Ophthalmology. Glaucoma最新文献

Clinical relevance: Glaucoma is a complex eye condition with varied morphological and clinical presentations, making diagnosis and management challenging. The lack of a consensus definition for glaucoma or glaucomatous optic neuropathy further complicates the development of universal diagnostic tools. Developing robust artificial intelligence (AI) models for glaucoma screening is essential for early detection and treatment but faces significant obstacles. Effective deep learning algorithms require large, well-curated datasets from diverse patient populations and imaging protocols. However, creating centralized data repositories is hindered by concerns over data sharing, patient privacy, regulatory compliance, and intellectual property. Federated Learning (FL) offers a potential solution by enabling data to remain locally hosted while facilitating distributed model training across multiple sites.

Methods: A comprehensive literature review was conducted on the application of Federated Learning in training AI models for glaucoma screening. Publications from 1950 to 2024 were searched using databases such as PubMed and IEEE Xplore with keywords including "glaucoma," "federated learning," "artificial intelligence," "deep learning," "machine learning," "distributed learning," "privacy-preserving," "data sharing," "medical imaging," and "ophthalmology." Articles were included if they discussed the use of FL in glaucoma-related AI tasks or addressed data sharing and privacy challenges in ophthalmic AI development.

Results: FL enables collaborative model development without centralizing sensitive patient data, addressing privacy and regulatory concerns. Studies show that FL can improve model performance and generalizability by leveraging diverse datasets while maintaining data security. FL models have achieved comparable or superior accuracy to those trained on centralized data, demonstrating effectiveness in real-world clinical settings.

Conclusions: Federated Learning presents a promising strategy to overcome current obstacles in developing AI models for glaucoma screening. By balancing the need for extensive, diverse training data with the imperative to protect patient privacy and comply with regulations, FL facilitates collaborative model training without compromising data security. This approach offers a pathway toward more accurate and generalizable AI solutions for glaucoma detection and management.

Financial disclosure(s): Proprietary or commercial disclosure may be found after the references in the Footnotes and Disclosures at the end of this article.

Purpose: Primary congenital glaucoma (PCG) is a potentially blinding disease, and the search for the best surgical option always remains. This study investigated the efficacy of Bent Ab-Interno Needle Goniectomy (BANG) compared to the established standard of traditional goniotomy.

Design: Parallel-group randomized controlled trial.

Participants: Infants with PCG aged 1 month to 1 year with similar clinical features in both eyes.

Intervention: The 2 eyes of eligible patients were randomized to either goniotomy or BANG using a 25-gauge needle bent as a reverse cystitome, and the surgeries were done on the same day in both eyes. Postoperatively each infant was followed up for a minimum period of 1 year.

Main outcome measures: The primary outcomes measured were intraocular pressure (IOP) control and the requirement for antiglaucoma medications (AGMs). The secondary outcome measures included corneal clarity enhancement, axial length stability, incidence of surgical complications, or the need for repeat surgery.

Results: Eight infants with both eyes eligible, were included. In each infant, 1 eye was randomized to BANG and the other to conventional goniotomy. The mean age was 7.6 ± 3.6 months. There was no significant difference in the mean preoperative IOP (16.8 ± 8.87 mm Hg vs. 17 ± 6.0 mm Hg; P = 0.48) in eyes randomized to goniotomy or BANG. The mean number of AGMs (1.7 ± 1.11 vs. 2 ± 0.81 respectively; P = 0.26) were similar in both groups. Postoperatively, the IOP at 6 months (14.05 ± 4.1 vs. 16.2 ± 4.07; P = 0.22) and 1 year (15.3 ± 3.4 vs. 17.1 ± 3.0; P = 0.15) were similar in eyes that underwent goniotomy or BANG respectively. Both procedures demonstrated significant improvements in corneal clarity and maintained normal axial length growth. However, the BANG group required slightly more AGMs than the goniotomy group. There were no serious complications in either group. Both eyes of 1 patient required repeat surgery for IOP control and underwent a combined trabeculotomy with trabeculectomy at 9 months and 1 year postoperatively, respectively.

Conclusions: This study indicates that goniotomy remains an effective surgical treatment for PCG. The absence of discernible superiority in IOP control or overall outcomes implies that the added complexity of excising the trabecular meshwork in BANG may not confer additional benefits over the established approach.

Financial disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective/purpose: Standardization of eye care data is important for clinical interoperability and research. We aimed to address gaps in the representations of glaucoma examination concepts within Systemized Nomenclature of Medicine - Clinical Terms (SNOMED-CT), the preferred terminology of the American Academy of Ophthalmology.

Design: Study of data elements.

Methods: Structured eye examination data fields from 2 electronic health records (EHR) systems (Epic Systems and Medisoft) were compared against existing SNOMED-CT codes for concepts representing glaucoma examination findings. Glaucoma specialists from multiple institutions were surveyed to identify high-priority gaps in representation, which were discussed among the SNOMED International Eye Care Clinical Reference Group. Proposals for new codes to address the gaps were formulated and submitted for inclusion in SNOMED-CT.

Main outcome measures: Gaps in SNOMED-CT glaucoma examination concept representations.

Results: We identified several gaps in SNOMED-CT regarding glaucoma examination concepts. A survey of glaucoma specialists identified high-priority data elements within the categories of tonometry and gonioscopy. For tonometry, there was consensus that we need to define new codes related to maximum intraocular pressure (IOP) and target IOP and delineate all methods of measuring IOP. These new codes were proposed and successfully added to SNOMED-CT for future use. Regarding gonioscopy, the current terminology did not include the ability to denote the gonioscopic grading system used (e.g., Shaffer or Spaeth), degree of angle pigmentation, iris configuration (except for plateau iris), and iris approach. There was also no ability to specify eye laterality or angle quadrant for gonioscopic findings. We proposed a framework for representing gonioscopic findings as observable entities in SNOMED-CT.

Conclusion: There are existing gaps in the standardized representation of findings related to tonometry and gonioscopy within SNOMED-CT. These are important areas for evaluating clinical outcomes and enabling secondary use of EHR data for glaucoma research. This international multi-institutional collaborative process enabled identification of gaps, prioritization, and development of data standards to address these gaps. Addressing these gaps and augmenting SNOMED-CT coverage of glaucoma examination findings could enhance clinical documentation and future research efforts related to glaucoma.

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: There is a longstanding belief that prostaglandin analogs (PGAs) may predispose patients with glaucoma to develop acute cystoid macular edema (CME). However, there is little solid evidence supporting this notion. The purpose of this study is to compare CME incidence rates among patients initiating treatment with different glaucoma medication classes.

Design: Database study.

Participants: A total of 39 948 patients who were newly prescribed glaucoma medications METHODS: Using data from 10 health systems contributing data to the Sight Outcomes Research Collaborative Ophthalmology Data Repository, we identified all adults with glaucoma who had been newly started on a topical glaucoma medication. Patients with pre-existing documentation of macular edema were excluded. We assessed the incidence of CME among patients with glaucoma who were newly started on PGAs, topical beta blockers (BBs), alpha agonists (AAs), and carbonic anhydrase inhibitors (CAIs). Using multivariable logistic regression, and adjusting for sociodemographic factors, we assessed the odds of developing CME among patients prescribed each of the 4 glaucoma medication classes. We also performed a subset regression analysis including lens status as a covariate.

Main outcome measures: Incidence of CME within 3 months of initiating therapy with different topical glaucoma medications.

Results: Among the 39 948 patients who were newly treated with a topical glaucoma medication, 139 (0.35%) developed CME. The incidence of CME was 0.13%, 0.65%, 0.55%, and 1.76% for users of PGAs, BBs, AAs, and CAIs, respectively. After adjusting for sociodemographic factors, users of topical BBs, AAs, and CAIs had substantially higher odds of developing CME compared with PGA users (P < 0.001 for all comparisons). The subset analysis also showed higher odds ratio of the non-PGA medication classes in association with CME.

Conclusions: Clinicians should reconsider the notion that PGAs carry a higher risk of CME versus other glaucoma medication classes. If additional studies support the findings of these analyses, clinicians may feel more comfortable prescribing PGAs to patients with glaucoma without fear they will predispose patients to CME.

Financial disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective: To explore the impact of the apolipoprotein E (APOE) E4 allele in the gender-specific aging process in glaucoma by illustrating the interaction between risk factors, including the APOE E4 allele, gender, and intraocular pressure (IOP), for age at diagnosis (AAD) of glaucoma.

Design: A cross-sectional study included UK Biobank participants with complete data (2006-2010) for analysis. Data were analyzed in December 2023.

Participants: Two thousand two hundred thirty-six glaucoma patients and 103 232 controls.

Methods: We evaluated multivariable-adjusted associations of AAD of glaucoma, APOE E4 allele (0: absence; 1: presence), and IOP using linear mixed model (LMM) analyses across groups stratified by AAD of mean age of menopause (50 years) and gender.

Main outcomes measures: Age at diagnosis of glaucoma, APOE E4 allele, and IOP.

Results: Patients with glaucoma were older and had a higher percentage of males and a higher mean IOP compared to controls (all P < 0.001). Further stratifying the patients with glaucoma by AAD of 50 and gender, lower IOP (model 1 adjusted by age, β_IOP = -0.096 ± 0.041, P = 0.019), and positive APOE E4 allele (model 2 adjusted by age and IOP, β_e4 = 1.093 ± 0.488, P = 0.026) were associated with an older AAD in females with an AAD <50 years under univariate LMM. In multivariate LMM adjusted by age (model 3), the effect size of both factors increased in the multivariate model as the beta-value increased (β_IOP = -0.111 ± 0.040, P = 0.007; β_e4 = 1.235 ± 0.485, P = 0.012) (model 1 vs. model 3: P = 0.011). In females with an AAD ≥50 years, only positive APOE E4 allele (adjusted by age and IOP, β_e4 = -1.121 ± 0.412, P = 0.007) was associated with a younger AAD. In males, only higher IOP was associated with an older AAD in those with an AAD ≥50 years (β_IOP = 0.088 ± 0.032, P = 0.006).

Conclusions: Apolipoprotein E E4 allele may initially delay and later accelerate the development of glaucoma in females around the transition period of 50 years, which is the mean age of menopause, and importantly, this is independent of IOP. Understanding the specific transition states and modifiable factors within each age phase is crucial for developing interventions or strategies that promote healthy aging.

Financial disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: To investigate associations between statin use and glaucoma in the 2017 to 2022 All of Us (AoU) Research Program.

Design: Cross-sectional, population-based.

Participants: 79 742 adult participants aged ≥40 years with hyperlipidemia and with electronic health record (EHR) data in the AoU database.

Methods: Hyperlipidemia, glaucoma status, and statin use were defined by diagnoses and medication information in EHR data collected by AoU. Logistic regression analysis was performed to evaluate the association between statin use and glaucoma likelihood. Logistic regression modeling was used to examine associations between glaucoma and all covariates included in adjusted analysis. Serum low-density lipoprotein cholesterol (LDL-C) was used to assess hyperlipidemia severity. Analyses stratified by LDL-C level and age were performed.

Main outcome measures: Any glaucoma as defined by International Classification of Diseases codes found in EHR data.

Results: Of 79 742 individuals with hyperlipidemia in AoU, there were 6365 (8.0%) statin users. Statin use was associated with increased glaucoma prevalence when compared with statin nonuse (adjusted odds ratio [aOR]: 1.13, 95% confidence interval [CI]: 1.01-1.26). Higher serum levels of LDL-C were associated with increased odds of glaucoma (aOR: 1.003, 95% CI: 1.003, 1.004). Statin users had significantly higher LDL-C levels compared to nonusers (144.9 mg/dL versus 136.3 mg/dL, P value < 0.001). Analysis stratified by LDL-C identified positive associations between statin use and prevalence of glaucoma among those with optimal (aOR = 1.39, 95% CI = 1.05-1.82) and high (aOR = 1.37, 95% CI = 1.09-1.70) LDL-C levels. Age-stratified analysis showed a positive association between statin use and prevalence of glaucoma in individuals aged 60 to 69 years (aOR = 1.28, 95% CI = 1.05-1.56).

Conclusions: Statin use was associated with increased glaucoma likelihood in the overall adult AoU population with hyperlipidemia, in individuals with optimal or high LDL-C levels, and in individuals 60 to 69 years old. Findings suggest that statin use may be an independent risk factor for glaucoma, which may furthermore be affected by one's lipid profile and age.

Financial disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: Loss to follow-up (LTFU) in primary open-angle glaucoma (POAG) can lead to undertreatment, disease progression, and irreversible vision loss. Patients who become LTFU either eventually re-establish glaucoma care after a lapse or never return to the clinic. The purpose of this study is to examine a large population of patients with POAG who became LTFU to determine the proportion that return to care and to identify demographic and clinical factors associated with nonreturn after LTFU.

Design: Retrospective longitudinal cohort study.

Participants: Patients with a diagnosis of POAG with a clinical encounter in 2014 in the IRIS® Registry (Intelligent Research in Sight).

Methods: We examined follow-up patterns for 553 663 patients with POAG who had an encounter in the IRIS Registry in 2014 by following their documented clinic visits through 2019. LTFU was defined as exceeding 1 calendar year without an encounter. Within the LTFU group, patients were classified as returning after a lapse in care (return after LTFU) or not (nonreturn after LTFU).

Main outcome measures: Proportion of patients with nonreturn after LTFU and baseline demographic and clinical characteristics associated with nonreturn among LTFU patients with POAG.

Results: Among 553 663 patients with POAG, 277 019 (50%) had at least 1 episode of LTFU over the 6-year study period. Within the LTFU group, 33% (92 471) returned to care and 67% (184 548) did not return to care. Compared to those who returned to care, LTFU patients with nonreturn were more likely to be older (age >80 years; relative risk [RR] = 1.48; 95% confidence interval [CI]: 1.47-1.50), to have unknown/missing insurance (RR = 1.31; 95% CI: 1.30-1.33), and to have severe-stage POAG (RR = 1.13; 95% CI: 1.11-1.15). Greater POAG severity and visual impairment were associated with nonreturn with a dose-dependent relationship in the adjusted model that accounted for demographic characteristics. Among those with return after LTFU, almost all returned within 2 years of last appointment (82 201; 89%) rather than 2 or more years later.

Conclusions: Half of patients with POAG in the IRIS Registry had at least 1 period of LTFU, and two thirds of LTFU patients with POAG did not return to care. More effort is warranted to re-engage the vulnerable patients with POAG who become LTFU.

Financial disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose: To examine racial and ethnic differences in the prevalence and treatment patterns for neovascular glaucoma (NVG) in at-risk individuals in the American Academy of Ophthalmology (Academy) IRIS® Registry (Intelligent Research in Sight).

Design: Observational retrospective cohort study.

Participants: Eyes in the IRIS Registry with a retinal ischemia based on a history of proliferative diabetic retinopathy, retinal vein occlusion, and/or ocular ischemic syndrome.

Methods: Race and ethnicity was defined as Asian, Black, Hispanic/Latino, non-Hispanic White, and other/unknown. In eyes with retinal ischemia, the outcome was NVG. In eyes with NVG, outcomes included treatment of retinal ischemia with pan-retinal photocoagulation (PRP), and surgery to lower intraocular pressure (IOP) with trabeculectomy, tube shunt, and cyclophotocoagulation (CPC). Covariates included age, sex, region of residence, insurance type, smoking status, and systemic and ocular comorbidities. Cox proportional hazards regression was used to examine adjusted associations between race and ethnicity and NVG and each type of NVG treatment.

Main outcome measures: Incidence of NVG, PRP, trabeculectomy, tube shunt, CPC, and any IOP-lowering surgery.

Results: Of 312 106 eyes with retinal ischemia, there were 5885 (1.9%) with NVG. Compared to eyes of individuals who identified as non-Hispanic White, eyes of individuals who were Black and Hispanic/Latino had higher hazards of NVG in adjusted analyses (hazards ratio [HR] = 1.28, 95% confidence interval [CI] = 1.15-1.43 [for Black]; HR = 1.32, 95% CI = 1.17-1.47 [for Hispanic/Latino]). Compared with eyes of individuals who were non-Hispanic White, there was higher hazards of trabeculectomy in eyes of individuals who were Hispanic/Latino (adjusted HR = 1.91, 95% CI = 1.08-3.39) and higher hazards of tube shunt (adjusted HR = 1.35, 95% CI = 1.07-1.69) and of any IOP-lowering surgery (adjusted HR = 1.29, 95% CI = 1.09-1.53) in eyes of individuals who were Black. There were no statistically significant differences in the hazards of PRP or CPC.

Conclusions: Eyes of Black and Hispanic/Latino individuals with retinal ischemia in the IRIS Registry had higher likelihood of NVG and of IOP-lowering surgery for NVG. Further study is needed to examine the medical and social factors that preclude optimal management of diabetic eye disease, in order to prevent its blinding complications.

Financial disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.