Advanced Glaucoma Research Articles

RE-DRAIN SURGERY IN PATIENTS WITH REFRACTORY GLAUCOMA

The choice of surgical treatment method for patients with refractory glaucoma of various etiologies is quite complicated. The most commonly performed surgeries are implantation of drainage devices or laser treatment methods. This article presents the results of repeated drainage surgery with Ahmed valve implantation in patients with previously implanted Ex-press shunt in patients with different types of refractory glaucoma.Objective. To present the results of surgical treatment of patients with advanced refractory glaucoma with implantation of Ahmed valve drainage after previous implantation of Ex-Press shunt.Methods. The study included 10 patients (10 eyes) with refractory glaucoma of various etiologies who had previously undergone Ex-Press implantation and subsequently received surgery with Ahmed valve implantation.Results. After surgical treatment, a statistically significant decrease in the level of intraocular pressure was detected in all cases. In the early postoperative period, in one case a choroidal detachment was detected. In the early postoperative period and also during the whole period of follow-up the drainage tube was in the correct position in anterior chamber. By the 6th month of follow-up hypotensive drops were required in 5 patients.Conclusion. At decompensation of intraocular pressure after antiglaucoma surgery with Ex-Press microshunt in patients with refractory glaucoma implantation of Ahmed valve drainage showed efficacy up to 3 years.

Effect of enhanced monofocal intraocular lenses on glaucoma patients' foveal threshold.

We investigated the effect of enhanced monofocal intraocular lenses (IOL) (TECNIS Eyhance DIB00V) on retinal sensitivity in glaucoma patients after cataract surgery by comparing results with of such patients implanted with non-enhanced monofocal intraocular lenses (TECNIS ZCB00V). This was a multi-facility retrospective study of glaucoma patients who had undergone cataract surgery. We measured the value of the foveal threshold with a Humphrey visual field analyzer before and after cataract surgery and considered this value to represent the sensitivity of the retina. As a sub-analysis, we also compared the mean deviation (MD), pattern standard deviation (PSD), thickness of ganglion cell complex (GCC), and best corrected visual acuity (BCVA) before and after surgery. We used t-tests to determine statistical differences between lens groups. We included 60 glaucoma patients (104 eyes) who underwent cataract surgery: enhanced group, n = 58 eyes; non-enhanced group, n = 46 eyes. In both groups, cataract surgery improved the retinal sensitivity (p < 0.001), MD (p < 0.001) and BCVA (p < 0.001). The postoperative foveal thresholds did not significantly differ by lens type (p = 0.673), at 34.41 ± 2.44dB in the enhanced group and 34.61 ± 2.19dB in the non-enhanced group. Likewise, there was no significant difference (p = 0.942) among advanced glaucoma patients, with postoperative foveal thresholds of 33.08 ± 2.35dB and 33.17 ± 3.45dB in the enhanced and non-enhanced, respectively. Implantation of enhanced monofocal IOLs in glaucoma patients did not result in any apparent loss of sensitivity compared with non-enhanced monofocal lens implantation.

Enhancing Detection of Glaucoma Progression: Utility of 24-2 Visual Field Central Points vs. 10-2 Visual Fields

PurposeTo test the hypothesis that a summary index derived from the central 12 points of the 24-2 visual field (MD12) could provide complementary information to that provided by the 24-2 visual field (VF) mean deviation (24-2 MD). DesignLongitudinal observational study Participants125 eyes (125 patients) with central damage or moderate to severe glaucoma from the Advanced Glaucoma Progression Study with four or more pairs of 10-2 and 24-2 SITA standard VFs. MethodsBaseline 10-2 and 24-2 VF dates were within six months, and the remaining pairs of VF tests were done in the same session. The MD12 index was calculated by averaging total deviation (TD) values from the central 12 points of 24-2 VF. Simple linear regression of MD against time was used to estimate 24-2 MD, 10-2 MD, and MD12 rates of change (RoC). Progression at the final follow-up visit was defined as a RoC <0 dB/year with p<0.05 for any summary index with confirmation. Main Outcome MeasuresProportion of progressing eyes based on 24-2 MD, 10-2 MD, and MD12 rates of change. ResultsThe average (SD) baseline 24-2 and 10-2 MD were –9.0 ± 6.2 and –8.5 ± 5.4 dB, respectively. The mean follow-up time was 5.7 (±1.6) years. The 3 summary indices were highly correlated at baseline: r (95% CI) =0.62 (0.52-0.74) between 10-2 MD and 24-2 MD, 0.84 (0.78-0.90) between MD12 and 24-2 MD, and 0.86 (0.80-0.92) between 10-2 MD and MD12. The corresponding correlations between RoC were weaker: r=0.41 (0.37-0.45), 0.80 (0.78-0.82), and 0.49 (0.45-0.53). Glaucoma progression was detected in 29 (23.2%), 22 (17.6%), and 23 eyes (18.4%) based on the 24-2, 10-2, and MD12 RoC, respectively; 7 eyes (9.6%) exhibited progression based on MD12 RoC and not with 24-2 MD; only 3 of these eyes progressed according to 10-2. ConclusionsMD12 rates of change and detection rates have a low level of agreement with those of 10-2 and hence do not replace the need for 10-2 VF MD to monitor central damage.

Two-Year Retrospective Study of Cataract Surgery and Schlemm Canal Hydrus Microstent in Black and Afro-Latino Patients.

The Hydrus Microstent has been shown to be efficacious in the treatment of Open-angle Glaucoma. We previously reported 1-year results of the Hydrus Microstent in Black and Afro-Latino patients. Here we report two-year results of the Hydrus Microstent in Black and Afro-Latino patients with mild to moderate open-angle glaucoma. This was a retrospective, nonrandomized study that was carried out at two private practices in Harlem, NY and Queens, NY. This study consisted of Black and Afro Latino patients who had a Hydrus Microstent implanted for the treatment of glaucoma. The evaluated parameters were intraocular pressure (IOP), reductions in the number of medications, mean deviation on visual field test and visual acuity. We excluded persons with advanced glaucoma and incomplete data. We included those with mild to moderate glaucoma and had complete two-year follow-up data. The study consisted of 86 patients and 86 eyes. The mean age was 69.The mean pre-op IOP was 14.1 on 2.17 medications. At two years the mean IOP was 14 (p = 0.651) on 0.42 medications (p = 0.000003); 88% of patients were medication free (p = 0.651), The MD on the visual field changed little from -5.73 preoperatively to -5.21 at two years. There were 3 intraocular pressure spikes and 1 case of hyphema that were treated and had complete resolution. No patients required secondary surgery. Our results show that at two years the Hydrus Microstent can maintain low intraocular pressures, reduce medication burden and, in aggregate, experienced little change in visual field Mean Deviation in Black and Afro Latino patients with mild to moderate glaucoma.

Unlocking Clinical Insights and the Life-Changing Impact of Low-Vision Devices in Primary Open-Angle Glaucoma Patients.

Objective To elucidate the clinical profile of visual impairment (VI) and the effect of low-vision devices (LVD) among patients with primary open-angle glaucoma (POAG). Methodology A retrospective observational study was used. Case records of patients who reported to the low-vision care clinic with POAG were recruited for the study. Glaucoma was defined according to the International Society for Geographical and EO classification. Demographic data, visual acuity (LogMAR), clinical diagnosis, visual fields, occupation, and LVD prescribed were extracted from the records. The visual acuity pre- and post-use of LVD was compared. Visual acuity improvement while using the LVD was noted. Results Of the 200 POAG cases, 20% (n=40) had severe, 15.5% (n=31) had profound (<3/60), 20.5% (n=41) profound (<1/60), and 26.5% (n=53) had total blindness in the VI category. Significant improvement was noted for both distance and near vision (p=0.004 and p=0.000, respectively) for single-vision glasses, and significant improvement (p=0.000) was also noted for patients corrected for both distance and near correction (bifocal/progressive). Patients with severe visual field loss (p=0.004) and with a visual field defect of <10 degrees (p=0.000) both showed a significant improvement in near vision with low-vision rehabilitation. The proportion of patients earning showed improvement following LVD use compared to those who did not have self-earning (60% vs. 40.24%,p=0.0116). Conclusion LVD significantly improved near vision in POAG patients with advanced glaucoma, a visual field defect of less than 10 degrees. To effectively manage POAG patients with low vision, it is vital to understand both the ocular diseases causing VI and the patient's visual requirements and provide timely management.

Outcomes of gonioscopy-assisted transluminal trabeculotomy in advanced pigmentary glaucoma

PurposeTo compare outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) over a 12-month period with trabeculectomy in patients with advanced pigmentary glaucoma (PG).MethodsThis was a pilot randomised controlled trial of patients with...

Clinical Outcomes of Stage 2 (Pivotal) Use of a Modified Keratoprosthesis Device (ORC-KPro) in Patients with End-stage Corneal Blindness.

To investigate the short-term results and performance of a modified Boston keratoprosthesis device manufactured by the Ophthalmic Research Center (ORC-KPro) in patients with end-stage corneal blindness. This prospective interventional case series was conducted on patients with corneal blindness who were candidates for KPro. The inclusion criterion comprised patients with a best-corrected visual acuity (BCVA) of less than 20/200 in both eyes, in whom the main reason for vision loss was corneal pathology. The ORC-KPro was implanted using the method previously described for Boston KPro. This study focused on 12 eyes of 12 patients with an average age of 45.9 16.8 (range, 19 to 70) years. Eleven patients were male. The KPro indication was corneal blindness due to chemical burns in nine patients (75%) and failure of multiple previous corneal grafts in three patients (25%). Anatomical success was achieved in all patients. The preoperative BCVA was light perception (LP) in 10 eyes and hand motion in 1 eye. Except for one patient who was diagnosed with grade C proliferative vitreoretinopathy during the surgery, the vision of all other patients (91.6%) improved after surgery. The retroprosthetic membrane (RPM) was formed in two eyes (18.1%) after six months. Of the 12 patients, 10 (83.3%) were under treatment with two antiglaucoma medications before surgery. The intraocular pressure of three eyes (25%) was estimated to be high by tactile palpation; however, it decreased in two eyes to the acceptable range. One patient underwent retinal surgery due to total retinal detachment, and two patients (16.7%) underwent vitrectomy due to endophthalmitis. The current study showed that, in the short term, the use of ORC-KPro achieved favorable anatomical success in patients with corneal blindness. However, the functional success rate was limited by the low visual potential due to advanced glaucoma in most patients.

Evaluating a foundation AI model for glaucoma detection in a diverse study population using color fundus photographs

PurposeTo evaluate RETFound, a foundation AI model, using a diverse clinical research dataset to assess its accuracy in detecting glaucoma using optic disc photographs. The model's accuracy for glaucoma detection was evaluated across race, age, glaucoma severity and various training cycles (epochs) and dataset sample sizes. DesignEvaluation of a diagnostic technology Subjects, Participants, and ControlsThe study included 9787 color fundus photographs (CFP) from 2329 participants of diverse race (White (73.3%), Black (13.6%) and other (13%) , disease severity (21.8% mild glaucoma, 7.2% moderate or advanced glaucoma, 60.3% not glaucoma, and 10.7% unreported), and age (48.8% <60 years, 51.1% > 60 years) from the Diagnostic Innovations in Glaucoma Study (DIGS) and the African Descent and Glaucoma Evaluation Study (ADAGES). All fundus photographs were graded as "Glaucomatous" or "Non-glaucomatous". MethodsThe study employed RETFound, a self-supervised learning model, to perform binary glaucoma classification. The diagnostic accuracy of RETFound was iteratively tested across different combinations of dataset sample sizes (50 to 2000 optic disc photographs), training cycles (5 to 50), and study subpopulations stratified by severity of glaucoma, age and race). Main Outcome MeasuresDiagnostic Accuracy (AUC) for classifying CFP as "Glaucomatous" or "Non-glaucomatous". ResultsPerformance increased with larger training datasets and more training cycles, improving from50 training images and 5 epochs (AUC: 0.52) to 2,000 training images and 50 epochs (AUC: 0.86), with reduced gain in performance from approximately 500 and 1000 training images (AUC of 0.82 and 0.83, respectively). Performance was consistent across race and age for all training size and cycle number combinations: Black (AUC=0.87) vs other (AUC=0.86), and >60 years (AUC=0.84) vs <60 years (AUC=0.87). Performance was significantly higher in patients with moderate to severe vs mild glaucoma (AUC=0.95 vs 0.84, respectively). ConclusionsGood RETFound performance was observed with a relatively small sample size of optic disc photographs used for fine tuning and across differences in race and age. RETFound’s ability to adapt across a range of CFP training conditions and populations suggests it is a promising tool to automate glaucoma detection in a variety of use cases.

Ab-Externo XEN Gel stent implantation effectively treated refractory glaucoma with prior failed shunt tube

PurposeTo assess the efficacy of a gelatin stent (XEN 45 Gel Stent; Allergan) implant in advanced glaucoma eyes that have failed prior aqueous shunt implantation.MethodsWe retrospectively reviewed 6 patients with refractory glaucoma, defined as persistently high IOP (> 21 mmHg) despite taking at least 3 IOP-lowering medications subsequent to undergoing a glaucoma drainage device (GDD) with or without a second GDD or cilioablative procedure. Eyes with previous failed GDD underwent subconjunctival 0.3 cc (0.4 mg/ml) mitomycin C, tenonectomy, and placement of an ab- externo XEN stent. The outcome measures included change in IOP and the number of glaucoma medications. Success was defined as patients achieving an IOP ≤ 18 mmHg with a percentage reduction of 25% or 15 mmHg and 40% mean IOP reduction from baseline while taking the same number or fewer medications.ResultsAll six eyes with age of 77.6 ± 7.82 years who underwent XEN implantation following previous GDD surgery had primary open-angle glaucoma. The IOP decreased significantly from 32.33 ± 5.99 to 12.67 ± 3.27 mmHg (p < 0.001) with a follow-up of 13.9 ± 2 (11.7–16.7) months. Visual acuity and visual field remained stable after XEN placement. Compared to the baseline number of medications of 4.2 ± 0.8, all medication was discontinued except in one eye on two drops at the end of the follow-up. The overall surgical success rate was 100%. No complications, needling, or additional procedures were required.ConclusionThis study described successful implantation of the XEN stent following failed GDD. XEN Gel stent implantation associated with mitomycin C and tenonectomy can be considered a viable surgical option for patients with a history of previously failed tube shunt requiring further IOP lowering.

Is primary trabeculectomy cost-effective for patients with advanced primary open angle glaucoma? Results from the Treatment of Advanced Glaucoma Study economic model

Background/aimsAdvanced primary open angle glaucoma (POAG) is a lifelong condition. The aim of this study is to compare medical treatment against trabeculectomy for patients presenting with advanced POAG using an...

Sources of Discrepancy between Retinal Nerve Fiber Layer and Bruch’s Membrane Opening-Minimum Rim Width Thickness in Eyes with Glaucoma

To compare the discrepancies between circumpapillary retinal nerve fiber layer (RNFL) and Bruch's membrane opening-minimum rim width (BMO-MRW) thickness in glaucoma eyes. A cross-sectional observational study. One hundred eighty-six eyes (118 patients) with glaucoma. OCT optic nerve head volume scans of patients enrolled in the Advanced Glaucoma Progression Study at the final available visit were exported. The RNFL and BMO-MRW measurements were averaged into corresponding 7.5° sectors, and the nasal sector data were excluded from analyses. A 2-stage screening process was used to identify true mismatches between the RNFL and BMO-MRW measurements, in which either the RNFL or BMO-MRW value was in the less than first percentile range while its counterpart was in the greater than first percentile range on the temporal-superior-nasal-inferior-temporal curve. The prevalence of these mismatches was mapped, and corresponding images were reviewed to determine the underlying cause of these discrepancies. Proportion of mismatches between RNFL and BMO-MRW, location of mismatches between RNFL and BMO-MRW, anatomical causes of mismatches between RNFL and BMO-MRW. Mismatch analysis revealed true mismatches between RNFL and BMO-MRW in 7.7% of sectors. High BMO-MRW with low corresponding RNFL mismatches were most frequently located at the 45° and 322.5° sectors, whereas high RNFL with corresponding low BMO-MRW mismatches peaked at the 75° sector. Large blood vessels accounted for 90.9% of high RNFL with low BMO-MRW mismatches. Small to large blood vessels accounted for 62.9% of high BMO-MRW with low RNFL mismatches; the remaining mismatches could be attributed to retinoschisis or inclusion of outer retinal layers in BMO-MRW measurements. Although overall agreement between RNFL and BMO-MRW measurements is good in areas with advanced damage, blood vessels and other anatomical factors can cause discrepancies between the 2 types of structural measurements and need to be considered when evaluating the utility of such measurements for detection of change. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Minimally Invasive Glaucoma Surgery (MIGS) recommendations in Clinical Practice Guidelines for open angle glaucoma and MIGS procedures: A scoping review.

Introduction: To assess the recommendations of open angle glaucoma Clinical Practice Guidelines (CPG) addressing Minimally Invasive Glaucoma Surgery (MIGS) or MIGS procedures CPG. Methods: A scoping review of CPG was conducted, based on an ongoing systematic review (CRD42024510656). A systematic literature search of CPG was carried out in November 2023, with an update in January 2024. CPG published in the last 8 years, full text available and addressing MIGS were selected. CPG details and recommendations concerning MIGS were extracted. Results: 13 CPG addressing MIGS were selected (8 recovered from databases and 5 from registers). Four health Technology Assessments were assessed but recommendations were not considered. Finnish and Swedish guidelines, published in 2024, and Japanese guidelines, published in 2023, are English versions of their native language guidelines, but none of them make specific recommendations about MIGS. The Spanish Glaucoma Society - Advanced Glaucoma guideline (2023) describes the available techniques but does not make recommendations about MIGS. The European Glaucoma Society (2023) guideline only makes recommendations for 4 devices and the National Institute for Health and Care Excellence Interventional procedures guidance makes recommendations both for specific procedures and devices. Conclusion: MIGS is a relevant topic that has not been adequately addressed in terms of updated evidence, available procedures, and recommendations in open angle glaucoma CPG or MIGS procedures CPG.

To identify risk factors for central visual field progression in moderate to advanced glaucoma.

To identify the risk factors for central visual field progression in moderate to advanced glaucoma. We included patients with moderate to advanced primary glaucoma who had undergone at least five reliable Humphrey visual field (HVF) 10-2 tests with follow-up of at least 2 years. Regression slopes for each threshold location on the 10-2 plot were calculated. A test location with a regression slope worsening more than -1 dB/year with P < 0.01 was labeled as a progressing point on point-wise linear regression (PLR) analysis. We compared point-wise progression with progression on the 10-2 mean deviation (defined as a negative MD slope P < 0.05). Ninety-six eyes of 74 patients with a median follow-up of 4 years (±1.97) were included. The median mean deviation 10-2 (MD) at inclusion was -19.01 dB (interquartile range [IQR] -13.2 to -24.14). Eighteen eyes (18.75%) had moderate glaucoma and 78 eyes (81.25%) had advanced glaucoma. The baseline median 24-2 MD in moderate glaucoma was -10.35 dB (IQR -11.35 to -9.25) and in advanced glaucoma was -24.96 dB (IQR -28.48 to -18.26). Based on 10-2 PLR, 27 eyes (28%) showed progression. On multivariate logistics regression analysis, the rate of change for 10-2 MD was a risk factor for progression based on 10-2 PLR analysis: odds ratio (OR) 0.04 (95% confidence interval [CI]: 0.006-0.323), P = 0.002, and for progression based on 10-2 MD analysis: OR 0.03 (95% CI: 0.002-0.602), P = 0.02. In addition, average MD 24-2 (OR 1.343 [95% CI: 1.006-1.793], P = 0.04) and visual field index (OR 0.787 [95% CI: 0.649-0.954], P = 0.01) were found to be risk factors based on 10-2 PLR. Rate of change for 10-2 mean deviation and baseline damage were predictors of point-wise progression.

Comparison of Retinal Nerve Fiber Layer and Ganglion Cell Complex Rates of Change in Patients With Moderate to Advanced Glaucoma

PurposeTo compare ganglion cell complex (GCC) and retinal nerve fiber layer (RNFL) rates of change (RoC) in eyes with central or moderate to advanced glaucoma. DesignProspective cohort study. Participants918 matched macular and RNFL OCT scan pairs from 109 eyes (109 patients) enrolled in the Advanced Glaucoma Progression Study with ≥2 years of follow-up and ≥4 OCT scans. MethodsWe exported GCC and RNFL thickness measurements in 49 central macular superpixels and 12 RNFL clock-hour sectors, respectively. We applied our latest Bayesian hierarchical longitudinal model to estimate population and subject-specific baseline thickness (intercepts) and rates of change (RoC) in macular superpixels and RNFL sectors. Global RNFL and GCC RoC were analyzed in a single bivariate longitudinal model to properly compare them accounting for the correlation between their RoC. Main Outcome MeasuresProportion of significant negative (deteriorating) and positive (improving) RoC expressed in μm/year. Standardized RoC were calculated by dividing RoC by the corresponding population SD. Analyses were repeated in eyes with visual field mean deviation (MD) ≤–6 and >–6 dB. ResultsAverage (SD) 24-2 visual field MD and follow-up length were –8.6 (6.3) dB and 4.2 (0.5) years, respectively. Global RNFL RoC (–0.70 µm/year) were faster than GCC (–0.44 µm/year) (p<.001); corresponding normalized RoC were not significantly different (p=0.052). In bivariate analysis, patients with a significant negative global RNFL RoC (n=63, 57%) or GCC (n=56, 51%) frequently did so for both outcomes (n=49, 45%). The average proportion of significantly decreasing RNFL sectors within an eye was 30.7% in eyes with MD >–6 dB compared to 20.5% in those with MD ≤–6 dB (p=0.014); the proportions for GCC superpixels were 21.1% vs. 18.7%, respectively (p=0.63). ConclusionsBoth GCC and RNFL measures can detect structural progression in glaucoma patients with central damage or moderate to advanced glaucoma. The clinical utility of RNFL imaging decreases with worsening severity of glaucoma.

Efficacy and Safety of Phaco-Goniosynechialysis in Advanced Primary Angle Closure Glaucoma With Severe Visual Field Loss.

Phacoemulsification with goniosynechialysis (phaco-GSL) demonstrates promise in safely and efficiently managing advanced primary angle closure glaucoma (PACG) cases with tunnel vision or limited temporal visual field. However, caution is advised for patients with only one functioning eye or high visual expectations. To assess the efficacy and safety of phaco-GSL in patients with end-stage PACG exhibiting tubular vision or temporal field island. This retrospective study evaluated 68 patients (74 eyes) diagnosed with advanced PACG and exhibiting either tubular vision or temporal field island. All patients underwent phaco-GSL and were monitored for at least 1 month postoperatively. The study analyzed changes in visual acuity (VA), intraocular pressure (IOP), medication use for antiglaucoma, and postoperative complications. The mean follow-up time was 9.11 ± 10.49 months. The mean preoperative visual field deviation and VA were -28.01 ± 3.30dB and 0.36 ± 0.37 log minimum angle of resolution unit, respectively. Postoperatively, the VA for over half (54.1%) of the eyes increased, 29.7% remained unchanged, and 16.2% worsened. The final IOP decreased significantly from 24.65 ± 8.61 to 14.81 ± 3.54mm Hg. Glaucoma medication use also reduced from 1.46 ± 1.43 to 0.88 ± 1.18. The success rate was 48.6% for complete and 89.2% for qualified. IOP spikes (27.0%) and wipe-out (8.1%) were the most common postoperative complications. Vision recovered gradually in 5 of 6 wipe-out patients. One eye (1.4%) developed permanent vision loss with VA decreasing to hand motion. Phaco-GSL appears safe and effective in treating advanced PACG cases with tubular vision or temporal field island. However, caution is warranted when considering this treatment option for patients at high wipe-out risk or those with high expectations for visual outcomes.

Wipe-Out following Gonioscopy-Assisted Transluminal Trabeculotomy combined with Phacoemulsification.

Précis: We report a case of a 62-year-old male patient who developed a wipe-out phenomenon after uncomplicated gonioscopy-assisted transluminal trabeculotomy combined with cataract surgery. A 62-year-old male patient with a diagnosis of pseudo-exfoliation and open-angle glaucoma underwent uncomplicated gonioscopy-assisted transluminal trabeculotomy (GATT) combined with phacoemulsification surgery due to advanced glaucomatous damage and high intraocular pressure. Postoperative decrease in visual acuity and central visual field deterioration suggested a wipe-out phenomenon. Although the wipe-out phenomenon has been reported after other surgeries in patients with advanced glaucoma, as far as we know, this is the first report of a wipe-out phenomenon secondary to GATT combined with phacoemulsification surgery. This complication, which can lead to severe vision loss, should be considered before the surgical decision.

Contributions of Brain Microstructures and Metabolism to Visual Field Loss Patterns in Glaucoma Using Archetypal and Information Gain Analyses.

To investigate the contributions of the microstructural and metabolic brain environment to glaucoma and their association with visual field (VF) loss patterns by using advanced diffusion magnetic resonance imaging (dMRI), proton magnetic resonance spectroscopy (MRS), and clinical ophthalmic measures. Sixty-nine glaucoma and healthy subjects underwent dMRI and/or MRS at 3 Tesla. Ophthalmic data were collected from VF perimetry and optical coherence tomography. dMRI parameters of microstructural integrity in the optic radiation and MRS-derived neurochemical levels in the visual cortex were compared among early glaucoma, advanced glaucoma, and healthy controls. Multivariate regression was used to correlate neuroimaging metrics with 16 archetypal VF loss patterns. We also ranked neuroimaging, ophthalmic, and demographic attributes in terms of their information gain to determine their importance to glaucoma. In dMRI, decreasing fractional anisotropy, radial kurtosis, and tortuosity and increasing radial diffusivity correlated with greater overall VF loss bilaterally. Regionally, decreasing intra-axonal space and extra-axonal space diffusivities correlated with greater VF loss in the superior-altitudinal area of the right eye and the inferior-altitudinal area of the left eye. In MRS, both early and advanced glaucoma patients had lower gamma-aminobutyric acid (GABA), glutamate, and choline levels than healthy controls. GABA appeared to associate more with superonasal VF loss, and glutamate and choline more with inferior VF loss. Choline ranked third for importance to early glaucoma, whereas radial kurtosis and GABA ranked fourth and fifth for advanced glaucoma. Our findings highlight the importance of non-invasive neuroimaging biomarkers and analytical modeling for unveiling glaucomatous neurodegeneration and how they reflect complementary VF loss patterns.

Optic cup morphology associated with glaucomatous damage: Findings from the Primary Open-Angle African American Glaucoma Genetics (POAAGG) Study

PurposeWhile it has been well established that advanced glaucoma is associated with a large cup-to-disc ratio (CDR), it is not known if the shape of the cup, particularly excavated cups with expanded lower portions (bean-pot cups), play any additional role in glaucomatous damage. We investigated this among individuals of African ancestry, a population that is more vulnerable to glaucoma than any other ethnic group. DesignCase-control study Methods SettingInstitutional (University of Pennsylvania) Subjects3,255 eyes from 1,734 glaucoma cases from the Primary Open-Angle African American Glaucoma Genetics (POAAGG) study. ProcedureTwo graders independently assessed quantitative and qualitative aspects of the optic cup, with any discrepancies adjudicated by an ophthalmologist. The predominant cup shape (>50 %) was chosen in cases in which features of two or more cup shapes were present in the same eye. Comparisons of demographic and ocular characteristics among three cup shape groups (conical, cylindrical, and bean-pot) performed using generalized linear models, and generalized estimated equations applied to account for inter-eye correlation. Main Outcome MeasuresQualitative features of cup shape and phenotypic traits, in conjunction with demographic and genetic information. ResultsOf 3,255 eyes, a total of 1,339 (41.1 %) exhibit a conical cup shape, 1,470 (45.2 %) have a cylindrical cup shape, and 446 (13.7 %) display a bean-pot cup shape. Compared to other cup morphology, bean-pot cups are significantly associated with lower MD, larger CDR, higher IOP, thinner RNFL, and worse VA in logMAR (all p < 0.001). Genetic analysis does not show any association between various genetic variants and cup shape. Factors independently predictive of bean-pot cupping include younger age at diagnosis (aOR 0.96 per 1 year increase in age of enrollment, p < 0.0001), CDR (adjusted odds ratio (aOR) 1.87, p < 0.0001), and the presence of certain optic disc features, including visible pores in the LC (aOR 2.76, p < 0.0001), nasalization of vessels (aOR 2.64, p < 0.0001), and vessel bayonetting (aOR 2.94, p < 0.0001). ConclusionThis study shows the clinical significance of different cup shapes in glaucoma in an African ancestry population and suggests that bean-pot cups are associated with the most severe glaucomatous damage, independent of cup-disc ratio. This association should be considered when determining prognosis following glaucoma interventions.

Glaucoma Severity Stage at First Visit at a University Eye Clinic in Congo.

Initial presentation of glaucoma at a major eye clinic mostly features advanced disease with a high proportion of blindness. This is likely a microcosm of a nationwide issue requiring concerted strategies to detect glaucoma early. To characterize the severity stage of new glaucoma patients and identify the predictors of late presentation in Congolese attending a university eye clinic. New glaucoma patients (n=118) were labelled as early or late presenters based visual field sensitivity in the worse eye. Predictors of late presentation were determined through logistic regression analytical models. Mean age was 58.9±15.7 years, 51.7% were males. Overall, the worse eye had advanced whereas the better eye had moderate glaucoma, with an asymmetry of -7.4dB (P<0.001). Blindness was present in 30.5% of worse and 5.1% of better eyes. Seventy-two patients (61.0%) were late presenters. Visual acuity was lower (P<0.001), intraocular pressure (IOP) higher (P=0.02), cup-to-disc ratio larger (P=0.011), and retinal nerve fiber layer thinner (P=0.001) in late presenters' worse than better eye. The worse and better eyes of late presenters had advanced glaucoma, with a -9.6dB interocular asymmetry (P<0.001); 40.3% and 8.3% were blind, respectively. In early presenters, the worse and better eye had moderate and early disease, respectively; the asymmetry was -3.2dB (P<0.001), and 15.2% were blind. Overall, 58.5% and 65.3% presented with advanced disease in the worse eye based on visual field and cup-to-disc ratio criteria of the Canadian Ophthalmological Society staging scale, respectively. Most new glaucoma patients had bilateral advanced but asymmetric disease. These findings call for the establishment of community-based measures for early detection of glaucoma and a referral network system connecting community healthcare to tertiary eye clinics.

Ocular blood flow biomarkers may predict long-term glaucoma progression

Background/aimTo examine the relationship between baseline blood flow biomarkers and long-term open-angle glaucoma (OAG) progression.Methods112 patients with early to moderate OAG (mean age 64.9±11.0 years; 68 female) were evaluated at...