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Selective laser trabeculoplasty vs. topical medications for step-up treatment in primary open angle glaucoma: comparing clinical effectiveness, quality of life and cost-effectiveness

Yong MH, Che Hamzah J

Med J Malaysia, 2020 07;75(4):342-348.
PMID: 32723992

INTRODUCTION: The aim of this study was to investigate the clinical effectiveness, health related quality of life (HRQoL) and cost effectiveness of selective laser trabeculoplasty (SLT) compared to topical anti-glaucoma medications in step-up treatment of patients with primary open angle glaucoma (POAG).
METHODS: Seventeen POAG patients with suboptimal IOP control despite pre-existing topical medications were subjected to adjunct SLT (50 applications 180 degrees) or second line medical therapy. Current medications were continued, and patients were followed up for 6 months for degree of intraocular pressure (IOP) lowering. HRQoL was assessed using Glaucoma Quality of Life 36-item (GlauQoL-36), Assessment of Quality of Life-7D (AQoL-7D) and Vision related Quality of Life (VisQoL). Costs involved were calculated and compared to the effect (IOP reduction) achieved in each arm.
RESULTS: Ten patients were in the SLT group and 7 in the topical medication (MED) group. Mean baseline intraocular pressure (IOP) was 18.90±3.48mmHg in SLT group and 15.57±2.23mmHg in MED group. Mean reduction of IOP was 4.30±1.64mmHg in SLT group and 2.71±2.56 mmHg in MED group at 6 months which was not statistically significant (p=0.14) between two groups. All the HRQoL questionnaires did not show significant changes in the groups or between groups when compared baseline with 6-month post treatment (p-values ranging from 0.247 to 0.987). For every 1mmHg reduction in IOP, cost involved in MED group (RM53.61) was 165% of the cost involved in SLT group (RM32.56).
DISCUSSION AND CONCLUSION: This study has shown that SLT was as effective clinically and tolerable as topical anti glaucoma medications and was possibly more cost effective in the step-up treatment of patients with POAG at 6 months follow- up.

Matched MeSH terms: Glaucoma/drug therapy*
Trabecular meshwork ECM remodeling in glaucoma: could RAS be a target?

Agarwal P, Agarwal R

Expert Opin Ther Targets, 2018 07;22(7):629-638.
PMID: 29883239 DOI: 10.1080/14728222.2018.1486822

INTRODUCTION: Disturbances of extracellular matrix (ECM) homeostasis in trabecular meshwork (TM) cause increased aqueous outflow resistance leading to elevated intraocular pressure (IOP) in glaucomatous eyes. Therefore, restoration of ECM homeostasis is a rational approach to prevent disease progression. Since renin-angiotensin system (RAS) inhibition positively alters ECM homeostasis in cardiovascular pathologies involving pressure and volume overload, it is likely that RAS inhibitors reduce IOP primarily by restoring ECM homeostasis. Areas covered: Current evidence showing the presence of RAS components in ocular tissue and its role in regulating aqueous humor dynamics is briefly summarized. The role of RAS in ECM remodeling is discussed both in terms of its effects on ECM synthesis and its breakdown. The mechanisms of ECM remodeling involving interactions of RAS with transforming growth factor-β, Wnt/β-catenin signaling, bone morphogenic proteins, connective tissue growth factor, and matrix metalloproteinases in ocular tissue are discussed. Expert opinion: Current literature strongly indicates a significant role of RAS in ECM remodeling in TM of hypertensive eyes. Hence, IOP-lowering effect of RAS inhibitors may primarily be attributed to restoration of ECM homeostasis in aqueous outflow pathways rather than its vascular effects. However, the mechanistic targets for RAS inhibitors have much wider distribution and consequences, which remain relatively unexplored in TM.

Matched MeSH terms: Glaucoma/drug therapy*
Acute uveitic glaucoma in ankylosing spondylitis

Ee CL, Sockalingam S, Kamalden TA

Postgrad Med J, 2018 Jul;94(1113):417.
PMID: 29907697 DOI: 10.1136/postgradmedj-2018-135560
Matched MeSH terms: Glaucoma/drug therapy
Fulltext Trabeculectomy outcomes in a Malaysian general hospital

Hooi ST, Hooi SH

Med J Malaysia, 2003 Oct;58(4):565-78.
PMID: 15190633

A retrospective study was conducted at the Hospital Sultanah Aminah Johor Bahru to determine the outcome of trabeculectomy surgeries over a period of 4 years. One hundred and two eyes were followed up to a maximum of 63 months (mean 34.2 months). The 2-year survival rates for plain trabeculectomies, 5-Fluorouracil augmented trabeculectomies and Mitomycin-C augmented trabeculectomies were 52.9%, 27.3% and 60.5% respectively. The commonest complications noted were cataract formation (25%) and hyphaema (11%). Mitomycin-C induced complications were rarely seen. At last follow-up, 54% of eyes had intraocular pressures below 21 mmHg without medication, while 34% of eyes had intraocular pressures below 21 mmHg with medication. Vitreous at the trabeculectomy site was a statistically significant predictor of operative failure.

Matched MeSH terms: Glaucoma/drug therapy
Future target molecules in antiglaucoma therapy: tgf-Beta may have a role to play

Agarwal R, Agarwal P

Ophthalmic Res, 2010;43(1):1-10.
PMID: 19829006 DOI: 10.1159/000246571

Glaucoma, a leading cause of irreversible blindness, is often associated with increased resistance to aqueous outflow in trabecular tissue. Increased outflow resistance has been attributed to increased extracellular matrix (ECM) deposition in trabecular tissue. A critical balance between the synthesis and breakdown of the components of extracellular tissue is important in keeping the intraocular pressure within the normal range. Multiple mechanisms have been shown to affect ECM turnover in trabecular tissue. In this review, we examine the related literature to understand the role of TGF-beta in ECM turnover, in the development and progression of glaucoma, and in possible therapeutic strategies that can be devised by targeting the TGF-beta signaling pathways.

Matched MeSH terms: Glaucoma/drug therapy*
Ocular Surface Disease in Glaucoma: Effect of Polypharmacy and Preservatives

Ramli N, Supramaniam G, Samsudin A, Juana A, Zahari M, Choo MM

Optom Vis Sci, 2015 Sep;92(9):e222-6.
PMID: 25730335 DOI: 10.1097/OPX.0000000000000542

PURPOSE: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD.
METHODS: This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading.
RESULTS: The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride-containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI.
CONCLUSIONS: Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride-containing eye drops, although this also occurs with the use of preservative-free eye drops.
Study site: Eye Clinic, University of Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia,

Matched MeSH terms: Glaucoma/drug therapy
Newer targets for modulation of intraocular pressure: focus on adenosine receptor signaling pathways

Agarwal R, Agarwal P

Expert Opin Ther Targets, 2014 May;18(5):527-39.
PMID: 24579961 DOI: 10.1517/14728222.2014.888416

The homeostatic role of adenosine in regulating intraocular pressure (IOP) is now widely recognized, and hence, the drugs targeting adenosine receptors have become the focus of investigation. In this review, we summarize the adenosine receptor signaling pathways, which could be potential therapeutic targets for the management of glaucoma.

Matched MeSH terms: Glaucoma/drug therapy*