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Importance: Physical activity levels are lower in visual impairment. However, additional factors, such as home environmental features, which can modify physical activity in this group, are unknown., Objective: To investigate the association between home environment features and home physical activity in patients with visual impairment., Design, Setting, and Participants: This cross-sectional study of clinical patients included participants with glaucoma suspect and primary glaucoma who were 60 years or older with varying degrees of visual field damage. Study participants were recruited from the Johns Hopkins Wilmer Eye Institute Glaucoma Clinic, Baltimore, Maryland, from September 2013 through March 2015. Data were analyzed from December 19, 2022, through December 25, 2022., Main Outcomes and Measures: Total in-home steps taken per day was the primary outcome measure; time in daily home physical activity and nonsedentary activity were secondary outcomes., Results: A total of 153 participants were included in analyses with mean age of 71 (SD, 7.8) years and 71 were female (46%). Sixty percent had more than 1 comorbid illness, about one-third took 5 or more prescription drugs, and median daily home steps were 1137. Median integrated visual field sensitivity was 28 dB. Better-eye median visual acuity in logMAR was 0.05 (20/22 Snellen equivalent). For every 0.1-log unit increment in average measured home lighting, participants took 5% more daily steps (rate ratio [RR], 1.05; 95% CI, 1.00-1.10; P = .04) and had a 3% faster average daily peak cadence (RR, 1.03; 95% CI, 1.01-1.05; P = .01). The average number of nonsedentary activity minutes (RR, 1.04; 95% CI, 1.00-1.07; P = .06), average bout duration (β = 0.03; 95% CI, 0.00-.07; P = .06), and activity fragmentation (β = -0.06; 95% CI, -0.13 to 0.00; P = .06) showed associations with home lighting. The number of hazards was not associated with any activity metric (steps: RR, 1.14; 95% CI, 0.96-1.34; P = .13; peak cadence: RR, 1.00; 95% CI, 0.93-1.08; P = .98; and nonsedentary time: RR, 1.11; 95% CI, 0.98-1.26; P = .11), nor was the frequency of hazards., Conclusions and Relevance: In this study, results demonstrated that home environment features, particularly lighting, may influence home activity metrics in older adults with visual impairment. Further prospective studies would be needed to confirm if home modifications can improve at-home activity.

Background: The diagnosis of dry eye and other common ophthalmological conditions can be supported using patient reported symptoms, which is increasingly useful in contexts such as telemedicine. We aim to ascertain visual symptoms that differentiate dry eye from cataract, glaucoma, or glaucoma suspects., Methods: Adults with dry eye, glaucoma, cataract, and suspected glaucoma (controls) completed a questionnaire to rate the frequency and severity of 28 visual symptoms. Univariate, followed by multivariable logistic regression with backward stepwise selection (p < 0.05), determined the individual symptoms and set of symptoms best distinguishing dry eye from each of the other conditions., Results: Mean age of 353 patients (94 glaucoma suspect controls, 79 glaucoma, 84 cataract, and 96 dry eye) was 64.1 years (SD = 14.1); 67% were female and 68% White. Dry eye patients reported more frequent light sensitivity (OR = 15.0, 95% CI = 6.3-35.7) and spots in vision (OR = 2.8, 95% CI = 1.2-6.3) compared to glaucoma suspect controls. Compared to glaucoma patients, dry eye patients experienced more frequent light sensitivity (OR = 9.2, 95% CI = 2.0-41.7), but less frequent poor peripheral vision (OR = 0.2, 95% CI = 0.06-0.7), difference in vision between eyes (OR = 0.09, 95% CI = 0.01-0.7), and missing patches of vision (OR = 0.06, 95% CI = 0.009-0.3). Compared to cataract patients, dry eye patients reported more frequent spots in vision (OR = 4.5, 95% CI = 1.5-13.4) and vision variability across the week (OR = 4.7, 95% CI = 1.2-17.7) and were less likely to report worsening vision (OR = 0.1, 95% CI = 0.03-0.4) and blindness (OR = 0.1, 95% CI = 0.02-0.8)., Conclusion: Visual symptoms may serve as a complementary tool to distinguish dry eye from various ocular conditions, though the symptoms that best distinguish dry eye differ across comparisons. Differentiating how patients visually perceive common eye diseases may be used in a variety of clinical settings to rule out specific conditions., (© 2024. The Author(s).)

To evaluate how well outcomes following cataract extraction and microinvasive glaucoma surgery in one eye predict outcomes in sequential second eye. Retrospective study of 78 patients who underwent cataract extraction and microinvasive glaucoma surgery in both eyes. Linear regressions using Pearson correlation coefficients were used to evaluate correlations in intraocular pressure and glaucoma medication change between eyes. Multivariable logistic regression models were used to evaluate the associations between first-eye variables and the likelihood of second-eye surgical success at 6 months. Surgical success was defined as meeting target intraocular pressure without additional medications compared to baseline or secondary surgical interventions. Baseline ocular characteristics were comparable between fellow eyes, with the majority having mild glaucoma. Intraocular pressure changes between fellow eyes at 6 months were modestly correlated between eyes (R = 0.48; P < .001). Changes in glaucoma medications were strongly correlated between eyes at all time points, and month 6 demonstrated the most significant correlation (R = 0.80; P < .001). First and second eye cohorts achieved 82% and 83% surgical success. Multivariate analysis for predictive factors of successful second eye surgery showed patients with successful first eye surgery at 6 months were significantly more likely to have successful second eye surgery (odds ratio, 20.67; P < .001). Reductions in intraocular pressure and glaucoma medications at 6 months following surgery in first eyes are correlated to second eye reductions. Successful surgical outcomes at 6 months following first eye surgeries are strongly associated with successful sequential second eye outcomes., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Prcis: Cataract, glaucoma, and glaucoma suspect patients report differing visual symptoms. Asking patients about their visual symptoms may provide useful diagnostic information and inform decision-making in patients with comorbid conditions., Purpose: To compare visual symptoms in glaucoma, glaucoma suspect (controls), and cataract patients., Methods: Glaucoma, cataract, and glaucoma suspect patients at Wilmer Eye Institute responded to a questionnaire rating the frequency and severity of 28 symptoms. Univariate and multivariable logistic regression determined the symptoms that best differentiate each disease pair., Results: In all, 257 patients (mean age: 67.4 ± 13.4 y; 57.2% female; 41.2% employed), including 79 glaucoma, 84 cataract, and 94 glaucoma suspect patients, participated. Compared with glaucoma suspects, glaucoma patients were more likely to report poor peripheral vision (OR 11.29, 95% CI: 3.73-34.16), better vision in 1 eye (OR 5.48, 95% CI: 1.33-22.64), and light sensitivity (OR 4.85, 95% CI: 1.78-13.24), explaining 40% of the variance in diagnosis (ie, glaucoma vs. glaucoma suspect). Compared with controls, cataract patients were more likely to report light sensitivity (OR 3.33, 95% CI: 1.56-7.10) and worsening vision (OR 12.20, 95% CI: 5.33-27.89), explaining 26% of the variance in diagnosis (ie, cataract vs. glaucoma suspect). Compared with cataract patients, glaucoma patients were more likely to report poor peripheral vision (OR 7.24, 95% CI: 2.53-20.72) and missing patches (OR 4.91, 95% CI: 1.52-15.84), but less likely to report worsening vision (OR 0.08, 95% CI 0.03-0.22), explaining 33% of the variance in diagnosis (ie, glaucoma vs. cataract)., Conclusions: Visual symptoms distinguish disease state to a moderate degree in glaucoma, cataract, and glaucoma suspect patients. Asking about visual symptoms may serve as a useful diagnostic adjunct and inform decision-making, for example, in glaucoma patients considering cataract surgery., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate the associations of neighborhood-level socioeconomic and environmental characteristics with physical activity in persons with glaucoma., Design: Cross-sectional study (N = 230)., Methods: Home addresses were used to extract neighborhood factors (NFs): Area Deprivation Index, crime rate, and the proportion of racial and ethnic minorities, poverty, college graduates, and park area in their census tract. Participants' average number of daily steps and nonsedentary minutes were collected over 7 days using an accelerometer. Visual field (VF) loss was quantified as integrated VF sensitivity. Multivariable negative binomial regression models and additional models with an interaction term evaluated the effect of NF on physical activity and whether these relationships differed by VF loss severity., Results: Participants were on average 70.6 years of age, 51.7% were male, and 27.8% were black. A higher Area Deprivation Index or poverty share was associated with fewer NSM (incidence rate ratio [IRR] = 0.96 per 1 Area Deprivation Index decile increment, P = .01; IRR = 0.92 per 10% poverty share increment, P = .02), while higher share of college graduates was associated with greater NSM (IRR = 1.03 per 10% increment; P = .03). Stronger associations were noted between both high crime rate and poverty share with NSM in individuals with severe VF damage as opposed to no/mild VF damage (IRR = 0.44, P = .001; IRR = 0.81, P = .02)., Conclusions: Select NFs (poverty share and crime rate) may disproportionately affect physical activity in patients with severe VF loss. Interventions to overcome activity limitations within the context of poverty and high socioeconomic disadvantage are important for addressing glaucoma-related disability, particularly in those with severe VF loss., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Prcis: Optical coherence tomography (OCT) estimated retinal nerve fiber layer (RNFL) thickness associated with glaucoma-related disability independent of the visual field (VF) damage and thus may provide additional patient-relevant disability information beyond what is captured by standard VF testing., Purpose: To examine whether OCT metrics [peripapillary RNFL thickness and macular ganglion cell/inner plexiform layer (GCIPL) thickness] are associated with quality of life (QoL) measures and additional disability metrics, and whether these associations are independent of VF damage., Methods: In this cross-sectional study, 156 patients with glaucoma or suspected glaucoma received VF testing and OCT scans to measure RNFL and GCIPL thickness. QoL was assessed using the Glaucoma Quality-of-Life 15 and additional disability measures including fear of falling, reading speed, and steps per day were assessed. Multivariable regression models adjusting for relevant covariates tested whether RNFL or GCIPL thickness from the less-impaired eye were associated with disability measures and whether associations were independent of VF damage., Results: Greater VF damage is associated with worse QoL (95% CI=0.4-1.4; P <0.001) and slower reading speed (CI=-0.06 to -0.02; P <0.001). Lower RNFL and GCIPL thicknesses were associated with lower QoL scores, but not with QoL scores or other disability metrics after correcting for VF damage. However, post hoc analyses in patients with better eye thicknesses between 55 and 75 µm demonstrated associations between lower RNFL thickness and worse QoL (CI=-2.2 to -0.1; P =0.04) and greater fear of falling (CI=-6.1 to -0.4; P =0.03) even after accounting for VF damage. No such associations were observed for GCIPL thickness., Conclusions: OCT RNFL, but not GCIPL, thickness is associated with multiple disability measures independent of VF damage severity., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To determine which patient-reported symptoms best distinguish patients with and without glaucoma and explain the most variance in visual field (VF) damage and to compare the amount of variance that can be explained by symptoms versus retinal nerve fiber layer (RNFL) thickness., Design: Cross-sectional study., Participants: Adults diagnosed with glaucoma or suspicion of glaucoma (controls)., Methods: Worse-eye VF damage was defined on the basis of perimetric testing. Thickness of RNFL was defined by OCT imaging. Patients rated their visual symptoms on questions collated from several published questionnaires, rating the frequency and severity of 28 symptoms on a scale of 1 (never/not at all) to 4 (very often/severe). Multivariable regression models identified patient-reported symptoms that contributed the highest variance in VF damage., Main Outcome Measures: Patient-reported symptoms that explained the most variance in VF damage and amount of variance in VF damage explained by patient-reported symptoms and RNFL., Results: A total of 170 patients (mean age: 64 years; 58% female; 47% employed) completed testing, including 95 glaucoma suspects and 75 glaucoma patients. In glaucoma patients, median mean deviation of VF damage in the worse eye was -19.3 and ranged from -5.3 to -34.7 decibels. Symptoms more common among glaucoma patients compared with glaucoma suspects included better vision in 1 eye, blurry vision, glare, sensitivity to light, cloudy vision, missing patches of vision, and little peripheral vision. Worse severity ratings for the symptom "little peripheral vision" explained the most variance in VF damage (43%). A multivariable model including the frequency of cloudy vision, severity of having little peripheral vision, missing patches, 1 eye having better vision, and vision worsening, plus sociodemographic features, explained 62% of the variance in VF damage. Comparatively, a multivariable model of worse-eye RNFL thickness and sociodemographic features explained 42% of the variance in VF damage, whereas a model including only sociodemographic features explained 8% of the variance in VF damage., Conclusions: Five patient-reported symptoms explain a significant amount of the variance in VF damage. Asking patients about their symptoms may optimize patient-physician communication and be a useful adjunct to clinical testing in some patients to estimate disease severity., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Unintentional falls among older adults are associated with an ensuing decline in physical activity. Our objective is to evaluate the associations between fall status and changes in excursions after a fall., Methods: Prospective cohort study of older adults with glaucoma or suspected glaucoma who reported falls for 1 year and wore a GPS device for 1-week at the baseline and 1 year later. GPS data were quantified into average: daily excursions, daily time away from home, and time per excursion. Fall status was categorized as fallers, injurious fallers, recurrent fallers, and recurrent injurious fallers. Multivariable negative binomial regression and generalized estimating equations models were employed to evaluate relationship between excursion parameters and fall status., Results: A total of 192 eligible participants were included in the analyses. Approximately half were males (50.5%) with a mean age of 70.1 years and one-fourth were Black (28.1%). There were no significant associations between fall status and end-of-study excursion parameters (p > 0.06 for all), and visual field damage did not modify these relationships (p > 0.07 for all). For instance, patients with multiple falls during a one-year study period did not demonstrate more daily excursions (incident rate ratio [IRR] = 1.16, 95% confidence interval [CI] = 0.85 to 1.57), longer time per excursion (IRR = 0.79, 95% CI =0.59 to 1.06), or more average daily time away (IRR = 1.05, 95% CI = 0.84 to 1.30) conducted at the end-of-the study. Excursion parameters at the final assessment were not significantly different from those at baseline (p > 0.09 for all) and the changes did not vary by fall status (p > 0.23 for all)., Conclusions: Older adults with glaucoma did not modify their travel away from home after experiencing a fall. Additional research is necessary to understand how often maintenance of travel outside the home after a fall reflects proper compensation for greater fall risk or continued activity despite the risk of falling., (© 2022. The Author(s).)

Purpose: This study examined characteristics of intraocular pressure (IOP) as measured during home tonometry in comparison with in-clinic tonometry in patients with glaucoma., Design: Retrospective cross-sectional study of glaucoma patients who completed 1 week of self-tonometry at a single academic center., Participants: Patients with glaucoma who completed home tonometry trials with the iCare HOME tonometer (iCare USA) for any reason., Methods: Home IOP measurements were compared with in-clinic tonometry performed during the 5 visits preceding home tonometry. Maximum daily IOP was correlated to time of day. Generalized estimating equations were used to evaluate patient characteristics and clinic-derived variables that predicted differences between home and clinic IOP., Main Outcome Measures: IOP mean, maximum, minimum, range, standard deviation and coefficient of variation were compared between clinic and home tonometry. IOP mean daily maximum (MDM) and mean daily range were calculated to describe recurrent IOP spiking., Results: A total of 107 eyes from 61 patients were analyzed. Mean age was 63.2 years (standard deviation [SD], 14.0 years) and 59.0% were women. Mean clinic and home IOPs were 14.5 mmHg (SD, 4.7 mmHg) and 13.6 mmHg (SD, 5.1 mmHg). Home tonometry identified significantly higher maximum IOP, lower minimum IOP, and greater IOP range than clinic tonometry (P < 0.001). Maximum daily IOP occurred outside of clinic hours (8 am-5 pm) on 50% of days assessed and occurred between 4:30 am and 8 am on 24% of days. Mean daily maximum IOP exceeded maximum clinic IOP in 44% of patients and exceeded target IOP by 3 mmHg, 5 mmHg, or 10 mmHg in 31%, 15%, and 6% of patients, respectively. Patient characteristics that predicted significant deviations between MDM and mean clinic IOP or target IOP in multivariate models included younger age, male gender, and absence of prior filtering surgery., Conclusions: Self-tonometry provides IOP data that supplements in-clinic tonometry and would not be detectable over daytime in-clinic diurnal curves. A subset of patients in whom home tonometry was ordered by their glaucoma clinician because of suspicion of occult IOP elevation demonstrated reproducible IOP elevation outside of the clinic setting. Such patients tended to be younger and male and not to have undergone previous filtering surgery., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To quantify the association of visual field (VF) damage on physical activity away-from-home, per away-from-home excursion, and at-home., Design: Prospective cohort study., Methods: Among 229 participants with glaucoma or suspected glaucoma, the severity of VF damage was defined as average sensitivity within the integrated VF (IVF). Participants wore accelerometers and global positioning system trackers for 7 days to measure physical activity and characterize activity location. Multivariable negative binomial regressions were used to test whether away-from-home activity per day, physical activity per away-from-home excursion, and at-home activity per day varied by the severity of VF damage., Results: Each 5-dB decrement in IVF sensitivity was associated with a lower number of away-from-home activities per day (18% less moderate and vigorous physical activity [MVPA] minutes/d, 95% confidence interval, 0.69-0.97) and physical activities per away-from-home excursion (20% less MVPA minutes/excursion, 95% confidence interval, 0.65-0.98). Similar findings were noted for other away-from-home activity measures (including active minutes/steps per day, or active minutes/steps per excursion). However, worse IVF sensitivity was not associated with measures of at-home activities (MVPA minutes/d, active minutes/d, and steps/d), time spent at or away from home, or excursions/wk (P > .1 for all)., Conclusions: Restriction of physical activity in more patients with severe glaucoma results mostly from activity restriction outside the home environment. These findings highlight the importance of maintaining a safe home environment (where activity is less restricted) and increasing confidence to perform activity, particular high-intensity activity, when leaving the home amongst patients with glaucoma., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To evaluate whether home hazards and lighting levels are associated with higher fall rates in adults with varying degrees of visual field (VF) damage from glaucoma., Methods: Participants with diagnosed or suspected glaucoma provided three years of prospective falls data via monthly falls diaries. A post-fall telephone questionnaire determined fall locations. Seven home areas were evaluated for hazards and lighting via an in-home assessment. Multivariate models adjusting for relevant confounders, including age, sex, comorbidity, and severity of VF damage, evaluated the influence of hazards and lighting on fall rates in each home region., Results: Mean baseline age for the 170 participants was 71.0 (7.6) years and 78 (46%) of participants were female. Fifty-nine participants experienced a total of 83 home falls, with the greatest number of falls occurring on the indoor stairs (n = 24, 29%) and bedroom (n = 17, 21%). Neither the number nor the percentage of hazardous items graded as hazardous was associated with the rate of falls (P > .26). Each 10-fold increase in room lighting was associated with 35% fewer falls in that home region (P = .02). The relation between lighting and the rate of falls did not differ with the degree of visual field damage (P > .3), and a lower fall rate was noted with better lighting even in participants with mild or no VF damage (rate ratio = 0.52/10-fold better lighting; P = 0.01)., Conclusions: Fewer home falls were found with better lighting, but not with fewer home hazards. Lighting improvements at home may reduce fall rates in older adults. NOTE: Publication of this article is sponsored by the American Ophthalmological Society., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Gait dysfunction is common in older people with visual impairment and is a major cause of falls., Objective: To compare 3-year longitudinal changes in gait measures across the spectrum of baseline visual field (VF) damage in glaucoma., Design, Setting, and Participants: A post hoc analysis was designed on September 1, 2018, following a prospective cohort study, which enrolled older adults with glaucoma or suspected glaucoma from September 2013 to March 2015 and followed up for up to 3 years. Baseline VF damage was defined by integrated VF (IVF) sensitivity and categorized as normal/mild (IVF >28 dB), moderate (IVF, 23-28 dB), and severe (IVF, <23 dB). Each participant walked on an electronic walkway back and forth twice at normal pace each study year. Linear mixed-effects models evaluated longitudinal change in gait outcomes (1) stratified within each VF severity category and (2) across the range of IVF sensitivity. Analysis took place from October 2019 to October 2020., Main Outcomes and Measures: Three-year changes in 7 gait assessments under usual-pace walking, including base support and its coefficient of variation, stride length and its coefficient of variation, stride velocity and its coefficient of variation, and cadence., Results: Of 241 participants, the mean (SD) age was 70.8 (7.7) years, 116 (48.2%) were women, and 70 (29.0%) were African American. When comparing longitudinal gait changes over 3 years across the spectrum of IVF sensitivity, each 5-unit (dB) decrement was associated with more rapid declines in stride velocity (-0.05 z score unit/y; 95% CI, -0.09 to -0.01; P = .01) and cadence (-0.07 z score unit/y; 95% CI, -0.10 to -0.03; P < .001). When evaluating gait changes within each glaucoma severity group, shorter stride length was associated with persons with normal/mild (-0.06 z score unit/y; 95% CI, -0.10 to -0.03; P = .001), moderate (-0.08 z score unit/y; 95% CI, -0.12 to -0.04; P < .001), and severe VF damage (-0.16 z score unit/y; 95% CI, -0.24 to -0.07; P < .001), while stride velocity (-0.18 z score unit; 95% CI, -0.28 to -0.07; P = .002) and slower cadence (-0.15 z score unit; 95% CI, -0.25 to -0.04; P = .006) were associated with those with severe VF damage., Conclusions and Relevance: At worse levels of baseline VF damage, patients with glaucoma in this study demonstrated an exacerbated decline in walking speeds (ie, stride velocity and cadence), indicating that mobility speeds decrease faster over time in older adults with glaucoma.

Understanding periods of the year associated with higher risk for falling and less physical activity may guide fall prevention and activity promotion for older adults. We examined the relationship between weather and seasons on falls and physical activity in a three-year cohort of older adults with glaucoma. Participants recorded falls information via monthly calendars and participated in four one-week accelerometer trials (baseline and per study year). Across 240 participants, there were 406 falls recorded over 7569 person-months, of which 163 were injurious (40%). In separate multivariable regression models incorporating generalized estimating equations, temperature, precipitation, and seasons were not significantly associated with the odds of falling, average daily steps, or average daily active minutes. However, every 10 °C increase in average daily temperature was associated with 24% higher odds of a fall being injurious, as opposed to non-injurious ( p = 0.04). The odds of an injurious fall occurring outdoors, as opposed to indoors, were greater with higher average temperatures (OR per 10 °C = 1.46, p = 0.03) and with the summer season (OR = 2.69 vs. winter, p = 0.03). Falls and physical activity should be understood as year-round issues for older adults, although the likelihood of injury and the location of fall-related injuries may change with warmer season and temperatures.

Background: Older adults with visual impairments experience a higher risk of falling, and are more vulnerable to adverse health consequences associated with falls than those with normal vision. This study characterizes longitudinal changes in objectively measured physical activity and fear of falling (FoF) occurring after various types of falls in visually impaired older adults., Design: Prospective cohort study., Setting: Hospital-based enrollment., Participants: People with glaucoma or suspected glaucoma., Measurements: Falls were defined as unintentionally coming to rest on the ground or a lower level, and injurious falls were determined though follow-up calls. Study participants were categorized into three groups-fallers with injurious consequences, fallers without injurious consequences, and non-fallers based on fall status in the first year. Physical activity was assessed by waist-bound accelerometer. FoF was evaluated by questionnaire, with Rasch modeling generating FoF scores where higher scores reflected worse FoF. The 3-year longitudinal changes of physical activity and FoF were modeled using mixed-effects models., Results: In linear models fully adjusted for visual field damage and other covariates, physical activity among injurious fallers showed greater annual (per year) declines in daily steps (-425 steps/d, 95% confidence interval (CI) = -793, -57), daily active minutes (-13 min/d, 95% CI = -21, -6), and daily moderate and vigorous physical activity (MVPA) minutes (-3 MVPA minutes/d, 95% CI = -5, 0) over the 3-year period as compared to non-fallers; however, physical activity did not significantly decline among non-injurious fallers. No longitudinal increases in FoF scores were observed in injurious or non-injurious fallers when compared to non-fallers., Conclusion: Among visually impaired older adults, injurious falls identified prospectively over 12 months contributed to a significant decline in physical activity over a 3-year period, while minimal changes were observed in FoF., (© 2021 The American Geriatrics Society.)

Purpose: To define and quantify patterns of objectively measured daily physical activity by level of visual field (VF) damage in glaucoma patients including: (1) activity fragmentation, a metric of health and physiologic decline, and (2) diurnal patterns of activity, a measure of rest and activity rhythms., Design: Prospective cohort study., Participants: Older adults diagnosed with glaucoma or suspected glaucoma., Methods: Degree of VF damage was defined by the average VF sensitivity within the integrated VF (IVF). Each participant wore a hip accelerometer for 1 week to measure daily minute-by-minute activity for 7 consecutive days. Activity fragmentation was calculated as the reciprocal of the average activity bout duration in minutes, with higher fragmentation indicating more transient, rather than sustained, activity. Multivariate linear regression was used to test for cross-sectional associations between VF damage and activity fragmentation. Multivariate linear mixed-effects models were used to assess the associations between VF damage and accumulation of activity across 6 3-hour intervals from 5 am to 11 pm., Main Outcome Measures: Activity fragmentation and amount of activity (steps) over the course of the day., Results: Each 5-dB decrement in IVF sensitivity was associated with 16.3 fewer active minutes/day (P < 0.05) and 2% higher activity fragmentation (P < 0.05), but not with the number of active bouts per day (P = 0.30). In time-of-day analyses, lower IVF sensitivity was associated with fewer steps over the 11 am to 2 pm, 2 pm to 5 pm, and 5 pm to 8 pm periods (106.6, 93.1, and 89.2 fewer steps, respectively; P < 0.05 for all), but not over other periods. The activity midpoint (the time at which half of the daily activity is completed) did not vary across level of VF damage., Conclusions: At worse levels of VF damage, glaucoma patients demonstrate shorter, more fragmented bouts of physical activity throughout the day and lower activity levels during typical waking hours, reflecting low physiologic functioning. Further work is needed to establish the temporality of this association and whether glaucoma patients with such activity patterns are at a greater risk of adverse health outcomes associated with activity fragmentation., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to characterize the impact of lighting changes on gait in elderly patients with glaucoma and evaluate whether associations are mediated by fear of falling (FOF)., Methods: Gait initiation and parameters measured with the GAITRite Electronic Walkway were captured in normal indoor light, then in dim light, and again in normal light (normal post dim [NPD]). Participants' right and left eye visual fields (VFs) were merged into integrated VF (IVF) sensitivities. FOF was evaluated using a Rasch-analyzed questionnaire. Multivariable regression models evaluated whether IVF sensitivity was associated with lighting-dependent gait changes and if this relationship was mediated by FOF., Results: In 213 participants (mean age = 71.4 years), gait initiation in dim light took longer with more VF damage ( P = 0.02). Greater VF damage was associated with slower gait in dim ( P < 0.001) and NPD ( P = 0.003) lighting, as well as shorter strides ( P = 0.02), broader stance ( P = 0.003), and more variable stride velocity and length in all lighting (all P < 0.03). When moving from normal to dim lighting, those with more VF damage slowed gait and cadence, shortened stride length, and lengthened double support time (all P < 0.001). Velocity, cadence, and double support time did not return to baseline in NPD lighting (all P < 0.05). Fear of falling did not appear to mediate the relationship between IVF sensitivity and lighting-dependent gait changes., Conclusions: Patients with more VF damage demonstrate gait degradation in extreme or changing lighting, which is not mediated by FOF., Translational Relevance: Quantitative spatiotemporal gait evaluation reveals lighting-associated impairment, supporting patient-reported difficulty with nonideal lighting and equipping providers to advise patients about limitations., Competing Interests: Disclosure: A.K. Bicket, None; A. Mihailovic, None; J.-Y. E, None; A. Nguyen, None; M.R. Mukherjee, None; D.S. Friedman, None; P.Y. Ramulu, None, (Copyright 2020 The Authors.)

Purpose: To evaluate the importance of central versus far peripheral visual field (VF) loss in assessing disability in glaucoma., Methods: In total, 231 patients with glaucoma or suspected glaucoma completed 24-2 VF testing and automated peripheral VFs using the suprathreshold 30- to 60-degree pattern. Questionnaires assessed fear of falling (FoF), quality of life (QOL), instrumental activities of daily living (IADLs), and driving habits; nonsedentary time, reading speed, and gait were objectively measured. Multivariable regression models analyzed the effect of central VF and/or peripheral VF damage on each outcome., Results: In models including both central and peripheral VF damage (independent effects), greater central, but not peripheral, VF damage was associated with greater FoF, worse QOL, fewer daily steps, and difficulty with IADLs (P < 0.02 for central; P > 0.5 for peripheral). For gait measures, greater peripheral, but not central, damage was associated with shorter steps and shorter strides, as well as greater variability in step length (P < 0.03 for peripheral; P > 0.14 for central). Model R2 values were not substantially higher (less than 5% additional explained variability) for models including both central and peripheral VF damage as compared to the best models incorporating only one region of VF damage (i.e., central or peripheral)., Conclusions: The relative importance of central 24 degrees versus more peripheral VF damage differs across functional domains in patients with glaucoma. Central damage is more strongly associated with most disability outcomes, although peripheral damage is more associated with specific gait measures. Studies examining the relative importance of various VF regions should assess functional domain separately and eschew integrated measures of quality of life/activity limitation.

Objective: Fear of falling (FoF) may alter mobility in older adults, especially among those with visual impairment. Using a longitudinal prospective cohort of older glaucoma patients, we investigated whether and how FoF is associated with future falls and physical activity., Design: Prospective observational cohort study., Setting: Hospital-based single-center recruitment., Participants: Individuals with glaucoma or suspected glaucoma., Measurements: FoF was measured annually over a 3-year period using the University of Illinois at Chicago FoF Questionnaire, with lower Rasch-analyzed FoF scores (in logit units) indicating less fear. Participants recorded falls prospectively over the 3-year period using monthly mail-in calendars. Daily steps were collected annually over 7 days using an accelerometer. Visual field (VF) sensitivity was derived by combining sensitivities from monocular VF results. Participants completed questionnaires to determine other demographic/health characteristics. Multivariate random effects models evaluated within-participant changes in fall rates and physical activity across study years., Results: At lower FoF levels (FoF≤0), each one-unit worsening in FoF score across study years was associated with 2.73 times higher odds of reporting at least one fall in the next year (95% confidence interval [CI] = 1.55-4.81) but was not associated with average daily steps (P = .44). Similar results were seen when fall rates were normalized by number of steps taken (P = .97). At higher FoF levels (FoF > 0), inter-year changes in FoF scores were not significantly associated with reporting a fall in the following year (P = .78) but were associated with 407 fewer average daily steps per one-unit change in FoF (95% CI = -743 to -71)., Conclusion: FoF is an important psychological factor associated with mobility in glaucoma patients, although specific aspects of mobility (fall rates vs activity levels) affected vary by the degree of FoF. Our findings suggest that customizing behavioral interventions for older adults based on their levels of FoF may be an important strategy for fall prevention and activity promotion. J Am Geriatr Soc 68:1847-1851, 2020., (© 2020 The American Geriatrics Society.)

Purpose: To investigate the association between balance and gait measures with fall rates in glaucoma patients., Methods: Balance and gait were measured for 239 participants with glaucoma or suspected glaucoma. Daily falls were evaluated over 24 months. Annual accelerometer trials captured average daily steps. Multivariable negative binomial models evaluated balance and gait associations with average daily steps and rates of falls per time or step, as well as whether balance and gait parameters mediated the association between integrated visual field (IVF) sensitivity and falls., Results: Average age was 70.5 years (SD = 7.6), and 22% of the participants had moderate to severe visual field damage. Over the first 12 months of the follow-up, the cumulative probability of falling one or more times was 44.8%, and the cumulative probability of falling two or more times was 17.7%. Gait deficits were associated with fewer daily steps (P < 0.03), but no balance parameters were (P > 0.19). Worse balance was associated with a higher rate of falls per year and step (P < 0.03). No gait measures were associated with the rate of falls per year (P > 0.17). More time in double support and greater swing time variability were associated with higher falls per step, and higher velocity and faster cadence were associated with fewer falls per step (P < 0.05 for all). Neither gait nor balance measures mediated the relationship between visual field damage and fall rates. IVF remained an independent predictor of falls per step (rate ratio = 1.36 to 1.48; P < 0.001 to P < 0.005) in multivariable models including individual balance/gait parameters., Conclusions: Although balance and gait measures are associated with fall rates, they do not explain why persons with greater visual field damage fall more frequently, suggesting the importance of other potential factors such as hazard perception.

Purpose: To assess the impact of OCT signal strength (SS) and artifact on retinal nerve fiber layer (RNFL) measurement reliability and to understand whether glaucoma severity modifies this relationship., Design: Retrospective, longitudinal cohort study., Participants: Two thousand nine hundred ninety-two OCT scans from 474 eyes of 241 patients with glaucoma or glaucoma suspect status., Methods: We extracted mean RNFL thickness and SS and manually graded scans for artifact. To analyze the effect of SS and artifact on OCT reliability, we (1) created a multilevel linear model using measured RNFL thickness values and demographic and clinical data to estimate the true (predicted) RNFL thickness, (2) calculated model residuals (ΔRNFL) as our reliability measure, and (3) created a second multilevel linear model with splines and interaction terms that modeled overall and quadrant specific reliability (ΔRNFL) as the outcome, using SS and artifact as predictors., Main Outcome Measures: Impact of SS and artifact on ΔRNFL., Results: For SS between 10 and 3, the impact of decreases in SS on OCT reliability is modest (-0.67 to -1.25 ΔRNFL per 1-point decrease in SS; P < 0.05). But at less than 3, changes in SS have a large impact on reliability (-15.70 to -16.34 ΔRNFL per 1-point decrease in SS; P < 0.05). At SS between 10 and 3, decreases in SS tend to have a larger impact on reliability in eyes with severe glaucoma (-1.25 per 1-point decrease in SS; P < 0.05) compared with eyes with mild or moderate glaucoma (-0.67 to -0.75 per 1-point decrease in SS; P < 0.05). The presence of artifact has a significant impact on OCT reliability independent of the effects of SS (-4.76 ΔRNFL; P < 0.05). Artifact affects reliability solely in the quadrant in which it occurs, with artifact in one quadrant showing no impact on ΔRNFL in the opposite quadrant (P > 0.05)., Conclusions: Signal strength decreases down to 3 have relatively mild impacts on OCT reliability. At less than 3, the impact of further decreases in SS on reliability are substantial. The effect of SS on reliability is greater in severe glaucoma. Artifacts result in a decrease in reliability independent of the effect of SS. We propose evidence-based guidelines to guide physicians on whether to trust the results of an OCT scan., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the importance of various vision parameters to functionality in glaucoma., Methods: Vision was measured using seven parameters: visual acuity (VA), contrast sensitivity (CS), integrated visual field (IVF), area under the log CS function (AULCSF), color vision, stereoacuity, and VA with noise (ViN). Likelihood ratio testing (LRT) determined if the full set of visual parameters significantly explained variability in 10 functional outcomes. For outcomes where the visual contribution was significant, dominance analysis determined the relative importance of the various visual parameters., Results: The analysis included 151 glaucoma patients. Mean age was 70 ± 6.8 years, and 47% were men. Significant visual contributions (LRT P < 0.05) were noted for glaucoma quality of life (GQL-15), reading speed, driving cessation, daily steps, and base of support while walking, but not for fear of falling, balance, gait velocity, stride velocity, and stride length while walking (LRT P > 0.05). The most important parameter (and percent contribution) to vision-explained variability were AULCSF for daily steps (45%), IVF for base of support (35%), VA for reading speed (34%), CS for GQL-15 (30%), and VA for driving cessation (26%)., Conclusions: Measures of visual ability are important for several aspects of quality of life and functionality. The most important vision parameter for functionality differs depending on the domain studied. Reading and driving were explained by VA and IVF sensitivity. On the other hand, GQL-15 and daily steps were more heavily influenced by CS and AULCSF, which are rarely performed clinically.

Precis: A modified closure for trabeculectomy in which the conjunctiva is incised posterior to the limbus and reapproximated using 2 nylon sutures, provided similar surgical outcomes to the standard trabeculectomy closure technique., Purpose: To examine the surgical outcomes of a modified trabeculectomy closure technique in which the conjunctiva is incised posterior to the limbus and reapproximated using 2 sutures, burying the posterior conjunctiva under an anterior lip of conjunctiva., Materials and Methods: This retrospective review included 73 eyes that underwent trabeculectomies between 2015 and 2017 at Johns Hopkins Hospital by a single surgeon. We analyzed traditional closures used from January 2015 to May 2016, and modified closures used from July 2016 to March 2017. The main outcome measures were a reduction in intraocular pressure at 3, 6, and 12 months, reduction in the number of medications at 12 months, and total number of postoperative complications., Results: There was no difference in reduction of intraocular pressure at 3 months (9.9±8.2 vs. 10.5±8.7 mm Hg), 6 months (10.8±9.6 vs. 10.6±8.3 mm Hg), or 12 months (12.2±8.9 vs. 10.0±9.3 mm Hg) in the standard (n=44) and modified groups (n=29), respectively. There was a similar reduction in the use of glaucoma medications in the standard group (1.2±1.5 vs. 1.0±1.1) compared with the modified group and no difference in the number of postoperative complications (25.0% vs. 17.2%, respectively) (P>0.05 for all)., Conclusions: The modified closure provided similar results to the standard closure for trabeculectomy. Further studies are needed to determine whether the 2 techniques differ in surgical outcomes over a longer follow-up or other surgical parameters (eg, ease, surgical time, learning curve).

Objective: To determine where glaucoma patients most often fall and how integrated visual field (IVF) damage affects falls rates per year (falls/year) and per step (falls/step) at and away from home., Design: Prospective, observational cohort study., Methods: In 225 patients with glaucoma or suspected glaucoma, falls data were collected via calendars, fall location was classified through follow-up questionnaires, and steps taken at and away from home were judged by integrating data from annual week-long accelerometer and GPS trials. Main outcome measures were the association of IVF sensitivity with fall rates per year or step, stratified by location., Results: Participants took more away steps than home steps (2366 vs 1524, P < .001), and differences in away vs home steps did not vary with IVF sensitivity (P = .22). A total of 57% of falls occurred at home, with each home step twice as likely to result in a fall as compared to each away step (rate ratio = 2.02, P < .001). Worse IVF sensitivity was not associated with a higher rate of home falls/year or away falls/year (P > .1 for both), but was associated with a higher rate of home falls/step (rate ratio = 1.34/5 dB worse sensitivity, P = .03) and away falls/step (rate ratio = 1.47/5 dB worse sensitivity, P = .003)., Conclusions: In this glaucoma population, most falls occurred at home, and the risk of any step resulting in a fall was higher at home. Those with greater VF damage were more likely to fall for each step taken both at and away from home. Efforts such as home environmental modification should be considered in the visually impaired to prevent falls while maintaining physical activity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To determine whether visual field (VF) damage or other factors confer a similar risk of falling when falls are ascertained as a rate over time (falls/year) as when ascertained over activity (falls/step)., Design: Prospective, observational cohort study., Setting: Clinic-based recruitment with real-world monitoring of falls and physical activity., Particpants: Individuals with glaucoma or suspected glaucoma (N=230)., Measurements: Participants recorded falls using daily calendars, with injuries identified in a follow-up questionnaire. Annual 1-week accelerometer trials were used to estimate steps. VF results from both eyes were merged to determine integrated VF sensitivity, with lower sensitivity indicating greater VF damage. Other potential risk factors for falls (age, sex, race, comorbid illness, polypharmacy) were determined using questionnaires., Results: The cumulative probability of falls was 45.2% at 12 months and 61.6% at 24 months; cumulative probability of injurious falls was 23.3% at 12 months and 40.0% at 24 months. Greater VF damage was associated with higher rates of falls/steps (incident rate ratio = 1.40/5 dB decrement in sensitivity; p = .004) but not with more falls/year (incident rate ratio = 1.25/5 dB decrement in sensitivity; p = .07). Several additional variables (older age, female sex, more comorbid disease) were also associated with a higher rate of falls/step (p < .02 for all) but not with falls/year (p > 0.10). Black participants had fewer falls/year than whites (p = .002) but did not differ in falls/step (p = .07). Similar results were obtained when injurious falls were analyzed., Conclusions: Risk factors associated with frequent falls when walking (falls/step) are not properly identified when analyzing falls as a rate over time (falls/year). Given the clinical importance of preventing falls while preserving physical activity, falls assessment integrated with activity measurement is recommended when determining whether a risk factor is associated with falls. J Am Geriatr Soc 67:87-92, 2019., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Purpose: The purpose of this study was to characterize the extent to which central visual field (VF) loss reflects peripheral VF loss in patients with varying degrees of glaucoma severity., Methods: A total of 232 patients with glaucoma or suspect glaucoma completed static central VF testing using the 24-2 pattern and peripheral VF testing using the suprathreshold 30-60 pattern. Points from 24-2 tests were reclassified as normal/abnormal based on pattern deviation values., Results: Strong positive correlations (r ≥ 0.7) were observed between the proportion of abnormal central and peripheral points for the full VF, superior hemifield, and inferior hemifield, although the percentage of total central and peripheral abnormal points differed by ≥10% in 45% of eyes. In eyes with an average of 10%-40% abnormal points in the central and peripheral VFs, 12.0% more abnormal peripheral points were noted compared with the percentage of abnormal central points (P < 0.001; SD, 16.7%; range, 61% more to 37% less). In eyes with an average of 60%-90% abnormal points in the central and peripheral VFs, 16.4% fewer abnormal peripheral points were noted compared with the percentage of abnormal central points (P = 0.04; SD, 20.9%; range, 19% more to 49% less)., Conclusions: Central 24-2 testing generally reflects the extent of damage to the more peripheral VF in glaucoma, although significant disagreement exists for individual eyes. Further work is needed to determine whether integration of peripheral test points can improve detection of true VF loss in early glaucoma or be useful in monitoring progressive glaucomatous damage to areas of preserved VF in advanced glaucoma.