Systemic Anti-Inflammatory Therapy Versus Fluocinolone Acetonide

The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study was a randomized, partially-masked, parallel treatment, comparative effectiveness trial comparing surgically placed fluocinolone acetonide intravitreous implant to systemic corticosteroids for the treatment of intermediate uveitis, posterior uveitis, and panuveitis. Systemic and implant therapies yielded similar visual outcomes through 54 months of treatment. Given the greater cost of implant therapy for bilateral disease, and the higher risk of ocular complications in the implant arm of the trial, systemic therapy may be the preferred initial therapy for most bilateral cases of active or recently active intermediate uveitis, posterior uveitis, and panuveitis. For unilateral cases, implant therapy seemed to be reasonably cost effective.

Argon Laser Photocoagulation for Extrafoveal Neovascular Maculopathy

The Macular Photocoagulation Study (MPS) comprised three randomized clinical trials: the Senile Macular Degeneration Study (SMDS), the Ocular Histoplasmosis Study (OHS), and the Idiopathic Neovascularization Study (INVS). The goal was to determine whether, in patients with visual symptoms due to choroidal neovascularization outside the fovea (at least 200 microns from the center of the foveal avascular zone and a best corrected visual acuity of 20/100 or better caused by senile macular degeneration (now known as age-related macular degeneration), histoplasmosis, or idiopathic causes, argon blue-green laser photocoagulation prevents significant loss of visual acuity. Based on the study findings, the authors recommended that eyes with well-defined extrafoveal choroidal neovascular membranes should be treated with argon blue-green laser photocoagulation to prevent or delay significant loss of visual acuity.

Tube Shunt Surgery Versus Trabeculectomy in Eyes with Prior Ocular Surgery and Uncontrolled Glaucoma

The Tube Versus Trabeculectomy (TVT) Study was a randomized clinical trial comparing tube shunt surgery to trabeculectomy with mitomycin C in patients with uncontrolled glaucoma (intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy) who had previously undergone cataract extraction with intraocular lens implantation and/or failed filtering surgery. The study did not demonstrate clear superiority of one glaucoma operation over the other, but indicated that both tube shunt surgery and trabeculectomy with mitomycin C were viable surgical options for treating medically uncontrolled glaucoma in this group of patients. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 5 years. Additional glaucoma surgery was needed more frequently after trabeculectomy with MMC than tube shunt placement.

Intraocular Pressure Reduction in the Treatment of Normal-Tension Glaucoma

The Collaborative Normal-Tension Glaucoma Study (CNTGS) was a randomized clinical trial to determine the effectiveness of a 30% reduction in intraocular pressure (IOP) (using either medical therapy or filtration surgery) on visual field (VF) progression in eyes with normal-tension glaucoma. The study found that reducing the IOP of patients with normal-tension glaucoma by 30% is beneficial to prevent progression of glaucomatous damage if the visual effects of cataracts are excluded from consideration. However, because not all untreated patients progressed, the natural history of normal-tension glaucoma must be considered before embarking on IOP reduction with therapy that may exacerbate cataract formation, unless normal-tension glaucoma threatens serious visual loss.

Is Argon Laser Trabeculoplasty Equivalent to Topical Medication as an Initial Treatment for Primary Open-Angle Glaucoma?

The Glaucoma Laser Trial (GLT) was a randomized, single-blind, controlled clinical trial comparing the efficacy and safety of argon laser trabeculoplasty (ALT) to treatment with topical medication for controlling intraocular pressure (IOP) in patients with newly diagnosed, previously untreated, primary open-angle glaucoma (POAG). The study showed that initial treatment of POAG with ALT is an efficacious and safe alternative to medication therapy, particularly in patients where medical therapy is contraindicated or poor compliance is suspected. The initial use of ALT in the short term has the benefit of reducing the nuisance, inconvenience, and systemic side effects of the topical glaucoma medication alternatives.

Topical Corticosteroids for Herpes Simplex Stromal Keratitis

The Herpetic Eye Disease Study (HEDS) was a randomized, double-masked, placebo-controlled, clinical trial to determine the efficacy of topical corticosteroids as adjunctive therapy in the treatment of herpes simplex stromal keratitis in patients who had not received any corticosteroids for at least 10 days before study enrollment. The study showed that topical corticosteroids can be used judiciously with protective antiviral cover in the acute treatment of patients with herpes simplex stromal keratitis who have not recently received corticosteroid therapy. Treatment reduced persistence or progression of stromal inflammation and shortened the duration of herpes simplex stromal keratitis. Postponing steroids during careful observation for a few weeks delayed resolution of stromal keratitis but did not worsen visual outcome at 6 months.

Effectiveness of Histocompatibility Matching in High-Risk Corneal Transplantation

The Collaborative Cornea Transplant Studies (CCTS) comprised two randomized, double-masked, clinical trials, the Antigen Matching Study (AMS) and the Crossmatch Study (CS), designed to determine whether matching HLA-A, -B, and/or HLA-DR antigens, donor-recipient crossmatching, or ABO compatibility reduced the risk of corneal allograft rejection and failure in high-risk patients. The studies showed that for patients needing a corneal graft with uncompromised immune systems and at high risk for corneal graft rejection: (1) neither HLA-A, -B, nor HLA-DR antigen matching substantially reduces the likelihood of corneal graft failure; (2) a positive donor-recipient crossmatch does not dramatically increase the risk of corneal graft failure; and (3) ABO blood group matching may be effective in reducing the risk of graft failure. Intensive steroid therapy after transplantation, frequent follow-up, medication and follow-up compliance, and patient education appear to play a significant role in corneal graft success.

Atropine or Patching for Treatment of Moderate Amblyopia in Children

The Patching Versus Atropine Trial was a randomized clinical trial in children less than seven years of age with moderate amblyopia and a visual acuity in the amblyopic eye between 20/40 and 20/100, to determine whether treatment with atropine drops was as effective as patching. The study found that patching and atropine were equally effective in the initial treatment of moderate amblyopia. Visual acuity in the amblyopic eye improved in both groups (improvement from baseline to 6 months was 3.16 lines in the patching group and 2.84 lines in the atropine group). Improvement was initially faster in the patching group, but, after 6 months, the difference in visual acuity between treatment groups was small and clinically inconsequential (mean difference at 6 months, 0.034 logMAR units).

Corticosteroids in the Treatment of Acute Optic Neuritis

The Optic Neuritis Treatment Trial (ONTT) was a randomized, placebo-controlled, clinical trial in patients with a history consistent with acute unilateral optic neuritis to determine whether treatment with either oral prednisone or intravenous methylprednisolone speeded the recovery of vision and improve visual outcome. The study found that intravenous methylprednisolone (started within eight days of symptom onset) followed by oral prednisone speeded the recovery of visual loss due to optic neuritis and resulted in slightly better vision at six months. Oral prednisone alone, however, was an ineffective treatment and may increase the risk of new episodes of optic neuritis.

Botulinum A Toxin Injection as a Treatment for Blepharospasm

In this chapter a case series is described of the use of botulinum A toxin for the treatment of blepharospasm in thirty-nine patients with blepharospasm due to various causes—essential, Meige’s syndrome, hand apraxia, cerebrovascular disease, and parkinsonism. A reduction of abnormal movement occurred in all patients, lasting up to 170 days. Both the amount and the duration of effect were dose dependent. Tearing, dry-eye symptoms, or transient ptosis occurred in 20% of injections, especially in patients who had had previous eyelid surgery. Botulinum A toxin injection into the orbicularis oculi muscle was found to be a safe, simple, and symptomatically helpful treatment for blepharospasm that can be repeated at intervals as required.