Combined phacoemulsification and goniotrephination in primary open-angle glaucoma and pseudoexfoliation glaucoma - a retrospective analysis

BACKGROUND: During the last few years combined cataract and glaucoma surgery is an established method to control intraocular pressure (IOP) and visual rehabilitation in patients with cataract and glaucoma. Despite this, there are currently only few data concerning the results of combined surgery for primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG). PATIENTS AND METHODS: To study the course of PEXG and POAG with respect to IOP regulation and visual acuity, 100 eyes with POAG (72 patients) and 22 with PEXG (19 patients) were evaluated which underwent a combined phacoemulsification and goniotrephination between 1993 and 1997. All patients had no glaucoma or other ocular surgery before. The mean follow up after operation was 39.5 (range 16 - 72) months. RESULTS: The mean preoperative IOP in PEXG (31.8 +/- 10.3 mm Hg) was significantly higher than in the POAG group (25.3 +/- 6.4 mm Hg) (p=0.0004). At follow up IOP decreased to 16.7 +/- 2.8 mm Hg (POAG) and 15.1 +/- 4.0 mm Hg (PEXG) (p < 0.0001). The absolute IOP lowering effect was significantly better for PEXG than for POAG (p=0.0003). All patients received medical treatment before surgery, whereas at follow up 59.0 % (POAG) and 81.8 % (PEXG) were untreated. The median preoperative visual acuity for the POAG was 0.32 (PEXG 0.25), visual outcome 0,63 (PEXG 0.5). CONCLUSION: The combined cataract and glaucoma surgery is a successful method of IOP control and visual rehabilitation. It seems that there is a tendency for a better efficiency and an untreated IOP regulation after surgery for PEXG. Thereby early surgical intervention could be an advantage for this glaucoma entity.     

Role of early trabeculectomy in primary open-angle glaucoma in the developing world

BACKGROUND: The lack of prospective data comparing early surgery and medical management in primary open-angle glaucoma (POAG) in the developing world led us to conduct a small randomised controlled clinical trial to evaluate acceptance and effectiveness of early trabeculectomy in these patients. METHODS: A total of 60 patients with moderately advanced POAG were randomised into three groups (Group I-Conventional medical management, Group II-Option for early trabeculectomy, Group III-Received an educational package about their disease before an option for early trabeculectomy). The patients were followed up for a period of 6 months for visual acuity, intraocular pressures (IOP), and subjective satisfaction. RESULTS: The three study groups were statistically similar with respect to mean IOP, demographic, and socio-economic profile. 35% of the patients accepted early surgery when offered a choice between early surgery and medical management in one of the groups. 65% of patients in another group expressed willingness for an early surgery after receiving health education on glaucoma. The mean IOP in the operated eyes was lower than the medically treated eyes at 2 weeks (16.6 vs 23.0 mmHg), 6 months (18.5 vs 22.8 mmHg), and 1-year review (17.9 vs 22.3 mmHg) (P<0.001). No significant difference was seen among the groups with regard to visual acuity and subjective satisfaction. CONCLUSION: There is a reasonable acceptance of early surgery in POAG patients in the developing world and increases on educating patients about their disease. Early surgery offers better IOP control with no long-term subjective adverse effects.     

原发性开角型和闭角型青光眼眼压降低前后视盘改变和筛板顺应性的对比研究

目的比较降跟压前后原发性慢性闭角型青光眼（PACG）与原发性开角型青光眼（POAG）的视盘结构改变,了解两者间筛板顺应性是否存在差异。设计前瞻性对比研究。研究对象PACG36例49眼和POAG35例49眼。方法眼压降低前全部患者进行海德堡视网膜断层扫描（HRT—II）及Humphrey静态视野检查。根据病情选择手术、激光或药物治疗,使眼压降至正常范围。眼压降低后1个月重复HRT检查和视野检查。比较POAG和PACG眼压降低前后HRT视盘参数的变化,采用多元线性逐步回归法校正治疗前眼压、眼压降低幅度、年龄、杯盘比等因素影响。主要指标眼压降低前后HRT视杯面积、盘沿面积、视杯容积、平均视杯深度的差值。结果PACG及POAG组的视杯面积、视杯容积、平均视杯深度等指标在眼压降低后均明显降低（P〈0．05）,盘沿面积在眼压降低后均明显增加（P〈0．05）。视杯面积、盘沿面积、视杯容积、平均视杯深度在跟压降低前后的差值两组间无显著性差异（P〉0．05）。眼压降低前后这4个参数的差值与眼压降低幅度及杯盘比有关（P〈0．05）;与年龄及治疗前眼压无关（P〉0．05）。结论眼压降低后青光眼视盘形态结构有一定回复;但在PACG和POAG间,视盘形态结构回复的程度无明显差异,PACG和POAG的筛板顺应性可能无差异。（眼科,2009,18：264—269）     

联合多种视功能检查对原发性开角型青光眼早期诊断的意义

了解原发性开角型青光眼视觉电生理和计算机自动视野检查结果的变化特征并对其视功能状况进行综合分析以寻找比较敏感和特异的参数，为原发性开角型青光眼较早期和早期诊断提供依据。方法：对３６例原发性开角型青光眼患者，８例可疑性青光眼患者，３０例正常对照者分别进行视网膜振荡电位，视网膜电图，视诱发电位和Ｈｕｍｐｈｅｒｙ计算机自动视野检查。     

Intraocular pressure and visual field loss in primary angle closure and primary open angle glaucomas

AIM: To compare the correlation between visual field loss and the pretreatment intraocular pressure (IOP) in primary angle closure glaucoma (PACG) and primary open angle glaucoma (POAG). METHODS: In a cross sectional observational study of 74 patients (43 PACG, 31 POAG), pretreatment IOP was measured at presentation, before treatment was initiated. The severity of visual field loss was assessed by AGIS score, mean deviation (MD), pattern standard deviation (PSD), and corrected pattern standard deviation (CPSD). Glaucomatous optic neuropathy was assessed from simultaneous stereo disc photographs. RESULTS: There was a stronger correlation between pretreatment IOP and the extent of visual field loss in PACG subjects than in those with POAG for both MD (PACG: Pearson correlation coefficient (r) = 0.43, p = 0.002; r(2) = 0.19), (POAG: r = 0.21, p = 0.13; r(2) = 0.04) and AGIS score (PACG: r = 0.41, p = 0.003; r(2) = 0.17), (POAG: r = 0.23, p = 0.19; r(2) = 0.05 respectively). No such associations were seen for pattern standard deviation (PSD) or corrected pattern standard deviation (CPSD) in either group (p> 0.29). Both horizontal and vertical cup-disc ratio were well correlated with severity of field loss but not with presenting IOP for either diagnosis. CONCLUSIONS: This is consistent with the hypothesis of a greater IOP dependence for optic nerve damage in PACG than POAG and, conversely, a greater importance of other, less pressure dependent mechanisms in POAG compared to PACG.     

Combined phacoemulsification and goniotrephination on eyes with primary open-angle glaucoma and classical pseudoexfoliation glaucoma

Background: Combined glaucoma and cataract operation has been demonstrated to be effective in controlling IOP and increasing visual acuity. Because of the differences between patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXEG), for cataract and glaucoma surgery alone we evaluated the effects and complications for simultanous surgical management.     

Effects of frequency-doubled Nd:YAG laser trabeculoplasty on diurnal intraocular pressure variations in primary open-angle glaucoma.

In order to investigate the effects of laser trabeculoplasty (LT) on diurnal intraocular pressure (IOP) variations in 36 eyes of 30 cases with primary open-angle glaucoma (POAG) in which medical treatment was terminated, the IOP curves, recorded 24 h before as well as 24 h and 12 weeks after LT were compared. Twelve weeks after LT, significant IOP decreases were observed: 36.42% in the mean IOP, 29. 77% in the mean peak IOP and 50.04% in the mean pressure range. LT might therefore have beneficial effects on the diurnal IOP variations in cases with POAG.     

右旋噻吗洛尔滴眼液临床观察及与其左旋异构体的比较

目的：评价右旋噻吗洛尔（D－timolol）治疗青光眼的疗效。方法：36名原发性开角型青光眼或高眼压病人随机分为两组,分别滴用1％D-timolol和0.5％左旋噻吗心安（L－timolol）。观察用药前后眼压、视野和眼血流的变化及副作用发生率。结果：两组单次滴药眼压均显著降低;长期用药眼压日曲线较用药前降低;随诊3个月降压幅度无显著差异;且D组降压幅度与用药前眼压呈线性相关。用药前后,两组眼血流无显著变化;视野平均光敏感D组显著上升而L组无显著改变。用药后的副作用轻微。结论：1％D-timolol是有效安全的抗青光眼药物。     

原发性开角型青光眼与正常人群搏动性眼血流量比较研究

目的　探讨原发性开角型青光眼 (POAG)的血流变化规律 ,及其作为诊断指标的敏感性和特异性。方法　选择POAG患者 10 0例 (10 0只眼 ) ,其中男、女各 5 0例 ,均取单眼测量。POAG诊断标准 :(1) 3次不同时间测量眼压值 >2 5mmHg(1mmHg =0 133kPa) ,眼压升高时房角开放 ;(2 ) 2 4h眼压差值 >8mmHg ;(3)典型青光眼性视乳头改变 ;(4)典型青光眼性视野缺损。正常对照者男、女各5 0例 (5 0只眼 ) ,选择条件 :(1)性别相同 ;(2 )年龄相差 <5岁 ;(3)屈光不正 ,屈光度数差异 <± 2 0 0DS。采用搏动性眼血流量 (POBF)测定仪 ,测量项目包括搏动性眼血流量、脉搏周期内眼压变化值(IOPPA)、脉率 (PR)、最大眼压值 (Max Iop)、最小眼压值 (Min IOP)、眼压均值 [(Max IOP Min IOP) /2次眼压均值 (Ave IOP) ]。青光眼组与正常对照组测定数值比较采用配对t检验 ,Ave IOP的变化值及视野检测均值和标准差与POBF的变化值做相关性分析 ;计算POBF值作为诊断指标的特异性和敏感性。结果　POAG组与正常对照组非研究因素有可比性 ,POAG组POBF值为 (9 72± 3 4 7) μl/s ,正常对照组POBF值为 (12 0 4± 4 6 8) μl/s;POAG患者的POBF、PV、PA、Ave IOP值均小于正常对照组 ,差异有显著意义 (P <0 0 5 )。视野检测均值和标准差与PO     

Primary lens extraction for glaucoma management: A review article

Recently, primary lens extraction alone gained more acceptance as an alternative surgical approach for glaucoma management. This view was supported by the advances in phacoemulsification and intraocular lenses with greater safety and visual recovery, in addition to a substantial reduction of intraocular pressure and deepening of the anterior chamber and filtration angle. The decrease in IOP after cataract surgery in primary open-angle glaucoma (POAG) is mild, less predictable, related to baseline levels, and may return to presurgical values after an initial period of reduction. Therefore, the IOP-lowering effect of primary cataract extraction in POAG may be insufficient to achieve adequate IOP control. The IOP reduction after lens extraction is consistently greater in eyes with primary angle closure glaucoma (PACG) than in eyes with POAG. Primary lens extraction in acute PACG eliminates, or at least, reduces the risk of recurrence of acute attacks and deepens the anterior chamber and widens the angle which reduces the risk of progression of peripheral anterior synechiae and development of chronic PACG. Primary lens extraction may be more preferable to glaucoma incisional surgery in mild to moderate PACG eyes with appositional angle closure. The decision to do lens extraction as a primary treatment for glaucoma should be individualized based upon several factors other than the effect on IOP. These factors include patients’ characteristics, surgeons’ skills and preferences, status of glaucoma control, type of cataract and intraocular lens implanted, and potential harm of laser treatment for late capsular opacification and fibrosis.     

选择性激光小梁成形术治疗原发性开角型青光眼观察

目的 观察选择性激光小梁成形术(SLT)治疗原发性开角型青光眼(POAG)的有效性和安全性.方法 原发性开角型青光眼患者23例36只眼,原发性开角型青光眼小梁切除术后高眼压患者6例6只眼,眼压(25.15±8.23)mmHg,倍频Q-开关532nmNd:YAG激光,单脉冲,脉冲时间3ns,光斑直径400um.应用房角镜鼻侧或颞侧房角180°范围内进行治疗,能量0.60～1.50mJ,点数(50±5)点.测量术后第1h眼压,术后1d,1周,2周,3周,1月,3月,6月,1年随访,对比术前术后眼压、最佳矫正视力、视野及杯盘比变化.结果 患者术前眼压(25.15±8.23)mmHg,术后1h为(18.14±5.36)mmHg,1d为(14.52±3.63)月mmHg,1周为(18.12±2.38)mmHg,1月为(17.96±3.35)mmHg,3月为(18.05±2.58)mmHg,6月为(17.48±2.12)mmHg,1年为(17.89±3.13)mmHg;术前患者杯盘比为0.65±0.30,术后1年为0.63±0.20;术前视力0.60±0.30,术后1年视力0.61±0.32;视野术前术后无变化.结论 选择性激光小梁成形术可以有效地降低原发性开角型青光眼及原发性开角型青光眼小梁切除术后高眼压患者的眼内压.

Abstract：

Objective To evaluate the efficiency and safety of selective laser trabeculoplasty (SLT) on primary open angle glaucoma (POAG). Methods A total of 36 eyes of 23 patients with POAG, 6 eyes of 6POAG patients with high intraocular pressure (IOP) after SLT therapy, IOP (25.15± 8.23) mmHg, and they were treated with a frequency-doubled, Q-switched Nd:YAG laser (532nm). A total of approximately 50± 5nonoverlaping spots were placed over 180° of the gonioscope nasal or temporal side at the energy levels ranging from 0.60-1.50m J/pulses. Every patient was asked for follow-up at 1h, 1d, 1w, 2w, 3w, 1m, 3m, 6m and 1yafter treatment. IOP, visual acuity, C/D and visual field were examined each time. Results The pretreatment IOP was (25.15± 8.23) mmHg. At the end of first 1h, 1d, 1w, 1m, 6m, 1y of the follow-up, the IOP was (18.14± 5.36)mmHg, (14.52± 3.63)mmHg, (17.96± 3.35)mmHg, (18.05± 2.58)mmHg, (17.48± 2.12)mmHg, (17.89± 3.13) mmHg respectively. The pretreatment cup/disc ratio was 0.65± 0.30, at the end of 1y of the follow-up, the C/D ratio was 0.63± 0.20; the pretreatment visual acuity was 0.60± 0.30, at the end of 1y of the follow-up, the visual was 0.61± 0.32, without significant difference in visual field. Conclusions SLT is a kind of effective method to treat POAG and special patients with high intraocular pressure after SLT therapy.     

Effects of glaucoma medications on the cardiorespiratory and intraocular pressure status of newly diagnosed glaucoma patients

AIMS: To evaluate the short term cardiovascular, respiratory, and intraocular pressure (IOP) effects of four glaucoma medications in newly diagnosed glaucoma patients. METHODS: 141 newly diagnosed glaucoma patients were recruited and underwent a full ocular, cardiovascular, and respiratory examination, including an electrocardiogram (ECG) and spirometry. They were prescribed one of four topical glaucoma medications and reviewed 3 months later. One eye of each patient was randomly chosen for analysis, performed using analysis of variance and the chi(2) test. RESULTS: Latanoprost had the greatest mean IOP lowering effect in both the primary open angle glaucoma (POAG) (p = 0.005) and the "presumed" normal tension glaucoma (NTG) groups (p = 0.33), reducing the IOP by 8.9 mm Hg and 4.1 mm Hg respectively. Timolol was associated with lowered pulse rates and reductions in the spirometry measurements. 41% of patients using brimonidine complained of systemic side effects and over 55% of patients using betaxolol complained of ocular irritation. 28% of patients required an alteration in their glaucoma management. CONCLUSIONS: Latanoprost appears to be a useful primary treatment for glaucoma patients, in view of superior IOP control and a low incidence of local and systemic side effects. Timolol causes a reduction in measurements of respiratory function, a concern in view of the potential subclinical reversible airways disease in the elderly glaucoma population. Brimonidine is associated with substantial, unpredictable systemic side effects and betaxolol causes ocular irritation and weak IOP control. Spirometry is advised in all patients receiving topical beta blocker therapy to control their glaucoma.     

曲伏前列素与布林佐胺治疗开角型青光眼或高眼压症的临床研究

目的:研究曲伏前列素与布林佐胺联合治疗原发性开角型青光眼(primary open angle glaucoma,POAG)、高眼压症(ocular hypertension,OHT)及抗青光眼术后高眼压的降眼压疗效及安全性。方法:将48例52眼POAG,OHT,抗青光眼术后高眼压的患者纳入为期2mo的前瞻性、单向性、开放性研究。经药物洗脱期测量眼压基线值。用药后2,4,8,12wk测量眼压、视力、视野,观察眼部症状、体征及全身副作用。计算12wk时眼压≤17mmHg患者百分比。结果:患者基线眼压28.08±2.50mmHg,4次随访眼压(17.12±1.42,16.71±1.55,16.13±1.52,16.12±1.49)mmHg,眼压下降均值10.35mmHg,最大下降率45%。用药后眼压与基线眼压比较差值有非常显著意义(P<0.01),用药12wk时,眼压≤17mmHg的患者占64%。常见的不良反应是结膜充血,偶见轻微烧灼感,轻度味觉异常等,对角膜、泪膜、视力、视野、血压、心率均未影响。结论:曲伏前列素与布林佐胺联合应用降眼压的效果明显,安全性好。联合用药,眼压≤17mmHg患者所占百分比显著。     

Combined phacoemulsification and goniotrephination on eyes with primary open-angle glaucoma and classical pseudoexfoliation glaucoma

BACKGROUND: Combined glaucoma and cataract operation has been demonstrated to be effective in controlling IOP and increasing visual acuity. Because of the differences between patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXEG), for cataract and glaucoma surgery alone we evaluated the effects and complications for simultanous surgical management. PATIENTS AND METHODS: In a retrospective study 103 patients were examined who underwent a combined phacoemulsification and goniotrephination between January 1993 and January 1997 and had no surgery before (110 eyes with POWG, 22 eyes with PXEG). RESULTS: The average age in the POAG group (75.1 +/- 8.7 years) was significantly less than in the PXEG group (79.3 +/- 5.9 years) (P < 0.05). The mean preoperative IOP in PXEG (31.8 +/- 10.3 mmHG) was significantly higher than in POAG (25.0 +/- 6.4 mmHg) (P < 0.0005). Due to the combined surgery the mean intraocular pressure decreased in both groups < 10 mmHg (days 1 and 7). PXEG had a significantly higher IOP at day 3 than POAG (12.3 +/- 8.4 mmHg versus 8.5 +/- 5.7 mmHg) (P < 0.05) and developed after combined operation IOP peaks > 25 mmHg into a significantly higher level (P < 0.05). Moreover, zonulolysis, rupture of the posterior capsule, vitreous loss and persistence of inflammatory response occurred more often in PXEG, but there was no significant difference compared to POAG. CONCLUSION: PXEG has an higher incidence of typical problems of phacoemulsification, a temporary increase of IOP and prolonged inflammation after combined cataract and glaucoma surgery than POAG, but there is a similar risk compared to a single procedure.     

几种视觉电生理检查对原发性开角型青光眼早期诊断的意义

目的：评价几种视觉电生理检查在原发性开角型青光眼早期诊断中的价值,为临床青光眼早期诊断提供客观敏感的指标。方法：选择36例（70眼）原发性开角型青光眼患者、8例（12眼）可疑性青光眼患者和30例（60眼）正常对照者分别进行闪光视网膜电图（FERG）、视网膜振荡电位（OPs）、闪烁光视网膜电图（FLERG）、图形视网膜电图（PERG）、图形视诱发电位（PVEP）检查,并与视野指数、眼压、视力等进行多元相关分析。结果：原发性开角型青光眼PERG、PVEP、OPs表现异常,与正常对照组相比差异有显著性意义（p＜0.05）。FLERG振幅降低,但和FERG同样与正常对照组相比差异无显著性意义（p＞0.05）。在原发性开角型青光眼早期（特别是视野改变出现前）,PERG的异常率较高。原发性开角型青光眼患者OPs与C／D负相关,与视野指数、眼压、视力不相关。PERG振幅与视野指数和眼压负相关,与C／D和视力不相关。PVEP潜伏期与视野指数和C／D正相关,而与眼压不相关。结论：统计学结果表明,对原发性开角型青光眼不同的表现形式,可选用不同的检查指标。在早期眼底改变出现前（C／D不大）,如眼压升高,PERG应为比较敏感的指标;而一旦眼底发生改变,尽管眼压不高,可选用OPs或PVER作为观察指标。对早期和中晚期青光眼,PERG诊断和监测价值较好。联合多种视功能检查对原发性开角型青光眼的早期诊断具有较好的意义。     

Quantifying the effect of intraocular pressure reduction on the occurrence of glaucoma

Purpose: To estimate the effect of reducing intraocular pressure (IOP) on: (i) the incidence of primary open‐angle glaucoma (POAG) in patients with ocular hypertension (OH), and (ii) the progression of glaucoma. Methods: A meta‐analysis of relevant randomized controlled trials was conducted. A literature search was performed to identify trials with: a randomized comparison of IOP‐lowering intervention versus placebo or no treatment; visual field loss or optic disc changes as outcome; and follow‐up >6 months. A pooled relative risk (RR) was calculated by a random effects model. Risk reduction of glaucoma conversion per mmHg of IOP reduction was quantified in a meta‐regression model. Results: We identified nine OH and one POAG trials. A meta‐analysis of OH trials gives a pooled RR of 0.61 [95% confidence interval (CI) 0.45–0.83]. A meta‐regression shows a decrease of the RR of glaucoma conversion by 14% with each mmHg extra IOP reduction (P = 0.045). No meta‐analysis of POAG trials was performed because only one study has been identified. Conclusion: There is sufficient evidence that OH therapy reduces the risk of conversion to glaucoma. This risk reduction increases with greater IOP reduction.     

Long-term outcome of primary glaucoma triple procedure with adjunctive 5-fluorouracil

· Purpose: To evaluate the long-term effect of adjunctive subconjunctival 5-fluorouracil (5-FU) on the filtration outcome of primary glaucoma triple procedure (PGTP) in primary open-angle glaucoma (POAG) patients. · Methods: Seventy-four POAG patients were randomly assigned to PGTP alone (36 patients) or PGTP with adjunctive subconjunctival 5-FU (5.0 ± 1.3 injections of 5 mg each, total of 24.8 mg) (38 patients). After surgery, the patients were examined at regular intervals for intraocular pressure (IOP), visual acuity, medical therapy requirements, and complications. Surgical success was defined as IOP ≤20 mmHg on postoperative medication ≤1 without additional glaucoma surgery. · Results: Over an average follow-up (±SD) of 45.3 ± 25.0 months, both 5-FU and control groups maintained significant improvement of IOP control and visual acuity. However, there were no statistically significant differences between the 5-FU and control groups with respect to postoperative IOP, number of glaucoma medications, visual acuity outcome, and success rate overall or in selected patients with one or more of the risk factors for filtration failure. · Conclusions: The use of low-dose subconjunctival 5-FU (mean dosage of 24.8 mg in 5.0 ± 1.3 injections) as an adjunct did not significantly improve the long-term filtration outcome of PGTP in POAG patients. Received: 29 July 1997 Revised version received: 10 October 1997 Accepted: 15 October 1997     

Target intraocular pressure and risk factors for progression of visual field loss in primary open-angle glaucoma

PURPOSE: Evaluation of intraocular pressure(IOP) control below the target level stated by Iwata and study of risk factors for progression of visual field loss in primary open-angle glaucoma (POAG) despite successful reduction of IOP. SUBJECTS AND METHODS: Statistical difference of visual field deterioration between 27 eyes of POAG with IOPs above target levels and 48 eyes of POAG with IOP below target levels was examined for 28.1 +/- 10.2(mean +/- standard deviation) months. The relationship between the progression of visual field loss and factors of initial visual field loss, mean IOP, variance of IOP, peripapillary atrophy (zone beta), records of glaucoma surgery, age, and sex were studied in 48 patients(48 eyes) with IOPs below target levels. RESULTS: Eight of the 48 eyes(16.7%) showed progression of visual field loss with IOPs below their target levels whereas 15 of the 27 eyes(55.6%) had IOPs above their target levels(p = 0.002). The risk factors for the progression of visual field loss in POAG despite good control of IOP were severity of initial visual field loss(p = 0.003), peripapillary atrophy(p = 0.002), and male sex(p = 0.03). CONCLUSIONS: The control of IOP below target level is beneficial for patients with POAG. However, the risk factors which represent circulatory damage, such as peripapillary atrophy, may have a bad influence on the continuing deterioration of visual fields in patients with severe visual field damage, independently of good control of IOP.     

Glaucoma management in developing countries: medical, laser, and surgical options for glaucoma management in countries with limited resources

PURPOSE OF REVIEW: Most people affected by glaucoma live in developing countries. Recent trials and reports provide sound evidence for management of glaucoma. This review extrapolates relevant articles to the developing world. RECENT FINDINGS: The predictive value of gonioscopy for progression of primary angle closure suspects (PACS) to primary angle closure (PAC) is only 22% (95% CI: 9.80-34.2). PACS are not uncommon; laser peripheral iridotomy (LPI) is neither indicated nor feasible for all. Twenty-eight and a half percent of PAC progress to primary angle closure glaucoma; the number needed to treat (NNT) for LPI to prevent progression is only 4. Laser peripheral iridoplasty controls acute angle closure glaucoma (AACG) faster than medical therapy alone. Primary lens extraction has also been suggested as treatment for AACG after control of the acute attack. A 5-year NNT for ocular hypertension (OH) of 20 is too high to allow treatment of all OH. High-risk OH and primary open angle glaucoma (POAG) have an NNT of 5 to 6 and merit treatment.Latanoprost and brimonidine are effective in lowering IOP in Asian eyes with POAG, but primary surgical therapy may be a more viable option.For cataract and coexistent glaucoma requiring filtration, trabeculectomy combined with the Blumenthal technique of cataract surgery may be as effective as trabeculectomy combined with phacoemulsification. SUMMARY: The principles of glaucoma management should be the same the world over. Considering the paucity of resources and competing opportunity costs, countries with limited resources have to extrapolate available information in a sensible and cost-effective manner.     

Management of ocular hypertension: a cost-effectiveness approach from the Ocular Hypertension Treatment Study

PURPOSE: The Ocular Hypertension Treatment Study (OHTS) demonstrated that medical treatment of people with intraocular pressure (IOP) of > or =24 mm Hg reduces the risk of the development of primary open-angle glaucoma (POAG) by 60%. There is no consensus on which people with ocular hypertension would benefit from treatment. DESIGN: Cost-utility analysis with the use of a Markov model. METHODS: We modeled a hypothetic cohort of people with IOP of > or =24 mm Hg. Four treatment thresholds were considered: (1) Treat no one; (2) treat people with a > or =5% annual risk of the development of POAG; (3) treat people with a > or =2% annual risk of the development of POAG, and (4) treat everyone. The incremental cost-effectiveness ratio was evaluated. RESULTS: The incremental cost-effectiveness ratios for treatment of people with ocular hypertension were 3670 US dollars per quality adjusted life-year (QALY) for the Treat > or =5% threshold and 42,430 US dollars/QALY for the Treat > or =2% threshold. "Treat everyone" cost more and was less effective than other options. Assuming a cost-effectiveness threshold of 50,000 to 100,000 US dollars/QALY, the Treat > or =2% threshold would result in the most net health benefit. The decision was sensitive to the incidence of POAG without treatment, treatment effectiveness, and the utility loss because of POAG. CONCLUSION: Although the treatment of individual patients is largely dependent on their attitude toward the risk of disease progression and blindness, the treatment of those patients with IOP of > or =24 mm Hg and a > or =2% annual risk of the development of glaucoma is likely to be cost-effective. Delay of treatment for all people with ocular hypertension until glaucoma-related symptoms are present appears to be unnecessarily conservative.