Prevalence of primary open angle glaucoma in the last 20 years: a meta-analysis and systematic review

Maculopapillary Bundle Degeneration in Optic Neuropathies

PURPOSE OF REVIEW

Degeneration of the maculopapillary bundle (MPB) is a prominent feature in a spectrum of optic neuropathies. MPB-selective degeneration is seen in specific conditions, such as nutritional and toxic optic neuropathies, Leber hereditary optic neuropathy (LHON), and dominant optic atrophy (DOA). Despite their distinct etiologies and clinical presentations, which encompass variations in age of incidence and monocular or binocular onset, these disorders share a core molecular mechanism: compromised mitochondrial homeostasis. This disruption is characterized by dysfunctions in mitochondrial metabolism, biogenesis, and protein synthesis. This article provides a comprehensive understanding of the MPB's role in optic neuropathies, emphasizing the importance of mitochondrial mechanisms in the pathogenesis of these conditions.

RECENT FINDINGS

Optical coherence tomography studies have characterized the retinal nerve fiber layer changes accompanying mitochondrial-affiliated optic neuropathies. Selective thinning of the temporal optic nerve head is preceded by thickening in early stages of these disorders which correlates with reductions in macular ganglion cell layer thinning and vascular atrophy. A recently proposed mechanism underpinning the selective atrophy of the MPB involves the positive feedback of reactive oxygen species generation as a common consequence of mitochondrial dysfunction. Additionally, new research has revealed that the MPB can undergo degeneration in the early stages of glaucoma, challenging the historically held belief that this area was not involved in this common optic neuropathy. A variety of anatomical risk factors influence the propensity of glaucomatous MPB degeneration, and cases present distinct patterns of ganglion cell degeneration that are distinct from those observed in mitochondria-associated diseases. This review synthesizes clinical and molecular research on primary MPB disorders, highlighting the commonalities and differences in their pathogenesis.

KEY POINTS (BOX)

1. Temporal degeneration of optic nerve fibers accompanied by cecocentral scotoma is a hallmark of maculopapillary bundle (MPB) degeneration. 2. Mechanisms of MPB degeneration commonly implicate mitochondrial dysfunction. 3. Recent research challenges the traditional belief that the MPB is uninvolved in glaucoma by showing degeneration in the early stages of this common optic neuropathy, yet with features distinct from other MPB-selective neuropathies. 4. Reactive oxygen species generation is a mechanism linking mitochondrial mechanisms of MPB-selective optic neuropathies, but in-vivo and in-vitro studies are needed to validate this hypothesis.

The accuracy of self-reported family history in glaucoma in Brazil

PURPOSE

To evaluate the accuracy of a positive self-reported glaucoma family history.

MATERIAL AND METHODS

Cross-sectional study. Each subject was asked if they had a first-degree relative diagnosed with glaucoma. If their answer was affirmative, the relative was invited to attend on ophthalmic evaluation and underwent complementary exams to confirm or exclude the glaucoma diagnosis. Only one relative was included per subject.

RESULTS

We included 204 subjects in the study (102 subjects and their respective relatives). The accuracy of family history of glaucoma was 76.96% of the cases. In the univariable analysis, subjects with college degree had 2.34 [(P = 0.010; 95% confidence interval (CI) 1.18-4.63)], with higher family income 3.72 (P = 0.003; 95% CI 1.57-8.85) and those with health insurance 3.42 (P = 0.001; 95% CI 1.67-6.98) more chances to have a true positive family history for glaucoma. In the multivariable logistic regression analysis, none of the variables presented significant association.

CONCLUSION

Around 24% of patients may not provide reliable information about family history for glaucoma. When asking about a glaucoma family history, clinicians should consider the real accuracy of this self-reported data.

Domain Adaptation-Based Deep Learning Model for Forecasting and Diagnosis of Glaucoma Disease

The main factor causing irreversible blindness is glaucoma. Early detection greatly reduces the risk of further vision loss. To address this problem, we developed a domain adaptation-based deep learning model called Glaucoma Domain Adaptation (GDA) based on 66,742 fundus photographs collected from 3272 eyes of 1636 subjects. GDA learns domain-invariant and domain-specific representations to extract both general and specific features. We also developed a progressive weighting mechanism to accurately transfer the source domain knowledge while mitigating the transfer of negative knowledge from the source to the target domain. We employed low-rank coding for aligning the source and target distributions. We trained GDA based on three different scenarios including eyes annotated as glaucoma due to 1) optic disc abnormalities regardless of visual field abnormalities, 2) optic disc or visual field abnormalities except ones that are glaucoma due to both optic disc and visual field abnormalities at the same time, and 3) visual field abnormalities regardless of optic disc abnormalities We then evaluate the generalizability of GDA based on two independent datasets. The AUCs of GDA in forecasting glaucoma based on the first, second, and third scenarios were 0.90, 0.88, and 0.80 and the Accuracies were 0.82, 0.78, and 0.72, respectively. The AUCs of GDA in diagnosing glaucoma based on the first, second, and third scenarios were 0.98, 0.96, and 0.93 and the Accuracies were 0.93, 0.91, and 0.88, respectively. The proposed GDA model achieved high performance and generalizability for forecasting and diagnosis of glaucoma disease from fundus photographs. GDA may augment glaucoma research and clinical practice in identifying patients with glaucoma and forecasting those who may develop glaucoma thus preventing future vision loss.

Increased late-onset glaucoma risk following vitrectomy for macular pucker or hole

OBJECTIVES

The long-term risk of developing glaucoma after vitrectomy remains uncertain. This retrospective population-based cohort study aimed to explore this risk following vitrectomy for macular pucker or hole.

METHODS

Utilizing Taiwan's National Health Insurance Research Database (NHIRD), we included patients who were older than 18 years and had undergone vitrectomy surgery between 2011 and 2019. Exclusions were made for patients with prior diagnoses of glaucoma, congenital or secondary glaucoma, as well as those who had received previous vitreoretinal treatments or had undergone multiple vitrectomies.

RESULTS

After an average follow-up period of 51 and 53 months respectively for the vitrectomized and non-vitrectomized group, our results showed a relative risk of 1.71 for glaucoma development in the vitrectomized group. Higher adjusted hazard ratios were also observed for open-angle glaucoma and normal tension glaucoma. Increased risks were associated with male sex, obstructive sleep apnoea, and migraine. In the subgroup analysis, phakic eyes at baseline and those who had undergone cataract surgery post-vitrectomy were associated with a lower risk of glaucoma development during follow-up. Among all glaucoma events, pseudophakic status at baseline had the shortest interval to glaucoma development following vitrectomy.

CONCLUSIONS

These findings underscore the potential relationship between vitrectomy and glaucoma onset, emphasizing the need for vigilant monitoring and early detection of glaucoma in post-vitrectomy patients.

Xiaoqing: A Q&A model for glaucoma based on LLMs

Glaucoma is one of the leading cause of blindness worldwide. Individuals affected by glaucoma, including patients and their family members, frequently encounter a deficit in dependable support beyond the confines of clinical environments. Seeking advice via the internet can be a difficult task due to the vast amount of disorganized and unstructured material available on these sites, nevertheless. This research explores how Large Language Models (LLMs) can be leveraged to better serve medical research and benefit glaucoma patients. We introduce Xiaoqing, a Natural Language Processing (NLP) model specifically tailored for the glaucoma field, detailing its development and deployment. To evaluate its effectiveness, we conducted two forms of experiments: comparative and experiential. In the comparative analysis, we presented 22 glaucoma-related questions in simplified Chinese to three medical NLP models (Xiaoqing LLMs, HuaTuo, Ivy GPT) and two general models (ChatGPT-3.5 and ChatGPT-4), covering a range of topics from basic glaucoma knowledge to treatment, surgery, research, management standards, and patient lifestyle. Responses were assessed for informativeness and readability. The experiential experiment involved glaucoma patients and non-patients interacting with Xiaoqing, collecting and analyzing their questions and feedback on the same criteria. The findings demonstrated that Xiaoqing notably outperformed the other models in terms of informativeness and readability, suggesting that Xiaoqing is a significant advancement in the management and treatment of glaucoma in China. We also provide a Web-based version of Xiaoqing, allowing readers to directly experience its functionality. The Web-based Xiaoqing is available at https://qa.glaucoma-assistant.com//qa.

Polygenic risk score-based phenome-wide association for glaucoma and its impact on disease susceptibility in two large biobanks

BACKGROUND

Glaucoma is a leading cause of worldwide irreversible blindness. Considerable uncertainty remains regarding the association between a variety of phenotypes and the genetic risk of glaucoma, as well as the impact they exert on the glaucoma development.

METHODS

We investigated the associations of genetic liability for primary open angle glaucoma (POAG) with a wide range of potential risk factors and to assess its impact on the risk of incident glaucoma. The phenome-wide association study (PheWAS) approach was applied to determine the association of POAG polygenic risk score (PRS) with a wide range of phenotypes in 377, 852 participants from the UK Biobank study and 43,623 participants from the Penn Medicine Biobank study, all of European ancestry. Participants were stratified into four risk tiers: low, intermediate, high, and very high-risk. Cox proportional hazard models assessed the relationship of POAG PRS and ocular factors with new glaucoma events.

RESULTS

In both discovery and replication set in the PheWAS, a higher genetic predisposition to POAG was specifically correlated with ocular disease phenotypes. The POAG PRS exhibited correlations with low corneal hysteresis, refractive error, and ocular hypertension, demonstrating a strong association with the onset of glaucoma. Individuals carrying a high genetic burden exhibited a 9.20-fold, 11.88-fold, and 28.85-fold increase in glaucoma incidence when associated with low corneal hysteresis, high myopia, and elevated intraocular pressure, respectively.

CONCLUSION

Genetic susceptibility to POAG primarily influences ocular conditions, with limited systemic associations. Notably, the baseline polygenic risk for POAG robustly associates with new glaucoma events, revealing a large combined effect of genetic and ocular risk factors on glaucoma incidents.

Global estimates on the number of people blind or visually impaired by glaucoma: A meta-analysis from 2000 to 2020

OBJECTIVES

To estimate global and regional trends from 2000 to 2020 of the number of persons visually impaired by glaucoma and their proportion of the total number of vision-impaired individuals.

METHODS

A systematic review and meta-analysis of published population studies and grey literature from 2000 to 2020 was carried out to estimate global and regional trends in number of people with vision loss due to glaucoma. Moderate or severe vision loss (MSVI) was defined as visual acuity of 6/60 or better but <6/18 (moderate) and visual acuity of 3/60 or better but <6/60 (severe vision loss). Blindness was defined as presenting visual acuity <3/60.

RESULTS

Globally, in 2020, 3.61 million people were blind and nearly 4.14 million were visually impaired by glaucoma. Glaucoma accounted for 8.39% (95% uncertainty intervals [UIs]: 6.54, 10.29) of all blindness and 1.41% (95% UI: 1.10, 1.75) of all MSVI. Regionally, the highest proportion of blindness relating to glaucoma was found in high-income countries (26.12% [95% UI: 20.72, 32.09]), while the region with the highest age-standardized prevalence of glaucoma-related blindness and MSVI was Sub-Saharan Africa. Between 2000 and 2020, global age-standardized prevalence of glaucoma-related blindness among adults ≥50 years decreased by 26.06% among males (95% UI: 25.87, 26.24), and by 21.75% among females (95% UI: 21.54, 21.96), while MSVI due to glaucoma increased by 3.7% among males (95% UI: 3.42, 3.98), and by 7.3% in females (95% UI: 7.01, 7.59).

CONCLUSIONS

Within the last two decades, glaucoma has remained a major cause of blindness globally and regionally.

Comparison of disease severity in glaucoma patients identified by screening in the 1990s and in routine clinical care in the 2010s in Sweden

BACKGROUND AND PURPOSE

In a previous study comparing the amount of visual field damage at presentation in patients having open-angle glaucoma (OAG) identified through screening and in patients diagnosed in routine clinical practice in the 1990s, the damage was considerably worse in the clinically diagnosed patients. In the present study we compare visual field damage at presentation in the same 402 screened patients with that seen in 281 newly detected previously untreated patients clinically diagnosed in the 2010s.

METHODS

The perimetric visual field index mean deviation (MD) was compared in the two groups of patients.

RESULTS

In the clinical patients diagnosed with bilateral visual field damage the median MD was -5.1 dB in the better eye and -13.0 dB in the worse eye. In the screened patients the median MD in the better eye was -6.5 dB and -11.5 dB in the worse eye. The differences between the clinical and screened patients were non-significant, p = 0.28 and p = 0.67 respectively. More clinical patients had severe visual field loss, defined as MD less than -20 dB, in the worse eye than in the screened patients, 18.5% versus 12.7% respectively, p = 0.037.

CONCLUSION

The visual field damage at presentation in clinically diagnosed OAG patients has improved in the past 20 years, but the proportion of patients with severe visual field loss in at least one eye, almost 20%, is still unacceptably high considering that severe visual field damage at presentation is the most important risk factor for later development of glaucoma blindness.

Investigating the Causal Relationship Between Sleep Behaviors and Primary Open-Angle Glaucoma: A Bidirectional Two-Sample Mendelian Randomization Study

Background

Although previous studies of sleep-related behaviors in relation to primary open-angle glaucoma (POAG) have been noted, the causal relationship remains unclear. The purpose of our present study was to investigate the relationships of genetically predicted sleep traits with POAG using a two-sample bidirectional Mendelian randomization (MR) method.

Methods

Summary-level data collected from publicly available genome-wide association studies (GWAS) of European decent were applied for the bidirectional MR analysis. After quality control steps, independent single-nucleotide polymorphisms for eight sleep behaviors and POAG were selected as the genetic instruments. The inverse-variance weighted (IVW) approach was adopted as the primary method, which was complemented by a series of sensitivity analyses to assess the robustness of the results by estimating heterogeneity and pleiotropy. Multivariable MR (MVMR) was used to assess the direct effect of sleep traits on POAG, after adjusting for several confounding factors.

Results

Our investigation revealed a positive correlation between genetically predicted ease of getting up in the morning and sleep duration and POAG using the IVW method (odds ratio (OR)=1.78, 95% confidence interval (CI):1.29-2.46, P = 4.33× 10-4; OR = 1.66, 95% CI:1.18-2.34, P = 3.38×10-3, respectively). Other supplementary MR methods also confirmed similar results. Moreover, the MVMR results also revealed that the adverse effects of these two sleep traits on POAG persisted after adjusting for body mass index, smoking, drinking, and education (all P < 0.05). Conversely, the relationships between genetic liability of POAG and different sleep behaviors were not statistically significant in the reverse-direction MR estimate (all P > 0.05).

Conclusion

Our study demonstrated that genetic prediction of getting up easily in the morning or sleep duration were associated with a higher risk of POAG, but not vice versa, in a European population. Further validation and clinical interventions are required to offer potential strategies to prevent and manage POAG.

Knowledge about glaucoma among adults in Africa: a systematic review

BACKGROUND

Africa is one of the continents with a substantial burden of glaucoma, where it is approximately twice as common as it is worldwide. If left untreated, glaucoma can cause blindness and permanent vision loss if it is not addressed promptly. Good knowledge is essential for preventing glaucoma's irreversible blindness and ocular damage. However, no systematic review has been done to report the pooled percentage of adults in Africa who have good knowledge about glaucoma. This study aimed to estimate the level of knowledge about glaucoma in Africa and its determinants.

METHODS

The study followed the PRISMA guidelines for systematic review. Seven electronic databases which include PubMed/MEDLINE, Web of Science, PROQUEST (PQDT), CINAHL (EBSCO), Google Scholar, African Journal Online, and WHO HINARI databases were searched from January 1, 2013, to July 31, 2023for studies conducted with a focus on the knowledge about glaucoma among adults in Africa. The quality of the final articles was assessed using the Joanna Briggs Institute quality assessment tool for cross-sectional studies.

RESULTS

In the present systematic review, 2781 articles were initially identified and evaluated. Of these, eight studies that met the inclusion criteria were included in the final analysis. In this review, the proportion of knowledge about glaucoma among adults in Africa was low. Educational status, family history of glaucoma, occupation, being a male, and having a history of eye examination were the main determinants of good knowledge about glaucoma among adults in Africa.

CONCLUSION

The systematic review found that only a few had good knowledge about glaucoma. Education campaigns and eye exam promotions are recommended to enhance awareness.

TRAIL REGISTRATION

This systematic review was registered on 30/07/2023 with PROSPERO ID: CRD42023430723.

Trabeculectomy in Eyes With High Myopia

PRCIS

Primary trabeculectomy was safe and effective at lowering intraocular pressure (IOP) in patients with primary open angle glaucoma and high myopia.

PURPOSE

To investigate the efficacy and safety of trabeculectomy in patients with glaucoma and high myopia.

PATIENT AND METHODS

Retrospective case-control study. Glaucomatous patients with high myopia undergoing primary trabeculectomy surgery with at least 1 year of follow-up were compared with an age-matched control group without high myopia undergoing the same procedure. Surgical success was defined as: IOP ≤ 15 mm Hg with (qualified) or without (complete) antiglaucoma medications and at least 20% reduction from baseline IOP at the end of 48 months of follow-up.

RESULTS

We included a total of 90 eyes from 90 patients (45 eyes with high myopia and 45 controls). Within the 90 eyes, 70 eyes underwent trabeculectomy and 20 eyes underwent combined phacoemulsification and trabeculectomy. Although patients with high myopia had higher chances for failure (37% vs. 22%) compared with controls, the difference was not statistically significant ( P =0.067). In the multivariable analysis, patients of African descent ( P =0.043) and those with juvenile glaucoma ( P =0.001) had more chances of failure, even after adjusting for myopia. There was no statistically significant difference between complication rates in both groups.

CONCLUSION

Trabeculectomy was effective in reducing IOP in patients with high myopia and glaucoma, without the additional risk of complications compared with a control group.

Stress and Allostatic Load in Patients With Primary Open Angle Glaucoma

PRCIS

This study evaluated the allostatic load (AL) in primary open angle glaucoma (POAG) patients and reported that the AL score was significantly higher in glaucoma patients compared with age-matched controls.

PURPOSE

To evaluate the AL in patients with POAG.

METHODS

This case-control study comprised 50 POAG (glaucoma patients) and 50 age-matched controls without glaucoma (controls). AL was estimated based on 13 variables: systolic blood pressure (BP), diastolic BP, homocysteine, triglycerides, total cholesterol, high-density lipoprotein, low-density lipoprotein, body mass index, serum cortisol, glycosylated hemoglobin, albumin, creatinine clearance, and C-reactive protein. High-risk thresholds were determined based on biological cutoffs of each biomarker. One point was assigned for each biomarker reading above cutoff and were summated to obtain AL score; score ≥4 was considered high.

RESULTS

Mean age of glaucoma patients was 60.82±6.26 and 60.14±6.72 years in controls ( P =0.602). All components of AL score (except C-reactive protein) had higher values in glaucoma patients. There was a statistically significant difference in homocysteine ( P =0.001), total cholesterol ( P =0.037), high-density lipoprotein ( P =0.005), and glycosylated hemoglobin ( P =0.003). Mean AL score was 4.68±2.09 in glaucoma patients and 3.32±1.34 in controls ( P <0.001). There was significant association of high AL score with older age ( P =0.006), low socioeconomic status ( P =0.020), and glaucoma severity ( P =0.001). Negative correlation was seen between AL and retinal nerve fiber layer thickness (Right Eye: r =-0.37, P <0.001; Left Eye: r =-0.298, P <0.001) and visual field mean deviation (Right Eye: r =-0.469, P <0.001; Left Eye: r =-0.520, P <0.001).

CONCLUSIONS

Glaucoma patients exhibited allostatic overload indicating physiological dysregulation to chronic stress although additional research is required to establish causality. A holistic approach with lifestyle modifications to reduce chronic stress should be an integral part of managing glaucoma patients as it would serve both to possibly reduce or prevent disease progression and improve overall health outcomes.

Association of GNB3, ACE polymorphisms with POAG and NTG

PURPOSE

Primary open-angle glaucoma (POAG) represents the most prevalent form of glaucoma and stands as a foremost contributor to irreversible vision impairment on a global scale. Despite notable strides made in comprehending the genetic underpinnings of POAG, investigations within the context of Russia remain constrained.

METHODS

The study cohort comprised a total of 235 individuals, with 135 of them exhibiting various forms of glaucoma encompassing both POAG and (NTG, while the remaining 100 individuals served as control subjects. Each participant underwent a comprehensive ocular examination to ascertain their ocular health status. Genotyping of the relevant single nucleotide polymorphisms (SNPs) was carried out using the Taq Man genotyping assay. Specifically, the two SNPs under scrutiny were GNB3 rs5443 gene and ACE rs4646994. Statistical analysis was performed to evaluate the association of these SNPs with glaucoma risk.

RESULTS

The presence of the T allele of rs5443 was found to be associated with NTG (p = .004). However, no statistically significant correlation was identified between this SNP and POAG (p = .88).

CONCLUSION

This study provides evidence of an association between the T allele of rs5443 and a reduced susceptibility NTG within the Russian population. These observations augment the comprehension of the genetic underpinnings of glaucoma and hold potential implications for the prospective development of targeted therapeutic interventions.

Identification of biomarker candidates for exfoliative glaucoma from autoimmunity profiling

BACKGROUND

Exfoliative glaucoma (XFG) is a subtype of open-angle glaucoma characterized by distinctive extracellular fibrils and a yet unknown pathogenesis potentially involving immune-related factors. The aim of this exploratory study was to identify biomarkers for XFG using data from autoimmunity profiling performed on blood samples from a Scandinavian cohort of patients.

METHODS

Autoantibody screening was analyzed against 258 different protein fragments in blood samples taken from 30 patients diagnosed with XFG and 30 healthy donors. The 258 protein fragments were selected based on a preliminary study performed on 3072 randomly selected antigens and antigens associated with the eye. The "limma" package was used to perform moderated t-tests on the proteomic data to identify differentially expressed reactivity between the groups.

RESULTS

Multiple associated genes were highlighted as possible biomarker candidates including FUT2, CDH5, and the LOX family genes. Using seven variables, our binary logistic regression model was able to classify the cases from the controls with an AUC of 0.85, and our reduced model using only one variable corresponding to the FUT2 gene provided an AUC of 0.75, based on LOOCV. Furthermore, over-representation gene analysis was performed to identify pathways that were associated with antigens differentially bound to self-antibodies. This highlighted the enrichment of pathways related to collagen fibril formation and the regulatory molecules mir-3176 and mir-876-5p.

CONCLUSIONS

This study suggests several potential biomarkers that may be useful in developing further models of the pathology of XFG. In particular, CDH5, FUT2, and the LOX family seem to have a relationship which merits additional exploration.

The effects of traditional Muslim prayer positions on intraocular pressure in subjects with and without glaucoma

PURPOSE

To compare the magnitude and duration of intraocular pressure (IOP) increase during the two principal Islamic prayer positions, Rukū (standing while bowing forward at a 90-degree angle), and Sujud (kneeling with the forehead touching the ground) in healthy subjects and patients with primary open-angle glaucoma (POAG).

METHODS

Prospective, observational case series. Ninety-five eyes of 47 patients (27 with POAG and 68 without POAG) were included. Eligible candidates underwent IOP measurements in the sitting position and in two prayer positions using the Goldmann applanation tonometer and the Icare-Pro tonometer. IOP was measured at set intervals until it returned to baseline.

RESULTS

Mean IOP increased from a sitting baseline value of 16.1  ±  2.9 mmHg (8.6-26) to 19.3  ±  4.2 mmHg (10.2-32.3) following 30 s of Rukū (p ≤ 0.0001) and from 16.1  ±  0.4 mmHg to 22.2  ±  3.1 mmHg (14.9-37) following Sujud (p ≤ 0.0001). IOP increased similarly in the POAG and non-POAG groups in both positions. Twenty-six eyes (27%) failed to normalize within 2mmHg of baseline, but all returned to baseline after another five minutes.

CONCLUSIONS

Performing traditional Muslim prayer positions increases IOP significantly. The increase did not resolve immediately in approximately a quarter of individuals. These findings may have a considerable impact on Muslim patients with glaucoma.

Efficacy of Continuous-Wave Transscleral Cyclophotocoagulation Post-Pars Plana Vitrectomy in Glaucoma Patients: A Retrospective Study from Poland

BACKGROUND Glaucoma, a vision-threatening condition, results from optic nerve damage and affects millions of people worldwide. Often asymptomatic, it is hereditary, with risk factors like hypertension, diabetes, and steroid use. Despite its link with intraocular pressure (IOP), not everyone with high IOP develops glaucoma. After pars plana vitrectomy (PPV), patients face increased IOP risks. Traditional treatment includes pharmacotherapy, and, when ineffective, surgical interventions. Continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) is an alternative for refractory glaucoma but can have complications. Our study compares the efficacy and safety of CW-TSCPC after PPV. MATERIAL AND METHODS The study group consisted of 18 patients diagnosed with glaucoma who underwent the CW-TSCP procedure as the first-choice therapy after conservative treatment of glaucoma proved ineffective. The comparison group consisted of 12 patients who underwent the CW-TSCP procedure after conservative drug treatment and in whom surgical treatment of glaucoma had been unsuccessful. All patients had inadequate control of IOP after PPV. RESULTS Study and comparison group patients showed a decrease in IOP during the follow-up, independent of the type of endotamponade used (P<0.05). When the indication for PPV was retinal detachment hemorrhage into the vitreous chamber, a significant decrease in IOP between 0 days and 180 days was only found in the study group (P<0.05). In contrast, when the indication for PPV was the state after uveitis or proliferative diabetic retinopathy, a significant decrease in IOP was found at 180 days in the study and comparison groups (P<0.05). CONCLUSIONS The analysis showed that the CW-TSCPC procedure can be recommended as the first-choice invasive treatment in patients with increased IOP after PPV.

Access to Eye Care Providers and Glaucoma Severity in the National Institutes of Health All of Us Research Program

PRCIS

In the "All of Us (AoU) Research Program," individuals with access to vision care were more likely to have mild, moderate, or severe glaucoma and undergo incisional surgery compared with those without vision care access.

PURPOSE

To examine the associations between access to eye care, glaucoma severity, and incisional glaucoma surgery using data from the National Institute of Health AoU Research Program.

MATERIALS AND METHODS

Individuals with International Classification of Diseases Ninth or 10th Revision codes and who answered the survey question about eye care access in AoU were included in the study. The exposure variable was access to eye care services, with outcome variables (1) glaucoma severitys and (2) likelihood of incisional surgery. Unadjusted multinomial logistic regression compared access to eye care services and glaucoma severity. In addition, unadjusted logistic regression models compared access to eye care and the likelihood of incisional surgery. These were repeated using adjusted analyses, controlling for sex assigned at birth, race and ethnicity, and age.

RESULTS

Compared with individuals without access to eye care services, those with access were more likely to have all levels of glaucoma severity [mild adjusted odds ratio (aOR): 5.81, 95% CI: 3.15-10.73, moderate aOR: 4.44, 95% CI: 2.45-8.02, severe aOR: 6.95, 95% CI: 2.69-17.93, and unspecified aOR: 3.06, 95% CI: 2.72, 3.45]. Access to eye care was associated with increased odds of any incisional glaucoma surgery (aOR: 3.00, 95% CI: 1.24-9.90) and of trabeculectomy (aOR: 3.30, 95% CI: 1.02-20.28) but not of tube shunt procedures (aOR: 2.65, 95% CI: 0.80-16.38).

CONCLUSIONS

This study demonstrated that access to eye care services was associated with a higher prevalence of all levels of glaucoma severity; those with access to eye care services were more likely to undergo incisional surgery than those without access. Future research should focus on methods to best encourage eye care to limit glaucoma progression.

Gender Disparities in Depression, Stress, and Social Support Among Glaucoma Patients

Purpose

To understand differences in measures of depression, stress, and social support by gender among those diagnosed with glaucoma.

Methods

We obtained a cohort of glaucoma patients (any type) ages 18 years and over who answered the COVID-19 Participant Experience (COPE) survey of the NIH All of Us Research Program. We analyzed several measures of depression, stress, and social support by gender. Logistic regression was used to evaluate the association among reported stress associated with social distancing, depression (using Patient Health Questionnaire-9 [PHQ-9] scores), and measures of social support by self-reported gender, with men as the reference group. Multivariable models were adjusted for age, race and ethnicity, health insurance status, education, and income.

Results

Of 3633 glaucoma patients, 56.8% were women. Many patients had a PHQ-9 score > 4 (33.3%), indicating mild, moderate, or severe depression. In multivariable models, women were significantly more likely to report a PHQ-9 score > 4 (odds ratio [OR] = 1.40; 95% confidence interval [CI], 1.20-1.62; P < 0.001) and some or a lot of stress (OR = 1.34; 95% CI, 1.14-1.57; P < 0.001) compared with men. Further, women were significantly less likely to report having help all or most of the time if they needed someone to prepare meals (OR = 0.78; 95% CI, 0.67-0.92; P = 0.002) or perform daily chores (OR = 0.79; 95% CI, 0.67-0.91; P = 0.003) than men.

Conclusions

Women with glaucoma were more likely to experience depression and stress and were less likely to have social support on some measures than men.

Translational Relevance

The disproportionate burden of psychosocial factors among women may complicate glaucoma management.

Acute angle closure glaucoma misdiagnosed as sinusitis

A 69-year-old woman developed severe right suprabulbar pain with blurred right-sided vision. There were no haloes around lights, photophobia, nausea or vomiting. Investigations in the emergency department excluded a posterior communicating/internal carotid artery aneurysm. However, she did not have an ophthalmological assessment and the initial diagnosis was of sinusitis-related headache. An urgent ear, nose and throat assessment found no abnormality, but a local ophthalmologist subsequently diagnosed and managed the patient's acute angle closure crisis. Periocular pain always deserves detailed assessment with an accurate history, visual acuity assessment and intraocular pressure measurement.

Integrated multi-omics single cell atlas of the human retina

Single-cell sequencing has revolutionized the scale and resolution of molecular profiling of tissues and organs. Here, we present an integrated multimodal reference atlas of the most accessible portion of the mammalian central nervous system, the retina. We compiled around 2.4 million cells from 55 donors, including 1.4 million unpublished data points, to create a comprehensive human retina cell atlas (HRCA) of transcriptome and chromatin accessibility, unveiling over 110 types. Engaging the retina community, we annotated each cluster, refined the Cell Ontology for the retina, identified distinct marker genes, and characterized cis-regulatory elements and gene regulatory networks (GRNs) for these cell types. Our analysis uncovered intriguing differences in transcriptome, chromatin, and GRNs across cell types. In addition, we modeled changes in gene expression and chromatin openness across gender and age. This integrated atlas also enabled the fine-mapping of GWAS and eQTL variants. Accessible through interactive browsers, this multimodal cross-donor and cross-lab HRCA, can facilitate a better understanding of retinal function and pathology.

XEN 45 Gel Stent Implantation in Open Angle Glaucoma: 5-Year Results of a Prospective Study

PRCIS

XEN 45 Gel Stent is safe and effective for 3 years. The study results provide useful insight into the outcome of XEN 45 Gel Stent surgery over 5 years in daily clinical practice.

PURPOSE

To evaluate 5-year outcomes of XEN 45 gel stent implantation (XEN) in patients with open angle glaucoma.

METHODS

This is a prospective, single-center, interventional study. XEN implantation either alone (XEN) or combined with phacoemulsification (Phaco + XEN) was performed on 170 consecutive eyes (126 patients) with uncontrolled intraocular pressure (IOP) or disease progression despite medical treatment. "Complete" surgical success at 60 months was defined as unmedicated IOP ≤15 mm Hg and a relative IOP reduction ≥20% from medicated baseline, while "qualified" success allowed fewer ocular hypotensive medications than at baseline. Other definitions of success with various IOP targets were also analyzed. Secondary outcomes included mean IOP and IOP-lowering medication changes and rates of reoperations.

RESULTS

Mean age was 78.1±9.2 years, and 70.3% were female. Mean medicated IOP decreased from 19.8±7.7 mm Hg [19.6±7.1 (XEN) vs. 19.8±7.0 mm Hg (Phaco+XEN)] at baseline to 12.6±3.1 mm Hg [12.5± 3.1 (XEN) vs. 12.6±3.1 (Phaco+XEN)] at 5 years (-37.0%; P < 0.001). Medications decreased from 2.0±1.3 [2.0±1.3 (XEN) vs. 2.0±1.3 (Phaco+XEN)] to 0.8±1.1 [0.8±1.1 (XEN) vs. 0.8±1.1 (Phaco + XEN)] (-60%; P <0.001). Needling was performed in 84 eyes (49%), and 19.4% underwent a secondary surgical intervention. Complete success at 3 years was a strong predictor of success at 5 years (odds ratio: 3.06, P <0.01), while needling was associated with higher rates of failure (odds ratio: 3.6, P <0.01).

CONCLUSIONS

At 5 years, XEN gel stent implantation was a safe procedure and achieved clinically meaningful IOP and medication reduction. Success at 3 years is a predictor of success at 5 years. Needling correlates with higher failure rates.

[Use of antiglaucomatous drugs in the urban adult population : New Insights into the prevalence of glaucoma from the Hamburg City Health Study]

BACKGROUND

Glaucoma is a widespread ophthalmological disease. Knowledge about the spread of the disease in the population is necessary with respect to further questions on comorbidities, risk factors and the provision of care.

OBJECTIVE

An analysis of the use of glaucoma medications and the prevalence of glaucoma in an urban adult population was carried out.

MATERIAL AND METHODS

The Hamburg City Health Study (HCHS) is a prospective, long-term, population-based cohort study that includes a random sample of 45,000 participants aged between 45 and 79 years from the general population of Hamburg, Germany. Apart from various medical parameters, data include premedication and the medical history of the participants. The use of antiglaucomatous medication among the first 10,000 study participants was analyzed and the prevalence of glaucoma was estimated according to the use of medications as well as by the self-reported history of glaucoma. Descriptive analysis and logistic regression analysis were performed to analyze the data and to calculate correlations by age and gender.

RESULTS

In the study population 319 persons were on medication to lower the intraocular pressure (IOP, mean age 67.1 years, SD = 7.57 years), which is equivalent to an estimated prevalence of 3.35% (95% confidence interval, CI 3.00-3.70%). A positive correlation was observed between age and the use of IOP-lowering medication, which is statistically highly significant (p = < 0.001). The analysis by gender showed a slightly higher prevalence among women, which was not statistically significant. The estimated prevalence according to glaucoma medication and history were only partly congruent.

DISCUSSION

This estimated prevalence of glaucoma is comparable to other epidemiological studies. The study results cover not only patients with manifest glaucoma but also persons who were treated for ocular hypertension. The inconsistency between the prevalence of glaucoma medication and the diagnosis of glaucoma can be explained by different treatment strategies and also by information deficits.

Effect of genotype on individual response to the pharmacological treatment of glaucoma: a systematic review and meta-analysis

The social impact of glaucoma is worth of note: primary open-angle glaucoma (POAG) is one of the leading causes of irreversible blindness worldwide, affecting some 68.56 million people with overall prevalence of 2.4%. Since one of the main risk factors for the development of POAG is the increase of intraocular pressure (IOP) causing retinal ganglion cells death, the medical treatment of POAG consists in the use of drugs endowed with neuroprotective effect and able to reduce IOP. These drugs include beta-blockers, prostaglandin analogues, carbonic anhydrase inhibitors, alpha or cholinergic agonists and rho kinase inhibitors. However, not all the patients respond to the same extent to the therapy in terms of efficacy and safety. Genetics and genome wide association studies have highlighted the occurrence of mutations and polymorphisms influencing the predisposition to develop POAG and its phenotype, as well as affecting the response to pharmacological treatment. The present systematic review and meta-analysis aims at identifying genetic variants and at verifying whether these can influence the responsiveness of patients to therapy for efficacy and safety. It follows the most updated Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 recommendations. The literature search was conducted consulting the most relevant scientific databases, i.e. PubMed/MEDLINE, Scopus, Web of Science and Public Health Genomics and Precision Health Knowledge Base up to June 14th, 2023. The search retrieved 1026 total records, among which eight met the eligibility criteria for inclusion in the analysis. The results demonstrated that the most investigated pharmacogenetic associations concern latanoprost and timolol, and that efficacy was studied more in depth than safety. Moreover, the heterogeneity of design and paucity of studies prompt further investigation in randomized clinical trials. In fact, adequately powered and designed pharmacogenetic association studies are needed to provide body of evidence with good certainty for a more appropriate use of medical therapy in POAG.PROSPERO registration: CRD42023434867.

A Systematic Review of Glaucoma Diagnosis in Prevalence Studies and Quality of Reporting

PRCIS

This systematic review has revealed that variable definitions of glaucoma continue to be used in prevalence studies, despite the introduction of the International Society of Geographic and Epidemiologic Ophthalmology (ISGEO) criteria.

PURPOSE

To systematically review diagnostic criteria and examinations performed in glaucoma prevalence studies over time and determine the quality of reporting. Accurate estimates of glaucoma prevalence are crucial to inform resource allocation. However, diagnosis of glaucoma comprises inherently subjective examinations and the cross-sectional nature of prevalence studies precludes monitoring for progression.

METHODS

A systematic review of PubMed, Embase, Web of Science, and Scopus was performed to examine diagnostic protocols used by glaucoma prevalence studies and evaluate uptake of the ISGEO criteria, introduced in 2002 to standardize glaucoma diagnosis in prevalence studies. Detection bias and compliance with the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guidelines were evaluated.

RESULTS

Ten thousand five hundred forty-four articles were identified. After deduplication, 5589 articles were screened, yielding 136 articles pertaining to 123 studies. An absence of data in many countries was identified. Ninety-two percent of studies stated diagnostic criteria, and 62% used the ISGEO criteria since their publication. Weaknesses of the ISGEO criteria were identified. Temporal variations in the performance of various examinations were observed, including heterogeneity in angle assessment. Mean STROBE compliance was 82% (range 59-100%); 72 articles had a low risk of detection bias, 4 had a high risk, and 60 had some concerns.

CONCLUSION

Heterogeneous diagnostic definitions persist in glaucoma prevalence studies, despite introduction of the ISGEO criteria. Standardization of criteria remains imperative and the development of new criteria represent a valuable opportunity to achieve this goal. In addition, methods of determining diagnoses are poorly reported, suggesting a need for improvement in study conduct and reporting. Accordingly, we propose the Reporting of quality Of GlaUcoma Epidemiological Studies (ROGUES) Checklist. We have also identified a need for further prevalence studies in regions with limited data and to update Australian angle closure glaucoma prevalence. Design and reporting of future studies can be informed by this review's insights into diagnostic protocols previously used.

Corneal Biomechanical Measures for Glaucoma: A Clinical Approach

Over the last two decades, there has been growing interest in assessing corneal biomechanics in different diseases, such as keratoconus, glaucoma, and corneal disorders. Given the interaction and structural continuity between the cornea and sclera, evaluating corneal biomechanics may give us further insights into the pathogenesis, diagnosis, progression, and management of glaucoma. Therefore, some authorities have recommended baseline evaluations of corneal biomechanics in all glaucoma and glaucoma suspects patients. Currently, two devices (Ocular Response Analyzer and Corneal Visualization Schiempflug Technology) are commercially available for evaluating corneal biomechanics; however, each device reports different parameters, and there is a weak to moderate agreement between the reported parameters. Studies are further limited by the inclusion of glaucoma subjects taking topical prostaglandin analogues, which may alter corneal biomechanics and contribute to contradicting results, lack of proper stratification of patients, and misinterpretation of the results based on factors that are confounded by intraocular pressure changes. This review aims to summarize the recent evidence on corneal biomechanics in glaucoma patients and insights for future studies to address the current limitations of the literature studying corneal biomechanics.

Adherence to Ocular Hypotensive Medication in Patients With Primary Open Angle Glaucoma in Ghana

PRCIS

There is a high rate of nonadherence to ocular hypotensive medications in a highly prevalent glaucoma setting, which warrants the attention of caregivers so as to inform their discussion of the possible barriers to adherence with their patients.

PURPOSE

To assess adherence to ocular hypotensive medication objectively among glaucoma patients in Ghana and to identify factors associated with adherence.

MATERIALS AND METHODS

The prospective, observational cohort study included consecutive patients with primary open angle glaucoma treated with Timolol at the Christian Eye Centre, Cape Coast, Ghana. Adherence was assessed using Medication Event Monitoring System (MEMS) for a period of 3 months. MEMS adherence was defined as the number of doses taken divided by the number of doses prescribed, expressed in percent. Patients with adherence of 75% or less were classified as nonadherent. Associations with glaucoma medication self-efficacy, eyedrop-taking behaviors, and health beliefs were also assessed.

RESULTS

Of the 139 patients (mean age, 65 y [SD, 13 y]) included in the study, 107 (77.0%) were nonadherent when assessed with MEMS, compared with only 47 (33.8%) who self-reported being nonadherent. Overall, mean adherence was 48.5%±29.7. In univariate analysis, MEMS adherence was significantly associated with educational level ( χ2 =9.18, P =0.01) and the number of systemic comorbidities ( χ2 =6.03, P =0.049).

CONCLUSION

Overall, mean adherence was low, and adherence was associated with educational level and number of systemic comorbidities in univariate analysis.

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

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

Optic Nerve Head Changes After Intraocular Pressure-Lowering Glaucoma Surgeries Using Optical Coherence Tomography

PRCIS

Optic nerve head (ONH) changes were detected with swept-source optical coherence tomography (SS-OCT) after intraocular pressure (IOP)-lowering glaucoma surgeries.

PURPOSE

The aim of this study was to detect changes in the ONH with SS-OCT after IOP-lowering procedures.

PATIENTS AND METHODS

Patients with progressing glaucoma who were referred for IOP-lowering procedures were included. The participants underwent a 24-2 visual field test and SS-OCT (DRI OCT Triton Plus; Topcon). IOP and SS-OCT scans were obtained during the preoperative period and up to 7 days and 30-90 days postoperatively. ONH parameters were measured with a B -scan at the center of the optic disc and an average of 5 central B -scans. The hypotenuse of the ONH cup (HOC) was calculated using the Pythagorean theorem: hypotenuse 2 = leg1 2 + leg2 2 , considering the length and depth of the cup as the legs of a right triangle. We also evaluated changes in Bruch membrane opening (BMO)-to-BMO diameter. Statistical analysis was performed using generalized estimating equations.

RESULTS

A total of 15 eyes were included. The mean patient age was 70 (SD, 11.04) years. The mean circumpapillary retinal nerve fiber layer was 60.13 (SD, 23.21) µm and the visual field mean deviation was -13.29 (SD, 8.5) dB. The mean IOP at each visit was: 20.5 (SD, 4.99); 11 (SD, 4.95), and 15.7 (SD, 5.04), respectively. The mean HOC, the mean depth and length of the ONH cup, and the BMO-to-BMO diameter decreased significantly after the IOP-lowering procedures.

CONCLUSIONS

The HOC evaluated with SS-OCT significantly decreased after IOP-lowering surgeries. This parameter was useful for evaluating short-term changes in the ONH.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

Immunomodulatory and Antioxidant Drugs in Glaucoma Treatment

Glaucoma, a group of diseases characterized by progressive retinal ganglion cell loss, cupping of the optic disc, and a typical pattern of visual field defects, is a leading cause of severe visual impairment and blindness worldwide. Elevated intraocular pressure (IOP) is the leading risk factor for glaucoma development. However, glaucoma can also develop at normal pressure levels. An increased susceptibility of retinal ganglion cells to IOP, systemic vascular dysregulation, endothelial dysfunction, and autoimmune imbalances have been suggested as playing a role in the pathophysiology of normal-tension glaucoma. Since inflammation and oxidative stress play a role in all forms of glaucoma, the goal of this review article is to present an overview of the inflammatory and pro-oxidant mechanisms in the pathophysiology of glaucoma and to discuss immunomodulatory and antioxidant treatment approaches.

Fairness and generalizability of OCT normative databases: a comparative analysis

PURPOSE

In supervised Machine Learning algorithms, labels and reports are important in model development. To provide a normality assessment, the OCT has an in-built normative database that provides a color base scale from the measurement database comparison. This article aims to evaluate and compare normative databases of different OCT machines, analyzing patient demographic, contrast inclusion and exclusion criteria, diversity index, and statistical approach to assess their fairness and generalizability.

METHODS

Data were retrieved from Cirrus, Avanti, Spectralis, and Triton's FDA-approval and equipment manual. The following variables were compared: number of eyes and patients, inclusion and exclusion criteria, statistical approach, sex, race and ethnicity, age, participant country, and diversity index.

RESULTS

Avanti OCT has the largest normative database (640 eyes). In every database, the inclusion and exclusion criteria were similar, including adult patients and excluding pathological eyes. Spectralis has the largest White (79.7%) proportionately representation, Cirrus has the largest Asian (24%), and Triton has the largest Black (22%) patient representation. In all databases, the statistical analysis applied was Regression models. The sex diversity index is similar in all datasets, and comparable to the ten most populous contries. Avanti dataset has the highest diversity index in terms of race, followed by Cirrus, Triton, and Spectralis.

CONCLUSION

In all analyzed databases, the data framework is static, with limited upgrade options and lacking normative databases for new modules. As a result, caution in OCT normality interpretation is warranted. To address these limitations, there is a need for more diverse, representative, and open-access datasets that take into account patient demographics, especially considering the development of supervised Machine Learning algorithms in healthcare.

Efficacy and safety of latanoprost/timolol fixed combination dosed twice daily compared to once daily in patients with primary open angle glaucoma

AIM

To evaluate whether latanoprost/timolol fixed combination (LTFC) dosed twice daily may provide further intraocular pressure (IOP) reduction and evaluate the safety profile at this dose.

METHODS

This is an open-labeled, randomized, prospective crossover study on fourty primary open angle glaucoma patients. Two weeks of washout period were followed by randomization to either once daily (OD, group A) or twice daily dosing (BD, group B) of LTFC for 4wk. After another 2-week washout period, the patients' treatment dose was crossed-over for another 4wk. IOP reduction alongside ocular and systemic side effects were evaluated.

RESULTS

Mean baseline IOP was 18.57±2.93 and 17.8±3.01 mm Hg before OD and BD dose respectively, (P=0.27). Mean IOP after BD dose was statistically lower (12.49±1.59 mm Hg) compared to OD (13.48±1.81 mm Hg, P=0.017). Although IOP reduction after BD dose was more (5.32±3.24 mm Hg, 29.89%) than after OD dosing (5.04 mm Hg, 27.14%), it did not reach statistical significance (P=0.68). Patients switched from OD to BD (group A) showed mean IOP reduction by 0.69 mm Hg [95% confidence interval (CI): -0.09 to 1.48 mm Hg, P=0.078]; but patients switched from BD to OD (group B) had significantly higher mean IOP by 1.25 mm Hg (95%CI: -2.04 to -0.46 mm Hg, P=0.006). BD dose had more ocular side effects albeit mild.

CONCLUSION

Mean IOP after LTFC dosed twice daily is statistically lower, with additional mild side effects.

Relative Importance of Glaucoma-Referral Indicators in Retinal Images in a Diabetic Retinopathy Screening Programme in Slovenia: A Cross-Sectional Study

Background and Objectives: Glaucoma is a major cause of irreversible visual impairment and blindness, so its timely detection is crucial. Retinal images from diabetic retinopathy screening programmes (DRSP) provide an opportunity to detect undiagnosed glaucoma. Our aim was to find out which retinal image indicators are most suitable for referring DRSP patients for glaucoma assessment and to determine the glaucoma detection potential of Slovenian DRSP. Materials and Methods: We reviewed retinal images of patients from the DRSP at the University Medical Centre Ljubljana (November 2019-January 2020, May-August 2020). Patients with at least one indicator and some randomly selected patients without indicators were invited for an eye examination. Suspect glaucoma and glaucoma patients were considered accurately referred. Logistic regression (LOGIT) with patients as statistical units and generalised estimating equation with logistic regression (GEE) with eyes as statistical units were used to determine the referral accuracy of indicators. Results: Of the 2230 patients reviewed, 209 patients (10.1%) had at least one indicator on a retinal image of either one eye or both eyes. A total of 149 (129 with at least one indicator and 20 without) attended the eye exam. Seventy-nine (53.0%) were glaucoma negative, 54 (36.2%) suspect glaucoma, and 16 (10.7%) glaucoma positive. Seven glaucoma patients were newly detected. Neuroretinal rim notch predicted glaucoma in all cases. The cup-to-disc ratio was the most important indicator for accurate referral (odds ratio 7.59 (95% CI 3.98-14.47; p < 0.001) and remained statistically significant multivariably. Family history of glaucoma also showed an impact (odds ratio 3.06 (95% CI 1.02-9.19; p = 0.046) but remained statistically significant only in the LOGIT multivariable model. Other indicators and confounders were not statistically significant in the multivariable models. Conclusions: Our results suggest that the neuroretinal rim notch and cup-to-disc ratio are the most important for accurate glaucoma referral from retinal images in DRSP. Approximately half of the glaucoma cases in DRSPs may be undiagnosed.

Slow-Coagulation Transscleral Cyclophotocoagulation Laser Treatment for Medically Uncontrolled Secondary Aphakic Adult Glaucoma

PRCIS

Slow-coagulation CW-TSCPC is an efficacious, relatively safe, and non-incisional laser treatment option as an initial surgical glaucoma management choice, in secondary aphakic adult glaucoma that is medically uncontrolled.

PURPOSE

This study evaluates the outcomes of slow-coagulation continuous wave transscleral cyclophotocoagulation (CW-TSCPC) laser for treating secondary aphakic adult glaucoma after complicated cataract surgery as a primary surgical intervention.

MATERIALS AND METHODS

A retrospective chart review of adult aphakic eyes with medically uncontrolled glaucoma underwent slow-coagulation CW-TSCPC as a primary surgical glaucoma intervention was performed. Surgical success was the primary outcome measure. Success was defined as postoperative intraocular pressure (IOP) between 6 and 21 mm Hg with ≥20% reduction compared with baseline and no need for further glaucoma surgeries or development of vision-threatening complications. The secondary outcomes included changes in IOP, glaucoma medication numbers, visual acuity, and postoperative complications during the first year after laser treatment after laser treatment.

RESULTS

This study included 41 eyes of 41 patients. The mean age of study participants was 66.7±13.1 years, with a mean follow-up duration of 19±3.5 months. At one year, the success rate was 63.4%. A statistically significant reduction of the IOP was observed, with the mean IOP decreasing from 29.6±5.8 mm Hg with a mean of 3.9±1.0 medications at baseline to a mean of 19.0±6.4 mm Hg with a mean of 2.5±1.2 medications at 12 months ( P <0.001). Four eyes received CW-TSCPC retreatment, and 2 eyes required incisional glaucoma surgeries. Reported postoperative complications included: visual acuity decline ≥2 lines in 7 eyes, iritis in 6 eyes, hyphema in 5 eyes, cystoid macular edema in 2 eyes, and transient hypotony in 1 eye.

CONCLUSION

Slow-coagulation CW-TSCPC is an efficacious, relatively safe, and non-incisional laser treatment option as an initial surgical glaucoma management choice, in secondary aphakic adult glaucoma that is medically uncontrolled.

A novel heterozygous c.733 T > G MYOC mutation associated with juvenile-onset open-angle glaucoma in a Chinese family

AIMS

To detect mutations in juvenile-onset open-angle glaucoma in a Chinese family and to describe the characteristic ophthalmic phenotypes of this pedigree.

METHODS

There were 14 individuals in this four-generation pedigree. All living members of the family underwent comprehensive ophthalmic examinations. Five patients presented with elevated intraocular pressures. All of them shared early-onset disease, with a mean onset age of 14.4 years and continuing aggressive damage to their optic nerves. Hyperpigmentation in the trabecular meshwork and sometimes-broad iris processes were noted in this family using gonioscopy. All exons of candidate genes (MYOC, OPTN, CYP1B1) were amplified using the polymerase chain reaction, and analysed with an ABI 3700XL Genetic Analyser.

RESULTS

A heterozygous missense mutation in exon 3 (c.733 T > G) of the MYOC gene was found in the five JOAG patients and one 7-year-old boy with no ophthalmic manifestation of glaucoma, but it was absent in other members of the family and in the controls. This mutation resulted in a transversion of cysteine to glycine (Cys245Gly).

CONCLUSIONS

We concluded the novel MYOC c.733 T > G mutation found in a Chinese family with JOAG caused a severe type of JOAG exhibiting early onset, high IOP, and severe optic nerve damage. Interestingly, unlike other reported MYOC mutation families, our patients exhibited marked angle pigmentation and iris processes.

Oxidative Stress: A Suitable Therapeutic Target for Optic Nerve Diseases?

Optic nerve disorders encompass a wide spectrum of conditions characterized by the loss of retinal ganglion cells (RGCs) and subsequent degeneration of the optic nerve. The etiology of these disorders can vary significantly, but emerging research highlights the crucial role of oxidative stress, an imbalance in the redox status characterized by an excess of reactive oxygen species (ROS), in driving cell death through apoptosis, autophagy, and inflammation. This review provides an overview of ROS-related processes underlying four extensively studied optic nerve diseases: glaucoma, Leber's hereditary optic neuropathy (LHON), anterior ischemic optic neuropathy (AION), and optic neuritis (ON). Furthermore, we present preclinical findings on antioxidants, with the objective of evaluating the potential therapeutic benefits of targeting oxidative stress in the treatment of optic neuropathies.

Rare protective variants and glaucoma-relevant cell stressors modulate Angiopoietin-like 7 expression

Rare missense and nonsense variants in the Angiopoietin-like 7 (ANGPTL7) gene confer protection from primary open-angle glaucoma (POAG), though the functional mechanism remains uncharacterized. Interestingly, a larger variant effect size strongly correlates with in silico predictions of increased protein instability (r = -0.98), suggesting that protective variants lower ANGPTL7 protein levels. Here, we show that missense and nonsense variants cause aggregation of mutant ANGPTL7 protein in the endoplasmic reticulum (ER) and decreased levels of secreted protein in human trabecular meshwork (TM) cells; a lower secreted:intracellular protein ratio strongly correlates with variant effects on intraocular pressure (r = 0.81). Importantly, accumulation of mutant protein in the ER does not increase expression of ER stress proteins in TM cells (P > 0.05 for all variants tested). Cyclic mechanical stress, a glaucoma-relevant physiologic stressor, also significantly lowers ANGPTL7 expression in primary cultures of human Schlemm's canal (SC) cells (-2.4-fold-change, P = 0.01). Collectively, these data suggest that the protective effects of ANGPTL7 variants in POAG stem from lower levels of secreted protein, which may modulate responses to physiologic and pathologic ocular cell stressors. Downregulation of ANGPTL7 expression may therefore serve as a viable preventative and therapeutic strategy for this common, blinding disease.

Clinical Profile of Primary Open-angle Glaucoma Patients at an Eye Center in Nigeria

Aim

Globally, one of the leading causes of preventable blindness is primary open-angle glaucoma (POAG). The study assessed the clinical presentations of POAG patients attending an eye center in Abuja, Nigeria.

Materials and methods

Records of 188 eyes, collected from 94 patients diagnosed with POAG for a period of 1 year at the eye center, were reviewed. Clinical records, including age, gender, visual acuity (VA), central cornea thickness (CCT), intraocular pressure (IOP), cup-to-disk ratios, and retinal nerve fiber layer (RNFL) thickness of the participants, were extracted and analyzed.

Results

The majority of the participants were males (56.4%) and adults (57.4%), most of whom had normal VA (>70% in each eye). Our analysis revealed normal average estimates of RNFL thickness, IOP, and CCT among the participants. Females had thicker RNFL compared to males (p = 0.02). Although CCT decreased with age (r = -0.28, p = 0.005), there was no such link between IOP and CCT (r = 0.09, p = 0.38).

Conclusion

Central cornea thickness (CCT), RNFL thickness, and IOP in isolation should not be used as early indicators for POAG; rather, a combination of these and other indices is recommended. Early detection through active screening and treatment in the community for at-risk groups is highly advised.

How to cite this article

Ezinne NE, Kwarteng MA, Ekemiri KK, et al. Clinical Profile of Primary Open-angle Glaucoma Patients at an Eye Center in Nigeria. J Curr Glaucoma Pract 2023;17(3):113-117.

Exploring the current use of animal models in glaucoma drug discovery: where are we in 2023?

INTRODUCTION

Animal models are widely used in glaucoma-related research. Since the elevated intraocular pressure (IOP) is a major risk factor underlying the disease pathogenesis, animal models with high IOP are commonly used. However, models are also used to represent the clinical context of glaucomatous changes developing despite a normal IOP.

AREAS COVERED

Herein, the authors discuss the various factors that contribute to the quality of studies using animal models based on the evaluation of studies published in 2022. The factors affecting the quality of studies using animal models, such as the animal species, age, and sex, are discussed, along with various methods and outcomes of studies involving different animal models of glaucoma.

EXPERT OPINION

Translating animal research data to clinical applications remains challenging. Our observations in this review clearly indicate that many studies lack scientific robustness not only in their experiment conduct but also in data analysis, interpretation, and presentation. In this context, ensuring the internal validity of animal studies is the first step in quality assurance. External validity, however, is more challenging, and steps should be taken to satisfy external validity at least to some extent.

Association Between Myopia and Primary Open-Angle Glaucoma by Race and Ethnicity in Older Adults in the California Medicare Population

Importance

Racial and ethnic differences in the association between myopia and primary open-angle glaucoma (POAG) are not well understood.

Objective

To investigate the association between myopia and POAG in the 2019 California Medicare population and to investigate whether there was evidence of effect measure modification of this association by race and ethnicity.

Design, Setting, and Participants

This cross-sectional study used administrative claims data from 2019 California Medicare beneficiaries 65 years or older with California residence and active coverage with Medicare parts A and B. Analysis took place between October 2021 and October 2023.

Exposures

The primary exposure was myopia, which was defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes.

Main Outcomes and Measures

The outcome of interest was POAG, which was defined by ICD-10-CM code.

Results

Of 2 717 346 California Medicare beneficiaries in 2019, 1 440 769 (53.0%) were aged 65 to 74 years, 1 544 479 (56.8%) identified as female, 60 211 (2.2%) had myopia, and 171 988 (6.3%) had POAG. Overall, 346 723 individuals (12.8%) identified as Asian, 117 856 (4.3%) as Black, 430 597 (15.8%) as Hispanic, 1 705 807 (62.8%) as White, and 115 363 (4.2%) as other race and ethnicity. In adjusted logistic regression analyses, beneficiaries with myopia had higher odds of POAG compared with beneficiaries without myopia (odds ratio [OR], 2.41; 95% CI, 2.35-2.47). In multivariable models stratified by race and ethnicity, the association between myopia and POAG was stronger in Asian (OR, 2.74; 95% CI, 2.57-2.92), Black (OR, 2.60; 95% CI, 2.31-2.94), and Hispanic (OR, 3.28; 95% CI, 3.08-3.48) beneficiaries compared with non-Hispanic White beneficiaries (OR, 2.14; 95% CI, 2.08-2.21).

Conclusions and Relevance

In the 2019 California Medicare population, myopia was associated with greater adjusted odds of POAG. This association was stronger among Asian, Black, and Hispanic beneficiaries compared with non-Hispanic White beneficiaries. These findings suggest possible disparities in glaucoma risk by race and ethnicity in individuals with myopia and may indicate greater need for glaucoma screening in individuals with myopia from racial and ethnic minority backgrounds.

Atypical responses to faces during binocular rivalry in early glaucoma

Purpose

Glaucoma is a progressive optic neuropathy that damages retinal ganglion cells and a neurodegenerative disease as it affects neural structures throughout the brain. In this study, we examined binocular rivalry responses in patients with early glaucoma in order to probe the function of stimulus-specific cortical areas involved in face perception.

Methods

Participants included 14 individuals (10 females, mean age 65 ± 7 years) with early pre-perimetric glaucoma and 14 age-matched healthy controls (7 females, mean age 59 ± 11 years). The 2 groups were equivalent in visual acuity and stereo-acuity. Three binocular rivalry stimulus pairs were used: (1) real face/house, (2) synthetic face/noise patch, and (3) synthetic face/spiral. For each stimulus pair, the images were matched in size and contrast level; they were viewed dichotically, and presented centrally and eccentrically at 3 degrees in the right (RH) and in the left hemifield (LH), respectively. The outcome measures were rivalry rate (i.e., perceptual switches/min) and time of exclusive dominance of each stimulus.

Results

For the face/house stimulus pair, rivalry rate of the glaucoma group (11 ± 6 switches/min) was significantly lower than that of the control group (15 ± 5 switches/min), but only in the LH location. The face dominated longer than the house in the LH for both groups. Likewise, for the synthetic face/noise patch stimulus pair, rivalry rate of the glaucoma group (11 ± 6 switches/min) was lower than that of the control group (16 ± 7 switches/min) in the LH, but the difference failed to reach significance. Interestingly, the mixed percept dominated less in glaucoma than in the control group. For the synthetic face/spiral stimulus pair, the glaucoma group had lower rivalry rate at all 3 stimulus locations.

Conclusion

This study reveals atypical responses to faces during binocular rivalry in patients with early glaucoma. The results may be suggestive of early neurodegeneration affecting stimulus-specific neural structures involved in face processing starting in the pre-perimetric phase of the disease.

Molecular genetics of primary open-angle glaucoma

Glaucoma is a series of linked optic diseases resulting in progressive vision loss and total blindness due to the acquired loss of retinal ganglion cells. This harm to the optic nerve results in visual impairment and, ultimately, total blindness if left untreated. Primary open-angle glaucoma (POAG) is the most frequent variety within the large family of glaucoma. It is a multifaceted and heterogeneous condition with several environmental and genetic variables aiding in its etiology. By 2040, there will be 111.8 million glaucoma patients globally, with Asia and Africa accounting for the vast majority. The goal of this review is to elaborate on the role of genes (nuclear and mitochondrial) as well as their variants in the pathogenesis of POAG. PubMed and Google Scholar databases were searched online for papers until September 2022. Prevalence and inheritance patterns vary significantly across different ethnic and geographic populations. Numerous causative genetic loci may exist; however, only a few have been recognized and characterized. Further investigation into the genetic etiology of POAG is expected to uncover novel and intriguing causal genes, allowing for a more precise pathogenesis pattern of the disease.

Matrix metalloproteinase-3 (MMP-3)-mediated gene therapy for glaucoma

Approximately 80 million people globally are affected by glaucoma, with a projected increase to over 110 million by 2040. Substantial issues surrounding patient compliance remain with topical eye drops, and up to 10% of patients become treatment resistant, putting them at risk of permanent vision loss. The major risk factor for glaucoma is elevated intraocular pressure, which is regulated by the balance between the secretion of aqueous humor and the resistance to its flow across the conventional outflow pathway. Here, we show that adeno-associated virus 9 (AAV9)-mediated expression of matrix metalloproteinase-3 (MMP-3) can increase outflow in two murine models of glaucoma and in nonhuman primates. We show that long-term AAV9 transduction of the corneal endothelium in the nonhuman primate is safe and well tolerated. Last, MMP-3 increases outflow in donor human eyes. Collectively, our data suggest that glaucoma can be readily treated with gene therapy-based methods, paving the way for deployment in clinical trials.

Depression scores are associated with retinal ganglion cells loss

BACKGROUND

Light is a known factor affecting mood and the circadian system. Light deficit is linked to deteriorated transduction of photic information to the brain, and reduced amplitude of the perceived circadian light signaling. Retinal ganglion cells (RGCs) loss due to advanced glaucoma can be a factor compromising light perception, with consequences for circadian rhythms, sleep and mood. This study aimed to estimate associations of RGCs loss with a depression score by multiple regression, accounting for other features of glaucoma.

METHODS

One hundred and fifteen patients diagnosed with primary open-angle glaucoma completed the Beck Depression Inventory II questionnaire. The damage to their RGCs was assessed by high-definition optical coherence tomography (HD-OCT) and their function by pattern electroretinogram (PERG). On fifteen of these patients, 24-h salivary melatonin patterns were determined under light-controlled laboratory conditions, and analysis of eight clock related gene polymorphisms was performed.

RESULTS

Backward stepwise multiple regression revealed that the BDI score was the strongest factor that was most closely associated with the HD-OCT-based percentage of global RGCs loss (standardized coefficient, b* = 0.784, p < 0.001), surpassing other related factors, including age, intraocular pressure, visual field loss, and PERG amplitude. A high BDI score was associated with the GNβ3 825C > T polymorphism (dbSNP rs5443).

LIMITATIONS

This study did not specifically address damage to intrinsically photoreceptive RGCs. The gene study is based on a limited number of volunteers.

CONCLUSIONS

Depression scores are strongly associated with RGCs loss, increasing abruptly above a threshold of 15 %, supporting the hypothesis that RGCs loss in advanced glaucoma may affect non-visual photic transduction and lead to mood disturbances.

Glaucoma and Systemic Disease

Glaucoma is the leading cause of irreversible blindness in the world. Due to its potential to cause permanent vision loss, it is important to understand how systemic conditions and their respective treatments can be associated with or increase the risk for developing glaucoma. In this review, we examined the literature for up-to-date discussions and provided commentary on glaucoma, its pathophysiology, and associated risk factors. We discuss systemic diseases and the impact, risk, and mechanism for developing glaucoma, including pharmacologically induced glaucoma; inflammatory and auto-immune conditions; infectious, dermatologic, cardiovascular, pulmonary, renal, urologic, neurologic, psychiatric and systemic malignancies: intraocular tumors; as well as pediatric, and genetic conditions. The goal of our discussion of systemic conditions including their commonality, mechanisms, treatments, and associations with developing glaucoma is to emphasize the importance of ocular examinations and follow-up with the multidisciplinary teams involved in the care of each patient to prevent unnecessary vision-loss.

Pulse trains to percepts: A virtual patient describing the perceptual effects of human visual cortical stimulation

The field of cortical sight restoration prostheses is making rapid progress with three clinical trials of visual cortical prostheses underway. However, as yet, we have only limited insight into the perceptual experiences produced by these implants. Here we describe a computational model or 'virtual patient', based on the neurophysiological architecture of V1, which successfully predicts the perceptual experience of participants across a wide range of previously published cortical stimulation studies describing the location, size, brightness and spatiotemporal shape of electrically induced percepts in humans. Our simulations suggest that, in the foreseeable future the perceptual quality of cortical prosthetic devices is likely to be limited by the neurophysiological organization of visual cortex, rather than engineering constraints.

Efficacy and Safety Outcomes of XEN Implantation and Gonioscopy-assisted Transluminal Trabeculotomy for the Management of Advanced Open-angle Glaucoma

Aim

Minimally invasive glaucoma surgery (MIGS) is not typically used in patients with advanced-stage glaucoma. This study describes the outcomes and complications of patients with advanced open-angle glaucoma (OAG) who underwent XEN implantation with cataract surgery or gonioscopy-assisted transluminal trabeculotomy (GATT) with cataract surgery.

Methods

This retrospective study identified patients who had undergone XEN implantation or GATT for the management of advanced OAG. Outcomes included surgical success, intraocular pressure (IOP) reduction, number of topical IOP-lowering drops, visual field mean deviation (MD), best-corrected visual acuity (BCVA), and complications. Surgical success was defined as an IOP of <14 mm Hg and a 20% reduction at 12 months without topical IOP-lowering drops (complete success) or with topical IOP-lowering drops (qualified success).

Results

Exactly 70 eyes were enrolled in this study, including 35 who had undergone XEN implantation and 35 who had undergone GATT. The overall surgical success rate was 74.3% (26 of 35) for eyes that underwent XEN implantation and 71.4% (25 of 35) for eyes that underwent GATT. Percent IOP reduction from baseline to 12 months postoperatively was 48% in the XEN cohort and 32% in the GATT cohort. Significant reduction in the use of topical IOP-lowering drops was demonstrated for both XEN (3.26 ± 1.15-1.23 ± 1.28) (p < 0.001) and GATT (2.46 ± 1.12-0.43 ± 0.78) (p < 0.001) cohorts at 12 months postoperatively. The only complication reported was transient hyphema, which occurred in three patients from the XEN group and four from the GATT group, and resolved spontaneously.

Conclusions

Both XEN implantation and GATT may be safe and effective management options when treating patients with advanced OAG. However, larger sample sizes are required to make direct statistical comparisons between these techniques.

Clinical significance

In this study, XEN implantation and GATT combined with cataract surgery were each associated with favorable outcomes in patients with advanced OAG.

How to cite this article

Ruparelia S, Sharif M, Shoham-Hazon N. Efficacy and Safety Outcomes of XEN Implantation and Gonioscopy-assisted Transluminal Trabeculotomy for the Management of Advanced Open-angle Glaucoma. J Curr Glaucoma Pract 2023;17(2):63-67.

Peripapillary Retinal Nerve Fiber Layer Thickness and its Ocular and Systemic Determinants in an Elderly Population: A Population-Based Study

Purpose

To determine the distribution, ocular, and systemic determinants of peripapillary retinal nerve fiber layer thickness (pRNFLT) using spectral-domain optical coherence tomography (SD-OCT) in an elderly population.

Methods

This report is a part of the Tehran Geriatric Eye Study, a population-based cross-sectional study conducted in Tehran, the capital of Iran. The study population was all residents aged 60 years and above in Tehran. The sampling was performed using a multi-stage stratified random cluster sampling method. All study participants underwent ocular examination (including measurement of visual acuity, objective and subjective refraction, and slit-lamp biomicroscopy), anterior segment imaging using Pentacam HR, and ocular biometry using IOLMaster 500. The OCT imaging was performed for a random subsample (1307 individuals) using Spectralis SD-OCT.

Results

Two thousand two hundred and forty-six eyes of 1189 individuals were analyzed for this report. Of these, 691 (58.1%) were female, and the mean age of the participants was 67.3 ± 5.9 years (60-94 years). The mean overall pRNFLT was 98.6 μ (95% confidence interval [CI]: 98.0-99.3). There was a statistically significant difference in pRNFLT between different quadrants; the highest and lowest mean pRNFLT was related to inferior and temporal quadrants, respectively (P < 0.001). The multiple generalized estimating equation model showed that older age (coefficient: -0.15 [95% CI: -0.24 to -0.06], P = 0.001), diabetes (coefficient: -1.69 [95% CI: -2.82 to -0.55], P = 0.004), and longer axial length (coefficient: -0.52 [95% CI: -0.83 to -0.22], P < 0.001) were significantly associated with a decreased overall pRNFLT. Higher body mass index was significantly related to an increased overall pRNFLT (coefficient: 0.19 [95% CI: 0.07 to 0.30], P = 0.002).

Conclusions

The results of the present study can be used as a reference database for pRNFLT in the elderly population. Considering ocular and systemic determinants of pRNFLT is necessary for correct clinical interpretation of this parameter.

Heritable Risk and Protective Genetic Components of Glaucoma Medication Non-Adherence

Glaucoma is the leading cause of irreversible blindness, affecting 76 million globally. It is characterized by irreversible damage to the optic nerve. Pharmacotherapy manages intraocular pressure (IOP) and slows disease progression. However, non-adherence to glaucoma medications remains problematic, with 41–71% of patients being non-adherent to their prescribed medication. Despite substantial investment in research, clinical effort, and patient education protocols, non-adherence remains high. Therefore, we aimed to determine if there is a substantive genetic component behind patients’ glaucoma medication non-adherence. We assessed glaucoma medication non-adherence with prescription refill data from the Marshfield Clinic Healthcare System’s pharmacy dispensing database. Two standard measures were calculated: the medication possession ratio (MPR) and the proportion of days covered (PDC). Non-adherence on each metric was defined as less than 80% medication coverage over 12 months. Genotyping was done using the Illumina HumanCoreExome BeadChip in addition to exome sequencing on the 230 patients (1) to calculate the heritability of glaucoma medication non-adherence and (2) to identify SNPs and/or coding variants in genes associated with medication non-adherence. Ingenuity pathway analysis (IPA) was utilized to derive biological meaning from any significant genes in aggregate. Over 12 months, 59% of patients were found to be non-adherent as measured by the MPR80, and 67% were non-adherent as measured by the PDC80. Genome-wide complex trait analysis (GCTA) suggested that 57% (MPR80) and 48% (PDC80) of glaucoma medication non-adherence could be attributed to a genetic component. Missense mutations in TTC28, KIAA1731, ADAMTS5, OR2W3, OR10A6, SAXO2, KCTD18, CHCHD6, and UPK1A were all found to be significantly associated with glaucoma medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10−3) (PDC80). While missense mutations in TINAG, CHCHD6, GSTZ1, and SEMA4G were found to be significantly associated with medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10−3) (MPR80). The same coding SNP in CHCHD6 which functions in Alzheimer’s disease pathophysiology was significant by both measures and increased risk for glaucoma medication non-adherence by three-fold (95% CI, 1.62–5.8). Although our study was underpowered for genome-wide significance, SNP rs6474264 within ZMAT4 (p = 5.54 × 10–6) was found to be nominally significant, with a decreased risk for glaucoma medication non-adherence (OR, 0.22; 95% CI, 0.11–0.42)). IPA demonstrated significant overlap, utilizing, both standard measures including opioid signaling, drug metabolism, and synaptogenesis signaling. CREB signaling in neurons (which is associated with enhancing the baseline firing rate for the formation of long-term potentiation in nerve fibers) was shown to have protective associations. Our results suggest a substantial heritable genetic component to glaucoma medication non-adherence (47–58%). This finding is in line with genetic studies of other conditions with a psychiatric component (e.g., post-traumatic stress disorder (PTSD) or alcohol dependence). Our findings suggest both risk and protective statistically significant genes/pathways underlying glaucoma medication non-adherence for the first time. Further studies investigating more diverse populations with larger sample sizes are needed to validate these findings.