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Bilateral Same-Day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project

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Bilateral Same-Day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project ORIGINAL STUDY Bilateral Same-day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project Michael Waisbourd, MD,* Anousheh Shafa, BS,* Radha Delvadia, BS,* Harjeet Sembhi, MPH,* Jeanne Molineaux, COA,* Jeffery Henderer, MD,w Laura T. Pizzi, PharmD, MPH,z Jonathan S. Myers, MD,* Lisa A. Hark, PhD, RD,* and L. Jay Katz, MD* reported in 2 patients (3%) and glare in 1 patient (1.5%). Thirteen Purpose: To report the outcomes of bilateral, same-day laser patients (19.7%) had repeat LPI treatment. All patients success- peripheral iridotomy (LPI) in the Philadelphia Glaucoma Detec- fully tolerated LPI treatment without serious complications. tion and Treatment Project. Conclusions: Performing bilateral, same-day LPI was well tolerated Methods: The Philadelphia Glaucoma Detection and Treatment in a large community-based, glaucoma detection and treatment Project was a community-based initiative aimed to improve project. Applying this treatment strategy may be considered in detection, management, treatment, and follow-up care of individ- similar settings, where patients’ access to eye care is limited and it uals at high risk for glaucoma. This novel project performed LPI, may be a cost-effective strategy. where 2 eyes received laser therapy on the same day. Of the 1649 patients examined between January 1, 2013 and May 31, 2014, Key Words: glaucoma detection, angle closure, laser peripheral patients who underwent bilateral, same-day LPI were included in iridotomy, bilateral same-day ocular procedures our analysis. Main outcome measures were visual acuity, intra- (J Glaucoma 2016;25:e821–e825) ocular pressure (IOP), and postoperative complication rates. Results: A total of 132 eyes of 66 patients underwent bilateral, aser iridotomy is aimed to eliminate the relative pupil- same-day LPI. Mean visual acuity remained unchanged following Llary block component of the angle-closure process.1 The treatment (P = 0.85). Eight patients (12.1%) had IOP spikes American Academy of Ophthalmology’s Preferred Practice >5 mm Hg following treatment, and 4 patients (6.1%) spiked >10 mm Hg. IOP returned to normal in all but 1 patient, who was Pattern Guidelines recommend considering this treatment diagnosed with chronic angle-closure glaucoma. Hyphema was for patients with iridotrabecular contact (ITC) and normal intraocular pressure (IOP) to reduce the risk of developing chronic angle-closure and acute angle-closure crisis.2 Received for publication June 30, 2015; accepted February 2, 2016. Treatment is often performed in both eyes with separate From the *Glaucoma Research Center, Wills Eye Hospital; wDepart- ment of Ophthalmology, Temple University School of Medicine; procedures on different office visits. However, little is and zThomas Jefferson University School of Pharmacy, Phila- known about the outcomes of performing bilateral laser delphia, PA. peripheral iridotomy (LPI) on the same day. The findings and conclusions in this report are those of the authors and Simultaneous bilateral ocular procedures and surgeries do not necessarily represent the official position of the United States 3–8 Centers for Disease Control and Prevention. have been gaining popularity in recent years. Several case Supported by the United States Centers for Disease Control and Pre- series showed that bilateral intravitreal antivascular endo- vention (grant number: 1U58DP004060-01). thelial growth factor injections were well tolerated in office- Lumenis (San Jose, CA) donated the Selecta Duet laser platform. based settings. In 1 study, none of the patients requested Disclosure: L.J.K.: receives consultant fees from Allergan, Alcon, Glaukos Corporation, Aerie Pharmaceuticals, Bausch & Lomb, alternating unilateral injections after receiving bilateral Inotek Corporation, Sensimed AG, Alimera Sciences, ForSight injections,4 and other studies reported similar complication Vision, and Mati Therapeutics; receives payment for lectures, rates to unilateral injections.6,9 Some authors have sug- including service on speakers’ bureaus, from Allergan, Alcon, gested that cataract surgery should be performed bilaterally Merck, and Lumenis; and has stock/stock options in Glaukos 3,10 10 Corporation, Mati Therapeutics, and Aerie Pharmaceuticals. on the same day, as the standard of care. Visual acuity M.W.: received travel/accommodations/meeting expenses payment (VA) improved, patients satisfaction increased, and no from Alcon for the CPE Glaucoma Fellows course. Research complications could be attributed to procedures performed Support: Iridex Corporation; Diopsys Inc.; Heidelberg; Allergan; bilaterally.3,8 Moreover, the risk of postoperative endoph- OrCam; Merck, Partridge Foundation; Pennsylvania Department of Health; United States Centers for Disease Control and Pre- thalmitis was as low as published rates for unilateral sur- vention. L.A.H: receives research support from the United States gery.9 The bilateral approach also generated substantial Centers for Disease Control and Prevention. H.S.: Receives savings in health care and non–health care-related research support from the United States Centers for Disease Con- 5,11,12 trol and Prevention. L.T.P: Receives research support from Thomas costs. In 2010, 2 unilateral cataract surgeries totaled Jefferson University. J.H. Receives Research Support from CMS. $1566, compared with $1059 for 1 bilateral cataract surgery J.S.M. receives consultant fees from Alcon, Allergan, Inotek, (32.4% reduction) in Canada.7 Reichert. Receives payment for lectures from Alcon and Allergan. In January 2013, the Wills Eye Glaucoma Research Receives Research Support from Aerie, Alcon, Allergan, Haag- Center initiated The Philadelphia Glaucoma Detection and Streit, Merck. The other authors have no conflict of interest to declare. Treatment Project. This unique project mobilized com- Reprints: Michael Waisbourd, MD, Wills Eye Hospital Glaucoma munity partners to plan, develop, and implement an inte- Research Center, Philadelphia, PA 19107 (e-mail: mwaisbourd@ grated community-based intervention to improve detection, willseye.org). management, treatment, and follow-up care of Philadel- Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000409 phians at high risk for glaucoma. At the community sites, J Glaucoma Volume 25, Number 10, October 2016 www.glaucomajournal.com | e821 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. Waisbourd et al J Glaucoma Volume 25, Number 10, October 2016 LPI was performed for high-risk persons on both eyes during the same day. The purpose of this study was to investigate the outcomes of performing bilateral, same-day LPI in community setting. METHODS The Institutional Review Board of Wills Eye Hospital approved the study and the study was in accordance with HIPAA regulations. Researchers from the Wills Eye Glaucoma Research Center retrospectively reviewed the records of patients who were examined in a community- based glaucoma detection and treatment project. The design and methodology of this project are described in detail elsewhere.13 In brief, the target population of this project was the underserved Philadelphia population composed of African FIGURE 1. The Philadelphia Glaucoma Detection and Treatment Americans over age 50 and other individuals over age 60. Project. A van transports the intervention team to the community With the help of local community partners (eg, government site, along with all the necessary equipment for examination, treatment, and follow-up. Following a slit-lamp examination, agencies, nonprofit organizations, and community-based fundus photography, and automated perimetry, laser peripheral organizations) that serve African Americans and older iridotomy was performed bilaterally on the same day onsite adults, we conducted glaucoma-awareness educational (Courtesy: Roger Barone, Wills Eye Hospital). workshops at the community, in which audiences learned about glaucoma, with an emphasis on the importance of also used pretreatment and posttreatment to reduce the risk early detection and treatment. Persons at risk who attended of a postoperative IOP spike. An YAG LPI was performed the workshop were invited to attend glaucoma-detection at energy levels of 5 to 15 mJ, typically using between 1 and examinations. 3 pulses, depending on the thickness of the iris stroma and A 5-person screening team comprised of a physician the iris pigment. Thicker and darker irides were treated with (glaucoma specialist or fellow), a mobile unit coordinator, more power than light-colored irides. The position of the an ophthalmic technician, and 2 coordinators performed LPI was most often at the 3 or 9 o’clock position. Indi- the examinations at community sites. A large van trans- viduals had their IOP checked postprocedure (after 30 min ported the intervention team, along with all the necessary to 2 h) and then were discharged. Patients were given equipment for examination, treatment, and follow-up care postoperative steroid drops, and advised to use them 4 (Fig. 1). The glaucoma evaluation consisted of ocular, times daily for 4 days. Follow-up appointments were medical, and family history, VA, corneal pachymetry, scheduled at the community sites 4 to 6 weeks’ post- biomicroscopy of the anterior segment, IOP measurement operative and 4 to 6 months’ postoperative. using Goldmann applanation tonometer, gonioscopy, The current study reviewed the charts of patients who optic-nerve evaluation by indirect biomicroscopy, visual underwent bilateral same-day
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