Abstract Differences in patient characteristics between the PTVT and TVT Studies, including the l... more Abstract Differences in patient characteristics between the PTVT and TVT Studies, including the level of preoperative intraocular pressure, contributed to the differences in surgical failure rates in each trial.
PURPOSE To assess the inpatient adherence rate and factors associated with adherence to topical g... more PURPOSE To assess the inpatient adherence rate and factors associated with adherence to topical glaucoma medications (TGMs) at a single academic institution throughout hospitalization before and after an educational intervention. DESIGN Nonrandomized, comparative, retrospective study. PARTICIPANTS Inpatients 18 years of age and older admitted to a single academic hospital from January 2014 through June 2019 with a diagnosis of glaucoma who also received TGMs. METHODS The medication administration record during admission was examined closely to determine if the TGMs were reconciled and administered correctly before and after an educational intervention with inpatient providers. A simple intervention reached various health care providers through an educational e-mail, communication in a weekly newsletter, and a morning report presentation. Adherence was defined as administration of more than 75% of recommended doses during the inpatient stay. Other collected variables included length of stay and primary diagnosis on admission. MAIN OUTCOME MEASURES Adherence rate to inpatient administration of TGMs. RESULTS One hundred eighty-four patients (n = 142 before intervention; n = 42 after intervention) were included. The preintervention group had a total of 275 TGMs, of which 207 (75.3%) were administered in accordance with the adherence definition of this study. After the intervention phase, 49 of 56 (87.5%) TGMs were administered with appropriate adherence (P = 0.047). Adherence was associated significantly with a known outpatient medication regimen (P = 0.006) and correct admission reconciliation (P < 0.001). CONCLUSIONS When glaucoma patients requiring topical treatment are admitted, approximately one quarter of patients seem to not receive their medications appropriately. In this study, a simple educational intervention was able to improve adherence. To prevent daily fluctuations in intraocular pressure for vulnerable glaucoma patients, inpatient adherence to appropriate medication administration should be stressed continuously. While in the care of health care providers, inpatients should be afforded at least the opportunity to maintain adequate adherence, just as is carried out for other medications related to other chronic medical conditions.
To report 1-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Multi... more To report 1-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter, randomized clinical trial. Two hundred forty-two eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 in the tube group and 117 in the trabeculectomy group. Patients were enrolled at 16 clinical centers and assigned randomly to treatment with a tube shunt (350-mmBaerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC; 0.4 mg/ml for 2 minutes). Intraocular pressure (IOP), glaucoma medical therapy, visual acuity, visual fields, surgical complications, and failure (IOP of more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision). The cumulative probability of failure during the first year of follow-up was 17.3% in the tube group and 7.9% in the trabeculectomy group (P = 0.01; hazard ratio, 2.59; 95% confidence interval, 1.2...
The purpose of this study is to evaluate the success and usefulness of patient education in eyedr... more The purpose of this study is to evaluate the success and usefulness of patient education in eyedrop self-administration technique via an educational handout and a short instructional video. Patients and methods: We conducted a prospective study that included 34 patients who were self-administering ophthalmic drops. Of the total patients included, 12% had used drops for ,12 months, and 88% had used drops for .12 months. Average age of patients in the study was 67 years, with an age range of 19-91 years. Of the total patients included, 82% had glaucoma, 6% had dry eyes, and 12% did not have a specific diagnosis. Subjects were video recorded and assessed by a trained observer on two occasions: at baseline and after they viewed a demonstrational video and handout. A maximum score of 15 points was awarded based on 15 criteria. A written self-assessment was administered at the end of each study. Results: Pre-and post-teaching assessment scores improved significantly with education. Patients initially scored an average 2.53 points compared to a post-education score of 6.15 out of 15 points, demonstrating a 2.43 (P=0.008) factor of improvement. After education, 94% of patients versus 47% pre-teaching (P=0.0001) pulled down their lower eyelids. A total of 91% pre-teaching versus 59% post-teaching (P=0.0042) patients squeezed one drop into the lower fornix, 74% pre-teaching versus 26% post-teaching (P=0.0002) patients released the eyelid and closed the eye for 1 minute, and 56% pre-teaching versus 3% post-teaching (P=0.0001) patients applied nasal digital pressure on each eye. We found no significant difference in score changes between those who previously received education and those who had not (P=0.37). A total of 91% patients responded in a postassessment survey that they now feel more confident of their ability to self-administer eyedrops as their doctor prescribed and that the educational materials were responsible. Conclusion: Participants demonstrated an immediate and statistically significant improvement in several areas of proper eyedrop self-administration after exposure to a demonstration video and instructional handout.
To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follo... more To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follow-up. Multicenter, prospective, randomized clinical trial. Settings: Sixteen international clinical centers. Two hundred seventy six subjects aged 18 to 85 years with previous intraocular surgery or refractory glaucoma with intraocular pressure of > 18 mmHg. Ahmed Glaucoma Valve FP7 or Baerveldt Glaucoma Implant BG 101-350. Late postoperative complications (beyond 3 months), reoperations for complications, and decreased vision from complications. Late complications developed in 56 subjects (46.8 ± 4.8 5 year cumulative % ± SE) in the Ahmed Glaucoma Valve group and 67 (56.3 ± 4.7 5 year cumulative % ± SE) in the Baerveldt Glaucoma Implant group (P = 0.082). The cumulative rates of serious complications were 15.9% and 24.7% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups respectively (P = 0.034) although this was largely driven by subjects who had tube occlusions in th...
In biometric photographs of 13 patients, we quantified the iris contour in eyes with central ante... more In biometric photographs of 13 patients, we quantified the iris contour in eyes with central anterior chamber depths ranging from 1.9 to 3.4 mm (epithelium to lens surface). This actu al profile was compared to that predicted by a theoretical analysis of the forces acting on the iris. The average discrepancy between the cal culated actual and the theoretically predicted iris position Was only-0.01 to +0.03 mm. The close agreement validates the model under normal conditions and in the presence of rela tive (nonsynechial) pupillary block. The theo retical iris shape may not occur under condi tions that violate the underlying physical assumptions bf the mathematical model, such as when iridectomy eliminates the pressure difference between the anterior and posterior chamber or when synechiae introduce addi tional forces on the iris other than the ones included in the analysis. To WHATEVER DEGREE there is resistance to flow of aqueous humor through the space between the iris and lens (relative pupillary block), a pressure difference develops between the pos terior and anterior chambers. The pressure dif ference lifts the iris off the lens surface, which allows aqueous flow sufficient to produce a balance between the increased posterior cham ber pressure and the resistance to flow into the pupillary passage. From basic physical principles, Tiedeman' constructed a mathematical model of this equi librium condition. Although the anterior bulge in the iris contour is produced by the posterior chamber pressure balancing the iris sphincter
A 24-year-old man had visual acuity of no light perception in the left eye after attempted autoen... more A 24-year-old man had visual acuity of no light perception in the left eye after attempted autoenucleation. An urgent lateral canthotomy was performed, followed by treatment with high-dose intravenous corticosteroids. Visual acuity improved to L.E.: 20/30. Visual field testing disclosed recovery of the central visual field with persistent arcuate visual field defects. Visual acuity of no light perception after attempted autoenucleation does not preclude the return of good visual acuity.
We conducted a randomized, double-masked, paired comparison of 0.1% thymoxamine vs placebo for th... more We conducted a randomized, double-masked, paired comparison of 0.1% thymoxamine vs placebo for the reversal of phenylephrine-induced mydriasis. Mydriasis was induced with 2.5% phenylephrine in each eye of 74 subjects (148 eyes). Each subject then received 0.1% thymoxamine in one eye and placebo in the other eye. Pupillary measurements were obtained at regular intervals during the ensuing 8 hours. At all intervals, a greater percentage of thymoxamine-treated eyes returned to baseline pupillary diameters compared with placebo-treated eyes (P less than or equal to .01). For subjects in whom both pupils returned to baseline, thymoxamine-treated eyes returned to baseline in a mean of 2.2 hours, vs 5.2 hours for placebo (P less than .0001). Among thymoxamine-treated eyes, those with light irides responded more rapidly than those with dark irides, returning to baseline in 1.6 vs 2.8 hours, respectively (P = .0046). After constriction to baseline pupillary diameter had been achieved, no patients experienced a rebound dilation.
for Quality Eye Care without any external financial support. Authors and reviewers of the guideli... more for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication.
New forms of refractive surgery result in corneas that are nearly doubled in thickness. To test t... more New forms of refractive surgery result in corneas that are nearly doubled in thickness. To test the reliability of standard instrumentation for the measurement of intraocular pressure in such eyes, the MacKay-Marg tonometer was used on eye bank eyes with and without epikeratophakia lenticules and/or bandage contact lenses. The Goldmann applanation prism in the hand-held Perkins portable tonometer and the MacKay-Marg tonometer were used to measure IOP in vivo in a primate eye with an epikeratophakia graft. Measurements were compared with actual intraocular readings from a transducer. The MacKay-Marg tonometer was reliable at pressures above 20 mm Hg; the extra thickness of the graft and/or the rigidity of the contact lens impaired the accuracy below 20 mm Hg. The Goldman tonometer was accurate over the entire range of pressures.
To describe the methodology of the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter r... more To describe the methodology of the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter randomized clinical trial. Patients with medically uncontrolled glaucoma and no prior incisional ocular surgery. Patients are being enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (0.4 mg/ml for 2 minutes). The primary outcome measure is the rate of surgical failure, defined as intraocular pressure (IOP) more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision. Secondary outcome measures include IOP, glaucoma medical therapy, visual acuity, visual fields, and surgical complications. Practice patterns vary in the surgical management of glaucoma, and opinions differ among surgeons regarding the preferred primary operation for glaucoma. The PTVT Study will provide valuable information comparing the...
Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective stu... more Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective study of the prevalence of ocular hypertension and glaucoma after pediatric cataract surgery has been performed. A prospective glaucoma evaluation was offered to all eligible subjects at least 5 years after automated lensectomy and vitrectomy for pediatric cataracts. Sixty-two (58%) of 107 eligible subjects received a glaucoma evaluation. One (4.5%) of 22 patients with bilateral cataracts had glaucoma, and a much higher percentage (45%) had ocular hypertension. Five (12.5%) of 40 patients with unilateral cataracts had glaucoma, and an additional 32.5% had ocular hypertension. For patients with monocular cataracts, the age and corneal diameter at the time of cataract surgery were related to the subsequent development of ocular hypertension or glaucoma. The majority of subjects were able to cooperate with a comprehensive glaucoma examination that included cycloplegic refraction, determination of intraocular pressure, examination of the optic nerve, and fundus photography, without requiring sedation. There is a high prevalence of ocular hypertension after pediatric cataract surgery. Children who are 5 years of age and older usually are able to cooperate with a glaucoma evaluation. The natural history of ocular hypertension after pediatric cataract surgery will be determined with longitudinal studies in the future.
Abstract Differences in patient characteristics between the PTVT and TVT Studies, including the l... more Abstract Differences in patient characteristics between the PTVT and TVT Studies, including the level of preoperative intraocular pressure, contributed to the differences in surgical failure rates in each trial.
PURPOSE To assess the inpatient adherence rate and factors associated with adherence to topical g... more PURPOSE To assess the inpatient adherence rate and factors associated with adherence to topical glaucoma medications (TGMs) at a single academic institution throughout hospitalization before and after an educational intervention. DESIGN Nonrandomized, comparative, retrospective study. PARTICIPANTS Inpatients 18 years of age and older admitted to a single academic hospital from January 2014 through June 2019 with a diagnosis of glaucoma who also received TGMs. METHODS The medication administration record during admission was examined closely to determine if the TGMs were reconciled and administered correctly before and after an educational intervention with inpatient providers. A simple intervention reached various health care providers through an educational e-mail, communication in a weekly newsletter, and a morning report presentation. Adherence was defined as administration of more than 75% of recommended doses during the inpatient stay. Other collected variables included length of stay and primary diagnosis on admission. MAIN OUTCOME MEASURES Adherence rate to inpatient administration of TGMs. RESULTS One hundred eighty-four patients (n = 142 before intervention; n = 42 after intervention) were included. The preintervention group had a total of 275 TGMs, of which 207 (75.3%) were administered in accordance with the adherence definition of this study. After the intervention phase, 49 of 56 (87.5%) TGMs were administered with appropriate adherence (P = 0.047). Adherence was associated significantly with a known outpatient medication regimen (P = 0.006) and correct admission reconciliation (P < 0.001). CONCLUSIONS When glaucoma patients requiring topical treatment are admitted, approximately one quarter of patients seem to not receive their medications appropriately. In this study, a simple educational intervention was able to improve adherence. To prevent daily fluctuations in intraocular pressure for vulnerable glaucoma patients, inpatient adherence to appropriate medication administration should be stressed continuously. While in the care of health care providers, inpatients should be afforded at least the opportunity to maintain adequate adherence, just as is carried out for other medications related to other chronic medical conditions.
To report 1-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Multi... more To report 1-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter, randomized clinical trial. Two hundred forty-two eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 in the tube group and 117 in the trabeculectomy group. Patients were enrolled at 16 clinical centers and assigned randomly to treatment with a tube shunt (350-mmBaerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC; 0.4 mg/ml for 2 minutes). Intraocular pressure (IOP), glaucoma medical therapy, visual acuity, visual fields, surgical complications, and failure (IOP of more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision). The cumulative probability of failure during the first year of follow-up was 17.3% in the tube group and 7.9% in the trabeculectomy group (P = 0.01; hazard ratio, 2.59; 95% confidence interval, 1.2...
The purpose of this study is to evaluate the success and usefulness of patient education in eyedr... more The purpose of this study is to evaluate the success and usefulness of patient education in eyedrop self-administration technique via an educational handout and a short instructional video. Patients and methods: We conducted a prospective study that included 34 patients who were self-administering ophthalmic drops. Of the total patients included, 12% had used drops for ,12 months, and 88% had used drops for .12 months. Average age of patients in the study was 67 years, with an age range of 19-91 years. Of the total patients included, 82% had glaucoma, 6% had dry eyes, and 12% did not have a specific diagnosis. Subjects were video recorded and assessed by a trained observer on two occasions: at baseline and after they viewed a demonstrational video and handout. A maximum score of 15 points was awarded based on 15 criteria. A written self-assessment was administered at the end of each study. Results: Pre-and post-teaching assessment scores improved significantly with education. Patients initially scored an average 2.53 points compared to a post-education score of 6.15 out of 15 points, demonstrating a 2.43 (P=0.008) factor of improvement. After education, 94% of patients versus 47% pre-teaching (P=0.0001) pulled down their lower eyelids. A total of 91% pre-teaching versus 59% post-teaching (P=0.0042) patients squeezed one drop into the lower fornix, 74% pre-teaching versus 26% post-teaching (P=0.0002) patients released the eyelid and closed the eye for 1 minute, and 56% pre-teaching versus 3% post-teaching (P=0.0001) patients applied nasal digital pressure on each eye. We found no significant difference in score changes between those who previously received education and those who had not (P=0.37). A total of 91% patients responded in a postassessment survey that they now feel more confident of their ability to self-administer eyedrops as their doctor prescribed and that the educational materials were responsible. Conclusion: Participants demonstrated an immediate and statistically significant improvement in several areas of proper eyedrop self-administration after exposure to a demonstration video and instructional handout.
To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follo... more To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follow-up. Multicenter, prospective, randomized clinical trial. Settings: Sixteen international clinical centers. Two hundred seventy six subjects aged 18 to 85 years with previous intraocular surgery or refractory glaucoma with intraocular pressure of > 18 mmHg. Ahmed Glaucoma Valve FP7 or Baerveldt Glaucoma Implant BG 101-350. Late postoperative complications (beyond 3 months), reoperations for complications, and decreased vision from complications. Late complications developed in 56 subjects (46.8 ± 4.8 5 year cumulative % ± SE) in the Ahmed Glaucoma Valve group and 67 (56.3 ± 4.7 5 year cumulative % ± SE) in the Baerveldt Glaucoma Implant group (P = 0.082). The cumulative rates of serious complications were 15.9% and 24.7% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups respectively (P = 0.034) although this was largely driven by subjects who had tube occlusions in th...
In biometric photographs of 13 patients, we quantified the iris contour in eyes with central ante... more In biometric photographs of 13 patients, we quantified the iris contour in eyes with central anterior chamber depths ranging from 1.9 to 3.4 mm (epithelium to lens surface). This actu al profile was compared to that predicted by a theoretical analysis of the forces acting on the iris. The average discrepancy between the cal culated actual and the theoretically predicted iris position Was only-0.01 to +0.03 mm. The close agreement validates the model under normal conditions and in the presence of rela tive (nonsynechial) pupillary block. The theo retical iris shape may not occur under condi tions that violate the underlying physical assumptions bf the mathematical model, such as when iridectomy eliminates the pressure difference between the anterior and posterior chamber or when synechiae introduce addi tional forces on the iris other than the ones included in the analysis. To WHATEVER DEGREE there is resistance to flow of aqueous humor through the space between the iris and lens (relative pupillary block), a pressure difference develops between the pos terior and anterior chambers. The pressure dif ference lifts the iris off the lens surface, which allows aqueous flow sufficient to produce a balance between the increased posterior cham ber pressure and the resistance to flow into the pupillary passage. From basic physical principles, Tiedeman' constructed a mathematical model of this equi librium condition. Although the anterior bulge in the iris contour is produced by the posterior chamber pressure balancing the iris sphincter
A 24-year-old man had visual acuity of no light perception in the left eye after attempted autoen... more A 24-year-old man had visual acuity of no light perception in the left eye after attempted autoenucleation. An urgent lateral canthotomy was performed, followed by treatment with high-dose intravenous corticosteroids. Visual acuity improved to L.E.: 20/30. Visual field testing disclosed recovery of the central visual field with persistent arcuate visual field defects. Visual acuity of no light perception after attempted autoenucleation does not preclude the return of good visual acuity.
We conducted a randomized, double-masked, paired comparison of 0.1% thymoxamine vs placebo for th... more We conducted a randomized, double-masked, paired comparison of 0.1% thymoxamine vs placebo for the reversal of phenylephrine-induced mydriasis. Mydriasis was induced with 2.5% phenylephrine in each eye of 74 subjects (148 eyes). Each subject then received 0.1% thymoxamine in one eye and placebo in the other eye. Pupillary measurements were obtained at regular intervals during the ensuing 8 hours. At all intervals, a greater percentage of thymoxamine-treated eyes returned to baseline pupillary diameters compared with placebo-treated eyes (P less than or equal to .01). For subjects in whom both pupils returned to baseline, thymoxamine-treated eyes returned to baseline in a mean of 2.2 hours, vs 5.2 hours for placebo (P less than .0001). Among thymoxamine-treated eyes, those with light irides responded more rapidly than those with dark irides, returning to baseline in 1.6 vs 2.8 hours, respectively (P = .0046). After constriction to baseline pupillary diameter had been achieved, no patients experienced a rebound dilation.
for Quality Eye Care without any external financial support. Authors and reviewers of the guideli... more for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication.
New forms of refractive surgery result in corneas that are nearly doubled in thickness. To test t... more New forms of refractive surgery result in corneas that are nearly doubled in thickness. To test the reliability of standard instrumentation for the measurement of intraocular pressure in such eyes, the MacKay-Marg tonometer was used on eye bank eyes with and without epikeratophakia lenticules and/or bandage contact lenses. The Goldmann applanation prism in the hand-held Perkins portable tonometer and the MacKay-Marg tonometer were used to measure IOP in vivo in a primate eye with an epikeratophakia graft. Measurements were compared with actual intraocular readings from a transducer. The MacKay-Marg tonometer was reliable at pressures above 20 mm Hg; the extra thickness of the graft and/or the rigidity of the contact lens impaired the accuracy below 20 mm Hg. The Goldman tonometer was accurate over the entire range of pressures.
To describe the methodology of the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter r... more To describe the methodology of the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter randomized clinical trial. Patients with medically uncontrolled glaucoma and no prior incisional ocular surgery. Patients are being enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (0.4 mg/ml for 2 minutes). The primary outcome measure is the rate of surgical failure, defined as intraocular pressure (IOP) more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision. Secondary outcome measures include IOP, glaucoma medical therapy, visual acuity, visual fields, and surgical complications. Practice patterns vary in the surgical management of glaucoma, and opinions differ among surgeons regarding the preferred primary operation for glaucoma. The PTVT Study will provide valuable information comparing the...
Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective stu... more Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective study of the prevalence of ocular hypertension and glaucoma after pediatric cataract surgery has been performed. A prospective glaucoma evaluation was offered to all eligible subjects at least 5 years after automated lensectomy and vitrectomy for pediatric cataracts. Sixty-two (58%) of 107 eligible subjects received a glaucoma evaluation. One (4.5%) of 22 patients with bilateral cataracts had glaucoma, and a much higher percentage (45%) had ocular hypertension. Five (12.5%) of 40 patients with unilateral cataracts had glaucoma, and an additional 32.5% had ocular hypertension. For patients with monocular cataracts, the age and corneal diameter at the time of cataract surgery were related to the subsequent development of ocular hypertension or glaucoma. The majority of subjects were able to cooperate with a comprehensive glaucoma examination that included cycloplegic refraction, determination of intraocular pressure, examination of the optic nerve, and fundus photography, without requiring sedation. There is a high prevalence of ocular hypertension after pediatric cataract surgery. Children who are 5 years of age and older usually are able to cooperate with a glaucoma evaluation. The natural history of ocular hypertension after pediatric cataract surgery will be determined with longitudinal studies in the future.
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