Patient-reported behavior and problems related to topical glaucoma medication

The purpose of this study is to evaluate the efficacy of intracameral ranibizumab (ICR) injections with subsequent mitomycin C (MMC) augmented trabeculectomy in the management of neovascular glaucoma (NVG). This is a prospective, interventional study of NVG, with research conducted between January 2010 and February 2011, at the Ophthalmology Department of Kasr El-Aini Hospital and Petrol Medical Center (Cairo, Egypt). Fifteen patients with NVG were included in the study, all of whom received intracameral ranibizumab (ICR) injections (0.5 mg) into their eyes 4 weeks before MMC augmented trabeculectomies were performed. All patients were followed up for a period of 6 months. Thirteen eyes (86.7%) achieved absence of clinically apparent iris neovascularization after 1 ICR injection and 2 eyes (13.3%) after a second injection. Eight eyes (53.3%) achieved complete success [if the intraocular pressure (IOP) was between 10 and 21 mm Hg] without topical antiglaucoma medications, 6 eyes (40%) had qualified success (if the IOP was within the same range) but with topical antiglaucoma medications, and failure occurred in 1 eye (6.7%) (because the IOP was above 21 mm Hg) despite the use of topical antiglaucoma medications. An ICR injection with subsequent MMC augmented trabeculectomy seems to be an effective combined technique in controlling IOP in eyes with NVG.

The prior long-term use of topical anti-glaucoma medications has been suggested as an adverse factor for the outcome of trabeculectomy. The mechanism of action is not known. This study investigates the effect of cholinergic medications on the proliferation and viability of human Tenon's capsule fibroblasts in tissue culture to see whether this may be one mechanism by which increased surgical failure occurs. We examined the effect of two commercial pilocarpine products, pure pilocarpine hydrochloride, and pure benzalkonium chloride, at various dilutions, on the proliferation (as assessed by 3H-thymidine uptake) and viability (assessed microscopically) of human Tenon's capsule fibroblasts in tissue culture. None of the tested compounds stimulated the proliferation of fibroblasts in tissue culture. Three of the compounds inhibited proliferation, and all compounds had toxic effects on cell morphology. At equivalent dilutions of commercially available concentration, pure benzalkonium chloride and the commercial product containing it appeared more toxic and antiproliferative to cells in culture than pure pilocarpine hydrochloride and the preservative-free commercial product. These results show an antiproliferative and toxic effect of medications on fibroblasts in tissue culture. They do not support the theory that topical medications directly stimulate fibroblast proliferation. The possible relevance of these results for the outcome of glaucoma surgery is discussed.

Purpose: To investigate the use of topical ocular anti-glaucoma medications by glaucomatous patients with obstructive pulmonary disease and their effect on related hospitalizations and emergency room visits. Participants: We followed the electronic medical records of all the members in a district of the largest health maintenance organization in Israel (the “central district” of Clalit Health Services) older than 20 years (317,469 members); 6597 of them were on chronic topical anti-glaucoma treatment of which 693 (10.5%) suffered from obstructive pulmonary disease (OPD). Methods: In a historical cohort study, we documented all anti-glaucoma prescriptions filled in the district between January 1, 2001, and December 31, 2003, and all emergency room (ER) visits and hospitalizations in internal medicine, geriatric, or pulmonology departments. Main Outcome Measures: The rate of hospitalization and emergency room visits during treatment with each anti-glaucoma medication. Results: Five hundred forty-four glaucomatous OPD patients (78.5%) were treated with topical β-blockers, but only 169 (31.1%) of them received a cardio-selective β-blocker (betaxolol). Patients treated with betaxolol each received more prescriptions per year than patients treated with timolol (p < 0.0001). Patients on topical betaxolol or timolol had 23.1 and 20.7 hospitalization days as well as 7.3 and 6.1 emergency room visits per 100 treatments per year, respectively, compared to a mean of 10 hospitalization days (p < 0.0001) and 5.0 ER visits for patients on non-β-blocker anti-glaucoma medications. Conclusions: A majority of glaucomatous patients with obstructive pulmonary disease were treated with topical β-blockers, mostly non-cardioselective (timolol). Those patients were more prone to be hospitalized or visit the emergency room while on the medication.

Aim: To determine the prevalence of dry eye in glaucoma patients using topical anti-glaucoma therapy. Study Design: Descriptive observational study Place and duration of study: Department of Ophthalmology, Shalimar Medical &amp; Dental College Lahore from 1st November 2020 to 30th April 2021. Methodology: Ninety patients of both genders were enrolled. Detailed demographics of enrolled cases age, sex and body mass index were recorded after taking informed written consent. Patients using topical anti-glaucoma therapy for more than 8 months and having symptoms of stinging and burning sensations itching, watering, irritation, due to regular use of topical antiglaucoma drugs were presented. Basal Schrimer’s test and tear film break-up time test was used to measure the frequency of dry eye syndrome as mild, moderate and severe. Results: There were 60 (66.7%) females and 30 (33.3%) patients were males. Mean age of the patients were 45.61±7.66 years with mean BMI 26.24±8.71 kg/m2. We found that 40 (44.4%) patients had burning and stinging sensations, itching found in 21 (23.3%), dry eye sensations were found in 16 (17.8%) patients and watering and irritation found in 13 (14.4%) .According to tear film break-up time test 20 (22.2%) cases did not show dry eye syndrome and 19 (21.1%) patients were normal in Basal Schrimer’s test. Conclusion: Use of topical anti-glaucoma medication resulted in dry eye syndrome as well as a decrease in the tear film's stability. Keywords: Anti-glaucoma therapy, Basal Schrimer`s test, Tear film break-up time, Anti-glaucoma therapy, Dry eye syndrome

Context: Nigerian glaucoma patients have an aversion to surgery and often rely on medical therapy to prevent disease progression. For medical therapy to be effective, the drugs have to be used as prescribed. Compliance has been reported to be low in the previous Nigerian studies. Aims: To evaluate the adherence rates of primary open angle glaucoma (POAG) patients on medical therapy using patient self-report. Settings and Design: A hospital-based cross-sectional design was used to assess consecutive POAG patients attending a glaucoma clinic in a Tertiary Hospital in Lagos, Nigeria. Subjects and Methods: Self-reported adherence was evaluated by trained interviewers. Comprehensive clinical assessment including intraocular pressure, gonioscopy, visual field assessment, and dilated binocular funduscopy using the slit lamp and + 78D fundus lens was done. Statistical Analysis Used: Data analysis was done using MedCalc Statistical Software. Results: One hundred and fourteen patients reported adherence rates ranging from 10% to 100% with a mean adherence rate of 82.33% ± 19.25%. Only 31 respondents (27.2%) reported 100% adherence. Duration of the disease was the only significant factor on multiple regression analysis. Conclusions: The development of strategies to improve compliance and persistence in glaucoma patients is crucial for the reduction of disease progression and blindness.

Background Glaucoma is a progressive optic neuropathy that may result in irreversible visual impairment and can diminish quality of life. Lowering intraocular pressure (IOP) through topical eyedrops is usually the primary approach to managing glaucoma. However, long-term treatment poses a risk to ocular surface health, leading to ocular surface disease (OSD). Preservative-containing eyedrops are implicated in OSD development due to their detrimental effects on the tear film and goblet cell density. OSD symptoms may impact patient compliance due to local side effects. This study aims to assess OSD in glaucoma patients receiving topical treatment, quantify symptoms and objective ocular surface parameters, and compare them to a control group not using topical glaucoma medications. Methodology Patients diagnosed with primary open-angle glaucoma receiving topical treatment and a control group were included in this study. To assess OSD, patients completed the Ocular Surface Disease Index (OSDI) questionnaire to evaluate symptoms and underwent objective measurements of ocular surface parameters using a keratograph. These parameters included assessments of bulbar redness and non-invasive keratograph tear break-up time (NIKTBUT). Results A cohort of 92 patients was subjected to examination, comprising 66 individuals diagnosed with glaucoma and 26 controls. Within the glaucoma patient subset, the mean number of IOP-lowering drugs administered was 2.42 ± 0.18, with 22.7% exclusively utilizing preservative-free eye drops. Our investigations unveiled a substantial prevalence of OSD symptoms, manifesting not only within the glaucoma cohort but also among the control group, with 72.7% and 53.8%, respectively (p = 0.224), reporting moderate-to-severe symptoms (OSDI > 23). Remarkably, OSDI scores exhibited higher values among female participants (p = 0.039) and glaucoma patients using prostaglandins (p<0.001) and were negatively correlated to the number of IOP-lowering drugs used (-0.448; p < 0.001). Furthermore, employing keratograph assessment, we discerned heightened bulbar redness (1.86 ± 0.07) in the glaucoma group compared to the control group (1.58 ± 0.07; p = 0.008). Glaucoma subgroup analyses further unveiled higher bulbar redness among glaucoma patients employing carbonic anhydrase inhibitors (p = 0.035) and applying medication preservatives (p = 0.045) but lower among individuals using beta-blockers (p = 0.018). However, the NIKTBUT did not show significant variance between the two groups (glaucoma group: 10.19 ± 0.85 seconds; control group: 10.96 ± 1.37 seconds; p = 0.499). Conclusions Our study revealed a significant prevalence of OSD in our sample, with the OSDI questionnaire showing limited specificity. The notable increase in bulbar redness pointed to an elevated prevalence of OSD among glaucoma patients, emphasizing the considerable impact of preservatives on ocular surface damage. Recognizing the potential damage to the tear film and ocular surface is crucial for glaucoma experts, who must employ comprehensive therapeutic strategies to mitigate symptoms, advocating for the preferential use of preservative-free medications, when possible, for optimizing long-term treatment.

56,000 ways to treat glaucoma

Background/Objectives: To compare the five-year efficacy and safety of the 63 µm (XEN63) vs. 45 µm (XEN45) XEN® Gel Stent in patients with open-angle glaucoma (OAG). Methods: This retrospective matched (1:1) cohort study included adults with OAG who underwent standalone ab interno implantation of the XEN63 or the XEN45 between 2014 and 2021 at a tertiary referral center in Belgium. The primary outcome was IOP at five years. The secondary outcomes included surgical success, topical medication use, postoperative hypotony, complications and interventions. Results: Thirty eyes of 30 patients (15 XEN63 and 15 XEN45) were analyzed. The baseline characteristics were comparable. At five years, the mean IOP did not differ between the XEN63 and the XEN45 (11.5 vs. 11.0 mmHg; p = 0.54). The XEN63 demonstrated higher complete success rates than the XEN45 for both the IOP < 18 mmHg (10 vs. four eyes; p = 0.016) and <15 mmHg criteria (10 vs. three eyes; p = 0.003). The topical medication use was low and comparable (0.6 vs. 0.9 medications; p = 0.57). The numerical (13 vs. five eyes; p = 0.008) and symptomatic (six vs. two eyes; p = 0.2) hypotony were more frequent after the XEN63 implantation. The two eyes with XEN63 and none with XEN45 experienced clinically significant hypotony. The needling procedures and secondary glaucoma surgeries were more frequent after the XEN45. Conclusions: The XEN63 implantation was associated with higher long-term success rates and also with a higher incidence of early postoperative hypotony. These findings indicate a trade-off between efficacy and safety and suggest that careful patient selection and postoperative management are essential when considering larger lumen subconjunctival drainage devices.

Glaucoma is a major cause of irreversible blindness worldwide. Reduction of intraocular-pressure (IOP) using topical anti-glaucoma medications remains the mainstay of treatment. However, prolonged use of these medications may induce adverse effects on the ocular surface. This cross-sectional observational study, conducted at the B.P. Koirala Lions Centre for Ophthalmic Studies, Maharjgunj Medical Campus from February 2023 to August 2024. Patients of primary open angle glaucoma receiving topical anti-glaucoma medications for at least three months were enrolled. Conjunctival- Impression Cytology samples were obtained and graded according to Nelson's grading system. Data analysis was done using SPSS version 16. A p-value <0.05 was considered statistically significant. 128 eyes from 128 glaucoma patients were analyzed, including 54 males (42.2%) and 74 females (57.8%), with mean age of 58.16 ± 14.44 years. Patients using prostaglandin-analogues demonstrated 39.3% Grade-2 and 27.3% Grade-3 changes. Duration of medication use exceeding three years was significantly associated with higher Nelson grades (p < 0.05). Older patients, particularly those aged 61-70 years, exhibited greater cytological changes (p = 0.005). A significant positive correlation was observed between duration of medication use and severity of conjunctival changes (r = 0.597, p < 0.001). Males exhibited more severe conjunctival changes than females (p = 0.009). Prostaglandin-analogues showed most severe conjunctival cytological alterations. Longer duration of medication use, advancing age, and male gender were significantly associated with conjunctival changes.

Medical vs surgical therapy in preventing visual field loss

PurposeTo evaluate the long-term efficacy of the bimatoprost sustained-release (SR) implant focusing on time to additional intraocular pressure (IOP) lowering intervention and changes in medication burden and IOP, with subgroup analyses by lens status and prior trabecular meshwork (TM) procedures.Patients and MethodsThis retrospective study included patients who received a single bimatoprost SR implant between September 2020 and June 2022 at a single center. Data was obtained from electronic medical records. The primary outcomes were time to failure defined as addition of IOP-lowering medications, procedures, or surgery, changes in topical medication use, and IOP over time. Kaplan-Meier survival analysis and linear mixed-effects models were used to assess overall outcomes and within subgroups.ResultsThe study included 223 eyes from 134 patients. At 6-, 12-, and 24-months post-implantation, 67.3%, 38.5%, and 20.5% of eyes, respectively, remained free of additional IOP-lowering treatment. The rates of survival were not statistically significant when stratified by lens status or history of TM procedures. The mean number of topical medications was 1.8 ± 1.3 at baseline and was significantly reduced beginning at 1 month and through 18 months (p < 0.001). There was not a significant IOP decrease post implantation. Subgroup analysis showed no significant differences in IOP and a borderline significant difference in medication use (p = 0.051) between phakic and pseudophakic eyes. Eyes with a history of TM procedures had higher IOP compared to those without prior intervention (p = 0.042), and medication use was not significantly different between groups.ConclusionIn this retrospective, single-center study the bimatoprost SR implant provided significant reduction in topical medication burden for 18 months. The implant provided six months of freedom from additional IOP lowering interventions in more than half of the eyes with an expected decline. A small group continued to be free from additional IOP lowering intervention for up to 24 months.

Glaucoma represents a progressive optic neuropathy characterized by optic nerve head damage, retinal nerve fiber layer thinning and visual field loss. There are significant disparities in the diagnosis, disease progression and treatment outcomes of glaucoma patients. Primary open angle glaucoma (OAG) patients of African descent have been found to have earlier and more severe disease than those of European descent. In 2020, half of the worldwide glaucoma patient population resided in Asia, where normal-tension and angle-closure glaucoma are more prevalent. The significant prevalence and diversity of OAG in Asia necessitates a better understanding of medical, laser, and surgical management in this growing population. PubMed and Embase database searches were conducted for all pertinent articles and abstracts published between January 1990 through January 2024 and review of the literature yielded 1,237 potential articles, from which 104 met the inclusion/exclusion criteria. The current literature suggests that prostaglandin analogues are efficacious and safe in OAG Asian patients, however little is known on other classes of hypotensive drugs. Published data on the laser and surgical management of glaucoma in Asian populations describe differences in outcomes between Asian and Caucasian populations including from minimally invasive glaucoma surgery. Longitudinal studies specifically designed to investigate treatment impact while accounting for access to care in the increasing global aging Asian population are warranted.

Fluocinolone acetonide sustained drug delivery device to treat severe uveitis

To evaluate the effects of oral acetazolamide (ACZ), anterior chamber paracentesis (ACP), or topical brimonidine tartrate (BT) to reduce intraocular pressure (IOP) elevation after intravitreal bevacizumab injection (IVBI). A total of 56 patients scheduled for IVBI (1.5 mg/0.06 mL) were randomly assigned to a pretreatment with ACZ (14 eyes), BT (14 eyes), as well as an immediately after ACP (14 eyes), or no treatment (control group-CG) (14 eyes). IOP was measured 90 minutes before injection (baseline), just before injection, and at 3, 10, 20, and 30 minutes after the procedure. IOP was increased at 3 minutes after injection in CG, 20.9±2.1 (mean±SE intraindividual change in mm Hg); BT, 15.5±2.3; ACZ, 13.7±1.7; but not in ACP, 0.3±1.2 (P<0.0001). At 30 minutes after injections, IOP difference to baseline was not significantly different in groups BT, 0.0±0.7; ACZ, -3.2±0.8; and ACP, -2.5±3.9, but was kept higher in the CG, 4.0±4.3 (P<0.0001). ACP prevents IOP elevation after IVBI, whereas ACZ and BT caused a faster return to baseline than untreated nonglaucomatous eyes. Further studies with larger number of subjects, including glaucomatous patients, and the use of other topical glaucoma medications are warranted to establish a standard recommendation.

Association between polypharmacy and mortality in the community dwelling elderly: A retrospective cohort study.