anterior chamber after trabeculectomy. At the 12-month follow-up visit, all 4 eyes had an important decrease in IOP and cupping after combined lensectomy, anterior vitrectomy, and sutured IOL and Molteno tube shunt placement. One eye had a transitory postoperative choroidal effusion and retinal detachment that resolved spontaneously. CONCLUSIONS Advanced chronic angle closure glaucoma in Weill-Marchesani syndrome may be treated with a combination of lensectomy, anterior vitrectomy, and sutured IOL and Molteno tube shunt surgery. In early cases, prophylactic peripheral iridotomies should be stressed.

A randomized clinical trial of selective laser trabeculoplasty versus argon laser trabeculoplasty in patients with pseudoexfoliation.

Purpose:To evaluate the efficacy of selective laser trabeculoplasty (SLT) versus argon laser trabeculoplasty (ALT) in lowering the intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension secondary to pseudoexfoliation. Design:Multicentered randomized clinical trial. ParticipantsA total of 76 eyes from 60 patients with pseudoexfoliation and uncontrolled IOP were recruited from 5 Canadian academic institutions. Patients with prior laser trabeculoplasty, ocular surgery within 6 months, previous glaucoma surgery, an advanced visual field defect, current steroid use, and monocular patients were excluded. Methods:Eyes were randomized to receive either 180-degree SLT or 180-degree ALT by a nonblocked randomization schedule stratified by center. Main Outcome Measurement:The primary outcome was the change in IOP at 6 months versus baseline and secondary outcomes included change in number of glaucoma medications after laser. Baseline variables included age, sex, angle grade, angle pigmentation, and number of glaucoma medications. Results:Of the 76 eyes, 45 eyes received SLT and 31 eyes received ALT. The overall age was 72.9 years (65% females). The baseline IOPs in the SLT and ALT groups were 23.1 and 25.2 mm Hg, respectively (P=0.03). The IOP reduction 6 months after SLT was −6.8 mm Hg and post-ALT was −7.7 mm Hg (P>0.05). The SLT group had reduced glaucoma medications by 0.16 medications at 6 months and the ALT group had no decrease in medications over the same time period (P=0.59). There were no postlaser IOP spikes in either group. Discussion:ALT and SLT are equivalent in lowering IOP at 6 months posttreatment in patients with PXF.

Baseline Factors Predictive of SLT Response: A Prospective Study

Purpose. To study the response to Selective Laser Trabeculoplasty (SLT) according to baseline medical treatment, angle pigmentation, age, diagnosis (open-angle glaucoma or ocular hypertension), and baseline intraocular pressure (IOP). Methods. 74 eyes of 74 patients were enrolled in this study. Baseline characteristics were recorded for each patient. IOP in the treated and fellow eyes was measured at baseline, and 1 month, 6 months, and 12 months following SLT. IOP changes in the different groups were compared using two-way ANOVA and Pearsons correlation. Results. The mean age of our cohort was 71 ± 10 years. The mean baseline IOP was 21.5 ± 5 mmHg, and the mean change in IOP from baseline in the treated eye at one year was −4.67 ± 3.40 mmHg. Higher baseline IOP was highly correlated with greater absolute IOP decrease. Prostaglandin analogue use at baseline was shown to be associated with a statistically decreased IOP-lowering response following SLT when corrected for baseline IOP. No significant differences in IOP response were found when comparing groups stratified for age, angle pigmentation, phakic status, gender, or diagnosis. Discussion. The results of this study confirm the finding that higher baseline IOP is a predictor of greater IOP response following SLT, and that pretreatment with prostaglandin analogue therapy is associated with a decreased IOP-lowering response following SLT. The study is limited by the small number of eyes with data available for complete case analysis.

Racial variability of glaucoma risk factors between African Caribbeans and Caucasians in a Canadian urban screening population.

BACKGROUND The significance of race in the development and progression of glaucoma remains controversial, although in most cases the evidence shows greater prevalence and progression of the disease in African American populations. The purpose of this study was to determine the impact of the African Caribbean race on the variability of risk factors for glaucoma in an urban Canadian screening population. STUDY DESIGN Population-based, cross-sectional study. PARTICIPANTS Participants with high risk for development of open-angle glaucoma. METHODS Participants underwent confocal scanning laser ophthalmoscopy (Heidelberg Retina Tomograph),frequency-doubling technology (FDT) perimetry, and complete ophthalmic examination during a high-risk glaucoma screening clinic. Statistical analysis was performed comparing the data gathered from these tests in the different racial groups. Students t tests as well as Pearsons c2 tests were done. RESULTS Racial breakdown included 64 African Caribbeans (22%) and 224 Caucasians (78%). Racial groups had similar female/male ratios, but Caucasians were significantly older (66 [SD 12] years) than African Caribbeans (56 [SD12] years) ( p = 0.001). African Caribbeans had significantly higher intraocular pressure (IOP) ( p < 0.001); thinner central corneal thickness (CCT) ( p < 0.001); greater cup/disc ratio ( p = 0.016), disc area ( p < 0.001), cup area ( p = 0.002), and cup/disc area ratio ( p = 0.009); and smaller rim/disc area ratio ( p = 0.009). The latter optic disc parameter differences were not statistically different when corrected for disc area differences. CONCLUSIONS In this study, African Caribbeans in a Canadian urban setting were associated with increased risk factors for open-angle glaucoma development, including higher IOP and thinner CCT. The larger cup/disc and cup/disc area ratios of the African Caribbean group were directly correlated to disc area differences between the 2 groups.

Anterior segment changes after pilocarpine and laser iridotomy for primary angle-closure suspects with Scheimpflug photography.

Purpose:To assess changes in Scheimpflug-based measurements of the anterior segment after pilocarpine administration and prophylactic laser peripheral iridotomy in narrow anterior chamber angles. Methods:Thirty-seven eyes in 37 patients with occludable angles were included in this prospective interventional case series. Primary angle-closure suspects (iridotrabecular contact in 3 quadrants or more) were enrolled. Patient evaluation included indentation gonioscopy, Goldmann tonometry, and optic nerve examination. The mean of 3 consecutive Pentacam measurements was taken at baseline, 45 minutes after 2% pilocarpine administration, and 1 month after laser peripheral iridotomy (LPI). Anterior chamber angle (ACA), anterior chamber volume (ACV), anterior chamber depth (ACD), pupil diameter, central corneal thickness, and intraocular pressure were measured. Results:ACV increased significantly after LPI (from a mean±standard error of 94.6±3.6 mm3 to 108.8±3.4 mm3, P<0.001), as did the ACA (26.7±0.9 degrees to 28.2±0.8 degrees, P<0.001). Central corneal thickness decreased significantly after LPI (558.1±5.3 &mgr;m to 552.6±5.7 &mgr;m, P=0.018). Central ACD increased slightly after LPI, but this was not statistically significant (2.13±0.05 mm to 2.15±0.05 mm, P=0.109). Pupil diameter and intraocular pressure also did not change significantly after LPI. After pilocarpine, the ACV decreased significantly (by 4.3±1.3 mm3, P=0.009), as did the central ACD (by 0.1 ±0.02 mm, P<0.001) and the pupil diameter (by 0.74±0.06 mm, P<0.001). Conclusions:Scheimpflug photography demonstrates significant anterior segment changes after pilocarpine and after LPI in primary angle-closure suspects.

Goniopuncture in the treatment of short-term post-Trabectome intraocular pressure elevation: a retrospective case series study.

Purpose:This study characterizes patients with post-Trabectome intraocular pressure (IOP) elevation induced by membrane growth and/or peripheral anterior synechiae and examines the results of Nd:YAG goniopuncture as its treatment. Methods:All Trabectome cases received standard postoperative care and no pilocarpine was given. Two groups were identified: (1) Trabectome-goniopuncture (TG) and (2) Trabectome alone (without goniopuncture) (TA). IOP and number of glaucoma medications (NGM) were collected by retrospective review. Information on whether cataract extraction was combined to the Trabectome was also recorded. Results:In TG group (n=8), pre-Trabectome IOP and NGM were 16.9±3.7 mm Hg and 2.5±1.0, respectively. IOP rose to 21.9±2.9 mm Hg before goniopuncture (P=0.03) but lowered to 16.1±4.8 mm Hg after the treatment (P=0.006). IOP reduction persisted at post-Trabectome 3 months (13.5±1.5 mm Hg), 6.5 months (15.3±9.3 mm Hg), and 10.5 months (13.4±1.0 mm Hg). No significant medication reduction was detected. In TA group (n=22), pre-Trabectome IOP and NGM were 18.1±2.5 mm Hg and 2.7±0.5, respectively. NGM was significantly lowered from post-Trabectome day 1 on (1.8±0.6, P=0.01) and IOP from 3 months on (15.2±1.8 mm Hg, P=0.03). Five (62.5%) TG cases and 18 (81.5%) TA cases underwent combined cataract extraction-Trabectome. Compared with the TA group, TG cases are associated with thinner pachymetry (P=0.034). Conclusions:Cleft closure may cause post-Trabectome pressure elevation. Not providing any medication-sparing effect, goniopuncture is, however, effective in lysing these closures and in normalizing the IOP back to its pre-Trabectome level.