Initial Visual Field Research Articles

Peripapillary Versus Macular Thinning to Detect Progression According to Initial Visual Field Loss Location in Normal-Tension Glaucoma

PurposeTo investigate the predictive capabilities of peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thinning to detect visual field (VF) progression in normal-tension glaucoma patients with an initial parafoveal scotoma (IPFS) or nasal step (INS). DesignRetrospective cohort study. Methods185 early-stage glaucoma eyes, followed for 10 years, were retrospectively stratified into IPFS and INS groups. Progressive pRNFL and mGCIPL thinning were assessed using spectral-domain optical coherence tomography and VF progression using both event- or trend-based analysis. Kaplan-Meier survival analysis compared VF survival in each VF phenotype with or without progressive pRNFL and mGCIPL thinning. Cox proportional regression analysis identified VF progression factors. ResultsVF progression was detected in 42 IPFS (n=86) and 47 INS (n=99) eyes. Among VF progressors, pRNFL thinning was significantly faster in INS group compared to IPFS group (P < 0.01), while mGCIPL thinning was similar (P = 0.16). At five years, eyes with progressive mGCIPL thinning showed significantly lower VF survival in both VF phenotypes (all P < 0.05). Progressive pRNFL thinning showed significantly lower VF survival only in INS eyes (P = 0.015). Cox multivariate regression revealed that mGCIPL thinning predicted subsequent VF progression in IPFS eyes, while mGCIPL and pRNFL thinning had significant associations with VF progression in INS eyes. ConclusionsmGCIPL outperforms pRNFL at early follow-up in detecting VF progression in IPFS eyes but not INS eyes. Appropriate selection of structural parameters (mGCIPL vs pRNFL) maximizes early VF progression detection according to initial VF defect location.

Associations of long-term fluctuation in blood pressure and ocular perfusion pressure with visual field progression in normal-tension glaucoma

BackgroudThe aim of this study was to investigate the associations between fluctuation in blood pressure (BP), ocular perfusion pressure (OPP) and visual field (VF) progression in normal-tension glaucoma (NTG).MethodsThis prospective, longitudinal study included 44 patients with NTG. Only newly diagnosed NTG patients who had not been treated with a glaucoma medication were included. Patients were examined every year for 7 years. Intraocular pressure (IOP), heart rate (HR), systolic BP (SBP), diastolic BP (DBP), ocular perfusion pressure (OPP), and diastolic ocular perfusion pressure (DOPP) were measured at the same time. Ophthalmic examinations, including perimetry, were performed also. Initial VF were compared with follow-up data after 7 years.ResultsAfter 7 years of follow-up, 9 of the 44 patients showed VF progression. The standard deviation (SD) of SBP and OPP were significantly associated with VF progression (P = 0.007, < 0.001, respectively). Multiple regression analysis showed that VF progression was significantly associated with SD of OPP (odds ratio, OR = 2.012, 95% CI = 1.016–3.985; P = 0.045).ConclusionsFluctuation in OPP was associated with VF progression in patients with NTG.

Optic nerve head factors associated with initial central visual field defect in primary open-angle glaucoma

We investigated optic nerve head factors associated with initial parafoveal scotoma (IPFS) in primary open-angle glaucoma. Eighty (80) patients with an IPFS and 84 patients with an initial nasal step (INS) were compared. Central retinal vascular trunk (CRVT) deviation from the Bruch’s membrane opening (BMO) center was measured as a surrogate of lamina cribrosa (LC)/BMO offset, and its obliqueness was defined as the absolute value of angular deviation from the fovea-BMO axis. Proximity of retinal nerve fiber layer defect (RNFLD) was defined as the angular deviation of the inner RNFLD margin from the fovea-BMO axis. Microvasculature dropout (MvD) was defined as a focal sectoral capillary dropout with no visible microvascular network identified in the choroidal layer. Factors associated with IPFS, as compared with INS, were assessed using logistic regression analyses and conditional inference tree analysis. The IPFS group had more oblique CRVT offset (P < 0.001), RNFLD closer to the fovea (P < 0.001), more MvD (P < 0.001), and more LC defects (P < 0.001) compared to the INS group. In logistic regression analyses, obliqueness of CRVT offset (P = 0.002), RNFLD proximity (P < 0.001), and MvD (P = 0.001) were significant factors influencing the presence of IPFS. Conditional inference tree analysis showed that RNFLD closer to the fovea (P < 0.001) in the upper level, more oblique CRVT offset (P = 0.013) and presence of MvD (P = 0.001) in the lower level were associated with the probability of having IPFS. IPFS was associated with closer RNFLD location to the fovea when assessed from the BMO. Oblique LC/BMO offset may not only mask RNFLD proximity to the fovea due to a deviated funduscopic disc appearance, but also potentiate IPFS via focal LC defect and MvD.

FRI322 Lack Of Tumor Size Change With Long-term Cabergoline For Prolactinoma

Abstract Disclosure: S. Bendaram: None. V. Kantorovich: None. Introduction: Prolactinomas are the most common tumors of the pituitary gland and account for about 40% of all Pituitary adenomas, of which 10% are macroprolactinomas measuring &amp;gt;1 cm. Dopamine Agonists (DAs) normalize the prolactin levels and aid in shrinkage of the tumor size. We present two cases of Macroprolactinomas with biochemical response to DAs but no shrinkage in size as expected. Case 1: 75-year-old male with history of hypertension, left frontal MCA stroke with residual aphasia who underwent brain MRI for a recent TIA, was found to have a new 2.3 x 1.9 x 2.4 cm mass in the pituitary fossa invading the right cavernous sinus, concerning for a pituitary macroadenoma. Prolactin levels were 4152 ng/ml on dilution study, low testosterone with inappropriately normal LH/FSH. He denied any symptoms from compression, hyperprolactinemia or hypogonadism. After starting Cabergoline 0.25 mg biweekly, repeat levels in 2 weeks showed a decline in prolactin levels to 808.7 ng/ml. Visual Field (VF) testing was abnormal but was unreliable due to high fixation losses. Same dose of cabergoline was continued, with decline in prolactin further to 37.8 ng/ml, while a repeat MRI Brain showed no substantial change in the size of the mass. Cabergoline was doubled, and a repeat MRI still demonstrated same size of the mass, despite prolactin levels decreasing to below normal range. Case 2: 62-year-old male with history of macroprolactinoma for &amp;gt;3 years, but non-adherent to medications, who presented to his PCP with persistent occipital headaches, and was referred to Endocrinology due to repeat MRI brain revealing interval increase in the size of sellar and suprasellar mass measuring 2.2 x 2.2 x 2.9 cm in size consistent with macroadenoma with mass-effect on the optic chiasm and prechiasmatic optic nerves. Evaluation of pituitary panel revealed prolactin levels of 1352 ng/ml, low testosterone and LH, while the rest of the labs were normal. He was started on cabergoline 0.5 mg biweekly, and a repeat prolactin level after a single dose of cabergoline improved to 469 ng/ml. He was continued on the same dose with prolactin dropping to 2.6 ng/ml in 2 months, and further to 1.8 ng/dl after 10 months of treatment. Initial VF testing also demonstrated some degree of defect with compression of optic chiasm. Repeat MRI 3 months after initiation of cabergoline revealed interval decrease in size of macroadenoma to 2.1 cm in the largest dimension, which stayed the same on the recent imaging. Discussion: DAs like Cabergoline are first line therapy for prolactinomas. Fibrotic changes from long standing adenomas might be a possibility causing resistance to shrinkage of tumor, however it would be interesting to know if any specific molecular mechanisms that could be involved. In tumors with significant mass effect or those not responding to MT, Surgery is the preferred next step, and neurosurgery evaluation is necessary for further management. Presentation: Friday, June 16, 2023

Risk Factors for Fellow Eye Involvement in Patients with Nonarteritic Anterior Ischemic Optic Neuropathy

Introduction: The aim of the study was to investigate the possible risk factors for fellow eye involvement in patients with nonarteritic anterior ischemic optic neuropathy (NAION). Methods: A total of 113 patients with unilateral NAION attack were included and divided into two groups according to whether fellow eye involvement was present over a mean follow-up period of 2.70 years (P25–P75: 0.77–3.54 years). General characteristics (including age, sex, diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea syndrome [OSAS]) and ocular characteristics (including initial best-corrected visual acuity, initial visual field damage of the first eye, and the presence/absence of a crowded disc) were analyzed and compared between the two groups. Cox regression was used to assess the risk factors for fellow eye involvement. Results: During the follow-up period, 40 patients developed fellow eye involvement. The initial best-corrected visual acuity (p = 0.048) and mean deviation of the visual field (VF) (p = 0.039) of the first eye in patients with fellow eye involvement were worse than those in patients without it. Diabetes (HR = 3.06, 95% CI: 1.50, 6.26, p = 0.002) and increased VF damage (moderate vs. mild, HR = 2.92, 95% CI: 1.03, 8.25, p = 0.043; severe vs. mild, HR = 5.01, 95% CI: 1.65, 15.20, p = 0.004) were associated with a significantly increased risk of fellow eye involvement. In 57 patients with apnea-hypopnea index (AHI) data for further study, an AHI score ≥23.2 was also found to be a risk factor (HR = 3.36, 95% CI: 1.17, 9.69, p = 0.025). Conclusion: Diabetes, severer initial VF damage, and more severe OSAS were risk factors for fellow eye involvement in NAION. For patients with these risk factors, more intensive follow-ups might be warranted.

Pointwise and Region-Wise Course of Visual Field Loss in Patients With Glaucoma.

PurposeAccurate assessment of visual field (VF) trend may help clinicians devise the optimum treatment regimen. This study was conducted to investigate the behavior of VF sequences using pointwise and region-wise linear, exponential, and sigmoid regression models.Materials and MethodsIn a retrospective cohort study, 277 eyes of 139 patients with glaucoma who had been followed for at least 7 years were investigated. Linear, exponential, and sigmoid regression models were fitted for each VF test location and Glaucoma Hemifield Test (GHT) region to model the trend of VF loss. The model with the lowest root mean square error (RMSE) was selected as the best fit.ResultsThe mean age (standard deviation [SD]) of the patients was 59.9 years (9.8) with a mean follow-up time of 9.3 (0.7) years. The exponential regression had the best fit based on pointwise and region-wise approaches in 39.3% and 38.1% of eyes, respectively. The results showed a better performance based on sigmoid regression in patients with initial VF sensitivity threshold greater than 22 dB (71.6% in pointwise and 62.2% in region-wise approaches). The overall RMSE of the region-wise regression model was lower than the overall RMSE of the pointwise model.ConclusionsIn the current study, nonlinear regression models showed a better fit compared to the linear regression models in tracking VF loss behavior. Moreover, findings suggest region-wise analysis may provide a more appropriate approach for assessing VF deterioration.Translational RelevanceFindings may confirm a nonlinear progression of VF deterioration in patients with glaucoma.

Anatomic and refractional correlations in earliest glaucomatous visual field defects.

In glaucoma, initial visual field scotomas can be peripheral or central, whereas central scotomas are more severe and can disrupt daily activities. Individual anatomical features may influence the distribution of retinal nerve fibers and the starting site of visual field defects in glaucoma. In this study, we aimed to correlate myopia and hyperopia or anatomical variation of the disk-fovea angle with initial central or peripheral lesions in the visual field. This cross-sectional study included patients with primary open-angle glaucoma divided into a group of isolated central or peripheral scotomas in the visual field with MD > or equal to -6 dB, correlating with the degree of ametropia and anatomical variations, such as the disk-fovea angle. We included 52 patients with glaucoma. Of 20 myopic patients, 6 (30%) had central scotomas, and 14 (70%) had peripheral scotomas. Of 32 hyperopic patients, 12 (37.5%) had central scotomas, and 20 (63.5%) had peripheral scotomas. Regarding the disk-fovea angle, 25 eyes had the disk-fovea angle of < -7°, with 9 (36%) eyes presenting with central scotoma, and 27 eyes presented with the disk-fovea angle of > -7°, with 9 (33.3%) eyes presenting with a central scotoma. This study showed an association between ametropia and scotomas on the perimetry in patients with glaucoma. Patients had a higher incidence of peripheral scotomas, but hyperopic patients had a greater number of central scotomas than myopic patients, and myopic patients had more peripheral scotomas than hyperopic patients. The disk-fovea angle was not correlated with scotomas in initial glaucoma.

Association between the number of visual fields and the accuracy of future prediction in eyes with retinitis pigmentosa

PurposeTo evaluate the minimum number of visual fields (VFs) required to precisely predict future VFs in eyes with retinitis pigmentosa (RP).MethodsA series of 12 VFs (Humphrey Field Analyzer 10–2 test...

Can Artificial Intelligence Predict Glaucomatous Visual Field Progression? A Spatial–Ordinal Convolutional Neural Network Model

To develop an artificial neural network model incorporating both spatial and ordinal approaches to predict glaucomatous visual field (VF) progression. Cohort study. Methods From a cohort of primary open-angle glaucoma patients, 9212 eyes of 6047 patients who underwent regular reliable VF examinations for >4 years were included. We constructed all possible spatial-ordinal tensors by stacking 3 consecutive VF tests (VF-blocks) with at least 3 years of follow-up. Trend-based, event-based, and combined criteria were defined to determine the progression. VF-blocks were considered "progressed" if progression occurred within 3 years; the progression was further confirmed after 3 years. We constructed 6 convolutional neural network (NN) models and 2 linear models: regression on global indices and pointwise linear regression (PLR). We compared area under the receiver operating characteristic curve (AUROC) of each model for the prediction of glaucomatous VF progression. Among 43,260 VF-blocks, 4406 (10.2%), 4376 (10.1%), and 2394 (5.5%) VF-blocks were classified as progression-based on trend-based and event-based and combined criteria. For all 3 criteria, the progression group was significantly older and had worse initial MD and VF index (VFI) than the nonprogression group (P < .001 for all). The best-performing NN model had an AUROC of 0.864 with a sensitivity of 0.42 at a specificity of 0.95. In contrast, an AUROC of 0.611 was estimated from a sensitivity of 0.28 at a specificity of 0.84 for the PLR. The NN models incorporating spatial-ordinal characteristics demonstrated significantly better performance than the linear models in the prediction of glaucomatous VF progression.

Predicting eyes at risk for rapid glaucoma progression based on an initial visual field test using machine learning.

ObjectiveTo assess whether machine learning algorithms (MLA) can predict eyes that will undergo rapid glaucoma progression based on an initial visual field (VF) test.DesignRetrospective analysis of longitudinal data.Subjects175,786 VFs (22,925 initial VFs) from 14,217 patients who completed ≥5 reliable VFs at academic glaucoma centers were included.MethodsSummary measures and reliability metrics from the initial VF and age were used to train MLA designed to predict the likelihood of rapid progression. Additionally, the neural network model was trained with point-wise threshold data in addition to summary measures, reliability metrics and age. 80% of eyes were used for a training set and 20% were used as a test set. MLA test set performance was assessed using the area under the receiver operating curve (AUC). Performance of models trained on initial VF data alone was compared to performance of models trained on data from the first two VFs.Main outcome measuresAccuracy in predicting future rapid progression defined as MD worsening more than 1 dB/year.Results1,968 eyes (8.6%) underwent rapid progression. The support vector machine model (AUC 0.72 [95% CI 0.70–0.75]) most accurately predicted rapid progression when trained on initial VF data. Artificial neural network, random forest, logistic regression and naïve Bayes classifiers produced AUC of 0.72, 0.70, 0.69, 0.68 respectively. Models trained on data from the first two VFs performed no better than top models trained on the initial VF alone. Based on the odds ratio (OR) from logistic regression and variable importance plots from the random forest model, older age (OR: 1.41 per 10 year increment [95% CI: 1.34 to 1.08]) and higher pattern standard deviation (OR: 1.31 per 5-dB increment [95% CI: 1.18 to 1.46]) were the variables in the initial VF most strongly associated with rapid progression.ConclusionsMLA can be used to predict eyes at risk for rapid progression with modest accuracy based on an initial VF test. Incorporating additional clinical data to the current model may offer opportunities to predict patients most likely to rapidly progress with even greater accuracy.

Relationship between peripheral vasospasm and visual field progression rates in patients with normal-tension glaucoma with low-teen intraocular pressure.

PurposeTo investigate the association between peripheral vasospasm and the visual field (VF) progression rate in patients with normal-tension glaucoma (NTG) with low-teen intraocular pressure (IOP).MethodsThe finger temperature of 113 NTG patients was measured before and after exposure to ice water using a Temperature gun (cold pressor test). These patients had confirmed VF progression, despite a low-teen IOP during a follow-up period of >5 years. VF progression rates were calculated as the slope of the visual field index (VFI) and mean deviation (MD) over time. Demographic, systemic, and ocular factors and VF progression rates were compared, based on the cold pressor test results. A regression analysis was used to investigate the factors affecting VF progression rates.ResultsMean age, initial IOP, mean IOP during the follow-up period, and initial VF MD were 57.1 years, 15.8 mmHg, 12.0 mmHg, and -5.2 dB, respectively. When patients were divided into two groups (less vasospasm and more vasospasm) according to changes in temperature after exposure to ice water, the VF progression rate was significantly faster in the group with more vasospasm. In a multiple regression analysis, older age, worse initial VF MD, and greater decrease in finger temperature after ice water exposure were significantly associated with faster VF progression rates.ConclusionAn excessive drop in finger temperature after exposure to ice water was significantly associated with faster VF progression in patients with low-teen NTG. This suggests that the blood flow in the optic nerve head may also be disturbed by peripheral vasospasm, accelerating glaucomatous damage regardless of IOP.

Prognostic value of optical coherence tomography in chronic chiasmal compression

Introduction. Sellar and parasellar region lesions, such as pituitary adenoma, often lead to the compression of the optic chiasm. Consequentialy, visual field (VF) defects and loss of visual acuity are common complaints in these patients. The aim of this report is to evaluate if optical coherence tomography, measuring retinal nerve fibre layer (RNFL) and ganglion cell complex thickness (GCC), offers a reliable prediction of visual outcome in patients with chronic chiasmal compression from a pituitary macroadenoma. Case outline. We present a case of chronic chiasmal compression from a pituitary macroadenoma with an initial binocular VF defect and low values of optical coherence tomography parameters binocularly. The average value of RNFL on the right eye pre/postoperatively was 48/79 ?m, while on the left eye it was 56/63 ?m. The average value of GCC pre/postoperatively was 47/46 microns on the right and 45/46 microns on the left eye. Six weeks after surgical optochiasmal decompression, macular GCC on both eyes and RNFL on the left eye remained largely unchanged, while RNFL of the right eye exhibited increases in thickness, as the postoperative consequence of the removal of the conduction block. Neither VF nor visual acuity showed postoperative improvement. Conclusion. Irreversible damage to the GCC and RNFL by longstanding compression results in poor visual outcome after surgery. Ganglion cell layer of the macula is a more accurate and reliable indicator of postoperative visual outcome.

Optic nerve sheath decompression saves sight in severe papilloedema: results from 81 eyes in 56 patients with pseudotumor cerebri.

To report the outcome of optic nerve sheath decompression (ONSD) for papilloedema in a teaching hospital in western Turkey. The charts of 56 patients who had ONSD surgery between April 2007 and September 2019 were collated; and a total of 81 operated and 31 fellow eyes were included. Pre- and postoperative ophthalmologic examination including best-corrected visual acuity (BCVA), colour vision (CV), visual field (VF) analysis, fundoscopic examination and demographic and medical characteristics of the patients were noted and outcomes after surgery were investigated. Of all study eyes, 49 (43.7%) eyes had BCVA 0.2 or less and 62 (55.3%) eyes had mean deviation (MD) below - 20.0dB. 62 (55.3%) eyes had Frisen grade 4 or 5 papilloedema. Almost half of the eyes had severe vision loss. After ONSD, BCVA, CV and MD in both operated and fellow non-operated eyes improved significantly (p<0.001, p=0.009 and p<0.001 for operated, p<0.001, p=0.007 and p<0.001 for fellow eyes, respectively). Earlier surgery and higher cerebrospinal fluid opening pressure were related to better outcomes. None of the patients had major operative complications. Optic nerve sheath decompression can safely improve vision not only of the operated but also of the non-operated eye, even in cases with severe vision loss from severe bilateral papilloedema. Regardless of initial VA and VF, patients may benefit from ONSD; the earlier it is done the more likely the better outcome.

Guidelines on prescribing and monitoring antimalarials in rheumatic diseases: a systematic review

The purpose of this systematic review was to identify existing guidelines for antimalarial prescribing and monitoring, specifically for hydroxychloroquine, and how these guidelines compare and have evolved over time. A literature search was conducted using Embase and Medline to identify guidelines published from 1946-2018. MeSH terms were used and alternative spelling and related words were entered as keywords to broaden results. 243 results were reviewed to obtain 11 recommendations. Ophthalmology sources included the American Academy of Ophthalmology, Royal College of Ophthalmologists and Canadian editorials. The American College of Rheumatology and Canadian Rheumatology Association consensus statements summarised rheumatology recommendations. Recently, American and British guidelines changed from suggesting hydroxychloroquine doses ≤6.5 mg/kg/day to ≤5 mg/kg/day. American guidelines recommended baseline visual field (VF) testing and annual screening after five years. Visual field (VF) testing evolved from the Amsler grid to current recommendations of 10-2 automated VF and spectral-domain optical coherence tomography (SD-OCT). The 2012 Canadian recommendations suggested initial VF testing every two years, with SD-OCT after 10 years. Older British guidelines advocated for baseline and annual assessment with Amsler grids during rheumatology clinic visits. The 2018 British guidelines supported baseline and annual screening after five years with 10-2 VF, SD-OCT and fundus autofluorescence. The newest recommendations are heterogeneous suggesting lower hydroxychloroquine dosing. Retinal toxicity is irreversible and the risk increases over time. Annual screening after five years with automated VF and SD-OCT may be warranted to detect early changes and discontinue therapy if necessary.

Three-dimensional Neuroretinal Rim Thickness and Visual Fields in Glaucoma: A Broken-stick Model.

In open-angle glaucoma, when neuroretinal rim tissue measured by volumetric optical coherence tomography (OCT) scans is below a third of the normal value, visual field (VF) damage becomes detectable. To determine the amount of neuroretinal rim tissue thickness below which VF damage becomes detectable. In a retrospective cross-sectional study, 1 eye per subject (of 57 healthy and 100 open-angle glaucoma patients) at an academic institution had eye examinations, VF testing, spectral-domain OCT retinal nerve fiber layer (RNFL) thickness measurements, and optic nerve volumetric scans. Using custom algorithms, the minimum distance band (MDB) neuroretinal rim thickness was calculated from optic nerve scans. "Broken-stick" regression was performed for estimating both the MDB and RNFL thickness tipping-point thresholds, below which were associated with initial VF defects in the decibel scale. The slopes for the structure-function relationship above and below the thresholds were computed. Smoothing curves of the MDB and RNFL thickness covariates were evaluated to examine the consistency of the independently identified tipping-point pairs. Plots of VF total deviation against MDB thickness revealed plateaus of VF total deviation unrelated to MDB thickness. Below the thresholds, VF total deviation decreased with MDB thickness, with the associated slopes significantly greater than those above the thresholds (P<0.014). Below 31% of global MDB thickness, and 36.8% and 43.6% of superior and inferior MDB thickness, VF damage becomes detectable. The MDB and RNFL tipping points were in good accordance with the correlation of the MDB and RNFL thickness covariates. When neuroretinal rim tissue, characterized by MDB thickness in OCT, is below a third of the normal value, VF damage in the decibel scale becomes detectable.

Hemisphere opposite to vascular trunk deviation is earlier affected by glaucomatous damage in myopic high-tension glaucoma.

PurposeTo investigate whether the position of the central vascular trunk, as a surrogate of lamina cribrosa (LC) shift, is associated with the initial hemisphere of visual field defect in myopic high-tension glaucoma (HTG) eyes.MethodsThe deviation of the central vascular trunk was measured from the center of the Bruch’s membrane opening (BMO), which was delineated by OCT imaging. The angular deviation was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The initial hemisphere developing visual field defect was defined as three connected abnormal points (having a P value with less than 0.5% probability of being normal) appearing in only one hemisphere in pattern deviation plots. If those points were observed in both hemispheres initially, the eye was classified as bi-hemispheric visual field defect.ResultsInitially, 36 eyes (44%) had superior visual field defects, 27 (33%) inferior visual field defects, and 18 (22%) bi-hemispheric visual field defects. After a mean follow-up of 5 years, the number of bi-hemispheric visual field defects had increased to 34 (42%). A logistic regression analysis revealed that inferior deviation of vascular trunk was the only factor associated with initial inferior visual field defect (P = 0.001), while initial bi-hemispheric visual field defects were associated with worse mean deviation at initial visits (P<0.001). A conditional inference tree analysis showed that both the angular deviation (P<0.001) and initial mean deviation (P = 0.025) determined the initial hemispheres developing visual field defect.ConclusionsAlthough both hemispheres were involved as glaucoma progression, the axons on the side counter to the vascular trunk deviation were damaged earlier in HTG. This finding implies the LC shift could add additional stress to axons exposed to high intraocular pressure.

Low-carbohydrate-diet scores and the risk of primary open-angle glaucoma: data from three US cohorts.

Background/objectivesTo assess the long-term association between low-carbohydrate dietary patterns and incident primary open-angle glaucoma (POAG), and POAG subtypes defined by highest untreated intraocular pressure (IOP) and by pattern of visual field (VF) loss at diagnosis.Subjects/methodsWe followed 185,638 participants of three large US prospective cohorts biennially (1976–2016, 1986–2016 and 1991–2017). Deciles of three low-carbohydrate-diet scores were calculated to represent adherence to diets lower in carbohydrate and higher in protein and fat from any source, animal sources or plant sources. We confirmed POAG cases (n = 2112) by medical record review and used Cox proportional hazards models to estimate multivariable-adjusted relative risks (MVRRs) and 95% confidence intervals (CIs).ResultsThere was no association between the three types of low-carbohydrate-diet scores and POAG: the MVRR for POAG in the highest vs. lowest deciles was 1.13 (95% CI, 0.91–1.39; Ptrend = 0.40) for the overall score; 1.10 (95% CI, 0.89–1.35; Ptrend = 0.38) for the animal score and 0.96 (95% CI, 0.79–1.18; Ptrend = 0.88) for the vegetable score. No differential associations by IOP level was found (Pheterogeneity ≥ 0.06). However, the vegetable score showed a suggestive inverse association with early paracentral VF loss (highest vs. lowest decile MVRR = 0.78 [95% CI, 0.55–1.10]; Ptrend = 0.12) but not with peripheral VF loss only (MVRR = 1.09 [95% CI, 0.83–1.44]; Ptrend = 0.14; Pheterogeneity = 0.03).ConclusionsLow-carbohydrate diets were not associated with risk of POAG. Our data suggested that higher consumption of fat and protein from vegetable sources substituting for carbohydrates was associated with lower risk of the POAG subtype with initial paracentral VF loss.

Characterization of Central Visual Field Loss in End-stage Glaucoma by Unsupervised Artificial Intelligence

Although the central visual field (VF) in end-stage glaucoma may substantially vary among patients, structure-function studies and quality-of-life assessments are impeded by the lack of appropriate characterization of end-stage VF loss. To provide a quantitative characterization and classification of central VF loss in end-stage glaucoma. This retrospective cohort study collected data from 5 US glaucoma services from June 1, 1999, through October 1, 2014. A total of 2912 reliable 10-2 VFs of 1103 eyes from 1010 patients measured after end-stage 24-2 VFs with a mean deviation (MD) of -22 dB or less were included in the analysis. Data were analyzed from March 28, 2018, through May 23, 2019. Central VF patterns were determined by an artificial intelligence algorithm termed archetypal analysis. Longitudinal analyses were performed to investigate whether the development of central VF defect mostly affects specific vulnerability zones. Among the 1103 patients with the most recent VFs, mean (SD) age was 70.4 (14.3) years; mean (SD) 10-2 MD, -21.5 (5.6) dB. Fourteen central VF patterns were determined, including the most common temporal sparing patterns (304 [27.5%]), followed by mostly nasal loss (280 [25.4%]), hemifield loss (169 [15.3%]), central island (120 [10.9%]), total loss (91 [8.3%]), nearly intact field (56 [5.1%]), inferonasal quadrant sparing (42 [3.8%]), and nearly total loss (41 [3.7%]). Location-specific median total deviation analyses partitioned the central VF into a more vulnerable superonasal zone and a less vulnerable inferotemporal zone. At 1-year and 2-year follow-up, new defects mostly occurred in the more vulnerable zone. Initial encroachments on an intact central VF at follow-up were more likely to be from nasal loss (11 [18.4%]; P < .001). One of the nasal loss patterns had a substantial chance at 2-year follow-up (8 [11.0%]; P = .004) to shift to total loss, whereas others did not. In this study, central VF loss in end-stage glaucoma was found to exhibit characteristic patterns that might be associated with different subtypes. Initial central VF loss is likely to be nasal loss, and 1 specific type of nasal loss is likely to develop into total loss.

Long-Term Follow-up on Glaucoma Patients With Initial Single-Hemifield Defect: Progression Patterns and Associated Factors.

The purpose of this study was to investigate the clinical outcomes of primary open-angle glaucoma (POAG) with an initial single-hemifield defect on visual field (VF) testing and the related risk factors for the involvement of the opposite hemifield during follow-up. This longitudinal observational study included 108 POAG eyes of 108 patients who met the following conditions: (1) single-hemifield defect at initial VF examination; (2) follow-up >5 years. Eyes having undergone noncataract surgeries and laser treatment during the follow-up period were excluded. Patients were divided into group A (sparing of opposite hemifield) and group B (involvement of opposite hemifield) according to the patterns of VF progression. Baseline demographic and clinical characteristics were compared between the 2 groups. The Cox proportional hazards model was used to identify the risk factors for the involvement of the opposite hemifield. A total of 63 eyes (58.3%) were classified as group A and 45 (41.7%) as group B. The average follow-up period was 7.9 years. Between the 2 groups, significant differences were found in the age (55.7±10.7 vs. 61.0±10.5 y, P=0.015) and presence of optic disc vertical tilt (54.0% vs. 28.9%, P=0.034). According to the multivariate Cox proportional hazards model, older age (hazard ratio=1.704; P=0.025) and absence of optic disc vertical tilt (hazard ratio=1.430; P=0.017) were risk factors for the involvement of the opposite hemifield. In 108 POAG eyes with an initial single-hemifield defect, 41.7% showed involvement of the opposite hemifield during the average 8.0-year follow-up. Older age and absence of optic disc vertical tilt were significantly associated with a greater probability of involvement of the opposite hemifield.

Making a Correct Diagnosis of Glaucoma: Data From the EMGT.

Précis:A correct diagnosis of glaucoma established at initial visits.Purpose:It has been suggested that a diagnosis of glaucoma cannot be certain until progression has been demonstrated. Our aim was to evaluate the correctness of a glaucoma diagnosis established after 2 initial visits.Patients and Methods:Patients included in the Early Manifest Glaucoma Trial (EMGT) who had continued follow-up for at least 15 years were included in this analysis. The patients had been recruited primarily through a population screening and were diagnosed with glaucoma if the Glaucoma Hemifield Test was outside normal limits in the same sector at two consecutive visits. A Glaucoma Hemifield Test classification of borderline was also diagnostic if corresponding optic disc findings were present. At least one of the following criteria had to be fulfilled during follow-up to confirm the initial diagnosis: (1) visual field progression in at least one eye according to the EMGT criterion; (2) development of manifest glaucoma in an initially ineligible fellow eye; (3) optic disc progression in at least one eye; (4) optic disc hemorrhages in at least 1 eye.Results:Of the 255 patients included in the EMGT, 117 were followed for at least 15 years, representing 147 eyes eligible for our study. During follow-up, 134 eyes (91%) showed visual field progression, and, of the remaining 13 eyes, only 4 (3%) did not fulfill any of the criteria to confirm the diagnosis.Conclusions:A diagnosis made applying strict criteria to 2 initial visual field tests, supported by optic disc findings if visual field findings were borderline, was almost always correct.