Researchers from Germany evaluated the performance of matrix metalloproteinase 9 and tear-film osmolarity in diagnosing early-stage dry-eye disease and determined that, similar to corneal staining, MMP-9 is likely a late-stage sign of dry eye that is rarely overexpressed in mild subjects. However, tear osmolarity tends to be a more frequent early indicator of ocular disequilibrium with mild cases of dry-eye disease.

A group of 20 patients aged 60 years and above, previously undiagnosed with dry-eye disease, were selected for this study. The following dry-eye disease tests were performed: tear osmolarity; MMP-9 (InflammaDry); Schirmer test; tear-film breakup time; Ocular Surface Disease Index questionnaire; corneal fluorescein staining; and conjunctival lissamine green staining. MMP-9 concentrations in tears collected through Schirmer strips were analyzed by an MMP-9 enzyme-linked immunosorbent assay. The 20 subjects were classified by symptoms (classification A: OSDI ≥10, n=nine); based on suspected mild dry eye (classification B, n=14); TFO difference >8 mOsm/L between both eyes (classification C, n=13); and TFO cutoff at 308 mOsm/L (classification D: >308 mOsm/L, n=11).

Eleven percent of the symptomatic and 14 percent of the suspected mild dry-eye patients were positive for MMP-9. InflammaDry MMP-9 tests were confirmed to be accurate through an ELISA. Sixty-seven percent of the symptomatic and 64 percent of the suspected mild dry eye patients were positive for tear osmolarity. None of the evaluated tear-film parameters showed a significant correlation, although tear osmolarity and symptoms trended towards significance (r2=0.443, p=0.06) whereas MMP-9 and corneal staining showed a positive association (r2=0.376, p=0.10).
Cornea 2015;43:739-744.
Chargus M, Ivanova S, Kakkassery V, Dick HB, Joachim S.

Time Burden in Treating and Managing Neovascular AMD
A 17-month multicenter study concluded that management of neovascular age-related macular degeneration imposes a substantial time burden on physicians, staff, patients and caregivers. Based on this, there may be a need for additional support and/or reimbursement for services required by patients and caregivers and provided by physicians.

The study was conducted at multiple sites from March 2011 through August 2012. Retina specialists administering ≥50 vascular endothelial growth factor-inhibitor injections monthly were surveyed and completed records for ≥five patients scheduled for office visits within three weeks for anti-VEGF injection or monitoring. A survey was administered to 75 neovascular AMD patients aged ≥50 years who received one or more anti-VEGF injections in the past six months. Telephone interviews were conducted with 13 neovascular AMD patient caregivers.

Fifty-six physicians provided data for 221 patients with neovascular AMD. Patients accounted for 20 percent of the health-care staff’s time per week, with an average of 23 staff members. An average patient visit for neovascular AMD was 90 minutes (range: 13 minutes to >4 hours). Patients reported an average time per visit of almost 12 hours, including pre-appointment preparation (16 minutes); waiting time (37 minutes); treatment time (43 minutes); and post-appointment recovery (nine hours). Patients stated that caregivers took time away from work (22 percent) and personal activities (28 percent) to provide transportation to appointments.
Am J Ophthalmol 2015;160:4:725-731.
Prenner J, Halperin L, Rycroft C, Hogue S, et al.

Trabeculectomy vs. Ex-PRESS Shunt: Efficacy and Safety
A study from
Israel comparing standard trabeculectomy with the Ex-PRESS miniature glaucoma shunt found the two have similar efficacy and safety profiles.

A retrospective review of the records of 100 eyes of 100 patients who underwent trabeculectomy or Ex-PRESS shunt implantation between July 2010 and June 2012 was conducted. Of these, 61 eyes (61 percent) underwent trabeculectomy and 39 eyes (39 percent) underwent Ex-PRESS shunt implantation. Demographic information, glaucoma type, surgical details, preoperative and postoperative data including intraocular pressure, number of medications, reoperation and occurrence of any complications were recorded.

No differences in IOP reduction or number of postop IOP-lowering medications were demonstrated between the two procedures. Success rates were 86.9 percent for trabeculectomy and 84.6 percent for Ex-PRESS shunt. Rates of failure and hypotony were not significantly different between the groups. No parameter was correlated with success or failure of any procedure. As the Ex-PRESS shunt is considerably more expensive, its use may be unjustified, especially as a primary procedure, the authors suggest.
J Glaucoma 2015;24:410-416.
Moisseiev E, Zunz E, Tzur R, Kurtz S, Shemesh G.

IOP in Neovascular AMD After IVI Aflibercept or Ranibizumab
Analyses from two
randomized, active-controlled, Phase III trials of intraocular pressure in patients with neovascular age-related macular degeneration indicates that eyes receiving intravitreal injections of aflibercept had lower IOP than eyes receiving intravitreal injections of ranibizumab.

A total of 2,457 patients with neovascular AMD were enrolled in the two trials. Patients received intravitreal aflibercept injection 2 mg every four weeks (2q4), 0.5 mg every four weeks (0.5q4), 2 mg every eight weeks (after three monthly doses; 2q8) or ranizibumab 0.5 mg every four weeks (Rq4) for 52 weeks. At week 52, patients were switched to a variable regimen requiring at least quarterly dosing and allowing interim injections based on anatomic and visual assessment. Pre-injection IOP was analyzed in study and uninjected fellow eyes from baseline to week 96. Prespecified end points included mean change in IOP from baseline and a prevalence of a >21 mmHg and >10 mmHg increase in IOP from baseline. Cumulative incidence of sustained (at two consecutive visits) IOP >21 mmHg, a single event of IOP >25 mmHg and sustained IOP increase from baseline (≥5 mmHg) were also evaluated.

Mean IOP change from baseline over 96 weeks in all IAI groups (2q4, 2q8, 0.5q4) was consistently lower than in the Rq4 group, and this finding was replicated in both trials. In an analysis integrating both studies, the proportion of study eyes with IOP >21 mmHg at week 96 was 20.2 percent for the Rq4 group, 14.2 percent for the 2q4 group, 12.1 percent for the 2q8 group and 12.5 percent for the 0.5q4 group. Reduction in risk, relative to Rq4, of having sustained IOP >21 mmHg over 96 weeks was 62 percent (95 percent confidence interval, 37 to 78 percent), 50 percent (95 percent CI, 19 to 70 percent) and 69 percent (95 percent CI, 45 to 84 percent) for 2q4, 2q8 and 0.5q4, respectively. Risk reduction in the IAI groups for a sustained IOP increase >5 mmHg was 31 percent in the 2q4 group (95 percent CI, 8 to 48 percent), 38 percent in the 2q8 group (95 percent CI, 17 to 54 percent) and 47 percent (95 percent CI, 27 to 61 percent). In uninjected fellow eyes only sustained IOP >21 mmHg events were higher in the Rq4 groups compared with all IAI groups.
Ophthalmology 2015;122:1802-1810.
Freund KB, Hoang QV, Saroj N, Thompson D.

Cardiovascular Risk Factors in Central Retinal Artery Occlusion
A well-defined, homogenous
group of patients (n=77) with nonarteritic central retinal artery occlusion who were enrolled in the European Assessment Group for Lysis in the Eye were analyzed for cardiovascular risk factors. Previously undiagnosed vascular risk factors were found in 78 percent of the patient group. The most meaningful risk factor was ipsilateral carotid artery stenosis. This suggests that a comprehensive and prompt diagnostic workup is mandatory for all CRAO patients.

Both vascular risk factor and underlying diseases were detected by questionnaire along with a standardized physical examination within one month after retinal artery occlusion. The standardized physical exam included carotid Doppler; ultrasonography; echocardiography; electrocardiography; blood pressure monitoring; pulse rate; urine analysis; body mass index analysis; and laboratory tests.

Fifty-two patients (67 percent) had cardiovascular risk factors in their medical history, and comprehensive phenotyping identified at least one new risk factor in 60 patients (78 percent; 95 percent confidence interval, 67 to 87 percent). In total, 71 patients (92 percent) had cardiovascular risk factors or events. Thirty-one patients (40 percent) had carotid artery stenosis of at least 70 percent. Eleven patients experienced a stroke, five of those within four weeks after CRAO occurred. Arterial hypertension was found in 56 patients (73 percent) and was newly diagnosed in 12 study participants (16 percent). Cardiac diseases were also highly prevalent (22 percent coronary artery disease; 20 percent atrial fibrillation; 17 percent valvular heart disease).
Ophthalmology 2015;122:1881-1888.
Callizo J, Feltgen N, Patenburg S, Wolf A, et al.