Baseline Characteristics of Participants in the Treatment of Advanced Glaucoma Study: A Multicenter Randomized Controlled Trial

Effects of socioeconomic status on baseline values and outcomes at 24 months in the Treatment of Advanced Glaucoma Study randomised controlled Trial

BACKGROUND/AIMS

Socioeconomic status (SES) is associated with late disease presentation and poorer outcomes. We evaluate the effect of SES on treatment outcomes and report the correlation between SES and baseline characteristics of participants in the Treatment of Advanced Glaucoma Study.

METHODS

Pragmatic multicentre randomised controlled trial. Four hundred and fifty-three patients presenting with advanced open-angle glaucoma in at least one eye (Hodapp-Parrish-Anderson classification). Participants were randomised to either glaucoma drops (medical arm) or trabeculectomy (surgery arm). Clinical characteristics, Quality of life measurement (QoL) and SES defined by the Index of Multiple Deprivation are reported. Subgroup analysis explored treatment effect modifications of SES at 24 months. Correlation between SES and baseline characteristics was tested with the χ2 test of association for dichotomous variables and pairwise Pearson's correlation for continuous variables.

RESULTS

The mean visual field mean deviation was -17.2 (6.7)dB for the most deprived quintile of participants and -13.0 (5.5) for the least deprived quintile in the index eye. At diagnosis, there was a strong correlation between SES and ethnicity, age, extent of visual field loss and number of visits to opticians prior to diagnosis. At 24 months, there was no evidence that the treatment effect was moderated by SES.

CONCLUSIONS

In patients presenting with advanced glaucoma. SES at baseline is correlated with poorer visual function, poorer Visual Function Questionnaire-25 QoL, ethnicity, age and number visits to an optician in the years preceding diagnosis. SES at baseline does not have an effect of the success of treatment at 24 months.

TRIAL REGISTRATION NUMBER

ISRCTN56878850.

Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study

PURPOSE

To determine whether primary trabeculectomy or medical treatment produces better outcomes in terms of quality of life (QoL), clinical effectiveness, and safety in patients with advanced glaucoma.

DESIGN

Multicenter randomized controlled trial.

PARTICIPANTS

Between June 3, 2014, and May 31, 2017, 453 adults with newly diagnosed advanced open-angle glaucoma in at least 1 eye (Hodapp classification) were recruited from 27 secondary care glaucoma departments in the United Kingdom. Two hundred twenty-seven were allocated to trabeculectomy, and 226 were allocated medical management.

METHODS

Participants were randomized on a 1:1 basis to have either mitomycin C-augmented trabeculectomy or escalating medical management with intraocular pressure (IOP)-reducing drops as the primary intervention and were followed up for 5 years.

MAIN OUTCOME MEASURES

The primary outcome was vision-specific QoL measured with the 25-item Visual Function Questionnaire (VFQ-25) at 5 years. Secondary outcomes were general health status, glaucoma-related QoL, clinical effectiveness (IOP, visual field, and visual acuity), and safety.

RESULTS

At 5 years, the mean ± standard deviation VFQ-25 scores in the trabeculectomy and medication arms were 83.3 ± 15.5 and 81.3 ± 17.5, respectively, and the mean difference was 1.01 (95% confidence interval [CI], -1.99 to 4.00; P = 0.51). The mean IOPs were 12.07 ± 5.18 mmHg and 14.76 ± 4.14 mmHg, respectively, and the mean difference was -2.56 (95% CI, -3.80 to -1.32; P < 0.001). Glaucoma severity measured with visual field mean deviation were -14.30 ± 7.14 dB and -16.74 ± 6.78 dB, respectively, with a mean difference of 1.87 (95% CI, 0.87-2.87 dB; P < 0.001). Safety events occurred in 115 (52.2%) of patients in the trabeculectomy arm and 124 (57.9%) of patients in the medication arm (relative risk, 0.92; 95% CI, 0.72-1.19; P = 0.54). Serious adverse events were rare.

CONCLUSIONS

At 5 years, the Treatment of Advanced Glaucoma Study demonstrated that primary trabeculectomy surgery is more effective in lowering IOP and preventing disease progression than primary medical treatment in patients with advanced disease and has a similar safety profile.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Two-Year Visual Field Outcomes of the Treatment of Advanced Glaucoma Study (TAGS)

PURPOSE

to compare visual field (VF) progression between the 2 arms of the Treatment of Advanced Glaucoma Study (TAGS).

DESIGN

Post hoc analysis of VF data from a 2-arm, multicenter, randomized controlled clinical trial.

METHODS

A total of 453 patients with newly diagnosed advanced open-angle glaucoma in at least 1 eye from 27 centers in the United Kingdom were randomized to either trabeculectomy (n = 227) or medication in their index eye (n = 226) and followed-up for 2 years with 2 24-2 VF tests at baseline, 4, 12, and 24 months. Data were analyzed for participants with a reliable VF (false positive rate < 15%) at baseline and at least 2 other time points. Average difference in rate of progression (RoP) was analyzed using a hierarchical Bayesian model. Time for each eye to progress from baseline beyond specific cut-offs (0.5, 1, 1.5, and 2 dB) was compared using survival analysis.

RESULTS

This study analyzed 211 eyes in the trabeculectomy first arm and 203 eyes in the medication first arm. The average RoP (estimate [95% credible intervals]) was -0.59 [-0.88, -0.31] dB/year in the medication first arm and -0.40 [-0.67, -0.13] dB/year in the trabeculectomy first arm. The difference was not significant (Bayesian P-value = .353). More eyes progressed in the medication first arm, but this difference was not significant.

CONCLUSIONS

There was no significant difference in the average RoP at 2 years.

Long-term Intraocular Pressure Fluctuation Is a Risk Factor for Visual Field Progression in Advanced Glaucoma

PRCIS

Intraocular pressure (IOP) fluctuations increase the risk of visual field progression of primary open-angle glaucoma (POAG) in the advanced stage even when IOP is maintained low on average.

PURPOSE

The purpose of this study was to identify risk factors associated with the progression of visual field defect in patients with advanced POAG.

MATERIALS AND METHODS

A retrospective review of medical records was conducted to identify patients who met the Hodapp-Parrish-Anderson criteria for advanced POAG. A total of 122 eyes of 122 patients had undergone IOP measurement with Goldmann applanation tonometer, standard automated perimetry, Cirrus optical coherence tomography, and fundus photography at 6-month intervals. Visual field progression was defined as the deterioration of a minimum of 3 visual field locations more than baseline at 5% levels in 4 consecutive visual fields with 24-2 SITA testing.

RESULTS

Thirty-six eyes of 122 eyes (29.5%, 51.9±13.9 y old) showed visual field progression during 100.7±44.2 months of follow-up. The progression group showed greater long-term IOP fluctuations (2.6±1.4 mm Hg) than the no progression group (53.5±13.5 y; 2.0±1.0 mm Hg, P=0.008). Disc hemorrhage was detected more frequently in the progression group (40.5% vs. 17.4%, P=0.005). Multivariate Cox regression analysis revealed long-term IOP fluctuations [hazard ratio (HR)=2.567, 95% confidence interval (CI): 1.327-5.370, P=0.012] and disc hemorrhage (HR=2.351, 95% CI: 1.120-4.931, P=0.024) to be independent risk factors of visual field progression. Patients who showed both disc hemorrhage and long-term IOP fluctuations were at greater risks of progression (HR=2.675, 95% CI: 1.072-6.457, P=0.035).

CONCLUSIONS

Long-term IOP fluctuations and disc hemorrhage are independent and additive risk factors of visual field progression in advanced glaucoma even at low IOPs. Patients in whom these risk factors are identified require close monitoring and vigorous treatment.

Primary trabeculectomy versus primary glaucoma eye drops for newly diagnosed advanced glaucoma: TAGS RCT

BACKGROUND

Patients diagnosed with advanced primary open-angle glaucoma are at a high risk of lifetime blindness. Uncertainty exists about whether primary medical management (glaucoma eye drops) or primary surgical treatment (augmented trabeculectomy) provide the best and safest patient outcomes.

OBJECTIVES

To compare primary medical management with primary surgical treatment (augmented trabeculectomy) in patients with primary open-angle glaucoma presenting with advanced disease in terms of health-related quality of life, clinical effectiveness, safety and cost-effectiveness.

DESIGN

This was a two-arm, parallel, multicentre, pragmatic randomised controlled trial.

SETTING

Secondary care eye services.

PARTICIPANTS

Adult patients presenting with advanced primary open-angle glaucoma in at least one eye, as defined by the Hodapp-Parrish-Anderson classification of severe glaucoma.

INTERVENTION

Primary medical treatment - escalating medical management with glaucoma eye drops. Primary trabeculectomy treatment - trabeculectomy augmented with mitomycin C.

MAIN OUTCOME MEASURES

The primary outcome was health-related quality of life measured with the Visual Function Questionnaire-25 at 2 years post randomisation. Secondary outcomes were mean intraocular pressure; EQ-5D-5L; Health Utilities Index 3; Glaucoma Utility Index; cost and cost-effectiveness; generic, vision-specific and disease-specific health-related quality of life; clinical effectiveness; and safety.

RESULTS

A total of 453 participants were recruited. The mean age of the participants was 67 years (standard deviation 12 years) in the trabeculectomy arm and 68 years (standard deviation 12 years) in the medical management arm. Over 65% of participants were male and more than 80% were white. At 24 months, the mean difference in Visual Function Questionnaire-25 score was 1.06 (95% confidence interval -1.32 to 3.43; p = 0.383). There was no evidence of a difference between arms in the EQ-5D-5L score, the Health Utilities Index or the Glaucoma Utility Index. At 24 months, the mean intraocular pressure was 12.40 mmHg in the trabeculectomy arm and 15.07 mmHg in the medical management arm (mean difference -2.75 mmHg, 95% confidence interval -3.84 to -1.66 mmHg; p < 0.001). Fewer types of glaucoma eye drops were required in the trabeculectomy arm. LogMAR visual acuity was slightly better in the medical management arm (mean difference 0.07, 95% confidence interval 0.02 to 0.11; p = 0.006) than in the trabeculectomy arm. There was no evidence of difference in safety between the two arms. A discrete choice experiment updated the utility values for the Glaucoma Utility Index. The within-trial economic analysis found a small increase in the mean EQ-5D-5L score (0.04) and that trabeculectomy has a higher probability of being cost-effective than medical management. The incremental cost of trabeculectomy per quality-adjusted life-year was £45,456. Therefore, at 2 years, surgery is unlikely to be considered cost-effective at a threshold of £20,000 per quality-adjusted life-year. When extrapolated over a patient's lifetime in a model-based analysis, trabeculectomy, compared with medical treatment, was associated with higher costs (average £2687), a larger number of quality-adjusted life-years (average 0.28) and higher incremental cost per quality-adjusted life-year gained (average £9679). The likelihood of trabeculectomy being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life year gained was 73%.

CONCLUSIONS

Our results suggested that there was no difference between treatment arms in health-related quality of life, as measured with the Visual Function Questionnaire-25 at 24 months. Intraocular pressure was better controlled in the trabeculectomy arm, and this may reduce visual field progression. Modelling over the patient's lifetime suggests that trabeculectomy may be cost-effective over the range of values of society's willingness to pay for a quality-adjusted life-year.

FUTURE WORK

Further follow-up of participants will allow us to estimate the long-term differences of disease progression, patient experience and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56878850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 72. See the NIHR Journals Library website for further project information.

Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS)

OBJECTIVE

To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma.

DESIGN

Pragmatic multicentre randomised controlled trial.

SETTING

27 secondary care glaucoma departments in the UK.

PARTICIPANTS

453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017.

INTERVENTIONS

Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months.

SECONDARY OUTCOMES

general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety.

RESULTS

At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare.

CONCLUSION

Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication.

TRIAL REGISTRATION

Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.