Analysis of reliability indices from Humphrey visual field tests in an urban glaucoma population

Pilot study comparing a new virtual reality-based visual field test to standard perimetry in children

PURPOSE

To assess the feasibility and performance of Vivid Vision Perimetry (VVP), a new virtual reality (VR)-based visual field platform.

METHODS

Children 7-18 years of age with visual acuity of 20/80 or better undergoing Humphrey visual field (HVF) testing were recruited to perform VVP, a VR-based test that uses suprathreshold stimuli to test 54 field locations and calculates a fraction seen score. Pearson correlation coefficients were calculated to evaluate correlation between HVF mean sensitivity and VVP mean fraction seen scores. Participants were surveyed regarding their experience.

RESULTS

A total of 37 eyes of 23 participants (average age, 12.9 ± 3.1 years; 48% female) were included. All participants successfully completed VVP testing. Diagnoses included glaucoma (12), glaucoma suspect (7), steroid-induced ocular hypertension (3), and craniopharyngioma (1). Sixteen participants had prior HVF experience, and none had prior VVP experience, although 7 had previously used VR. Of the 23 HVF tests performed, 9 (39%) were unreliable due to fixation losses, false positives, or false negatives. Similarly, 35% of VVP tests were unreliable (as defined by accuracy of blind spot detection). Excluding unreliable HVF tests, the correlation between HVF average mean sensitivity and VVP mean fraction seen score was 0.48 (P = 0.02; 95% CI, 0.09-0.74). When asked about preference for the VVP or HVF examination, all participants favored the VVP, and 70% were "very satisfied" with VVP.

CONCLUSIONS

In our cohort of 23 pediatric subjects, VVP proved to be a clinically feasible VR-based visual field testing, which was uniformly preferred over HVF.

Gene replacement therapy in Bietti crystalline corneoretinal dystrophy: an open-label, single-arm, exploratory trial

Bietti crystalline corneoretinal dystrophy is an inherited retinal disease caused by mutations in CYP4V2, which results in blindness in the working-age population, and there is currently no available treatment. Here, we report the results of the first-in-human clinical trial (NCT04722107) of gene therapy for Bietti crystalline corneoretinal dystrophy, including 12 participants who were followed up for 180-365 days. This open-label, single-arm exploratory trial aimed to assess the safety and efficacy of a recombinant adeno-associated-virus-serotype-2/8 vector encoding the human CYP4V2 protein (rAAV2/8-hCYP4V2). Participants received a single unilateral subretinal injection of 7.5 × 1010 vector genomes of rAAV2/8-hCYP4V2. Overall, 73 treatment-emergent adverse events were reported, with the majority (98.6%) being of mild or moderate intensity and considered to be procedure- or corticosteroid-related; no treatment-related serious adverse events or local/systemic immune toxicities were observed. Compared with that measured at baseline, 77.8% of the treated eyes showed improvement in best-corrected visual acuity (BCVA) on day 180, with a mean ± standard deviation increase of 9.0 ± 10.8 letters in the 9 eyes analyzed (p = 0.021). By day 365, 80% of the treated eyes showed an increase in BCVA, with a mean increase of 11.0 ± 10.6 letters in the 5 eyes assessed (p = 0.125). Importantly, the patients' improvement observed using multifocal electroretinogram, microperimetry, and Visual Function Questionnaire-25 further supported the beneficial effects of the treatment. We conclude that the favorable safety profile and visual improvements identified in this trial encourage the continued development of rAAV2/8-hCYP4V2 (named ZVS101e).

Development and evaluation of Order of Magnitude (OM): a virtual reality-based visual field analyzer for glaucoma detection

PURPOSE

This study introduces the Order of Magnitude (OM), a cost-effective, indigenous, virtual reality-based visual field analyzer designed for detecting glaucomatous visual field loss.

METHODS

The OM test employs a two-step supra-thresholding algorithm utilizing stimuli of 0.43°diameter (equivalent to Goldmann size III) at low and high thresholds. A comparative analysis was conducted against the Humphrey visual field (HVF) test, considered the gold standard in clinical practice. Participants, including those with glaucoma and normal individuals, underwent comprehensive eye examinations alongside the OM and HVF tests between April and October 2019. Diagnostic sensitivity and specificity of the OM test were assessed against clinical diagnoses made by specialists.

RESULTS

We studied 157 eyes (74 glaucomatous, 83 control) of 152 participants. Results demonstrated a high level of reliability for both OM and HVF tests, with no significant difference observed (P = 0.19, Chi-square test). The sensitivity and specificity of the OM test were found to be 93% (95% CI 86-100%) and 83% (95% CI 72.4-93%), respectively, while the HVF test showed sensitivity and specificity of 98% (95% CI 93.9-100%) and 83% (95% CI 73.9-92.8%), respectively.

CONCLUSION

These findings suggest that the OM test is non-inferior to the reference standard HVF test in identifying glaucomatous visual field loss.

Factors Associated With Visual Field Testing Reliability in Children With Glaucoma or Suspected Glaucoma

PURPOSE

To evaluate Humphrey Visual Field (HVF) test reliability and its associated risk factors in children with glaucoma or glaucoma suspect.

DESIGN

Retrospective cohort study.

METHODS

None.

SETTING

Single-center childhood glaucoma clinic.

PATIENT POPULATION

One hundred thirty-six patients aged ≤18 years with glaucoma/glaucoma suspect, and least 1 completed 24 to 2 HVF test between 2018 and 2023.

OBSERVATION PROCEDURE

Demographic and clinical characteristics including age, primary language, visual acuity (VA), and glaucoma diagnosis were extracted from electronic health records.

MAIN OUTCOME MEASURES

HVF 24 to 2 testing metrics, including FP, FN, and FL. Tests were defined as reliable using manufacturer guidelines of ≤33% FP, ≤33% FN, and ≤20% FL. For each patient, a reliability score was calculated as the percentage of reliable tests among all tests completed. A multivariable logistic regression model was used to determine factors associated with test-level reliability (yes/no). A multivariable linear regression model was used to determine factors associated with patient-level reliability score.

RESULTS

Among 634 HVFs from 136 patients (Mean ± SD age at first test 12.0 ± 3.2 years, 47.8% female), 51.3% were reliable. Older age, better baseline VA, and English as primary language were associated with greater odds of test-level reliability (P < .04). Mean ± SD patient-level reliability score was 51.7 ± 38.1%. Older age at first clinic visit, better baseline VA, and English as primary language were associated with higher reliability scores (all P < .02), and number of prior VF tests was not (P = .56).

CONCLUSIONS

Younger age, worse visual acuity, and non-English as primary language were associated with decreased reliability and should be considered when interpreting VF testing in children. A significant learning effect was not observed with repeated testing.

Comparison of Structural and Functional Features in Primary Angle Closure and Open Angle Glaucomas

PRCIS

Using a large data set, we showed structural and functional differences between primary angle closure glaucoma (PACG) and primary open angle glaucoma (POAG). Primary angle closure glaucoma has relative structural preservation and worse functional loss inferiorly.

PURPOSE

To identify structural and functional differences in PACG and POAG.

MATERIALS AND METHODS

In this large cross-sectional study, differences in structural and functional damage were assessed among patients with POAG and PACG with optical coherence tomography and reliable visual field testing.

RESULTS

In all, 283 patients with PACG and 4110 patients with POAG were included. Despite similar mean deviation on visual fields (mean [SD] -7.73 [7.92] vs. -7.53 [6.90] dB, P =0.72), patients with PACG had thicker global retinal nerve fiber layer (RNFL), smaller cup volume, smaller cup-to-disc ratio, and larger rim area than POAG (77 [20] vs. 71 [14] µm, 0.32 [0.28] vs. 0.40 [0.29] mm 3 , 0.6 [0.2] vs. 0.7 [0.1], 1.07 [0.40] vs. 0.89 [0.30] mm 2 , P <0.001 for all), while patients with POAG had more pronounced inferior RNFL thinning (82 [24] vs. 95 [35] µm, P <0.001). In a multivariable analysis, hyperopia [odds ratio (OR): 1.24, confidence interval (CI): 1.13-1.37], smaller cup-to-disc ratio (OR: 0.69, CI: 0.61-0.78), thicker inferior RNFL (OR: 1.15, CI: 1.06-1.26) and worse mean deviation (OR: 0.95, CI: 0.92-0.98) were associated with PACG. Functionally, POAG was associated with superior paracentral loss and PACG with inferior field loss. After adjusting for average RNFL thickness, PACG was associated with more diffuse loss than POAG (total deviation differences 1.26-3.2 dB).

CONCLUSIONS

Patients with PACG had less structural damage than patients with POAG despite similar degrees of functional loss. Regional differences in patterns of functional and structural loss between POAG and PACG may improve disease monitoring for these glaucoma subtypes.

Reliability of Binocular Esterman Visual Field Test in Patients with Glaucoma and Other Ocular Conditions

The binocular Esterman visual field test (EVFT) of 120 points was the first method to quantify the defects in the binocular visual field. It is used in many parts of the world as a standard test to determine whether an individual has the visual capabilities to drive safely. In Japan, it is required for the grading and issuance of visual disability certificates. The purpose of this study was to determine the reliability of the EVFT results. We studied 104 patients who had undergone the binocular EVFT at Mie University Hospital. Their mean age was 68.0 ± 11.4 years, and the best-corrected visual acuity of the better eye was 0.18 ± 0.38 logMAR units. The EVFT was performed twice on the same day, and the results of the first and second tests were compared. The mean Esterman scores for the first and second test were 89.3 ± 30.5 and 89.1 ± 30.2, respectively, and the test times were 338.9 ± 86.8 and 336.7 ± 76.4 s, respectively. The differences were not significant (p = 0.69 and p = 0.33). In the Bland-Altman analyses (second-first test) of the Esterman scores, the mean difference was 0.38 without significant fixed errors (p = 0.20) or proportional errors (p = 0.27). The limits of agreement within the 1.96 standard deviation were -8.96 to +9.45 points. The agreement rate for the most peripheral 24 test points was significantly lower than the agreement rate for the other 96 test points (p < 0.01). The agreement rate of the upper visual field was significantly lower than that of the lower field (p < 0.01). The overall reliability rate of the EVFT is acceptable, but the peripheral and upper test points have relatively low reliability rates. These findings are important for interpretations of the EVFT results.

Identifying Rapid Glaucoma Progression Using Hemifield Rates of Progression

PRCIS

Hemifield rates of progression are more sensitive to focal progression (or faster progression) than global rates. This can aid in tailoring management and treatment decisions.

PURPOSE

To determine if the rate of progression (ROP) of each hemifield of the 24-2 visual field (VF) aids in the detection of rapidly progressing eyes.

METHODS

In this retrospective longitudinal study, we evaluated 1658 eyes of 1658 consecutive glaucoma patients with global mean deviation (MD) VF loss between -3 and -15 dB at baseline and ≥8 reliable VF tests (Swedish Interactive Thresholding Algorithm 24-2) with over ≥3 years of follow-up. The ROP (dB/year) based on global MD, superior hemifield MD, and inferior hemifield MD was calculated. The worst hemifield ROP (ROPworst) and hemifield ROP absolute difference (ROPdiff) were determined for each eye. Eyes were categorized based on the ROP from each metric as slow (-0.5 dB/year or better), rapid (worse than -0.5 dB/year), very rapid (worse than -1.0 dB/year), and catastrophic (worse than -2.0 dB/year) progression. The rate of significant asymmetric hemifield progression rate (ROPdiff ≥0.5 dB/year) was also evaluated.

RESULTS

On average, ROPworst was faster than ROPglobal by 0.25±0.3 dB/year ( P <0.001). Based on ROPworst, 422 eyes (25%) were classified as progressing more rapidly than the ROPglobal classification. Over 40% (153/339) of the eyes classified as rapid progressors by ROPglobal were classified as very rapid or catastrophic progressors based on ROPworst. Eyes that progressed more rapidly based on ROPworst also had a higher rate of asymmetric progression.

CONCLUSION

Hemifield ROPs are more sensitive to focal progression (or faster progression) than global rates and can aid in tailoring management and treatment decisions.

Retest variability and patient reliability indices of quantitative fundus autofluorescence in age-related macular degeneration: a MACUSTAR study report

This study aimed to determine the retest variability of quantitative fundus autofluorescence (QAF) in patients with and without age-related macular degeneration (AMD) and evaluate the predictive value of patient reliability indices on retest reliability. A total of 132 eyes from 68 patients were examined, including healthy individuals and those with various stages of AMD. Duplicate QAF imaging was conducted at baseline and 2 weeks later across six study sites. Intraclass correlation (ICC) analysis was used to evaluate the consistency of imaging, and mean opinion scores (MOS) of image quality were generated by two researchers. The contribution of MOS and other factors to retest variation was assessed using mixed-effect linear models. Additionally, a Random Forest Regressor was trained to evaluate the extent to which manual image grading of image quality could be replaced by automated assessment (inferred MOS). The results showed that ICC values were high for all QAF images, with slightly lower values in AMD-affected eyes. The average inter-day ICC was found to be 0.77 for QAF segments within the QAF8 ring and 0.74 for peripheral segments. Image quality was predicted with a mean absolute error of 0.27 on a 5-point scale, and of all evaluated reliability indices, MOS/inferred MOS proved most important. The findings suggest that QAF allows for reliable testing of autofluorescence levels at the posterior pole in patients with AMD in a multicenter, multioperator setting. Patient reliability indices could serve as eligibility criteria for clinical trials, helping identify patients with adequate retest reliability.

Influence of Refractive Error on Circumpapillary Structure-Function Versus Vessel Density-Function Relationships in Open Angle Glaucoma

PRCIS

In Japanese open angle glaucoma (OAG) eyes correlation of 30-degree visual field mean deviation (MD) and visual field index (VFI) with circumpapillary vessel density is systematically stronger than that with circumpapillary retinal nerve fiber layer thickness (RNFLT), and is preserved in myopia and high myopia.

PURPOSE

The purpose of this study was to investigate the influence of refractive error on the relationship between circumpapillary retinal nerve fiber layer thickness (cpRNFLT) and circumpapillary vessel density (cpVD), respectively, and global visual field parameters in Japanese open angle glaucoma (OAG) eyes.

MATERIAL AND METHODS

One eye of 81 Japanese OAG patients (spherical equivalent refractive error: +3.0 to -9.0 D) underwent 360-degree cpRNFLT and cpVD measurements with Cirrus HD 5000-AngioPlex optical coherence tomography and 30-2 Humphrey visual field testing for mean deviation (MD) and visual field index (VFI) within 1 month. Correlations were determined for the whole population and each refractive error subgroups, separately: emmetropia/hyperopia (n=24), mild (n=18), moderate (n=20), and high myopia (n=19).

RESULTS

For the total population, significant strong to very strong correlations were found between MD, VFI, and both cpRNFLT and cpVD, respectively, with consistently higher r -values for cpVD (highest r -values: 0.532 for cpRNFLT, P <0.001; 0.722 for cpVD, P <0.001). Of the refractive subgroups, statistically significant correlations between cpRNFLT and the visual field parameters were maintained only in the hyperopia/emmetropia and moderate myopia groups. In contrast, statistically significant, strong to very strong correlations between cpVD and both MD and VFI, always exceeding the corresponding r -values found for cpRNFLT were found in all refractive subgroups, with r -values ranging between 0.548 ( P =0.005) and 0.841 ( P <0.001).

CONCLUSIONS

Our results suggest that in Japanese OAG eyes the relationship of MD and VFI with cpVD is strong. It is systematically stronger than that with cpRNFLT and preserved in each conventional refractive error category including high myopia.

Toward a Real-world Optical Coherence Tomography Reference Database: Optometric Practices as a Source of Healthy Eyes

SIGNIFICANCE

The reports from optical coherence tomography (OCT) instruments depend on a reference database (RDB) of healthy eyes. Although these RDBs tend to be relatively small, they are time consuming and expensive to obtain. A larger RDB should improve our ability to screen for diseases such as glaucoma.

PURPOSE

To explore the feasibility of developing a large RDB from OCT scans obtained by optometrists as part of their pre-test gathering of information, we tested the hypothesis that these scans are of sufficient quality for an RDB and contain a relatively low base rate of glaucoma and other pathologies (OPs).

METHODS

Optical coherence tomography widefield (12 × 9 mm) scans from 400 eyes of 400 patients were randomly selected from a data set of more than 49,000 scans obtained from four optometry sites. Based on a commercial OCT report and a previously validated reading center method, two OCT graders categorized eyes as unacceptable to use for RDB, healthy (H), optic neuropathy consistent with glaucoma (ON-G), glaucoma suspect, or OPs.

RESULTS

Overall, 29 (7.25%) of the eyes were graded unacceptable. Of the remaining 371 eyes, 352 (94.9%) were graded H. Although, for one site, 7.4% of the eligible eyes were graded ON-G, the average for the other three sites was 1.4%. Adjustments of the reading center criteria resulted in exclusion of more than half of these ON-G and OP eyes.

CONCLUSIONS

The OCT scans obtained from optometry practices as part of their pre-test regimen are of sufficient quality for an RDB and contain a relatively low base rate of glaucoma and OPs. With the suggested exclusion criteria, the scans from optometry practices that are primarily involved in refraction and medical screening services should yield a large, real-world RDB with improved specificity and a base rate of glaucoma and/or OPs comparable with existing RDB.

Relationship between the Macular Microvasculature and Central Visual Field Sensitivity in Patients with Advanced Glaucoma

PURPOSE

To evaluate the relationship between central visual field sensitivity (cVFS) and the structural parameters in patients with advanced glaucoma.

DESIGN

Cross-sectional study.

METHODS

In total, 226 eyes of 226 patients with advanced glaucoma were classified into the "minor central defect" (mean deviation on 10-2 visual field test [MD10] > -10 dB) and "significant central defect" (MD10 ≤ -10 dB) groups. We examined the structural parameters using RTVue OCT and angiography, including the retinal nerve fiber layer, ganglion cell complex, peripapillary vessel density (VD), and superficial and deep macular VD (mVD). The assessment of cVFS included MD10 and the mean deviation of the central 16 points on the 10-2 VF test (MD16). We used Pearson correlation and segmented regression to assess the global and regional relationships between the structural parameters and cVFS.

MAIN OUTCOME MEASURES

Correlation between structural parameters and cVFS.

RESULTS

In the minor central defect group, the best global correlations existed between the superficial macular and parafoveal mVD and MD16 (r = 0.52 and 0.54, P < 0.001). In the significant central defect group, superficial mVD best correlated with MD10 (r = 0.47, P < 0.001). Segmented regression between superficial mVD and cVFS revealed no breakpoint was found as MD10 declined, but a breakpoint was identified at -5.95 dB for MD16, which was statistically significant (P < 0.001). The regional correlations between the grid VD and sectors of the central 16 points were significant (r = 0.20-0.53, P= 0.010 ∼P < 0.001).

CONCLUSIONS

The fair global and regional relationships between mVD and cVFS suggest that mVD may be beneficial for monitoring cVFS in patients with advanced glaucoma.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A Data-Driven Model for Simulating Longitudinal Visual Field Tests in Glaucoma

Purpose

To develop a simulation model for glaucomatous longitudinal visual field (VF) tests with controlled progression rates.

Methods

Longitudinal VF tests of 1008 eyes from 755 patients with glaucoma were used to learn the statistical characteristics of VF progression. The learned statistics and known anatomic correlations between VF test points were used to automatically generate progression patterns for baseline fields of patients with glaucoma. VF sequences were constructed by adding spatially correlated noise templates to the generated progression patterns. The two one-sided test (TOST) procedure was used to analyze the equivalence between simulated data and data from patients with glaucoma. VF progression detection rates in the simulated VF data were compared to those in patients with glaucoma using mean deviation (MD), cluster, and pointwise trend analysis.

Results

VF indices (MD, pattern standard deviation), MD linear regression slopes, and progression detection rates for the simulated and patients' data were practically equivalent (TOST P < 0.01). In patients with glaucoma, the detection rates in 7 years using MD, cluster, and pointwise trend analysis were 24.4%, 26.2%, and 38.4%, respectively. In the simulated data, the mean detection rates (95% confidence interval) for MD, cluster, and pointwise trend analysis were 24.7% (24.1%-25.2%), 24.9% (24.2%-25.5%), and 35.7% (34.9%-36.5%), respectively.

Conclusions

A novel simulation model generates glaucomatous VF sequences that are practically equivalent to longitudinal VFs from patients with glaucoma.

Translational Relevance

Simulated VF sequences with controlled progression rates can support the evaluation and optimization of methods to detect VF progression and can provide guidance for the interpretation of longitudinal VFs.

Optical coherence tomography detects early optic nerve damage before visual field defect in patients with pituitary tumors

Optical coherence tomography (OCT) is a useful tool for predicting visual recovery after the removal of pituitary tumors. However, the utility of OCT in patients with pituitary tumors and a normal visual field is unclear. We aimed to analyze OCT features in pituitary tumors without visual field defects. Pituitary tumors without visual field defects were selected. A total of 138 eyes from 69 patients, assessed by the Humphrey visual field test and OCT, were enrolled in this study. Using preoperative coronal sections of MR images, patients were divided into chiasmal compression (CC) and non-chiasmal compression (non-CC) groups, and OCT characteristics were examined. The CC and non-CC groups consisted of 40 and 29 patients, respectively. There were no differences in age, sex, tumor type, or degree of visual field testing, but the tumor size was different between the two groups. On OCT, macular thickness ganglion cell complex (mGCC) was significantly thinner in the CC group than that in the non-CC group (112.5 vs 117.4 um, P < 0.05). Based on a database of healthy participants, 24% and 2% of eyes in the CC and non-CC groups had abnormal mGCC thickness (P < 0.01), respectively. In a sub-analysis of the CC group, patients with an abnormal mGCC thickness were older than a normal one (58.2 vs 41.1 years, p < 0.01). OCT can detect early optic nerve damage due to optic CC by pituitary tumors, even in normal visual fields. The degree of mGCC thinning may provide an appropriate surgical timing for pituitary tumors that compress the optic chiasm.

Home Monitoring of Glaucoma Using a Home Tonometer and a Novel Virtual Reality Visual Field Device: Acceptability and Feasibility

OBJECTIVE

Our aim was to assess the acceptability and feasibility of iCare HOME tonometer (HT) and Virtual Field (VF) devices in the home monitoring of glaucoma.

DESIGN

Prospective feasibility and acceptability study.

SUBJECTS

Twenty patients (39 eyes) with primary open-angle glaucoma, open-angle glaucoma, ocular hypertension, or suspected glaucoma.

METHODS

Patients were trained and instructed to bring 2 devices home for 1 week and use the HT 4 times/day for 4 days and the VF 3 times total.

MAIN OUTCOME MEASURES

For acceptability, we conducted satisfaction surveys and semistructured, qualitative interviews with a thematic analysis. Feasibility was assessed by device usage and quality of tests.

RESULTS

Most patients (73.7%) felt that the HT was easy to use, and 100% of them found the HT useful. All patients (100%) felt that VF was easy to use, and 94.4% of them found the VF useful. All patients (100%) obtained acceptable intraocular pressure and completed a VF test at home. We identified 4 key themes, with 33 subthemes. The key themes include the following: (1) advantages of home monitoring; (2) difficulties with home monitoring; (3) future considerations in home monitoring; and (4) the experience of patients with glaucoma.

CONCLUSIONS

The HT and VF were acceptable and feasible in a small cohort of motivated subjects. Patients were able to perform these tests proficiently at home, and they were generally enthused to obtain more data about their intraocular health, as it allowed them a heightened sense of security and insight about their chronic disease, as well as a reduction in foreseeable barriers to care. Home monitoring may also improve upon glaucoma care by enhancing patient empowerment and fostering community bonds. The VF should be further evaluated to ensure validity.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Teleglaucoma Using a New Smartphone-Based Tool for Visual Field Assessment

PRCIS

COVID-19 underlines the importance of telemedical diagnostics. The smartphone-based campimetry (Sb-C) is a newly developed digital application allowing visual field testing using a head-mounted device and a smartphone. It enables visual field screening remotely from a clinic.

BACKGROUND

Sb-C is a newly developed tool for functional ophthalmic diagnosis. This study aimed to examine the comparability of the Sb-C and Octopus 900 to ensure ophthalmological care in times of social distancing.

METHODS

Total 93 eyes were included in the study. After an ophthalmological examination, the visual field was tested by the Octopus program G1 and by the smartphone-based campimeter. The Sb-C was performed using VR glasses and an iPhone 6. The software Sb-C was downloaded and installed as SmartCampiTracker app and is examining the 30-degree visual field with 59 test positions corresponding to the G pattern of Octopus G1. Sensitivities were recorded and saved on the app. In addition, test-retest reliability was tested on 6 ophthalmologically healthy participants.

RESULTS

The group comprised 48 women and 45 men (mean age: 62.52±12.2 y) including 19 controls, 17 patients with ocular hypertension, 11 preperimetric glaucomas, and 46 perimetric glaucomas. The mean sensitivity (MS) of all points of G1 perimetry was 23.13 dB (95% CI, 22.08-24.18). The MS of the Sb-C was 21.23 dB (95% CI, 20.37-22.08). The correlation between the mean MS measured by G1 perimetry and the Sb-C was strong ( r =0.815, P <0.05). The test-retest reliability showed a correlation of r =0.591 ( P <0.05) .

CONCLUSIONS

With some technical adjustments, the Sb-C shows promise for screening glaucoma and monitoring disease progression remotely from an ophthalmologic clinic.

Assessing Surface Shapes of the Optic Nerve Head and Peripapillary Retinal Nerve Fiber Layer in Glaucoma with Artificial Intelligence

Purpose

To assess 3-dimensional surface shape patterns of the optic nerve head (ONH) and peripapillary retinal nerve fiber layer (RNFL) in glaucoma with unsupervised artificial intelligence (AI).

Design

Retrospective study.

Participants

Patients with OCT scans obtained between 2016 and 2020 from Massachusetts Eye and Ear.

Methods

The first reliable Cirrus (Carl Zeiss Meditec, Inc) ONH OCT scans from each eye were selected. The ONH and RNFL surface shape was represented by the vertical positions of the inner limiting membrane (ILM) relative to the lowest ILM vertical position in each eye. Nonnegative matrix factorization was applied to determine the ONH and RNFL surface shape patterns, which then were correlated with OCT and visual field (VF) loss parameters and subsequent VF loss rate. We tested whether using ONH and RNFL surface shape patterns improved the prediction accuracy for associated VF loss and subsequent VF loss rates measured by adjusted r² and Bayesian information criterion (BIC) difference compared with using established OCT parameters alone.

Main Outcome Measures

Optic nerve head and RNFL surface shape patterns and prediction of the associated VF loss and subsequent VF loss rates.

Results

We determined 14 ONH and RNFL surface shape patterns using 9854 OCT scans from 5912 participants. Worse mean deviation (MD) was most correlated (r = 0.29 and r = 0.24, Pearson correlation; each P < 0.001) with lower coefficients of patterns 10 and 12 representing inferior and superior para-ONH nerve thinning, respectively. Worse MD was associated most with higher coefficients of patterns 5, 4, and 9 (r = –0.16, r = –0.13, and r = –0.13, respectively), representing higher peripheral ONH and RNFL surfaces. In addition to established ONH summary parameters and 12–clock-hour RNFL thickness, using ONH and RNFL surface patterns improved (BIC decrease: 182, 144, and 101, respectively; BIC decrease ≥ 6; strong model improvement) the prediction of accompanied MD (r² from 0.32 to 0.37), superior (r² from 0.27 to 0.31), and inferior (r² from 0.17 to 0.21) paracentral loss and improved (BIC decrease: 8 and 8, respectively) the prediction of subsequent VF MD loss rates (r² from 0 to 0.13) and inferior paracentral loss rates (r² from 0 to 0.16).

Conclusions

The ONH and RNFL surface shape patterns quantified by unsupervised AI techniques improved the structure–function relationship and subsequent VF loss rate prediction.

Cognitive Performance on the Montreal Cognitive Assessment Test and Retinal Structural and Functional Measures in Glaucoma

Background: Glaucoma, the leading cause of irreversible blindness, is classified as a neurodegenerative disease, and its incidence increases with age. Pathophysiological changes, such as the deposition of amyloid-beta plaques in the retinal ganglion cell layer, as well as neuropsychological changes, including cognitive decline, have been reported in glaucoma. However, the association between cognitive ability and retinal functional and structural measures in glaucoma, particularly glaucoma subtypes, has not been studied. We studied the association between cognitive ability and the visual field reliability indices as well as the retinal ganglion cell (RGC) count estimates in a cohort of glaucoma patients. Methods: A total of 95 eyes from 61 glaucoma patients were included. From these, 20 were normal-tension glaucoma (NTG), 25 were primary open-angle glaucoma (POAG), and 16 were glaucoma suspects. All the participants had a computerised Humphrey visual field (HVF) assessment and optical coherence tomography (OCT) scan and were administered the written Montreal Cognitive Assessment (MoCA) test. RGC count estimates were derived based on established formulas using the HVF and OCT results. A MoCA cut-off score of 25 and less was designated as cognitive impairment. Student’s t-test was used to assess differences between the groups. The Pearson correlation coefficient was used to assess the association between MoCA scores and retinal structural and functional measures. Results: Significant associations were found between MoCA scores and the false-negative and pattern standard deviation indices recorded on the HVF (r = −0.19, r = −0.22, p < 0.05). The mean IOP was significantly lower in the cognitively impaired group (i.e., MOCA ≤ 25) (13.7 ± 3.6 vs. 15.7 ± 4.5, p < 0.05). No significant association was found between RGC count estimates and MoCA scores. Analysis of these parameters in individual glaucoma subtypes did not reveal any group-specific significant associations either.

Tools and Biomarkers for the Study of Retinal Ganglion Cell Degeneration

The retina is part of the central nervous system, its analysis may provide an idea of the health and functionality, not only of the retina, but also of the entire central nervous system, as has been shown in Alzheimer’s or Parkinson’s diseases. Within the retina, the ganglion cells (RGC) are the neurons in charge of processing and sending light information to higher brain centers. Diverse insults and pathological states cause degeneration of RGC, leading to irreversible blindness or impaired vision. RGCs are the measurable endpoints in current research into experimental therapies and diagnosis in multiple ocular pathologies, like glaucoma. RGC subtype classifications are based on morphological, functional, genetical, and immunohistochemical aspects. Although great efforts are being made, there is still no classification accepted by consensus. Moreover, it has been observed that each RGC subtype has a different susceptibility to injury. Characterizing these subtypes together with cell death pathway identification will help to understand the degenerative process in the different injury and pathological models, and therefore prevent it. Here we review the known RGC subtypes, as well as the diagnostic techniques, probes, and biomarkers for programmed and unprogrammed cell death in RGC.

Trends in Utilization of Visual Field Tests for Glaucoma Patients: A Nationwide Study Using the Korean Health Insurance Review and Assessment Database

Purpose

To analyze 10-year trends in utilization of visual field tests for adult glaucoma or glaucoma-suspect patients using the Korean Health Insurance Review and Assessment data.

Methods

Health claims for the years 2010 to 2019, as recorded via Korea’s Health Insurance Review and Assessment service, were accessed. We identified glaucoma patients using the glaucoma diagnostic codes H40 (glaucoma) and H42 (glaucoma in other diseases classified elsewhere). For verification of the glaucoma diagnosis, information on any antiglaucoma medication prescriptions and ocular surgery history also was obtained. Visual field testing data was isolated using procedural codes E6690 (kinetic perimetry) and E6691 (standard automated perimetry [SAP]) performed in tertiary hospitals. Any changes in visual field test utilization were identified using regression trend analysis.

Results

From 2010 to 2019, the total number of SAP procedures performed in tertiary hospitals for either glaucoma or glaucoma-suspect patients increased gradually from 93,459 to 216,433. With regard to kinetic perimetry examinations, the total number decreased gradually from 6,364 to 3,792. The yearly average SAP number per patient showed a slight increase, from 1.168 to 1.248 (β = 0.008, R² = 0.669, p = 0.004). Meanwhile, the yearly average number of kinetic perimeter examinations per patient showed a significant decrease, from 1.093 to 0.940 (β = −0.013, R² = 0.580, p = 0.010).

Conclusions

Between 2010 and 2019, the yearly average number of SAP procedures performed per glaucoma or glaucoma-suspect patient increased in Korea. Meanwhile, the yearly average number of kinetic perimetry examinations per patient significantly decreased.

Subclinical Signs of Retinal Involvement in Hereditary Angioedema

To explore retinal abnormalities using spectral domain optical coherence tomography (SD-OCT) and OCT-angiography (OCT-A) in a highly selective cohort of patients with type I hereditary angioedema (HAE). This prospective case-control study included 40 type I HAE patients and 40 age-/sex-matched healthy subjects (HC). All participants underwent SD-OCT-scanning of retinal posterior pole (PP), peripapillary retinal nerve fiber layer (pRNFL), and optic nerve head (ONH). Superficial/deep capillary density was analyzed by OCT-A. A total of 80 eyes from 40 HAE and 40 eyes from HC were evaluated. The pRNFL was thicker in HAE than in HC in nasal superior (p < 0.0001) and temporal quadrants (p = 0.0005 left, p = 0.003 right). The ONH thickness in HAE patients was greater than in HC in the nasal (p = 0.008 left, p = 0.01 right), temporal (p = 0.0005 left, p = 0.003 right), temporal inferior (p = 0.007 left, p = 0.0008 right), and global (p = 0.005 left, p = 0.007 right) scans. Compared to HC, HAE showed a lower capillary density in both superficial (p = 0.001 left, p = 0.006 right) and deep (p = 0.008 left, p = 0.004 right) whole images, and superficial (p = 0.03 left) and deep parafoveal (p = 0.007 left, p = 0.005 right) areas. Our findings documented subclinical retinal abnormalities in type I HAE, supporting a potential role of the retinal assessment by SD-OCT/OCT-A as a useful tool in the comprehensive care of HAE patients.

Visual field progression in Malay patients with primary glaucoma: survival analysis and prognostic factors

PURPOSE

This study aims to determine the 5-year visual field progression and identify the prognostic factors for progression in Malay patients with primary glaucoma.

METHODS

A retrospective cohort record review study was conducted among 222 patients (222 eyes) with primary glaucoma who were selected from a glaucoma research database of a tertiary center in Malaysia. The patients were Malays and diagnosed with primary open-angle glaucoma (POAG) or primary angle-closure glaucoma (PACG). Patients who were followed up regularly for at least 6 months between 1 January 2009 and 31 December 2014 and completed another 1-year follow-up after recruitment (between 1 January 2015 and 31 December 2015) were selected. Multiple prognostic factors that influence visual field progression were identified. Progression of visual field loss was based on the Advanced Glaucoma Intervention Study and Hodapp-Parrish-Anderson scores. Kaplan-Meier survival and Cox proportional hazard regression analyses were performed.

RESULTS

Sixty-three patients (28.4%) developed visual field progression after a mean (SD) follow-up of 6.9 (3.3) years. Those with POAG progressed faster (mean time, 10.6 years; 95% confidence interval [CI], 9.3, 11.9) than those with PACG (17.3 years; 95% CI, 14.8, 19.9) but not statistically significant. Disc hemorrhage and history of eye pain increased the risk of progression by 2.8-folds (95% CI, 1.6, 4.8) and 2.5-folds (1.4, 4.4), respectively.

CONCLUSION

The 5-year survival of the Malay primary glaucoma patients with visual field progression was similar with that of other Asian populations. However, aggressive management is required for those with disc hemorrhages and eye pain related to increased intraocular pressure.

Response time and response time variability as indicators of response quality during static automated perimetry

PURPOSE

Perimetry is a both demanding and strenuous examination method that is often accompanied by signs of fatigue, leading to false responses and thus incorrect results. Therefore, it is essential to monitor the response quality. The purpose of this study was to evaluate the response time (RT) and its variability (RTV) as quality indicators during static automated perimetry.

METHODS

Size III Goldmann stimuli (25.7') were shown with the OCTOPUS 900 perimeter in four visual field locations with 13 different stimulus luminance levels (0.04-160 cd/m²). An increased rate of false-positive and false-negative catch trials (25% each) served to monitor the response quality simultaneously together with response time recording. Data evaluation was divided into global and individual analysis. For global analysis, the agreement indices (AI, agreement between time periods with an increased number of false responses to catch trials and time periods with pathological response to time-based values set into relation to time periods in which only one of the two criteria was considered pathological) and for individual analysis, the Spearman correlation coefficients were calculated. Ophthalmologically normal subjects with a visual acuity ≥ 0.8, and a maximum spherical/cylindrical ametropia of ± 8.00/2.50 dpt were included.

RESULTS

Forty-eight subjects (18 males, 30 females, age 22-78 years) were examined. The total number of false responses to catch trials was (median/maximum): 6/82. RT and RTV were compared to the occurrence of incorrect responses to catch trials. The resulting individual Spearman correlation coefficients (median/maximum) were for RT: ρ_RT = 0.05/0.35 and for RTV: ρ_RTV = 0.27/0.61. The global analysis of the RTV showed agreement indices (median/maximum) of AI_RTV = 0.14/0.47.

CONCLUSIONS

According to this study, an increased portion of catch trials is suitable as a verification tool for possible response quality indicators. The RTV is a promising parameter for indicating the response quality.

Optical coherence tomographic angiography study of perfusion recovery after surgical lowering of intraocular pressure

We investigated the time and location of retinal perfusion recovery after surgical intraocular pressure (IOP) lowering in glaucoma by using optical coherent tomography angiography (OCTA). Seventeen patients were analyzed. The 4.5 × 4.5-mm OCTA scans centered on the disc were performed preoperatively and postoperatively at 6 weeks, 3 months, and 6 months. The peripapillary retinal nerve fiber layer (NFL) thickness, NFL plexus capillary density (NFLP-CD) and visual field (VF) were measured overall and in 8 corresponding sectors. The low-perfusion area (LPA) was used to assess the cumulative area where local NFLP-CD was significantly below normal. At 6 months, the average IOP decreased 5.3 mmHg (P = 0.004), LPA decreased by 15% (P = 0.005), and NFLP-CD improved by 12% (P < 0.001). The NFL thickness and VF mean deviation didn’t change significantly at any time point. Among the sectors with significant preoperative NFLP-CD loss, the recovery at 6 months was greatest in sectors with minimal preoperative NFL thinning (P < 0.001). In conclusion, surgical IOP lowering may improve NFLP capillary perfusion after 6 months. The perfusion recovery tended to occur in areas with minimal NFL thinning at baseline. OCTA parameters may have potential usefulness as pharmacodynamic biomarkers for glaucoma therapy.

Visual Performance as a Function of Clear Central Aperture Diameter with a Defocused Myopic Periphery

SIGNIFICANCE

Visual performance is affected least by a 15° radial aperture surrounded by peripheral myopic defocus. This finding has important applications for spectacle and contact lens designs and myopia control optimization.

PURPOSE

The purpose of this study was to assess the effect of clear central apertures of different diameters with a defocused retinal periphery, using a range of visual performance tasks.

METHODS

Thirty visually normal subjects (mean age, 24.4 ± 3.3 years; 20 females; mean spherical equivalent of -1.28 D) were enrolled. Subjects wore five different spectacles during testing, all corrected for distance refraction, in random order: three single-vision spectacles with clear central apertures of 10, 12.5, and 15° radii with the periphery defocused using Fresnel "press-on" lenses (+3.5 D sphere), progressive addition lens (PAL) spectacles with a +3.5 D addition, and single-vision lens (SVL) spectacles with no peripheral defocus. Static and kinetic visual field sensitivities, reading rate and comprehension, head movements, global saccadic tracking, and saccadic visual search were evaluated.

RESULTS

Reading rate and comprehension did not differ across the five test conditions; however, increased head movement was found with the smallest aperture compared with the PAL condition with adjusted P < .05. Static visual field sensitivity was reduced for all three apertures in eccentric regions when compared with the SVL and PAL conditions with adjusted P < .05, whereas kinetic sensitivity did not differ for any lens condition. The 15° aperture was superior to the 10 and 12.5° apertures based on its similarity to the SVL and PAL spectacle conditions in head movement during reading, the Michigan Tracking Test, and the vertical results of the Developmental Eye Movement Test.

CONCLUSIONS

Visual performance is least affected adversely by a 15° aperture surrounded by a peripheral myopic defocus. This finding has important applications for spectacle and contact lens designs to optimize myopia treatment with minimal impact on visual performance.

Predicting Global Test-Retest Variability of Visual Fields in Glaucoma

PURPOSE

To model the global test-retest variability of visual fields (VFs) in glaucoma.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Test-retest VFs from 4044 eyes of 4044 participants.

METHODS

We selected 2 reliable VFs per eye measured with the Humphrey Field Analyzer (Swedish interactive threshold algorithm 24-2) within 30 days of each other. Each VF had fixation losses (FLs) of 33% or less, false-negative results (FNRs) of 20% or less, and false-positive results (FPRs) of 20% or less. Stepwise linear regression was applied to select the model best predicting the global test-retest variability from 3 categories of features of the first VF: (1) base parameters (age, mean deviation, pattern standard deviation, glaucoma hemifield test results, FPR, FNR, and FL); (2) total deviation (TD) at each location; and (3) computationally derived archetype VF loss patterns. The global test-retest variability was defined as root mean square deviation (RMSD) of TD values at all 52 VF locations.

MAIN OUTCOME MEASURES

Archetype models to predict the global test-retest variability.

RESULTS

The mean ± standard deviation of the root mean square deviation was 4.39 ± 2.55 dB. Between the 2 VF tests, TD values were correlated more strongly in central than in peripheral VF locations (intraclass coefficient, 0.66-0.89; P < 0.001). Compared with the model using base parameters alone (adjusted R2 = 0.45), adding TD values improved prediction accuracy of the global variability (adjusted R2 = 0.53; P < 0.001; Bayesian information criterion [BIC] decrease of 527; change of >6 represents strong improvement). Lower TD sensitivity in the outermost peripheral VF locations was predictive of higher global variability. Adding archetypes to the base model improved model performance with an adjusted R2 of 0.53 (P < 0.001) and lowering of BIC by 583. Greater variability was associated with concentric peripheral defect, temporal hemianopia, inferotemporal defect, near total loss, superior peripheral defect, and central scotoma (listed in order of decreasing statistical significance), and less normal VF results and superior paracentral defect.

CONCLUSIONS

Inclusion of archetype VF loss patterns and TD values based on first VF improved the prediction of the global test-retest variability than using traditional global VF indices alone.

The Effect of Ametropia on Glaucomatous Visual Field Loss

Myopia has been discussed as a risk factor for glaucoma. In this study, we characterized the relationship between ametropia and patterns of visual field (VF) loss in glaucoma. Reliable automated VFs (SITA Standard 24-2) of 120,019 eyes from 70,495 patients were selected from five academic institutions. The pattern deviation (PD) at each VF location was modeled by linear regression with ametropia (defined as spherical equivalent (SE) starting from extreme high myopia), mean deviation (MD), and their interaction (SE × MD) as regressors. Myopia was associated with decreased PD at the paracentral and temporal VF locations, whereas hyperopia was associated with decreased PD at the Bjerrum and nasal step locations. The severity of VF loss modulated the effect of ametropia: with decreasing MD and SE, paracentral/nasal step regions became more depressed and Bjerrum/temporal regions less depressed. Increasing degree of myopia was positively correlated with VF depression at four central points, and the correlation became stronger with increasing VF loss severity. With worsening VF loss, myopes have increased VF depressions at the paracentral and nasal step regions, while hyperopes have increased depressions at the Bjerrum and temporal locations. Clinicians should be aware of these effects of ametropia when interpreting VF loss.

The effect of low light levels on postural stability in older adults with age-related macular degeneration

PURPOSE

To investigate the effect of low light levels on postural stability in older adults with and without age-related macular degeneration (AMD).

METHODS

Participants included 28 older adults [14 with AMD (mean age ± S.D., 83.4 ± 6.7 years) and 14 controls with normal vision (74.6 ± 3.3 years)]. Postural stability was assessed with eyes open on both a firm and foam surface under four lighting conditions in a randomised order: photopic (~436 lux, vertically at the eye), sudden reduction to mesopic (~436 to ~1 lux), adapted mesopic (~1 lux) and adapted mesopic with a light emitting diode (LED) door frame lighting system (~1.3 lux), using the root mean square (RMS) of the centre of pressure measures derived from an electronic force plate in the anterior-posterior (AP) and medio-lateral (ML) directions. Visual function was assessed binocularly (visual acuity, contrast sensitivity and visual fields), physical function was assessed using standardised measures (sit-to-stand, grip strength and the timed walk test) and self-reported difficulties under low light levels were recorded using the Low Luminance Questionnaire. Data were analysed using linear mixed models.

RESULTS

For all participants, low light levels significantly increased postural sway on the foam surface in the AP (p = 0.01) but not ML (p = 0.80) direction, but had no effect on postural stability on the firm surface. On the foam surface, while AP-RMS sway was significantly greater in the sudden (p < 0.001) and adapted (p = 0.02) mesopic compared to the photopic condition, sway for the adapted mesopic with the LED lighting system was not significantly different to the photopic condition (p = 0.20). On the foam surface, AP-RMS (p = 0.02) and ML-RMS (p < 0.001) sway were significantly greater in the AMD compared to the control group. None of the measures of visual function was significantly associated with AP- or ML-RMS sway.

CONCLUSIONS

On the foam surface, low light levels significantly reduced postural stability in older adults with and without AMD, and postural stability was significantly reduced for the AMD group compared to controls, regardless of light level. Importantly, the LED lighting system reduced sway under mesopic conditions, which was not significantly greater than that measured under photopic conditions in either group. These findings have important implications for enhancing the visual environment for older adults with and without AMD to improve postural stability and reduce the risk of falls in low lighting environments.

Tear Film Cytokine Profile of Patients With the Boston Keratoprosthesis Type 1: Comparing Patients With and Without Glaucoma

Purpose

Inflammatory cytokines are involved in glaucoma pathogenesis. The purpose is to compare cytokine levels in the tear film of Boston keratoprosthesis (KPro) patients with and without glaucoma, relative to controls, and correlate levels with clinical parameters.

Methods

This cross-sectional study enrolled 58 eyes (58 patients): 41 KPro eyes with glaucoma, 7 KPro eyes without glaucoma, and 10 healthy controls. Twenty-seven cytokines were measured by multiplex bead immunoassay. Intraocular pressure (IOP), cup-to-disk ratio (CDR), retinal nerve fiber layer, visual acuity, topical medications, and angle closure were assessed in all KPro eyes. Cytokine levels between groups were analyzed by nonparametric tests, and correlations with clinical parameters by Spearman's test.

Results

Levels of TNF-ɑ, IL-1β, FGF-basic, and IFN-ɣ were significantly higher in KPro with glaucoma compared to KPro without (P = 0.020; 0.008; 0.043; 0.018, respectively). KPro groups had similar characteristics and topical antibiotic/steroid regimen. Levels of IL-1Ra, IL-15, VEGF, and RANTES were significantly higher in KPro with glaucoma compared to controls (P < 0.001; = 0.034; < 0.001; = 0.001, respectively). IL-1β and IFN-ɣ levels were positively correlated with CDR (r = 0.309, P = 0.039 and r = 0.452, P = 0.006, respectively) and IOP (r = 0.292, P = 0.047 and r = 0.368, P = 0.023, respectively). TNF-α and FGF-basic levels were positively correlated with CDR (r = 0.348, P = 0.022 and r = 0.344, P = 0.021, respectively).

Conclusions

TNF-α, IL-1β, FGF-basic, IFN-ɣ are elevated in tears of KPro patients with glaucoma and correlate with CDR and IOP. These results show, for the first time in humans, concordance with documented elevations of TNF-α and IL-1β in the murine KPro model. Ocular surface inflammation may reflect inflammatory processes of KPro glaucoma.

Artifactual Visual Field Defects Identified on Technically "Reliable" Visual Field Studies in a Neuro-Ophthalmology Practice

Purpose

To assess the reliability of automated visual field studies with neurological abnormalities and normal reliability indices that were inconsistent with the remainder of the neuro-ophthalmic assessment.

Methods

Retrospective observational study from the clinical practice of a neuro-ophthalmologist at a tertiary referral center.

Results

From 2230 patient charts, ten cases were identified that met the inclusion criteria. In eight of the cases repeat visual field testing had no reproducible abnormality. Four of these cases were concerning for a bitemporal or homonymous hemianopia. None of the patients, including the two cases with a reproducible defect, developed any convincing manifestations of an organic disease related to the visual field defect.

Conclusion

Our findings suggest that even marked neurological abnormalities on reliable automated visual field tests can be false. When the remainder of the neuro-ophthalmic evaluation is inconsistent with the test result, we recommend that clinicians attempt to immediately repeat the visual field study.

Uptake, Persistence, and Performance of Weekly Home Monitoring of Visual Field in a Large Cohort of Patients With Glaucoma

PURPOSE

This study examines the short-term uptake, compliance, and performance of a tablet device used for home monitoring of visual field (VF-Home) by glaucoma patients.

DESIGN

Single-center, observational, longitudinal, compliance study.

METHODS

Participants who were glaucoma suspects or had stable glaucoma in at least one eye were recruited during a regular clinic review. Baseline in-clinic visual field (VF) was recorded with the Humphrey Field Analyser (HFA, SITA standard) and repeated at 6 months. Participants were tasked with performing 6 VF examinations from home, at weekly intervals, using a loaned iPad tablet. Uptake was defined as returning at least 1 test from home. Reliability and global indices from VF-Home were compared to in-clinic outcomes. Data are shown as either mean ± [standard deviation] or median [quartile 1-3 range], and group comparisons were achieved with bootstrap.

RESULTS

We recruited 186 eyes of 101 participants. VF-Home uptake was excellent, with 88% of participants successfully completing ≥1 home examination and 69% completing all 6 examinations. The median duration between tests was 7.0 [7.0-8.0] days. Barriers to uptake and compliance involved information technology (IT) logistical reasons, lack of motivation, or competing life demands. VF-Home gave greater fixation loss but a similar level of False Positives (FP) as the HFA. A high correlation was found for the mean defect between in-clinic and at-home outcomes (R = 0.85).

CONCLUSIONS

VF-Home can return a high level of short-term compliance and results comparable to those found by in-clinic testing. IT logistical reasons and lack of motivation are barriers to uptake and compliance.

Comparison of the Performance of a Novel, Smartphone-based, Head-mounted Perimeter (GearVision) With the Humphrey Field Analyzer

PRECIS

The agreement between a head-mounted perimeter [GearVision (GV)] and Humphrey field analyzer (HFA) for total threshold sensitivity was a mean difference of -1.9 dB (95% limits of agreement -5 to 1). GV was the preferred perimeter in 68.2% of participants.

PURPOSE

The purpose of this study was to compare reliability indices and threshold sensitivities obtained using a novel, smartphone-based, head-mounted perimeter (GV) with the HFA in normal, glaucoma suspect and glaucoma patients. A secondary objective was to evaluate the subjective experience participants had with both perimeters using a questionnaire.

METHODS

In a prospective, cross-sectional study; 107 eyes (34 glaucoma, 18 glaucoma suspect, and 55 normal) of 54 participants underwent HFA and GV in random order. The main outcome measure was the agreement of threshold sensitivities using Bland and Altman analysis. Participants also completed a questionnaire about their experience with the devices.

RESULTS

Median false-positive response rate for GV was 7% (4% to 12%), while for HFA it was 0% (0% to 6%, P<0.001). Median false-negative response rate was similar for both tests. In all, 84 eyes with reliable HFA and GV results were included in the final analysis. Median threshold sensitivity of all 52 points on HFA was 29.1 dB (26.5 to 30.7 dB) and for GV was 30.6 dB (29.1 to 32.6 dB; P<0.001). Mean difference (95% limits of agreement) in total threshold sensitivity between HFA and GV was -1.9 dB (-5 to 1 dB). The 95% limits of agreement were fairly narrow (-8 to 2 dB) across the 6 Garway-Heath sectors. Most participants preferred to perform GV (68.2%) if required to repeat perimetry compared with HFA (20.6%, P<0.001).

CONCLUSIONS

There was fairly good agreement between the threshold sensitivities of GV and HFA. GV was also preferred by most patients and could potentially supplement HFA as a portable or home perimeter.

A Single Low-Dose of Methylphenidate Improves Abnormal Visual Field Testing

PURPOSE

To evaluate the effect of methylphenidate on visual field testing in healthy adults with abnormal visual field results.

METHODS

This prospective, randomized, controlled interventional clinical trial comprised all patients who had abnormal visual field test results and normal eye examination and ophthalmic history. Eligible patients were randomly assigned to either the study group or the control group. All patients repeated their visual field testing. Study group patients received a single dose of 10 mg methylphenidate prior to that. The main outcome measures were the percent difference in mean deviation and pattern standard deviation between the second and first visual fields.

RESULTS

The methylphenidate group had greater improvement in all parameters. Mean deviation improved by median 68% (IQR 19%-78%) in the methylphenidate group vs. 27% [-5% to 55%] in the controls. However, this was not statistically significant (p = .83). Pattern standard deviation improved by median 49% (22%-59%) vs. 7% [-9% to 45%], respectively (p = .012). The visual fields were also reviewed by 3 masked experienced ophthalmologists. They indicated that the second visual field improved in 76.2% of the methylphenidate group vs. 48.5% of the controls (p = .04). A normal repeat visual field occurred in 57.7% vs. 21.2%, respectively. A subgroup analysis of patients with prior experience in visual field testing yielded an even more striking improvement in the methylphenidate group vs. controls.

CONCLUSIONS

A single low dose of methylphenidate can improve visual field testing in subjects without ocular pathology, and even more in those with prior experience in perimetry.

RETeval Portable Electroretinogram Parameters in Different Severity Stages of Glaucoma

PRéCIS:: Four parameters of the noninvasive, portable RETeval electroretinogram (ERG) system were found to correlate with visual field mean deviation and optical coherence tomography (OCT) thickness parameters, and may therefore be suitable for glaucoma detection.

PURPOSE

To investigate the RETeval full-field ERG parameters for accuracy of separating glaucoma and normal eyes, and correlation with glaucoma severity.

PATIENTS AND METHODS

Sixty-two eyes of 62 primary open-angle glaucoma patients [visual field mean deviation (MD) range: -0.44 to -31.15 dB] and 39 eyes of 39 healthy controls underwent one RETeval test (photopic negative response protocol), OCT imaging, and Humphrey 30-2 visual field testing. The glaucoma patients were divided into early (MD≥-6dB, n=33) and moderate-to-advanced (MD<-6 dB, n=29) groups.

RESULTS

Significant correlations were found between the best-performing 4 RETeval ERG parameters and the glaucoma severity measures (MD and OCT thickness parameters) for all eyes, all glaucoma eyes and the moderate-to-advanced glaucoma eyes [photopic negative response amplitude at 72 ms (PhNR 72) and MD: r=-0.333, -0.414, and -0.485, respectively, P≤0.008; PhNR 72 and average circumpapillary retinal nerve fiber layer thickness; r=-0.429, -0.450, and -0.542, respectively, P≤0.002]. Except for P-ratio, there was no significant difference between the area under the receiver-operating characteristic (AUROC) values of the OCT thickness parameters (range: 0.927 to 0.938) and the 4 best-performing RETeval ERG parameters (range: 0.839 to 0.905) in the early glaucoma versus control separation. For differentiating the control and the moderate-to-advanced glaucoma eyes, the AUROC values of the 4 best-performing RETeval ERG parameters ranged between 0.924 and 0.958, and no significant difference was found between them and those of the OCT parameters.

CONCLUSIONS

The noninvasive, portable RETeval full-field ERG device may be useful to detect glaucoma in moderate-to-advanced stages.

Detecting apoptosis as a clinical endpoint for proof of a clinical principle

The transparent eye media represent a window through which to observe changes occurring in the retina during pathological processes. In contrast to visualising the extent of neurodegenerative damage that has already occurred, imaging an active process such as apoptosis has the potential to report on disease progression and therefore the threat of irreversible functional loss in various eye and brain diseases. Early diagnosis in these conditions is an important unmet clinical need to avoid or delay irreversible sight loss. In this setting, apoptosis detection is a promising strategy with which to diagnose, provide prognosis, and monitor therapeutic response. Additionally, monitoring apoptosis in vitro and in vivo has been shown to be valuable for drug development in order to assess the efficacy of novel therapeutic strategies both in the pre-clinical and clinical setting. Detection of Apoptosing Retinal Cells (DARC) technology is to date the only tool of its kind to have been tested in clinical trials, with other new imaging techniques under investigation in the fields of neuroscience, ophthalmology and drug development. We summarize the transitioning of techniques detecting apoptosis from bench to bedside, along with the future possibilities they encase.

Inter-Eye Association of Visual Field Defects in Glaucoma and Its Clinical Utility

Purpose

To investigate intereye associations of visual field (VF) defects.

Methods

We selected 24-2 VF pairs of both eyes from 63,604 patients tested on the same date with mean deviation (MD) ≥ −12 dB. VFs were decomposed into one normal and 15 defect patterns previously identified using archetypal analysis. VF pattern weighting coefficients were correlated between the worse and better eyes, as defined by MD. VF defect patterns (weighting coefficients > 10%) in the better eye were predicted from weighting coefficients of the worse eye by logistic regression models, which were evaluated by area under the receiver operating characteristic curve (AUC).

Results

Intereye correlations of archetypal VF patterns were strongest for the same defect pattern between fellow eyes. The AUCs for predicting the presence of 15 defect patterns in the better eye based on the worse eye ranged from 0.69 (superior nasal step) to 0.92 (near total loss). The AUC for predicting superior paracentral loss was 0.89. Superior paracentral loss in the better eye was positively correlated with coefficients of superior paracentral loss, central scotoma, superior altitudinal defect, nasal hemianopia, and inferior paracentral loss in the worse eye, and negatively correlated with coefficients of the normal VF, superior peripheral defect, concentric peripheral defect, and temporal wedge. The parameters are presented in the descending order of statistical significance.

Conclusions

VF patterns of the worse eye are predictive of VF defects in the better eye.

Translational Relevance

Our models can potentially assist clinicians to better interpret VF loss under measurement uncertainty.

Using natural viewing behavior to screen for and reconstruct visual field defects

There is a need for simple and effective ways to screen for visual field defects (VFD). Watching a movie is a simple task most humans are familiar with. Therefore we assessed whether it is possible to detect and reconstruct visual field defects based on free viewing eye movements, recorded while watching movie clips. Participants watched 90 movie clips of one minute, with and without simulated visual field defects (sVFD), while their eye movements were tracked. We simulated homonymous hemianopia (HH) (left and right sided) and glaucoma (small nasal arc, large nasal arc, and tunnel vision). We generated fixation density maps of the visual field and trained a linear support vector machine to predict the viewing conditions of each trial of each participant based on these maps. To reconstruct the visual field defect, we computed “viewing priority” maps and maps of differences in fixation density of the visual field of each participant. We were able to classify the simulated visual field condition with more than 85% accuracy. In simulated HH, the viewing priority distribution over the visual field indicated the location of the sVFD in the simulated HH condition. In simulated glaucoma the difference in fixation density to the control condition indicated the location of the sVFD. It is feasible to use natural viewing behavior to screen for and reconstruct (simulated) visual field defects. Movie clip viewing in combination with eye tracking may thus provide an alternative to or supplement standard automated perimetry, in particular in patients who cannot perform the latter technique.

SD-OCT parameters and visual field defect in chiasmal compression and the diagnostic value of neural network model

PURPOSE

To evaluate the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) measurements using spectral domain optical coherence tomography (SD-OCT) in patients with chiasmal compression and analyze the diagnostic value of a neural network model.

METHODS

Forty-seven patients with chiasmal compressive disorder were recruited and divided into two groups depending on the visual field defect (perimetric; group 1 and preperimetric; group 2). Fifty-seven normal subjects were also recruited (group 3). Peripapillary RNFL and macular GCIPL were analyzed in each group. A multilayer perceptron was trained using a training dataset and derived a neural network model. The diagnostic performances were compared using the area under the receiver operating curve (AUROC) between each parameters and neural network model.

RESULTS

All macular GCIPL parameters, except inferotemporal GCIPL thickness, were thinner in group 1 than in group 2 and group 3, with barely any difference between group 2 and group 3 parameter values. The diagnostic power of the neural network model, minimum GCIPL, and inferonasal GCIPL were superior when compared with other parameters; the diagnostic values of these three parameters are not significantly different in discriminating the patients and normal control. However, the neural network exhibited the best diagnostic power in distinguishing group 2 and group 3.

CONCLUSION

Macular GCIPL was reduced in chiasmal compression patients with visual field defect which was not evident in the preperimetric state. Neural network model showed superior diagnostic value in discriminating the preperimetric patients from normal control. The results suggest that neural networks may be helpful in the early diagnosis of chiasmal compression.

The Human Touch: Using a Webcam to Autonomously Monitor Compliance During Visual Field Assessments

Purpose

To explore the feasibility of using various easy-to-obtain biomarkers to monitor non-compliance (measurement error) during visual field assessments.

Methods

Forty-two healthy adults (42 eyes) and seven glaucoma patients (14 eyes) underwent two same-day visual field assessments. An ordinary webcam was used to compute seven potential biomarkers of task compliance, based primarily on eye gaze, head pose, and facial expression. We quantified the association between each biomarker and measurement error, as defined by (1) test–retest differences in overall test scores (mean sensitivity), and (2) failures to respond to visible stimuli on individual trials (stimuli −3 dB or more brighter than threshold).

Results

In healthy eyes, three of the seven biomarkers were significantly associated with overall (test–retest) measurement error (P = 0.003–0.007), and at least two others exhibited possible trends (P = 0.052–0.060). The weighted linear sum of all seven biomarkers was associated with overall measurement error, in both healthy eyes (r = 0.51, P < 0.001) and patients (r = 0.65, P < 0.001). Five biomarkers were each associated with failures to respond to visible stimuli on individual trials (all P < 0.001).

Conclusions

Inexpensive, autonomous measures of task compliance are associated with measurement error in visual field assessments, in terms of both the overall reliability of a test and failures to respond on particular trials (“lapses”). This could be helpful for identifying low-quality assessments and for improving assessment techniques (e.g., by discounting suspect responses or by automatically triggering comfort breaks or encouragement).

Translational Relevance

This study explores a potential way of improving the reliability of visual field assessments, a crucial but notoriously unreliable clinical measure.

Artificial Intelligence Classification of Central Visual Field Patterns in Glaucoma

PURPOSE

To quantify the central visual field (VF) loss patterns in glaucoma using artificial intelligence.

DESIGN

Retrospective study.

PARTICIPANTS

VFs of 8712 patients with 13 951 Humphrey 10-2 test results from 13 951 eyes for cross-sectional analyses, and 824 patients with at least 5 reliable 10-2 test results at 6-month intervals or more from 1191 eyes for longitudinal analyses.

METHODS

Total deviation values were used to determine the central VF patterns using the most recent 10-2 test results. A 24-2 VF within a 3-month window of the 10-2 tests was used to stage eyes into mild, moderate, or severe functional loss using the Hodapp-Anderson-Parrish scale at baseline. Archetypal analysis was applied to determine the central VF patterns. Cross-validation was performed to determine the optimal number of patterns. Stepwise regression was applied to select the optimal feature combination of global indices, average baseline decomposition coefficients from central VFs archetypes, and other factors to predict central VF mean deviation (MD) slope based on the Bayesian information criterion (BIC).

MAIN OUTCOME MEASURES

The central VF patterns stratified by severity stage based on 24-2 test results and a model to predict the central VF MD change over time using baseline test results.

RESULTS

From cross-sectional analysis, 17 distinct central VF patterns were determined for the 13 951 eyes across the spectrum of disease severity. These central VF patterns could be divided into isolated superior loss, isolated inferior loss, diffuse loss, and other loss patterns. Notably, 4 of the 5 patterns of diffuse VF loss preserved the less vulnerable inferotemporal zone, whereas they lost most of the remaining more vulnerable zone described by the Hood model. Inclusion of coefficients from central VF archetypical patterns strongly improved the prediction of central VF MD slope (BIC decrease, 35; BIC decrease of >6 indicating strong prediction improvement) than using only the global indices of 2 baseline VF results. Eyes with baseline VF results with more superonasal and inferonasal loss were more likely to show worsening MD over time.

CONCLUSIONS

We quantified central VF patterns in glaucoma, which were used to improve the prediction of central VF worsening compared with using only global indices.

Defective angles of localized retinal nerve fiber layer reflect the severity of visual field defect- a cross-sectional analysis

Background

In order to detect glaucomatous optic nerve damages early on and evaluate the severity of glaucoma, a previously developed analytic method based on photographic retinal nerve fiber layer (RNFL) angle defect was proposed. However, the correlation between these defective angles and the severity of visual field defect has not been verified. This study aimed to confirm the correlation described above.

Methods

We reviewed a total of 227 glaucomatous eyes (38 enrolled, 189 excluded) during an interval of 5 years. The angles of all eyes were measured on RNFL photograph, of which angle α is the angular width between the macula center and the proximity of RNFL defect, and angle β (+c) is the sum of angular width(s) of localized RNFL defect. The severity of visual field defect was determined by mean deviation (MD), pattern standard deviation (PSD), and visual field index (VFI). Correlation analysis was performed on angle α and angle β (+c) with the presence of central scotoma and visual field defect parameters, respectively.

Results

Angle β (+c) showed significant correlation with MD (P = 0.007), PSD (P = 0.02), VFI (P = 0.03), and average RNFL thickness (P = 0.03). No correlation was found between angle α and the presence of central scotoma.

Conclusions

In conclusion, measuring the angular width of localized RNFL defect is a viable method for determining the severity of visual field defect.

A Multimodal Eye Assessment in Psoriatic Arthritis Patients sine-Psoriasis: Evidence for a Potential Association with Systemic Inflammation

Background: Ocular involvement in Psoriatic Arthritis (PsA) patients is mainly associated with uveitis but there remains a paucity of data on dry eye and retinal abnormalities. We aimed to analyze dry eye and subclinical retinal abnormalities in a cohort of PsA patients sine-psoriasis (PsO). Methods: PsA patients sine-PsO were enrolled. Best-corrected-visual-acuity, ocular-surface-disease-index (OSDI), Schirmer test, tear film breakup-time, standard-automated-perimetry (SAP, mean deviation—MD, pattern standard deviation—PSD), fundus-perimetry (FP), and spectral-domain-optical-coherence-tomography (SD-OCT) were performed. Results: A total of 80 eyes from 40 PsA patients with moderate-severe disease activity, and 70 eyes from 35 healthy control (HC) were evaluated. Higher dry eye prevalence occurred in PsA than HC (p < 0.0001). ESR was positively related with OSDI (p < 0.001) and negatively related with Schirmer (p = 0.007). In PsA, SAP registered higher MD (p < 0.0001) and higher PSD (p = 0.005) in comparison with HC. PSD resulted positively correlated with ESR (p = 0.04) and CRP (p = 0.01), while MD showed a negative correlation with CRP (p = 0.01). Both FP mean differential sensitivity and mean defect were lower in PsA then HC (p < 0.0001). In PsA, FP differential sensitivity was directly related with cumulative steroids (p = 0.02). Conclusions: In PsA patients sine-PsO, dry eye and subclinical abnormalities in visual functions occurred being potentially related to systemic inflammation.

Left-Right and Upper-Lower Light Sensitivity Asymmetry in Visual Field Defects Caused by Pituitary Adenoma: A Retrospective Observational Study

Purpose

The purpose of this study was to quantitatively investigate light sensitivity asymmetry both between left and right eyes and between upper and lower quadrant in the 30-degree visual field of patients with visual field defects caused by pituitary adenoma.

Patients and Methods

Preoperative Humphrey 30–2 perimetry results were reviewed retrospectively using the charts of 28 pituitary adenoma patients who underwent surgery. Inter-eye light sensitivity comparisons of the temporal and nasal hemifields between the left and right eyes were conducted in each patient to study left-right asymmetry. Upper-lower asymmetry was investigated by comparing the frequency of severe scotoma (light sensitivity 5 dB or less) in the upper and lower visual field quadrants in the temporal and nasal hemifields.

Results

Left-right asymmetry was demonstrated in 61% of cases in the temporal hemifield and in 57% of cases in the nasal hemifield. Severe scotoma test points were investigated in the worse eye of each patient and were more frequent in the superotemporal quadrant of the visual field compared with the inferotemporal quadrant (P = 0.00029) and in the inferonasal quadrant compared to the superonasal quadrant (P = 0.00268).

Conclusion

Asymmetric visual field defects between left and right eyes are common in patients with pituitary adenoma. Severe scotoma is more frequent in the upper quadrant of the temporal hemifield and in the lower quadrant of the nasal hemifield.

Characterization of Central Visual Field Loss in End-stage Glaucoma by Unsupervised Artificial Intelligence

Importance

Although the central visual field (VF) in end-stage glaucoma may substantially vary among patients, structure-function studies and quality-of-life assessments are impeded by the lack of appropriate characterization of end-stage VF loss.

Objective

To provide a quantitative characterization and classification of central VF loss in end-stage glaucoma.

Design, Setting, and Participants

This retrospective cohort study collected data from 5 US glaucoma services from June 1, 1999, through October 1, 2014. A total of 2912 reliable 10-2 VFs of 1103 eyes from 1010 patients measured after end-stage 24-2 VFs with a mean deviation (MD) of -22 dB or less were included in the analysis. Data were analyzed from March 28, 2018, through May 23, 2019.

Main Outcomes and Measures

Central VF patterns were determined by an artificial intelligence algorithm termed archetypal analysis. Longitudinal analyses were performed to investigate whether the development of central VF defect mostly affects specific vulnerability zones.

Results

Among the 1103 patients with the most recent VFs, mean (SD) age was 70.4 (14.3) years; mean (SD) 10-2 MD, -21.5 (5.6) dB. Fourteen central VF patterns were determined, including the most common temporal sparing patterns (304 [27.5%]), followed by mostly nasal loss (280 [25.4%]), hemifield loss (169 [15.3%]), central island (120 [10.9%]), total loss (91 [8.3%]), nearly intact field (56 [5.1%]), inferonasal quadrant sparing (42 [3.8%]), and nearly total loss (41 [3.7%]). Location-specific median total deviation analyses partitioned the central VF into a more vulnerable superonasal zone and a less vulnerable inferotemporal zone. At 1-year and 2-year follow-up, new defects mostly occurred in the more vulnerable zone. Initial encroachments on an intact central VF at follow-up were more likely to be from nasal loss (11 [18.4%]; P < .001). One of the nasal loss patterns had a substantial chance at 2-year follow-up (8 [11.0%]; P = .004) to shift to total loss, whereas others did not.

Conclusions and Relevance

In this study, central VF loss in end-stage glaucoma was found to exhibit characteristic patterns that might be associated with different subtypes. Initial central VF loss is likely to be nasal loss, and 1 specific type of nasal loss is likely to develop into total loss.

Evaluation of retinal microvascular perfusion in hereditary angioedema: a case-control study

Evidence supports that hereditary angioedema (HAE) may be considered as a paroxysmal permeability disorder with defective but self-limiting endothelial barrier dysfunction. A potential subclinical abnormal vascular permeability at retinal capillaries could induce damage resulting in retinopathy. We aimed at exploring for the first time the presence of microangiopathy at retinal level from a highly selective cohort of patients with HAE due to C1 esterase inhibitor protein (C1INH) deficiency (type I). We conducted a pilot, prospective, case-control study including 20 type I HAE patients and 20 age−/sex-matched healthy controls (HC). All participants underwent standard ophthalmological examination including visual fields. Superficial and deep capillary plexi in the retina were analyzed by using new optical coherence tomography angiography (OCT-A). A total of 40 eyes from 20 HAE patients and 20 eyes from HC were evaluated. Perimetric indices of visual field were slightly worse in HAE than in controls. OCT-angiograms documented in HAE patients a lower retinal capillary density in both superficial and deep scans and a higher retinal thickness compared to healthy eyes. Our findings firstly documented subclinical abnormalities in retinal microvascular network in type I HAE patients that might be associated with early subtle functional changes. This preliminary evidence supports the hypothesis of a recurrent endothelial barrier failure at retinal level in HAE patients potentially resulting in chronic damage.

Comparison of Humphrey Field Analyzer and imo visual field test results in patients with glaucoma and pseudo-fixation loss

The aim of this cross-sectional study was to evaluate the results of a visual field (VF) test for patients with glaucoma and pseudo-fixation loss. These patients exhibit fixation loss (FL) rates >20% with the Humphrey Field Analyzer (HFA); however, actual fixation stabilizes when a head-mounted perimeter (imo) is used. This device is able to adjust the stimulus presentation point by tracking eye movements. We subjected 54 eyes of 54 patients with glaucoma and pseudo-FL to the HFA 30–2 or 24–2 Swedish Interactive Threshold Algorithm -Standard protocol. All patients also underwent the imo 30–2 or 24–2 Ambient Interactive Zipper Estimated Sequential Testing protocol after HFA measurement. We compared HFA and imo reliability indices [including false-positive (FP) responses, false-negative (FN) responses, and FL rate], global indices [including mean deviation (MD), visual field index (VFI), and pattern standard deviation (PSD)], and retinal sensitivity for each test point. There were no significant differences in MD, VFI, and PSD between HFA and imo, and these measures were strongly correlated (r > 0.96, p < 0.01). There were no significant differences in FP and FN between both devices, while FL measured with HFA (27.5%) was significantly reduced when measured with imo (13.2%) (p < 0.01). There was no correlation in FL and FN between both devices, and a weak correlation for FP (r = 0.29, p = 0.04). At each test point, retinal sensitivity averaged 1.7 dB higher with HFA, compared with imo (p < 0.01). There was no significant variability in global indices in patients with pseudo-FL. The FP response rate might have influenced measures of FL in patients with glaucoma and pseudo-FL.

Optical Coherence Tomography Angiography Compared With Optical Coherence Tomography Macular Measurements for Detection of Glaucoma

Importance

Whether optical coherence tomography angiography (OCT-A) outperforms OCT to detect glaucoma remains inconclusive.

Objective

To compare (1) the diagnostic performance for detection of glaucoma and (2) the structure-function association between inner macular vessel density and inner macular thickness.

Design, Setting, and Participants

This cross-sectional study included 115 patients with glaucoma and 35 healthy individuals for measurements of retinal thickness and retinal vessel density, segmented between the anterior boundary of internal limiting membrane and the posterior boundary of the inner plexiform layer, over the 3 × 3-mm2 macula using swept-source OCT. All participants were Chinese. Visual sensitivity corresponding to the 3 × 3-mm2 macular region was expressed in unlogged 1/lambert for investigation of the structure-function associations. Diagnostic performance was evaluated with area under the receiver operating characteristic curves (AUCs). The study was conducted between January 12, 2016, and December 12, 2016.

Main Outcomes and Measures

Area under the receiver operating characteristic curve and R2 analysis.

Results

Of the 115 patients with glaucoma, 42 (36.5%) were women (mean [SD] age, 53.5 [13.4] years); of the 35 individuals with healthy eyes, 25 (71.4%) were women (age, 60.6 [5.9] years). Inner macular vessel density and thickness were 4.3% (95% CI, 2.4%-6.1%) and 21.1 μm (95% CI, 17.4-24.9 μm) smaller, respectively, in eyes with glaucoma compared with healthy eyes. The AUC of mean inner macular thickness for glaucoma detection was greater than that of mean inner macular vessel density (difference, 0.17; 95% CI, 0.01-0.31; P = .03). At 90% specificity, the sensitivity of mean inner macular thicknesses for detection of glaucoma was greater than that of mean inner macular vessel densities (difference, 29.2%; 95% CI, 11.5%-64.6%; P = .02). The strength of the structure-function association was stronger for mean inner macular thickness than mean inner macular vessel density in the linear (difference in R2 = 0.38; 95% CI, 0.22-0.54; P < .001) and nonlinear (difference in R2 = 0.36; 95% CI, 0.21-0.51; P < .001) regression models.

Conclusions and Relevance

In this study, OCT measurement of inner macular thickness shows a higher diagnostic performance to detect glaucoma and a stronger structure-function association than the currently used OCT-A measurement of inner macular vessel density. These findings may suggest that OCT-A of the macula has a limited role in the diagnostic evaluation of glaucoma.

Vision to improve: quality improvement in ophthalmology

Improving quality of care and patient outcomes is a professional duty of all health care workers. Quality improvement is a part of health policy, an accreditation requirement of residency programs, and a recognized sub-specialty in academic medicine. Given the increasing need for ophthalmological services with our aging population, it is critical for ophthalmologists and their staff to develop the necessary skills in quality improvement to ensure access to care that is safe, patient-centered, effective, efficient, equitable, and timely. This narrative review outlines tools that are used in a recognized framework, including the creation of an aim statement, Ishikawa diagram, Pareto analysis, process maps, Plan-Do-Study-Act cycles, and run charts. We also discuss common challenges that occur when conducting quality initiatives. Two quality improvement projects conducted in the Department of Ophthalmology at University of Toronto are used as examples to illustrate these tools. The aim of the first project was to improve visual field test reliability and the aim of the second was to ensure secure email communication between residents and staff in caring for emergency patients. This primer provides the foundations ophthalmologists and their staff can use to support and guide their quality improvement efforts.

Effect of physical activity on severity of primary angle closure glaucoma

Objective:

To determine the association between physical activity and severity of primary angle closure glaucoma in Malay patients.

Methods:

A cross-sectional study was conducted involving 150 primary angle closure glaucoma patients between April 2014 and August 2016. Using the International Physical Activity Questionnaire, the physical activity status was assessed and divided into three categories: mild, moderate and heavy physical activity. The duration of physical activity and corresponding minimum energy requirements were calculated. Ocular examination was performed including Humphrey visual field 24-2 analysis assessment. Based on two consecutive reliable Humphrey visual fields, the severity of glaucoma was scored according to modified Advanced Glaucoma Intervention Study and classified as mild (0–5), moderate (6–11) and severe (12–20). Association between physical activity and Advanced Glaucoma Intervention Study score was determined with multiple linear regression analysis.

Results:

A total of 150 Malay patients with primary angle closure glaucoma were included (50 patients with mild, 50 with moderate and 50 with severe glaucoma). Physical activity showed inverse association with the severity of primary angle closure glaucoma. After calculating adjustments for age, sex, duration of glaucoma, body mass index, systemic co-morbidities, family history of glaucoma, myopia and educational status [adjusted b –3.41, 95% confidence interval (–5.23, –1.59), p < 0.001], there was also an inverse relationship with Advanced Glaucoma Intervention Study score. Every increase in physical activity level reduces the Advanced Glaucoma Intervention Study score by 3.4 point.

Conclusion:

Physical activity is the potential modifiable risk factor in reducing the severity of glaucoma among primary angle closure glaucoma patients. However, there is possibility of the severity of glaucoma restricted the physical activity of primary angle closure glaucoma patients.

An Artificial Intelligence Approach to Detect Visual Field Progression in Glaucoma Based on Spatial Pattern Analysis

Purpose

To detect visual field (VF) progression by analyzing spatial pattern changes.

Methods

We selected 12,217 eyes from 7360 patients with at least five reliable 24-2 VFs and 5 years of follow-up with an interval of at least 6 months. VFs were decomposed into 16 archetype patterns previously derived by artificial intelligence techniques. Linear regressions were applied to the 16 archetype weights of VF series over time. We defined progression as the decrease rate of the normal archetype or any increase rate of the 15 VF defect archetypes to be outside normal limits. The archetype method was compared with mean deviation (MD) slope, Advanced Glaucoma Intervention Study (AGIS) scoring, Collaborative Initial Glaucoma Treatment Study (CIGTS) scoring, and the permutation of pointwise linear regression (PoPLR), and was validated by a subset of VFs assessed by three glaucoma specialists.

Results

In the method development cohort of 11,817 eyes, the archetype method agreed more with MD slope (kappa: 0.37) and PoPLR (0.33) than AGIS (0.12) and CIGTS (0.22). The most frequently progressed patterns included decreased normal pattern (63.7%), and increased nasal steps (16.4%), altitudinal loss (15.9%), superior-peripheral defect (12.1%), paracentral/central defects (10.5%), and near total loss (10.4%). In the clinical validation cohort of 397 eyes with 27.5% of confirmed progression, the agreement (kappa) and accuracy (mean of hit rate and correct rejection rate) of the archetype method (0.51 and 0.77) significantly (P < 0.001 for all) outperformed AGIS (0.06 and 0.52), CIGTS (0.24 and 0.59), MD slope (0.21 and 0.59), and PoPLR (0.26 and 0.60).

Conclusions

The archetype method can inform clinicians of VF progression patterns.