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To evaluate the ocular and systemic determinants of the choriocapillaris flow deficits percentage (CC FD%) in normal eyes.Observational cross-sectional study.Healthy Chinese participants without ocular or systemic diseases underwent detailed ophthalmic evaluations, including swept-source optical coherence tomography angiography (SS-OCTA) with 6- × 6-mm macular choriocapillaris images. The CC FD% was assessed in circular regions with diameters of 1.0 and 5.0 mm, rings with 1.0- to 2.5-mm diameters, and rings with 2.5- to 5.0-mm diameters.The study included 830 individuals (mean ± SD age 58.66 ± 8.75 years). CC FD% (mean ± SD 22.05% ± 1.13%) was the lowest in the 2.5- to 5.0-mm ring, followed by the 1.0- to 2.5-mm ring, and highest in the 1.0-mm circle. In multivariable analysis, a higher CC FD% was associated with older age (β = 0.16 [95% confidence interval {CI}] 0.08-0.24, P.001), higher intraocular pressure (β = 0.34 [95% CI 0.25-0.42], P.001), higher serum concentrations of high-density lipoprotein cholesterol (β = 0.24 [95% CI 0.17-0.32], P.001), and lower image quality score (β = -0.22 [95% CI -0.30 to -0.14], P.001). CC FD% was also independent of axial length.In healthy adult Chinese individuals, a higher CC FD% was associated with older age, higher intraocular pressure, and higher high-density lipoprotein cholesterol serum concentration. These factors may influence clinical assessments of the choriocapillaris. The lack of an association between CC FD% and axial length is consistent with similar findings for Bruch membrane thickness, macular retinal thickness, and macular retinal pigment epithelium cell density.

Purpose To develop and validate a multimodal artificial intelligence algorithm, FusionNet, using the pattern deviation probability plots from visual field (VF) reports and circular peripapillary OCT scans to detect glaucomatous optic neuropathy (GON). Design Cross-sectional study. Subjects Two thousand four hundred sixty-three pairs of VF and OCT images from 1083 patients. Methods FusionNet based on bimodal input of VF and OCT paired data was developed to detect GON. Visual field data were collected using the Humphrey Field Analyzer (HFA). OCT images were collected from 3 types of devices (DRI-OCT, Cirrus OCT, and Spectralis). Two thousand four hundred sixty-three pairs of VF and OCT images were divided into 4 datasets: 1567 for training (HFA and DRI-OCT), 441 for primary validation (HFA and DRI-OCT), 255 for the internal test (HFA and Cirrus OCT), and 200 for the external test set (HFA and Spectralis). GON was defined as retinal nerve fiber layer thinning with corresponding VF defects. Main Outcome Measures Diagnostic performance of FusionNet compared with that of VFNet (with VF data as input) and OCTNet (with OCT data as input). Results FusionNet achieved an area under the receiver operating characteristic curve (AUC) of 0.950 (0.931–0.968) and outperformed VFNet (AUC, 0.868 [95% confidence interval (CI), 0.834–0.902]), OCTNet (AUC, 0.809 [95% CI, 0.768–0.850]), and 2 glaucomatologists (glaucomatologist 1: AUC, 0.882 [95% CI, 0.847–0.917]; glaucomatologist 2: AUC, 0.883 [95% CI, 0.849–0.918]) in the primary validation set. In the internal and external test sets, the performances of FusionNet were also superior to VFNet and OCTNet (FusionNet vs VFNet vs OCTNet: internal test set 0.917 vs 0.854 vs 0.811; external test set 0.873 vs 0.772 vs 0.785). No significant difference was found between the 2 glaucomatologists and FusionNet in the internal and external test sets, except for glaucomatologist 2 (AUC, 0.858 [95% CI, 0.805–0.912]) in the internal test set. Conclusions FusionNet, developed using paired VF and OCT data, demonstrated superior performance to both VFNet and OCTNet in detecting GON, suggesting that multimodal machine learning models are valuable in detecting GON.

Purpose To develop and evaluate the performance of a 3-dimensional (3D) deep-learning–based automated digital gonioscopy system (DGS) in detecting 2 major characteristics in eyes with suspected primary angle-closure glaucoma (PACG): (1) narrow iridocorneal angles (static gonioscopy, Task I) and (2) peripheral anterior synechiae (PAS) (dynamic gonioscopy, Task II) on OCT scans. Design International, cross-sectional, multicenter study. Participants A total of 1.112 million images of 8694 volume scans (2294 patients) from 3 centers were included in this study (Task I, training/internal validation/external testing: 4515, 1101, and 2222 volume scans, respectively; Task II, training/internal validation/external testing: 378, 376, and 102 volume scans, respectively). Methods For Task I, a narrow angle was defined as an eye in which the posterior pigmented trabecular meshwork was not visible in more than 180° without indentation in the primary position captured in the dark room from the scans. For Task II, PAS was defined as the adhesion of the iris to the trabecular meshwork. The diagnostic performance of the 3D DGS was evaluated in both tasks with gonioscopic records as reference. Main Outcome Measures The area under the curve (AUC), sensitivity, and specificity of the 3D DGS were calculated. Results In Task I, 29.4% of patients had a narrow angle. The AUC, sensitivity, and specificity of 3D DGS on the external testing datasets were 0.943 (0.933–0.953), 0.867 (0.838–0.895), and 0.878 (0.859–0.896), respectively. For Task II, 13.8% of patients had PAS. The AUC, sensitivity, and specificity of 3D DGS were 0.902 (0.818–0.985), 0.900 (0.714–1.000), and 0.890 (0.841–0.938), respectively, on the external testing set at quadrant level following normal clinical practice; and 0.885 (0.836–0.933), 0.912 (0.816–1.000), and 0.700 (0.660–0.741), respectively, on the external testing set at clock-hour level. Conclusions The 3D DGS is effective in detecting eyes with suspected PACG. It has the potential to be used widely in the primary eye care community for screening of subjects at high risk of developing PACG.

Purpose The purpose of this study was to determine the longitudinal changes in macular retinal and choroidal microvasculature in normal healthy and highly myopic eyes. Methods Seventy-one eyes, including 32 eyes with high myopia and 39 healthy control eyes, followed for at least 12 months and examined using optical coherence tomography angiography imaging in at least 3 visits, were included in this study. Fovea-centered 6 × 6 mm scans were performed to measure capillary density (CD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC). The rates of CD changes in both groups were estimated using a linear mixed model. Results Over a mean 14-month follow-up period, highly myopic eyes exhibited a faster rate of whole image CD (wiCD) loss (−1.44%/year vs. −0.11%/year, P = 0.001) and CD loss in the outer ring of the DCP (−1.67%/year vs. –0.14%/year, P < 0.001) than healthy eyes. In multivariate regression analysis, baseline axial length (AL) was negatively correlated with the rate of wiCD loss (estimate = −0.27, 95% confidence interval [CI] = −0.48 to −0.06, P = 0.012) and CD loss in the outer ring (estimate = −0.33, 95% CI = −0.56 to −0.11, P = 0.005), of the DCP. The CD reduction rates in the SCP and CC were comparable in both groups (all P values > 0.05). Conclusions The rate of CD loss in the DCP is significantly faster in highly myopic eyes than in healthy eyes and is related to baseline AL. The CD in the outer ring reduces faster in eyes with longer baseline AL.

Purpose To characterize longitudinal changes in macular microvasculature as quantified from optical coherence tomography angiography (OCTA) metrics in primary open-angle glaucoma (POAG) eyes with and without high myopia. Methods In total, 63 and 61 POAG eyes with and without high myopia, respectively, underwent swept-source OCTA imaging in at least four follow-up visits at an ophthalmic center, with a scanning protocol of 3- × 3-mm centered at the fovea. The foveal avascular zone (FAZ) area, FAZ circularity, and vessel density (VD) in both the superficial (SCP) and deep capillary plexuses (DCP) were measured. The rate of change in macular OCTA metrics over time was estimated using linear mixed-effects models in both groups of POAG eyes. Results The mean follow-up time and number of visits were 27.72 ± 8.57 months and 8.5 (8 to 13) times, and 30.95 ± 10.19 months and 10 (8‒13) times in POAG eyes with and without high myopia, respectively. VD in the DCP reduced significantly more quickly in POAG eyes with high myopia than in those without high myopia (−5.14%/year vs. −3.71%/year, P = 0.008). Moreover, lower baseline VD in the DCP was significantly associated with faster VD reduction in POAG with high myopia eyes (P < 0.001). Conversely, the VD reduction rate in the SCP, FAZ area, and FAZ circularity in both the SCP and DCP were similar in both groups (all Ps > 0.05). Conclusions VD in DCP reduced significantly more quickly in POAG eyes with high myopia over time. Density in the DCP reduced more quickly when baseline VD was low.

IntroductionMyopic maculopathy and glaucoma belong to the most common causes of irreversible blindness worldwide and, having an ocular axial elongation as one of their main risk factors, can occur together. The detection of glaucomatous optic neuropathy (GON) in highly myopic eyes is clinically and technically difficult, and there is no information available, neither about the natural course of GON or about the course of GON under intraocular pressure-lowering therapy. We therefore designed this study to explore the natural course of GON in highly myopic eyes.Methods and analysisIn this single-centred longitudinal registry cohort study, 813 highly myopic individuals will be recruited and undergo detailed ophthalmic examinations. High myopia is defined by a myopic refractive error of ≥−6 D or an axial length of ≥26.5 mm. GON is defined by a glaucomatous appearance of the optic nerve head or glaucomatous visual field (VF) defects. GON progression is defined by either change of the optic disc or VF.Ethics and disseminationEthical approval has been obtained from the ethical committee of the Zhongshan Ophthalmic Center (ZOC), Sun Yat-sen University, China (ID: 2019KYPJ079). All the participants are required to provide informed consents. Results will be disseminated through scientific meetings and published in peer-reviewed journals. The data will be deposited at the clinical research centre in ZOC using electronic data capture system, and a copy of paper files will also be kept. Only members of the project team will have access to these data.Trial registration numberNCT04302220.

BackgroundTo investigate whether quantitative optical coherence tomography angiography (OCTA) metrics of the superficial/deep macular retina and optic disc are associated with glaucoma progression risk.MethodsA total of 238 eyes from 119 patients with open angle glaucoma or ocular hypertension, and no history of systemic hypertension or diabetes mellitus were included. All participants underwent OCTA imaging with a swept-source OCT (DRI-OCT 1, Topcon, Japan). OCTA metrics of superficial capillary plexus (SCP) and deep capillary plexus (DCP) in the macular region, and radial peripapillary capillary network of the optic disc were measured by a customised MATLAB program to obtain foveal avascular zone (FAZ) area, FAZ circularity and capillary density of SCP/DCP, and capillary density of the peripapillary region. Relationships between baseline OCTA metrics, visual field (VF) metrics, intraocular pressure fluctuation and risk of glaucoma progression were analysed with the Cox proportional hazards model. A frailty model was used to adjust for intereye correlation.ResultsDuring a mean follow-up duration of 29.39 months (range 12–56 months), 50, 48 and 16 eyes were determined to have retinal nerve fibre layer (RNFL), ganglion cell-inner plexiform layer (GC-IPL) and VF progression respectively. FAZ area per SD increase at baseline were significantly associated with both RNFL thinning (HR 1.73 95% CI 1.04 to 2.90); p=0.036) and GC-IPL thinning (HR 2.62, 95% CI 1.59 to 4.31; pConclusionEnlarged FAZ area measured by OCTA was associated with a higher risk of RNFL and GC-IPL thinning associated with glaucoma, but not with functional deterioration in glaucoma.

High myopia is among the most common causes of vision impairment, and it is mainly characterized by abnormal elongation of the axial length, leading to pathologic changes in the ocular structures. Owing to the close relationship between high myopia and glaucoma, the association between intraocular pressure (IOP) and high myopia progression has garnered attention. However, whether lowering IOP can retard the progression of high myopia is unclear. On reviewing previous studies, we suggest that lowering IOP plays a role in progressive axial length elongation in high myopia, particularly in pathologic myopia, wherein the sclera is more remodeled. Based on the responses of the ocular layers, we further proposed the potential mechanisms. For the sclera, lowering the IOP could inhibit the activation of scleral fibroblasts and then reduce scleral remodeling, and a decrease in the scleral distending force would retard the ocular expansion like a balloon. For the choroid, lowering IOP results in an increase in choroidal blood perfusion, thereby reducing scleral hypoxia and slowing down scleral remodeling. The final effect of these pathways is slowing axial elongation and the development of scleral staphyloma. Further animal and clinical studies regarding high myopia with varied degree of IOP and the changes of choroid and sclera during IOP fluctuation in high myopia are needed to verify the role of IOP in the pathogenesis and progression of high myopia. It is hoped that this may lead to the development of a prospective treatment option to prevent and control high myopia progression.