Yves Lachkar

Prevalence and risk factors for ocular surface disease among patients treated over the long term for glaucoma or ocular hypertension.

Purpose. To determine the prevalence of ocular surface diseases and identify risk factors in a population of patients receiving antiglaucomatous eyedrops over the long term. Methods. An observational cross-sectional study was designed to investigate ocular surface signs and symptoms using simple clinical tools. An ocular surface disease intensity score was calculated based on 10 questions regarding ocular surface symptoms and signs with a 4-grade scale. Patients were classified into 3 groups (A, B, and C) according to this total score. A multinomial logistic regression was performed in order to identify risk factors for surface disease. Results. In an overall population of 516 patients, 49% belonged to group A, 30% to group B, and 21% to group C. The multivariate analysis showed that the following factors were correlated with the severity of ocular surface disease: patient age, number of daily eyedrops, past topical treatment changes for ocular intolerance (found in the history of 40% of the patients), intraocular pressure (found to be significantly higher in patients with more severe ocular surface disease), and glaucoma severity. Conclusions. Patients treated for primary open-angle glaucoma or ocular hypertension often have ocular surface diseases, more often and more severely in older patients receiving more drugs and presenting with more severe glaucoma. These high prevalence values might therefore have consequences on the burden of the disease in terms of adherence to treatment and quality of life.

Trabeculectomy with intraoperative sponge 5-fluorouracil in Afro-Caribbeans

AIM To study the efficacy and safety of intraoperative 5-fluorouracil (5-FU) in Afro-Caribbean patients. METHODS The results of trabeculectomy in 18 eyes of 18 Afro-Caribbean patients in whom a sponge soaked in 25 mg/ml solution of 5-FU was applied between Tenon’s capsule and sclera for 5 minutes before excision of the trabecula were compared with 16 eyes of 16 Afro-Caribbean patients matched for age, quantity, and duration of preoperative medications, who underwent trabeculectomy without 5-FU. RESULTS The mean postoperative intraocular pressure (IOP) at 1 month was 15.6 (SD 6.1) mm Hg in the 5-FU group and 18.0 (5.2) mm Hg in the control group (p=0.15). There was no significant difference in the IOP at 6, 12, 15, 18, and 24 months in the two groups. Success rate at 18 months defined as an IOP less than or equal to 21 mm Hg with no adjunctive medication was 56% in the 5-FU group and 55% in the control group. No major complications were noted in either group. CONCLUSION Intraoperative sponge 5-FU alone is safe but does not appear to decrease the risk of failure of trabeculectomy in Afro-Caribbeans.

Cyclocoagulation of the Ciliary Bodies by High-Intensity Focused Ultrasound: A 12-Month Multicenter Study

PURPOSE To evaluate the safety and efficacy of high-intensity focused ultrasound (HIFU) cyclocoagulation in reducing intraocular pressure (IOP) in patients with refractory glaucoma by using a novel miniaturized delivery device (EyeOP1). METHODS We conducted a 12-month open-label multicenter prospective study (EyeMUST1 Study). Patients with primary (primary open-angle glaucoma [POAG]) or secondary refractory glaucoma were treated in two groups depending on the duration of each ultrasound shot (group 1: 4 seconds; group 2: 6 seconds). The primary efficacy outcome was based on IOP reduction at 6 and 12 months. RESULTS Fifty-two patients were enrolled: 36 (69%) had POAG and 16 (31%) had secondary glaucoma. Group 1 (n = 24) and group 2 (n = 28) had similar demographics and baseline characteristics. In group 1, IOP was reduced from a mean preoperative value of 29.7 ± 7.7 mm Hg (n = 3.5 glaucoma medications) to a mean postoperative value of 21.3 ± 6.7 mm Hg (n = 3.5 glaucoma medications) and 20.1 ± 6.7 mm Hg (n = 3.2 glaucoma medications) at 6 and 12 months, respectively. In group 2, IOP was reduced from a mean preoperative value of 29.0 ± 7.4 mm Hg (n = 3.3 glaucoma medications) to a mean postoperative value of 20.2 ± 7.4 mm Hg (n = 3.4 glaucoma medications) and 18.5 ± 6.6 mm Hg (n = 3.5 glaucoma medications) at 6 and 12 months, respectively. At 12 months, the IOP reduction was sustained in both groups (32% IOP reduction in group 1 and 36% IOP reduction in group 2). The overall tolerance of the technique was good, with no serious adverse events. CONCLUSIONS The new miniaturized HIFU EyeOP1 delivery device seems to be effective in decreasing IOP in patients with refractory glaucoma. The technology offers a good safety profile. (ClinicalTrials.gov number, NCT01338467.).

Multicenter evaluation of tendency-oriented perimetry (TOP) using the G1 grid.

Purpose The G1-TOP program is a short automated perimetric strategy which sub-divides the G1 grid of 59 points into four sub-grids. Each point is tested only once, but each patients response is used to modify that particular point and the surrounding ones from the remaining sub-grids. This study compared the results of the G1-TOP program with the Standard Bracketing strategy. Methods Eleven participating institutions provided data from 213 patients (406 eyes). The main group consisted of 284 glaucomas and 55 glaucoma suspects. Other groups included 31 eyes with neurological disorders, 20 with chorioretinal lesions and 16 normal eyes. Mean age was 62.7 ± 15.4 (range 14–88) years. All subjects had previous perimetric experience and visual acuity better than 0.5. Examination included G1-Standard Bracketing and G1-TOP testing, in interchangeable order, with the Octopus 1-2-3 perimeter. Results The correlation coefficient for mean defect (MD) was 0.95. Standard error (YX) for MD, square root of loss variance (LV) and individual thresholds were 1.86 dB, 1.29 dB, and 4.72 dB, respectively. Mean sensitivity values were similar (difference 0.04 ± 1.87 dB) (p>0.05). Mean duration for G1-TOP was 2.19 ± 0.26 min, while G1-Standard Bracketing took 11.51 ± 1.52 min (ratio 1/5.1, or a net reduction of 80.4%). The sensitivity of G1-TOP versus G1-Standard Bracketing was: glaucoma 77.1/78.5, glaucoma suspects 38.2/47.3, neurological disorders 87.1/87.1 and chorioretinal lesions 80.0/85.0. Conclusions The G1-TOP program gave very similar results to G1-Standard Bracketing in only 20% of the time required by the standard strategy.

Efficacité et complications d'une technique de mini-trabéculectomie ajustable

Efficacy and complications of a mini-trabeculectomy technique A. Labbe, Y. Lachkar, H. Cohn Objective: To assess the outcome and the complication rate of an adjustable mini-trabeculectomy in medically uncontrolled glaucoma. Patients and methods: This study retrospectively evaluated the medical records of 40 patients undergoing primary mini-trabeculectomy. All patients were followed at least 24 months, with a mean follow-up of 60.85 ± 37.7 months. Visual acuity, intraocular pressure (IOP), visual field (MD, Humphrey ® ), number of antiglaucoma medications, intra- and postoperative complications, postoperative procedures (laser suture lysis, 5-fluorouracil subconjunctival injections, or a new trabeculectomy) were analyzed. Results: Preoperative IOP was 23.2 ± 6.48 mmHg (range, 13–53 mmHg) with 2.42 ± 0.74 (range, 1–4) antiglaucoma medications. At last examination, after 60.85 ± 37.7 months (mean ± standard deviation; minimum 24 months) of postoperative follow-up, IOP was 12.55 ± 2.12 mmHg with 0.42 ± 0.78 antiglaucoma medications ( p p p =0.018); nevertheless, there was no statistically significant difference between preoperative and postoperative MD (–10.46±9.37 dB and –10.65±4.36 dB, respectively; p =0.971, for 23 patients). Conclusion: Adjustable mini-trabeculectomy controlled postoperative filtration. Easy to perform, this surgical technique seemed to be safe and effective, and it reduced the rate of early postoperative complications in the surgical management of patients with glaucoma.

Nerve fiber analysis and optic disc parameters with the glaucoma-scope.

Purpose: We evaluated the ability of optic disc parameters and nerve fiber analysis with the Glaucoma-scope to distinguish glaucoma from normal or hypertensive eyes. Methods: Glaucoma-scope examination was performed on 68 eyes of 44 patients split into following groups based on Humphrey 24-2 visual field and clinical criteria of glaucoma: normal eyes (n = 17), ocular hypertension (n = 19), early glaucoma (n = 17), moderately advanced glaucoma (n = 15). The contour of the juxta papillary nerve fiber layers was measured in the four groups. We also evaluated a global index as the mean disc depth corrected for the disc size by dividing by the disc area (MP/D). Results: We found a statistical difference (p < 0.001) between the four groups with the global index MP/D: normal eyes MP/D = − 17.42, hypertensive eyes MP/D = − 26.34, early glaucoma MP/D = − 82.33, moderately advanced glaucoma MP/D = − 99.69. We also found a statistical difference between the first two groups (normal visual field) compared to the two glaucoma groups for the mean fiber layer height in the superior and the inferior quadrant. Conclusion: Nerve fiber analysis and optic nerve head index calculated with the Glaucoma-scope could prove to be an interesting tool for glaucoma diagnosis and follow-up.

Reproducibility of optic nerve head topographic measurements with the glaucoma-scope

Purpose: Glaucoma is an optic neuropathy in which optic nerve changes are important in diagnosis and progression, because the visual field may remain normal even while the optic nerve is undergoing significant damage. Accurate methods to objectively document the appearance of the optic nerve are necessary. In order for an optic disc imaging system to be clinically useful for detecting change, its reprodu-cibility must be established.Methods: We measured the reproducibility of duplicate measurements in 59 eyes of 31 consecutive patients, grouped into glaucoma subjects (n = 29) and eyes with glaucoma (n = 30), with the 3.10 OIS Glaucoma-Scope. In order to simulate two visits on one day, sets of three optic disc images were obtained first, followed by a repeat set, and the best disc images of each (chosen by the computer) were compared.Results: The coefficients of variation of duplicate measurements for glaucoma suspects and patients with glaucoma were respectively: vertical cup/disc (c/d) ratio, 6.3% and 3.47%; horizontal c/d ratio, 4.61% and 2.97%; c/d area, 3.29% and 1.37%; cup area, 1.82% and 1.72%; mean position (MP) disc, 13.3% and 10.42%; MP total, 10.1% and 13.2%. For three eyes the examination was not possible (opacification of posterior capsule, miosis).Conclusion: These results suggest that the 3.10 version of the OIS Glaucoma-Scope allows reproducible measurements in living eyes.

Sensitivity and specificity of optic disc variables and analysis of a new variable (MP/D) for glaucoma diagnosis with the Glaucoma-Scope

AIM In an attempt to use the quantitative optic disc measurements of the Glaucoma-Scope (OIS Sacramento, CA, USA) to distinguish glaucomatous from normal optic discs, a new variable was investigated, the mean disc corrected for the disc size by dividing by the disc area: MP/D. METHODS Glaucoma-Scope disc evaluation was performed on 81 eyes of 51 patients split into the following groups based on Humphrey 24-2 visual field and clinical criteria of glaucoma: chronic glaucoma n=27 (including only early, n=17, and low tension glaucoma, n=10), ocular hypertension n=24, pseudoglaucomatous large discs, n=12, and normal eyes, n=18. Classic optic disc variables (the vertical and horizontal c/d ratios, and the c/d area) were compared with the new MP/D index calculating receiver operating characteristic curves. RESULTS The MP/D ratio was able to identify the glaucomatous eyes more easily than other ratios. Areas under the curves were: 0.91 (MP/D); 0.87 (c/d area); 0.85 (c/d vertical); and 0.80 (c/d horizontal). The MP/D index was also correlated with the mean deviation (r=0.466; p=0.001). CONCLUSION MP/D may prove useful in detecting glaucomatous optic nerve damage and could be an interesting screening tool for primary open angle glaucoma.

Change in Visual Field Progression Following Treatment Escalation in Primary Open-angle Glaucoma

Purpose: To evaluate the effect of treatment escalation on the rate of visual field progression in patients with primary open-angle glaucoma (POAG). Patients and Methods: Multicenter database study. We reviewed the electronic records of 171 patients with POAG under medical hypotensive treatment who underwent 5 consecutive visits 6 months apart before and after medical treatment escalation or additive laser trabeculoplasty. We calculated the rate of visual field progression (mean deviation change per year) before and after treatment escalation. Results: The mean duration of follow-up was 5.1±0.5 years and the mean number of visual field examinations was 10.2±0.2. In 139 eyes with medical treatment escalation, the rate of progression was significantly reduced [from −0.57 to −0.29 dB/y; P=0.022; intraocular pressure (IOP) reduction 11.1%]. In detail, the rate of progression was significantly reduced after escalation from mono to dual therapy, dual to triple therapy, and from mono to triple therapy (−0.35 to −0.24 dB/y, P=0.018; −1.01 to −0.48 dB/y, P=0.038; −1.04 to −0.35 dB/y, P=0.020, respectively). In 32 eyes with additive laser trabeculoplasty, the rate of progression was significantly reduced (−0.60 to −0.24 dB/y; P=0.014; IOP reduction 9.4%). Conclusions: Medical treatment escalation or additive laser trabeculoplasty significantly reduced the rate of visual field progression in POAG. Larger IOP reduction has a greater probability of reducing glaucoma progression.

Ultrasonic Circular Cyclo Coagulation in patients with Primary Open-Angle Glaucoma: a Multicenter Clinical Trial

Purpose To evaluate the efficacy and safety of the Ultrasonic Circular Cyclo Coagulation (UC3) procedure in patients with primary open-angle glaucoma (POAG). Methods Prospective multicenter clinical trial. 42 eyes of 42 patients with POAG, intraocular pressure (IOP) > 21 mmHg, an average of 1.65 failed previous surgeries and an average of 3.2 hypotensive medications were insonified with a probe comprising 6 piezoelectric transducers. 18 patients (group 1) were treated with a 4 seconds exposure time for each shot and 24 patients (group 2) with a 6 seconds exposure time. Follow-up visits were performed at 1 day, 1 week, 1, 2, 3, 6 and 12 months after. Results IOP was significantly reduced in both groups (p 20%) was achieved in 12 of 18 (67%) eyes of the group 1 and in 17 of 24 (71%) eyes of the group 2. Four patients were re-treated. No major intra- or post-operative complications occurred. Conclusion UC3 seems to be an effective and well-tolerated method to reduce intraocular pressure in patients with POAG. Commercial interest