MERCURY-3: a randomized comparison of netarsudil/latanoprost and bimatoprost/timolol in open-angle glaucoma and ocular hypertension

PURPOSE   : To compare the efficacy and safety of the fixed-dose combination (FDC) of netarsudil 0.02%/latanoprost 0.005% ophthalmic solution (NET/LAT; Roclanda®) with bimatoprost 0.03%/timolol maleate 0.5% (BIM/TIM; Ganfort®) ophthalmic solution in the treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT).

METHODS

MERCURY-3 was a 6-month prospective, double-masked, randomized, multicenter, active-controlled, parallel-group, non-inferiority study. Patients (≥ 18 years) with a diagnosis of OAG or OHT in both eyes that was insufficiently controlled with topical medication (IOP ≥ 17 mmHg in ≥ 1 eye and < 28 mmHg in both eyes) were included. Following washout, patients were randomized to once-daily NET/LAT or BIM/TIM for up to 6 months; efficacy was assessed at Week 2, Week 4, and Month 3; safety was evaluated for 6 months. Comparison of NET/LAT relative to BIM/TIM for mean IOP at 08:00, 10:00, and 16:00 h was assessed at Week 2, Week 6, and Month 3. Non-inferiority of NET/LAT to BIM/TIM was defined as a difference of ≤ 1.5 mmHg at all nine time points through Month 3 and ≤ 1.0 mmHg at five or more of nine time points through Month 3.

RESULTS

Overall, 430 patients were randomized (NET/LAT, n = 218; BIM/TIM, n = 212), and all received at least one dose of study medication. Efficacy analyses were performed at Month 3 on 388 patients (NET/LAT, n = 184; BIM/TIM, n = 204). NET/LAT demonstrated non-inferiority to BIM/TIM, with a between-treatment difference in IOP of ≤ 1.5 mmHg achieved at all time points and ≤ 1.0 mmHg at the majority of time points (six of nine) through Month 3. Mean diurnal IOP during the study ranged from 15.4 to 15.6 mmHg and 15.2 to 15.6 mmHg in the NET/LAT and BIM/TIM groups respectively, with no between-group statistically significant difference. No significant differences were observed in key secondary endpoints. No serious, treatment-related adverse events (AEs) were observed, and AEs were typically mild/moderate in severity. The most common treatment-related AEs were conjunctival hyperemia (NET/LAT, 30.7%; BIM/TIM, 9.0%) and cornea verticillata (NET/LAT, 11.0%; BIM/TIM, 0%).

CONCLUSIONS

Once-daily NET/LAT was non-inferior to BIM/TIM in IOP reduction in OAG and OHT, with AEs consistent with previous findings. NET/LAT offers a compelling alternative FDC treatment option for OAG and OHT.

Isolated posterior capsule rupture after blunt eye injury

Isolated posterior capsule rupture of the crystalline lens after blunt eye injury is a rare complication and demands a special surgical management strategy in order to achieve a good visual outcome.

Anterior Capsule Opening Contraction and Late Intraocular Lens Dislocation after Cataract Surgery in Patients with Weak or Partially Absent Zonular Support

Background and Objectives: To evaluate anterior capsule opening (ACO) contraction and late intraocular lens (IOL) dislocation after cataract surgery in patients with weak or partially absent zonular support and assess methods of reducing these complications. Materials and Methods: For this prospective study, we enlisted cataract surgery patients in our hospital with preoperative diagnoses of weak zonules. All patients received phacoemulsification surgery with implantation of a hydrophobic acrylic IOL and capsular tension ring (CTR). ACO reductions were measured for six months after enrolment. Data on late IOL dislocations were collected five years after enrolment of the last patient. Results: Fifty-three patients were enrolled from 2011 to 2015. Over the six-month active follow-up period, ACO area reduction was 23% in patients receiving CTRs of 11 mm diameter and 8% for patients with CTRs of 12 mm, with an overall mean of 15% reduction. Five years after the last patient was enrolled, seven patients (13%) had experienced late IOL-CTR-capsular bag dislocation. For these patients, the mean ACO reduction in the first six months of follow-up was 33%, including for those who had received neodymium-doped yttrium aluminum garnet (Nd: YAG) anterior capsulotomies. Conclusion: Use of hydrophobic acrylic lenses and CTR reduces ACO contraction, with rates comparable to those after cataract surgery without ocular comorbidity. Our patients experienced a relatively high rate of late IOL-CTR-capsular bag dislocation. However, dislocated complexes were easily repositioned and few patients required IOL exchange. Frequent visits are warranted to promptly detect late complications of cataract surgery in patients with weak zonular support.

Corneal Perforation Self-Healing with an Iris Plug in the Cornea

Keratitis treatment outcome is usually dependent on the targeted treatment of the cause. We want to present a small corneal ulcer of unidentified origin that progressed into corneal melting and resulted in corneal perforation. The patient had a widespread antibacterial and fungal treatment and an ophthalmological follow-up with slit-lamp examination and AS-OCT. The spontaneous iris plug in the cornea helped to solve the anterior chamber collapse and made permanent anatomical changes in the anterior part. A 45-week follow-up found a hyperdense stromal corneal scar with 556-µm-wide stable iris-cornea contact and BCVA of 0.8. As a result, an iris plug in the cornea after corneal perforation can have a positive effect on healing and lead to good visual outcome.

Long-Term Outcome of Cataract Surgery in Eyes with Pseudoexfoliation Syndrome Associated with Weak Zonules: A Case Report

A cataract surgery in both eyes was scheduled for an 81-year-old female patient. However, ophthalmic examination revealed marked iridodonesis, phacodonesis and pseudoexfoliative material on the surface of the lens in both eyes indicating weak zonules caused by pseudoexfoliation syndrome, which was more pronounced in the left eye. Cataract surgery was performed initially in the left eye by phacoemulsification. Additionally, iris hooks and capsular tension ring (CTR) were used to stabilize the capsular bag, and the haptic of the intraocular lens (IOL) was sutured to the iris at the end of the surgery. The same procedure except haptic suturing was performed in the right eye after 6 months. The left eye remained stable, whereas the right eye developed considerable anterior capsular contraction 2 months postoperatively. Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy was performed to treat the condition. Moreover, 3 years after the initial surgery, late IOL-CTR-capsular-bag complex dislocation developed in the right eye, and reposition surgery was performed. Three days after IOL-CTR-capsular-bag complex reposition surgery, endophthalmitis developed; the eye responded well to 1 mg intravitreal vancomycin treatment. IOL in the right eye remained stable 3 years postoperatively.

Factors influencing myopic shift in children after intraocular lens implantation

Introduction:

Intraocular lenses have always been a controversial topic in pediatric cataract surgery. In the early 1990s in the post-Soviet states of Eastern Europe, intraocular lenses promised an easier full-time correction and amblyopia treatment. Since 1991, ophthalmologists in Latvia have been implanting intraocular lenses in infants. Amount of the postoperative myopic shift and its influencing factors, analyzed in this article, are important indicators of congenital cataract treatment.

Materials and methods:

A retrospective chart review off 85 children (137 eyes) who underwent foldable posterior chamber intraocular lens implantation at the Clinical University Hospital in Riga, Latvia, from 1 January 2006 until 31 December 2016, was performed. Depending on the age at surgery, patients were divided into six groups: 1–6, 7–12, 13–24, 25–48, 49–84, and 85–216 months.

Results:

The largest and more variable myopic shift was found in a group of diffuse/total and nuclear cataract with surgery before the age of 6 months. There was a statistically significant correlation between the acquired best-corrected visual acuity and the amount of myopic shift (rs = 0.33; p < 0.001). Comparing the amount of myopic shift in two groups of different intraocular lens implantation target refraction tactics, we did not find statistically significant differences. Comparing the amount of myopic shift and implanted intraocular lens power, a negative, statistically significant correlation was found.

Conclusion:

The earlier the cataract extraction surgery and intraocular lens implantation is performed, the larger the myopic shift. The morphological type of cataract, best-corrected visual acuity, secondary glaucoma, and intraocular lens power influence the amount of myopic shift.

Adjunctive Use of Tafluprost with Timolol Provides Additive Effects for Reduction of Intraocular Pressure in Patients with Glaucoma

Purpose

This study investigated the efficacy and safety of tafluprost as an adjunctive therapy to timolol in patients with open-angle glaucoma or ocular hypertension, uncontrolled by timolol monotherapy.

Methods

This was a randomized, double-masked, parallel-group, multinational and multicenter 12-week phase III study. Tafluprost 0.0015% (once daily: 20:10) or vehicle were administered as adjunctive therapy to timolol 0.5% (twice daily: 08:00 and 20:00) for 6 weeks, after which all patients received tafluprost for 6 weeks. Intraocular pressure (IOP) measurements were conducted at 08:00, 10:00, and 16:00 at baseline, and weeks 2, 4, 6, and 12.

Results

A total of 185 patients were randomized to tafluprost (n = 96) or vehicle (n = 89). Reductions in IOP were seen in both groups, which were consistently more pronounced with tafluprost. At week 6, the change from baseline in diurnal IOP ranged from −5.49 to −5.82 mm Hg, and the overall treatment difference (tafluprost vehicle) was −1.49 mmHg (upper 95% confidence interval, −0.66; p<0.001, intention-to-treat population, repeated measurements of the analysis of covariance model). At week 12, the change from baseline ranged from −6.22 to −6.79 mmHg in the tafluprost group. Patients switched from vehicle to tafluprost achieved a similar decrease in IOP to those who received tafluprost throughout the study (group difference at 12 weeks, −0.09 mmHg, p=0.812). There were more ocular adverse events with tafluprost compared with vehicle (42% vs. 29%, respectively), but most were mild in severity.

Conclusions

As adjunctive therapy to timolol, tafluprost achieved a consistently greater reduction in IOP compared with vehicle, and was well tolerated.

Association of NT-proANP Level in Plasma and Humor Aqueous with Primary Open-Angle Glaucoma

PURPOSE

The aim of this study is to determine differences in the levels of NT-proANP in the plasma and aqueous humor of glaucoma and cataract patients and to evaluate whether any relationships are present.

METHODS

The study group consisted of 58 patients with primary-open glaucoma (POAG) undergoing trabeculectomy surgery. The control group was comprised of 32 age-matched cataract patients. The concentration of the N-terminal fragment of the proatrial natriuretic peptide (NT-proANP, 1-98) in the aqueous humor and blood plasma samples was measured using an immunochemical method (ELISA).

RESULTS

The plasma NT-proANP concentration was significantly increased in patients with POAG compared to that in the control group (7.00 vs. 4.65 nmol/L, P = 0.0054). Similarly, the NT-proANP concentration in the aqueous humor was significantly higher in the POAG patients (0.47 vs. 0.09 nmol/L, P = 0.0112). However, there was no correlation between the NT-proANP values in the aqueous humor and the plasma of the POAG patients, as well as between the NT-proANP values in the aqueous humor and the intraocular pressure.

CONCLUSIONS

We identified an association between the levels of NT-proANP in the plasma and the aqueous humor with POAG. Our data support the idea of the involvement of NP system in the development of POAG and highlight ANP as a possible biomarker of glaucoma.

Point mutations associated with Leber hereditary optic neuropathy in a Latvian population

PURPOSE

To study mutations associated with Leber hereditary optic neuropathy (LHON) in patients suspected of having this mitochondrial disorder in a Latvian population. Additional aims were to determine the heteroplasmy status of all non-synonymous polymorphisms identified in the current study and to identify the mitochondrial haplogroups of the studied participants because these factors may contribute to the manifestation of LHON.

METHODS

Twelve patients, including patients in two families, were enrolled in the current study. LHON was suspected based on the findings of ophthalmologic examinations. In clinically affected individuals, the presence of all previously reported LHON-associated mutations was assessed with sequencing analysis. Additionally, the SURVEYOR endonuclease assay was used to detect heteroplasmy. The mitochondrial haplogroups were identified with restriction analysis and the sequencing of hypervariable segment 1.

RESULTS

In one family (mother and son), there was one primary LHON-associated mutation, G11778A. In addition, one rare previously reported LHON-associated polymorphism, A13637G, was detected in two unrelated patients. A non-synonymous polymorphism at T6253C was found in one individual. This mutation was reported in the background of the 3460 mutation among LHON patients in a Chinese population. No non-synonymous point mutations in mitochondrial DNA were found in five of the study participants.

CONCLUSIONS

Molecular analysis of 12 patients with suspected LHON confirmed the diagnosis in four patients and allowed the use of appropriate prophylactic measures and treatment. Further investigations and additional studies of different populations are necessary to confirm the role of the non-synonymous polymorphisms A13637G and T6253C in the manifestation of LHON and the associations of these polymorphisms with mitochondrial haplogroups and heteroplasmy.

Evaluation of axonal optic nerve damage using visual evoked potentials and optical coherence tomography in patients with multiple sclerosis

BACKGROUND AND OBJECTIVE

Axonal tissue impairment plays a substantial role in the development of disability in multiple sclerosis. The aim of our study was to analyze the clinical utility of visual evoked potentials (VEP) and optical coherence tomography (OCT) in the diagnosis of optic nerve axonal damage and to determine the correlation between the retinal nerve fiber layer at the temporal quadrant (RNFLT) thickness and the VEP amplitude in multiple sclerosis patients with and without a history of acute optic neuritis (ON).

MATERIAL AND METHODS

This cross-sectional study included 69 relapsing-remitting patients with multiple sclerosis from Pauls Stradins Clinical University Hospital, who were divided into 2 groups: with and without a history of ON. The RNFLT thickness and the VEP amplitude were measured. RESULTS. A total of 25 clinically affected eyes were studied. VEP showed a higher sensitivity (64%) than OCT (50%) in supporting a clinical diagnosis of ON. A significant correlation was found between the RNFLT thickness in the temporal segment and the average VEP amplitude both in the eyes of MS patients with (rs=0.42, P=0.01) and without a history of ON (rs=0.44, P<0.001).

CONCLUSIONS

The evidence from this study suggests that diagnostics of optic nerve axonal damage is feasible by means of using the average VEP amplitude instead of OCT alone. However, the combination of VEP and OCT increases the chance to confirm the existence of ON. A significant correlation was found between structural and functional vision parameters for both patients with and without a history of ON.

Efficacy and safety of travoprost/timolol vs dorzolamide/timolol in patients with open-angle glaucoma or ocular hypertension

Purpose:

To compare the intraocular pressure- (IOP-) lowering efficacy of fixed combinations travoprost 0.004%/timolol 0.5% and dorzolamide 2%/timolol 0.5% in patients with ocular hypertension or open-angle glaucoma.

Methods:

In this prospective, multicenter, double-masked, randomized clinical trial, 319 qualifying patients received either travoprost/timolol once daily in the morning (n = 157) or dorzolamide/timolol twice daily (n = 162). IOP was assessed morning and evening at 2 and 6 weeks. The primary outcome measure was mean diurnal IOP.

Results:

Baseline mean IOP values were similar between groups. Mean pooled diurnal IOP was significantly lower in the travoprost/timolol group (16.5 mmHg ± 0.23) than in the dorzolamide/timolol group (17.3 mmHg ± 0.23; P = 0.011). Mean IOP was significantly lower in the travoprost/timolol group compared to the dorzolamide/timolol group at the 9 AM time point both at Week 2 (P = 0.006) and Week 6 (P = 0.002). The travoprost/timolol combination produced mean IOP reductions from baseline of 35.3% to 38.5%, while the dorzolamide/timolol combination produced mean IOP reductions from baseline of 32.5% to 34.5%.

Conclusions:

The fixed combination travoprost 0.004%/timolol 0.5% dosed once daily in the morning demonstrated superior mean diurnal IOP-lowering efficacy compared to dorzolamide 2%/timolol 0.5% dosed twice daily in patients with ocular hypertension or open-angle glaucoma.

Kynurenine and neopterin in the aqueous humor of the anterior chamber of the eye and in serum of cataract patients

Serum kynurenine, neopterin, selenium concentrations; neopterin concentrations in aqueous humour from anterior chamber of eye and selenium content in lenses were determined in 40 catarat patients with and in 51--without pseudoexfoliation (PES). Significantly increased kynurenine and neopterin levels in serum and neopterin concentration in aqueous humour were observed in mature cataract patients with PES compared to whose without. These patients also presented with the lowest content of selenium in serum and lens, compared with cataract patients without PES. Increased concentrations of neopterin in serum and aqueous humour of anterior chamber of eyes suggest an increased degree of oxidative stress in patients with PES. Thus, the results support the role of oxidative stress in the development of PES in cataract patients. The decreased content of selenium may elicit immune system activation via an increased oxidative stress as it is indicated by the increased formation of kynurenine and neopterin.

Neopterin and kynurenine concentrations in aqueous humour of the anterior chamber of the eye and in serum of cataract patients with pseudoexfoliation

In 40 cataract patients and in 51 patients without pseudoexfoliation (PES) we determined serum concentrations of neopterin, kynurenine, and selenium and concentrations of neopterin in aqueous humour from the anterior chamber of the eye. In addition, selenium content in lenses was determined. Significantly increased kynurenine and neopterin concentrations in serum and neopterin concentrations in aqueous humour were observed in mature cataract patients with PES compared to those without. These patients also presented with the lowest content of selenium in serum and lens, compared with cataract patients without PES. Increased concentrations of neopterin in serum and aqueous humour of the anterior chamber of eyes suggest an increased degree of oxidative stress in patients with PES. Thus, the results support the role of oxidative stress in the development of PES in cataract patients. The decreased content of selenium may elicit immune system activation via an increased oxidative stress as it is indicated by the increased formation of kynurenine and neopterin.

[Dislocation of artificial lenses into the vitreous body. Long-term follow-up of 6 patients]

BACKGROUND

Dislocation of an artificial intraocular lens (IOL) into the vitreous is a rare complication in cataract surgery. The removal of the IOL from the vitreous can be associated with various difficulties. As vitreal surgery in Latvia has been developed only during the last two years, patients with IOL dislocation prior to that time were only observed. The aim this study was the long-term observation of this patients.

PATIENTS AND METHODS

6 patients with dislocated IOLs in the vitreous were observed over various periods of time: 1 patient for 6 years, 2 patients for 3 years, 2 patients for 2 years and in 1 patient for 1 year. A second IOL was implanted into the anterior chamber in two cases.

RESULTS

In all cases the retina remained attached. Intraocular pressure was below 20 mmHg. Visual acuity was 0.4 (20/28) and 0.5 (20/40) in the two cases with secondary anterior chamber IOL. In the other cases visual rehabilitation was achieved with spectacles or contact lenses. Visual acuity was 0.7 (20/28) in one patient, 0.4 (20/50) in two patients and 0.1 (20/200) in one patient.

CONCLUSION

Dislocated artificial intraocular lenses can remain in the vitreous for a long time without serious complications, if no vitreal surgery is possible.