Journal of Glaucoma最新文献

Precis: This study demonstrated that the compliance levels with International Council of Ophthalmology (ICO) Guidelines for glaucoma eye care were low for all the elements in both public and private healthcare settings.

Purpose: To determine the compliance with the ICO guidelines for glaucoma eye care among Pakistani ophthalmologists and to compare differences among ophthalmologists practicing in public and private healthcare settings.

Methods: This was a retrospective chart review, and the records were reviewed according to ICO guidelines. The ICO recommends that each patient with glaucoma be evaluated for 19 items from three elements which are history, examination, and investigations. Mean compliance was recorded for each of the three elements. The compliance of each item was also checked, and then a compared between the two settings i.e. public and private healthcare settings.

Results: A total of 394 records were analyzed, with a mean age of 51.9+14.9 years and 232 (58.9%) male patients. Most records were from private settings 339 (86%), and primary open-angle glaucoma 163 (41.4%) was the most common diagnosis. Compliance was low for all elements; history (31.8%), examination (61.3%), and investigation (6%). Pupil reaction differed significantly between the two groups (P=0.001).

Conclusion: Pakistan's ophthalmologists, whether in public or private healthcare settings, lack knowledge of ICO guidelines for glaucoma eye care. This study emphasizes the importance of implementing these guidelines in the general ophthalmology curriculum.

Purpose: To determine the frequency at which patients newly diagnosed with glaucoma in sub-Saharan Africa (SSA) decline recommended therapy and to characterize the reasons for declining therapy.

Methods: This was a multicenter, cross-sectional study conducted on adult patients at the time of glaucoma diagnosis at 27 centers in 10 countries in SSA. Data collected from the diagnostic encounter included demographics, clinical glaucoma characteristics, treatment recommendations, patient acceptance of therapy, and reasons for declining therapy.

Results: Among 2,282 eyes of 1,198 patients offered treatment for glaucoma, initially recommended treatment was accepted in 2,126 eyes (93.2%). Acceptance of therapy varied with the nature of treatment offered, with medical therapy accepted in 99.2% of eyes, laser therapy in 88.3%, and surgical therapy in 69.3%. The most common reasons cited for declining therapy were fear (42.9%) and cost (41.7%); cost was the primary reason for declining medical and laser therapy, while fear was the most common reason for declining surgical therapy. Most patients declining laser or surgical therapy accepted medical therapy as an alternate therapy (98.1%).

Conclusions: Patients' acceptance of glaucoma therapy was high overall, but lower for surgery than for laser or medical therapy. Most patients who declined laser or surgical therapy accepted medical therapy as an alternate therapy when offered. Educational interventions, sustainable incentives, and other approaches are needed to enhance patient acceptance of glaucoma therapy in this setting, particularly surgery when needed.

Precis: In early pseudoexfoliation glaucoma, radial peripapillary capillary vessel density (RPC-VD) was reduced nasally, while the retinal nerve fiber layer (RNFL) thinned from the nasal to temporal sectors. Nonglaucomatous fellow eyes demonstrated no RPC-VD or RNFL loss in comparison to the controls.

Purpose: To evaluate peripapillary and macular vessel density (VD) in unilateral early pseudoexfoliation glaucoma (PXG) and unaffected fellow eyes compared to healthy controls.

Methods: This cross-sectional study included 28 eyes with PXG and 28 nonglaucomatous, pseudoexfoliation-free fellow eyes of 28 patients and 28 eyes of 28 healthy participants. All subjects underwent optical coherence tomography angiography (OCTA) imaging. Radial peripapillary capillary VD (RPC-VD), macular VD, retinal nerve fiber layer (RNFL) thickness, and ganglion cell complex (GCC) thickness were compared among the groups.

Results: The average RPC-VD and RNFL thickness were significantly reduced in PXG eyes compared to both fellow eyes and the control group (P<0.001-0.002). In fellow eyes, neither RNFL thickness nor RPC-VD parameters differed from controls. In sector-based analysis, RPC-VD loss in the PXG eyes was significant in the nasal-superior, nasal-inferior, superonasal, and inferonasal sectors (P=0.005-0.031), while RNFL thinning extended from the nasal sectors toward the superotemporal and temporal-superior sectors (P<0.001-0.014). RPC-VD was strongly correlated with average and all sector RNFL thicknesses (r=0.402-0.759, P<0.001-0.034). While perifoveal GCC differed from both fellow and control eyes (P<0.001), there was no significant difference in macular VD parameters among the groups. RPC-VD and RNFL had comparable area under receiver operating curve (AUROC) values in the average and nasal sectors, while RPC-VD had no ability to distinguish PXG from controls in the superotemporal and inferotemporal sectors.

Conclusion: In the early stages of PXG, RNFL parameters mostly appear to have better diagnostic ability than RPC-VD parameters. Fellow eyes in the preclinical stage may not exhibit any RPC-VD and RNFL loss detectable by current OCTA technology.

Purpose: Evaluate the relationship between CYP3A4 phenotype, the gene encoding the enzyme that metabolizes exogenous steroid, and the rate of steroid-induced intraocular pressure (IOP) response.

Materials and methods: Lymphocyte-derived DNA sequencing of CYP3A4 from 10073 patients was completed using the PGRN-Seq assay. Subjects with CYP3A4 intermediate metabolizer or slower phenotypes were identified and compared with controls matched by age, race and sex. All subjects had at least three eye exams with at least an exam while on topical/systemic/local steroid in any body location except the eye. Patients with pre-existing glaucoma or glaucoma suspect were excluded.

Results: Of the 10073 patients, there were 63 patients who had CYP3A4 poor or intermediate metabolizer phenotype. Of the 63 patients, 22 had documented steroid use. Fifty-nine percent (13/22) of patients with CYP3A4 poor/intermediate metabolizer had a steroid-induced IOP response of 3 mmHg or more, significantly higher compared to 23% (5/22) of matched controls (P=0.031). Although more poor /intermediate metabolizers were steroid responders, the average IOP elevation in steroid responders in both groups were similar (5.0 ± 2.5 mmHg in CYP3A4 poor/intermediate metabolizers compared to 4.1 ± 2.1mmHg in controls, P=0.327). Family history of glaucoma was similar in both groups (7/22 vs. 8/22, P=1.0).

Conclusion: Reduced CYP3A4 phenotypes may help identify patients at a higher risk of steroid-induced IOP elevation.

Prcis: This retrospective study examined patients with sequenced CYP3A4, a gene encoding an enzyme that metabolizes exogenous steroids. When compared to normal metabolizers, CYP3A4 poor or intermediate metabolizers have a higher steroid-induced IOP response rate.

Precis: There were statistically significant differences across multiple socioeconomic characteristics and self-reported barriers to care among primary glaucoma patients with severity staging data versus those missing this data in the NIH All of Us database.

Purpose: To characterize missing data among glaucoma patients within All of Us.

Patients and methods: We used diagnosis codes to define cohorts of primary glaucoma patients with and without severity staging specified. Descriptive analyses were conducted by presence of disease severity stage. Analysis of missing data was conducted using a set intersection plot and Little's Test of Missing Completely at Random. T-tests were performed to evaluate differences.

Results: Of 2982 participants, 1714 (57%) did not have glaucoma severity stage specified, and 11 of 23 analyzed variables had missing data. Little's Test indicated data was not missing completely at random (P<0.001). Significant differences existed between the two cohorts with respect to age, age of first glaucoma diagnosis, gender, ethnicity, education, income, insurance, history of glaucoma surgery and medication use, and answers regarding ability to afford eyeglasses and having seen an eye care provider in the last 12 months (all P values≤0.01).

Conclusion: There were significant differences between glaucoma participants with glaucoma severity stage specified versus those with unstaged disease across multiple socioeconomic characteristics and self-reported barriers to care. Glaucoma severity staging data was not missing completely at random. The unstaged cohort included higher rates of multiple underrepresented communities, which may potentially contribute to bias in ophthalmology research as participants from vulnerable populations may be disproportionately excluded from electronic health records or claims data studies where diagnosis codes with severity/staging levels are used to examine risk factors for disease, progression, and treatment efficacy.

Purpose: To identify ocular hypertension (OHT) subtypes with different trends of visual field (VF) progression based on unsupervised machine learning and to discover factors associated with fast VF progression.

Design: Cross-sectional and longitudinal study.

Participants: A total of 3133 eyes of 1568 ocular hypertension treatment study (OHTS) participants with at least five follow-up VF tests were included in the study.

Methods: We used a latent class mixed model (LCMM) to identify OHT subtypes using standard automated perimetry (SAP) mean deviation (MD) trajectories. We characterized the subtypes based on demographic, clinical, ocular, and VF factors at the baseline. We then identified factors driving fast VF progression using generalized estimating equation (GEE) and justified findings qualitatively and quantitatively.

Main outcome measure: Rates of SAP mean deviation (MD) change.

Results: The LCMM model discovered four clusters (subtypes) of eyes with different trajectories of MD worsening. The number of eyes in clusters were 794 (25%), 1675 (54%), 531 (17%) and 133 (4%). We labeled the clusters as Improvers (cluster 1), Stables (cluster 2), Slow progressors (cluster 3), and Fast progressors (cluster 4) based on their mean of MD decline rate, which were 0.08, -0.06, -0.21, and -0.45 dB/year, respectively. Eyes with fast VF progression had higher baseline age, intraocular pressure (IOP), pattern standard deviation (PSD) and refractive error (RE), but lower central corneal thickness (CCT). Fast progression was associated with being male, heart disease history, diabetes history, African American race, and stroke history.

Conclusion: Unsupervised clustering can objectively identify OHT subtypes including those with fast VF worsening without human expert intervention. Fast VF progression was associated with higher history of stroke, heart disease and diabetes. Fast progressors were more from African American race , males and had higher incidence of glaucoma conversion. Subtyping can provide guidance for adjusting treatment plans to slow vision loss and improve quality of life of patients with a faster progression course.

Prcis: High perceived stress from academic pressure is associated with intraocular pressure elevation and reduced fluctuation in juvenile-onset open-angle glaucoma patients. Personalized stress assessment and relief strategies may serve as an adjunct therapy in glaucoma.

Objective: To evaluate the effect of higher perceived stress, resulting from academic pressure, on intraocular pressure (IOP) in juvenile-onset open-angle glaucoma (JOAG) patients compared to healthy individuals.

Participants and methods: The study included 48 university students aged 18 to 27, comprising 24 JOAG patients on antiglaucoma eyedrops and 24 healthy controls. In an examiner-blind pretest-posttest design, participants' IOP was measured weekly using Goldmann tonometry during three follow-up visits at the beginning and end of the academic semester. Perceived Stress Scale (PSS) scores were also evaluated at these two time points to capture the contrast in perceived stress between periods of low and high academic pressure.

Results: Baseline PSS score at the semester's start was lower in both groups (14.1±1.9 in glaucoma vs. 13.5±2.4 in control) and significantly increased by the end of the semester (29.2±2.1 vs. 28.5±1.3; P<0.001), indicating increased perceived stress. Concurrently, IOP rose from 22.01±5.87 mmHg to 25.08±5.84 mmHg in the glaucoma group and from 11.36±2.03 mmHg to 13.65±2.11 mmHg in the control group. Factorial analysis revealed a significant interaction between stress and JOAG [F(1,94)=15.94, P=0.001], partial η2=0.08, with stress having a greater increase on IOP in the glaucoma group (+3.10 mmHg) compared to the control group (+2.23 mmHg) [t(94)=4.457, P<0.001].

Conclusions: Higher perceived stress significantly increases IOP, especially in JOAG patients, suggesting personalised stress management as a potential adjunct therapy for patients.

Prcis: Central lamina cribrosa thickness was found to be higher in eyes with ocular hypertension, compared to primary open angle glaucoma and healthy controls.

Purpose: To evaluate the anatomical features of lamina cribrosa (LC) and the optic disc (OD) using swept-source optical coherence tomography (OCT) in eyes with ocular hypertension (OHT).

Materials and methods: Treatment naive eyes with OHT and primary open angle glaucoma (POAG) and healthy eyes were included. All eyes underwent a complete ophthalmological examination in addition to swept-source OCT of optic disc. Anatomical features of LC, including central LC thickness(LCT), LC depth (LCD), prelaminar depth (PLD), pre-laminar tissue thickness (PLTT) were measured manually using the internal caliper function of the OCT device and compared within groups. Optic disc ovality, disc-foveal angle and optic disc torsion were measured on colored photographs, using imageJ software.

Results: Seventy one eyes of 37 patients in OHT group, 41 eyes of 26 patients in POAG group and 30 eyes of 30 patients in healthy control (HCs) group were enrolled in the study. Groups were similar for age and gender distribution. Central LCT was significantly higher in OHT group, compared to HCs (333.8±50.5µm vs. 304.5±46.3µm, P=0.02) and POAG group (286.7±140.4, P=0.001). PLD and LCD were both highest in POAG (282.3±145.5µm and 471.3±195.2µm) followed by OHT (244.8±30.2µm and 440.7±18.7µm) and HCs(170.1±152.6 µm and 412.8±80µm), only the difference between POAG and HCs in PLD was statistically significant(P=0.03). PLTT, OD torsion, disc-foveal angle and disc-ovality showed no significant difference.

Conclusion: LC was significantly thicker in eyes with OHT, compared to POAG and HCs. This finding may be relevant to optic nerve protection from high intraocular pressure in patients with ocular hypertension.

Precis: Minimum Rim width (MRW) is thinner in patients with non-glaucomatous pseudoexfoliation syndrome (XFS) and may be the first parameter affected in these patients due to the vascular nature of this disease.

Purpose: To evaluate the macular inner layers, circumpapillary retinal nerve fiber layer (cp-RNFL), and MRW in non-glaucomatous XFS compared to healthy subjects.

Methods: In this prospective study, using Heidelberg Spectralis optical coherence tomography (OCT) with glaucoma module premium edition, 8×8 grids of macular inner layers were exported, and the global, superior, and inferior thicknesses were used. Also, on the deviation map, the elliptical annulus around the fovea, which was 4.8×4 mm in size, was analyzed. Moreover, both groups calculated cp-RNFL and MRW values in three superior and three inferior sectors.

Results: Thirty-two eyes of thirty-two subjects with clinically detected non-glaucomatous XFS and 30 right eyes of age-sex-matched healthy controls were included. No significant difference was found between the case and control groups concerning the intraocular pressure (IOP) (14.94±2.09 mmHg vs. 15.27±2.27, respectively, P value= 0.556). The MRW of the superotemporal segment (MRW-TS) was significantly thinner in the XFS group compared with the control ones (303.69±60.49 µm vs. 341.43±56.19 µm, P = 0.014). No significant differences were found in the other sectors of MRW, macular inner layers, and cp-RNFL thickness between the groups.

Conclusion: These findings indicate that the MRW, especially in the superotemporal sector, may show early eye damage in patients with non-glaucomatous XFS, and it may be used to detect the early stage of glaucoma in XFS.

Prcis: Analysis of AIZE Rapid test variability in stable glaucoma patients showed that the 95% prediction interval of the MD value, potentially an index for judging progression, was ±1.63 to ±1.78 dB in early-to-moderate-stage patients.

Purpose: To explore the 95% prediction interval of the mean deviation (MD) value using the AIZE Rapid test strategy for glaucoma observation.

Method: This study included seventy-two patients with stable or suspected glaucoma who underwent the imo AIZE Rapid test three times or more within two years. Both eyes from each patient were classified as better or worse eyes. They were divided based on baseline MD values into the following four groups: MD > -3 dB, -6 dB < MD ≤ -3 dB, -12 dB < MD ≤ -6 dB, and MD ≤ -12 dB. The variability of MD during the observation period and the 95% prediction intervals were analyzed. Pointwise variability of limits at each test locations were also calculated.

Results: The numbers of better and worse eyes included in the study were forty-six and thirty-three. The median follow-up period was 1.3 years (range: 0.5 to 1.9 years). The 95% prediction intervals for MD values were ±1.41 dB for better eyes (n = 46) and ±1.47 dB for worse eyes (n = 33). The 95% prediction intervals in the MD > -3 dB, -6 dB < MD ≤ -3 dB, -12 dB < MD ≤ -6 dB, and MD ≤ -12 dB groups were ±1.63 dB, ±1.34 dB, ±1.78 dB, and ±1.33 dB, respectively. Pointwise variability of worse eyes was larger than better eyes especially in between 10 to 15 dB.

Conclusion: In the case of a difference in MD greater than the 95% prediction intervals when compared with the previous visual field result, we should pay much attention to the possibility of progression of the glaucomatous visual field in stable glaucoma patients.