Background Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment. Objectives To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways. Design A 36-month pragmatic, unmasked, multicentre randomised controlled trial. Settings Six collaborating specialist glaucoma clinics across the UK. Participants Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than –12 dB in the better eye or –15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT. Interventions SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines. Main outcome measures The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety. Results Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st – Medicine-1st) 0.01, 95% confidence interval (CI) –0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between –£585 and –£345). Limitation An unmasked design, although a limitation, was essential to capture any treatment effects on patients’ perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL. Conclusions Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes. Future work Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways. Trial registration Current Controlled Trials ISRCTN32038223. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.

/pdf/selective-laser-trabeculoplasty-versus-drops-for-newly-5407cm68ns.pdf

Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT.

Longitudinal Macular Structure-Function Relationships in Glaucoma.

The OCT angular sign of Henle fiber layer (HFL) hyperreflectivity (ASHH) and the pathoanatomy of the HFL in macular disease

Development of a Spatial Model of Age-Related Change in the Macular Ganglion Cell Layer to Predict Function From Structural Changes.

Clinical Course and Risk Factors for Visual Field Progression in Normal-Tension Glaucoma With Myopia Without Glaucoma Medications.

Background/aims To study whether the structure–function (S-F) relationship in glaucoma differs according to macular location using spectral-domain optical coherence tomography (SD-OCT) and standard automated perimetry 10-2 and 24-2 visual fields (VFs). Methods We enrolled 151 eyes of 151 healthy, preperimetric and perimetric glaucomatous subjects. Macular ganglion cell-inner plexiform layer thicknesses at different parafoveal locations were measured using Cirrus SD-OCT. The mean sensitivity of 10–2 and 24–2 VFs was recorded in the decibel and 1/L scales. The topographic relationships between structure and function were assessed at different parafoveal and hemimacular locations using ‘weighted’ correlation coefficients. The strength of S-F relationships between macular ganglion cell-inner plexiform layer thickness measurements and VF mean sensitivity in various parafoveal locations and in superior and inferior hemimacula was compared using Steiger9s test. Results The temporal parafoveal sector showed a significantly greater S-F relationship in each hemimacula compared with other parafoveal sectors (p Conclusions The strength of the S-F associations at the temporal parafoveal location is significantly greater than that of the central or nasal parafoveal location in each hemimacula. The strength of the S-F association is significantly greater in the inferior hemimacula than in the superior hemimacula.

https://bjo.bmj.com/content/bjophthalmol/early/2015/03/31/bjophthalmol-2014-306538.full.pdf

Macular structure–function relationship at various spatial locations in glaucoma

Purpose To investigate visual field (VF) progression rates in glaucomatous eyes with myopic optic disc appearance, refractive error, and progressive VF changes and to compare the rates with those of a nonmyopic group. Patients and methods Data on 158 eyes from 131 patients with open-angle glaucoma who had progressive VF deterioration during follow-up were retrospectively analyzed. The myopic and nonmyopic groups were compared in terms of rates of change of mean thresholds in global and regional areas using central 10 degrees, peripheral 10 to 24 degrees, and glaucoma hemifield test maps by using a linear-mixed model and controlling for confounding covariates. Clinical factors associated with rapid VF progression at global and regional VF areas were investigated in each group. Results The 2 groups did not significantly differ in the mean global VF progression rate (-0.36 vs. -0.35 dB/y, respectively; P=0.951). Likewise, both groups showed similar VF progression rates at all regional clusters (P>0.05). No significant association was found between the rate of VF change and clinical factors in the myopic group. The mean follow-up intraocular pressure was significantly associated with VF progression rates in the nonmyopic group (P Conclusions Open-angle glaucoma eyes with myopic optic disc appearance experiencing progressive VF changes showed similar VF progression rates globally and regionally when compared with nonmyopic eyes after controlling for clinical factors related to VF progression. None of the clinical factors in the myopic group were significantly associated with VF progression rate, whereas the mean follow-up intraocular pressure was in the nonmyopic group.

Is Myopic Optic Disc Appearance a Risk Factor for Rapid Progression in Medically Treated Glaucomatous Eyes With Confirmed Visual Field Progression

Reply: To PMID 26052089.

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Macular structure–function relationship at various spatial locations in glaucoma

Is Myopic Optic Disc Appearance a Risk Factor for Rapid Progression in Medically Treated Glaucomatous Eyes With Confirmed Visual Field Progression

Reply: To PMID 26052089.