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ABSTRACT: PURPOSE: To report the risk of endophthalmitis and other long-term complications in patients randomized to trabeculectomy in the Collaborative Initial Glaucoma Treatment Study. DESIGN: A longitudinal cohort study using data collected from a multicenter, randomized clinical trial. METHODS: Long-term postoperative complications in the 300 patients randomized to trabeculectomy in the Collaborative Initial Glaucoma Treatment Study were tabulated. Kaplan-Meier analyses were used to estimate the time-related probabilities of blebitis, hypotony, and endophthalmitis. RESULTS: Two hundred eighty-five patients were included in the final trabeculectomy cohort after accounting for declining treatment assignment and other early events. Patients were followed up for an average of 7.2 years. One hundred sixty-three patients (57%) received 5-fluorouracil during surgery. Of the 247 patients with at least 5 years of follow-up, 50 required further treatment for glaucoma. Cataract extraction was performed in 57 patients (20%). Forty patients (14%) required bleb revision at least once. Bleb-related complications included bleb leak (n = 15), blebitis (n = 8), and hypotony (n = 4). Three patients were noted to have endophthalmitis, although the diagnosis in 2 patients was presumptive. The occurrences of blebitis, hypotony, or endophthalmitis were not significantly associated with 5-fluorouracil use. The Kaplan-Meier calculated risks of blebitis and hypotony at 5 years were both 1.5%, whereas the risk of endophthalmitis was 1.1%. CONCLUSIONS: The potential efficacy of trabeculectomy must be weighed against the long-term risk of complications, especially endophthalmitis, when selecting treatments for patients with open-angle glaucoma. We report a low 5-year risk of endophthalmitis (1.1%) and other bleb-related complications in the trabeculectomy cohort of the Collaborative Initial Glaucoma Treatment Study.
American journal of ophthalmology 12/2012; · 3.83 Impact Factor
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ABSTRACT: OBJECTIVE To determine whether racial disparities exist in the use of ancillary testing to evaluate individuals with open-angle glaucoma. METHODS We identified all enrollees aged 40 years and older in a large US managed care network with retinal or optic nerve conditions that could warrant the use of ancillary testing. Among persons with open-angle glaucoma or glaucoma suspects, we performed repeated-measures multivariable logistic regression to determine the odds and probabilities each year of undergoing visual field testing, fundus photography, and other ocular imaging for black, white, Hispanic, and Asian American men and women and compared the groups. RESULTS Among the 797 879 eligible enrollees, 149 018 individuals had open-angle glaucoma. The odds of undergoing visual field testing decreased for all groups from 2001 through 2009, decreasing most for Hispanic men and women (63% and 57%, respectively) (adjusted odds ratio [AOR], 0.37; 95% CI, 0.31-0.43 and AOR, 0.43; 95% CI, 0.37-0.50, respectively) and least (36%) for Asian American men (AOR, 0.64; 95% CI, 0.51-0.80). By comparison, the odds of undergoing other ocular imaging increased for all groups from 2001 through 2009, increasing most (173%) for black men and women (AOR, 2.73; 95% CI, 2.34-3.18 for men and AOR, 2.73; 95% CI, 2.40-3.09 for women) and least (77%) for Hispanic women (AOR, 1.77; 95% CI, 1.49-2.09). CONCLUSION Hispanic men and women had considerably reduced odds of undergoing visual field testing and other ocular imaging compared with other groups during the decade. Although increases in glaucoma testing have been noted in recent years among Hispanic men and women for some types of ancillary tests, efforts should be made to better understand and overcome some of the persistent barriers to monitoring for glaucoma in this group.
Archives of ophthalmology 12/2012; 130(12):1579-88. · 3.86 Impact Factor
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Louis R Pasquale,
Stephanie J Loomis,
Jae H Kang,
Brian L Yaspan,
Wael Abdrabou,
Donald L Budenz,
Teresa C Chen,
Elizabeth Delbono,
David S Friedman,
Douglas Gaasterland, [......],
Gadi Wollstein,
Donald J Zack,
R Rand Allingham,
Margaret A Pericak-Vance,
Robert N Weinreb,
Kang Zhang,
Michael A Hauser,
Julia E Richards,
Jonathan L Haines,
Janey L Wiggs
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ABSTRACT: PURPOSE: To assess the association between single nucleotide polymorphisms (SNPs) of the gene region containing cyclin-dependent kinase inhibitor 2B antisense noncoding RNA (CDKN2B-AS1) and glaucoma features among primary open-angle glaucoma (POAG) patients. DESIGN: Retrospective observational case series. METHODS: We studied associations between 10 CDKN2B-AS1 SNPs and glaucoma features among 976 POAG cases from the Glaucoma Genes and Environment (GLAUGEN) study and 1971 cases from the National Eye Institute Glaucoma Human Genetics Collaboration (NEIGHBOR) consortium. For each patient, we chose the feature from the eye with the higher value. We created cohort-specific multivariable models for glaucoma features and then meta-analyzed the results. RESULTS: For 9 of the 10 protective CDKN2B-AS1 SNPs with minor alleles associated with reduced disease risk (eg, the G allele at rs2157719), POAG patients carrying these minor alleles had smaller cup-to-disc ratio (0.05 units smaller per G allele at diagnosis; 95% CI: -0.08, -0.03; P = 6.23E-05) despite having higher intraocular pressure (IOP) (0.70 mm Hg higher per G allele at DNA collection; 95% CI: 0.40, 1.00; P = 5.45E-06). For the 1 adverse rs3217992 SNP with minor allele A associated with increased disease risk, POAG patients with A alleles had larger cup-to-disc ratio (0.05 units larger per A allele at diagnosis; 95% CI: 0.02, 0.07; P = 4.74E-04) despite having lower IOP (-0.57 mm Hg per A allele at DNA collection; 95% CI: -0.84, -0.29; P = 6.55E-05). CONCLUSION: Alleles of CDKN2B-AS1 SNPs, which influence risk of developing POAG, also modulate optic nerve degeneration among POAG patients, underscoring the role of CDKN2B-AS1 in POAG.
American journal of ophthalmology 10/2012; · 3.83 Impact Factor
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Janey L Wiggs,
Michael A Hauser,
Wael Abdrabou,
Robert Rand Allingham,
Donald L Budenz,
Elizabeth Delbono,
David S Friedman,
Jae H Kang,
Douglas Gaasterland,
Terry Gaasterland, [......],
Douglas Vollrath,
Robert N Weinreb,
Gadi Wollstein,
Brian L Yaspan,
Sachiko Yoneyama,
Don Zack,
Kang Zhang,
Margaret Pericak-Vance,
Louis R Pasquale,
Jonathan L Haines
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ABSTRACT: Primary open-angle glaucoma (POAG) is a common disease with complex inheritance. The identification of genes predisposing to POAG is an important step toward the development of novel gene-based methods of diagnosis and treatment. Genome-wide association studies (GWAS) have successfully identified genes contributing to complex traits such as POAG however, such studies frequently require very large sample sizes, and thus, collaborations and consortia have been of critical importance for the GWAS approach. In this report we describe the formation of the NEIGHBOR consortium, the harmonized case control definitions used for a POAG GWAS, the clinical features of the cases and controls, and the rationale for the GWAS study design.
Journal of glaucoma 07/2012; · 1.74 Impact Factor
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ABSTRACT: Three types of open-angle glaucoma (OAG)-primary, pigmentary and pseudoexfoliative-are frequently encountered. The aim of this study was to compare demographic, ocular and systemic medical information collected on people with these three OAG types at diagnosis, and determine if the OAG type affected the prognosis.
Information on 607 participants of the Collaborative Initial Glaucoma Treatment Study was accessed. Descriptive statistics characterised their demographic, ocular and medical status at diagnosis. Comparisons were made using analysis of variance and χ(2) or Fisher's exact tests. Multinomial, mixed and logistic regression analyses were also performed.
Relative to people with primary OAG, those with pigmentary OAG were younger, more likely to be white, less likely to have a family history of glaucoma, and were more myopic. Those with pseudoexfoliative OAG were older, more likely to be white, more likely to be women, less likely to have bilateral disease, and presented with higher intraocular pressure (IOP) and better visual acuity. The type of glaucoma was not associated with IOP or visual field progression during follow-up.
Characteristics of newly diagnosed enrollees differed by the type of OAG. While some of these differences relate to the pathogenesis of OAG type, other differences are noteworthy for further evaluation within population-based samples of subjects with newly diagnosed OAG.
The British journal of ophthalmology 07/2012; 96(9):1180-4. · 2.92 Impact Factor
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Janey L Wiggs,
Brian L Yaspan,
Michael A Hauser,
Jae H Kang,
R Rand Allingham,
Lana M Olson,
Wael Abdrabou,
Bao J Fan,
Dan Y Wang,
Wendy Brodeur, [......],
Kang Zhang,
Robert N Weinreb,
Jason Ernst,
Manolis Kellis,
Tomohiro Masuda,
Don Zack,
Julia E Richards,
Margaret Pericak-Vance,
Louis R Pasquale,
Jonathan L Haines
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ABSTRACT: Optic nerve degeneration caused by glaucoma is a leading cause of blindness worldwide. Patients affected by the normal-pressure form of glaucoma are more likely to harbor risk alleles for glaucoma-related optic nerve disease. We have performed a meta-analysis of two independent genome-wide association studies for primary open angle glaucoma (POAG) followed by a normal-pressure glaucoma (NPG, defined by intraocular pressure (IOP) less than 22 mmHg) subgroup analysis. The single-nucleotide polymorphisms that showed the most significant associations were tested for association with a second form of glaucoma, exfoliation-syndrome glaucoma. The overall meta-analysis of the GLAUGEN and NEIGHBOR dataset results (3,146 cases and 3,487 controls) identified significant associations between two loci and POAG: the CDKN2BAS region on 9p21 (rs2157719 [G], OR = 0.69 [95%CI 0.63-0.75], p = 1.86×10⁻¹⁸), and the SIX1/SIX6 region on chromosome 14q23 (rs10483727 [A], OR = 1.32 [95%CI 1.21-1.43], p = 3.87×10⁻¹¹). In sub-group analysis two loci were significantly associated with NPG: 9p21 containing the CDKN2BAS gene (rs2157719 [G], OR = 0.58 [95% CI 0.50-0.67], p = 1.17×10⁻¹²) and a probable regulatory region on 8q22 (rs284489 [G], OR = 0.62 [95% CI 0.53-0.72], p = 8.88×10⁻¹⁰). Both NPG loci were also nominally associated with a second type of glaucoma, exfoliation syndrome glaucoma (rs2157719 [G], OR = 0.59 [95% CI 0.41-0.87], p = 0.004 and rs284489 [G], OR = 0.76 [95% CI 0.54-1.06], p = 0.021), suggesting that these loci might contribute more generally to optic nerve degeneration in glaucoma. Because both loci influence transforming growth factor beta (TGF-beta) signaling, we performed a genomic pathway analysis that showed an association between the TGF-beta pathway and NPG (permuted p = 0.009). These results suggest that neuro-protective therapies targeting TGF-beta signaling could be effective for multiple forms of glaucoma.
PLoS Genetics 04/2012; 8(4):e1002654. · 8.69 Impact Factor
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ABSTRACT: To assess trends in the use of ancillary diagnostic tests in the evaluation of patients with open-angle glaucoma (OAG) and glaucoma suspects over the past decade.
Retrospective, longitudinal cohort analysis.
A total of 169 917 individuals with OAG and 395 721 individuals with suspected glaucoma aged ≥40 years enrolled in a national United States managed care network between 2001 and 2009.
Claims data were analyzed to assess trends in visual field (VF) testing, fundus photography (FP), and other ocular imaging (OOI) testing for patients with OAG or suspected glaucoma between 2001 and 2009. Repeated-measures logistic regression was performed to identify differences in the odds of undergoing these procedures in 2001, 2005, and 2009 and whether differences exist for patients under the exclusive care of optometrists versus ophthalmologists.
Odds and annual probabilities of undergoing VF testing, FP, and OOI for OAG from 2001 to 2009.
For patients with OAG, the odds of undergoing VF testing decreased by 36% from 2001 to 2005, by 12% from 2005 to 2009, and by 44% from 2001 to 2009. By comparison, the odds of having OOI increased by 100% from 2001 to 2005, by 24% from 2005 to 2009, and by 147% from 2001 to 2009. Probabilities of undergoing FP were relatively low (13%-25%) for both provider types and remained fairly steady over the decade. For patients cared for exclusively by optometrists, the probability of VF testing decreased from 66% in 2001 to 44% in 2009. Among those seen exclusively by ophthalmologists, the probability of VF testing decreased from 65% in 2001 to 51% in 2009. The probability of undergoing OOI increased from 26% in 2001 to 47% in 2009 for patients of optometrists and from 30% in 2001 to 46% in 2009 for patients of ophthalmologists. By 2008, patients with OAG receiving care exclusively by optometrists had a higher probability of undergoing OOI than VF testing.
From 2001 to 2009, OOI increased dramatically whereas VF testing declined considerably. Because OOI has not been shown to be as effective at detecting OAG or disease progression compared with VF testing, increased reliance on OOI technology, in lieu of VF testing, may be detrimental to patient care.
Ophthalmology 01/2012; 119(4):748-58. · 5.45 Impact Factor
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ABSTRACT: To evaluate the impact of measures of intraocular pressure (IOP) control on progression of visual field (VF) loss during long-term treatment for open-angle glaucoma (OAG).
Longitudinal, randomized clinical trial.
We included 607 participants with newly diagnosed OAG.
Study participants were randomly assigned to initial treatment with medications or trabeculectomy, and underwent examination at 6-month intervals. Standardized testing included Goldmann applanation tonometry and Humphrey 24-2 full threshold VFs. Summary measures of IOP control during follow-up included the maximum, mean, standard deviation (SD), range, proportion less than 16, 18, 20, or 22 mmHg, and whether all IOP values were less than each of these 4 cutpoints. Predictive models for VF outcomes were based on the mean deviation (MD) from VF testing, and were adjusted for age, gender, race, baseline VF loss, treatment, and time. Each summary IOP measure was included as a cumulative, time-dependent variable, and its association with subsequent VF loss was assessed from 3 to 9 years postrandomization. Both linear mixed models, to detect shifts in MD levels, and logistic models, to detect elevated odds of substantial worsening (≥3 dB), were used.
We measured the MD from Humphrey 24-2 full threshold VF tests.
The effect of the summary IOP measures differed between the medicine and surgery groups in models that addressed the continuous MD outcome. After adjustment for baseline risk factors, in the medicine group larger values of 3 IOP control measures-maximum IOP (P = 0.0003), SD of IOP (P = 0.0056), and range of IOP (P<0.0001)-were significantly associated with lower (worse) MD over the 3- to 9-year period. No IOP summary measure was significantly associated with MD over time in the surgery group. The same 3 IOP summary measures were also significantly associated with substantial worsening of MD; however, the effects were similar in both treatment groups. In models predicting inadequate IOP control, consistently significant predictors of higher maximum, SD, and range of IOP included black race, higher baseline IOP, and clinical center.
These results support considering more aggressive treatment when undue elevation or variation in IOP measures is observed.
Ophthalmology 05/2011; 118(9):1766-73. · 5.45 Impact Factor
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Yutao Liu,
Jason Gibson,
Joshua Wheeler,
Lydia Coulter Kwee,
Cecile M Santiago-Turla,
Stephen K Akafo, Paul R Lichter,
Douglas E Gaasterland,
Sayoko E Moroi,
Pratap Challa,
Leon W Herndon,
Christopher A Girkin,
Donald L Budenz,
Julia E Richards,
R Rand Allingham,
Michael A Hauser
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ABSTRACT: DNA copy number variants (CNVs) have been reported in many human diseases including autism and schizophrenia. Primary Open Angle Glaucoma (POAG) is a complex adult-onset disorder characterized by progressive optic neuropathy and vision loss. Previous studies have identified rare CNVs in POAG; however, their low frequencies prevented formal association testing. We present here the association between POAG risk and a heterozygous deletion in the galactosylceramidase gene (GALC). This CNV was initially identified in a dataset containing 71 Caucasian POAG cases and 478 ethnically matched controls obtained from dbGAP (study accession phs000126.v1.p1.) (p = 0.017, fisher's exact test). It was validated with array comparative genomic hybridization (arrayCGH) and realtime PCR, and replicated in an independent POAG dataset containing 959 cases and 1852 controls (p = 0.021, OR (odds ratio) = 3.5, 95% CI -1.1-12.0). Evidence for association was strengthened when the discovery and replication datasets were combined (p = 0.002; OR = 5.0, 95% CI 1.6-16.4). Several deletions with different endpoints were identified by array CGH of POAG patients. Homozygous deletions that eliminate GALC enzymatic activity cause Krabbe disease, a recessive Mendelian disorder of childhood displaying bilateral optic neuropathy and vision loss. Our findings suggest that heterozygous deletions that reduce GALC activity are a novel mechanism increasing risk of POAG. This is the first report of a statistically-significant association of a CNV with POAG risk, contributing to a growing body of evidence that CNVs play an important role in complex, inherited disorders. Our findings suggest an attractive biomarker and potential therapeutic target for patients with this form of POAG.
PLoS ONE 01/2011; 6(11):e27134. · 4.09 Impact Factor
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ABSTRACT: To evaluate the relationship between glaucoma medication use and death.
This study uses longitudinal data from 2003 to 2007 on persons 40 years and older with glaucoma or suspected glaucoma enrolled in a large managed care network. Cox regression analysis was performed to estimate the hazard of death associated with the use of various glaucoma medication classes and combinations thereof. Multivariable models were adjusted for demographic characteristics and comorbid medical conditions.
Of 21 506 participants with glaucoma or suspected glaucoma, 237 (1.1%) died during the study period. The use of any class of glaucoma medication was associated with a 74% reduced hazard of death (adjusted hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.16-0.40) compared with no glaucoma medication use. This association was observed for use of a single agent alone, such as a topical beta-antagonist (0.44; 0.24-0.83) or a prostaglandin analogue (0.31; 0.18-0.54), and for use of different combinations of drug classes.
After adjustment for potential confounding variables, the use of glaucoma medications was associated with a reduced likelihood of death in this large sample of US adults with glaucoma. Future investigations should explore this association further because these findings may have important clinical implications.
Archives of ophthalmology 02/2010; 128(2):235-40. · 3.86 Impact Factor
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ABSTRACT: Relationships between physicians and industry including pharmaceutical companies and device manufacturers are being closely scrutinized by the public and the media. These companies can contribute beneficially to patient outcomes by supporting research that improves eye care. However, ethical issues may arise that affect practicing ophthalmologists, researchers, academic faculty, and ophthalmologic organizations. These topics were discussed at a symposium sponsored by the American Ophthalmological Society in May 2008. After this meeting, the council of the society developed this perspective to clarify some of the issues at the interface of industry and ophthalmology. The perspective is intended to provide some guidance to physicians, researchers, and professional societies and to enhance further dialogue.
Archives of ophthalmology 09/2009; 127(9):1194-202. · 3.86 Impact Factor
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Paul R Lichter
American journal of ophthalmology 04/2009; 147(3):563-564. · 3.83 Impact Factor
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ABSTRACT: To determine the effect of intraocular pressure (IOP) lowering on the optic disc in patients of the Collaborative Initial Glaucoma Treatment Study (CIGTS) after 5 years.
Randomized clinical trial.
The baseline and 5-year stereoscopic optic disc photographs of 348 eyes (patients) randomized to medical or surgical treatment of open-angle glaucoma (OAG) were assessed by 2 independent readers for change in a masked side-by-side comparison, and confirmed by an independent committee.
Three hundred and three (87.1%) eyes showed no change, 22 (6.3%) showed enlargement of the cup along any meridian (progression), and 23 (6.6%) showed a reduction in the cup along any meridian (reversal of cupping). Incidence of optic disc progression was higher (P = .007) in the medicine group, 18/185 (10%) than in the surgical group 4/163 (3%); and the incidence of reversal of cupping was higher (P < .001) in the surgical group, 21/163 (13%), than the medicine group, 2/185 (1%), (P < .001). Visual field (VF) worsening (mean deviation) was significantly associated with progression of optic disc cupping (P < .001). Reversal of cupping was also associated with lower postoperative IOP (P < .001). Reversal of cupping was not associated with improvement of either visual acuity or central VFs.
Surgery prevents or delays glaucomatous progression as measured by optic disc criteria in patients with early OAG. Reversal of cupping occurs more frequently in the surgical group than in the medical treatment group. Reversal is associated with lower IOP, but is not associated with improved visual function.
American journal of ophthalmology 01/2009; 147(4):717-724.e1. · 3.83 Impact Factor
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ABSTRACT: To evaluate factors associated with visual field (VF) progression, using all available follow-up through 9 years after treatment initiation, in the Collaborative Initial Glaucoma Treatment Study (CIGTS).
Longitudinal follow-up of participants enrolled in a randomized clinical trial.
Six hundred seven newly diagnosed glaucoma patients.
In a randomized clinical trial, 607 subjects with newly diagnosed open-angle glaucoma initially were treated with either medication or trabeculectomy. After treatment initiation and early follow-up, subjects were evaluated clinically at 6-month intervals. Study participants in both arms of the CIGTS were treated aggressively in an effort to reduce intraocular pressure (IOP) to a level at or below a predetermined, eye-specific target pressure. Visual field progression was analyzed using repeated measures models.
Visual field progression, measured by Humphrey 24-2 full-threshold testing and assessed by the change in the mean deviation (MD), and an indicator of substantial worsening of the VF (MD decrease of > or =3 dB from baseline), assessed at each follow-up visit.
Follow-up indicated minimal change from baseline in each initial treatment group's average MD. However, at the 8-year follow-up examination, substantial worsening (> or =3 dB) of MD from baseline was found in 21.3% and 25.5% of the initial surgery and initial medicine groups, respectively. The effect of initial treatment on subsequent VF loss was modified by time (P<0.0001), baseline MD (P = 0.03), and diabetes (P = 0.01). Initial surgery led to less VF progression than initial medicine in subjects with advanced VF loss at baseline, whereas subjects with diabetes had more VF loss over time if treated initially with surgery.
The CIGTS intervention protocol led to a lowering of IOP that persisted over time in both treatment groups. Progression in VF loss was seen in a subset, increasing to more than 20% of the subjects. The findings regarding initial surgery being beneficial for subjects with more advanced VF loss at presentation, but detrimental for patients with diabetes, are noteworthy and warrant independent confirmation.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Ophthalmology 11/2008; 116(2):200-7. · 5.45 Impact Factor
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Paul R Lichter
Ophthalmology 11/2008; 115(10):1852-3; author reply 1853. · 5.45 Impact Factor
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Paul R Lichter
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ABSTRACT: To call attention to the myths that surround physician-industry conflicts of interest, to refute their validity, and to propose ways to address them so as to insure that physicians make medical practice decisions in the best interest of their patients.
Perspective.
Review, analysis, and discussion of the implications of selected pertinent literature.
Physicians often have voluntary financial relationships with industry based on behaviors and motivations that include entitlement, recognition, belonging, and money. The pharmaceutical and device industry spends billions of dollars annually in marketing to physicians. The sophisticated marketing plan seeks access to physicians through gifting mechanisms to ingratiate them and to influence them to prescribe industry's drugs and to purchase its products. Despite widely accepted studies that demonstrate that industry's marketing activities influence physicians' medical practice behavior to the detriment of patients and the public, physicians persist in voicing myths to justify their partaking of industry's largesse. Many physicians believe that their voluntary financial conflicts of interest with industry can be managed by simply disclosing them and by "being honest." Yet there is no support from well-conducted studies to support the effectiveness of this approach.
Medical organizations and academic institutions are the ones to take the lead in recognizing that these voluntary financial conflicts of interest are unacceptable and should be stopped. Such conflicts mainly relate to the acceptance of gifts and money that are designed to influence behavior and are a form of financial coercion.
American Journal of Ophthalmology 07/2008; 146(2):159-71. · 4.22 Impact Factor
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ABSTRACT: To evaluate, both at initial glaucoma diagnosis and during treatment, the role of demographic and clinical factors on intraocular pressure (IOP).
Cohort study of patients enrolled in a randomized clinical trial.
Six hundred seven patients with newly diagnosed open-angle glaucoma (OAG) were enrolled at 14 centers in the United States.
After randomization to initial surgery or medications, patients were followed at 6-month intervals. Intraocular pressure was measured by Goldmann applanation tonometry. Predictive factors for IOP at baseline and during follow-up were analyzed using linear mixed models.
Intraocular pressure at baseline and during follow-up.
The mean baseline IOP was 27.5 mmHg (standard deviation, 5.6 mmHg). Predictive factors for higher baseline IOP included younger age (0.7 mmHg per 10 years), male gender (2.4 mmHg higher than females), pseudoexfoliative glaucoma (5.4 mmHg higher than primary OAG), and pupillary defect (2.2 mmHg higher than those without a defect). During 9 years of follow-up, both surgery and medications dramatically reduced IOP from baseline levels, but the extent of IOP reduction was consistently greater in the surgery group. Over follow-up years 2 through 9, mean IOP was 15.0 versus 17.2 mmHg for surgery versus medicine, respectively. Predictive associations with higher IOP during follow-up included higher baseline IOP (P<0.0001), worse baseline visual field (mean deviation; P<0.0001), and lower level of education (P = 0.0019). Treatment effect was modified by smoking status: nonsmokers treated surgically had lower IOP than smokers treated surgically (14.6 vs. 16.7 mmHg, respectively; P = 0.0013). Clinical center effects were significant (P<0.0001) in both the baseline and follow-up models.
In this large cohort of newly diagnosed glaucoma patients, predictors of pretreatment IOP and IOP measurements over 9 years of follow-up were identified. Our findings lend credence to the postulate that sociodemographic, economic, compliance, or other environmental influences play a role in IOP control during treatment.
Ophthalmology 07/2008; 115(6):927-33. · 5.45 Impact Factor
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Archives of Ophthalmology 02/2008; 126(1):122-4. · 3.71 Impact Factor
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Paul R Lichter
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ABSTRACT: To show how physicians' conditioned response to "keeping up" has helped industry's opportunistic funding of continuing medical education (CME) and to propose ways to counter the conditioned response to the benefit of patients and the public.
Review of the literature and commentary on it.
The pharmaceutical and device industries (hereafter referred to as industry) have a long history of bribing physicians to prescribe and use their products. Increasing pressure from Congress and the public has been brought to bear on industry gifting. This pressure, coinciding with increasing financial problems for the providers of CME, provided industry with reason and opportunity to expand its role in the financing of CME. Industry's incentive to make its CME funding appear to be an arm's-length transaction has spawned medical education service supplier (MESS) companies. Industry makes "unrestricted grants" to the MESS, and the MESS puts on the CME program. Helped by these CME programs, industry is able to subtly "buy" physicians one at a time, so that under the cover of "education" they and their academic institutions and medical organizations lose sight of being CME pawns in industry's sole objective: profit.
Despite a vast literature showing how physician integrity is easy prey to industry, the medical profession continues to allow industry to have a detrimental influence on the practice of medicine and on physician respectability. It will take resolute action to change the medical profession's conditioned response to industry's CME bell and its negative effect on patients and the public.
Transactions of the American Ophthalmological Society 02/2008; 106:39-43; discussion 44-5.
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ABSTRACT: The objective of this study was to describe the prevalence of fear of blindness (FOB) and the factors associated with FOB during 5 years of follow-up in the Collaborative Initial Glaucoma Treatment Study.
Randomized controlled clinical trial.
A total of 607 newly diagnosed patients with open-angle glaucoma were recruited from 14 clinical centers in the United States.
Patients were assigned randomly either to initial medical therapy or initial trabeculectomy. Study participants received clinical examinations and quality-of-life (QOL) evaluations at baseline and 6-month intervals. The QOL questionnaire was administered by trained telephone interviewers at a centralized interviewing center.
The QOL questionnaire included an assessment of FOB, measures of vision-related functioning, and measures of general physical and psychosocial well being. Ordinal logistic regression analyses were used to assess clinical and QOL measures associated with FOB over time.
After being told about the glaucoma diagnosis but before randomization, 34% of patients reported at least a moderate amount of FOB. This percent dropped to 11% at 5 years. In multivariable ordinal logistic regression models, younger age, being white, and having less education and a lower income were associated with increased FOB (all P<0.05). At the 36-month follow-up, visual field progression was associated significantly with increased FOB (P = 0.006); visual acuity loss, although related to increased FOB, did not achieve statistical significance (P = 0.327). Self-reported visual function measures explained more of the variation in FOB over time than did demographic, clinical, or physical or psychosocial measures. Initial treatment assignment (medicine or surgery) was not associated with FOB. The most significant correlate over time with FOB was the perceived impact on an individual's ability to perform visual tasks.
More attention to reducing glaucoma patients' FOB at diagnosis and over time is warranted. Fear of blindness over time is related more to how much an individual is bothered by their inability to perform visual tasks than to their monocular visual acuity or visual field assessments.
Ophthalmology 12/2007; 114(12):2213-20. · 5.45 Impact Factor
