Short-Term Changes in the Photopic Negative Response Following Intraocular Pressure Lowering in Glaucoma

Addressing neurodegeneration in glaucoma: Mechanisms, challenges, and treatments

Glaucoma is the leading cause of irreversible blindness globally. The disease causes vision loss due to neurodegeneration of the retinal ganglion cell (RGC) projection to the brain through the optic nerve. Glaucoma is associated with sensitivity to intraocular pressure (IOP). Thus, mainstay treatments seek to manage IOP, though many patients continue to lose vision. To address neurodegeneration directly, numerous preclinical studies seek to develop protective or reparative therapies that act independently of IOP. These include growth factors, compounds targeting metabolism, anti-inflammatory and antioxidant agents, and neuromodulators. Despite success in experimental models, many of these approaches fail to translate into clinical benefits. Several factors contribute to this challenge. Firstly, the anatomic structure of the optic nerve head differs between rodents, nonhuman primates, and humans. Additionally, animal models do not replicate the complex glaucoma pathophysiology in humans. Therefore, to enhance the success of translating these findings, we propose two approaches. First, thorough evaluation of experimental targets in multiple animal models, including nonhuman primates, should precede clinical trials. Second, we advocate for combination therapy, which involves using multiple agents simultaneously, especially in the early and potentially reversible stages of the disease. These strategies aim to increase the chances of successful neuroprotective treatment for glaucoma.

Retinal Ganglion Cell Function and Perfusion following Intraocular Pressure Reduction with Preservative-Free Latanoprost in Patients with Glaucoma and Ocular Hypertension

(1) Background: Given the global prevalence of glaucoma and the crucial role of intraocular pressure (IOP) reduction in the management of the disease, understanding the immediate effects on retinal structure and function is essential. (2) Methods: This study aimed to assess the effects of preservative-free latanoprost on morphological and functional parameters in treatment-naïve patients with ocular hypertension and open-angle glaucoma. (3) Results: This study showed a significant reduction in IOP by an average of 30.6% after treatment with preservative-free latanoprost. Despite the significant reduction in IOP, no statistically significant changes were observed in the electroretinogram (ERG) nor the optical coherence tomography/angiography (OCT/OCTA) parameters compared to baseline. An exploration of the correlation between IOP changes and various parameters revealed a significant association solely with the macular IPL/INL plexus vessel density (VD) measured with OCTA. (4) Conclusions: This finding suggests a possible association between IOP reduction and changes in the macular microcirculation and provides valuable insights into the differential effects of latanoprost. Acknowledging the study limitations, this study emphasizes the need for larger, longer-term investigations to comprehensively assess the sustained effects of preservative-free latanoprost on both IOP and retinal parameters. In addition, exploring systemic factors and conducting subgroup analyses could improve personalized approaches to glaucoma treatment.

Early changes in photopic negative response in eyes with glaucoma with and without choroidal detachment after filtration surgery

BACKGROUND/AIMS

To evaluate the electroretinographic (ERG) changes in the early postoperative period following glaucoma filtration surgery, and its relationship with choroidal detachment (CD).

METHODS

This retrospective observational single-centre study included 57 consecutive patients with primary open-angle glaucoma who underwent unilateral glaucoma filtration surgery. The patients were divided into two groups according to the presence or absence of CD. ERG components, including the photopic negative response (PhNR), a-wave and b-wave were compared before and after surgery using skin electrodes.

RESULTS

There were 46 patients in the non-CD group and 11 in the CD group. ERG was recorded within 5.1 (2.1 to 8.1) (mean (95% CI)) days after surgery. In the non-CD group, the PhNR amplitude, PhNR/b-wave amplitude ratio and PhNR implicit time improved significantly after surgery (p=0.008, 0.002 and 0.039, respectively). In the CD group, the amplitude of the PhNR, a-wave and b-wave were significantly deteriorated after surgery (p=0.002, 0.001 and 0.001, respectively). Postoperative intraocular pressure (IOP) (p=0.031) and postoperative CD (p<0.001) were significantly associated with change in the PhNR amplitude in the univariate models. In the multivariate analysis, severe CD (stage 3) cases tended to be deteriorated more.

CONCLUSION

Even in the early postoperative period within several days, the PhNR amplitude increased with IOP lowering following filtration surgery in the absence of CD. The presence of CD may arrest the improvement of the retinal ganglion cell function. The present results enhance understanding the structural and functional recovery after glaucoma surgery and the role of postoperative CD.

Nobiletin protects retinal ganglion cells in models of ocular hypertension in vivo and hypoxia in vitro

Glaucoma, a common cause of blindness, is characterized by the progressive loss of retinal ganglion cells (RGCs). Growing evidence suggests that nobiletin (NOB) is a promising neuroprotective drug; however, its effects on glaucomatous neurodegeneration remain unknown. Using rat models of microbead occlusion in vivo and primary RGCs model of hypoxia in vitro, we first demonstrate that NOB reduces RGC apoptosis by a TUNEL assay, Hoechst 33342 staining and FluoroGold (FG) retrograde labeling. This effect does not depend on intraocular pressure (IOP) lowering. Additionally, NOB partially restored the functional and structural damage of inner retinas, attenuated Müller glial activation and oxidative stress caused by ocular hypertension. At 2 weeks after IOP elevation, NOB further enhanced Nrf2/HO-1 pathway in RGCs to withstand the cumulative damage of ocular hypertension. With the administration of HO-1 inhibitor tin-protoporphyrin IX (SnPP), the protective effect of NOB was attenuated. Overall, these results indicate that NOB exerts an outstanding neuroprotective effect on RGCs of glaucomatous neurodegeneration. Besides, interventions to enhance activation of Nrf2/HO-1 pathway can slow the loss of RGCs and are viable therapies for glaucoma.

Time-Frequency Analysis of ERG With Discrete Wavelet Transform and Matching Pursuits for Glaucoma

Purpose

To examine the performance of two time-frequency feature extraction techniques applied to electroretinograms (ERGs) for the prediction of glaucoma severity.

Methods

ERGs targeting the photopic negative response were obtained in 103 eyes of 55 patients with glaucoma. Features from the ERG recordings were extracted using two time-frequency extraction techniques based on the discrete wavelet transform (DWT) and the matching pursuit (MP) decomposition. Amplitude markers of the time-domain signal were also extracted. Linear and multivariate adaptive regression spline (MARS) models were fitted using combinations of these features to predict estimated retinal ganglion cell counts, a measure of glaucoma disease severity derived from standard automated perimetry and optical coherence tomography imaging.

Results

Predictive models using features from the time-frequency analyses-using both DWT and MP-combined with amplitude markers outperformed predictive models using the markers alone with linear (P = 0.001) and MARS (P ≤ 0.011) models. For example, the proportions of variance (R2) explained by the MARS model using the DWT and MP features with amplitude markers were 0.53 and 0.63, respectively, compared to 0.34 for the model using the markers alone (P = 0.011 and P = 0.001, respectively).

Conclusions

Novel time-frequency features extracted from the photopic ERG substantially added to the prediction of glaucoma severity compared to using the time-domain amplitude markers alone.

Translational Relevance

Substantial information about retinal ganglion cell dysfunction exists in the time-frequency domain of ERGs that could be useful in the management of glaucoma.

Novel Machine-Learning Based Framework Using Electroretinography Data for the Detection of Early-Stage Glaucoma

Purpose

Early-stage glaucoma diagnosis has been a challenging problem in ophthalmology. The current state-of-the-art glaucoma diagnosis techniques do not completely leverage the functional measures' such as electroretinogram's immense potential; instead, focus is on structural measures like optical coherence tomography. The current study aims to take a foundational step toward the development of a novel and reliable predictive framework for early detection of glaucoma using machine-learning-based algorithm capable of leveraging medically relevant information that ERG signals contain.

Methods

ERG signals from 60 eyes of DBA/2 mice were grouped for binary classification based on age. The signals were also grouped based on intraocular pressure (IOP) for multiclass classification. Statistical and wavelet-based features were engineered and extracted. Important predictors (ERG tests and features) were determined, and the performance of five machine learning-based methods were evaluated.

Results

Random forest (bagged trees) ensemble classifier provided the best performance in both binary and multiclass classification of ERG signals. An accuracy of 91.7 and 80% was achieved for binary and multiclass classification, respectively, suggesting that machine-learning-based models can detect subtle changes in ERG signals if trained using advanced features such as those based on wavelet analyses.

Conclusions

The present study describes a novel, machine-learning-based method to analyze ERG signals providing additional information that may be used to detect early-stage glaucoma. Based on promising performance metrics obtained using the proposed machine-learning-based framework leveraging an established ERG data set, we conclude that the novel framework allows for detection of functional deficits of early/various stages of glaucoma in mice.

Effectiveness of Netarsudil as an Additional Therapy for Glaucoma in Patients Already on Maximally Tolerated Medical Therapy

Purpose

This study seeks to evaluate the effectiveness of netarsudil (Rhopressa) in patients with inadequately controlled IOP on otherwise maximally tolerated medical therapy.

Methods

This is a retrospective study of patients started on netarsudil at Stanford University. Exclusion criteria included glaucoma surgery or laser within 6 months of starting netarsudil and other modifications to the baseline medication regimen within 4 weeks of starting netarsudil. The primary outcome was treatment success, defined as IOP reduction meeting a predetermined target, and no further medication, laser, or surgery recommended subsequent to starting netarsudil.

Results

Sixty-two eyes were included, and 36 (58%) achieved treatment success at first follow-up. Mean baseline IOP was 19.5 ± 5.6 mmHg on a mean of 3.5 ± 0.7 ocular hypotensive medications. The mean change in IOP from baseline to first follow-up was -3.53 mmHg (-17%). In patients who achieved treatment success, mean IOP change was -5.22 mmHg (-28.0%). Of the eyes with baseline IOP ≤ 20 mmHg, 69% achieved treatment success, compared to only 17% of eyes with baseline IOP ≥ 21 mmHg (P < 0.05).

Conclusion

Netarsudil is effective in lowering IOP for patients on otherwise maximally tolerated medical therapy, for which glaucoma laser or surgery would have been the only remaining therapeutic options. Treatment success was more likely in eyes with baseline IOP under 20 mmHg.

Asymmetric Functional Impairment of ON and OFF Retinal Pathways in Glaucoma

Purpose

To investigate ON-pathway versus OFF-pathway dysfunction in glaucoma using handheld electroretinography (ERG) with a temporally modulated sinusoidal flicker stimulus.

Design

Cross-sectional study.

Participants

Fifty-nine participants accounting for 104 eyes, comprised of 19 control eyes, 26 glaucoma suspect eyes, and 59 glaucoma eyes.

Methods

Participants underwent portable ERG testing, which included the photopic flash, photopic flicker, photopic negative response stimulus, ON-OFF stimulus, and a custom-written sinusoidal flicker stimulus that was modulated from 50 to 0.3 Hz.

Main Outcome and Measures

The ERG response amplitudes were measured by the handheld ERG. For the custom-written sinusoidal flicker stimulus, we derived and compared the log10 first harmonic frequency response amplitudes. Patient discomfort and fatigue after ERG testing were rated on a scale from 1 to 5.

Results

Baseline demographics were not significantly different between groups, except for ocular characteristics. Analysis was performed adjusting for participant age, sex, race, and dilation status, and the sinusoidal frequency responses were stratified at 10 Hz because higher frequencies are associated with the OFF-pathway, whereas lower frequencies are associated with the ON-pathway. After stratification, glaucoma eyes showed an adjusted decrease of 32.1% at frequencies of more than 10 Hz (95% confidence interval [CI], -51.8% to -4.1%; P = 0.03). For 10 Hz stimulus frequencies or less, an adjusted 11.5% reduction was found (95% CI, -39.5% to 29.1%; P = 0.50). Glaucoma suspect eyes did show a decreased response, but this was not significant at either frequency range. When comparing handheld ERG with traditional visual field assessments, participants found the handheld ERG to result in much less discomfort and fatigue.

Conclusions

Our finding that glaucoma participants showed greater decreases in ERG response at higher frequencies supports the hypothesis that the OFF-pathway may be more vulnerable in human glaucoma. Using a handheld ERG device with a sinusoidal flicker stimulus may provide an objective assessment of visual function in glaucoma.

Targeting Diet and Exercise for Neuroprotection and Neurorecovery in Glaucoma

Glaucoma is a leading cause of blindness worldwide. In glaucoma, a progressive dysfunction and death of retinal ganglion cells occurs, eliminating transfer of visual information to the brain. Currently, the only available therapies target the lowering of intraocular pressure, but many patients continue to lose vision. Emerging pre-clinical and clinical evidence suggests that metabolic deficiencies and defects may play an important role in glaucoma pathophysiology. While pre-clinical studies in animal models have begun to mechanistically uncover these metabolic changes, some existing clinical evidence already points to potential benefits in maintaining metabolic fitness. Modifying diet and exercise can be implemented by patients as an adjunct to intraocular pressure lowering, which may be of therapeutic benefit to retinal ganglion cells in glaucoma.