The prospective, randomized multicenter clinical trial examined 203 patients with predominantly classic choroidal neovascularization secondary to AMD to compare the efficacy and safety of early retreatment. Of those 203 patients, 103 (mean age: 75.1 years) were randomized to receive the standard treatment, while 100 (mean age: 72.7 years) received early treatment.
Throughout the first six months of follow-up, patients received retreatment with verteporfin therapy either every two months (the early treatment group, or Group A) or three months (standard treatment group, or Group B). From six to 12 months, both groups received retreatment at three-month intervals.
The primary outcome of the study was best-corrected mean visual acuity as measured using the Early Treatment Diabetic Retinopathy Study protocol. The secondary outcomes were percentage of patients losing at least three lines of vision; percentage of patients losing at least one line of vision; lesion size, based on the greatest linear dimension documented by fluorescein angiography; impact of initial lesion size; and retreatment rate, as well as safety.
Visual acuity was similar in both groups at baseline with a mean visual acuity of 20/100-1. During the 12 months of follow-up, mean visual acuity was better in the early retreatment group at all intervals; however, no statistically significant benefit was seen in the overall population an any time (p>0.1). At month 12, mean visual acuity was 20/160+1 in group A and 20/160-1 in group B. There was a trend for better outcomes in the early retreatment group with regard to loss of less than three lines of vision at 12 months (61 percent vs. 51.7 percent). No statistically significant difference was seen with regard to lesion size for either group throughout follow-up, with a final GLD of 2790 µm (Group A) and 2996 µm (Group B). However, subgroups analysis indicated a statistically relevant benefit (p<0.004) for patients with small lesions (GLD<2000 µm) at baseline receiving early retreatment.
(Ophthalmology 2005;112:2070-2075.)
Michaels S, Wachtlin J, Gamulescu MA, Heimann H, Prünte C, Inhoffen W, Krebs I, Schmidt-Erfurth U.
Transconjunctival Suture Adjustment Aids IOP Control
Tying scleral flap sutures tightly with transconjunctival adjustment of the sutures allows excellent control of early postop IOP in certain patients undergoing trabeculectomy. An experimental human eye model of trabeculectomy had shown that scleral flap suture adjustment allows predictable control of intraocular pressure, but the approach had not previously been described in clinical use until this study by researchers in the UK and New Zealand.
The prospective, non-comparative interventional case series included 33 consecutive patients, 22 left eyes and 18 right, undergoing trabeculectomy. The 40 procedures were performed using a 3 mm x 4 mm scleral flap with two apical adjustable 10-0 nylon sutures under a fornix-based conjunctival flap. Intraoperatively the scleral flap sutures were tied tightly to appose the edges of the flap. All trabeculectomies were augmented with antimetabolite intraoperatively.
On day one, patients with an IOP greater than 15 mmHg had their suture tension adjusted to lower their IOP to a target range (10 to 15 mmHg). Major outcome measures were IOP before and after adjustment and success at last follow-up (IOP<15 mmHg on no glaucoma medication and no clinically significant complications) without and with adjunctive needling. Other outcomes measured were postoperative complications, bleb needling, final bleb morphology, and visual acuity change from preoperation to final follow-up.
The average day-one IOP was 14.8 mmHg (SD 7.8). Fourteen patients had a day one IOP over 15 mmHg and underwent suture adjustments, lowering IOP to between 10 and 15 mmHg, with a mean post-adjustment IOP of 10.7 mmHg (SD 3.6). One patient had a conjunctival tear intraoperatively. Four patients had transient wound leaks. No patients had shallow anterior chambers. All but four had diffuse blebs at last follow-up. Success rate without any further surgical intervention was 75 percent, and success rate with adjunctive needling was 100 percent. The mean duration of follow-up was 6.3 months, with a range of one to 12 months.
(J Glaucoma 2005;14:435-440)
Ashraff NN, Wells AP.
Racial Differences in Glaucoma Care Examined
A review of Medicare claims by a group at Duke University and RAND Health Sciences reveals no systemic pattern of undertreatment of glaucoma in blacks relative to whites after diagnosis.
The investigators sought to determine whether racial differences exist in longitudinal care patterns for Medicare beneficiaries with glaucoma. They studied national longitudinal Medicare claims data from January 1991 through December 1999 in 21,644 Medicare beneficiaries linked to the National Long-Term Care Survey, a longitudinal study of elderly persons. The analysis found higher rates of surgery among blacks, which might indicate delayed onset of care and/or greater disease severity.
Logistic regression was used to predict whether a person underwent eye examination or eye surgery during the year, and negative binomial regression was used to predict the number of eye examinations and surgical procedures for glaucoma per year. Annual use of eye examinations was nearly identical for black persons (1.85 per year) and white persons (1.89 per year), whereas surgery rates were higher among blacks (0.15) than whites (0.08, p<.001).
The analysis showed that blacks were more likely than whites to have glaucoma diagnosed, but rates among whites were higher than in prior population-based studies. Controlling for other data, the doctors found blacks were not significantly less likely to undergo eye examination during the year; however, blacks were 78 percent more likely to undergo surgery (p<.001) and had 76 percent higher rates of surgical procedures (p<.001).
(Arch Ophthalmol 2005;123:1693-1698)
Ostermann J, Sloan FA, Herndon L, Lee PP.
Lidocaine Gel Helps Patient Comfort During Anesthesia
Anesthesia with lidocaine 2% gel provides satisfactory patient comfort for administration of intravitreal injection and causes less chemosis and hemorrhage than subconjunctival injection (SC) anesthesia, according to a group of doctors at the Shiley Eye Center in La Jolla, Calif.
The researchers studied 18 patients, divided into two groups, and compared pain sensation. Group one was a crossover group in which patients received both injection and gel anesthesia on different occasions. In the second group, patients received only one anesthetic, either gel or injection.
There was no difference in pain score between gel and SC within the first group (p=0.67, paired, nonparametric test) and no difference in pain score comparing patients who had either SC or gel anesthesia before 27.5-gauge intravitreal injections (p=0.82, unpaired t-test) in the second group. However, they did find there were significant differences in incidence of chemosis (p=<0.001) and subconjunctival hemorrhage (p=0.001) after injection versus gel anesthesia in both groups.
(Retina 2005;25:994-998)
Kozak I, Cheng L, Freeman W.
IOP Assessment in Myopic LASIK Patients
Both corneal thickness and anterior corneal curvature affect intraocular pressure assessment in patients with myopic LASIK, according to researchers at the Hong Kong Eye Hospital. The group found a significant difference (9.16 +1.96 mmHg, p<0.10) between the mean preoperative noncontact tonometry (15.46 +2.50 mmHg) and postop NCT (6.30 +1.57 mmHg). They found that although correction formulas can be used to estimate the actual IOP, alternative methods should be investigated to assess IOP independent of corneal thickness and curvature.
Researchers retrospectively analyzed 62 patients (123 eyes) who had myopic LASIK to evaluate the IOP measurements using NCT before and after the procedure. The preoperative NCT was compared with postop NCT, as well as postop corneal thickness and curvature.
Preoperative NCT significantly correlated with postop NCT (p<0.001), postop corneal thickness (p=0.006), and postop anterior corneal curvature (p<0.010).
(Cornea 2006;25:26-28.)
Cheng ACK, Fan D, Tang E, Lam DSC.
