Determine how procedural treatments for glaucoma have changed between 1994-2012.
Retrospective, observational analysis.
Medicare Part B beneficiaries.
We analyzed Medicare fee-for-service paid claims ...data between 1994-2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year.
Number of glaucoma-related procedures performed.
Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994-2003, but then decreased 48% from 11 018 to 5728 between 2003-2012. Mini-shunts done via an external approach (including ExPRESS Alcon Inc, Fort Worth, TX) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005-2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994-2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994-2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively.
Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure-lowering procedures highlights the need for well-designed clinical trials comparing these procedures.
Although it is a relatively rare disease, primarily found in the Caucasian population, uveal melanoma is the most common primary intraocular tumor in adults with a mean age-adjusted incidence of 5.1 ...cases per million per year. Tumors are located either in iris (4%), ciliary body (6%), or choroid (90%). The host susceptibility factors for uveal melanoma include fair skin, light eye color, inability to tan, ocular or oculodermal melanocytosis, cutaneous or iris or choroidal nevus, and BRCA1-associated protein 1 mutation. Currently, the most widely used first-line treatment options for this malignancy are resection, radiation therapy, and enucleation. There are two main types of radiation therapy: plaque brachytherapy (iodine-125, ruthenium-106, or palladium-103, or cobalt-60) and teletherapy (proton beam, helium ion, or stereotactic radiosurgery using cyber knife, gamma knife, or linear accelerator). The alternative to radiation is enucleation. Although these therapies achieve satisfactory local disease control, long-term survival rate for patients with uveal melanoma remains guarded, with risk for liver metastasis. There have been advances in early diagnosis over the past few years, and with the hope survival rates could improve as smaller tumors are treated. As in many other cancer indications, both early detection and early treatment could be critical for a positive long-term survival outcome in uveal melanoma. These observations call attention to an unmet medical need for the early treatment of small melanocytic lesions or small melanomas in the eye to achieve local disease control and vision preservation with the possibility to prevent metastases and improve overall patient survival.
Objective
To report the surgical excision of an iridociliary adenoma and iridal melanocytoma using a postero‐anterior cyclo‐iridectomy in two dogs.
Procedure
A 7 year old neutered male English ...springer spaniel (case 1) and a 7 year old neutered male Labrador mix (case 2) were presented for evaluation of an intrairidal mass OS.
Results
Complete ophthalmic examination revealed a large, dorsonasal, well‐demarcated, intrairidal mass OS. A tan to pink intrairidal mass extending into the iridocorneal angle (case 1) and a pigmented intrairidal mass (case 2) were present. B‐mode ultrasonography showed a focal, soft tissue, homogenous mass within the uvea adjacent to and contacting the lens. Neither pars plana involvement nor vitreal extension was present. A postero‐anterior cyclo‐iridectomy was performed through a polyhedral scleral flap. Thermocautery was used to complete the cyclo‐iridectomy (case 1) and partial iridectomy (case 2) to excise the mass en bloc. Histopathology revealed a completely excised iridociliary adenoma (case 1) and iris melanocytoma (case 2). The surgery sites healed without complication. Mild uveitis (cases 1 and 2), scant vitreal hemorrhage (case 1), and mild hyphema (case 2) were present three days postoperatively but had resolved ten days postoperatively. The patients remain visual twenty‐two months (case 1) and seven months (case 2) postoperatively with a normal intraocular examination other than an iridal defect and mild dorsonasal lens capsular opacities.
Conclusions
The surgical approach described in these cases is utilized in physician‐based medicine. This approach and the use of thermocautery provide a viable surgical option for excision of large iridociliary tumors in dogs.
Purpose
To evaluate the efficacy of vitrectomy combined with hyaloido‐zonula‐iridectomy from an anterior or a posterior approach in patients with treatment‐resistant aqueous misdirection (chronic ...aqueous misdirection) by systematically reviewing existing literature in combination with presentation of a case series.
Methods
A systematic literature review was performed in PubMed, EMBASE and Cochrane Library databases using search terms: malignant glaucoma, ciliary block, ciliolenticular block and aqueous misdirection. A consecutive series of three pseudophakic patients (5 eyes) diagnosed with chronic aqueous misdirection after cataract surgery is presented.
Results
A literature search identified 31 articles describing treatment of chronic aqueous misdirection with vitrectomy and a hyaloido‐zonula‐iridectomy. Studies, where patients were treated with a complete vitrectomy from pars plana in combination with a hyaloido‐zonula‐iridectomy, reported low relapse rates. Studies describing a surgical approach with vitrectomy performed from the anterior chamber, followed by a hyaloido‐zonula‐iridectomy, also reported low relapse rates except for one reporting relapse in nearly half of the patients. In our case series, a complete vitrectomy combined with a hyaloido‐zonula‐iridectomy resolved the chronic aqueous misdirection in all five eyes after one procedure except one eye where the hyaloido‐zonula‐iridectomy was repeated due to an insufficient opening. Some of the eyes still needed antiglaucomatous treatment due to chronic angle closure.
Conclusion
In treatment‐resistant malignant glaucoma, vitrectomy combined with a hyaloido‐zonula‐iridectomy should be considered performed to ensure communication between the anterior chamber and the vitreous cavity. If the condition has been unresolved for a long time, extensive synechiae of the angle may decrease the success rate due to chronic angle closure.
To examine the efficacy of laser peripheral iridotomy (LPI) in patients who received a diagnosis of primary angle-closure suspect (PACS).
Prospective, randomized controlled trial.
This multicenter, ...randomized controlled trial (ClinicalTrials.gov identifier, NCT00347178) enrolled 480 patients older than 50 years from glaucoma clinics in Singapore with bilateral asymptomatic PACS (defined as having ≥2 quadrants of appositional angle closure on gonioscopy).
Each participant underwent prophylactic LPI in 1 randomly selected eye, whereas the fellow eye served as a control. Patients were followed up yearly for 5 years.
The primary outcome measure was development of primary angle closure (PAC; defined as presence of peripheral anterior synechiae, intraocular pressure IOP of >21 mmHg, or both or acute angle closure AAC) or primary angle-closure glaucoma (PACG) over 5 years.
Of the 480 randomized participants, most were Chinese (92.7%) and were women (75.8%) with mean age of 62.8 ± 6.9 years. Eyes treated with LPI reached the end point less frequently after 5 years (n = 24 5.0%; incidence rate IR, 11.65 per 1000 eye-years) compared with control eyes (n = 45 9.4%; IR, 21.84 per 1000 eye-years; P = 0.001). The adjusted hazard ratio (HR) for progression to PAC was 0.55 (95% confidence interval CI, 0.37-0.83; P = 0.004) in LPI-treated eyes compared with control eyes. Older participants (per year; HR, 1.06; 95% CI, 1.03-1.10; P < 0.001) and eyes with higher baseline IOP (per millimeter of mercury; HR, 1.35; 95% CI, 1.22-1.50; P < 0.0001) were more likely to reach an end point. The number needed to treat to prevent an end point was 22 (95% CI, 12.8-57.5).
In patients with bilateral asymptomatic PACS, eyes that underwent prophylactic LPI reached significantly fewer end points compared with control eyes over 5 years. However, the overall incidence of PAC or PACG was low.
The purpose of this study was to measure intraocular pressure (IOP) elevation while applying standard gonioscopy, selective laser trabeculoplasty (SLT), and laser iridotomy procedural lenses.
Twelve ...cadaver eyes were mounted to a custom apparatus and cannulated with a pressure transducer which measured IOP. The apparatus was mounted to a load cell which measured the force on the eye. Six ophthalmologists performed simulated gonioscopy (Sussman 4 mirror lens), SLT (Latina lens), and laser iridotomy (Abraham lens) while a computer recorded IOP (mm Hg) and force (grams). The main outcome measures were IOP and force applied to the eye globe during ophthalmic diagnostics and procedures.
The average IOP's during gonioscopy, SLT, and laser iridotomy were 43.2 ± 16.9 mm Hg, 39.8 ± 9.9 mm Hg, and 42.7 ± 12.6 mm Hg, respectively. The mean force on the eye for the Sussman, Latina, and Abraham lens was 40.3 ± 26.4 grams, 66.7 ± 29.8 grams, and 65.5 ± 35.9 grams, respectively. The average force applied to the eye by the Sussman lens was significantly lower than both the Latina lens (P = 0.0008) and the Abraham lens (P = 0.001). During gonioscopy indentation, IOP elevated on average to 80.5 ± 22.6 mm Hg. During simulated laser iridotomy tamponade, IOP elevated on average to 82.3 ± 27.2 mm Hg.
In cadaver eyes, the use of standard ophthalmic procedural lenses elevated IOP by approximately 20 mm Hg above baseline.
Identifying primary angle closure suspect (PACS) eyes at risk of angle closure is crucial for its management. However, the risk of progression and its prediction are still understudied in long-term ...longitudinal studies about PACS.
To explore baseline predictors and develop prediction models for the 14-year risk of progression from PACS to primary angle closure (PAC).
This cohort study involved participants from the Zhongshan Angle Closure Prevention trial who had untreated eyes with PACS. Baseline examinations included tonometry, ultrasound A-scan biometry, and anterior segment optical coherence tomography (AS-OCT) under both light and dark conditions. Primary angle closure was defined as peripheral anterior synechiae in 1 or more clock hours, intraocular pressure (IOP) greater than 24 mm Hg, or acute angle closure. Based on baseline covariates, logistic regression models were built to predict the risk of progression from PACS to PAC during 14 years of follow-up.
The analysis included 377 eyes from 377 patients (mean SD patient age at baseline, 58.28 4.71 years; 317 females 84%). By the 14-year follow-up visit, 93 eyes (25%) had progressed from PACS to PAC. In multivariable models, higher IOP (odds ratio OR, 1.14 95% CI, 1.04-1.25 per 1-mm Hg increase), shallower central anterior chamber depth (ACD; OR, 0.81 95% CI, 0.67-0.97 per 0.1-mm increase), and shallower limbal ACD (OR, 0.96 95% CI, 0.93-0.99 per 0.01 increase in peripheral corneal thickness) at baseline were associated with an increased 14-year risk of progression from PACS to PAC. As for AS-OCT measurements, smaller light-room trabecular-iris space area (TISA) at 500 μm from the scleral spur (OR, 0.86 95% CI, 0.77-0.96 per 0.01-mm2 increase), smaller light-room angle recess area (ARA) at 750 μm from the scleral spur (OR, 0.93 95% CI, 0.88-0.98 per 0.01-mm2 increase), and smaller dark-room TISA at 500 μm (OR, 0.89 95% CI, 0.80-0.98 per 0.01-mm2 increase) at baseline were identified as predictors for the 14-year risk of progression. The prediction models based on IOP and central and limbal ACDs showed moderate performance (area under the receiver operating characteristic curve, 0.69; 95% CI, 0.63-0.75) in predicting progression from PACS to PAC, and inclusion of AS-OCT metrics did not improve the model's performance.
This cohort study suggests that higher IOP, shallower central and limbal ACDs, and smaller TISA at 500 μm and light-room ARA at 750 μm may serve as baseline predictors for progression to PAC in PACS eyes. Evaluating these factors can aid in customizing PACS management.
PDF
