Summary Background Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two. Methods In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223). Findings Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI −0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3–78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained. Interpretation Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice. Funding National Institute for Health Research, Health and Technology Assessment Programme.

Aim-The presence of traumatic angle recession is a risk factor for failure of glaucoma filtration surgery and a previous study has suggested that antimetabolite treatment should be used in these patients. This study was undertaken to determine for the first time the mid term results of trabeculectomy with intraoperative application of mitomycin C in patients with post-traumatic angle recession glaucoma. Methods-A retrospective analysis was made of 43 consecutive trabeculectomy procedures in 41 young black/mixed race patients followed for a mean period of 25 months (range 2-66 months). Mitomycin C 0.02% was applied between the sclera and conjunctiva for 1-5 minutes at the time of surgery. The intraocular pressure and visual acuity were measured postoperatively. The success of this technique was analysed by using a Kaplan-Meier cumulative survival curve. Results-The intraocular pressure was successfully controlled at last follow up without topical treatment in 77% (33/43 eyes) and the visual acuity was the same or better in 81% (35/43 eyes). Cumulative probability of success was 85% at 1 year follow up, 81% at 2 years, and 66% at 3 years and thereafter. Hypotonous maculopathy occurred in one patient and no cases of late bleb infection were found. Conclusions-In medically uncontrolled post-traumatic angle recession glaucoma trabeculectomy with mitomycin C is an eVective surgical procedure with an acceptable complication rate. Good intraocular pressure control and preservation of vision can be expected in most patients. (Br J Ophthalmol 2001;85:159-163)

on behalf of the Laser in Glaucoma and Ocular Hypertension Trial Study Group* Purpose: To report clinical efficacy, predictors of success, and safety of primary selective laser trabeculoplasty (SLT) used in treatment-naive patients with open-angle glaucoma (OAG) or ocular hypertension (OHT). Design: Post hoc analysis of a multicenter, prospective, randomized, controlled trial. Participants: Treatment-naive patients with OAG or OHT. Methods: Patients randomized to SLT or topical medication and treated to predefined target intraocular pressures (IOPs) requiring !20% IOP reduction from baseline for all disease severity levels. Outcome Measures: Initial (early) absolute IOP-lowering at 2 months. Achievement of drop-free diseasecontrol: meeting target IOP without disease progression or need for additional topical medication over 36 months after SLT. Predictors of early absolute IOP-lowering and drop-free disease-control after single initial SLT. Frequency of laser-related complications. Results: A total of 611 eyes (195 OHT and 416 OAG) of 355 patients received SLT, and 622 eyes (185 OHT and 437 OAG) of 362 patients received topical medication at baseline. Early absolute IOP-lowering after SLT was no different between OHT and OAG eyes (adjusted mean difference ¼ À0.05 mmHg; 95% confidence interval [CI], À0.6 to 0.5 mmHg; P ¼ 0.85). No difference was noted in early absolute IOP-lowering between topical medication and primary SLT (adjusted mean difference ¼ À0.1 mmHg; 95% CI, À0.6 to 0.4 mmHg; P ¼ 0.67). Early absolute IOP-lowering with primary SLT was positively associated with baseline IOP (coefficient 0.58; 95% CI, 0.53e0.63; P < 0.001) and negatively with female gender (coefficient À0.63; 95% CI, À1.23 to À0.02; P ¼ 0.04). At 36 months, 536 eyes (87.7% of 611 eyes) of 314 patients (88.5% of 355 patients) were available for analysis. Some 74.6% of eyes (400 eyes) treated with primary SLT achieved drop-free disease-control at 36 months; 58.2% (312 eyes) after single SLT. Total SLT power and 2-month IOP were predictors of drop-free disease-control at 36 months after single SLT. Six eyes of 6 patients experienced immediate post-laser IOP spike (>5 mmHg from pretreatment IOP) with 1 eye requiring treatment. Conclusions: Primary SLT achieved comparable early absolute IOP-lowering in OHT versus OAG eyes. Drop-free disease-control was achieved in approximately 75% eyes at 36 months after 1 or 2 SLTs, the majority of these after single SLT. These analyses are exploratory but support primary SLT to be effective and safe in treatment-naive OAG and OHT eyes.

Aims The purpose of this randomized clinical trial was to compare the effectiveness and safety of viscocanalostomy (visco) with trabeculectomy (trab) in the management of primary open angle glaucoma (POAG). Methods Patients were randomized to have a viscocanalostomy (25 eyes) or a trabeculectomy (25 eyes) performed by one surgeon (TDM) and followed up prospectively. Patients were examined preoperatively, at day 1, day 3 if required, day 6, week 2 and thereafter as near as possible to 1,3,6,12, 18, 24, 30, 36, 48, 54, and 60 months. We recorded intraocular pressure (IOP), presence or absence of any complications, presence and description of any bleb, visual acuity with glasses, and full examinations as routine to monitor any progression of the glaucoma. Bleb interventions including needling and antimetabolites were allowed and recorded in both groups. YAG laser goniopuncture was allowed in the viscocanalostomy group. Results Mean follow-up was 40 months (SD 15), with a range from 6 to 60 months. Forty-two percent (n ¼ 10) of the patients in the trabeculectomy group had a successful outcome (IOPo18 mm Hg with no treatment) at last follow-up visit, compared to 21% (n ¼ 5) in the viscocanalostomy group. IOP was lower in the trab group with differences in IOP being statistically significant at month 12 (P ¼ o0.001), 24 (P ¼ o0.001), 30 (P ¼ 0.030), 36 (P ¼ o0.001), and 48 (P ¼ 0.018). The trabeculectomy group required less postoperative topical IOP-lowering medication (P ¼ 0.011). ConclusionIn this study, we found trabeculectomy to be more effective at lowering IOP than viscocanalostomy in POAG patients.

Background-Anterior chamber aspirates on completion of extracapsular cataract surgery contain significant numbers of organisms, particularly coagulase negative staphylococci, an important cause of endophthalmitis. Methods-Culture rates were compared in 50 patients after phacoemulsification surgery, which allows the possible benefits of a small, self sealing wound and maintenance of positive intraocular pressure, with a similar number of extracapsular cases.Results-A culture positive rate of 20% and 24% respectively was found, an insignificant difference. Conclusion-Small incision surgery has no proved advantage over extracapsular surgery in terms of reducing the intraoperative bacterial inoculum. The significance of this result in terms of causation of endophthalmitis is discussed. (Br_J Ophthalmol 1995; 79: 878-880) Recent studies by this and other groups have confirmed that the anterior chambers of eyes following extracapsular cataract surgery are frequently contaminated by small numbers of bacteria.1-3 Contamination rates of 29-43% have been reported. This group found a rate of 24% in two groups of 40 patients, and that preoperative topical antibiotics (norfloxacin, MSD) had no effect on culture rates. The organisms found are in small numbers (10-40 colony forming units/ml), and are most commonly skin commensals, especially coagulase negative staphylococci. These organisms are a leading cause of endophthalmitis. It has been assumed that one route of entry is from fluid circulating in the conjunctival sac at the time of surgery, but although both povidone-iodine4 5 and topical antibiotics6 are effective in reducing skin commensals (as shown by conjunctival swabs), efforts to sterilise the conjunctival sac preoperatively are only one approach to the problem, and according to our previous work may not be reducing intraocular contamination.Phacoemulsification allows a smaller wound, and is usually combined with a scleral tunnel which has a degree of self sealing properties. The eye is, therefore, less accessible to contamination from any external source, be it conjunctiva, lashes, or air. Studies of intraoperative pressure changes do suggest that positive intraocular pressure is easier to maintain with this type of wound,7 and this, together with the small wound, should minimise influx of conjunctival fluid from the wound margins.This study has been designed to examine the contamination of anterior chambers of eyes at the completion of phacoemulsification cataract surgery, and to compare this with previous observations from extracapsular surgery. Materials and methodsFifty patients undergoing routine phacoemulsification cataract surgery were recruited into this prospective study. Written consent for aqueous samples to be taken was obtained. Exclusion criteria included: (a) history or evidence of previous surgery or penetrating injury to the eye; (b) local or systemic infection at the time of surgery; (c) perioperative complications such as posterior capsule rupture or conversion to extracapsular surger...