iStent inject? and cataract surgery for mild-to-moderate primary open angle glaucoma in Japan: a cost-utility analysis

AIM: To evaluate the cost-utility of iStent inject;with cataract surgery vs cataract surgery alone in patients with mild-to-moderate primary open angle glaucoma(POAG) in the Japanese setting from a public payer’s perspective.METHODS: A Markov model was adapted to estimate the cost-utility of iStent inject;plus cataract surgery vs cataract surgery alone in one eye in patients with mild-tomoderate POAG over lifetime horizon from the perspective of Japanese public payer. Japanese sources were used for patients’ characteristics, clinical data, utility, and costs whenever available. Non-Japanese data were validated by Japanese clinical experts. RESULTS: In the probabilistic base case analysis, iStent inject;with cataract surgery was found to be cost-effective compared with cataract surgery alone over a lifetime horizon when using the ￥5 000 000/quality-adjusted life year(QALY)willingness-to-pay threshold. The incremental cost-utility ratio(ICUR) was estimated to be ￥1 430 647/QALY gained and the incremental cost-utility ratio(ICER) was estimated to be ￥12 845 154/blind eye avoided. iStent inject;with cataract surgery vs cataract surgery alone was found to increase costs(￥1 025 785 vs ￥933 759, respectively) but was more effective in increasing QALYs(12.80 vs 12.74) and avoiding blinded eyes(0.133 vs 0.141). The differences in costs were mainly driven by costs of primary surgery(￥279 903 vs ￥121 349). In the scenario analysis from a societal perspective, which included caregiver burden, iStent inject;with cataract surgery was found to dominate cataract surgery alone.CONCLUSION: The iStent inject;with cataract surgery is a cost-effective strategy over cataract surgery alone from the public payer’s perspective and cost-saving from the societal perspective in patients with mild-to-moderate POAG in Japan.

Evaluation of refractive correction for standard automated perimetry in eyes wearing multifocal contact lenses

AIM：To evaluate the refractive correction for standard automated perimetry（SAP）in eyes with refractive multifocal contact lenses（CL）in healthy young participants.METHODS：Twenty-nine eyes of 29 participants were included.Accommodation was paralyzed in all participants with 1%cyclopentolate hydrochloride.SAP was performed using the Humphrey SITA-standard 24-2 and 10-2 protocol under three refractive conditions：monofocal CL corrected for near distance（baseline）;multifocal CL corrected for distance（m CL-D）;and m CL-D corrected for near vision using a spectacle lens（m CL-N）.Primary outcome measures were the foveal threshold,mean deviation（MD）,and pattern standard deviation（PSD）.RESULTS：The foveal threshold of m CL-N with both the24-2 and 10-2 protocols significantly decreased by 2.2-2.5 d B（P〈0.001）,while that of m CL-D with the 24-2 protocol significantly decreased by 1.5 d B（P=0.0427）,as compared with that of baseline.Although there was no significant difference between the MD of baseline and m CL-D with the24-2 and 10-2 protocols,the MD of m CL-N was significantly decreased by 1.0-1.3 d B（P〈0.001）as compared with that of both baseline and m CL-D,with both 24-2 and 10-2 protocols.There was no significant difference in the PSD among the three refractive conditions with both the 24-2 and 10-2 protocols.CONCLUSION：Despite the induced mydriasis and the optical design of the multifocal lens used in this study,our results indicated that,when the dome-shaped visual field test is performed with eyes with large pupils and wearing refractive multifocal CLs,distance correction without additional near correction is to be recommended.

Comparison of corneal biomechanical properties in normal tension glaucoma patients with different visual field progression speed

AIM：To compare the corneal biomechanical properties difference by ocular response analyzer（ORA） in normal tension glaucoma（NTG） patients with different visual field（VF） progression speed. METHODS：NTG patients with well-controlled Goldmann applanation tonometer（GAT） who routinely consulted Kitasato University Hospital Glaucoma Department between January 2010 and February 2014 were enrolled.GAT and ORA parameters including corneal compensated intraocular pressure（lOPcc）,Goldmann estimated intraocular pressure（lOPg）,corneal hysteresis（CH）,corneal resistance factor（CRF） were recorded.VF was tested by Swedish interactive threshold algorithm（SITA）-standard 30-2 fields.All patients underwent VF measurement regularly and GAT did not exceed 15 mm Hg at any time during the 3y follow up.Patients were divided into four groups according to VF change over 3y,and ORA findings were compared between the upper 25th percentile group（slow progression group） and the lower 25th percentile group（rapid progression group）.RESULTS：Eighty-two eyes of 56 patients were studied.There were 21 eyes（21 patients） each in rapid and slow progression groups respectively.GAT,lOPcc,lOPg,CH,CRF were 12.1＋1.4 mm Hg,15.8±1.8 mm Hg,12.8±2.0 mm Hg,8.4±1.1 mm Hg,7.9±1.3 mm Hg respectively in rapid progression group and 11.5±1.3 mm Hg,13.5±2.1 mm Hg,11.2±1.6 mm Hg,9.3±1.1 mm Hg,8.2±0.9 mm Hg respectively in slow progression group（P=0.214,〈0.001,0.007,0.017,0.413,respectively）.In bivariate correlation analysis,lOPcc,lOPcc-GAT and CH were significant correlated with m△MD（r =-0.292,-0.312,0.228 respectively,P =0.008,0.004,0.039 respectively）.CONCLUSION：Relatively rapid VF progression occurred in NTG patients whose lOPcc are rather high,CH are rather low and the difference between lOPcc and GAT are relatively large.Higher lOPcc and lower CH are associated with VF progression in NTG patients.This study suggests that GAT measures might underestimate the IOP in such patients.

Influence of corneal power on circumpapillary retinal nerve fiber layer and optic nerve head measurements by spectral-domain optical coherence tomography

AIM：To evaluate the influence of corneal power on circumpapillary retinal nerve fiber layer（cp RNFL）and optic nerve head（ONH）measurements by spectral-domain optical coherence tomography（SD-OCT）.METHODS：Twenty-five eyes of 25 healthy participants（mean age 23.6±3.6y）were imaged by SD-OCT using horizontal raster scans.Disposable soft contact lenses of different powers（from-11 to＋5 diopters including 0diopter）were worn to induce 2-diopter changes in corneal power.Differences in the cp RNFL and ONH measurements per diopter of change in corneal power were analyzed.RESULTS：As corneal power increased by 1 diopter,total and quadrant cp RNFL thicknesses,except for the nasal sector,decreased by-0.19 to-0.32μm（P〈0.01）.Furthermore,the disc,cup,and rim areas decreased by-0.017,-0.007,and-0.015 mm2,respectively（P〈0.001）;the cup and rim volumes decreased by-0.0013 and-0.006 mm3,respectively（P〈0.01）;and the vertical and horizontal disc diameters decreased by-0.006 and-0.007 mm,respectively（P〈0.001）.CONCLUSION：For more precise OCT imaging,the ocular magnification should be corrected by considering both the axial length and corneal power.However,the effect of corneal power changes on cp RNFL thickness and ONH topography are small when compare with those of the axial length.

The Effect of Monocular Blur on the Binocular Visual Field

Purpose/Aim: We aimed to investigate the effect of monocular blur on the binocular visual field. Materials and Methods: A total of 13 healthy young volunteers participated in this study. The mean subjective refractive error of the dominant eye (DE) was -3.33 ± 1.65D, and the non-dominant eye (NDE) was -3.15 ± 2.84D. The DE was determined by using the hole-in-the-card test. The visual field was examined by the Humphrey Visual Field Analyzer using the 30-2 SITA Standard program. The visual field was measured while wearing soft contact lens under three conditions;① both eyes: near vision correction;② DE: near vision correction +3.00D added, NDE: near vision correction;and ③ DE: near vision correction, NDE: near vision correction +3.00D added. The foveal threshold, mean deviation (MD), and pattern standard deviation (PSD) values were investigated. Results: The foveal threshold value (dB) at ①, ②, and ③ was 41.2, 37.8, and 38.1, respectively. The values at ② and ③ were both significantly lower than that at ① (p Conclusion: These results suggest that monocular blur reduced the sensitivity within the binocular visual field.

Comparison of the Normal, Preperimetric Glaucoma, and Glaucomatous Eyes with Upper-Hemifield Defects Using SD-OCT

Purpose: We compared the thickness of circumpapillary retinal nerve fiver layer (cpRNFL) and macular ganglion cell layer with inner plexiform layer (GCL + IPL) using Cirrus HD-OCT (Ver.6.0: Carl Zeiss). Materials and Methods: This study included 12 eyes of normal controls, 10 eyes of preperimetric glaucoma (PPG) with loss of RNFL either in superior or in inferior hemisphere without visual field defects, and 22 eyes of glaucoma eyes with visual field defects restricted to upper hemifield (UHFD: early 10 eyes, severe 12 eyes). The cpRNFL thickness analyzed from disk center by dividing into 12 sectors. The GCL + IPL thickness analyzed from central fovea by dividing into six sectors. Both compared between normal eye group and other 3 groups using the average value of each sectors. Result: The cpRNFL and the GCL + IPL thickness were obviously thin as compared with normal eyes. Conclusion: Even if it is in the state where abnormalities are not detected using the Humphrey field Analyzer, it is suggested that the early structural change of glaucoma has already arisen.

Switching Study of Tafluprost/Timolol Fixed-Combination Ophthalmic Solution, Following Unfixed Combination of Tafluprost Ophthalmic Solution 0.0015% and Timolol Ophthalmic Gel-Forming Solution 0.5%

Purpose: Fixed-combination medication to treat glaucoma can reduce intraocular pressure (IOP) without negative effects of concomitant medication. Tafluprost/timolol fixed-combination ophthalmic solution (TTFC) has been reported to show similar effectiveness in lowering IOP, compared with concomitant use of its component drugs, tafluprost and timolol. However, the difference in IOP-lowering effects between TTFC and concomitant use of tafluprost and gel-forming timolol is unknown. Hence, we conducted this switching study from tafluprost and gel-forming timolol to TTFC in glaucoma patients undergoing multi-drug therapy. Design: Multi-center, open-label, interventional clinical study. Methods: Twenty-eight patients (28 eyes;safety analysis set) with primary open-angle glaucoma and ocular hypertension, who had completed the 4-week-concomitant phase of tafluprost and gel-forming timolol, were treated for 8 weeks with TTFC. IOP, adherence, ocular surface safety, and the usability of ophthalmic solution were compared before and after switching. This study was approved by the ethics committees of Kitasato University Hospital and all other study sites. All patients provided written informed consent to participate. Results: IOP at 8 weeks after switching was significantly lower than before switching (P = 0.0001) in the efficacy analysis set (n = 24). The self-reported adherence rate remained high after switching;moreover, there was no meaningful change in ocular surface safety. Patient questionnaires regarding usability of medication revealed that 85.7% of patients preferred their instillation prescription after switching, including TTFC. Among the safety analysis set (n = 28), no adverse events were reported in relation to the study drug. Conclusion: TTFC showed greater IOP reduction than concomitant therapy. Thus, TTFC may be a better option in glaucoma patients than concomitant therapy.

The Effect of Ocular Dominance on Accommodation and Miosis under Binocular Open Viewing Conditions

Background/Aims: We investigated the relationship between ocular dominance and accommodation on the pupils of the dominant eye and the non-dominant eye under binocular open viewing conditions. Methods: Seventeen healthy young volunteers participated in this study. The dominant eye was determined using the hole-in-the-card test. The objective refraction and pupil diameter were measured under binocular open viewing and monocular single viewing conditions using a binocular open auto-refractor, the WAM-5500 (SHIGIYA MACHINERY WORKS LTD., Hiroshima, Japan). The accommodative response was calculated using the objective refraction, and the rate of miosis was calculated using the pupil diameter. These values were then compared between the dominant and the non-dominant eyes. Results: Under binocular open viewing conditions, the accommodative response in the dominant eye was greater than in the non-dominant eye (p = 0.001). In contrast, under monocular single viewing conditions, there were no differences in the accommodative response between the dominant and non-dominant eyes. In both binocular open viewing and monocular single viewing conditions, there were no differences in the miosis ratio between the dominant and non-dominant eyes. Conclusion: These results suggest that the accommodative response under binocular open viewing conditions is influenced by ocular dominance.

Surgically induced astigmatismCorneal astigmatismMeanSummated vector meanCentroidVector analysisTemporal incisionSuperior incisionICL implantation

BackgroundTo compare the arithmetic mean (M-SIA) and the summated vector mean of surgically induced astigmatism (SVM-SIA) according to the incision site after phakic intraocular lens (Visian implantable collamer lens (ICL), STAAR Surgical) implantation.MethodsThis study comprised 121 eyes of 121 consecutive patients undergoing ICL surgery through a 3.0-mm temporal or superior clear corneal incision. The magnitude and the axis of corneal astigmatism preoperatively and 3 months postoperatively were measured using an automated keratometer. The M-SIA and the SVM-SIA were determined according to the incision site.ResultsThe magnitude of corneal astigmatism significantly increased from 1.23 ± 0.59 D preoperatively to 1.46 ± 0.72 D postoperatively in the temporal incision group (Wilcoxon signed-rank test, P < 0.001), but it significantly decreased from 1.09 ± 0.36 D preoperatively to 0.86 ± 0.41 D postoperatively in the superior incision group (P < 0.001). The M-SIA was 0.48 ± 0.30 D, and the SVM-SIA was 0.23 ± 0.52 D at a meridian of 82° in the temporal incision group. The M-SIA was 0.57 ± 0.30 D, and the SVM-SIA was 0.47 ± 0.45 D at a meridian of 1° in the superior incision group.ConclusionsICL implantation induces the M-SIA by approximately 0.5 D, but the SVM-SIA decreased to 50% and 80% of the M-SIA in magnitude through temporal and superior incisions, respectively. The direction of the SVM-SIA showed a tendency toward corneal flattening to the incisional site. It should be noted that the M-SIA is somewhat different from the SVM-SIA according to the incision site.

Comparison of magnitude and summated vector mean of surgically induced astigmatism vector according to incision site after phakic intraocular lens implantation

Background:To compare the arithmetic mean(M-SIA)and the summated vector mean of surgically induced astigmatism(SVM-SIA)according to the incision site after phakic intraocular lens(Visian implantable collamer lens(ICL),STAAR Surgical)implantation.Methods:This study comprised 121 eyes of 121 consecutive patients undergoing ICL surgery through a 3.0-mm temporal or superior clear corneal incision.The magnitude and the axis of corneal astigmatism preoperatively and 3 months postoperatively were measured using an automated keratometer.The M-SIA and the SVM-SIA were determined according to the incision site.Results:The magnitude of corneal astigmatism significantly increased from 1.23±0.59 D preoperatively to 1.46±0.72 D postoperatively in the temporal incision group(Wilcoxon signed-rank test,P<0.001),but it significantly decreased from 1.09±0.36 D preoperatively to 0.86±0.41 D postoperatively in the superior incision group(P<0.001).The M-SIA was 0.48±0.30 D,and the SVM-SIA was 0.23±0.52 D at a meridian of 82°in the temporal incision group.The M-SIA was 0.57±0.30 D,and the SVM-SIA was 0.47±0.45 D at a meridian of 1°in the superior incision group.Conclusions:ICL implantation induces the M-SIA by approximately 0.5 D,but the SVM-SIA decreased to 50%and 80%of the M-SIA in magnitude through temporal and superior incisions,respectively.The direction of the SVM-SIA showed a tendency toward corneal flattening to the incisional site.It should be noted that the M-SIA is somewhat different from the SVM-SIA according to the incision site.