Summary Background Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the ...crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment. Methods From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607. Findings Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 SD 0·12), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean intraocular pressure (16·6 SD 3·5 mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events. Interpretation Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment. Funding Medical Research Council.
Glaucoma: now and beyond Jayaram, Hari; Kolko, Miriam; Friedman, David S ...
The Lancet (British edition),
11/2023, Letnik:
402, Številka:
10414
Journal Article
Recenzirano
The glaucomas are a group of conditions leading to irreversible sight loss and characterised by progressive loss of retinal ganglion cells. Although not always elevated, intraocular pressure is the ...only modifiable risk factor demonstrated by large clinical trials. It remains the leading cause of irreversible blindness, but timely treatment to lower intraocular pressure is effective at slowing the rate of vision loss from glaucoma. Methods for lowering intraocular pressure include laser treatments, topical medications, and surgery. Although modern surgical innovations aim to be less invasive, many have been introduced with little supporting evidence from randomised controlled trials. Many cases remain undiagnosed until the advanced stages of disease due to the limitations of screening and poor access to opportunistic case finding. Future research aims to generate evidence for intraocular pressure-independent neuroprotective treatments, personalised treatment through genetic risk profiling, and exploration of potential advanced cellular and gene therapies.
We performed a systematic review to summarize the association of diabetes and blood glucose levels with glaucoma, intraocular pressure (IOP), and ocular hypertension in the general population.
...Diabetes has been proposed as a risk factor for glaucoma, but epidemiologic studies have been inconsistent, and the association is still controversial. Furthermore, no systematic reviews evaluated other metabolic abnormalities, such as the metabolic syndrome, with the risk of glaucoma.
We identified the studies by searching the PubMed and EMBASE databases. We used inverse-variance weighted random-effects models to summarize relative risks across studies.
We identified 47 studies including 2 981 342 individuals from 16 countries. The quality of evidence generally was higher in the cohort compared with case-control or cross-sectional studies. The pooled relative risk for glaucoma comparing patients with diabetes with those without diabetes was 1.48 (95% confidence interval CI, 1.29-1.71), with significant heterogeneity across studies (I(2) = 82.3%; P < 0.001). The risk of glaucoma increased by 5% (95% CI, 1%-9%) for each year since diabetes diagnosis. The pooled average difference in IOP comparing patients with diabetes with those without diabetes was 0.18 mmHg (95% CI, 0.09-0.27; I(2) = 73.2%), whereas the pooled average increase in IOP associated with an increase in 10 mg/dl in fasting glucose was 0.09 mmHg (95% CI, 0.05-0.12; I(2) = 34.8%).
Diabetes, diabetes duration, and fasting glucose levels were associated with a significantly increased risk of glaucoma, and diabetes and fasting glucose levels were associated with slightly higher IOP.
Primary open-angle glaucoma (POAG) is a highly prevalent condition worldwide and the most common cause of irreversible sight loss. The objective is to assess the comparative effectiveness of ...first-line medical treatments in patients with POAG or ocular hypertension through a systematic review and network meta-analysis, and to provide relative rankings of these treatments.
Treatment for POAG currently relies completely on lowering the intraocular pressure (IOP). Although topical drops, lasers, and surgeries can be considered in the initial treatment of glaucoma, most patients elect to start treatment with eye drops.
We included randomized controlled trials (RCTs) that compared a single active topical medication with no treatment/placebo or another single topical medication. We searched CENTRAL, MEDLINE, EMBASE, and the Food and Drug Administration's website. Two individuals independently assessed trial eligibility, abstracted data, and assessed the risk of bias. We performed Bayesian network meta-analyses.
We included 114 RCTs with data from 20 275 participants. The overall risk of bias of the included trials is mixed. The mean reductions (95% credible intervals) in IOP in millimeters of mercury at 3 months ordered from the most to least effective drugs were as follows: bimatoprost 5.61 (4.94; 6.29), latanoprost 4.85 (4.24; 5.46), travoprost 4.83 (4.12; 5.54), levobunolol 4.51 (3.85; 5.24), tafluprost 4.37 (2.94; 5.83), timolol 3.70 (3.16; 4.24), brimonidine 3.59 (2.89; 4.29), carteolol 3.44 (2.42; 4.46), levobetaxolol 2.56 (1.52; 3.62), apraclonidine 2.52 (0.94; 4.11), dorzolamide 2.49 (1.85; 3.13), brinzolamide 2.42 (1.62; 3.23), betaxolol 2.24 (1.59; 2.88), and unoprostone 1.91 (1.15; 2.67).
All active first-line drugs are effective compared with placebo in reducing IOP at 3 months. Bimatoprost, latanoprost, and travoprost are among the most efficacious drugs, although the within-class differences were small and may not be clinically meaningful. All factors, including adverse effects, patient preferences, and cost, should be considered in selecting a drug for a given patient.
Primary angle-closure glaucoma affects 20 million people worldwide. People classified as primary angle closure suspects have a higher but poorly quantified risk of developing glaucoma. We aimed to ...assess efficacy and safety of laser peripheral iridotomy prophylaxis against primary angle-closure glaucoma in Chinese people classified as primary angle closure suspects.
In this randomised controlled trial, bilateral primary angle closure suspects aged 50–70 years were enrolled at the Zhongshan Ophthalmic Center, a tertiary specialised hospital in Guangzhou, China. Eligible patients received laser peripheral iridotomy in one randomly selected eye, with the other remaining untreated. The primary outcome was incident primary angle closure disease as a composite endpoint of elevation of intraocular pressure, peripheral anterior synechiae, or acute angle-closure during 72 months of follow-up in an intention-to-treat analysis between treated eyes and contralateral controls. This trial is registered with the ISRCTN registry, number ISRCTN45213099.
Of 11 991 screened individuals, 889 individuals were randomly assigned from June 19, 2008 (889 treated and 889 untreated eyes). Incidence of the primary outcome was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes (hazard ratio 0·53; 95% CI 0·30–0·92; p=0·024). A primary outcome event occurred in 19 treated eyes and 36 untreated eyes with a statistically significant difference using pair-wise analysis (p=0·0041). No serious adverse events were observed during follow-up.
Incidence of angle-closure disease was very low among individuals classified as primary angle closure suspects identified through community-based screening. Laser peripheral iridotomy had a modest, albeit significant, prophylactic effect. In view of the low incidence rate of outcomes that have no immediate threat to vision, the benefit of prophylactic laser peripheral iridotomy is limited; therefore, widespread prophylactic laser peripheral iridotomy for primary angle-closure suspects is not recommended.
Fight for Sight, the Sun Yat-Sen University 5010 Project Fund, Moorfields Eye Charity, and the National Natural Science Foundation of China.
Assess the impact of false-positives (FP), false-negatives (FN), fixation losses (FL), and test duration (TD) on visual field (VF) reliability at different stages of glaucoma severity.
Retrospective.
...A total of 10 262 VFs from 1538 eyes of 909 subjects with suspect or manifest glaucoma and ≥5 VF examinations.
Predicted mean deviation (MD) was calculated with multilevel modeling of longitudinal data. Differences between predicted and observed MD (ΔMD) were calculated as a reliability measure. The impact of FP, FN, FL, and TD on ΔMD was assessed using multilevel modeling.
ΔMD associated with a 10% increment in FP, FN, and FL, or a 1-minute increase in TD.
FL had little impact on ΔMD (<0.2 decibels dB per 10% abnormal catch trials), and no level of FL produced ≥1 dB of ΔMD at any disease stage. FP yielded greater than expected MD, with a 10% increment in abnormal catch trials associated with a ΔMD = 0.42, 0.73, and 0.66 dB in mild (MD >-6 dB), moderate (-6 ≤MD <-12 dB), and severe (-12 ≤MD ≤-20 dB) disease, respectively, up to 20% abnormal catch trials, and a ΔMD = 1.57, 2.06, and 3.53 dB beyond 20% abnormal catch trials. FNs generally produced observed MDs below expected MDs. FN were minimally impactful up to 20% abnormal catch trials (ΔMD per 10% increment >-0.14 dB at all levels of severity). Beyond 20% abnormal catch trials, each 10% increment in abnormal catch trials was associated with a ΔMD = -1.27, -0.53, and -0.51 dB in mild, moderate, and severe disease, respectively. |ΔMD| ≥1 dB occurred with 22% FP and 26% FN in early, 14% FP and 34% FN in moderate, and 16% FP and 51% FN in severe disease. A 1-minute increment in TD produced ΔMDs between -0.35 and -0.40 dB.
FL have little impact on reliability in patients with established glaucoma. FP, and to a lesser extent FNs and TD, significantly affect reliability. The impact of FP and FN varies with disease severity and over the range of abnormal catch trials. On the basis of our findings, we present evidence-based, severity-specific standards for classifying VF reliability for clinical or research applications.
Abstract Purpose Estimate prevalence of presenting near-vision impairment (PNVI) among people =50years in the United States (US) and examine associations with socio-demographic characteristics. ...Design Cross-sectional study Methods 11016 of 12781 (88.5%) US adults =50 years participated in the National Health and Nutrition Examination Survey (NHANES) between 1999-2008 with recorded near visual acuity. PNVI was defined as presenting near-vision worse than 20/40; functional near-vision impairment (FNVI) was defined as at least “moderate-difficulty” with either reading newsprint or near-work. Prevalence of PNVI and FNVI were estimated accounting for NHANES multistage probability sampling design. Multivariable regression models were used to determine socio-demographic characteristics associated with PNVI. Results 13.6% of participants had PNVI with 25.9% reporting concurrent FNVI. Higher odds of PNVI was associated with non-White race, older-age, male-sex, less than high-school education, lack of private health-insurance, income <poverty level, lacking/not using near-vision correction at time of examination, and impaired distance-vision. While the majority of participants with PNVI (82.9%) had normal distance-vision or uncorrected refractive error, less than half (46.1%) used near-vision correction. Not using near correction was associated with non-White race, younger-age, male-sex and lack of access to healthcare. Conclusions Approximately 1 in 8 Americans =50 years have PNVI with 1 in 4 reporting concurrent FNVI. Demographic factors shown to be important in access to eye-care likely influence PNVI and utilization of near-vision correction in the US. As the majority of PNVI is likely correctable with spectacles, allocation of resources to provide corrective lenses to those in need likely has great public health implications.
Within a surveillance of the prevalence and causes of vision impairment in high-income regions and Central/Eastern Europe, we update figures through 2015 and forecast expected values in 2020.
Based ...on a systematic review of medical literature, prevalence of blindness, moderate and severe vision impairment (MSVI), mild vision impairment and presbyopia was estimated for 1990, 2010, 2015, and 2020.
Age-standardised prevalence of blindness and MSVI for all ages decreased from 1990 to 2015 from 0.26% (0.10-0.46) to 0.15% (0.06-0.26) and from 1.74% (0.76-2.94) to 1.27% (0.55-2.17), respectively. In 2015, the number of individuals affected by blindness, MSVI and mild vision impairment ranged from 70 000, 630 000 and 610 000, respectively, in Australasia to 980 000, 7.46 million and 7.25 million, respectively, in North America and 1.16 million, 9.61 million and 9.47 million, respectively, in Western Europe. In 2015, cataract was the most common cause for blindness, followed by age-related macular degeneration (AMD), glaucoma, uncorrected refractive error, diabetic retinopathy and cornea-related disorders, with declining burden from cataract and AMD over time. Uncorrected refractive error was the leading cause of MSVI.
While continuing to advance control of cataract and AMD as the leading causes of blindness remains a high priority, overcoming barriers to uptake of refractive error services would address approximately half of the MSVI burden. New data on burden of presbyopia identify this entity as an important public health problem in this population. Additional research on better treatments, better implementation with existing tools and ongoing surveillance of the problem is needed.
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