Date of Award
Medical Doctor (MD)
M. Bruce Shields
Although no validated treatment algorithm has emerged in the management of patients with open angle glaucoma (OAG), incisional surgery is typically reserved as a third-line therapy, after medications and laser treatments have failed to control disease progression. However, medications and laser therapies have numerous shortcomings, including high cost, low compliance, and little incremental efficacy over time. The purpose of this thesis is to review the trends in treatment patterns over time, and to evaluate the impact that a safer, more effective glaucoma operation might have on the therapeutic algorithm for patients with OAG. A multi-pronged approach was used to identify and characterize trends in the management of patients with glaucoma, including an extensive literature search and review. Additionally, leading glaucoma academicians and innovators were interviewed regarding the historical and expected future development of novel incisional approaches to the management of OAG. Then, members of the American Glaucoma Society (AGS) were surveyed online about a hypothetical ideal glaucoma drainage device (GDD) procedure with specifically defined metrics for greater efficacy, safety, and ease-of-implantation, compared to current glaucoma surgery. Participants were asked how such an operation would influence their management of patients with OAG. The results were aggregated from an 11-point Likert scale to calculate the mean and standard deviation, and a repeated measures analysis of variance (ANOVA) was performed to determine whether surgeon preferences for the device differed between six patient categories. Post-hoc contrasts were used to assess the significance of responses for each patient category. Overall, the trend in glaucoma surgery over the past decade has shifted towards the use of GDDs and away from a conventional glaucoma filtering procedure, though both still largely remain third-line therapies. In this survey, of the 126 respondents (31% of those surveyed), glaucoma specialists indicated that an improved operation would enter into their treatment algorithm in all six clinical settings, especially among those patients who required repeat surgery (mean 86.9%; SD 19.4%), were being considered for primary surgery (mean 65%; SD 29.4%), or were uncontrolled on 3 or more medicines (mean 58.8%; SD 31.6%). Specialists also felt that they would consider this improved surgery in patients otherwise requiring trabeculoplasty (mean 33.7%; SD 27.8%), or who were uncontrolled on 2 medicines (mean 28.9%; SD 25.7%) or 1 medicine (mean 10.9%; SD 16.5%). Repeated measures ANOVA showed a statistically significant surgical preference for this ideal surgical procedure between patient categories (overall p-value <0.001). These findings suggest that glaucoma specialists may recommend incisional surgery earlier in the therapeutic algorithm for patients with OAG, if an operation was available that is safer, more effective, and easier to perform than current procedures. Continued work to develop and validate such an operation is justified.
Goldberg, Roger A., "An Evaluation of the Therapeutic Trends in Glaucoma and the Potential Impact of Improved Glaucoma Surgery" (2009). Yale Medicine Thesis Digital Library. 410.