Management Of Open-angle Glaucoma Research Articles

Role of fixed combinations in the management of open-angle glaucoma

The first-line option for lowering intraocular pressure (IOP) is a single hypotensive agent, but patients frequently require additional IOP-lowering agents to reach their target pressures. Disadvantages of this multi-therapy approach include washout effect, inconvenience and poor adherence. Fixed combinations (FCs) combine two or more hypotensive agents in a single bottle, providing a convenient once-daily therapy, which tends to improve adherence. FCs generally offer equivalent efficacy to concomitant use of the individual components, with equivalent or superior tolerability. Studies also show that FCs can be more cost effective than nonfixed combinations. In terms of optimizing IOP control, minimizing visual field deterioration, preventing visual disability and minimizing associated healthcare costs, FCs are an important component of glaucoma management.

Travoprost/timolol fixed combination in the management of open-angle glaucoma: a clinical review

Introduction: Many patients with glaucoma require multiple medications for adequate disease control. This review summarizes the efficacy and safety of the travoprost/timolol fixed combination in lowering intraocular pressure in eyes with glaucoma.Areas covered: Phase III and IV evaluations of travoprost/timolol are reviewed, including trials comparing the fixed combination with constituents, with unfixed concomitant therapy and with other unfixed and fixed combinations of glaucoma medications. The safety of travoprost/timolol is also reviewed.Expert opinion: The role of fixed-combination drugs, including travoprost/timolol, in the management of glaucoma is discussed. Unmet needs in glaucoma therapy, including long-acting drug delivery systems and therapies that treat glaucoma via mechanisms other than reduction of intraocular pressure, are also presented.

Effectiveness of Dorzolamide–Timolol (COSOPT) in Patients Who Were Treatment Naive for Open-Angle Glaucoma or Ocular Hypertension: The COSOPT First-Line Study

The aim of this study was to assess the effectiveness of dorzolamide-timolol (DT) in the management of open-angle glaucoma (OAG) and ocular hypertension. An open-label, 12-week, multicenter, Canadian study was conducted. Patients with untreated OAG or ocular hypertension received DT for 12 weeks to reduce intraocular pressure (IOP). If target IOP was not reached after the first 6-week treatment period, a prostaglandin (PG) (latanoprost) was added for the remaining 6 weeks. Primary outcome measures were changes in IOP from baseline to 6 and 12 weeks of treatment, and secondary outcome measures included the proportion of patients achieving target IOP and the proportion of patients achieving therapeutic response defined as a reduction of 5.0 mmHg or 20% in IOP from baseline. IOP values were the mean of 2 measures taken before and at least 2 h after patients administered the study medication. A total of 164 patients were enrolled. Mean [standard deviation (SD)] population age was 63.0 (12.3) years and 53.0% of the patients were men. At week 6, the mean (SD) absolute and percent change in IOP for the total population was (-11.1) (4.9) and (-36.4)% (13.9%), respectively, and 92.1% of the patients achieved a reduction in IOP of at least 5 mmHg. Therapeutic target was achieved by 136 (82.9%) patients (DT subgroup) at 6 weeks, whereas 28 (17.1%) patients were changed to a combination therapy of DT and latanoprost [DT plus PG (DT & PG) subgroup]. Between weeks 6 and 12, DT was effective in sustaining the IOP within therapeutic target, whereas addition of latanoprost reduced the IOP of the DT & PG subgroup by an additional 6.3 mmHg or 22.1% (20.1%). At week 12, patients in the DT subgroup experienced a clinically and statistically significant mean (SD) decrease in IOP from a baseline of 12.2 mmHg or 40.4% (11.9%) (P < 0.001), whereas these values corresponded to 13.4 mmHg and 39.7% (15.7%) (P < 0.001), respectively, in the DT & PG subgroup. The proportion of patients who achieved therapeutic response during the entire 12-week study period was over 82%. Treatment-related adverse events (AEs) were reported by 19 (14.0%) patients in the DT subgroup and by 6 (21.4%) patients in the combination subgroup. Eye disorders and nervous system disorders were among the most common treatment-related AEs in both subgroups. No serious AEs were reported during the study period. DT alone and DT in combination with a PG are effective in significantly reducing IOP in patients with untreated OAG or ocular hypertension. The treatment was safe and well tolerated with a low incidence of AEs.

Trabectome®—Forging a New Frontier in Primary Open Angle Glaucoma Management An Advanced Medical Device which Greatly Reduces Glaucoma Surgery Time and Improves Outcome

Trabectome®—Forging a New Frontier in Primary Open Angle Glaucoma Management An Advanced Medical Device which Greatly Reduces Glaucoma Surgery Time and Improves Outcome

Revisiting Angle Surgery in Adults and Children for Management of Open-angle Glaucoma

Revisiting Angle Surgery in Adults and Children for Management of Open-angle Glaucoma

The role of diurnal pressure measurements in the management of open angle glaucoma.

The measurement of intraocular pressure (IOP) is essential in the diagnosis and management of open-angle glaucoma, but a single measurement in the ophthalmologist's office may or may not reflect what the IOP is at other times of the day or night. It is well documented that the range of the daily fluctuations in IOP is greater in patients with glaucoma than in normal individuals, and a report by Asrani et al. suggested that the range of the diurnal fluctuation may be an independent risk factor for the progression of visual field loss. There have been reports of nocturnal increases in IOP, particularly in patients with normal tension glaucoma, and some ophthalmologists believe these may account for progression of visual field loss in some patients with glaucoma. This review will analyze recent articles that report the impact of various glaucoma therapies on the diurnal IOP curve and the use of diurnal curves in glaucoma diagnosis. A number of recent publications document that antiglaucoma medications with a long duration of action reduce the range of diurnal fluctuation more than the shorter duration medications. Laser trabeculoplasty and trabeculectomy also narrow the range of diurnal fluctuation, and at least one recent study finds that trabeculectomy reduces the diurnal range more than medical therapy does. Several recent studies of diurnal IOP in patients with glaucoma have failed to document such diurnal IOP spikes, so the published data available have not supported this hypothesis. One recent report has reconfirmed that a single IOP measurement in the office may not accurately indicate what is happening to the IOP of a patient with glaucoma throughout the day. Other reports have confirmed that treatment that lowers IOP narrows the range of diurnal IOP fluctuation, and one of these reports suggests that surgical reduction of IOL may narrow the fluctuation more than medical reduction of IOP. The reports of IOP during the night have not provided clear answers about what happens to IOP during sleep.

Diagnosis and management of open angle glaucoma: suggested guidelines for optometrists

Objective: The aims of this review are to define open angle glaucoma, to outline its prevalence and its financial and personal costs, to discuss the difficulties encountered in establishing the diagnosis and monitoring treatment, and to suggest initial clinical guidelines for the comanagement of glaucoma between ophthalmologists and optometrists. Methods: The literature was selectively reviewed to permit deductions that can be directed toward an effective comanagement strategy for patients with open angle glaucoma. Conclusions: Comanagement of patients having open angle glaucoma is a viable option, provided the opportunity for improved monitoring and better compliance is available. The basis for successful management rests with the ability to detect change in the optic disc and surrounding retina, visual fields and intraocular pressure. All these signs are continuous variables for which there are no known limits of normality.The division of responsibilities of management will be established initially by legislation and in the future modified according to experience and the emergence of new therapies.

Management of Primary Open-Angle Glaucoma and Ocular Hypertension: The Potential Role of Latanoprost

Primary open-angle glaucoma (POAG) is a chronic progressive disease characterised by damage to the optic nervehead (optic disc) which leads to visual field loss and may eventually result in blindness if left untreated. Intraocular pressure (IOP) is elevated in the majority of patients. Early intervention, based on reduction of IOP, can prevent or delay visual impairment and topical ocular hypotensive therapy is the mainstay of management. Argon laser trabeculoplasty or filtration surgery are most often used after failure of topical therapy but are also used as the initial intervention in some cases. Latanoprost is an ester prodrug analogue of prostaglandin F2a available for the topical management of open-angle glaucoma and ocular hypertension. It lowers diurnal IOP by approximately 25 to 35%, by enhancing uveoscleral outflow of aqueous humour. This mechanism differs from that of other ocular hypotensive agents. Because its ocular hypotensive effects last for at least 24 hours after a single dose, latanoprost is administered once daily. Comparative studies have shown that latanoprost 0.005% once daily is more effective than timolol 0.5% twice daily in lowering IOP. Additional reductions in IOP are achieved when latanoprost is used in combination with topical timolol or dipivefrin, or with oral acetazolamide. The most common local adverse effects associated with latanoprost are eye irritation (burning, stinging, tearing and/or itching), mild conjunctival hyperaemia, superficial punctate keratopathy and foreign body sensation. Increased pigmentation of the iris occurs in a variable proportion of patients treated with latanoprost. This phenomenon appears to be permanent, is most likely to occur in eyes with mixed iris colour and its long term clinical significance is unknown. In contrast with timolol, latanoprost is not associated with systemic adverse effects, having essentially no effect on heart rate or systemic blood pressure. Latanoprost is currently recommended for use in patients who respond inadequately to, or are unable to tolerate, other ocular hypotensive agents, or as firstline therapy, depending on the market. However, it has a number of favourable properties, which suggests that it has considerable potential for much wider use. Although further long term tolerability data are required, it appears possible that latanoprost and other topical prostaglandin analogues might largely replace β-adrenergic antagonists as first-line therapy for management of POAG and ocular hypertension in the future.

Present challenges in the global prevention of blindness

Cataract is responsible for 50% of world blindness, with at present an estimated backlog of 13.5 million cases in need of surgery. Low-cost cataract surgery must be made more available in developing countries, making use of alternative approaches for outpatient surgery and optimal management of available resources. Trachoma control needs to be targeted at the worst affected areas in endemic countries, with more emphasis on behavioural, educational and community aspects of the disease. Vitamin A deficiency and xerophthalmia control are becoming matters of maternal and child health care, with early intervention during infancy in view of the mortality issue. There are good prospects for the prevention of blindness from onchocerciasis, through the availability of ivermectin, but large-scale distribution schemes are still needed in most of the African countries concerned. The early detection and management of open-angle glaucoma still poses a major problem in developing countries, and further development of appropriate technology is needed in this field. Another area where more efforts are needed is ocular trauma, which is commonly the cause of unilateral loss of vision. General preventive measures must be enforced and better training provided to health personnel to deal competently with such cases, in order to prevent late complications. Diabetes, finally, is on the increase in many developing countries, giving rise to problems in dealing effectively with the ensuing retinopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Diode laser trabeculoplasty

Diode laser is a solid state Gallium Aluminium Arsenide (Ga AlAs) laser with a wavelength of approximately 800 nm (near infrared radiation). It has a similar penetration to, and absorption within the ocular tissues as, Krypton red. Diode laser trabeculoplasty (DLT) was carried out on 20 glaucomatous eyes resulting in a mean fall in intraocular pressure of 6.35 mmHg at one month and 6.45 mmHg at three months. Over this early period DLT has an effect similar to argon laser trabeculoplasty (ALT) in the management of open-angle glaucoma.

Long-term Efficacy of Repeat Argon Laser Trabeculoplasty

The role of repeat argon laser trabeculoplasty (RALT) in the management of open-angle glaucoma is controversial. To determine the long-term efficacy of RALT, the authors reviewed case records of 44 patients (50 eyes) who received RALT for uncontrolled glaucoma at the Wills Eye Hospital before 1986. Success was defined as a 3 mmHg or greater decrease in intraocular pressure (IOP) to less than 22 mmHg, and no further surgical intervention. By life table analysis, RALT was successful in 35% of eyes at 6 months, in 21 at 12 months, in 11% at 24 months, and in 5% at 48 months. Thirty-three percent of eyes in which primary ALT was successful for 1 year were successful 12 months after RALT. Complications included IOP spikes in 12%. In conclusion, RALT was generally not effective for long-term control of open-angle glaucoma, but may be useful as a temporizing measure. However, this use of RALT must be weighed against the risks of complications and the additional progression of disease before more definitive surgical intervention.

Clinical and scientific basis for the management of open angle glaucoma.

Open angle glaucoma is characterized by optic atrophy, field loss corresponding to a nerve fiber bundle distribution, increased outflow resistance, and elevated intraocular pressure. Clinical signs or manifestations of different pathogenetic processes appear quite similar because tissues have only a limited number of visible reactions to different insults. The<i>final</i>pathway for damage is common, but the<i>initiating</i>or primary mechanisms for damage may vary. It would not be difficult to imagine that glaucoma represents a syndrome, a final collection of similar signs produced by different pathogenetic mechanisms. The disease would then comprise subgroups, each with signs and sequences of signs that vary in both space and time. For example, there are individuals whose glaucomatous field loss progresses at both an early and a late phase of disease in spite of what is ordinarily considered adequate pressure control. In his time, Gifford¹was one among several ophthalmologists who, along with

Iridectomy with scleral cautery.

I have described modifications that have evolved over the years in doing iridectomy with cautery and have reviewed some of my experiences with the method. All filtering operations leave a great deal to be desired. Each technique has certain advantages and disadvantages. A great advantage of the cautery procedure is its safety and simplicity. It is as effective in lowering pressure as most other procedures. Even if the operation fails to control pressure, little harm is done to the eye, and it can be repeated. One of the great advances in management of open-angle glaucoma in recent years has been the adoption of stringent indications for surgery. Surgery should not be advised until a thorough trial of maximal medical therapy has been made. In many instances, however, the pendulum has been allowed to swing too far. When medical treatment has failed, and the patient is faced with progressive loss of vision if control of pressure is not achieved, the ophthalmic surgeon should resist the temptation to procrastinate. Surgery should be done promptly and deterioration should not be allowed to occur. Should a cataract occur, it can be removed. Endophthalmitis can be prevented or cured by antibiotic therapy. Although filtering operations leave a great deal to be desired, when effective, they will preserve a functioning optic nerve.

The size and location of the normal blind spot.

The size of the normal blind spot was found to be markedly dependent upon the stimulus value of the target. Minor reduction in value of clinically useful stimuli produces significant enlargement of the normal blind spot. This increase involves mainly the upper and lower poles and may break through the isopter producing true baring of the blind spot. The size of the normal blind spot was not related to ocular pressure level or to family history of glaucoma. Changes in blind spot size cannot be usefully employed in the diagnosis or management of open-angle glaucoma.

COMPARISON BETWEEN PILOCARPINE AND ECHOTHIOPHATE FOR CHRONIC SIMPLE GLAUCOMA. A COMPARISON BETWEEN 4 PER CENT PILOCARPINE AND 0.06 PER CENT ECHOTHIOPHATE IODINE IN THE DIURNAL MANAGEMENT OF CHRONIC SIMPLE GLAUCOMA.

The use of 0.25 and 0.125% echothiophate iodide (Phospholine Iodide) in the management of open-angle glaucoma has been widely accepted. Its use has been confined to those patients in whom the more conventional medical therapy has failed. Initial local side effects, sometimes quite severe, have been an unpleasant feature with this drug, but in many patients these settle after a week or two. Echothiophate iodide 0.06% has recently been introduced in an endeavor to cut down on the unpleasant side effects. Reports of the efficacy of this medication have appeared, 1-3 and the suggestion was made that even this low concentration of echothiophate iodide is more effective in maintaining the intraocular pressures on a diurnal basis (round the clock) than the more frequent instillation of pilocarpine. 1 The present study was concerned with a comparison of the diurnal pressure control and side effects in open-angle glaucoma between 4% pilocarpine administered

Importance of Status of Visual Field and Optic Disc : In Management of Open-Angle Glaucoma

Importance of Status of Visual Field and Optic Disc : In Management of Open-Angle Glaucoma

A new stabilized form of epinephrine for the treatment of open-angle glaucoma.

A new stabilized form of epinephrine with a pH of 7.4 has been developed * specifically for use in the management of open-angle glaucoma. It is a complex formula as a result of a reaction between epinephrine and boric acid. Its advantages over the forms of epinephrine now in use are that it is nonirritating to ocular tissues and is stable at room temperatures even after the bottle has been opened for more than a month. At least theoretically it has a greater physiologic activity than other forms of epinephrine, since it should penetrate the cornea more easily than the solutions of low pH now available. Also, the lack of irritation means less dilution of the drug by tears. A preliminary clinical trial on a small number of patients with open-angle glaucoma has yielded encouraging results. Although there were several earlier reports of the use of epinephrine in the treatment of

The influence of epinephrine and phenylephrine on intraocular pressure.

The use of epinephrine and phenylephrine in the management of open-angle glaucoma is well known to ophthalmologists. Reports of clinical investigations on the influence of epinephrine and phenlyephrine on the intraocular pressure have frequently appeared in the international literature. 1-5 Thus far, none of these reports have mentioned that a significant rise in intraocular pressure could occur in open-angle glaucoma after the topical application of epinephrine or phenylephrine. We have found three patients in whom the pressure actually rose although the angles remained wide and open. The purpose of this paper is to present information concerning the various effects (on intraocular pressure, facility of aqueous outflow, and rate of flow) of epinephrine and phenylephrine topically applied to glaucomatous and to normal eyes. Procedures and Materials The effects of epinephrine and phenylephrine individually were examined in 19 patients. Twelve had open-angle glaucoma, and seven were normal controls. Seven of the twelve