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This study examined the integrity of binocular summation function in patients with mild glaucoma. We found that binocular summation of visual acuity is preserved in these patients, despite their reduced monocular inputs.Binocular summation represents superiority of binocular to monocular performance. In this study we examined the integrity of binocular summation function in patients with early glaucoma who had structural glaucomatous changes but otherwise had no significant interocular acuity asymmetry or other functional deficit detected with standard clinical measures.Participants included 48 patients with early glaucoma according to Hodapp, Anderson, and Parrish 2 (HAP2) criteria (age 65±12 y) and 42 healthy controls (age 60±12 y), matched for stereoacuity. Visual acuity was assessed binocularly and monocularly at high (95%) and low (25%) contrast using the ETDRS charts at 6m. Binocular acuity summation was evaluated utilising a binocular ratio (BR).Overall, binocular and monocular visual acuity of the control group was better than that of the glaucoma group for both contrast levels, P=0.001. For the glaucoma group, there was a significant difference between BRs at high and low contrast, 0.01±0.05 and 0.04±0.06 (P=0.003), respectively. For the control group, the difference between BR at high and low contrast was not statistically significant, 0.00±0.07 and 0.02±0.06 (P=0.25), respectively.For patients with early glaucoma, binocular summation function for visual acuity was preserved at both contrast levels. This suggests an adaptation of the visual system in early stages of glaucoma that allows for normal binocular summation in the presence of reduced monocular visual input.

Purpose To evaluate long-term (4.5 to 6 y) changes in the position of Ahmed glaucoma valve (AGV) tubes. Materials and methods Adult patients aged 18 years and above, 1 to 2 months post-AGV implantation were enrolled. Tube position was evaluated using anterior segment optical coherence tomography at baseline and final follow-up. The intracameral tube length (ICL), tube-cornea (TC) distance, and cornea-tube angle were measured. Wilcoxon-signed rank test was used to assess whether the changes in parameters from baseline were significant. Results In total, 11 eyes of 9 patients were included in the analysis. Mean duration of follow-up was 5.2±0.8 years (4.4 to 6.1 y). The ICL increased from 1.58±0.40 to 1.74±0.62 mm (P=0.18). The TC decreased from 0.36±0.12 to 0.29±0.05 mm (P=0.04). The cornea-tube angle decreased from 27.76±5.57 to 24.82±5.69 degrees (P=0.08). Overall, 73% of the tubes moved toward the cornea (mean 0.11 mm, over 4.4 to 6.1 y). In total, 73% showed an increase in ICL; 45% showed an increase of >0.3 mm [mean 0.50 mm (33%) increase]. Two of 11 tubes (18%) showed no significant change in the parameters (ICL, 0.03 and 0.01 mm increase; TC, 0 and 0.01 mm increase); these tubes were noted to lie on the iris. Conclusions Tubes tend to move toward the cornea over time. To avoid corneal damage and involvement of the visual axis in the future, tubes should be reasonably short and inserted tangentially, preferably in the posterior one third of the anterior chamber.

We report a case of acute angle closure with significantly elevated intraocular pressure 9 hours after implantation of a phakic intraocular lens for high myopia.

This study evaluated the effect of preoperative brimonidine tartrate 0.2% on intraocular pressure (IOP) during robotic-assisted laparoscopic radical prostatectomy in steep Trendelenburg position (sTBURG).In this prospective randomized controlled masked interventional trial, eligible patients scheduled for robotic-assisted laparoscopic radical prostatectomy in sTBURG at the Toronto General Hospital had one eye randomized to placebo (artificial tears) or drug (brimonidine tartrate 0.2%) preoperatively. Visual acuity (VA), tonometry, disc photography, visual field (VF), and retinal nerve fiber layer (RNFL) assessments were performed preoperatively and postoperatively. A standardized anesthetic protocol was followed intraoperatively. IOP was measured using Tono-Pen AVIA (Reichert Inc., New York, NY) as follows: preanesthesia supine, anesthetized supine, hourly in sTBURG and awake supine. The primary outcome was IOP in sTBURG in the drug group compared with the placebo group. Secondary outcomes were changes in VA, VF, RNFL thickness, mean arterial pressure, and ocular perfusion pressure. This study was approved by University Health Network Research Ethics Board.In total, 26 eligible patients, mean age 61.9±5.1 years, were randomized to brimonidine (11 patients) and placebo (15 patients). Baseline IOP was not significantly different between the drug and placebo groups (P=0.42). Significant and sustained IOP elevation of1.5X baseline in the sTBURG was noted in both groups. The mean IOP 1 hour after sTBURG was 29.4±6.9 and 27.2±3.4 mm Hg in the drug and placebo groups, respectively (P=0.35). No significant changes were noted in VA, VF, or RNFL.Significant and sustained IOP increases occur during sTBURG. Preoperative brimonidine does not prevent IOP spikes in sTBURG.

PURPOSE To measure the influence of body weight on postural intraocular pressure (IOP) changes and to determine if significant weight loss effects IOP. PATIENTS AND METHODS In this prospective case-control study 25 morbidly obese subjects scheduled for bariatric surgery and 25 age-matched and sex-matched normal weight controls were recruited. Subjects had tonometry performed in 7 positions with the order randomized: sitting with the neck in neutral position, neck flexion at 30 degrees, extension at 30 degrees, supine, right, and left lateral decubitus, and with the head and upper body elevated at 30 degrees. The obese subjects were reassessed 1 to 2 years after bariatric surgery. RESULTS Mean IOP in the obese group was significantly higher than the control group across all positions by a mean of 2.5±0.4 mm Hg (P

Purpose The purpose of this study was to determine the risk of a steroid pressure response from inhaled corticosteroids. Patients and methods This randomized, double-masked, placebo-controlled trial included 22 adults with well-controlled open-angle glaucoma or ocular hypertension. Consenting participants were randomized to a 6-week course of twice-daily fluticasone propionate 250-μg metered-dose inhaler or saline placebo metered-dose inhaler. Biweekly clinic visits included masked Goldmann applanation tonometry and assessment to identify adverse effects. Primary outcome was mean intraocular pressure (IOP) at week 6. Secondary outcomes included IOP elevation of >20% at 2 consecutive visits, adherence, side effects, and logMAR visual acuity. Results A total of 10 patients in each arm completed the study. There were no statistically significant differences in IOP between groups at baseline (14.3±3.0 and 15.6±3.6 mm Hg in steroid and placebo groups, respectively, P=0.39) or at week 6 (14.7±2.4 and 14.8±3.8 mm Hg in steroid and placebo groups, respectively, P=0.92). Adherence was >80% for all participants. There were no statistically significant differences between groups in any secondary measures. One patient in the steroid group met the secondary end point of >20% elevation in IOP (IOP increased from baseline of 9 to 11 mm Hg at weeks 2 and 4). Conclusions We found no clinically significant increase in mean IOP in patients with well-controlled open-angle glaucoma and ocular hypertension after 6 weeks of twice-daily inhaled fluticasone propionate compared with inhaled placebo. No participants exceeded their individualized target IOP. There were no differences in secondary outcomes.

PURPOSE To investigate if glaucoma severity and the presence of self-reported glare and difficulty with dark adaptation are associated with driving difficulty or cessation. PATIENTS AND METHODS Individuals with glaucoma, age 50+ and visual acuity in the better eye ≥20/50 were included. Glaucoma severity was defined by the visual field mean deviation (MD) in the better eye and was classified into 2 groups: mild (MD>-6 dB) and moderate/severe (MD≤-6 dB). Patient responses to the glare and dark adaptation subscales in Glaucoma Quality of Life-15 questionnaire were used to measure relevant visual disability. Associations were assessed utilizing prevalence ratios (PR). RESULTS A total of 99 participants (57% female) were included with 19% (19/99) reporting driving cessation. Patients with moderate/severe glaucoma when compared with mild glaucoma reported a significantly higher percentage of driving cessation (33% vs. 8%; P=0.002), presence of glare (27% vs. 6%; P=0.012), and difficulty with dark adaptation (31% vs. 10%; P=0.011).Individuals with self-perceived difficulty with dark adaptation were about 4 times more likely than those without to have difficulty driving at night (adjusted PR=3.94; P

PURPOSE To assess the long-term outcomes of glaucoma drainage device (GDD) exposure repair with corneal lamellar patch graft covered by a buccal mucous membrane graft sutured to surrounding conjunctiva. METHODS In this retrospective longitudinal study, the charts of all patients who underwent buccal mucous membrane grafts combined with corneal lamellar patch grafts for exposed GDD tubes between the years 2006 to 2013 were reviewed. A minimum follow-up of 3 years was required for inclusion. Primary outcomes were categorized as complete success: adequate coverage throughout the study period without further intervention after 1 repair; qualified success: adequate coverage despite minor additional procedures (eg, suturing); failure: re-erosion of the GDD tube. RESULTS A total of 23 tube exposures were included. Average time from GDD insertion to first erosion was 54.0±38.9 months (range, 5 to 120). Complete success was achieved in 19 cases (82.6%), and qualified success in 1 case (4.3%). There were 3 failures (13.1%). Overall success (complete+qualified) after 1 or 2 buccal mucous membrane graft repairs was achieved in 22 of 23 cases (95.7%). Average follow-up time for the successful cases (complete+qualified) was 69.5±25.4 months (median, 72.5; range, 36 to 124). There was no difference in time to first erosion between the success (complete+qualified) and failure groups: 53.8±38.3 months (range, 5 to 120) and 62.3±51.6 months (range, 5 to 105), respectively (P=0.78). CONCLUSIONS Buccal mucous membrane grafts in combination with a lamellar corneal patch graft is a viable surgical strategy for eroded GDDs, providing good long-term outcomes; however, later interventions may be needed.

To compare the rate of visual recovery after Ex-PRESS implantation versus standard trabeculectomy.Subjects enrolled in a prospective randomized controlled trial comparing Ex-PRESS to trabeculectomy were analyzed for postoperative changes in visual acuity (VA). Risk factors for visual loss (split fixation, cup-disc ratio, intraocular pressure, visual field mean deviation, and hypotony) were evaluated.Sixty-four subjects were enrolled (33 Ex-PRESS, 31 trabeculectomy). There was no significant difference in mean logMAR VA between groups at baseline or any study visit. VA was significantly reduced up to week 2 following surgery in both the groups. However, by month 1, VA in the Ex-PRESS group was no longer significantly different from baseline (P=0.23) and remained nonsignificant at subsequent visits up to 6 months. In the trabeculectomy group, VA remained significantly lower than baseline at each study visit. At 6 months, 47% of the trabeculectomy eyes compared with 16% of the Ex-PRESS eyes had lost ≥2 Snellen lines (P=0.01). Reasons for VA loss included cataract, central retinal vein occlusion, and diabetic retinopathy, however, in a significant number of cases no cause could be determined. None of the risk factors evaluated were associated with vision loss.Although there was no difference in mean VA between the Ex-PRESS and trabeculectomy groups at any time point, trabeculectomy eyes were more likely to lose ≥2 Snellen lines. In addition, VA recovered faster in the Ex-PRESS group.

PURPOSE To investigate the relationship between sociodemographic factors and nonpersistence with topical glaucoma medication. DESIGN This was a retrospective, observational cohort study. PATIENTS AND METHODS We invited glaucoma patients on medical therapy from a general ophthalmology practice to complete a standardized questionnaire between November 2011 and April 2012. Nonpersistence was defined as having ≥ 1 gaps (≥ 14 d without medication) in therapy over the last year. Patients' pharmacy records, dating back 1 year from study enrollment, were used to determine the total number of gaps and the cumulative number of days off therapy in the last year. Prevalence ratios (PR) and 95% confidence intervals (CI) were used to assess the relationship between sociodemographic factors and nonpersistence. The relationships between sociodemographic factors and the median number of gaps, as well as the median number of days off, were also assessed. RESULTS Sixty-one patients were included for analysis. The mean age was 72 years; 61% were male patients and 71% were on one medication for glaucoma. Fifty-four percent of patients (n=33) were nonpersistent with glaucoma medications over the 1 year study period. Median numbers of gaps and days off therapy were 1 and 11, respectively. Patients reporting below average income were twice as likely to be nonpersistent (prevalence ratio, 2.02; 95% confidence interval, 1.37-2.96; P

Purpose To compare the efficacy and safety of the Ex-PRESS glaucoma shunt with standard trabeculectomy. Patients and methods Consenting patients with medically uncontrolled open-angle glaucoma were prospectively randomized to trabeculectomy or Ex-PRESS shunt both with mitomycin-C. Exclusion criteria included previous ocular surgery with the exception of clear cornea phaco or 1 previous trabeculectomy, uveitis, and vitreous in the anterior chamber. Standardized data collection sheets were completed at baseline and postoperative day 1, weeks 1 and 2, and months 1, 2, 3, 6, and 12. Primary outcome was intraocular pressure (IOP). Complete success was defined as an IOP between 5 and 18 mm Hg and a 20% reduction from baseline without medication. A sample size calculation determined that 52 eyes were required to detect a 2.0 mm Hg IOP difference with a power of 80%. Results Sixty-four subjects were enrolled, 33 in the Ex-PRESS and 31 in the trabeculectomy group. IOP was not statistically significantly different between groups. Baseline and 1-year mean IOP was 22.0±6.8 versus 22.7±10.3 mm Hg (P=0.76) and 11.6±4.5 versus 11.3±4.5 mm Hg (P=0.81) in the trabeculectomy versus Ex-PRESS groups, respectively. Complete success was 57% versus 70% (P=0.28) in the trabeculectomy versus Ex-PRESS groups, respectively. There were no statistically significant differences in surgical time, number of glaucoma medications, visual acuity, central corneal thickness, endothelial cell counts, complications, interventions, or bleb morphology between the trabeculectomy and the Ex-PRESS groups. Conclusions There was no statistically significant difference between the trabeculectomy and Ex-PRESS groups regarding IOP, success rates, complications, additional interventions, and bleb morphology.

Conjunctival complications may occur after glaucoma drainage device surgery. We analyzed the frequency, risk factors, management and outcomes of Ahmed glaucoma valve (AGV)-related conjunctival complications.Retrospective review of postoperative conjunctival complications in patients undergoing AGV insertion. Only subjects with ≥1-year follow-up were included.The charts of 158 subjects with a median age of 64±16.2 years were reviewed. Median follow-up was 43.5 months (range, 12 to 103 mo). Fifty-three (33.5%) wound dehiscences and 14 (8.9%) device exposures were diagnosed 31.6±35.7 and 996±735 days after procedure, respectively (P0.001). Ninety-one subjects (57.6%) had no conjunctival complications. This uncomplicated group used 3.3 (±1.1) [95% confidence interval (CI): 3.07, 3.51] hypotensive medications before surgery as compared with 3.8 (±1.1) (95% CI: 3.48, 4.10) and 3.9 (±0.9) (95% CI: 3.36, 4.36) for dehiscence and exposure groups, respectively (P=0.01). The inferonasal quadrant was associated with the highest rate of dehiscences (4/7, 57.1%) (95% CI: 18.4, 90.1), followed by the inferotemporal quadrant (30/65, 46.2%) (95% CI: 33.1, 58.2), the superotemporal (15/61, 24.6%) (95% CI: 12.9, 33.8), and the superonasal (4/25, 16%) (95% CI: 10.9-52.0; P0.0073). There were no differences in dehiscence and exposure rates between limbal versus fornix-based approaches (P=0.54; 95% CI: 24.8-44.9, 24.4-45.7, 5.9-19.6, 3-45.1, respectively). Forty-eight (90.6%) dehiscent wounds resolved with conservative management and 5 were resutured, whereas all exposed devices were managed surgically.Conjunctival dehiscence is usually a benign, common complication after AGV insertion. It does not need repair as long as the tube is well covered. AGV tube or plate exposures are less common, occur later and were promptly repaired as per current practice. Important factors predisposing to these problems include a greater number of preoperative hypotensive medications and the implantation quadrant.

Purpose To evaluate the effect of 6 weeks administration of beclomethasone nasal spray on intraocular pressure (IOP) in patients with ocular hypertension or controlled primary open-angle glaucoma. Patients and methods Randomized double-masked controlled trial. Patients were randomized to twice daily beclomethasone versus placebo saline nasal spray. There were a total of 4 study visits: baseline and weeks 2, 4, 6 after starting the spray. Each study visit was at the same time within a 1-hour time window. Primary outcome measure was IOP. Secondary measures included visual acuity, anterior segment changes, patient reported side effects, and compliance. Study endpoint was 6 weeks from the start of treatment or an IOP increase of >20% from baseline. A sample size calculation suggested that 8 patients in each arm would be sufficient to detect a difference of 3.2 mm Hg with a power of 80%. Results Nineteen consecutive consenting patients completed the study-9 in the steroid arm and 10 in the placebo arm. There were no statistically significant differences between groups in baseline characteristics, IOP at each study visit, or change in IOP from baseline at any time point. At 6 weeks, the change in mean IOP from baseline was +0.50±1.52 versus +0.70±1.44 mm Hg in the steroid and saline nasal spray groups, respectively (P=0.77). Conclusions Patients with ocular hypertension and primary open-angle glaucoma showed no evidence of IOP elevation after 6 weeks use of beclomethasone nasal spray.

OBJECTIVE To analyze trends in bilateral, same-day laser iridotomies, and trabeculoplasties in Ontario over the last decade. METHODS Ontario Health Insurance Plan billing service claims between 2000 and 2013 were analyzed for the yearly number of glaucoma laser procedures. The annual number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS The volume of same-day bilateral trabeculoplasties increased from 15.3 per 1000 with POAG in 2000 to 74.7 in 2013 (4.9-fold). The proportion that were same-day bilateral procedures increased from 22.7% in 2000 to 40.2% in 2004 (76.9% increase) and remained stable from 2009 to 2013, reaching 38.5% in 2013. The number of same-day bilateral laser iridotomies increased from 3126 in 2000 to 11,716 in 2013 (3.75-fold). The proportion of iridotomies that were bilateral increased from 39% in 2000 to 54.6% in 2006 (40% increase) and remained stable from 2006 to 2013, reaching 56.7% in 2013. CONCLUSIONS The increase in same-day bilateral trabeculoplasties coincided with the introduction of selective laser trabeculoplasty. The proportion of this practice remained constant for the last 3 years of the study period. In 2013, 56.7% of iridotomies and 38.5% of trabeculoplasties were performed as same-day bilateral procedures. We recommend comparison studies between same-day and sequential laser therapies to assess complication rates and patient satisfaction to provide an evidence-based treatment approach, as there are limited data to support this practice.

Purpose Earlier studies have reported wide regional variability in glaucoma procedure rates, suggesting nonclinical factors influencing procedure rates. This study was designed to investigate the possible influence of fees on procedure rates. Methods Databases were accessed to obtain yearly provincial population, procedure and ophthalmologist numbers, and physician fees for trabeculoplasties, trabeculectomies, and glaucoma drainage device (GDD) implantations from 1992 to 2007. Regression models using generalized estimating equation methods were used to evaluate the influence of fees on procedure rates after adjusting for temporal trends and the number of ophthalmologists per 1000 persons with glaucoma. Results Trends in glaucoma procedure rates and fees varied widely among provinces: decrease of 98% to an increase of 380% for trabeculoplasties, decrease of 72% to an increase of 42% for trabeculectomies, and decrease of 32% to an increase of 1292% for GDD. In 2007, provincial remuneration varied from $125 to $553 for trabeculoplasties, $370 to $748 for trabeculectomies, and $426 to $956 for GDD. The regression models found for every 1000 persons with glaucoma, a $100 increase in fee was associated with 0.68 more trabeculoplasties (P=0.94), 1.2 fewer trabeculectomies (P=0.17), and 0.18 more GDD implantations (P=0.18); and for every additional ophthalmologist per 1000 persons with glaucoma, 53.8 more trabeculoplasties (P=0.24), 0.34 more trabeculectomies (P=0.86), and 0.79 more GDD implantations (P=0.0004). A regression model examining procedure substitution effect did not find any association between relative remuneration and procedure rate. Conclusion Our analysis did not show an influence of physician remuneration fee on procedure rates in Canada during the study period.

To compare the effect of topical steroids versus nonsteroidal anti-inflammatory drugs on intraocular pressure (IOP) and the hypertensive phase (HP) after Ahmed glaucoma valve surgery.Prospective, randomized, double-masked controlled trial. Twenty-eight consecutive consenting patients scheduled for Ahmed glaucoma valve surgery were randomized to receive either postoperative topical dexamethasone or ketorolac. The main outcome measure was IOP. Secondary outcomes included incidence of HP, visual acuity, number of glaucoma medications, postoperative complications, and subsequent procedures.The mean postoperative IOP (in mm Hg) in the ketorolac versus dexamethasone arms respectively was as follows: 8.8±4.7 versus 10.0±4.5 at week 1 (P=0.500); 10.7±6.7 versus 17.5±10.4 at week 2 (P=0.053); 11.0±6.5 versus 18.0±7.3 at week 4 (P=0.013); 14.8±8.6 versus 17.5±5.2 at week 6 to 8 (P=0.323); and 14.8±9.6 versus 17.8±7.5 at week 10 to 12 (P=0.374). Four patients (31%) in the ketorolac arm versus 8 patients (53%) in the dexamethasone arm exhibited the HP (P=0.276). Wound leak was the most severe complication and there were 3 cases (23%) in the ketorolac group versus nil in the steroid group (P=0.087). Conjunctival retraction was observed in 8 patients (62%) in the ketorolac arm versus 2 patients (13%) in the dexamethasone arm (P=0.016).Mean IOP was greater at all time points postoperatively in the steroid group with the difference between groups statistically significant at week 4. The nonsteroidal anti-inflammatory drug group showed greater wound-healing problems.

Latanoprost, travoprost, and bimatoprost are prostaglandin or prostamide-type ocular hypotensive medications, all of which are effective and safe for lowering intraocular pressure (IOP). Most studies with these types of drugs have included patients mainly from European or white ethnic backgrounds; however, some reports have suggested that there is a difference in response between patients of white and African racial heritage. On account of the possibility that drugs may act differently in people of different ethnic background, we decided to study the effectiveness and safety of all 3 drugs in people from various ethnic heritages. Our hypothesis was that there might be a possible ethnic-based difference in IOP-lowering effectiveness between the 3 medications.This was a prospective randomized investigator-masked multicenter study. Patients newly diagnosed with open-angle glaucoma (primary, pseudoexfoliative, or pigmentary), or whose pressure became elevated after a washout period, were randomized to receive 1 of 3 prostaglandin/prostamide drugs. Assignment of drug was balanced by racial group and study site, and the investigator was masked to the drug used. The patients were requested to self-identify their racial group as White, African, East Indian, Asian, or Hispanic; to minimize the possibility of heterogeneity, all 4 grandparents had to be known to originate from the same group. However, for purposes of analysis, the patients were divided into 2 groups--White or Other. Patients were followed at 2, 6, 12, and 24 weeks; IOP and local side effects were assessed at each visit.Eighty-three patients were recruited from 9 sites. The mean age of the patients was 61.5 ± 10.5 years. There were no differences in mean age or the distribution of sex between the patients whether examined by the 2 racial groups or the 3 drug groups. There was a highly statistically significant decrease in IOP from baseline to 12 weeks and from baseline to 24 weeks (F = 439.3, P0.0001; F = 305.94, P0.0001). There were no differences in treatment effect between the 3 drugs or between the 2 ethnic groups, (P0.05 for all comparisons) and there was no interaction between race and drug.All 3 prostaglandin/amide drugs are highly effective at lowering IOP. No differences in effect between the drugs or between members of different racial groups were detected, although the study sample size was too small to be certain to detect differences, if they existed.

PURPOSE To assess the association between glaucoma severity and participation in diverse social roles. DESIGN Cross-sectional survey. PATIENTS AND METHODS Individuals with glaucoma, 50+, with visual acuity in the better eye >20/50 were enrolled. They were classified into 3 groups based on visual field loss in the better eye: mild [mean deviation (MD)>-6 dB], moderate (MD, -6 to -12 dB), and severe (MD

PURPOSE To assess the validity of a preimplantation flow test to predict early hypotony [intraocular pressure (IOP)≤5 mm Hg on 2 consecutive visits and hypertensive phase (HP) (IOP>21 mm Hg) after Ahmed Glaucoma Valve (AGV) implantation. PATIENTS AND METHODS Prospective interventional study on patients receiving an AGV. A preimplantation flow test using a gravity-driven reservoir and an open manometer was performed on all AGVs. Opening pressure (OP) and closing pressure (CP) were defined as the pressure at which fluid was seen to flow or stop flowing through the AGV, respectively. OP and CP were measured twice per AGV. Patients were followed for 12 weeks. RESULTS In total, 20 eyes from 19 patients were enrolled. At 12 weeks the mean IOP decreased from 29.2±9.1 to 16.8±5.2 mm Hg (P

Purpose To correlate trends of laser trabeculoplasties (LTPs) with the introduction of medical therapies for glaucoma and to assess whether these trends changed after the introduction of selective laser trabeculoplasty (SLT) in 2001. Methods A retrospective analysis of LTP numbers, filtration surgeries, glaucoma medications dispensed, and population distribution by age in Ontario, Canada, between April 1992 and March 2005. Results The number of LTP per 1,000 persons estimated to have primary open angle glaucoma (POAG) increased from 138.05 in 1992 to a maximum of 149.23 in 1996 (8.1% increase, 1.96% annual increase) and then steadily decreased to 70.65 in 2001 (47.3% decrease, 14% annual decrease). From 2001 to 2004, the LTP rate increased to 162.54 (230% increase, 32% annual increase). The number of filtration surgeries per 1,000 persons estimated to have POAG steadily decreased from 1996 to 2004 by 21.42% (2.4% annual decrease). The number of glaucoma medications dispensed in Ontario increased from 1992 to 2004 by 91.5% (10.5% annual increase). There were no significant correlations between the LTP rates and the new glaucoma medications rates (r=-0.35 to 0.09; P=0.34 to 0.82) or filtration surgeries rates (r=0.007; P=0.98). Conclusions There was a substantial reduction in the number of LTP between 1997 and 2001 coinciding, but not correlated with the introduction of medications for the treatment of glaucoma. Between 2002 and 2004 the LTP rates increased, coinciding with the introduction of SLT.

Purpose: Ex-PRESS shunt is an alternative filtration procedure to trabeculectomy. This study aimed to compare the 1-year cost differences between the 2 operations. Methods: Subjects were enrolled in a randomized controlled trial comparing Ex-PRESS to trabeculectomy. Surgical cost difference and 1-year postoperative costs (follow-up visits, additional procedures, and medications) were determined and compared. The 95% confidence interval of incremental cost-effectiveness ratio was estimated using bootstrap method. Results: Forty-three subjects with 1-year follow-up were included. Success rate was not significantly different for Ex-PRESS (65%) versus trabeculectomy (55%, P=0.49). Ex-PRESS had a net surgical cost of $956 greater than trabeculectomy. There was no significant difference in the overall postoperative cost [median (interquartile range); $485 (337, 822) vs. $609 (387, 820), P=0.78], cost of follow-up visits [$303 (275, 358) vs. $317 (275, 385), P=0.75], additional procedures [$182 (0, 365) vs. $182 (0, 365), P=0.69], or glaucoma medication [$0 (0, 68) vs. $0 (0, 90), P=0.8] for Ex-PRESS versus trabeculectomy, respectively. The overall 1-year cost was significantly greater for Ex-PRESS and the incremental cost-effectiveness ratio was $9625 (95% confidence interval, $2435-548,084). Conclusions: Ex-PRESS is associated with greater surgical cost compared with trabeculectomy. This needs to be considered in conjunction with efficacy and safety if Ex-PRESS is to supersede trabeculectomy.

Purpose To investigate the relationship between bleb morphology, recorded using the Indiana Bleb Appearance Grading Scale (IBAGS), and intraocular pressure (IOP) after phacotrabeculectomy. Methods Two years postphacotrabeculectomy, a single observer compared bleb morphology to the IBAGS standard photographs in 76 eyes of 76 patients. In addition, the presence or absence of microcysts was recorded. IOP was also measured. Results On multivariate analysis increasing bleb height was associated with a low IOP (P=0.017). An increase in IBAGS height score by 1 U resulted in a reduction in IOP of 2.16 mm Hg (95% confidence interval=0.40-3.92 mm Hg). In this study, there was no association between vascularity, bleb extent or microcysts, and IOP. There were no cases of bleb leak in this series. Conclusions Two years postphacotrabeculectomy increased bleb height, as measured by the IBAGS, was associated with a decrease in IOP, with a 1 point increase in IBAGS height score resulting in a decrease of 2.16 mm Hg. We found no association between bleb extent, vascularity, or the presence or absence of conjunctival microcysts. As there were no cases of bleb leak in this study this characteristic could not be evaluated.

Purpose To describe a novel approach to early postoperative intraocular pressure (IOP) control after glaucoma drainage device (GDD) implantation. Methods Two patients with elevated IOP after GDD implantation underwent internal GDD tube fenestration using a 30-gauge needle to perforate the GDD tube. Results IOP was lowered in each case by over 50% without complication. Conclusions Transanterior chamber internal GDD tube fenestration is a novel, straightforward approach to early IOP control after GDD implantation. This procedure adds to our armamentarium of methods for controlling IOP during the early postoperative period.

To determine the pressure required to prime an Ahmed Glaucoma Valve (AGV) and determine whether the valve can be damaged by "over-priming pressure."Three AGVs, a syringe pump, and a manometer were used to assess priming pressure. Balanced salt solution was pumped through the AGV tube at increasing pressures until a jet of fluid was seen to eject from the AGV, as per manufacturer instructions. This was repeated 3 times for 3 different virgin AGVs giving the "priming pressure." A second experiment used the same experimental set up to determine the "over-priming pressure" on 3 other AGVs. Fluid was pumped through the AGV at increasing pressures until evidence of damage was seen. The valve function was assessed before and after the "over-priming" stress test. Valve function was determined by the closing pressure, which is the pressure at which the valve closes and fluid was no longer seen passing through the valve.The priming pressure in the 3 AGVs was 2844, 3154, and 3051 mm Hg (mean, 3017±158 mm Hg). The maximum pressure generated using the syringe pump was 10,860, 10,343, and 10,860 mm Hg (mean, 10,688±299 mm Hg). No damage was observed in the valve mechanism. AGV closing pressure before the "over-priming" stress test was 8, 6, and 13 mm Hg and after the stress test was 6, 7, and 13 mm Hg.This study demonstrates that the priming pressure is consistent at around 3000 mm Hg. In addition, over-priming is not likely to damage or disturb the closing pressure.

PURPOSE To determine the prevalence, types, and associated factors of complementary and alternative medicine (CAM) use in glaucoma patients. PATIENTS AND METHODS Prospective, multicenter, cross-sectional survey. A total of 1516 consecutive patients attending 2 tertiary glaucoma clinics were surveyed on CAM use. Information gathered on standardized data collection sheets included demographic variables, ophthalmic history, glaucoma treatment history, and details of CAM use. RESULTS The response rate was 92.5%. A total of 166 patients (10.9%) reported current use of CAM therapy specifically for glaucoma whereas 41 patients (2.7%) reported past use of CAM. Of the patients who reported CAM use, 62.5% had not disclosed the use of CAM to their ophthalmologist and 40.5% believed that the treatments were helping their glaucoma. The most commonly used types of CAM were herbal medications (34.5%), dietary modifications (22.7%), and vitamin/mineral supplements (18.8%). Of the 207 patients who reported current or past CAM use for their glaucoma, 3 (1.4%) indicated that they used conventional glaucoma treatments < prescribed because of their CAM use. CONCLUSIONS Approximately 1 in 9 glaucoma patients use CAM for their disease. Many of these patients do not disclose the use of CAM to their ophthalmologist, but the vast majority report that they still take conventional glaucoma medications as prescribed.

PURPOSE: Multiuse of the G-probe transscleral cyclophotocoagulation (TSCPC) device can lead to contamination. We evaluated the mechanical stability and clinical efficacy of a disposable sterile barrier for the G-probe footplate. METHODS: We measured diode laser output with and without the G-probe barrier both before and after cadaver TSCPC (18 shots at 2000 mW for 2000mS). Qualitative analyses of the laser aiming beam were made before each trial in the barrier and nonbarrier state. After each trial, the G-probe barrier was examined for microperforations and footplate for debris and/or damage. Microbiology was taken on the cadaver eye and the G-probe before and after 20 cycles. Histologic analysis after TSCPC with and without barrier was carried out on a cadaver eye. RESULTS: Qualitatively, laser focus dispersion was minimized by the G-probe cover. Mean (95% CI) laser output was measured for the nonbarrier, with barrier pre-TSCPC and with barrier post-TSCPC, respectively as 980 mW (899,1061), 1247 mW (1115, 1378), and 1240 mW (1132, 1347). The difference between the nonbarrier and barrier both preTSCPC and postTSCPC was statistically significant (df=2, F=36.26, P