Association of macular OCT and OCTA parameters with visual acuity in glaucoma

BACKGROUND/AIMS

To investigate the association of macular optical coherence tomography (OCT)/OCT angiography (OCTA) parameters with visual acuity (VA) in glaucoma.

METHODS

144 pseudophakic primary open-angle glaucoma eyes were included. Foveal (fVD), parafoveal (pf), perifoveal (perifVD) and whole-image vessel densities (wiVD) of superficial and deep layers, and their corresponding ganglion cell complex (GCC) thicknesses were obtained from OCTA 6×6 mm2 macula scans. Foveal avascular zone (FAZ) area, FAZ circumference and foveal density-300 (FD300) were measured. Correlation between OCT/OCTA parameters and Logarithm of the Minimum Angle of Resolution VA (logMAR VA) in early and moderate-advanced glaucoma was evaluated with age and Signal Strength Index-adjusted mixed models. Area under receiver operating characteristic (AUC) was used to evaluate discriminative power of OCT/OCTA for decreased VA (<20/25).

RESULTS

In early glaucoma (80 eyes), no parameter correlated with VA. In moderate-advanced glaucoma (64 eyes), greater FAZ area (β=0.228) and circumference (β=0.063) correlated with worse VA (p<0.05), but not FD300. fThinner sectoral and global GCC was associated with worse VA (β=0.002-0.003, p<0.05), except for inferior hemifield perifGCC and wiGCC. For VD, lower superior hemifield superficial perifVD and wiVD (β=0.007-0.008) and deep fVD (β=0.004) correlated with worse VA (p<0.05). OCT/OCTA parameters showed modest ability to discriminate decreased VA, with the superior hemifield performing better than the inferior hemifield. In early glaucoma, GCC and VD showed similar discrimination (AUC=0.67-0.77). In moderate-advanced glaucoma, fGCC and pfGCC yielded higher AUC (0.75-0.81) than VD (AUC=0.63-0.72).

CONCLUSIONS

Some macular OCT/OCTA parameters were associated with VA in moderate-advanced, but not early glaucoma. These structural parameters may help identify glaucoma patients with impaired vision and reduced quality of life.

TRIAL REGISTRATION NUMBER

NCT00221897.

Greater Outflow Facility Increase After Targeted Trabecular Bypass in Angiographically Determined Low-low Regions

PURPOSE

To investigate the impact of trabecular bypass surgery targeted to angiographically determined high- vs. low-aqueous humor outflow areas on outflow facility (C) and intraocular pressure (IOP).

DESIGN

Ex vivo comparative study.

SUBJECTS

Postmortem ex vivo porcine and human eyes.

METHODS

Porcine (n = 14) and human (n = 13) whole globes were acquired. In both species, anterior segments were dissected, mounted onto a perfusion chamber, and perfused using Dulbecco's phosphate buffered solution containing glucose in a constant flow paradigm to achieve a stable baseline. Fluorescein was perfused into the anterior chamber and used to identify baseline segmental high- and low-flow regions of the conventional outflow pathways. The anterior segments were divided into 2 groups, and a 5 mm needle goniotomy was performed in either a high- or low-flow area. Subsequently, C and IOP were quantitatively reassessed and compared between surgery in baseline "high-flow" and "low-flow" region eyes followed by indocyanine green angiography.

MAIN OUTCOME MEASURES

Outflow facility.

RESULTS

In all eyes, high- and low-flow segments could be identified. Performing a 5-mm goniotomy increased outflow facility to a variable extent depending on baseline flow status. In the porcine high-flow group, C increased from 0.31 ± 0.09 to 0.39 ± 0.09 μL/mmHg/min (P = 0.12). In the porcine low-flow group, C increased from 0.29 ± 0.03 to 0.56 ± 0.10 μL/mmHg/min (P < 0.001). In the human high-flow group, C increased from 0.38 ± 0.20 to 0.41 ± 0.20 μL/mmHg/min (P = 0.02). In the human low-flow group, C increased from 0.25 ± 0.11 to 0.32 ± 0.11 μL/mmHg/min (<0.001). There was statistically significant greater increase in C for eyes where surgery was targeted to baseline low-flow regions in both porcine (0.07 ± 0.09 vs. 0.27 ± 0.13, P = 0.007 μL/mmHg/min, high vs low flow) and human eyes (0.03 ± 0.03 vs. 0.07 ± 0.02, P = 0.03 μL/mmHg/min, high vs. low flow).

CONCLUSIONS

Targeting surgery to low-flow areas of the trabecular meshwork yields higher overall facility increase and IOP reduction compared to surgery in high-flow areas.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Associations of smoking and alcohol consumption with the development of open angle glaucoma: a retrospective cohort study

OBJECTIVES

To investigate the associations of alcohol consumption and smoking with the development of perimetric glaucoma in patients with suspected glaucoma.

DESIGN

A retrospective cohort study of patients suspected to have glaucoma enrolled in the Diagnostic Innovations in Glaucoma Study (DIGS) and the African Descent and Glaucoma Evaluation Study (ADAGES).

SETTING

Three tertiary glaucoma centres in the USA.

PARTICIPANTS

825 eyes of 610 patients with glaucoma suspect eyes with normal visual fields (VF) at baseline were followed over an average of 9 years from the DIGS and ADAGES studies.

OUTCOME MEASURES

Development of glaucoma was defined as occurrence of three consecutive abnormal VF tests during follow-up. Univariable and multivariable Cox regression models were used to investigate lifestyle-related factors associated with development of VF loss over time.

RESULTS

VF tests were abnormal three times in a row in 235 (28.5%) eyes. Alcohol consumption was associated with a higher risk of developing glaucoma (HR 1.57, 95% CI 1.03 to 2.38, p=0.037). In men, the risk of developing glaucoma in alcohol drinkers (HR 1.92, 95% CI 1.00 to 3.68, p=0.048) was greater than non-alcohol drinkers. In individuals of African descent, the risk of developing glaucoma in alcohol drinkers (HR 1.79, 95% CI 1.02 to 3.15, p=0.043) was greater than non-alcohol drinkers. Age was a modifier of the relationship between smoking and glaucomatous VF defects (p=0.048). The risk of developing glaucoma in smokers (HR 1.73, 95% CI 1.10 to 2.72, p=0.019) was greater than never smokers after adjustment for confounding factors in older patients (age >61 years).

CONCLUSION

Alcohol consumption was associated with an increased risk of developing glaucoma, particularly in men and individuals of African descent. The risk of developing glaucoma among smokers suspected of having glaucoma was influenced by age, with older individuals having a higher risk than younger people.

TRIAL REGISTRATION NUMBER

NCT00221897 and NCT00221923.

Impact of smoking on choroidal microvasculature dropout in glaucoma: a cross-sectional study

OBJECTIVE

To investigate the effect of smoking on choroidal microvasculature dropout (MvD) in glaucoma.

DESIGN

Cross-sectional study.

SETTING

Tertiary glaucoma centre.

PARTICIPANTS

223 eyes of 163 patients with primary open-angle glaucoma who had undergone imaging with optical coherence tomography angiography and completed a questionnaire on smoking from the Diagnostic Innovations in Glaucoma Study.

PRIMARY OUTCOME MEASURES

Linear mixed-effects models were used to determine the effect of each parameter on MvD area and angular circumference. The sensitivity analysis was performed by categorising the glaucoma severity determined by visual field mean deviation (MD).

RESULTS

MvD was found in 37 (51.4%) eyes with smoking history and in 67 (44.4%) eyes with non-smokers (p=0.389). Larger MvD area and wider angular circumference were found in smokers compared with non-smokers (p=0.068 and p=0.046, respectively). In a multivariable model, smoking intensity was significantly associated with MvD area (0.30(95% CI 0.01 to 0.60) each 0.01 mm2 per 10 pack-years; p=0.044). In eyes with moderate-severe glaucoma (MD <-6), smoking intensity was associated with larger MvD area (0.47 (95% CI 0.11 to 0.83) each 0.01 mm2 per 10 pack-years; p=0.011), whereas no significant association was found in early glaucoma (MD ≥-6) (-0.08 (95% CI -0.26 to 0.11), p=0.401).

CONCLUSIONS

Smoking intensity was associated with larger choroidal MvD area in eyes with glaucoma, especially in patients with more severe disease.

TRIAL REGISTRATION NUMBER

NCT00221897.

Adherence and Persistence to Medical Therapy in Glaucoma: An Overview

Glaucoma is a group of progressive optic neuropathies characterized by loss of retinal ganglion cells and visual field deterioration. Despite the fact that the underlying pathophysiology of glaucoma remains unknown, elevated intraocular pressure (IOP) is a well-established risk factor, and the only factor that can be modified. Robust evidence from epidemiological studies and clinical trials has clearly demonstrated the benefits of IOP control in reducing the risk of glaucoma progression. IOP-lowering therapy by the means of eye drops remains a first-line treatment option. However, like other chronic and asymptomatic conditions, many patients with glaucoma have difficulties in maintaining high rates of adherence persistence to prescribed medications. On average, patients with chronic medical conditions take 30-70% of the prescribed medication doses, and on average 50% discontinue medications in the first months of therapy. The ophthalmic literature shows similarly low rates of adherence to treatment. Indeed, poor adherence is associated with disease progression and increased complication rates, as well as healthcare costs. The present review analyzes and discusses the causes of variability of the adherence to the prescribed drugs. The education of patients about glaucoma and the potential consequences of insufficient adherence and persistence seems fundamental to maximize the probability of treatment success and therefore prevent visual disability to avoid unnecessary healthcare costs.

Effect of eyelid muscle action and rubbing on telemetrically obtained intraocular pressure in patients with glaucoma with an IOP sensor implant

BACKGROUND

Patients with glaucoma on topical glaucoma medication are often affected by dry eye symptoms and thus likely to rub or squeeze their eyelids. Here, we telemetrically measure peak intraocular pressure (IOP) during eyelid manoeuvres and eyelid rubbing.

METHODS

Eleven patients with primary open-angle glaucoma (POAG) previously implanted with a telemetric IOP sensor (Eyemate-IO) were instructed to look straight ahead for 1 min as a baseline measurement. Next, 6 repeats of blinking on instruction with 10 s intervals in between were performed. In addition, 5 repeats of eyelid closure (n=9), eyelid squeezing and eyelid rubbing (n=7) were performed with 15 s intervals in between. IOP was recorded via an external antenna placed around the study eye. Average peak IOP increases from baseline were analysed and tested against zero (no change) with one-sample t-tests.

RESULTS

For eyelid rubbing, the average peak ∆ IOP increase (mean±SEM) was 59.1±9.6 mm Hg (p<0.001) from baseline. It was 42.2±5.8 mm Hg (p<0.0001) for eyelid squeezing, 3.8±0.6 mm Hg (n=9, p<0.01) for eyelid closure and 11.6±2.4 mm Hg (p<0.001) for voluntary blinking. No IOP change except for a short irregularity in the ocular pulse was observed during involuntary blinking.

CONCLUSION

Eyelid manoeuvres in patients with POAG elicited brief increases in IOP that were particularly large with squeezing and rubbing. Further investigation of the potential implications for glaucoma progression is warranted.

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

PRCIS

An optical coherence tomography (OCT)-based multimodal deep learning (DL) 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.

BACKGROUND/AIMS

To evaluate the diagnostic accuracy of a multimodal DL classifier using wide OCT optic nerve head cube scans in eyes with and without axial high myopia.

MATERIALS AND METHODS

Three hundred seventy-one primary open angle glaucoma (POAG) eyes and 86 healthy eyes, all without axial high myopia [axial length (AL) ≤ 26 mm] and 92 POAG eyes and 44 healthy eyes, all with axial high myopia (AL > 26 mm) 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 were used to compare model accuracy.

RESULTS

Adjusted area under the receiver operating curve 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 with 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).

CONCLUSIONS

Combining OCT-based RNFL thickness maps with texture-based en face images showed a better ability to discriminate between healthy and POAG than thickness maps alone, particularly in high axial myopic eyes.

Factors associated with choroidal microvascular dropout change

BACKGROUND/AIMS

To investigate the factors associated with choroidal microvasculature drop-out (MvD) enlargement detected by optical coherence tomography angiography (OCT-A) in glaucomatous eyes.

METHODS

Ninety-one eyes of 68 primary open-angle glaucoma patients were enrolled. Only eyes with a minimum of four good quality OCT-A and OCT scans of the optic nerve head acquired at least and with a minimum of 2 years follow-up were included. Area and angular circumference of MvD were analysed on en face images. Univariable and multivariable mixed effects models were constructed to identify the factors contributing to MvD area and angular circumference change over time.

RESULTS

Peripapillary MvD was detected in 53 (58.2%) eyes at baseline and in an additional 17 (18.6%) eyes during follow-up, whereas MvD was not detected in 21 (23.0 %) eyes during the entire follow-up period. In multivariable analysis, worse baseline visual field (VF) mean deviation (MD) (ß=0.27, 95% CI 0.10 to 0.44, p=0.002), greater intraocular pressure (IOP) fluctuations (ß=0.86, 95% CI 0.24 to 1.48, p=0.007), higher peak IOP (ß=0.17, 95% CI -0.01 to 0.35, p=0.067) and greater number of IOP lowering medications (ß=1.36, 95% CI 0.67 to 2.05, p<0.001) were associated with faster MvD area enlargement. Worse baseline VF MD and greater IOP fluctuation were also associated with significantly faster MvD circumferential enlargement in multivariable models.

CONCLUSION

Greater IOP fluctuation, higher peak IOP, worse baseline VF MD and greater number of glaucoma medications were significantly associated with MvD enlargement in glaucomatous eyes. The identification of factors associated with MvD enlargement may improve our understanding of the role of choroidal vasculature in glaucoma.

Quality of life in glaucoma

BACKGROUND

An essential goal of glaucoma management is to prevent a patient's visual impairment that compromises their health-related quality of life (QOL). The disease itself, in addition to the medical or surgical treatment, can have a large impact on one's life. We aim to briefly review and evaluate aspects of QOL in glaucoma.

METHODS

The PubMed database was utilized for the literature examination of this review. Keywords that were searched included glaucoma, quality of life, vision-related QOL (VRQOL), quality of life questionnaire, and glaucoma therapy.

RESULTS

The main topics identified and analyzed during the literature review stages include factors affecting VRQOL, the assessment of VRQOL using questionnaires, QOL in early and severe glaucoma, glaucoma and activities of daily living, glaucoma treatments, and new advances in clinically assessing QOL. The study findings indicate a relationship between the deterioration of visual field and the quality of life. The investigation shows that visual loss can result in a range of daily life challenges, which include compromised mental health status and difficulties with driving, reading, and recognizing people.

CONCLUSION

Glaucoma-induced visual field loss can significantly impact different aspects of patients' life, and several methods exist for evaluating changes in quality of life. Quality of life assessments have their limitations as they are subjective. As potential future steps, we suggest exploring technological advancements such as virtual reality to improve patient care and outcomes.

Human retinal ganglion cell neurons generated by synchronous BMP inhibition and transcription factor mediated reprogramming

In optic neuropathies, including glaucoma, retinal ganglion cells (RGCs) die. Cell transplantation and endogenous regeneration offer strategies for retinal repair, however, developmental programs required for this to succeed are incompletely understood. To address this, we explored cellular reprogramming with transcription factor (TF) regulators of RGC development which were integrated into human pluripotent stem cells (PSCs) as inducible gene cassettes. When the pioneer factor NEUROG2 was combined with RGC-expressed TFs (ATOH7, ISL1, and POU4F2) some conversion was observed and when pre-patterned by BMP inhibition, RGC-like induced neurons (RGC-iNs) were generated with high efficiency in just under a week. These exhibited transcriptional profiles that were reminiscent of RGCs and exhibited electrophysiological properties, including AMPA-mediated synaptic transmission. Additionally, we demonstrated that small molecule inhibitors of DLK/LZK and GCK-IV can block neuronal death in two pharmacological axon injury models. Combining developmental patterning with RGC-specific TFs thus provided valuable insight into strategies for cell replacement and neuroprotection.

Agreement and precision of wide and cube scan measurements between swept-source and spectral-domain OCT in normal and glaucoma eyes

This study aimed to evaluate agreement of Wide scan measurements from swept-source optical coherence tomography (SS-OCT) Triton and spectral-domain OCT (SD-OCT) Maestro in normal/glaucoma eyes, and to assess the precision of measurements from Wide and Cube scans of both devices. Three Triton and three Maestro operator/device configurations were created by pairing three operators, with study eye and testing order randomized. Three scans were captured for Wide (12 mm × 9 mm), Macular Cube (7 mm × 7 mm-Triton; 6 mm × 6 mm-Maestro), and Optic Disc Cube (6 mm × 6 mm) scans for 25 normal eyes and 25 glaucoma eyes. Parameter measurements included circumpapillary retinal nerve fiber layer(cpRNFL), ganglion cell layer + inner plexiform layer (GCL+), and ganglion cell complex (GCL++). A two-way random effect analysis of variance model was used to estimate the repeatability and reproducibility; agreement was evaluated by Bland-Altman analysis and Deming regression. The precision estimates were low, indicating high precision, for all thickness measurements with the majority of the limits < 5 µm for the macula and < 10 µm for the optic disc. Precision of the Wide and Cube scans were comparable. Excellent agreement between the two devices was found for Wide scans, with the mean difference < 3 µm across all measurements (cpRNFL < 3 µm, GCL+  < 2 µm, GCL ++  < 1 µm), indicating interoperability. A single Wide scan covering the peripapillary and macular regions may be useful for glaucoma diagnosis and management.

Macula structural and vascular differences in glaucoma eyes with and without high axial myopia

AIMS

To identify clinically relevant parameters for identifying glaucoma in highly myopic eyes, an investigation was conducted of the relationship between the thickness of various retinal layers and the superficial vessel density (sVD) of the macula with axial length (AL) and visual field mean deviation (VFMD).

METHODS

270 glaucoma patients (438 eyes) participating in the Diagnostic Innovations in Glaucoma cross-sectional study representing three axial myopia groups (non-myopia: n=163 eyes; mild myopia: n=218 eyes; high myopia (AL>26 mm): n=57 eyes) who completed macular optical coherence tomography (OCT) and OCT-angiography imaging were included. Associations of AL and VFMD with the thickness of the ganglion cell inner plexiform layer (GCIPL), macular retinal nerve fibre layer (mRNFL), ganglion cell complex (GCC), macular choroidal thickness (mCT) and sVD were evaluated.

RESULTS

Thinner Global GCIPL and GCC were significantly associated with worse VFMD (R2=34.5% and R2=32.9%; respectively p<0.001), but not with AL (all p>0.1). Thicker mRNFL showed a weak association with increasing AL (R2=2.4%; p=0.005) and a positive association with VFMD (global R2=19.2%; p<0.001). Lower sVD was weakly associated with increasing AL (R2=1.8%; p=0.028) and more strongly associated with more severe glaucoma VFMD (R2=29.6%; p<0.001). Thinner mCT was associated with increasing AL (R2=15.5% p<0.001) and not associated with VFMD (p=0.194). mRNFL was thickest while mCT was thinnest in all sectors of high myopic eyes.

CONCLUSIONS

As thinner GCIPL and GCC were associated with increasing severity of glaucoma but were not significantly associated with AL, they may be useful for monitoring glaucoma in highly myopic eyes.

Optic Nerve Head Abnormalities in Nonpathologic High Myopia and the Relationship With Visual Field

PURPOSE

To describe the optic nerve head (ONH) abnormalities in nonpathologic highly myopic eyes based on swept-source optical coherence tomography (OCT) and the relationship with visual field (VF).

DESIGN

Secondary analysis from a longitudinal cohort study.

METHODS

Highly myopic patients without myopic maculopathy of category 2 or higher were enrolled. All participants underwent a swept-source OCT examination focused on ONH. We differentiated between 3 major types (optic disc morphologic abnormality, papillary/peripapillary tissue defect, and papillary/peripapillary schisis) and 12 subtypes of ONH abnormalities. The prevalence and characteristics of ONH abnormalities and the relationship with VF were analyzed.

RESULTS

A total of 857 participants (1389 eyes) were included. Among the 1389 eyes, 91.86%, 68.61%, and 34.92% of them had at least 1, 2, or 3 ONH abnormalities, respectively, which corresponded to 29.55%, 31.79%, and 35.67% of VF defects, respectively. Among the 12 subtypes of the 3 major types, peripapillary hyperreflective ovoid mass-like structure, visible retrobulbar subarachnoid space, and prelaminar schisis were the most common, respectively. Perimetric defects corresponding to OCT abnormalities were more commonly found in eyes with peripapillary retinal detachment, peripapillary retinoschisis, and peripapillary hyperreflective ovoid mass-like structure. Glaucoma-like VF defects were more common in eyes with deep optic cups (28.17%) and with optic disc pit/pit-like change (18.92%).

CONCLUSIONS

We observed and clarified the ONH structural abnormalities in eyes with nonpathologic high myopia. These descriptions may be helpful to differentiate changes in pathologic high myopia or glaucoma.

Racial, Ethnic, and Socioeconomic Disparities in Glaucoma Onset and Severity in a Diverse Nationwide Cohort in the United States

PRCIS

Racial/ethnic minorities are diagnosed with glaucoma at younger ages, and Blacks are more likely to be diagnosed with moderate-to-severe glaucoma. In addition, we highlight a gap in the use of diagnosis codes.

PURPOSE

The purpose of this study was to analyze patterns of diagnosis coding usage and validate epidemiologic patterns of glaucoma onset and severity among primary glaucoma patients within the National Institutes of Health All of Us database.

PATIENTS AND METHODS

We used International Classification of Disease diagnosis codes to build 4 cohorts of patients with mild, moderate, severe, and unspecified stage glaucoma (N=2982). Descriptive analyses were stratified by disease stage, and mean age at diagnosis was compared across racial and ethnic groups. Multivariable ordinal regression was used to examine risk factors for increasing glaucoma severity.

RESULTS

Of 2982 participants, 1714 (57%) had unspecified severity staging. Black/African Americans and other races were diagnosed with glaucoma at significantly younger ages compared with Whites (means 60 and 60 vs. 66 y; P <0.001). Hispanic/Latino participants also had an earlier mean age of diagnosis (61 vs. 65 y; P =0.001). Black/African Americans had higher odds of more severe glaucoma (odds ratio: 2.20, 95% CI, 1.62-3.30; P <0.001) than Whites when adjusting for socioeconomic characteristics.

CONCLUSIONS

Black, Hispanic/Latino, and other minority participants are diagnosed with glaucoma at younger ages, and Blacks are more likely to be diagnosed with moderate-to-severe glaucoma. These findings validate prior population-based studies. Furthermore, we observed a gap in the use of diagnosis codes, as only 43% of participants had a specified severity stage in this national cohort. This may have implications for large-scale observational research concerning glaucoma severity, as electronic health records and claims databases typically lack other measures of disease progression, such as imaging and visual field data.

Availability of Physical Activity Tracking Data from Wearable Devices for Glaucoma Patients

Physical activity has been found to potentially modulate glaucoma risk, but the evidence remains inconclusive. The increasing use of wearable physical activity trackers may provide longitudinal and granular data suitable to address this issue, but little is known regarding the characteristics and availability of these data sources. We performed a scoping review and query of data sources on the availability of wearable physical activity data for glaucoma patients. Literature databases (PubMed and MEDLINE) were reviewed with search terms consisting of those related to physical activity trackers and those related to glaucoma, and we evaluated results at the intersection of these two groups. Biomedical databases were also reviewed, for which we completed database queries. We identified eight data sources containing physical activity tracking data for glaucoma, with two being large national databases (UK BioBank and All of Us) and six from individual journal articles providing participant-level information. The number of glaucoma patients with physical activity tracking data available, types of glaucoma-related data, fitness devices utilized, and diversity of participants varied across all sources. Overall, there were limited analyses of these data, suggesting the need for additional research to further investigate how physical activity may alter glaucoma risk.

Progressive Visual Field Loss and Subsequent Quality of Life Outcomes in Glaucoma

PURPOSE

To evaluate the association between baseline severity of visual field (VF) damage and the initial rates of VF progression with quality of life (QOL) outcomes over an extended follow-up in glaucoma.

DESIGN

Retrospective cohort study.

METHODS

Both eyes of 167 glaucoma or suspected glaucoma patients were followed for 10.0±0.3 years. The National Eye Institute Visual Function Questionnaire (NEI-VFQ)-25 was performed at the end of the follow-up. Separate linear regression models included the VF parameters of the better eye, the worse eye, and the central and peripheral points of the integrated binocular VF to evaluate the association of baseline and initial rates of change of VF parameters (first half of the follow-up) with NEI-VFQ-25 Rasch-calibrated disability scores over an extended follow-up.

RESULTS

All models demonstrated association of worse baseline severity of VF damage with worse subsequent NEI-VFQ-25 scores. Faster rates of decline in VF mean deviation of the better eye and the mean sensitivity of the central and peripheral test locations of the integrated binocular VF were significantly associated with worse subsequent NEI-VFQ-25 scores. VF parameters of the better eye performed better than those of the worse eye (R2 of 0.21, and 0.15, respectively), and the VF parameters of the central test locations performed better than those of the peripheral test locations (R2 of 0.25, and 0.20, respectively).

CONCLUSIONS

Baseline severity and initial rates of change of VF damage are associated with QOL outcomes over an extended follow-up. Assessment of longitudinal VF changes, especially in better eye, provides prognostic utility to identify glaucoma patients at a higher risk for developing disease-related disability.

Temporal Optic Disc Microvasculature Dropout in Glaucoma

PURPOSE

To assess the clinical characteristics of focal temporal optic disc microvasculature dropout (MvD-D) in primary open-angle glaucoma (POAG) patients.

METHODS

One hundred and eighty-seven eyes of 187 POAG patients having MvD-D on Swept-Source optical coherence tomography angiography (SS-OCTA) were enrolled. Three groups were categorized according to the presence of temporal MvD-D within the upper and lower 45° of the fovea-Bruch's membrane (BM) opening axis: focal temporal MvD-D (Group 1, isolated focal temporal MvD-D; 44 eyes), supero/inferotemporal MvD-D (Group 2, MvD-D only in superotemporal or inferotemporal sector; 78 eyes), and diffuse temporal MvD-D (Group 3, MvD-D spanning ≥ 2 consecutive sectors, at least one of which being temporal sector; 65 eyes).

RESULTS

Group 1 had a significantly longer axial length and β-zone parapapillary atrophy without BM. There also was a larger horizontal tilt angle and ovality index than the other two groups (P < 0.001). Group 1 had a significantly thinner retinal nerve fiber layer (RNFL) in the temporal sector than did Group 2 (P < 0.001), despite similar thicknesses in all other areas (P > 0.05). Group 3 had significantly worse visual field mean deviation and thinner RNFL than the other two groups in all areas other than the nasal, temporal, and superotemporal sectors (P < 0.05).

CONCLUSIONS

Focal temporal MvD-D detected by SS-OCTA was associated with a longer axial length and related subsequent morphological changes of the optic disc and parapapillary area. This suggests that stretching of the optic disc consequent on axial elongation may lead to absence of temporal optic disc microvasculature.

Posterior scleral application of a mitomycin C-soaked sponge during trabeculectomy

AIM

To evaluate the safety and efficacy of posterior scleral application (a modified technique) of an antimetabolite mitomycin C-soaked sponge in trabeculectomy for patients with glaucoma.

METHODS

This retrospective study included 101 patients (115 eyes) with glaucoma (aged 12-83y) who underwent trabeculectomy using a modified mitomycin C-soaked sponge placement method. A piece of 3.5×10 mm2 sponge was placed vertically and posteriorly with the long side perpendicular to the limbus. The mitomycin C concentration and exposure time were 0.2-0.5 mg/mL and 1-5min, respectively. Intraocular pressure, best-corrected visual acuity, and hypotensive medications were recorded at baseline and at the final visit. Complications, interventions required, and bleb morphology were recorded postoperatively. The primary outcome was trabeculectomy safety, including complications and bleb morphology; the secondary outcome was the trabeculectomy success rate.

RESULTS

At the final follow-up [median 28mo, range 7-67mo and interquartile range (IQR) 13mo], the qualified (cumulative) success rate was 93.0% and the complete success rate was 60.0%. No bleb-related complications were observed. The mean height, extent, and vascularity grades were 0.6±0.9, 1.1±0.4, and 2.4±0.9, respectively. All Seidel tests were negative. The mean posteriority grade was 0.8±0.4.

CONCLUSION

Trabeculectomy with the long side of a mitomycin C-soaked sponge placed perpendicular to the corneal limbus is safe and effective.

Review of Visualization Approaches in Deep Learning Models of Glaucoma

Glaucoma is a major cause of irreversible blindness worldwide. As glaucoma often presents without symptoms, early detection and intervention are important in delaying progression. Deep learning (DL) has emerged as a rapidly advancing tool to help achieve these objectives. In this narrative review, data types and visualization approaches for presenting model predictions, including models based on tabular data, functional data, and/or structural data, are summarized, and the importance of data source diversity for improving the utility and generalizability of DL models is explored. Examples of innovative approaches to understanding predictions of artificial intelligence (AI) models and alignment with clinicians are provided. In addition, methods to enhance the interpretability of clinical features from tabular data used to train AI models are investigated. Examples of published DL models that include interfaces to facilitate end-user engagement and minimize cognitive and time burdens are highlighted. The stages of integrating AI models into existing clinical workflows are reviewed, and challenges are discussed. Reviewing these approaches may help inform the generation of user-friendly interfaces that are successfully integrated into clinical information systems. This review details key principles regarding visualization approaches in DL models of glaucoma. The articles reviewed here focused on usability, explainability, and promotion of clinician trust to encourage wider adoption for clinical use. These studies demonstrate important progress in addressing visualization and explainability issues required for successful real-world implementation of DL models in glaucoma.

Associations Between Thyroid Eye Disease and Glaucoma Among Those Enrolled in the National Institutes of Health All of Us Research Program

PURPOSE

To assess the association between thyroid eye disease (TED) and glaucoma.

METHODS

Patients 18 years of age and over enrolled in the NIH All of Us Research Program, a nationwide cohort, were extracted. Those with conditions relating to TED were identified and compared with 2020 US Census-matched controls without a diagnosis of TED in a 1:4 ratio. The authors used Pearson's χ 2 tests to study demographics by TED status, and logistic regression to generate odds ratios and 95% confidence intervals to evaluate the association between TED and glaucoma (any type, including glaucoma suspect), using those without TED as the reference group. Multivariable models were adjusted for age, gender, race/ethnicity, eye doctor visits, and smoking status.

RESULTS

A total of 393 cases of TED and 1,572 US Census-matched controls were identified. The median age of the cohort was 63 years (interquartile range: 48-73 years). Age, gender, and race/ethnicity varied by TED status ( p < 0.001). Overall, 114 (29.0%) of TED cases had a diagnosis of glaucoma, compared with 94 (6.0%) of non-TED controls. On bivariate logistic regression models, those diagnosed with TED were significantly more likely to be diagnosed with glaucoma compared with controls (odds ratio: 6.42; 95% confidence interval: 4.76-8.70; p < 0.001). This trend persisted on multivariable logistic regression controlling for confounding factors (odds ratio: 3.37; 95% confidence interval: 1.85-6.20 p < 0.001).

CONCLUSIONS

Individuals with TED were significantly more likely to be diagnosed with glaucoma. Clinicians caring for patients with TED should be aware of this elevated risk and arrange glaucoma evaluation, accordingly.

Associations between Socioeconomic Factors and Visit Adherence among Patients with Glaucoma in the All of Us Research Program

PURPOSE

To identify socioeconomic factors associated with visit adherence among patients with glaucoma in a nationwide cohort.

DESIGN

Cross-sectional study.

SUBJECTS

All subjects were participants in the National Institutes of Health All of Us Research Program. This study cohort consists of participants who were diagnosed with glaucoma and who answered the question on the Health Care Access and Utilization Survey regarding whether they have seen an eye care provider in the last 12 months.

METHODS

Descriptive analyses were conducted based on participant age, gender, race/ethnicity, insurance status, level of education, and income bracket. Multivariable logistic regression adjusting for these factors was used to generate odds ratios (ORs) for the association between socioeconomic factors and visit adherence.

MAIN OUTCOME MEASURE

Visit adherence, defined as reporting seeing an eye care provider in the last 12 months.

RESULTS

Among 4517 patients with glaucoma, 730 (16.3%) indicated that they had not seen or spoken to an eye doctor in the last 12 months. In multivariable models, those with some college education (OR: 1.91; 95% confidence interval [CI]: 1.19-3.04) and those with a college degree or advanced degree (OR: 2.25; 95% CI: 1.39-3.60) and those with the highest annual income of ≥ $200 000 (OR: 1.64; 95% CI: 1.10-2.45) were more likely to have seen an eye doctor in the past year compared with those in the lowest education and income categories, respectively.

CONCLUSION

Lower income and education levels were significantly associated with lower odds of seeing an eye doctor in the past year among all patients with glaucoma in All of Us. This highlights an important health disparity and may inform subsequent interventions to promote improved adherence to clinical guidelines regarding eye care for glaucoma monitoring and management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Agreement and Precision of Wide and Cube Scan Measurements between Swept-source and Spectral-domain OCT in Normal and Glaucoma Eyes

This study aimed to evaluate agreement of Wide scan measurements from swept-source optical coherence tomography(SS-OCT) Triton and spectral-domain OCT(SD-OCT) Maestro in normal/glaucoma eyes, and to assess the precision of measurements from Wide and Cube scans of both devices. Three Triton and three Maestro operator/device configurations were created by pairing three operators, with study eye and testing order randomized. Three scans were captured for Wide (12mm×9mm), Macular Cube (7mmx7mm-Triton; 6mmx6mm-Maestro), and Optic Disc Cube (6mmx6mm) scans for 25 normal eyes and 25 glaucoma eyes. Thickness of circumpapillary retinal nerve fiber layer(cpRNFL), ganglion cell layer+inner plexiform layer(GCL+), and ganglion cell complex(GCL++) was obtained from each scan. A two-way random effect analysis of variance model was used to estimate the repeatability and reproducibility; agreement was evaluated by Bland-Altman analysis and Deming regression. Precision limit estimates were low: <5µm for macular and <10µm for optic disc parameters. Precision for Wide and Cube scans of both devices were comparablein both groups. Excellent agreement between the two devices was found for Wide scans, with the mean difference<3µm across all measurements (cpRNFL<3µm, GCL+<2µm, GCL++<1µm), indicating interoperability. A single Wide scan covering the peripapillary and macular regions may be useful for glaucoma management.

Association Between Longitudinal 10-2 Central Visual Field Change and the Risk of Visual Acuity Loss in Mild-to-moderate Glaucoma

PRECIS

Faster worsening of 10-2 visual field (VF) was associated with the development of visual acuity (VA) loss in mild-to-moderate glaucoma, suggesting longitudinal 10-2 VF change is associated with the risk of VA impairment.

PURPOSE

To examine if longitudinal 10-2 central visual field (VF) change is associated with the risk of visual acuity (VA) loss in glaucoma.

METHODS

Primary open angle glaucoma and glaucoma suspect eyes with ≥ 3 years and 5 visits of 10-2 VF examinations were included. Cox proportional hazard modeling with shared frailty was used to evaluate the hazard ratio (HR) of 10-2 VF mean deviation (MD), superior hemifield mean sensitivity (hemi-MS), and inferior hemi-MS worsening rates for developing VA loss, defined as a change in logMAR VA ≥ 95% test-retest variability.

RESULTS

Among the 252 eyes (148 participants, mean follow-up=5.8 y), 30 eyes (21 participants, mean follow-up=4.9 y) developed VA loss. There was no difference in baseline VF between eyes with and without VA loss (P>0.05). Eyes with VA loss showed faster 10-2 VF MD worsening (-0.39 [95% CI:-0.60, -0.18] dB/year) and hemi-MS decrease (range:-0.42~-0.38 dB/year), as compared to no-VA loss eyes (10-2 VF MD change=-0.11 [-0.16, -0.07] dB/year; hemi-MS change: -0.12~-0.07 dB/year; P<0.05). In the multivariable model, faster 10-2 VF MD worsening (HR [95% CI]=4.05 [1.61, 10.22], per 1 dB/year faster), superior hemi-MS decrease (HR [95% CI]=7.07 [2.48, 20.14], per 1 dB/year faster), and inferior hemi-MS decrease (HR [95% CI]=8.32 [1.99, 34.91], per 1 dB/year faster) were all associated with increased risk of developing VA loss (P<0.05).

CONCLUSIONS

Faster 10-2 VF MD and hemi-field MS worsening is associated with the development of VA loss. Monitoring the longitudinal central 10-degree VF change may suggest that there is impending VA impairment in glaucoma.

Fast Progressors in Glaucoma: Prevalence Based on Global and Central Visual Field Loss

PURPOSE

To determine the prevalence of fast global and central visual field (VF) progression in individuals with glaucoma under routine care.

DESIGN

Observational study.

PARTICIPANTS

Six hundred ninety-three eyes of 461 individuals with glaucoma followed up over a median of 4.5 years.

METHODS

This study included (1) patients at a private ophthalmology clinic in Melbourne, Australia, and (2) individuals in 2 prospective longitudinal observational studies across 3 sites in the United States. All individuals had a diagnosis of glaucoma and were under routine care, and had performed 5 or more reliable 24-2 VF tests over a 1- to 5-year period. Ordinary least squares regression analyses were used to calculate the rate of global mean deviation (MD) change over time and the rate of the mean total deviation values of the 12 test locations within the central 10° region (MTD10) for each eye.

MAIN OUTCOME MEASURES

Prevalence of progression based on the rate of MD and the MTD10 change across various fixed cutoffs and cutoffs based on the estimated normal distribution (from the positive slopes).

RESULTS

Based on the MD and the MTD10, 12.5% and 11.7% of the eyes, respectively, exhibited a rate of change that was less than -1.0 dB/year (being a rate that typically is defined as "fast progression" for MD values), and 29.0% of the eyes showed a change of less than -0.5 dB/year on MTD10. Furthermore, 12.7% and 9.1% of the eyes exhibited a rate of change that exceeded the 1% cutoff of the estimated normal distribution MD and the MTD10 values, respectively.

CONCLUSIONS

This study found that approximately 1 in 8 eyes with glaucoma receiving routine care showed fast progression based on global MD values (< -1.0 dB/year) and that nearly 1 in 3 eyes showed a < -0.5 dB/year decline centrally. These findings highlight the clinical importance of assessing progressive central VF loss and reinforce the need for new therapies to prevent functional disability in a notable proportion of individuals who continue to exhibit fast progression.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Epidemiology and factors associated with cannabis use among patients with glaucoma in the All of Us Research Program

Purpose

To examine the epidemiology and factors of cannabis use among open-angle glaucoma (OAG) patients.

Methods

In this cross-sectional study, OAG participants in the All of Us database were included. Cannabis ever-users were defined based on record of cannabis use. Demographic and socioeconomic data were collected and compared between cannabis ever-users and never-users using Chi-Square tests and logistic regression. Odds ratios (OR) of potential factors associated with cannabis use were examined in univariable and multivariable models.

Results

Among 3723 OAG participants, 1436 (39%) were cannabis ever-users. The mean (SD) age of never-users and ever-users was 72.9 (10.4) and 69.2 (9.6) years, respectively (P < 0.001). Compared to never-users, Black (34%) and male (55%) participants were better represented in ever-users, while Hispanic or Latino participants (6%) were less represented (P < 0.001). Diversity was also observed in socioeconomic characteristics including marital status, housing security, and income/education levels. A higher percentage of ever-users had a degree ≥12 grades (91%), salaried employment (26%), housing insecurity (12%), and history of cigar smoking (48%), alcohol consumption (96%), and other substance use (47%) (P < 0.001). In the multivariable analysis, Black race (OR [95% CI] = 1.33 [1.06, 1.68]), higher education (OR = 1.19 [1.07, 1.32]), and history of nicotine product smoking (OR: 2.04-2.83), other substance use (OR = 8.14 [6.63, 10.04]), and alcohol consumption (OR = 6.80 [4.45, 10.79]) were significant factors associated with cannabis use. Increased age (OR = 0.96 [0.95, 0.97]), Asian race (OR = 0.18 [0.09, 0.33]), and Hispanic/Latino ethnicity (OR = 0.43 [0.27, 0.68]) were associated with decreased odds of use (P < 0.02).

Conclusions

This study elucidated the previously uncharacterized epidemiology and factors associated with cannabis use among OAG patients, which may help to identify patients requiring additional outreach on unsupervised marijuana use.

Deep Optic Nerve Head Structures Associated With Increasing Axial Length in Healthy Myopic Eyes of Moderate Axial Length

PURPOSE

To elucidate which swept-source optical coherence tomography (OCT)-derived optic nerve head (ONH) parameters are associated with longer axial length (AXL) in healthy myopic eyes.

DESIGN

Prospective cross-sectional observational study.

METHODS

Two hundred eleven healthy eyes of 140 participants (96 emmetropic-mild myopic [AXL: 22.2-24.5 mm], 83 moderately myopic [24.5-26.0 mm], and 32 highly myopic [26.0-27.4 mm] eyes) were enrolled. Bruch membrane opening (BMO), anterior scleral canal opening (ASCO) area and ovality, minimum rim width, parameters defining misalignment between the BMO and ASCO planes, OCT-defined region of perineural canal retinal epithelium atrophy and externally oblique choroidal border tissue, circumpapillary retinal nerve fiber layer thickness (cpRNFLT), circumpapillary choroidal thickness (cpChT), lamina cribrosa parameters, and peripapillary scleral (PPS) angle were calculated from BMO-centered radial scans reconstructed from 3D raster scans. Multivariate linear mixed models were used to elucidate ONH parameters that are independently associated with AXL.

RESULTS

Longer AXL was associated with a greater misalignment between ASCO and BMO planes, larger region of externally oblique choroidal border tissue, thinner cpChT, larger PPS angle, larger ASCO area, and thicker cpRNFLT (all P < .040 after Bonferroni's correction for number of included explanatory variables).

CONCLUSIONS

A greater misalignment between BMO and ASCO planes, thinner choroid, a more posteriorly bowed PPS, an enlargement of ASCO, and thicker cpRNFLT were each associated with longer AXL. An enhanced understanding of these AXL-associated configurations should provide essential information to improve our ability to detect glaucoma-induced ONH morphology in myopic eyes.

Vision-Related Quality of Life Among Healthy, Preperimetric Glaucoma, and Perimetric Glaucoma Patients

PURPOSE

To investigate the association of vision-related quality of life (VRQOL) with the central visual field and macular ganglion cell complex (GCC) thickness in healthy control participants, patients with preperimetric glaucoma, and patients with perimetric glaucoma.

DESIGN

Retrospective cross-sectional study.

METHODS

A total of 39 healthy, 34 preperimetric glaucoma, and 145 perimetric glaucoma patients completed the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ). A linear mixed-effect models was used to investigate the association between the glaucoma stage as measured by binocular 10-2 visual field mean sensitivity (VFMS) and GCC thickness with the Rasch-calibrated NEI-VFQ score.

RESULTS

A total of 436 eyes from 218 participants (mean age = 67.2 [95% CI = 65.1 to 69.2] years) were enrolled. VRQOL calculated by the NEI-VFQ Rasch-calibrated score was worst for patients with perimetric glaucoma (50.7 [95% CI = 47.2 to 54.2]), followed by patients with preperimetric glaucoma (41.2 [95% CI = 34.5 to 47.9]) and healthy controls (29.3 [95% CI = 24.0 to 34.7]. Worse VRQOL had a moderate association with a worse global binocular 10-2 VFMS (-3.4 [95% CI = -5.0 to -1.9] dB per 1 score; P < .001; adjusted R² = 0.27), but not with a thinner global GCC in the better eye (-0.1 [95% CI = -0.2 to 0.1] µm per 1 score; P =.0485; adjusted R² = 0.17).

CONCLUSIONS

These findings suggest that patients with perimetric and preperimetric glaucoma have worse VRQOL than patients with healthy eyes. As compared to macular thickness measurements, the central visual field is more strongly associated with VRQOL and may better help to identify patients in need of intervention.

Association of Rates of Ganglion Cell and Inner Plexiform Thinning With Development of Glaucoma in Eyes With Suspected Glaucoma

Importance

In eyes with suspected glaucoma, it is clinically relevant to find diagnostic tests for the risk of development of perimetric glaucoma.

Objective

To investigate the association between rates of ganglion cell/inner plexiform layer (GCIPL) and circumpapillary retinal nerve fiber layer (cpRNFL) thinning and the development of perimetric glaucoma in eyes with suspected glaucoma.

Design, Setting, and Participants

This observational cohort study used data collected in December 2021 from a tertiary center study and a multicenter study. Participants with suspected glaucoma were followed up for 3.1 years. The study was designed in December 2021 and finalized in August 2022.

Exposures

Development of perimetric glaucoma was defined as having 3 consecutive results showing abnormal visual fields. Using linear mixed-effect models, rates of GCIPL were compared between eyes with suspected glaucoma that did and did not develop perimetric glaucoma. A joint longitudinal multivariable survival model was used to investigate the performance of rates of GCIPL and cpRNFL thinning in predicting the risk of developing perimetric glaucoma.

Main Outcomes and Measures

Rates of GCIPL thinning and hazard ratio (HR) of developing perimetric glaucoma.

Results

Among a total of 462 participants, the mean (SD) age was 63.3 (11.1) years, and 275 patients (60%) were female. Of 658 eyes, 153 eyes (23%) developed perimetric glaucoma. The mean rates of GCIPL thinning were faster in eyes that developed perimetric glaucoma (-1.28 vs -0.66 μm/y for minimum GCIPL thinning; difference, -0.62; 95% CI, -1.07 to -0.16; P = .02). Based on the joint longitudinal survival model, every 1-μm/y faster rate of minimum GCIPL and rate of global cpRNFL thinning were associated with a 2.4 and 1.9 higher risk of developing perimetric glaucoma, respectively (HR, 2.4; 95% CI, 1.8 to 3.2, and HR, 1.99; 95% CI, 1.76 to 2.22, respectively; P < .001). Among the predictive factors, African American race (HR, 1.56; 95% CI, 1.05 to 2.34; P = .02), male sex (HR, 1.47; 95% CI, 1.02 to 2.15; P = .03), 1-dB higher baseline visual field pattern standard deviation (HR, 1.73; 95% CI, 1.56 to 1.91; P < .001), and 1-mm Hg higher mean intraocular pressure during follow-up (HR, 1.11; 95% CI, 1.05 to 1.17; P < .001) were associated with higher risk of developing perimetric glaucoma.

Conclusions and Relevance

This study found that faster rates of GCIPL and cpRNFL thinning were associated with higher risks of developing perimetric glaucoma. Rates of cpRNFL thinning and specifically GCIPL thinning may be useful measures for monitoring eyes with suspected glaucoma.

Safety and performance of a suprachoroidal sensor for telemetric measurement of intraocular pressure in the EYEMATE-SC trial

AIM

To investigate the safety and performance of a telemetric suprachoroidal intraocular pressure (IOP) sensor (EYEMATE-SC) and the accuracy of its IOP measurements in open angle glaucoma (OAG) patients undergoing simultaneous non-penetrating glaucoma surgery (NPGS).

METHODS

Prospective, multicentre, open-label, single-arm, interventional clinical trial. Twenty-four eyes of 24 patients with OAG regularly scheduled for NPGS (canaloplasty or deep sclerectomy) were simultaneously implanted with an EYEMATE-SC sensor. Six-month follow-up on the sensor's safety and performance as well as on the level of agreement between the EYEMATE-SC measurements and IOP measurements with Goldmann applanation tonometry (GAT).

RESULTS

The eyes underwent canaloplasty (n=15) or deep sclerectomy (n=9) and achieved successful implantation of the sensor. No device migration, dislocation or serious device-related complications occurred. A total of 367 comparisons were included in the IOP agreement analysis. The overall mean difference between GAT and EYEMATE-SC measurements was 1.31 mm Hg (lower limit of agreement (LoA) 7.55 mm Hg; upper LoA -4.92 mm Hg). The maximum difference of 2.5 mm Hg ±3.96 (LoA 0.30-2.29) was reached on day 10 and continuously improved to an agreement of -0.15 mm Hg ±2.28 (LoA -1.24 to 0.89) after 6 months. Accordingly, the percentage of eyes within an IOP difference of ±5 mm Hg improved from 78% (day 3) to 100% (6 months).

CONCLUSIONS

After 6 months, the EYEMATE-SC sensor was safe and well tolerated, and allowed continual IOP monitoring.

TRIAL REGISTRATION NUMBER

NCT03756662.

Outcomes of Partial vs Complete Goniotomy With or Without Phacoemulsification For Primary Open-angle Glaucoma: A Multi-Center Study

PRECIS

120° goniotomy with or without phacoemulsification was sufficient to lower the intraocular pressure and reduce hyphema for primary open-angle glaucoma.

PURPOSE

To compare the surgical outcomes and safety profiles of 120° and 360° goniotomy (GT) with or without phacoemulsification cataract extraction and intraocular lens implantation (PEI) for primary open-angle glaucoma (POAG).

MATERIALS AND METHODS

This multicenter retrospective study consisted of 139 eyes and were divided into four groups: (1) 120° GT, (2) 360° GT, (3) PEI+120° GT, and (4) PEI+360° GT. Intraocular pressure (IOP), number of topical hypotensive medications, and complications were recorded and evaluated at baseline and at the final visit. The complete and qualified success rate and their potential associated factors were also investigated. The effectiveness and safety profile of the surgery were compared between different subgroups.

RESULTS

After a mean follow-up of 8.6 months, the IOP reduction was 13.2±8.3 (38.8±28.8%), 12.4±8.3 (41.6±18.2%), 12.8±9.9 (39.4±34.5%), and 13.8±7.2 (46.0±17.1%) mmHg in 120°, 360°, PEI+120°, and PEI+360° GT, respectively. No significant difference was found in IOP, decline of IOP from baseline, topical hypotensive medication, and complete or qualified success between either standalone 120° vs 360° GT, or PEI+120° vs PEI+360° GT (all Ps>0.05). The PEI+120° group had a lower final IOP than the 120° GT group (P=0.0002) whereas there was no difference between PEI+360°GT and 360° GT group (P=0.893). Both 360° GT and PEI+360° groups had a significantly higher incidence of hyphema than the 120° GT and PEI+120° GT groups (all Ps<0.0001).

CONCLUSIONS

Goniotomy of 120 or 360 degrees lowered IOP equally with or without cataract surgery, and hyphema was most commonly noted following complete goniotomy. Partial goniotomy alone or in combination with cataract surgery was an effective and safe approach to manage patients with open angle glaucoma.

Usability and Clinician Acceptance of a Deep Learning-Based Clinical Decision Support Tool for Predicting Glaucomatous Visual Field Progression

PRCIS

We updated a clinical decision support tool integrating predicted visual field (VF) metrics from an artificial intelligence model and assessed clinician perceptions of the predicted VF metric in this usability study.

PURPOSE

To evaluate clinician perceptions of a prototyped clinical decision support (CDS) tool that integrates visual field (VF) metric predictions from artificial intelligence (AI) models.

METHODS

Ten ophthalmologists and optometrists from the University of California San Diego participated in 6 cases from 6 patients, consisting of 11 eyes, uploaded to a CDS tool ("GLANCE", designed to help clinicians "at a glance"). For each case, clinicians answered questions about management recommendations and attitudes towards GLANCE, particularly regarding the utility and trustworthiness of the AI-predicted VF metrics and willingness to decrease VF testing frequency.

MAIN OUTCOMES AND MEASURES

Mean counts of management recommendations and mean Likert scale scores were calculated to assess overall management trends and attitudes towards the CDS tool for each case. In addition, system usability scale scores were calculated.

RESULTS

The mean Likert scores for trust in and utility of the predicted VF metric and clinician willingness to decrease VF testing frequency were 3.27, 3.42, and 2.64, respectively (1=strongly disagree, 5=strongly agree). When stratified by glaucoma severity, all mean Likert scores decreased as severity increased. The system usability scale score across all responders was 66.1±16.0 (43rd percentile).

CONCLUSIONS

A CDS tool can be designed to present AI model outputs in a useful, trustworthy manner that clinicians are generally willing to integrate into their clinical decision-making. Future work is needed to understand how to best develop explainable and trustworthy CDS tools integrating AI before clinical deployment.

Differences in Outflow Facility Between Angiographically Identified High- Versus Low-Flow Regions of the Conventional Outflow Pathways in Porcine Eyes

Purpose

To investigate differences in outflow facility between angiographically determined high- and low-flow segments of the conventional outflow pathway in porcine eyes.

Methods

Porcine anterior segments (n = 14) were mounted in a perfusion chamber and perfused using Dulbecco's phosphate buffered solution with glucose. Fluorescein angiography was performed to determine high- and low-flow regions of the conventional outflow pathways. The trabecular meshwork (TM) was occluded using cyanoacrylate glue, except for residual 5-mm TM areas that were either high or low flow at baseline, designating these eyes as "residual high-flow" or "residual low-flow" eyes. Subsequently, outflow was quantitatively reassessed and compared between residual high-flow and residual low-flow eyes followed by indocyanine green angiography.

Results

Fluorescein aqueous angiography demonstrated high-flow and low-flow regions. Baseline outflow facilities were 0.320 ± 0.08 and 0.328 ± 0.10 µL/min/mmHg (P = 0.676) in residual high-flow and residual low-flow eyes before TM occlusion, respectively. After partial trabecular meshwork occlusion, outflow facility decreased to 0.209 ± 0.07 µL/min/mmHg (-32.66% ± 19.53%) and 0.114 ± 0.08 µL/min/mmHg (-66.57% ± 23.08%) in residual high- and low-flow eyes (P = 0.035), respectively. There was a significant difference in the resulting IOP increase (P = 0.034).

Conclusions

Angiographically determined high- and low-flow regions in the conventional outflow pathways differ in their segmental outflow facility; thus, there is an uneven distribution of local outflow facility across different parts of the TM.

Direct Costs of Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation (The Assists Trial)

PRCIS

The cost of cyclophotocoagulation is less than the cost of a second glaucoma drainage device.

PURPOSE

To compare the total direct costs of implantation of a second glaucoma drainage device (SGDD) with transscleral cyclophotocoagulation (CPC) for patients with inadequately controlled intraocular pressure (IOP) reduction, despite the presence of a preexisting glaucoma drainage device in the ASSISTS clinical trial.

METHODS

We compared the total direct cost per patient, including the initial study procedure, medications, additional procedures, and clinic visits during the study period. The relative costs for each procedure during the 90-day global period and the entire study period were compared. The cost of the procedure, including facility fees and anesthesia costs, were determined using the 2021 Medicare fee schedule. Average wholesale prices for self-administered medications were obtained from AmerisourceBergen.com. The Wilcoxon rank sum test was used to compare costs between procedures.

RESULTS

Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). One CPC eye was lost to follow-up after initial treatment and was excluded. The mean (±SD, median) duration of follow-up was 17.1 (±12.8, 11.7) months and 20.3 (±11.4, 15.1) months for SGDD and CPC, respectively ( P =0.42, 2 sample t test). The mean total direct costs (±SD, median) per patient during the study period were $8790 (±$3421, $6805 for the SGDD group) and $4090 (±$1424, $3566) for the CPC group ( P <0.001). Similarly, the global period cost was higher in the SGDD group than in the CPC group [$6173 (±$830, $5861) vs. $2569 (±$652, $2628); P <0.001]. The monthly cost after the 90-day global period was $215 (±$314, $100) for SGDD and $103 (±$74, $86) for CPC ( P =0.31). The cost of IOP-lowering medications was not significantly different between groups during the global period ( P =0.19) or after the global period ( P =0.23).

CONCLUSION

The total direct cost in the SGDD group was more than double that in the CPC group, driven largely by the cost of the study procedure. The costs of IOP-lowering medications were not significantly different between groups. When considering treatment options for patients with a failed primary GDD, clinicians should be aware of differences in costs between these treatment strategies.

Effect of Corneal Hysteresis on the Rates of Microvasculature Loss in Glaucoma

PURPOSE

To investigate the association between corneal hysteresis (CH) and rates of optic nerve head whole image capillary density (wiCD) loss over time in open-angle glaucoma (OAG).

DESIGN

Observational cohort.

PARTICIPANTS

One hundred seventy-four eyes (122 OAG and 52 glaucoma suspect eyes) from 112 patients over more than 2 years and 4 visits or more.

METHODS

Baseline CH measurements were acquired with the Ocular Response Analyzer. Linear mixed-effect models were designed to investigate the effect of CH, average intraocular pressure (IOP) during follow-up, and baseline visual field (VF) mean deviation (MD) on the rates of wiCD loss and circumpapillary retinal nerve fiber layer (cpRNFL) thinning over time, while adjusting for confounders. Interaction between CH or baseline MD and average IOP during follow-up were included in final models to evaluate the effect of baseline MD or average IOP during follow-up on structural changes for different values of CH.

MAIN OUTCOME MEASURE

Effect of CH, IOP, and baseline MD on the rates of wiCD loss and cpRNFL thinning over time.

RESULTS

The average follow-up time was 3.9 years. In the multivariable model, non-Black race, higher average IOP during follow-up, lower baseline CH, lower baseline VF MD, and higher numbers of IOP-lowering medications were associated with faster rates of wiCD loss over time. For CH values 6 mmHg and 12 mmHg, every 1-mmHg increase in average IOP during follow-up was associated with 0.23% per year faster and 0.07% per year slower rates of wiCD loss over time, respectively. While every 1-mmHg decrease in CH was associated with 1.89% per year faster rate of wiCD loss for MD of -12 dB, it was associated with 0.81% per year faster rate of wiCD loss for MD of -3 dB.

CONCLUSION

Lower CH values were significantly associated with faster rates of wiCD loss over time. In eyes with lower CH, both higher average IOP during follow-up and more severe glaucoma damage at baseline were associated with faster rates of wiCD loss and cpRNFL thinning. These results support CH as a useful parameter for risk assessment of glaucoma progression.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

A Deep Learning Approach to Improve Retinal Structural Predictions and Aid Glaucoma Neuroprotective Clinical Trial Design

PURPOSE

To investigate the efficacy of a deep learning regression method to predict macula ganglion cell-inner plexiform layer (GCIPL) and optic nerve head (ONH) retinal nerve fiber layer (RNFL) thickness for use in glaucoma neuroprotection clinical trials.

DESIGN

Cross-sectional study.

PARTICIPANTS

Glaucoma patients with good quality macula and ONH scans enrolled in 2 longitudinal studies, the African Descent and Glaucoma Evaluation Study and the Diagnostic Innovations in Glaucoma Study.

METHODS

Spectralis macula posterior pole scans and ONH circle scans on 3327 pairs of GCIPL/RNFL scans from 1096 eyes (550 patients) were included. Participants were randomly distributed into a training and validation dataset (90%) and a test dataset (10%) by participant. Networks had access to GCIPL and RNFL data from one hemiretina of the probe eye and all data of the fellow eye. The models were then trained to predict the GCIPL or RNFL thickness of the remaining probe eye hemiretina.

MAIN OUTCOME MEASURES

Mean absolute error (MAE) and squared Pearson correlation coefficient (r²) were used to evaluate model performance.

RESULTS

The deep learning model was able to predict superior and inferior GCIPL thicknesses with a global r² value of 0.90 and 0.86, r² of mean of 0.90 and 0.86, and mean MAE of 3.72 μm and 4.2 μm, respectively. For superior and inferior RNFL thickness predictions, model performance was slightly lower, with a global r² of 0.75 and 0.84, r² of mean of 0.81 and 0.82, and MAE of 9.31 μm and 8.57 μm, respectively. There was only a modest decrease in model performance when predicting GCIPL and RNFL in more severe disease. Using individualized hemiretinal predictions to account for variability across patients, we estimate that a clinical trial can detect a difference equivalent to a 25% treatment effect over 24 months with an 11-fold reduction in the number of patients compared to a conventional trial.

CONCLUSIONS

Our deep learning models were able to accurately estimate both macula GCIPL and ONH RNFL hemiretinal thickness. Using an internal control based on these model predictions may help reduce clinical trial sample size requirements and facilitate investigation of new glaucoma neuroprotection therapies.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Mental health and social support among glaucoma patients enrolled in the NIH All of Us COVID-19 Participant Experience (COPE) survey

BACKGROUND

The COVID-19 pandemic created many challenges for our society. In this study, we explore how measures of mental health, coping strategies, and social support during the pandemic varied by glaucoma status.

METHODS

A cohort of patients aged 40 and over enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, who answered the COVID-19 Participant Experience (COPE) survey was obtained. We analyzed several measures of mental health, coping strategies, and social support used during the early stages of the COVID-19 pandemic. Surveys were recurring and answered from May 2020 to February 2021. Demographics and the most recently answered survey responses were obtained and stratified by glaucoma status. Pearson's Chi-squared tests and multivariable logistic regressions adjusting for age, gender, race, ethnicity, and income were used to generate p-values, odds ratios (ORs) and 95% confidence intervals (CIs) between outcome measures and glaucoma status.

RESULTS

Of 42,484 patients who responded to All of Us COPE survey items, 2912 (6.9%) had a diagnosis of glaucoma. On Pearson's Chi-squared tests glaucoma patients were less likely to report drinking alcohol (P = 0.003), eating more food than usual (P = 0.004), and using marijuana (P = 0.006) to cope with social distancing than those without a diagnosis of glaucoma. Further, glaucoma patients had lower rates of probable mild, moderate, or severe depression as calculated by Patient Health Questionnaire-9 (PHQ-9) scores (P < 0.001) and had lower rates of reporting some or a lot of stress from social distancing (P < 0.001). However, glaucoma patients were less likely to report having someone to help prepare meals (P = 0.005) or help with daily chores (P = 0.003) if they became sick with COVID-19. In multivariable logistic regression analyses adjusting for confounding factors, no differences were found for measures of mental health or social support.

CONCLUSIONS

Glaucoma patients did not fare worse on many measures of mental health and coping strategies during the early stages of the COVID-19 pandemic compared those without glaucoma. However, a substantial proportion of glaucoma patients still endorsed stress, social isolation, and probable depression, representing challenges for disease management.

Combining Optical Coherence Tomography and Optical Coherence Tomography Angiography Longitudinal Data for the Detection of Visual Field Progression in Glaucoma

PURPOSE

To use longitudinal optical coherence tomography (OCT) and OCT angiography (OCTA) data to detect glaucomatous visual field (VF) progression with a supervised machine learning approach.

DESIGN

Prospective cohort study.

METHODS

One hundred ten eyes of patients with suspected glaucoma (33.6%) and patients with glaucoma (66.4%) with a minimum of 5 24-2 VF tests and 3 optic nerve head and macula images over an average follow-up duration of 4.1 years were included. VF progression was defined using a composite measure including either a "likely progression event" on Guided Progression Analysis, a statistically significant negative slope of VF mean deviation or VF index, or a positive pointwise linear regression event. Feature-based gradient boosting classifiers were developed using different subsets of baseline and longitudinal OCT and OCTA summary parameters. The area under the receiver operating characteristic curve (AUROC) was used to compare the classification performance of different models.

RESULTS

VF progression was detected in 28 eyes (25.5%). The model with combined baseline and longitudinal OCT and OCTA parameters at the global and hemifield levels had the best classification accuracy to detect VF progression (AUROC = 0.89). Models including combined OCT and OCTA parameters had higher classification accuracy compared with those with individual subsets of OCT or OCTA features alone. Including hemifield measurements significantly improved the models' classification accuracy compared with using global measurements alone. Including longitudinal rates of change of OCT and OCTA parameters (AUROCs = 0.80-0.89) considerably increased the classification accuracy of the models with baseline measurements alone (AUROCs = 0.60-0.63).

CONCLUSIONS

Longitudinal OCTA measurements complement OCT-derived structural metrics for the evaluation of functional VF loss in patients with glaucoma.

Deep Learning Estimation of 10-2 Visual Field Map Based on Circumpapillary Retinal Nerve Fiber Layer Thickness Measurements

PURPOSE

To estimate central 10-degree visual field (VF) map from spectral-domain optical coherence tomography (SD-OCT) retinal nerve fiber layer thickness (RNFL) measurements in glaucoma with artificial intelligence.

DESIGN

Artificial intelligence (convolutional neural networks) study.

METHODS

This study included 5352 SD-OCT scans and 10-2 VF pairs from 1365 eyes of 724 healthy patients, patients with suspected glaucoma, and patients with glaucoma. Convolutional neural networks (CNNs) were developed to estimate the 68 individual sensitivity thresholds of 10-2 VF map using all-sectors (CNN_A) and temporal-sectors (CNN_T) RNFL thickness information of the SD-OCT circle scan (768 thickness points). 10-2 indices including pointwise total deviation (TD) values, mean deviation (MD), and pattern standard deviation (PSD) were generated using the CNN-estimated sensitivity thresholds at individual test locations. Linear regression (LR) models with the same input were used for comparison.

RESULTS

The CNN_A model achieved an average pointwise mean absolute error of 4.04 dB (95% confidence interval [CI] 3.76-4.35) and correlation coefficient (r) of 0.59 (95% CI 0.52-0.64) over 10-2 map and the mean absolute error and r of 2.88 dB (95% CI 2.63-3.15) and 0.74 (95% CI 0.67-0.80) for MD, and 2.31 dB (95% CI 2.03-2.61) and 0.59 (95% CI 0.51-0.65) for PSD estimations, respectively, significantly outperforming the LR_A model.

CONCLUSIONS

The proposed CNN_A model improved the estimation of 10-2 VF map based on circumpapillary SD-OCT RNFL thickness measurements. These artificial intelligence methods using SD-OCT structural data show promise to individualize the frequency of central VF assessment in patients with glaucoma and would enable the reallocation of resources from patients at lowest risk to those at highest risk of central VF damage.

Central macular OCTA parameters in glaucoma

BACKGROUND/AIMS

To investigate the relationship between the foveal avascular zone (FAZ) parameters assessed by optical coherence tomography angiography (OCTA) and central visual field parameters in glaucoma and healthy subjects.

METHODS

One hundred and eighty-eight subjects (248 eyes), including 24 healthy (38 eyes), 37 glaucoma suspect (42 eyes, and 127 primary open angle glaucoma (POAG) patients (168 eyes), underwent imaging using OCTA and standard automated perimetry using the 24-2 and 10-2 Swedish Interactive Thresholding Algorithm. OCTA-based and OCT-based FAZ parameters (superficial FAZ area, FAZ circumference), foveal vessel density (FD300) and foveal thickness were measured. The correlation between FAZ parameters and visual field parameters was assessed using linear mixed model.

RESULTS

Axial length adjusted-FAZ area was not different among the three groups (mean (95% CI)): in healthy 0.31 (0.27 to 0.36) mm², glaucoma suspect 0.29 (0.26 to 0.31) mm² and POAG eyes 0.28 (0.27 to 0.30) mm² (p=0.578). FD300 was lower in glaucoma suspect 49.1% (47.9% to 50.4%) and POAG eyes 48.7% (48.1% to 49.4%) than healthy eyes 50.5% (49.3% to 51.7%) though the difference was not statistically significant (p=0.071). Lower FD300 was associated with worse 24-2 and 10-2 visual field mean deviation and foveal threshold in multivariable linear mixed models (all p<0.05). In addition, a smaller FAZ area was associated with lower intraocular pressure (IOP) (p=0.026).

CONCLUSIONS

The FD300, but not the FAZ area was correlated with 10° central visual field mean deviation and foveal threshold in healthy, glaucoma suspect and POAG eyes. In contrast, a smaller FAZ area was associated with lower IOP.

Bimatoprost Implant Biodegradation in the Phase 3, Randomized, 20-Month ARTEMIS Studies

Purpose: To evaluate the time course of biodegradation of an intracameral, biodegradable, sustained-release bimatoprost implant that lowers intraocular pressure without the need for daily eye drops. Methods: In 2 identically designed, randomized, phase 3 clinical trials, adults with open-angle glaucoma or ocular hypertension and open iridocorneal angles inferiorly in the study eye were administered 10- or 15-μg bimatoprost implant (day 1 and weeks 16 and 32) or twice-daily topical timolol 0.5%. Implants were assessed on gonioscopy throughout the studies. Investigators reported whether implants were visible, estimated the size of visible implants relative to their initial size at implantation, and reported the implant location. Data for 10-μg implant placed on day 1 were pooled from both studies for analysis. Results: A total of 372 patients received the 10-μg bimatoprost implant. The degree of implant biodegradation at each follow-up time point was variable among patients. The implant frequently swelled during the initial phase of biodegradation from 6 to 28 weeks. Accelerated biodegradation occurred between 31 and 52 weeks, resulting in 82% of implants absent or ≤25% of initial size by 52 weeks. By month 20, 95% of implants had biodegraded to absent or ≤25% of initial size. The implant was predominantly located inferiorly in the iridocorneal angle. Conclusions: Bimatoprost implant biodegradation in phase 3 studies showed some degree of variability among patients. Clinically significant implant biodegradation was observed in the majority of patients by 12 months. Clinical studies are in progress to further understand implant biodegradation and the ideal timing for implant re-administration. ClinicalTrials.gov NCT02247804; ClinicalTrials.gov NCT02250651.

Review of glaucoma medication adherence monitoring in the digital health era

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA in the Human Eye

PURPOSE

To determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in postmortem ocular specimens of patients with severe COVID-19 disease.

PATIENTS AND METHODS

Postmortem conjunctival (28 samples), aqueous humor (30 samples) and vitreous humor (30 samples) specimens were obtained bilaterally from the eyes of 15 deceased COVID-19 patients within one hour of death. The presence of viral RNA was evaluated in samples using Real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Positive RT-PCR SARS-COV-2 results were found in one conjunctival and 2 vitreous humor samples. All aqueous humor samples tested negative for the presence of SARS-COV-2 RNA. Of note, three positive samples were obtained from three different patients. The overall prevalence of positive RT-PCR ocular samples was 3.4% among all samples and 20% at the patient level.

CONCLUSION

SARS-CoV-2 RNA is detectable in postmortem conjunctival and vitreous humor samples of patients with severe COVID-19.

Effect of Testing Frequency on the Time to Detect Glaucoma Progression With Optical Coherence Tomography (OCT) and OCT Angiography

PURPOSE

To determine how the frequency of testing affects the time required to detect statistically significant glaucoma progression for circumpapillary retinal nerve fiber layer (cpRNFL) with optical coherence tomography (OCT) and circumpapillary capillary density (cpCD) with OCT angiography (OCTA).

DESIGN

Retrospective, observational cohort study.

METHODS

In this longitudinal study, 156 eyes of 98 patients with glaucoma followed up over an average of 3.5 years were enrolled. Participants with 4 or more OCT and OCTA tests were included to measure the longitudinal rates of cpRNFL thickness and cpCD change over time using linear regression. Estimates of variability were then used to re-create real-world cpRNFL and cpCD data by computer simulation to evaluate the time required to detect progression for various loss rates and different testing frequencies.

RESULTS

The time required to detect a statistically significant negative cpRNFL and cpCD slope decreased as the testing frequency increased, albeit not proportionally. cpCD detected progression slightly earlier than cpRNFL. Eighty percent of eyes with a cpCD loss of -1%/y were detected after 6.0, 4.2, and 4 years when testing was performed 1, 2, and 3 times per year, respectively. Progression in 80% of eyes with a cpRNFL loss of -1 µm/y was detected after 6.3, 5.0, and 4.2 years, respectively.

CONCLUSIONS

cpRNFL and cpCD are comparable in detecting progression. As there were only small changes in the time to detect progression when testing increased from 2 to 3 times per year, testing twice per year may provide sufficient information for detecting progression with either OCT or OCTA in clinical settings.

Association Between Rate of Ganglion Cell Complex Thinning and Rate of Central Visual Field Loss

Importance

Whether rapid ganglion cell complex (GCC) thinning during an initial follow-up period is associated with rates of central visual field loss over time is unclear but important to understand because risk of glaucoma progression can help guide treatment intensity.

Objective

To investigate the association between the rate of GCC thinning during initial follow-up and the rate of central visual field loss.

Design, Setting, and Participants

This retrospective cohort study assessed patients older than 18 years with glaucoma at a tertiary glaucoma center who were followed up from June 18, 2014, to January 11, 2019. Data analysis for the current study was undertaken in March 2022.

Main Outcomes and Measures

Initial rates of GCC thinning were obtained from global GCC thickness values of the first 3 optical coherence tomography (OCT) scans. Rates of central visual field loss were assessed as the change in central (10-2) visual field mean deviation during the 4.7-year follow-up period by univariable and multivariable linear mixed-effects models. Eyes were categorized as slow (>-1 μm/y) or fast (≤-1 μm/y) progressors based on rates of GCC thinning.

Results

The cohort consisted of 202 eyes of 139 patients (mean [SD] age, 68.7 [10.0] years; 72 male [51.8%]); 44 African American patients (31.7%), 13 Asian patients (9.4%), 80 White patients (57.6%), and 2 patients who identified as other race and ethnicity (1.4%) were analyzed. The rate of GCC change was -0.56 μm/y (95% CI, -0.66 to -0.46 μm/y) during a mean initial follow-up of 1.8 years (95% CI, 1.7-2.0 years). A total of 163 eyes (80.7%) were slow OCT progressors, and 39 (19.3%) were fast OCT progressors, with rates of GCC thinning of -0.3 μm/y (95% CI, -0.4 to -0.2 μm/y) and -1.6 μm/y (-1.8 to -1.3 μm/y), respectively. The rates of 10-2 visual field mean deviation worsening among slow and fast OCT progressors were -0.10 dB/y (95% CI, -0.16 to 0.00 dB/y) and -0.34 dB/y (95% CI, -0.51 to -0.16 dB/y), respectively (difference, -0.26 dB/y; 95% CI, -0.45 to -0.07 dB/y; P = .008).

Conclusions and Relevance

In this cohort study, rapid GCC thinning during an initial follow-up period was associated with faster rates of central visual field decline. These findings support use of longitudinal macular OCT scans assisting clinical decision-making for glaucoma and also may guide possible intensification of therapy in high-risk patients.

Healthcare Access and Utilization Among Glaucoma Patients in a Nationwide Cohort

PRCIS

Despite having lower socioeconomic status on several measures, glaucoma patients do not report more barriers to healthcare access and utilization than non-glaucoma patients.

PURPOSE

To characterize measures of socioeconomic status and barriers to healthcare access and utilization between patients with and without a diagnosis of glaucoma.

METHODS

Patients aged 65 years and over who enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, were extracted. We analyzed demographic information and several measures of socioeconomic status and healthcare access and utilization. Survey responses were compared by glaucoma status (any type) with Pearson χ 2 tests, univariable logistic regression, and multivariable logistic regression adjusting for age, gender, race/ethnicity, and insurance status.

RESULTS

Of the 49,487 patients who answered at least 1 question on the All of Us Healthcare Access and Utilization Survey, 4441 (9.0%) had a diagnosis of glaucoma. Majority of the cohort was female (28,162, 56.9%) and nonHispanic White (42,008, 84.9%). Glaucoma patients were observed to have lower rates of education ( P =0.004), employment ( P <0.001), and home ownership ( P <0.001) on χ 2 tests. On multivariable logistic regression models, those with glaucoma were significantly more likely to speak to an eye doctor (Odds ratio: 2.46; 95% confidence interval: 2.16 to 2.81) and significantly less likely to have trouble affording eyeglasses (OR: 0.85 95% CI: 0.72 to 0.99) in the prior year than those without a diagnosis of glaucoma. No significant association was found for other measures of healthcare access and utilization by glaucoma status.

CONCLUSION

Although glaucoma patients aged 65 years and over fared worse on several measures of socioeconomic status, no significant difference was found in measures of healthcare access and utilization.

Relative Stability of Regional Facial and Ocular Temperature Measurements in Healthy Individuals

Purpose

Non-contact measurement of facial temperature using infrared thermography has been used for mass screening of body temperature during a pandemic. We investigated the relative stability of temperature measurement in different facial regions of healthy individuals.

Methods

Twenty healthy subjects underwent two experiments. In the first experiment, subjects washed their faces with a 20°C wet towel for 1 minute. Temperature changes compared to baseline in the forehead, cornea, inner canthus, and outer canthus were determined using an infrared camera for 10 minutes. In the second experiment, lubricating eye drops at 20°C were instilled over one eye. Temperature changes in the same regions of interest were monitored for 5 minutes.

Results

Baseline temperatures before face washing in the forehead and cornea, inner canthus, and outer canthus of the right eye were 33.4°C ± 0.8°C (mean ± SD), 33.3°C ± 0.8°C, 34.3°C ± 0.7°C, and 32.8°C ± 0.7°C, respectively. Reductions in temperature due to face washing were most significant for the forehead and least significant for the cornea. One minute after face washing, the corresponding changes were -2.8°C ± 0.6°C, -0.3°C ± 0.6°C, -0.6°C ± 0.7°C, and -0.9°C ± 0.7°C for the forehead, cornea, inner canthus, and outer canthus, respectively. After administering the eye drops, no significant temperature changes were observed.

Conclusions

When facial temperature was exogenously cooled, the cornea had the most stable temperature readings.

Translational Relevance

When using infrared thermography to screen facial temperature, the measurement of corneal temperature is probably a better representative if the stability of temperature readings is critical.

Stress induced aging in mouse eye

Aging, a universal process that affects all cells in an organism, is a major risk factor for a group of neuropathies called glaucoma, where elevated intraocular pressure is one of the known stresses affecting the tissue. Our understanding of molecular impact of aging on response to stress in retina is very limited; therefore, we developed a new mouse model to approach this question experimentally. Here we show that susceptibility to response to stress increases with age and is primed on chromatin level. We demonstrate that ocular hypertension activates a stress response that is similar to natural aging and involves activation of inflammation and senescence. We show that multiple instances of pressure elevation cause aging of young retina as measured on transcriptional and DNA methylation level and are accompanied by local histone modification changes. Our data show that repeated stress accelerates appearance of aging features in tissues and suggest chromatin modifications as the key molecular components of aging. Lastly, our work further emphasizes the importance of early diagnosis and prevention as well as age-specific management of age-related diseases, including glaucoma.

Assessing Usability of Smartwatch Digital Health Devices for Home Blood Pressure Monitoring among Glaucoma Patients

Glaucoma is a leading cause of blindness worldwide. Blood pressure (BP) dysregulation is a known risk factor, and home-based BP monitoring is increasingly used, but the usability of digital health devices to measure BP among glaucoma patients is not well studied. There may be particular usability challenges among this group, given that glaucoma disproportionately affects the elderly and can cause visual impairment. Therefore, the goal of this mixed-methods study was to assess the usability of a smart watch digital health device for home BP monitoring among glaucoma patients. Adult participants were recruited and given a smartwatch blood pressure monitor for at-home use. The eHEALS questionnaire was used to determine baseline digital health literacy. After a week of use, participants assessed the usability of the BP monitor and related mobile app using the Post-study System Usability Questionnaire (PSSUQ) and the System Usability Scale (SUS), standardized instruments to measure usability in health information technology interventions. Variations in scores were evaluated using ANOVA and open-ended responses about participants' experience were analyzed thematically. Overall, usability scores corresponded to the 80th-84th percentile, although older patients endorsed significantly worse usability based on quantitative scores and additionally provided qualitative feedback describing some difficulty using the device. Usability for older patients should be considered in the design of digital health devices for glaucoma given their disproportionate burden of disease and challenges in navigating digital health technologies, although the overall high usability scores for the device demonstrates promise for future clinical applications in glaucoma risk stratification.