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Purpose: The quality of life (QoL) of glaucoma patients is affected by many factors. In particular, patient activity is compromised by the chronicity of the disease. In this study, we evaluated the change in QoL and its impact on activities over a period of 8 years., Methods: A total of 43 patients with glaucomatous optic nerve damage were enrolled in this retrospective longitudinal observational study. Changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA) and visual field (VF) parameters, number of IOP-lowering eye drops and IOP-lowering surgery were assessed over a period of 8 years. Assessment of QoL was obtained by patient-reported visual functioning using the Rasch-calibrated glaucoma activity limitation 9 (GAL-9) questionnaire at baseline and after 8 years., Results: The BCVA of the better eye changed from 0.16 ± 0.22 to 0.21 ± 0.14 logMAR, whereas there was a change from 0.27 ± 0.25 to 1.39 ± 1.1 logMAR in the worse eye. The VF parameter mean deviation (MD) of the better eye changed from -2.39 ± 4.55 dB to -4.83 ± 5.09 dB, while it altered significantly from -8.86 ± 5.86 dB to -12.05 ± 8.07 dB in the worse eye. Values of GAL‑9 changed from -2.39 ± 2.14 to -1.38 ± 2.78 (in the Rasch analysis, more negative values account for a better QoL), according to a sum score change from 79.17 ± 19.63 to 69.22 ± 27.95. This change showed a highly significant correlation with the MD at follow-up, especially with the worse eye (r = 0.43). The impact of the MD at follow-up on QoL could also be well predicted in a regression model., Conclusion: The QoL of glaucoma patients decreased significantly over time. Changes in the VF, particularly of the worse eye, have a great impact on reported functioning. Careful treatment, especially of the eye with greater glaucomatous damage, is mandatory., (© 2021. The Author(s).)

Purpose: To structurally determine patients' and physicians' preferences for glaucoma diagnostic methods in order to improve glaucoma patient care and improve patient compliance with follow-up visits., Methods: Forty-one patients with glaucoma and 32 ophthalmologists were included in this cross-sectional study. Profiles representing glaucoma examinations were created using conjoint analysis (CA). The following factors of a glaucoma examination method were evaluated: (1) examination comfort, (2) examination frequency, (3) follow-up examination necessary in case of suspicious result, (4) cost for the patient, (5) travel time to examination site, (6) sensitivity and (7) specificity of the examination method., Results: Preferences were highest in both groups for examination sensitivity, followed by cost and specificity for the patient group. For the physician group, specificity was second most important, followed by cost. Least important was travel time for the patients and follow-up examinations for the physicians., Conclusions: Participants would rather pay more and travel longer to get a highly sensitive examination. This form of care is present in university eye hospitals. Consequently, it would be advisable to enhance capacities of these centers. Outpatient practices that offer glaucoma service should be fully equipped and should employ a glaucoma specialist., (© 2021. The Author(s).)

Purpose: Lowering the intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG) with filtration surgery can induce morphological changes to the bulbus and structures of the retina. In this study, we have evaluated changes of Bruch's membrane-based parameters and retinal nerve fiber layer (RNFL) derived by spectral-domain optical coherence tomography (SD-OCT) in eyes that have undergone glaucoma filtration surgery., Patients and Methods: SD-OCT imaging of the optic nerve head (ONH) and of the RNFL was performed in 54 eyes of 54 patients with medically uncontrolled POAG before and after IOP-lowering surgery (trabeculectomy or deep sclerectomy). The ONH parameter minimum rim width (MRW) and the size of the Bruch's membrane opening (BMO-Area) were derived from 24 radial B-scans centered on the ONH., Results: The average preoperative IOP was 23.1 ± 7.5 mmHg. One month postoperatively, the average IOP decreased to 12.1 ± 4.6 mmHg (p < 0.01), which caused a significant increase in the thickness of neuroretinal rim. There was no significant change in the automatically detected BMO-Area (p = 0.32). The pressure-related increase in MRW correlated well with the postoperative IOP and cup-to-disc ratio (CDR). In regression analysis, the alteration in thickness of the neuroretinal rim could be well predicted in a model including CDR, change of IOP and mean deviation (MD) (R 2 = 0.414, p < 0.001). RNFL showed a significant increase as well., Conclusion: IOP-lowering surgery in patients with medically uncontrolled POAG causes an increased thickness of the SD-OCT derived ONH parameters. The changes of the RNFL after surgery showed no significant correlations with IOP changes. In contrast to this, highly significant correlations of MRW values with the IOP could be observed. The BMO-Area remained completely stable A preferred use of RNFL for follow-up should be discussed., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Koenig and Hirneiss.)

Background: The STARflo Glaucoma Device (iSTAR Medical, Wavre, Belgium) offers a new approach to bleb-free filtering surgery in which the intraocular pressure (IOP) is lowered by supporting outflow of the aqueous humor into the suprachoroidal space., Materials and Methods: On the basis of a case series of 9 patients with open-angle glaucoma (OAG) unmanageable by drug-based treatment, intra- and postoperative experiences with the implant are presented. The implant, the implantation procedure, and the first results 6 months postoperatively are described., Results: No intraoperative complications were observed. Postoperative complications such as increased astigmatism or ocular hypotony were rare and transient. After 6 months there was an IOP reduction from 29.1 mm Hg ± 6.1 mm Hg with 2.7 ± 1.1 local IOP-lowering medications to 16.1 ± 4.1 mm Hg (IOP reduction of 44.7%) with additional 2.0 ± 0.8 local IOP-lowering medications., Discussion: The new STARflo Glaucoma Device shows promising results in reducing the IOP of medically uncontrolled OAG. Further investigations concerning the long-time efficacy of the implant and additional IOP-lowering medication are still ongoing.

Purpose: This study was performed to evaluate the structure-function relationship between Bruch's membrane opening (BMO) parameters of the optic nerve head (ONH) and visual field (VF) sensitivity., Methods: Forty-six right eyes of 46 patients with open-angle glaucoma (OAG) in the patient group and 12 right eyes in the control group were included. Standard automated perimetry (SAP) and spectral-domain optical coherence tomography (SD-OCT) were assessed. Three BMO-based distances and two areas of the neuroretinal rim were used for correlation: the minimum rim width (MRW), the perpendicular rim width (PRW), the horizontal rim width (HRW), the minimum rim area (MRA) within the neuroretinal tissue defined by the MRW, and the perpendicular rim area (PRA) within the neuroretinal tissue defined by the PRW. These parameters were correlated with global and sectoral VF sensitivities. Spearman's correlation coefficients between BMO parameters and global and sectoral VF sensitivities were obtained., Results: Within the patient group, significant correlations could be observed between global and sectoral VF sensitivities and BMO parameters, with PRW and PRA showing the highest values. In the sectoral analysis the highest correlations were found for the temporal-inferior VF sector (MD-TI): PRW-TI (ρ = 0.72394; P < 0.00001) and PRA-TI (ρ = 0.77205; P < 0.00001). Minimum rim width and MRA performed more weakly than PRW and PRA., Conclusions: The BMO-based parameters PRW and PRA presented with a very good structure-function relationship in glaucoma patients, statistically at least equal to MRW and MRA. Using new BMO-based parameters might allow early objective assessments of functional glaucomatous impairments.

Screening is a strategy used in a systematic approach to identify an unrecognized disease or risk factors in individuals in a population without signs or symptoms. The test characteristics (specificity and sensitivity) and the prevalence of the disease are of vital importance for the achievable quality of prediction. Multidimensional decision-making must not only consider the benefits of screening but also its potential disadvantages, such as overtreatment, diagnostics of unclear findings and the psychological impact on healthy individuals. Besides medical, ethical and test theoretical considerations, economic considerations also have to be included in decision-making on a screening program. In Germany, a nationwide screening for diabetic retinopathy and regional programs for amblyopia screening exist. Screening for glaucoma or age-related macular degeneration is currently not funded by the statutory health insurance.

Purpose: To assess the impact of VA loss on patient reported utilities taking both eyes into account compared to taking only the better or the worse eye into account., Methods: In this cross-sectional study 1085 patients and 254 controls rated preferences with the generic health-related (EQ-5D; n = 868) and vision-specific (Vision and Quality of Life Index (VisQoL); n = 837) multi-attribute utility instruments (MAUIs). Utilities were calculated for three levels of VA in the better and worse eyes, as well as for 6 different vision states based on combinations of the better and worse eye VA., Results: Using the VisQoL, utility scores decreased significantly with deteriorating vision in both the better and worse eyes when analysed separately. When stratified by the 6 vision states, VisQoL utilities decreased as VA declined in the worse eye despite stable VA in the better eye. Differences in VisQoL scores were statistically significant for cases where the better eye had no vision impairment and the worse seeing fellow eye had mild, moderate or severe vision impairment. In contrast, the EQ-5D failed to capture changes in better or worse eye VA, or any of the six vision states., Conclusions: Calculating utilities based only on better eye VA or using a generic MAUI is likely to underestimate the impact of vision impairment, particularly when the better eye has no or little VA loss and the worse eye is moderately to severely visually impaired. These findings have considerable implications for the assessment of overall visual impairment as well as economic evaluations within eye health.

Purpose: Multi-attribute utility instruments (MAUIs), which contain a descriptive system, including several health dimensions with associated levels of increasing severity, are used commonly to measure utilities. However, the validity of the descriptive systems rarely is examined using modern psychometric theory. Therefore, we evaluated the psychometric properties of the German version of the Vision and Quality of Life Index (VisQol), a six-item vision-related MAUI., Methods: The German VisQol was self-administered to 340 patients and 280 controls. All subjects underwent a full ophthalmologic examination, including best-corrected visual acuity (VA) testing. The psychometric properties of the VisQoL were assessed using Rasch analysis., Results: The VisQoL's descriptive system did not function in controls. In patients, after collapsing response categories to resolve disordered thresholds and omitting misfitting persons, the measurement properties (i.e., precision, unidimensionality, and targeting) of the German VisQoL were satisfactory. Most person misfit related to unexpected responses to item 4 ("organizing assistance"). Rasch-generated person estimates were not different between age categories, sex, or underlying ocular condition, but decreased significantly with presence of visual impairment in the better eye (LogMAR ≥ 0.5, 1.20 ± 4.62 compared to 3.46 ± 3.52, P < 0.001)., Conclusions: The German VisQoL's descriptive system displayed adequate fit to the Rasch model after removal of a large proportion of patients with poor fit statistics. However, the wording of item four should be revised to reduce respondent confusion and measurement "noise." The scale's descriptive system does not function in a sample of visually unimpaired persons, most likely due to a lack of variance in the measured trait.