IMPORTANCETo date, only a few studies have directly compared nonpenetrating surgery (NPS) and trabeculectomy (TE). Therefore, there is no strong evidence as to which surgical technique leads to the best results in terms of ocular hypotensive effect and safety.OBJECTIVE To compare the hypotensive effect and safety of NPS and TE in terms of intraocular pressure (IOP) reduction and incidence of complications.DATA SOURCES The MEDLINE and EMBASE databases were searched for studies potentially eligible in any language published up to March 31, 2013.STUDY SELECTION Systematic review and meta-analysis of comparative studies of 2 or more surgical techniques (1 of which had to be TE), including patients with open-angle glaucoma. DATA EXTRACTION AND SYNTHESISThe considered interventions were TE, deep sclerectomy (DS), viscocanalostomy, and canaloplasty. MAIN OUTCOMES AND MEASURESThe primary outcome was the mean between-group difference in the reduction in diurnal IOP from baseline to the 6-or 12-month follow-up evaluation. We also considered the incidence of complications, expressed as relative risk.RESULTS Eighteen articles, accounting for 20 comparisons, were selected for data extraction and analysis. Analysis of the 6-month follow-up data showed that the pooled estimate of the mean between-group difference was −2.15 mm Hg (95% CI, −2.85 to −1.44) in favor of TE. There was no difference between the NPS subgroups. In the subgroup antimetabolite analysis, the addition of mitomycin C to TE and DS decreased the difference in the reduction in IOP (TE and DS without mitomycin C: −2.65 mm Hg [95% CI, −3.90 to −1.39]; TE and DS with mitomycin C: −0.83 mm Hg [95% CI, −2.40 to 0.74]). In the subgroup analysis by implant addition, no significant difference induced by DS with or without drainage devices was detected (test for subgroup differences: χ 2 1 = 0.24; P = .62). The absolute risk of hypotony, choroidal effusion, cataract, and flat or shallow anterior chamber was higher in the TE group than in the NPS group. CONCLUSIONS AND RELEVANCE Trabeculectomy seems to be the most effective surgical procedure for reducing IOP in patients with open-angle glaucoma. However, as expected, it was associated with a higher incidence of complications when compared with NPS.

The ultimate goal of glaucoma management is the preservation of patients’ visual function and quality of life (QoL). The disease itself as well as the medical or surgical treatment can have an enormous impact on a patient’s QoL. Even the mere diagnosis of a chronic, irreversible, potentially blinding disorder can adversely affect the patient’s sense of well-being and QoL by eliciting significant anxiety. Patients with primary open-angle glaucoma rarely present with visual symptoms, at least early in the course of the disease. A better understanding of patient-reported QoL can improve patient–physician interaction and enhance treatment adherence by customizing treatment options based on individual patient profile, thus optimizing long-term prognosis. These aspects are summarized and critically appraised in this article.

Abstract. This review analyzes the currently available literature on circadian rhythms of intraocular pressure (IOP), blood pressure, and calculated ocular perfusion pressure (OPP) in patients with openangle glaucoma. Although adequately powered, prospective trials are not available. The existing evidence suggests that high 24-hour IOP and OPP fluctuations can have detrimental effects in eyes with glaucoma. The currently emerging continuous IOP monitoring technologies may soon offer important contributions to the study of IOP rhythms. Once telemetric technologies become validated and widely available for clinical use, they may provide an important tool towards a better understanding of longand short-term IOP fluctuations during a patient's daily routine. Important issues that need to be investigated further include the identification of appropriate surrogate measures of IOP and OPP fluctuation for patients unable to undergo 24-hour measurements, the determination of formulae that best describe the relationship between systemic blood pressure and IOP with OPP, and the exact clinical relevance of IOP and OPP fluctuation in individual patients. Despite the unanswered questions, a significant body of literature suggests that OPP assessment may be clinically relevant in a significant number of glaucoma patients. (Surv Ophthalmol 58:26--41, 2013. Ó 2013 Elsevier Inc. All rights reserved.) Key words. glaucoma circadian rhythm intraocular pressure blood pressure ocular perfusion pressure I. Physiological ConsiderationsThe principal physiological entities that affect intraocular pressure (IOP) and its characteristics are the aqueous humor (AH) dynamics in healthy and glaucomatous eyes.The production of AH involves two consecutive processes. First, a portion of the plasma that reaches the vascular plexus of the ciliary processes is filtered through the fenestrated capillaries into the interstitial space between the vessels and the ciliary epithelia. Next, a portion of the filtrate is actively secreted by the ciliary epithelial cells into the posterior chamber.In humans, these processes are affected by age, circadian rhythm, topical and systemic medications, and the presence of glaucoma. 63,64,70,109,121 The rate of AH formation decreases with age: by 15--35% between age 20 and 80 years. 15,30 The rate of AH production in humans is significantly lower at night, 99,119 attributed to decreased endogenous circulating catecholamine levels, which may partly explain the decreased nocturnal efficacy of topical 26

Latanoprost seemed to induce a uniform reduction in IOP during the 24-hour period, although timolol was as effective as latanoprost during the daytime, and dorzolamide are as effective as latanoprost at night. SBP and DBP were significantly decreased by either timolol or brimonidine. In this study of patients with newly diagnosed POAG, only dorzolamide and latanoprost significantly increased mean 24-hour DOPP.

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