Bimatoprost in the treatment of ocular hypertension and chronic glaucoma

PURPOSE: The aim of this study was to evaluate the efficacy and the safety of bimatoprost in an outpatient glaucoma practice and to correlate the responsiveness to this treatment with the central corneal thickness. MATERIALS AND METHODS: Our retrospective analysis included 55 consecutive patients (mean age, 66 years). Bimatoprost was administered in monotherapy in 32 patients and in combined treatment in 23. Mean follow-up was 5.5 months. In bilateral treatments (33/55 patients), only one eye (with the more severe defect and/or the higher IOP) was included in the analysis. The patients were considered as responders to bimatoprost when the observed reduction of IOP was > or = 20% and/or at least 3 mmHg compared with the pretreatment IOP. The mean central corneal thickness (CCT) was extrapolated from five consecutive measurements with the ultrasonic pachymeter Pachette. RESULTS: Overall, the mean IOP was reduced from a pretreatment value of 21.1 mmHg to 17.3 mmHg at the last visit (mean IOP decrease, 3.6 mmHg, or 17%) (p < 0.05). Except for four patients (7.3%) who discontinued bimatoprost secondary to local or systemic adverse effects, ocular tolerance of bimatoprost was excellent in 62%. Moderate conjunctival hyperemia was present in 18%. The mean IOP reduction was 19% in monotherapy and 15% in combined treatments. Concomitantly, the percentage of responders was slightly higher in patients only receiving bimatoprost than in patients receiving bimatoprost associated with other medication (s). In monotherapy, bimatoprost induced a further IOP decrease of 12% compared with a previous association of two medications that did not include a prostaglandin (10 patients). In the 20 patients in whom bimatoprost had replaced another prostaglandin, a further mean IOP reduction of 11% was observed. The frequency of distribution of the responders to bimatoprost was not correlated with CCT (chi2, p > 0.05). CONCLUSIONS: Considering the limits of this study, our results suggested that bimatoprost was effective and well tolerated in most patients. The decrease in IOP and responsiveness to treatment appeared to be slightly higher in monotherapy than in combined treatments, equivalent to a combination of two medications without prostaglandin and equivalent to or slightly higher than other prostaglandins. The degree of responsiveness did not seem to be correlated with CCT.     

Angle recession glaucoma: review and two case reports

The natural course of angle recession in a previously traumatized eye and its relationship to the development of glaucoma is still not well defined. Two cases of late-onset glaucoma occurring some 19 and 23 years after the initial contusion injuries to the eye are described. Medical therapy alone was inadequate, and surgical intervention was required in both cases. Life-long follow-up is indicated in patients with significant angle injury following trauma.     

Low tension glaucoma: A critical review and new material

Low tension glaucoma (LTG) is a condition consisting of typical glaucomatous disc and field changes, an open angle and pressures within the statistically normal range. The controversy surrounding low tension glaucoma pertains not only to the definition and characteristics of the entity itself, but to the fundamental questions it raises regarding the causal relationship between intraocular pressure and disc and field changes. This review of LTG is based on material from three major sources: Sjögren's review from 1857 to 1946; the author's review of the world literature from 1947 through 1979; and an analysis of 32 of the author's cases. 767 cases from clinic and private practice and 241 cases from defined populations are considered. Definitions, incidence, characteristics, differential diagnosis and management of LTG are discussed, as are its relationship to primary open angle glaucoma and its possible association with various other entities. Pathogenesis and possible mechanisms are also explored.     

Systemic associations of retinal microvascular signs: a review of recent population-based studies

Retinal microvascular signs, such as generalized retinal arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking and retinal haemorrhages, microaneurysms and cotton wool spots, are common fundus findings in the general population, even in individuals without hypertension or diabetes. Recent population-based studies have provided new insights into the systemic associations and clinical significance of these retinal signs. Studies show that these retinal microvascular signs are strongly associated with elevated blood pressure (BP). Generalized retinal arteriolar narrowing may be associated with markers of inflammation and risk of diabetes and hypertension. Retinal haemorrhages, microaneurysms and cotton wool spots are associated with risk of subclinical and clinical stroke, cognitive impairment, renal dysfunction and cardiovascular mortality, independent of BP and cardiovascular risk factors. A consistent pattern of association between retinal microvascular signs and ischaemic heart disease has not been demonstrated. This suggests that patients with some retinopathy signs (retinal haemorrhages, microaneurysms and cotton wool spots) may benefit from a careful systemic evaluation and, if supported by further research, appropriate risk reduction therapy.     

Efficacy and safety of a systematic switch from latanoprost to travoprost in patients with glaucoma

PURPOSE: To assess the efficacy and safety of systematically switching a large number of hospital-based glaucoma patients from latanoprost to travoprost therapy. MATERIALS AND METHODS: In this prospective observational study, patients on latanoprost were systematically switched to travoprost without washout and followed-up for 12 weeks. The main outcome measures were control of intraocular pressure (IOP), rate of switching back, and tolerability. IOP was measured at baseline (while on latanoprost), and at weeks 6 and 12 after switching to travoprost. Adverse effects were assessed and conjunctival hyperemia was graded using a standardized scale. RESULTS: Ninety-three consecutive patients (mean age 63.3 +/- 12.1 y) were enrolled. Nine patients were lost to follow-up. Four patients (4.3%) were switched back to latanoprost after 6 weeks due to travoprost intolerance. There was no significant difference between mean IOP at baseline [16.4 +/- 3.4 mm Hg, 95% confidence interval (CI) 15.6-17.2] and that at week 6 (15.9 +/- 4.2 mm Hg, 95% CI 14.9-16.8) (P=0.2) and week 12 (16.4 +/- 5.7 mm Hg, 95% CI 15.1-17.7) (P=0.99). There was no significant difference in the mean hyperemia score at week 12 compared with baseline (P=0.09). The majority of patients (86.9%) felt that both medications were comparable in terms of degree of comfort; 5 felt that travoprost caused more redness. CONCLUSIONS: In this study, when glaucoma patients were systematically switched from latanoprost to travoprost, the efficacy and safety of the 2 medications were found to be comparable. A high switch rate (95.2%) was achieved with average hyperemia scores being comparable.     

Emergencies in glaucoma: a review

Most severe eye diseases and injuries ultimately require intervention by an ophthalmologist. The urgency of referral depends on various factors, including level of vision loss, duration of symptoms, and presence of comorbid diseases. Of special importance are five acute eye problems in which emergency management by primary care physicians can be critical to visual outcome: high-velocity injuries, chemical injuries, acute angle-closure glaucoma, arteritic ischemic optic neuropathy, and central retinal artery occlusion. This paper will focus on emergencies in glaucoma, especially primary and secondary closed-angle glaucoma and secondary open-angle glaucoma. Delay in presentation, and unresponsiveness to medical treatment of the acute ocular hypertension attack carry a significant risk of chronic glaucoma, whatever the mechanism of disease is. Whenever the acute glaucoma crisis does not cease with an appropriate medical treatment, a laser and/or surgical intervention needs to be urged.     

Bevacizumab in glaucoma: a review

Recent research has shown that a large number of growth factors are responsible for neovascularization. Vascular endothelial growth factor has been identified as playing a key role in ocular angiogenesis. Bevacizumab, a humanized monoclonal antibody that binds to all isoforms of vascular endothelial growth factor, has shown promising results in regression of neovascularization. The use of bevacizumab has been reported extensively in various retinal pathologies, including proliferative diabetic retinopathy, cystoid macular edema, neovascular age-related macular degeneration, and neovascular glaucoma, but the clinical use in glaucoma is not yet clear. Glaucoma filtering surgery entails fashioning an external filter for aqueous drainage, and a prerequisite to its optimum functioning is a patent filtering bleb. Since fibroblast function and growth of new vessels is a component of healing of the bleb, there have been attempts to retard this healing by the use of bevacizumab. This article reviews current clinical studies documenting the use of bevacizumab in glaucoma.     

Randomized crossover study of latanoprost and travoprost in eyes with open-angle glaucoma

Introduction  

To compare the intraocular pressure (IOP)-lowering effects of 0.005% latanoprost to that of 0.004% travoprost in eyes with open-angle glaucoma (OAG).     

Surgical management of glaucoma: a review

This review will briefly describe the history of surgical glaucoma treatment and concentrate on the current surgical strategies for managing glaucoma. A discussion of treatments for angle closure, open-angle glaucoma and paediatric glaucoma with an emphasis on drainage surgery are included. The role of cataract surgery is also briefly described. Drainage surgery evolved from peripheral iridectomy and sclerotomy with an increasing understanding of aqueous flow within the eye and the production of a functioning bleb. The current mainstays include trabeculectomy, glaucoma drainage devices as well as goniotomy and trabeculotomy, which have all been in existence for more than 40 years. Their various advantages as well as methods used to minimize their disadvantages, including the antimitotics and case selection are discussed. We finish by discussing the preliminary results of some newer forms of drainage surgery illustrating the energetic search for methods to minimize the problems of hypotony and bleb failure.     

Screening for open angle glaucoma: systematic review of cost-effectiveness studies

PURPOSE: To systematically review current evidence on the cost-effectiveness of screening strategies for open angle glaucoma (OAG). MATERIALS AND METHODS: Studies that reported both costs and outcomes of alternative screening strategies for OAG were identified by a highly sensitive search of electronic databases (eg, MEDLINE, EMBASE, NHS EED, HTA Database), last search December 2005. Data on costs regarding cases and years of visual impairment prevented, cases of blindness prevented, and cases of OAG detected were extracted. Incremental cost-effectiveness ratios were calculated using data provided in the included studies. RESULTS: Four studies met the inclusion criteria. The latest of these was published in 1997. The screening tests and treatments reported in these studies are now not considered to be best practice. Furthermore, data were not reported in sufficient detail to reinterpret the results of the studies in terms of a common outcome measure. Finally, these studies suffered from methodologic weaknesses that further limit their usefulness for decision making. CONCLUSIONS: Currently, there is insufficient economic evidence on which to base recommendations regarding screening for OAG. New technologies, potentially suitable as screening devices, and new treatments are available. Further research, both in terms of economic models and conduct of clinical trials with concurrent economic evaluation, may help inform policy makers regarding cost-effectiveness and acceptability of screening for OAG.     

Juvenile onset primary open-angle glaucoma: three case studies and review.

BACKGROUND: Common clinical characteristics of juvenile onset primary open-angle glaucoma (JPOAG) include increased intraocular pressure, optic nervehead damage, visual-field loss, and a normal-appearing iridocorneal angle by gonioscopy. Histologic analysis of the angle structures may show varying developmental abnormalities that are observed to be less obvious as age of onset increases. Individuals who are African-American, male in gender, and myopio, are at highest risk--particularly if a positive family history exists. A genetic locus for juvenile onset primary open-angle glaucoma has been isolated to the long arm of chromosome 1. CASE REPORTS: Three separate cases of JPOAG diagnosed in a 16-year-old African-American girl, a 9-year-old African-American boy, and a 28-year-old African-American woman are presented and reviewed. The symptoms, clinical presentation, disease progression, and treatment options are discussed in detail. CONCLUSION: Early recognition of this disease is possible through screening on all patients--particularly those who exhibit increased cupping with increased intraocular pressures and risk factors, such as youthful age, male gender, myopic refractive error, and African-American heritage with a positive family history of glaucoma. Family members should also be examined.