Rony Rachmiel

Laser trabeculoplasty trends with the introduction of new medical treatments and selective laser trabeculoplasty.

PurposeTo correlate trends of laser trabeculoplasties (LTPs) with the introduction of medical therapies for glaucoma and to assess whether these trends changed after the introduction of selective laser trabeculoplasty (SLT) in 2001. MethodsA retrospective analysis of LTP numbers, filtration surgeries, glaucoma medications dispensed, and population distribution by age in Ontario, Canada, between April 1992 and March 2005. ResultsThe number of LTP per 1000 persons estimated to have primary open angle glaucoma (POAG) increased from 138.05 in 1992 to a maximum of 149.23 in 1996 (8.1% increase, 1.96% annual increase) and then steadily decreased to 70.65 in 2001 (47.3% decrease, 14% annual decrease). From 2001 to 2004, the LTP rate increased to 162.54 (230% increase, 32% annual increase). The number of filtration surgeries per 1000 persons estimated to have POAG steadily decreased from 1996 to 2004 by 21.42% (2.4% annual decrease). The number of glaucoma medications dispensed in Ontario increased from 1992 to 2004 by 91.5% (10.5% annual increase). There were no significant correlations between the LTP rates and the new glaucoma medications rates (r=−0.35 to 0.09; P=0.34 to 0.82) or filtration surgeries rates (r=0.007; P=0.98). ConclusionsThere was a substantial reduction in the number of LTP between 1997 and 2001 coinciding, but not correlated with the introduction of medications for the treatment of glaucoma. Between 2002 and 2004 the LTP rates increased, coinciding with the introduction of SLT.

Ahmed glaucoma valve implantation in uveitic glaucoma versus open-angle glaucoma patients.

BACKGROUND The poor long-term success rate of repeat trabeculectomies in refractory uveitic glaucoma (UG) patients has led to the use of glaucoma drainage devices (GDDs). However, the success and complication rates of GDDs in UG patients utilizing a control group with standard demographic data, design, and surgical technique have never been evaluated. METHODS Fifteen patients (15 eyes) with chronic uveitis and 53 patients (53 eyes) with uncontrolled open-angle glaucoma (OAG) who underwent Ahmed glaucoma valve (AGV) implantation were included in a retrospective, comparative, case-controlled study. Postoperative intraocular pressure (IOP), number of antiglaucoma medications, visual acuity, and complications were compared. RESULTS There was a significant difference between the UG versus the OAG group with respect to age only (59.3 years vs 68.4 years, p = 0.006). Regression analysis of the postoperative IOP controlled for age and glaucoma type, and preoperative IOP revealed significantly lower IOP in the UG group at 1 month (p = 0.04; 95% confidence interval [CI] -5.9 to 0.15) and 2 months (p = 0.008; 95% CI -6.0 to 0.97). No significant differences were found at 3, 6, 12, 24, and 30 months. The cumulative success rates at 3 to 30 months for the UG and OAG groups were 80% to 66.6% versus 84.9% to 57% (p = 0.713), respectively. The only complication between the 2 groups that was significantly different was tube removal, which occurred more often in the UG group (p = 0.018). INTERPRETATION AGV implantation is an effective and safe procedure in the management of UG, similar to primary OAG.

Retinal Arteriolar Vascular Reactivity in Untreated and Progressive Primary Open-Angle Glaucoma

Purpose. To determine (1) the magnitude of retinal arteriolar vascular reactivity to normoxic hypercapnia in patients with untreated primary open-angle glaucoma (uPOAG) or progressive (p)POAG and in control subjects and (2) the effect of treatment with 2% dorzolamide on retinal vascular reactivity in uPOAG. Methods. The sample comprised 11 patients with uPOAG (after undergoing treatment, they became treated (t)POAG), 17 patients with pPOAG (i.e., manifesting optic disc hemorrhage), and 17 age-similar control subjects. The partial pressure of end-tidal CO(2) (PetCO(2)) was stabilized at 38 mm Hg at baseline. After baseline (10 minutes), normoxic hypercapnia was then induced (15 minutes) with an automated gas flow controller. Retinal arteriolar and optic nerve head (ONH) blood hemodynamics were assessed. The procedures were repeated after treatment with 2% dorzolamide for 2 weeks in tPOAG. Results. Baseline arteriolar hemodynamics were not different across the groups. In control subjects, diameter, velocity, and flow increased (P < 0.001) in response to normoxic hypercapnia. There was no change in all three hemodynamic parameters to normoxic hypercapnia in uPOAG, whereas only blood flow increased (P = 0.030) in pPOAG. Vascular reactivity was decreased in uPOAG and pPOAG patients compared with that in control subjects. After treatment with topical 2% dorzolamide for 2 weeks, the tPOAG group showed an increase in diameter, velocity, and flow (P </= 0.04) in response to normoxic hypercapnia. Similar trends were noted for ONH vascular reactivity. Conclusions. A reduced magnitude of arteriolar vascular reactivity in response to normoxic hypercapnia was shown in uPOAG and in pPOAG. Vascular reactivity improved after dorzolamide treatment in POAG.

Glaucoma laser and surgical procedure rates in Canada: a long-term profile

BACKGROUND New laser and surgical techniques have had a significant effect on glaucoma therapy. A precise understanding of how these developments are affecting overall glaucoma management is fundamental to health services planning. The objective of this study was to synthesize Canadian national and provincial data regarding glaucoma laser and surgical procedure rates from 1992 to 2004. METHODS Canadian provincial health insurance databases, which cover virtually all surgical procedures provided domestically to Canadians, were accessed to ascertain yearly total glaucoma procedure numbers. To estimate the number of individuals with glaucoma, an age-stratified glaucoma prevalence model was applied to population census data. RESULTS Laser trabeculoplasty rates dramatically increased between 2001 and 2004 with the national Canadian rate more than doubling. However, this increase varied widely across regions, ranging from 0% to 530%. Trabeculectomy surgery rates slowly increased from 1992 to 1995, then declined by 29% nationally between 1995 and 2004. Implantation rates of glaucoma drainage devices increased 12-fold nationally between 1992 and 2004; by 2004 this procedure accounted for 10% of incisional glaucoma surgical procedures in Canada. INTERPRETATION In Canada, laser trabeculoplasty rates have risen significantly over recent years. Trabeculectomy rates have recently declined, and implantation of glaucoma drainage devices is playing an increasingly important role in glaucoma management in this country.

Intermediate-term outcome and success of superior versus inferior Ahmed Glaucoma Valve implantation.

PurposeThe superotemporal quadrant is usually the implantation site of choice for glaucoma drainage devices. Inferior placement of glaucoma drainage device is considered technically difficult. The purpose was to determine the success rates, complications, and visual outcome of superior versus inferior Ahmed Glaucoma Valve implantation. Patients and MethodsA retrospective review of the records of 83 eyes (77 patients) that underwent Ahmed Glaucoma Valve surgery from 1997 to 2004. Thirty-one eyes had superior insertion (SI) versus 52 eyes with inferior insertion (II). Demographic, preoperative, and postoperative data including intraocular pressure (IOP), visual acuity, and number of medications, and complications were recorded. Success was defined as postoperative IOP between 5 and 21 mm Hg and at least a 20% reduction from baseline IOP. ResultsThe mean postoperative IOPs at 6 months, 1, 2, 2.5, and 3 years were 13.5±3.2 mm Hg versus 12.8±3.6 mm Hg (P=0.76), 12.5±3.1 mm Hg versus 13.0±4.0 mm Hg (P=0.5), 15.7±6.2 mm Hg versus 12.6±4.7 mm Hg (P=0.06), 13.2±3.0 mm Hg versus 12.6±3.3 mm Hg (P=0.70), and 14.5±3.0 mm Hg versus 13.7±5.0 mm Hg (P=0.73) in the SI group versus the II group, respectively. The success rates were similar between the groups over the study period with 87.0% versus 86.5%, 71.5% versus 73.0%, and 71.5% versus 64.6% for SI versus II at 12, 24, and 36 months, respectively. There were more complications in the II group; however, only wound dehiscence and transient diplopia were statistically significant (P=0.04 and 0.001, respectively). The number of glaucoma medications was lower in the SI during the first 3 months but nonsignificant thereafter. ConclusionsThere was no significant difference in IOP control between SI and II over 36 months. II should be considered when there are limitations to SI.

Topical Bevacizumab for Neovascular Glaucoma: A Pilot Study

Background/Aims: Bevacizumab (Avastin), an anti-vascular endothelial growth factor drug, has been successfully used in recent years to treat ocular pathologies, mostly by intravitreal administration. The aim of this study was to investigate the safety and efficacy of topically applied bevacizumab for the treatment of neovascular glaucoma (NVG). Methods: Patients with NVG were treated with topical bevacizumab (25 mg/ml) 4 times daily during 2 weeks. The following parameters were evaluated at baseline and on days 3, 7 and 14: visual acuity, slit-lamp examination, intraocular pressure (IOP), heart rate and systemic blood pressure. Iris neovascularization was documented using slit-lamp color photos at baseline and on day 14. Results: Eight eyes of 8 patients with NVG were evaluated. After the 2-week treatment, mean IOP was lowered from 34.9 mm Hg (SD 12.8) at baseline to 28.8 mm Hg (SD 9.9) on day 14, representing a mean reduction of 6.1 mm Hg (17.5%). Three patients had clinical regression of their iris neovascularization. Ocular adverse events were transient and included mild upper eyelid swelling, mild exacerbation of superficial punctate keratitis and mild corneal epithelial bullae in an already edematous cornea. There were no serious systemic adverse events. Conclusions: Topical application of bevacizumab may lower IOP and result in regression of neovascularization in patients with NVG.

Intraocular pressure after penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty

OBJECTIVE To compare the intraocular pressure (IOP) during the first postoperative year after penetrating keratoplasty (PK) and Descemets stripping automated endothelial keratoplasty (DSAEK). DESIGN Retrospective chart review. PARTICIPANTS Fifty-three pseudophakic eyes of 53 patients who underwent PK or DSAEK because of endothelial dysfunction between January 2006 and December 2010 were included. METHODS Surgeries consisted of 19 (35.8%) PK procedures and 34 (64.2%) DSAEK procedures. Demographic, preoperative, and postoperative data including IOP, number of medications, rejection and occurrence, and complications were recorded. RESULTS Patients who had undergone DSAEK had statistically significant lower IOP throughout 12 months after surgery than those who had undergone PK (p = 0.028), despite similar use of IOP-lowering medications during this time. Measurements of postoperative IOP greater than 21 mm Hg and greater than 30 mm Hg were significantly more common in patients who had undergone PK than DSAEK (p = 0.015 and 0.022, respectively). Complication rates were similar between the 2 groups. IOP was not correlated with patient age, sex, background illnesses, or previous glaucoma. CONCLUSIONS IOP is significantly lower after DSAEK compared with PK. Several mechanisms explaining this difference are proposed. New corneal transplantation modalities such as DSAEK, with a better postoperative IOP control, may reduce the risk for later visual loss caused by postoperative glaucomatous damage.

Finger massage versus a novel massage device after trabeculectomy

BACKGROUND Ocular massage is a common technique employed after trabeculectomy to aid filtration. This pilot study compares a novel ocular massage device (MD) with finger massage (FM) after trabeculectomy. The device provides the patient with audio feedback about correctly applied force, and the force applied can be customized for each patient. METHODS A prospective, randomized study was performed comparing the effects of FM versus MD on intraocular pressure (IOP) and complication rates. All patients were given a standardized tutorial in ocular massage. The efficiency of their massage technique was evaluated at 1 week by having the patient perform the massage in front of the ophthalmologist, with IOP measurements taken before and after massage. Information on bleb morphology, IOP, ocular medications, and complications were recorded on a weekly basis. The patient perspective was recorded by questionnaire at 1 week, 1 month, and 3 months after initiation of the massage. RESULTS Twenty-five patients were enrolled in the study, 12 randomly assigned to the FM and 13 to the MD groups. Patients in the MD group were much more confident that they were doing the massage correctly (p = 0.009) and reported a greater ease of use and lower pain scores. The mean difference in IOP in the 2 groups was not statistically significant in the first 3 weeks, and IOP after 3 months was statistically similar in both groups. Laser suture lysis was performed in 8 patients (66%) in the FM versus 6 (46%) in the MD group (p = 0.42). Wound leaks developed in 4 patients (3 in the FM group vs. 1 in the MD group, p = 0.32). INTERPRETATION The massage device shows promise as an adjunctive tool in the postoperative management of trabeculectomies.

Double Use of Corneal Graft for Descemet Stripping Automated Endothelial Keratoplasty and Coverage of Glaucoma Drainage Device Tube

PurposeTo describe the efficacy and safety of using a single corneal graft for 2 different ocular surgeries, Descemet stripping automated endothelial keratoplasty in one patient and coverage of a glaucoma drainage device tube in another patient. Materials and MethodsThe records of 12 consecutive patients who underwent Ahmed glaucoma valve implantation using the anterior lamella of a donor cornea that had been previously used for Descemet stripping automated endothelial keratoplasty were reviewed. ResultsNine eyes (75%) had superotemporal Ahmed valve implantation and 3 eyes (25%) had inferotemporal implantation. No intraoperative complications were encountered in any of these cases. During postoperative follow-up there were no graft rejections, wound dehiscences, tube exposures, or any glaucoma drainage device-related complications. In 1 patient, graft thinning was noticed 12 months after surgery, but without erosion of the conjunctiva or exposure of the tube. Mean intraocular pressure (IOP) before surgery was 32.8±9.3 mm Hg. The mean postoperative IOPs were 13.2±6.8 mm Hg (P<0.001) at day 1, 10.5±2.7 (P<0.001) at week 1, 12.2±3.5 (P<0.001) at month 1, 12.9±3.0 (P<0.001) at month 3, 14.2±7.0 (P<0.001) at month 6, and 13.0±6.4 (P<0.001) at the final visit. The mean reduction in IOP was 59%. Mean follow-up time after surgery was 21.7±7.5 months. ConclusionsThe use of the anterior corneal graft cap for patching a tube is safe and effective. The double use of a corneal graft is economically worthwhile and especially useful in countries where there is shortage of donor corneal tissues.

Other Testing in Glaucoma: Optic Nerve Blood Flow I

The body of evidence to date does not yet support the suggestion that blood flow in the optic nerve should be routinely measured in glaucoma and glaucoma suspect patients. This is primarily due to the fact that no single blood flow device at present can simultaneously evaluate all the vascular beds relevant to glaucoma [1]. Also, the currently available methods provide limited information on quantitative blood flow. They typically measure some surrogate parameters that are assumed to reflect volumetric perfusion, such as vessel diameter, pulsatility and velocity of flow, or they extrapolate on change in blood flow as a result of a provocative test (including flicker stimulation, O2 and CO2 inhalation and cold pressor tests). Therefore, the ideal test to measure comprehensive ocular blood flow (OBF) in the routine patient is yet to be developed [1–3].