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BACKGROUND: Intraocular pressure (IOP) monitoring in glaucoma management is evolving with novel devices. We investigated the reproducibility of 24 hour profiles on two consecutive days and after 30 days of self-measurements via telemetric IOP monitoring. METHODS: Seven primary patients with open-angle glaucoma previously implanted with a telemetric IOP sensor in one eye underwent automatic measurements throughout 24 hours on two consecutive days (day 1 and day 2). Patients wore an antenna adjacent to the study eye connected to a reader device to record IOP every 5 min. Also, self-measurements in six of seven patients were collected for a period of 30 days. Analysis included calculation of hourly averages to correlate time-pairs of day 1 versus day 2 and the self-measurements vers day 2. RESULTS: The number of IOP measurements per patient ranged between 151 and 268 on day 1, 175 and 268 on day 2 and 19 and 1236 during 30 days of self-measurements. IOP time-pairs of automatic measurements on day 1 and day 2 were significantly correlated at the group level (R=0.83, p

BackgroundTo examine long-term retinal nerve fibre layer thickness (RNFLT) variability and associated clinical factors in African (AD) and European descent (ED) individuals with glaucoma.MethodsThis retrospective cohort study included glaucoma eyes of AD and ED from Diagnostic Innovations in Glaucoma Study/The African Descent and Glaucoma Evaluation Study with ≥4 visits/2 years of follow-up. We calculated optic nerve head RNFLT variability per-examination/visit as the absolute error of its residuals across follow-up. Full, baseline and parsimonious linear-mixed models were fit to evaluate the effects of clinical factors (demographics and ocular characteristics, prior/intervening glaucoma surgeries and cataract extraction (CE), RNFLT thinning rate, scan quality, visit/testing frequency, etc) on RNFLT variability in both races.ResultsThere were 376 and 625 eyes (226 and 349 participants) of AD and ED, and the mean (95% CI) RNFLT variability was 1.62 (1.52, 1.71) µm and 1.42 (1.34, 1.50) µm, respectively (p=0.002). AD and ED had some shared predictors of RNFLT variability, including intraocular pressure fluctuation and scan quality, although the effects varied (p

Background/aimsTo investigate the association between longitudinal changes of foveal avascular zone (FAZ) area and the rate of structural and functional progression in glaucoma.MethodsA longitudinal cohort included 115 eyes (46 glaucoma suspect and 66 primary open-angle glaucoma) of 81 patients having ≥2 year follow-up, and ≥4 visits with optical coherence tomography angiography and visual field (VF). Eyes in the longitudinal cohort with a slope greater than that found in 95 percentile of separate healthy test-retest series for FAZ area were categorised into FAZ progressors; all other eyes were defined as FAZ non-progressors. A generalised linear mixed-effect model was used to investigate the association of FAZ progressors with demographic and clinical characteristics.ResultsFaster ganglion cell complex (GCC) thinning and faster VF mean deviation (MD) loss were found in eyes with FAZ progressors compared with FAZ non-progressors (mean difference: -0.7 (95% CI, -1.4 to -0.1) µm/y; p=0.026, -0.3 (-0.5 to -0.1) dB/y; p=0.017, respectively), while whole image vessel density was not associated with FAZ progressors (p=0.929). SD of intraocular pressure (IOP) and IOP range were also associated with FAZ progressors in separate multivariable models (OR: 1.54 (1.02 to 2.32) per 1 mm Hg higher, p=0.041; OR: 1.20 (1.01 to 1.41) per 1 mm Hg higher; p=0.035, respectively).ConclusionsSignificant FAZ increase was weakly associated with moderately faster rates of both GCC thinning and VF MD loss, but not macular vessel density change in glaucoma eyes. Additional studies are needed to elucidate the pathophysiological associations between macula GCC thinning and FAZ area increases in glaucoma.

AIM: We tested the hypothesis that visual field (VF) progression can be predicted with a deep learning model based on longitudinal pairs of optic disc photographs (ODP) acquired at earlier time points during follow-up. METHODS: 3919 eyes (2259 patients) with ≥2 ODPs at least 2 years apart, and ≥5 24-2 VF exams spanning ≥3 years of follow-up were included. Serial VF mean deviation (MD) rates of change were estimated starting at the fifth visit and subsequently by adding visits until final visit. VF progression was defined as a statistically significant negative slope at two consecutive visits and final visit. We built a twin-neural network with ResNet50-backbone. A pair of ODPs acquired up to a year before the VF progression date or the last VF in non-progressing eyes were included as input. Primary outcome measures were area under the receiver operating characteristic curve (AUC) and model accuracy. RESULTS: The average (SD) follow-up time and baseline VF MD were 8.1 (4.8) years and -3.3 (4.9) dB, respectively. VF progression was identified in 761 eyes (19%). The median (IQR) time to progression in progressing eyes was 7.3 (4.5-11.1) years. The AUC and accuracy for predicting VF progression were 0.862 (0.812-0.913) and 80.0% (73.9%-84.6%). When only fast-progressing eyes were considered (MD rate < -1.0 dB/year), AUC increased to 0.926 (0.857-0.994). CONCLUSIONS: A deep learning model can predict subsequent glaucoma progression from longitudinal ODPs with clinically relevant accuracy. This model may be implemented, after validation, for predicting glaucoma progression in the clinical setting.

Background/aimsTo assess the long-term variability of macular optical coherence tomography (OCT)/OCT angiography (OCTA) and visual field (VF) parameters.MethodsHealthy and glaucoma eyes with ≥1-year follow-up were included. 24-2 VF and macular OCT/OCTA parameters, including VF mean deviation (MD), whole-image vessel density (wiVD) and ganglion cell complex thickness (wiGCC) were analysed. Intraclass correlation coefficient (ICC), root mean squared error (RMSE), within-subject test-retest SD (Sw) and test-retest variability were calculated for stable eye cohort (max follow-up=1.5 years). Rates of change and RMSE were evaluated in the extended cohort including all eyes (unlimited follow-up).ResultsFrom a total of 230 eyes (150 participants; age=67.7 years), 86 eyes (37%, 62 participants) were stable. In stable eyes, OCT parameters showed the highest mean (95%) ICC (wiGCC=0.99 (0.99, 0.99)), followed by VF (VF MD=0.91 (0.88, 0.93)) and OCTA (wiVD=0.82 (0.75, 0.87)). RMSE and Sw for VF MD were 0.92 dB and 0.81 dB, respectively, for wiVD were 1.64% and 1.48%, respectively, and for wiGCC, 0.91 µm and 0.78 µm, respectively. The long-term test-rest variability of VF MD, wiVD and wiGCC was 2.2 dB, 4.1% and 2.2 µm, respectively. In the extended cohort (mean follow-up=3.0 years), all parameters had significant rates of change (p

Background/aimsTo evaluate the relationship over time between intraocular pressure (IOP) and the rate of macula whole image vessel density (wiVD) loss and whole image ganglion cell complex (wiGCC) thinning in glaucoma METHODS: From 62 patients in the Diagnostic Innovations in Glaucoma Study, 59 Primary open-angle glaucoma and 27 glaucoma suspect eyes with mean follow-up of 3.2 years were followed. Optical coherence tomography angiography (OCT-A)-based vessel density and OCT-based structural thickness of the same 6×6 mm GCC scan slab were evaluated. Univariable and multivariable linear mixed models were performed for all eyes and also a subset of them in which peak IOP

Background/aimsTo evaluate the association of macular vessel density (VD) and ganglion cell complex (GCC) thickness with 10-2 central visual field (CVF) progression in glaucoma.MethodsIn this retrospective cohort study, patients with glaucoma from Diagnostic Innovation in Glaucoma Study with≥five 10-2 visual field (VF) tests and 3-year follow-up before optical coherence tomography (OCT) and OCT angiography (OCTA) imaging were included. Whole-image GCC thickness (wiGCC) and superficial VD (wiVD) were obtained from 6*6 macula scans. The association of wiVD and wiGCC with past rate of 10-2 VF mean deviation worsening, and with past CVF progression (defined using clustered linear regression criteria) was evaluated using linear mixed models after adjusting for confounders.ResultsFrom 238 eyes (141 patients), 25 eyes (11%) of 16 patients were CVF progressors. In the multivariable analysis of the association between OCT/OCTA parameters and past rate of 10-2 CVF worsening, lower wiVD (β=-0.04 (-0.05, -0.02); p

BACKGROUND: Patients with glaucoma on topical glaucoma medication are often affected by dry eye symptoms and thus likely to rub or squeeze their eyelids. Here, we telemetrically measure peak intraocular pressure (IOP) during eyelid manoeuvres and eyelid rubbing. METHODS: Eleven patients with primary open-angle glaucoma (POAG) previously implanted with a telemetric IOP sensor (Eyemate-IO) were instructed to look straight ahead for 1 min as a baseline measurement. Next, 6 repeats of blinking on instruction with 10 s intervals in between were performed. In addition, 5 repeats of eyelid closure (n=9), eyelid squeezing and eyelid rubbing (n=7) were performed with 15 s intervals in between. IOP was recorded via an external antenna placed around the study eye. Average peak IOP increases from baseline were analysed and tested against zero (no change) with one-sample t-tests. RESULTS: For eyelid rubbing, the average peak ∆ IOP increase (mean±SEM) was 59.1±9.6 mm Hg (p

Background/aimsTo investigate the factors associated with choroidal microvasculature drop-out (MvD) enlargement detected by optical coherence tomography angiography (OCT-A) in glaucomatous eyes.MethodsNinety-one eyes of 68 primary open-angle glaucoma patients were enrolled. Only eyes with a minimum of four good quality OCT-A and OCT scans of the optic nerve head acquired at least and with a minimum of 2 years follow-up were included. Area and angular circumference of MvD were analysed on en face images. Univariable and multivariable mixed effects models were constructed to identify the factors contributing to MvD area and angular circumference change over time.ResultsPeripapillary MvD was detected in 53 (58.2%) eyes at baseline and in an additional 17 (18.6%) eyes during follow-up, whereas MvD was not detected in 21 (23.0 %) eyes during the entire follow-up period. In multivariable analysis, worse baseline visual field (VF) mean deviation (MD) (ß=0.27, 95% CI 0.10 to 0.44, p=0.002), greater intraocular pressure (IOP) fluctuations (ß=0.86, 95% CI 0.24 to 1.48, p=0.007), higher peak IOP (ß=0.17, 95% CI -0.01 to 0.35, p=0.067) and greater number of IOP lowering medications (ß=1.36, 95% CI 0.67 to 2.05, p

Background/aimsTo investigate the relationship between ganglion cell complex (GCC) thinning and baseline deep and superficial macular vessel density (VD) in glaucoma.Methods97 eyes of 69 primary open-angle glaucoma (POAG) and glaucoma suspect patients from the Diagnostics Innovations in Glaucoma Study with a minimum of 4 visits and 2 years of follow-up after baseline optical coherence tomography angiography (OCTA) examination were included. OCTA 3×3 mm2 macular scans were acquired at each visit and used to calculate superficial and deep parafoveal VD (pfVD) and OCT-based parafoveal GCC (pfGCC) thickness. Association of baseline superficial and deep pfVD with pfGCC thinning rate was evaluated using linear mixed model.ResultsThe included subjects had a baseline mean visual field mean deviation (95% CI) of -2.9 (-3.7 to -2.1) dB and a mean follow-up period of 3.6 years. In the univariable model, lower baseline superficial pfVD and higher mean intraocular pressure (IOP) during follow-up were significantly associated with a faster pfGCC thinning rate (p

Background/aimsTo investigate the rate of ganglion cell complex (GCC) thinning in primary open-angle glaucoma (POAG) patients with and without deep-layer microvasculature drop-out (MvD).MethodsPOAG patients who had at least 1.5 years of follow-up and a minimum of three visits were included from the Diagnostic Innovations in Glaucoma Study. MvD was detected at baseline by optical coherence tomography angiography (OCT-A). Area and angular circumference of MvD were evaluated on en face choroidal vessel density images and horizontal B-scans. Rates of global and hemisphere GCC thinning were compared in MvD and non-MvD eyes using linear mixed-effects models.ResultsThirty-six eyes with MvD and 37 eyes without MvD of 63 patients were followed for a mean of 3.3 years. In 30 out of 36 eyes, MvD was localised in the inferotemporal region. While mean baseline visual field mean deviation was similar between the two groups (p=0.128), global GCC thinning was significantly faster in eyes with MvD than in those without MvD (mean differences: -0.50 (95% CI -0.83 to -0.17) µm/year; p=0.003)). Presence of MvD, area and angular circumference of MvD were independently associated with a faster rate of thinning (p=0.002, p=0.031 and p=0.013, respectively).ConclusionIn POAG eyes, GCC thinning is faster in eyes with MvD. Detection of MvD in OCT-A images can assist clinicians to identify patients who are at higher risk for central macula thinning and glaucomatous progression and may require more intensive management.

Background/aimsTo assess and compare long-term reproducibility of optic nerve head (ONH) and macula optical coherence tomography angiography (OCTA) vascular parameters and optical coherence tomography (OCT) thickness parameters in stable primary open-angle glaucoma (POAG), glaucoma suspect and healthy eyes.MethodsEighty-eight eyes (15 healthy, 38 glaucoma suspect and 35 non-progressing POAG) of 68 subjects who had at least three visits within 1-1.5 years with OCTA and OCT imaging (Angiovue; Optovue, Fremont, California, USA) on the same day were included. A series of vascular and thickness parameters were measured including macular parafoveal vessel density (pfVD), ONH circumpapillary capillary density (cpCD), macular parafoveal ganglion cell complex (pfGCC) and ONH circumpapillary retinal nerve fibre layer (cpRNFL). A random effects analysis of variance model was used to estimate intraclass correlation (ICC) coefficients and long-term variability estimates.ResultsICC was lower for OCTA (pfVD 0.823 (95% CI 0.736 to 0.888) and cpCD 0.871 (0.818 to 0.912)) compared with OCT (pfGCC 0.995 (0.993 to 0.997) and cpRNFL 0.975 (0.964 to 0.984)). Within-subject test-retest SD was 1.17% and 1.22% for pfVD and cpCD, and 0.57 and 1.22 µm for pfGCC and cpRNFL. Older age and lower signal strength index were associated with decreasing long-term variability of vessel densities.ConclusionsOCTA-measured macula and ONH vascular parameters have good long-term reproducibility, supporting the use of this instrument for longitudinal analysis. OCTA long-term reproducibility is less than OCT-measured thickness reproducibility. This needs to be taken into consideration when serial OCTA images are evaluated for change.Trial registration numberNCT00221897.

BACKGROUND/AIMS: To identify clinical characteristics and factors associated with microcystic macular edema (MME) in patients with primary open-angle glaucoma (POAG). METHODS: We included 315 POAG eyes between 2010 and 2019 with good-quality macular volume scans that had reliable visual fields (VF) available within 6 months in this observational retrospective cohort study. Eyes with retinal pathologies except for epiretinal membrane (ERM) were excluded. The inner nuclear layer was qualitatively assessed for the presence of MME. Global mean deviation (MD) and Visual Field Index (VFI) decay rates, superior and inferior MD rates and pointwise total deviation rates of change were estimated with linear regression. Logistic regression was performed to identify baseline factors associated with the presence of MME and to determine whether MME is associated with progressive VF loss. RESULTS: 25 out of 315 eyes (7.9%) demonstrated MME. The average (±SD) age and MD in eyes with and without MME was 57.2 (±8.7) versus 62.0 (±9.9) years (p=0.02) and -9.8 (±5.7) versus -4.9 (±5.3) dB (p0.49). CONCLUSIONS: More severe glaucoma and younger age were associated with MME. MME was not associated with faster global VF decay in this cohort. MME may confound monitoring of glaucoma with full macular thickness.

AimTo investigate the safety and performance of a telemetric suprachoroidal intraocular pressure (IOP) sensor (EYEMATE-SC) and the accuracy of its IOP measurements in open angle glaucoma (OAG) patients undergoing simultaneous non-penetrating glaucoma surgery (NPGS).MethodsProspective, multicentre, open-label, single-arm, interventional clinical trial. Twenty-four eyes of 24 patients with OAG regularly scheduled for NPGS (canaloplasty or deep sclerectomy) were simultaneously implanted with an EYEMATE-SC sensor. Six-month follow-up on the sensor's safety and performance as well as on the level of agreement between the EYEMATE-SC measurements and IOP measurements with Goldmann applanation tonometry (GAT).ResultsThe eyes underwent canaloplasty (n=15) or deep sclerectomy (n=9) and achieved successful implantation of the sensor. No device migration, dislocation or serious device-related complications occurred. A total of 367 comparisons were included in the IOP agreement analysis. The overall mean difference between GAT and EYEMATE-SC measurements was 1.31 mm Hg (lower limit of agreement (LoA) 7.55 mm Hg; upper LoA -4.92 mm Hg). The maximum difference of 2.5 mm Hg ±3.96 (LoA 0.30-2.29) was reached on day 10 and continuously improved to an agreement of -0.15 mm Hg ±2.28 (LoA -1.24 to 0.89) after 6 months. Accordingly, the percentage of eyes within an IOP difference of ±5 mm Hg improved from 78% (day 3) to 100% (6 months).ConclusionsAfter 6 months, the EYEMATE-SC sensor was safe and well tolerated, and allowed continual IOP monitoring.Trial registration numberNCT03756662.

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Background/aimsTo investigate the relationship between the foveal avascular zone (FAZ) parameters assessed by optical coherence tomography angiography (OCTA) and central visual field parameters in glaucoma and healthy subjects.MethodsOne hundred and eighty-eight subjects (248 eyes), including 24 healthy (38 eyes), 37 glaucoma suspect (42 eyes, and 127 primary open angle glaucoma (POAG) patients (168 eyes), underwent imaging using OCTA and standard automated perimetry using the 24-2 and 10-2 Swedish Interactive Thresholding Algorithm. OCTA-based and OCT-based FAZ parameters (superficial FAZ area, FAZ circumference), foveal vessel density (FD300) and foveal thickness were measured. The correlation between FAZ parameters and visual field parameters was assessed using linear mixed model.ResultsAxial length adjusted-FAZ area was not different among the three groups (mean (95% CI)): in healthy 0.31 (0.27 to 0.36) mm2, glaucoma suspect 0.29 (0.26 to 0.31) mm2 and POAG eyes 0.28 (0.27 to 0.30) mm2 (p=0.578). FD300 was lower in glaucoma suspect 49.1% (47.9% to 50.4%) and POAG eyes 48.7% (48.1% to 49.4%) than healthy eyes 50.5% (49.3% to 51.7%) though the difference was not statistically significant (p=0.071). Lower FD300 was associated with worse 24-2 and 10-2 visual field mean deviation and foveal threshold in multivariable linear mixed models (all p

PurposeTo evaluate the superficial vascular density of the optic nerve head in different stages of pseudoexfoliation disease using optical coherence tomography angiography (OCTA).MethodsIn this cross-sectional study, 57 normal eyes, 41 eyes with pseudoexfoliation syndrome (PXS), 82 eyes with pseudoexfoliation glaucoma (PXG) and 27 non-glaucomatous fellow eyes of PXG (NL-PXG) that had OCTA were included. Circumpapillary RNFL (cpRNFL) thickness and circumpapillary capillary density (cpCD) were compared among the groups after adjusting for confounders using linear-mixed model.ResultsPXG eyes had thinner global RNFL and lower cpCD (74.2±14.3 µm and 36.7±10.0%) than control (103.3±8.6 µm and 52.5±2.3%), PXS (96.8±8.8 µm and 51.5±2.3%), and NL-PXG eyes (96.3±11.1 µm and 50.1±3.9%) (p

Background: There is limited data regarding the morbidity and progression to primary angle closure glaucoma in those presenting with acute primary angle closure (APAC) in the UK. We aim to report on the vision and intraocular pressure (IOP) outcomes and treatment required after an APAC episode and to identify any risk factors that could predict worse outcomes., Methods: A retrospective observational case series review including 117 consecutive patients (121 eyes) attending Moorfields Eye Hospital, at a tertiary referral unit in the UK, with APAC was performed., Results: Most patients (73%) had visual acuities of ≥6/12, meeting the UK driving standard, at the final follow-up. Only 15% (17 eyes) had severe visual impairment, as defined by the WHO, in the affected eye, of which 6.6% (eight eyes) were due to glaucoma. The delayed presentation was linked to a higher need for further medical treatment (OR=2.83, 95% CI 1.09 to 7.40, p=0.03). Patients who underwent phacoemulsification were at lower risk of having blindness in the affected eye (OR 0.18, 95% CI 0.05 to 0.69, p=0.01), having elevated IOP (OR 0.10, 95% CI 0.01 to 0.75, p=0.02) or requiring further medical treatment (OR 0.34, 95% CI 0.12 to 0.99, p=0.04). Older age (OR 1.26, 95% CI 1.08 to 1.48, p<0.01) was associated with worse visual outcomes., Conclusions: APAC causes low long-term visual and treatment morbidity in this largely Caucasian patient group in the UK. Phacoemulsification as a treatment may enhance visual outcomes and reduce the need for further IOP-lowering treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: Intravitreal injection (IVT) of anti-vascular endothelial growth factor agents is the standard of care for several retinal diseases but can cause intraocular pressure (IOP) elevations. This study investigates short-term postinjection IOP changes following aflibercept 8 mg and faricimab, compared with aflibercept 2 mg., Methods: This observational, prospective study included 90 patients with age-related macular degeneration or diabetic macular oedema, divided into three groups, receiving aflibercept 2 mg, aflibercept 8 mg or faricimab. IOP was measured using an iCare IC200-tonometer preinjection (T0) and at 30 s (T1), 5 min (T2) and 15 min (T3) postinjection. Primary outcomes included IOP changes at the four time points within and between treatment groups. The incidence of transient visual loss requiring paracentesis was recorded., Results: All groups experienced a significant IOP increase at T1, with mean IOP increase being 41.47±12.95 mm Hg for aflibercept 2 mg, 43.46±8.97 mm Hg for aflibercept 8 mg and 32.19±11.06 mm Hg for faricimab. By T2, IOP differences were not significant, and by T3, mean IOP returned within normal limits across all groups. Faricimab showed a smaller initial IOP spike than both aflibercept formulations, but this difference was not statistically significant at T2 and T3., Conclusion: Transient IOP spikes are observed post-IVT of aflibercept 8 mg and faricimab, with similar trends to aflibercept 2 mg. The initial IOP elevation normalised within 15 min. Faricimab had a lower initial spike, but overall IOP profiles were comparable across different agents., Competing Interests: Competing interests: AC provided consulting and/or speaker services for Santen. GG provided consulting and/or speaker services for Abbvie, Apellis, Bayer and Roche. MM provided consulting and/or speaker services for Abbvie, Apellis, Bayer, Novartis, Roche, and he is consultant and holds equity of Endogena.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. All authors received an unrestricted grant from Bayer AG Switzerland, intended to support research activities at their hospital in a broader sense., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate nyctohemeral effects of topical beta-adrenoceptor blocking agents and their fixed combinations on intraocular pressure (IOP) in patients with primary open-angle glaucoma implanted with an ocular telemetry sensor., Methods: 22 patients who had previously been implanted with a sulcus-based IOP sensor (eyemate) were included in this prospective clinical trial. Three classes of medications were analysed: beta-blockers (BB), fixed combination of BB and carbonic anhydrase inhibitors (BB-CAI), and combinations of BB and prostaglandin analogues (BB-PGAs). SD and IQR of IOP were calculated and used as surrogates of nyctohemeral IOP variation., Results: The mean (±SD) age of patients was 67.8±6.8 years (36.4% female). A total of 50 920 IOP measurements over 4084 days from 10 eyes were included. The mean 24-hour IOP (±SE) with BB-PGA (17.3±1.1 mm Hg) was significantly (p<0.001) less than that with BB (18.8±1.1 mm Hg). Mean 24-hour IOP with BB-CAI (18.4±1.1 mm Hg) was similar (p>0.05) to that with the other two medications. Mean 24-hour SD of IOP with BB-PGA (1.9±0 .2 mm Hg) and BB-CAI (2.0±0.2 mm Hg) were significantly (p<0.05) less than that with BB (2.4±0.2 mm Hg). Mean 24-hour IQR of IOP with BB-PGA (2.3±0.4 mm Hg) was significantly less than that with both BB (3.8±0.4 mm Hg) and BB-CAI (3.2±0.4 mm Hg)., Conclusion: Continual IOP monitoring shows that combinations of BB-PGAs have more pronounced effects on lowering 24-hour IOP fluctuations than BB-CAIs and BBs alone., Trial Registration Number: NCT03651336., Competing Interests: Competing interests: KM: Santen (C), Alcon (S), AbbVie (C), iStar Medical (C), Bayer (C), Zeiss (C), ImplanData (C); HLR: Santen (C), Carl-Zeiss Meditec (S), Allergan (C); RNW: Aerie Pharmaceuticals (C), Allergan (C), Amydis (C), Editas (C), IOPtic (C), iStar Medical (C), Eyenovia (C), Equinox (C), ImplanData (C), Santen (C), MeditecZeiss (S), Optovue (S), Centervue (S), Heidelberg Engineering (S), Konan (S), Bausch & Lomb (S); Others: None., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To investigate the physiological nyctohemeral intraocular pressure (IOP) rhythms of normal Chinese adults using a novel contact lens sensor system (CLS) that can output IOP in millimetres of mercury (mm Hg) continuously., Methods: Fifty-nine eyes of 59 normal Chinese adults completed 24-hour IOP monitoring using the novel CLS. A descriptive analysis was conducted on the 24-hour IOP mean, peak and acrophase, trough and bathyphase, fluctuation, and mean amplitude of intraocular pressure excursion (MAPE). The continuous data were analysed at several periods (diurnal period, 08:00-20:00 hours; nocturnal period, 22:00-06:00 hours; sleep time, 0:00-06:00 hours), and compared between right and left eyes, males and females, and different age ranges (<30, and ≥30), respectively., Results: Normal adults had a lower peak, higher trough, smaller fluctuation and smaller MAPE (p<0.05 for all comparisons) but non-significantly different mean (p=0.695) in the nocturnal period or sleep time compared with the diurnal period. The 24-hour IOP peak and trough showed the frequency of occurrence ranging from 1.69% to 15.25% at an interval of 2 hours. No IOP parameter showed significant difference between right and left eyes (p>0.1 for all comparisons). The male group had larger 24-hour and diurnal IOP fluctuation and MAPE (p<0.05 for all comparisons). Subjects aged 30 or over had higher 24-hour and diurnal mean, higher peak, and larger MAPE (p<0.05 for all comparisons)., Conclusion: Continuous 24-hour IOP output from the CLS in normal Chinese was stable with a comparable mean level between day and night, as well as scattered acrophase and bathyphase. The 24-hour IOP mean increased with age, and IOP variations were positively correlated to age and male sex., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To investigate any association between intraocular pressure (IOP) reduction amount and open-angle glaucoma (OAG) progression in highly myopic eyes and to determine the associated risk factors., Methods: One hundred and thirty-one (131) eyes of 131 patients with highly myopic OAG, all of whom had received topical medications and been followed for 5 years or longer, were enrolled. Based on the IOP reduction percentage, patients were categorised into tertile groups, and subsequently, the upper-tertile and lower-tertile groups were compared for the cumulative probability of glaucoma progression. Kaplan-Meier survival analysis and log-rank testing were applied in the comparison, and multivariate analysis with Cox's proportional hazard model, additionally, was performed to identify progression risk factors., Results: Throughout the average 11.6±4.4 year follow-up on the 131 eyes (mean age, 41.2 years at initial visit; baseline IOP, 16.4 mm Hg), 72 eyes (55.0%) showed glaucoma progression. The upper-tertile group (IOP reduction percentage>23.7%) showed a high cumulative probability of non-progression relative to the lower-tertile group (IOP reduction percentage<11.0%; p=0.034), according to the Kaplan-Meier analysis. Presence of disc haemorrhage (DH; HR=2.189; p=0.032) was determined by the multivariate Cox's proportional hazard model to be significantly associated with glaucoma progression. For progressors, the average rate of retinal nerve fibre layer thickness thinning was -0.88±0.74 µm/year, while the MD change was -0.42±0.36 dB/year., Conclusions: Glaucoma progression is associated with amount of IOP reduction by topical medications in highly myopic eyes, and DH occurrence is a glaucoma progression risk factor., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To describe the effectiveness and side-effect profile of adding difluprednate therapy to patients with anterior scleritis being treated systemically., Methods: Retrospective chart review. Charts from all patients with anterior scleritis who were treated with topical difluprednate in addition to systemic therapy from 1 January 2018 to 1 January 2020 were reviewed. Data collected included: demographics, scleritis type, systemic diagnosis, presence of nodules or necrosis, changes in scleritis activity, intraocular pressure (IOP), number of difluprednate drops used, type of systemic treatment used, best-corrected visual acuity (BCVA) and lens status. The primary outcome was clinical resolution of scleritis. Secondary outcomes included BCVA loss ≥2 lines, change in lens status or cataract surgery and IOP ≥24 mm Hg., Results: Thirty-two patients (44 eyes) were analysed. The median age was 57 years (IQR 52, 72); 59% were female; 72% were Caucasian. An associated systemic disease was present in 59%. Systemic therapies used when difluprednate was added were: 65% immunosuppressive agents, 43% prednisone and 25% non-steroidal anti-inflammatory drugs. The addition of difluprednate resulted in clinical resolution in 79.6% of the treated eyes. Median time to inactivity was 9 weeks (IQR 5, 20). Eyes initially using 2-4 drops per day had a higher response rate (89%, p=0.005). Over a median follow-up of 34 weeks (IQR 21, 74), 11 eyes had IOP elevation; 6 eyes lost ≥2 lines of BCVA, 5 eyes had cataract progression., Conclusion: Most eyes treated with difluprednate achieved inactivity. The addition of difluprednate to systemic therapies provides an alternative to achieve control of inflammation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

AimTo analyse ab interno trabeculectomy (AIT) with the trabectome and combined phacoemulsification with AIT (phaco-AIT) by Shaffer angle grade (SG).MethodsProspective study of AIT and phaco-AIT with narrow angles of SG≤2 versus open angles ≥3. Outcomes included intraocular pressure (IOP), medications, complications, secondary surgery and success (IOP 20% reduction without further surgery). Exclusion criteria were missing preoperative data and 0.05).ConclusionsSG≤2 is not associated with worse outcomes in AIT or phaco-AIT.

AimTo assess the efficacy and safety of latanoprostene bunod (LBN) compared with latanoprost 0.005%, and to determine the optimum drug concentration(s) of LBN in reducing intraocular pressure (IOP) in subjects with open angle glaucoma or ocular hypertension.MethodsRandomised, investigator-masked, parallel-group, dose-ranging study. Subjects instilled one drop of study medication in the study eye once daily each evening for 28 days and completed five study visits. The primary efficacy endpoint was the reduction in mean diurnal IOP at Day 28.ResultsOf the 413 subjects randomised (LBN 0.006%, n=82; LBN 0.012%, n=85; LBN 0.024%, n=83; LBN 0.040%, n=81; latanoprost, n=82), 396 subjects completed the study. Efficacy for LBN was dose-dependent reaching a plateau at 0.024%-0.040%. LBN 0.024% led to significantly greater reductions in diurnal IOP compared with latanoprost at the primary endpoint, Day 28 (p=0.005), as well as Days 7 (p=0.033) and 14 (p=0.015). The incidence of adverse events, mostly mild and transient, was numerically higher in the LBN treatment groups compared with the latanoprost group. Hyperaemia was similar across treatments.ConclusionsLBN 0.024% dosed once daily was the lower of the two most effective concentrations evaluated, with significantly greater IOP lowering and comparable side effects relative to latanoprost 0.005%. LBN dosed once daily for 28 days was well tolerated.Clinical trial numberNCT01223378.

AimTo evaluate outcomes of ab interno trabeculectomy (AIT) with the trabectome following failed trabeculectomy.MethodsProspective study of AITs and phaco-AITs after a failed trabeculectomy. The indication for AIT was intraocular pressure (IOP) above target on maximally tolerated therapy, and for phaco-AIT a visually significant cataract and need to lower IOP or glaucoma medications. Outcomes included IOP, medications, complications, secondary procedures and success, defined as IOP of less than 21 mm Hg and a greater than 20% reduction from baseline without further surgery. Exclusion criteria were trabeculectomy less than 3 months prior to AIT or follow-up under 1 year.ResultsSeventy-three eyes of 73 patients with 1 year follow-up were identified. At 1 year, mean IOP in AIT significantly decreased by 28% from 23.7±5.5 mm Hg, and medications from 2.8±1.2 to 2±1.3 (n=58). In phaco-AIT, the mean IOP decreased 19% from 20±5.9 mm Hg and medications from 2.5±1.5 to 1.6±1.4 (n=15). Transient hypotony occurred in 7%, and further surgery was necessary in 18%. For AIT and phaco-AIT, the 1-year cumulative probability of success was 81% and 87%, respectively.ConclusionsBoth AIT and phaco-AIT showed a reduction in IOP and medication use after 1 year, suggesting that AIT with or without cataract surgery is a safe and effective option following failed trabeculectomy.

Purpose: To assess intraocular pressure (IOP)-induced and gaze-induced optic nerve head (ONH) strains in subjects with high-tension glaucoma (HTG) and normal-tension glaucoma (NTG)., Design: Clinic-based cross-sectional study., Methods: The ONH from one eye of 228 subjects (114 subjects with HTG (pre-treatment IOP≥21 mm Hg) and 114 with NTG (pre-treatment IOP<21 mm Hg)) was imaged with optical coherence tomography (OCT) under the following conditions: (1) OCT primary gaze, (2) 20° adduction from OCT primary gaze, (3) 20° abduction from OCT primary gaze and (4) OCT primary gaze with acute IOP elevation (to approximately 33 mm Hg). We then performed digital volume correlation analysis to quantify IOP-induced and gaze-induced ONH tissue deformations and strains., Results: Across all subjects, adduction generated high effective strain (4.4%±2.3%) in the LC tissue with no significant difference (p>0.05) with those induced by IOP elevation (4.5%±2.4%); while abduction generated significantly lower (p=0.01) effective strain (3.1%±1.9%). The lamina cribrosa (LC) of HTG subjects exhibited significantly higher effective strain than those of NTG subjects under IOP elevation (HTG: 4.6%±1.7% vs NTG: 4.1%±1.5%, p<0.05). Conversely, the LC of NTG subjects exhibited significantly higher effective strain than those of HTG subjects under adduction (NTG: 4.9%±1.9% vs HTG: 4.0%±1.4%, p<0.05)., Conclusion: We found that NTG subjects experienced higher strains due to adduction than HTG subjects, while HTG subjects experienced higher strain due to IOP elevation than NTG subjects-and that these differences were most pronounced in the LC tissue., Competing Interests: Competing interests: MJAG is the co-founder of the AI start-up company Abyss Processing Pte Ltd., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To assess dynamic change of iris area (Iarea) and volume (VOL) with physiologic pupil dilation for progression of primary angle closure suspects., Methods: Participants underwent baseline examinations including gonioscopy and anterior segment OCT (AS-OCT) as part of the Zhongshan Angle Closure Prevention Trial. The AS-OCT images were obtained both in the dark and light. Progression was defined as development of primary angle closure or an acute angle closure attack. Static ocular biometrics and dynamic changes were compared between progressors and non-progressors and multivariable logistic regression was developed to assess risk factors for progression., Results: A mean 16.8% decrease in Iarea and a mean 6.26% decrease in VOL occurred with pupil dilation, while 22.96% non-progressors and 40% progressors presented VOL increases with pupil dilation. Iarea in light and dark and VOL in light were significantly smaller in progressors. In a multivariable logistic model, older age (p=0.008), narrower horizontal angle opening distance (AOD) 250 µm from the scleral spur (AOD250, p=0.001), flatter iris curvature (IC, p=0.006) and lower loss of iris volume (ΔVOL, p=0.04) were significantly associated with progression. With receiver operating characteristic analysis, the area under the curve for ΔVOL alone was 0.621, while that for the combined index (age, AOD250, IC and ΔVOL) was 0.824. Eyes with elevated intraocular pressure had less VOL loss compared with progressors developing peripheral anterior synechiae alone (p=0.055 for ΔVOL adjusted for pupil enlargement)., Conclusion: A smaller change in ΔVOL is an additive risk factor to identify eyes more likely to develop angle closure disease., Trial Registration Number: ISRCTN45213099., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To characterise the relationship between a deep-layer microvasculature dropout (MvD) and central visual field (VF) damage in primary open-angle glaucoma (POAG) patients with and without high axial myopia., Design: Cross-sectional study., Methods: Seventy-one eyes (49 patients) with high axial myopia and POAG and 125 non-highly myopic POAG eyes (97 patients) were enrolled. Presence, area and angular circumference of juxtapapillary MvD were evaluated on optical coherence tomography angiography B-scans and en-face choroidal images., Results: Juxtapapillary MvD was detected more often in the highly myopic POAG eyes (43 eyes, 86%) than in the non-highly myopic eyes (73 eyes, 61.9%; p=0.002). In eyes with MvD, MvD area and angular circumference (95% CI) were significantly larger in the highly myopic eyes compared with the non-highly myopic eyes (area: (0.69 (0.40, 0.98) mm 2 vs 0.31 (0.19, 0.42) mm 2 , p=0.011) and (angular circumference: 84.3 (62.9, 105.8) vs 74.5 (58.3, 90.9) degrees, p<0.001), respectively. 24-2 VF mean deviation (MD) was significantly worse in eyes with MvD compared with eyes without MvD in both groups (p<0.001). After adjusting for 24-2 MD VF, central VF defects were more frequently found in eyes with MvD compared with eyes without MvD (82.7% vs 60.9%, p<0.001). In multivariable analysis, higher intraocular pressure, worse 24-2 VF MD, longer axial length and greater MvD area and angular circumference were associated with worse 10-2 VF MD., Conclusions: MvD was more prevalent and larger in POAG eyes with high myopia than in non-highly myopic POAG eyes. In both groups, eyes with MvD showed worse glaucoma severity and more central VF defects., Competing Interests: Competing interests: Financial disclosures: EM: none; NE-N: none; TN: none; SM: none; JR: none; MAF: National Eye Institute (F), Heidelberg Engineering (F), Topcon (F); MHS: none; CB: none; AB: none; MC: none; JBJ: European patent EP 3 271 392, JP 2021-119187 and US 2021 0340237 A1: agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia; RW: Abbvie (C), Alcon (C), Amydis (C), Eyenovia (C), Topcon (C), Nicox (C), Topcon (C), Heidelberg Engineering (F), Implandata (C), IOPtic (C), Carl Zeiss Meditec (F), Konan Medical (F), OptoVue (F), Topcon (F), Centervue (F), National Eye Institute (F), National Institute of Minority Health (F); LMZ: National Eye Institute (F), Carl Zeiss Meditec Inc. (F), Heidelberg Engineering GmbH (F), OptoVue Inc. (F, R), Topcon Medical Systems Inc (F, R) and Abbvie (C)., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Glaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard., Methods: Post hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman's rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma., Results: 382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma., Conclusion: This study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma., Competing Interests: Competing interests: GG reports personal fees from Alcon, Allergan, Belkin, Equinox, Genentech–Roche, Glaukos, Ivantis, Reichert, Sight Sciences, and Thea; grants from Belkin, Santen and Thea; and non-financial involvement with the patient advocacy group GlaucomaUK, outside the submitted work; he is also a coinvestigator on three other major SLT trials (LIGHT, COAST and Belkin laser). All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background/aims: To compare the influence of choroidal microvasculature dropout (cMvD) on progressive retinal nerve fibre layer (RNFL) thinning in glaucomatous eyes with parapapillary β-zones and γ-zones., Methods: 294 eyes with primary open-angle glaucoma (POAG) and parapapillary atrophy (PPA) underwent optical coherence tomography (OCT) to determine the type of PPA and OCT angiography scanning of the optic nerve head to determine the presence of cMvD. Eyes were classified based on the type of PPA (β-zones and γ-zones), and their clinical characteristics were compared. Factors associated with the rate of rapid progressive RNFL thinning were determined in each group, including the presence of cMvD as an independent variable., Results: Of the 294 eyes, 186 and 108 were classified as having β-zones and γ-zones, respectively. The rate of RNFL thinning was slower (p<0.001), axial length was longer (p<0.001) and presence of cMvD was less frequent (57.4% vs 73.1%, p=0.006) in eyes with γ-zone than those with β-zone. Multivariate analyses showed that greater lamina cribrosa curvature (p=0.047) and the presence of cMvD (p=0.010) were associated with a faster rate of RNFL thinning in eyes with β-zone, whereas larger intraocular pressure fluctuation (p<0.001), shorter axial length (p=0.042) and greater baseline RNFL thickness (p<0.001) were associated with a faster rate of RNFL thinning in eyes with γ-zone., Conclusions: The presence of cMvD was significantly associated with a faster rate of RNFL thinning in POAG eyes with β-zone, but not γ-zone. The pathogenic consequences of cMvD in POAG eyes may depend on accompanying peripapillary structures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: To report a first-in-human trial in open-angle glaucoma (OAG) subjects treated with a new microinterventional biostent-reinforced cyclodialysis technique to enhance supraciliary aqueous drainage., Methods: Subjects (N=10; 74.1±7.9 years old) with OAG and cataracts underwent combined phacoemulsification cataract surgery with implantation of a permanent endoscleral supraciliary biostent to reinforce a controlled cyclodialysis cleft. The biostent comprised decellularised scleral allograft tissue microtrephined into a polymer tubular implant intraoperative/postoperative safety, intraocular pressure (IOP) and glaucoma medications were tracked through 12 months postimplantation., Results: Baseline medicated IOP averaged 24.2±6.9 mm Hg with subjects using 1.3±0.8 IOP-lowering medications. Successful biostent implantation was achieved in all individuals without significant complications. Immediate IOP lowering was sustained through 1 year. Twelve-month mean IOP was reduced 40% from baseline to 14.6±3.2 mm Hg (p=0.004; paired two-tailed t-test), and 80% of patients achieved >20% IOP reduction. Biostenting reduced glaucoma medication use 62%, from a baseline mean of 1.3 required medications to 0.5 medications (p=0.037) at postoperative 12 months. The biotissue implant was well tolerated and demonstrated good endothelial safety with only 11% endothelial cell loss at 12 months after combined phaco-biostenting surgery, similar to that expected after phacoemulsification alone. Mean BCVA increased from baseline 20/130 Snellen to 20/36 at postoperative 12 months (p=0.001)., Conclusion: Supraciliary biostenting in OAG patients is well tolerated, has a good safety profile and produces long-term IOP-lowering while reducing glaucoma medication requirements., Competing Interests: Competing interests: TI is a consultant for Iantrek, and holds a patent for the biostent. RNW is a board member and consultant for Iantrek. GK, RP and IKA are consultants for Iantrek., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: Socioeconomic status (SES) is associated with late disease presentation and poorer outcomes. We evaluate the effect of SES on treatment outcomes and report the correlation between SES and baseline characteristics of participants in the Treatment of Advanced Glaucoma Study., Methods: Pragmatic multicentre randomised controlled trial. Four hundred and fifty-three patients presenting with advanced open-angle glaucoma in at least one eye (Hodapp-Parrish-Anderson classification). Participants were randomised to either glaucoma drops (medical arm) or trabeculectomy (surgery arm). Clinical characteristics, Quality of life measurement (QoL) and SES defined by the Index of Multiple Deprivation are reported. Subgroup analysis explored treatment effect modifications of SES at 24 months. Correlation between SES and baseline characteristics was tested with the χ 2 test of association for dichotomous variables and pairwise Pearson's correlation for continuous variables., Results: The mean visual field mean deviation was -17.2 (6.7)dB for the most deprived quintile of participants and -13.0 (5.5) for the least deprived quintile in the index eye. At diagnosis, there was a strong correlation between SES and ethnicity, age, extent of visual field loss and number of visits to opticians prior to diagnosis. At 24 months, there was no evidence that the treatment effect was moderated by SES., Conclusions: In patients presenting with advanced glaucoma. SES at baseline is correlated with poorer visual function, poorer Visual Function Questionnaire-25 QoL, ethnicity, age and number visits to an optician in the years preceding diagnosis. SES at baseline does not have an effect of the success of treatment at 24 months., Trial Registration Number: ISRCTN56878850., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate whether quantitative optical coherence tomography angiography (OCTA) metrics of the superficial/deep macular retina are associated with the development of visual field (VF) loss in the fellow eyes of normal tension glaucoma (NTG) patients with unilateral VF loss., Methods: A longitudinal study was conducted in which 61 eyes with normal VF (mean VF mean deviation -0.7±1.6 dB) from 61 NTG patients were included. All subjects underwent OCTA imaging, spectral-domain-OCT imaging and VF testing. OCTA metrics of superficial capillary plexus and deep capillary plexus (DCP) in the macular region were measured. Relationships between baseline OCTA metrics, demographics and ocular characteristics and the risk of VF glaucoma progression were analysed with a Cox proportional hazards model., Results: During a mean follow-up of 38 months, 11 fellow eyes (18.0%) with normal VF at baseline were determined to have VF progression, while 21.3% of affected eyes had VF progression. After adjustment for potential confounding factors, decreased baseline DCP in the fellow eyes was significantly associated with future VF progression (HR 1.33, 95% CI 1.03 to 1.73, p=0.031)., Conclusion: Decreased DCP was associated with a higher risk of developing VF damage in NTG patients with unilateral VF loss. Assessments of DCP may help improve the evaluation of the risk of functional deterioration in fellow eyes with an initially normal VF., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: To use artificial intelligence (AI) to: (1) exploit biomechanical knowledge of the optic nerve head (ONH) from a relatively large population; (2) assess ONH robustness (ie, sensitivity of the ONH to changes in intraocular pressure (IOP)) from a single optical coherence tomography (OCT) volume scan of the ONH without the need for biomechanical testing and (3) identify what critical three-dimensional (3D) structural features dictate ONH robustness., Methods: 316 subjects had their ONHs imaged with OCT before and after acute IOP elevation through ophthalmo-dynamometry. IOP-induced lamina cribrosa (LC) deformations were then mapped in 3D and used to classify ONHs. Those with an average effective LC strain superior to 4% were considered fragile, while those with a strain inferior to 4% robust. Learning from these data, we compared three AI algorithms to predict ONH robustness strictly from a baseline (undeformed) OCT volume: (1) a random forest classifier; (2) an autoencoder and (3) a dynamic graph convolutional neural network (DGCNN). The latter algorithm also allowed us to identify what critical 3D structural features make a given ONH robust., Results: All three methods were able to predict ONH robustness from a single OCT volume scan alone and without the need to perform biomechanical testing. The DGCNN (area under the curve (AUC): 0.76±0.08) outperformed the autoencoder (AUC: 0.72±0.09) and the random forest classifier (AUC: 0.69±0.05). Interestingly, to assess ONH robustness, the DGCNN mainly used information from the scleral canal and the LC insertion sites., Conclusions: We propose an AI-driven approach that can assess the robustness of a given ONH solely from a single OCT volume scan of the ONH, and without the need to perform biomechanical testing. Longitudinal studies should establish whether ONH robustness could help us identify fast visual field loss progressors., Precis: Using geometric deep learning, we can assess optic nerve head robustness (ie, sensitivity to a change in IOP) from a standard OCT scan that might help to identify fast visual field loss progressors., Competing Interests: Competing interests: MJAG and AHT are the co-founders of the AI start-up company Abyss Processing., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare the rates of peripapillary vessel density (pVD) loss and retinal nerve fibre layer (RNFL) thinning in normal tension glaucoma (NTG) and primary angle closure glaucoma (PACG)., Methods: Baseline age and severity-matched NTG and PACG eyes (75 eyes of 60 patients for each subtype) were observed longitudinally. All participants' RNFL thickness were measured by optical coherence tomography (OCT); pVD were measured by swept-source OCT-angiography (OCT-A) and quantified by a customised MATLAB program. The rate of pVD loss and RNFL thinning were estimated by linear mixed-effects models., Results: NTG eyes had significant pVD loss in all sectors (p≤0.05) while PACG eyes' pVD loss was borderline significant in the global region (p=0.05). Significant RNFL thinning was detected in the inferotemporal and superonasal regions of both groups, and the superotemporal region in the NTG group (all p≤0.02). NTG had faster rate of pVD loss in the global (difference (95% CI) -1.08 (-1.90 to -0.27) %/year), temporal (-1.57 (-2.91 to -0.23) %/year) and superotemporal (-1.46 (-2.65 to -0.26) %/year) regions than PACG (all p ≤ 0.02), without significant difference of the rate of RNFL thinning. A lower baseline mean deviation (MD) was associated with a faster rate of global pVD loss, while a lower baseline pVD was associated with a slower rate of global pVD loss in multivariable analyses (both p≤0.04)., Conclusions: NTG had more extensive and faster rate of pVD loss than PACG. Baseline global pVD and MD were independently associated with the rate of pVD loss in NTG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To investigate the incidence of and risk factors for bleb-related infection (BRI) in patients who underwent mitomycin C-augmented primary trabeculectomy., Methods: We reviewed the medical charts of consecutive patients who had received primary trabeculectomy in Taipei Veterans General Hospital. We recorded the demographic and clinical characteristics of patients before, during and after surgery. Furthermore, we recorded the time interval between surgery and infection onset, clinical manifestations and visual outcomes of patients with BRI. The cumulative incidence of BRI was estimated using the Kaplan-Meier method. A Cox proportional hazards model was used to explore factors associated with BRI., Results: In total, 1663 eyes were postoperatively followed up for 94.57±65.23 months. The cumulative incidence of BRI was 1.86 per 1000 person-years during the 28-year follow-up period: 24 (1.44%) patients developed BRI and 6 (0.36%) patients additionally developed endophthalmitis. A multivariate analysis revealed a significant association of BRI with wound manipulation, high myopia and hyperlipidaemia. Patients younger than 60 years were more likely to receive wound manipulation than their elderly counterparts (<0.001). One year after BRI, the best corrected visual acuity of the eyes with blebitis did not change significantly, whereas that of the eyes with endophthalmitis worsened significantly., Conclusion: Risk factors for BRI after trabeculectomy include wound manipulation, high myopia and hyperlipidaemia. Considering myopia is highly prevalent throughout the world and is a risk factor for glaucoma, the lifelong risk of BRI after trabeculectomy in eyes with high myopia warrants the attention of ophthalmologists., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: To determine a cluster of test points: visual subfield (VSF) of Humphrey Field Analyzer 10-2 test (HFA 10-2) of which baseline sensitivities were associated with future worsening of visual acuity (VA) in eyes with advanced glaucoma., Methods: A total of 175 advanced glaucoma eyes of 175 advanced glaucoma patients with well controlled intraocular pressure (IOP), a mean deviation of the Humphrey Field Analyzer 24-2 (HFA 24-2) test ≤ -20 decibels and best corrected VA ≥20/40, were included. At baseline, HFA 24-2 and HFA 10-2 tests were performed along with VA measurements. All patients underwent prospective follow-up of 5 years, and VA was measured every 6 months. The Cox proportional hazards model was used to identify visual field sensitivities associated with deterioration of VA and also blindness., Results: Deterioration of VA and blindness were observed in 15.4% and 3.4% of the eyes, respectively. More negative total deviation (TD) values in the temporal papillomacular bundle VSF were significantly associated with deterioration in VA. Averages of the TD values in this area of the HFA 10-2 test had the most predictive power of future VA deterioration (OR: 0.92, p<0.001). A very similar tendency was observed for blindness., Conclusion: In advanced glaucoma eyes with well-controlled IOP, careful attention is needed when the mean TD values in the temporal papillomacular bundle VSF, measured with a HFA 10-2 test is deteriorated. TD values of this VSF indicate higher risks for future deterioration of VA and also blindness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: The accuracy of pattern deviation (PD) in estimating the damage to the glaucomatous visual field (VF) in the central 10° in eyes with glaucoma and cataract is unclear., Methods: This retrospective study includes 63 eyes of 52 glaucoma patients who successfully underwent cataract surgery or cataract surgery plus iStent implantation. Using the Humphrey Field Analyser 10-2 test, VF was measured within 6 months preoperatively and postoperatively (VF pre and VF post , respectively). The mean total deviation values in VF post (mTD post ) indicates glaucomatous damage without cataract and the difference between this value and mean PD values in VF pre (mPD pre ) was evaluated (εmPD). The effect of cataract was then evaluated as the difference between mTD post and mTD pre (ΔmTD), while the effects of mTD post and ΔmTD on εmPD were also assessed. In addition, based on preoperative visual acuity (VA pre ) and VF pre , the optimal model for predicting mTD post was identified. The error of this method (εOptimalModel) was estimated as the difference against mTD post , which was compared with εmPD., Results: Compared with mTD pre , there was a significant improvement in mTD post (p=0.028). A significant difference was observed between mPD pre and mTD post (p<0.001). Further, εmPD significantly increased with the increase of mTD post or ΔmTD (p<0.001 and p=0.0444, respectively). The absolute εOptimalModel was significantly smaller than the absolute εmPD (p<0.001)., Conclusions: This study warns clinicians that PD of the central 10° VF might underestimate the glaucomatous VF damage with the progression of glaucoma and overestimate it as a cataract progresses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To evaluate the efficacy and safety of anterior segment reconstruction (ASR) in congenital fibrovascular pupillary membrane-induced secondary glaucoma (CFPMSG) basing ultrasound biomicroscopy (UBM) classification., Methods: This ambispective cohort study enrolled patients with CFPMSG who underwent ASR between January 2014 and September 2020. Comprehensive ophthalmic examinations and UBM were performed before surgery and postoperatively. The patients were classified into three types according to the UBM configurations. Anterior chamber recovery (ACR) was defined as deepening in anterior chamber (≥1.5 mm all through final follow-up (FFU), while success following ASR was defined as ACR and intraocular pressure (IOP)≤21 mm Hg., Results: 25 eyes of 25 patients underwent ASR (average age at operation 5.8±5.0 months, 48% girls) with FFU 15.8±16.9 months. Enrolled subjects were classified into type Ⅰ (11 eyes), type Ⅱ (11 eyes) and type Ⅲ (3 eyes). After ASR, 23 eyes (92%) achieved ACR, and the mean ACD increased in all groups (p=0.006, <0.001 and 0.003, respectively). Eyes with types Ⅰ and Ⅱ demonstrated a reduction of IOP (p=0.009 and 0.002, respectively). ASR success rate was highest in type Ⅰ (72.9%) compared with types Ⅱ and Ⅲ (18.2% and 0%, respectively; p=0.011). ASR led to decreased number of antiglaucoma medications for type Ⅰ CFPMSG at FFU (p=0.016). No vision-threatening postoperative complications occurred., Conclusions: ASR for CFPMSG results in increased ACD and improvement in IOP. Postoperative IOP control was best in type Ⅰ CFPMSG but not as effective in types Ⅱ and Ⅲ. UBM-based classification helps to predict the surgical outcome of ASR in CFPMSG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Glaucoma is a leading cause of visual impairment and a significant public health concern, but despite ongoing advances in our understanding of the disease, several important clinical challenges remain. With the number of affected people projected to increase substantially over coming decades, novel approaches to screening, risk stratification, therapy and glaucoma research are essential to deal with this expanding burden in an efficient and cost-effective manner. Genomics may hold the key to unlocking further biological insights and enabling precision medicine, in which glaucoma care is tailored to the individual patient, based on their unique profile for disease. Here, we provide an overview of how genomics may enable cost-effective targeted population screening and personalised predictions of risk, response to treatment and effective lifestyle advice. Given rapid advances in genetic testing technology and a move towards population-level genotyping, these early results have several important implications that promise to revolutionise the way in which glaucoma is detected and managed in years to come., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite, the potential clinical utility of 60-4 visual fields, they are not frequently used in clinical practice partly, due to the purported impact of facial contour on field defects. The purpose of this study was to design and test an artificial intelligence-driven platform to predict facial structure-dependent visual field defects on 60-4 visual field tests., Methods: Subjects with no ocular pathology were included. Participants were subject to optical coherence tomography, 60-4 Swedish interactive thresholding algorithm visual field tests and photography. The predicted visual field was compared with observed 60-4 visual field results in subjects. Average and point-specific sensitivity, specificity, precision, negative predictive value, accuracy, and F1-scores were primary outcome measures., Results: 30 healthy were enrolled. Three-dimensional facial reconstruction using a convolution neural network (CNN) was able to predict facial contour-dependent 60-4 visual field defects in 30 subjects without ocular pathology. Overall model accuracy was 97%±3% and 96%±3% and the F1-score, dependent on precision and sensitivity, was 58%±19% and 55%±15% for the right eye and left eye, respectively. Spatial-dependent model performance was observed with increased sensitivity and precision within the far inferior nasal field reflected by an average F1-score of 76%±20% and 70%±29% for the right eye and left eye, respectively., Conclusions: This pilot study reports the development of a CNN-enhanced platform capable of predicting 60-4 visual field defects in healthy controls based on facial contour. Further study with this platform may enhance understanding of the influence of facial contour on 60-4 visual field testing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Hypotony is a well-recognised, sight-threatening complication of uveitis. It can also be the final common endpoint for a multitude of disease entities. Multiple mechanisms underlie hypotony, and meticulous clinical history alongside ocular phenotyping is necessary for choosing the best intervention and therapeutic management. In this narrative review, a comprehensive overview of medical and surgical treatment options for the management of non-surgically induced hypotony is provided. Management of ocular hypotony relies on the knowledge of the aetiology and mechanisms involved. An understanding of disease trajectory is vital to properly educate patients. Both anatomical and functional outcomes depend on the underlying pathophysiology and choice of treatment., Competing Interests: Competing interests: The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare the outcomes of the Aurolab aqueous drainage implant (AADI) placed in eyes with refractory primary congenital glaucoma (PCG) versus aphakic glaucoma (APG)., Design: Retrospective comparative interventional case series., Methods: Case files of consecutive eyes with PCG or APG that underwent AADI surgery between January 2013 and December 2016 and had a minimum 4 years follow-up were extracted from a computerised database. Failure was defined as intraocular pressure (IOP)>21 mm Hg or reduced<20% below baseline on two consecutive follow-up visits after 3 months, IOP≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for glaucoma or a complication, or loss of light perception., Results: Eighty-nine eyes underwent AADI placement, including 42 eyes (47%) with PCG and 47 eyes (53%) with APG. Both groups were comparable at baseline. At 1 year, the APG group had lower mean IOP (13.6±8.1 mm Hg vs 17.6±7.5 mm Hg, p=0.02) with use of fewer IOP-lowering medications (0.8±1.0 vs 1.5±1.0, p=0.01) than the PCG group. The cumulative failure rate at 4 years was 57% (95% CI 43% to 72%) in PCG versus 40% (95% CI 28% to 56%) in the APG eyes (p=0.11). Eyes with PCG had greater tube-related complications (48% vs 38%, p=0.07) and number of reoperations (40% vs 32%, p=0.02) compared with eyes with APG., Conclusions: Eyes with APG had relatively better outcomes after AADI placement compared with PCG during 4 years of follow-up. Reoperations accounted for more than 70% of the failures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To evaluate whether baseline vessel density (VD) parameters derived from optical coherence tomography angiography (OCT-A) is associated with the development of glaucomatous visual field (VF) defects in preperimetric glaucoma (PPG) patients., Methods: One eye from each of 200 consecutive PPG patients with a normal standard automated perimetry and OCT-A at baseline was retrospectively analysed. OCT-A was used to measure the circumpapillary VD (cpVD) and the parafoveal and perifoveal VD. The retinal nerve fibre layer (RNFL) and macular ganglion cell-inner plexiform layer thicknesses were measured as reference standards. Two patient groups were stratified based on the development of repeatable glaucomatous VF loss. A Cox proportional hazards model was constructed to determine the predictive ability of OCT-A parameters for VF defects. The correlation between these baseline OCT-A parameters and the rate of global VF sensitivity loss (dB/year) was calculated using linear regression analysis., Results: During a 3.1-year average follow-up period, 18 eyes (9.0%) developed glaucomatous VF defects. At baseline, the lower inferior temporal cpVD (HR (95% CI)=0.934 (0.883 to 0.988); p=0.017) and thinner inferior RNFL (HR (95% CI)=0.895 (0.839 to 0.956); p=0.001) were predictive of glaucomatous VF loss. A lower inferior temporal cpVD and thinner RNFL at baseline were associated with faster rate of global VF sensitivity loss (β=0.015; p=0.001)., Conclusion: In PPG eyes, a lower baseline inferior temporal cpVD is significantly associated with glaucomatous VF defect development and a faster rate of global VF loss., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to investigate the prevalence of glaucoma with associated factors in the rural populations of 10 provinces in China., Design: A population-based cross-sectional study., Methods: All participants aged 6 years or older from 10 provinces completed visual acuity testing, slit-lamp examination, ophthalmoscopy and non-contact tonometry. Glaucoma suspects underwent fundus photography, Goldmann applanation tonometry, visual field testing and gonioscopy. Glaucoma was determined according to the International Society of Geographical and Epidemiological Ophthalmology classification scheme. Associations of demographics and medical factors with glaucoma were assessed using multiple logistic regression models., Results: From June 2017 to October 2018, 48 398 of 52 041 participants were included in the final analyses. The age-standardised prevalence of glaucoma was 1.7% (95% CI 1.55% to 1.78%) among the participants older than 6 years, which was 2.1% (95% CI 1.93% to 2.23%) in participants aged over 40 years. The constituent ratios of glaucoma were: 44.4% primary angle-closure glaucoma (PACG), 34.7% primary open-angle glaucoma, 2.6% congenital glaucoma and 18.3% other types of glaucoma. Increasing age, smoking, cerebral stroke, type 2 diabetes, higher education (college or more) and higher personal income were significant risk factors for PACG. The unilateral and bilateral blindness rates in the entire study population were 4.692% and 1.068%, respectively. A family history of glaucoma was a significant risk factor for the prevalence of glaucoma and blindness in at least one eye., Conclusions: Rural populations have a high prevalence of glaucoma, which should be included in chronic disease management programmes in China for long-term care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/aims: Neurofilament light chain (NfL) levels in cerebrospinal fluid and serum are reliable indicators for neuroaxonal damage in a broad spectrum of neurodegenerative diseases. Herein, we investigate NfL levels in serum and anterior chamber fluid of patients with glaucoma., Methods: Patients scheduled for routine glaucoma or cataract surgery were recruited for this study. Retinal nerve fibre layer thickness was measured by optical coherence tomography (OCT, Heidelberg Spectralis). NfL levels in serum and in anterior chamber fluid were analysed with Simoa SR-X Analyzer (Quanterix; NFLIGHT, Lexington, Massachusetts, USA). T-test was used for parametric data and Mann-Whitney-U test for nonparametric data. Spearman's rank-order correlation was used to investigate correlations. P values<0.05 were considered as statistically significant., Results: Sixty patients with glaucoma and 58 controls were enrolled. Serum NfL concentration of patients with glaucoma was similar to serum NfL concentration in controls (median (IQR); 22.7 (18.9) pg/mL vs 22.5 (24.0) pg/mL; p=0.763). A positive correlation of serum NfL with age was observed in both patients with glaucoma (r=0.77; p<0.001) and in the control group (r=0.82, p<0.001). In the anterior chamber fluid, the NfL concentration was substantially increased in patients with glaucoma compared with controls (20.7 (101.3) pg/mL vs 3.1 (2.9) pg/mL; p<0.001). Furthermore, we found a positive correlation of anterior chamber fluid NfL with preoperative intraocular pressure (r=0.39, p=0.003) and with retinal nerve fibre layer thickness (r=0.58, p<0.001)., Conclusion: NfL levels in anterior chamber fluid are elevated in patients with glaucoma and correlate with intraocular pressure and retinal nerve fibre layer thickness. The presented data strongly support anterior chamber fluid NfL as a new marker for glaucoma., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)