Glaucomatous Eyes Research Articles

Optical Coherence Tomography and Optical Coherence Tomography Angiography: Essential Tools for Detecting Glaucoma and Disease Progression.

Early diagnosis and detection of disease progression are critical to successful therapeutic intervention in glaucoma, the leading cause of irreversible blindness worldwide. Optical coherence tomography (OCT) is a non-invasive imaging technique that allows objective quantification in vivo of key glaucomatous structural changes in the retina and the optic nerve head (ONH). Advances in OCT technology have increased the scan speed and enhanced image quality, contributing to early glaucoma diagnosis and monitoring, as well as the visualization of critically important structures deep within the ONH, such as the lamina cribrosa. OCT angiography (OCTA) is a dye-free technique for noninvasively assessing ocular microvasculature, including capillaries within each plexus serving the macula, peripapillary retina and ONH regions, as well as the deeper vessels of the choroid. This layer-specific assessment of the microvasculature has provided evidence that retinal and choroidal vascular impairments can occur during early stages of glaucoma, suggesting that OCTA-derived measurements could be used as biomarkers for enhancing detection of glaucoma and its progression, as well as to reveal novel insights about pathophysiology. Moreover, these innovations have demonstrated that damage to the macula, a critical region for the vision-related quality of life, can be observed in the early stages of glaucomatous eyes, leading to a paradigm shift in glaucoma monitoring. Other advances in software and hardware, such as artificial intelligence-based algorithms, adaptive optics, and visible-light OCT, may further benefit clinical management of glaucoma in the future. This article reviews the utility of OCT and OCTA for glaucoma diagnosis and disease progression detection, emphasizes the importance of detecting macula damage in glaucoma, and highlights the future perspective of OCT and OCTA. We conclude that the OCT and OCTA are essential glaucoma detection and monitoring tools, leading to clinical and economic benefits for patients and society.

Cystoid macular edema associated with omidenepag isopropyl in a phakic eye with an implantable collamer lens: a case report

BackgroundCystoid macular edema is a known complication of omidenepag isopropyl usage. Omidenepag isopropyl is a selective prostanoid EP2 receptor agonist, and its association with macular edema has mainly been identified in pseudophakic eyes. Herein, we report a case of cystoid macular edema caused by omidenepag isopropyl use in a phakic eye with an implantable collamer lens.Case presentationA 38-year-old woman was diagnosed with left eye glaucoma and prescribed omidenepag isopropyl. She had undergone bilateral implantation of implantable collamer lenses approximately 12 years prior to the glaucoma diagnosis. After 9 months of using omidenepag isopropyl, she presented with blurred vision in the left eye; swept source optical coherence tomography revealed cystoid macular edema in this eye. Omidenepag isopropyl usage was discontinued, and bromfenac sodium hydrate was administered twice daily instead. After 2 months, the patient’s visual discomfort was completely ameliorated. Additionally, an optical coherence tomography examination confirmed that the macula had normalized.ConclusionsWe report a case of cystoid macular edema development after omidenepag isopropyl use in a patient with glaucoma who had undergone bilateral implantable collamer lens implantation. This case shows that the possibility of cystoid macular edema occurrence should be considered when omidenepag isopropyl is used, even in phakic eyes, after the insertion of implantable collamer lenses.

Association Between Optic Disc Perfusion Determined by Swept-Source Optical Coherence Tomography Angiography and Visual Field Progression in Glaucoma.

Reduced optic disc vessel density determined by swept-source optical coherence tomography angiography (SS-OCTA) was associated with visual field (VF) deterioration in glaucomatous eyes, which suggested that this parameter can be a potential biomarker that correlates well with functional deterioration. The purpose of this study was to identify the association between optic disc perfusion evaluated by SS-OCTA and VF progression in primary open angle glaucoma (POAG) eyes. A total of 266 POAG eyes of 266 patients (5.4y of mean follow-up) were included. Optic nerve head SS-OCTA was performed to evaluate the optic disc vessel density (dVD), parapapillary choroidal vessel density (pcVD), choroidal microvascular dropout (cMvD), and optic disc microvascular dropout (dMvD). VF progression was defined using Early Manifest Glaucoma Trial criteria. Factors associated with VF worsening were assessed by Cox proportional hazard analysis. Eighty (30.1%) out of the 266 POAG eyes showed VF progression. The progression group showed a significantly higher proportion of disc hemorrhage, cMvD, and dMvD but lower dVD and pcVD than the stable group (all P <0.05). Considering the strong association between the parameters [dMvD vs. dVD ( r = -0.757, P =0.010], cMvD vs. pcVD ( r = -0.745, P =0.012), dMvD vs. cMvD ( r = 0.802, P <0.001], dVD vs. pcVD ( r = 0.862, P <0.001), CMvD vs. dVD ( r = -0.698, P =0.031), and dMvD vs. pcVD ( r = -0.688, P =0.034)], 6 models with different combinations of covariates compensating for multicollinearity were developed. Younger age, presence of disc hemorrhage, and lower dVD were consistently associated with progression in all models that included these parameters. Optic disc perfusion, represented as dVD, may be a useful biomarker that correlates well with functional deterioration in POAG eyes.

Optic Nerve Head Morphology is Associated with the Initial Location of Structural Progression in Early Open-Angle Glaucoma.

To investigate the effects of clinical variables on the temporal relationship between macular ganglion cell-inner plexiform layer (mGCIPL) loss and peripapillary retinal nerve fiber layer (pRNFL) loss in glaucoma. Glaucoma eyes with a small cup-to-disc ratio tend to show retinal nerve fiber layer progression earlier than ganglion cell-inner plexiform layer progression. This retrospective observational study used medical records of patients diagnosed with open-angle glaucoma. Structural change was determined using guided progression analysis software of Cirrus optical coherence tomography. Based on the time of detection of pRNFL and mGCIPL changes, eyes showing progressive layer loss were categorized into the pRNFL-first and mGCIPL-first groups. The association between sites of layer thinning and clinical variables such as major retinal arterial angles and several optic disc measurements including disc area, average cup-to-disc ratio (CDR), and vertical CDR were analyzed. A total of 282 eyes were included in the study, of which 104 showed structural progression either in the mGCIPL or pRNFL. Out of these, 49 eyes showed first progression in pRNFL, while 37 eyes showed first progression in mGCIPL. The minimum mGCIPL thickness, pRNFL thickness, average CDR, vertical CDR, and location of progression were significantly different between the two groups (P=0.041, P=0.034, P=0.015, P<0.001, and P<0.001, respectively). In multivariate analysis, average CDR and vertical CDR were significantly associated with the progression site (P=0.033 and P=0.006, respectively). The structural changes in the inferoinferior area and the superior vulnerability zone were significantly associated with RNFL-first progression (P<0.001 for both). The location of layer loss and CDR are related to the layer where loss is first detected (either pRNFL or mGCIPL) in open-angle glaucoma.

Improving Compliance with Medical Treatment Using Eye Drop Aids

Achieving optimal treatment outcomes in glaucoma requires patients to adhere to their medication regimens. Possible barriers to patients’ cooperation include the misunderstanding of a treatment’s importance or errors in applying instructions, forgetfulness, financial constraints and others. Due to the fact that glaucoma usually causes no apparent symptoms or pain, on the one hand, and the significant inconvenience that the eye drops used for glaucoma treatment can cause due to local irritation, on the other, patient compliance is a challenge. To address this challenge, we require strategies for improving adherence to glaucoma treatment. The importance of proper eye drop administration techniques cannot be overstated, particularly for vulnerable populations such as the elderly, the sick and the visually handicapped. Studies have shown that failure to comply with glaucoma treatment is a significant factor affecting disease progression, emphasizing the need for interventions that improve patient compliance. Educational interventions, medication reminders and the use of assistive devices such as eye drop aids have been shown to improve adherence to glaucoma treatment. By promoting strategies that can be used to enhance treatment adherence, healthcare providers can ensure that glaucoma patients receive the full benefits of their treatment plans, reducing the risk of disease progression. Many patients struggle with the complexity of their treatment regimens and the challenges of administering eye drops. This entry provides a comprehensive overview of the different barriers to patient adherence to glaucoma eye drop treatment, emphasizing the difficulties associated with eye drop instillation. This entry examines a range of eye drop aids available to patients, evaluating their modes of action, benefits, drawbacks and effectiveness in improving patient compliance. By providing detailed information on the barriers to adherence and the range of eye drop aids available, this entry aims to support healthcare providers in helping glaucoma patients to achieve better treatment adherence and outcomes.

Rate of Retinal Nerve Fiber Layer Thinning in Glaucomatous Eyes with Optic Disc and Parapapillary Deep-Layer Microvasculature Loss.

Microvasculature dropout in the parapapillary choroidal layer was a more important biomarker of glaucomatous nerve fiber layer thinning when it presented with deep-layer microvasculature of the optic disc rather than when it presents by itself. To characterize open-angle glaucoma (OAG) eyes with optic nerve head (ONH) deep-layer microvasculature dropout (MvD-D) and parapapillary choroidal layer microvasculature dropout (MvD-P) and compare their retinal nerve fiber layer (RNFL) thinning rate. This study included 122 OAG eyes that underwent ≥5 serial spectral-domain optical coherence tomography (OCT) scans during a mean follow-up of 5.4 years. Swept-source OCT angiography (SS-OCTA) was used to evaluate MvD-P and MvD-D. Subjects were classified into three groups according to the presence of MvD-P and MvD-D: (1) no dropout (n=37); (2) solely MvD-P (n=40), and (3) both MvD-P and MvD-D (n=45). The RNFL thinning rate was compared among the three groups, and the associated factors were assessed by Cox proportional hazard analysis. RNFL thinning rates were highest in the group with both MvD-P and MvD-D, followed by the group with solely MvD-P and finally by the no dropout group (-0.24 vs. -0.65 vs. -1.20μm/year, P<0.001). Thinner central corneal thickness (hazard ratio [HR]=0.990, P=0.003), presence of disc hemorrhage (HR=1.802, P=0.035), and coexistence of MvD-P and MvD-D (HR=2.941, P<0.001) were the factors associated with RNFL thinning. The coexistence of MvD-P and MvD-D was associated with faster RNFL thinning than MvD-P alone or no dropout, which suggested that observing the optic disc deep microvasculature along with parapapillary choroidal layer using SS-OCTA may be clinically relevant in monitoring glaucoma progression.

Optic Nerve Head, Peripapillary and Macular Microvascular Characteristics in Patients with Unilateral Pseudoexfoliation Glaucoma.

In unilateral pseudoexfoliation glaucoma (PEXG), there may be decreased choroidal vascularity index (CVI), radial peripapillary capillary plexus' perfusion and flow. CVI may also be reduced in fellow eyes, suggesting that PEXG is bilateral disease. Evaluation of peripapillary and macular choroidal microvascularity and radial peripapillary capillary plexus (RPC) in both eyes with unilateral pseudoexfoliation glaucoma (PEXG) and healthy eyes. Ninety-six eyes of 48 patients with unilateral PEXG (PEX (+): 48 eyes with PEXG; PEX (-): 48 eyes without PEX) and the right eyes of 45 age- and sex-matched healthy controls were included in the study. Choroidal vascular index (CVI) was calculated on enhanced depth imaging optical coherence tomography (EDI-OCT) scans. RPC vascular layer were evaluated by OCT-Angiography (OCTA). Macular CVI (mCVI), temporal and nasal peripapillary CVI (pCVI) was significantly decreased in the PEX (+) compared to the PEX (-) and control group (P<0.05 for all). While there was a significant difference between PEX (-) and the control group in terms of mCVI and temporal pCVI, there was no significant difference between the two groups in terms of nasal pCVI (P=0.008, P=0.036 and P=0.604, respectively). There was a significant difference in perfusion density (PD) and flux index (FI) between PEX (+) group, PEX (-) group and control group in all quadrants and average value (P<0.05 for all). Although the PD and FI values in all quadrants and average values of the PEX (-) group were lower than the control group, this difference was not significant. CVI in the macula and peripapillary region tends to decrease in eyes with PEXG. Similarly, PD and FI were lower in eyes with PEXG. Low mCVI and temporal pCVI can also be seen in eyes without PEX.

Multimodal Deep Learning Classifier for Primary Open-angle Glaucoma Diagnosis Using Wide-field Optic Nerve Head Cube Scans in Eyes With and Without High Myopia.

An OCT-based multimodal deep learning classification model including texture information is introduced that outperforms single-modal models and multimodal models without texture information for glaucoma diagnosis in eyes with and without high myopia. To evaluate the diagnostic accuracy of a multimodal deep learning (DL) classifier using wide optical coherence tomography (OCT) optic nerve head cube scans in eyes with and without axial high myopia. 371 primary open-angle glaucoma (POAG) eyes and 86 healthy eyes, all without axial high myopia (axial length AL≤26mm) and 92 POAG eyes and 44 healthy eyes, all with axial high myopia (AL>26mm) were included. The multimodal DL classifier combined features of 3 individual VGG-16 models: 1) texture-based en face image, 2) retinal nerve fiber layer (RNFL) thickness map image and 3) confocal scanning laser ophthalmoscope (cSLO) image. Age, AL, and disc area adjusted area under the receiver operating curves (AUROC) were used to compare model accuracy. Adjusted AUROC for the multimodal DL model was 0.91 (95% CI = 0.87, 0.95). This value was significantly higher than the values of individual models (0.83 [0.79, 0.86] for texture based en face image; 0.84 [0.81, 0.87] for RNFL thickness map; and 0.68 [0.61, 0.74] for cSLO image; all P≤0.05). Using only highly myopic eyes, the multimodal DL model showed significantly higher diagnostic accuracy (0.89 [0.86 , 0.92]) compared to texture en face image (0.83 [0.78 , 0.85]), RNFL (0.85 [0.81 , 0.86]) and cSLO image models (0.69 [0.63 , 0.76]) (all P≤0.05). Combining OCT-based RNFL thickness maps with texture based en face images showed better ability to discriminate between healthy and POAG than thickness maps alone, particularly in high axial myopic eyes.

Sigma-1 Receptor Activation Is Protective against TGFβ2-Induced Extracellular Matrix Changes in Human Trabecular Meshwork Cells.

The trabecular meshwork (TM) route is the principal outflow egress of the aqueous humor. Actin cytoskeletal remodeling in the TM and extracellular matrix (ECM) deposition increase TM stiffness, outflow resistance, and elevate intraocular pressure (IOP). These alterations are strongly linked to transforming growth factor-β2 (TGFβ2), a known profibrotic cytokine that is markedly elevated in the aqueous humor of glaucomatous eyes. Sigma-1 receptor (S1R) has been shown to have neuroprotective effects in the retina, but data are lacking about its role in the TM. In this study, we identified the presence of S1R in mouse TM tissue and investigated the effect of an S1R agonist fluvoxamine (FLU) on TGFβ2-induced human TM cells regarding cell proliferation; ECM-related functions, including F-actin reorganization; and the accumulation of ECM elements. TGFβ2 increased the proliferation, cytoskeletal remodeling, and protein levels of fibronectin, collagen type IV, and connective tissue growth factor, and decreased the level of matrix metalloproteinase-2. Most importantly, FLU reversed all these effects of TGFβ2, suggesting that S1R agonists could be potential candidates for preserving TM function and thus maintaining normal IOP.

Structural measurements and vessel density of spectral-domain optic coherence tomography in early, moderate, and severe primary angle-closure glaucoma.

To compare the macular ganglion cell-inner plexiform layer (GCIPL) thickness, retinal nerve fiber layer (RNFL) thickness, optic nerve head (ONH) parameters, and retinal vessel density (VD) measured by spectral-domain optical coherence tomography (SD-OCT) and analyze the correlations between them in the early, moderate, severe primary angle-closure glaucoma (PACG) and normal eyes. Totally 70 PACG eyes and 20 normal eyes were recruited for this retrospective analysis. PACG eyes were further separated into early, moderate, or severe PACG eyes using the Enhanced Glaucoma Staging System (GSS2). The GCIPL thickness, RNFL thickness, ONH parameters, and retinal VD were measured by SD-OCT, differences among the groups and correlations within the same group were calculated. The inferior and superotemporal sectors of the GCIPL thickness, rim area of ONH, average and inferior sector of the retinal VD were significantly reduced (all P<0.05) in the early PACG eyes compared to the normal and the optic disc area, cup to disc ratio (C/D), and cup volume were significantly higher (all P<0.05); but the RNFL was not significant changes in early and moderate PACG. In severe group, the GCIPL and RNFL thickness were obvious thinning with retinal VD were decreasing as well as C/D and cup volume increasing than other three groups (all P<0.01). In the early PACG subgroup, there were significant positive correlations between retinal VD and GCIPL thickness (except superonasal and inferonasal sectors, r=0.573 to 0.641, all P<0.05), superior sectors of RNFL thickness (r=0.055, P=0.049). More obvious significant positive correlations were existed in moderate PACG eyes between retinal VD and superior sectors of RNFL thickness (r=0.650, P=0.022), and temporal sectors of RNFL thickness (r=0.740, P=0.006). In the severe PACG eyes, neither GCIPL nor RNFL thickness was associated with retinal VD. The ONH damage and retinal VD loss appears earlier than RNFL thickness loss in PACG eyes. As the PACG disease progressed from the early to the moderate stage, the correlations between the retinal VD and RNFL thickness increases.

Clinical Factors Associated With Long-Term OCT Variability in Glaucoma

To examine clinical factors associated with long-term optical coherence tomography (OCT)-measured retinal nerve fiber layer thickness (RNFLT) variability in glaucoma. Retrospective cohort study. Glaucoma eyes from DIGS/ADAGES with≥2-years and 4-visits follow-up were included. RNFLT variability was calculated per-visit as the absolute error of optic nerve head RNFLT residuals across longitudinal follow-up. Clinical factors examined included general demographics, baseline ocular measurements, prior and intervening cataract extraction (CE) or glaucoma surgery, scan quality, baseline RNFLT and RNFLT thinning rate, follow-up duration, visit/testing frequency, etc. Three multivariable linear mixed models (full model, baseline model, and parsimonious model) were fit to evaluate the effects of clinical factors on RNFLT variability, with ten-fold cross-validation to estimate real-world model performance. A total of 1140 eyes (634 patients) were included. The overall mean (95% CI) RNFLT variability was 1.51(1.45, 1.58) µm. Across different models, African-American race (β[standard error, SE] = 0.18[0.06]), intervening CE (β[SE] = 0.52[0.07]), intervening glaucoma surgeries (β[SE] = 0.15[0.03]), and more positive RNFLT thinning rate (β[SE] = 0.06[0.02] per 1um/year more positive) showed consistent association with greater RNFLT variability, whereas more frequent visits/testing (β[SE] = -0.11[0.05] per 1 visit/year higher) was associated with smaller RNFLT variability (P<0.05 for all). Relevant clinical factors affecting long-term RNFLT variability in glaucoma were identified. These data enhance the evaluation of longitudinal structural change. Increasing the testing frequency, especially in eyes at risk of higher measurement variability, and resetting of baseline imaging after intervening procedures may help to more reliably detect OCT progression.

The Curvature, Collagen Network Structure, and Their Relationship to the Pressure-Induced Strain Response of the Human Lamina Cribrosa in Normal and Glaucoma Eyes.

The lamina cribrosa (LC) is a connective tissue in the optic nerve head (ONH). The objective of this study was to measure the curvature and collagen microstructure of the human LC, compare the effects of glaucoma and glaucoma optic nerve damage, and investigate the relationship between the structure and pressure-induced strain response of the LC in glaucoma eyes. Previously, the posterior scleral cups of 10 normal eyes and 16 diagnosed glaucoma eyes were subjected to inflation testing with second harmonic generation (SHG) imaging of the LC and digital volume correlation (DVC) to calculate the strain field. In this study, we applied a custom microstructural analysis algorithm to the maximum intensity projection of SHG images to measure features of the LC beam and pore network. We also estimated the LC curvatures from the anterior surface of the DVC-correlated LC volume. Results showed that the LC in glaucoma eyes had larger curvatures p≤0.03), a smaller average pore area (p = 0.001), greater beam tortuosity (p < 0.0001), and more isotropic beam structure (p = 0.01) than in normal eyes. The difference measured between glaucoma and normal eyes may indicate remodeling of the LC with glaucoma or baseline differences that contribute to the development of glaucomatous axonal damage.

Evaluation of the Hypertensive Phase after Ahmed Glaucoma Valve Implantation in Neovascular Glaucoma.

To compare Ahmed glaucoma valve (AGV) outcomes in neovascular glaucoma (NVG) eyes with and without a postoperative (PO) hypertensive (HTN) phase. Retrospective study at a single tertiary care center of patients who underwent AGV implantation for NVG treatment with ≥6-month follow-up. Main outcome measures included intraocular pressure (IOP), number of glaucoma medications (GM), and failure at month 6 or at the most recent visit. Failure was defined as decline to no light perception (NLP) vision, IOP >21 mm Hg, or need for glaucoma reoperations (all with GM). A total of 76 eyes of 74 patients (37 without HTN phase and 39 with HTN phase) with a mean follow-up duration of 28.9 ± 25.7 months (p = 0.602) were included. Both groups had similar demographics, visual acuity (VA), number of GM, etiology of NVG, and retina treatment perioperatively. Baseline IOP was significantly higher in the HTN phase group (p = 0.001). Compared to eyes without an HTN phase, HTN phase eyes more commonly met failure criteria at month 6 (33.3 vs 9.1%; p = 0.01), but both groups had a comparable cumulative failure for the entire follow-up period (p = 0.180). At the most recent visit, the number of GM was higher in the HTN phase group (p = 0.019), but IOP was similar in both groups. PO complications were comparable and uncommon in both groups. Hypertensive (HTN) phase following AGV implantation for NVG is associated with higher preoperative IOP and greater failure by PO month (POM) 6. However, eyes with and without the HTN phase had similar needs for GM and failure rates over the long term. Ramesh S, Shalaby WS, Myers JS, et al. Evaluation of the Hypertensive Phase after Ahmed Glaucoma Valve Implantation in Neovascular Glaucoma. J Curr Glaucoma Pract 2023;17(2):91-97.

Evaluation of microvascular changes in the retina and choriocapillaris in primary glaucoma and neuromyelitis optica spectrum disorder with optical coherence tomography angiography

BackgroundTo assess quantitatively the microvascular changes in the retina and choroid of healthy eyes, eyes of subjects with primary angle-closure glaucoma (PACG), primary open-angle glaucoma (POAG) and neuromyelitis optica spectrum disorder (NMOSD) using optical coherence tomography angiography (OCTA). MethodsA series of healthy individuals and subjects with PACG, POAG and NMOSD were recruited in this cross-sectional study. OCTA was performed to capture the optic nerve head and macula images and the vessel density (VD) and retinal nerve fiber layer (RNFL) thickness were quantified. The choriocapillary flow density (CFD) was calculated as the percentage of flow area to the whole selected area. ResultsA total of 68 PACG subjects, 25 POAG subjects, 51 NMOSD subjects and 37 healthy controls were enrolled. Significant decreases in peripapillary VD and RNFL thickness were observed in PACG (p < 0.001) and POAG (p < 0.001) eyes and also in NMOSD subjects with an optic neuritis history (p < 0.001) compared with healthy controls. Unaffected eyes in PACG and POAG subjects had lower baseline peripapillary VD than healthy controls (p = 0.002 and p = 0.011, respectively). PACG eyes showed a lower baseline CFD than POAG (p = 0.0027) and the CFD in early and advanced PACG eyes showed a significantly much more decrease than POAG (p = 0.002 and p < 0.001, respectively). ConclusionsThe peripapillary vessel density and RNFL thickness was reduced in glaucomatous and NMOSD eyes compared with healthy controls. PACG eyes showed a lower CFD than POAG and the distinct peripapillary and choriocapillaris microvasculature changes may be correlated to different PACG and POAG pathogenesis.

Recruiting Populations at Higher Risk for Glaucoma and Other Eye Diseases Experiencing Eye Health Disparities

ABSTRACT Purpose We compared recruitment of participants at high risk for glaucoma and other eye diseases in three community-based studies designed to improve access to eye care in underserved populations in New York City, Alabama, and Michigan. Methods We used (1) participant data collected at enrollment (e.g. demographic, medical conditions, healthcare access, and method of hearing about study) and (2) interviews with study staff to assess effective recruitment strategies in enrolling people at high risk for eye disease. We analyzed participant data using descriptive statistics and interview data using content analysis to categorize responses to questions. Results In these community-based studies, all sites recruited greater proportions of populations with increased risk of eye disease compared to their estimates in the US population. High-risk characteristics varied based on the setting (i.e. Federally Qualified Health Centers or affordable housing buildings). Older adults represented 35% to 57%; 43% to 56% identified as Black; 1% to 40% as Hispanic/Latino; 20% to 42% reported a family history of glaucoma; 32% to 61% reported diabetes; and 50% to 67% reported high blood pressure. Social risk factors for under-utilization of eye care due to poverty included that 43% to 70% of participants had high school or lower education; 16% to 40% were employed; and 7% and 31% had no health insurance. From a qualitative perspective, active, personalized, culturally sensitive methods were most effective in recruiting participants. Conclusion Implementing eye disease detection interventions in community-based settings facilitated recruiting individuals at high risk for glaucoma and other eye diseases.

Improving glaucoma staging in clinical practice by combining the ICD-10 glaucoma severity classification system and optical coherence tomography

ObjectiveThe International Classification of Disease, 10th revision (ICD-10) codes used for glaucoma severity classification are based on the 24-2 visual-field (VF) test. This study aim was to assess the added value of providing clinicians with optical coherence tomography (OCT) data, in addition to functional data, for glaucoma staging in clinical practice.ExposureDisease classification was determined for 54 glaucoma eyes, according to the principles of the ICD-10 guidelines. Eyes were independently graded in a masked fashion using the 24-2 VF test and 10-2 VF test, with and without OCT information. The reference standard (RS) for severity was determined using a previously published automated structure-function topographic agreement for glaucomatous damage using all available information.ResultsThe RS classified eyes as mild, moderate and advanced in 3, 16 and 35 cases, respectively. Individual and combined 24-2 and 10-2 based gradings were significantly different from the RS (all P < 0.005), with Kappa agreements of 0.26, 0.45 and 0.42 respectively (P < 0.001). Classifications using OCT combined with either of the VF were not-significantly different from the RS (P > 0.3) with Kappa agreements of 0.56 and 0.57 respectively (P < 0.001). Combining 24-2 with OCT had less severity overestimations while 10-2 with OCT had fewer underestimations.ConclusionCombining OCT and VF data provides better staging of glaucoma severity than VF data alone. The 24-2 and OCT combination seems most appropriate given the high concordance with the RS and less overestimation of severity. Incorporating structural information into disease stages allows clinicians to set more appropriate severity-based treatment targets for individual patients.

Binocular head-mounted chromatic pupillometry can detect structural and functional loss in glaucoma.

The aim of this study is to evaluate the utility of binocular chromatic pupillometry in detecting impaired pupillary light response (PLR) in patients with primary open-angle glaucoma (POAG) and to assess the feasibility of using binocular chromatic pupillometer in opportunistic POAG diagnosis in community-based or telemedicine-based services. In this prospective, cross-sectional study, 74 patients with POAG and 23 healthy controls were enrolled. All participants underwent comprehensive ophthalmologic examinations including optical coherence tomography (OCT) and standard automated perimetry (SAP). The PLR tests included sequential tests of full-field chromatic stimuli weighted by rods, intrinsically photosensitive retinal ganglion cells (ipRGCs), and cones (Experiment 1), as well as alternating chromatic light flash-induced relative afferent pupillary defect (RAPD) test (Experiment 2). In Experiment 1, the constricting amplitude, velocity, and time to maximum constriction/dilation were calculated in three cell type-weighted responses, and the post-illumination response of ipRGC-weighted response was evaluated. In Experiment 2, infrared pupillary asymmetry (IPA) amplitude and anisocoria duration induced by intermittent blue or red light flashes were calculated. In Experiment 1, the PLR of POAG patients was significantly reduced in all conditions, reflecting the defect in photoreception through rods, cones, and ipRGCs. The variable with the highest area under the receiver operating characteristic curve (AUC) was time to max dilation under ipRGC-weighted stimulus, followed by the constriction amplitude under cone-weighted stimulus and the constriction amplitude response to ipRGC-weighted stimuli. The impaired PLR features were associated with greater visual field loss, thinner retinal nerve fiber layer (RNFL) thickness, and cupping of the optic disk. In Experiment 2, IPA and anisocoria duration induced by intermittent blue or red light flashes were significantly greater in participants with POAG than in controls. IPA and anisocoria duration had good diagnostic value, correlating with the inter-eye asymmetry of visual field loss. We demonstrate that binocular chromatic pupillometry could potentially serve as an objective clinical tool for opportunistic glaucoma diagnosis in community-based or telemedicine-based services. Binocular chromatic pupillometry allows an accurate, objective, and rapid assessment of retinal structural impairment and functional loss in glaucomatous eyes of different severity levels.

Stage specific glaucomatous changes of the macula recorded using spectral domain optical coherence tomography

BackgroundThis study aimed to compare the thickness of different macular retinal layers in glaucomatous eyes and healthy controls, and evaluate the diagnostic performance of spectral domain optical coherence tomography (SD-OCT) parameters. MethodsIn this cross-sectional comparative study, 48 glaucomatous eyes and 44 healthy controls were included. The thickness of the total retina and all retinal layers were obtained using the Early Treatment Diagnostic Retinopathy Study (ETDRS) grid. The minimal and average values of outer and inner ETDRS-rings were calculated. The diagnostic performance for detection of glaucoma was evaluated using the area under the receiver operating characteristic curve (AUC). ResultsThe thickness of the total retina, ganglion cell layer (GCL), and inner-plexiform layer (IPL) was significantly thinner in glaucomatous eyes in all sectors except the center (all p<0.05). The thickness of retinal nerve fiber layer (RNFL) was significantly thinner in the glaucoma group except in the center, nasal inner, and temporal outer sectors (all p<0.05). Layer thinning advanced with glaucoma severity. The minimal outer GCL thickness showed the highest AUC value for discrimination between glaucomatous eyes and healthy controls(0.955). The minimal outer IPL showed the highest AUC value for discriminating early-stage glaucomatous eyes from healthy controls (0.938). ConclusionsGlaucomatous eyes were found to have significant thinning in the macular region. GCL and IPL showed high ability to discriminate glaucomatous and early-stage glaucomatous eyes from controls. Applying the minimal value to the ETDRS grid has the potential to provide good diagnostic abilities in glaucoma screening.

All Consecutive Ab Externo SIBS Microshunt Implantations With Mitomycin C: One-Year Outcomes and Risk Factors for Failure

To present the effectiveness, risk factors for surgical failure, and adverse events over 12 months in a consecutive diverse cohort of glaucoma patients who underwent solo or combined ab externo SIBS microshunt with mitomycin C (MMC) with or without previous subconjunctival surgery. Retrospective, consecutive, interventional case series. Consecutive glaucomatous eyes on maximally tolerated medical therapy received ab externo SIBS microshunt with MMC implantation as a solo or combined procedure with phacoemulsification from July 2015 to January 2020. The primary outcome was the proportion of eyes at 12-months with the following: (1) no 2 consecutive intraocular pressures (IOPs) >17 mm Hg or clinical hypotony, without (complete success) or with (qualified success) glaucoma medications; and (2) ≥20% reduction from baseline IOP. Secondary outcomes included upper IOP thresholds of 14 and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, postoperative interventions, complications, and reoperations. A total of 436 eyes underwent surgery; 86 (20%) combined with phacoemulsification, 127 (29%) in eyes with refractory glaucoma, and 234 (51%) stand-alone procedures in non-refractory eyes. Complete success (6-17 mm Hg with no medications) was achieved in 64.0% of combined eyes, 58.1% of refractory eyes, and 74.8% of stand-alone non-refractory eyes; and qualified success rates (6-17 mm Hg with medications) were 90.7%, 84.7%, and 92.4% of eyes, respectively. At 12 months, 67% of eyes were medication free. Significant risk factors for failure included combined procedures in refractory eyes (hazard ratio [HR]=3.2; 95% CI=1.4-7.4), receiving <0.4 mg/mL of MMC (HR=2.2; 95% CI=1.6-3.1), refractory eyes (HR=1.7; 95% CI=1.2-2.5), combined procedures (HR=1.6; 95% CI=1.0-2.5), and each additional baseline medication class (HR=1.3; 95% CI=1.1-1.5). Postoperative complications occurred in 31% of eyes, and more often in those receiving ≥0.4 mg/mL MMC (odds ratio [OR]=2.2, 95% CI 1.2-3.8). Needling occurred in 12% of eyes, with significantly higher frequency in refractory eyes (23%) and combined procedures (13%) compared to stand-alone (7%; P < .001). Revisions and reoperations occurred in 4% and 1.4% of eyes, respectively. The 1-year follow-up data from this large and diverse cohort support promising rates of qualified and complete surgical success with decreased medication burden and few postoperative complications and interventions. Combined phacoemulsification, refractory glaucoma, and receiving <0.4 mg/mL MMC significantly reduced surgical success rates.

Efficacy of ripasudil in reducing intraocular pressure and medication score for ocular hypertension with inflammation and corticosteroid.

To investigate the efficacy of ripasudil, a Rho kinase inhibitor, in reducing intraocular pressure (IOP) and medication scores of anti-glaucoma drugs in patients with ocular hypertension with inflammation and corticosteroid. The study included 11 patients diagnosed with ocular hypertension with inflammation and corticosteroid, all of whom were prescribed ripasudil eye drops and followed up for at least 2y after the initiation of treatment. IOP was measured using a non-contact tonometer before enrollment and at each follow-up visit. The medication score of glaucoma eye drops was calculated for each patient. The mean IOP (26.4±2.9 mm Hg before treatment) significantly decreased after ripasudil therapy (13.7±3.3 mm Hg at 3mo) and remained stable in the low-teens during the 2-year follow-up period (P<0.0001). A significant decrease in the medication score was observed at 12mo or later after the initiation of ripasudil therapy (P<0.05). Both baseline medication scores and glaucomatous optic disc change rates were significantly higher in the five eyes that required glaucoma surgery during the 2-year observation period than the 10 eyes that did not require surgery. Our results demonstrate the efficacy of ripasudil, in reducing IOP and the medication score over a 2-year treatment period in patients with ocular hypertension with inflammation and corticosteroid. Our findings also suggest that ripasudil could reduce the IOP in uveitic glaucoma patients with both lower baseline medication score and lower glaucomatous optic disc change rate.