Faculty Bibliography

The ocular hypotensive efficacy and safety of brimonidine tartrate 0.2%, a highly selective alpha 2-adrenergic agonist, was compared with that of timolol 0.5%, a nonselective beta-blocker in two multicenter, randomized, double-masked studies. Combined data from a 12-month completed study and 6-month interim data from an ongoing study are reported. Efficacy and safety were evaluated at baseline, weeks 1 and 2, and months 1, 2, 3, 6, 9, and 12. Intraocular pressure (IOP) was measured at peak (2 hours after the morning dose) and trough (12 hours after the evening dose). Patients (n = 926) instilled either brimonidine tartrate 0.2% or timolol maleate 0.5% twice daily. At peak, the mean decreases from baseline IOP ranged from 5.9 +/- 3.2 mm Hg to 7.6 +/- 3.6 mm Hg for brimonidine and 6.0 +/- 3.4 mm Hg to 6.6 +/- 3.6 mm Hg for timolol (p < 0.001 within groups compared with baseline). No significant between-group differences were seen at peak except for weeks 1 and 2 and month 3 (p < or = 0.04), when brimonidine had lower mean IOP. At trough the mean decreases from baseline ranged from 3.7 +/- 4.0 mm Hg to 5.0 +/- 3.0 mm Hg for brimonidine and 5.9 +/- 3.4 to 6.6 +/- 3.0 for timolol. A significant between-group difference was seen at trough at all visits (< 0.001), when timolol had a lower mean IOP. Brimonidine and timolol showed sustained efficacy. Both drugs were well-tolerated. The brimonidine group had more ocular allergy, oral dryness and conjunctival follicles. The timolol group had more burning and stinging. In the brimonidine group, 38/513 (7.4%) discontinued treatment due to ocular allergy. The timolol group had significantly lower mean heart rate compared to baseline. The effect on blood pressure was minimal for both drugs. Brimonidine showed efficacy similar to timolol and a relatively low rate of ocular allergy. Brimonidine 0.2% administered twice daily is an effective and safe ocular hypotensive agent that maintains IOP-lowering in chronic use.

Purpose: To learn the long-term outcome of ciliary ablation with diode laser contact transscleral cyclophotocoagulation (TSCPC) in eyes with recalcitrant, severe glaucoma. Methods: Twenty-seven eyes of 27 patients with medically and surgically uncontrollable glaucoma and no previous ciliary ablation enrolled in this study. After baseline measurements and informed consent, the authors performed contact TSCPC. There were 14 pseudophakic, 7 aphakic, and 6 phakic eyes; 15 of these had primary open-angle glaucoma and the remainder had various secondary or open- or closed-angle glaucomas. Median follow-up was 19 months (range, 6 weeks to 27 months). initially after laser surgery, glaucoma medications were continued, except for a 2-week interruption of miotics; the ophthalmologist later adjusted medications in accordance with the patient's status. The authors define failure of TSCPC in two ways, based on IOP measurements during two consecutive study examinations 6 weeks or more after intervention or at the final examination: (1) less than 20% intraocular pressure (IOP) reduction from baseline, and (2) either less than 20% reduction of IOP from baseline or IOP greater than 22 mmHg. Results: For 27 eyes, the baseline IOP (mean +/- standard deviation) was 36.4 +/- 12.4 mmHg (range, 20-70 mmHg). The mean IOP at last examination was 20.3 +/- 8.7 mmHg. With failure definition 1, the cumulative probability of success was 84% at 1 year and 62% at 2 years. With failure definition 2 the cumulative probability of success was 72% at 1 year and 52% at 2 years. At the last examination, 19 eyes (70%) had visual acuity improved within one line of visual acuity at eligibility. One of these eyes, with light perception vision at entry, declined to no light perception. Three eyes (11%) lost two lines of vision and five (19%) lost three or more lines. Conclusions: Contact diode laser TSCPC yields long-term improvement of IOP and preservation of visual acuity in a substantial proportion of eyes with severe, medically uncontrolled glaucoma.