Staging Functional Damage in Glaucoma: Review of Different Classification Methods

Analysis of the relationship between VEGF, NLRP3 inflammatory complex, EPO levels, and ocular hemodynamics in patients with primary open-angle glaucoma

OBJECTIVE

Our study aimed to investigate the relationship between vascular endothelial growth factor (VEGF), NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammatory complex, erythropoietin (EPO) levels, and ocular hemodynamics in patients diagnosed with primary open-angle glaucoma (POAG).

METHODS

This is a prospective observational study. Patients diagnosed with POAG at The Sixth Hospital of Wuhan hospital between November 2022 and February 2023were enrolled.The patients were categorized into three groups based on the average visual field defect (mean deviation, MD) value: severe injury group (MD > 12 dB, 93 cases), moderate injury group (7 ≤ MD ≤ 12 dB, 89 cases), and mild injury group (MD < 7 dB, 85 cases). The levels of VEGF, NLRP3 inflammatory complex, EPO, and ocular hemodynamics were compared among the groups. Furthermore, the relationship between VEGF, NLRP3, EPO levels, and ocular hemodynamics in patients with POAG was analyzed using Pearson correlation analysis. After adjusting for confounding factors such as age and gender, multivariate Logistic regression analysis was performed with the ocular hemodynamics indexes being used as dependent variables, and VEGF, NLRP3, ASC, Caspase-1, and EPO being used as independent variables.

RESULTS

A total of267 patients with POAG were enrolled. There were no significant differences in sex, age, body mass index, systolic blood pressure, diastolic blood pressure, smoking, alcohol consumption, and blood glucose between the two groups (P > 0.05). The levels of NLRP3, ASC, Caspase-1, and EPO in the severe and moderate injury groups were higher than those in the mild injury group, whereas the VEGF levels were lower in the severe and moderate groups compared to the mild group, showing significant differences (P < 0.05). The severe group exhibited higher levels of NLRP3, ASC, Caspase-1, and EPO than the moderate group, while the VEGF levels were lower in the severe group compared to the moderate group, showing significant differences (P < 0.05). The peak systolic velocity(PSV) and resistance index (RI) were higher in the severe and moderate groups than in the mild group, whereas the EDV was significantly lower in the severe and moderate groups compared to the mild group (P < 0.05). The severe group exhibited higher PSV and RI values compared to the moderate group, while the EDV was lower in the severe group compared to the moderate group, showing significant differences (P < 0.05). Pearson correlation analysis was performed to examine the relationship between VEGF, NLRP3, EPO levels, and ocular hemodynamics in patients with POAG. VEGF, NLRP3, ASC, Caspase-1, and EPO showed positive correlations with PSV and RI, and negative correlations with EDV in patients with POAG. Regression analysis showed that VEGF, NLRP3, ASC, Caspase-1 and EPO were significantly correlated with ocular hemodynamics in POAG (all P < 0.001).

CONCLUSION

We demonstrated that the levels of VEGF, NLRP3 inflammatory complex, and EPO were highly associated with ocular hemodynamics in patients diagnosed with POAG.

Multiple medications and quality of life of Nigerians with primary open angle glaucoma

PURPOSE

To determine the impact of multiple medications on the quality of life of primary open angle glaucoma (POAG) patients on medical treatment at Guinness Eye Centre Onitsha, Nigeria.

MATERIALS AND METHODS

Adult patients diagnosed with POAG who were undergoing medical therapy were selected through systematic sampling. They were asked to provide information on socio-demographic background, the number and types of glaucoma medications they were using and any adverse effects encountered while using these medications. The patients' quality of life was assessed by utilizing the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) and all patients completed ocular examination. Data analysis was with Statistical Package for Social Sciences (SPSS) version 23.

RESULTS

One hundred and seventy-one patients, aged 40-83 years, mean 59.1 ± 11.1 were studied; there were 79(46.2%) males and 92(53.8%) females. One hundred and nine (63.7%) patients were on multiple medications. Side effects of treatment increased with increasing number of medications. The mean quality of life score in monotherapy group and double therapy group were 89.3 ± 15.8 and 80.2 ± 21.1 respectively; while that in ≥ triple therapy group was 78.9 ± 18.8. This decrease in mean quality of life score with increasing number of medications was statistically significant in bivariate analysis (P < 0.01), however, multiple regression analysis showed that the number of medications did not significantly affect the quality of life scores after adjusting for confounding variables(p = 0.881).

CONCLUSION

Among the patients studied, use of multiple medications, unlike visual acuity (VA) and severity of glaucoma, was not an independent predictor of quality of life.

Understanding Patterns of Preserved Retinal Ganglion Cell Layer in Advanced Glaucoma as Seen With Optical Coherence Tomography

PRCIS

Using optical coherence tomography (OCT), eyes with advanced glaucoma were found to have a wide range of patterns of damage that were consistent with the natural history of progression based on a model of macular progression.

PURPOSE

To understand the patterns of preserved retinal ganglion cells in eyes with advanced glaucoma using OCT and a model of progression of the central macula.

METHODS

OCT GCL thickness was measured in 94 eyes with advanced glaucoma, defined as glaucomatous eyes with a 24-2 MD (mean deviation) worse than -12 dB. A commercial report supplied the GCL thickness in 6 sectors of the thick, donut-shaped GCL region around the fovea. For each eye, the 6 sectors were coded as green (within normal limits, WNL), yellow (≤5th, ≥1st percentile), or red (<1st percentile).

RESULTS

In all 94 eyes, one or more of the 6 sectors of the donut were abnormal (red or yellow), while all 6 sectors were red in 52 (55%) of the eyes. On the other hand, 33 eyes had one or more sectors WNL (green). While the pattern of donut damage varied widely across these 33 eyes, 61 of the 66 hemiretinas were consistent with a temporal-to-nasal progression of damage within each hemiretina as predicted by our model.

CONCLUSIONS

All eyes with advanced glaucoma had damage to the critically important central, donut-shaped GCL region. This region showed a wide range of patterns of damage, but these patterns were consistent with the natural history of progression based on a model of macular progression. These results have implications for the clinical identification of macular progression, as well as for inclusion criteria for clinical trials seeking to preserve central macular function.

A validated web-application (GFDC) for automatic classification of glaucomatous visual field defects using Hodapp-Parrish-Anderson criteria

Subjectivity and ambiguity of visual field classification limits the accuracy and reliability of glaucoma diagnosis, prognostication, and management decisions. Standardised rules for classifying glaucomatous visual field defects exist, but these are labour-intensive and therefore impractical for day-to-day clinical work. Here a web-application, Glaucoma Field Defect Classifier (GFDC), for automatic application of Hodapp-Parrish-Anderson, is presented and validated in a cross-sectional study. GFDC exhibits perfect accuracy in classifying mild, moderate, and severe glaucomatous field defects. GFDC may thereby improve the accuracy and fairness of clinical decision-making in glaucoma. The application and its source code are freely hosted online for clinicians and researchers to use with glaucoma patients.

Quantitative Assessment of Fundus Tessellated Density in Highly Myopic Glaucoma Using Deep Learning

Purpose

To characterize the fundus tessellated density (FTD) in highly myopic glaucoma (HMG) and high myopia (HM) for discovering early signs and diagnostic markers.

Methods

This retrospective cross-sectional study included hospital in-patients with HM (133 eyes) and HMG (73 eyes) with an axial length ≥26 mm at Zhongshan Ophthalmic Center. Using deep learning, FTD was quantified as the average exposed choroid area per unit area on fundus photographs in the global, macular, and disc regions. FTD-associated factors were assessed using partial correlation. Diagnostic efficacy was analyzed using the area under the curve (AUC).

Results

HMG patients had lower global (0.20 ± 0.12 versus 0.36 ± 0.09) and macular FTD (0.25 ± 0.14 vs. 0.40 ± 0.09) but larger disc FTD (0.24 ± 0.11 vs. 0.19 ± 0.07) than HM patients in the tessellated fundus (all P < 0.001). In the macular region, nasal FTD was lowest in the HM (0.26 ± 0.13) but highest in the HMG (0.32 ± 0.13) compared with the superior, inferior, and temporal subregions (all P < 0.05). A fundus with a macular region nasal/temporal (NT) FTD ratio > 0.96 (AUC = 0.909) was 15.7 times more indicative of HMG than HM. A higher macular region NT ratio with a lower horizontal parapapillary atrophy/disc ratio indicated a higher possibility of HMG than HM (AUC = 0.932).

Conclusions

FTD differs in degree and distribution between HMG and HM. A higher macular NT alone or with a lower horizontal parapapillary atrophy/disc ratio may help differentiate HMG.

Translational Relevance

Deep learning-based FTD measurement could potentially assist glaucoma diagnosis in HM.

Detection and characterisation of visual field defects using Octopus perimetry in congenital glaucoma

PURPOSE

To detect and characterise visual field (VF) defects using static Octopus perimetry in patients with primary congenital glaucoma (PCG) and to determine VF quality and time duration.

MATERIAL AND METHODS

Eighty-eight eyes of 70 patients diagnosed with PCG were included. Assessments were performed using an Octopus 900 and each eye was assessed with the tendency-oriented perimetry (G-TOP) algorithm. Quantitative VF data were collected: quality data (false positive and negative response, and time duration) and results of mean deviation (MD) and square root of loss variance (sLV). Qualitative data were collected: the presence of diffuse and localized defects, the affected hemifield and grade of defects using the Aulhorn and Karmeyer classification. Correlations between perimetric results and clinical variables were analysed.

RESULTS

Median age was 11 (8-17) years. 65.9% (58/88) of PCG eyes showed VF defects. Diffuse defects were observed in 10/58 eyes (16.94%) (mean MD = 23.92 [SD: 2.52]) dB) and localized defects in 48/58 eyes (82.75%). The most frequent defect was spot-like/stroke-like/incipient paracentral scotoma (n = 15), nasal step (n = 8), adding arcuate defect (n = 2), half ring-shaped (n = 13) and concentric defect with a central island (n = 9). And the most frequent affected visual hemifield was inferior hemifield. Mean test duration was 2 min 12 s (SD: 21.6 s). MD and sLV values were correlated with best corrected visual acuity (BCVA), cup to disc ratio and number of antiglaucoma surgeries (all P < .001).

CONCLUSION

A high number of diffuse and localized defects were identified using Octopus perimetry in PCG patients. The most frequent defect was paracentral scotoma and inferior hemifield was the most affected.

An Artificial Intelligence Enabled System for Retinal Nerve Fiber Layer Thickness Damage Severity Staging

Purpose

To develop an objective glaucoma damage severity classification system based on OCT-derived retinal nerve fiber layer (RNFL) thickness measurements.

Design

Algorithm development for RNFL damage severity classification based on multicenter OCT data.

Subjects and Participants

A total of 6561 circumpapillary RNFL profiles from 2269 eyes of 1171 subjects to develop models, and 2505 RNFL profiles from 1099 eyes of 900 subjects to validate models.

Methods

We developed an unsupervised k-means model to identify clusters of eyes with similar RNFL thickness profiles. We annotated the clusters based on their respective global RNFL thickness. We computed the optimal global RNFL thickness thresholds that discriminated different severity levels based on Bayes' minimum error principle. We validated the proposed pipeline based on an independent validation dataset with 2505 RNFL profiles from 1099 eyes of 900 subjects.

Main Outcome Measures

Accuracy, area under the receiver operating characteristic curve, and confusion matrix.

Results

The k-means clustering discovered 4 clusters with 1382, 1613, 1727, and 1839 samples with mean (standard deviation) global RNFL thickness of 58.3 (8.9) μm, 78.9 (6.7) μm, 87.7 (8.2) μm, and 101.5 (7.9) μm. The Bayes' minimum error classifier identified optimal global RNFL values of > 95 μ m , 86 to 95 μ m , 70 to 85 μ m , and < 70 μ m for discriminating normal eyes and eyes at the early, moderate, and advanced stages of RNFL thickness loss, respectively. About 4% of normal eyes and 98% of eyes with advanced RNFL loss had either global, or ≥ 1 quadrant, RNFL thickness outside of normal limits provided by the OCT instrument.

Conclusions

Unsupervised machine learning discovered that the optimal RNFL thresholds for separating normal eyes and eyes with early, moderate, and advanced RNFL loss were 95 μ m , 85 μm, and 70 μ m , respectively. This RNFL loss classification system is unbiased as there was no preassumption or human expert intervention in the development process. Additionally, it is objective, easy to use, and consistent, which may augment glaucoma research and day-to-day clinical practice.

Financial Disclosures

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

Optical coherence tomography angiography in glaucoma

The use of optical coherence tomography angiography (OCTA) holds significant promise for optometrists in the diagnosis and management of glaucoma. It offers reliable differentiation of glaucomatous eyes from healthy ones and extends monitoring capabilities for advanced cases. OCTA represents a valuable addition to traditional assessment methods, particularly in complex cases. Glaucoma, a major cause of irreversible blindness, is traditionally diagnosed using structural and functional metrics. With growing interest, OCTA is being explored to diagnose, monitor, and manage glaucoma. This review focuses on the application of OCTA in glaucoma patients. A database search was carried out using Embase Elsevier (n = 664), PubMed (n = 574), and Cochrane Central Register of Controlled Trials (n = 19) on 15 August 2023. After deduplication and screening, 272 original papers were included in the narrative review. Inclusion criteria comprised English-language original studies on OCTA use in human glaucoma patients, with or without healthy controls. Exclusion criteria encompassed animal studies, in-vivo/in-vitro research, reviews, and congress abstracts. OCTA has good repeatability and reproducibility. OCTA metrics have good discriminatory power to differentiate glaucomatous eyes from healthy eyes and show strong associations with structural changes and visual field defects. OCTA can extend the monitoring of advanced glaucoma, addressing the 'floor effect' of traditional structural measurements. OCTA metrics can be affected by the choice of OCTA machine, post-image processing algorithms, systemic diseases, and ocular factors. Image artefacts can affect the accuracy of OCTA measurements, and proper scan quality evaluation is crucial to ensure reliable results. Additionally, artificial intelligence techniques offer promise for enhancing the diagnostic accuracy of OCTA by combining data from various retinal layers and regions. OCTA complements traditional methods in assessing glaucoma, especially in challenging cases, providing valuable insights for detection and management. Further research and clinical validation are needed to integrate OCTA into routine practice.

Performance of perimetric glaucoma staging systems and their preference patterns among the Indian eye care practitioners

CONTEXT

Various systems are available to stage glaucomatous field defects into different severity grades. Still, the preference for such systems among Indian eye care practitioners (ECPs) and the consensus between them are not explored.

PURPOSE

To compare the clinical performance of perimetric glaucoma staging systems and to assess their preference patterns among Indian ECPs.

SETTING AND DESIGN

Retro-prospective cross-sectional study.

METHODS

Three investigators stratified 400 perimetry reports using four systems: Hodapp Anderson Parrish (HAP), enhanced Glaucoma Severity Staging (eGSS), Advanced Glaucoma Intervention Study (AGIS), and Collaborative Initial Glaucoma Treatment Study (CIGTS). Their performance was compared in terms of agreement and association. Following this, 30 ECPs from across the country segregated a subset of reports (n = 20) into different stages based on their system of choice, and their preferences/perceptions about the available perimetry staging systems were enquired and documented.

STATISTICAL ANALYSIS USED

Descriptive statistics, Kruskal-Wallis, Cohen's kappa, and Spearman's correlation.

RESULTS

For the consolidated severity stages, substantial agreements (K ranging from 0.61 to 0.75) were found between all the systems, except for HAP-CIGTS (K = 0.58) and AGIS-CIGTS (K = 0.51). All ECPs were aware of perimetry staging systems, and a high preference was reported for HAP (97%) due to ease of implementation and interpretation.

CONCLUSION

Among the four staging systems, the highest agreement was found between HAP and eGSS. A majority of ECPs proposed the need for a uniform classification system across the practices for clinical comparisons and patient education.

Differentiating stages of functional vision loss from glaucoma using the Disc Damage Likelihood Scale and cup:disc ratio

BACKGROUND

Glaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard.

METHODS

Post hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman's rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma.

RESULTS

382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma.

CONCLUSION

This study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma.

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

PURPOSE

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

DESIGN

Observational study.

PARTICIPANTS

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Effectiveness of Glaucoma Screening and Factors Associated with Follow-up Adherence among Glaucoma Suspects in a Safety-Net Teleretinal Screening Program

PURPOSE

To evaluate rates and risk factors associated with follow-up adherence to in-person glaucoma evaluations and confirmed glaucoma diagnosis in glaucoma suspects identified through teleretinal diabetic retinopathy screening (TDRS).

DESIGN

Retrospective cohort study SUBJECTS: Patients with diabetes identified through teleretinal screening to have large or asymmetric cup-to-disc ratios in a Los Angeles County safety-net primary care-based TDRS program.

METHODS

Retrospective chart review was performed to obtain demographic and clinical information for patients with cup-to-disc ratios concerning for glaucoma on TDRS. Patients who completed an in-person follow-up appointment within 1 year of teleretinal screening were adherent. Factors associated with follow-up adherence and diagnosis of glaucoma were analyzed with chi-square and independent t tests along with multivariable logistic regressions.

MAIN OUTCOME MEASURES

The proportion of patients with suspected glaucoma who adhered with in-person follow-up examination, proportion of patients with confirmed glaucoma diagnosis, and factors associated with follow-up adherence and glaucoma diagnosis.

RESULTS

Eight-hundred seventeen patients with optic discs suspicious for glaucoma were included. Five-hundred thirty-four (65.4%) patients successfully completed an in-person glaucoma evaluation. Among these patients, 62.9% and 24.5% received a diagnosis of glaucoma suspect and glaucomatous optic neuropathy, respectively. Compared with patients aged < 50 years, patients aged 50 to 64 years had 1.57 times higher odds of being adherent with in-person visits (P = 0.036), whereas no difference was seen in those aged ≥ 65 years. For every $10 000 increase in the zip code median income, patients had 11% lower odds of being adherent (P = 0.031). Compared with Latino patients, Black patients had 3.52 times (P < 0.001) higher odds of having confirmed glaucoma.

CONCLUSION

The majority of patients referred as glaucoma suspects on TDRS completed a follow-up examination, and nearly a quarter of those examined received a confirmed glaucoma diagnosis. Patients aged ≥ 50 and < 65 years along with those from lower-income neighborhoods were more likely to follow up for an in-person evaluation. Compared with Latino patients, Black patients had a higher risk for a confirmed glaucoma diagnosis. This demonstrates the effectiveness of glaucoma detection in a large-scale TDRS program for a safety-net patient population.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

The Patterns of Visual Field Defects in Primary Angle-Closure Glaucoma Compared to High-Tension Glaucoma and Normal-Tension Glaucoma

INTRODUCTION

The aim of this study was to compare the patterns of visual field (VF) defects in primary angle-closure glaucoma (PACG) to control groups of eyes with high-tension glaucoma (HTG) and normal-tension glaucoma (NTG).

METHODS

Forty-eight eyes with PACG were enrolled, and control eyes with HTG and NTG matched for age, sex, and mean deviation of VF defect were selected. VF tests were performed using the 24-2 program of the Humphrey field analyzer. VF defects were classified into six patterns with the Ocular Hypertension Treatment Study classification system and were categorized into three stages (early, moderate, and advanced). Each hemifield was divided into five regions according to the Glaucoma Hemifield Test (GHT). The mean total deviation (TD) of each GHT region was calculated.

RESULTS

Compared with HTG and NTG groups, the partial arcuate VF defects were more common in the PACG group. In the PACG group, the nasal GHT region in the inferior hemifield had the worst mean TD (-8.48 ± 8.62 dB), followed by the arcuate 1 (-7.81 ± 7.91 dB), arcuate 2 (-7.46 ± 7.43 dB), paracentral (-7.19 ± 7.98 dB), and central (-5.14 ± 6.24 dB) regions; the mean TD of the central region was significantly better than those for all other regions (all p < 0.05). A similar trend was observed in the superior hemifield in the PACG group but not the VF hemifields of the HTG and NTG groups.

CONCLUSION

Patterns of VF defect in PACG patients differ from those with HTG and NTG. This discrepancy might be due to the differences in the pathogenic mechanisms of glaucomatous optic neuropathy.

Performance of a Glaucoma Screening Program Compared With Opportunistic Detection in China

PRCIS

Health examination center-based screening provide a good supplement to clinic-based glaucoma care by detecting early-stage glaucoma, especially those with normal intraocular pressure (IOP) and less visual impairment.

PURPOSE

Opportunistic glaucoma screening for early case identification is of great value in the prevention of severe visual impairment, however, novel, low-cost models are needed. We aimed to determine whether health examination center-based glaucoma screening identifies diseases earlier than outpatient cases in China.

MATERIALS AND METHODS

In this case-control study, 76 patients with primary glaucoma identified from a health examination center-based glaucoma screening program and 272 consecutive outpatient cases at the same hospital were enrolled from March 21 to September 30, 2016. Demographic characteristics, best-corrected visual acuity, IOP, mean deviation (MD), and pattern standard deviation (PSD) on Humphrey visual field testing in the better-seeing eye were compared between groups.

RESULTS

Screening-detected glaucoma patients had significantly lower IOP (18.3±4.2 mm Hg) than out-patient cases (26.7±12.6 mm Hg, P <0.001). Most (71.1%) of the screening-detected patients had IOP<21 mm Hg compared with 37.1% in the clinic group ( P <0.001). Seventy-five patients (98.7%) in the screening group were diagnosed as primary open angle glaucoma, compared with 44.1% in the clinic group ( P <0.001). Screening-detected patients had significantly less visual impairment than the clinic group (6.6% vs. 38.6%, P <0.05). Mean MD (-4.4±5.0 dB) and PSD (4.4±3.6 dB) for the screening group were superior to the clinic group (MD: -16.5±10.5 dB, P <0.001; PSD: 6.5±3.7 dB, P <0.001).

CONCLUSION

The glaucoma screening program was effective at detecting early disease, especially normal tension glaucoma and supplemented opportunistic detection of glaucoma.

Machine-Identified Patterns of Visual Field Loss and an Association with Rapid Progression in the Ocular Hypertension Treatment Study

PURPOSE

To identify patterns of visual field (VF) loss based on unsupervised machine learning and to identify patterns that are associated with rapid progression.

DESIGN

Cross-sectional and longitudinal study.

PARTICIPANTS

A total of 2231 abnormal VFs from 205 eyes of 176 Ocular Hypertension Treatment Study (OHTS) participants followed over approximately 16 years.

METHODS

Visual fields were assessed by an unsupervised deep archetypal analysis algorithm and an OHTS-certified VF reader to identify prevalent patterns of VF loss. Machine-identified patterns of glaucoma damage were compared against those patterns previously identified (expert-identified) in the OHTS in 2003. Based on the longitudinal VFs of each eye, VF loss patterns that were strongly associated with rapid glaucoma progression were identified.

MAIN OUTCOME MEASURES

Machine-expert correspondence and type of patterns of VF loss associated with rapid progression.

RESULTS

The average VF mean deviation (MD) at conversion to glaucoma was -2.7 decibels (dB) (standard deviation [SD] = 2.4 dB), whereas the average MD of the eyes at the last visit was -5.2 dB (SD = 5.5 dB). Fifty out of 205 eyes had MD rate of -1 dB/year or worse and were considered rapid progressors. Eighteen machine-identified patterns of VF loss were compared with expert-identified patterns, in which 13 patterns of VF loss were similar. The most prevalent expert-identified patterns included partial arcuate, paracentral, and nasal step defects, and the most prevalent machine-identified patterns included temporal wedge, partial arcuate, nasal step, and paracentral VF defects. One of the machine-identified patterns of VF loss predicted future rapid VF progression after adjustment for age, sex, and initial MD.

CONCLUSIONS

An automated machine learning system can identify patterns of VF loss and could provide objective and reproducible nomenclature for characterizing early signs of visual defects and rapid progression in patients with glaucoma.

An Objective and Easy-to-Use Glaucoma Functional Severity Staging System Based on Artificial Intelligence

OBJECTIVE

The objective of this study was to develop an objective and easy-to-use glaucoma staging system based on visual fields (VFs).

SUBJECTS AND PARTICIPANTS

A total of 13,231 VFs from 8077 subjects were used to develop models and 8024 VFs from 4445 subjects were used to validate models.

METHODS

We developed an unsupervised machine learning model to identify clusters with similar VF values. We annotated the clusters based on their respective mean deviation (MD). We computed optimal MD thresholds that discriminate clusters with the highest accuracy based on Bayes minimum error principle. We evaluated the accuracy of the staging system and validated findings based on an independent validation dataset.

RESULTS

The unsupervised k -means algorithm discovered 4 clusters with 6784, 4034, 1541, and 872 VFs and average MDs of 0.0 dB (±1.4: SD), -4.8 dB (±1.9), -12.2 dB (±2.9), and -23.0 dB (±3.8), respectively. The supervised Bayes minimum error classifier identified optimal MD thresholds of -2.2, -8.0, and -17.3 dB for discriminating normal eyes and eyes at the early, moderate, and advanced stages of glaucoma. The accuracy of the glaucoma staging system was 94%, based on identified MD thresholds with respect to the initial k -means clusters.

CONCLUSIONS

We discovered that 4 severity levels based on MD thresholds of -2.2, -8.0, and -17.3 dB, provides the optimal number of severity stages based on unsupervised and supervised machine learning. This glaucoma staging system is unbiased, objective, easy-to-use, and consistent, which makes it highly suitable for use in glaucoma research and for day-to-day clinical practice.

Changes of macular blood flow and structure in acute primary angle closure glaucoma

PURPOSE

We assessed the relationship between acute primary angle closure glaucoma (APACG) severity and macular microcirculation, as well as the diagnostic ability of blood flow and macular structural parameters on optical coherence tomography angiography (OCTA) for APACG.

METHODS

APACG patients were assigned to mild, moderate, and severe groups in this cross-sectional study. Age-matched primary angle closure suspect (PACS) and healthy control groups were also recruited. The vessel density (VD) and foveal avascular zone (FAZ) in each macular superficial area were measured using OCTA. The retinal nerve fiber layer thickness (RNFLT) and ganglion cell complex thickness (GCCT) of the corresponding regions were measured using OCT.

RESULTS

All parameters in the control, PACS, and mild APACG groups differed significantly from those in the moderate and severe APACG groups (all P < 0.05). VD and RNFLT showed high and moderate diagnostic ability, respectively, to distinguish moderate APACG from PACS, with significant differences (P < 0.05) in areas under the receiver operating characteristic curve (AUCs) for VD and RNFLT in six macular areas. The diagnostic abilities of VD and RNFLT for distinguishing severe APACG from PACS were increased, with significant differences in the AUCs for VD and RNFLT in five macular areas (P < 0.05). All macular VDs and GCCTs were similar among the three APACG groups (P > 0.05).

CONCLUSIONS

Damage to the VD and FAZ in the macula increased with APACG severity. VD in the macular superficial layer showed a higher diagnostic ability than RNFLT, which was equivalent to that of GCCT.

Prediction of Central Visual Field Severity in Glaucoma

PRCIS

The severity of central visual field (VF) defects on 24-2 VF and related scotomas on 10-2 VF may be predicted by assessing perimetric defects at abnormal central 12 points on 24-2 VF in early glaucoma.

PURPOSE

Investigating the association between perimetric parameters at abnormal central 12 points on 24-2 VF and the severity of central visual field defects (CVFDs) on 24-2 VF and related parafoveal scotomas on 10-2 VF.

METHODS

We examined 64 eyes of 56 glaucoma patients with CVFDs on 24-2 VF with a mean deviation better than -7 dB and completed 24-2 and 10-2 VF testing within 6 months. On the basis of 10-2 VFs' pattern defects, eyes were grouped into 3: an arcuate parafoveal scotoma, severe defect; partial arcuate, moderate defect; and minimal defect. VF parameters at abnormal points (P<1%) within the central-most 4 and paracentral 8 points on total deviation/pattern deviation plots on 24-2 VF were analyzed to predict the severity of CVFDs.

RESULTS

Eyes with arcuate scotoma showed more functional loss than eyes without arcuate scotoma on 10-2 VF (P<0.001). A significant association was observed between abnormal 24-2 VF points' (<1%) threshold sensitivity lower than 20 dB [odds ratio (OR)=7.2; P=0.002 and OR=5.1; P=0.003 for the central 4 and paracentral 8 points, respectively] and defect values worse than -15 dB (OR=8.0 and 5.6 for the central 4 and paracentral 8 points, respectively, P=0.005) with arcuate scotoma on 10-2 VF. Superior nasal defect in the central 5 degrees on 24-2 VF was significantly associated with an arcuate defect on 10-2 VF (P<0.001).

CONCLUSION

Clinicians may predict the severity of CVFDs on 24-2 VF and parafoveal scotomas on 10-2 VF by measuring threshold sensitivities and defect values at abnormal central 12 points (<1%) on 24-2 VF in early glaucoma.

Detection of Intraocular Hypertension during Opportunity Screening (Check-Up Medical Inspections)

The aim of the study is the early detection of OHT (Ocular hypertension) in patients, in the activity of secondary prophylaxis (opportunity screening-medical check-up), to prevent blindness caused by POAG (Primary Open Angle Glaucoma). In Romania, medical examination of personnel with responsibilities in Transport Safety (TS) is legally regulated, being mandatory as a result of the internal transposition of European legislation in the field. The addressability of the patients for examination was determined by personal choice, depending on the accessibility of the medical service on the profile market (availability and price). The design of the study is epidemiological, observational, descriptive and retrospective. The standardized medical protocol included: personal medical history (anamnesis), physical ophthalmological examination, Intraocular pressure (IOP) measurement and Visual Field (VF) performance, with Automated Perimeter “Optopol PTS 910” through “Fast Threshold” strategy. The specialized medical research was completed with a dichotomous questionnaire entitled “Symptom Inventory”, made according to the recommendations of patients resulting from “Focus group” research. The study was carried out within the “Check-up” type medical controls upon request, only for personnel with positions in Transport Safety (TS), during January−December 2021 at S.C. ARTIMED S.R.L. Oradea, Bihor County. Health analysis was performed for 820 people, of whom 71 people (8.65%) tested positive for IOP > 21 mmHg, (suspected OHT) compared to 749 (91.35%) with normal values (Normal intraocular pressure-NIOP); the two lots being statistically significantly different (x2 = 560.590, df = 1, p = 0.000). The study involved 754 men (92.0%) and 66 women (8.0%), the sex ratio is 11.42 (Exp (B) = 0.782, Sig = 0.558, 95% CI = 0.343−1783; sex is not a significant predictor at the 5% level). The prevalence of OHT was 8.66% for the whole group, 8.48% for men and 10.60% for women. In the screening action for the whole group of patients the following was determined: IOP reference = 20.85 mmHg, Sensitivity (Se) = 91.5% and 1-Specificity (Sp) = 0.073, (Sp = 92.7%). The predictive value of the screening test was: Positive Predictive Value (PPV) = 90.1% and Negative Predictive Value (NPV) = 91.7%; Area under the ROC Curve (Receiver Operating Characteristic) = 0.986, Sig. = 0.000, CI95% = 0.979−0.993. A binary logistical model of a questionnaire was developed to determine the screening parameters which significantly predicted OHT: IOP (OR = 4.154, 95% CI: 3.155−5.469), Age < 40 years (OR = 0.408, 95% CI: 0.239−0.698) and Pattern Defect (PD) (OR = 1.475% CI: 1.130−1.925). The results of this study assess health status through regular medical examinations, and highlight their importance and usefulness in secondary prevention activity. The particularity of this “check-up” type for personnel with attributions in transport safety is based on two essential aspects: the legal obligation to perform it and the fact it is financed by the beneficiary (the employer). In patients suspected of OHT after antiglaucoma treatment, IOP statistically significantly decreased.

Long-term Intraocular Pressure Fluctuation Is a Risk Factor for Visual Field Progression in Advanced Glaucoma

PRCIS

Intraocular pressure (IOP) fluctuations increase the risk of visual field progression of primary open-angle glaucoma (POAG) in the advanced stage even when IOP is maintained low on average.

PURPOSE

The purpose of this study was to identify risk factors associated with the progression of visual field defect in patients with advanced POAG.

MATERIALS AND METHODS

A retrospective review of medical records was conducted to identify patients who met the Hodapp-Parrish-Anderson criteria for advanced POAG. A total of 122 eyes of 122 patients had undergone IOP measurement with Goldmann applanation tonometer, standard automated perimetry, Cirrus optical coherence tomography, and fundus photography at 6-month intervals. Visual field progression was defined as the deterioration of a minimum of 3 visual field locations more than baseline at 5% levels in 4 consecutive visual fields with 24-2 SITA testing.

RESULTS

Thirty-six eyes of 122 eyes (29.5%, 51.9±13.9 y old) showed visual field progression during 100.7±44.2 months of follow-up. The progression group showed greater long-term IOP fluctuations (2.6±1.4 mm Hg) than the no progression group (53.5±13.5 y; 2.0±1.0 mm Hg, P=0.008). Disc hemorrhage was detected more frequently in the progression group (40.5% vs. 17.4%, P=0.005). Multivariate Cox regression analysis revealed long-term IOP fluctuations [hazard ratio (HR)=2.567, 95% confidence interval (CI): 1.327-5.370, P=0.012] and disc hemorrhage (HR=2.351, 95% CI: 1.120-4.931, P=0.024) to be independent risk factors of visual field progression. Patients who showed both disc hemorrhage and long-term IOP fluctuations were at greater risks of progression (HR=2.675, 95% CI: 1.072-6.457, P=0.035).

CONCLUSIONS

Long-term IOP fluctuations and disc hemorrhage are independent and additive risk factors of visual field progression in advanced glaucoma even at low IOPs. Patients in whom these risk factors are identified require close monitoring and vigorous treatment.

A Structure-Related Fine-Grained Deep Learning System With Diversity Data for Universal Glaucoma Visual Field Grading

Purpose

Glaucoma is the main cause of irreversible blindness worldwide. However, the diagnosis and treatment of glaucoma remain difficult because of the lack of an effective glaucoma grading measure. In this study, we aimed to propose an artificial intelligence system to provide adequate assessment of glaucoma patients.

Methods

A total of 16,356 visual fields (VFs) measured by Octopus perimeters and Humphrey Field Analyzer (HFA) were collected, from three hospitals in China and the public Harvard database. We developed a fine-grained grading deep learning system, named FGGDL, to evaluate the VF loss, compared to ophthalmologists. Subsequently, we discuss the relationship between structural and functional damage for the comprehensive evaluation of glaucoma level. In addition, we developed an interactive interface and performed a cross-validation study to test its auxiliary ability. The performance was valued by F1 score, overall accuracy and area under the curve (AUC).

Results

The FGGDL achieved a high accuracy of 85 and 90%, and AUC of 0.93 and 0.90 for HFA and Octopus data, respectively. It was significantly superior (p < 0.01) to that of medical students and nearly equal (p = 0.614) to that of ophthalmic clinicians. For the cross-validation study, the diagnosis accuracy was almost improved (p < 0.05).

Conclusion

We proposed a deep learning system to grade VF of glaucoma with a high detection accuracy, for effective and adequate assessment for glaucoma patients. Besides, with the convenient and credible interface, this system can promote telemedicine and be used as a self-assessment tool for patients with long-duration diseases.

Structure-function analysis of MP3 microperimetry versus Octopus perimetry in central glaucomatous visual field defects

INTRODUCTION

To compare the structure-function relationship with microperimetry and Octopus perimetry in primary open angle glaucoma (POAG) patients with central visual field (VF) defects.

METHODS

40 eyes of 24 patients with POAG were enrolled. Circumpapillary retinal nerve fiber layer (cpRNFL) analysis measured by spectral-domain optical coherence tomography (SD-OCT) of the superotemporal, temporal, and inferotemporal optic nerve head (ONH) sectors were related to corresponding microperimetric and Octopus VF clusters using the G2 grid-pattern with dynamic strategy, respectively. The structure-function relationships of both devices were assessed via a segmented regression, as well as linear regression across overall SD-OCT cpRNFL values and outside normative (<1%) SD-OCT cpRNFL values.

RESULTS

Linear and segmented regression fits were similar with both devices. Across overall cpRNFL sectorial values, structure-function relations for the superotemporal, temporal and inferotemporal sectors were R2=0.176 (p=<0.001), R2=0.008 (p=0.069), and R2=0.294 (p=<0.001) for microperimetry, and R2= 0.189 (p=<0.001), R2= 0.020 (p=0.002), and R2= 0.326 (p=<0.001) for Octopus perimetry. For corresponding values outside normative limits (<1%), the relationships were R2=0.113 (p=<0.001), R2=0.001 (p=0.836), and R2=0.420 (p=<0.001) for microperimetry, and R2= 0.192 (p=<0.001), R2= 0.002, (p=0.336), and R2= 0.366 (p=<0.001) for Octopus perimetry.

DISCUSSION/CONCLUSION

Structure-function analysis was similar for both devices. Fundus-tracking should be further evaluated in a longitudinal setting in patients affected by glaucoma.

Correlation Between Optical Coherence Tomography and Photopic Negative Response of Flash Electroretinography in Ganglion Cell Complex Assessment in Glaucoma Patients

Purpose

To investigate the correlation between the photopic negative response (PhNR) of the light-adapted flash electroretinography (ERG) and measurements of standard automated perimetry (SAP) and optical coherence tomography (OCT) in assessment of retinal ganglion cells’ (RGCs) affection in glaucoma.

Patients and Methods

A cross-sectional study included 40 eyes of glaucoma patients and 40 eyes of age- and gender-matched normal subjects. Participants underwent a complete ophthalmologic assessment, SAP, OCT, and light-adapted flash ERG using the extended PhNR protocol of the International Society for Clinical Electrophysiology of Vision (ISCEV). Glaucomatous eyes were divided into 3 subgroups: mild (n = 15), moderate (n = 11) and severe glaucoma (n = 14) according to the mean deviation (MD) of SAP. Measurements of SAP, OCT and ERG parameters were analyzed, and correlations between PhNR measurements and other study measurements were evaluated.

Results

PhNR amplitudes and PhNR/b-wave ratios were significantly reduced in glaucoma cases compared to healthy controls, and they showed a significant and progressive decline across the three glaucoma subgroups (P < 0.05). An exception to this is PT (b-wave peak to PhNR trough) PhNR amplitude where its reduction was statistically non-significant when comparing between controls and mild glaucoma cases (P = 0.178), and between moderate and severe glaucoma cases (P = 0.714). PhNR amplitudes and PhNR/b-wave ratios correlated significantly with SAP and OCT parameters (P < 0.05).

Conclusion

PhNR correlates well with SAP and OCT parameters in glaucoma assessment. PhNR could be a valuable supplementary tool for objective assessment of the RGCs’ function in glaucoma.

Exploring the effect of glaucomatous visual field defects of current drivers on a neuropsychological test battery

PURPOSE

This study explores the effect of glaucomatous visual field defects on several neuropsychological tests that are often used in research and in clinical settings.

METHODS

Nineteen glaucoma patients and nineteen healthy participants, which are current drivers and older than 65 years old were included. All participants completed the Montreal Cognitive Assessment (MoCA), the Trail Making Test (TMT), the Benton Visual Retention Test (BVRT), the Snellgrove Maze Task (SMT) and the Digit Span Test (DST). All participants were also tested on contrast sensitivity and near and far visual acuity. For the glaucoma patients, visual field tests were downloaded from hospital servers.

RESULTS

On the MoCA test, glaucoma patients scored lower than the healthy group, but not significantly. On the MoCA-Blind, the difference was statistically significant. Glaucoma patients also had lower percentile scores on the TMT, with a significant difference in the TMT-A, but this difference largely disappeared in the calculated TMT B-A index, which isolates the cognitive component. The BVRT and SMT showed no significant differences between both groups. In the only non-visual test, the DST, glaucoma patients outperformed the healthy group. Glaucoma severity did not influence results, except for the BVRT on which the moderate/severe group has better scores.

CONCLUSION

Using visual items might lead to conclusions about cognition when it should be one about vision. Therefore, careful selection of tests is needed when examining cognition in glaucoma patients.

Combining OCT and OCTA for Focal Structure-Function Modeling in Early Primary Open-Angle Glaucoma

Purpose

To investigate modeling of the focal visual field (VF) loss by combining structural measurements and vascular measurements in eyes with early primary open-angle glaucoma (POAG).

Methods

In this cross-sectional study, subjects with early glaucoma (VF mean deviation, ≥−6 dB) underwent optical coherence tomography (OCT) imaging, optical coherence tomography angiography (OCTA) imaging, and Humphrey 24-2 VF tests. Capillary perfusion densities (CPDs) were calculated after the removal of large vessels in the OCTA images. Focal associations between VF losses at the individual VF test locations, circumpapillary retinal nerve fiber layer (RNFL) thickness measurements from OCT, and CPDs were determined using nerve fiber trajectory tracings. Linear mixed models were used to model focal VF losses at each VF test location.

Results

Ninety-seven eyes with early POAG (VF mean deviation, −2.47 ± 1.64 dB) of 71 subjects were included. Focal VF modeling using a combined RNFL–CPD approach resulted in a median adjusted R² value of 0.30 (interquartile range [IQR], 0.13–0.55), whereas the RNFL-only and CPD-only approaches resulted in median values of 0.22 (IQR, 0.10–0.51) and 0.26 (IQR, 0.10–0.52), respectively. Seventeen VF locations with the combined approach had an adjusted R² value greater than 0.50. Likelihood testing at each VF test location showed that the combined approach performed significantly better at the superior nasal VF regions of the eyes compared with the univariate approaches.

Conclusions

Modeling of focal VF losses showed improvements when structural thickness and vascular parameters were included in tandem. Evaluation of VF defects in early glaucoma may benefit from considering both RNFL and OCTA characteristics.

[Static automated perimetry in the diagnosis of glaucoma. Part 2: Research protocol, glaucoma classifications, perimetric defects through the prism of structural-functional correlation]

Examination of the central visual field is currently required for glaucoma diagnosis. Modern computer perimeters make it possible to qualitatively and quantitatively evaluate defects of light sensitivity. Perimetric indices are calculated showing the severity of the defects. This allows the use of perimetric results to create universal classifications of glaucoma. Recently, new perimeter programs based on optical coherence tomography data have appeared. The possibility of personalizing perimeter programs are being tested. This review attempts to systematize data on the capabilities of computer perimeters in assessing functional defects, presents the widely used glaucoma classifications, and describes ways of developing static perimetry programs for earlier diagnosis of glaucoma with respect to structural and functional correlations.

Demographic, Comorbid, and Clinical Variables Associated With Pointwise Visual Field Damage in Glaucoma: Data From the AGIS and CIGTS Clinical Trials

Purpose

To investigate differences across the visual field (VF) in the rate of glaucomatous progression, the likelihood of defect in four disease severity cross-sections, and comparisons of subgroups in each of between 12 demographic, comorbid, and clinical variables.

Methods

Two long-term glaucoma clinical trials used Humphrey Field Analyzer 24-2 VFs to calculate pointwise deviations from age-matched normal controls. Slopes of glaucomatous progression over time were calculated per participant using linear mixed models. Pointwise differences between subgroups in slopes and cross-sectional categories were tested, adjusting for multiple comparisons using false discovery rate (FDR) and Q values.

Results

Pointwise data were available for 1118 patients who had 15,073 VFs. On average, defects were seen at all VF points. Of the 12 variables, six had average pointwise slopes where Subgroup 1 had significantly faster progression than Subgroup 2 at all or many of the 52 VF points: participants who were older (≥65 vs. younger), 52/52; were male, 13/52; had diabetes, 29/52; had hypertension, 46/52; had a larger cup-to-disc ratio (≥0.7), 36/52; or had larger differences in absolute mean deviation (MD) between eyes (>3 dB), 52/52. Cross-sectional patterns at MD severity of -12 to -6.1 dB showed strong midline effects for gender and other patterns for hypertension, cup-to-disc ratio, absolute difference in MD between eyes, and disc notching.

Conclusions

The approach used provides new longitudinal and cross-sectional insights into variation across the VF associated with demographic, comorbid, and clinical variables.

Translational Relevance

This exploration and characterization of variable effects in the setting of pointwise VF testing may enable clinicians to anticipate patterns of VF loss based on demographic, comorbid, and clinical associations.

Corneal Hysteresis in Thais and Variation of Corneal Hysteresis in Glaucoma

PURPOSE

To collect the normal value data of corneal hysteresis in Thais and study the variation of corneal hysteresis in glaucomatous eyes.

METHODS

Retrospective cross-sectional study of corneal hysteresis (CH) in healthy non-glaucomatous and glaucomatous eyes. Demographic data, type and staging of glaucoma, Goldmann applanation tonometry (GAT) and ocular response analyzer parameters; CH, corneal-compensated intraocular pressure (IOPcc) and Goldmann-correlated intraocular pressure (IOPg) were collected.

RESULTS

Data from one eye of 465 normal participants were included for the normal value data of CH. Mean CH, IOPcc and IOPg were 10.18 ± 1.48, 15.01 ± 3.04 and 14.16 ± 3.06 mmHg, respectively. Average age was 57.21 ± 14.4 years. CH at the fifth percentile was 8.0 mmHg. Women had significantly higher CH than men (10.29 ± 1.46 vs 9.90 ± 1.49 mmHg, p=0.009). Moderate negative correlation was found between age and CH, r = -0.338, p<0.001. There were 695 glaucomatous eyes from 429 patients including primary-open angle glaucoma (POAG), primary close-angle glaucoma (PACG), normal tension glaucoma (NTG) and ocular hypertension (OHT). CH in each glaucoma type and severity stage (early, moderate and severe) were as follows: POAG: 8.74 ± 1.52 mmHg (9.22 ± 1.47, 8.74 ± 1.23 and 7.92 ± 1.40 mmHg, p<0.001), PACG: 9.09 ± 1.72 mmHg (9.85 ± 1.45, 9.04 ± 1.68 and 8.45 ± 1.74 mmHg, p= 0.004), NTG: 9.55 ± 1.67 mmHg (9.47 ± 1.38, 9.75 ± 2.42 and 9.77 ± 1.34 mmHg, p 0.525) and OHT: 10.10 ± 1.40 mmHg.

CONCLUSION

Compared with normal value data of corneal hysteresis, CH in glaucomatous eyes was lower. The more advanced glaucoma stage was associated with lower CH. Arising from normal value data, a low percentile of CH could be applied as the deviation value from normal and this dynamic property of CH could represent a glaucoma predictor in an effort to improve glaucoma care.

Global Glaucoma Staging System (GGSS): A New Method to Simultaneously Assess the Severity of Both Functional and Structural Damage in Glaucoma

BACKGROUND

The classification of damage in glaucoma is usually based either on visual field or optical coherent tomography (OCT) assessment. No currently available method is able to simultaneously categorize functional and structural damage.

MATERIAL AND METHODS

In this study, 283 patients with chronic open-angle glaucoma (OAG) at different stages and 67 healthy subjects were tested with both standard automated perimetry and spectral domain OCT for retinal nerve fiber layer (RNFL) assessment. The visual field data were classified using the Glaucoma Staging System 2, whereas OCT results were processed with the OCT Glaucoma Staging System. These data were used to create a new staging system (global glaucoma staging system, GGSS), in which the severity of visual field and RNFL damage is reported on the Y and X axis, respectively. The GGSS was tested in a different sample of 147 patients with manifest OAG, 56 with preperimetric glaucoma and 43 normal subjects. A six-stage clinical classification, based on the analysis of visual fields and optic disc appearance, was used as gold standard.

RESULTS

The GGSS was able to correctly classify in the same stage or within the immediately adjacent stages 145 cases on 147 (98.6%). Fifty-four preperimetric cases (96.4%) were classified as borderline or abnormal (Stage 1 or 2). Here, 41 normal eyes out of 43 were correctly classified as Stage 0, with a specificity of 95.3%.

CONCLUSIONS

Preliminary results from this study are encouraging and suggest that the new GGSS is able to provide information concerning the severity of structural and functional damage in an integrated manner.

Central-most Visual Field Defects in Early Glaucoma

PRCIS

This study demonstrates the substantial association between visual field (VF) defect within the central-most 4 points in 24-2 VF and the VF defect exhibited by 10-2 test pattern relative to the initial defect in 24-2 VF.

PURPOSE

To evaluate the significance of central-most visual field defects (CMVFDs) in 24-2 VF in early glaucoma.

METHODS

This cross-sectional study examined 29 eyes of 28 glaucoma patients with CMVFDs. CMVFD was defined as a glaucomatous defect with at least 1 abnormal point at P<1% within the central 5 degrees on 3 consecutive 24-2 VF tests. 10-2 VFs were categorized into 3 groups by severity of pattern defects: deep arcuate, partial arcuate, and minimal defect. The deep arcuate group was interpreted as the most severe defect on the 10-2 VF. Mann-Whitney test was used to compare the perimetric parameters differences between 24-2 VFs with CMVFD and 10-2 VFs related to the initial defect.

RESULTS

CMVFD was observed in 82% eyes, predominantly in the superior hemifield (86%). Arcuate-like defects (72%) on the 10-2 VF were mostly in superior hemifield (82%). The deep arcuate group showed significantly worse mean deviation (MD) and pattern standard deviation (PSD), (MD= -9.1±4, PSD =10.7±2.1 dB), than partial arcuate and minimal defect groups (all P<0.001). Eyes with deep arcuate defect had severely depressed defect depth (-26 to -35 dB) and low sensitivity (<0 to 10 dB) at abnormal points in the central 5 degrees in 24-2 VF. A significant difference among deep arcuate, partial arcuate (P<0.001), and minimal defect groups (P<0.001) was observed at abnormal points' threshold sensitivity and defect depth.

CONCLUSIONS

Given the significance and effect of perimetric factors at abnormal test points in the central 5 degrees of 24-2 VFs, these eyes deserve attention to determine the severity of and functional impact on the CMVFD in early glaucoma by performing 10-2 test.

Deep Relation Transformer for Diagnosing Glaucoma With Optical Coherence Tomography and Visual Field Function

Glaucoma is the leading reason for irreversible blindness. Early detection and timely treatment of glaucoma are essential for preventing visual field loss or even blindness. In clinical practice, Optical Coherence Tomography (OCT) and Visual Field (VF) exams are two widely-used and complementary techniques for diagnosing glaucoma. OCT provides quantitative measurements of the optic nerve head (ONH) structure, while VF test is the functional assessment of peripheral vision. In this paper, we propose a Deep Relation Transformer (DRT) to perform glaucoma diagnosis with OCT and VF information combined. A novel deep reasoning mechanism is proposed to explore implicit pairwise relations between OCT and VF information in global and regional manners. With the pairwise relations, a carefully-designed deep transformer mechanism is developed to enhance the representation with complementary information for each modal. Based on reasoning and transformer mechanisms, three successive modules are designed to extract and collect valuable information for glaucoma diagnosis, the global relation module, the guided regional relation module, and the interaction transformer module, namely. Moreover, we build a large dataset, namely ZOC-OCT&VF dataset, which includes 1395 OCT-VF pairs for developing and evaluating our DRT. We conduct extensive experiments to validate the effectiveness of the proposed method. Experimental results show that our method achieves 88.3% accuracy and outperforms the existing single-modal approaches with a large margin. The codes and dataset will be publicly available in the future.

Efficacy and Safety of PreserFlo® MicroShunt After a Failed Trabeculectomy in Eyes with Primary Open-Angle Glaucoma: A Retrospective Study

Introduction

To evaluate the efficacy and safety of PreserFlo^® MicroShunt in primary open angle glaucoma (POAG) eyes after a single failed trabeculectomy.

Methods

Retrospective review of POAG eyes with a failed trabeculectomy that underwent PreserFlo^® MicroShunt implantation from March 2019 to November 2019, in two Italian glaucoma centers. Pre- and postoperative data were collected and compared.

Results

A total of 31 surgeries in 31 patients were reviewed. Mean preoperative IOP and mean preoperative number of medications were 24.12 ± 3.14 mmHg and 3.29 ± 0.64, respectively, and decreased to 12.56 ± 2.64 mmHg and 0.46 ± 0.77 at the 12-month postoperative follow-up visit (p < 0.01). The most frequent adverse events were transient hypotony (6 eyes, 19.3%) and choroidal effusion (3 eyes, 9.6%). In all cases spontaneous resolution was observed, with no intervention.

Conclusion

In POAG eyes with a single failed trabeculectomy, the PreserFlo^® MicroShunt was safe and effective in reducing the IOP after a 12-month follow-up. The PreserFlo^® MicroShunt may represent a viable choice as a second surgery.

Association of peripheral anterior synechiae with anterior segment parameters in eyes with primary angle closure glaucoma

To investigate the association of peripheral anterior synechiae (PAS) with intraocular pressure (IOP) and anterior-segment parameters in subjects with primary angle-closure glaucoma (PACG). A total of 267 subjects with PACG were recruited and underwent gonioscopy and anterior-segment optical coherence tomography (ASOCT). Customized software was used to measure ASOCT parameters, including angle opening distance (AOD750) and trabecular-iris-space-area (TISA750) at 750 µm from the scleral spur, anterior chamber depth, width, area and volume (ACD, ACW, ACA, ACV), iris thickness (IT750), iris area (IAREA), and lens vault (LV). Presenting IOP was defined as the first IOP reading before the initiation of IOP-lowering treatment. The mean age of the 267 subjects was 67.0 ± 8.9 years, 140 (52.4%) were male, and 246 (92.1%) were of Chinese ethnicity. PAS was present in 122 (45.7%) subjects, and was most frequently found in the superior quadrant (79.5%). Subjects with PAS had greater presenting IOP (28.7 ± 12.9 vs 22.4 ± 9.7 mmHg, p < 0.001), narrower AOD750 (p < 0.001), smaller TISA750 (p < 0.001), ACD (p = 0.04), ACA (p = 0.02), ACV (p = 0.01) and larger LV (p = 0.01) compared to PACG eyes without PAS. No significant differences were noted for iris parameters. A multivariate logistic regression analysis showed that higher presenting IOP (β = 0.20, p < 0.001), worse visual field mean deviation (β = - 0.20, p = 0.01) and narrower AOD750 (β = - 0.25, p = 0.03) were the only parameters that significantly correlated with the extent of PAS in clock hours. Almost one-half of the subjects with PACG demonstrated PAS; these eyes were associated with higher presenting IOP, smaller anterior segment dimensions and more severe disease.

Intraocular asymmetry of visual field defects in primary angle-closure glaucoma, high-tension glaucoma, and normal-tension glaucoma in a Chinese population

Direct comparison data on spatial patterns of visual field (VF) defects among primary angle-closure glaucoma (PACG), high-tension glaucoma (HTG) and normal-tension glaucoma (NTG) are not available. We aimed to compare the intraocular asymmetry of VF loss among patients with PACG, NTG and HTG across different severity levels. A total of 162 eyes of 114 patients with PACG, 111 eyes of 74 patients with HTG and 148 eyes of 102 patients with NTG were included. VF defects were categorized into 3 stages (early, moderate, and advanced), and each hemifield was divided into 5 regions according to the Glaucoma hemifield test (GHT). The mean total deviation (TD) of each GHT region was calculated. In the early stage, the paracentral, peripheral arcuate 1 and peripheral arcuate 2 regions in the superior hemifield in the NTG group had significantly worse mean TDs than their corresponding regions in the inferior hemifield. In the advanced stage, the central region in the superior hemifield in the PACG group had a significantly worse mean TD than that in the inferior hemifield. There was no significant difference in the mean TD for any of the five regions between hemifields across all severity levels in the in the HTG group. The superior hemifield was affected more severely than the inferior hemifield in all three subtypes of primary glaucoma. This asymmetric tendency was more pronounced in NTG than in PACG and HTG.

The Effect of Medical Lowering of Intraocular Pressure on Peripapillary and Macular Blood Flow as Measured by Optical Coherence Tomography Angiography in Treatment-naive Eyes

PRCIS

Reduction of intraocular pressure (IOP) by latanoprost in treatment-naive eyes is significantly correlated to an increase in vessel density (VD) at the optic nerve head (ONH).

PURPOSE

To evaluate the effect of topical latanoprost on ocular microvasculature using optical coherence tomography angiography (OCTA).

PATIENTS AND METHODS

In this prospective case-control study, 26 eyes from 18 treatment-naive subjects in whom prostaglandin analogue (PGA) latanoprost 0.005% was initiated were included as cases. In 10 out of the 18 subjects, medication was initiated in only 1 eye; their contralateral untreated eyes were used as controls. OCTA (AngioVue, Optovue Inc., Fremont, CA) was performed at baseline and ≥3 weeks after commencing treatment. Main outcome measures were change in flow area and VD at the ONH, radial peripapillary capillaries (RPC), and macula. Comparison between the 2 visits was performed using a linear mixed model adjusted for intereye correlation and mean ocular perfusion pressure.

RESULTS

IOP decreased by 26.1%±11.3% (P<0.001) in the cases and 0.18%±12.2% (P=0.63) in controls. Significant correlations between change in IOP and change in ONH VD (correlation coefficient [r]=-0.42, P=0.04), and between change in IOP and change in RPC VD (r=-0.48, P=0.02) were observed in the cases, whereas none were observed in the controls. When multiple testing was considered, no significant changes in flow area and VD were observed in cases and controls.

CONCLUSIONS

The reduction of IOP by a PGA in treatment-naive eyes was significantly correlated to the increase in ONH VD and RPC VD. This may indicate a mechanism by which IOP reduction modulates the risk of glaucoma progression by improving ocular microperfusion.

Agreement between the newly developed OCT glaucoma staging system and the standardized visual field glaucoma staging system 2

PURPOSE

The purpose of this research was to assess the agreement between the new optical coherence tomography (OCT) glaucoma staging system (GSS) and the visual field (VF) GSS 2 (GSS2).

METHODS

This is a cross-sectional study of 161 eyes of 110 patients with controlled primary open-angle glaucoma (POAG). All eyes were subjected to VF examination using standard automated perimetry and Humphrey field analyzer II 750. GSS2 was used for the classification of the VF defects' severity. OCT of the optic disc and the macular ganglion cell complex (GCC) was performed using RTVue. Patients were classified by OCT GSS into six stages.

RESULTS

The study examined 161 eyes of 110 patients with controlled POAG. The staging according to VF GSS2 was as follows: stage 0 (12.42%), border stage (12.42%), stage 1 (13.04%), stage 2 (14.29%), stage 3 (14.28%), stage 4 (14.28%), and stage 5 (19.25%). The staging by OCT GSS was as follows: stage 0 (18.6 %), border stage (17.3%), stage 1 (6.8%), stage 2 (9.31%), stage 3 (6%), stage 4 (11.8%), and stage 5 (30.43%). The sensitivity of the new OCT GSS was different in different stages of glaucoma. In this study, no normal control group was considered; thus, the specificity could not be calculated. There was moderate agreement between the two staging systems.

CONCLUSIONS

OCT GSS is a reliable and objective method for diagnosing and monitoring glaucoma. Correlations were found between GSS2, inferior and total macular GCC thickness values, and cup-to-disc ratios, so considering these items as additional parameters may make this new classification even more sensitive than VF GSS2.

Development and Validation of Automated Visual Field Report Extraction Platform Using Computer Vision Tools

Purpose: To introduce and validate hvf_extraction_script, an open-source software script for the automated extraction and structuring of metadata, value plot data, and percentile plot data from Humphrey visual field (HVF) report images.

Methods: Validation was performed on 90 HVF reports over three different report layouts, including a total of 1,530 metadata fields, 15,536 value plot data points, and 10,210 percentile data points, between the computer script and four human extractors, compared against DICOM reference data. Computer extraction and human extraction were compared on extraction time as well as accuracy of extraction for metadata, value plot data, and percentile plot data.

Results: Computer extraction required 4.9-8.9 s per report, compared to the 6.5-19 min required by human extractors, representing a more than 40-fold difference in extraction speed. Computer metadata extraction error rate varied from an aggregate 1.2-3.5%, compared to 0.2-9.2% for human metadata extraction across all layouts. Computer value data point extraction had an aggregate error rate of 0.9% for version 1, <0.01% in version 2, and 0.15% in version 3, compared to 0.8-9.2% aggregate error rate for human extraction. Computer percentile data point extraction similarly had very low error rates, with no errors occurring in version 1 and 2, and 0.06% error rate in version 3, compared to 0.06-12.2% error rate for human extraction.

Conclusions: This study introduces and validates hvf_extraction_script, an open-source tool for fast, accurate, automated data extraction of HVF reports to facilitate analysis of large-volume HVF datasets, and demonstrates the value of image processing tools in facilitating faster and cheaper large-volume data extraction in research settings.

A simplified combined index of structure and function for detecting and staging glaucomatous damage

Glaucomatous damage results in characteristics structural and functional changes on optical coherence tomography (OCT) imaging and standard automated perimetry (SAP) testing. The clinical utility of these measures differs based on disease severity, as they are evaluated along different measurement scales. This study therefore sought to examine if a simplified combined structure-function index (sCSFI) could improve the detection and staging of glaucomatous damage, compared to the use of average retinal nerve fiber layer thickness (RNFL) measurements from OCT and mean deviation (MD) values from SAP alone, and also an estimated retinal ganglion cell counts (eRGC) measure derived using empirical formulas described previously. Examining 577 eyes from 354 participants with perimetric glaucoma and 241 normal eyes from 138 healthy participants, we found that the sCSFI performed significantly better than average RNFL, MD and eRGC count for discriminating between glaucoma and healthy eyes (P ≤ 0.008 for all). The sCSFI also performed significantly better than RNFL and eRGC count at discriminating between different levels of visual field damage in glaucoma eyes (P < 0.001 for both). These findings highlight the clinical utility of combining structural and functional information for detecting and staging glaucomatous damage using the simplified index developed in this study.

Saccadic reaction time in mirror image sectors across horizontal meridian in eye movement perimetry

In eye movement perimetry (EMP), the saccadic reaction time (SRT) to ‘seen’ visual stimuli are delayed in glaucoma. Evaluating SRT behaviour in hemi-field sectors could refine its clinical implication. The development phase included 60 controls retrospectively and for the test cohort in evaluation phase, another 30 healthy subjects and 30 glaucoma patients were recruited prospectively. The SRTs were used to calculate the normative limits within 5 predefined hemi-field sectors. Scores were assigned to probabilities for SRT at the level of 5%, 2.5% 1% and 0.5%. Per sector pair, a probability score limit (PSL) was calculated at each of the four levels and were compared with the scores obtained from the test cohort. The classification accuracy ‘normal versus abnormal’ was assessed for PSL in EMP and compared with glaucoma hemi-field test in standard automated perimetry. We found no statistically significant differences in SRTs between the mirror sectors in healthy subjects. The PSL at 2.5% had moderate classification accuracy with a specificity of 77% and sensitivity 70%. This could be suggestive of an SRT delay in the overall visual field in glaucoma.

Plateau Iris and Severity of Primary Angle Closure Glaucoma

PURPOSE

To compare the distribution of plateau iris in eyes across varying severity of primary angle closure glaucoma (PACG) using standardized ultrasound biomicroscopy (UBM) criteria.

DESIGN

Cross-sectional study.

METHODS

UBM was performed on 210 patients with PACG who had previously undergone laser peripheral iridotomy. Plateau iris was defined as the presence of all the following UBM criteria in ≥2 quadrants of the angle: anteriorly directed ciliary body, absent ciliary sulcus, iris angulation, flat iris plane, and iridotrabecular contact. Disease severity was based on the visual field mean deviation (MD) and classified as early-to-moderate (MD ≥ -12 dB), advanced (-12.01 dB to -20 dB), and severe (MD < -20 dB).

RESULTS

Of 210 subjects recruited, 23 were excluded because of poor quality UBM images. The remaining 187 patients were categorized as having early-to-moderate (n = 103), advanced (n = 38), and severe PACG (n = 46). Of these subjects, 48.1% were male, and 90.9% were of Chinese ethnicity. The overall proportion of plateau iris was 36.9%, with 32.0% (33/103) in early-to-moderate, 34.2% (13/38) in advanced, and 50% (23/46) in severe PACG (P = .03, comparing severe PACG with early-to-moderate groups). Among the severe PACG group, those with plateau iris configuration had significantly smaller anterior chamber area (P = .03) and volume (P = .01) compared with those without plateau iris.

CONCLUSION

The higher proportion of plateau iris configuration in eyes with severe PACG compared with early-to-moderate PACG suggest that this may be a contributory factor for disease severity.

Waveform parameters of retrobulbar vessels in glaucoma patients with different demographics and disease severity

Introduction:

To identify novel velocity waveform parameters of the ophthalmic artery and central retinal artery by computer-aided image processing of Doppler ultrasonography measurements, and to evaluate correlations between the waveform parameters and different demographics and disease severity of open-angle glaucoma patients.

Methods:

Thirty-six images of 36 open-angle glaucoma patients were considered. A semiautomated image processing code was used to detect the digitalized ophthalmic artery and central retinal artery velocity waveforms and to extract the waveform parameters. Concordance correlation coefficient, two-sample t-test, and Pearson’s correlation coefficient were used to test for similarities, differences, and associations among variables.

Results:

Female glaucoma patients showed a statistically higher ophthalmic artery normalized distance between ascending and descending limb (p = 0.004), hypertensive glaucoma patients a statistically higher ophthalmic artery peak systolic velocity time (p = 0.025), glaucoma patients with hyperlipidemia a statistically higher ophthalmic artery resistivity index (p = 0.023) and a statistically higher ophthalmic artery peak systolic velocity acceleration (p = 0.025), glaucoma patients with cardiovascular diseases a statistically lower central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.033) and a statistically higher central retinal artery period (p = 0.028), and patients with different body mass index a statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.016). Groups with different disease severity, classified following the Brusini glaucoma staging system 2, showed statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p < 0.001) and central retinal artery period (p = 0.016). No statistical differences were found in regard to race, diabetes status, glaucoma family history, and smoking.

Discussion:

Ophthalmic artery and central retinal artery computer-aided analysis of velocity waveforms could identify novel waveform parameters capable of differentiating among different demographics and disease severity of open-angle glaucoma patients.

Associations of Ganglion Cell-Inner Plexiform Layer and Optic Nerve Head Parameters with Visual Field Sensitivity in Advanced Glaucoma

PURPOSE

To evaluate the associations of optical coherence tomography (OCT)-derived macular ganglion cell-inner plexiform layer thickness (mGCIPLT), circumpapillary retinal nerve fiber layer thickness (cpRNFLT), and optic nerve head (ONH) parameters with visual field (VF) sensitivity in advanced glaucoma.

METHODS

In this cross-sectional study, 102 eyes from 102 patients with advanced glaucoma (defined as a 24-2 VF mean deviation (MD) of ≤-12 dB) were included. mGCIPLT, cpRNFLT, and ONH parameters (including the rim area, average cup-to-disc [C:D] ratio, and vertical C:D ratio) were measured using Cirrus high-definition OCT, and 24-2 and 10-2 VF sensitivity tests were performed using standard automated perimetry. Pearson correlations and linear models were used to analyze relationships between OCT-derived parameters and VF parameters.

RESULTS

The mGCIPLT and rim area were significantly positively correlated with the 24-2 VF MD, 24-2 VF pattern standard deviation, 24-2 VF visual field index, and 10-2 VF MD, but cpRNFLT was not significantly correlated with VF parameters. In addition, the average and vertical C:D ratios were significantly negatively correlated with VF parameters. The mGCIPLT and rim area were significantly positively correlated with the 10-2 VF MD (r ranging between 0.542 and 0.621, p < 0.001), while the average and vertical C:D ratios were significantly negatively correlated with the 10-2 VF MD (r = -0.537, p < 0.001, and r = -0.428, p < 0.001, respectively). Each 1-µm change in the average mGCIPLT was associated with an approximately 0.368-dB change in the 24-2 VF MD and 0.677-dB change in the 10-2 VF MD (R2 = 0.268, p < 0.001, and R2 = 0.385, p < 0.001, respectively). The 10-2 VF MD showed a significantly stronger association with inferonasal mGCIPLT than did the 24-2 VF MD in advanced glaucoma (p = 0.007).

CONCLUSIONS

mGCIPLT and ONH parameters were associated with the severity of VF damage and reflected functional damage better than cpRNFLT in advanced glaucoma. Our results suggested that structural measurements of mGCIPLT and ONH parameters and functional measurement of the 10-2 VF may be useful for monitoring progression in advanced glaucoma.

Evaluation of Primary Angle-Closure Glaucoma Susceptibility Loci for Estimating Angle Closure Disease Severity

PURPOSE

To investigate whether recently identified genetic loci for primary angle-closure glaucoma (PACG) are associated with disease severity.

DESIGN

Case-control study.

PARTICIPANTS

Eight hundred four PACG patients and 943 control participants of Chinese ethnicity from Singapore.

METHODS

The 8 PACG-associated single nucleotide polymorphisms (SNPs; rs11024102 at PLEKHA7, rs3753841 at COL11A1, rs1015213 located between PCMTD1 and ST18 on chromosome 8q, rs3816415 at EPDR1, rs1258267 at CHAT, rs736893 at GLIS3, rs7494379 at FERMT2, and rs3739821 mapping in between DPM2 and FAM102A) identified from genome-wide association studies were tested for association with disease severity using logistic regression adjusted for age and gender. A P value of 0.006 was set as significant after Bonferroni correction for testing of 8 loci. We also calculated the weighted genetic risk score (GRS) weighted by the estimated individual SNP effect size on PACG calculated as logarithm of the odds ratio (OR). Disease severity was based on the visual field mean deviation (MD) and classified as early to moderate (MD, >-12 dB) and severe (MD, <-20 dB).

MAIN OUTCOME MEASURES

Association of PACG loci with severe disease.

RESULTS

Of the 804 PACG patients, genotyping data were available for 768 individuals and included 436 with mild-to-moderate PACG and 206 with severe PACG. The PACG patients were significantly older (mean age, 64.3 ± 9.1 years vs. 56.4 ± 8.9 years; P < 0.001) and there were proportionately more women compared with control participants (58.4% vs. 49.0%; P < 0.001). Of the 8 loci investigated, we observed significant evidence of association with severe PACG at 1 SNP, namely rs3816415 in EPDR1 (OR, 2.03; 95% confidence interval [CI], 1.49-2.78; P = 1 × 10^-5). A higher-weighted GRS was associated significantly with severe PACG, with an OR of 3.11 (95% CI, 1.95-4.96) comparing the lowest quartile with the highest quartile.

CONCLUSIONS

Our results show that EPDR1 is associated significantly with severe PACG, suggesting that it may predispose patients to more aggressive disease development. Individuals with PACG with a higher GRS were associated with a higher risk of severe PACG.

Macular Vascular Microcirculation in Eyes With Open-angle Glaucoma Using Different Visual Field Severity Classification Systems

PRECIS

We found significant differences in macular vascular microcirculation between normal and glaucomatous eyes using optical coherence tomography angiography (OCTA). Macular vascular microcirculation changes also showed significant correlations with visual field (VF) severity classification systems.

PURPOSE

To correlate VF severity defined by different classification systems and macular vascular microcirculation in eyes with glaucoma using OCTA.

PATIENTS AND METHODS

Twenty normal and 58 open-angle glaucoma (OAG) eyes were scanned using a swept-source OCTA (Plex Elite 9000) and macular vascular microcirculation was measured by calculating the overall blood flux index (BFI) and vessel area density (VAD) over the entire 6×6 mm area excluding the big retinal vessels. Glaucomatous eyes were staged into severity groups based on 4 VF severity classifications: Hodapp-Parrish-Anderson scale, Glaucoma Severity Staging system, ICD-10 glaucoma staging definitions, and VF mean deviation. Central 10-degree VF mean sensitivity (CMS) was calculated based on 24-2 VF. One-way analysis of variance was used to analyze the differences and correlation between macular vascular microcirculation and other clinical parameters.

RESULTS

Glaucomatous eyes had significantly lower ganglion cell and inner plexiform layer BFI and VAD (P<0.0001) compared with normal eyes. In OAG patients, BFI and VAD were significantly higher in mild OAG compared with severe OAG with all VF disease severity classification systems (P<0.001). Glaucoma Severity Staging had the highest correlation with changes in macular vascular microcirculation metrics (r=0.734 for BFI; r=0.647 for VAD) and VF CMS had highest correlation with macular vascular microcirculation metrics (r=0.887 for BFI; r=0.903 for VAD).

CONCLUSION

Macular vascular microcirculation metrics detected by OCTA correlate with disease severity in glaucomatous eyes. VF CMS, calculated from only 12 tested central 10-degree points, correlated best with macular OCTA.

Comparison of perimetric Glaucoma Staging Systems in Asians with primary glaucoma

BACKGROUND

To compare functional staging classifications in Vietnamese patients with primary open angle glaucoma (POAG) and chronic primary angle closure glaucoma (PACG).

METHODS

A retrospective cross-section study was conducted at a national setting. Two hundred seven eyes of 207 patients were recruited. Patients were tested with standard automated perimetry. Field loss was generally classified in four stages (normal, early, moderate, and severe), using four classification strategies: (1) Hodapp-Parrish-Anderson (HPA), (2) enhanced Glaucoma Staging System (eGSS), (3) modified Glaucoma Staging System (mGSS) and (4) the Advanced Glaucoma Intervention Study (AGIS). AGIS as a standard method was used to judge the staging performance of the other three classifications in terms of agreement (Cohen Kappa-K) and association (Chi-Square Test-Cramer's V).

RESULTS

The agreement between AGIS and mGSS (K = 0.687; p < 0.001) and HPA (K = 0.686; p < 0.001) was substantial while that between AGIS and eGSS was slight (K = 0.103; p < 0.001). The association between AGIS and mGSS (V = 0.748; p < 0.001) and HPA (V = 0.748; p < 0.001) was greater than eGSS (V = 0.594; p < 0.001).

CONCLUSIONS

MGSS and HPA showed stronger agreement and closer association with AGIS than eGSS. We recommend mGSS should be used in managing a glaucoma clinic because of its simplicity and convenience over HPA and AGIS.

Convex Representations Using Deep Archetypal Analysis for Predicting Glaucoma

Goal: The purpose of this study was to identify clinically relevant patterns of glaucomatous vision loss through convex representation to predict glaucoma several years prior to disease onset. Methods: We developed a deep archetypal analysis to identify patterns of glaucomatous vision loss, and then projected visual fields over the identified patterns. Projections provided a representation that was more accurate in detecting glaucomatous vision loss, thus, more appropriate for recognizing preclinical signs of glaucoma prior to disease development. To overcome the class imbalance in prediction, we implemented a class-balanced bagging with neural networks. Results: Using original visual field as features of the class-balanced bagging classification provided an area under the receiver-operating characteristic curve (AUC) of 0.55 for predicting glaucoma approximately four years prior to disease development. Using convex representation of the visual fields as input features provided an AUC of 0.61 while using deep convex representation as input features improved the AUC to 0.71. Relevance vector machine (RVM) achieved an AUC of 0.64. Conclusion: Deep archetypal analysis representation of visual functional features with balanced bagging classification could serve as an automated tool for predicting glaucoma. Significance: Glaucoma is the second leading cause of worldwide blindness. Most people with glaucoma have no early symptoms or pain, delaying diagnosis in many patients until they reach late irreversible vision loss stages. In fact, about 50% of people with glaucoma are unaware they have the disease. Deep archetypal analysis models may impact clinical practice in effectively identifying at-risk glaucoma patients well prior to disease development.