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      Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial

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          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.

          Related collections

          Most cited references28

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          Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial.

          Treatments for open-angle glaucoma aim to prevent vision loss through lowering of intraocular pressure, but to our knowledge no placebo-controlled trials have assessed visual function preservation, and the observation periods of previous (unmasked) trials have typically been at least 5 years. We assessed vision preservation in patients given latanoprost compared with those given placebo.
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            Categorizing the stage of glaucoma from pre-diagnosis to end-stage disease.

            To provide a reliable, comprehensive staging system to assess glaucoma stage in the absence of an universally accepted glaucoma staging system (GSS) on the basis of visual field results. Literature review and GSS adaptation. After a review of published GSSs was conducted, the Bascom Palmer (Hodapp-Anderson-Parrish) GSS was selected as an appropriate platform for a retrospective GSS on the basis of visual fields. The system was modified by a panel of glaucoma specialists, and additional modifications were made after pilot testing to cover the full range of disease progression, from preglaucoma diagnosis to complete blindness; the ordered stages reflect the typical progression of glaucoma. The GSS is comprised of six ordered stages and is on the basis of the Humphrey visual field. The completed GSS was validated by reviewing patient charts from 12 US glaucoma centers. The GSS allows accurate staging of 100% of glaucoma on the basis of visual fields and other data, enabling evaluation of disease progression and resource utilization at various glaucoma stages. Additionally, treatment costs may be assigned to determine cost-effectiveness of treatment. Research utilizing the GSS has found that cost of care increases with increasing disease severity. The GSS may be used as the basis for creating treatment guidelines, which have the potential to delay glaucoma progression and lower treatment costs.
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              Risk of falls and motor vehicle collisions in glaucoma.

              To investigate the risk of falls and motor vehicle collisions (MVCs) in patients with glaucoma. The sample comprised 48 patients with glaucoma (mean visual field mean deviation [MD] in the better eye = -3.9 dB; 5.1 dB SD) and 47 age-matched normal control subjects, who were recruited from a university-based hospital eye care clinic and are enrolled in an ongoing prospective study of risk factors for falls, risk factors for MVCs, and on-road driving performance in glaucoma. Main outcome measures at baseline were previous self-reported falls and MVCs, and police-reported MVCs. Demographic and medical data were obtained. In addition, functional independence in daily living, physical activity level and balance were assessed. Clinical vision measures included visual acuity, contrast sensitivity, standard automated perimetry, useful field of view (UFOV), and stereopsis. Analyses of falls and MVCs were adjusted to account for the possible confounding effects of demographic characteristics, medications, and visual field impairment. MVC analyses were also adjusted for kilometers driven per week. There were no significant differences between patients with glaucoma and control subjects with respect to number of systemic medical conditions, body mass index, functional independence, and physical activity level (P > 0.10). At baseline, 40 (83%) patients with glaucoma and 44 (94%) control subjects were driving. Compared with control subjects, patients with glaucoma were over three times more likely to have fallen in the previous year (odds ratio [OR](adjusted) = 3.71; 95% CI, 1.14-12.05), over six times more likely to have been involved in one or more MVCs in the previous 5 years (OR(adjusted) = 6.62; 95% CI, 1.40-31.23), and more likely to have been at fault (OR(adjusted) = 12.44; 95% CI, 1.08-143.99). The strongest risk factor for MVCs in patients with glaucoma was impaired UFOV selective attention (OR(adjusted) = 10.29; 95% CI, 1.10-96.62; for selective attention >350 ms compared with
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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier
                0140-6736
                1474-547X
                13 April 2019
                13 April 2019
                : 393
                : 10180
                : 1505-1516
                Affiliations
                [a ]NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK
                [b ]Institute of Ophthalmology, University College London, London, UK
                [c ]Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, UK
                [d ]The Research Department of Primary Care and Population Health, University College London, London, UK
                [e ]Department of Statistical Science, University College London, London, UK
                [f ]School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
                [g ]London School of Hygiene & Tropical Medicine, London, UK
                Author notes
                [* ]Correspondence to: Dr Gus Gazzard FRCOphth, NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, London, UK gus.gazzard@ 123456moorfields.nhs.uk
                [†]

                Names listed at the end of the Article

                Article
                S0140-6736(18)32213-X
                10.1016/S0140-6736(18)32213-X
                6495367
                30862377
                66a148e8-d26f-41a3-a300-736501f5131f
                © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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                Medicine
                Medicine

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