Vision related quality of life and topical glaucoma treatment side effects

Ophthalmic and Glaucoma Treatment Characteristics Associated With Changes in Health-related Quality of Life Before and After Newly Diagnosed Primary Open-angle Glaucoma in Nurses' Health Study Participants

PURPOSE

To identify attributes related to glaucoma diagnosis or early glaucoma treatment patterns that are associated with changes in health-related quality of life among those with newly diagnosed primary open-angle glaucoma.

METHODS

Among Nurses' Health Study participants with incident medical record-confirmed primary open-angle glaucoma diagnosed in 1992 to 2000, we included 317 women who completed the Short Form-36 Health Survey prediagnosis and postdiagnosis. The 2 primary outcomes were 4-year changes (1992 to 1996 or 1996 to 2000) in the physical and mental component summary scores. Multiple regression models were used to estimate differences in score changes by early treatment pattern history and characteristics as of diagnosis (ie, number of eyes affected, history of cataract, macular degeneration, cup-to-disc ratio, intraocular pressure, visual field loss type).

RESULTS

In multivariable models, no ophthalmologic characteristics were associated with physical component score change. However, compared with treatment with eye drops or pills only, laser trabeculoplasty treatment (concomitant with history of treatment with eye drops or pills in 84%) was associated with a worse mental component score change over 4 years (-2.5 units; 95% confidence interval: -4.6, -0.3); this association was stronger with a family history of glaucoma (P-interaction=0.04) or with bilateral disease (P-interaction=0.001).

CONCLUSIONS

Among patients with incident glaucoma, no major factors were associated with change in physical well being. However, compared with medical treatment only, a history of laser trabeculoplasty, which was commonly accompanied with a history of medical treatment and likely represented the need for a second line of treatment, was associated with a worse decline in mental well being.

New prostaglandin analog formulation for glaucoma treatment containing cyclodextrins for improved stability, solubility and ocular tolerance

Latanoprost is a practically insoluble prostaglandin F2α analog considered a first-line agent for glaucoma treatment. From a pharmaceutical point of view, latanoprost is challenging to be formulated as an eye drop due to its poor water solubility and the presence of an ester bond that needs to be cleaved in vivo but maintained unchanged during storage. Cyclodextrins (CDs) are known to form complexes with hydrophobic drugs, influencing their stability, availability, solubility, and tolerance in a non-predictable manner. A variety of CDs including native α, β, and γCDs as well as substituted hydroxypropylβCD, hydroxypropylγCD, dimethylβCD, sulphatedβCD, and propylaminoβCD were screened and the most appropriate CD for the formulation of latanoprost for an ocular topical application was selected. Among the tested CDs, propylaminoβCD had the best trade-off between latanoprost stability and availability, which was confirmed by its complex constant value of 3129M(-1). Phase-solubility and NMR investigations demonstrated that the propylaminoβCD effectively formed a complex involving the ester group of latanoprost providing protection to its ester bond, while ensuring proper latanoprost solubilization. Furthermore, in vivo experiments demonstrated that the latanoprost-propylaminoβCD formulation led to lower ocular irritation than the commercial latanoprost formulation used as a reference. The latanoprost-propylaminoβCD formulation was demonstrated to successfully address the main stability, solubility, and tolerance limitations of topical ocular latanoprost therapy for glaucoma.

Comparison of the ocular surface changes following the use of two different prostaglandin F2α analogues containing benzalkonium chloride or polyquad in rabbit eyes

OBJECTIVE

The aim of this study is to compare the effect of prostaglandin analogues preserved with either 0.015% or 0.001% benzalkoium chloride (BAK); or 0.001% polyquad (PQ) on the ocular surface of rabbit eyes.

METHODS

Forty white rabbits were randomized to receive four-times daily instillation of either 0.0015% tafluprost (TF) preserved with 0.001% BAK (TF-BAK); 0.004% travoprost (TR) with 0.015% BAK (TR-BAK) or 0.001% PQ (TR-PQ); or preservative-free artificial tears in one eye for a 4-week period. Tear samples collected from the 40 rabbits were analyzed by enzyme-linked immunosorbent assays (ELISA) to identify the presence of inflammatory cytokines: interleukin (IL)-1β and IL-6 on day 14. Subsequently, harvested cornea and bulbar conjunctiva were evaluated using light and transmission electron microscopy (TEM).

RESULTS

IL-6 was significantly increased in TF-BAK and TR-BAK groups compared to controls and TR-PQ group (p = 0.005); however, IL-1β level was not significantly different among four groups (p = 0.360). Rabbits treated with TR-BAK showed decreased goblet cell density of bulbar conjunctiva and increased pyknotic change and vacuolization of corneal epithelial cells on light microscopy; similar change occurred but was less severe in TF-BAK group. The TR-PQ group showed similar results as the controls. The destruction of the microvillar architecture of bulbar conjunctiva and cornea was most prominent in the TR-BAK group.

CONCLUSIONS

Preservatives included in the anti-glaucoma eye-drops showed different ocular surface changes according to the concentration and type in the rabbits. Prostaglandin analogues preserved with higher level of BAK may cause more harmful effects on the ocular surface than PQ-preserved medications.

Latanoprost in the treatment of glaucoma

Prostaglandins are approved by the European Glaucoma Society guidelines as first-line treatment for glaucoma. This review focuses on latanoprost, an ester prodrug of prostaglandin (PG) F_2α, which was the first of the currently available topical PGF_2α analogs to be launched for glaucoma or ocular hypertension and which still accounts for the majority of prescriptions. It is better absorbed than the parent compound through the cornea, and peak concentration of the active drug is in the aqueous humor 1–2 hours after topical dosing (15–30 ng/mL). Metabolism occurs mainly in the liver. Latanoprost (0.005%) has been very well studied in clinical trials and meta-analyses that show it to be generally as effective as the other PG analogs (bimatoprost, travoprost, and tafluprost) and more effective than timolol, dorzolamide, and brimonidine. Latanoprost has good short- and long-term safety and tolerability profiles. In common with other prostaglandins, it lacks systemic effects, but can cause ocular adverse events such as conjunctival hyperemia, pigmentation of the iris, periocular skin or eyelashes, hypertrichosis, and ocular surface effects or irritation. Latanoprost is significantly better tolerated than either bimatoprost or travoprost. Patients treated with latanoprost have better compliance and persist with therapy longer than those that are given other drugs. An improved formulation of latanoprost without the preservative benzalkonium chloride has recently been developed. It is as effective as conventional latanoprost, has a lower incidence of hyperemia, and can be stored at room temperature. In conclusion, latanoprost has the best efficacy–tolerability ratio of the PG analogs available for glaucoma treatment, and has good compliance and persistence. These factors should be improved further by the recent development of preservative-free latanoprost.

A randomized control trial to evaluate the effect of adjuvant selective laser trabeculoplasty versus medication alone in primary open-angle glaucoma: preliminary results

Background

The objective of this study was to investigate the effects of adjuvant selective laser trabeculoplasty (SLT) versus medication alone on intraocular pressure (IOP) control, medication use, and quality of life in patients with primary open-angle glaucoma.

Methods

This prospective, randomized control study recruited 41 consecutive primary open-angle glaucoma subjects with medically-controlled IOP ≤21 mmHg. The SLT group (n=22) received a single 360-degree SLT treatment. The medication-only group (n=19) continued with their usual treatment regimen. In both groups, medication was titrated to maintain a target IOP defined as a 25% reduction from baseline IOP without medication, or <18 mmHg, whichever was lower. Outcomes, which were measured at baseline and at 6 months, included the Glaucoma Quality of Life-15 (GQL-15) and Comparison of Ophthalmic Medications for Tolerability (COMTOL) survey scores, IOP, and the number of antiglaucoma medicines.

Results

The baseline IOP was 15.8±2.7 mmHg and 14.5±2.5 mmHg in the SLT and medication-only groups, respectively (P=0.04). Both groups had a comparable number of baseline medication (P=0.2), GQL-15 (P=0.3) and COMTOL scores (P=0.7). At 6 months, the SLT group had a lower IOP (P=0.03) and required fewer medications compared with both baseline (P<0.0001) and with the medication-only group (P=0.02). There was no statistically significant difference in the 6-month GQL-15 or COMTOL score as compared to baseline (P≥0.4) or between the two treatment groups (P≥0.2).

Conclusion

A single session of adjuvant SLT provided further reductions in IOP and medication without substantial changes in quality of life or medication tolerability at 6 months.

Criteria for choosing clinically effective glaucoma treatment: A discussion panel consensus

Abstract.

BACKGROUND

In the clinical management of patients at risk for or diagnosed with primary open-angle glaucoma (POAG), the aim of medical treatment is to reduce intraocular pressure (IOP) and then maintain it over time at a level that preserves both the structure and function of the optic nerve.

OBJECTIVE

The objective of this report was to establish a consensus on the criteria that should be used to determine the characteristics of IOP-lowering medication.

METHODS

Discussion was held among a panel of 12 physicians considered to be experts in glaucoma to develop a consensus on the criteria used by them to determine the characteristics of the IOP-lowering medication chosen for initial monotherapy and adjunctive treatment of ocular hypertension (OHT) or POAG. Consensus development combined available evidence and the impressions of these physicians regarding the clinical effectiveness of IOP-lowering medication for OHT and POAG. Once the panel identified the criteria, the order of priority and the relative importance of these criteria were then established in the setting of 3 risk categories (low, medium, and high) for a patient to experience significant visual disability from glaucoma over their expected life span.

RESULTS

The panel identified 5 criteria to determine the characteristics of IOP-lowering medication for OHT and POAG: IOP-lowering effect, systemic adverse events (AEs), ocular tolerability, compliance/administration, and cost of treatment. IOP-lowering effect was consistently ranked as the highest priority and cost as the lowest. The priority of compliance/administration did not vary by clinical situation. Systemic AEs and ocular tolerability were ranked as higher priorities in initial monotherapy than in adjunctive treatment and ranked lower as the risk for visual disability increased. The priority given to the criteria used to determine clinical effectiveness varied both with the risk for functional vision loss from glaucoma and whether initial monotherapy or adjunctive treatment was being considered.

CONCLUSION

Glaucoma treatment should be assessed with regard to the need not only to lower IOP but also to minimize systemic and ocular AEs, promote patient compliance, and minimize cost. The order of priority and relative importance given to these treatment criteria will vary as part of individualizing patient care.

National Eye Institute Visual Function Questionnaire: usefulness in glaucoma

The National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) is the most commonly used patient-reported outcome measure to assess vision-related quality of life in patients with glaucoma. Glaucoma negatively affects the composite and several NEI-VFQ subscale scores; this effect is correlated with the severity of glaucomatous visual field loss. Contrast sensitivity, glare, and dark adaptation are potential items that could be added to the NEI-VFQ to make it more responsive to changes in vision-related quality of life in patients with glaucoma.

Preservative-free tafluprost in the treatment of naive patients with glaucoma and ocular hypertension

PURPOSE

The study reported here investigated the efficacy, tolerability, and safety of the preservative-free prostaglandin analog tafluprost 0.0015% in treatment-naive patients.

PATIENTS AND METHODS

Data were collected in two non-interventional, prospective, multicenter, observational, open-label studies of identical design that were conducted in Germany and the Czech Republic. All subjects received preservative-free tafluprost 0.0015% once daily. Intraocular pressure (IOP) levels were recorded for each eye at untreated baseline and 3 months after initiation of medical treatment. The primary outcome was change in mean IOP from baseline to month 3. In the primary open-angle glaucoma (POAG) and ocular hypertension (OH) patient subgroups, analyses were stratified by the level of baseline IOP: ≥20 to 23 mmHg versus ≥24 mmHg. In addition, responder rates and the achievement of pre-specified IOP levels at month 3 were evaluated. Local tolerance of preservative-free tafluprost was evaluated by the patients at final visit. Overall satisfaction with the medical treatment was evaluated by both patients and physicians. All adverse events were recorded.

RESULTS

A total of 579 treatment-naive patients with POAG (n = 349), OH (n = 105), normal tension glaucoma (n = 71), exfoliative glaucoma (n = 27), or other glaucomas (n = 27) were included in this observational study. Mean IOP level at baseline for all patients was 23.6 ± 4.0 mmHg. Mean IOP at month 3 was 16.8 ± 2.9 mmHg (-28.8% vs baseline). At month 3, significant reductions in mean IOP (P < 0.001) were seen in all patients and all subgroups. Preservative-free tafluprost lowered mean IOP significantly in patients with POAG and OH with IOP levels ≥ 20 to 23 mmHg from 21.9 ± 1.1 mmHg at baseline to 16.5 ± 2.2 mmHg, and in the subgroup with IOP levels ≥ 24 mmHg from 26.2 ± 2.4 mmHg to 17.9 ± 2.4 mmHg. In the subgroups of patients with POAG and OH, an IOP response ≥20%, ≥30%, and ≥40% was achieved by 83.4%, 44.1%, and 12.8%, respectively. Overall, patients with higher baseline IOP values showed a better response than patients with lower baseline IOP levels. Preservative-free tafluprost was well tolerated and safe. After 3 months, 97.9% of all patients remained on therapy.

CONCLUSION

In this real-world observational study, treatment with once-daily preservative-free tafluprost proved efficacious, well tolerated, and safe in treatment-naive patients.

Comparison of resource utilization in the treatment of open-angle glaucoma between two cities in Finland: is more better?

INTRODUCTION

Glaucoma is a progressive optic neuropathy associated with neural rim loss of the optic disc and the retinal nerve fibre layer typically causing visual field (VF) deterioration. Generally, glaucomatous lesions in the eye and in the visual field progress slowly over the years. In population-based cross-sectional studies, the percentage of unilateral or bilateral visual impairment varied between 3-12%. In screening studies, 0.03-2.4% of patients have been found to suffer visual impairment. Glaucoma has previously been associated with substantial healthcare costs and resource consumption attributable to the treatment of the disease. The disease also causes reduction in health-related quality of life (HRQoL) in patients with glaucoma.

OBJECTIVE AND METHODS

This study compares patients with diagnosed open-angle glaucoma from two geographically different regions in Finland. A total of 168 patients were examined, 85 subjects from an area with higher per patient treatment costs (Oulu) and 83 patients from a region with lower per patient treatment costs (Turku). All patients had a history of continuous glaucoma medication use for a period of 11 years. For each patient, the total direct costs from glaucoma treatment were calculated and the total amount of resource consumption was determined from registries and patient records. Each patient underwent a clinical examination with visual field assessment and fundus photography. These data were used to determine the current stage of disease for each patient. Health-related quality of life questionnaire (15D) was used in determining each patient's subjective HRQoL score.

RESULTS

When applying the current diagnostic criteria for open-angle glaucoma, a total of 40% of patients did not to display any structural or functional damage suggesting glaucoma after 11 years of continuous medical treatment and follow-up. Patients with higher glaucoma stage (worse disease) were found to have statistically higher treatment costs compared with those at lower disease stages. Resource consumption was also greater in the patients in higher glaucoma stage. Patients in the Oulu district consumed more resources, and glaucoma treatment was more expensive than in the Turku area. The total treatment cost in Oulu and Turku was 6010 € and 4452 €, respectively, for the whole 11-year period. There was no statistically significant difference in quality-of-life scores between the two areas. No difference was noted between the higher-spending and lower-spending areas in this respect. However, when the population was analysed as a whole, patients with higher glaucoma stage were found to have lower vision-based 15D scores compared with those at lower disease stages. This observation was made also at both districts independently.

CONCLUSIONS

Major cost source in open-angle glaucoma treatment is medication, up to 74% of annual costs. In addition, it seems that higher resource consumption and higher treatment costs do not increase the patients' HRQoL as assessed by the 15D instrument.

Tear film osmolarity in patients treated for glaucoma or ocular hypertension

PURPOSE

To evaluate tear film osmolarity in patients treated with intraocular pressure-lowering medications.

METHODS

Forty patients treated for glaucoma or ocular hypertension (OHT) were consecutively recruited for the study. Each patient was asked to complete an evaluation of ocular surface disease symptoms, the Ocular Surface Disease Index, and underwent a complete evaluation of the ocular surface including measurement of tear film osmolarity, Schirmer test, tear breakup time (TBUT), and corneal and conjunctival staining.

RESULTS

Twenty-four patients (60%) reported ocular surface disease symptoms. Nineteen patients (47.5%) had a tear osmolarity ≤308 mOsms/L, 11 (27.5%) between 309 and 328 mOsms/L, and 10 (25%) >328 mOsms/L. A tear deficiency was observed in 20 patients (50%). Twenty-seven patients (67.5%) had an abnormal tear quality analyzed with TBUT, and 16 patients (40%) showed positive staining using the Oxford schema. Tear osmolarity was significantly correlated to Ocular Surface Disease Index (r = 0.486; P = 0.002) and TBUT (r = -0.49; P = 0.009). There was a statistically significant correlation between tear osmolarity and the number of drugs (r = 0.409; P = 0.009), the number of instillations (r = 0.405; P = 0.01), and the number of instillations of preserved eye drops (r = 0.629; P < 0.0001). Using the multiple regression method, tear osmolarity remained significantly correlated to the number of instillations of preserved eye drops (P = 0.004).

CONCLUSION

Tear osmolarity was increased in patients treated for glaucoma or OHT, particularly in those using multiple preserved eye drops. The evaluation of the ocular surface of patients treated for glaucoma or OHT may benefit from such analysis, and future trials for new intraocular pressure-lowering eye drops should thus evaluate tear osmolarity.

Controversy: Is Benzalkonium Chloride Necessary in Antiglaucoma Drops?

Medical therapy is the first-line option in glaucoma management, with benzalkonium chloride (BAC) being the most frequently used preservative in antiglaucoma medications. Its use is however, known to be associated with deleterious effects on the ocular surface. This review is an attempt to critically evaluate whether BAC really is indispensable for better bioavailability of antiglaucoma drugs and consequently, better IOP control.

How to cite this article: Louati Y, Shaarawy T. Controversy: Is Benzalkonium Chloride Necessary in Antiglaucoma Drops? J Current Glau Prac 2012;6(3):104-107.

Prevalence and risk factors for ocular surface disease among patients treated over the long term for glaucoma or ocular hypertension

Purpose. To determine the prevalence of ocular surface diseases and identify risk factors in a population of patients receiving antiglaucomatous eyedrops over the long term. Methods. An observational cross-sectional study was designed to investigate ocular surface signs and symptoms using simple clinical tools. An ocular surface disease intensity score was calculated based on 10 questions regarding ocular surface symptoms and signs with a 4-grade scale. Patients were classified into 3 groups (A, B, and C) according to this total score. A multinomial logistic regression was performed in order to identify risk factors for surface disease. Results. In an overall population of 516 patients, 49% belonged to group A, 30% to group B, and 21% to group C. The multivariate analysis showed that the following factors were correlated with the severity of ocular surface disease: patient age, number of daily eyedrops, past topical treatment changes for ocular intolerance (found in the history of 40% of the patients), intraocular pressure (found to be significantly higher in patients with more severe ocular surface disease), and glaucoma severity. Conclusions. Patients treated for primary open-angle glaucoma or ocular hypertension often have ocular surface diseases, more often and more severely in older patients receiving more drugs and presenting with more severe glaucoma. These high prevalence values might therefore have consequences on the burden of the disease in terms of adherence to treatment and quality of life.

[Arguments against pressure-lowering treatment of ocular hypertension. Prophylactic treatment is unnecessary]

The main argument against a pressure-lowering treatment for patients with ocular hypertension (OHT) is the principle of "first do no harm". The imprecision of intraocular pressure (IOP) measurements and the fact that increased IOP is only a risk factor for glaucoma raise major doubts on a clinical definition of OHT. The use of IOP-lowering treatment in the absence of functional or morphological glaucomatous changes should only be initiated if the IOP is very high (>32 mmHg). If the IOP is between 21 and 32 mmHg the glaucoma conversion risk of the individual patient should be estimated. The risk factors as proven in major prospective trials (OHTS/EGPS) should be assessed using the risk calculator. Only patients with a high risk (>13%) of conversion profit from prophylactic IOP-lowering treatment. For all patients with intermediate or low risk of conversion the potential side-effects (local and systemic) of the treatment outweigh the possible benefit, so that the principle of "watchful waiting" is the best for patients with OHT. If morphological or functional progression is observed IOP-lowering treatment should be started immediately.

Nanomedicine for glaucoma: liposomes provide sustained release of latanoprost in the eye

Purpose:

To report the development and therapeutic evaluation of a liposomal nanocarrier for sustained release of latanoprost, in the rabbit eye.

Methods:

We fabricated latanoprost-loaded egg-phosphatidylcholine (EggPC) liposomes using the film hydration technique. The delivery vehicles were nano-sized (Z avg = 109 ± 18 nm), had a narrow poly dispersity index (PDI = 0.19 ± 0.04), and a very high loading efficiency (94% ± 5%). Based on in vitro data, we evaluated this formulation for lowering intraocular pressure (IOP) in rabbit eyes. Following a single subconjunctival injection of the latanoprost loaded formulation, the eyes were clinically monitored and the IOP recorded.

Results:

Latanoprost-loaded EggPC liposomes demonstrated a high drug/lipid mole ratio of 0.181, remained stable for at least 6 months on storage (4°C), and at least 1 month at 25°C. A slow and sustained release of 60% of latanoprost was achieved by 14 days in the in vitro release study. The same formulation demonstrated a greater sustained IOP lowering effect compared with daily administration of topical latanoprost beyond 90 days (4.8 ± 1.5 vs 2.5 ± 0.9 mmHg; P < 0.001). No signs of inflammation were evident in the eyes from slit-lamp examination analysis.

Conclusion:

The loading required for a long-term sustained delivery of latanoprost for up to 90 days in the rabbit eyes was achieved with EggPC liposomes. A single injection of latanoprost-loaded EggPC liposomes can lower the IOP for up to 90 days, with a greater IOP lowering effect than daily topical administration of latanoprost.

Perspectives on Quality of Life in Glaucoma

Chronic diseases are invariably associated with decreased functioning ability of the individual in one form or the other depending upon the system/organ involved. Disability consequent to the disease is the major factor affecting the patient's physical and psychosocial well-being; in other words, the 'Quality of Life (QOL)'. Besides the disease itself, the treatment and its consequences are also major determinants of QOL of the patients. Globally, glaucoma, which is emerging as one of the leading causes of blindness, is one such chronic ophthalmic disease characterized by a progressive loss of visual function and a potential to cause irreversible blindness, if not treated at an early stage. Patients of glaucoma need to take lifelong medications in order to keep their intraocular pressure within limits. It's impact on the daily life of patients cannot be overexpressed and compounded by the fact that it remains asymptomatic for a considerable time after the disease has set in; has led to new imperatives in diagnosis, treatment and epidemiological and outcome studies. Assessment of the debilitating effect of glaucoma and side effects of its treatment on the emotional and physical QOL of the patient is therefore an important criterion for arriving at the treatment regimen. An extensive literature search was done on Pubmed Central, Pubmed and Google Scholar using the keywords 'glaucoma', 'quality of life in glaucoma', 'management in POAG' and 'QOL assessment tools'. Various tools available for the assessment of QOL, and their advantages and limitations have been reviewed in this article.

Ocular surface disease and quality of life in patients with glaucoma

PURPOSE

To investigate the relationship between ocular surface disease and glaucoma-related quality of life (QoL), glaucoma severity, and treatment in patients with open-angle glaucoma.

DESIGN

Cross-sectional study.

METHODS

SETTING

Clinical practice.

STUDY POPULATION

One hundred twenty-four participants-patients with mild (n = 48), moderate (n = 34), or severe (n = 19) glaucoma and 23 controls (glaucoma suspects) not receiving glaucoma treatment-were enrolled. Severity was stratified according to binocular visual field loss. OBSERVED PROCEDURES: Demographic information, the Ocular Surface Disease Index (OSDI), and Glaucoma Quality of Life-15 (GQL-15) questionnaires were administered.

MAIN OUTCOME MEASURES

OSDI score, GQL-15 score, number and type of glaucoma medications, daily dose of benzalkonium chloride (BAK), and visual field indices.

RESULTS

OSDI scores and the number of patients with OSD increased with increasing glaucoma severity (P < .001 and P < .005). GQL-15 scores reflected decreased QoL with increasing glaucoma severity (P < .001). These trends were maintained after sub-stratification for age and sex. On univariate regression OSDI was significantly correlated with GQL-15 summary score, glaucoma severity, multiple topical glaucoma medications, worse eye mean deviation and pattern standard deviation, use of topical beta blockers, topical carbonic anhydrase inhibitors, daily dose of BAK, and glaucoma filtration surgery. On multivariate regression GQL-15 summary score (odds ratio [OR] 4.14, 95% confidence interval [CI] 2.59-6.63, P < .001) and a daily dose of BAK greater than 3 (OR 2.47, 95% CI 1.17-5.21, P = .018) were predictive of OSDI score.

CONCLUSIONS

OSD is more common in patients with increasing glaucoma severity and is associated with poorer glaucoma-related QoL and higher exposure to BAK.

The Surgical Treatment of Neovascular Glaucoma with Ex-PRESS P-50 Miniature Glaucoma Shunt

Surgical treatment for neovascular glaucoma has evolved from cyclodestructive procedures to full-thickness filtration surgery, to trabeculectomy with antifibrosis drugs and glaucoma drainage implant surgery. The choice of a surgical approach may be influenced by several factors, including the stage of the disease. Many surgeons favor drainage implants when the disease is more advanced or when severe inflammation is present, which would be associated with a poorer prognosis if trabeculectomy were chosen. New devices are being developed to allow surgeons increased control with more predictable postoperative results. One such device, the Ex-PRESS™ mini glaucoma shunt, has undergone changes in design and method of insertion making it more appealing for use in patients requiring IOP-lowering surgery. This report highlights the use of Ex-PRESS mini glaucoma shunt in neovascular glaucoma, surgical technique and summarize pertinent literature on the role of this device in glaucoma surgery.

[Corneal sensitivity in patients treated medically for glaucoma or ocular hypertension]

PURPOSE

To evaluate the corneal sensitivity in patients treated with intraocular pressure (IOP)-lowering medications.

INTRODUCTION

Chronic administration of anti-glaucoma drops is associated with numerous tissue changes on the ocular surface. The purpose of this study was to investigate the effect of these medications and their preservative, benzalkonium chloride (BAK), on corneal sensitivity.

PATIENTS AND METHODS

Thirty-nine patients treated for glaucoma or ocular hypertension (OHT) and nine untreated patients were included in this study. Treated patients were divided into three groups according to the daily number of preserved eyedrops (0, 1 and ≥2). Corneal sensitivity was assessed using the Cochet-Bonnet esthesiometer. All patients underwent a complete examination of the ocular surface including Schirmer testing, tear film breakup time (BUT) and corneal and conjunctival fluorescein staining. The Ocular Surface Disease Index (OSDI) questionnaire was used to evaluate symptoms.

RESULTS

Corneal sensitivity was 58.8±2.8mm, 56.2±5.2mm, 50.3±12.5mm and 44.3±13.6mm in untreated patients, in patients treated with none, one and two or more instillations of preserved eyedrops, respectively. Corneal sensitivity in patients treated with preserved eyedrops was significantly lower as compared to untreated patients (P<0.001) and patients treated with preservative-free eyedrops (P=0.012). Corneal sensitivity of patients treated with intraocular pressure-lowering medications was negatively correlated to the number of instillations of preserved eyedrops (r=-0.390 ; P<0.001) as well as to the duration of treatment (R=-0.357 ; P=0.001). BUT and fluorescein staining were significantly altered in treated patients compared to the untreated control group ; however, no significant difference was observed between the treated groups. There was no significant difference for OSDI or Schirmer testing between the various groups.

CONCLUSION

Chronic administration of BAK-containing anti-glaucoma eyedrops appears to alter corneal sensitivity. These results could explain the absence of correlation between clinical signs and symptoms sometimes observed in patients treated for glaucoma or OHT.

Emotional well-being and adjustment to vision loss in later life: a meta-synthesis of qualitative studies

PURPOSE

To review perceived emotional well-being in older people with visual impairment and perceived factors that inhibit/facilitate psychosocial adjustment to vision loss.

METHOD

The databases of MEDLINE, EMBASE, PsycINFO and CINAHL were searched for studies published from January 1980 to December 2010, which recruited older people with irreversible vision loss, and used qualitative methods for both data collection and analysis. Results sections of the papers were synthesised using a thematic-style analysis to identify the emergent and dominant themes.

RESULTS

Seventeen qualitative papers were included in the review, and five main themes emerged from the synthesis: 1) the trauma of an ophthalmic diagnosis, 2) impact of vision loss on daily life, 3) negative impact of visual impairment on psychosocial well-being, 4) factors that inhibit social well-being, and 5) factors that facilitate psychological well-being. We found the response shift model useful for explaining our synthesis.

CONCLUSIONS

Acquired visual impairment can have a significant impact on older people's well-being and make psychosocial adjustment to the condition a major challenge. Acceptance of the condition and a positive attitude facilitate successful psychosocial adjustment to vision loss as well as social support from family, friends and peers who have successfully adjusted to the condition.

Sustained release of an anti-glaucoma drug: demonstration of efficacy of a liposomal formulation in the rabbit eye

Topical medication remains the first line treatment of glaucoma; however, sustained ocular drug delivery via topical administration is difficult to achieve. Most drugs have poor penetration due to the multiple physiological barriers of the eye and are rapidly cleared if applied topically. Currently, daily topical administration for lowering the intra-ocular pressure (IOP), has many limitations, such as poor patient compliance and ocular allergy from repeated drug administration. Poor compliance leads to suboptimal control of IOP and disease progression with eventual blindness. The delivery of drugs in a sustained manner could provide the patient with a more attractive alternative by providing optimal therapeutic dosing, with minimal local toxicity and inconvenience. To investigate this, we incorporated latanoprost into LUVs (large unilamellar vesicles) derived from the liposome of DPPC (di-palmitoyl-phosphatidyl-choline) by the film hydration technique. Relatively high amounts of drug could be incorporated into this vesicle, and the drug resides predominantly in the bilayer. Vesicle stability monitored by size measurement and DSC (differential scanning calorimetry) analysis showed that formulations with a drug/lipid mole ratio of about 10% have good physical stability during storage and release. This formulation demonstrated sustained release of latanoprost in vitro, and then tested for efficacy in 23 rabbits. Subconjunctival injection and topical eye drop administration of the latanoprost/liposomal formulation were compared with conventional daily administration of latanoprost eye drops. The IOP lowering effect with a single subconjunctival injection was shown to be sustained for up to 50 days, and the extent of IOP lowering was comparable to daily eye drop administration. Toxicity and localized inflammation were not observed in any treatment groups. We believe that this is the first demonstration, in vivo, of sustained delivery to the anterior segment of the eye that is safe and efficacious for 50 days.

Ophthalmic preservatives: focus on polyquaternium-1

INTRODUCTION

Ophthalmic preservatives, such as polyquaternium-1 (PQ-1), are critical for the inhibition of growth of microbial contaminants in multi-dose bottles of topical medications. These antimicrobial agents must have a high efficacy against pathogenic organisms, while maintaining a favorable tolerability and safety profile.

AREAS COVERED

This review focuses on the ophthalmic preservative PQ-1. For comparison purposes, the most commonly used preservative, benzalkonium chloride (BAK), is also discussed. This survey focuses primarily on data collected during the past 10 years.

EXPERT OPINION

Effective drug delivery requires more than just an active ingredient that achieves its desired biological effect on end-target tissues. In addition, drugs must be stable in the containers that they are stored in, and must possess minimal undesired local and systemic side effects that can cause patients to decrease their adherence. In addressing these concerns, specifically in topical ophthalmic drops, one must take into account the active ingredients, vehicle components and preservatives. Medications with fewer adverse effects may lead to enhanced adherence to therapy; therefore, the induction of such adverse outcomes must be considered by physicians when treating patients with chronic ocular disease. Although BAK will continue to be used in ophthalmic medications, due to its familiarity and compatibility with a broad range of topical ocular formulations, PQ-1 is certainly a viable alternative in the preservative formulary armamentarium.

[The influence of ocular surface diseases in the management of glaucoma]

INTRODUCTION

The medical treatment of glaucoma is frequently used as a first-line treatment. Often effective, this treatment is administered over the long term. Chronic administration of eye drops is implicated in ocular surface disease. The objective of this study was to determine the prevalence of ocular surface diseases (OSDs) in patients treated for glaucoma or ocular hypertension (OHT) as well as their influence on therapeutic management.

PATIENTS AND METHODS

Eighty-eight patients followed at the Quinze-Vingts National Ophthalmology Hospital for glaucoma or OHT were evaluated. All patients had a complete ocular examination including an evaluation of the ocular surface. A questionnaire derived from the Ocular Surface Disease Index (OSDI) was used to assess ocular surface symptoms and the related impairment of quality of life. According to the clinical evaluation of the ocular surface, patients were classified into three groups (A, no OSD; B, moderate OSD; C, severe OSD. The patients for whom ocular surface disease had modified the therapeutic management of glaucoma were identified.

RESULTS

In this study, 72 patients (82 %) showed significant symptoms of OSDs (OSDI score>22). A moderate or severe OSD was observed in 67 patients (76 %). For 33 patients (38 %), the OSD influenced the choice of glaucoma or OHT treatment. Among these patients, six had glaucoma surgery, one had laser trabeculoplasty, and 26 required one or several changes in eyedrops.

CONCLUSION

This study confirmed the high prevalence of OSDs in patients treated for glaucoma or OHT. For numerous patients, these pathologies influenced not only their quality of life but also their therapeutic management.

A patient preference comparison of Azarga (brinzolamide/timolol fixed combination) vs Cosopt (dorzolamide/timolol fixed combination) in patients with open-angle glaucoma or ocular hypertension

Purpose

To determine patient preference of and ocular discomfort with fixed combination brinzolamide/timolol compared with fixed combination dorzolamide/timolol.

Methods

In a prospective, double-masked, randomized, active-controlled, crossover, multicenter study, patients received 1 drop of brinzolamide/timolol and dorzolamide/timolol in both eyes on consecutive days in random order. Ocular discomfort was rated 1 minute after instillation of each medication, and preference was noted on Day 2. Adverse events, if any, were solicited at each visit.

Results

127 subjects with ocular hypertension or open-angle glaucoma were included in the intent-to-treat analysis. Of the 106 subjects who expressed a drug preference, 79.2% preferred brinzolamide/timolol (p < 0.0001). Ocular discomfort scores were significantly higher with dorzolamide/timolol than brinzolamide/timolol (2.9 vs 1.4, respectively; p < 0.0001). Significantly more patients reported ocular pain and discomfort after dorzolamide/timolol instillation and transient blurred vision after brinzolamide/timolol instillation.

Conclusions

Patients with ocular hypertension or open-angle glaucoma preferred the brinzolamide/timolol fixed combination over the dorzolamide/timolol fixed combination. This is likely due to the greater ocular discomfort associated with dorzolamide/timolol. The differences in preference, discomfort, and adverse events are likely attributable to formulation differences given the similarities of the active ingredients. Stronger patient preference for brinzolamide/timolol may lead to better therapeutic compliance.

Switching patients from preserved prostaglandin-analog monotherapy to preservative-free tafluprost

Purpose:

Efficacy, tolerability and safety of the novel preservative-free prostaglandin tafluprost 0.0015% were investigated for the treatment of patients with glaucoma or ocular hypertension in a clinical setting.

Patients and methods:

Data were collected in a non-interventional, prospective, multi-center, observational, open label study. 118 patients were treated with a prostaglandin analog (PGA) monotherapy (preserved formulations of latanoprost, travoprost or bimatoprost) prior to baseline. Intraocular pressure (IOP) readings were recorded for each eye at baseline (previous therapy), 4–6 weeks, and 12 weeks after changing medical treatment to preservative-free tafluprost once-daily. We analyzed the change in IOP over the study period for all patients as well as for a subgroup of patients with prior PGA monotherapy. Subjective symptoms and objective ocular signs were determined. Comfort was measured using a 4 step scale. All adverse events were recorded. Paired t-tests were conducted to compare IOP values at baseline to IOP values after treatment with tafluprost 0.0015%. Bowker’s test of symmetry was used for statistical evaluation of changes of clinical signs (hyperemia).

Results:

In total 118 patients were eligible for evaluation. In these patients with prior PGA monotherapy (n = 118) IOP decreased significantly from 16.2 ± 4.3 mm Hg (95% CI: 0.55) at treated baseline to 14.8 ± 3.2 mm Hg (95% CI: 0.43; P < 0.001) at final visit on tafluprost. In a subset of patients with prior latanoprost monotherapy (n = 68) mean IOP at baseline (±SD) was reduced from 16.2 ± 4.6 mm Hg (95% CI: 0.77) 14.8 ± 3.1 mm Hg at final visit (95% CI: 0.54, P < 0.001), in patients with prior travoprost monotherapy (n = 32) from 16.2 ± 4.3 mm Hg (95% CI: 1.05) to 14.9 ± 3.3 mm Hg (95% CI: 0.91; P < 0.05) and in patients with prior bimatoprost monotherapy (n = 18) from 16.4 ± 3.5 mm Hg (95% CI: 1.14) to 15.0 ± 3.3 mm Hg (95% CI: 1.14; P = 0.252). Both, objective clinical signs and subjective symptoms improved after changing medication to preservative-free tafluprost until final visit. The number of patients with moderate and severe hyperemia decreased from 51 (43.2%) at baseline to 2 (1.9%) at final visit.

Conclusion:

Preservative-free tafluprost 0.0015% was effective, well tolerated and safe. IOP was controlled effectively and ocular symptoms and clinical signs were improved after changing medication to a monotherapy with preservative-free tafluprost in patients previously treated with a preserved latanoprost, travoprost or bimatoprost monotherapy.

[Managing treatment side effects: the respective roles of the active ingredient and the preservative]

The side effects of glaucoma hypotensive treatments usually remain moderate and limited to local side effects - conjunctival hyperemia, itching, discomfort after instillation - but are very often a leading source of poor compliance to treatment and thereby may decrease its efficacy. Moreover, these symptoms usually reflect progressive and irreversible major ocular surface changes. These ocular surface changes induced by glaucoma eyedrops may include subconjunctival fibrosis, increasing the risk of failure of a further glaucoma surgery. All the components of the hypotensive eye drops, including the active ingredient, the preservatives, and the excipients, may be involved in the occurrence of these side effects. It is therefore important to identify the agents involved and the mechanisms of these side effects, in order to choose a treatment minimizing their risk and the discomfort felt by patients, and therefore increasing the likelihood of good compliance. When available, preservative-free solutions should be considered.

Identification of noncompliant glaucoma patients using Bayesian networks and the Eye-Drop Satisfaction Questionnaire

Objective:

To identify poorly compliant glaucoma patients, using the Eye-Drop Satisfaction Questionnaire (EDSQ).

Methods:

This was an observational cross-sectional study with compliance data collected by an electronic monitoring device. Patients with primary open-angle glaucoma or ocular hypertension completed the EDSQ, a six-dimension self-reported questionnaire addressing “treatment concern”, “disease concern”, “patient–clinician relationship”, “positive beliefs”, “treatment convenience”, and “self-declared compliance”. A Bayesian network (BN) was applied to explore compliance associations with EDSQ.

Results:

Among 169 patients who completed the EDSQ, 113 had valid Travalert® data, of whom 25 (22.1%) demonstrated low compliance. All six EDSQ dimensions were associated directly, or indirectly, with compliance. Two profiles exhibited low compliance, ie, patients aged younger than 77.5 years with a poor patient–physician relationship and self-declared poor compliance and patients aged older than 77.5 years with a poor patient–physician relationship and self-declared good compliance. The third profile showed high compliance, ie, patients aged younger than 77.5 years with a good patient-physician relationship and self-declared good compliance.

Conclusion:

Our results confirm a central role for the patient–physician relationship in the compliance process. Age, self-declared compliance, and patient satisfaction with the patient–physician relationship are all dimensions worth exploring before glaucoma medication is switched or proceeding to laser treatment or surgery.

Efficacy and patient tolerability of travoprost BAK-free solution in patients with open-angle glaucoma and ocular hypertension

The medical treatment of glaucoma has evolved significantly over the past several decades. The main driving forces behind this evolution are the safety profiles and efficacy of these medications. Prostaglandin (PG) analogues are shown to be superior to older drugs in both efficacy and tolerability. Though there are much fewer side effects that manifest after using PG analogues, the adherence and compliance to medication regimens are surprisingly lower than expected. A commonly sited reason is the ocular irritation and inflammation with these medications. Much of this inflammation can be attributed to the preservative, benzalkonium chloride (BAK). The chronic clinical and subclinical inflammation becomes increasingly detrimental when filtration surgery fails from bleb fibrosis secondary to this hypercellularity. A BAK-free formulation of a PG analogues recently became available. BAK-free travoprost is reviewed here. It has demonstrated equal efficacy and less ocular surface toxicity than its preserved counterparts. It is expected to serve as an instrumental resource in managing ocular hypertension and glaucoma in patients who demonstrate significant sensitivity to BAK. More randomized, controlled, double-blind studies are encouraged to evaluate its improved safety and tolerability.

IOP-lowering efficacy and tolerability of preservative-free tafluprost 0.0015% among patients with ocular hypertension or glaucoma

OBJECTIVE

Tafluprost, the first preservative-free prostaglandin analogue for topical ophthalmic use to lower IOP, was introduced in Germany in 2008. After the approval for ophthalmic use, an open-label, multicentre, observational study was conducted between October 2008 and April 2009. Major objectives of this study were to evaluate the real world efficacy, local tolerability and safety of this first in class preservative-free prostaglandin preparation in patients with ocular hypertension and glaucoma.

METHODS

A total of 544 patients were treated with the preservative-free formulation of tafluprost 0.0015%. The majority of these patients had poor IOP control and/or poor local tolerance of their medication prior change of medication. The decision to change the previous therapy or to initiate treatment was made solely by the participating ophthalmologists. IOP readings were recorded at baseline before changing medication or initiating treatment in newly diagnosed patients, 4-6 weeks and 12 weeks after change of medication or initiation of treatment with preservative-free tafluprost. In addition, patient demographics, subjective symptoms (i.e. burning, foreign body sensation, itching and stinging) and objective clinical signs such as conjunctival hyperaemia were collected. Subjective symptoms were evaluated using a 4 point scale ranging from 'no symptoms', 'mild symptoms', 'moderate symptoms' to 'severe symptoms'. As a clinical sign severity of conjunctival hyperaemia was evaluated. All adverse events were collected.

RESULTS

Three hundred and sixty patients were switched from monotherapy, 45 patients were naïve to treatment. A total of 139 patients were treated with fixed or non-fixed combinations prior to changing medication. In these patients preservative-free tafluprost was used either as a substitution for the fixed or non-fixed combination, as an add-on to the existing combination therapy or as one agent in a newly initiated treatment regimen. Preservative-free tafluprost provided an IOP decrease in most pre-treatment subgroups, with an overall reduction of IOP in all patients (N = 544) from 19.4 +/- 5.0 mmHg at baseline to 15.7 +/- 4.1 mmHg after 4 to 6 weeks and to 15.3 +/- 3.5 mmHg after 12 weeks. Both values were significantly lower than treated baseline IOP (p < 0.001). An IOP of <or=18 mmHg was achieved in 79.5% of eyes treated with the preservative-free formulation of tafluprost 12 weeks after changing medication. Both subjective symptoms and objective clinical signs improved after changing medication. Only a few adverse events occurred during the follow-up period.

CONCLUSIONS

Although this study was limited by its observational design, the results demonstrate that preservative-free tafluprost is an effective, well tolerated, and safe medication in a patient population with poor IOP control and/or tolerability issues with their medication prior used.

Sensitive and real-time method for evaluating corneal barrier considering tear flow

We developed a new electrophysiological method mimicking tear flow to evaluate the epithelial tight junction of rabbit cornea quantitatively. We investigated the effect of tear flow on the corneal damage induced by ophthalmic preservatives using this method. An Ussing chamber system with Ag/AgCl electrodes was used in the electrophysiological experiment. The excised rabbit cornea was mounted in the Ussing chamber and the precorneal solution in the chamber was perfused with a peristaltic pump at the rate of human tear flow. Corneal transepithelial electrical resistance (TEER) was monitored as corneal barrier ability. In the electrophysiological method mimicking tear flow, we observed stable TEER, which rapidly decreased with benzalkonium chloride (BAC), an eye drop preservative. Using this system, we first found that 0.004% BAC decreased corneal TEER reversibly. A high concentration of BAC showed strong irreversible damage to the tight junction. The influence of BAC on corneal TEER was not only concentration-dependent but also tear flow rate-dependent. The electrophysiological method mimicking tear flow was useful to evaluate the corneal barrier quantitatively. Using this method, we clarified that the tear flow was important to protect the corneal damage induced by preservatives.

[Treatment of glaucoma in patients with dry eye syndrome]

The treatments of glaucoma or ocular hypertension are associated with numerous ocular surface changes. Similarly, these ocular surface modifications directly impact the effectiveness of these therapies. The management of patients with glaucoma or ocular hypertension also suffering from dry eye syndrome needs to reduce eye drop-induced toxicity as well as a specific treatment for the ocular surface.

Preservatives in eyedrops: the good, the bad and the ugly

There is a large body of evidence from experimental and clinical studies showing that the long-term use of topical drugs may induce ocular surface changes, causing ocular discomfort, tear film instability, conjunctival inflammation, subconjunctival fibrosis, epithelial apoptosis, corneal surface impairment, and the potential risk of failure for further glaucoma surgery. Subclinical inflammation has also been described in patients receiving antiglaucoma treatments for long periods of time. However, the mechanisms involved, i.e., allergic, toxic, or inflammatory, as well as the respective roles of the active compound and the preservative in inducing the toxic and/or proinflammatory effects of ophthalmic solutions, is still being debated. The most frequently used preservative, benzalkonium chloride (BAK), has consistently demonstrated its toxic effects in laboratory, experimental, and clinical studies. As a quaternary ammonium, this compound has been shown to cause tear film instability, loss of goblet cells, conjunctival squamous metaplasia and apoptosis, disruption of the corneal epithelium barrier, and damage to deeper ocular tissues. The mechanisms causing these effects have not been fully elucidated, although the involvement of immunoinflammatory reactions with the release of proinflammatory cytokines, apoptosis, oxidative stress, as well as direct interactions with the lipid components of the tear film and cell membranes have been well established. Preservative-induced adverse effects are therefore far from being restricted to only allergic reactions, and side effects are often very difficult to identify because they mostly occur in a delayed or poorly specific manner. Care should therefore be taken to avoid the long-term use of preservatives, otherwise a less toxic alternative to BAK should be developed, as this weakly allergenic but highly toxic compound exerts dose- and time-dependent effects. On the basis of all these experimental and clinical reports, it would be advisable to use benzalkonium-free solutions whenever possible, especially in patients with the greatest exposure to high doses or prolonged treatments, in those suffering from preexisting or concomitant ocular surface diseases, and those experiencing side effects related to the ocular surface. Indeed, mild symptoms should not be underestimated, neglected, or denied, because they may very well be the apparent manifestations of more severe, potentially threatening subclinical reactions that may later cause major concerns.

Detrimental effect of preservatives in eyedrops: implications for the treatment of glaucoma

Antiglaucoma medications are often associated with ocular adverse reactions such as dry eye, and burning or stinging sensations. These undesirable effects may lead to treatment discontinuation and reduced quality of life in patients with glaucoma. Antiglaucoma medications usually contain benzalkonium chloride (BAK) as a preservative. Animal studies, in vitro studies and in vivo experiments have demonstrated various adverse effects of BAK. Clinical studies have also shown an increased incidence of adverse events with BAK and have demonstrated that the withdrawal of preservatives reduces these effects. Collectively, these data suggest that preservative-free antiglaucoma treatments have clinically relevant benefits for patients.

Development of the conceptual framework for the Eye-Drop Satisfaction Questionnaire (EDSQ) in glaucoma using a qualitative study

Background

Compliance is a major issue in glaucoma care. It is usually poor in glaucomatous patients, and may ultimately result in an acceleration of the disease progression and a risk of blindness. Reasons for this poor compliance are complex and multifactorial, amongst which patient satisfaction can be counted. The objective of this study was to develop a questionnaire to assess patient satisfaction and compliance with eye-drop treatment.

Methods

A qualitative study was carried out to develop the questionnaire. An interview guide was developed based on a literature review. Structured interviews of fifteen French and English patients with primary open-angle glaucoma or intraocular hypertension were conducted by trained interviewers of the native language of the interviewees. General concepts and subconcepts were identified from the transcripts. The questionnaire was developed using the patient verbatim, and submitted to six patients (French and English) for cognitive debriefing. Following patients' comments, items were modified and restructured, and a pilot questionnaire was designed.

Results

Analysis of data from the interviews with patients and clinicians resulted in the elicitation of concepts related to patient satisfaction and compliance with glaucomatous treatment. These were further refined and used to generate a test questionnaire, which consisted of 46 items grouped into 6 domains: patient characteristics, treatment characteristics, patient-clinician relationship, patient experience with the disease and the treatment, interaction between the patient and the treatment, and patient knowledge of the disease and the treatment.

Conclusion

The Eye-Drop Satisfaction Questionnaire (EDSQ) conceptual framework and items were developed simultaneously in French and in English. This questionnaire could be used to evaluate patient satisfaction and compliance with eye-drop treatment and would facilitate the identification of patients at risk of being non-compliant prior to clinical trials or innovative device tests. A psychometric study is under way to validate the questionnaire.

Prostaglandin analogues for the treatment of glaucoma and ocular hypertension: a systematic review of economic evidence

We conducted a systematic review of economic studies of prostaglandin analogues for the treatment of glaucoma to assess the scope of current cost-effectiveness evidence and its relevance to decision-makers. The literature search retrieved 102 studies published before July 2005; after additional hand searching of conference proceedings, 13 full-text articles and 13 abstracts met the inclusion criteria. The reviewers extracted the key characteristics of each of the economic evaluations, and all studies received a grade in five categories to summarise the quality of the study: methodology, transparency, sensitivity, relevance and overall score. The current economic literature is predominantly focused on identifying the short-term direct cost of glaucoma treatment, particularly the precise quantification of glaucoma drug costs. Using the European and US treatment guidelines as a benchmark, it is evident that the current body of literature does not satisfy the needs of decision-makers, although certain studies provide some valuable information, which is a step towards reaching this goal. The main methodological issue in the economic models is an absence of a clinically relevant long-term effectiveness measure, or where this measure is produced, there is a lack of transparency and validation of the methods used. More attention needs to be given to modelling the consequences of treatment, and those consequences should include patient compliance, control of intraocular pressure and progression of visual field deficit, since these drive both the costs and the overall outcomes. We recognise that constructing the 'ideal' clinical outcome measure represents a major challenge to researchers. As such, we have outlined a modelling framework that could be used to produce the required level of economic evidence, and ongoing clinical research (such as the Early Manifest Glaucoma Trial) could provide the validated link between intraocular pressure and disease progression, which forms an essential part of such models.

The glaucoma research foundation patient survey: patient understanding of glaucoma and its treatment

PURPOSE

Determine patients' understanding of glaucoma and its treatment, their sources of information about glaucoma, their preferences for treatment, their experience with medication side effects, and their reasons for changing eye doctors.

DESIGN

Prospective, nonrandomized patient survey study.

METHODS

A questionnaire was developed and sent to the 22,000 subscribers of the Gleams newsletter who have glaucoma.

RESULTS

Questionnaires were returned by 4310 glaucoma patients. Most respondents received glaucoma information from their eye doctor. Only 28% of respondents reported having changed eye doctors for reasons related to their glaucoma. Of those who had, 60% cited poor communication as the reason. When queried about specific side effects associated with their medication, over 85% of responding patients were never or rarely bothered by headaches and eyelid darkening. Most respondents (67% and 55%, respectively) were rarely or never disturbed by red eye or burning and stinging. Most respondents understood the importance of intraocular pressure (IOP) lowering in glaucoma, and of those patients who expressed a preference, 92% reported that they would prefer the medication that lowers IOP the most, even if it caused red eye for a few weeks, over a medication that caused no red eye but did not get IOP as low.

CONCLUSIONS

Patients who subscribe to Gleams and responded to the survey rely most on their doctors for information about glaucoma and its treatment. Most understand the importance of maintaining low IOP to decrease the risk of vision loss, and most will tolerate temporary ocular side effects to achieve low IOP.

What do glaucoma specialists know about their patients?

BACKGROUND

Although interaction between doctor and patient is undoubtedly influenced by their mutual expectations, little information is available about the knowledge and expectations of glaucoma doctors concerning their patients' attitudes and treatment patterns. The aim of our prospective study was to compare the actual responses of glaucoma patients concerning various issues related to their disease and the responses the glaucoma doctors expected their patients to give.

METHODS

Glaucoma patients consecutively sent to our glaucoma centre were asked to complete a standardised questionnaire about their glaucoma history, treatment routines and opinions on issues related to glaucoma. Ophthalmologists at the glaucoma centre were asked to predict patients' answers.

RESULTS

One hundred and twenty-eight consecutive glaucoma patients completed the patients' questionnaire and 12 glaucoma specialists completed the corresponding questionnaire for doctors. Frequency of intraocular pressure (IOP) measurements and visual field testing, as well as the number of topical medications, were relatively accurately predicted by the glaucoma doctors. Differences between the doctors' predictions and patients' responses were found concerning discomfort after surgery and the influence of stress or environmental factors on IOP. The largest range of doctors' predictions (0-100%) was observed concerning the portion of patients claiming a 100% adherence to glaucoma medication.

CONCLUSION

Glaucoma specialists are familiar with the treatment patterns of their patients. The knowledge of glaucoma specialists of their patients' subjective attitudes to glaucoma-related issues deserves further investigation, as discrepancies between doctors' and patients' responses were observed in this area.

A Three-Month, Multicenter, Double-Masked Study of the Safety and Efficacy of Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution Compared to Travoprost 0.004% Ophthalmic Solution and Timolol 0.5% Dosed Concomitantly in Subjects With Open Angle Glaucoma or Ocular Hypertension

PURPOSE

The primary objective of this study was to compare the intraocular pressure (IOP)-lowering efficacy of travoprost 0.004%/timolol 0.5% fixed combination to the concomitant administration of travoprost 0.004% (TRAVATAN) and timolol 0.5% in subjects with open angle glaucoma or ocular hypertension.

METHODS

This was a randomized, multicenter, double-masked, active-controlled, parallel group study. Three hundred sixteen patients with open angle glaucoma or ocular hypertension were randomly assigned to travoprost 0.004%/timolol 0.5% ophthalmic solution fixed combination once daily in the morning or concomitant administration of timolol 0.5% once daily in the morning and travoprost 0.004% ophthalmic solution once daily in the evening. The efficacy and safety of the fixed combination were compared with concomitant therapy over three months. The primary efficacy outcome measure was mean intraocular pressure.

RESULTS

Both travoprost 0.004%/timolol 0.5% fixed combination and the concomitant administration of travoprost 0.004% and timolol 0.5% produced statistically significant reductions from baseline in IOP, with mean IOP ranging from 15.2 to 16.5 mm Hg in the patients using travoprost 0.004%/timolol 0.5% fixed combination compared with 14.7 to 16.1 mm Hg in the concomitant group. The upper 95.1% confidence limit for the differences in mean IOP (fixed combination minus concomitant) was < or =1.5 mm Hg at 7 of 9 visits, including all three 8 AM time points, 24-hours post-dose. Mean IOP reductions from baseline ranged from 7.4 to 9.4 mm Hg in the fixed combination group compared with 8.4 to 9.4 mm Hg with concomitant therapy. Safety analysis demonstrated equivalent safety between the two treatment groups.

CONCLUSIONS

A fixed combination of travoprost 0.004% and timolol 0.5% produced clinically relevant IOP reductions in patients with open angle glaucoma or ocular hypertension that were comparable to concomitant therapy with its components. Safety and tolerability of the fixed combination were also equivalent to concomitant therapy. Travoprost 0.004%/timolol 0.5% fixed combination offers IOP reduction equivalent to concomitant therapy, with potential benefits that include convenience (fewer bottles and drops per day), improved compliance, cost savings (based on fewer co-payments), and elimination of potential washout effects.

Treatment and vision-related quality of life in the early manifest glaucoma trial

PURPOSE

To evaluate the effect of treatment, visual function, and other factors on vision-targeted health-related quality of life (HRQOL) of patients with early glaucoma.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Two hundred fifty-five patients with newly detected open-angle glaucoma and repeatable early visual field (VF) defects, 50 to 80 years old (66% female).

METHODS

Patients were randomized to receive either betaxolol plus laser trabeculoplasty in eligible eye(s) or no initial treatment and had ophthalmologic examinations every 3 months. A Swedish translation of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was self-administered at 2 follow-up visits (3 and 6 years after randomization).

MAIN OUTCOME

Multiple linear regression analyses determined the effect of treatment and other factors on (1) VFQ-25 composite scores at the first administration and (2) change in scores between administrations.

RESULTS

Two hundred thirty-three patients had 1 NEI VFQ-25 administration and 167 patients had 2 administrations. Internal consistency reliability was high for the composite VFQ-25 score (Cronbach alpha = 0.88) and satisfactory (alpha> or =0.76) for most subscale scores. At the first administration, the composite score was high (88.8+/-11.7). Mean subscale scores were also generally high (98.0-58.3) and were similar for each study group when analyzed separately. Most lower subscale scores were modestly but significantly related to worse visual acuity (VA) or mean deviation (MD) (better eye, r = 0.15-0.35). Composite scores were similar for treated and untreated patients. Lower composite scores were associated with low VA in the better eye (worse than 0.70) and worse perimetric MD (<4.16 decibels) and nuclear lens opacities (Lens Opacities Classification System II grade > or = 2), but not with age, gender, VF progression, intraocular pressure, cardiovascular disease, or hypertension. Between VFQ-25 administrations, larger decreases in the composite score were associated with larger decreases in VA (P<0.05), female gender (P = 0.001), and older age at first administration (P = 0.006). Treatment (assigned at randomization or later in the study) was not associated with change in HRQOL.

CONCLUSIONS

Results suggest that absence or delay of treatment did not influence vision-targeted HRQOL in these newly diagnosed glaucoma patients. However, visual function affected vision-targeted quality of life up to 6 years after Early Manifest Glaucoma Trial enrollment.

Central visual function and the NEI-VFQ-25 near and distance activities subscale scores in people with type 1 and 2 diabetes

PURPOSE

To investigate relationships between clinical measures of central visual function and NEI-VFQ-25 Near and Distance Activities subscales in patients with diabetic retinopathy.

DESIGN

Clinic-based, cross-sectional, observational study.

METHODS

The NEI-VFQ-25 was administered to 170 people with type 1 or 2 diabetes before an ocular examination that included visual acuity, contrast sensitivity, and central visual fields. Multiple linear regression and exact multiple logistic regression were used to assess the relationship between poor acuity (<69 letters), poor contrast sensitivity (<1.5 log units), and abnormal visual fields (mean deviation < or = -5dB) and NEI-VFQ-25 subscale scores.

RESULTS

Final multivariable linear models explained a beta = 4.7 letter difference (P < or = .001) for each 25-point Near Activities subscale score difference. Similar effects were observed for the Distance Activities subscale, although the magnitudes of regression and partial correlation coefficients were lower (beta = 3.3 letters, P < or = .01). Final logistic regression models on abnormal clinical categories of central visual function demonstrated relationships only with the Near Activities subscale. For a 1-point change in Near Activities subscale score, the odds of obtaining a poor score for visual acuity, central visual fields, and contrast sensitivity changed by 0.08 (P < or = .001), 0.07 (P < or = .05), and 0.12 (P < or = .001), respectively.

CONCLUSIONS

NEI-VFQ-25 Near and Distance Activities subscales demonstrate utility as measures of central visual function in persons with type 1 or 2 diabetes. Low scores on the NEI-VFQ-25 may reflect poor central visual fields and contrast sensitivity in addition to poor visual acuity.