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Effectiveness of Single-Digit IOP Targets on Decreasing Global And

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Effectiveness of Single-Digit IOP Targets on Decreasing Global And ORIGINAL STUDY Effectiveness of Single-Digit IOP Targets on Decreasing Global and Localized Visual Field Progression After Filtration Surgery in Eyes With Progressive Normal-Tension Glaucoma Shawn M. Iverson, DO, Scott K. Schultz, MD, Wei Shi, MS, William J. Feuer, MS, and David S. Greenfield, MD progression,4–8 glaucoma can exist even among individuals Purpose: To examine the effectiveness of achieving single-digit for whom IOP measurements are within the statistically intraocular pressure (IOP) targets with filtration surgery on defined “normal range.”9–12 Although an artificial con- decreasing global and localized visual field (VF) progression in eyes struct, normal-tension glaucoma (NTG) is a widely used with progressive normal-tension glaucoma (NTG). term to classify the disease in patients with glaucomatous Methods: A retrospective chart review was conducted to identify optic neuropathy with or without visual field (VF) loss NTG patients who underwent trabeculectomy with mitomycin C whose pressures are within the 95th percentile of the normal between 2006 and 2010 for progressive VF loss with preoperative distribution of IOP measurements in the healthy population IOPr15 mm Hg during the 12 months before surgery. All eyes had (IOP < 22 mm Hg using Goldmann applanation tonom- glaucomatous optic neuropathy and progressive VF loss, uncon- etry).1–2 NTG is a common disorder and accounts for trolled IOP on maximum therapy, and a minimum of 2 baseline approximately 20% to 30% of open-angle glaucoma cases preoperative and 4 postoperative VF examinations. VF progression in the United States1–4 and a significantly higher proportion was assessed using Guided Progression Analysis (GPA) and Pro- 13 gressor software. in other parts of the world, particularly Korea (77%) and Japan (92%).5 Results: Fifteen eyes of 14 patients (mean age 71.8 ± 7.5 y) were The beneficial effect of reducing IOP by 30% in eyes enrolled with mean follow-up of 71 ± 26 months. Mean post- with NTG has been demonstrated.7–11 Most patients ach- operative IOP (8.5 ± 3.5 mm Hg) was significantly (P < 0.001) ieve this therapeutic target using nonsurgical therapy reduced compared with preoperatively (13.1 ± 1.5 mm Hg). The including antiglaucomatous medication and laser trabecu- probability of achieving an IOP goal r10 mm Hg was 66% at 4 years’ follow-up. The overall rate of postoperative VF progression loplasty. The treatment of progressive NTG that fails to using any method was 13.3% (1 eye using Progressor; 1 eye using respond to medical therapy represents a therapeutic chal- GPA and Progressor). Average postoperative slope of MD lenge, particularly in eyes in which progression has occur- (À0.25 ± 0.86 dB/y) and pattern SD (0.49 ± 0.83 dB/y) were red at low IOP levels. Glaucoma filtration surgery in NTG improved (P = 0.05 and 0.07) compared with the preoperative eyes has been well described.9,12,14–16 Aoyama et al12 dem- slopes (À1.05 ± 0.66 and 1.21 ± 0.71 dB/y). onstrated that VF progression in NTG patients was halted Conclusions: Achieving single-digit IOP targets with filtration sur- in a large proportion of patients after trabeculectomy when gery has a beneficial effect on reducing global and localized rates of IOP was reduced by at least 20%, with better efficacy if VF progression in NTG eyes with progression at low IOP. lowered by 30%. Eyes with progressive VF loss at very low preoperative Key Words: normal-tension glaucoma, filtration surgery, intra- IOP have a therapeutic window that is considerably more ocular pressure, visual field, progression narrow and represent a unique challenge. The risk-to-ben- (J Glaucoma 2016;25:408–414) efit ratio must be carefully considered given that trabecu- lectomy in eyes with NTG carries an increased risk of hypotony, hypotony maculopathy, and choroidal effu- sion.15–17 To avoid such complications, many clinicians will laucoma is a progressive disorder characterized by avoid surgical intervention in these patients despite pro- Gstructural and functional abnormalities of the optic 1–3 gressive VF loss. We have recently reported that trabecu- nerve. Even though intraocular pressure (IOP) is the lectomy with antifibrosis therapy is a safe and effective most important modifiable risk factor for disease onset and strategy for achieving long-term IOP reduction of 20% to 40% in NTG eyes with VF progression at very low pre- Received for publication August 4, 2014; accepted January 9, 2015. operative IOP levels.18 In the present study, we examined From the Bascom Palmer Eye Institute, University of Miami Miller the effectiveness of achieving single-digit IOP targets with School of Medicine, Miami, FL. Supported by University of Miami Core Grant (P30-EY014801), glaucoma filtration surgery on decreasing global and Bethesda, MD; an unrestricted grant from Research to Prevent localized VF progression in eyes with progressive NTG. Blindness, New York, NY; a grant from the Department of Defense (W81XWH-09-1-0675); The Maltz Family Endowment for Glau- coma Research, Cleveland, OH. METHODS Disclosure: The authors declare no conflict of interest. Reprints: David S. Greenfield, MD, Bascom Palmer Eye Institute, Study Population University of Miami Miller School of Medicine, 7101 Fairway After Institutional Review Board approval was Drive, Palm Beach Gardens, Miami, FL 33418 (e-mail: dgreenfi[email protected]). obtained from the University of Miami Miller School of Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Medicine Clinical Research Ethics Board, a retrospective DOI: 10.1097/IJG.0000000000000240 chart review was conducted. Consecutive open-angle 408 | www.glaucomajournal.com J Glaucoma Volume 25, Number 5, May 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. J Glaucoma Volume 25, Number 5, May 2016 Single-Digit IOP Targets glaucoma patients who had undergone trabeculectomy by a absence of VF progression using event-based and trend- single surgeon (D.S.G.) at Bascom Palmer Eye Institute, based methods. For event-based progression analysis, we Palm Beach Gardens, Florida between February 1, 2006 used GPA, a method that uses statistical criteria designed and October 31, 2010 were identified. Patients with NTG for the Early Manifest Glaucoma Trial19 and compares the had glaucomatous optic neuropathy consisting of neuro- locations on pattern deviation change probability map of retinal rim narrowing, progressive VF loss, and initial follow-up VFs to the average of 2 baseline examinations. untreated IOP < 21 mm Hg, with no single reading An automated analysis identifies test locations that show >22 mm Hg. The baseline IOP of each patient was change greater than the expected variability in pattern reported as the average of consecutive IOP measurements deviation at the 95% significance level. Progression was during the 12-month period before surgery. Patients with defined as a significant change detected in Z3 points, and mean preoperative IOPr15 mm Hg during the 12-month repeated in the same locations on 3 consecutive tests, and period before surgery were enrolled. Exclusion criteria categorized by the GPA software as “Likely Progression.” consisted of age 18 years and below, recorded IOP > 22 The trend-based analysis method used automated pointwise mm Hg on any visit, ocular disease other than glaucoma, linear regression (PLR) analysis of VF sensitivity values prior incisional surgery except uncomplicated cataract extraction, follow-up period of <12 months, <2 pre- operative or 4 postoperative VF examinations using a TABLE 1. Baseline Clinical Characteristics of the Study Swedish Interactive Threshold Algorithm (SITA) standard Population (n = 15) 24-2 strategy (Humphrey Field Analyzer II; Carl Zeiss Clinical Variables No. Patients (%) Meditec, Dublin, CA), or VFs other than standard white- on-white using a size III stimulus. Only reliable VF results Age (y) consisting of <15% fixation losses and <30% false neg- Mean (±SD) 71.8 ± 7.5 Median (range) 71 (54-85) ative or false positives were included. Sex All patients had preoperative glaucomatous pro- Male 4 (27) gression evaluated using the Humphrey Field Analyzer Female 11 (73) Guided Progression Analysis (GPA, software version 4.2; Race Carl Zeiss Meditec), defined as a significant decrease from White 13 (86) baseline (2 examinations) pattern deviation at Z3 of the Black 1 (7) same test points on 3 consecutive tests, or by serial review Hispanic 1 (7) of longitudinal VFs with confirmatory testing in referral Anticoagulation/antiplatelet 9 (60) patients. Intraocular pressure (mm Hg) Mean ± SD 13.1 ± 1.5 Glaucoma surgery was indicated in patients with VF Median (range) 12.5 (11.1-15.5) progression and in whom the IOP was considered unsat- BCVA (logMAR) isfactory for the extent of glaucomatous damage. Trabe- Mean ± SD 0.21 ± 0.28 culectomy was performed in a standardized manner. A Median (range) 0.1 (0-1) superior limbus-based or fornix-based flap was created, and 20/20-20/40 12 (80) a fluid-retaining sponge soaked with MMC (0.4 mg/mL) 20/50-20/80 2 (13) was applied to the superior sclera for 1 to 3.5 minutes. A 20/100-20/200 1 (7) single highly myopic patient received intraoperative 5-flu- Spherical equivalent À orouracil (50 mg/mL, 5 min duration) at the time of trabe- Mean ± SD 1.97 ± 2.99 Median (range) À1.25 (À7.25 to 1.5) culectomy. A partial-thickness scleral flap was dissected, Glaucoma medications and a paracentesis was made. A block of limbal tissue was Mean ± SD 2.53 ± 1.25 excised underneath the trabeculectomy flap. The scleral flap Median (range) 3 (0-4) was reapproximated to the scleral bed with interrupted 10-0 Prior surgery nylon sutures. The conjunctiva was closed, and Seidel Cataract extraction 4 (27) testing was performed at the conclusion of the case. Laser trabeculoplasty 7 (47) Surgical failure was defined as inadequate IOP Lens status* reduction (categorized as <30% reduction from the base- Phakic 11 (73) line IOP on 2 consecutive follow-up visits after 3 mo), Pseudophakic 4 (27) Visual field (dB) reoperation for glaucoma, or loss of light perception vision.
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