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Hood DC, La Bruna S, Durbin M, Lee C, Hsiao YS, De Moraes CG, Tsamis E. Anatomical Features can Affect OCT Measures Used for Clinical Decisions and Clinical Trial Endpoints. Transl Vis Sci Technol 2024; 13:27. [PMID: 38639929 PMCID: PMC11037497 DOI: 10.1167/tvst.13.4.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 04/20/2024] Open
Abstract
Purpose To understand the association between anatomical parameters of healthy eyes and optical coherence tomography (OCT) circumpapillary retinal nerve fiber layer (cpRNFL) thickness measurements. Methods OCT cpRNFL thickness was obtained from 396 healthy eyes in a commercial reference database (RDB). The temporal quadrant (TQ), superior quadrant (SQ), inferior quadrant (IQ), and global (G) cpRNFL thicknesses were analyzed. The commercial OCT devices code these values based on percentiles (red, <1%; yellow, ≥1% and <5%), after taking age and disc area into consideration. Four anatomical parameters were assessed: fovea-to-disc distance, an estimate of axial length, and the locations of the superior and the inferior peaks of the cpRNFL thickness curve. Pearson correlation values were obtained for the parameters and the thickness measures of each of the four cpRNFL regions, and t-tests were performed between the cpRNFL thicknesses coded as abnormal (red or yellow, <5%) versus normal (≥5%). Results For each of the four anatomical parameters, the correlation with the thickness of one or more of the TQ, SQ, IQ, and G regions exceeded the correlation with age or disc area. All four parameters were significantly (P < 0.001) associated with the abnormal cpRNFL values. The significant parameters were not the same for the different regions; for example, a parameter could be negatively correlated for the TQ but positively correlated with the SQ or IQ. Conclusions In addition to age and disc area, which are used for inferences in normative databases, four anatomical parameters are associated with cpRNFL thickness. Translational Relevance Taking these additional anatomical parameters into consideration should aid diagnostic accuracy.
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Affiliation(s)
- Donald C. Hood
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, NY, USA
- Department of Psychology, Columbia University, New York, NY, USA
| | - Sol La Bruna
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | - Emmanouil Tsamis
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, NY, USA
- Department of Psychology, Columbia University, New York, NY, USA
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Keye P, Lübke J. [Primary Open Angle Glaucoma]. Klin Monbl Augenheilkd 2023; 240:1221-1235. [PMID: 37586400 DOI: 10.1055/a-2129-1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Primary open angle glaucoma is the most frequent type among the glaucomas. It is characterized by a progressive loss of retinal ganglion cells and a corresponding visual field loss. Risk factors include older age, ethnicity, family history of glaucoma and, most important, an elevated intraocular pressure (IOP). The IOP is the only modifiable risk factor for glaucoma progression. Therapeutic approaches aim to lowering the IOP and incorporate topical pressure lowering medication, laser treatment, and different surgical approaches. Surgery aims to reducing the outflow resistance of the aqueous humor. This may be achieved by surgically opening the trabecular meshwork or Schlemm's canal. Penetrating glaucoma surgery comprises classic trabeculectomy and other draining devices.
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El-Nimri NW, Moghimi S, Nishida T, Yarmohammadi A, Zangwill LM, Hou H, Proudfoot J, Walker E, Fazio MA, Girkin CA, Liebmann JM, Weinreb RN. Racial Differences in Detection of Glaucoma Using Retinal Nerve Fiber Layer Thickness and Bruch Membrane Opening Minimum Rim Width. Am J Ophthalmol 2023; 246:223-235. [PMID: 36662535 DOI: 10.1016/j.ajo.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE To compare the sensitivities and specificities of the retinal nerve fiber layer thickness (RNFLT) and Bruch membrane opening minimum rim width (BMO-MRW) reference database-based criteria for detection of glaucoma in individuals of European descent (ED) and individuals of African descent (AD). DESIGN Comparative diagnostic analysis by race METHODS: 382 eyes of 255 glaucoma patients (ED = 170, AD = 85) and 94 eyes of 50 healthy individuals (ED = 30, AD = 20) with global and sectoral RNFLT and BMO-MRW measured with Spectralis optical coherence tomography (OCT) were included. Six diagnostic criteria were evaluated: global measurement below the 5th or 1st percentile, ≥1 of the 6 sector measurements below the 5th or 1st percentile, and superotemporal (ST) and/or inferotemporal (IT) measurement below the 5th or 1st percentile. The sensitivities and specificities of these measurements for detection of glaucoma were compared using bootstrapping methods. RESULTS ST and/or IT RNFLT below the 5th percentile has the best performance for detection of glaucoma among RNFLT classifications with a sensitivity (95% CI) of 89.5% (86.1, 92.5) and specificity of 87.2% (77.8, 95.1). In AD individuals, sensitivities of ST and IT RNFLT and BMO-MRW measurements below the 5th percentile criteria were lower than in ED individuals (RNFLT: 83.7% vs 92.5%, and BMO-MRW: 72.1% vs 88.5%, respectively), as well as specificities (AD RNFLT: 73.7% and BMO-MRW: 89.5% vs ED RNFLT: 96.4% and BMO-MRW: 98.2%, respectively). CONCLUSIONS RNFLT and BMO-MRW had consistently lower diagnostic performance in AD individuals compared with ED individuals. BMO-MRW criteria might fail to detect as many as one-third of eyes with glaucoma, specifically in AD individuals. With the current reference database, RNFLT, and especially BMO-MRW, criteria are not adequate for diagnosing glaucoma in AD individuals.
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Affiliation(s)
- Nevin W El-Nimri
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Sasan Moghimi
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.).
| | - Takashi Nishida
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Adeleh Yarmohammadi
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Linda M Zangwill
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Huiyuan Hou
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - James Proudfoot
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Evan Walker
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
| | - Massimo A Fazio
- Department of Ophthalmology and Visual Sciences, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama (M.A.F., C.A.G.) and
| | - Christopher A Girkin
- Department of Ophthalmology and Visual Sciences, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama (M.A.F., C.A.G.) and
| | - Jeffrey M Liebmann
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York (J.M.L.), USA
| | - Robert N Weinreb
- From the Hamilton Glaucoma Center, Shiley Eye Institute, and the Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California (N.W.E.-N., S.M., T.N., A.Y., L.M.Z., H.H., J.P., E.W., R.N.W.)
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Kim S, Jo YH. Changes of Optical Coherence Tomography Parameters after Cataract Surgery in Primary Open-Angle Glaucoma Eyes. KOREAN JOURNAL OF OPHTHALMOLOGY 2023; 37:1-11. [PMID: 36281574 PMCID: PMC9935070 DOI: 10.3341/kjo.2022.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/22/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To investigate the impact of uncomplicated cataract surgery on the measurement of Bruch's membrane opening-minimum rim width (BMO-MRW) and retinal nerve fiber layer thickness (RNFLT) using spectral domain optical coherence tomography (SD-OCT) in primary open-angle glaucoma (POAG) patients. METHODS This retrospective study included 63 eyes of 63 patients, including 32 POAG eyes and 31 normal eyes who underwent uneventful cataract surgery and follow-up for at least 6 months. Using SD-OCT, BMO-MRW and RNFLT were measured preoperatively and postoperatively at 6 months. Paired t-test was used to compare intraocular pressure (IOP), BMO-MRW, RNFLT, and image quality before and after surgery. These parameters and their changes were compared between POAG and normal groups. Univariate and multivariate linear regression analyses were performed to determine the factors associated with the postoperative change (Δ) in RNFLT and BMO-MRW. RESULTS BMO-MRW and RNFLT were significantly increased and IOP was decreased after phacoemulsification in both groups (p < 0.001, respectively). The ΔRNFLT was significantly greater in POAG eyes compared with the normal eyes (p < 0.001). The ΔRNFLT was associated with the postoperative IOP reduction and glaucoma diagnosis (p < 0.001 and p = 0.001, respectively). In the normal group, only the ΔIOP had a significant influence on the ΔRNFLT (p = 0.003), but in the POAG group, not only the ΔIOP (p = 0.044) but also preoperative visual field mean deviation (p = 0.029) showed a significant influence. The ΔBMO-MRW showed no difference between POAG and normal eyes. CONCLUSIONS The postoperative increase of RNFLT was significantly greater in the POAG group, and the postoperative increase of RNFLT was associated with the preoperative visual field mean deviation and ΔIOP in POAG eyes and with the ΔIOP in normal eyes. Our results imply that RNFLT is more affected than BMO-MRW in POAG eyes compared to normal eyes by cataract surgery.
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Affiliation(s)
- SoHyeon Kim
- Department of Ophthalmology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Youn Hye Jo
- Department of Ophthalmology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Tsamis E, La Bruna S, Leshno A, De Moraes CG, Hood D. Detection of Early Glaucomatous Damage: Performance of Summary Statistics From Optical Coherence Tomography and Perimetry. Transl Vis Sci Technol 2022; 11:36. [PMID: 35353149 PMCID: PMC8976935 DOI: 10.1167/tvst.11.3.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose To evaluate the diagnostic performance of optical coherence tomography (OCT) and visual field (VF) summary statistics (metrics) that are available in OCT and VF reports. Methods OCT disc and macular scans and 24-2 and 10-2 VFs were obtained from 56 healthy control (HC) eyes/participants and 61 eyes/patients with 24-2 mean deviation of better than –6 dB. All metrics were obtained from OCT radial, circle, and posterior pole cube scans and 24-2 and 10-2 VFs. Their diagnostic performances were evaluated, in isolation and in combinations. For specificity, the 56 HC eyes were used. For sensitivity, 40 of the 61 patient eyes were deemed likely glaucomatous based on an automated topographic method that evaluates structure–function (S–F) agreement. Any 1 of these 40 eyes not judged as abnormal by any given metric was considered a false negative. Results All single OCT and VF metrics misclassified HCs as glaucomatous and missed likely glaucomatous eyes. The best performing single metric was the temporal inferior thickness of the 3.5-mm circle scan, with 96% specificity and 83% sensitivity. Combinations of OCT–OCT and OCT–VF metrics markedly improved specificity. A newly proposed metric that evaluates structure–structure (S–S) agreement at a hemifield level had the highest accuracy. This S–S metric had 98% specificity and 80% sensitivity. Conclusions OCT and VF metrics, single or in combinations, have only moderate sensitivity for eyes with early glaucoma. Translational Relevance OCT and VF metrics combinations evaluating S–S or S–F agreement can be highly specific, which is an important implication for clinical and research purposes.
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Affiliation(s)
- Emmanouil Tsamis
- Department of Psychology, Columbia University, New York, NY, USA
| | - Sol La Bruna
- Department of Psychology, Columbia University, New York, NY, USA
| | - Ari Leshno
- Bernard and Shirlee Glaucoma Research Lab, Department of Ophthalmology, Columbia University, New York, NY, USA.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Sheba Talpiot Leader Program, Sheba Medical Center Hospital- Tel Hashomer, Ramat Gan, Israel
| | - Carlos Gustavo De Moraes
- Bernard and Shirlee Glaucoma Research Lab, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Donald Hood
- Department of Psychology, Columbia University, New York, NY, USA.,Bernard and Shirlee Glaucoma Research Lab, Department of Ophthalmology, Columbia University, New York, NY, USA
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La Bruna S, Rai A, Mao G, Kerr J, Amin H, Zemborain ZZ, Leshno A, Tsamis E, De Moraes CG, Hood DC. The OCT RNFL Probability Map and Artifacts Resembling Glaucomatous Damage. Transl Vis Sci Technol 2022; 11:18. [PMID: 35289836 PMCID: PMC8934545 DOI: 10.1167/tvst.11.3.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to improve the diagnostic ability of the optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) probability (p-) map by understanding the frequency and pattern of artifacts seen on the p-maps of healthy control (HC) eyes resembling glaucomatous damage. Methods RNFL p-maps were generated from wide-field OCT cube scans of 2 groups of HC eyes, 200 from a commercial normative group (HC-norm) and 54 from a prospective study group, as well as from 62 patient eyes, which included 32 with early glaucoma (EG). These 32 EG eyes had 24-2 mean deviation (MD) better than -6 dB and perimetric glaucoma as defined by 24-2 and 10-2 criteria. For the HC groups, "glaucoma-like" arcuates were defined as any red region near the temporal half of the disc. Results Seven percent of the 200 HC-norm and 11% of the 54 HC RNFL p-maps satisfied the definition of "glaucoma-like," as did all the patients' p-maps. The HC p-maps showed two general patterns of abnormal regions, "arcuate" and "temporal quadrant," and these patterns resembled those seen on some of the RNFL p-maps of the EG eyes. A "vertical midline" rule, which required the abnormal region to cross the vertical midline through the fovea, had a specificity of >99%, and a sensitivity of 75% for EG and 93% for moderate to advanced eyes. Conclusions Glaucoma-like artifacts on RNFL p-maps are relatively common and can masquerade as arcuate and/or widespread/temporal damage. Translational Relevance A vertical midline rule had excellent specificity. However, other OCT information is necessary to obtain high sensitivity, especially in eyes with early glaucoma.
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Affiliation(s)
- Sol La Bruna
- Department of Psychology, Columbia University, New York, NY, USA
| | - Anvit Rai
- Department of Psychology, Columbia University, New York, NY, USA
- Albert Einstein College of Medicine, New York, NY, USA
| | - Grace Mao
- Department of Psychology, Columbia University, New York, NY, USA
| | - Jennifer Kerr
- Department of Psychology, Columbia University, New York, NY, USA
| | - Heer Amin
- Department of Psychology, Columbia University, New York, NY, USA
- Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Zane Z. Zemborain
- Department of Psychology, Columbia University, New York, NY, USA
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Ari Leshno
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Columbia University Irving Medical Center, New York, NY, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmanouil Tsamis
- Department of Psychology, Columbia University, New York, NY, USA
| | - Carlos Gustavo De Moraes
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Columbia University Irving Medical Center, New York, NY, USA
| | - Donald C. Hood
- Department of Psychology, Columbia University, New York, NY, USA
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Department of Ophthalmology, Columbia University Irving Medical Center, New York, NY, USA
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Koenig SF, Hirneiss CW. Changes of Neuroretinal Rim and Retinal Nerve Fiber Layer Thickness Assessed by Optical Coherence Tomography After Filtration Surgery in Glaucomatous Eyes. Clin Ophthalmol 2021; 15:2335-2344. [PMID: 34113077 PMCID: PMC8184240 DOI: 10.2147/opth.s298045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose Lowering the intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG) with filtration surgery can induce morphological changes to the bulbus and structures of the retina. In this study, we have evaluated changes of Bruch's membrane-based parameters and retinal nerve fiber layer (RNFL) derived by spectral-domain optical coherence tomography (SD-OCT) in eyes that have undergone glaucoma filtration surgery. Patients and Methods SD-OCT imaging of the optic nerve head (ONH) and of the RNFL was performed in 54 eyes of 54 patients with medically uncontrolled POAG before and after IOP-lowering surgery (trabeculectomy or deep sclerectomy). The ONH parameter minimum rim width (MRW) and the size of the Bruch's membrane opening (BMO-Area) were derived from 24 radial B-scans centered on the ONH. Results The average preoperative IOP was 23.1 ± 7.5 mmHg. One month postoperatively, the average IOP decreased to 12.1 ± 4.6 mmHg (p < 0.01), which caused a significant increase in the thickness of neuroretinal rim. There was no significant change in the automatically detected BMO-Area (p = 0.32). The pressure-related increase in MRW correlated well with the postoperative IOP and cup-to-disc ratio (CDR). In regression analysis, the alteration in thickness of the neuroretinal rim could be well predicted in a model including CDR, change of IOP and mean deviation (MD) (R2 = 0.414, p < 0.001). RNFL showed a significant increase as well. Conclusion IOP-lowering surgery in patients with medically uncontrolled POAG causes an increased thickness of the SD-OCT derived ONH parameters. The changes of the RNFL after surgery showed no significant correlations with IOP changes. In contrast to this, highly significant correlations of MRW values with the IOP could be observed. The BMO-Area remained completely stable A preferred use of RNFL for follow-up should be discussed.
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Eguia MD, Tsamis E, Zemborain ZZ, Sun A, Percival J, De Moraes CG, Ritch R, Hood DC. Reasons why OCT Global Circumpapillary Retinal Nerve Fiber Layer Thickness is a Poor Measure of Glaucomatous Progression. Transl Vis Sci Technol 2020; 9:22. [PMID: 33150048 PMCID: PMC7585398 DOI: 10.1167/tvst.9.11.22] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose To assess the effects of local defects, segmentation errors, and improper image alignment on the performance of the commonly used optical coherence tomography (OCT) measure of progression, that is the change in global (average) circumpapillary retinal nerve fiber layer (cpRNFL) thickness (ΔG). Methods One hundred fifty eyes suspected of, or with, early glaucoma had OCT circle and cube scans obtained using eye tracking on two occasions at least 1 year apart. Statistical progression was defined by fixed values of ΔG (3-8 um) and quantile regression. For a reference standard, four authors identified 30 eyes as "likely progressed," and 61 eyes that "likely had not progressed" based on OCT reports from both baseline and follow-up tests. Results A ΔG criterion of 4 um had the best accuracy: 77%, with 5 false positive (8.2%) and 16 false negative (53%). A post hoc analysis of circular b-scans and OCT probability maps of these eyes indicated that segmentation errors and local progression accounted for most of these mistakes. Segmentation errors, although less common, were also present in true positives and true negatives. Conclusions Local defects and segmentation errors are the primary reasons for the poor performance of cpRNFL thickness G metric. Because these problems are difficult, if not impossible, to eliminate, the G metric should not be relied on in isolation for detecting glaucomatous progression. Translational Relevance Local defects and segmentation errors are easily identified by viewing OCT circumpapillary images, which should be part of the standard protocol for detecting glaucomatous progression.
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Affiliation(s)
- Melvi D. Eguia
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | - Emmanouil Tsamis
- Department of Psychology, Columbia University, New York, NY, USA
| | | | - Ashley Sun
- Department of Psychology, Columbia University, New York, NY, USA
| | - Joseph Percival
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | - C. Gustavo De Moraes
- Department of Ophthalmology, Columbia University Irving Medical Center, New York, NY, USA
| | - Robert Ritch
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | - Donald C. Hood
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
- Department of Ophthalmology, Columbia University Irving Medical Center, New York, NY, USA
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