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Current management of glaucoma
Kenneth Schwartza and Donald Budenzb
Purpose of review
Introduction
This study reviews current concepts in the goals of glaucoma The management of glaucoma typically proceeds from therapy, interventional sequence, and options for the interventions that are the safest and the least invasive, to management of glaucoma in light of recent clinical trials.
those that expose the patient to greater risk and are the Recent findings
most invasive. Glaucoma therapy involves medicines, la- Recent randomized prospective trials of ocular hypertension and glaucoma have provided evidence for more specifictreatment goals in glaucoma therapy. In addition, the advent of Treatment modality follows diagnosis, and the type and the prostaglandin analogs, advances in laser technology, and severity of disease must be determined before an appro- innovative techniques for filtering surgery have expanded the priate intervention can be selected. Recent, large, pro- armamentarium that ophthalmologists use in the treatment of spective studies have examined more closely the role of intraocular pressure (IOP) lowering in the prevention of progression of glaucomatous disease. The Collaborative Despite continued advances in laser and incisional surgery, Normal Tension Glaucoma Study, Advanced Glaucoma medical therapy still appears to be the primary means by which Intervention Study, Collaborative Initial Glaucoma intraocular pressure is controlled. Initial medical therapy has Study, Ocular Hypertensive Treatment Study, and the changed with the introduction of prostaglandin analogs, which Early Manifest Glaucoma Treatment Study all provide are replacing ␤-antagonists as the drug of first choice. Laser evidence that reduction of IOP reduces the rate of dis- trabeculoplasty, using either photocoagulative (argon and diode) or photodisruptive (frequency doubled Nd:YAG) lasers,is still reserved for patients who do not improve with medical Goals of glaucoma therapy
therapy, although there is good evidence that initial laser The goal of glaucoma therapy in ocular hypertension is trabeculoplasty is just as effective as initial medical therapy.
to lower IOP by at least 20% in patients at moderate to Trabeculectomy with antifibrotic agents (5-fluorouracil or high risk. In patients with perimetry-proven glaucoma, mitomycin C) is still the next step in intraocular pressure IOP should be lowered by at least 30% in early to mod- control, and glaucoma drainage implants are reserved for erate glaucoma, and perhaps 40% to 50% in severe refractory cases. Cyclophotocoagulation is a last resort glaucoma. A number of prospective, randomized clinical procedure because of poor visual outcomes and is reserved trials, including the Collaborative Normal Tension Glau- for patients with intractable pain and vision thought not to be coma Study [1,2], Advanced Glaucoma Intervention Study [3], Collaborative Initial Glaucoma Study [4], Ocu-lar Hypertension Treatment Study [5••], and Early Keywords
Manifest Glaucoma Study [6••] provide evidence that glaucoma, prostaglandin, SLT, filtering surgery the above treatment parameters may be useful in settingthe initial IOP goal in patients with glaucoma. However, Curr Opin Ophthalmol 15:119–126. 2004 Lippincott Williams & Wilkins.
because of individual variability in susceptibility to dam-age of the optic nerve, continued vigilance for progres-sion, using automated static perimetry and optic nervestereo photography, is necessary to determine whether individual patients will progress at the initial target IOP The Georgetown University Hospital/Washington Hospital Center Washington, DC, and bBascom Palmer Eye Institute, University of Miami School of Medicine, [7]. Visual fields and optic nerve photos should be moni- tored for signs of change, and IOP should be lowered an Correspondence to Donald L. Budenz, MD, 900 NW 17th Street, Miami, FL additional 15% if progression is detected [7].
33136, USATel: 305 326 6384; fax: 305 326 6337; e-mail: [email protected] Glaucoma management options
Current Opinion in Ophthalmology 2004, 15:119–126
Medical therapy
2004 Lippincott Williams & Wilkins There are three general categories of management op- tions available for IOP lowering. Each has been shown tobe effective in lowering IOP and preventing glaucomaprogression. Most clinicians begin with medical therapy,then go on to laser surgery, and finally perform surgery if Glaucoma
the IOP is not adequately controlled [Fig. 1]. This step- Table 2. Relative monotherapy efficacy and approximate
wise approach reflects the safety and efficacy of these percentage intraocular pressure lowering of currently
available topical glaucoma medications
treatments, although several clinical trials have studiedusing laser first [8] or incisional surgery first [4,9], and have gotten comparable results to medicine first.
Table 1 shows the available classes of medication used for chronic management of glaucoma. All work by low- ering IOP, either by improving aqueous humor outflow or reducing its production [10]. The exact mechanismsby which this is accomplished may differ between tions in that class group. There are conflicting data in the classes. For instance, prostaglandin derivatives improve literature regarding differences in efficacy between la- aqueous outflow primarily through the uveoscleral path- tanoprost and bimatoprost. Several studies have shown a way, whereas cholinergic agonists exert their effect on minor (0.5 to 2 mm Hg) difference in IOP-lowering ef- the trabecular meshwork outflow system exclusively.
fect in favor of bimatoprost [17–19•], although all butone of these [19•] failed to show a statistically significant The osmotic agents (mannitol, glycerin, urea) are in- difference with properly performed statistical analyses.
cluded in the interest of completeness. These potent An initial report on travoprost purported a better re- agents are used in two situations: (1) in the acute man- sponse to travoprost than latanoprost in black subjects agement of elevated IOP (such as acute angle closure [20]. However, this was true at only a few time points, glaucoma), or (2) before incisional surgery where the IOP and proper statistical analysis of these data, taking into is elevated or the eye may be open for a long time, to account differences in baseline IOPs, fails to show a dif- prevent expulsive suprachoroidal hemorrhage. The ference in favor of one drug over the other in black pa- mechanism of action of these drugs, as traditionally tients [21]. Subsequent studies comparing travoprost and taught, is to shrink the vitreous by increasing the osmotic latanoprost or bimatoprost have failed to detect any sta- gradient between the plasma and the eye, thereby low- tistically significant differences in response in black sub- ering the IOP by reducing the volume in the eye. The jects [22•,23•]. In the only randomized prospective trial exact mechanism whereby these drugs work is still un- comparing latanoprost, bimatoprost, and travoprost, no statistically significant differences in IOP lowering werefound, even in a subanalysis of black subjects [23•]. So, When prescribing initial medical therapy for glaucoma or regarding efficacy within the prostaglandin derivative ocular hypertension, there are a number of factors to class, the only conclusive studies show that unoprostone consider. Efficacy, side effects, cost, convenience of dos- is significantly less effective at lowering IOP than the ing, and a new possible consideration, differences in di- other three in this class. Latanoprost, bimatoprost, and urnal fluctuation, all must be considered. Entire mono- travoprost appear to have similar efficacy.
graphs have been written to address these issues [11,12].
Figure 1. Glaucoma treatment decision tree
Table 2 shows the approximate range of IOP loweringthat one may expect based on well-performed controlledclinical trials of these medications. More complete sum-maries are available in the references [11–13,14•].
Classes of medications have been split into individualmedications when appropriate. For instance, betaxolol, a␤-1 selective ␤-blocker, is not as effective as nonselec-tive ␤-blockers such as timolol or levobunolol. And uno-prostone, a prostaglandin derivative, is less effective thanlatanoprost [15,16•] and, most likely, the other medica- Table 1. Mechanism of action of glaucoma medications
Treatment options for glaucoma, based on responses. CAI, carbonic anhydrase inhibitors; IOP, intraocular pressure; OHT, ocular hypertension; ON, optic nerve; PG, prostaglandin; VF, visual field.
Current management of glaucoma Schwartz and Budenz
One important point is that the above efficacies are from Table 4. Relative frequency/severity of systemic side effects of
clinical trial data from patients with open angle glauco- current topical glaucoma medications
mas who started with IOPs in the mid to upper 20s. If one starts with a higher IOP, then percentage lowering may be more than if one starts at a lower IOP. Also, these approximations only apply if the medicine is used at the frequency recommended by the package insert. In par- ticular, the topical carbonic anhydrase inhibitors and bri- PG, prostaglandin. Adapted with permission [13].
monidine are labeled as three times daily medicationsbecause twice-daily dosing results in significant trougheffects when used as monotherapy [24–26]. However, in In general, topical medications for glaucoma are very combination therapy with a nonselective ␤-blocker, well tolerated systemically [10]. There are minor differ- these two medications seem to be equivalent whether ences, however, in individual medications and in particu- used twice daily or three times daily.
lar patient groups. For example, nonselective ␤-blockersare usually well tolerated, but may cause an exacerbation Our decision about which medication to choose for our of respiratory symptoms in patients with reactive airway patient is never really based on efficacy alone. Other- disease (such as asthma) and bradycardia in susceptible wise, all of our patients with glaucoma would be on sys- patients. Impotence and decreased exercise tolerance temic carbonic anhydrase inhibitors! Ocular and systemic have also been reported with ␤-blockers. Betaxolol, a ␤-1 tolerability, dosing regimen, and cost must be considered receptor selective antagonist, has fewer respiratory side effects, although the other side effects mentioned for the␤-blockers are no less in betaxolol-treated patients. Bri- Table 3 rates classes of topical glaucoma medications, monidine has been associated with respiratory and car- and medications within classes where they differ, on the diac depression in infants and is contraindicated under basis of the frequency and severity of ocular side effects age 2, and caution is indicated in all pediatric patients [13]. Cholinergic medicines, such as pilocarpine, have and nursing mothers. Both brimonidine and topical car- excellent efficacy and cost, but have been largely aban- bonic anhydrase inhibitors can cause fatigue and drowsi- doned because of the severity of their ocular side effects ness in adults (elderly patients are particularly suscep- compared with newer agents available. Brimonidine has tible), and thus are not as well tolerated systemically as a relatively high rate of allergic response, and the dis- the prostaglandin derivatives and cholinergic agonists. In continuation rate for this medication because of ocular addition, many patients complain of a metallic taste per- adverse events is relatively high compared with the other version while using topical carbonic anhydrase inhibitors.
medications. In a well-performed 12-month study com- Table 4 rates the available topical glaucoma agents ac- paring brimonidine to timolol, the discontinuation rate was 45% for brimonidine, primarily because of ocularadverse events, compared with only 17% for timolol [26].
Dosing regimen is an important factor in patient compli-ance. Although there is good evidence in the ophthalmicliterature to suggest that compliance is worse with four Within the prostaglandin derivative class, latanoprost times daily compared with twice daily dosing regimens and unoprostone appear to have better ocular tolerability [27,28], evidence for differences in compliance between than travoprost and bimatoprost, specifically because of twice daily and every day dosing is lacking. In fact, a the higher rate and severity of ocular hyperemia associ- large review of the literature on compliance with oral ated with the latter two medications [23]. An excellent medications found 70% compliance with twice daily or table comparing the frequency of ocular adverse events every day dosing [29], compared with 52% for three reported in the Phase 3 clinical trials on the prostaglan- times daily dosing and 42% with four times daily dosing.
dins may be found in [12], pages 132 to 133.
Differences in the cost of glaucoma medications aremostly related to the availability of these medicines in Table 3. Relative frequency/severity of ocular side effects of
current topical glaucoma medications
generic form. The nonselective ␤-blockers and choliner-gic agonists have been around for more than 25 years; thus, generics are available and relatively inexpensive ($0.38 to $0.50 per day for bilateral therapy with generics vs $0.90 to $1.33 per day for newer agents) [30•]. A ge- neric form of brimonidine recently became available, and the cost to pharmacies is approximately half the cost of the branded formulation [31]. However, it is unclear Glaucoma
whether pharmacies will pass this cost-savings on to pa- sources. Phase II of the Ocular Hypertension Treatment Study has just received funding to try to answer thisimportant issue.
A recent study suggests that high diurnal fluctuation ofIOP, even in treated patients, can result in more progres- Laser surgery
sion compared with patients who do not show high di- Laser surgery for open angle glaucoma generally refers to urnal fluctuations [32]. A subsequent study showed that laser trabeculoplasty, although endolaser laser photoco- latanoprost-treated patients show less diurnal variation in agulation of the ciliary processes has become more IOP than patients treated with timolol or dorzolamide widely used in the management of glaucoma. Photoco- [33]. There is an excellent review on the importance of agulation of the ciliary processes, using either an endo- diurnal fluctuation in glaucoma management by Jacob laser or transscleral technique, has generally been re- Wilensky, MD, in this edition of Current Opinion in served for eyes refractory to all other medical or surgical treatments. Some have advocated endolaser cyclophoto-coagulation as a viable earlier treatment modality [37,38] Although IOP-lowering therapy medically has been in developed countries, and others have advocated trans- shown to be beneficial in delaying or preventing the scleral cyclophotocoagulation in developing countries onset of glaucoma in ocular hypertensives and delaying [39], where healthcare resources do not permit the usual or preventing visual field loss in those with glaucoma, stepwise approach to glaucoma management that are there must be a consideration of the potential downside available here in the United States and the remainder of of therapy in general and of specific therapies. For ex- ample, in a 90-year-old ocular hypertensive patient withno visual field loss, observation to see if the patient de- Laser trabeculoplasty has been used in the management velops glaucoma might be better than lowering the IOP of open angle glaucomas for more than 20 years. Initially by 20%, especially if your therapy introduces the risk of performed with the argon blue-green wavelength ocular or systemic side effects or high medication costs.
[40,41], the same effect may be achieved using argon At the other end of the spectrum, let’s consider a 60- green, diode green, and a frequency-doubled Nd:YAG year-old patient with severe, progressive glaucoma who laser, known as selective laser trabeculoplasty. There are has IOPs in the mid-20s on maximal medical therapy and some advantages to laser trabeculoplasty when compared has already received laser trabeculoplasty. The risk of with medical treatment or incisional surgery. It does re- permanent disability is high without IOP lowering, and duce IOP in most patients, there is no risk of bleeding or the benefits of successful trabeculectomy are high. One infection because it is relatively noninvasive, there is less would probably be willing to accept the small risk of dependence on patient compliance to provide IOP con- complications from trabeculectomy surgery in this case.
trol, and the IOP becomes less susceptible to diurnalvariation [42].
There is some debate as to whether treating IOP earlyprovides more benefit than waiting until one establishes Laser trabeculoplasty results in an IOP reduction of 20% that glaucoma is present and, if it is, what the rate of to 30% in most patients. However, the effect wears off in progression is. Advocates of early treatment believe that 5% to 10% of patients per year, and the 5-year and 10- prolonged elevation of IOP triggers a series of events year success rate is approximately 50% and 32%, respec- that results in progressive loss of ganglion cells even after tively [43]. The poor long-term success may be because IOP is adequately controlled. This hypothesis may ex- of progression of the disease with worsening IOP or plain why some patients continue to progress despite structural changes in the trabecular meshwork over time, adequate control of IOP [34]. If this is true, it suggests such as scarring and fusion of trabecular beams [44,45].
early intervention for elevated IOP is necessary. If earlytreatment turns out not to be very important, then wait- The Glaucoma Laser Trial was a prospective, random- ing for signs of manifest glaucoma (optic nerve changes ized study comparing the efficacy and safety of medical or visual field abnormalities) is a reasonable strategy in therapy first versus argon laser trabeculoplasty (ALT) ocular hypertension management. Observing patients first in the management of glaucoma [8]. In each previ- with glaucoma for evidence of progression to determine ously untreated patient, one eye was randomized to ALT the rate of progression and then tailoring treatment to first and the other to medical therapy with timolol 0.5% reduce this rate is a reasonable option. This debate is an first. Two-year success rates for the Glaucoma Laser important one in public health circles, because treating Trial showed a success rate of 44% if eyes were treated everyone with ocular hypertension is a costly endeavor.
with laser alone, or controlled with a combination of laser The Framingham Eye Study [35] and The Baltimore first and any medication at 2 years. This gave support to Eye Survey [36] found that 4% to 7% of people older laser therapy when compared with the 30% figure for than age 40 have elevated IOP; thus, treating all of them eyes treated with timolol 0.5% alone. Seventy percent of would place a tremendous burden on health care re- eyes treated with laser followed by timolol alone had Current management of glaucoma Schwartz and Budenz
controlled IOP at 2 years, whereas 66% of eyes treated is fairly limited, even among glaucoma subspecialists.
with a stepwise medical regimen alone were successful at This is because studies have not shown IOP lowering in 2 years. Eighty-nine percent of patients thought that the most patients to be as good as trabeculectomy, although idea of laser trabeculoplasty is a reasonable initial treat- the complication rate is less [58•,59••]. Glaucoma drain- age implants have traditionally been reserved for pa-tients who have refractory glaucoma (neovascular, in- Despite the successful results of laser trabeculoplasty as flammatory) or those who have not improved with an initial treatment modality in the Glaucoma Laser trabeculectomy or have conjunctival scarring from previ- Trial, members of the American Glaucoma Society (who ous ocular surgery. Success rates with these devices are were polled 1 to 2 years after the results of the Glaucoma comparable to that of trabeculectomy, although there are Laser Trial were published) were only rarely or never limited data from randomized prospective trials [60].
performing this procedure as an initial management op-tion [46].
Trabeculectomy has been used for more than 20 yearsfor the surgical management of glaucoma and is currently Selective laser trabeculoplasty (SLT) is a frequency- the most widely used incisional procedure worldwide.
doubled Nd:YAG laser that delivers a brief duration (3 When initial trabeculectomy was compared with medical nS), large spot (400 µm), relatively low-energy (approxi- therapy in the Collaborative Initial Glaucoma Study, it mately 0.75 mJ) spot to the trabecular beams [47]. It was found to provide lower IOPs than medical therapy, reportedly targets pigmented trabecular meshwork cells, although the rate of visual field progression was negli- possibly stimulating them to divide and provide im- gible in both groups [4]. There was no difference in proved outflow through the trabecular meshwork [48].
quality of life noted between the initial trabeculectomy Histologic studies in human cadaver eyes have demon- versus medical group, either [61]. Other advantages of strated much less damage to surrounding trabecular trabeculectomy over medical therapy include stabiliza- beams with SLT compared with ALT [49]. This may tion of IOP (minimizing diurnal fluctuation), less reli- result in improved long-term success and the ability to ance on patient compliance to take medications, and less retreat the meshwork in the future with more success dependence on patient financial resources to stay com- using SLT compared with ALT. There is a single pro- spective randomized trial comparing ALT and SLT inthe literature by Damji et al. [50]. In this 6-month trial,they found the same degree of IOP lowering using both Despite these advantages, in developed countries tra- lasers, approximately 21%. Just under half of patients in beculectomy is still performed after medications and la- each group had already undergone ALT, therefor this ser surgery have failed. This is probably because of the group of patients would not be expected to be particu- risk of immediate visual loss from complications of sur- larly responsive to further laser treatment.
gery, such as choroidal effusion, hypotony maculopathy,suprachoroidal hemorrhage, or optic nerve snuffing.
In the only published report on SLT used as initial There are also long-term risks to vision, such as hypotony therapy for glaucoma, Melamed et al. [51••] found an maculopathy, bleb infections, and cylindrical changes in average 30% drop in IOP in the overall group, a number similar to that obtained with initial medical therapy withprostaglandin derivatives shown in other studies with Glaucoma drainage implants are most commonly used in similar baseline IOPs. A randomized prospective trial patients with glaucoma refractory to trabeculectomy or comparing initial SLT to initial medical therapy is on- with neovascular [62,63] or inflammatory glaucomas [64•]. Recently, however, there has been interest in per-forming glaucoma drainage tube implants as an alterna- Incisional surgery
tive to trabeculectomy in primary procedures [60]. More Incisional surgery has traditionally been reserved for pa- studies are needed to determine the safety and efficacy tients who do not improve with medical and laser of glaucoma drainage implants compared directly to tra- therapy for glaucoma, except in congenital and infantile glaucomas. Trabeculectomy remains the most commonlyperformed incisional surgery for glaucoma. This may beperformed with antifibrotic agents, such as 5-fluorouracil Treatment algorithm
or mitomycin C in high-risk patients [53–56]. There is The figure represents our thought process in treating reasonable evidence that these agents enhance success glaucoma. This algorithm is not meant to be a cookbook in primary filtering surgery (those with no prior incisional approach to treatment. Rather, it forms the architecture surgery) [57]. Although deep sclerectomy and viscoca- of a decision-making tree that must be tempered with nalostomy (nonpenetrating filtration surgery) have the individual situation of the patient and an overall ge- gained popularity overseas, their use in the United States stalt of the nature of that patient’s disease.
Glaucoma
First, the decision to initiate treatment in an ocular hy- time of trabeculectomy, and which one to choose, is vari- pertensive patient is variable. This decision is based able among glaucoma specialists. Most glaucoma special- upon an individual patient’s risk factors for the develop- ists are using adjunctive antifibrotic agents at the time of ment of glaucoma, such as level of IOP elevation, optic nerve appearance, family history of glaucoma, race, age,central corneal thickness, and the patient’s own prefer- References and recommended reading
ence for preventative medicine therapy. Generally, Papers of particular interest, published within the annual period of review, therapy is initiated with medications, although laser tra- beculoplasty is a reasonable first-line agent. Of the classes of medicines available for lowering IOP, the pros- taglandins have the best balance between efficacy (25% Collaborative Normal-tension Glaucoma Study Group: Comparison of glau-comatous progression between untreated patients with normal-tension glau- to 30% lowering), safety, and ease of dosing regimen. If coma and patients with therapeutically reduced intraocular pressures. Am J the patient cannot afford prostaglandin therapy, then a topical ␤-blocker can be started if there are no systemic Collaborative Normal-tension Glaucoma Study Group: The effectiveness of contraindications. If only a minimal decrement in IOP is intraocular pressure reduction in the treatment of normal-tension glaucoma.
Am J Ophthalmol 1998, 126:498–505.
seen, the patient is switched to a different class of medi- The AGIS Investigators: The Advanced Glaucoma Intervention Study (AGIS) cine, usually the ␤-blockers, because of their efficacy, 7: The relationship between control of intraocular pressure and visual field tolerability, and ease of dosing. If the IOP does go down deterioration. Am J Ophthalmol 2000, 130:429–440.
a bit with a prostaglandin, but is not at target IOP, a Lichter PR, Musch DC, Gillespie BW, et al., for the CIGITS Study Group.: ␤-blocker is added. Then, if these maneuvers are unsuc- Interim clinical outcomes in the Collaborative Initial Glaucoma TreatmentStudy comparing initial treatment randomized to medication or surgery. Oph- cessful, one can add a topical carbonic anhydrase inhibi- tor, usually in the form of the fixed combination of ti- Kass MA, Heuer DK, Higginbotham EJ, et al., and the Ocular Hypertension molol 0.5% and dorzolamide, again attempting to keep Treatment Study Group. The Ocular Hypertension Treatment Study. A ran- the dosing regimen simple. If this does not work, the domized trial determines that topical ocular hypotensive medication delays orprevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002, dorzolamide is stopped and substituted with bri- monidine. Once three or four medicines have been tried Large, randomized, prospective, multicenter study that examined the effects oftreatment versus nontreatment in ocular hypertensives. The goal in the medication and the IOP remains refractory, laser trabeculoplasty is group was to reduce the IOP by 20% or more and to reach an IOP of 24 mm Hg or performed. If it seems unlikely that laser will make less. At 5 years, the cumulative probability of developing primary open-angle glau-coma was 4.4% in the medication group and 9.5% in the observation group.
enough of an impact on IOP, trabeculectomy is recom- Heijl A, Leske MC, Bengtsson B, et al.: Reduction of intraocular pressure and mended. Usually primary trabeculectomy is completed glaucoma progression. Results form the Early Manifest Glaucoma Trial. Arch with intraoperative and possibly postoperative 5-fluoro- Large, randomized prospective study performed in Sweden to evaluate glaucoma- uracil, unless the patient has risk factors for scarring, such tous progression in patients with early manifest glaucoma. Two hundred fifty-five as young age or prior incisional eye surgery, in which case patients with open-angle glaucoma were randomized to ALT plus topical betaxololor no treatment and were followed up every 3 months. Results showed that treated patients had half the risk of progression of their nontreated counterparts. Disk hem-orrhage, higher IOP, pseudoexfoliation, worse mean deviation, and older age wereall risk factors for progression.
Conclusion
Although there are a number of options that have been
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Schuman JS, Horwitz B, Choplin NT, et al.: A 1-year study of brimonidine Kramer TR, Noecker RJ: Comparison of the morphologic changes after se- twice daily in glaucoma and ocular hypertension. A controlled, randomized, lective laser trabeculoplasty and argon laser trabeculoplasty in human eye multicenter clinical trial. Chronic Brimonidine Study Group. Arch Ophthalmol bank eyes. Ophthalmology 2001, 108:773–779.
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Kass MA, Meltzer DW, Gordon M, et al.: Compliance with topical pilocarpine This study explored the safety and efficacy of SLT as primary treatment for patients treatment. Am J Ophthalmol 1986, 101:515–523.
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and effective treatment for newly diagnosed ocular hypertension and open-angle Greenberg RN: Overview of patient compliance with medication dosing: a literature review. Clin Ther 1984, 6:592–599.
http://www.som.tulane.edu/tccep/slt/slt.htm Fiscella RG, Green A, Patuszynski DH, et al.: Medical therapy cost consider- Fluorouracil Filtering Surgery Study one-year follow-up: The Fluorouracil Fil- ations for glaucoma. Am J Ophthalmol 2003, 136:18–25.
tering Study Group. Am J Ophthalmol 1989, 108:625–635.
This study attempted to calculate the daily patient cost of medical glaucomatherapy and review cost trends. Findings were that all generic timolol, Betimol, Three year follow-up of the Fluorouracil Filtering Surgery Study: The Fluoro- OptiPranolol, Timoptic, and Timoptic XE ranged from 38 cents to 50 cents per day.
uracil Filtering Study Group. Am J Ophthalmol 1993, 115:82–92.
Cosopt (US$1.05 per day) was less costly than separate bottles of a topical Chen CW: Enhanced intraocular pressure controlling effectiveness of tra- ␤-blocker and a topical carbonic anhydrase inhibitor. The prostaglandin analogs beculectomy by local application of mitomycin-C. Trans Asia-Pacific Acad ranged from 90 cents per day (Rescula) to $1.25 per day (Xalatan).
Gonzalez: Serafin, RPh, Pharmacy Director, Anne Bates Leach Eye Hospital.
Palmer SS: Mitomycin as adjunct chemotherapy with trabeculectomy. Oph- Glaucoma
Singh K, Mehta K, Shaikh NM, et al.: Trabeculectomy with intraoperative mi- Initial Glaucoma Treatment Study: interim quality of life findings after initial tomycin C versus 5-fluorouracil. Prospective randomized clinical trial. Oph- medical or surgical treatment of glaucoma. Ophthalmology 2001, Lachkar Y, Hamard P: Nonpenetrating filtering surgery. Curr Opin Ophthal- Mermoud A, Salmon JF, Alexander P, et al.: Molteno tube implantation for neovascular glaucoma. Long-term results and factors influencing the out- This article provides a thorough review of the various modalities of nonpenetrating come. Ophthalmology 1993, 100:897–902.
filtering surgery. The article examines techniques, efficacy, and results from clinicaltrials.
Sidoti PA, Dunphy TR, Baerveldt G, et al.: Experience with the Baerveldtglaucoma implant in treating neovascular glaucoma. Ophthalmology 1995, Carassa RG, Bettin P, Fiori M, Brancato R: Viscocanalostomy versus trabec- ulectomy in white adults affected by open-angle glaucoma: a 2-year random-ized, controlled trial. Ophthalmology 2003, 110:882–887.
Ceballos EM, Parrish RK 2nd, Schiffman JC: Outcome of Baerveldt glaucoma Single-masked, prospective, randomized 24 month trial comparing the effective- drainage implants for the treatment of uveitic glaucoma. Ophthalmology ness and safety of viscocanalostomy and trabeculectomy in adults with uncon- trolled open-angle glaucoma. The group randomized to viscocanalostomy Retrospective, noncomparative case series that looked at 24 eyes of 24 patients achieved IOP between 6 mm Hg and 21 mm Hg 76% of the time versus 80% of the who received Baerveldt glaucoma drainage implants for the treatment of uveitic time for trabeculectomy with no intraoperative antimetabolites. A lower pressure, glaucoma. Success (IOP 5 to 21 mm Hg) was achieved in 91.7% of the patients at albeit with a greater complication rate and more labor-intensive postoperative 24 months. The study concluded that these drainage implants provide reasonable course, was achieved more often with trabeculectomy.
safety and effectiveness for the control of IOP in eyes with uveitis and refractory Wilson MR, Mendis U, Smith SD, et al.: Ahmed glaucoma valve implant vs trabeculectomy in the surgical treatment of glaucoma: a randomized clinical trial. Am J Ophthalmol 2000, 130:267–273.
Chen PP, Yamamoto T, Sawada A, et al.: Use of antifibrosis agents and glau-coma drainage devices in the American and Japanese Glaucoma Societies. J Janz NK, Wren PA, Lichter PR, et al.: CIGTS Study Group. The Collaborative

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