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With chronic diseases, patient adherence plays a crucial role in delaying disease progression and in determining the success of therapy. Problems arise not only from low medication adherence, but also non-adherence to recommended follow-up examinations. Obtaining an accurate estimate of adherence is difficult, especially in glaucoma patients, due to the fact that most antihypertensive drugs are administered in the form of eye drops. There is great variability in the published adherence values for glaucoma patients. Most studies report an average medication adherence of approximately 70%, with around 50% of patients having good adherence (at least 80% of medication administered as planned). Furthermore, 6.8 - 31.4% of the eye drops do not end up in the patient's eye, which means there is even less active ingredient to achieve a therapeutic effect. Glaucoma patients also show low persistence and adherence to follow-up appointments. Since diabetes increases the risk for POAG and secondary glaucoma and given that diabetics have particularly low adherence, the question arose whether a diabetes diagnosis is associated with reduced adherence in glaucoma patients. Previous studies found no significant association between diabetes and reduced adherence in glaucoma patients, although a significant impact of elevated HbA 1c on adherence in glaucoma patients was found in one study. However, this connection still needs to be examined more closely in studies with larger samples., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht./The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: The quality of life (QoL) of glaucoma patients is affected by many factors. In particular, patient activity is compromised by the chronicity of the disease. In this study, we evaluated the change in QoL and its impact on activities over a period of 8 years., Methods: A total of 43 patients with glaucomatous optic nerve damage were enrolled in this retrospective longitudinal observational study. Changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA) and visual field (VF) parameters, number of IOP-lowering eye drops and IOP-lowering surgery were assessed over a period of 8 years. Assessment of QoL was obtained by patient-reported visual functioning using the Rasch-calibrated glaucoma activity limitation 9 (GAL-9) questionnaire at baseline and after 8 years., Results: The BCVA of the better eye changed from 0.16 ± 0.22 to 0.21 ± 0.14 logMAR, whereas there was a change from 0.27 ± 0.25 to 1.39 ± 1.1 logMAR in the worse eye. The VF parameter mean deviation (MD) of the better eye changed from -2.39 ± 4.55 dB to -4.83 ± 5.09 dB, while it altered significantly from -8.86 ± 5.86 dB to -12.05 ± 8.07 dB in the worse eye. Values of GAL‑9 changed from -2.39 ± 2.14 to -1.38 ± 2.78 (in the Rasch analysis, more negative values account for a better QoL), according to a sum score change from 79.17 ± 19.63 to 69.22 ± 27.95. This change showed a highly significant correlation with the MD at follow-up, especially with the worse eye (r = 0.43). The impact of the MD at follow-up on QoL could also be well predicted in a regression model., Conclusion: The QoL of glaucoma patients decreased significantly over time. Changes in the VF, particularly of the worse eye, have a great impact on reported functioning. Careful treatment, especially of the eye with greater glaucomatous damage, is mandatory., (© 2021. The Author(s).)

Background: The STARflo Glaucoma Device (iSTAR Medical, Wavre, Belgium) offers a new approach to bleb-free filtering surgery in which the intraocular pressure (IOP) is lowered by supporting outflow of the aqueous humor into the suprachoroidal space., Materials and Methods: On the basis of a case series of 9 patients with open-angle glaucoma (OAG) unmanageable by drug-based treatment, intra- and postoperative experiences with the implant are presented. The implant, the implantation procedure, and the first results 6 months postoperatively are described., Results: No intraoperative complications were observed. Postoperative complications such as increased astigmatism or ocular hypotony were rare and transient. After 6 months there was an IOP reduction from 29.1 mm Hg ± 6.1 mm Hg with 2.7 ± 1.1 local IOP-lowering medications to 16.1 ± 4.1 mm Hg (IOP reduction of 44.7%) with additional 2.0 ± 0.8 local IOP-lowering medications., Discussion: The new STARflo Glaucoma Device shows promising results in reducing the IOP of medically uncontrolled OAG. Further investigations concerning the long-time efficacy of the implant and additional IOP-lowering medication are still ongoing.

Purpose: To evaluate the relationship between functional parameters of repeated flicker-defined form perimetry (FDF) and structural parameters of spectral-domain optical coherence tomography (SD-OCT) in glaucoma suspects with normal findings in achromatic standard automated perimetry (SAP)., Methods: Patients with optic nerve heads (ONH) clinically suspicious for glaucoma and normal SAP findings were enrolled in this prospective study. Each participant underwent visual field (VF) testing with FDF perimetry, using the Heidelberg Edge Perimeter (HEP, Heidelberg Engineering, Heidelberg, Germany) at two consecutive visits. Peripapillary RNFL thickness was obtained by SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany). Correlations and regression analyses of global and sectoral peripapillary RNFL thickness with corresponding global and regional VF sensitivities were investigated., Results: A consecutive series of 65 study eyes of 36 patients were prospectively included. The second FDF test (HEP II) was used for analysis. Cluster-point based suspicious VF defects were found in 34 eyes (52%). Significant correlations were observed between mean global MD (PSD) of HEP II and SD-OCT-based global peripapillary RNFL thickness (r = 0.380, p = 0.003 for MD and r = -0.516, p < 0.001 for PSD) and RNFL classification scores (R 2 = 0.157, p = 0.002 for MD and R 2 = 0.172, p = 0.001 for PSD). Correlations between mean global MD and PSD of HEP II and sectoral peripapillary RNFL thickness and classification scores showed highest correlations between function and structure for the temporal superior and temporal inferior sectors whereas sectoral MD and PSD correlated weaker with sectoral RNFL thickness. Correlations between linear RNFL values and untransformed logarithmic MD values for each segment were less significant than correlations between logarithmic MD values and RNFL thickness., Conclusions: In glaucoma suspects with normal SAP, global and sectoral peripapillary RNFL thickness is correlated with sensitivity and VF defects in FDF perimetry.

Background: The goal of glaucoma treatment is to maintain the patient's visual function and related quality of life, at a sustainable cost. In this review, methods of measuring quality of life are presented, together with their impact in clinical practice., Methods: Searches were from the inception of the database to date. Electronic databases searched included Medline (Ovid), Medline In-Process (Ovid), and Embase (Ovid). In a semistructured approach, the articles were checked for their eligibility to provide information about the measurement and application of quality of life in glaucoma patients., Results: Well established questionnaires are available to measure quality of life in glaucoma patients, as well as instruments to measure benefits. Performance-based measures are more time-consuming. The Glaucoma Activity Limitation-9 Questionnaire (GAL-9) is a glaucoma-specific questionnaire in German, with a Rasch analysis. In eye diseases with central visual field defects, it is the better eye that determines the patient's quality of life, whereas in glaucoma patients with peripheral defects, it is the worse eye that has a stronger influence. Structural changes in glaucoma are less well correlated with quality of life than are functional impairments. There have been a few initial reports of patterns of visual field defects that correlate with subjective impairments., Conclusions: The data can help to improve our understanding of individual patient impairment and support our efforts to improve the medical advice and therapy that these patients receive., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: To evaluate if repeated flicker-defined form (FDF) perimetry can detect visual field (VF) defects in glaucoma suspects with normal findings in achromatic standard automated perimetry (SAP)., Methods: Patients with optic nerve heads (ONHs) or retinal nerve fiber layer (RNFL) findings clinically suspicious for glaucoma and normal SAP were enrolled. Patients underwent VF testing with FDF perimetry (Heidelberg Edge Perimetry, HEP) at two consecutive visits (HEP I and HEP II) and confocal scanning laser ophthalmoscopy with the Heidelberg Retina Tomograph (HRT). Abnormal HEP was defined by cluster-point analysis (CPA) and by the HEP specific glaucoma hemi-field test (GHT). Results were compared with an age-matched control group of healthy individuals., Results: In 65 eyes of 36 glaucoma suspects, the mean deviation (MD) in SAP was -0.9 ± 1.3 dB. In HEP I and HEP II, mean MD was -3.6 ± 3.0 and -3.3 ± 3.7 dB, respectively (p = 0.276). The HRT assessed CDR was significantly correlated with the MD in HEP II (r = -0.281, p = 0.04). In HEP I, VF defects on CPA testing were found in 38 study eyes (58.5%). In HEP II, 34 eyes (51.8%) had VF defects on CPA testing. In 46 eyes of 46 age-matched healthy individuals in the control group, the mean MD was -0.2 ± 1.1 and -1.6 ± 2.3 dB in SAP and HEP testing, respectively. The FDF was abnormal in 21.7% in the control group compared to 58.5% in the glaucoma suspect group in HEP I., Conclusions: In more than half of the patients with ONHs or RNFLs clinically suspicious for glaucoma and normal SAP second FDF perimetry depicts VF defects.

Background: To evaluate the impact of structural changes of the retinal nerve fiber layer (RNFL), and visual field loss, on functional impairment assessed by patient-reported visual functioning in glaucoma., Methods: Patients with glaucomatous optic nerve damage were enrolled in this cross-sectional study. Peripapillary RNFL thickness was obtained with spectral-domain optical coherence tomography (SD-OCT). Function was assessed by patient-reported visual functioning using the Rasch-calibrated Glaucoma Activity Limitation 9 (GAL-9) questionnaire and standard automated perimetry. The impact of peripapillary RNFL loss on functional impairment was analyzed with correlation and linear regression analyses., Results: A total of 176 eyes from 88 glaucoma patients were included. The SD-OCT assessed temporal-superior and temporal-inferior RNFL sector of the worse eye revealed significant correlation with the GAL-9 scores (r=-0.298, p=0.011 and r=-0.251, p=0.033, respectively). In mutivariate regression analysis, the best predictors for patient-reported visual functioning were visual acuity of the better eye and mean defect of the worse eye (R(2)=0.334), while structural parameters could not enhance the prediction of GAL-9 scores., Conclusions: Self-reported visual functioning of patients with glaucoma is better predicted by visual performance data than structural parameters. However, some structural changes of the worse eye are significantly correlated with patient-reported visual functioning.

Introduction: Glaucoma is one of the leading causes of irreversible blindness worldwide and can have a significant impact on patient quality of life and vision-related functioning. The Glaucoma Quality of Life 15 (GQL-15) questionnaire is a disease-specific instrument to evaluate and quantify functional impairment of patients with glaucoma. This study evaluated the German version of the GQL-15 including correlations with perimetric parameters., Methods: A German version of the GQL-15 containing 15 items was developed and evaluated in 98 patients with glaucoma in different stages of the disease. The GQL-15 results were correlated with the perimetric parameters mean deviation (MD) and pattern standard deviation (PSD) of the better and worse eye. Classical and probabilistic test analyses (Rasch model) were performed., Results: The mean GQL-15 value was 77.3 ± 21.7 (SD) and most items of the GQL-15 correlated significantly with the MD of the worse eye (r = -0.416; p = 0.0014) and the better eye (r = -0.304; p = 0.02). There was also a highly significant correlation between glaucoma-specific QoL and visual acuity. A short version containing nine items yielding a higher psychometric performance can also be used., Conclusions: The German version of the GQL-15 is a potent instrument to evaluate impairment in vision-specific functioning of patients with glaucoma. The GQL-15 values are better correlated with the sensitivity of the eye with the more severe glaucomatous damage. The data can help for a better understanding of individual patient impairment to improve medical advice and therapy of patients with glaucoma.

Purpose: To investigate, using Rasch analysis, whether the 15-item Glaucoma Quality of Life-15 (GQL-15) forms a valid scale and to optimize its psychometric properties., Methods: One hundred eighteen glaucoma patients (mean age, 65.7 years) completed the German-version of the GQL-15. Rasch analysis was performed to assess category function (how respondents differentiated between the response options), measurement precision (discriminative ability), unidimensionality (whether items measure a single construct), targeting (whether items are of appropriate difficulty for the sample), and differential item functioning (whether comparable subgroups respond differently to an individual item). Where any of these attributes were outside acceptable ranges, steps were taken to improve the instrument., Results: The five-response categories of the GQL-15 were well differentiated by respondents, as demonstrated by ordered and well-spaced category thresholds. The GQL-15 had an excellent measurement precision but demonstrated poor targeting of item difficulty to person ability and multidimensionality, indicating that it was measuring more than one construct. Removal of six misfitting items created a nine-item unidimensional instrument with good measurement precision and no differential item functioning but poor targeting. A new name, the Glaucoma Activity Limitation (GAL-9) questionnaire, is proposed for the short version, which better reflects the construct under measurement., Conclusions: The GAL-9 has superior psychometric properties over the GQL-15. Its only limitation is poor targeting of item difficulty to person ability, which is an inevitable attribute of a vision-related activity limitation instrument for glaucoma patients, most of whom have only peripheral visual field defects and little difficulty with daily activities.

The application of value-based medicine (VBM) tenets in the area of glaucoma research requires valid and reliable data concerning the quality of life with glaucoma. A multitude of instruments for measuring quality of life of patients with glaucoma have been employed in the past. Any instrument used would need to capture peripheral vision loss and its influence on patient-reported quality of life as this is one of the hallmarks of this disease. Cost-utility analyses can then be based on the reported quality of life and the cost of glaucoma therapy. Several cost-utility analyses have been applied in the field of glaucoma screening as well as treating ocular hypertension and based on this a recommendation regarding population subgroups which can be treated cost efficiently can be made.

Purpose: Screening for glaucoma can detect undiagnosed patients, and treatment can prevent blindness. There are defined criteria for screening programs, but economic aspects of screening programs and cost utility estimations are of increasing importance., Methods: Medical databases (CDSR, HTA, MEDLINE, EMBASE) were searched on the topics of glaucoma screening, screening strategies and tools, and relevant health-economic analyses for glaucoma screening. In this article, the most important findings are presented and discussed using epidemiological data., Results: Glaucoma screening meets most of the relevant criteria for screening strategies. The best single screening test at this time is the frequency doubling technique. The cost-effectiveness depends mainly on the prevalence of the disease, the specificity of the screening test, the costs of screening and disease, and the impairment of quality of life due to glaucoma. Two recently published cost utility studies from Finland and the United Kingdom are presented. A common result is that a population screening is not cost-effective, whereas targeted screening of high-risk groups is., Conclusion: Glaucoma screening of the general population is not cost-effective, but screening of groups at risk (e.g., those of a certain age, family history, or ethnicity) may be cost-effective. Clear cutoff points regarding whom to screen can be determined by economic analyses using high-quality data. These data influence health policy decision makers.

Purpose: The aim of this study was to evaluate patients' acceptance and intraocular pressure (IOP) readings of a new digital mobile tonometer (TGDc-01) and compare it to Goldmann applanation tonometry., Method: Measurements repeated five times with the TGDc-01 and three times with Goldmann tonometry were performed in 100 eyes of 100 patients by two independent investigators. Patients' acceptance of both techniques was evaluated by a visual analogue scale (VAS)., Results: The mean IOP with the TGDc-01 yielded 15.4 mmHg for investigator 1 and 12.7 mmHg for investigator 2 (range: 4-43 mmHg). Results of the measurements with Goldmann tonometry showed 17.6 mmHg for investigator 1 and 17.3 mmHg for investigator 2 (9-42 mmHg). The IOP difference of the two tonometry methods was highly significant (p<0.001). The intraobserver variability was 29% for investigator 1 and 8% for investigator 2. Mean IOP values of the two investigators taken with the TGDc-01 differed significantly (p<0.01) from each other by a mean of 2.6 mmHg., Conclusions: The new mobile tonometer TGDc-01 is better accepted by patients but IOP values are significantly lower compared to Goldmann tonometry and variability is high. Regarding glaucoma diagnostics it seems to be less suitable than Goldmann tonometry.

Susanna Friederike Koenig,1 Christoph Wolfgang Hirneiss2 1Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK; 2Ludwig-Maximilians University, Eye Clinic, Campus Innenstadt, Munich, D-80336, GermanyCorrespondence: Susanna Friederike KoenigMoorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD Email susanna.koenig@nhs.netPurpose: Lowering the intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG) with filtration surgery can induce morphological changes to the bulbus and structures of the retina. In this study, we have evaluated changes of Bruch’s membrane-based parameters and retinal nerve fiber layer (RNFL) derived by spectral-domain optical coherence tomography (SD-OCT) in eyes that have undergone glaucoma filtration surgery.Patients and Methods: SD-OCT imaging of the optic nerve head (ONH) and of the RNFL was performed in 54 eyes of 54 patients with medically uncontrolled POAG before and after IOP-lowering surgery (trabeculectomy or deep sclerectomy). The ONH parameter minimum rim width (MRW) and the size of the Bruch’s membrane opening (BMO-Area) were derived from 24 radial B-scans centered on the ONH.Results: The average preoperative IOP was 23.1 ± 7.5 mmHg. One month postoperatively, the average IOP decreased to 12.1 ± 4.6 mmHg (p < 0.01), which caused a significant increase in the thickness of neuroretinal rim. There was no significant change in the automatically detected BMO-Area (p = 0.32). The pressure-related increase in MRW correlated well with the postoperative IOP and cup-to-disc ratio (CDR). In regression analysis, the alteration in thickness of the neuroretinal rim could be well predicted in a model including CDR, change of IOP and mean deviation (MD) (R2 = 0.414, p < 0.001). RNFL showed a significant increase as well.Conclusion: IOP-lowering surgery in patients with medically uncontrolled POAG causes an increased thickness of the SD-OCT derived ONH parameters. The changes of the RNFL after surgery showed no significant correlations with IOP changes. In contrast to this, highly significant correlations of MRW values with the IOP could be observed. The BMO-Area remained completely stable A preferred use of RNFL for follow-up should be discussed.Keywords: glaucoma, optic nerve head, ONH, OCT, retinal nerve fiber layer, RNFL, Bruch’s membrane opening, BMO

Purpose A close interaction between neurosensory retina and the retinal pigmentepithelium (RPE) is a prerequisite for normal vision. Glaucomatous damage is characterized by neuroretinal degeneration. As a result, an imbalanced interaction exists. However, there is only limited evidence regarding RPE involvement in glaucoma patients' eyes. This study investigates the correlation between retinal nerve fiber layer (RNFL) thickness and RPE alterations as detected by widefield fundus autofluorescence (FAF). Methods Peripapillary RNFL thickness was quantified by optical coherence tomography (OCT). The six corresponding retinal areas were defined by a standardized grid and FAF intensity/irregularities were assessed and correlated to RNFL measurements. Results 84 glaucomatous eyes were investigated. A correlation between RNFL thickness and standardized FAF in the corresponding topographic retina segments was observed. Correlation coefficients ranged between ‐0.12 to 0.35 and were statistically significant in the temporal inferior central field (r=0.35, p=0.02) and the temporal inferior peripheral field (r=0.31, p=0.04). Conclusion This study provides early evidence that in glaucoma RNFL degeneration may be accompanied by corresponding RPE alterations [ABSTRACT FROM AUTHOR]