Publications by authors named "Thasarat Vajaranant"

63 Publications

Experience with netarsudil 0.02% and latanoprostene bunod 0.024% as adjunctive therapy for glaucoma.

Eur J Ophthalmol 2021 Mar 2:1120672121998913. Epub 2021 Mar 2.

Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA.

Purpose: To assess the effectiveness and safety of adjunctive topical netarsudil 0.02% and latanoprostene bunod 0.024% in patients with glaucoma.

Methods: A retrospective, multi-center, cohort study of patients with glaucoma treated with netarsudil 0.02% or latanoprostene bunod from five tertiary care centers. Inclusion criteria included patients with glaucoma treated with either medication as adjunctive therapy. Outcomes included mean absolute intraocular pressure (IOP) reduction and relative IOP reduction from baseline. Adverse reactions and reasons for discontinuation were reported. One-way analysis of variance, Kruskal-Wallis rank sum test, and Mann Whitney test compared the outcomes.

Results: A total of 95 eyes (95 patients) on netarsudil and 41 eyes (41 patients) on latanoprostene bunod were analyzed. Mean duration of use was 54.3 ± 28 days for netarsudil and 82.9 ± 51.2 days for latanoprostene bunod. At the final visit, mean IOP reduction was 3.9 ± 4.6 mmHg (17.5 ± 6.0%) ( < 0.0001) with netarsudil and 2.9 ± 3.7 mmHg (13.6 ± 16.3%) ( < 0.0001) with latanoprostene bunod. IOP lowering did not depend on baseline number of IOP-lowering medications. The most common reason for discontinuation was non-effectiveness in both groups.

Conclusion: Similar to monotherapy, netarsudil and latanoprostene bunod demonstrated efficacy in lowering IOP when used as adjunctive therapy.
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http://dx.doi.org/10.1177/1120672121998913DOI Listing
March 2021

Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review.

Asia Pac J Ophthalmol (Phila) 2020 Dec;9(6):481-490

Department of Ophthalmology, Prince of Wales Hospital/University of New South Wales, Sydney, Australia.

Glaucoma-related ocular surface disease (G-OSD) is a significant, yet often underdiagnosed, ocular co-morbidity affecting 40% to 59% of glaucoma patients worldwide. Although the use of topical glaucoma medications represents a proven strategy to control the untoward effects of high intraocular pressure, this treatment can profoundly disrupt the homeostasis of the tear film. The cumulative effect of medications, preservatives, and excipients alter underlying cellular structures which results in tear film abnormalities and instability of the ocular surface. Furthermore, these chronic inflammatory changes have been shown to impact efficacy of glaucoma treatment, patient compliance with therapy and overall quality of life. The pathogenesis of G-OSD is multifactorial and involves a vicious self-perpetuating cycle of inflammatory cytokines and proteins. The diagnosis of such disease is based on similar tests used in assessing traditional dry eye, taking into consideration findings specific to this patient population. The hallmark of treatment for these patients is to minimize the ocular surface inflammatory response by choosing glaucoma therapies that spare the ocular surface such as preservative free formulations and initiating dry eye treatment early in the course of care. In summary, glaucoma affects millions of patients around the world and chronic use of topical glaucoma medications may negatively impact the patient's ocular surface, symptoms, and vision. Understanding the pathogenesis of G-OSD, recognizing its risk factors and incorporating diagnostic and therapeutic strategies that restore and maintain ocular surface homeostasis will result in improved care for our patients.
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http://dx.doi.org/10.1097/APO.0000000000000327DOI Listing
December 2020

Effect of dietary modification and antioxidant supplementation on intraocular pressure and open-angle glaucoma.

Eur J Ophthalmol 2020 Oct 2:1120672120960337. Epub 2020 Oct 2.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.

Primary open-angle glaucoma (POAG) is an age-dependent, intraocular pressure (IOP)-related degeneration of the retinal ganglion cells (RGC). At present, IOP is the only modifiable factor that has been identified to prevent glaucomatous vision loss. Though the pathogenesis of glaucomatous optic neuropathy is still not well understood, increasing evidence suggests oxidative stress may contribute to the induction and progression of glaucoma. Furthermore, antioxidant use may be protective against glaucoma through various mechanisms, including reducing IOP, preserving vascular health, and preventing ganglion cell loss. This article provides a comprehensive review of the effect of oxidative stress, diet, and antioxidant therapy on IOP and open-angle glaucoma.
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http://dx.doi.org/10.1177/1120672120960337DOI Listing
October 2020

An African American Man With Progressive Loss of Iris Pigmentation in Both Eyes.

JAMA Ophthalmol 2020 10;138(10):1089-1090

Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago.

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http://dx.doi.org/10.1001/jamaophthalmol.2020.1417DOI Listing
October 2020

Glaucoma Care of Prison Inmates at an Academic Hospital.

JAMA Ophthalmol 2020 04;138(4):358-364

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago.

Importance: Glaucoma care for prison inmates is underrepresented in the literature even though managing the treatment of such patients may provide unique challenges.

Objectives: To evaluate the glaucoma profile of prison inmates treated at an academic ophthalmology center and to report on the medical and surgical management and follow-up metrics.

Design, Setting, And Participants: This retrospective cohort study assessed data from 82 incarcerated patients treated at the glaucoma clinic, an academic referral center at the University of Illinois at Chicago, between January 2013 and December 2017.

Main Outcomes And Measures: Diagnosis, glaucoma severity, medical and surgical interventions, and patient-reported medication adherence were recorded for each visit. Recommended and actual follow-up times were recorded and compared. Data analyses were conducted from January 2013 to December 2018.

Results: In total, 82 patients (161 eyes) had 375 visits during the study period. All patients were male and ranged from 20 to 75 years of age (mean [SD] age, 50.8 [11.9] years). Most participants were black patients (65 [79.3%]). The most common diagnoses were primary open-angle glaucoma (POAG; 53 eyes [32.9%]) and POAG suspect (52 eyes [32.3%]). Glaucoma severity ranged from mild (25 of 77 eyes [32.5%]) to advanced (41 of 77 eyes [53.2%]). Overall, 59 patients (73.2%) were treated medically with up to 4 topical agents (40.0%). Of those treated, 70.0% of patients (95% CI, 57.7%-81.2%) reported medication nonadherence during at least 1 visit. Medication nonadherence was more common among those taking 4 different topical medications (21 of 24 [87.5%]) compared with others taking fewer medications (20 of 35 [57.1%]), for a difference of 30.4% (95% CI, 7.0%-53.6%; P = .02), and among those with advanced disease (22 of 26 [84.6%]) compared with glaucoma suspect (6 of 13 [46.2%]), for a difference of 38.4% (95% CI, 9.3%-67.5%; P = .02). Nineteen office procedures, including laser peripheral iridotomy and laser trabeculoplasty, were performed on 14 eyes. Seventeen incisional glaucoma procedures were performed on 15 eyes, including glaucoma drainage device implant (11 procedures [64.7%]) and trabeculectomy (3 procedures [17.6%]). Only 26.6% of return office visits (95% CI, 21.3%-32.3%) occurred within the recommended follow-up time frame. Furthermore, 93 patients (34.8%; 95% CI, 28.2%-40.0%) were seen more than 1 month after the recommended follow-up.

Conclusions And Relevance: Despite incarceration in prison, where medication administration and appointment attendance are theoretically controlled, the results of this study suggested that substantial medication and follow-up nonadherence exists among inmates.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042904PMC
April 2020

A Meta-analysis on the Outcome of Sequential Glaucoma Drainage Implantation.

J Glaucoma 2020 03;29(3):184-190

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL.

Precis: A meta-analysis shows that second glaucoma drainage implantation can be effective after a failed drainage implant. There is a need for continued glaucoma medications and the risk of corneal decompensation.

Purpose: Studies on second glaucoma drainage implantation are small and exploratory. We performed a meta-analysis on the efficacy of second glaucoma drainage implantation.

Materials And Methods: The intraocular pressure (IOP) and the number of glaucoma medications were compared preoperative to postoperative after second drainage implantation. Kaplan-Meier survival curves were aggregated and compared with the survival curve from the Tube versus Trabeculectomy study.

Results: Nine studies, all retrospective, were included in the meta-analysis. Our results showed that second drainage implantation significantly lowered the IOP and reduced the number of medications. Most patients still required medications for adequate IOP control. Second drainage implants tended to fail earlier than first drainage implants in the Tube versus Trabeculectomy study. The most common complication after second drainage implants was corneal decompensation.

Conclusions: Second glaucoma drainage implantation can be considered a viable approach after a failed drainage implant, but patients should be counseled on the need for continued medical therapy and the risk of corneal decompensation.
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http://dx.doi.org/10.1097/IJG.0000000000001424DOI Listing
March 2020

Resolution of an exposed pars plana Baerveldt shunt in a patient with a Boston keratoprosthesis type 1 without surgery.

Ther Adv Ophthalmol 2019 Jan-Dec;11:2515841419868559. Epub 2019 Aug 12.

Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA.

Patients with a keratoprosthesis often develop complications including glaucoma, requiring glaucoma drainage devices. In most of these patients, glaucoma drainage devices have been shown to be safe and effective. However, occasionally, a glaucoma drainage device in the setting of a keratoprosthesis can lead to conjunctival erosion with mechanical trauma. While repeat surgical intervention may appear necessary, we report a case of a patient who had improved conjunctival erosion and glaucoma drainage device exposure after refitting of a therapeutic contact lens. Therapeutic contact lenses can be used to maintain hydration and decrease exposure while improving cosmesis and refractive error. Complications following keratoprosthesis surgery are an understudied area, particularly regarding glaucoma drainage devices, and we seek to show that careful fitting of therapeutic contact lenses may avoid the risks of repeat surgical intervention.
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http://dx.doi.org/10.1177/2515841419868559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6691656PMC
August 2019

An Association Between Large Optic Nerve Cupping and Cognitive Function.

Am J Ophthalmol 2019 10 1;206:40-47. Epub 2019 Jun 1.

Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois, USA.

Purpose: To determine if a larger cup-to-disc ratio is associated with poor cognitive function in postmenopausal women without glaucoma or ocular hypertension.

Methods: We used data from the Women's Health Initiative (WHI) hormone trial, originally designed to test effects of hormone therapy (HT) on various health outcomes. Large cup-to-disc ratio was defined as greater than 0.6 in either eye based on stereoscopic optic nerve photographs. Global cognitive function was assessed annually by Modified Mini-Mental State Examination (3MSE) in the WHI Memory Study. Exclusions were no information on optic nerve grading; no 3MSE scores at the time of the eye examination, ocular hypertension (intraocular pressure >23 mm Hg, Goldmann applanation tonometry), or glaucoma medication use. A generalized linear model for log-transformed 3MSE scores was used for determining the association between large cup-to-disc ratio and 3MSE scores, adjusting for age, race, diabetes, body mass index, cardiovascular disease, smoking, HT randomization, education, and diabetic retinopathy.

Results: Analyses included 1636 women (mean age ± standard deviation, 69.57 ± 3.64 years; 90.39% white). Of those, 122 women had large cup-to-disc ratio. The mean 3MSE scores in women with vs without large cup-to-disc ratio were 95.4 ± 6 vs 96.6 ± 5. In the adjusted model, women with large cup-to-disc ratio had statistically significantly lower 3MSE scores, compared with those without large cup-to-disc ratio, yielding the predicted mean difference in 3MSE scores of 0.75 with a standard error of 0.05 units (P = .04).

Conclusions: Postmenopausal women who had large cup-to-disc ratio without glaucoma or ocular hypertension exhibited lower global cognitive function. Further investigation is warranted. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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http://dx.doi.org/10.1016/j.ajo.2019.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775038PMC
October 2019

Dietary Antioxidants, Macular Pigment, and Glaucomatous Neurodegeneration: A Review of the Evidence.

Nutrients 2019 May 1;11(5). Epub 2019 May 1.

University of Wisconsin, Department of Ophthalmology and Visual Sciences, 610 N. Walnut Street 1069 WARF Building, Madison, WI 53726, USA.

Primary open-angle glaucoma (POAG) is a leading cause of irreversible blindness worldwide, and the prevalence is projected to increase to 112 million worldwide by 2040. Intraocular pressure is currently the only proven modifiable risk factor to treat POAG, but recent evidence suggests a link between antioxidant levels and risk for prevalent glaucoma. Studies have found that antioxidant levels are lower in the serum and aqueous humor of glaucoma patients. In this review, we provide a brief overview of the evidence linking oxidative stress to glaucomatous pathology, followed by an in-depth discussion of epidemiological studies and clinical trials of antioxidant consumption and glaucomatous visual field loss. Lastly, we highlight a possible role for antioxidant carotenoids lutein and zeaxanthin, which accumulate in the retina to form macular pigment, as evidence has emerged supporting an association between macular pigment levels and age-related eye disease, including glaucoma. We conclude that the evidence base is inconsistent in showing causal links between dietary antioxidants and glaucoma risk, and that prospective studies are needed to further investigate the possible relationship between macular pigment levels and glaucoma risk specifically.
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http://dx.doi.org/10.3390/nu11051002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6567242PMC
May 2019

Corneal ectasia associated with postoperative hypotony.

Can J Ophthalmol 2019 02 5;54(1):e40-e43. Epub 2018 Jun 5.

Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois, Chicago, Ill. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2018.03.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048191PMC
February 2019

Beyond Mechanical Trauma-Why the Cornea May Decompensate After Glaucoma Surgery.

JAMA Ophthalmol 2019 May;137(5):479-480

Illinois Eye and Ear Infirmary, University of Illinois, Chicago.

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http://dx.doi.org/10.1001/jamaophthalmol.2019.0173DOI Listing
May 2019

Longitudinal Study of Peripapillary Thinning in Sickle Cell Hemoglobinopathies.

Am J Ophthalmol 2019 06 14;202:30-36. Epub 2019 Feb 14.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA. Electronic address:

Purpose: To determine the rate of retinal nerve fiber layer (RNFL) thinning in patients with sickle cell hemoglobinopathies.

Design: This was a prospective cohort study.

Methods: Sixty-seven patients averaging 35.8 ± 11.5 years of age at enrollment with electrophoretically confirmed sickle cell hemoglobinopathies followed by the University of Illinois at Chicago retina clinic for ≥1 year were included. Exclusion criteria included a history of diabetes, uncontrolled hypertension, glaucoma, ocular opacities, other retinopathies, and previous retinal procedures. The optic nerve head RNFL thicknesses were measured with spectral-domain optical coherence tomography (Heidelberg Engineering, Inc) at enrollment and subsequent follow-ups. Linear mixed models were used to estimate rates of thinning.

Results: A total of 122 eyes were followed for 3.8 ± 2.0 years (range 1-8 years). Mean global peripapillary RNFL thickness was 100.9 ± 13.0 μm at baseline. Global peripapillary RNFL thickness decreased at a rate of 0.98 μm per year (95% confidence interval [CI] 0.77-1.19 μm/year). A history of stroke was associated with a faster rate of global RNFL thinning (1.72 ± 0.20 vs 0.79 ± 0.12 μm/year, P < .001), whereas a history of hypertension was associated with a slower rate of thinning (0.33 ± 0.27 vs 1.14 ± 0.12 μm/year, P = .002).

Conclusions: Peripapillary RNFL thinning in patients with sickle cell hemoglobinopathies occurred faster in patients with a history of stroke and slower in patients with controlled hypertension. Future studies will compare these rates to those of healthy age- and race-matched individuals.
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http://dx.doi.org/10.1016/j.ajo.2019.02.006DOI Listing
June 2019

Staged ocular fornix reconstruction for glaucoma drainage device under neoconjunctiva at the time of Boston type 1 Keratoprosthesis implantation.

Ocul Surf 2019 04 8;17(2):336-340. Epub 2019 Feb 8.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, United States.

Purpose: Glaucoma is the leading cause of vision loss in eyes with Boston Keratoprosthesis (KPro). Glaucoma drainage devices (GDDs) have been shown to be effective in controlling glaucoma with KPro. Cicatricial conjunctival disease with forniceal shortening is a major challenge and limitation to the use of GDD. In our series, we report the success of fornix reconstruction in cicatricial ocular surface disease as a staged procedure prior to a combined KPro/GDD surgery.

Methods: Retrospective case series involving 4 eyes with surface cicatricization. Three patients with chemical burns and one patient with Ectrodactyly Ectodermal Dysplasia-Clefting syndrome. Preoperative data, surgical interventions, and clinical outcomes were reviewed.

Conclusion: This series represents the first report of fornix reconstruction for combined KPro/GDD surgery. Fornix reconstruction with the aid of AMT with or without OMM grafting is a relatively safe and effective way to manage complex cicatricial surface disease associated with corneal scarring and glaucoma, allowing for subsequent successful implantation of GDD and KPro in cases that were otherwise poor surgical candidates.
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http://dx.doi.org/10.1016/j.jtos.2019.01.010DOI Listing
April 2019

Brimonidine tartrate for the treatment of glaucoma.

Expert Opin Pharmacother 2019 Jan 8;20(1):115-122. Epub 2018 Nov 8.

a Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary , University of Illinois at Chicago , Chicago , IL , USA.

Introduction: Brimonidine tartrate is a commonly used eyedrop for short- and long-term lowering of intraocular pressure. Its use has been popularized due to its effects on aqueous suppression and uveoscleral outflow, as well as the suggestion of neuroprotection. Although available with alternative preservative vehicles, brimonidine is associated with high rates of local allergy and is contraindicated in breastfeeding women, neonates, young children, and the elderly due to risk of central nervous system depression. Other topical agents with differing advantages have challenged brimonidine's role in the treatment algorithm of ocular hypertension and glaucoma. Areas covered: The authors review the development of topical alpha-adrenergic agonists, with particular attention to the currently available formulations of brimonidine tartrate. Its mechanism of action, pharmacodynamics and safety, and clinical efficacy are analyzed. Expert opinion: Despite clinical familiarity with brimonidine after two decades of use, agents that offer daily dosing, nocturnal effect, and more favorable ocular and systemic side effect profiles have ultimately led to brimonidine's adjunctive use in patients with elevated intraocular pressure or high- or low-tension glaucomas. Still, brimonidine may be advantageous in patients undergoing laser trabeculoplasty or iridotomy, in certain forms of glaucoma, or in pregnant individuals prior to the last trimester, underscoring its clinical importance.
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http://dx.doi.org/10.1080/14656566.2018.1544241DOI Listing
January 2019

Racial Differences in the Effects of Hormone Therapy on Incident Open-Angle Glaucoma in a Randomized Trial.

Am J Ophthalmol 2018 11 4;195:110-120. Epub 2018 Aug 4.

Department of Psychiatry and Psychology, University of Illinois at Chicago, Chicago, Illinois, USA.

Purpose: We conducted a secondary analysis of a randomized, placebo-controlled trial to test if hormone therapy (HT) altered the risk of open-angle glaucoma (OAG), and if the risk reduction varied by race.

Design: Secondary analysis of randomized controlled trial data.

Methods: We linked Medicare claims data to 25 535 women in the Women's Health Initiative. Women without a uterus were randomized to receive either oral conjugated equine estrogens (CEE 0.625 mg/day) or placebo, and women with a uterus received oral CEE and medroxyprogesterone acetate (CEE 0.625 mg/day + MPA 2.5 mg/day) or placebo. We used Cox proportional hazards models to calculate hazard ratios (HR) and 95% confidence interval.

Results: After exclusion of women with prevalent glaucoma or without claims for eye care provider visits, the final analysis included 8102 women (mean age = 68.5 ± 4.8 years). The OAG incidence was 7.6% (mean follow-up = 11.5 ± 5.2 years; mean HT duration = 4.4 ± 2.3 years). Increased age (P trend = .01) and African-American race (HR = 2.69, 95% CI = 2.13-3.42; white as a reference) were significant risk factors for incident OAG. We found no overall benefit of HT in reducing incident OAG (HR = 1.01, 95% CI = 0.79-1.29 in the CEE trial, and HR = 1.05, 95% CI = 0.85-1.29 in the CEE + MPA trial). However, race modified the relationship between CEE use and OAG risk (P interaction = .01), and risk was reduced in African-American women treated with CEE (HR = 0.49, 95% CI = 0.27-0.88), compared to placebo. Race did not modify the relation between CEE + MPA use and OAG risk (P interaction = .68).

Conclusions: Analysis suggests that HT containing estrogen, but not a combination of estrogen and progesterone, reduces the risk of incident OAG among African-American women. Further investigation is needed.
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http://dx.doi.org/10.1016/j.ajo.2018.07.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775037PMC
November 2018

Systemic Disease and Long-term Intraocular Pressure Mean, Peak, and Variability in Nonglaucomatous Eyes.

Am J Ophthalmol 2018 09 6;193:184-196. Epub 2018 Jul 6.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA; Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA. Electronic address:

Purpose: Elevated intraocular pressure (IOP) is a well-known risk factor in glaucoma development and progression. As most glaucoma risk factors are not modifiable, IOP remains the sole focus of medical and surgical therapy. Identifying modifiable factors and their effects on IOP, such as systemic diseases, is therefore of interest. The objective is to assess the long-term, longitudinal relationship between systemic diseases and IOP mean, peak, and variability, including diabetes, hypertension, body mass index (BMI), and smoking status.

Design: Secondary analysis of randomized clinical trial data.

Methods: Longitudinal IOP and systemic disease data from the Age-Related Eye Disease Study (AREDS), a randomized clinical trial of high-dose antioxidants, was analyzed.

Study Population: A total of 3909 older participants without a reported diagnosis of glaucoma or glaucoma treatment during AREDS with up to 12 years of annual IOP and systemic disease data.

Main Outcome Measures: Independent systemic disease risk factors associated with IOP.

Results: Univariate analysis identified numerous systemic disease factors associated with IOP mean, peak, and variability. Longitudinal adjusted models identified diabetes, obesity, and systolic hypertension as significantly associated with increased IOP, while systemic beta-blocker use was inversely associated.

Conclusions: Results demonstrate a relationship between multiple systemic diseases and IOP; moreover, they demonstrate that systemic diseases influence additional parameters beyond mean IOP, such as IOP peak and variability. Although only to be taken within the context of IOP, these population-level trends reveal potentially modifiable factors in IOP control, and are particularly important in the context of increasing obesity and diabetes prevalence rates in American adults.
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http://dx.doi.org/10.1016/j.ajo.2018.06.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457143PMC
September 2018

Pathophysiology and management of glaucoma associated with phakomatoses.

J Neurosci Res 2019 01 1;97(1):57-69. Epub 2018 Apr 1.

Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois.

The phakomatoses, encephalotrigeminal angiomatosis (ETA; Sturge-Weber Syndrome), neurofibromatosis type 1 (NF1 or von Recklinghausen disease), Von Hippel-Lindau (VHL) disease, tuberous sclerosis (TSC), oculodermal melanocytosis (ODM), and phakomatosis pigmentovascularis are a group of neurocutaneous disorders that have characteristic systemic and ocular manifestations. Through many different mechanisms, they may cause glaucomatous damage of the optic nerve and subsequent vision loss varying from mild to severe. Glaucoma commonly affects patients with ETA (43-72%), orbito-facial NF1 (23-50%), and ODM (10%). Rarely, it may present as neovascular glaucoma in VHL and TSC. In ETA, glaucoma typically occurs ipsilateral to the port-wine stain, which is caused by a mutation in the GNAQ gene. Specifically, mechanical malformation of the anterior chamber angle and elevated episcleral venous pressure has been implicated as causes of glaucoma in ETA. In NF1, which is caused by a mutation in the NF1 tumor suppressor gene, glaucoma commonly occurs ipsilateral to lid plexiform neurofibromas. Histological studies of eyes with NF1 have revealed direct anterior chamber infiltration by neurofibromas, secondary angle closure, fibrovascularization, and developmental angle abnormalities as mechanisms of glaucoma. Lastly, phakomatosis pigmentovascularis is a rare combination of ODM and port-wine stain. Affected patients are at very high risk of developing glaucoma. Despite the many different mechanisms of glaucomatous damage, management follows similar principles as that for congenital glaucoma and primary open angle glaucoma. First-line therapy is topical intraocular pressure-lowering eye drops. Surgical management, including goniotomy, trabeculotomy, trabeculectomy, and tube shunt placement may be required for more severe cases.
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http://dx.doi.org/10.1002/jnr.24241DOI Listing
January 2019

Assessment of Glaucomatous Damage After Boston Keratoprosthesis Implantation Based on Digital Planimetric Quantification of Visual Fields and Optic Nerve Head Imaging.

Cornea 2018 May;37(5):602-608

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL.

Purpose: To investigate glaucomatous damage in Boston keratoprosthesis type I (KPro) patients through structural analysis of the optic nerve head and digital planimetric quantification of Goldmann visual fields, a novel method of monitoring perimetric changes in KPro patients.

Methods: Records of patients undergoing KPro implantation from 2007 to 2015 at a single institution were reviewed. Parameters related to glaucoma status and KPro outcomes were analyzed.

Results: Twenty-two eyes from 21 patients met inclusion criteria, with mean follow-up of 49.4 months (range 15-90). Mean results for the following parameters before KPro implantation and at last follow-up were (pre-KPro; at last follow-up): best-corrected visual acuity (2.07; 0.70 logMAR), number of glaucoma medications (1.14; 1.05), intraocular pressure (IOP) (18.4; 18.4 mm Hg), vertical cup-to-disc ratio (C/D) (0.48; 0.50), and horizontal C/D (0.52; 0.52). IOP-lowering procedures were performed pre-KPro (5/22), concurrently with KPro (10/22), post-KPro (6/22), or never (6/22). An increase in C/D ≥0.1 and loss of V4e isopter area >30% occurred in 22.7% and 12.5%, respectively. Development of post-KPro glaucoma, progression of preexisting or post-KPro glaucoma, and no glaucoma development as evidenced by an objective assessment of structural and functional parameters were seen in 2/22 (9.1%), 7/22 (31.8%), and 6/22 (27.3%) eyes, respectively.

Conclusions: Clinicians should strive to vigilantly monitor for glaucoma despite the inherent difficulties in tonometry, optic nerve visualization and imaging, and visual field testing in KPro patients. Meticulous glaucoma surveillance with structural and functional testing combined with earlier IOP-lowering surgical intervention may result in decreased rates of glaucomatous vision loss in KPro patients.
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http://dx.doi.org/10.1097/ICO.0000000000001544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878109PMC
May 2018

Progressive Bilateral Scleral Pigmentation in a Patient With Ocular Hypertension.

JAMA Ophthalmol 2018 05;136(5):587-588

Department of Ophthalmology and Visual Sciences, University of Illinois College of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1001/jamaophthalmol.2017.5148DOI Listing
May 2018

Testosterone Pathway Genetic Polymorphisms in Relation to Primary Open-Angle Glaucoma: An Analysis in Two Large Datasets.

Invest Ophthalmol Vis Sci 2018 02;59(2):629-636

Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.

Purpose: Sex hormones may be associated with primary open-angle glaucoma (POAG), although the mechanisms are unclear. We previously observed that gene variants involved with estrogen metabolism were collectively associated with POAG in women but not men; here we assessed gene variants related to testosterone metabolism collectively and POAG risk.

Methods: We used two datasets: one from the United States (3853 cases and 33,480 controls) and another from Australia (1155 cases and 1992 controls). Both datasets contained densely called genotypes imputed to the 1000 Genomes reference panel. We used pathway- and gene-based approaches with Pathway Analysis by Randomization Incorporating Structure (PARIS) software to assess the overall association between a panel of single nucleotide polymorphisms (SNPs) in testosterone metabolism genes and POAG. In sex-stratified analyses, we evaluated POAG overall and POAG subtypes defined by maximum IOP (high-tension [HTG] or normal tension glaucoma [NTG]).

Results: In the US dataset, the SNP panel was not associated with POAG (permuted P = 0.77), although there was an association in the Australian sample (permuted P = 0.018). In both datasets, the SNP panel was associated with POAG in men (permuted P ≤ 0.033) and not women (permuted P ≥ 0.42), but in gene-based analyses, there was no consistency on the main genes responsible for these findings. In both datasets, the testosterone pathway association with HTG was significant (permuted P ≤ 0.011), but again, gene-based analyses showed no consistent driver gene associations.

Conclusions: Collectively, testosterone metabolism pathway SNPs were consistently associated with the high-tension subtype of POAG in two datasets.
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http://dx.doi.org/10.1167/iovs.17-22708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5795896PMC
February 2018

COMPARISON OF VISUAL AND ANATOMICAL OUTCOMES OF EYES UNDERGOING TYPE I BOSTON KERATOPROSTHESIS WITH COMBINATION PARS PLANA VITRECTOMY WITH EYES WITHOUT COMBINATION VITRECTOMY.

Retina 2018 09;38 Suppl 1:S125-S133

Department of Ophthalmology and Visual Sciences, University of Illinois, Chicago, Illinois.

Purpose: To determine whether 1-year visual and anatomical results after surgery combining pars plana vitrectomy, Boston keratoprosthesis, and a glaucoma drainage device as needed are similar, better, or worse than Boston keratoprosthesis initial implantation alone.

Methods: We performed a retrospective review of adult patients undergoing Boston keratoprosthesis at our institution. Visual acuity outcomes, anatomical results, and complication rates of patients undergoing combination surgery (including pars plana vitrectomy and a posterior glaucoma drainage device) were compared with those undergoing keratoprosthesis placement alone.

Results: There were 70 eyes in the keratoprosthesis alone group and 55 eyes in the keratoprosthesis with pars plana vitrectomy group. Mean follow-up durations were 54.67 months in the keratoprosthesis alone group and 48.41 months in the combination group. Baseline mean Snellen equivalent visual acuities were worse for the combination group compared with the keratoprosthesis alone group (P = 0.027). Visual acuities improved postoperatively by 1 month after keratoprosthesis implantation for both groups and improved three or more lines of Snellen acuity in the majority of eyes for both groups (≥72% by 12 months). Eyes undergoing pars plana vitrectomy had lower rates of de novo (P = 0.015) and significantly lower rates of secondary procedures (P = 0.002) at 1 year. One year complications rates for retroprosthetic membrane formation, retinal detachment, hypotony, cystoid macular edema, epiretinal membrane formation, endophthalmitis, and corneal melting were similar for both groups.

Conclusion: Compared with keratoprosthesis alone, combining keratoprosthesis with pars plana vitrectomy and a glaucoma drainage device as needed, resulted in lower rates of de novo glaucoma, lower rates of additional surgical procedures, similar visual acuity outcomes at 1 year, and did not result in higher complication rates.
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http://dx.doi.org/10.1097/IAE.0000000000002036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056324PMC
September 2018

Three Dimensional Stimulus Source for Pattern Electroretinography in Mid- and Far-peripheral Retina.

Transl Vis Sci Technol 2018 Jan 19;7(1). Epub 2018 Jan 19.

Department of Bioengineering, University of Illinois at Chicago, Chicago, IL, USA.

Purpose: The pattern electroretinogram (pERG) response reflects, in part, ganglion cell function. However, probing retinal ganglion cell (RGC) function in the mid- and far peripheral retina is difficult with conventional flat-panel pERG stimulus sources. A pattern stimulus source is presented for probing the peripheral retina. Peripheral pERG (ppERG) responses were evaluated versus luminance, reversal rate, and field subtended, and were compared with conventional pERG in healthy eyes.

Methods: Eleven normally-sighted subjects were recruited. A hemispherical surface was used to present a reversing checkerboard pattern to the peripheral retina, from approximately 35° to 85° of visual field, in all directions. Responses to stimuli presented to peripheral field sectors (superior, nasal, inferior, temporal) were also recorded. Conventional pERG responses were recorded on the same day. Amplitudes and implicit times of waveform peaks were evaluated.

Results: Robust pERG responses from peripheral retina resemble conventional pERG responses but with shorter implicit times and reduced positive component. Responses to high-luminance patterns include high-frequency components resembling flash ERG oscillatory potentials. Negative response component amplitudes increased with increasing pattern luminance, and decreased with increasing reversal rate.

Conclusions: Peripheral-field pERG responses are robust and repeatable; the unique response properties reflect differences between central and peripheral retina. Field-sector response ratios can be used to probe for sectoral dysfunction associated with disease.

Translational Relevance: The ppERG approach provides direct measurement of proximal retinal function beyond the fields probed by conventional perimetry and pERG, providing access to a relatively under studied part of the retina relevant to early stage glaucoma.
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http://dx.doi.org/10.1167/tvst.7.1.8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777171PMC
January 2018

Blepharospasm as a masquerade of glaucomatous visual field defects.

Can J Ophthalmol 2017 Jun 9;52(3):e99-e102. Epub 2017 Jan 9.

Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois.

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http://dx.doi.org/10.1016/j.jcjo.2016.11.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757416PMC
June 2017

Innovative approaches to glaucoma management of Boston keratoprosthesis type 1.

Curr Ophthalmol Rep 2016 Sep 26;4(3):147-153. Epub 2016 Jul 26.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, IL, USA.

Glaucoma remains a prevalent disorder and visual limiting factor after Boston keratoprosthesis type 1 implantation. Patients with glaucoma have worse initial and late visual acuity outcomes after otherwise successful keratoprosthesis implantation. Management of glaucoma in the setting of a keratoprosthesis is challenging because of relatively rapid progression and an inability to accurately measure intraocular pressure (IOP). In addition, there are no standard guidelines for glaucoma surveillance and monitoring after keratoprosthesis surgery. This report provides a review of the current literature and offers innovative strategies that will overcome the challenges in managing glaucoma in the setting of a Boston keratoprosthesis type 1 implant. The topics that will be discussed in this section include alternative methods for IOP measurement, rationales and surgical techniques for a pars plana tube placement for glaucoma drainage device, effective medical and laser treatment, the risk for IOP elevations after YAG laser, and practical guides to glaucoma surveillance and monitoring.
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http://dx.doi.org/10.1007/s40135-016-0102-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435373PMC
September 2016

Topical treatment of glaucoma: established and emerging pharmacology.

Expert Opin Pharmacother 2017 Jun;18(9):885-898

b King Khaled Eye Specialist Hospital , Riyadh , Kingdom of Saudi Arabia.

Introduction: Glaucoma is a collection of optic neuropathies consisting of retinal ganglion cell death and corresponding visual field loss. Glaucoma is the leading cause of irreversible vision loss worldwide and is forecasted to precipitously increase in prevalence in the coming decades. Current treatment options aim to lower intraocular pressure (IOP) via topical or oral therapy, laser treatment to the trabecular meshwork or ciliary body, and incisional surgery. Despite increasing use of trabecular laser therapy, topical therapy remains first-line in the treatment of most forms of glaucoma. Areas covered: Novel glaucoma therapies are a long-standing focus of investigational study. More than two decades have passed since the last United States Food and Drug Administration (FDA) approval of a topical glaucoma drug. Here, the authors review established topical glaucoma drops as well as those currently in FDA phase 2 and 3 clinical trial, nearing clinical use. Expert opinion: Current investigational glaucoma drugs lower IOP, mainly through enhanced trabecular meshwork outflow. Although few emerging therapies show evidence of retinal ganglion cell and optic nerve neuroprotection in animal models, emerging drugs are focused on lowering IOP, similar to established medicines.
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http://dx.doi.org/10.1080/14656566.2017.1328498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7794042PMC
June 2017

M&S Smart System Contrast Sensitivity Measurements Compared With Standard Visual Function Measurements in Primary Open-Angle Glaucoma Patients.

J Glaucoma 2017 Jun;26(6):528-533

*Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL †Saint Louis University, St. Louis, MO.

Purpose: To evaluate the nature and extent of letter contrast sensitivity (CS) deficits in glaucoma patients using a commercially available computer-based system (M&S Smart System II) and to compare the letter CS measurements to standard clinical measures of visual function.

Methods: Ninety-four subjects with primary open-angle glaucoma participated. Each subject underwent visual acuity, letter CS, and standard automated perimetry testing (Humphrey SITA 24-2). All subjects had a best-corrected visual acuity (BCVA) of 0.3 log MAR (20/40 Snellen equivalent) or better and reliable standard automated perimetry (fixation losses, false positives, and false negatives <33%). CS functions were estimated from the letter CS and BCVA measurements. The area under the CS function (AUCSF), which is a combined index of CS and BCVA, was derived and analyzed.

Results: The mean (± SD) BCVA was 0.08±0.10 log MAR (∼20/25 Snellen equivalent), the mean CS was 1.38±0.17, and the mean Humphrey Visual Field mean deviation (HVF MD) was -7.22±8.10 dB. Letter CS and HVF MD correlated significantly (r=0.51, P<0.001). BCVA correlated significantly with letter CS (r=-0.22, P=0.03), but not with HVF MD (r=-0.12, P=0.26). A subset of the subject sample (∼20%) had moderate to no field loss (≤-6 dB MD) and minimal to no BCVA loss (≤0.3 log MAR), but had poor letter CS. AUCSF was correlated significantly with HVF MD (r=0.46, P<0.001).

Conclusions: The present study is the first to evaluate letter CS in glaucoma using the digital M&S Smart System II display. Letter CS correlated significantly with standard HVF MD measurements, suggesting that letter CS may provide a useful adjunct test of visual function for glaucoma patients. In addition, the significant correlation between HVF MD and the combined index of CS and BCVA (AUCSF) suggests that this measure may also be useful for quantifying visual dysfunction in glaucoma patients.
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http://dx.doi.org/10.1097/IJG.0000000000000659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453812PMC
June 2017

Diffuse Retinal Hemorrhages After Uncomplicated Glaucoma Drainage Implantation.

JAMA Ophthalmol 2017 03;135(3):281-282

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary.

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http://dx.doi.org/10.1001/jamaophthalmol.2016.3823DOI Listing
March 2017

Age-Related Macular Degeneration and Mortality in the Age-Related Eye Disease Study (AREDS): The Effect of Sex and Time.

Ophthalmol Retina 2017 Jan - Feb;1(1):49-58. Epub 2016 Nov 18.

Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois.

Purpose: Age-related macular degeneration (AMD) shares similar risk factors and pathogeneses with cardiovascular diseases (CVDs). Epidemiologic studies over the past 2 decades analyzing the association between AMD and all-cause and CVD-specific mortality have failed to yield conclusive results. The purpose of this analysis is to investigate the sex-specific association between AMD and all-cause and CVD-specific mortality, and to assess whether duration of follow-up alters the strength of association.

Design: The database of Genotypes and Phenotypes (dbGaP) data set for the Age-Related Eye Disease Study, a randomized clinical trial of high-dose antioxidants in AMD prevention, with participants enrolled from 1992 to 1998 and followed through 2005, was used in the analysis.

Participants: There were 4757 Age-Related Eye Disease Study participants aged 55 through 80 years (mean, 69.4 years; 44.1% male) recruited from 11 retinal specialty clinics. Participants had standard Age-Related Eye Disease Study AMD categories (category 1, n = 1117; category 2, n = 1062; category 3, n = 1621; category 4, n = 957).

Methods: The sex-specific adjusted hazard ratio (HR) between baseline AMD and all-cause and CVD-specific mortality was determined at multiple time points (e.g., 5, 7, 10, and all years), adjusting for age, race, diabetes, hypertension, angina, cancer, smoking, obesity, clinical trial antioxidant treatment category, and education.

Main Outcome Measures: Sex-specific all-cause and CVD-specific mortality.

Results: Mean follow-up was 9.6 years (range, 0.5-12.5 years), with 1087 deaths (category 1, n = 197 [17.6%]; category 2, n = 200 [18.8%]; category 3, n = 356 [22.0%]; category 4, n = 326 [34.1%]). Sex-stratified models demonstrated sex differences; in women, a significant association between AMD category 4 and all-cause mortality existed compared with category 1 at each period (HR, 1.5-2.3; all P ≤ 0.005); similar category 4 findings were present with CVD-specific mortality, strengthening with shorter periods (HR, 1.9-4.6; all P ≤ 0.01). Among men, a significant association between all AMD stages and all-cause (HR, 1.5-2.3; all P ≤ 0.05) and CVD-specific mortality (HR, 1.6-4.0; all P ≤ 0.05) existed for nearly all periods.

Conclusions: Substantial late AMD cases and deaths exceed those in previous population-based studies to better test mortality-related hypotheses. Age-related macular degeneration was significantly associated with all-cause and CVD-specific mortality. Relationships weakened over a longer duration of follow-up, and sex seems to modify the association. Future analyses are warranted to interrogate the possible clinical usefulness of these relationships.
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http://dx.doi.org/10.1016/j.oret.2016.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433027PMC
November 2016

Evidence-Based Approaches to Glaucoma Management During Pregnancy and Lactation.

Curr Ophthalmol Rep 2016 Dec 12;4(4):198-205. Epub 2016 Oct 12.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, Chicago, IL, USA.

With increasing maternal age in this decade, there is a parallel rise in the number of pregnant and lactating women affected by glaucoma worldwide. Understanding the diagnosis and management of glaucoma during pregnancy and lactation is essential to preventing blindness from glaucoma in this vulnerable population. This report provides a review of the current literature and offers effective strategies that will overcome the challenges in managing glaucoma during pregnancy and lactation. Practically, glaucoma management during pregnancy and lactation presents a unique challenge for the physician, as the benefit of any treatment must be weighed against the potential risks to the fetus. Prior to initiating or continuing treatment, the physician should be familiar with the various treatment options to manage intraocular pressure during pregnancy and lactation, including the safety of various anti-glaucoma medications as supported by the existing literature and based on the food and drug administration guidelines. A collaborative team effort between the ophthalmologist, obstetrician, and neonatologist in high-risk pregnancies is recommended to optimize care for the mother and fetus.
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http://dx.doi.org/10.1007/s40135-016-0112-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773175PMC
December 2016

Primary Baerveldt Shunt Implantation: Outcomes and Complications.

Ophthalmol Ther 2016 Dec 25;5(2):253-262. Epub 2016 Jul 25.

Illinois Eye and Ear Infirmary, University of Illinois at Chicago College of Medicine, Chicago, IL, USA.

Introduction: This study is a retrospective case series to evaluate the outcomes and complications of Baerveldt glaucoma implant surgery (BGI) in patients without prior cataract or incisional glaucoma surgery.

Methods: Patients who underwent 350-mm BGI through the Glaucoma Service of the University of Illinois at Chicago between 2010 and 2015 were included in this study. Outcome measures included age, sex, ethnicity, operated eye, preoperative diagnosis, preoperative, and sequential postoperative intraocular pressure (IOP), visual acuity, glaucoma medications, and postoperative complication and interventions. Statistical analyses were performed using the two-sided Student t test for continuous variables.

Results: Thirty-seven patients were studied. IOP was consistently and statistically significantly lower at 3 months (17.4 ± 6.4, p = 3 × 10), 6 months (13.9 ± 5.1, p = 2 × 10), 1 year (12.2 ± 4.0, p = 9 × 10), and 2 years (14.6 ± 3.3, p = 0.0004) postoperatively compared to IOP at baseline (27.5 ± 8.1). Fewer glaucoma medications were used at 3 months (2.8 ± 1.3, p = 0.04), 6 months (2.6 ± 1.2, p = 0.02), 1 year (2.7 ± 1.7, p = 0.04), and 2 years (2.0 ± 1.2, p = 0.03) postoperatively compared to baseline (3.4 ± 1.1). A total of six cases (16%) had failure. A total of five patients (15%) had postoperative complications. Mean Snellen visual acuity was not statistically different at 6 months (0.5 ± 0.6, p = 0.88) or 1 year (0.4 ± 0.4, p = 0.57) postoperatively from baseline (0.5 ± 0.6).

Conclusions: Primary BGI is effective at reducing IOP and the medication burden in patients suffering glaucomatous optic neuropathy. Further randomized prospective studies are needed to compare various procedures in the primary surgical management of patients with uncontrolled glaucoma.

Funding: This study was funded by an unrestricted grant from Research to Prevent Blindness.
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http://dx.doi.org/10.1007/s40123-016-0056-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125118PMC
December 2016