Winkler, Nelson S.

Purpose: The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD). Methods: In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan–Meier analysis with risk factors determined by proportional hazard models. Results: Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001). Conclusions: Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty.

Purpose: To determine the effect of a protocol for a new physician-led, team-based glaucoma care model implemented in 2008 at Mayo Clinic’s campus in Rochester, Minnesota (MCR), to increase conformance with the American Academy of Ophthalmology (AAO) Preferred Practice Pattern guidelines for treatment of primary open-angle glaucoma. Methods: Records of 591 patients with newly diagnosed glaucoma were assessed retrospectively for the completion of 9 AAO Preferred Practice Pattern recommended metrics including measured corneal thickness, intraocular pressure (IOP), cup to disk ratio, visual acuity, recorded IOP target, gonioscopy, fundus photos, ocular coherence tomography, and visual field in the 3 years before and 3 years after protocol implementation. Treatment by the glaucoma care team at MCR was compared with treatment at a community-based general ophthalmology practice and with a group of comprehensive ophthalmologists at MCR without team care, which served as controls. Results: Adherence to AAO recommendations increased for the documentation of target IOP (+24%, 42.6% to 66.7%; P=0.007), gonioscopy (+27%, 66.7% to 93.3%; P≤0.001), fundus photos (+29%, 44.4% to 73.3%; P≤0.001), and ocular coherence tomography (+20%, 48.1% to 68.0%; P=0.02) after protocol initiation. No change in pattern of testing occurred in the control groups without team care during the same time period. Type and severity of glaucoma were similar between MCR and community practice. Conclusions: An increase in compliance with AAO guidelines was found after implementation of our protocol for a physician-led, team-based care model to standardize glaucoma care among providers.

Abstract Elevated intraocular pressure (IOP) is the most prevalent risk factor for glaucoma. All treatments, whether surgical or pharmaceutical, are aimed at lowering IOP. Prostaglandin analogues are a first line therapy for glaucoma due to their ability to reduce IOP, once-daily dosing, efficacy, and minimal side-effect profile. Whereas prostaglandin analogues have been known to alter aqueous humor outflow through the unconventional (uveoscleral) pathway, more recent evidence suggests their action also occurs through the conventional (trabecular) pathway. Understanding how prostaglandin analogues successfully lower IOP is important, as this information may lead to the discovery of new molecular targets for future therapeutic intervention. This review explores the current understanding of prostaglandin analogue biology as it pertains to IOP reduction and improved aqueous humor outflow facility.