Teresa Rolle

Ganglion cell complex and retinal nerve fiber layer measured by fourier-domain optical coherence tomography for early detection of structural damage in patients with preperimetric glaucoma.

Aims To evaluate the capability of Fourier-domain optical coherence tomography (FD-OCT) to detect structural damage in patients with preperimetric glaucoma. Methods A total of 178 Caucasian subjects were enrolled in this cohort study: 116 preperimetric glaucoma patients and 52 healthy subjects. Using three-dimensional FD-OCT, the participants underwent imaging of the ganglion cell complex (GCC) and the optic nerve head. Sensitivity, specificity, likelihood ratios, and predictive values were calculated for all parameters at the first and fifth percentiles. Areas under the curves (AUCs) were generated for all parameters and were compared (Delong test). For both the GCC and the optic nerve head protocols, the OR logical disjunction (Boolean logic operator) was calculated. Results The AUCs didn’t significantly differ. Macular global loss volume had the largest AUC (0.81). Specificities were high at both the fifth and first percentiles (up to 97%), but sensitivities were low, especially at the first percentile (55%–27%). Conclusion Macular and papillary diagnostic accuracies did not differ significantly based on the 95% confidence interval. The computation of the Boolean OR operator has been found to boost diagnostic accuracy. Using the software-provided classification, sensitivity and diagnostic accuracy were low for both the retinal nerve fiber layer and the GCC scans. FD-OCT does not seem to be decisive for early detection of structural damage in patients with no functional impairment. This suggests that there is a need for analysis software to be further refined to enhance glaucoma diagnostic capability.

Micropulse diode laser trabeculoplasty (MDLT): A phase II clinical study with 12 months follow-up

Objective This pilot study evaluates the pressure lowering potential of subthreshold micropulse diode laser trabeculoplasty (MDLT) for a clinically meaningful duration in patients with medically uncontrolled open angle glaucoma (OAG). Design prospective interventional case series. Participants Thirty-two eyes of 20 consecutive patients with uncontrolled OAG (12 bilateral and 8 unilateral). Methods Confluent subthreshold laser applications over the inferior 180° of the anterior TM using an 810 nm diode laser in a micropulse operating mode. The intraocular pressure (IOP) was measured at baseline and at 1 hour, 1 day, 1 week, 3, 6, 9, and 12 months post-treatment. Flare was measured with a Kowa FM 500 flare-meter at baseline and at 3 hours, 1 day, 1 week, and 12 months post-treatment. After treatment, the patients were maintained on their pre-treatment drug regimen. Main outcome measures Criteria for treatment response were IOP reduction ≥3 mm Hg and IOP ≤21 mm Hg within the first week after MDLT. Eyes not complying to the above criteria during the follow-up were considered treatment failure. Mean IOP change and percentage of IOP reduction during the follow-up were calculated. Results One eye was analyzed for bilateral patients. A total of 20 eyes were thus included. Four eyes (20%) did not respond to treatment during the first week. One additional eye failed at the 6 month visit. The treatment was successful in 15 eyes (75%) at 12 months. The IOP was significantly lower throughout follow-up (p < 0.01). At 12 months, the mean percentage of IOP reduction in the 15 respondent eyes was 22.1% and 12 eyes (60%) had IOP reduction higher than 20%. During the first two postoperative days, one eye with pigmentary glaucoma experienced a significant increase of flare associated with an IOP spike (34 mm Hg) that was controlled with systemic drugs; afterwards it qualified as a respondent and completed the study. No increase of flare was found in any other patient. No peripheral anterior synechiae formed. Conclusions In this case series, MDLT was effective in reducing IOP in 75% of medically insufficiently controlled OAG eyes without significant complications. This justifies randomized clinical studies to compare MDLT with current IOP lowering strategies.

Hydrus microstent compared to selective laser trabeculoplasty in primary open angle glaucoma: One year results

To compare the reduction of intraocular pressure (IOP) and glaucoma medications following selective laser trabeculoplasty (SLT) versus stand‐alone placement of the Hydrus microstent, a microinvasive glaucoma surgery device.

Micro-Bypass Implantation for Primary Open-Angle Glaucoma Combined with Phacoemulsification: 4-Year Follow-Up.

Purpose. To report the long-term follow-up results in patients with cataract and primary open-angle glaucoma (POAG) randomly assigned to cataract surgery combined with micro-bypass stent implantation or phacoemulsification alone. Methods. 36 subjects with cataract and POAG were randomized in a 1 : 2 ratio to either iStent implantation and cataract surgery (combined group) or cataract surgery alone (control group). 24 subjects agreed to be evaluated again 48 months after surgery. Patients returned one month later for unmedicated washout assessment. Results. At the long-term follow-up visit we reported a mean IOP of 15,9 ± 2,3 mmHg in the iStent group and 17 ± 2,5 mmHg in the control group (p = NS). After washout, a 14,2% between group difference in favour of the combined group was statistically significant (p = 0,02) for mean IOP reduction. A significant reduction in the mean number of medications was observed in both groups compared to baseline values (p = 0,005 in the combined group and p = 0,01 in the control group). Conclusion. Patients in the combined group maintained low IOP levels after long-term follow-up. Cataract surgery alone showed a loss of efficacy in controlling IOP over time. Both treatments reduced the number of ocular hypotensive medications prescribed. This trial is registered with: NCT00847158.

The effects of dorzolamide 2% and dorzolamide/timolol fixed combination on retinal and optic nerve head blood flow in primary open-angle glaucoma patients.

PurposeTo compare the effect of dorzolamide hydrochloride 2%, timolol maleate 0.5%, and their fixed combination on intraocular pressure (IOP) and retinal and optic nerve head haemodynamics in primary open-angle glaucoma patients.MethodsTwenty-eight patients with early-moderate glaucomatous damage treated with β-blockers (>6 months) with IOP values ranging from 18 to 22 mmHg at trough participated in this trial. After a 4-week washout period, patients were randomized in two groups: group I started with dorzolamide 2% monotherapy and group II with timolol 0.50% monotherapy for 4 weeks. After this period, both groups switched to dorzolamide/timolol fixed combination for 4 weeks. IOP, ocular diastolic perfusion pressure (ODPP), heart rate, and Scanning Laser Doppler Flowmetry measurements at the peripapillary retina and neuroretinal rim were taken at T0 (enrolment), T1 (wash out), T2 (monotherapy), and T3 (dorzolamide/timolol). Data were compared between different study times. Statistical analysis was conducted using a paired t-test.ResultsBetween T1 and T3, IOP decreased significantly in group I (−21.40%) (P<0.001) and in group II (−21.25%) (P<0.001). At the same time intervals, blood flow increased significantly at rim level for group I (+30.03%) (P<0.05) and also when all patients were considered (rim +17.99%) (P<0.05). Between T1 and T3, we also observed a significant increase of ODPP in group I (+7.24%) (P<0.01) and in group II (+6.08%) (P<0.05) and when all patients were considered (+8.43%) (P<0.01).ConclusionsDorzolamide/timolol fixed combination increased blood flow significantly at the neuroretinal rim showing a combination of hypotensive and haemodynamic effects.

Blindness and Glaucoma: A Multicenter Data Review from 7 Academic Eye Clinics

Purpose To evaluate frequency, conversion rate, and risk factors for blindness in glaucoma patients treated in European Universities. Methods This multicenter retrospective study included 2402 consecutive patients with glaucoma in at least one eye. Medical charts were inspected and patients were divided into those blind and the remainder (‘controls’). Blindness was defined as visual acuity≤0.05 and/or visual field loss to less than 10°. Results Unilateral and bilateral blindness were respectively 11.0% and 1.6% at the beginning, and 15.5% and 3.6% at the end of the observation period (7.5±5.5 years, range:1–25 years); conversion to blindness (at least unilateral) was 1.1%/year. 134 eyes (97 patients) developed blindness by POAG during the study. At the first access to study centre, they had mean deviation (MD) of -17.1±8.3 dB and treated intraocular pressure (IOP) of 17.1±6.6 mmHg. During follow-up the IOP decreased by 14% in these eyes but MD deteriorated by 1.1±3.5 dB/year, which was 5-fold higher than controls (0.2±1.6 dB/year). In a multivariate model, the best predictors for blindness by glaucoma were initial MD (p<0.001), initial IOP (p<0.001), older age at the beginning of follow-up (p<0.001), whereas final IOP was found to be protective (p<0.05). Conclusions In this series of patients, blindness occurred in about 20%. Blindness by glaucoma had 2 characteristics: late diagnosis and/or late referral, and progression of the disease despite in most cases IOP was within the range of normality and target IOP was achieved; it could be predicted by high initial MD, high initial IOP, and old age.

Ocular Surface Alterations and Topical Antiglaucomatous Therapy: A Review

Ocular Surface Disease (OSD) is prevalent among medically treated patients with glaucoma. This is basically related to three key-points: OSD and glaucoma are both prevalent in elderly and are common comorbidities in the same patient; the role of the active ingredient of the medical antiglaucomatous therapy; the role of the preservative agent of this medical therapy. Considering the actual state of literature we can state that the active glaucoma agent have a role in OSD, but the main cause seems to be the preservative agent, in particular referring to benzalkonium chloride, BAK. In the clinical evaluation of dry eye patients there is no actually established gold standard. Since the ocular surface injury not only causes dry eye, red eye, eye itching, photophobia and other discomforts, but also increases the risk of failure of glaucoma surgery in patients, it becomes fundamental a complete and good clinical evaluation of OSD (considering Schirmer’s test, tear breakup time, corneal and conjunctival staining) together with a good evaluation of patients’ quality of life (with validated questionnaires). Development of complex preparations, preservative-free and/or novel preservative preparations for glaucoma therapy could provide a promising approach in the prevention of ocular surface injuries.

Timogel® vs timolol 0.5% ophthalmic solution: efficacy, safety, and acceptance.

Purpose To evaluate the efficacy, safety, and tolerability of Timogel® preservative-free once daily compared to timolol 0.5% ophthalmic solution bid in patients with ocular hypertension (OHT) and patients with primary open-angle glaucoma (POAG). Methods A total of 75 patients with OHT and patients with POAG treated with timolol 0.5% bid with intraocular pressure (IOP) ≤21 mmHg were enrolled. They underwent complete ophthalmologic examination, IOP measurements (at trough and daytime curve), evaluation of side effects, Schirmer test, break-up time [BUT], blood pressure, heart rate, ocular diastolic perfusion pressure measurements, and acceptance (Comparison of Ophthalmic Medications for Tolerability). Patients switched to Timogel® and were re-evaluated 3 months later. The analysis of variance and the Pearson χ2 tests were used to test differences between the treatments. Results Intraocular pressure reduction at trough was 23.6% with timolol 0.5% and 22.3% with Timogel®. No statistical differences were observed in IOP values at trough and in the daytime curve between the 2 treatments. Local and systemic side effects were less frequent with Timogel® (hazard ratio: p<0.05). Patients demonstrated a significant improvement of Schirmer test and BUT (p<0.05) and a reduction of dryness and foreign body sensation (42.6% vs 15.4%; p<0.01) after switching to Timogel®. Mild and short-lasting blurred vision after Timogel® instillation occurred in about 18.5% of patients. A total of 82% of patients were satisfied or very satisfied with Timogel® vs 61% with previous treatment (p<0.01). Conclusions Timogel® preservative-free dosed once every morning has a 24-hour hypotensive effect with a better safety profile than timolol 0.5% bid and it is well-accepted by patients. The once-daily dosing improved acceptance and compliance.

Diagnostic Power of Macular Retinal Thickness Analysis and Structure-Function Relationship in Glaucoma Diagnosis Using SPECTRALIS OCT.

Abstract Aims: To evaluate the diagnostic power of the Posterior Pole Asymmetry Analysis (PPAA) from the SPECTRALIS OCT in glaucoma diagnosis and to define the correlation between the visual field sensitivity (VFS) and macular retinal thickness (MRT). Methods: 90 consecutive open-angle glaucoma patients and 23 healthy subjects were enrolled. All subjects underwent Visual Field test (Humphrey Field Analyzer, central 24-2 SITA-Standard) and SD-OCT volume scans (SPECTRALIS, Posterior Pole Asymmetry Analysis). The areas under the Receiving Operating Characteristic curve (AROC) were calculated to assess discriminating power for glaucoma, at first considering total MRT values and hemisphere MRT value and then quadrant MRT values from 16 square cells in a 8 x 8 posterior pole retinal thickness map that were averaged for a mean retinal thickness value. Structure function correlation was performed for total values, hemisphere values and for each quadrant compared to the matching central test points of the VF. Results: The AROCs ranged from 0.70 to 0.82 (p < 0.0001), with no significant differences between each other. The highest AROC observed was in inferior nasal quadrant. The VFS showed a strong correlation only with the corresponding MRT value s for quadrant analysis: Superior Temporal (r = 0.33, p = 0.0013), Superior Nasal (r = 0.43, p < 0.0001), Inferior Temporal (r = 0.57, p < 0.0001) and Inferior Nasal (r = 0.55, p < 0.0001). Conclusion: the quadrant analysis showed statistically significant structure-function correlations and may provide additional data for the diagnostic performance of SPECTRALIS OCT.

Retinal nerve fibre layer and macular thickness analysis with Fourier domain optical coherence tomography in subjects with a positive family history for primary open angle glaucoma

Aim To detect early structural changes of retinal nerve fibre layer (RNFL) and macular ganglion cell complex (GCC) in subjects with a positive family history for primary open angle glaucoma (POAG) using Fourier domain optical coherence tomography (FD-OCT) (RTVue-100). Methods This was a cross-sectional observational study. First and second degree relatives of POAG patients, healthy subjects, and subjects with preperimetric glaucoma (PPG) without a family history for glaucoma, were enrolled. All participants underwent complete ophthalmic examination, visual field test and FD-OCT (RTVue-100) imaging. Average RNFL and GCC thicknesses were measured and a pattern analysis was applied to the GCC map. Analysis of variance (ANOVA), least significant difference post-hoc test, and multiple ANOVA were used. Results The final analysis included 271 eyes divided into several groups: 163 eyes of first and second degree relatives (85 healthy, 40 with ocular hypertension and 38 with PPG); and 108 eyes of subjects without a positive family history (60 healthy and 48 PPG). RNFL and GCC thickness values of these five groups were statistically different (p<0.001). RNFL superior, GCC average, GCC superior, and GCC inferior were found to be significantly thinner and the global loss volume was higher in normal relatives than in healthy subjects without a positive family history of POAG (p=0.04, p=0.001, p=0.005, p=0.004, p=0.009). RNFL and GCC thicknesses obtained by dividing the family members by the degree of consanguinity showed statistically significant thinning in siblings of glaucomatous subjects than in offspring. Conclusions Our study shows that the eyes of subjects with a positive family history for POAG have significantly thinner RNFL and GCC than normal eyes and a more accurate follow-up has to be performed.