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After atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to clinical outcomes at 36 months.

Primary angle-closure glaucoma affects 20 million people worldwide. People classified as primary angle closure suspects have a higher but poorly quantified risk of developing glaucoma. We aimed to assess efficacy and safety of laser peripheral iridotomy prophylaxis against primary angle-closure glaucoma in Chinese people classified as primary angle closure suspects. In this randomised controlled trial, bilateral primary angle closure suspects aged 50–70 years were enrolled at the Zhongshan Ophthalmic Center, a tertiary specialised hospital in Guangzhou, China. Eligible patients received laser peripheral iridotomy in one randomly selected eye, with the other remaining untreated. The primary outcome was incident primary angle closure disease as a composite endpoint of elevation of intraocular pressure, peripheral anterior synechiae, or acute angle-closure during 72 months of follow-up in an intention-to-treat analysis between treated eyes and contralateral controls. This trial is registered with the ISRCTN registry, number ISRCTN45213099. Of 11 991 screened individuals, 889 individuals were randomly assigned from June 19, 2008 (889 treated and 889 untreated eyes). Incidence of the primary outcome was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes (hazard ratio 0·53; 95% CI 0·30–0·92; p=0·024). A primary outcome event occurred in 19 treated eyes and 36 untreated eyes with a statistically significant difference using pair-wise analysis (p=0·0041). No serious adverse events were observed during follow-up. Incidence of angle-closure disease was very low among individuals classified as primary angle closure suspects identified through community-based screening. Laser peripheral iridotomy had a modest, albeit significant, prophylactic effect. In view of the low incidence rate of outcomes that have no immediate threat to vision, the benefit of prophylactic laser peripheral iridotomy is limited; therefore, widespread prophylactic laser peripheral iridotomy for primary angle-closure suspects is not recommended. Fight for Sight, the Sun Yat-Sen University 5010 Project Fund, Moorfields Eye Charity, and the National Natural Science Foundation of China.

This study investigated the distinctive features and management outcomes of combined exfoliation syndrome and angle-closure glaucoma (XFS-PACG) through a prospective, multicenter observational cohort study including 350 patients (118 XFS, 127 PACG, 105 combined XFS-PACG). Combined pathology demonstrated unique characteristics including bimodal diurnal IOP fluctuations, asymmetric angle closure correlating with exfoliation material distribution, and accelerated zonular weakness with progressive anterior lens displacement. Disease progression was significantly more aggressive in combined cases (visual field deterioration − 2.9 ± 0.8 dB/year versus − 1.7 ± 0.6 and − 1.4 ± 0.5 dB/year in XFS and PACG respectively). Therapeutic response evaluation revealed that prostaglandin-alpha2agonist combinations were most effective pharmacologically in combined cases, while traditional laser peripheral iridotomy achieved limited sustained control (38.1%). Early phacoemulsification with minimally invasive glaucoma surgery demonstrated superior surgical outcomes (72.4% complete success) compared to filtering procedures (53.3%). These findings support an individualized treatment approach for combined XFS-PACG, with early intervention and condition-specific protocols to optimize outcomes in this challenging clinical entity.

Background/aimsTo assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria.MethodsThis study is a secondary analysis of EAGLE data where we define the primary outcome of ‘good responders’ as those with IOP<21 mm Hg without requiring additional surgery and ‘optimal responders’ as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response.ResultsA total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined ‘good response’ criterion compared with 67% in the LPI arm, and 66% met ‘optimal response’ criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months.ConclusionPatients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.

Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment. From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607. Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events. Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment. Medical Research Council.

PurposeTo describe the results of darkroom prone provocative testing (DRPPT) in primary angle closure suspects (PACS) and to compare the findings to controls with open angles.Methods889 subjects with PACS in the Zhongshan Angle Closure Prevention Trial (a randomised controlled trial to compare prophylactic laser iridotomy to no treatment in PACS) and 89 with open angles in the 5-year follow-up of Liwan Eye Study were placed in a darkroom face down for 15 min. Intraocular pressure (IOP) was measured immediately before and after DRPPT.ResultsPACS participants were of similar age than controls (59.3 vs 60.5), more often female (82.9% vs 58.4%) and had lower IOP (14.3 vs 15.2 mm Hg). The average IOP increases after DRPPT was 4.3±3 mm Hg in PACS and 5.2±2.8 in controls (p<0.05). 20.5% of controls and 13.9 % of those with PACS developed an IOP spike ≥8 mm Hg after DRPPT (p<0.05). Among PACS, 15.8 % of those with all four quadrants closed had an IOP elevation of ≥ 8 mm Hg as opposed to 10.0%–12.4 % with two or three closed quadrants (p<0.05). DRPPT failed to predict who would reach a clinical trial endpoint over 6-year follow-up of those with PACS.ConclusionsA modified DRPPT failed to separate PACS from those with open angle. Although the test resulted in greater IOP elevation among those PACS participants with all four quadrants closed than in those with two or three closed quadrants, it did not offer any insight into the risk of developing acute or chronic angle closure disease over 6-year follow-up.

Objective To evaluate safety and efficacy of 0.1 mg/ml versus 0.2 mg/ml mitomycin-C (MMC), applied for 1 min subconjunctivally, during trabeculectomy for primary adult glaucoma in previously un-operated eyes. Materials and methods This is a randomised controlled, non-inferior, clinical trial consisting of 50 consecutive POAG or CPACG patients uncontrolled on maximal hypotensive therapy, meeting all inclusion criteria. Patients were randomized into two groups and underwent a standard limbus-based trabeculectomy with MMC: Group I, 0.1 mg/ml and Group II, 0.2 mg/ml. The pre-operative and post-operative intraocular pressure (IOP), bleb morphology, and visual acuity were recorded every 6 months for 2 years. Complete success (primary outcome) was defined as IOP ≤ 15 mmHg without any additional medications at the end of 2 years. Results The average age of patients was 62.6 ± 9.8 years and 61.2 ± 8.1 years in Group 1 and 2, respectively; p  = 0.57. The mean preoperative IOP was 22.5 ± 1.4 mmHg and 23.3 ± 1.8 mmHg; p  = 0.10. The mean IOP at 2 years was 11.1 ± 1.6 mmHg and 10.8 ± 2.8 mmHg, a mean reduction in IOP of 50.6 ± 1.23 %, and 53.7 ± 2.25 % in Group I and II, respectively. The complete success was 92.0 % and 91.7 % in the two groups, respectively ( p  = 0.99), and there was one failure (Group II, post trauma). A wider bleb extent and larger areas of thin, transparent conjunctiva over the bleb were seen with the 0.2 mg/ml MMC group ( p  < 0.001) and in PACG eyes; p  < 0.04. Conclusion A 1-min subconjunctival application of low dose 0.1 mg/ml MMC is non-inferior to 0.2 mg/ml and is probably a safer alternative, as thinning of the bleb is significantly less frequent in the long term.

Small clinics are important in providing health care in local communities. Accurately predicting their closure would help manage health care resource allocation. There have been few studies on the prediction of clinic closure using machine learning techniques. This study aims to test the feasibility of predicting the closure of medical and dental clinics (MCs and DCs, respectively) and investigate important factors associated with their closure using machine running techniques. The units of analysis were MCs and DCs. This study used health insurance administrative data. The participants of this study ran and closed clinics between January 1, 2020, and December 31, 2021. Using all closed clinics, closed and run clinics were selected at a ratio of 1:2 based on the locality of study participants using the propensity matching score of logistic regression. This study used 23 and 19 variables to predict the closure of MCs and DCs, respectively. Key variables were extracted using permutation importance and the sequential feature selection technique. Finally, this study used 5 and 6 variables of MCs and DCs, respectively, for model learning. Furthermore, four machine learning techniques were used: (1) logistic regression, (2) support vector machine, (3) random forest (RF), and (4) Extreme Gradient Boost. This study evaluated the modeling accuracy using the area under curve (AUC) method and presented important factors critically affecting closures. This study used SAS (version 9.4; SAS Institute Inc) and Python (version 3.7.9; Python Software Foundation). The best-fit model for the closure of MCs with cross-validation was the support vector machine (AUC 0.762, 95% CI 0.746-0.777; P<.001) followed by RF (AUC 0.736, 95% CI 0.720-0.752; P<.001). The best-fit model for DCs was Extreme Gradient Boost (AUC 0.700, 95% CI 0.675-0.725; P<.001) followed by RF (AUC 0.687, 95% CI 0.661-0.712; P<.001). The most significant factor associated with the closure of MCs was years of operation, followed by population growth, population, and percentage of medical specialties. In contrast, the main factor affecting the closure of DCs was the number of patients, followed by annual variation in the number of patients, year of operation, and percentage of dental specialists. This study showed that machine running methods are useful tools for predicting the closure of small medical facilities with a moderate level of accuracy. Essential factors affecting medical facility closure also differed between MCs and DCs. Developing good models would prevent unnecessary medical facility closures at the national level.