The Effects of Menopause and Hormone Replacement Therapy on Quality and Quantity of Tear, Intraocular Pressure and Ocular Blood Flow

Lessons From The Glaucoma Foundation Think Tank 2023: A Patient-Centric Approach to Glaucoma

PRCIS

The main takeaways also included that BIG DATA repositories and AI are important combinatory tools to foster novel strategies to prevent and stabilize glaucoma and, in the future, recover vision loss from the disease.

PURPOSE

To summarize the main topics discussed during the 28th Annual Glaucoma Foundation Think Tank Meeting "A Patient-Centric Approach to Glaucoma" held in New York on June 9 and 10, 2023.

METHODS

The highlights of the sessions on BIG DATA, genetics, modifiable lifestyle risk factors, female sex hormones, and neuroprotection in the field of primary open angle glaucoma (POAG) were summarized.

RESULTS

The researchers discussed the importance of BIG DATA repositories available at national and international levels for POAG research, including the United Kingdom Biobank. Combining genotyped large cohorts worldwide, facilitated by artificial intelligence (AI) and machine-learning approaches, led to the milestone discovery of 312 genome-wide significant disease loci for POAG. While these loci could be combined into a polygenic risk score with clinical utility, Think Tank meeting participants also provided analytical epidemiological evidence that behavioral risk factors modify POAG polygenetic risk, citing specific examples related to caffeine and alcohol use. The impact of female sex hormones on POAG pathophysiology was discussed, as was neuroprotection and the potential use of AI to help mitigate specific challenges faced in clinical trials and speed approval of neuroprotective agents.

CONCLUSIONS

The experts agreed on the importance of genetics in defining individual POAG risk and highlighted the additional crucial role of lifestyle, gender, blood pressure, and vascular risk factors. The main takeaways also included that BIG DATA repositories and AI are important combinatory tools to foster novel strategies to prevent and stabilize glaucoma and, in the future, recover vision loss from the disease.

Prevalence and Severity of Glaucoma in the California Medicare Population

PURPOSE

To examine the prevalence of glaucoma by type and severity in the 2019 California (CA) Medicare population, and to identify associated demographic and systemic factors.

DESIGN

Retrospective cross-sectional design.

METHODS

The study population included all 2019 CA Medicare beneficiaries ≥65 years of age with Part A and Part B coverage. Outcomes included prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma (ACG). Covariates included age, sex, race and ethnicity, Charlson Comorbidity Index (CCI) score, pseudophakia, and age-related macular degeneration. Logistic regression modeling was used to examine multivariable predictors of each type of glaucoma.

RESULTS

Of 5,856,491 beneficiaries in the 2019 California Medicare population, there were 220,662 (3.8%) with any glaucoma, 171,988 (2.9%) with POAG, 8,827 (0.2%) with SOAG, and 12,978 (0.2%) with ACG. The largest proportion of beneficiaries had moderate to severe glaucoma (68,553 of 220,662 [31.0%] for any glaucoma moderate stage, 3,168 of 12,978 [24.4%] for ACG severe stage). Multivariable predictors of any glaucoma included age ≥85 years vs 65 to 69 years (adjusted odds ratio [aOR] = 2.03, 95% CI = 2.00, 2.06), female vs male sex (aOR = 1.03, 95% CI = 1.02, 1.04), Black vs non-Hispanic White race and ethnicity (aOR = 1.70, 95% CI = 1.67, 1.73), and CCI ≥5 vs 0 (aOR = 5.59, 95% = 5.51, 5.67).

CONCLUSIONS

In the 2019 CA Medicare population, multiple demographic and systemic factors were associated with increased likelihood of glaucoma, and beneficiaries with glaucoma had a high prevalence of moderate to severe disease. Strategies are needed to improve early screening and diagnosis for elderly individuals at risk for glaucoma in California.

Chorioretinal biomarkers in hypothalamic amenorrhea

PURPOSE

The aim of our study was to evaluate changes in the retinal and choriocapillaris circulations in patients with hypothalamic amenorrhea.

METHODS

Prospective, cross-sectional observational study on 25 patients (50 eyes) diagnosed with hypothalamic amenorrhea and 25 age-matched healthy women. Optical coherence tomography angiography (OCTA) was used to evaluate the vessel density (VD) of superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris VD layers in whole 6.4 × 6.4-mm image and in fovea grid-based image. In patients' group, systemic parameters were collected: body mass index (BMI), endometrial rhyme thickness, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, insulin, and cortisol.

RESULTS

SCP and DCP did not show any statistical difference when comparing patients and controls (all p > 0.05). Differently, choriocapillaris VD in the whole region showed a non-significant tendency toward higher values in the patients group in both eyes (p = 0.038 for right eye [RE], p = 0.044 for left eye [LE]). Foveal choriocapillaris VD was higher in hypothalamic amenorrhea women vs. healthy controls (66.0 ± 2.4 vs. 63.7 ± 6.6%, p = 0.136 for RE; 65.0 ± 2.4 vs. 61.6 ± 7.0%, p = 0.005 for LE). Focusing on correlation with systemic parameters, SCP and DCP foveal density had a medium/high effect size with endometrial rhyme, along with DCP in the fovea area vs. cortisol and SCP in the whole area vs. FSH.

CONCLUSION

When comparing hypothalamic amenorrhea patients to healthy subjects, OCTA detected changes in the choriocapillaris layer, showing increased VD in the early stage of the systemic pathology, suggesting that microvascular "compaction" could be a first phase of hypoestrogenism adaptation.

Estrogen dysregulation, intraocular pressure, and glaucoma risk

Characterized by optic nerve atrophy due to retinal ganglion cell (RGC) death, glaucoma is the leading cause of irreversible blindness worldwide. Of the major risk factors for glaucoma (age, ocular hypertension, and genetics), only elevated intraocular pressure (IOP) is modifiable, which is largely regulated by aqueous humor outflow through the trabecular meshwork. Glucocorticoids such as dexamethasone have long been known to elevate IOP and lead to glaucoma. However, several recent studies have reported that steroid hormone estrogen levels inversely correlate with glaucoma risk, and that variants in estrogen signaling genes have been associated with glaucoma. As a result, estrogen dysregulation may contribute to glaucoma pathogenesis, and estrogen signaling may protect against glaucoma. The mechanism for estrogen-related protection against glaucoma is not completely understood but likely involves both regulation of IOP homeostasis and neuroprotection of RGCs. Based upon its known activities, estrogen signaling may promote IOP homeostasis by affecting extracellular matrix turnover, focal adhesion assembly, actin stress fiber formation, mechanosensation, and nitric oxide production. In addition, estrogen receptors in the RGCs may mediate neuroprotective functions. As a result, the estrogen signaling pathway may offer a therapeutic target for both IOP control and neuroprotection. This review examines the evidence for a relationship between estrogen and IOP and explores the possible mechanisms by which estrogen maintains IOP homeostasis.

Effects of Androgens on the Thickness of Retinal Layers in Transgender Men and in Women with Polycystic Ovarian Syndrome

Purpose

This study aimed to evaluate the relationship between androgens and the retinal thickness by comparing the macular thickness (MT), retinal nerve fiber layer (RNFL), and ganglion cell complex (GCC) thickness of female-to-male transgender men (TGM), women with polycystic ovary syndrome (PCOS), and cisgender women (CW).

Methods

Thirty-four eyes of 34 TGM, 34 eyes of 34 women with PCOS, and 45 eyes of 45 CW were evaluated by optical coherence tomography. One-way analysis of variance and body mass index (BMI)-adjusted one-way analysis of covariance were conducted to test the differences between groups for statistical evaluation.

Results

The parafoveal MT in TGM was significantly higher than women with PCOS and CW (p<0.001 and p=0.022, respectively). After adjusting for BMI, the perifoveal MT in TGM was significantly higher than women with PCOS and CW (p=0.041 and p=0.021, respectively). The nasal RNFL thickness in TGM was significantly higher than women with PCOS and CW (p=0.021 and p=0.009, respectively). The means of average and inferior RNFL, fovea, and the mean of all GCC values were higher in the TGM group than women with PCOS and CW, but these results were not statistically significant.

Conclusions

In this study, there was a significant difference between the TGM group and the CW group for the thickness of the nasal RNFL and parafoveal and perifoveal macular area. Androgens may have the potential to increase retinal thickness in TGM; however, there is a need for validation in larger study groups. Clinical Trial Registration Number: HNEAH-KAEK 2021/4.

Comparison of retinochoroidal microvascular circulation in menstrual and postmenopausal periods using swept-source optical coherence tomography angiography

PURPOSE

We aimed to examine the possible effects of the postmenopausal period on retinal and choroidal microvascular circulation using swept-source optical coherence tomography angiography (SS-OCTA).

METHODS

This cross-sectional study included 45 eyes of 45 subjects in menstrual group and 40 eyes of 40 subjects in postmenopausal group. SS-OCTA was used for the assessment of vessel density (VD), foveal avascular zone (FAZ), choroidal thickness (CT), choriocapillaris VD, central macular thickness (CMT), nerve fiber layer thickness (RNFL), and ganglion cell layer (GCL) measurements.

RESULT

The VDs of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) measurements were similar in both group. FAZ area was wider in postmenopausal group (0.305 mm² (range, 0.212-0.498 mm²)) compared to menstrual group (0.271 mm² (range, 0.131-0.464 mm²)) (p = 0.013). Choriocapillaris VD was significantly lower in postmenopausal group (p = 0.049). CT was thicker in the postmenopausal group, but with no statistically significant difference (p = 0.066). Central macular thickness, RNFL, and GCL were similar in both groups.

CONCLUSION

This is the first study in the literature to evaluate the retinochoroidal microcirculation in the menstrual and postmenopausal periods with SS-OCTA. We observed an increase in both superficial and deep FAZ area and a decrease in choroidal blood flow in the postmenopausal period. We think that this enlargement in the FAZ area may be related to the decreased amount of estrogen.

Evidence for Menopause as a Sex-Specific Risk Factor for Glaucoma

Glaucoma is a leading cause of irreversible blindness worldwide and is characterized by progressive loss of visual function and retinal ganglion cells (RGC). Current epidemiological, clinical, and basic science evidence suggest that estrogen plays a role in the aging of the optic nerve. Menopause, a major biological life event affecting all women, coincides with a decrease in circulating sex hormones, such as estrogen. While 59% of the glaucomatous population are females, sex is not considered a risk factor for developing glaucoma. In this review, we explore whether menopause is a sex-specific risk factor for glaucoma. First, we investigate how menopause is defined as a sex-specific risk factor for other pathologies, including cardiovascular disease, osteoarthritis, and bone health. Next, we discuss clinical evidence that highlights the potential role of menopause in glaucoma. We also highlight preclinical studies that demonstrate larger vision and RGC loss following surgical menopause and how estrogen is protective in models of RGC injury. Lastly, we explore how surgical menopause and estrogen signaling are related to risk factors associated with developing glaucoma (e.g., intraocular pressure, aqueous outflow resistance, and ocular biomechanics). We hypothesize that menopause potentially sets the stage to develop glaucoma and therefore is a sex-specific risk factor for this disease.

[Predictors of the success of laser peripheral iridotomy and lensectomy in the early stages of primary angle closure disease]

The article reviews literature data on the search for predictors of the success of laser peripheral iridotomy (LPI) and lensectomy in the early stages of primary angle closure disease (PACD) and presents a trend analysis of the studies conducted on individuals identified as primary angle closure suspects (PACs) and those with primary angle closure (PAC). The concept of the review was determined by the ambiguous choice of treatment for patients at the stage of PAC onset. Determining the success predictors of LPI or lensectomy plays a key role in optimizing the treatment of PACD. The results of literature analysis are contradictory, which indicates the need for further research taking into account modern methods of visualization of the eye structures such as optical coherence tomography (OCT), Swept Source OCT (SS-OCT), and the use of uniform criteria for evaluating the effectiveness of treatment.

The Association of Female Reproductive Factors with Glaucoma and Related Traits: A Systematic Review

TOPIC

This systematic review summarizes evidence for associations between female reproductive factors (age at menarche, parity, oral contraceptive [OC] use, age at menopause, and postmenopausal hormone [PMH] use) and intraocular pressure (IOP) or open-angle glaucoma (OAG).

CLINICAL RELEVANCE

Understanding the associations between female reproductive factors and glaucoma may shed light on the disease pathogenesis and aid clinical prediction and personalized treatment strategies. Importantly, some factors are modifiable, which may lead to new therapies.

METHODS

Two reviewers independently extracted articles in MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials databases to identify relevant studies. Eligibility criteria included studies with human subjects aged > 18 years; a measured outcome of either IOP or OAG; a cohort, case-control, cross-sectional, or randomized controlled trial design; a reported measure of association, such as the hazard ratio, relative risk, odds ratio, or mean difference, with an associated confidence interval; and a measured exposure of at least 1 of the following variables: age at menarche, parity, OC use, age at menopause, or PMH use.

RESULTS

We included a total of 27 studies. Substantial differences in study designs, exposure and treatment levels, treatment durations, and variable reporting precluded a meaningful quantitative synthesis of the identified studies. Overall, relatively consistent associations between PMH use and a lower IOP were identified. Estrogen-only PMH use may be associated with lower OAG risk, which may be modified by race. No significant associations were found with combined estrogen-and-progesterone PMH use. No strong associations between parity or age at menarche and glaucoma were found, but a younger age at menopause was associated with an increased glaucoma risk, and adverse associations were identified with a longer duration of OC use, though no overall association with OC use was found.

CONCLUSIONS

The association between PMH use and lower IOP or OAG risk is a potentially clinically relevant and modifiable risk factor and should be investigated further, although this needs to be interpreted in the context of a high risk of bias across included studies. Future research should examine associations with IOP specifically and how the relationship between genetic factors and OAG risks may be influenced by female reproductive factors.

Association Between Sex Hormones and Visual Field Progression in Women With Primary Open Angle Glaucoma: A Cross-Sectional and Prospective Cohort Study

Purpose: We evaluated the level of sex hormones in female patients with primary open angle glaucoma (POAG) to determine whether they are associated with the onset and/or progression of POAG.

Methods: The cross-sectional study enrolled 63 women with POAG and 56 healthy women as normal control subjects. Furthermore, 57 women with POAG were included and followed-up for at least 2 years in the cohort study. All subjects were evaluated for serum concentration of sex hormones [prolactin (PRL), luteinizing hormone (LH), testosterone (TESTO), follicle-stimulating hormone (FSH), progesterone (PROG), and estrogen (E2)] and underwent visual field (VF) examination. In the cross-sectional study, Spearman analysis, linear regression analysis, and logistic regression analysis were performed to assess risk factors for POAG in women. In the cohort study, Cox regression analyses and Kaplan–Meier survival analysis were performed to identify factors associated with VF progression in women with POAG.

Results: In the cross-sectional study, the level of E2 was significantly lower in the POAG group than in the normal group (p < 0.05). Multiple logistic regression showed that the decreased level of E2 was a risk factor of POAG (OR = 0.27, 95% CI = 0.09–0.78, p < 0.05), especially in premenopausal subjects. In the cohort study, there were 29 non-progression subjects and 28 progression subjects. Patients in the progression group had significantly lower levels of E2 than those in the no progression group (p < 0.01). The decreased level of E2 at baseline was associated with POAG progression (HR = 0.08, 95% CI = 0.02–0.46, p < 0.05), especially in premenopausal subjects. Patients with POAG and with lower baseline E2 levels had significantly lower VF non-progression rates than patients with higher E2 levels (log-rank test p < 0.001), especially premenopausal subjects (log-rank test p < 0.05). Additionally, logistic regression analyses, Cox regression analyses, and Kaplan–Meier survival analysis showed that PROG, LH, FSH, and TESTO were risk factors of POAG and/or significantly associated with POAG progression.

Conclusion: A decreased E2 level is a POAG risk factor and is associated with VF progression in women with POAG, especially in premenopausal subjects. Additionally, other sex hormones (PROG, LH, FSH, and TESTO) might also play a role in POAG pathogenesis.

Influence of Sex on Neuroretinal Degeneration: Six-Month Follow-Up in Rats With Chronic Glaucoma

Purpose

To evaluate differences by sex in the neuroretina of rats with chronic glaucoma over 24 weeks of follow-up, and to assess by sex the influence on neurodegeneration of different methods of inducing ocular hypertension.

Methods

Forty-six Long-Evans rats-18 males and 28 females-with induced chronic glaucoma were analyzed. Glaucoma was achieved via 2 models: repeatedly sclerosing the episcleral veins (9 male/14 female) or by injecting poly(lactic-co-glycolic acid) microspheres measuring 20 to 10 µm (Ms20/10) into the anterior chamber (9 male/14 female). The IOP was measured weekly by tonometer; neuroretinal function was recorded by dark/light-adapted electroretinography at baseline and weeks 12 and 24; and structure was analyzed by optical coherence tomography using the retina posterior pole, retinal nerve fiber layer and ganglion cell layer protocols at baseline and weeks 8, 12, 18, and 24.

Results

Males showed statistically significant (P < 0.05) higher IOP in both chronic glaucoma models, and greater differences were found in the episcleral model at earlier stages. Males with episclerally induced glaucoma showed a statistically higher increase in retinal thickness in optical coherence tomography recordings than females and also when comparing Ms20/10 at 12 weeks. Males showed a higher percentage of retinal nerve fiber layer thickness loss in both models. Ganglion cell layer thickness loss was only detected in the Ms20/10 model. Males exhibited worse dark/light-adapted functionality in chronic glaucoma models, which worsened in the episcleral sclerosis model at 12 weeks, than females.

Conclusions

Female rats with chronic glaucoma experienced lower IOP and structural loss and better neuroretinal functionality than males. Sex and the ocular hypertension-inducing method influenced neuroretinal degeneration.

Identification of Estrogen Signaling in a Prioritization Study of Intraocular Pressure-Associated Genes

Elevated intraocular pressure (IOP) is the only modifiable risk factor for primary open-angle glaucoma (POAG). Herein we sought to prioritize a set of previously identified IOP-associated genes using novel and previously published datasets. We identified several genes for future study, including several involved in cytoskeletal/extracellular matrix reorganization, cell adhesion, angiogenesis, and TGF-β signaling. Our differential correlation analysis of IOP-associated genes identified 295 pairs of 201 genes with differential correlation. Pathway analysis identified β-estradiol as the top upstream regulator of these genes with ESR1 mediating 25 interactions. Several genes (i.e., EFEMP1, FOXC1, and SPTBN1) regulated by β-estradiol/ESR1 were highly expressed in non-glaucomatous human trabecular meshwork (TM) or Schlemm’s canal (SC) cells and specifically expressed in TM/SC cell clusters defined by single-cell RNA-sequencing. We confirmed ESR1 gene and protein expression in human TM cells and TM/SC tissue with quantitative real-time PCR and immunofluorescence, respectively. 17β-estradiol was identified in bovine, porcine, and human aqueous humor (AH) using ELISA. In conclusion, we have identified estrogen receptor signaling as a key modulator of several IOP-associated genes. The expression of ESR1 and these IOP-associated genes in TM/SC tissue and the presence of 17β-estradiol in AH supports a role for estrogen signaling in IOP regulation.

The Association Between Genetic Polymorphisms in Estrogen Receptor Genes and the Risk of Ocular Disease: A Meta-Analysis

Objectives:

To evaluate the association between estrogen receptor (ER) genes polymorphisms and the risk of ocular disease.

Materials and Methods:

A meta-analysis was performed of all available studies that investigated the association between ER gene polymorphisms and the risk of ocular disease.

Results:

Studies that were selected based on inclusion criteria reported 5 and 4 single-nucleotide polymorphisms (SNPs) identified in the ESR1 (ERα) (rs2234093, rs12154178, rs1884054, rs1801132, and rs9340799) and ESR2 (ERβ) (rs1268656, rs7159462, rs1256031, and rs4986938) genes, respectively. The pooled result showed a significant association between ESR2 rs1256031 gene polymorphism and ocular disease (odds ratio: 0.55, 95% confidence interval: 0.41-0.74, p<0.0001).

Conclusion:

The recessive genotype of ESR2 rs1256031 gene polymorphism had a protective effect against ocular disease, which supports the hypothesis that the estrogen-signaling pathway through ERβ plays a pivotal role in the pathogenesis of ophthalmic disorders.

Characteristics of Visual Field Defects in Korean Advanced Glaucoma

Purpose: We investigated the clinical characteristics of visual field (VF) defects in Korean advanced glaucoma patients.Methods: The present study included 109 eyes of 109 advanced glaucoma patients whose mean deviation (MD) is under -12 dB. The subjects were classified into primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) group. Average numeric decibel in each VF points were visualized with color topographic image and dot graph image using python 3.5. VF was divided into four quadrants or two half fields, and the differences in the degree of VF defects in each locations were assessed with raw decibel data. Additionally, mean sensitivity of central 12 points were compared between the two groups.Results: Generally the features of VF defects were severely depressed VF sensitivity at the superonasal quadrant and relatively preserved central area and inferotemporal quadrant in both of the glaucoma groups. But we found the extent of deflection for VF defect in the NTG eyes was higher than that of the POAG eyes (p < 0.05). The POAG eyes tended to show more diffuse and evenly distributed VF defect, whereas NTG eyes tended to have more severely depressed VF at the superonasal quadrant and relatively preserved VF at the inferotemporal quadrant. There was no significant difference in the degree of central VF defects between the two groups.Conclusions: The characteristics of VF defect in Korean advanced glaucoma revealed different features based on the glaucoma diagnosis. The POAG eyes tended to show diffuse VF defects, whereas NTG eyes tended to have more severely depressed VF sensitivity at the superonasal quadrant and relatively preserved VF at the inferotemporal quadrant.

Effects of testosterone on intraocular pressure, thicknesses of retinal nerve fiber layer, ganglion cell complex, macula and on ocular blood flow in female-to-male transgender persons

PURPOSE

To compare the effects of testosterone on intraocular pressure (IOP), thicknesses of retinal nerve fiber layer (RNFL), ganglion cell complex (GCC), macula and on ocular blood flow between female-to-male transgender (FMT) persons who use testosterone and healthy women and healthy men.

METHOD

The study included 39 eyes of 20 FMT(Group 1), 40 eyes of 20 healthy women (Group 2), and 42 eyes of 21 healthy men (Group 3). In all subjects, RNFL, GCC and, macular thicknesses (MT) were measured by optical coherence tomography (OCT). Ocular blood flow was measured by Color Doppler Ultrasonography in all subjects.

RESULTS

IOP levels in FMT were significantly higher than men (p = 0.025). Superior (Sup), inferior (Inf) thicknesses of parafovea, and nasal thickness of perifovea in FMT were significantly higher than the Group 2 (p = 0.024, p = 0.037, p = 0.018). Sup thickness of perifovea in FMT was significantly higher than Group 3 (p = 0.011). Inf thickness of perifovea in FMT was significantly higher than Group 2 and 3 (p = 0.038, p = 0.002). Mean thickness of RNFL Inf in FMT was significantly higher than the Group 2 and 3 (p = 0.039, p = 0.032). Avg and Inf thicknesses of GCC in FMT were significantly higher than group 2 (p = 0.02, p = 0.005). In correlation test, systole/diastole ratio(S/D) in ophthalmic artery (OA) (r = 0.504, p = 0.028) and Inf thickness of perifovea (r = 0.485, p = 0.035) were positively correlated with the serum levels of testosterone in FMT.

CONCLUSIONS

We found that the use of supraphysiologic testosterone dose increased IOP and the thicknesses of macula, RNFL, and GCC in FMT. Serum testosterone level was positively correlated with S/D ratio in the OA.

The association between hormonal contraceptive use and glaucoma in women of reproductive age

AIMS

We aimed to investigate the association between hormonal contraceptive (HC) use and the incidence of glaucoma in females of reproductive age with a focus on duration and type of HCs used.

METHODS

A retrospective cohort study with a case-control analysis (nested case-control) was undertaken using data from IQVIA's electronic medical record (IQVIA, USA) from 2008 to 2018. Within a cohort of 4 871 504 women, cases of glaucoma or ocular hypertension were identified. Subjects were followed to the first diagnosis of glaucoma. Each glaucoma case was matched to four controls by age, body mass index and follow up time. The main outcome measure was the first diagnosis of glaucoma defined by the first ICD-9/10 code for glaucoma or ocular hypertension.

RESULTS

Among 4 871 504 women identified, there were 2366 cases of glaucoma and 9464 controls. Regular users of hormonal contraceptives had an elevated risk of glaucoma compared to non-users with an adjusted incident rate ratio (aIRR) of 1.57 (95% CI: 1.29-1.92). Current users were of greatest risk (aIRR of 2.38, 95% CI: 1.81-3.13), whereas the aIRR among past users was 1.08 (95% CI: 0.82-1.43). The aIRR for glaucoma increased from 0.82 (95% CI: 0.70-0.95) among those with one or two prescriptions in the 2 years prior to the first diagnosis of glaucoma to 1.54 (95% CI: 1.32-1.81) among those with greater than four prescriptions.

CONCLUSIONS

This nested case-control study demonstrated an elevated risk, albeit low, of glaucoma in females of reproductive age who use regular hormonal contraception. Future studies are needed to confirm these findings.

A Phase II, Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial of a Topical Estradiol Ophthalmic Formulation in Postmenopausal Women with Moderate-to-Severe Dry Eye Disease

INTRODUCTION

Dry eye disease (DED) is a multifactorial disorder of the ocular surface. The current phase II study was performed to assess the safety and dose regimen of a recently developed topical estradiol formulation for the treatment of DED.

METHODS

A total of 104 postmenopausal women suffering from moderate-to-severe DED were included. Topical 17-β-estradiol-3-phosphate eye drops were administered in three different dosage groups (group 1, 0.05% twice daily; group 2, 0.1% morning, vehicle in the evening; group 3, 0.1% twice daily) and vehicle twice daily as control group for a total period of 3 months. Clinical signs including Schirmer's test and corneal staining were assessed at baseline and at days 14, 30, 60, and 90. Symptoms of DED were measured using the symptom assessment in dry eye (SANDE) test at the same time points. Safety was assessed via frequency of adverse events.

RESULTS

Schirmer's test II wetting distance significantly increased in all four groups from baseline to day 90 without significant difference between groups (group 1, + 5.6 ± 6.7 mm/5 min; group 2, + 3.7 ± 4.2 mm/5 min; group 3, + 4.8 ± 4.5 mm/5 min; group 4, + 4.0 ± 5.3 mm/5 min). Statistical significance versus baseline was reached earlier in the treatment groups versus the control group. Corneal staining was significantly reduced after the 3-month treatment period with no significant difference between treatment groups. Staining of the inferior cornea, however, showed a significantly more pronounced decrease in the highest dose group compared to vehicle (p = 0.0463). Symptoms score as assessed with the SANDE test decreased at the end of the treatment period in all four groups. Estradiol eye drops showed a favorable safety profile.

CONCLUSION

Our results show that both estradiol eye drops and vehicle are safe and reduce signs and symptoms in postmenopausal women with moderate-to-severe DED. Although the study failed to reach the primary outcome to demonstrate a significant difference between the estradiol eye drops and vehicle in Schirmer's test, improvement occurred earlier in the active groups compared to the control group. The data of the current study will serve as a basis for a larger phase III study to establish a potential therapeutic effect of topical estradiol eye drops.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov registry NCT03821415.

Age and Menopause Effects on Ocular Compliance and Aqueous Outflow

Purpose

Glaucoma is the second leading cause of blindness worldwide. Recent work suggests that estrogen and the timing of menopause play a role in modulating the risk of developing glaucoma. Menopause is known to cause modest changes in intraocular pressure; yet, whether this change is mediated through the outflow pathway remains unknown. Menopause also affects tissue biomechanical properties throughout the body; however, the impact of menopause on ocular biomechanical properties is not well characterized.

Methods

Here, we simultaneously assessed the impact of menopause on aqueous outflow facility and ocular compliance, as a measure of corneoscleral shell biomechanics. We used young (3-4 months old) and middle-aged (9-10 months old) Brown Norway rats. Menopause was induced by ovariectomy (OVX), and control animals underwent sham surgery, resulting in the following groups: young sham (n = 5), young OVX (n = 6), middle-aged sham (n = 5), and middle-aged OVX (n = 5). Eight weeks postoperatively, we measured outflow facility and ocular compliance.

Results

Menopause resulted in a 34% decrease in outflow facility and a 19% increase in ocular compliance (P = 0.011) in OVX animals compared with sham controls (P = 0.019).

Conclusions

These observations reveal that menopause affects several key physiological factors known to be associated with glaucoma, suggesting that menopause may contribute to an increased risk of glaucoma in women.

Significant intraocular pressure associated with open-angle glaucoma: Korea National Health and Nutrition Examination Survey 2010-2011

Objectives

To investigate significant intraocular pressure (IOP) levels associated with the risk of open-angle glaucoma (OAG) in the treatment-naïve Korean population.

Methods

Participants ≥20 years of age in Korea National Health and Nutrition Examination Survey 2010–2011 were divided into two groups, those with higher and lower IOP values, compared with the reference IOP value. We compared the risk of OAG in each group using regression analyses. The IOP value that yielded the highest statistical significance was determined as an IOP significantly associated with the OAG risk.

Results

A total of 7,650 participants (7,292 control, 358 OAG) were included. The mean IOP was significantly higher in OAG group (14.4 ± 2.9 mmHg), compared to control group (13.9 ± 2.7 mmHg, P = 0.022). In association with an increased risk of OAG, the significant IOP value was 18 mmHg (Odds ratio [OR] = 1.79, 95% confidence interval [CI] 1.14–2.80, P = 0.011). Additionally, sex-difference was identified and they were 19 mmHg (OR = 2.79, 95% CI 1.27–6.16, P = 0.011) in men and 18 mmHg (OR = 2.65, 95% CI 1.32–5.33, P = 0.006) in women. The IOP values associated with significantly decreased risk of glaucoma were determined to be 14 mmHg in men (OR = 0.68, 95% CI 0.47–0.99, P = 0.042) and 16 mmHg in women (OR = 0.47, 95% CI 0.27–0.81, P = 0.007).

Conclusions

In consideration of the risk to benefit ratio, the reference IOP level for screening or setting the target IOP for treatment could be considered different from traditional 21 mmHg in Korean population.

The effect of hormone therapy on the ocular surface and intraocular pressure for postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of the study was to investigate the impact of hormone therapy (HT) on the ocular surface and intraocular pressure in postmenopausal women.

METHODS

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. PubMed, EMBASE, Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure were searched from inception to November 2019 without language restrictions. Only randomized controlled trials that evaluated the impact of HT on the ocular surface and intraocular pressure in postmenopausal women were eligible. The trials had to report at least one of the following outcomes: break-up time, Schirmer test, corneal staining, ocular surface symptom score, and intraocular pressure. Two investigators independently extracted the information, assessed the risk of bias, and evaluated the publication bias. All data were analyzed by Review Manager V.5.3. Sensitivity analysis and subgroup analysis were performed to find the source of heterogeneity and evaluate the different effects among subgroups.

RESULTS

Nine randomized controlled trials (N = 612) were included. The HT group showed significant improvements compared with the control group in break-up time (mean difference [MD] = 2.09, 95% confidence interval [CI] 1.00-3.19, P = 0.0002), Schirmer test without anesthesia (MD = 4.17, 95% CI 1.55-6.80, P = 0.002), Schirmer test with anesthesia (MD = 1.44, 95% CI 0.71-2.18, P = 0.0001), and corneal staining scores (standardized mean difference [SMD] = -0.85, 95% CI -1.39 to -0.30, P = 0.002). Moreover, significant beneficial effects were observed on all four symptoms, including dryness (SMD = -1.21, 95% CI -1.99 to -0.44, P = 0.002), foreign body sensation (SMD = -1.02, 95% CI -1.29 to -0.76, P < 0.00001), ocular fatigue (SMD = -1.74, 95% CI -2.12 to -1.36, P < 0.00001), and burning (SMD = -0.53, 95% CI -0.78 to -0.29, P < 0.0001) after HT. Subgroup analysis revealed that, in terms of break-up time, postmenopausal women younger than 55 years achieved more improvements (MD = 0.88, 95% CI 0.16-1.59, P = 0.02) than women older than 55 years old (MD = 2.60, 95% CI -1.34 to 6.55, P = 0.20), and the estrogen subgroup received more benefits (MD = 3.11, 95% CI 0.93-5.30, P = 0.005) than the estrogen plus progestogen subgroup (MD = 0.42, 95% CI -0.02 to 0.85, P = 0.06). Sensitivity analysis and subgroup analysis suggested that the heterogeneity might derive from the methodological quality, the age of participants, and the intervention of the control group. Intraocular pressure (MD = -1.54, 95% CI -3.39 to 0.32, P = 0.10) was not evidently decreased after HT. No more specific adverse events (relative risk  = 1.66, 95% CI 0.41-6.77, P = 0.48) were found in the HT group.

CONCLUSIONS

Our study revealed that HT could improve ocular surface function in postmenopausal women effectively and safely, especially for those who were younger than 55 years, and estrogen only showed more improvements than estrogen plus progestogen. The effectiveness of HT in treating dry eye in postmenopausal women is, however, still a controversial topic. In addition, we did not find HT led to a significant reduction of intraocular pressure.

Gender-related Influences on Superficial Papillary Microcirculation Measured with Optical Coherence Tomography Angiography in Patients with Glaucoma

Purpose: To evaluate the optic nerve head (ONH), macular vessel density, and retinal nerve fiber layer (RNFL) thickness differences between the genders. Material and methods: In this prospective case-control cross-sectional study 111 healthy subjects and 130 primary open-angle glaucoma (OAG) patients were examined with optical coherence tomography angiography (OCT-A (RS-3000 Advance (Nidek, Gamagori, Japan))). The vessel density in the peripapillary and macular area as well as the RNFL thickness was evaluated. Results: Men appeared to have less RNFL thickness compared with women in early glaucomatous group, being significant at the whole circumpapillary retinal nerve fiber layer (cpRNFL) thickness and inferior and nasal quadrants: (cpRNFL) (71.01 ± 9.32 vs 77.64 ± 9.95 μm; P = .001), superior quadrant (89.10 ± 16.63 vs 92.97 ± 17.53 μm; P = .284), inferior quadrant (83.03 ± 19.17 vs 95.07 ± 21.70 μm; P = .006), temporal quadrant (57.11 ± 10.36 vs 61.78 ± 11.37 μm; P = .043), nasal quadrant (54.81 ± 11.42 vs 60.73 ± 11.62 μm; P = .016). Circumpapillary (wcpVD) and macular (wmVD) vessel density values were lower in men than women in the early stage OAG group, being wmVD significantly lower: wcpVD (15.53 ± 2.45% vs 16.81 ± 3.17%, P = .032) and wmVD values (12.51 ± 2.21 vs 13.63 ± 2.28%, P = .019), but not in the moderate OAG group (wcpVD 14.46 ± 2.20% vs 16.61 ± 3.10%, P = .056 and wmVD 12.61 ± 2.40% vs 12.74 ± 2.54%, P = .870). There were no significant differences between men and women for RNFL thickness and the vessel density parameters in normal group. Conclusion: Both, the thickness of the nerve fiber layer and peripapillary and macular vessel density are lower in men than in women with glaucoma, more markedly in early stage glaucomatous patients.

The association of estrogen-signaling pathways and susceptibility to open-angle glaucoma

Background

Glaucoma is a complex multivariate disorder characterized by retinal ganglion cell (RGC) loss and optic nerve degeneration. Evidence suggests the role of estradiol (E2) and the etiology of glaucoma. Therefore, this present study evaluates the association between estrogen-signaling pathways and the risk of open-angle glaucoma (OAG).

Results

Meta-analysis was performed from available studies that investigated intraocular pressure (IOP) in patients treated with or without hormone replacement therapy (HRT) and studies that evaluated the associations between estrogen receptor (ER) polymorphisms and the risk of OAG. The pooled result showed that HRT had a positive effect in lowering IOP. Moreover, ERβ polymorphisms showed a significant association with the risk of OAG.

Conclusion

This report supports the notion that estrogen-signaling pathways play a pivotal role in the development of OAG.

Influence of Sociodemographic Factors on Disease Characteristics and Vision-related Quality of Life in Primary Open-angle Glaucoma Patients: The Italian Primary Open Angle Glaucoma Study (IPOAGS)

PURPOSE

The purpose of this article was to evaluate the potential association between sociodemographic factors with clinical characteristics, vision-related quality of life (QoL), and glaucoma-related symptoms scores in a large cohort of primary open-angle glaucoma patients.

MATERIALS AND METHODS

Multicenter, cross-sectional study involving academic and nonacademic centers. Previously diagnosed primary open-angle glaucoma patients aged >18 years were enrolled. At baseline, information on demographic characteristics, social, medical and ocular history, clinical presentation and treatments was collected. Vision-related QoL was evaluated by means of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), while glaucoma-related symptoms were evaluated using the Glaucoma Symptom Scale (GSS) questionnaire. The associations between sociodemographic factors with clinical characteristics (mean deviation, pattern standard deviation, best-corrected visual acuity), NEI-VFQ-25, and GSS scores were evaluated by means of univariate and multivariate general linear models.

RESULTS

A total of 3227 patients were enrolled. Older age and male sex were significantly associated with lower mean deviation (P<0.01) and higher pattern standard deviation (P<0.01), whereas older age was associated with lower best-corrected visual acuity (P<0.01). The composite GSS score was related to age (P=0.02), sex (P<0.01), employment (P=0.01), and profession (P=0.04), while the total NEI-VFQ-25 score was associated with sex (P<0.01), marital status (P=0.02), and employment (P=0.02).

CONCLUSIONS

Age and sex were significantly associated with almost all indicators of glaucoma severity at baseline. Other variables, such as employment, profession, and marital status were significantly associated with vision-related QoL scores.

Sex hormone levels and risk of primary open-angle glaucoma in postmenopausal women

OBJECTIVE

We evaluated the relation of prediagnostic sex hormone levels in postmenopausal women with primary open-angle glaucoma (POAG) and intraocular pressure (IOP).

METHODS

Among postmenopausal participants of the Nurses' Health Study, POAG cases (n = 189; diagnosed 1990-2008) and controls (n = 189) were matched on age, fasting status, and postmenopausal hormone use at blood draw (1989-1990). Plasma concentrations of estrone sulfate, estradiol, testosterone, sex hormone binding globulin, and dehydroepiandrosterone sulfate were assessed. The primary outcome was POAG; in secondary analyses, among cases only, we evaluated maximum untreated IOP at diagnosis. Multivariable-adjusted logistic/multiple linear regression models were used to evaluate tertiles (Ts) of biomarker levels and the two outcomes, adjusting for various potential confounders.

RESULTS

We observed no significant associations of estrone, estradiol, sex hormone binding globulin, or dehydroepiandrosterone sulfate with POAG risk or with maximum IOP at glaucoma diagnosis among cases. Suggestive significant associations were observed with highest testosterone and POAG risk (T3 vs T1 multivariable-adjusted odds ratio 1.84; 95% confidence interval 1.02, 3.33; P trend 0.10). Similarly, for maximum IOP at diagnosis among cases only (mean 8 years after blood draw), higher testosterone was significantly associated with higher IOP (multivariable-adjusted difference in IOP T3 vs T1 2.17 mm Hg; 95% confidence interval 0.34, 3.99; P trend 0.02).

CONCLUSIONS

Overall, plasma sex hormone levels in postmenopausal women were not associated with POAG risk; however, a trend of higher testosterone levels being associated with higher POAG risk and higher IOP at diagnosis was observed and needs confirmation.

Effects of Sex Hormones on Ocular Blood Flow and Intraocular Pressure in Primary Open-angle Glaucoma: A Review

Primary open-angle glaucoma (POAG) is a multifactorial optic neuropathy characterized by progressive retinal ganglion cell death and visual field loss. Some speculate that sex plays a role in the risk of developing POAG and that the physiological differences between men and women may be attributed to the variable effects of sex hormones on intraocular pressure, ocular blood flow, and/or neuroprotection. Estrogen, in the form of premenopausal status, pregnancy, and postmenopausal hormone therapy is associated with an increase in ocular blood flow, decrease in intraocular pressure and neuroprotective properties. The vasodilation caused by estrogen and its effects on aqueous humor outflow may contribute. In contrast, although testosterone may have known effects in the cardiovascular and cerebrovascular systems, there is no consensus as to its effects in ocular health or POAG. With a better understanding of sex hormones in POAG, sex hormone-derived preventative and therapeutic considerations in disease management may provide for improved sex-specific patient care.

A review of systemic medications that may modulate the risk of glaucoma

With increasing longevity, patients are developing more and more chronic diseases that require treatment with medications. Yet, it is not fully understood the extent by which these systemic medications affect ocular structures and whether they may increase or decrease the risk of sight-threatening ocular diseases. This review provides a summary of reported associations between different systemic medications and the risk of developing glaucoma or experiencing disease progression. Medication classes covered in this review that are known to or may modulate the risk of open-angle glaucoma include corticosteroids, beta blockers, calcium channel blockers, metformin, statins, selective serotonin reuptake inhibitors, bupropion, postmenopausal hormones, and cannabinoids. Medication classes addressed in this review that may increase the risk of angle closure glaucoma include anticholinergics, adrenergic agonists, certain classes of antidepressants, sulfonamides, and topiramate.

The Association Between Body Mass Index and Open-angle Glaucoma in a South Korean Population-based Sample

PURPOSE

The purpose of this article is to investigate the association between body mass index (BMI) and open-angle glaucoma (OAG) in a sample of the South Korean population.

MATERIALS AND METHODS

The sample consisted of a cross-sectional, population-based sample of 10,978 participants, 40 years of age and older, enrolled in the 2008 to 2011 Korean National Health and Nutrition Examination Survey. All participants had measured intraocular pressure <22 mm Hg and open anterior chamber angles. OAG was defined using disc and visual field criteria established by the International Society for Geographical and Epidemiological Ophthalmology. Multivariable analyses were performed to determine the association between BMI and OAG. These analyses were also performed in a sex-stratified and age-stratified manner.

RESULTS

After adjusting for potential confounding variables, lower BMI (<19 kg/m) was associated with greater risk of OAG compared with normal BMI (19 to 24.9 kg/m) [odds ratio (OR), 2.28; 95% confidence interval (CI), 1.22-4.26]. In sex-stratified analyses, low BMI remained adversely related to glaucoma in women (OR, 3.45; 95% CI, 1.42-8.38) but not in men (OR, 1.72; 95% CI, 0.71-4.20). In age-stratified analyses, lower BMI was adversely related to glaucoma among subjects 40- to 49-year old (OR, 5.16; 95% CI, 1.86-14.36) but differences in glaucoma prevalence were not statistically significant between those with low versus normal BMI in other age strata.

CONCLUSIONS

Lower BMI was associated with increased odds of OAG in a sample of the South Korean population. Multivariate analysis revealed the association to be statistically significant in women and those in the youngest age stratum.

Hormone replacement therapy for dry eye disease patients: systematic review and meta-analysis

Hormone replacement therapy (HRT) is used by women to get relief from menopausal symptoms, including dry eyes. However, it is not entirely certain that HRT helps relieve dry eye disease (DED). The focus of this study is to systematically review the literature of the relevant studies to understand and determine the correlation between HRT and DED. Literature was systematically reviewed using Distiller SR. Meta-analysis was conducted using STATA 15.0. Standardized mean difference (SMD) and 95% confidence interval (CI) were calculated, and heterogeneity was assessed using statistics. Fixed-effect and random-effects models were computed based on heterogeneity. Subgroups analysis was done by follow-up. Our meta-analysis results indicated significant reduction in dry eye with HRT treatment at 1-month follow-up (SMD = -1.97; CI: -3.83, -0.11), a nonsignificant increase in tear breakup time at 3-month (SMD = -0.91; CI: -3.26, 1.44) and 6-month (SMD = -1.05; CI: -3.91, 1.82) follow-ups. Our meta-analysis results indicated a nonsignificant improvement in DED with HRT treatment at 1-month (SMD = -0.97; CI: -2.35, 0.4), 3-month (SMD = 0.19; CI: -0.91, 1.29), and 6-month (SMD = -0.48; CI: -1.39, 0.43) follow-ups.Overall, nonsignificant improvement in postoperative tear production, as well as tear breakup time, was seen after HRT treatment at follow-ups in dry eye patients. More good-quality randomized control trials are needed to make accurate conclusions.

Sex Hormones and Optic Nerve Disorders: A Review

Aim: This review article presents a comprehensive overview of the literature on sex hormones (estrogens, androgens, progesterone) and optic nerve disorders, with a discussion of the implications for therapy and prevention.

Methods: Epidemiological, pre-clinical and clinical studies were reviewed.

Results: Analysis of the biological basis for a relationship between eye diseases and sex hormones showed that some types of hormones can exert a protective effect either directly on the retina and optic nerve or indirectly by modulating ocular blood flow. For example, it seems that estrogen exposure has a protective effect against glaucoma, whereas its deficit may lead to early onset of the disease. If further studies confirm the data in the literature, estrogen therapy, because of its antioxidant action, may be effective in the treatment of Leber's hereditary optic neuropathy, whereas, in the light of current studies, there does not seem to be an influence of estrogen on non-arteritic anterior ischemic optic neuritis (NAION).

Conclusions: Although there is some evidence that in some optic nerve pathologies the sex hormones seem to play an important role there are still too few studies providing evidence for its wider use in clinical practice.

Racial Differences in the Effects of Hormone Therapy on Incident Open-Angle Glaucoma in a Randomized Trial

PURPOSE

We conducted a secondary analysis of a randomized, placebo-controlled trial to test if hormone therapy (HT) altered the risk of open-angle glaucoma (OAG), and if the risk reduction varied by race.

DESIGN

Secondary analysis of randomized controlled trial data.

METHODS

We linked Medicare claims data to 25 535 women in the Women's Health Initiative. Women without a uterus were randomized to receive either oral conjugated equine estrogens (CEE 0.625 mg/day) or placebo, and women with a uterus received oral CEE and medroxyprogesterone acetate (CEE 0.625 mg/day + MPA 2.5 mg/day) or placebo. We used Cox proportional hazards models to calculate hazard ratios (HR) and 95% confidence interval.

RESULTS

After exclusion of women with prevalent glaucoma or without claims for eye care provider visits, the final analysis included 8102 women (mean age = 68.5 ± 4.8 years). The OAG incidence was 7.6% (mean follow-up = 11.5 ± 5.2 years; mean HT duration = 4.4 ± 2.3 years). Increased age (P trend = .01) and African-American race (HR = 2.69, 95% CI = 2.13-3.42; white as a reference) were significant risk factors for incident OAG. We found no overall benefit of HT in reducing incident OAG (HR = 1.01, 95% CI = 0.79-1.29 in the CEE trial, and HR = 1.05, 95% CI = 0.85-1.29 in the CEE + MPA trial). However, race modified the relationship between CEE use and OAG risk (P interaction = .01), and risk was reduced in African-American women treated with CEE (HR = 0.49, 95% CI = 0.27-0.88), compared to placebo. Race did not modify the relation between CEE + MPA use and OAG risk (P interaction = .68).

CONCLUSIONS

Analysis suggests that HT containing estrogen, but not a combination of estrogen and progesterone, reduces the risk of incident OAG among African-American women. Further investigation is needed.

The Association between Female Reproductive Factors and Open-Angle Glaucoma in Korean Women: The Korean National Health and Nutrition Examination Survey V

Purpose

We investigated associations between female reproductive factors and open-angle glaucoma (OAG) in Korean females using the Korea National Health and Nutrition Examination Survey (KNHANES).

Methods

A nationwide, population-based, cross-sectional study was conducted. We enrolled 23,376 participants from the KNHANES who had undergone ophthalmologic exams from 2010 through 2012. Associations between undiagnosed OAG and female reproductive factors such as age at menarche and menopause, parity, history of lactation, and administration of oral contraceptives (OC) or hormone replacement therapy (HRT) were determined using stepwise logistic regression analyses.

Results

Of the enrolled participants, 6,860 participants (397 with OAG and 6,463 without OAG) met our study criteria and were included in the analyses. In the multivariate logistic regression analysis after adjusting for all potential confounding factors, only early menopause (younger than 45 years) was significantly associated with OAG in participants with natural menopause (OR 2.28, 95% CI 1.17–4.46). Age at menarche, parity, history of lactation, and administration of OC or HRT were not significantly associated with OAG.

Conclusions

Only early menopause was associated with an increased risk of OAG in our study, in contrast to previous Western studies reporting both early menopause and late menarche as associated factors.

Comparison of Visual Function and Ocular Hemodynamics between Pre- and Post-Menopausal Women

Purpose

The incidence of eye disease increases with age and can often be linked to worsening cardiovascular function and increasing intraocular pressure. Estrogen is known to have vasodilatory effects in the systemic circulation. Decreased estrogen levels during menopause may therefore complicate or contribute to ocular pathologies as estrogen receptors are found in both retinal and choroidal tissue. The purpose of this investigation was to determine the effects of menopause on visual function and cardiovascular and ocular hemodynamics.

Methods

Twelve premenopausal and 24 postmenopausal women were evaluated at the Indiana University School of Medicine during a single study visit. Vision screening and ocular blood flow evaluations were performed, including blood pressure, heart rate, visual acuity, contrast sensitivity, intraocular pressure, and retinal capillary and retrobulbar blood flow imaging. Vision and ocular hemodynamics were compared using unpaired Student t-tests with pp<0.05 regarded as statistically significant.

Results

The premenopausal group had significantly lower heart rate (-16.1 b/m, p=0.0001) and systolic blood pressure (-17.7 mmHg, p=0.003) than postmenopausal subjects. Contrast sensitivity was significantly higher (measured in log units) in premenopausal women in both the right (0.25, p=0.039; 0.16, p=0.039) and left (0.45, p=0.001; 0.27, p=0.032) eyes at 9 and 18 cycles per degree, respectively. Premenopausal women also had significantly lower intraocular pressure in both the right (-2.19 mmHg, p=0.024) and left (-1.74 mmHg, p=0.035) eyes. Total ocular perfusion was not significantly different between groups.

Conclusions

This pilot work suggests that postmenopausal women have lower contrast sensitivity detection and elevated intraocular pressures compared to premenopausal women. Premenopausal women have lower cardiovascular risk factors, while total ocular circulation was similar to post-menopausal women.

Gonadal Hormones and Retinal Disorders: A Review

AIM

Gonadal hormones are essential for reproductive function, but can act on neural and other organ systems, and are probably the cause of the large majority of known sex differences in function and disease. The aim of this review is to provide evidence for this hypothesis in relation to eye disorders and to retinopathies in particular.

METHODS

Epidemiological studies and research articles were reviewed.

RESULTS

Analysis of the biological basis for a relationship between eye diseases and hormones showed that estrogen, androgen, and progesterone receptors are present throughout the eye and that these steroids are locally produced in ocular tissues. Sex hormones can have a neuroprotective action on the retina and modulate ocular blood flow. There are differences between the male and the female retina; moreover, sex hormones can influence the development (or not) of certain disorders. For example, exposure to endogenous estrogens, depending on age at menarche and menopause and number of pregnancies, and exposure to exogenous estrogens, as in hormone replacement therapy and use of oral contraceptives, appear to protect against age-related macular degeneration (both drusenoid and neurovascular types), whereas exogenous testosterone therapy is a risk factor for central serous chorioretinopathy. Macular hole is more common among women than men, particularly in postmenopausal women probably owing to the sudden drop in estrogen production in later middle age. Progestin therapy appears to ameliorate the course of retinitis pigmentosa. Diabetic retinopathy, a complication of diabetes, may be more common among men than women.

CONCLUSION

We observed a correlation between many retinopathies and sex, probably as a result of the protective effect some gonadal hormones may exert against the development of certain disorders. This may have ramifications for the use of hormone therapy in the treatment of eye disease and of retinal disorders in particular.

Local synthesis of sex hormones: are there consequences for the ocular surface and dry eye?

Sex hormones are associated with the physiology and pathophysiology of almost all organs in the body, as well as most diseases. Interest in the associations between sex hormones and ocular tissues has increased in recent years. Androgens may have a positive effect on dry eye, whereas the effects of oestrogen on ocular conditions remain unclear. Intracrinology, the local synthesis and metabolism of hormones that is unique to humans, is of relevance to the eye and may help to explain why studies of the relationship between oestrogens and dry eye signs and symptoms are inconclusive. Knowledge of the pathways of hormone formation and metabolism is crucial to understanding the pathogenesis of ocular disease including dry eye. This review examines the mechanisms of steroidal sex hormone biosynthesis and reviews the significance of locally produced sex hormones, with a focus on ocular surface tissues. Much of the current literature is based on animal studies, which may not be transferable to humans due to the absence of intracrine production in animals. A large proportion of the human studies investigate systemic hormone levels rather than local levels. There is subsequently a need for additional studies to provide a better understanding of the local production of sex hormones within the human eye and ocular surface and to clarify the relationships between ocular levels of sex hormones and conditions including dry eye.

TFOS DEWS II Sex, Gender, and Hormones Report

One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.

The association between periodontal disease and age-related macular degeneration in the Korea National health and nutrition examination survey: A cross-sectional observational study

Periodontal disease (PD) is associated with various systemic diseases. We investigated the association between PD and age-related macular degeneration (AMD).For this population-based, cross-sectional study, we enrolled 13,072 adults at least 40 years of age with gradable retinal fundus photographs and community periodontal index (CPI) data from the Korean National Health and Nutrition Examination Survey (KNHANES) (2008-2010 and 2012). Participants were divided into a middle age group (age ≤62 years) and old age group (age >62 years). PD was divided into 2 categories of mild and severe. Logistic regression analysis was used to evaluate the association between PD and AMD (early and late).The prevalence of PD and AMD in the study population was 37.4% ± 0.8% and 5.6% ± 0.2%, respectively. Overall, there was no significant difference in the proportion of participants with PD between those with and without AMD. Only participants with AMD in the middle age group had more any PD than those without AMD (P = 0.031). Multivariate logistic regression model after adjusting for all confounding factors showed that PD was not significantly associated with AMD (odds ratio [OR] 1.03, 95% confidence interval [CI] 0.86-1.22). However, according to degree of PD, participants with severe PD in the middle age group were 1.61 times more likely to have AMD (OR 1.61, 95% CI 1.02-2.54).Our data, collected from an Asian population, showed that only severe PD is independently associated with AMD in individuals aged 62 years or younger.

Transient Monocular Vision Loss on Awakening: A Benign Amaurotic Phenomenon

BACKGROUND

Transient monocular vision loss (TMVL) is an alarming symptom owing to potentially serious etiologies such as thromboembolism or giant cell arteritis. Our objective is to describe the phenomenon of TMVL present on awakening, which may represent a distinct and benign entity.

METHODS

We performed a retrospective observational case series of 29 patients who experienced TMVL on awakening. Patients who described monocular dimming or blackout of vision were included, and those with blurred vision, concurrent eye pain, and binocular vision loss were excluded. Descriptive statistics were used to summarize the study population.

RESULTS

Of the 29 patients we studied, 90% (n = 26) were female and 48% had crowded discs (cup-to-disc ratio ≤0.2). The mean age was 45.4 years, although women were significantly younger than men (mean ages 43.4 and 62.7 years, respectively, P = 0.017). Brain magnetic resonance imaging and vascular imaging (magnetic resonance angiography, computed tomographic angiography, or carotid Doppler) were performed in 69% and 55% of cases, respectively, and were uniformly negative. In 14 patients for whom clear follow-up data could be obtained, no medically or visually significant sequelae of this syndrome were found, and 50% experienced resolution of symptoms.

CONCLUSIONS

Evaluation was uniformly negative when patients described waking with isolated vision loss in 1 eye with subsequent resolution, usually in less than 15 minutes. The natural history seems benign with symptoms frequently remitting spontaneously. This visual phenomenon may represent an autoregulatory failure resulting in a supply/demand mismatch during low-light conditions.

Contribution of the Nurses' Health Study to the Epidemiology of Cataract, Age-Related Macular Degeneration, and Glaucoma

OBJECTIVES

To review the contribution of the Nurses' Health Study (NHS) to understanding the genetic and lifestyle factors that influence the risk of cataract, age-related macular degeneration, and glaucoma.

METHODS

We performed a narrative review of the publications of the NHS between 1976 and 2016.

RESULTS

The NHS has helped to elucidate the roles of genetics, lifestyle factors (e.g., cigarette smoking associated with cataract extraction and age-related macular degeneration), medical conditions (e.g., diabetes associated with cataract extraction and glaucoma), and dietary factors (e.g., greater carotenoid intake and lower glycemic diet associated with lower risk of age-related macular degeneration) in the etiology of degree and progression of lens opacities, cataract extraction, age-related macular degeneration, primary open-angle glaucoma, and exfoliation glaucoma.

CONCLUSIONS

The findings from the NHS, combined with those of other studies, have provided compelling evidence to support public health recommendations for helping to prevent age-related eye diseases: abstinence from cigarette smoking, maintenance of healthy weight and diabetes prevention, and a healthy diet rich in fruits and vegetables.

Effects of Hormone Therapy on Intraocular Pressure: The Women's Health Initiative-Sight Exam Study

PURPOSE

Previous studies suggest that hormone therapy favorably affects intraocular pressure (IOP). Here, we examined the association between hormone therapy use and IOP in the context of a large randomized trial.

DESIGN

Secondary data analysis from a randomized controlled trial.

METHODS

We used data from the Women's Health Initiative-Sight Exam (WHISE). Women with prior hysterectomy received oral conjugated equine estrogen (0.625 mg/day) or placebo. Women with a uterus received estrogen plus progestin (medroxyprogesterone acetate 2.5 mg/day) or placebo. IOP was measured 5 years after randomization. Adjusted linear regression models were used to assess the association between hormone therapy and IOP.

RESULTS

The WHISE included 1668 women in the estrogen-alone trial (aged 63-86, mean 72 years) and 2679 women in the estrogen-plus-progestin trial (aged 63-87, mean 72 years). In multivariate analyses, compared to placebo treatment, treatment with estrogen alone was associated with a 0.5 mm Hg reduction of the IOP in the right eye (95% CI: -0.8, -0.1, P = .005) and a 0.6 mm Hg (95% CI: -0.9, -0.3, P < .001) reduction of the IOP in the left eye. In the estrogen-plus-progestin trial, there was no significant difference in IOP between the treatment and placebo groups (P = .30 right eye and P = .43 left eye).

CONCLUSIONS

This study represents an IOP analysis in the largest hormone trial available. Estrogen-alone therapy in postmenopausal women is associated with a small but significant IOP reduction of 0.5 mm Hg. The clinical significance of this small decrease remains to be determined.

Oral Contraceptive Use and Prevalence of Self-Reported Glaucoma or Ocular Hypertension in the United States

PURPOSE

To investigate the association between oral contraceptive (OC) use and glaucoma prevalence in the United States.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 3406 female participants, aged 40 years or older, from the 2005 to 2008 National Health and Nutrition Examination Survey, who reported a presence or absence of glaucoma or ocular hypertension completed both the vision and the reproductive health questionnaires and underwent eye examinations.

METHODS

Multivariate regression analysis was used to assess the correlation between OC use and self-reported glaucoma or ocular hypertension (n = 231 cases), controlling for potential confounders, including age, ethnicity, systemic comorbidities such as hypertension and stroke, ocular diseases such as cataract and diabetic retinopathy, and reproductive health factors, including age at menopause, age at menarche, history of hormone replacement therapy, and gynecological surgical history.

MAIN OUTCOME MEASURES

The outcome variable was self-reported glaucoma or ocular hypertension.

RESULTS

After adjusting for confounders, those with ≥3 years of OC use had greater odds (odds ratio, 1.94; 95% confidence interval, 1.22-3.07) of self-reported glaucoma or ocular hypertension. Other factors associated with higher glaucoma or ocular hypertension prevalence included older age, African American race, and later age at menarche.

CONCLUSIONS

Oral contraceptive use may be associated with increased risk of self-reported glaucoma or ocular hypertension.

Association Between Glaucoma and the Risk of Dementia

We investigated the association of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) with the risk of dementia by evaluating their clinical and epidemiological similarities by using a nationally representative sample in Taiwan. Data were collected from the National Health Insurance Research Database of Taiwan. In total, 6509 patients with glaucoma (3304 with POAG and 3205 with PACG) were enrolled, and a comparison cohort of 26,036 individuals without glaucoma was established after matching for age and sex. The cumulative incidence curve of overall dementia for each cohort was evaluated. The risk of dementia was analyzed using univariate and multivariate Cox proportional hazard models after adjustment for demographic characteristics and comorbidities. The patients with glaucoma exhibited a significantly higher risk of dementia than the individuals without glaucoma did (hazard ratio [HR] = 1.13, 95% confidence interval [CI] = 1.01-1.27). The patients with POAG exhibited a 1.21-fold increased risk of dementia compared with the individuals without glaucoma (HR = 1.21, 95% CI = 1.02-1.43). However, the patients with PACG were not significantly associated with an increased risk of dementia compared with the individuals without glaucoma (HR = 1.09, 95% CI = 0.95-1.26). Patients with POAG aged ≥65 years were significantly associated with an increased risk of dementia compared with the individuals without glaucoma (HR = 1.28, 95% CI = 1.07-1.54). Females with POAG exhibited a 1.34-fold increased risk of dementia compared with females without glaucoma (95% CI = 1.06-1.69). This study demonstrated that patients with POAG but not those with PACG were associated with an increased risk of dementia compared with the general population.

Is Estrogen a Therapeutic Target for Glaucoma?

This article's objective is to provide an overview of the association between estrogen and glaucoma. A literature synthesis was conducted of articles published in peer-reviewed journals screened through May 5, 2015, using the PubMed database. Keywords used were "estrogen and glaucoma," "reproductive factors and glaucoma," and "estrogen, nitric oxide and eye." Forty-three journal articles were included. Results indicated that markers for lifetime estrogen exposure have been measured by several studies and show that the age of menarche onset, oral contraceptive (OC) use, bilateral oophorectomy, age of menopause onset and duration between menarche to menopause are associated with primary open-angle glaucoma (POAG) risk. The Blue Mountain Eye Study found a significantly increased POAG risk with later (>13 years) compared with earlier (≤12 years) age of menarche. Nurses' Health Study (NHS) investigators found that OC use of greater than 5 years was associated with a 25% increased risk of POAG. The Mayo Clinic Cohort Study of Oophorectomy and Aging found that women who underwent bilateral oophorectomy before age 43 years had an increased risk of glaucoma. The Rotterdam Study found that women who went through menopause before reaching the age of 45 years had a higher risk of open-angle glaucoma (2.6-fold increased risk), while the NHS showed a reduced risk of POAG among women older than 65 who entered menopause after age ≥ 54 years. Increased estrogen states may confer a reduced risk of glaucoma or glaucoma-related traits such as reduced intraocular pressure (IOP). Pregnancy, a hyperestrogenemic state, is associated with decreased IOP during the third trimester. Though the role of postmenopausal hormone (PMH) use in the reduction of IOP is not fully conclusive, PMH use may reduce the risk of POAG. From a genetic epidemiologic perspective, estrogen metabolic pathway single nucleotide polymorphisms (SNPs) were associated with POAG in women and polymorphisms in endothelial nitric oxide synthase, a gene receptive to estrogen regulation, are associated with glaucoma. The study concluded that increasing evidence suggests that lifetime exposure to estrogen may alter the pathogenesis of glaucoma. Estrogen exposure may have a neuroprotective effect on the progression of POAG but further studies need to confirm this finding. The role of sex-specific preventive and therapeutic treatment may be on the horizon.

Natural compounds and retinal ganglion cell neuroprotection

Glaucoma, the second leading cause of blindness in the world, is a chronic optic neuropathy often associated with increased intraocular pressure and characterized by progressive retinal ganglion cell (RGC) axons degeneration and death leading to typical optic nerve head damage and distinctive visual field defects. Although the pathogenesis of glaucoma is still largely unknown, it is hypothesized that RCGs become damaged through various insults/mechanisms, including ischemia, oxidative stress, excitotoxicity, defective axonal transport, trophic factor withdrawal, and neuroinflammation. In this review, we summarize the potential benefits of several natural compounds for RGCs neuroprotection.

Longitudinal analysis of age-related changes in intraocular pressure in South Korea

PURPOSE

To assess the changes in intraocular pressure (IOP) with age in South Korea.

METHODS

Subjects aged 20-79 who had been receiving health examinations at a university hospital were enrolled. They completed physical and ophthalmic examinations. Subjects with ocular disease that could possibly affect their IOP were excluded. The relationships between IOP and age, blood pressure, heart rate, body mass index, blood chemistry, and electrolyte were analyzed using a linear mixed model.

RESULTS

Of the 33 712 subjects, 31 857 participants were enrolled. In a cross-sectional analysis, IOP also showed a negative correlation in all age groups (respectively, P<0.001). In particular, patients in their 60s~80s had a less steep decreasing slope of IOP with age than patients in their 20s~30s (correlation coefficient -0.260 and -0.168, respectively). In longitudinal analysis, negative trend was shown in the slope of tendency in total subjects. When analyzing the effect of gender on the relationship between age and IOP, females had a less steep decreasing slope of IOP with age than males by 0.05 mm Hg. With regard to systemic parameters, systolic blood pressure and heart rate were positively correlated with IOP (P<0.001).

CONCLUSION

IOP was significantly decreased with age, although the amount of change was small. In women and older age groups, IOP was less decreased than that of men and young age groups. In addition, IOP was positively associated with systolic blood pressure and heart rate.

[Treating severe keratoconjunctivitis sicca]

Keratoconjunctivitis sicca is a widespread disease with a complex multifactorial pathogenesis. Current understanding of its pathogenesis and existing treatments are summarized in this literature review.