What Do We Really Know about the Effectiveness of Glaucoma Interventions?: An Overview of Systematic Reviews

Surgical Glaucoma Treatment in Patients with Juvenile Idiopathic Arthritis-Associated Uveitis: Results after Trabeculectomy or Ahmed Glaucoma Valve Implantation

PURPOSE

Patients with juvenile idiopathic arthritis (JIA) associated uveitis (JIAU) are at risk for secondary glaucoma, frequently requiring surgical management. We compared the success rates for trabeculectomy (TE) and Ahmed glaucoma valve (AGV) implantation.

METHODS

We conducted a retrospective analysis of TE (45 eyes), primary AGV (pAGV) (7 eyes), or secondary AGV (sAGV) implantation after TE (11 eyes) in JIAU at the 2-year follow-up.

RESULTS

All groups achieved significant pressure reduction. After 1 year, the overall success rate was higher in the Ahmed groups (p = 0.03). After adjusting the p-value according to Benjamin Hochberg, there is no significant difference between the groups in the Kaplan-Meier, despite a significant logrank test between all groups (p = 0.0194) and a better performance in the Ahmed groups.

CONCLUSION

Slightly better success rates were achieved with pAGV in managing JIAU patients with glaucoma refractory to medical treatment.

Interventions for Dry Eye: An Overview of Systematic Reviews

Importance

Dry eye is a common ocular disease that can have substantial morbidity. Systematic reviews provide evidence for dry eye interventions and can be useful for patients, clinicians, and clinical guideline developers. Overviews of reviews use explicit and systematic methods to synthesize findings from multiple systematic reviews, but currently, there are no overviews of systematic reviews investigating interventions for dry eye.

Objective

To summarize the results of reliable systematic reviews of dry eye interventions and to highlight the evidence gaps identified.

Evidence Review

We searched the Cochrane Eyes and Vision US satellite database and included reliable systematic reviews evaluating dry eye interventions published from 2016 to 2022. We reported the proportion of systematic reviews that were reliable with reasons for unreliability. Critical and important outcomes from reliable systematic reviews were extracted and verified. Critical outcomes included dry eye-related patient-reported outcome measures. Results were synthesized from reliable systematic reviews to provide summaries of evidence for each intervention. Evidence for each intervention was defined as conclusive or inconclusive depending on whether high-certainty evidence across systematic reviews was available according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and whether findings reached statistical or clinical significance. Recommendations were made for further research.

Findings

Within the Cochrane Eyes and Vision US satellite database, 138 potentially relevant systematic reviews were identified, 71 were considered eligible, and 26 (37%) were assessed as reliable. Among reliable systematic reviews, no conclusive evidence was identified for any dry eye intervention. Inconclusive evidence suggested that environmental modifications, dietary modifications, artificial tears and lubricants, punctal occlusion, intense pulsed light therapy, vectored thermal pulsation therapy (Lipiflow), topical corticosteroids, topical cyclosporine A, topical secretagogues, and autologous serum may be effective. Only unreliable systematic reviews evaluated lifitegrast, oral antibiotics, and moisture chamber devices.

Conclusions and Relevance

This overview of systematic reviews found some evidence that dry eye interventions may be effective, but no conclusive evidence was available. The conduct and reporting of most systematic reviews for dry eye interventions warrant improvement, and reliable systematic reviews are needed to evaluate lifitegrast, oral antibiotics, and moisture chamber devices.

European Glaucoma Society - A guide on surgical innovation for glaucoma

PROLOGUE: Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the "advent" of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill? Hippocrates taught us "bring benefit, not harm" and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an 'add-on' to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions. The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation. The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists. EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS's Vision and Mission. Fotis Topouzis EGS President

Cost-utility analysis of commonly used anti-glaucoma interventions for mild-to-moderate primary open-angle glaucoma patients in rural and urban China

OBJECTIVE

An increasing number of studies have explored the clinical effects of antiglaucoma surgical procedures; however, economic evidence was scarce. We aimed to compare the cost-effectiveness between maximal medical treatment (MMT) and commonly used surgical procedures (trabeculectomy, Ahmed glaucoma valve implantation, gonioscopy-assisted transluminal trabeculotomy and ab interno canaloplasty).

DESIGN AND SETTING

A Markov model study.

PARTICIPANTS

A hypothetical cohort of 100 000 patients with mild-to-moderate primary open-angle glaucoma (POAG).

OUTCOMES

Data were obtained from public sources. The main outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years (QALYs). Sensitivity analyses were conducted to verify the robustness and sensitivity of base-case results.

MAIN RESULTS

Both cumulative costs and QALYs gained from surgical procedures (US$6045-US$13 598, 3.33-6.05 QALYs) were higher than those from MMT (US$3117-US$6458, 3.14-5.66 QALYs). Compared with MMT, all surgical procedures satisfied the cost-effectiveness threshold (lower than US$30 501 and US$41 568 per QALY gained in rural and urban settings, respectively). During the 5-year period, trabeculectomy produced the lowest ICUR (US$21 462 and US$15 242 per QALY gained in rural and urban settings, respectively). During the 10-year-follow-up, trabeculectomy still produced the lowest ICUR (US$13 379 per QALY gained) in urban setting; however, gonioscopy-assisted transluminal trabeculotomy (US$19 619 per QALY gained) and ab interno canaloplasty (US$18 003 per QALY gained) produced lower ICURs than trabeculectomy (US$19 675 per QALY gained) in rural areas. Base-case results were most sensitive to the utilities and costs of initial treatment and maintenance.

CONCLUSIONS

The long-term cost-effectiveness of commonly used surgical procedures could be better than the short-term cost-effectiveness for mild-to-moderate POAG patients in China. Health economic studies, supported by more rigorous structured real-world data, are needed to assess their everyday cost-effectiveness.

TFOS Lifestyle - Evidence quality report: Advancing the evaluation and synthesis of research evidence

Evidence-based practice is a dominant paradigm in healthcare that emphasizes the importance of ensuring the translation of the best available, relevant research evidence into practice. An Evidence Quality Subcommittee was established to provide specialized methodological support and expertise to promote rigorous and evidence-based approaches for the Tear Film and Ocular Surface Society (TFOS) Lifestyle Epidemic reports. The present report describes the purpose, scope, and activity of the Evidence Quality Subcommittee in the undertaking of high-quality narrative-style literature reviews, and leading prospectively registered, reliable systematic reviews of high priority research questions, using standardized methods for each topic area report. Identification of predominantly low or very low certainty evidence across the eight systematic reviews highlights a need for further research to define the efficacy and/or safety of specific lifestyle interventions on the ocular surface, and to clarify relationships between certain lifestyle factors and ocular surface disease. To support the citation of reliable systematic review evidence in the narrative review sections of each report, the Evidence Quality Subcommittee curated topic-specific systematic review databases and relevant systematic reviews underwent standardized reliability assessment. Inconsistent methodological rigor was noted in the published systematic review literature, emphasizing the importance of internal validity assessment. Based on the experience of implementing the Evidence Quality Subcommittee, this report makes suggestions for incorporation of such initiatives in future international taskforces and working groups. Content areas broadly relevant to the activity of the Evidence Quality Subcommittee, including the critical appraisal of research, clinical evidence hierarchies (levels of evidence), and risk of bias assessment, are also outlined.

Evaluation of the Efficacy Duration of Topical Therapies in Eyes with Primary Open-Angle Glaucoma

Background: To investigate the efficacy interval of the topical therapies available for primary open-angle glaucoma (POAG) and the ocular and systemic features potentially associated. Methods: This retrospective study included 190 patients with POAG undergoing first topical therapy, throughout a follow-up of 15 years. The patients started one topical intraocular pressure (IOP)-lowering drug within single molecules such betablockers, prostaglandin or dorzolamide, or fixed combinations such as betablockers + prostaglandin, betablockers + dorzolamide, or betablockers + brimonidine. Efficacy duration was measured as the time between the start of the therapy and the change due to IOP increase or visual field worsening. For each patient, ocular and systemic features and comorbidities were analysed to detect any significant correlation with the length of effectiveness of every drug used. Results: The molecules explored showed some discrepancies in terms of mean duration of efficacy; however, no significant differences were demonstrated (p > 0.05). Furthermore, when evaluating the overall cohort, no systemic or ocular features correlated significantly with the effectiveness of the molecules explored. However, the same analysis carried out upon stratifying the different groups according to the IOP-lowering drops they received, demonstrated that the drug efficacy could be influenced by several ocular and systemic features. Conclusion: Data observed in this study suggest that there is no difference in using one of the medications evaluated as first choice of treatment of POAG if the patients are accurately evaluated and the most recent guidelines are adopted.

Effectiveness of interventions for dry eye: a protocol for an overview of systematic reviews

INTRODUCTION

Dry eye is a leading cause of ocular morbidity and economic and societal burden for patients and healthcare systems. There are several treatment options available for dry eye and high-quality systematic reviews synthesise the evidence for their effectiveness and potential harms.

METHODS AND ANALYSIS

We will search the Cochrane Eyes and Vision US satellite (CEV@US) database of eyes and vision systematic reviews for systematic reviews on interventions for dry eye. CEV@US conducted an initial search of PubMed and Embase to populate the CEV@US database of eyes and vision systematic reviews in 2007, which was updated most recently in August 2021. We will search the database for systematic reviews published since 1 January 2016 because systematic reviews more than 5 years are unlikely to be up to date. We will consider Cochrane and non-Cochrane systematic reviews eligible for inclusion. Two authors will independently screen articles. We will include studies that evaluate interventions for dry eye and/or meibomian gland dysfunction with no restriction on types of participants or review language. We will select reliable systematic reviews (ie, those meeting pre-established methodological criteria) for inclusion, assessed by one investigator and verified by a second investigator. We will extract ratings of the certainty of evidence from within each review. We will report the degree of overlap for systematic reviews that answer similar questions and include overlapping primary studies. We will present results of the overview in alignment with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions (Online Chapter 5: Overviews of Reviews), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and an overview of reviews quality and transparency checklist. The anticipated start and completion dates for this overview are 1 May 2021 and 30 April 2022, respectively.

ETHICS AND DISSEMINATION

This overview will not require the approval of an Ethics Committee because it will use published studies. We will publish results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021279880.

Association of the Effectiveness of Eye Drop Self-instillation and Glaucoma Progression

PRCIS

Among patients with glaucoma or ocular hypertension, ineffective self-instillation of eye drops was associated with an increased long-term risk of progression or advancement of treatment to incisional surgery.

PURPOSE

The purpose of this study was to evaluate the association between the efficacy of self-instillation of eye drops and long-term glaucoma outcomes.

METHODS

In a previous study, video recordings of eye drop self-instillation by patients with glaucoma or ocular hypertension were graded as effective or ineffective depending on whether the patient successfully instilled at least 1 drop on the right ocular surface. Glaucomatous progression was then retrospectively defined as retinal nerve fiber layer thinning as measured by either optical coherence tomography, visual field progression, or need for incisional glaucoma surgery as determined by a glaucoma specialist unaware of patient performance in the eye drop instillation study. Subjects with at least 2 follow-up optical coherence tomography or visual field studies were included in the current study.

RESULTS

The original study enrolled 119 patients. Sufficient follow-up data were available for 101 patients. Eighty-eight patients (87.1%) were effective in eye drop instillation at baseline. Mean follow-up was 5.1 years, during which time 73 patients (72.3%) had progression or underwent incisional surgery in either eye. A significantly higher proportion of patients in the ineffective group met the criteria for progression or underwent incisional surgery (effective: 68.2%; ineffective: 100%; N=101; P=0.017, Fisher exact test). Kaplan-Meier survival analyses showed a significantly faster time to reaching an endpoint in the ineffective group (N=101; P=0.012, log-rank test). There was no difference in age, baseline intraocular pressure, or baseline retinal nerve fiber layer thickness between the groups.

CONCLUSION

Ineffective self-installation of eye drops was associated with an increased risk of glaucoma progression or treatment advancement to incisional surgery.

Glaucoma Is Not Associated With Alzheimer's Disease or Dementia: A Meta-Analysis of Cohort Studies

Background: Previous studies evaluating the relationships of glaucoma with Alzheimer's disease (AD) and dementia showed inconsistent results. We performed a meta-analysis of cohort studies to evaluate the association between glaucoma with incidence of AD, all-cause dementia, and non-AD dementia. Methods: Cohort studies which evaluated the association between glaucoma with incidence of AD, all-cause dementia, and non-AD dementia in adult population with multivariate analyses were identified by systematic search of PubMed, Embase, and Cochrane's Library databases. A random-effects model incorporating the potential intra-study heterogeneity was used for the meta-analysis. Results: Eleven cohort studies including 4,645,925 participants were included. Results showed that compared to those without glaucoma at baseline, adult patients with glaucoma was not independently associated with increased incidence of AD [adjusted risk ratio (RR): 1.03, 95% confidence interval (CI): 0.93-1.05, P = 0.55; I ² = 83%], all-cause dementia (adjusted RR: 1.08, 95% CI: 0.97-1.19, P = 0.15; I ² = 79%), or non-AD dementia (adjusted RR: 1.05 95% CI: 0.91-1.21, P = 0.49; I ² = 82%). Sensitivity analyses by excluding one study at a time did not significantly affect the results of the meta-analyses. Moreover, subgroup analyses showed consistent results in meta-analysis of prospective or retrospective cohort studies, and in meta-analysis of patients with primary open-angle glaucoma or primary angle-closure glaucoma (P-values for subgroup difference all > 0.05). Conclusions: Current evidence from cohort studies did not support that glaucoma is an independent risk factor of AD, all-cause dementia, or non-AD dementia in adult population.

Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis

IMPORTANCE

Glaucoma affects more than 75 million people worldwide. Intraocular pressure (IOP)-lowering surgery is an important treatment for this disease. Interest in reducing surgical morbidity has led to the introduction of minimally invasive glaucoma surgeries (MIGS). Understanding the comparative effectiveness and safety of MIGS is necessary for clinicians and patients.

OBJECTIVE

To summarize data from randomized clinical trials of MIGS for open-angle glaucoma, which were evaluated in a suite of Cochrane reviews.

DATA SOURCES

The Cochrane Database of Systematic Reviews including studies published before June 1, 2021.

STUDY SELECTION

Reviews of randomized clinical trials comparing MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy.

DATA EXTRACTION AND SYNTHESIS

Data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines by one investigator and confirmed by a second. Methodologic rigor was assessed using the AMSTAR 2 appraisal tool and random-effects network meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

The proportion of participants who did not need to use medication to reduce intraocular pressure (IOP) postsurgery (drop-free). Outcomes were analyzed at short-term (<6 months), medium-term (6-18 months), and long-term (>18 months) follow-up.

RESULTS

Six eligible Cochrane reviews were identified discussing trabecular bypass with iStent or Hydrus microstents, ab interno trabeculotomy with Trabectome, subconjunctival and supraciliary drainage devices, and endoscopic cyclophotocoagulation. Moderate certainty evidence indicated that adding a Hydrus safely improved the likelihood of drop-free glaucoma control at medium-term (relative risk [RR], 1.6; 95% CI, 1.4 to 1.8) and long-term (RR, 1.6; 95% CI, 1.4 to 1.9) follow-up and conferred 2.0-mm Hg (95% CI, -2.7 to -1.3 mm Hg) greater IOP reduction at long-term follow-up, compared with cataract surgery alone. Adding an iStent also safely improved drop-free disease control compared with cataract surgery alone (RR, 1.4; 95% CI, 1.2 to 1.6), but the short-term IOP-lowering effect of the iStent was not sustained. Addition of a CyPass microstent improved drop-free glaucoma control compared with cataract surgery alone (RR, 1.3; 95% CI, 1.1 to 1.5) but was associated with an increased risk of vraision loss. Network meta-analyses supported the direction and magnitude of these results.

CONCLUSIONS AND RELEVANCE

Based on data synthesized in Cochrane reviews, some MIGS may afford patients with glaucoma greater drop-free disease control than cataract surgery alone. Among the products currently available, randomized clinical trial data associate the Hydrus with greater drop-free glaucoma control and IOP lowering than the iStent; however, these effect sizes were small.