Primary Open-Angle Glaucoma Preferred Practice Pattern®

Prostaglandin-based rAAV-mediated glaucoma gene therapy in Brown Norway rats

Prostaglandin analogs are first-line treatments for open angle glaucoma and while effective at lowering intraocular pressure, they are undermined by patient non-compliance, causing atrophy of the optic nerve and severe visual impairment. Herein, we evaluate the safety and efficacy of a recombinant adeno-associated viral vector-mediated gene therapy aimed at permanently lowering intraocular pressure through de novo biosynthesis of prostaglandin F2α within the anterior chamber. This study demonstrated a dose dependent reduction in intraocular pressure in normotensive Brown Norway rats maintained over 12-months. Crucially, therapy could be temporarily halted through off-type riboswitch activation, reverting intraocular pressure to normal. Longitudinal multimodal imaging, electrophysiology, and post-mortem histology revealed the therapy was well tolerated at low and medium doses, with no major adverse effects to anterior chamber health, offering a promising alternative to current treatment strategies leading to clinically relevant reductions in intraocular pressure without the need for adherence to a daily treatment regimen.

The Frequency of Visual Field Testing in a US Nationwide Cohort of Individuals with Open-Angle Glaucoma

PURPOSE

Visual field testing that is not frequent enough results in delayed identification of open-angle glaucoma (OAG) progression. Guidelines recommend at least annual testing. It is not known how frequently patients with OAG across the United States receive visual field testing and how patient characteristics and circumstances influence this frequency. If US patients with OAG do not receive visual field tests frequently enough, interventions to increase this frequency or to develop other forms of testing visual function may reduce unidentified OAG vision loss.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The TruvenHealth MarketScan Commercial Claims Database (IBM) contains demographic and claims data for > 160 million individuals across the United States from 2008 to 2017. We identified enrollees in the database with a recorded diagnosis of OAG (International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification codes 356.1x and H40.1x, respectively). We excluded those aged < 40 years at the time of their first OAG diagnosis, those without at least 1 confirmatory OAG diagnosis at a subsequent visit, and those with < 4 years of follow-up data after OAG diagnosis.

METHODS

We calculated the number of visual field tests that each enrollee with OAG underwent per year and categorized the enrollees based on that number (0, > 0 to < 0.9, ≥ 0.9 to ≤ 1.1, > 1.1 to ≤ 2.1, and > 2.1). We used negative binomial regression to investigate the demographic or health variables that were associated with the frequency of visual field tests that enrollees with OAG received.

MAIN OUTCOME MEASURES

Frequency of visual field testing among enrollees with OAG.

RESULTS

Of the 380 029 enrollees included in the study, 33 267 (8.8%) did not receive a visual field test during the study period, 259 349 (68.2%) underwent > 0 to < 0.9 visual field tests per year, 42 129 (11.1%) underwent ≥ 0.9 to ≤ 1.1 visual field tests per year, 42 301 (11.1%) underwent > 1.1 to ≤ 2.1 visual field tests per year, and 2983 (0.8%) underwent ≥ 2.1 visual field tests per year. The median number of visual field tests per year was 0.63 (interquartile range, 0.33-0.88; mean, 0.65).

CONCLUSIONS

More than 75% of enrollees with OAG received < 1 visual field test per year and, thus, did not receive guideline-adherent glaucoma monitoring.

Artificial Intelligence to Aid Glaucoma Diagnosis and Monitoring: State of the Art and New Directions

Recent developments in the use of artificial intelligence in the diagnosis and monitoring of glaucoma are discussed. To set the context and fix terminology, a brief historic overview of artificial intelligence is provided, along with some fundamentals of statistical modeling. Next, recent applications of artificial intelligence techniques in glaucoma diagnosis and the monitoring of glaucoma progression are reviewed, including the classification of visual field images and the detection of glaucomatous change in retinal nerve fiber layer thickness. Current challenges in the direct application of artificial intelligence to further our understating of this disease are also outlined. The article also discusses how the combined use of mathematical modeling and artificial intelligence may help to address these challenges, along with stronger communication between data scientists and clinicians.

Glaucoma Genetic Risk Scores in the Million Veteran Program

PURPOSE

Primary open-angle glaucoma (POAG) is a degenerative eye disease for which early treatment is critical to mitigate visual impairment and irreversible blindness. POAG-associated loci individually confer incremental risk. Genetic risk score(s) (GRS) could enable POAG risk stratification. Despite significantly higher POAG burden among individuals of African ancestry (AFR), GRS are limited in this population. A recent large-scale, multi-ancestry meta-analysis identified 127 POAG-associated loci and calculated cross-ancestry and ancestry-specific effect estimates, including in European ancestry (EUR) and AFR individuals. We assessed the utility of the 127-variant GRS for POAG risk stratification in EUR and AFR Veterans in the Million Veteran Program (MVP). We also explored the association between GRS and documented invasive glaucoma surgery (IGS).

DESIGN

Cross-sectional study.

PARTICIPANTS

MVP Veterans with imputed genetic data, including 5830 POAG cases (445 with IGS documented in the electronic health record) and 64 476 controls.

METHODS

We tested unweighted and weighted GRS of 127 published risk variants in EUR (3382 cases and 58 811 controls) and AFR (2448 cases and 5665 controls) Veterans in the MVP. Weighted GRS were calculated using effect estimates from the most recently published report of cross-ancestry and ancestry-specific meta-analyses. We also evaluated GRS in POAG cases with documented IGS.

MAIN OUTCOME MEASURES

Performance of 127-variant GRS in EUR and AFR Veterans for POAG risk stratification and association with documented IGS.

RESULTS

GRS were significantly associated with POAG (P < 5 × 10-5) in both groups; a higher proportion of EUR compared with AFR were consistently categorized in the top GRS decile (21.9%-23.6% and 12.9%-14.5%, respectively). Only GRS weighted by ancestry-specific effect estimates were associated with IGS documentation in AFR cases; all GRS types were associated with IGS in EUR cases.

CONCLUSIONS

Varied performance of the GRS for POAG risk stratification and documented IGS association in EUR and AFR Veterans highlights (1) the complex risk architecture of POAG, (2) the importance of diverse representation in genomics studies that inform GRS construction and evaluation, and (3) the necessity of expanding diverse POAG-related genomic data so that GRS can equitably aid in screening individuals at high risk of POAG and who may require more aggressive treatment.

Effect of idiopathic epiretinal membrane on macular ganglion cell complex measurement in eyes with glaucoma

Background/objectives

Co-existing idiopathic epiretinal membrane (ERM) and glaucoma complicate the estimation of glaucoma severity via optical coherence tomography (OCT). We investigated the effect of ERM and a new associated parameter, SUKIMA (space between the ERM and retinal surface), on ganglion cell complex (GCC) thickness in eyes with glaucoma, based on a matched comparison of visual field defects.

Subjects/methods

We retrospectively recruited 41 eyes from 34 glaucoma patients with idiopathic ERM and 41 eyes from 41 glaucoma patients without ERM as controls (matched by age, axial length, and mean visual field deviation). The thicknesses of GCC layers [retinal nerve fiber layer (RNFL), ganglion cell layer + inner plexiform layer (GCIPL), and GCC (RNFL + GCIPL)] were measured with swept-source OCT. We investigated the presence of SUKIMA and its effect on GCC measurements.

Results

RNFL, GCIPL, and GCC were thicker in ERM (+) eyes than in control eyes (31.0 ± 12.3 μm vs. 22.7 ± 10.8 μm, 62.6 ± 12.2 μm vs. 53.8 ± 5.9 μm, and 91.8 ± 16.6 μm vs. 76.8 ± 13.3 μm, respectively; P &lt; 0.01). Eyes in the ERM-associated SUKIMA (+) group had thicker GCIPL and GCC than those in the ERM-associated SUKIMA (−) and control groups (P &lt; 0.01).

Conclusion

ERM-associated SUKIMA affects GCC thickness and can result in underestimations of glaucoma severity. We should check for the presence of ERM using a B mode scan as well as check for the SKIMA sign.

Canaloplasty and trabeculotomy with the OMNI® surgical system in OAG with prior trabecular microbypass stenting

Purpose

Evaluate effectiveness and safety outcomes for patients treated with canaloplasty and trabeculotomy previously treated with a trabecular microbypass stent (TBS).

Methods

Retrospective, multicenter, IRB approved study. Patients treated with TBS (iStent/iStent inject, Glaukos) and subsequently with OMNI surgical system (OSS) (Sight Sciences). From 5 practices in 5 US states. Open-angle glaucoma (OAG), minimum 3 months follow-up after OSS surgery, Pre-OSS IOP ≥ 17 mmHg on ≥ 1 medication. No glaucoma procedures between TBS and OSS. Endpoints: proportion with ≥ 20% reduction in IOP, IOP between 6 and 18 mmHg, mean IOP, change in IOP, mean number of medications. Adverse events and secondary surgical interventions (SSI). Mann–Whitney rank sum test compared pre-OSS IOP and medications with follow-up.

Results

Twenty seven patients. Average age (SD) 72.2 (10.8), 22/27 primary OAG (82%), mean MD − 6.2 (7.0) dB. Mean IOP before OSS 22.3 (4.3) mmHg on 2.2 (1.3) medications. At last follow-up (mean 11 months) IOP was 17.2 mmHg on 1.8 medications, − 5.1 mmHg (− 23%, p < .001), − 0.4 meds (− 18%, p = .193); ≥ 20% IOP reduction (41%), IOP ≤ 18 (56%). Adverse events were non-serious. Hyphema > 1 mm (3, 11%), BCVA decrease (4, 15%), IOP spike (2, 7%). SSI (4, 15%) had higher pre-OSS IOP (23.4 mmHg) and worse MD (− 9.6 dB).

Conclusion

Patients uncontrolled by medication and a prior TBS would once have been candidates for trabeculectomy and tube shunts. OSS offered a minimally invasive option that provided IOP control and avoidance of traditional surgery for the majority over follow-up averaging 11 months and up to 42 months.

Aqueous Humor Growth Factor Levels and Trabeculectomy Outcomes in Primary Open-Angle Glaucoma Patients: A 2-Year Prospective Study

Purpose

Maintenance of a filtering bleb is essential for long-term intraocular pressure control after trabeculectomy. Surgical site fibrosis and excessive extracellular matrix production are common causes of trabeculectomy failure, mediated by several growth factors. We aimed to evaluate the levels of five growth factors and their correlation with trabeculectomy outcomes in patients with primary open-angle glaucoma (POAG).

Methods

We collected aqueous humor samples intraoperatively from patients with POAG who underwent trabeculectomy and measured the concentrations of transforming growth factor-β (TGF-β), acidic fibroblast growth factor (aFGF), insulin-like growth factor-1, vascular endothelial growth factor, and platelet-derived growth factor using multiplexed immunoassay kits. Intraocular pressure was measured with Goldmann applanation tonometry at 1 week and at 1, 3, 6, 12, 18, and 24 months after trabeculectomy. We allocated the eyes based on surgical outcome into a success or failure group.

Results

Significantly high levels of aFGF and TGF-β were observed in the failure group (both P < 0.0001) and were significant risk factors for trabeculectomy outcomes. Higher success rates were observed over the 24-month follow-up period in eyes with low aFGF and TGF-β levels compared to eyes with high levels (P = 0.0031 and P = 0.0007, respectively). The levels of TGF-β were significantly positively correlated with aFGF.

Conclusions

In POAG patients, high aFGF and TGF-β levels were significant risk factors for trabeculectomy failure.

Translational Relevance

Modulation of aFGF and TGF-β expression may have potential clinical applications after filtration surgery.

Loss to Follow up among Glaucoma Patients at a Tertiary Eye Center over 10 Years: Incidence, Risk Factors, and Clinical Outcomes

PURPOSE

To assess the incidence, risk factors, and clinical consequences of loss to follow up (LTFU) among glaucoma patients at our institution over a 10-year period.

METHODS

This retrospective study examined LTFU among a cohort of glaucoma patients with a clinical encounter in 2010. LTFU was defined as 52 weeks or more without an encounter and without alternative reason for discontinued care, such as discharge, documented move, or death. Baseline demographic and clinical characteristics were collected and compared between LTFU and non-LTFU groups using a logistic regression model to identify risk factors for LTFU. Odds ratios (ORs) are reported with 95% confidence intervals. Clinical outcomes were documented for LTFU patients who returned after a lapse in care.

RESULTS

Among the 395 included patients, 132 (33%) were LTFU over the 10-year study period. Characteristics associated with LTFU in a logistic regression model included greater disease severity (OR = 1.03 [1.01-1.05], p = .023, for each worsening decibel of mean deviation) and in-state rather than out-of-state residence (OR = 2.76 [1.12-6.80], p = .027). Other potential risk factors that did not reach significance included male gender (OR = 1.39 [0.92-2.13], p = .124), Black race (OR = 1.40 [0.91-2.16] p = .123), and legal blindness (OR = 1.58 [0.91-2.76] p = .107). Among the 132 patients who were LTFU, only 23 (17%) later returned to care, two-thirds (15/23) of whom returned with disease progression or complication.

CONCLUSION

One-third of glaucoma patients became LTFU over a 10-year period, and LTFU may be associated with poor clinical outcomes. More research is needed to understand reasons for LTFU and to promote regular glaucoma care.

Aqueous column changes in the episcleral veins after the instillation of ripasudil versus latanoprost: a randomized, double-blind, crossover clinical trial

To investigate whether the topical administration of ripasudil ophthalmic solution enhances aqueous outflow in the episcleral vein of the human eye. Two-sequence, prospective, randomized, double-blind, crossover trial. Sixteen eyes of 16 healthy participants were recruited in this study. Participants were randomized into one of the two crossover sequences to the instillation of ripasudil or the control drug, latanoprost, followed by a washout period of more than 2 days, and crossed over to the alternative instillation. The aqueous columns in the episcleral veins were recorded using a video capture system connected to a slit-light microscope (hemoglobin video imaging) before and 2 and 8 h after the instillation. Comparisons between ripasudil and latanoprost for the changes of the aqueous column width after the instillation. Two hours after the instillation, the ripasudil group had significantly greater dilation of the aqueous column width than the latanoprost group. Eight hours after the instillation, the ripasudil group had significantly greater dilation of the aqueous column width than the latanoprost group. Hemoglobin video imaging revealed that the topical administration of ripasudil ophthalmic solution enhanced aqueous outflow in the episcleral vein of the human eye.

Mispositioned Hydrus Microstents: A Case Series Imaged with NIDEK GS-1 Gonioscope

Introduction. The Hydrus microstent has become a common procedure in glaucoma surgery intended to improve outcomes of cataract surgery to lower intraocular pressure. Despite proper placement, this device can subsequently be noted to not be in the proper position. In this case series, we report mispositioned Hydrus microstents in five different patients and use NIDEK GS-1 gonioscopy. Case Report. We report five different patients who had cataract surgery and who were subsequently noted to have mispositioned Hydrus stents. No stents needed to be removed. All patients had improved vision and stable visual fields, and none required secondary surgery. Management and Outcome. In each case of mispositioned stents, vision was significantly improved and there was no inflammation or other complications noted. Discussion. Hydrus stents can be noted to be mispositioned during the post-operative period after successful insertion. This can often be well tolerated requiring no further intervention.

Minimally Invasive Glaucoma Surgery in Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is responsible for half of the glaucoma-related blindness worldwide. Cataract surgery with or without trabeculectomy has been considered to be the first-line treatment in eyes with medically uncontrolled PACG. While minimally invasive glaucoma surgery has become an important surgical approach for primary open-angle glaucoma, its indications and benefits in PACG are less clear. This review summarizes the efficacy and safety profile of minimally invasive glaucoma surgery in PACG to unfold new insights into the surgical management of PACG.

Factors associated with vision loss in Black or Hispanic patients 1 year after standalone or combined Ahmed glaucoma valve surgery

PURPOSE

To determine factors associated with vision loss 1 year after Ahmed glaucoma valve (AGV) surgery in Black or Hispanic patients, who bear disproportionate glaucoma burdens yet have been underrepresented in pivotal trials.

METHODS

This retrospective study included Black or Hispanic patients who received AGVs standalone or combined with phacoemulsification and/or cyclodestructive lasers. Univariate and multivariate generalized estimating equations evaluated the effects of baseline, surgical, and postoperative factors on vision loss of two Snellen lines or more at the 1-year follow-up visit. The primary term was the hypertensive phase (HP), which signified an intraocular pressure (IOP) reading > 21 mmHg within the first 3 postoperative months after reduction below 22 in the first week, without other tube malfunction.

RESULTS

Of 241 eyes from 186 patients, vision loss of ≥ 2 lines at the 1-year follow-up visit occurred in 21.6% (N = 52). Vision loss of ≥ 2 lines occurred in 52.5% of eyes at week 1, 36.9% of eyes at month 1, and 27.0% of eyes at month 3. Between 6 months and 1 year, vision loss frequencies stabilized. In the multivariate model, HP (OR = 4.71 (2.14, 10.38)), total quadrants with split fixation (1.47 (1.20, 1.81)), follow-up non-glaucomatous eye pathology (2.89 (1.44, 5.80)), and concurrent cataract surgery (0.42 (0.22, 0.82)) each met significance (p < 0.05).

CONCLUSION

Post-AGV vision loss in the early follow-up period among Black or Hispanic patients was often transient. Hypertensive phase and split fixation each increased the odds of vision loss at 1 year, while concurrent cataract surgery decreased the odds.

Intraocular Pressure and Medication Burden With Cataract Surgery Alone, or Cataract Surgery Combined With Trabecular Bypass or Goniotomy

PRCIS

When compared with cataract surgery in glaucoma patients, trabecular micro-bypass and goniotomy resulted in a large decrease in the incidence of intraocular pressure (IOP) spikes, a modest effect on IOP, and a minimal effect on medication burden.

PURPOSE

To compare changes in IOP and ocular hypotensive medications in 3 surgical cohorts: cataract surgery, cataract surgery with trabecular micro-bypass (cataract/trabecular), and cataract surgery with goniotomy (cataract/goniotomy).

MATERIALS AND METHODS

We included 138 eyes diagnosed with open-angle glaucoma: (1) 84 eyes with cataract surgery alone, (2) 25 eyes with cataract/trabecular surgery, and (3) 29 eyes with cataract/goniotomy surgery. We compared the groups for postoperative IOP and the number of ocular hypotensive medications. We adjusted for preoperative IOP, and preoperative and postoperative number of ocular hypotensive medications. We defined an IOP spike as IOP ≥21 mm Hg and 10 mm Hg higher than preoperative on postoperative day 1.

RESULTS

All 3 surgeries showed a decrease in IOP (P≤0.004) and medication burden (P≤0.001) at 3 and 6 months postoperatively when compared with their own preoperative baselines. When compared with cataract surgery alone, cataract/trabecular and cataract/goniotomy had similar IOP lowering at 1 month postoperatively, and variable results at 3 and 6 months. The change in ocular hypotensive medications was not statistically different between the surgical groups at any postoperative visit. Cataract/trabecular and cataract/goniotomy decreased IOP on postoperative day 1, and had relative risk reduction of ~70% for IOP spikes (P≤0.001 for both).

CONCLUSION

Trabecular micro-bypass and goniotomy when added to cataract surgery resulted in a large decrease in IOP spikes, a modest effect on IOP, and a minimal effect on medication burden when compared with cataract surgery alone in glaucoma patients.

Evaluation of Compliance Issues to Anti-glaucoma Medications Before and After a Structured Interventional Program

Background Glaucoma is one of the most common eye diseases in the elderly and the major cause of irreversible vision loss worldwide. Adherence to life-long therapies is crucial to prevent glaucoma progression. The current study aims to assess the educational element and its impact on glaucoma medication compliance over short and long periods. Methods This was a survey-based, prospective, interventional study, conducted via interviews of all glaucoma patients presented to the Ophthalmology Center at King Abdullah Medical City (KAMC), Makkah, Saudi Arabia. To achieve the study's aim, a questionnaire with 31 items was utilized, followed by a structured program between September 2019 to June 2021. After that, a second questionnaire was used after a one month to one year to re-evaluate the intervention. Data was automatically collected in Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and entered into IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, New York, United States) for analysis. Results Non-compliance was detected in 15.7% of all recruited patients (n=134). However, the non-compliance percentage dropped to 10 (7.5%) after the structured program (P=0.028). Contributing factors were low educational level, bilateral eye disease, duration of treatment more than two years, and having more than two eye treatment bottles; however, the P-value was insignificant. Conclusions About one-sixth of our glaucoma patients were found to be non-compliant. However, the non-compliance reduced by more than half after the structured educational program. Treatment adherence can be improved by implementing awareness and correcting the beliefs about illness and medicines, thus potentially delaying disease development.

Comparison of Retinal Nerve Fiber Layer and Ganglion Cell-Inner Plexiform Layer Thickness Values Using Spectral-Domain and Swept-Source OCT

Purpose

To compare peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thickness measurements obtained with spectral domain optical coherence tomography (SD-OCT) and swept-source OCT (SS-OCT) using an OCT-angiography scanning protocol, and their ability to distinguish among patients with glaucoma, glaucoma suspects (GS), and healthy controls (HC).

Methods

Cross-sectional study of 196 eyes (81 glaucoma, 48 GS, and 67 HC) of 119 participants. Participants underwent peripapillary and macular OCT with SD-OCT and SS-OCT. Parameters of interest were average and sector-wise pRNFL and mGCIPL thickness. Inter-device agreement was investigated with Bland-Altman statistics. Conversion formulas were developed with linear regression. Diagnostic performances were evaluated with area under the receiver operating characteristic curves.

Results

Both SD-OCT and SS-OCT detected a significant pRNFL and mGCIPL thinning in glaucoma patients compared to HC and GS for almost all study sectors. A strong linear relationship between the two devices was present for all quadrants/sectors (R2 ≥ 0.81, P < 0.001), except for the nasal (R2 = 0.49, P < 0.001) and temporal (R2 = 0.62, P < 0.001) pRNFL quadrants. SD-OCT and SS-OCT measurements had a proportional bias, which could be removed with conversion formulas. Overall, the two devices showed similar diagnostic abilities.

Conclusions

Thickness values obtained with SD-OCT and SS-OCT are not directly interchangeable but potentially interconvertible. Both devices have a similar ability to discriminate glaucoma patients from GS and healthy subjects.

Translational Relevance

OCT-Angiography scans can be reliably used to obtain structural metrics in glaucoma patients.

Single Administration of Intracameral Bimatoprost Implant 10 µg in Patients with Open-Angle Glaucoma or Ocular Hypertension

Introduction

This study evaluated the intraocular pressure (IOP)-lowering efficacy and safety of a single intracameral administration of bimatoprost implant 10 µg in adults with open-angle glaucoma or ocular hypertension.

Methods

Two identically designed, randomized, 20-month, parallel-group, phase 3 clinical trials (one study eye/patient) compared three administrations of 10- or 15-µg bimatoprost implant (day 1, weeks 16 and 32) with twice-daily topical timolol maleate 0.5%. An open-label, 24-month, phase 1/2 clinical trial compared one or two implants administered in the study eye with once-daily topical bimatoprost 0.03% in the fellow eye. Separate analyses of the pooled phase 3 and phase 1/2 study datasets evaluated outcomes in the 10-µg bimatoprost implant and comparator treatment arms after a single implant administration, up to the time of implant re-administration or rescue with IOP-lowering medication.

Results

In the phase 3 studies, 10-µg bimatoprost implant single administration demonstrated IOP reductions (hour 0) of 4.9–7.0 mmHg through week 15 from a mean (standard deviation, SD) baseline IOP of 24.5 (2.6) mmHg (n = 374); IOP in the topical timolol BID group was reduced by 6.0–6.3 mmHg from a mean (SD) baseline IOP of 24.5 (2.6) mmHg (n = 373). In the phase 1/2 study (n = 21), median time to use of additional IOP-lowering treatment (Kaplan–Meier analysis) was 273 days (approximately 9 months), and 5 of 21 enrolled patients (23.8%) required no additional IOP-lowering treatment up to 24 months after single administration. In each study, after a single implant administration there were no reports of corneal edema, corneal endothelial cell loss, or corneal touch, and no patients had 20% or greater loss in corneal endothelial cell density.

Conclusions

Bimatoprost implant single administration lowers IOP and has a favorable safety profile. Additional studies are needed to further evaluate the duration of effect and factors predicting long-term IOP lowering after a single implant administration.

Trial registration numbers

ClinicalTrials.gov NCT02247804, NCT02250651, and NCT01157364.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00527-6.

Unmet needs in glaucoma therapy: The potential role of hydrogen sulfide and its delivery strategies

Glaucoma is an optic neuropathy disorder marked by progressive degeneration of the retinal ganglion cells (RGC). It is a leading cause of blindness worldwide, prevailing in around 2.2% of the global population. The hallmark of glaucoma, intraocular pressure (IOP), is governed by the aqueous humor dynamics which plays a crucial role in the pathophysiology of the diesease. Glaucomatous eye has an IOP of more than 22 mmHg as compared to normotensive pressure of 10-21 mmHg. Currently used treatments focus on reducing the elevated IOP through use of classes of drugs that either increase aqueous humor outflow and/or decrease its production. However, effective treatments should not only reduce IOP, but also offer neuroprotection and regeneration of RGCs. Hydrogen Sulfide (H₂S), a gasotransmitter with several endogenous functions in mammalian tissues, is being investigated for its potential application in glaucoma. In addition to decreasing IOP by increasing aqueous humor outflow, it scavenges reactive oxygen species, upregulates the cellular antioxidant glutathione and protects RGCs from excitotoxicity. Despite the potential of H₂S in glaucoma, its delivery to anterior and posterior regions of the eye is a challenge due to its unique physicochemical properties. Firstly, development of any delivery system should not require an aqueous environment since many H₂S donors are susceptible to burst release of the gas in contact with water, causing potential toxicity and adverse effects owing to its inherent toxicity at higher concentrations. Secondly, the release of the gas from the donor needs to be sustained for a prolonged period of time to reduce dosing frequency as per the requirements of regulatory bodies. Lastly, the delivery system should provide adequate bioavailability throughout its period of application. Hence, an ideal delivery system should aim to tackle all the above challenges related to barriers of ocular delivery and physicochemical properties of H₂S itself. This review discusses the therapeutic potential of H₂S, its delivery challenges and strategies to overcome the associated chalenges.

Efficacy and Safety of Omidenepag Isopropyl 0.002% Ophthalmic Solution: A Retrospective Analysis of Real-World Data in Japan

Introduction

This study aimed to clarify the efficacy and safety of omidenepag isopropyl (OMDI) in a retrospective, real-world, multicenter setting.

Methods

A retrospective medical chart review of patients with glaucoma and ocular hypertension receiving OMDI from November 2018 to November 2019 with at least 12 weeks of follow-up was conducted in 11 eye clinics in Japan. The participants were categorized into three therapy groups, designated the naïve monotherapy, switching monotherapy, and concomitant therapy groups. The main outcome measures were the change in intraocular pressure (IOP) at week 4 and week 12 after the initiation of OMDI treatment, and frequency of adverse drug reactions.

Results

Data were collected from 827 patients. The baseline IOP in the naïve group was 16.6 ± 4.2 mmHg. The mean IOP reduction at week 4 and week 12 was − 2.9 ± 3.2 mmHg (P < 0.0001) and − 2.5 ± 2.9 mmHg (P < 0.0001), respectively. Eyes with baseline IOP less than 16 mmHg also showed a significant reduction of IOP of − 1.4 ± 2.0 mmHg at week 12. OMDI significantly reduced IOP not only in eyes with primary open-angle glaucoma but also in eyes with primary angle-closure glaucoma and secondary glaucoma. In the switching monotherapy group, IOP did not change significantly after switching from most classes of medications to OMDI, but further IOP reduction was observed in the case of switching from beta-blockers to OMDI. The frequency of adverse drug reactions was 14.1% in all participants, and the most common adverse reaction was ocular hyperemia (7.6%). No serious and severe side effects were observed in this study.

Conclusion

OMDI showed an IOP-lowering effect in eyes with various types of glaucoma and using various therapeutic regimens in real-world clinical practice. In addition, OMDI did not show any serious and severe side effects, suggesting the potential of OMDI as a first-line medicine for the treatment of glaucoma.

Trial Registration

University Hospital Medical Information Network (UMIN): 000040040.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02069-6.

An IRIS® Registry-Based Assessment of Primary Open-Angle Glaucoma Practice Patterns in Academic versus Non-Academic Settings

PURPOSE

To compare patient demographic data; level of severity; and clinical, diagnostic, and surgical practice patterns in patients with primary open-angle glaucoma (POAG) in an academic setting (AS) versus non-academic setting (NAS) using the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

METHODS

A retrospective cohort study of IRIS® Registry data that included patients with POAG who were seen between January 2016 and December 2019 and had at least one year of follow-up.

RESULTS

Of 3,707,084 distinct eyes with POAG, 3% (109,920) were included in the academic subcohort and 97% (3,597,164) were included in the non-academic subcohort. Among the findings of greatest note (P < .0001 for all comparisons) were a higher proportion of eyes of Black patients, a higher proportion of eyes with level 3 severity, and a higher mean cup-to-disc ratio in eyes in the AS. The relative frequency of gonioscopy, pachymetry, and visual field testing in conjunction with new patient visits was also notably higher in the AS. For glaucoma surgical procedures, the greatest proportional differences in relative frequency were seen for tube shunt procedures (2.55-fold higher in the AS), iStent and Hydrus procedures (2.52-fold higher in the NAS), and endoscopic cyclophotocoagulation (5.80-fold higher in the NAS).

CONCLUSIONS

Based on IRIS® Registry data, notable differences appear to exist with regard to ethno-racial groups, glaucoma severity, and diagnostic and surgical practice patterns in AS versus NAS. By understanding these differences, potential opportunities exist in the development of educational programs related to clinical and surgical glaucoma care.

How glaucoma care changed for the better after the pandemic

PURPOSE OF REVIEW

The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution.

RECENT FINDINGS

Literature from the review period (2020-2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients.

SUMMARY

Glaucoma specialists, patients, and staff have adapted to a 'new normal' of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Correlation of myopia onset and progression with corneal biomechanical parameters in children

BACKGROUND

Recent epidemiological studies have shown that general eye measurement parameters and corneal biomechanical properties can predict the speed of myopic progression in children.

AIM

To investigate the correlation between the onset and progression of myopia and corneal biomechanical parameters in children.

METHODS

The study included 102 cases in the emmetropia group, 207 cases in the myopic group, and 109 cases in the hyperopic group. The correlation between the change in corneal biomechanical indexes and the change in general ocular measurement parameters was analyzed. A one-way ANOVA test compared general ocular measurement and corneal biomechanical parameters. Pearson’s correlation coefficient was analyzed to correlate corneal biomechanical and general ocular measurement parameters.

RESULTS

The general ophthalmometric parameters: Spherical equivalent (SE), intraocular pressure (IOP), and axial length (AL), differed significantly among subjects in myopia, emmetropia, and hyperopic groups. Children’s SE positively correlated with corneal biomechanical parameters: Second velocity of applanation (A2V), peak distance (PD), and deformation amplitude (DA) (P < 0.05), and second applanation length (A2L) (P < 0.05). But it was negatively correlated with PD, DA and integral radius (IR) (P < 0.05). Also, IOP was negatively correlated with A2L and IR (P < 0.05). AL positively correlated with A2V and negatively correlated with second applanation time (A2T), highest concavity, and PD. Central corneal thickness positively correlated with first applanation length, first applanation time, first applanation deformation amplitude, A2V, A2L, A2T, second applanation deformation amplitude, central curvature radius at highest concavity (HCR), PD, DA, IR, ambrosia relational thickness-horizontal, first applanation stiffness parameter, corvis biomechanical index, topographic and biomechanics index and the first velocity of applanation. The general ocular Km in children positively correlated with corneal biomechanical parameters DA and IR and negatively correlated with A2L, HCR, and PD. There was a positive correlation between the general ocular measurement parameters ΔSE and corneal biomechanical parameters ΔA2V and ΔA2L, and a negative correlation with ΔIR. The increase in general ocular measurement parameter ΔKm positively correlated with changes in corneal biomechanical parameters, ΔDA and ΔIR, and negatively correlated with ΔHCR and ΔPD.

CONCLUSION

Myopia development in children was associated with multiple corneal biomechanical parameters.

Association between Sodium Glucose Co-transporter 2 Inhibitors and Incident Glaucoma in Patients with Type 2 Diabetes: A Multi-institutional Cohort Study in Taiwan

PURPOSE

Type 2 diabetes (T2D) is an important risk factor for glaucoma, and sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to protect the optic nerves. We therefore aimed to evaluate the association between SGLT2 inhibitors and incident glaucoma.

METHODS

This retrospective cohort study analyzed the largest multi-institutional electronic medical records database in Taiwan, containing data of over a million individuals. We included T2D patients newly prescribed SGLT2 inhibitors or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) from 2016 to 2018. Our primary outcome was incident glaucoma diagnosis between initiation of SGLT2 inhibitors or GLP-1 RAs, and 31st March 2021. After applying inverse probability of treatment weighting (IPTW) to increase homogeneity between the two treatment groups, we estimated hazard ratios (HR) with 95% confidence intervals (CI) for the risk of glaucoma, based on Cox proportional hazards regression models.

RESULTS

We included 9,927 and 1,065 T2D patients who had been newly prescribed SGLT2 inhibitors or GLP-1 RAs, respectively. Lower risk of incident glaucoma was observed in patients receiving SGLT2 inhibitors (7.9 events per 1,000 person-years), compared to those receiving GLP-1 RAs (10.0 events per 1,000 person-years), with an HR of 0.81 (95% CI: 0.69-0.95). Multiple sensitivity analyses and a negative control outcome analysis confirmed the robustness of our main findings.

CONCLUSION

This study suggests that T2D patients newly prescribed SGLT2 inhibitors have a reduced risk of incident glaucoma, compared to those prescribed GLP-1 RAs, in clinical practice. Future prospective studies are suggested to confirm this association.

Current situation and progress of drugs for reducing intraocular pressure

Glaucoma, the most common cause of irreversible blindness worldwide, usually causes characteristic optic nerve damage. Pathological intraocular pressure (IOP) elevation is a major risk factor. Drug reduction of IOP is the preferred treatment for clinicians because it can delay the progression of disease. However, the traditional IOP-lowering drugs currently used by patients may be poorly tolerated. Therefore, in recent years, some new drugs have been put into clinical application or in clinical phase I–III studies. They have a better IOP-lowering effect and fewer adverse reactions. Because glaucoma is a chronic disease, drugs need to be administered continuously for a long time. For patients, good compliance and high drug bioavailability have a positive effect on the prognosis of the disease. Therefore, clinicians and scientists have developed drug delivery systems to solve this complex problem. In addition, natural compounds and dietary supplements have a good effect of reducing IOP, and they can also protect the optic nerve through antioxidant action. We summarize the current traditional drugs, new drugs, sustained-release drug delivery systems, and complementary drugs and outline the mechanism of action and clinical effects of these drugs on glaucoma and their recent advances.

A Modified Technique in Applying Sponge Soaked with Mitomycin C in Trabeculectomy

ABSTRACT

Trabeculectomy with adjunctive use of Mitomycin C (MMC) has been a benchmark for glaucoma filtration surgery for decades. However, there are many variations in the ways that the sponges soaked with MMC are applied during the trabeculectomy surgery. We herein describe our way of placing the MMC-soaked sponges to improve the safety and efficacy of the trabeculectomy. The sponges are placed vertically and posteriorly with the long side of the sponge perpendicular to the limbus, not parallel. This will reduce the size of the conjunctival wound at the limbus to preserve more virgin conjunctiva that can be used for repeated trabeculectomy when needed. This will also facilitate a more posteriorly directed flow of aqueous drainage that, in turn, may increase the success rate of the trabeculectomy. We have obtained encouraging results in our practice, and further large-scale randomized studies seem warranted.

Comparison of Corneal Wave Speed and Ocular Rigidity in Normal and Glaucomatous Eyes

PRECIS

Ocular biomechanics were compared between treated glaucoma patients and healthy subjects matched for age, intraocular pressure (IOP), and axial length. There was no difference in corneal wave propagation speed, but ocular rigidity was lower in glaucomatous eyes.

PURPOSE

Ocular biomechanical properties are important in understanding glaucoma pathogenesis but the affected tissues are unclear. In this study, we compared corneal wave speed (a measure of corneal elasticity) and ocular rigidity coefficient between glaucomatous and normal eyes.

MATERIALS AND METHODS

Twenty glaucomatous eyes from 10 patients and 20 normal eyes from 13 controls, matched for age, IOP, and axial length were included. Ocular rigidity was calculated based on the difference in supine IOP by pneumatonometry with and without a 10-g weight. Corneal wave speed was determined by ultrasound surface wave elastography. A small, 0.1-second harmonic vibration at 100 Hz was generated through the closed eyelids. Wave propagation was captured by an ultrasound transducer, and wave speed was determined from the phase change with distance. Comparisons were performed using generalized estimating equation models.

RESULTS

There were no significant differences in corneal wave speed between glaucomatous and normal eyes (2.16±0.25 vs. 2.07±0.16 m/s, P=0.17). However, ocular rigidity was significantly lower in glaucomatous eyes (0.0218±0.0033 vs. 0.0252±0.0050/μL, P=0.01). Corneal wave speed was not correlated with age and IOP in either group (P≥0.23) but was correlated with ocular rigidity (R=0.48, P=0.02) and inversely correlated with axial length (R=-0.53, P=0.01) in glaucomatous eyes.

CONCLUSION

Glaucomatous eyes tend to have lower ocular rigidity than healthy eyes with similar age, IOP, and axial length. However, the lack of a difference in corneal wave speed suggests that corneal tissue may not be significantly affected, and scleral changes likely play a more important role in glaucoma.

Suppression of Diurnal (9AM-4PM) IOP Fluctuations with Minimally Invasive Glaucoma Surgery: An Analysis of Data from the Prospective, Multicenter, Single-Arm GEMINI Study

PURPOSE

This study analyzes diurnal IOP data (9AM, 12PM, 4PM) from a prospective 12-month trial of the OMNI Surgical System in open-angle glaucoma (OAG) patients with the aim of evaluating effect of MIGS surgery on the amplitude of the diurnal IOP profile pre- and postoperatively.

SETTING

Fifteen ophthalmology practices and surgery centers located in 14 states in the United States.

DESIGN

Prospective, multicenter, IRB approved study. Patients treated with canaloplasty (360°) and trabeculotomy (180°). Patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on zero to four hypotensive medications.

METHODS

Post-hoc analysis of diurnal IOP data from the multicenter GEMINI study. Analysis includes comparison of IOP preoperatively and at month 12 for each of the diurnal time points, 9AM, 12PM, 4PM, change in magnitude of spread between the maximum IOP and minimum IOP for each patient and the proportions of patients preoperatively and at month 12 with IOPs at or below 25, 21, 18, and 15 mmHg, average variability (standard deviation of the 9AM, 12PM, and 4PM IOP) preoperatively and at month 12.

RESULTS

A total of 128 patients included in this analysis. IOP at each diurnal timepoint was significantly lower postoperatively (p<0.0001). The difference between highest and lowest IOP measurement for each patient averaged 2.8 mmHg preoperatively (SD 2.4, MAX 14, MIN 0) and 1.8 mmHg (SD 1.7, MAX 10, MIN 0) month 12 (P<0.00001). The proportion with IOP ≤ to 25, 21, 18, and 15 mmHg increased; 75%-97%, 27%-88%, 1%-79%, and <1%-56%, respectively. The average variability was greater at all time points preoperatively (P<0.0001).

CONCLUSION

This study demonstrates that eyes with OAG can benefit from an overall decreased IOP and degree of IOP fluctuations for as long as 12 months after surgical treatment with canaloplasty and trabeculotomy.

What Do We Really Know about the Effectiveness of Glaucoma Interventions?: An Overview of Systematic Reviews

PURPOSE

To identify systematic reviews of interventions for glaucoma conditions and to assess their reliability, thereby generating a list of potentially reliable reviews for updating glaucoma practice guidelines.

DESIGN

Cross-sectional study.

PARTICIPANTS

Systematic reviews of interventions for glaucoma conditions.

METHODS

We used a database of systematic reviews and meta-analyses in vision research and eye care maintained by the Cochrane Eyes and Vision United States Satellite. We examined all Cochrane systematic reviews of interventions for glaucoma conditions published before August 7, 2019, and all non-Cochrane systematic reviews of interventions for glaucoma conditions published between January 1, 2014, and August 7, 2019.

MAIN OUTCOME MEASURES

We assessed eligible reviews for reliability, extracted characteristics, and summarized key findings from reviews classified as reliable.

RESULTS

Of the 4451 systematic reviews in eyes and vision identified, 129 met our eligibility criteria and were assessed for reliability. Of these, we classified 49 (38%) as reliable. We found open-angle glaucoma (22/49) to be the condition with the most reviews and medical management (17/49) and intraocular pressure (IOP; 43/49) to be the most common interventions and outcomes studied. Most reviews found a high degree of uncertainty in the evidence, which hinders the possibility of making strong recommendations in guidelines. These reviews found high-certainty evidence about a few topics: reducing IOP helps to prevent glaucoma and its progression, prostaglandin analogs are the most effective medical treatment for lowering IOP, laser trabeculoplasty is as effective as medical treatment as a first-line therapy in controlling IOP, the use of IOP-lowering medications in the perioperative or postoperative periods to accompany laser (e.g., trabeculoplasty) reduces the risk of postoperative IOP spikes, conventional surgery (i.e., trabeculectomy) is more effective than medications in reducing IOP, and antimetabolites and β-radiation improve IOP control after trabeculectomy. The evidence is weak regarding the effectiveness of minimally invasive glaucoma surgeries.

CONCLUSIONS

Most systematic reviews evaluating interventions for glaucoma are of poor reliability. Even among those that may be considered reliable, important limitations exist in the value of information because of the uncertainty of the evidence as well as small and sometimes unimportant clinical differences between interventions.

Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis

IMPORTANCE

Glaucoma affects more than 75 million people worldwide. Intraocular pressure (IOP)-lowering surgery is an important treatment for this disease. Interest in reducing surgical morbidity has led to the introduction of minimally invasive glaucoma surgeries (MIGS). Understanding the comparative effectiveness and safety of MIGS is necessary for clinicians and patients.

OBJECTIVE

To summarize data from randomized clinical trials of MIGS for open-angle glaucoma, which were evaluated in a suite of Cochrane reviews.

DATA SOURCES

The Cochrane Database of Systematic Reviews including studies published before June 1, 2021.

STUDY SELECTION

Reviews of randomized clinical trials comparing MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy.

DATA EXTRACTION AND SYNTHESIS

Data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines by one investigator and confirmed by a second. Methodologic rigor was assessed using the AMSTAR 2 appraisal tool and random-effects network meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

The proportion of participants who did not need to use medication to reduce intraocular pressure (IOP) postsurgery (drop-free). Outcomes were analyzed at short-term (<6 months), medium-term (6-18 months), and long-term (>18 months) follow-up.

RESULTS

Six eligible Cochrane reviews were identified discussing trabecular bypass with iStent or Hydrus microstents, ab interno trabeculotomy with Trabectome, subconjunctival and supraciliary drainage devices, and endoscopic cyclophotocoagulation. Moderate certainty evidence indicated that adding a Hydrus safely improved the likelihood of drop-free glaucoma control at medium-term (relative risk [RR], 1.6; 95% CI, 1.4 to 1.8) and long-term (RR, 1.6; 95% CI, 1.4 to 1.9) follow-up and conferred 2.0-mm Hg (95% CI, -2.7 to -1.3 mm Hg) greater IOP reduction at long-term follow-up, compared with cataract surgery alone. Adding an iStent also safely improved drop-free disease control compared with cataract surgery alone (RR, 1.4; 95% CI, 1.2 to 1.6), but the short-term IOP-lowering effect of the iStent was not sustained. Addition of a CyPass microstent improved drop-free glaucoma control compared with cataract surgery alone (RR, 1.3; 95% CI, 1.1 to 1.5) but was associated with an increased risk of vraision loss. Network meta-analyses supported the direction and magnitude of these results.

CONCLUSIONS AND RELEVANCE

Based on data synthesized in Cochrane reviews, some MIGS may afford patients with glaucoma greater drop-free disease control than cataract surgery alone. Among the products currently available, randomized clinical trial data associate the Hydrus with greater drop-free glaucoma control and IOP lowering than the iStent; however, these effect sizes were small.

Combined structure-function analysis in glaucoma screening

AIM

To assess the applicability of a structure-function (S-F) analysis combining spectral-domain optical coherence tomography (SD-OCT) and standard automated perimetry (SAP) in glaucoma screening in a middle-aged population.

METHODS

A randomised sample of 3001 Caucasian participants aged 45-49 years of the Northern Finland Birth Cohort Eye Study was examined. We performed an eye examination, including 24-2 SAP, optic nerve head (ONH) and retinal nerve fibre layer (RNFL) photography and SD-OCT of the peripapillary RNFL. The S-F report was generated by Forum Glaucoma Workplace software. OCT, SAP and the S-F analysis were evaluated against clinical glaucoma diagnosis, that is, the positive '2 out of 3' rule based on the clinician's evaluation of ONH and RNFL photographs and visual fields (VFs).

RESULTS

At a specificity of 97.5%, the sensitivity for glaucomatous damage was 26% for abnormal OCT, 35% for SAP and 44% for S-F analysis. Estimated areas under the curve were 0.74, 0.85 and 0.76, and the corresponding positive predictive values were 8 %, 10% and 12%, respectively. By applying a classification tree approach combining OCT, SAP and defect localisation data, a sensitivity of 77% was achieved at 90% specificity. In a localisation analysis of glaucomatous structural and functional defects, the correlation with glaucoma increased significantly if the abnormal VF test points were located on borderline or abnormal OCT zones.

CONCLUSION

SAP performs slightly better than OCT in glaucoma screening of middle-aged population. However, the diagnostic capability can be improved by S-F analysis.

Corneal nerve changes following treatment with neurotoxic anticancer drugs

Survival rates of cancer has improved with the development of anticancer drugs including systemic chemotherapeutic agents. However, long-lasting side effects could impact treated patients. Neurotoxic anticancer drugs are specific agents which cause chemotherapy-induced peripheral neuropathy (CIPN), a debilitating condition that severely deteriorates quality of life of cancer patients and survivors. The ocular surface is also prone to neurotoxicity but investigation into the effects of neurotoxic chemotherapy on the ocular surface has been more limited compared to other systemic etiologies such as diabetes. There is also no standardized protocol for CIPN diagnosis with an absence of a reliable, objective method of observing nerve damage structurally. As the cornea is the most densely innervated region of the body, researchers have started to focus on corneal neuropathic changes that are associated with neurotoxic chemotherapy treatment. In-vivo corneal confocal microscopy enables rapid and objective structural imaging of ocular surface microscopic structures such as corneal nerves, while esthesiometers provide means of functional assessment by examining corneal sensitivity. The current article explores the current guidelines and gaps in our knowledge of CIPN diagnosis and the potential role of in-vivo corneal confocal microscopy as a diagnostic or prognostic tool. Corneal neuropathic changes with neurotoxic anticancer drugs from animal research progressing through to human clinical studies are also discussed, with a focus on how these data inform our understanding of CIPN.