Suspicion Of Glaucoma Research Articles

Even-number measurement bias with Goldmann applanation tonometry in patients with glaucoma and glaucoma suspects

ABSTRACT Clinical Relevance Goldmann applanation tonometry is widely used for the diagnosis and management of glaucoma and its use is considered standard of care. However, the precision of this method may be reduced by a clinician tendency to round to even numbers. Background Studies have previously demonstrated an even-number measurement bias with Goldmann applanation tonometry during examination of a general patient population. Since it has not been determined whether this bias persists among glaucoma suspects and patients with glaucoma, further investigation was conducted. Methods A retrospective analysis was conducted on a random sample from a large dataset of >69,000 patients seen during a six-year period at an urban, academic primary eye care service. Patients without suspicion of glaucoma, patients with a suspicion of glaucoma, and patients with glaucoma were selected who had Goldmann tonometry performed. Chart reviews were performed to confirm status, and even/odd-numbered Goldmann tonometry measurement frequencies were compared. Results The analysis included 961 controls, 506 glaucoma suspects, 159 ocular hypertensives not taking medication, and 314 patients taking medications who carried a diagnosis of glaucoma or ocular hypertension. Among controls the Goldmann tonometry even/odd digit proportions were 62.8%/37.2% (N = 961, p < 0.0001), and the even-number bias persisted among the other groups with specific even/odd distributions being 61.9%/38.1% (N = 506, p < 0.0001) for glaucoma suspects not taking medications, 66.0%/34.0% (N = 159, p < 0.0001) for ocular hypertensives not taking medications, and 64.3%/35.7% (N = 314, p < 0.0001) for glaucoma/ocular hypertension patients taking medications. Conclusion An even-number measurement bias with Goldmann tonometry may be prevalent even when the examiner is aware of there being greater importance for intraocular pressure measurement accuracy.

Incidence of primary open angle glaucoma in the Andhra Pradesh Eye Disease Study (APEDS).

To report 15-year incidence rate of primary open angle glaucoma (POAG) in the Andhra Pradesh Eye Disease Study (APEDS). A population-based longitudinal study was carried out at three rural study sites. Phakic participants aged ≥40 years who participated at baseline (APEDS I) and the mean 15-year follow-up visit (APEDS III) were included. A comprehensive ophthalmic examination was performed on all participants. Mean intraocular pressure (IOP) was average of IOPs of right and left eyes. The definition of glaucoma was based on the International Society of Geographical and Epidemiological Ophthalmology (ISGEO) classification. The main outcome measure was incidence of POAG during the follow-up period in participants without glaucoma or suspicion of glaucoma at baseline. Data from the available and eligible participants from the original cohort (1241/2790; 44.4%) were analysed. The mean age (standard deviation) of participants at baseline was 50.2 (8.1) years; 580 (46.7%) were men. Thirty-six participants developed POAG [bilateral in 17 (47.2%)] over 15 years. The incidence rate of POAG per 100-person years (95% confidence interval) was 2.83 (2.6, 3.08). Compared to baseline, the reduction in mean IOP [median (range) mm Hg] was -0.75 (-7.5, 9) in participants with incident POAG and -2.5 (-14.5, 14.5) in those without. The inter-visit difference in mean IOP was a significant risk factor on logistic regression analysis. We report the long-term incidence of POAG in rural India. A longitudinal change in IOP, specifically a less pronounced reduction in IOP with increasing age, was a novel risk factor.

Recovery from Upper Eyelid Sulcus Deepening Following Switch from Prostaglandin Analogues to EP2 Receptor Agonist

Purpose: To report a case of recovery from deepening of the upper eyelid sulcus after switching from prostaglandin FP receptor agonists to an EP2 receptor agonist.Case summary: A 65-year-old male patient with suspicion of glaucoma presented for detailed examinations. At the initial visit, his best-corrected visual acuity was 1.0 in both eyes, and the intraocular pressure (IOP) was 14/14 mmHg. Examination revealed no specific findings in the anterior segment, mild early cataracts bilaterally, and moderate glaucomatous changes. Therefore, bimatoprost/timolol fixed-combination eye drops were administered in both eyes. After 1 month, the IOP was 11/11 mmHg and no evidence of glaucoma progression was found. After 10 months, the IOP was 17/18 mmHg and there was deepening of the upper eyelid sulcus bilaterally. Consequently, bimatoprost/timolol fixed combination eye drops were switched to omidenepag isopropyl. Within 2 months of the switch, the deepening of the upper eyelid sulcus recovered completely and the IOP was 14/13 mmHg.Conclusions: Patients with prostaglandin-associated periorbitopathy should be switched to non-prostaglandin drugs or EP2 receptor agonists. Our patient exhibited complete recovery of the upper eyelid sulcus deepening after switching to an EP2 agonist.

Telemedicine for glaucoma: the state-of-the-art and trends of development

Glaucoma is the top leading cause of ophthalmic-related disability in almost all Russian regions. It is a chronic lifelong disease which requires regular monitoring (once a year or more often) in a medical facility. Since the population is aging, the prevalence of glaucoma is steadily increasing, which hampers access to medical care. Advances in telecommunications and diagnostic technologies have given rise to programs of TV glaucoma, which are used to pass the basic glaucoma parameters on to a specialist working remotely for interpretation. The Federal Law No 242-FZ on telemedicine came into force on January 1, 2018, but the COVID-19 pandemic sped up the development of information technologies in medicine in general and telemedicine communication in particular. The review presents the data on TV glaucoma programs which point to their effectiveness and provides practical advice. Potentially, telemedicine can facilitate access to medical care. The analysis of the economic factors shows that remote consulting is more cost-effective than traditional face-to-face examination of the patient. TV glaucoma programs often help detect glaucomatous changes in the ONH, so more patients with suspicion of glaucoma are referred for screening.. Publications focused on the experience in using active programs contribute to their further development and introduction to the public health system, which will eventually facilitate the access to quality medical care for patients with glaucoma.

Posture-related fluctuations of intraocular pressure in healthy children with suspicion of glaucoma

PurposeCurrently, there are no specific data on the circadian course of intraocular pressure (IOP) in children, especially for IOP measurements in the supine position. The study aimed to characterize the diurnal and nocturnal IOP fluctuations in supine and sitting positions in patients less than 18 years of age.MethodsSeventy-nine eyes of 79 patients under 18 years of age with suspicious optic nerve heads or ocular hypertension could be included in this study. All included patients showed an inconspicuous retinal nerve fiber layer thickness and Bruch’s membrane minimum rim width by coherence tomography. IOP measurements during the 24-h IOP profile were retrospectively evaluated. Measurements were taken at 10:00, 16:00, 20:00, and 23:00 h in the sitting position and at 6:00 h in the morning in the supine position using iCare rebound tonometry on 2 consecutive days.ResultsThirty-four of 79 children (43.0%) had peak nocturnal IOP values > 25 mmHg. The mean daily IOP was 18.8 ± 5.6 mmHg, and the mean daily fluctuation was 6.1 ± 4.0 mmHg. At 6 am, supine measurements were elevated to 25.1 ± 8.0 mmHg. Extensive fluctuations with values > 40 mmHg in the nocturnal supine measurement occurred in a relevant share of patients (n = 5).ConclusionThere appear to be relevant diurnal and nocturnal IOP fluctuations in healthy children (< 18 years). Nocturnal IOP measurements in supine patients with risk factors for glaucoma may provide important additional information to identify critical patients for further follow-up.

CLINICAL EVALUATION OF INTRAOCULAR PRESSURE MEASUREMENTS USING DIFFERENT TONOMETERS IN PATIENTS OF VARIOUS REFRACTIVE ERRORS

Background: Intraocular pressure (IOP)is an important rst indicator of probability and suspicion of Glaucoma. The virtual IOP status is grossly inuenced by multiple factors including Refractive errors, corneal biomechanics ,central corneal thickness(CCT) and Scleral rigidity. Aim: To compare relative IOP measurements and its variability in Emmetropes, myopic and hypermetropic patients using Schiotz, Goldmann Applanation(GAT)and I-Care Rebound tonometer to establish an equation between virtual and real time IOP. Materials and Methods: This observational prospective study comprised of 100 subjects above the age of 18 years inclusive37 Emmetropes , 31 Hypermetropes and remaining 32 belonged to myopia . Statistical Analysis : Descriptive statistics were performed using SPSS for Windows version 17.0 to calculate the demographic characteristics of the study cohort. The data were expressed as mean values including the standard deviation (SD) and the 95% condence interval (CI). Mean IOP measurements between Schiotz, I-Care and GAT were compared by One way ANOVA along with Individual pair wise comparison by applying Post Hoc Tukey Test for comparison of IOP measurements using a particular method of Tonometry in individuals of myopia, hypermetropia and emmetropia. Results: The highest mean value of CCT 536.667 mum was in Hypermetropes whereas the lowest CCT value of 507.031mum was in myopic eyes with statistically signicant (P&lt;0.05). The mean value for IOP in Emmetropes was16.665 mm Hg for Schiotz , 15.027 Hg for GAT and 15.081 mm Hg for I –Care .Whereas Hypermetropes revealed mean value of 15.055 mm Hg for Schiotz , 14.323 mm Hg for GAT and 14.065 mm Hg for I –Care . The mean value for IOP in Myopic eyes was 16.875 mm Hg for Schiotz , 14.375 mm Hg for GAT and 14.688 mm Hg for I –Care . Conclusion : The study had revealed higher mean value of IOP in Myopic eyes as compare to Emetropic and Hypermetropic subjects. IOP measurements by the Schiotz tonometer were signicantly higher as compare to GAT and I-Care tonometer. Whereas recordings by GAT and I Care tonometers were almost in agreement .Denitive correlation could not be established between pachymetry readings and adjusted IOP following GAT and I –Care tonometry .

Frontloading SITA-Faster Can Increase Frequency and Reliability of Visual Field Testing at Minimal Time Cost

To report the outcomes of frontloaded visual field (VF) testing (2 tests per eye on the same visit) over 2 longitudinal, consecutive visits using SITA-Faster (SFR) in terms of global indices, reliability metrics, and test duration. Prospective longitudinal study. A total of 902 eyes of 463 subjects with normal, suspect, or manifest glaucoma. Two intravisit SFR VF tests (T1 and T2) per eye at an initial (Ti) and follow-up (Tf) visit. Intra- and intervisit global indices, reliability metrics, and test durations. The mean age of the subjects was 63.6 years, and 58.3% were male. Seven hundred ninety eyes (87.4%) had a diagnosis of glaucoma or glaucoma suspicion. The mean duration between visits was 265.0 (standard deviation 98.8) days. In total, 3608 VF tests were analyzed, with the correlation of mean deviation (MD) values of the frontloaded tests at each visit high (T1/T2 MD correlation at initial visit r= 0.83, root mean squared error [RMSE]= 1.26, follow-up visit r= 0.83, RMSE= 1.25, P < 0.0001) and greater than the correlation of MD between visits (Ti1/Tf1 MD correlation r= 0.72, RMSE= 1.31). There was a significant intra-visit decrease in rates of abnormally high sensitivity in the glaucoma hemifield test (3.2% vs. 1.6%, P= 0.0023) and rates of unreliable test results (15.4% vs. 9.2%, P= 0.002) from T1 to T2 in both visits, with a corresponding significant decrease in MD (-1.28 dB vs. -1.68 dB, P < 0.0001) and VF index (P= 0.03). The mean duration of each SFR test was 132.6 (SD 27.2) seconds. Frontloading VFs using SFR produced sets of repeatable perimetric data with significant improvement of reliability indices from the first to second test. This may help increase testing frequency at minimal time cost to meet recommended guidelines and for evaluating patients prone to high variability. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Validation of 16S rRNA Gene Sequencing of the Periocular Microbiome and Lack of Alteration by Topical Eyedrops.

Genomic techniques for characterizing the ocular microbiome require further validation. We compared the microbiome of patients' eyelids through both conventional culture and 16S rRNA analysis and analyzed the impact of eyedrop use on microbiome diversity. Ninety-eight patients followed for management of glaucoma or suspicion of glaucoma had eyelid swabs performed with Isohelix MS Mini DNA Swabs (98 participants) and ESwabs (49 participants) for 16S rRNA analysis and conventional culture, respectively. The effect of preservative-containing eyedrops on the microbiomes detected using these two techniques were analyzed and compared across techniques. Forty-five of the 50 (non-unique) genera (90%) identified by conventional culture were also identified by each individual's 16S rRNA analysis within the top 14 most abundant organisms present based on operational taxonomic unit. All conventional cultures performed had at least one or more genera also identified by each participant's 16S rRNA analysis. There was no difference in the conventional culture positivity rate or proportion of participants with a particular genus present on conventional culture based on whether preservative-containing eyedrops were regularly used. Similarly, in eyes using versus not using eyedrops, no differences were observed in the proportions of participants with a particular genus present or the Shannon index as determined by 16S rRNA analysis. 16S rRNA analysis correlates well with conventional culture results for the eyelid microbiome, with results from neither technique demonstrating an association of microbiome composition and eyedrop use. The clinical relevance of the large numbers of microbes detected via 16S rRNA analysis requires further study. 16S rRNA analysis of the periocular microbiome is consistent with conventional culture and enables further study of physiologic and pathologic ocular processes possibly related to microbiome diversity.

Glaucoma Incidence and Progression in Diabetics: The Canary Islands Study Using the Laguna ONhE Application.

Background: Laguna ONhE provides a globin distribution function (GDF), in which a glaucoma discriminator based on deep learning plays an important role, and there is also an optimized globin individual pointer (GIP) for progression analysis. Methods: Signs of optic nerve glaucoma were identified in 1,124,885 fundus images from 203,115 diabetics obtained over 15 years and 117,813 control images. Results: A total of 743,696 images from 313,040 eyes of 173,661 diabetics were analysed. Some exclusions occurred due to excessive illumination, poor quality, or the absence of optic discs. Suspicion of glaucoma was reported in 6.70%, for an intended specificity of 99% (GDF < −15). More signs of glaucoma occur in diabetics as their years of disease increase, and after age 60, compared to controls. The GIP detected progression (p < 0.01) in 2.59% of cases with 4 controls and in 42.6% with 14 controls was higher in cases with lower GDF values. The GDF was corrected for the disc area and proved to be independent of it (r = 0.001925; p = 0.2814). Conclusions: The GDF index suggests a higher and increasing glaucoma probability in diabetics over time. Doubling the number of check-ups from four to eight increases the ability to detect GIP index progression by a factor of 5.

PREVALENCE OF GLAUCOMA IN NORTH COSTAL ANDHRA PRADESH

Aim: To study the prevalence of Glaucoma and its sub types in North costal Andhra Pradesh in South India. Results: Among the total number of 2,98,971 General ophthalmic OPD individuals, 4836 individuals referred to Glaucoma clinic on suspicion of glaucoma and 4320 patients are confirmed to have glaucoma after doing relevant investigations. 1884 primary open angle glaucoma (POAG), 1057 Primary Angle closure disease (PACD), 702 glaucoma suspect or at risk, 82 Juvenile Open angle glaucoma, 43 Normal Tension Glaucoma, 41 Ocular hypertension, 489 Secondary glaucoma, 22 congenital &amp; Developmental Glaucoma are identified. Conclusion: This study revealed the prevalence of various subtypes of glaucoma which varies ethnic wise. The prevalence of POAG is more (43.6%), followed by PACG (24.5%), secondary glaucoma (11.3%), Juvenile Open angle glaucoma (1.9%), Normal Tension Glaucoma (1%), ocular hypertension (0.9%), congenital glaucoma (0.5%).

Особенности назначения местной гипотензивной терапии пациентам с первичной открытоугольной глаукомой

Purpose. To evaluate the dynamics of local hypotensive therapy in patients with primary open-angle glaucoma (POAG) under dynamic observation. Material and methods. A retrospective study of the administration of local antihypertensive medications to patients who are registered and dynamically monitored by an ophthalmologist for POAG (n = 254) was conducted. Among the examined persons there were 183 men (72 %) and 71 women (28 %). The age of the patients was 76,8 ± 9,5 years. The duration of the disease from the moment of diagnosis was 9,3 ± 6,3 years, the duration of observation in the polyclinic was 3,9 ± 2,9 years. Results. To assess the dynamics of local antihypertensive therapy, a retrospective study of the administration of local antihypertensive medications to patients with primary open – angle glaucoma (POAG) (n = 254, 183 people – men (72 %) and 71 people-women (28 %)) was conducted. Age: 76.8 ± 9.5 years. Duration of the disease: 9.3 ± 6.3 years, duration of follow-up: 3.9 ± 2.9 years. Suspicion of glaucoma was determined in 6 people (2 %), POAG I st. – 118 people (46 %), POAG II st. – 43 people (17 %), POAG III st. – 70 people (28 %), POAG IV st. – 17 people (7 %). Concomitant organ pathology was detected in 250 people (99.6 %). Conclusion. The appointment of local hypotensive therapy was required by 98 % of patients with glaucoma. In the dynamic follow-up of patients with glaucoma, there was a significant decrease by 18.4 % in the proportion of people who were prescribed monotherapy, and a significant increase by 19.2 % in the proportion of people who received combination therapy. Strengthening of the instillation regime during the observation period was required in 42.3 % of cases. As a result of the treatment and follow-up, the target IOP levels were achieved in 76.6 % of cases: in 97.3 % of cases with POAG I st., in 59.3 % with POAG II st., in 55.4 % with POAG III st., and in 47.1 % with POAG IV st. Keywords: primary open-angle glaucoma, drug treatment, eye drops.

Outcomes and Revenue Generation of a Community-based Screening at a Center in the United States: The SToP Glaucoma Program.

Of 611 individuals seen at referral clinic visits following community screenings, 76% were diagnosed with ≤1 eye condition needing treatment, generating a total of $213,110 in collections for the institution over 2.5 years. The purpose of this study was to examine the outcomes and revenue generation of community-based eye screenings. Individuals aged 50 years and above screened at community sites in Baltimore, MD, with abnormal ophthalmic findings were referred for one free-of-charge definitive eye examination at the Wilmer Eye Institute. Diagnoses, treatment, and billing information were abstracted from electronic medical records of patients subsequently seen at Wilmer from January 1, 2016, to July 31, 2018. A total of 611 individuals attended 3696 encounters at Wilmer during this time period. Most patients were female (60.3%) and African American (83.7%). At the screening event, 82.9% reported difficulty seeing when not wearing corrective eyewear, although only 49.8% reported having visited an eye doctor within the last 2 years. The majority (60.2%) reported having Medicare/Medicaid coverage, and 8.1% reported being uninsured. At the definitive eye examination after the screening, 75.5% of patients were diagnosed with ≥1 eye condition, most commonly cataract (30.3%), suspicion of glaucoma (24.9%), manifest glaucoma (11.9%), diabetic retinopathy (5.4%), and ocular hypertension (2.6%). Overall, 430 (70.4%) individuals required treatment including surgery (n=106), intravitreal injections (n=14), laser procedures (n=9), and medications (n=48). A total of $213,110 was collected for visits and procedures after the initial referral visit during the study period. A large community-based vision screening program in Baltimore was able to identify ocular conditions requiring treatment in underserved older adults and connect them to eyecare. Our findings also highlight that this model simultaneously generates new revenue streams for the institution organizing the community screenings.

Incidence and risk factors for post-penetrating keratoplasty glaucoma.

Purpose:To carry out a prospective study to analyze the incidence and various preoperative, intraoperative, and postoperative risk factors for the development of PPKG.Methods:A total of 207 patients were analyzed prospectively, who were operated for penetrating keratoplasty (PK) in a tertiary eye care hospital between the time period of August 1, 2017 and February 28, 2018 and were followed up till the sixth month. Each patient was analyzed at every visit to determine the factors responsible for post-keratoplasty glaucoma.Results:Out of 207 eyes, post-PK glaucoma developed in 84 cases, which yielded an incidence of 41%. Incidence of PPKG (Post PK glaucoma) in various conditions was as follows: in repeat PK 62%, in perforated corneal ulcer 33%, in nonperforated corneal ulcer 29%, in corneal scar including adherent leukoma 37.2%, and in pseudophakic bullous keratopathy and aphakic bullous keratopathy, 14% and 80%, respectively. In age- and sex-adjusted multivariate analysis, the significant risk factors were age (P-value- 0.006), presence of PAS (P-value 0.001), and fellow eye glaucoma (P-value 0.04). Aphakia and combined surgery were not found to be significantConclusion:Our study recommends a meticulous examination of the fellow eye to assess the presence of glaucoma as it can increase the suspicion of glaucoma in the eye to be operated. The presence of PAS and age are important risk factors for developing PPKG. The risk of developing PPKG increases exponentially as the number of risk factors increases, but the presence of more than three risk factors does not add to the development of PPKG.

Comparison of the Automated Pattern-Noise (PANO) Glaucoma Test with the HFA, an FDT Stimulus, and the Fundus Area Cup-to-disk Ratio.

Aim and objectiveTo compare the results of a new automated glaucoma test—Pattern–Noise (PANO)—to the Humphrey Visual Field Analyzer-II (HFA), the fundus area cup-to-disk ratio (CDR), and a frequency doubling technology (FDT) stimulus.Materials and methodsThis was a prospective study performed in the West-Region of Cameroon. Two hundred and nineteen eyes of 122 adult patients were included with a clinical suspicion of normal-tension or primary open-angle glaucoma and no other major ocular pathology. Eyes were examined with PANO, HFA (24-2 SITA standard), and FDT-stimulus in a randomized order followed by clinical assessment of the CDR.ResultsParametric correlation of the mean contrast threshold of PANO with the mean contrast threshold of FDT-stimulus, total deviation of HFA, and area CDR was 0.94, −0.85, and 0.62, respectively (p < 0.001 for all values). Spatial distribution of sensitivity thresholds is highly correlated (p < 0.001) at all points in the visual field between PANO and HFA. With cut-off values of 3 ± 1 dB for HFA mean deviation and 4 ± 1 for PANO mean contrast threshold and after eliminating borderline cases, PANO's sensitivity was 95% and specificity 60%. The mean patient age was 45.2 ± 15.8 years. Mean thresholds of PANO and FDT-stimulus decreased with increasing age. Mean examination time was 7.1 ± 1.8 minutes for PANO, 5.9 ± 1.3 minutes for HFA, and 4.7 ± 1.3 minutes for FDT-stimulus. The mean percentage of false-positives per examination was 4.95% for PANO, 4.62% (p = 0.025) for FDT-stimulus, and 2.10% for HFA.ConclusionThe results showed that PANO was successful in suspecting the presence of glaucoma. Pattern–Noise examination led to findings that were significantly correlated to HFA, FDT stimulus, and area CDR. Some patterns of defect were also correlated. Furthermore, PANO showed a reasonable examination time and error rate.Clinical significanceAffordable and robust visual field devices are lacking in large parts of the developing world. Comparing them to established methods is a prerequisite to their clinical use.How to cite this articleHannen T, El-Khoury S, Patel R, et al. Comparison of the Automated Pattern–Noise (PANO) Glaucoma Test with the HFA, an FDT Stimulus, and the Fundus Area Cup-to-disk Ratio. J Curr Glaucoma Pract 2021;15(3):132–138.

Glaucoma suspects referred by general ophthalmologists to a tertiary center in Brazil: outcomes of the glaucoma specialist assessment.

To characterize patients with suspected glaucoma who were referred to the clinic for suspected glaucoma in a tertiary public hospital in southern Brazil and to evaluate differences in functional and structural damages between patients diagnosed with different types of glaucoma, those with normal eye examination results, and those who remained as glaucoma suspects. This is a cohort study of patients referred by general ophthalmologists to the clinic for suspected glaucoma at Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, between March 2016 and December 2018. The patients were followed up until they had undergone reliable examinations (eye examination, visual field screening, and optic coherence tomography for classification as normal and having a suspected glaucoma, glaucoma with an elevated intraocular pressure, normotensive glaucoma, or ocular hypertension. A total of 135 patients were included in this study. Of the patients, 117 subjects completed all examinations and met the inclusion criteria. Most patients were normal (36.8%), followed by those with suspected glaucoma (25.64%), normal tension glaucoma (18.8%), glaucoma with elevated intraocular pressure (12%), and ocular hypertensive (6%). The main reason for referral was increased optic nerve head cupping. The patients with normal tension glaucoma were older than the other subjects on average (p=0.03). In addition, the normal tension glaucoma group had a significantly worse baseline visual field index and mean deviation of the visual field than the normal, glaucoma suspect, and ocular hypertensive groups. The circumpapillary retinal nerve fiber layer on OCT was thinner on average in the normal tension glaucoma group than in the normal and glaucoma suspect groups (p<0.002) but did not significantly differ between the glaucoma group with elevated intraocular pressure and the other groups. Patients with normal tension glaucoma tend to be diagnosed later because of their normal intraocular pressures; thus, the optic nerve cupping must be greater to raise the suspicion of glaucoma. In this study, we found that the patients with normal tension glaucoma had worse disease at the time of diagnosis.

Patient-Reported Symptoms Demonstrating an Association with Severity of Visual Field Damage in Glaucoma

To determine which patient-reported symptoms best distinguish patients with and without glaucoma and explain the most variance in visual field (VF) damage and to compare the amount of variance that can be explained by symptoms versus retinal nerve fiber layer (RNFL) thickness. Cross-sectional study. Adults diagnosed with glaucoma or suspicion of glaucoma (controls). Worse-eye VF damage was defined on the basis of perimetric testing. Thickness of RNFL was defined by OCT imaging. Patients rated their visual symptoms on questions collated from several published questionnaires, rating the frequency and severity of 28 symptoms on a scale of 1 (never/not at all) to 4 (very often/severe). Multivariable regression models identified patient-reported symptoms that contributed the highest variance in VF damage. Patient-reported symptoms that explained the most variance in VF damage and amount of variance in VF damage explained by patient-reported symptoms and RNFL. A total of 170 patients (mean age: 64 years; 58% female; 47% employed) completed testing, including 95 glaucoma suspects and 75 glaucoma patients. In glaucoma patients, median mean deviation of VF damage in the worse eye was-19.3 and ranged from-5.3 to-34.7 decibels. Symptoms more common among glaucoma patients compared with glaucoma suspects included better vision in 1 eye, blurry vision, glare, sensitivity to light, cloudy vision, missing patches of vision, and little peripheral vision. Worse severity ratings for the symptom "little peripheral vision" explained the most variance in VF damage (43%). A multivariable model including the frequency of cloudy vision, severity of having little peripheral vision, missing patches, 1 eye having better vision, and vision worsening, plus sociodemographic features, explained 62% of the variance in VF damage. Comparatively, a multivariable model of worse-eye RNFL thickness and sociodemographic features explained 42% of the variance in VF damage, whereas a model including only sociodemographic features explained 8% of the variance in VF damage. Five patient-reported symptoms explain a significant amount of the variance in VF damage. Asking patients about their symptoms may optimize patient-physician communication and be a useful adjunct to clinical testing in some patients to estimate disease severity.

Intraocular pressure decreases in eyes with glaucoma-related diagnoses after conversion to aflibercept for treatment-resistant age-related macular degeneration.

To understand intraocular pressure (IOP) response after switching from intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) to intravitreal aflibercept (IVA) for treatment-resistant neovascular age-related macular degeneration (nAMD) in patients with and without coexisting glaucoma-related diagnoses. Retrospective, cross-sectional comparative case series of 62 eyes of 58 patients treated with intravitreal injection for nAMD from March 2010 to April 2018. Patients with glaucoma-related diagnoses, defined here as open-angle glaucoma or suspicion of open-angle glaucoma, ocular hypertension, and/or narrow-angle glaucoma, were compared to those without glaucoma. IOP data were collected at baseline, at the three visits where patients received loading doses of IVB/IVR, and at all of the visits following the switch to IVA through the end of follow-up. 19 eyes with pre-existing glaucoma-related diagnoses were compared to 43 eyes without such diagnoses. Baseline IOP was similar for glaucoma and non-glaucoma patients. The loading doses of IVB/IVR did not impact IOP; however, a small, sustained rise in IOP was noted among patients with glaucoma-related diagnoses by the final IVB/IVR injections before the switch to IVA (∆IOP 1.61 ± 0.52 mmHg, P < 0.002). After conversion to IVA, pre-injection IOP declined in eyes both with (-1.59 ± 0.54 mmHg, P < 0.001) and without (-0.99 ± 0.28 mmHg, P < 0.001) glaucoma-related diagnoses. IOP in patients with glaucoma-related diagnoses appears to be more sensitive to intravitreal injections than it is in patients without glaucoma-related diagnoses. It rises with IVB/IVR and declines after the switch to IVA. Switching patients with nAMD to IVA may present an opportunity to lower IOP in patients with glaucoma.

Comparison of diagnostic ability of standard automated perimetry, short wavelength automated perimetry, retinal nerve fiber layer thickness analysis and ganglion cell layer thickness analysis in early detection of glaucoma.

Purpose:The aim of this study was to compare the diagnostic ability of macular ganglion cell layer (GCL) analysis using spectral domain optical coherence tomography against retinal nerve fiber layer analysis (RNFL), short-wavelength automated perimetry (SWAP), and standard automated perimetry (SAP) in early detection of glaucoma.Methods:Participants fulfilling the inclusion criteria were consecutively enrolled from the glaucoma clinic of tertiary care eye hospital in Western India from November 2015 to October 2016. The subjects underwent a detailed evaluation by trained glaucoma specialists. On suspicion of glaucoma, the patients underwent SAP, SWAP, and SD-OCT for GCL and RNFL analysis.Results:There were 91 patients in total of which experts classified 54 eyes into GON and 37 eyes into nonglaucomatous group. Sensitivity of SAP (42.59%) was significantly lower (P < 0.05) than that of average GCL thickness (79.63%) and average RNFL thickness (72.22%). Specificity and positive LR of SWAP (97.3% and 19.19, respectively) and SAP (94.6% and 7.88, respectively) were greater than those of GCL (81.08% and 4.21) and RNFL (67.57% and 2.23) parameters. Negative LR of average GCL thickness (0.25) was superior to that of average RNFL thickness (0.411), SWAP (0.495), and SAP (0.607).Conclusion:Macular GCL parameters perform better than RNFL parameters in patients with early glaucomatous damage. There is superior ability of SWAP over SAP in detecting glaucomatous changes in glaucoma suspect group. GCL thickness analysis has higher sensitivity and negative likelihood ratio, whereas SWAP had higher specificity and positive likelihood ratio. Thus, combining both tests can lead to better diagnostic ability for early glaucomatous damage.

MON-LB49 Atypical Presentation for a 5.5-cm Macroprolactinoma: Unilateral Visual Loss and Only Partial Hypopituitarism; Asymptomatic Hypogonadism

Background: Macroprolactinoma is an uncommon pituitary tumor which presents mainly in males. The usual presentation is headache, bitemporal hemianopia, and signs/symptoms of hypogonadism. Ours is a case report of 5.5 –cm macroprolactinoma presented with unilateral optic nerve atrophy and asymptomatic hypogonadism. Clinical case: A 50-year-old male with past medical history of type 2 diabetes mellitus and essential hypertension presented with progressive blurred vision of the left eye for 6 months. He was able to perceive color but had difficulty reading. There was occasional headache with left periorbital pain. He was seen by an optometrist and was found to have left optic disc atrophy with suspicion of glaucoma. Subsequent visual field test showed entire left and right superior temporal loss. MRI of the pituitary showed 5.5 x 5.6 x 5.3 cm enhancing mass centered in the sellar/suprasellar region. There was significant mass effect with compression of the optic chiasm, temporal lobe and brainstem. The patient reported mood changes, normal libido, but loss of morning erection. He has family history of pituitary macroadenoma with left optic nerve compression. On physical examination, there were left visual field defect and decreased visual acuity. There were no signs of Cushing’s syndrome, hypothyroidism, acromegaly, or hypogonadism. Laboratory tests showed prolactin of >200 ng/ml and 16,610 ng/ml after dilution (male <13), total testosterone 92 ng/dl (240-950) and free testosterone 1.20 mg/dl (4.26-16.40). Surprisingly, other pituitary hormones were normal: AM cortisol 20.3 µg/dl (6-27), GH 0.24 ng/ml (0.01-0.97), IGF-1 58 ng/ml (40-259), FSH 4 IU/l (1-18), LH 3 IU/l (1.3-9.6), TSH 1.38 µIU/ml (0.34-3), and free T4 0.8 ng/dl (0.6-1.6). The patient underwent surgery with partial resection. Pathology revealed lactotroph adenoma. Postoperative prolactin level was 11,900 ng/ml. Medical treatment with cabergoline 0.25 mg twice weekly has been started. Conclusion: Even though profoundly hypogonadal by labs, the presentation for this 5.5-cm prolactinoma was acute vision loss. The highly elevated prolactin level correlates with the size of macroadenoma. The typical presentation of local mass effect is bitemporal hemianopia, but in our case the patient presented with unilateral optic nerve atrophy. Despite a 5.5-cm lesion, there is partial hypopituitarism; hypogonadism. Based on the size, one would have expected panhypopituitarism. Given a family history of macroadenoma, there might be genetic predisposition. Molecular testing is planned.

Rebound Self-tonometry Acquisition Time and Ease of Use Evaluated by Newly Trained Optometry Students and Optometrists

Peak IOP and IOP fluctuations have been implicated as risk factors for glaucoma progression. Peak 24-hour IOP can be significantly higher than in-office measurements. Icare HOME could be a useful adjunct in glaucoma management if positively appraised by individuals familiar with eye care. The purpose of this study was to measure the time needed for a nonclinical convenience sample of optometry students and optometrists to self-measure IOP using Icare HOME and to determine their perceptions of rebound self-tonometry. A total of 234 subjects were enrolled, with 226 (97%) having a complete data set. Self-measurement was performed on the study eye using Icare HOME while seated and without contact lenses. Examiners self-measured IOP while subjects observed; examiners then measured subjects' IOP. Subjects then completed self-measurement while timed. Only one attempt was allowed. Time and study eye were recorded, and subjects completed a short survey. Descriptive statistics were conducted. Mean ± standard deviation age was 34.6 ± 13.3 years (58.3% female, 52.3% contact lens wearers). Test time ranged from 3 to 366 seconds, with 38% able to self-measure in 10 seconds or less, 74% in 60 seconds or less, and 92.8% in 120 seconds or less; 5.8% were unable to self-measure IOP. There was no significant correlation between test time and age (r = -0.03, P = .67). The device was reported to be easy or very easy to use by 69.7% of subjects and comfortable or very comfortable by 90.4% of subjects. After the study, 89.1% of subjects perceived that rebound self-tonometry has a role in the management of patients with glaucoma and suspicion of glaucoma. The majority of neophyte subjects perceived self-measurement of IOP as having a role in the management of glaucoma and suspicion of glaucoma. They rated Icare HOME as comfortable and easy to use and were able to self-measure IOP on the first attempt.