Fundus examination using a wide-angle viewing system and intraocular illumination through the corneal incision during cataract surgery: a case series

PURPOSE

To report a new technique for fundus examination using a wide-angle viewing system combined with intraocular illumination without accessing the vitreous cavity.

STUDY DESIGN

Retrospective case series METHODS: Consecutive patients with atopic dermatitis-related cataracts who underwent standard cataract surgery and the novel fundus examination technique were included. After phacoemulsification, the anterior and posterior chambers were filled with ocular viscoelastic devices. A 27-gauge endo-illumination probe was inserted into the anterior chamber through a corneal incision made for cataract surgery. The fundus examination was performed with a wide-angle viewing system and scleral indentation. If any retinal breaks/detachments were detected, they were treated simultaneously. Finally, an intraocular lens was implanted.

RESULTS

Ten patients (13 eyes) were included (mean age 26.8 years; 9 men). Retinal breaks were detected in 5 eyes (38%); 2 of the 5 had rhegmatogenous retinal detachment (RRD) (15%). Intraoperative cryopexy was performed for 3 eyes with retinal breaks, while 2 eyes with RRD underwent a scleral buckling procedure (SBP) during the same surgery. There were no intra- or postoperative complications, including posterior capsule damage. The average surgical time was 22 minutes for cases requiring only fundus examination and about 28 and for eyes with cryopexy and 80 minutes for SBP.

CONCLUSION

The described technique may reduce the disadvantages of creating scleral incisions and provide comparable visibility to inserting the illuminator into the vitreous cavity.

Effects of Deep Optic Nerve Head Structures on Bruch's Membrane Opening- Minimum Rim Width and Peripapillary Retinal Nerve Fiber Layer

PURPOSE

To explore the effects of deep optic nerve head (ONH) structures on Bruch's membrane opening (BMO)-minimum rim width (MRW) and peripapillary retinal nerve fiber layer thickness (pRNFLT) in healthy eyes.

DESIGN

Prospective cross-sectional study.

METHODS

Two hundred five healthy eyes of 141 subjects (mean ± standard deviation of age and axial length (AXL): 46.9 ± 10.0 years and 24.79 ± 1.15 mm) were enrolled. Best fit multivariable linear mixed models identified factors associated with BMO-MRW and pRNFLT. Explanatory variables included age, gender, AXL, BMO and anterior scleral canal opening (ASCO) area and ovality, magnitude of BMO and ASCO shift, peripapillary choroidal thickness, lamina cribrosa (LC) parameters, prelaminar thickness, and peripapillary scleral (PPS) angle.

RESULTS

Thinner BMO-MRW was associated with older age, smaller ASCO/BMO offset magnitude, larger BMO area, thinner prelaminar thickness, deeper LC, and thinner pRNFLT (P = .011, <.001, .004, <.001, <.001, <.001 respectively). Thinner pRNFLT was associated with shorter AXL, smaller ASCO area, a more posteriorly bowed PPS, shallower LC and thinner BMO-MRW. (P = .030, .002, .035, .012, <.001 respectively) CONCLUSIONS: BMO-MRW and pRNFLT were influenced by several deep ONH structures such as BMO and ASCO position shift, BMO or ASCO area, prelaminar thickness, PPS bowing and LC depth in addition to patient characteristics such as age and AXL. The degree and/or direction of associations varied between deep ONH structures and BMO-MRW or pRNFLT. Despite both BMO-MRW and pRNFLT being surrogate parameters for RGC loss, a complex relationship with ONH deep-layer morphology was indicated.

Prevalence, Associated Factors, and Inter-Eye Differences of Refractive Errors in a Population-Based Japanese Cohort: The Tohoku Medical Megabank Eye Study

PURPOSE

To investigate the prevalence, associated factors, and inter-eye differences of myopia and astigmatism in an adult Japanese population-based cohort.

METHODS

A total of 4282 participants from the Tohoku Medical Megabank Organization Eye Study (ToMMo Eye Study) underwent comprehensive ocular examinations as well as extensive physiological tests and a lifestyle questionnaire. The spherical equivalent (SE) and cylinder power were obtained as refractive parameters. The age- and gender-stratified prevalences of high myopia (SE < -5D), myopia (SE < -0.5D), hyperopia (SE > 0.5D), astigmatism (cylinder power < -0.5D), and anisometropia (SE difference >1D) were calculated. Multivariable analyses were performed to identify associated factors for refractive error (RE). Distribution and associated factors of the inter-eye difference in RE were also investigated.

RESULTS

The age-adjusted prevalence of high myopia, myopia, hyperopia, astigmatism, and anisometropia was 15.9%, 63.5%, 14.7%, 51.1%, and 14.7%, respectively. Both myopia and high myopia were more prevalent in the younger age group, while astigmatism was more prevalent in the older age group. Age, education, blood pressure, intraocular pressure, and corneal thickness are significantly associated with myopic refraction. Age, gender, intraocular pressure, and corneal thickness are correlated with astigmatism. Older age was associated with against-the-rule astigmatism. Older age, myopia, and longer education showed a significant correlation with large inter-eye differences in SERE.

CONCLUSIONS

This study demonstrated the high prevalence of myopia in young Japanese, which may be caused by a generational shift. This study also confirmed the influence of age and education on both the prevalence and inter-eye differences of RE.

Association of Bergmeister Papilla and Deep Optic Nerve Head Structures With Prelaminar Schisis of Normal and Glaucomatous Eyes

PURPOSE

To investigate factors associated with the severity of prelaminar schisis (PLS) in heathy subjects and glaucoma patients.

DESIGN

Prospective cross-sectional study.

METHODS

A total of 217 eyes of 217 subjects (110 normal eyes and 107 open angle glaucoma eyes) were studied. Frequency and severity of PLS were compared between normal and glaucomatous eyes. Multivariate logistic models were used to assess factors associated with the severity of PLS. Factors considered were age, axial length, glaucomatous damage indices, Bruch membrane opening (BMO) and anterior scleral canal opening parameters, tractional forces (posterior vitreous staging and presence of Bergmeister papilla), circumpapillary choroidal thickness, lamina cribrosa (LC) parameters, and peripapillary scleral (PPS) angle.

RESULTS

The frequency of PLS was 70.9% in normal eyes and 72.0% in glaucomatous eyes. There was no difference in frequency and severity between the groups. The presence of Bergmeister papilla was the strongest predictor of a more severe PLS in both normal and glaucomatous eyes (odds ratio [OR] + 9.78, 12.5; both P < .001). A larger PPS angle in normal eyes (OR = 1.19; P = .003) and a larger BMO area and a deeper LC depth in glaucomatous eyes (OR = 1.08, 1.05; both P = .038) were associated with severity of PLS.

CONCLUSIONS

The severity of PLS was strongly associated with the presence of Bergmeister papilla, suggesting a traction-related phenomenon. Correlation of PLS severity with larger BMO area and deeper LC depth, which are optic nerve head structures associated with glaucoma, suggested its possible relationship with glaucomatous damage.

Computational study on the effects of central retinal blood vessels with asymmetric geometries on optic nerve head biomechanics

Optic nerve head (ONH) biomechanics are associated with glaucoma progression and have received considerable attention. Central retinal vessels (CRVs) oriented asymmetrically in the ONH are the single blood supply source to the retina and are believed to act as mechanically stable elements in the ONH in response to intraocular pressure (IOP). However, these mechanical effects are considered negligible in ONH biomechanical studies and received less attention. This study investigated the effects of CRVs on ONH biomechanics taking into consideration three-dimensional asymmetric CRV geometries. A CRV geometry was constructed based on CRV centerlines extracted from optical coherence tomography ONH images in eight healthy subjects and superimposed in the idealized ONH geometry established in previous studies. Mechanical analyses of the ONH in response to the IOP were conducted in the cases with and without CRVs for comparison. Obtained results demonstrated that the CRVs induced anisotropic ONH deformation, particularly in the lamina cribrosa and the associated upper neural tissues (prelamina) with wide ranges of spatial strain distributions. These results indicated that the CRVs result in anisotropic deformation with local strain concentration, rather than function to mechanically support in response to the IOP as in the conventional thinking in ophthalmology.

Head-Tilt Perfluorocarbon-Air Exchange Technique With Heads-Up Surgery for Giant Retinal Tear-Associated Retinal Detachments to Prevent Retinal Slippage Without Using Silicone Oil

PURPOSE

To report the efficacy of the perfluorocarbon liquid-air exchange with a head tilt toward the area of the giant retinal tear (GRT) using the heads-up surgery system to prevent retinal slippage during vitrectomy for GRT-associated retinal detachments.

METHODS

Eyes with GRT-associated retinal detachments underwent vitrectomy using the heads-up surgery system and perfluorocarbon liquid-air exchange with a head tilt 45° toward the GRT to put the area of the tear in the most dependent position to drain fluid. This technique was evaluated to prevent retinal slippage.

RESULTS

Five consecutive cases were evaluated. The mean GRT size was 174° (range, 90-240°) and the GRT was located temporally in two eyes, nasally in two eyes, and superiorly in one eye. The tamponade types were air (1 eye), sulfur hexafluoride (3 eyes), and perfluoropropane (1 eye). Our technique was feasible and the slippage did not occur in any eyes. Although the microscope needed to be tilted for optimal fundus visualization, heads-up surgery allowed surgeons to maintain ergonomic postures. Retinal reattachment was achieved with a single surgery in all eyes.

CONCLUSION

The head-tilt perfluorocarbon liquid-air exchange with heads-up surgery is useful in preventing retinal slippage in eyes with GRT.

Birefringence-derived artifact in optical coherence tomography imaging of the lamina cribrosa in eyes with glaucoma

We investigated birefringence-derived artifacts that potentially mimic focal defects of the lamina cribrosa (focal LC defects) in optical coherence tomography (OCT) imaging of eyes with glaucoma. This study included 74 eyes of 48 patients with glaucoma. Five horizontal line B-scan images of the optic disc were obtained using commercial swept-source OCT. From a dataset of prototype swept-source polarization-diversity OCT, we calculated the following types of OCT images: polarization-dependent, polarization-dependent attenuation-coefficient, polarization-independent, and polarization-independent attenuation-coefficient. We assessed the commercial OCT images for the presence of birefringence-derived artifacts by comparison with the polarization-diversity OCT images. Commercial OCT showed suggestive findings of focal LC defects in 17 of 74 eyes. Reevaluation using polarization-independent OCT revealed that the focal LC defects in one of 17 eyes (5.9%) were actually birefringence-derived artifacts. This study demonstrated the existence of birefringence-derived artifacts mimicking focal LC defects in commercial OCT imaging and indicated that polarization-diversity OCT is an effective tool to evaluate the presence of these artifacts.

Deep Optic Nerve Head Structures Associated With Increasing Axial Length in Healthy Myopic Eyes of Moderate Axial Length

PURPOSE

To elucidate which swept-source optical coherence tomography (OCT)-derived optic nerve head (ONH) parameters are associated with longer axial length (AXL) in healthy myopic eyes.

DESIGN

Prospective cross-sectional observational study.

METHODS

Two hundred eleven healthy eyes of 140 participants (96 emmetropic-mild myopic [AXL: 22.2-24.5 mm], 83 moderately myopic [24.5-26.0 mm], and 32 highly myopic [26.0-27.4 mm] eyes) were enrolled. Bruch membrane opening (BMO), anterior scleral canal opening (ASCO) area and ovality, minimum rim width, parameters defining misalignment between the BMO and ASCO planes, OCT-defined region of perineural canal retinal epithelium atrophy and externally oblique choroidal border tissue, circumpapillary retinal nerve fiber layer thickness (cpRNFLT), circumpapillary choroidal thickness (cpChT), lamina cribrosa parameters, and peripapillary scleral (PPS) angle were calculated from BMO-centered radial scans reconstructed from 3D raster scans. Multivariate linear mixed models were used to elucidate ONH parameters that are independently associated with AXL.

RESULTS

Longer AXL was associated with a greater misalignment between ASCO and BMO planes, larger region of externally oblique choroidal border tissue, thinner cpChT, larger PPS angle, larger ASCO area, and thicker cpRNFLT (all P < .040 after Bonferroni's correction for number of included explanatory variables).

CONCLUSIONS

A greater misalignment between BMO and ASCO planes, thinner choroid, a more posteriorly bowed PPS, an enlargement of ASCO, and thicker cpRNFLT were each associated with longer AXL. An enhanced understanding of these AXL-associated configurations should provide essential information to improve our ability to detect glaucoma-induced ONH morphology in myopic eyes.

Comparing Surgical Outcomes in Neovascular Glaucoma between Tube and Trabeculectomy: A Multicenter Study

OBJECTIVE

To compare the surgical outcomes between Baerveldt glaucoma implant (BGI) surgery and trabeculectomy with mitomycin C for patients with neovascular glaucoma (NVG).

DESIGN

Retrospective clinical cohort study at 5 clinical centers in Japan.

PARTICIPANTS

Patients treated with trabeculectomy or BGI for NVG between April 1, 2012, and December 31, 2019, at 5 clinical centers were recruited.

METHODS

The inclusion criteria were age ≥ 20 years and having NVG. The exclusion criteria were eyes with no light perception vision and with previous tube-shunt surgery. If both eyes in the same patient satisfied the inclusion criteria, the eye that was treated first was investigated. We included 100 eyes undergoing BGI surgery and 204 eyes undergoing trabeculectomy.

MAIN OUTCOME MEASURES

The primary outcome was surgical success or failure, with failure being defined according to 3 criteria: < 20% reduction of the preoperative intraocular pressure (IOP) or criterion A (IOP > 21 mmHg), criterion B (IOP > 17 mmHg), or criterion C (IOP > 14 mmHg). Cases of reoperation, a loss of light perception vision, or hypotony were also considered failures.

RESULTS

The probability of success was significantly higher in patients undergoing BGI surgery than in those receiving trabeculectomy for criteria A (P < 0.01) and B (P = 0.01). Trabeculectomy was significantly associated with surgical failure in the multivariable analysis for criterion A (hazard ratio, 1.70) and criterion B (hazard ratio, 1.50). The overall incidence of postoperative complications was similar between the 2 groups. Reoperations for glaucoma were required significantly more frequently in the trabeculectomy group than in the BGI surgery group (20.1 % vs. 5.0%; P < 0.01).

CONCLUSIONS

Baerveldt glaucoma implant surgery had a higher success rate compared with trabeculectomy in patients with NVG for a target IOP < 21 mmHg or < 17 mmHg. The rates of postoperative complications were similar between both surgical procedures. Additional glaucoma surgery was required more frequently after trabeculectomy than after BGI surgery.

Treatment of Descemet's membrane detachment after primary Descemet's stripping automated endothelial keratoplasty during surgery using intraoperative optical coherence tomography

Purpose

To present a novel microscope-integrated optical coherence tomography (iOCT)-guided surgical technique wherein Descemet's membrane detachment (DMD), occurring during vitrectomy, was treated intraoperatively in a patient who had previously undergone Descemet's stripping automated endothelial keratoplasty (DSAEK).

Observations

The surgical technique was performed on a 75-year-old man with a history of DSAEK to intraoperatively treat DMD, which occurred during vitrectomy in the left eye. A fine needle mounted on a syringe was inserted into the supra-Descemet's space under iOCT guidance. The location of the needle was easily identified by its high reflection. The interface fluid was safely aspirated under excellent visualization of the needle tip and the interface. Successful aspiration of the interface fluid was confirmed via iOCT imaging at the end of the surgery. The graft has remained well attached to the cornea throughout the one-year postoperative follow-up.

Conclusion and importance

iOCT-guided surgical interventions provide a safe and accurate approach for treating intraoperative complications in eyes with a history of DSAEK.

Three-Dimensional Volume Calculation of Intrachoroidal Cavitation Using Deep-Learning-Based Noise Reduction of Optical Coherence Tomography

Purpose

Intrachoroidal cavitations (ICCs) are peripapillary pathological lesions generally associated with high myopia that can cause visual field (VF) defects. The current study aimed to evaluate a three-dimensional (3D) volume parameter of ICCs segmented from volumetric swept-source optical coherence tomography (SS-OCT) images processed using deep learning (DL)-based noise reduction and to investigate its correlation with VF sensitivity.

Methods

Thirteen eyes of 12 consecutive patients with peripapillary ICCs were enrolled. DL-based denoising and further analyses were applied to parapapillary 6 × 6-mm volumetric SS-OCT scans. Then, 3D ICC volume and two-dimensional depth and length measurements of the ICCs were calculated. The correlations between ICC parameters and VF sensitivity were investigated.

Results

The ICCs were located in the inferior hemiretina in all eyes. ICC volume (P = 0.02; regression coefficient [RC], −0.007) and ICC length (P = 0.04; RC, −4.51) were negatively correlated with the VF mean deviation, whereas ICC depth (P = 0.15) was not. All of the parameters, including ICC volume (P = 0.01; RC, −0.004), ICC depth (P = 0.02; RC, −0.008), and ICC length (P = 0.045; RC, −2.11), were negatively correlated with the superior mean total deviation.

Conclusions

We established the volume of ICCs as a new 3D parameter, and it reflected their influence on visual function. The automatic delineation and 3D rendering may lead to improved detection and pathological understanding of ICCs.

Translational Relevance

This study demonstrated the correlation between the 3D volume of ICCs and VF sensitivity.

Evaluating Visual Field Progression in Advanced Glaucoma Using Trend Analysis of Targeted Mean Total Deviation

PURPOSE

Trend analysis of visual field (VF) global indices may underestimate the rate of progression in severe glaucoma because of the influence of test points without detectable sensitivity. To test this hypothesis, we compared the rates of change of VF global indices with and without exclusion of undetectable points at various disease stages.

MATERIALS AND METHODS

Six hundred and forty-eight eyes of 366 glaucoma patients with 8 or more reliable 30-2 standard automated perimetry over more than 2 years were enrolled. We calculated targeted mean total deviation (TMTD) by averaging total deviation except points which were consistently undetectable in 3 baseline tests. Eyes were classified as early (≥-6 dB), moderate (-6 dB to -12 dB), advanced (-12 dB to -20 dB), and severe (<-20 dB) based on baseline mean deviation (MD). The rates of change of MD and TMTD in each stage were statistically compared.

RESULTS

Mean age±SD at baseline was 56.9±11.9 years. The MD slope (-0.34 dB/y) in severe glaucoma was significantly slower than TMTD slope (-0.42 dB/y, P=0.028) and was slower than MD slopes in the other stages. Difference between MD slopes and TMTD slopes was most prominent in eyes with MD values less than -25 dB (P=0.002).

CONCLUSIONS

Undetectable locations in eyes with severe glaucoma may underestimate the rates of VF progression. Trend analysis of TMTD rather than global indices offers a practical and simple approach for alleviating underestimation of VF progression in severe glaucoma.

Corneal tomographic changes during corneal rigid gas-permeable contact lens wear in keratoconic eyes

Background/Aims

We aimed to investigate the refractive changes in the posterior corneal surface in keratoconus (KC) associated with wearing spherical corneal rigid gas-permeable contact lenses (corneal GPs) with apical touch or three-point touch fitting and the effect of spherical corneal GPs on corneal biomechanics.

Methods

Patients with KC wearing corneal GPs every day without facing complications were enrolled as a single group. Corneal tomographic data were obtained using a three-dimensional anterior segment optical coherence tomography from the same eye with and without corneal GPs. Dioptric data from the central 3-mm zone of the posterior corneal surface were decomposed into spherical, regular astigmatism, asymmetry and higher-order irregularity components using Fourier harmonic analysis. The corneal biomechanical indices were deformation amplitude ratio within 2 mm, integrated radius, stiffness parameter at first applanation and linear Corvis Biomechanical Index. Correlations between the difference in Fourier indices with and without corneal GPs and the corneal biomechanical parameters were analysed.

Results

Thirty-two eyes of 32 patients with KC were enrolled. Spherical, regular astigmatism and asymmetry components were significantly smaller with corneal GP wear than without the wear (all p<0.001). All biomechanical indices were significantly correlated with the difference in the spherical components with and without corneal GPs.

Conclusion

Corneal biomechanical properties of KC were correlated with posterior corneal surface flattening induced by wearing corneal GPs on the spherical components. This effect is greater in biomechanically weaker corneas.

Early Three-Dimensional Intrableb Structural Changes in Primary-Open Angle Glaucoma and Exfoliation Glaucoma After Ex-PRESS Surgery

Purpose

To compare early-stage intrableb structural changes after Ex-PRESS surgery using anterior-segment optical coherence tomography between primary open-angle glaucoma (POAG) and exfoliation glaucoma (XFG).

Methods

Twenty-five POAG eyes and 15 XFG eyes that underwent Ex-PRESS surgery were evaluated. Intrableb images were classified into four categories based on previously reported scattering intensity: high-, medium-, and low-scattering walls and fluid-filled spaces. Bleb measurements were evaluated in both groups throughout 6 postoperative months. The 3-year surgical success was defined by the criteria intraocular pressure (IOP) < 18 mmHg and IOP < 15 mmHg with or without medications.

Results

The fluid-filled space volume at 3 and 6 months (P = 0.005 and P = 0.022, respectively) and the volume ratio of the low-scattering wall to the bleb wall (P = 0.028) at 6 months were significantly smaller in XFG than POAG postoperatively. The volume ratio of the high-scattering wall to the bleb wall was correlated positively (P = 0.007) with the IOP, and that of the low-scattering wall to the bleb wall was correlated negatively (P = 0.002) with the IOP in XFG. The 3-year surgical success rates for both criteria were significantly lower in XFG than POAG.

Conclusions

Fluid-filled spaces were smaller in XFG than in POAG after Ex-PRESS surgery. The proportion of the high-scattering wall tended to increase and the low-scattering wall tended to decrease in XFG eyes with high IOP. Early-stage intrableb structural changes differed between POAG and XFG and may affect the prognosis.

Translational Relevance

Our cutting-edge observation of intrableb fibrosis can be an important predictor of the surgical outcome.

Diagnosis of Choroidal Disease With Deep Learning-Based Image Enhancement and Volumetric Quantification of Optical Coherence Tomography

Purpose

The purpose of this study was to quantify choroidal vessels (CVs) in pathological eyes in three dimensions (3D) using optical coherence tomography (OCT) and a deep-learning analysis.

Methods

A single-center retrospective study including 34 eyes of 34 patients (7 women and 27 men) with treatment-naïve central serous chorioretinopathy (CSC) and 33 eyes of 17 patients (7 women and 10 men) with Vogt-Koyanagi-Harada disease (VKH) or sympathetic ophthalmitis (SO) were imaged consecutively between October 2012 and May 2019 with a swept source OCT. Seventy-seven eyes of 39 age-matched volunteers (26 women and 13 men) with no sign of ocular pathology were imaged for comparison. Deep-learning-based image enhancement pipeline enabled CV segmentation and visualization in 3D, after which quantitative vessel volume maps were acquired to compare normal and diseased eyes and to track the clinical course of eyes in the disease group. Region-based vessel volumes and vessel indices were utilized for disease diagnosis.

Results

OCT-based CV volume maps disclose regional CV changes in patients with CSC, VKH, or SO. Three metrics, (i) choroidal volume, (ii) CV volume, and (iii) CV index, exhibit high sensitivity and specificity in discriminating pathological choroids from healthy ones.

Conclusions

The deep-learning analysis of OCT images described here provides a 3D visualization of the choroid, and allows quantification of features in the datasets to identify choroidal disease and distinguish between different diseases.

Translational Relevance

This novel analysis can be applied retrospectively to existing OCT datasets, and it represents a significant advance toward the automated diagnosis of choroidal pathologies based on observations and quantifications of the vasculature.

Effect of Prostaglandin Analogues on Corneal Biomechanical Parameters Measured With a Dynamic Scheimpflug Analyzer

PRCIS

Treatment with topical prostaglandin analogues (PGAs) induces increased corneal compliance in glaucoma eyes measured with a dynamic Scheimpflug analyzer.

PURPOSE

The purpose of this study was to evaluate the effect of topical PGAs on the corneal biomechanical properties.

METHODS

We retrospectively studied the biomechanical parameters of 31 eyes of 19 consecutive patients with glaucoma measured using a dynamic Scheimpflug analyzer (Corvis ST) before and after initiation of treatment with topical PGAs. No patients had a history of glaucoma treatment before the study and no other antiglaucoma medication was used during the study period. Nine biomechanical parameters were evaluated before and 61.6±28.5 days (range: 21 to 105 d) after initiation of the treatment. The changes in the corneal biomechanical parameters before and after treatment were analyzed using multivariable models adjusting for intraocular pressure and central corneal thickness. The Benjamini-Hochberg method was used to correct for multiple comparison.

RESULTS

In multivariable models, PGA treatment resulted in shorter inward applanation time (P=0.016, coefficient=-0.151) and larger deflection amplitude (P=0.023, coefficient=0.055), peak distance (P=0.042, coefficient=0.131), and deformation amplitude ratio at 1 mm (P=0.018, coefficient=0.028). These associations consistently indicated increased corneal compliance (deformability) after PGA treatment.

CONCLUSION

Topical PGAs resulted in greater corneal compliance, suggesting that the changes in the corneal biomechanical properties may lead to overestimation of the intraocular pressure-lowering effects.

Predicting 10-2 Visual Field From Optical Coherence Tomography in Glaucoma Using Deep Learning Corrected With 24-2/30-2 Visual Field

Purpose

To investigate whether a correction based on a Humphrey field analyzer (HFA) 24-2/30-2 visual field (VF) can improve the prediction performance of a deep learning model to predict the HFA 10-2 VF test from macular optical coherence tomography (OCT) measurements.

Methods

This is a multicenter, cross-sectional study. The training dataset comprised 493 eyes of 285 subjects (407, open-angle glaucoma [OAG]; 86, normative) who underwent HFA 10-2 testing and macular OCT. The independent testing dataset comprised 104 OAG eyes of 82 subjects who had undergone HFA 10-2 test, HFA 24-2/30-2 test, and macular OCT. A convolutional neural network (CNN) DL model was trained to predict threshold sensitivity (TH) values in HFA 10-2 from retinal thickness measured by macular OCT. The predicted TH values was modified by pattern-based regularization (PBR) and corrected with HFA 24-2/30-2. Absolute error (AE) of mean TH values and mean absolute error (MAE) of TH values were compared between the CNN-PBR alone model and the CNN-PBR corrected with HFA 24-2/30-2.

Results

AE of mean TH values was lower in the CNN-PBR with HFA 24-2/30-2 correction than in the CNN-PBR alone (1.9dB vs. 2.6dB; P = 0.006). MAE of TH values was lower in the CNN-PBR with correction compared to the CNN-PBR alone (4.2dB vs. 5.3 dB; P < 0.001). The inferior temporal quadrant showed lower prediction errors compared with other quadrants.

Conclusions

The performance of a DL model to predict 10-2 VF from macular OCT was improved by the correction with HFA 24-2/30-2.

Translational Relevance

This model can reduce the burden of additional HFA 10-2 by making the best use of routinely performed HFA 24-2/30-2 and macular OCT.

Optical Quality in Keratoconus Is Associated With Corneal Biomechanics

PURPOSE

To evaluate the correlations between corneal biomechanical indices from dynamic Scheimpflug assessment and optical quality assessed as higher-order aberrations (HOAs) using a Hartmann-Shack ocular wavefront sensor in patients with keratoconus (KC).

METHODS

In this prospective, observational case series, the eyes with KC or KC suspect (KCS) from Osaka University Hospital, Osaka, Japan, were analyzed. Corneal biomechanical assessment was performed using Corvis ST (Oculus Optikgeräte GmbH, Wetzlar, Germany), and ocular wavefront aberrations were measured using the KR-1W (Topcon Corp, Tokyo, Japan). Correlations between the biomechanical indices and ocular HOAs were assessed. Corneal biomechanical indices included the deformation amplitude ratio within 2 mm, integrated radius, stiffness parameter at the first applanation, and the linear Corvis Biomechanical Index. Wavefront data of the central 4-mm region were expanded up to the sixth order of Zernike polynomials. The magnitudes of trefoil, coma, tetrafoil, secondary astigmatism, and spherical aberration were calculated by Zernike vector analysis and then used as ocular HOA parameters along with total HOAs.

RESULTS

Thirty-four KC eyes and 37 KCS eyes were included. KC eyes showed significant correlations between ocular HOAs and biomechanics, whereas there were few significant correlations in KCS eyes. In KC eyes, deformation amplitude ratio within 2 mm, integrated radius, and Corvis Biomechanical Index beta showed stronger correlations with coma among the wavefront parameters.

CONCLUSIONS

Corneal biomechanical indices correlated with ocular HOAs in patients with KC. In particular, there was a strong association with the increase in coma caused by inferosuperior asymmetry of the shape of the cornea in patients with KC.

Biomechanical Glaucoma Factor and Corneal Hysteresis in Treated Primary Open-Angle Glaucoma and Their Associations With Visual Field Progression

Purpose

To investigate the relationship between biomechanical glaucoma factor (BGF) measured with Corvis ST and glaucomatous visual field (VF) progression, compared to corneal hysteresis (CH) measured with ocular response analyzer using a longitudinal dataset of primary open-angle glaucoma (POAG). The discriminative powers of BGF and CH were also compared using a cross-sectional dataset.

Methods

The longitudinal dataset included 166 POAG eyes. The rate of VF change during the follow-up period was evaluated using the mean of 52 pointwise total deviations in the Humphrey 24-2 field test. Variables associated with the VF progression rate were identified from BGF, CH, age, baseline VF severity, and intraocular pressure during the VF follow-up period by identifying the optimal model. The cross-sectional dataset included 68 POAG eyes and 68 healthy eyes. Using this dataset, the area under the curve (AUC) values of the receiver-operating curve were compared between CH and BGF.

Results

The optimal multivariate linear mixed model to describe the VF rate included age and CH, but not BGF. Between POAG and healthy eyes, CH was statistically different (P < 0.001), although this was not the case with BGF. The AUC values were 0.61 and 0.71 for BGF and CH, respectively (P = 0.027).

Conclusions

CH, but not BGF, was associated with VF progression in POAG patients under treatment. BGF was not useful to discriminate POAG between treated and normal eyes.

Relationship Between Macular Ganglion Cell Thickness and Ocular Elongation as Measured by Axial Length and Retinal Artery Position

Purpose

We recently reported on the usefulness of retinal artery trajectory in estimating the magnitude of retinal stretch due to myopia. The purpose of the present study was to elucidate the relationship between the peripapillary retinal artery angle (PRAA) and thickness of the macular ganglion cell–inner plexiform layer (GCIPL).

Methods

This r included 138 healthy eyes of 79 subjects older than 20 years of age without any known eye disease. GCIPL thickness was separated into eight sectors according to quadrant and eccentricity from the fovea. The PRAA was calculated as the angle between the superior and inferior retinal arteries. Relationships between whole GCIPL thickness (average and sectorial) and the values of PRAA and axial length (AL) were investigated using a linear mixed model.

Results

Average GCIPL thickness in the whole scanned area decreased significantly with narrowing of the PRAA with and without adjusting for AL. Sectorized macular GCIPL thickness also decreased significantly, with narrowing of the PRAA in seven out of the eight with the adjustment of AL, the exception being the inferior peripheral temporal sector.

Conclusions

Macular GCIPL thickness decreased significantly with narrowing of the PRAA on average and in seven out of eight sectors.

Investigating the clinical usefulness of definitions of progression with 10-2 visual field

BACKGROUND/AIM

To investigate the clinical validity of the Guided Progression Analysis definition (GPAD) and cluster-based definition (CBD) with the Humphrey Field Analyzer 10-2 test in diagnosing glaucomatous visual field (VF) progression, and to introduce a novel definition with optimised specificity by combining the 'any-location' and 'cluster-based' approaches (hybrid definition).

METHODS

64 400 stable glaucomatous VFs were simulated from 664 pairs of 10-2 tests (10 sets × 10 VF series × 664 eyes; data set 1). Using these simulated VFs, the specificity to detect progression and the effects of changing the parameters (number of test locations or consecutive VF tests, and percentile cut-off values) were investigated. The hybrid definition was designed as the combination where the specificity was closest to 95.0%. Subsequently, another 5000 actual glaucomatous 10-2 tests from 500 eyes (10 VFs each) were collected (data set 2), and their accuracy (sensitivity, specificity and false positive rate) and the time needed to detect VF progression were evaluated.

RESULTS

The specificity values calculated using data set 1 with GPAD and CBD were 99.6% and 99.8%. Using data set 2, the hybrid definition had a higher sensitivity than GPAD and CBD, without detriment to the specificity or false positive rate. The hybrid definition also detected progression significantly earlier than GPAD and CBD (at 3.1 years vs 4.2 years and 4.1 years, respectively).

CONCLUSIONS

GPAD and CBD had specificities of 99.6% and 99.8%, respectively. A novel hybrid definition (with a specificity of 95.5%) had higher sensitivity and enabled earlier detection of progression.

Correlation Between Angle Parameters and Central Corneal Thickness in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To evaluate the correlation between anterior chamber parameters and central corneal thickness (CCT) or peripheral corneal thickness (PCT) in patients with Fuchs endothelial corneal dystrophy (FECD) using anterior segment optical coherence tomography.

METHODS

This case-control study included 20 eyes from 20 patients with FECD and 31 eyes from 31 patients with healthy corneas. CCT was measured as an indicator of FECD severity. Anterior chamber angle parameters, including trabecular-iris angle (TIA500) and angle opening distance (AOD500), were measured as an indicator of peripheral anterior chamber morphology. We also analyzed PCT and lens vault (LV). The relationships between CCT or PCT and anterior chamber parameters were also analyzed in patients with FECD.

RESULTS

Patients with FECD had a larger CCT (593.9 ± 54.6 μm vs. 533.0 ± 25.4 μm, P < 0.001), smaller TIA500 (21.8 ± 9.9 vs. 32.5 ± 11.2 degrees, P = 0.002), smaller AOD500 (0.21 ± 0.11 vs. 0.34 ± 0.18 mm, P = 0.002), and greater LV (0.60 ± 0.27 vs. 0.40 ± 0.29 mm, P = 0.02) than control subjects. In patients with FECD, CCT was negatively correlated with the angle parameters TIA500 (R = 0.29, P = 0.009) and AOD500 (R = 0.19, P = 0.03). There were no significant correlations between PCT and TIA500 (R = 0.008, P = 0.29) or AOD500 (R = 0.007, P = 0.29). There were also no significant correlations between CCT and LV (R = 0.02, P = 0.55).

CONCLUSIONS

Larger CCT was significantly associated with narrower anterior chamber angle width, but not with LV. We showed that the severity of FECD is associated with angle chamber morphology.

Intravitreal Aflibercept in Japanese Patients with Neovascular Glaucoma: The VEGA Randomized Clinical Trial

Introduction

Neovascular glaucoma is characterized by neovascularization of the iris and the anterior angle chamber. Intravitreal anti-vascular endothelial growth factor agents may improve intraocular pressure (IOP) and neovascularization.

Methods

The VEGA trial assessed the efficacy and safety of intravitreal aflibercept (IVT-AFL) in patients with neovascular glaucoma in a 13-week, randomized, double-masked, sham-controlled, phase 3 study performed at multiple sites in Japan that enrolled patients with anterior segment neovascularization and IOP > 25 mmHg. Patients received background therapy plus IVT-AFL (2 mg) or sham injection at baseline. Patients were re-treated if presenting with IOP > 21 mmHg and incomplete regression of iris neovascularization, receiving additional sham or IVT-AFL injections at week 1 and IVT-AFL injections at weeks 5 and/or 9. Double-masking was maintained throughout. The primary endpoint was change in IOP from baseline to week 1.

Results

Fifty-four patients were randomly assigned (full analysis set); the per-protocol set comprised 52 patients. At week 1, the least squares mean change in IOP was −9.9 mmHg for IVT-AFL versus −5.0 mmHg for sham [full analysis set: difference −4.9 mmHg (95% confidence interval −10.2 to 0.3; P = 0.06); per-protocol set: −5.5 mmHg (95% CI −10.8 to −0.2; P = 0.04)]. At week 1, a greater proportion of patients administered IVT-AFL versus sham achieved IOP ≤ 21 mmHg and had improved neovascularization grades. Patients in the sham group who met re-treatment criteria and received IVT-AFL at week 1 [n = 22 (81.5%)] had an additional mean IOP decrease of 9.2 mmHg by week 2, and the proportion with improvement in neovascularization grades increased from 11.5% to 69.2%. Increases in the proportion of patients with improved neovascularization grades and the proportion who achieved IOP control (≤ 21 mmHg) were also observed by week 2 in this group. Overall, 77.8% and 74.1% of patients treated with IVT-AFL and sham/IVT-AFL, respectively, received a single IVT-AFL injection. The most common ocular treatment-emergent adverse event was punctate keratitis (9.3%: 7.4% and 11.1% in the IVT-AFL and sham/IVT-AFL groups, respectively).

Conclusions

IVT-AFL was associated with clinically meaningful improvements in IOP control, indicating that IVT-AFL may be a potential treatment option for patients with neovascular glaucoma.

Trial Registration

Clinicaltrials.gov identifier, NCT02396316.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01579-5) contains supplementary material, which is available to authorized users.

Predicting the central 10 degrees visual field in glaucoma by applying a deep learning algorithm to optical coherence tomography images

We aimed to develop a model to predict visual field (VF) in the central 10 degrees in patients with glaucoma, by training a convolutional neural network (CNN) with optical coherence tomography (OCT) images and adjusting the values with Humphrey Field Analyzer (HFA) 24–2 test. The training dataset included 558 eyes from 312 glaucoma patients and 90 eyes from 46 normal subjects. The testing dataset included 105 eyes from 72 glaucoma patients. All eyes were analyzed by the HFA 10-2 test and OCT; eyes in the testing dataset were additionally analyzed by the HFA 24-2 test. During CNN model training, the total deviation (TD) values of the HFA 10-2 test point were predicted from the combined OCT-measured macular retinal layers’ thicknesses. Then, the predicted TD values were corrected using the TD values of the innermost four points from the HFA 24-2 test. Mean absolute error derived from the CNN models ranged between 9.4 and 9.5 B. These values reduced to 5.5 dB on average, when the data were corrected using the HFA 24-2 test. In conclusion, HFA 10-2 test results can be predicted with a OCT images using a trained CNN model with adjustment using HFA 24-2 test.

Validating the usefulness of sectorwise regression of visual field in the central 10°

AIM

To evaluate the usefulness of the application of the clustering method to the trend analysis (sectorwise regression) in comparison with the pointwise linear regression (PLR).

METHODS

This study included 153 eyes of 101 patients with open-angle glaucoma. With PLR, the total deviation (TD) values of the 10th visual field (VF) were predicted using the shorter VF sequences (from first 3 to 9) by extrapolating TD values against time in a pointwise manner. Then, 68 test points were stratified into 29 sectors. In each sector, the mean of TD values was calculated and allocated to all test points belonging to the sector. Subsequently, the TD values of the 10th VF were predicted by extrapolating the allocated TD value against time in a pointwise manner. Similar analyses were conducted to predict the 11th-16th VFs using the first 10 VFs.

RESULTS

When predicting the 10th VF using the shorter sequences, the mean absolute error (MAE) values were significantly smaller in the sectorwise regression than in PLR. When predicting from the 11th and 16th VFs using the first 10 VFs, the MAE values were significantly larger in the sectorwise regression than in PLR when predicting the 11th VF; however, no significant difference was observed with other VF predictions.

CONCLUSION

Accurate prediction was achieved using the sectorwise regression, in particular when a small number of VFs were used in the prediction. The accuracy of the sectorwise regression was not hampered in longer follow-up compared with PLR.

Predicting the Glaucomatous Central 10-Degree Visual Field From Optical Coherence Tomography Using Deep Learning and Tensor Regression

PURPOSE

To predict the visual field (VF) of glaucoma patients within the central 10° from optical coherence tomography (OCT) measurements using deep learning and tensor regression.

DESIGN

Cross-sectional study.

METHODS

Humphrey 10-2 VFs and OCT measurements were carried out in 505 eyes of 304 glaucoma patients and 86 eyes of 43 normal subjects. VF sensitivity at each test point was predicted from OCT-measured thicknesses of macular ganglion cell layer + inner plexiform layer, retinal nerve fiber layer, and outer segment + retinal pigment epithelium. Two convolutional neural network (CNN) models were generated: (1) CNN-PR, which simply connects the output of the CNN to each VF test point; and (2) CNN-TR, which connects the output of the CNN to each VF test point using tensor regression. Prediction performance was assessed using 5-fold cross-validation through the root mean squared error (RMSE). For comparison, RMSE values were also calculated using multiple linear regression (MLR) and support vector regression (SVR). In addition, the absolute prediction error for predicting mean sensitivity in the whole VF was analyzed.

RESULTS

RMSE with the CNN-TR model averaged 6.32 ± 3.76 (mean ± standard deviation) dB. Significantly (P < .05) larger RMSEs were obtained with other models: CNN-PR (6.76 ± 3.86 dB), SVR (7.18 ± 3.87 dB), and MLR (8.56 ± 3.69 dB). The absolute mean prediction error for the whole VF was 2.72 ± 2.60 dB with the CNN-TR model.

CONCLUSION

The Humphrey 10-2 VF can be predicted from OCT-measured retinal layer thicknesses using deep learning and tensor regression.

Dynamic Scheimpflug Ocular Biomechanical Parameters in Untreated Primary Open Angle Glaucoma Eyes

Purpose

To characterize the corneal biomechanical properties of glaucoma eyes by comparing the dynamic Scheimpflug biomechanical parameters between untreated glaucoma and control eyes.

Methods

Cross-sectional observational data of dynamic Scheimpflug analyzer (Corvis ST) examinations were retrospectively collected from 35 eyes of 35 consecutive patients with untreated normal tension glaucoma and 35 eyes of 35 healthy patients matched on age and IOP. Ten biomechanical parameters were compared between the two groups using multivariable models adjusting for IOP, central corneal thickness, age, and axial length. The Benjamini-Hochberg method was used to correct for multiple comparison.

Results

In multivariable models, glaucoma was associated with smaller applanation 1 time (P < 0.001, coefficient = −0.5865), applanation 2 time (P = 0.012, coefficient = −0.1702), radius (P = 0.006, coefficient = −0.5447), larger peak distance (P = 0.011, coefficient = 0.1023), deformation amplitude ratio at 1 mm (P < 0.001, coefficient = 0.072), and integrated radius (P < 0.001, coefficient = 1.094). These associations consistently indicate greater compliance of the cornea in glaucoma eyes.

Conclusions

Untreated normal tension glaucoma eyes were more compliant than healthy eyes. The greater compliance (smaller stiffness) of normal tension glaucoma eyes may increase the risk of optic nerve damage. These results suggest the relevance of measuring biomechanical properties of glaucoma eyes.

Deep learning model to predict visual field in central 10° from optical coherence tomography measurement in glaucoma

BACKGROUND/AIM

To train and validate the prediction performance of the deep learning (DL) model to predict visual field (VF) in central 10° from spectral domain optical coherence tomography (SD-OCT).

METHODS

This multicentre, cross-sectional study included paired Humphrey field analyser (HFA) 10-2 VF and SD-OCT measurements from 591 eyes of 347 patients with open-angle glaucoma (OAG) or normal subjects for the training data set. We trained a convolutional neural network (CNN) for predicting VF threshold (TH) sensitivity values from the thickness of the three macular layers: retinal nerve fibre layer, ganglion cell layer+inner plexiform layer and outer segment+retinal pigment epithelium. We implemented pattern-based regularisation on top of CNN to avoid overfitting. Using an external testing data set of 160 eyes of 131 patients with OAG, the prediction performance (absolute error (AE) and R² between predicted and actual TH values) was calculated for (1) mean TH in whole VF and (2) each TH of 68 points. For comparison, we trained support vector machine (SVM) and multiple linear regression (MLR).

RESULTS

AE of whole VF with CNN was 2.84±2.98 (mean±SD) dB, significantly smaller than those with SVM (5.65±5.12 dB) and MLR (6.96±5.38 dB) (all, p<0.001). Mean of point-wise mean AE with CNN was 5.47±3.05 dB, significantly smaller than those with SVM (7.96±4.63 dB) and MLR (11.71±4.15 dB) (all, p<0.001). R² with CNN was 0.74 for the mean TH of whole VF, and 0.44±0.24 for the overall 68 points.

CONCLUSION

DL model showed considerably accurate prediction of HFA 10-2 VF from SD-OCT.

The usefulness of the Deep Learning method of variational autoencoder to reduce measurement noise in glaucomatous visual fields

The aim of the study was to investigate the usefulness of processing visual field (VF) using a variational autoencoder (VAE). The training data consisted of 82,433 VFs from 16,836 eyes. Testing dataset 1 consisted of test-retest VFs from 104 eyes with open angle glaucoma. Testing dataset 2 was series of 10 VFs from 638 eyes with open angle glaucoma. A VAE model to reconstruct VF was developed using the training dataset. VFs in the testing dataset 1 were then reconstructed using the trained VAE and the mean total deviation (mTD) was calculated (mTDVAE). In testing dataset 2, the mTD value of the tenth VF was predicted using shorter series of VFs. A similar calculation was carried out using a weighted linear regression where the weights were equal to the absolute difference between mTD and mTDVAE. In testing dataset 1, there was a significant relationship between the difference between mTD and mTDVAE from the first VF and the difference between mTD in the first and second VFs. In testing dataset 2, mean squared prediction errors with the weighted mTD trend analysis were significantly smaller than those form the unweighted mTD trend analysis.

Usefulness of data augmentation for visual field trend analyses in patients with glaucoma

AIM

To investigate the usefulness of data augmentation in visual field (VF) trend analyses in patients with glaucoma.

METHOD

This study included 6380 VFs from 638 eyes of 417 patients with open-angle glaucoma. Various affine transformations were applied to augment the VF data: (1) rotation, (2) scaling, (3) vertical and horizontal shift and (4) a combination of these different transformations. Using pointwise linear regression (PLR), the total deviation (TD) values of a patient's 10th VF were predicted using TD values from shorter VF series (from first to third VFs (VF1-3) to first to ninth VFs (VF1-9)) with and without VF data augmentation, and the root mean squared error (RMSE) was calculated.

RESULTS

With PLR, mean RMSE without VF augmentation averaged from 3.95 (VF1-3) to 19.01 (VF1-9) dB. The RMSE was significantly improved by applying the different transformations: (1) rotation (from VF1-3 to VF1-7), (2) scaling (from VF1-3 to VF1-6), (3) vertical and horizontal shifts (from VF1-3 to VF1-4) and (iv) a combination of these (from VF1-3 to VF1-7). Progression rates in VF1-10 had better agreement with those in shorter VF series when a combination of affine transformation was applied. The differences in rates were between 1.9 (VF1-3) and 0.39 (VF1-9) dB if augmentation was used, which was significantly smaller than that observed when augmentation was not applied (from 2.6 with VF1-3 to 0.26 dB with VF1-9).

CONCLUSION

It is useful to apply VF data augmentation techniques when predicting future VF progression in glaucoma using PLR, especially with short VF series.

Detection of Subclinical Corneal Ectasia Using Corneal Tomographic and Biomechanical Assessments in a Japanese Population

PURPOSE

To test the detection of subclinical corneal ectasia using integrated Scheimpflug tomography and biomechanical assessment in a Japanese population.

METHODS

This prospective, case-control study included 23 patients with very asymmetric ectasia (VAE) and 70 normal controls. Patients with VAE had defined clinical ectasia in one eye and a fellow eye with normal topography (VAE-NT). Objective topography for confirming normal topography in VAE-NT cases included having 0% similarity and 0% severity derived from Placido-disk based topography. Scheimpflug-based corneal tomography and corneal biomechanical assessment were performed. The Belin/Ambrósio Enhanced Ectasia Deviation index (BAD-D), Corvis Biomechanical Index (CBI), and Tomographic Biomechanical Index (TBI) were compared and their discriminating ability for detecting ectasia was assessed.

RESULTS

For differentiating normal and VAE-NT eyes, the areas under the receiver operating curve for the BAD-D, CBI, and TBI were 0.668, 0.660, and 0.751, respectively. The TBI cut-off of 0.259 provided 52.17% sensitivity and 88.57% specificity. Fourteen VAE-NT cases (60.9%) were abnormal in at least one of the criteria of the BAD-D > 1.60 (39.1%), CBI > 0.5 (26.1%), or TBI > 0.29 (43.5%). Conversely, nine VAE-NT cases (39.1%) exhibited normal values for the BAD-D, CBI, and TBI.

CONCLUSIONS

In the current study, 40% of VAE-NT eyes were classified as normal by the BAD-D, CBI, and TBI. Although some of these cases may truly represent unilateral ectasia, further advances are needed to enhance ectasia detection and characterize the susceptibility for ectasia progression. [J Refract Surg. 2019;35(6):383-390.].

Deep learning based noise reduction method for automatic 3D segmentation of the anterior of lamina cribrosa in optical coherence tomography volumetric scans

A deep-learning (DL) based noise reduction algorithm, in combination with a vessel shadow compensation method and a three-dimensional (3D) segmentation technique, has been developed to achieve, to the authors best knowledge, the first automatic segmentation of the anterior surface of the lamina cribrosa (LC) in volumetric ophthalmic optical coherence tomography (OCT) scans. The present DL-based OCT noise reduction algorithm was trained without the need of noise-free ground truth images by utilizing the latest development in deep learning of de-noising from single noisy images, and was demonstrated to be able to cover more locations in the retina and disease cases of different types to achieve high robustness. Compared with the original single OCT images, a 6.6 dB improvement in peak signal-to-noise ratio and a 0.65 improvement in the structural similarity index were achieved. The vessel shadow compensation method analyzes the energy profile in each A-line and automatically compensates the pixel intensity of locations underneath the detected blood vessel. Combining the noise reduction algorithm and the shadow compensation and contrast enhancement technique, medical experts were able to identify the anterior surface of the LC in 98.3% of the OCT images. The 3D segmentation algorithm employs a two-round procedure based on gradients information and information from neighboring images. An accuracy of 90.6% was achieved in a validation study involving 180 individual B-scans from 36 subjects, compared to 64.4% in raw images. This imaging and analysis strategy enables the first automatic complete view of the anterior LC surface, to the authors best knowledge, which may have the potentials in new LC parameters development for glaucoma diagnosis and management.

Validating the efficacy of the binomial pointwise linear regression method to detect glaucoma progression with multicentral database

BACKGROUND/AIM

We previously reported the benefit of applying binomial pointwise linear regression (PLR: binomial PLR) to detect 10-2 glaucomatous visual field (VF) progression. The purpose of the current study was to validate the usefulness of the binomial PLR to detect glaucomatous VF progression in the central 24°.

METHODS

Series of 15 VFs (Humphrey Field Analyzer 24-2 SITA-standard) from 341 eyes of 233 patients, obtained over 7.9±2.1 years (mean±SD), were investigated. PLR was performed by regressing the total deviation of all test points. VF progression was determined from the VF test points analyses using the binomial test (one side, p<0.025). The time needed to detect VF progression was compared across the binomial PLR, permutation analysis of PLR (PoPLR) and mean total deviation (mTD) trend analysis.

RESULTS

The binomial PLR was comparable with PoPLR and mTD trend analyses in the positive predictive value (0.18-0.87), the negative predictive value (0.89-0.95) and the false positive rate (0.057-0.35) to evaluate glaucomatous VF progression. The time to classify progression with binomial PLR (5.8±2.8 years) was significantly shorter than those with mTD trend analysis (6.7±2.8 years) and PoPLR (6.6±2.7 years).

CONCLUSIONS

The binomial PLR method, which detected glaucomatous VF progression in the central 24° significantly earlier than PoPLR and mTD trend analyses, shows promise for improving our ability to detect visual field progression for clinical management of glaucoma and in clinical trials of new glaucoma therapies.

Cross-Sectional Imaging Analysis of Epiretinal Membrane Involvement in Unilateral Open-Angle Glaucoma Severity

Purpose

To determine the relevance of epiretinal membranes (ERMs) in primary open-angle glaucoma (POAG) and potential risk for glaucoma severity.

Methods

Sixty eyes of 30 patients with POAG who had a unilateral ERM were analyzed; 60 nonglaucomatous eyes of 30 patients with a unilateral ERM also were recruited in this institutional cross-sectional study. Patients underwent swept-source (SS) optical coherence tomography (OCT) imaging and visual field testing. Intraindividual differences in the SS-OCT retinal nerve fiber layer (RNFL) disc cupping area measurements and visual field outcomes were analyzed in the two groups.

Results

In patients with POAG, the mean circumpapillary RNFL thickness in the eyes with an ERM was 75.6 ± 16.5 μm superiorly and 71.8 ± 26.0 inferiorly compared with the fellow eyes without an ERM (87.2 ± 23.6 μm, P = 0.0061 and 81.3 ± 27.7 μm, P = 0.034, respectively). The areas of disc cupping and cup-to-disc ratio seen on OCT horizontal and vertical B-scans were larger in eyes with an ERM than in the fellow eyes without ERM (P = 0.0004 and P = 0.0011, respectively). The average mean deviations were -11.6 ± 7.5 dB in the ERM group and -8.19 ± 6.4 dB in the group with no ERM (P = 0.029). Eyes with an ERM received more antiglaucoma eye drops (P = 0.018). Those differences were not seen between eyes with an ERM or fellow eyes in patients without glaucoma.

Conclusions

The presence of an ERM can be a potential risk factor for unilateral severity in eyes with POAG.

Using Deep Learning and Transfer Learning to Accurately Diagnose Early-Onset Glaucoma From Macular Optical Coherence Tomography Images

PURPOSE

We sought to construct and evaluate a deep learning (DL) model to diagnose early glaucoma from spectral-domain optical coherence tomography (OCT) images.

DESIGN

Artificial intelligence diagnostic tool development, evaluation, and comparison.

METHODS

This multi-institution study included pretraining data of 4316 OCT images (RS3000) from 1371 eyes with open angle glaucoma (OAG) regardless of the stage of glaucoma and 193 normal eyes. Training data included OCT-1000/2000 images from 94 eyes of 94 patients with early OAG (mean deviation > -5.0 dB) and 84 eyes of 84 normal subjects. Testing data included OCT-1000/2000 from 114 eyes of 114 patients with early OAG (mean deviation > -5.0 dB) and 82 eyes of 82 normal subjects. A DL (convolutional neural network) classifier was trained using a pretraining dataset, followed by a second round of training using an independent training dataset. The DL model input features were the 8 × 8 grid macular retinal nerve fiber layer thickness and ganglion cell complex layer thickness from spectral-domain OCT. Diagnostic accuracy was investigated in the testing dataset. For comparison, diagnostic accuracy was also evaluated using the random forests and support vector machine models. The primary outcome measure was the area under the receiver operating characteristic curve (AROC).

RESULTS

The AROC with the DL model was 93.7%. The AROC significantly decreased to between 76.6% and 78.8% without the pretraining process. Significantly smaller AROCs were obtained with random forests and support vector machine models (82.0% and 67.4%, respectively).

CONCLUSION

A DL model for glaucoma using spectral-domain OCT offers a substantive increase in diagnostic performance.

Validating Variational Bayes Linear Regression Method With Multi-Central Datasets

Purpose

To validate the prediction accuracy of variational Bayes linear regression (VBLR) with two datasets external to the training dataset.

Method

The training dataset consisted of 7268 eyes of 4278 subjects from the University of Tokyo Hospital. The Japanese Archive of Multicentral Databases in Glaucoma (JAMDIG) dataset consisted of 271 eyes of 177 patients, and the Diagnostic Innovations in Glaucoma Study (DIGS) dataset includes 248 eyes of 173 patients, which were used for validation.

Prediction accuracy was compared between the VBLR and ordinary least squared linear regression (OLSLR). First, OLSLR and VBLR were carried out using total deviation (TD) values at each of the 52 test points from the second to fourth visual fields (VFs) (VF2–4) to 2nd to 10th VF (VF2–10) of each patient in JAMDIG and DIGS datasets, and the TD values of the 11th VF test were predicted every time. The predictive accuracy of each method was compared through the root mean squared error (RMSE) statistic.

Results

OLSLR RMSEs with the JAMDIG and DIGS datasets were between 31 and 4.3 dB, and between 19.5 and 3.9 dB. On the other hand, VBLR RMSEs with JAMDIG and DIGS datasets were between 5.0 and 3.7, and between 4.6 and 3.6 dB. There was statistically significant difference between VBLR and OLSLR for both datasets at every series (VF2–4 to VF2–10) (P < 0.01 for all tests). However, there was no statistically significant difference in VBLR RMSEs between JAMDIG and DIGS datasets at any series of VFs (VF2–2 to VF2–10) (P > 0.05).

Conclusions

VBLR outperformed OLSLR to predict future VF progression, and the VBLR has a potential to be a helpful tool at clinical settings.

En Face Optical Coherence Tomography Imaging of Beta and Gamma Parapapillary Atrophy in High Myopia

PURPOSE

Recent studies have suggested that OCT-based classification of parapapillary atrophy (PPA) may be helpful in distinguishing glaucomatous from myopic optic disc changes. However, the pathologic implications of PPA may be different in highly myopic eyes that exhibit optic disc deformations distinct from low-to-moderate myopia. Therefore, we conducted the current study to investigate factors associated with OCT-defined PPA zones measured in en face reconstructed swept-source OCT (SS OCT) images in highly myopic eyes.

DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

Seventy-seven eyes of 55 subjects with high myopia (spherical equivalent refractive error ≤ -8 diopters or axial length ≥26.5 mm) were included. Forty-nine eyes of 33 subjects had open-angle glaucoma (MG group), and 28 eyes of 22 did not (M group).

METHODS

The beta zone and the gamma zone PPA areas were measured in en face images reconstructed from 3-dimensional SS OCT volumetric scans. Relationships between the PPA areas and patient characteristics such as glaucoma, axial length, and age were evaluated using multivariate mixed-effects models. The diagnostic capability of each PPA zone area for detecting glaucoma was assessed with the receiver operating characteristic (ROC) curve analysis. Main outcome measures were areas of the beta zone and the gamma zone PPA measured in en face OCT images and factors associated with each PPA area.

RESULTS

Average ± standard deviation area of the beta and the gamma zone was 1.1±1.1 and 1.1±1.1 mm². The gamma zone was positively correlated with axial length (P = 0.006) and age (P = 0.04951) but not with glaucoma (P = 0.776). The beta zone was positively correlated with both axial length (P = 0.039) and glaucoma (P = 0.011). The areas under the ROC curve of the beta zone and the gamma zone areas were 0.686 and 0.560, respectively.

CONCLUSIONS

The OCT-defined beta zone was associated with glaucoma and axial length, whereas the gamma zone was correlated with axial length but not with glaucoma, in highly myopic eyes. The OCT-based classification showed poor diagnostic performance for glaucoma. Relationships between PPA areas and baseline clinical factors may be different between high myopia and non-high myopia.

Anterior segment Scheimpflug imaging for detecting primary angle closure disease

PURPOSE

To evaluate the capability of anterior segment Scheimpflug imaging for detecting primary angle closure disease (PACD): primary angle closure suspect, primary angle closure, and primary angle closure glaucoma, using cutoff points derived from reference databases of healthy subjects.

METHODS

Eighty-seven patients with PACD and 49 age-matched control subjects were included. We evaluated the sensitivity and specificity of anterior chamber depth (ACD), anterior chamber volume (ACV), and anterior chamber angle (ACA) to differentiate patients with PACD from controls. Additionally, the study's raw data was analyzed via receiver operating characteristic curves for comparison.

RESULTS

One standard deviation from the normative data's mean values was used as the cutoff point and yielded a sensitivity and specificity of 96.2% and 92.6% for ACD, 97.1% and 75.9% for ACV, and 93.3% and 72.2% for ACA, respectively. Receiver operating characteristic analysis of the raw data showed the area under the curve to be 0.984, 0.975, and 0.931 for ACD, ACV, and ACA, respectively.

CONCLUSIONS

Our study demonstrated that the parameters of anterior segment Scheimpflug imaging, particularly ACD, accurately discriminate PACD. This was the first study to validate the device's normative data in a separate population. With its high reproducibility, ease of use, non-invasiveness, and speed, anterior segment Scheimpflug imaging is a potentially powerful screening tool for PACD.

Early results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for locally advanced gastric cancer

Background

Neoadjuvant chemotherapy (NAC) is a promising method of improving the survival of resectable gastric cancer. Cisplatin/S-1 (CS) and docetaxel/cisplatin/S-1 (DCS) are both effective against metastatic gastric cancer. This report clarified the impact of these regimens on early endpoints, including the pathological responses, chemotherapy-related toxicities, and surgical results.

Methods

Patients with M0 and either T4 or T3 in case of junctional cancer or scirrhous type received two or four courses of cisplatin (60 mg/m2 at day 8)/S-1 (80 mg/m2 for 21 days with 1 week rest) or docetaxel (40 mg/m2 at day 1)/cisplatin (60 mg/m2 at day 1)/S-1 (80 mg/m2 for 14 days with 2 weeks rest) as NAC. Patients then underwent D2 gastrectomy and adjuvant S-1 chemotherapy for 1 year. The primary endpoint was the 3-year overall survival.

Results

Between October 2011 and September 2014, 132 patients were assigned to receive CS (n = 66; 33 in 2 courses and 33 in 4 courses) or DCS (n = 66; 33 in 2 courses and 33 in 4 courses). The respective major grade 3 or 4 hematological toxicities (CS/DCS) were leukocytopenia (14.1%/26.2%), neutropenia (29.7%/47.7%), anemia (14.1%/12.3%), and platelet reduction (3.1%/1.5%). The rate of pathological response, defined as a complete response or < 10% residual cancer remaining, was 19.4% in the CS group and 15.4% in the DCS group, and 15.6% in the two-course group and 19.0% in the 4-course group. The R0 resection rate was 72.7% in the CS group and 81.8% in the DCS group and 80.3% in the two-course group and the 74.2% in the four-course group. No treatment-related deaths were observed.

Conclusions

Our results do not support three-drug therapy with a taxane over two-drug therapy, or any further treatment beyond two cycles as an attractive candidate for the test arm of NAC.

Measurement repeatability of the dynamic Scheimpflug analyzer

PURPOSE

To evaluate the repeatability of corneal deformation parameters measured using a dynamic Scheimpflug analyzer and the impact of baseline clinical factors on the repeatability of each parameter.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

Forty-eight eyes (48 healthy subjects; mean age, 49.0 ± 19.5 years) underwent repeated examinations with the Scheimpflug analyzer to evaluate the test-retest variability. The intraclass correlation coefficient (ICC) and repeatability coefficient as indicators of variability were computed for 35 parameters measured with the Scheimpflug analyzer. The associations between the magnitude of the test-retest variability and baseline factors, such as age, axial length (AL), intraocular pressure (IOP), and central corneal thickness (CCT), were analyzed.

RESULTS

The test-retest repeatability was excellent for 22 (62.9%) of 35 parameters (ICC ≥ 0.75), good for seven (20%), (ICC ≥ 0.6), fair for four (11.4%), (ICC ≥ 0.4), and poor for two (5.7%) parameters (ICC < 0.4). Age was associated positively with the magnitude of variability in 13 (37.1%) parameters; measurement variability was affected significantly by AL (5 parameters, 14.3%) and CCT (7 parameters, 20%) but, except for one parameter not by IOP.

CONCLUSION

Most parameters of the dynamic Scheimpflug analyzer showed favorable measurement reliability in healthy subjects. However, six parameters showed poor-to-fair repeatability. Age, AL, and CCT significantly affected the repeatability of several parameters. These results should be considered when clinicians use this device in clinical practice.

Factors Associated With Corneal Deformation Responses Measured With a Dynamic Scheimpflug Analyzer

Purpose

The purpose of this study was to clarify correlations between corneal deformation parameters measured with a dynamic Scheimpflug analyzer and baseline factors such as axial length, intraocular pressure (IOP), age, central corneal thickness (CCT), and corneal curvature.

Methods

Ninety-six eyes of 96 healthy subjects (mean 55.2 ± 16.1 years of age) were examined using a dynamic Scheimpflug analyzer. Eighteen of 35 deformation parameters were selected for analyses based on measurement reliability and clinical relevance. The associations between corneal deformation parameters and axial length, IOP, age, CCT, and average corneal power were evaluated using multivariate regression analyses.

Results

Deformation parameters were correlated significantly with axial length (n = 13), IOP (n = 13), age (n = 8), and CCT (n = 6) in the multivariate models. Longer axial length corresponded with greater corneal deformability, less viscous damping, and less movement of the entire eye. Higher IOP was associated with greater corneal resistance and less movement of the entire eye. Older age was associated with less corneal deformability and greater movement of the entire eye. Corneal curvature was correlated significantly with only three deformation parameters.

Conclusions

This study clarified the substantial impact of axial length, age, and IOP on the biomechanical responses of the cornea and the entire eye. In contrast, corneal curvature did not affect most of the deformation parameters. The current results confirmed the importance of corneal biomechanics, especially in eyes with longer axial length and in older subjects.

Investigating the usefulness of a cluster-based trend analysis to detect visual field progression in patients with open-angle glaucoma

BACKGROUND/AIMS

To investigate the usefulness of the Octopus (Haag-Streit) EyeSuite's cluster trend analysis in glaucoma.

METHODS

Ten visual fields (VFs) with the Humphrey Field Analyzer (Carl Zeiss Meditec), spanning 7.7 years on average were obtained from 728 eyes of 475 primary open angle glaucoma patients. Mean total deviation (mTD) trend analysis and EyeSuite's cluster trend analysis were performed on various series of VFs (from 1st to 10th: VF1-10 to 6th to 10th: VF6-10). The results of the cluster-based trend analysis, based on different lengths of VF series, were compared against mTD trend analysis.

RESULT

Cluster-based trend analysis and mTD trend analysis results were significantly associated in all clusters and with all lengths of VF series. Between 21.2% and 45.9% (depending on VF series length and location) of clusters were deemed to progress when the mTD trend analysis suggested no progression. On the other hand, 4.8% of eyes were observed to progress using the mTD trend analysis when cluster trend analysis suggested no progression in any two (or more) clusters.

CONCLUSION

Whole field trend analysis can miss local VF progression. Cluster trend analysis appears as robust as mTD trend analysis and useful to assess both sectorial and whole field progression. Cluster-based trend analyses, in particular the definition of two or more progressing cluster, may help clinicians to detect glaucomatous progression in a timelier manner than using a whole field trend analysis, without significantly compromising specificity.

Measurements of the parapapillary atrophy zones in en face optical coherence tomography images

OBJECTIVE

To measure the parapapillary atrophy (PPA) area in en face images obtained with swept-source optical coherence tomography (SS-OCT), and to evaluate its relationship to glaucoma, myopia, and age in non-highly myopic subjects.

DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

Fifty eyes of 30 subjects with open-angle glaucoma (G group) and forty-three eyes of 26 healthy control subjects (C group). Eyes with high myopia (spherical equivalent refractive error ≤ -8 diopters or axial length ≥ 26.5 mm) were excluded.

METHODS

Mean age ± standard deviation was 59.9 ± 12.4 years. The beta zone and the gamma zone PPA areas were measured in en face images reconstructed from three-dimensional SS-OCT images. Relationship between the PPA areas and patient characteristics such as glaucoma, axial length, and age was statistically evaluated using multivariate mixed-effects models.

MAIN OUTCOME MEASURES

Areas of the beta zone and the gamma zone PPA measured on en face OCT images.

RESULTS

Average ± standard deviation area of the beta and the gamma zone was 0.64 ± 0.79 and 0.16 ± 0.30 mm2, respectively. In multivariate models, the gamma zone significantly correlated with axial length (P = 0.001) but not with glaucoma (P = 0.944). In contrast, the beta zone significantly correlated with age (P = 0.0249) and glaucoma (P = 0.014).

CONCLUSIONS

En face images reconstructed from 3D SS-OCT data facilitated measurements of the beta and the gamma PPA zones even in eyes with optic disc distortion. The OCT-defined beta zone is associated with glaucoma and age, whereas the gamma zone correlated with myopia but not with glaucoma. This study confirmed the clinical usefulness of OCT-based classification of the PPA zones in distinguishing glaucomatous damage of the optic nerve from myopic damage in non-highly myopic eyes.

Clinical characteristics and outcomes of adenovirus infection of the urinary tract after renal transplantation

BACKGROUND

Urinary tract infection caused by human adenovirus (HAdV) after renal transplantation (RT) results in graft loss because of concomitant nephropathy and acute rejection and may result in death because of systemic dissemination.

METHODS

We assessed the time period between RT and disease onset, symptoms, treatment details, disease duration, renal graft function, outcomes, and complications.

RESULTS

HAdV infection of the urinary tract occurred in 8 of 170 renal transplant recipients. Symptoms were macrohematuria in all 8 patients, dysuria in 7, and fever in 5. The median period from RT to disease onset was 367 (range, 7-1763) days, and the median disease duration was 15 (range, 8-42) days. The mean serum creatinine (sCr) level prior to onset was 1.35 ± 0.48 mg/dL and the mean maximum sCr level during disease was 2.34 ± 1.95 mg/dL. These values were increased by ≥25% in 5 patients. The mean sCr levels when symptoms resolved was 1.54 ± 0.67 mg/dL, and no significant difference was seen before, during, or after disease onset (P = 0.069). Two patients were diagnosed with HAdV viremia and 1 with acute tubulointerstitial nephritis revealed on biopsy. In addition to a reduction in immunosuppressant dosage, 2 patients received gammaglobulins and 5 received ganciclovir.

CONCLUSION

Symptoms of all patients were alleviated, although some patients developed nephritis or viremia. Hence, the possibility of exacerbation should always be considered. Adequate follow-up observation should be conducted, and diligent and aggressive therapeutic intervention is required to prevent the condition from worsening.

Effects of ocular and systemic factors on the progression of glaucomatous visual field damage in various sectors

BACKGROUND/AIM

To investigate the effects of ocular and systemic risk factors for glaucomatous progression in different sectors of the visual field (VF).

METHOD

409 eyes from 268 patients with 10 reliable VFs from the Japanese Archive of Multicentral Databases in Glaucoma (JAMDIG) were investigated. VFs were divided into six sectors (mean total deviation (mTD)_s20+, mTD_s10-20 and mTD_s0-10, >20°, 10-20° and <10° in the superior hemifield, respectively; and mTD_i20+, mTD_i10-20 and mTD_i0-10, >20°, 10-20° and <10° in the inferior hemifield, respectively). The relationship between sectorial progression rate and eight variables (age, mTD at baseline VF, average intraocular pressure (IOP), SD of IOP, systemic hypertension, migraine, family history of glaucoma and smoking status) was investigated.

RESULT

The mTD progression rate was -0.21 dB/year. Older age was related to progression of mTD_s20+, mTD_s10-20, mTD_i20+ and mTD_i10-20. Mean IOP was not related to progression in any VF sector; however, a larger SD of IOP was related to progression of mTD_s20+, mTD_i0-10, mTD_i10-20 and mTD_i20+. Smoking status was related to progression in all inferior VF sectors (mTD_i0-10, mTD_i10-20 and mTD_i20+).

CONCLUSIONS

Smoking status is related to glaucomatous VF progression in all sectors of the inferior hemifield.

Evaluation of Glaucoma Progression in Large-Scale Clinical Data: The Japanese Archive of Multicentral Databases in Glaucoma (JAMDIG)

PURPOSE

To develop a large-scale real clinical database of glaucoma (Japanese Archive of Multicentral Databases in Glaucoma: JAMDIG) and to investigate the effect of treatment.

METHODS

The study included a total of 1348 eyes of 805 primary open-angle glaucoma patients with 10 visual fields (VFs) measured with 24-2 or 30-2 Humphrey Field Analyzer (HFA) and intraocular pressure (IOP) records in 10 institutes in Japan. Those with 10 reliable VFs were further identified (638 eyes of 417 patients). Mean total deviation (mTD) of the 52 test points in the 24-2 HFA VF was calculated, and the relationship between mTD progression rate and seven variables (age, mTD of baseline VF, average IOP, standard deviation (SD) of IOP, previous argon/selective laser trabeculoplasties (ALT/SLT), previous trabeculectomy, and previous trabeculotomy) was analyzed.

RESULTS

The mTD in the initial VF was -6.9 ± 6.2 dB and the mTD progression rate was -0.26 ± 0.46 dB/year. Mean IOP during the follow-up period was 13.5 ± 2.2 mm Hg. Age and SD of IOP were related to mTD progression rate. However, in eyes with average IOP below 15 and also 13 mm Hg, only age and baseline VF mTD were related to mTD progression rate.

CONCLUSIONS

Age and the degree of VF damage were related to future progression. Average IOP was not related to the progression rate; however, fluctuation of IOP was associated with faster progression, although this was not the case when average IOP was below 15 mm Hg.

Ethnic specific association of the CAV1/CAV2 locus with primary open-angle glaucoma

A single-nucleotide polymorphism (SNP) rs4236601 at the CAV1/CAV2 locus is associated with primary open-angle glaucoma (POAG). Rs4236601 is common in Caucasians but rare in East Asians. Here we conducted a haplotype-tagging SNP analysis followed by replication in a total of 848 POAG cases and 1574 controls drawn from 3 cities in China and 1 city in Japan. Two SNPs, rs4236601 (odds ratio [OR] = 6.25; P = 0.0086) and a tagging-SNP rs3801994 (OR = 1.32; P = 0.042), were associated with POAG in the Hong Kong Chinese cohort after age and gender adjustments. Rs4236601 was associated with POAG also in Shantou (OR = 6.09; P = 0.0037) and Beijing (OR = 3.92; P = 0.030) cohorts after age and gender adjustment, with a pooled-OR of 5.26 (P = 9.0 × 10(-6)) in Chinese; but it is non-polymorphic in the Osaka cohort. SNP rs3801994 showed a similar trend of effect in the Shantou and Beijing cohorts, with a pooled-OR of 1.23 (P = 0.022) and 1.20 (P = 0.063) in Chinese, prior to and after age and gender adjustment, respectively; but it showed a reverse effect in the Osaka cohort (OR = 0.58; P = 0.033) after the adjustments. We have thus confirmed the association of rs4236601 with POAG in different Chinese cohorts. Also, we found a common SNP rs3801994 of diverse associations with POAG between Chinese and Japanese.