The connective tissue phenotype of glaucomatous cupping in the monkey eye - Clinical and research implications

Role of T cell-induced autoimmune response in the pathogenesis of glaucoma

PURPOSE

This review aims to elucidate the role of T cell-induced autoimmune responses in the pathogenesis of glaucoma, focusing on the immunological changes contributing to retinal ganglion cell (RGC) damage.

METHODS

A comprehensive review of recent studies examining immunological mechanisms in glaucoma was conducted. This included analyses of T cell interactions, heat shock proteins (HSPs), and resultant autoimmune responses. Key findings from experimental models and clinical observations were synthesized to present a coherent understanding of immune dynamics in glaucoma.

RESULTS

Glaucoma is a neurodegenerative disease marked by optic nerve atrophy and irreversible vision loss due to RGC damage. The disease is etiologically heterogeneous, with multiple risk factors and pathogenic mechanisms. Recent research highlights the dual immunomodulatory role of T cells in immune protection and injury. T cells, pre-sensitized by bacterial HSPs, can cross-react with endogenous HSPs in RGCs under stress, leading to autoimmune damage. Elevated levels of HSP autoantibodies and abnormal T cell activity have been observed in glaucoma patients, indicating a significant autoimmune component in disease progression.

CONCLUSIONS

T cell-induced autoimmune responses are crucial in the pathogenesis of glaucoma, contributing to RGC degeneration beyond the effects of elevated intraocular pressure. Understanding these immunological mechanisms is vital for developing targeted neuroprotective therapies for glaucoma.

Ferroptosis in Glaucoma: A Promising Avenue for Therapy

Glaucoma, a blind-leading disease largely since chronic pathological intraocular high pressure (ph-IOP). Hitherto, it is reckoned incurable for irreversible neural damage and challenges in managing IOP. Thus, it is significant to develop neuroprotective strategies. Ferroptosis, initially identified as an iron-dependent regulated death that triggers Fenton reactions and culminates in lipid peroxidation (LPO), has emerged as a focal point in multiple tumors and neurodegenerative diseases. Researches show that iron homeostasis play critical roles in the optic nerve (ON) and retinal ganglion cells (RGCs), suggesting targeted treatments could be effective. In glaucoma, apart from neural lesions, disrupted metal balance and increased oxidative stress in trabecular meshwork (TM) are observed. These disturbances lead to extracellular matrix excretion disorders, known as sclerotic mechanisms, resulting in refractory blockages. Importantly, oxidative stress, a significant downstream effect of ferroptosis, is also a key factor in cell senescence. It plays a crucial role in both the etiology and risk of glaucoma. Moreover, ferroptosis also induces non-infectious inflammation, which exacerbate glaucomatous injury. Therefore, the relevance of ferroptosis in glaucoma is extensive and multifaceted. In this review, the study delves into the current understanding of ferroptosis mechanisms in glaucoma, aiming to provide clues to inform clinical therapeutic practices.

Aging, Cellular Senescence, and Glaucoma

Aging is one of the most serious risk factors for glaucoma, and according to age-standardized prevalence, glaucoma is the second leading cause of legal blindness worldwide. Cellular senescence is a hallmark of aging that is defined by a stable exit from the cell cycle in response to cellular damage and stress. The potential mechanisms underlying glaucomatous cellular senescence include oxidative stress, DNA damage, mitochondrial dysfunction, defective autophagy/mitophagy, and epigenetic modifications. These phenotypes interact and generate a sufficiently stable network to maintain the cell senescent state. Senescent trabecular meshwork (TM) cells, retinal ganglion cells (RGCs) and vascular endothelial cells reportedly accumulate with age and stress and may contribute to glaucoma pathologies. Therapies targeting the suppression or elimination of senescent cells have been found to ameliorate RGC death and improve vision in glaucoma models, suggesting the pivotal role of cellular senescence in the pathophysiology of glaucoma. In this review, we explore the biological links between aging and glaucoma, specifically delving into cellular senescence. Moreover, we summarize the current data on cellular senescence in key target cells associated with the development and clinical phenotypes of glaucoma. Finally, we discuss the therapeutic potential of targeting cellular senescence for the management of glaucoma.

Retrolaminar Demyelination of Structurally Intact Axons in Nonhuman Primate Experimental Glaucoma

Purpose

To determine if structurally intact, retrolaminar optic nerve (RON) axons are demyelinated in nonhuman primate (NHP) experimental glaucoma (EG).

Methods

Unilateral EG NHPs (n = 3) were perfusion fixed, EG and control eyes were enucleated, and foveal Bruch's membrane opening (FoBMO) 30° sectoral axon counts were estimated. Optic nerve heads were trephined; serial vibratome sections (VSs) were imaged and colocalized to a fundus photograph establishing their FoBMO location. The peripheral neural canal region within n = 5 EG versus control eye VS comparisons was targeted for scanning block-face electron microscopic reconstruction (SBEMR) using micro-computed tomographic reconstructions (µCTRs) of each VS. Posterior laminar beams within each µCTR were segmented, allowing a best-fit posterior laminar surface (PLS) to be colocalized into its respective SBEMR. Within each SBEMR, up to 300 axons were randomly traced until they ended (nonintact) or left the block (intact). For each intact axon, myelin onset was identified and myelin onset distance (MOD) was measured relative to the PLS. For each EG versus control SBEMR comparison, survival analyses compared EG and control MOD.

Results

MOD calculations were successful in three EG and five control eye SBEMRs. Within each SBEMR comparison, EG versus control eye axon loss was -32.9%, -8.3%, and -15.2% (respectively), and MOD was increased in the EG versus control SBEMR (P < 0.0001 for each EG versus control SBEMR comparison). When data from all three EG eye SBEMRs were compared to all five control eye SBEMRs, MOD was increased within the EG eyes.

Conclusions

Structurally intact, RON axons are demyelinated in NHP early to moderate EG. Studies to determine their functional status are indicated.

Multifunctional adaptive optics optical coherence tomography allows cellular scale reflectometry, polarimetry, and angiography in the living human eye

Clinicians are unable to detect glaucoma until substantial loss or dysfunction of retinal ganglion cells occurs. To this end, novel measures are needed. We have developed an optical imaging solution based on adaptive optics optical coherence tomography (AO-OCT) to discern key clinical features of glaucoma and other neurodegenerative diseases at the cellular scale in the living eye. Here, we test the feasibility of measuring AO-OCT-based reflectance, retardance, optic axis orientation, and angiogram at specifically targeted locations in the living human retina and optic nerve head. Multifunctional imaging, combined with focus stacking and global image registration algorithms, allows us to visualize cellular details of retinal nerve fiber bundles, ganglion cell layer somas, glial septa, superior vascular complex capillaries, and connective tissues. These are key histologic features of neurodegenerative diseases, including glaucoma, that are now measurable in vivo with excellent repeatability and reproducibility. Incorporating this noninvasive cellular-scale imaging with objective measurements will significantly enhance existing clinical assessments, which is pivotal in facilitating the early detection of eye disease and understanding the mechanisms of neurodegeneration.

Dense optic nerve head deformation estimated using CNN as a structural biomarker of glaucoma progression

PURPOSE

To present a new structural biomarker for detecting glaucoma progression based on structural transformation of the optic nerve head (ONH) region over time.

METHODS

Dense ONH deformation was estimated using deep learning methods namely DDCNet-Multires, FlowNet2, and FlowNetCorrelation, and legacy computational methods namely the topographic change analysis (TCA) and proper orthogonal decomposition (POD) methods. A candidate biomarker was estimated as the average magnitude of deformation of the ONH and evaluated using longitudinal confocal scans of 12 laser treated and 12 contralateral normal eyes of 12 primates from the LSU Experimental Glaucoma Study (LEGS); and 36 progressing eyes and 21 longitudinal normal eyes from the UCSD Diagnostic Innovations in Glaucoma Study (DIGS). Area under the ROC curve (AUC) was used to assess the diagnostic accuracy of the biomarker.

RESULTS

AUROC (95% CI) for LEGS were: 0.83 (0.79, 0.88) for DDCNet-Multires; 0.83 (0.78, 0.88) for FlowNet2; 0.83 (0.78, 0.88) for FlowNet-Correlation; 0.94 (0.91, 0.97) for POD; and 0.86 (0.82, 0.91) for TCA methods. For DIGS: 0.89 (0.80, 0.97) for DDCNet-Multires; 0.82 (0.71, 0.93) for FlowNet2; 0.93 (0.86, 0.99) for FlowNet-Correlation; 0.86 (0.76, 0.96) for POD; and 0.86 (0.77, 0.95) for TCA methods. Lower diagnostic accuracy of the learning-based methods for LEG study eyes were due to image alignment errors in confocal sequences.

CONCLUSION

Deep learning methods trained to estimate generic deformation were able to estimate ONH deformation from image sequences and provided a higher diagnostic accuracy. Our validation of the biomarker using ONH sequences from controlled experimental conditions confirms the diagnostic accuracy of the biomarkers observed in the clinical population. Performance can be further improved by fine-tuning these networks using ONH sequences.

Three-Dimensional Structural Phenotype of the Optic Nerve Head as a Function of Glaucoma Severity

Importance

The 3-dimensional (3-D) structural phenotype of glaucoma as a function of severity was thoroughly described and analyzed, enhancing understanding of its intricate pathology beyond current clinical knowledge.

Objective

To describe the 3-D structural differences in both connective and neural tissues of the optic nerve head (ONH) between different glaucoma stages using traditional and artificial intelligence-driven approaches.

Design, Setting, and Participants

This cross-sectional, clinic-based study recruited 541 Chinese individuals receiving standard clinical care at Singapore National Eye Centre, Singapore, and 112 White participants of a prospective observational study at Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania. The study was conducted from May 2022 to January 2023. All participants had their ONH imaged using spectral-domain optical coherence tomography and had their visual field assessed by standard automated perimetry.

Main Outcomes and Measures

(1) Clinician-defined 3-D structural parameters of the ONH and (2) 3-D structural landmarks identified by geometric deep learning that differentiated ONHs among 4 groups: no glaucoma, mild glaucoma (mean deviation [MD], ≥-6.00 dB), moderate glaucoma (MD, -6.01 to -12.00 dB), and advanced glaucoma (MD, <-12.00 dB).

Results

Study participants included 213 individuals without glaucoma (mean age, 63.4 years; 95% CI, 62.5-64.3 years; 126 females [59.2%]; 213 Chinese [100%] and 0 White individuals), 204 with mild glaucoma (mean age, 66.9 years; 95% CI, 66.0-67.8 years; 91 females [44.6%]; 178 Chinese [87.3%] and 26 White [12.7%] individuals), 118 with moderate glaucoma (mean age, 68.1 years; 95% CI, 66.8-69.4 years; 49 females [41.5%]; 97 Chinese [82.2%] and 21 White [17.8%] individuals), and 118 with advanced glaucoma (mean age, 68.5 years; 95% CI, 67.1-69.9 years; 43 females [36.4%]; 53 Chinese [44.9%] and 65 White [55.1%] individuals). The majority of ONH structural differences occurred in the early glaucoma stage, followed by a plateau effect in the later stages. Using a deep neural network, 3-D ONH structural differences were found to be present in both neural and connective tissues. Specifically, a mean of 57.4% (95% CI, 54.9%-59.9%, for no to mild glaucoma), 38.7% (95% CI, 36.9%-40.5%, for mild to moderate glaucoma), and 53.1 (95% CI, 50.8%-55.4%, for moderate to advanced glaucoma) of ONH landmarks that showed major structural differences were located in neural tissues with the remaining located in connective tissues.

Conclusions and Relevance

This study uncovered complex 3-D structural differences of the ONH in both neural and connective tissues as a function of glaucoma severity. Future longitudinal studies should seek to establish a connection between specific 3-D ONH structural changes and fast visual field deterioration and aim to improve the early detection of patients with rapid visual field loss in routine clinical care.

Neuroretinal Rim Response to Transient Intraocular Pressure Challenge Predicts the Extent of Retinal Ganglion Cell Loss in Experimental Glaucoma

Purpose

To determine if the optic nerve head (ONH) response to transient elevated intraocular pressure (IOP) can predict the extent of neural loss in the nonhuman primate experimental glaucoma model.

Methods

The anterior chamber pressure of 21 healthy animals (5.4 ± 1.2 years, 8 female) was adjusted to 25 mm Hg for two hours followed by 10 mm Hg for an additional two hours. For the duration of IOP challenge the ONH was imaged using radial optical coherence tomography (OCT) scans at five-minute intervals. Afterward, a randomized sample of 14 of these subjects had unilateral experimental glaucoma induced and were monitored with OCT imaging, tonometry, and ocular biometry at two-week intervals.

Results

With pressure challenge, the maximum decrease in ONH minimum rim width (MRW) was 40 ± 10.5 µm at 25 mm Hg and was correlated with the precannulation MRW, Bruch's membrane opening (BMO) position, and the anterior lamina cribrosa surface position (P = 0.01). The maximum return of MRW at 10 mm Hg was 16.1 ± 5.0 µm and was not associated with any precannulation ONH feature (P = 0.24). However, healthy eyes with greater thickness return at 10 mm Hg had greater loss of MRW and retinal nerve fiber layer (RNFL) at a cumulative IOP of 1000 mm Hg · days after induction of experimental glaucoma. In addition, MRW and RNFL thinning was correlated with an increase in axial length (P < 0.01).

Conclusion

This study's findings suggest that the ONH's response to transient changes in IOP are associated with features of the ONH and surrounding tissues. The neural rim properties at baseline and the extent of axial elongation are associated with the severity of glaucomatous loss in the nonhuman primate model.

Effects of Myopia and Glaucoma on the Neural Canal and Lamina Cribrosa Using Optical Coherence Tomography

PRCIS

Glaucoma was associated with axial bowing and rotation of Bruchs membrane opening (BMO) and anterior laminar insertion (ALI), skewed neural canal, and deeper anterior lamina cribrosa surface (ALCS). Longer axial length was associated with wider, longer, and more skewed neural canal and flatter ALCS.

PURPOSE

Investigate the effects of myopia and glaucoma in the prelaminar neural canal and anterior lamina cribrosa using 1060-nm swept-source optical coherence tomography.

PATIENTS

19 control (38 eyes) and 38 glaucomatous subjects (63 eyes).

MATERIALS AND METHODS

Participants were imaged with swept-source optical coherence tomography, and the images were analyzed for the BMO and ALI dimensions, prelaminar neural canal dimensions, and ALCS depth.

RESULTS

Glaucomatous eyes had more bowed and nasally rotated BMO and ALI, more horizontally skewed prelaminar neural canal, and deeper ALCS than the control eyes. Increased axial length was associated with a wider, longer, and more horizontally skewed neural canal and a decrease in the ALCS depth and curvature.

CONCLUSION

Our findings suggest that glaucomatous posterior bowing or cupping of lamina cribrosa can be significantly confounded by the myopic expansion of the neural canal. This may be related to higher glaucoma risk associated with myopia from decreased compliance and increased susceptibility to IOP-related damage of LC being pulled taut.

Silicone Oil-Induced Glaucomatous Neurodegeneration in Rhesus Macaques

Previously, we developed a simple procedure of intracameral injection of silicone oil (SO) into mouse eyes and established the mouse SOHU (SO-induced ocular hypertension under-detected) glaucoma model with reversible intraocular pressure (IOP) elevation and significant glaucomatous neurodegeneration. Because the anatomy of the non-human primate (NHP) visual system closely resembles that of humans, it is the most likely to predict human responses to diseases and therapies. Here we tried to replicate the mouse SOHU glaucoma model in rhesus macaque monkeys. All six animals that we tested showed significant retinal ganglion cell (RGC) death, optic nerve (ON) degeneration, and visual functional deficits at both 3 and 6 months. In contrast to the mouse SOHU model, however, IOP changed dynamically in these animals, probably due to individual differences in ciliary body tolerance capability. Further optimization of this model is needed to achieve consistent IOP elevation without permanent damage of the ciliary body. The current form of the NHP SOHU model recapitulates the severe degeneration of acute human glaucoma, and is therefore suitable for assessing experimental therapies for neuroprotection and regeneration, and therefore for translating relevant findings into novel and effective treatments for patients with glaucoma and other neurodegenerations.

Optic nerve cavitations in glaucoma suspect and glaucoma patients

Purpose

Glaucoma is associated with structural changes of the optic nerve head such as deformation, lamina cribosa defects, prelaminar schisis, and peripapillary retinal schisis. We describe optic nerve cavitations that were detected by routine spectral domain optical coherence tomography (OCT).

Observations

OCT imaging showed cavitations in 5 eyes of 4 patients with an initial diagnosis of glaucoma or glaucoma suspect. The cavitations were seen as hyporeflective spaces that are sharply delineated from surrounding tissue. They were centered inferonasally, anterior to the lamina cribosa, and at least partially within the Bruch's membrane opening (BMO). They extended from 3 to 6 clock hours.

Conclusion

AND IMPORTANCE: We describe a new OCT finding in patients with a diagnosis of glaucoma and glaucoma suspect. While previous reports describe cavitations in the choroid in patients with pathological myopia, our patients had minimal refractive error and the cavitations were located within the optic nerve. We will examine these patients over time to determine the impact of this finding on longitudinal changes in structure and function.

Optic Nerve Head Myelin-Related Protein, GFAP, and Iba1 Alterations in Non-Human Primates With Early to Moderate Experimental Glaucoma

Purpose

The purpose of this study was to test if optic nerve head (ONH) myelin basic protein (MBP), 2′,3′-cyclic nucleotide 3′-phosphodiesterase (CNPase), glial fibrillary acidic protein (GFAP), and ionized calcium binding adaptor molecule 1 (Iba1) proteins are altered in non-human primate (NHP) early/moderate experimental glaucoma (EG).

Methods

Following paraformaldehyde perfusion, control and EG eye ONH tissues from four NHPs were paraffin embedded and serially (5 µm) vertically sectioned. Anti-MBP, CNPase, GFAP, Iba1, and nuclear dye-stained sections were imaged using sub-saturating light intensities. Whole-section images were segmented creating anatomically consistent laminar (L) and retrolaminar (RL) regions/sub-regions. EG versus control eye intensity/pixel-cluster density data within L and two RL regions (RL1 [1-250 µm]/RL2 [251-500 µm] from L) were compared using random effects models within the statistical program “R.”

Results

EG eye retinal nerve fiber loss ranged from 0% to 20%. EG eyes’ MBP and CNPase intensity were decreased within the RL1 (MBP = 31.4%, P < 0.001; CNPase =62.3%, P < 0.001) and RL2 (MBP = 19.6%, P < 0.001; CNPase = 56.1%, P = 0.0004) regions. EG eye GFAP intensity was decreased in the L (41.6%, P < 0.001) and RL regions (26.7% for RL1, and 28.4% for RL2, both P < 0.001). Iba1+ and NucBlue pixel-cluster density were increased in the laminar (28.2%, P = 0.03 and 16.6%, P = 0.008) and both RL regions (RL1 = 37.3%, P = 0.01 and 23.7%, P = 0.0002; RL2 = 53.7%, P = 0.002 and 33.2%, P < 0.001).

Conclusions

Retrolaminar myelin disruption occurs early in NHP EG and may be accompanied by laminar and retrolaminar decreases in astrocyte process labeling and increases in microglial/ macrophage density. The mechanistic and therapeutic implications of these findings warrant further study.

Difference in topographic morphology of optic nerve head and neuroretinal rim between normal tension glaucoma and central retinal artery occlusion

Although central retinal artery occlusion (CRAO) has its own defining pathomechanism and clinical characteristics, morphologic feature of the optic nerve head (ONH) during its later stage is not diagnostic, which makes it difficult to differentiate CRAO from other optic neuropathies. This cross-sectional study was performed to investigate the differences in the topographic morphology of the ONH in eyes with normal-tension glaucoma (NTG) and CRAO. Thirty-one eyes with NTG; 31 eyes with CRAO; and 31 healthy fellow eyes of the subjects with CRAO were included. ONH morphology was evaluated by measuring horizontal rim width (HRW), minimal rim width in the selected horizontal image (MRW), and lamina cribrosa curvature index (LCCI) in horizontal B-scan images obtained using enhanced depth-imaging optical coherence tomography. HRW was smaller and LCCI was larger in NTG eyes than in both CRAO and healthy fellow eyes (both P < 0.001), while both were comparable between CRAO and healthy fellow eyes. MRW differed significantly among the three groups, being smallest in NTG eyes followed by CRAO and healthy fellow eyes (P < 0.001). NTG and CRAO eyes with a similar degree of RNFL loss differed in ONH morphology, indicating that mechanisms of ONH damage differ between these two conditions.

From Bench to Bed: The Current Genome Editing Therapies for Glaucoma

Glaucoma is a group of optic neuropathies featured by degeneration of retinal ganglion cells and loss of their axons in the optic nerve. The only currently approved therapies focus on lowering intraocular pressure with medication and surgery. Over the previous few decades, technological advances and research progress regarding pathogenesis has brought glaucomatous gene therapy to the forefront. In this review, we discuss the three current genome editing methods and potential disease mechanisms of glaucoma. We further summarize different genome editing strategies that are being developed to target a number of glaucoma-related genes and pathways from four aspects including strategies to lower intraocular pressure, neuroprotection, RGC and optic nerve neuro-regeneration, and other strategies. In summary, genome therapy is a promising therapy for treating patients with glaucoma and has great potential to be widely applied in clinical practice.

Postradiation Optic Atrophy Is Associated With Intraocular Pressure and May Manifest With Neuroretinal Rim Thinning

BACKGROUND

To determine risk factors for postradiation optic atrophy (PROA) after plaque radiotherapy for uveal melanoma.

METHODS

A single center, retrospective cohort study of patients diagnosed with uveal melanoma involving choroid and/or ciliary body treated with plaque between January 1, 2008, and December 31, 2016. Outcomes included development of PROA with pallor alone or with concomitant neuroretinal rim thinning (NRT). Cox regression analysis was performed to identify risk factors for PROA.

RESULTS

Of 78 plaque-irradiated patients, PROA developed in 41 (53%), with concomitant NRT in 15 (19%). Risk factors for PROA of any type included presentation with worse visual acuity (odds ratio [95% confidence interval] 5.6 [2.3-14.1], P < 0.001), higher baseline intraocular pressure (IOP; 14 vs 16 mm Hg) (1.1 [1.0-1.2], P = 0.03), shorter tumor distance to optic disc (1.3 [1.2-1.5], P < 0.001) and foveola (1.2 [1.1-1.3], P < 0.001), subfoveal subretinal fluid (3.8 [2.0-7.1], P < 0.001), greater radiation prescription depth (1.3 [1.1-1.6], P = 0.002), dose to fovea (point dose) (1.01 [1.01-1.02], P < 0.001), and mean (1.02 [1.02-1.03], P < 0.001) and maximum dose to optic disc per 1 Gy increase (1.02 [1.01-1.03], P < 0.001). On multivariate modeling, dose to disc, baseline IOP, and subfoveal fluid remained significant. Subanalysis revealed risk factors for pallor with NRT of greater mean radiation dose to disc (1.03 [1.01-1.05], P = 0.003), higher maximum IOP (17 vs 20 mm Hg) (1.4 [1.2-1.7], P < 0.001), and subfoveal fluid (12 [2-63], P = 0.004).

CONCLUSION

PROA may result in NRT in addition to optic disc pallor. Risk factors for PROA included higher radiation dose to optic disc, higher baseline IOP, and subfoveal fluid. Higher maximum IOP contributed to concomitant NRT.

Corneal Biomechanics in Glaucoma

Now that is possible to measure the biomechanical parameters of the cornea in vivo, scientific and clinical interest has increased in changes in these parameters in glaucoma. These parameters may act as biomarkers for early diagnosis, but also serve to emphasize the increased vulnerability to intraocular pressure, reduced blood flow or changing ocular perfusion pressure. Measuring and interpreting these parameters may help in achieving better and individually tailored glaucoma management.

Bruch Membrane Opening Minimum Rim Width and Retinal Nerve Fiber Layer Helps Differentiate Compressive Optic Neuropathy From Glaucoma

PURPOSE

To compare optical coherence tomography-measured Bruch membrane opening minimum rim width (MRW), peripapillary retinal nerve fiber layer (pRNFL) measurements, and MRW:pRNFL ratios in eyes with compressive optic neuropathy (CON) and glaucoma and controls, and evaluate the ability of these parameters to differentiate CON from glaucoma.

DESIGN

Prospective, cross-sectional study.

METHODS

Setting: Single-center tertiary hospital and outpatient clinic.

PATIENT POPULATION

One hundred fifteen eyes of 77 participants, 34 with CON from chiasmal lesions, 21 with glaucoma, and 22 healthy controls.

OBSERVATION PROCEDURES

Optical coherence tomography-measured MRW, pRNFL, and MRW:pRNFL ratios for each optic disc sector and global average.

MAIN OUTCOME MEASURES

MRW, pRNFL, and MRW:pRNFL ratios compared using generalized estimated equations. Area under the receiver operating characteristic curve and positive and negative likelihood ratios were calculated.

RESULTS

MRW and pRNFL measurements were significantly reduced in CON and glaucoma compared with controls. In glaucoma, MRW was thinner than in CON in the global, inferotemporal, superonasal, inferonasal, and vertical average measurements, but a significant overlap was observed in many parameters. MRW:pRNFL ratios increased the ability to discriminate between CON and glaucoma, as shown by the high area under the receiver operating characteristic curve, high positive likelihood ratios, and low negative likelihood ratios, especially in the nasal disc sector and the nasal and temporal average.

CONCLUSIONS

MRW measurements alone cannot reliably distinguish CON from glaucoma, but the combination of MRW, pRNFL, and MRW:pRNFL ratios significantly improves accuracy. When comparing the 2 conditions, MRW:pRNFL ratios yielded higher area under the receiver operating characteristic curve and positive and negative likelihood ratios, suggesting this parameter may be helpful in clinical practice.

Lamina cribrosa vessel and collagen beam networks are distinct

Our goal was to analyze the spatial interrelation between vascular and collagen networks in the lamina cribrosa (LC). Specifically, we quantified the percentages of collagen beams with/without vessels and of vessels inside/outside of collagen beams. To do this, the vasculature of six normal monkey eyes was labeled by perfusion post-mortem. After enucleation, coronal cryosections through the LC were imaged using fluorescence and polarized light microscopy to visualize the blood vessels and collagen beams, respectively. The images were registered to form 3D volumes. Beams and vessels were segmented, and their spatial interrelationship was quantified in 3D. We found that 22% of the beams contained a vessel (range 14%-32%), and 21% of vessels were outside beams (13%-36%). Stated differently, 78% of beams did not contain a vessel (68%-86%), and 79% of vessels were inside a beam (64%-87%). Individual monkeys differed significantly in the fraction of vessels outside beams (p < 0.01 by linear mixed effect analysis), but not in the fraction of beams with vessels (p > 0.05). There were no significant differences between contralateral eyes in the percent of beams with vessels and of vessels outside beams (p > 0.05). Our results show that the vascular and collagenous networks of the LC in monkey are clearly distinct, and the historical notions that each LC beam contains a vessel and all vessels are within beams are inaccurate. We postulate that vessels outside beams may be relatively more vulnerable to mechanical compression by elevated IOP than are vessels shielded inside of beams.

Clinical Features of Advanced Glaucoma With Optic Nerve Head Prelaminar Schisis

PURPOSE

To investigate the clinical characteristics of optic nerve head (ONH) prelaminar schisis in eyes with advanced glaucoma.

DESIGN

Cross-sectional study.

METHODS

One hundred sixteen eyes with advanced glaucoma (30-2 mean deviation <-12 dB) were included. ONH prelaminar schisis was identified using the spectral-domain optical coherence tomography independently by 2 evaluators and only eyes that reached consensus for the presence of ONH prelaminar schisis were included. Bruch membrane opening-minimum rim width (BMO-MRW), thickness and depth of lamina cribrosa (LC), peripapillary retinal nerve fiber layer (RNFL) thickness, macular thickness (total, RNFL, ganglion cell layer, inner plexiform layer), and peripapillary and subfoveal choroidal thickness were additionally obtained. Clinical characteristics were compared between the 2 groups based on the presence of ONH prelaminar schisis.

RESULTS

ONH prelaminar schisis was identified in 48 of 116 eyes. Multivariate logistic regression analysis revealed that short axial length, thin and deep LC, and thick macula were associated with the presence of ONH prelaminar schisis. When the structure-function relationships were determined, macular structural parameters tended to have a better relationship with functional parameters than the BMO-MRW and peripapillary RNFL thickness parameters in eyes with ONH prelaminar schisis.

CONCLUSIONS

The ONH prelaminar schisis was associated with thin and deep LC, short axial length, and generally thick macula. In patients with this features, the macular measurements, rather than peripapillary or ONH measurements, better predict the functional status of the eye. Our findings may have significant clinical implications for management of advanced glaucoma eyes with and without ONH prelaminar schisis.

Age and intraocular pressure in murine experimental glaucoma

Age and intraocular pressure (IOP) are the two most important risk factors for the development and progression of open-angle glaucoma. While IOP is commonly considered in models of experimental glaucoma (EG), most studies use juvenile or adult animals and seldom older animals which are representative of the human disease. This paper provides a concise review of how retinal ganglion cell (RGC) loss, the hallmark of glaucoma, can be evaluated in EG with a special emphasis on serial in vivo imaging, a parallel approach used in clinical practice. It appraises the suitability of EG models for the purpose of in vivo imaging and argues for the use of models that provide a sustained elevation of IOP, without compromise of the ocular media. In a study with parallel cohorts of adult (3-month-old, equivalent to 20 human years) and old (2-year-old, equivalent to 70 human years) mice, we compare the effects of elevated IOP on serial ganglion cell complex thickness and individual RGC dendritic morphology changes obtained in vivo. We also evaluate how age modulates the impact of elevated IOP on RGC somal and axonal density in histological analysis as well the density of melanopsin RGCs. We discuss the challenges of using old animals and emphasize the potential of single RGC imaging for understanding the pathobiology of RGC loss and evaluating new therapeutic avenues.

Strain by virtual extensometers and video-imaging optical coherence tomography as a repeatable metric for IOP-Induced optic nerve head deformations

PURPOSE

To determine if in vivo strain response of the Optic Nerve Head (ONH) to IOP elevation visualized using Optical Coherence Tomography (OCT) video imaging and quantified using novel virtual extensometers was able to be provided repeatable measurements of tissue specific deformations.

METHODS

The ONHs of 5 eyes from 5 non-human primates (NHPs) were imaged by Spectralis OCT. A vertical and a horizontal B-scan of the ONH were continuously recorded for 60 s at 6 Hz (video imaging mode) during IOP elevation from 10 to 30 mmHg. Imaging was repeated over three imaging sessions. The 2D normal strain was computed by template-matching digital image correlation using virtual extensometers. ANOVA F-test (F) was used to compare inter-eye, inter-session, and inter-tissue variability for the prelaminar, Bruch's membrane opening (BMO), lamina cribrosa (LC) and choroidal regions (against variance the error term). F-test of the ratio between inter-eye to inter-session variability was used to test for strain repeatability across imaging sessions (FIS).

RESULTS

Variability of strain across imaging session (F = 0.7263, p = 0.4855) and scan orientation was not significant (F = 1.053, p = 0.3066). Inter session variability of strain was significantly lower than inter-eye variability (FIS = 22.63, p = 0.0428) and inter-tissue variability (FIS = 99.33 p = 0.00998). After IOP elevation, strain was highest in the choroid (-18.11%, p < 0.001), followed by prelaminar tissue (-11.0%, p < 0.001), LC (-3.79%, p < 0.001), and relative change in BMO diameter (-0.57%, p = 0.704).

CONCLUSIONS

Virtual extensometers applied to video-OCT were sensitive to the eye-specific and tissue-specific mechanical response of the ONH to IOP and were repeatable across imaging sessions.

Advanced Retinal Imaging and Ocular Parameters of the Rhesus Macaque Eye

Purpose

To determine the range of normal ocular biometry and perform advanced retinal imaging and functional assessment of the rhesus macaque eye.

Methods

We performed ocular phenotyping on rhesus macaques at the California National Primate Research Center. This process consisted of anterior and posterior segment eye examination by ophthalmologists, advanced retinal imaging, and functional retinal electrophysiology.

Results

Full eye examinations were performed on 142 animals, consisting of pupillary light reflex, tonometry, external examination and photography, anterior slit lamp examination, and posterior segment examination by indirect ophthalmoscopy. Ages of the rhesus macaques ranged from 0.7 to 29 years (mean, 16.4 ± 7.5 years). Anterior segment measurements such as intraocular pressure (n = 142), corneal thickness (n = 84), lens thickness (n = 114), and axial length (n = 114) were acquired. Advanced retinal imaging in the form of fundus photography (n = 78), optical coherence tomography (n = 60), and quantitative autofluorescence (n = 44) was obtained. Electroretinography (n = 75) was used to assay retinal function. Quantitative analyses of the macular structure, retinal layer segmentation, and rod and cone photoreceptor electrical responses are reported. Quantitative assessments were made and variations between sexes were analyzed to compare with established sex changes in human eyes.

Conclusions

The rhesus macaque has an ocular structure and function very similar to that of the human eye. In particular macular structure and retinal function is very similar to humans, making this species particularly useful for the study of macular biology and development of therapies for cone photoreceptor disorders.

Translational Relevance

Rhesus macaques are an ideal model for future vision science studies of human eye diseases.

Optic Nerve Head Morphological Changes Over 12 Hours in Seated and Head-Down Tilt Postures

Purpose

The purpose of this study was to determine changes in optic nerve head (ONH) morphology in seated and 6° head-down tilt (HDT) postures over a 12-hour period.

Methods

Thirty eyes of 30 healthy human subjects (15 females) were included. Composite radial and circular optical coherence tomography (OCT) scans centered on the ONH, intraocular pressure (IOP), and optic nerve sheath diameter (ONSD) were acquired every two hours from 7 a.m. to 7 p.m. for both seated (n = 30) and HDT (n = 10) sessions. Global minimum rim width (BMO-MRW), total retinal thickness (TRT), retinal nerve fiber layer thickness (RNFLT), and Bruch's membrane opening (BMO) height were quantified.

Results

BMO-MRW decreased an average of 9.55 ± 8.03 µm (P < 0.01) over 12 hours in a seated position (range, -26.64 to +3.36 µm), and thinning was greater in females (-13.56 vs. -5.55 µm, P = 0.004). Modest decreases in TRT from the BMO to 500 µm (P < 0.04) and RNFLT for the 2.7, 3.5, and 4.2 mm circular scans (P < 0.02) were also observed. BMO-MRW thinning was not related to changes in IOP or ONSD (P = 0.34). In HDT, IOP and ONSD increased, BMO height moved anteriorly, and BMO-MRW thinning did not occur (P > 0.1).

Conclusions

The neuroretinal rim thins throughout the day in healthy individuals, and this change cannot be explained by changes in IOP or ONSD during the same time period. A HDT posture blunts the neuroretinal rim thinning observed in a seated position, suggesting a role of the translaminar pressure difference.

Reduced Oxidative Phosphorylation and Increased Glycolysis in Human Glaucoma Lamina Cribrosa Cells

Purpose

The lamina cribrosa (LC) is a key site of damage in glaucomatous optic neuropathy. We previously found that glaucoma LC cells have an increased profibrotic gene expression, with mitochondrial dysfunction in the form of decreased mitochondrial membrane potential. Altered cell bioenergetics have recently been reported in organ fibrosis and in cancer. In this study, we carried out a systematic mitochondrial bioenergetic assessment and measured markers of alternative sources of cellular energy in normal and glaucoma LC cells.

Methods

LC cells from three glaucoma donors and three age-matched normal controls were assessed using VICTOR X4 Perkin Elmer (Waltham, MA) plate reader with different phosphorescent and luminescent probes. adenosine triphosphate levels, oxygen consumption rate, and extracellular acidification were measured and normalized to total protein content. RNA and protein expression levels of MCT1, MCT4, MTFHD2, and GLS2 were quantified using real-time RT-PCR and Western blotting.

Results

Glaucoma LC cells contain significantly less adenosine triphosphate (P < .05) when supplied with either glucose or galactose. They also showed significantly diminished oxygen consumption in both basal and maximal respiration with more lactic acid contribution in ECA. Both mRNA and protein expression levels of MCT1, MCT4, MTHFD2, and GLS2 were significantly increased in glaucoma LC cells.

Conclusions

We demonstrate evidence of metabolic reprogramming (The Warburg effect) in glaucoma LC cells. Expression of markers of glycolysis, glutamine, and one carbon metabolism are elevated in glaucoma cells at both the mRNA and protein levels. A better understanding of bioenergetics in glaucoma may help in the development of new therapeutics.

So-Called Lamina Cribrosa Defects May Mitigate IOP-Induced Neural Tissue Insult

Purpose

The prevailing theory about the function of lamina cribrosa (LC) connective tissues is that they provide structural support to adjacent neural tissues. Missing connective tissues would compromise this support and therefore are regarded as “LC defects”, despite scarce actual evidence of their role. We examined how so-called LC defects alter IOP-related mechanical insult to the LC neural tissues.

Methods

We built numerical models incorporating LC microstructure from polarized light microscopy images. To simulate LC defects of varying sizes, individual beams were progressively removed. We then compared intraocular pressure (IOP)-induced neural tissue deformations between models with and without defects. To better understand the consequences of defect development, we also compared neural tissue deformations between models with partial and complete loss of a beam.

Results

The maximum stretch of neural tissues decreased non-monotonically with defect size. Maximum stretch in the model with the largest defect decreased by 40% in comparison to the model with no defects. Partial loss of a beam increased the maximum stretch of neural tissues in its adjacent pores by 162%, compared with 63% in the model with complete loss of a beam.

Conclusions

Missing LC connective tissues can mitigate IOP-induced neural tissue insult, suggesting that the role of the LC connective tissues is more complex than simply fortifying against IOP. The numerical models further predict that partial loss of a beam is biomechanically considerably worse than complete loss of a beam, perhaps explaining why defects have been reported clinically but partial beams have not.

Changes in circumpapillary retinal vessel density after acute primary angle closure episode via OCT angiography

PURPOSE

To investigate the changes and evaluate the diagnosis value of circumpapillary vessel density (VD) in cases of acute primary angle closure (APAC).

DESIGN

Case-control study.

METHODS

APAC patients with a history of unilateral acute attack were enrolled. The eyes with acute episode constituted the case group while the contralateral eyes without attack consisted of the control group. Ophthalmic examinations including slit-lamp examination, best-corrected visual acuity, intraocular pressure and visual field were carried out. Retinal nerve fiber layer (RNFL), macular ganglion cell complex (GCC) were measured by spectral-domain optical coherence tomography, while VD was assessed by optical coherence tomography angiography.

RESULTS

The whole en face image vessel density (wiVD), circumpapillary vessel density (cpVD) and inside disk VD for both all vessels and capillary were all significantly lower in the APAC eyes compared to the fellow eyes (P < 0.01 for all). In APAC eyes, the wiVD, inside disk VD and cpVD both for all vessels and capillary were all positively correlated with RNFL and GCC thicknesses but negatively correlated with the mean deviation (MD), pattern standard deviation (PSD) and the duration of acute attack (all P < 0.01). From the ROC curve, the cpVD_cap, wiVD_cap, cpVD_all and wiVD_all all showed comparable diagnostic ability with RNFL, GCC and MD to differentiate eyes with APAC from the fellow eyes (all P > 0.05). The inside disk VD_cap and VD_all demonstrated significant lower diagnostic ability than the cpVD_cap, wiVD_cap, cpVD_all and wiVD_all (all P < 0.001).

CONCLUSIONS

In APAC eyes, circumpapillary VD decreased significantly compared with the fellow unaffected eyes. They were significantly correlated with thicknesses of RNFL and GCC, and visual field MD and PSD in the APAC eyes. The patients with longer duration of acute attack were more likely to have lower cpVD. For APAC, the diagnostic ability of wiVD and cpVD was similar with RNFL, GCC and MD and was higher than inside disk VD.

Individual-Specific Modeling of Rat Optic Nerve Head Biomechanics in Glaucoma

Glaucoma is the second leading cause of blindness worldwide and is characterized by the death of retinal ganglion cells (RGCs), the cells that send vision information to the brain. Their axons exit the eye at the optic nerve head (ONH), the main site of damage in glaucoma. The importance of biomechanics in glaucoma is indicated by the fact that elevated intraocular pressure (IOP) is a causative risk factor for the disease. However, exactly how biomechanical insult leads to RGC death is not understood. Although rat models are widely used to study glaucoma, their ONH biomechanics have not been characterized in depth. Therefore, we aimed to do so through finite element (FE) modeling. Utilizing our previously described method, we constructed and analyzed ONH models with individual-specific geometry in which the sclera was modeled as a matrix reinforced with collagen fibers. We developed eight sets of scleral material parameters based on results from our previous inverse FE study and used them to simulate the effects of elevated IOP in eight model variants of each of seven rat ONHs. Within the optic nerve, highest strains were seen inferiorly, a pattern that was consistent across model geometries and model variants. In addition, changing the collagen fiber direction to be circumferential within the peripapillary sclera resulted in more pronounced decreases in strain than changing scleral stiffness. The results from this study can be used to interpret data from rat glaucoma studies to learn more about how biomechanics affects RGC pathogenesis in glaucoma.

Association of Optic Nerve Head Prelaminar Schisis With Glaucoma

PURPOSE

To compare the frequency of observing optic nerve head (ONH) prelaminar schisis by optical coherence tomography (OCT) in glaucoma and glaucoma suspect (GL/S) eyes vs healthy control (HC) eyes and to assess its association with other markers of glaucoma severity.

METHODS

This cross-sectional study included 298 eyes of 150 GL/S patients and 88 eyes of 44 HCs. OCT scans were obtained, including 24 radial B-scans, each composed of 768 A-lines spanning 15°, centered on the ONH. Two reviewers masked to all other clinical, demographic, and ocular information independently graded the OCT scans for the presence of ONH prelaminar schisis on a 4-point scale of 0 (none) to 3 (severe). The probability of ONH schisis was compared between groups and against demographic and ocular factors, including structural and functional measures of glaucoma severity.

RESULTS

The frequency and severity of ONH prelaminar schisis were greater in GL/S than in HC (P = .009). Among the GL/S group, 165 eyes (55.4%) had no visible schisis (Grade 0), 71 (23.8%) had Grade 1, 46 (15.4%) had Grade 2 and 16 (5.4%) had Grade 3 schisis. Among HC eyes, 59 (67.0%) had Grade 0, 24 (27.3%) had Grade 1, 5 (5.7%) had Grade 2, none had Grade 3. ONH schisis was more common in eyes with thinner MRW and a deeper cup.

CONCLUSIONS

ONH prelaminar schisis may be a sign of glaucomatous deformation and reflect ongoing pathophysiological damage. ONH prelaminar schisis can impact OCT image segmentation and diagnostic parameters, resulting in substantial overestimation of the true rim tissue thickness and underestimation of cup depth.

Microstructure and resident cell-types of the feline optic nerve head resemble that of humans

The lamina cribrosa (LC) region of the optic nerve head (ONH) is considered a primary site for glaucomatous damage. In humans, biology of this region reflects complex interactions between retinal ganglion cell (RGC) axons and other resident ONH cell-types including astrocytes, lamina cribrosa cells, microglia and oligodendrocytes, as well as ONH microvasculature and collagenous LC beams. However, species differences in the microanatomy of this region could profoundly impact efforts to model glaucoma pathobiology in a research setting. In this study, we characterized resident cell-types, ECM composition and ultrastructure in relation to microanatomy of the ONH in adult domestic cats (Felis catus). Longitudinal and transverse cryosections of ONH tissues were immunolabeled with astrocyte, microglia/macrophage, oligodendrocyte, LC cell and vascular endothelial cell markers. Collagen fiber structure of the LC was visualized by second harmonic generation (SHG) with multiphoton microscopy. Fibrous astrocytes form glial fibrillary acidic protein (GFAP)-positive glial columns in the pre-laminar region, and cover the collagenous plates of the LC region in lamellae oriented perpendicular to the axons. GFAP-negative and alpha-smooth muscle actin-positive LC cells were identified in the feline ONH. IBA-1 positive immune cells and von Willebrand factor-positive blood vessel endothelial cells are also identifiable throughout the feline ONH. As in humans, myelination commences with a population of oligodendrocytes in the retro-laminar region of the feline ONH. Transmission electron microscopy confirmed the presence of capillaries and LC cells that extend thin processes in the core of the collagenous LC beams. In conclusion, the feline ONH closely recapitulates the complexity of the ONH of humans and non-human primates, with diverse ONH cell-types and a robust collagenous LC, within the beams of which, LC cells and capillaries reside. Thus, studies in a feline inherited glaucoma model have the potential to play a key role in enhancing our understanding of ONH cellular and molecular processes in glaucomatous optic neuropathy.

Visible-Light Optical Coherence Tomography Fibergraphy for Quantitative Imaging of Retinal Ganglion Cell Axon Bundles

Purpose

To develop a practical technique for visualizing and quantifying retinal ganglion cell (RGC) axon bundles in vivo.

Methods

We applied visible-light optical coherence tomography (vis-OCT) to image the RGC axon bundles, referred to as vis-OCT fibergraphy, of healthy wild-type C57BL/6 mice. After vis-OCT imaging, retinas were flat-mounted, immunostained with anti-beta-III tubulin (Tuj1) antibody for RGC axons, and imaged with confocal microscopy. We quantitatively compared the RGC axon bundle networks imaged by in vivo vis-OCT and ex vivo confocal microscopy using semi-log Sholl analysis.

Results

Side-by-side comparison of ex vivo confocal microscopy and in vivo vis-OCT confirmed that vis-OCT fibergraphy captures true RGC axon bundle networks. The semi-log Sholl regression coefficients extracted from vis-OCT fibergrams (3.7 ± 0.8 mm^–1) and confocal microscopy (3.6 ± 0.3 mm^–1) images also showed good agreement with each other (n = 6).

Conclusions

We demonstrated the feasibility of using vis-OCT fibergraphy to visualize RGC axon bundles. Further applying Sholl analysis has the potential to identify biomarkers for non-invasively assessing RGC health.

Translational Relevance

Our novel technique for visualizing and quantifying RGC axon bundles in vivo provides a potential measurement tool for diagnosing and tracking the progression of optic neuropathies.

Relationship between Three-Dimensional Magnetic Resonance Imaging Eyeball Shape and Optic Nerve Head Morphology

PURPOSE

To determine if the 3-dimensional (3D) eyeball shape is associated with the positions of the central retinal vascular trunk (CRVT) and the externally oblique border (EOB) in the optic nerve head (ONH).

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

Fifty-six subjects (112 eyes) with a diagnosis of glaucoma or glaucoma suspect.

METHODS

The eyeball shape on 3D magnetic resonance imaging (MRI) scans was classified according to the dimension of the longest diameter: axial dimension (prolate sphere), group 1; horizontal dimension (horizontally oblate sphere), group 2; and vertical dimension (vertically oblate sphere), group 3. The deviation of the CRVT, as a surrogate of lamina cribrosa (LC) shift, was measured from the center of the Bruch's membrane opening (BMO) demarcated by OCT imaging, with the horizontal midline as 0° and the superior location as a positive value. The angular location of the longest EOB was also measured.

MAIN OUTCOME MEASURE

Positions of CRVT and EOB according to the 3D eyeball shape.

RESULTS

Among 112 eyes, 54 (48%) had a prolate shape (group 1), 23 (21%) had a horizontally oblate shape (group 2), and 35 (31%) had a vertically oblate shape (group 3). The angular deviation of the CRVT differed among the groups: to the nasal side in group 1, to the temporal side in group 2, and along the vertical meridian in group 3. In cases of asymmetric eyeball shape, the CRVT was deviated toward the undergrown side from the overgrown side, regardless of grouping. The angular location of the longest EOB was in the direction opposite to the CRVT position (P < 0.001). A generalized estimating equation analysis revealed that the temporal location of the CRVT was associated with older age (P = 0.001), nasal location of the longest EOB (P < 0.001), and oblate shape of the eyeball (P < 0.001, group 2; P = 0.007, group 3).

CONCLUSIONS

The position of the CRVT and EOB were associated with the 3D eyeball shape. Considering that infant ONH morphology is highly uniform, various modes of eyeball expansion during growth can result in diverse directionalities of offset between the LC and the BMO in adults.

Comparison of Lamina Cribrosa Morphology in Eyes with Ocular Hypertension and Normal-Tension Glaucoma

Purpose

To characterize differences in the lamina cribrosa (LC) morphology between healthy, ocular hypertension (OHT), and naive normal-tension glaucoma (NTG) eyes.

Methods

Each group consisted of 80 eyes of 80 participants who were matched for age, sex, and axial length. The participants underwent enhanced-depth-imaging volume scanning of the optic nerve head using spectral-domain optical coherence tomography. The lamina cribrosa curvature index (LCCI) and lamina cribrosa thickness (LCT) were measured in horizontal B-scan images spaced equidistantly across the vertical diameter of the optic disc.

Results

The LCCIs in all seven planes were smaller in both OHT and healthy eyes than in NTG eyes (all P < 0.001), and did not differ significantly between the OHT and healthy eyes. The LCTs in all three planes were greatest in OHT eyes followed by healthy and then NTG eyes (all P < 0.001). Overall, the larger LCCI was associated with smaller LCT (P < 0.001).

Conclusions

The LC was thin and steeply curved in NTG eyes than in healthy and OHT eyes. In OHT eyes, the LC was thick, and its curvature was comparable to healthy eyes. Longitudinal studies are required to examine whether the straight and thickened LCs in OHT eyes precede the onset of OHT or are a protective response to elevated intraocular pressure.

Role of radially aligned scleral collagen fibers in optic nerve head biomechanics

Collagen fibers organized circumferentially around the canal in the peripapillary sclera are thought to provide biomechanical support to the sensitive tissues within the optic nerve head (ONH). Recent studies have demonstrated the existence of a family of fibers in the innermost sclera organized radially from the scleral canal. Our goal was to determine the role of these radial fibers in the sensitivity of scleral canal biomechanics to acute increases in intraocular pressure (IOP). Following the same general approach of previous parametric sensitivity studies, we created nonlinear generic finite element models of a posterior pole with various combinations of radial and circumferential fibers at an IOP of 0 mmHg. We then simulated the effects of normal and elevated IOP levels (15 and 30 mmHg). We monitored four IOP-induced geometric changes: peripapillary sclera stretch, scleral canal displacement, lamina cribrosa displacement, and scleral canal expansion. In addition, we examined the radial (maximum tension) and through-thickness (maximum compression) strains within the ONH tissues. Our models predicted that: 1) radial fibers reduced the posterior displacement of the lamina, especially at elevated IOP; 2) radial fibers reduced IOP-induced radial strain within the peripapillary sclera and retinal tissue; and 3) a combination of radial and circumferential fibers maintained strains within the ONH at a level similar to those conferred by circumferential fibers alone. In conclusion, radial fibers provide support for the posterior globe, additional to that provided by circumferential fibers. Most importantly, a combination of both fiber families can better protect ONH tissues from excessive IOP-induced deformation than either alone.

Clinical Assessment of Scleral Canal Area in Glaucoma Using Spectral-Domain Optical Coherence Tomography

PURPOSE

To investigate anterior scleral canal (ASC) area in the eyes with glaucoma using spectral-domain optical coherence tomography (SDOCT).

DESIGN

Cross-sectional study.

METHODS

This study included 206 eyes of 103 patients with glaucoma, classified as 66 eyes of 33 patients with unilateral glaucoma and 140 eyes of 70 patients with bilateral glaucoma. Radial scan enhanced depth imaging SDOCT centered on the optic disc was performed, and parameters that present ASC area such as ASC opening and the largest ASC area were obtained in each eye. The largest ASC area was the largest cross-sectional area of the ASC region identified between the ASC opening and anterior lamina cribrosa insertion. These parameters were compared between eyes with and without glaucoma in unilateral glaucoma, and eyes with worse and better visual field defect (VFD) in bilateral glaucoma.

RESULTS

In the patients with unilateral glaucoma, ASC opening and largest ASC area were significantly larger in the eyes with glaucoma than in those without glaucoma (both P < .001). In bilateral glaucoma, these parameters were significantly larger in the eyes with worse VFD than in those with better VFD (P = .0080 and P = .0018, respectively). Intereye differences of the ASC parameters in the glaucoma patients were significantly greater than that in the normal subjects.

CONCLUSIONS

Significantly larger ASC area was first observed in the living human eyes with glaucoma compared to the normal eyes. Further longitudinal studies are required to determine if the ASC area is useful in the prevention and treatment of glaucoma.

Factors affecting optic nerve head biomechanics in a rat model of glaucoma

Glaucoma is the leading cause of irreversible blindness and is characterized by the death of retinal ganglion cells, which carry vision information from the retina to the brain. Although it is well accepted that biomechanics is an important part of the glaucomatous disease process, the mechanisms by which biomechanical insult, usually due to elevated intraocular pressure (IOP), leads to retinal ganglion cell death are not understood. Rat models of glaucoma afford an opportunity for learning more about these mechanisms, but the biomechanics of the rat optic nerve head (ONH), a primary region of damage in glaucoma, are only just beginning to be characterized. In a previous study, we built finite-element models with individual-specific rat ONH geometries. Here, we developed a parametrized model of the rat ONH and used it to perform a sensitivity study to determine the influence that six geometric parameters and 13 tissue material properties have on rat optic nerve biomechanical strains due to IOP elevation. Strain magnitudes and patterns in the parametrized model generally matched those from individual-specific models, suggesting that the parametrized model sufficiently approximated rat ONH anatomy. Similar to previous studies in human eyes, we found that scleral properties were highly influential: the six parameters with highest influence on optic nerve strains were optic nerve stiffness, IOP, scleral thickness, the degree of alignment of scleral collagen fibres, scleral ground substance stiffness and the scleral collagen fibre uncrimping coefficient. We conclude that a parametrized modelling strategy is an efficient approach that allows insight into rat ONH biomechanics. Further, scleral properties are important influences on rat ONH biomechanics, and additional efforts should be made to better characterize rat scleral collagen fibre organization.

Inducible rodent models of glaucoma

Glaucoma is one of the leading causes of vision impairment worldwide. In order to further understand the molecular pathobiology of this disease and to develop better therapies, clinically relevant animal models are necessary. In recent years, both the rat and mouse have become popular models in glaucoma research. Key reasons are: many important biological similarities shared among rodent eyes and the human eye; development of improved methods to induce glaucoma and to evaluate glaucomatous damage; availability of genetic tools in the mouse; as well as the relatively low cost of rodent studies. Commonly studied rat and mouse glaucoma models include intraocular pressure (IOP)-dependent and pressure-independent models. The pressure-dependent models address the most important risk factor of elevated IOP, whereas the pressure-independent models assess "normal tension" glaucoma and other "non-IOP" related factors associated with glaucomatous damage. The current article provides descriptions of these models, their characterizations, specific techniques to induce glaucoma, mechanisms of injury, advantages, and limitations.

Connective Tissue Remodeling in Myopia and its Potential Role in Increasing Risk of Glaucoma

Myopia and glaucoma are both increasing in prevalence and are linked by an unknown mechanism as many epidemiologic studies have identified moderate to high myopia as an independent risk factor for glaucoma. Myopia and glaucoma are both chronic conditions that lead to connective tissue remodeling within the sclera and optic nerve head. The mechanobiology underlying connective tissue remodeling differs substantially between both diseases, with different homeostatic control mechanisms. In this article, we discuss similarities and differences between connective tissue remodeling in myopia and glaucoma; selected multi-scale mechanisms that are thought to underlie connective tissue remodeling in both conditions; how asymmetric remodeling of the optic nerve head may predispose a myopic eye for pathological remodeling and glaucoma; and how neural tissue deformations may accumulate throughout both pathologies and increase the risk for mechanical insult of retinal ganglion cell axons.

Association of Corneal Hysteresis With Lamina Cribrosa Curvature in Primary Open Angle Glaucoma

Purpose

To investigate whether corneal biomechanical properties are associated with the lamina cribrosa (LC) curvature in eyes with primary open angle glaucoma (POAG).

Methods

Corneal biomechanical properties and LC curvature were assessed in 65 treatment-naïve POAG patients. Corneal biomechanical properties, including corneal hysteresis (CH), corneal resistance factor (CRF), and corneal-compensated intraocular pressure (IOPcc), were measured using an ocular response analyzer (ORA; Reichert Ophthalmic Instruments). LC curvature was assessed by measuring the LC curvature index (LCCI) on B-scan images obtained using spectral-domain optical coherence tomography (OCT). The LCCI was determined by measuring LC curve depth on the anterior LC surface and the width of the reference line.

Results

The LCCI was correlated with CH (P = 0.001), CRF (P = 0.012) and IOPcc (P = 0.001) in the univariate analysis. To adjust multicollinearity, principal component analysis was performed, and multivariate regression analyses were conducted using one variable from each component. The larger LCCI was associated with larger IOPcc (P < 0.001), smaller CRF (P = 0.001) and smaller CH (P < 0.001).

Conclusions

Lower CH was associated with a more posteriorly curved LC in treatment naïve POAG patients. This finding may provide a basic explanation for the reported association between CH and an increased risk for glaucoma development and progression, and support a potential value of CH for risk assessment for glaucoma.

A neuroglia-based interpretation of glaucomatous neuroretinal rim thinning in the optic nerve head

Neuroretinal rim thinning (NRR) is a characteristic glaucomatous optic disc change. However, the precise mechanism of the rim thinning has not been completely elucidated. This review focuses on the structural role of the glioarchitecture in the formation of the glaucomatous NRR thinning. The NRR is a glia-framed structure, with honeycomb geometry and mechanically reinforced astrocyte processes along the transverse plane. When neural damage selectively involves the neuron and spares the glia, the gross structure of the tissue is preserved. The disorganization and loss of the glioarchitecture are the two hallmarks of optic nerve head (ONH) remodeling in glaucoma that leads to the thinning of NRR tissue upon axonal loss. This is in contrast to most non-glaucomatous optic neuropathies with optic disc pallor where hypertrophy of the glioarchitecture is associated with the seemingly absent optic disc cupping. Arteritic anterior ischemic optic neuropathy is an exception where pan-necrosis of ONH tissue leads to NRR thinning. Milder ischemia indicates selective neuronal loss that spares glia in non-arteritic anterior ischemic optic neuropathy. The biological reason is the heterogeneous glial response determined by the site, type, and severity of the injury. The neuroglial interpretation explains how the cellular changes underlie the clinical findings. Updated understandings on glial responses illustrate the mechanical, microenvironmental, and microglial modulation of activated astrocytes in glaucoma. Findings relevant to the possible mechanism of the astrocyte death in advanced glaucoma are also emerging. Ultimately, a better understanding of glaucomatous glial response may lead to glia-targeting neuroprotection in the future.

Increased Optic Nerve Head Capillary Blood Flow in Early Primary Open-Angle Glaucoma

Purpose

Blood flow in the optic nerve head (ONH) is known to be reduced in eyes with advanced glaucoma. However, experimental results from non-human primates suggest an initial increase in ONH blood flow at the earliest stages of damage. This study assesses flow and pulsatile hemodynamics across a range of severities to test the hypothesis that this also occurs in human glaucoma.

Methods

Laser speckle flowgraphy was used to measure average mean blur rate (MBR_ave) within ONH tissue (a correlate of capillary blood flow) and the pulsatile waveform in 93 eyes with functional loss and 74 glaucoma suspect/fellow eyes without functional loss. These were compared against results from 92 healthy control eyes. Parameters produced by the instrument's software were age-corrected, then compared between groups using generalized estimating equation models.

Results

The mean MBR_ave in the control eyes was 12.5 units. In glaucoma suspect/fellow eyes, the mean was 16.4 units, higher with P < 0.0001. In eyes with functional loss, the mean was 13.8 units, lower than eyes without functional loss with P < 0.0001, although still higher than control eyes with P = 0.0096. Analysis of the pulsatile waveform suggested that the deceleration in flow as it approaches its maximum across the cardiac cycle was delayed in glaucoma.

Conclusions

Blood flow within ONH capillaries was higher in glaucoma suspect eyes than in healthy controls. It was less elevated in eyes that had developed functional loss. The mechanisms causing these changes and their relation to concurrent changes in pulsatile hemodynamics remain under investigation.

Towards A Microbead Occlusion Model of Glaucoma for a Non-Human Primate

Glaucoma is a group of optic neuropathies associated with aging and sensitivity to intraocular pressure (IOP). The disease causes vision loss through the degeneration of retinal ganglion cell neurons and their axons in the optic nerve. Using an inducible model of glaucoma, we elevated IOP in the squirrel monkey (Saimiri boliviensis) using intracameral injection of 35 μm polystyrene microbeads and measured common pathogenic outcomes in the optic projection. A 42% elevation in IOP over 28 weeks reduced anterograde transport of fluorescently-labeled cholera toxin beta from retina to the lateral geniculate nucleus (60% decrease), and to the superior colliculus (49% decrease). Pressure also reduced survival of ganglion cellaxons in the optic nerve by 22%. The same elevation caused upregulation of proteins associated with glaucomatous neurodegeneration in the retina and optic nerve, including complement 1q, interleukin 6, and brain-derived neurotrophic factor. That axon degeneration in the nerve lagged deficits in anterograde transport is consistent with progression in rodent models, while the observed protein changes also occur in tissue from human glaucoma patients. Thus, microbead occlusion in a non-human primate with a visual system similar to our own represents an attractive model to investigate neurodegenerative mechanisms and therapeutic interventions for glaucoma.

Comparison of Diagnostic Power of Optic Nerve Head and Posterior Sclera Configuration Parameters on Myopic Normal Tension Glaucoma

PURPOSE

The aim of this study was to compare the diagnostic power of optic nerve head and posterior scleral configuration parameters obtained with the swept-source optical coherence tomography (SSOCT) on myopic normal-tension glaucoma (NTG).

MATERIALS AND METHODS

A total of 203 eyes of 203 participants with myopia diagnosed at Seoul Saint Mary's Hospital between September 2016 and February 2018 were divided into myopic NTG group (n=113) and nonglaucomatous myopia group (n=90). Established optic nerve head (ONH) parameters such as disc torsion, horizontal tilt, and vertical tilt, and novel parameters representing posterior sclera, were quantified using SSOCT. The posterior sclera was presented with the relative position of the deepest point of the eye (DPE) from the optic disc by measuring the distance, depth, and angle. The mean and the statistical distribution of each index were calculated. Differences in distribution led to another novel marker, absolute misaligned angle, which represents the displaced direction of the ONH from the sclera. The ONH was classified as misaligned when the degree of misalignment was >15 degrees in either direction. The area under the receiver operating characteristic curves and multivariate logistic regression analysis were used to test the diagnostic power in the presence of myopic NTG.

RESULTS

No significant difference was observed with respect to age, sex, refractive error, axial length, and central corneal thickness between the 2 groups. However, 20 (22.22%) of 90 eyes in the nonglaucomatous group showed misalignment, whereas 60 (53.09%) of 113 eyes in the NTG group had misalignment (odds ratio: 3.962, P<0.001). The absolute misaligned angle (0.696) and the horizontal tilt (0.682) were significantly associated with myopic NTG, which significantly exceeded other parameters in area under the receiver operating characteristic curves (both P<0.001). The multivariate logistic regression also showed that the absolute misaligned angle (hazard ratio=1.045, 95% confidence interval=1.023-1.068, P<0.001) and the horizontal tilt (hazard ratio=1.061, 95% confidence interval=1.015-1.109, P=0.009) were associated significantly with the presence of NTG.

CONCLUSIONS

The diagnostic power of absolute misaligned angle and the horizontal tilt angle significantly exceeded other parameters on myopic NTG. These parameters may be associated with a displaced direction of the ONH to the posterior sclera, which can be linked to the altered sclera configuration of myopic NTG subjects.

Border Tissue Morphology Is Spatially Associated with Focal Lamina Cribrosa Defect and Deep-Layer Microvasculature Dropout in Open-Angle Glaucoma

PURPOSE

To investigate the topographic relationship among focal lamina cribrosa (LC) defect, microvasculature dropout (MvD) and border tissue morphology in open angle glaucoma (OAG) eyes using spectral-domain (SD) optical coherence tomography (OCT) and OCT angiography.

DESIGN

Cross-sectional study.

METHODS

One hundred twenty-six OAG eyes and 97 normal eyes were included. The maximum externally oblique border tissue (EOBT) length was measured by using enhanced depth imaging SD-OCT as well as focal LC defect size. Circumferential MvD width and height ratio were measured using OCT angiography.

RESULTS

Significant correlations were found among the locations of focal LC defect, MvD and maximum EOBT length. The mean absolute locational difference was 29.1° (95% CI, -47.6 to 105.7) between focal LC defect and MvD, 10.0° (95% CI, -79.4 to 99.4) between focal LC defect and maximum EOBT length, and 10.6° (95% CI, -71.1 to 92.3) between MvD and maximum EOBT length. In multivariate logistic regression analysis, a worse VF defect was significantly associated with the presence of focal LC defects and MvDs (P < .002; P = .002, respectively). MvD circumferential width was associated with glaucoma severity (R = -0.66, P < .001), whereas focal LC defect size and MvD height ratio were associated with maximum EOBT length (R = 0.48, P < .001; R = 0.65, P < .001, respectively) and AL (R = 0.53, P < .001; R = 0.52, P < .001, respectively).

CONCLUSIONS

There was a topographical correlation among the locations of focal LC defect, MvD and maximum border length. In addition, the presence of focal LC defect and MvD were also strongly associated with glaucoma severity. Thus, it is thought that focal LC defect and MvD may be biomarkers that reflect glaucoma severity especially at the location of maximum border tissue elongation.

Factors Influencing Central Lamina Cribrosa Depth: A Multicenter Study

Purpose

To quantify the influence of ocular and demographic factors on central laminar depth (LD) in healthy participants.

Methods

A total of 362 normal subjects underwent optical coherence tomography (OCT) enhanced depth imaging of the optic nerve head (ONH) with a 24 radial B-scan pattern aligned to the fovea–to–Bruch's membrane opening (BMO) axis. BMO, anterior lamina, anterior scleral canal opening (ASCO), Bruch's membrane (BM), and the peripapillary scleral surface were manually segmented. The extent of laminar segmentation was quantified within 72 ASCO subsectors. Central LD was quantified relative to four reference planes: BMO, ASCO, BM, and scleral. The effects of age, sex, ethnicity, IOP, BMO area, ASCO area, and axial length on LD were assessed.

Results

Laminar visibility was most consistent within the central ASCO (median 89%, range, 69%–95%). LD_BMO and LD_BM were significantly shallower in eyes with greater age, BMO area, and axial length and in females. LD_ASCO was shallower in eyes with greater ASCO area and axial length and in European and Hispanic descent compared to African descent eyes. LD_Sclera behaved similarly, but was not associated with axial length. BMO and ASCO area were not different between African descent and European descent eyes.

Conclusions

Central LD was deeper in African descent eyes and influenced least by age, axial length, and sex, but more by ASCO area, when measured relative to the ASCO and sclera. However, the magnitude of these effects for all four reference planes was small, and their clinical importance in the detection of glaucoma and its progression remains to be determined.

Future clinical applicability of optical coherence tomography angiography

Optical coherence tomography angiography (OCT-A) is an emerging technology that allows for the non-invasive imaging of the ocular microvasculature. Despite the wealth of observations and numerous research studies illustrating the potential clinical uses of OCT-A, this technique is currently rarely used in routine clinical settings. In this review, technical and clinical aspects of OCT-A imaging are discussed, and the future clinical potential of OCT-A is considered. An understanding of the basic principles and limitations of OCT-A technology will better inform clinicians of its future potential in the diagnosis and management of ocular diseases.

Protruded retinal layers within the optic nerve head neuroretinal rim

PURPOSE

To determine the frequency with which retinal tissues other than the nerve fibre layer, hereafter referred to as protruded retinal layers (PRL), are a component of optical coherence tomography (OCT) neuroretinal rim measurements.

METHODS

Ninety healthy (30 White, Black and Japanese, respectively) subjects were included in the study. A radial scan pattern (24 B-scans centred on Bruch's membrane opening [BMO]) was used. For each of the 48 minimum rim width (MRW) measurement points, we determined whether PRL were present, absent or indeterminate. When present, the proportion of PRL within the MRW was quantified.

RESULTS

Protruded retinal layers were present in 503 (11.6%), absent in 3805 (88.1%) and indeterminate in 12 (0.3%) measurement points. Overall, 69 (76.6%) subjects had ≥1 points with PRL, with White subjects having the highest frequency and Japanese the lowest (29 [97%] and 18 [60%], respectively; p < 0.01). PRL were present in one-third of points in the temporal sector, but ≤5% in other sectors. When present, the median PRL thickness was 53.0 (interquartile range [IQR]: 33.0 to 78.5) μm, representing 20.6 (IQR: 13.0 to 28.5)% of MRW. Globally, the median PRL thickness comprised 1.3 (IQR: 0.2 to 3.5)% of the MRW; however, in the temporal sector, it exceeded 30% of MRW in some subjects.

CONCLUSIONS

Protruded retinal layers are a component of MRW measurements in most normal subjects, occurring in almost 12% of all measurement points analysed. There were racial variations in the presence of PRL and a significantly higher frequency of PRL in the temporal sector.