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Purpose: To characterize anatomical dimensions of a disc notch using novel methods using spectral domain optical coherence tomography (SD-OCT)., Participants: All age- and severity-matched glaucoma patients with disc notch (defined as complete loss of neural rim with no residual rim between disc and cup) seen from 2014 to 2015 who underwent enhanced depth imaging with SD-OCT (Cirrus HD-OCT version 6.5, Carl Zeiss, USA) were included for this retrospective observational study., Methods: Using known dimensions of the 200 * 200 optic disc cube (6 * 6 mm), the notch width was calculated from the margins of the notch on either side using ImageJ software. The height was calculated from the lowest margin of the cup to the lowest point of the defect on the optic disc. These were compared with the quadrant retinal nerve fiber layer (qRNFT) and sectoral retinal nerve fiber layer (sRNFLT) thickness in notch and the sector 2 clock hours adjacent to the notch region (SaRNFLT)., Results: The height and width of the notch in 31 eyes of 27 patients were 2.6 ± 0.48 mm and 2.23 ± 0.31 mm. The RNFL thickness in the same sector as that of the notch was 41 ± 21.06 µm while the adjacent two sectors measured 62 ± 26.5 and 64 ± 26.5 µm on either sides of the sector of the notch. The difference between the sRNFLT and s a RNFLT ranged from -9 to 67 and -13 to 50 µm, respectively. This difference was significantly associated with height of the notch (R 2  = 20.8, p = 0.01)., Conclusion: Automated analysis of a notch and RNFL thickness in that sector can help in precise glaucoma monitoring in the region of interest.

Purpose: To investigate and compare the visual field performance following three different types of visual field instruction strategies., Method: Ninety consecutive visual field-naïve glaucoma patients who can perform the test and understand instructions were imparted three forms of instructions prior to the visual field test. Patients with visual acuity <20/200, central corneal opacities, or anterior segment pathology and patients unable to understand general instructions/uncooperative were excluded. All forms of instructions were given by a trained optometrist in the patients' own language as an instruction leaflet read out in 5 min for a verbal group (group1) and by a 5 min video created in house (group 2). Group 3 patients were shown the video first, followed by verbal instructions. We evaluated the reliability parameters in each group after visual field testing by an independent optometrist blinded to the form of instruction given., Results: Among the three groups, group 3 patients had the least number of repeat tests. Eyes with MD<-12Db had better reliability than that of the other groups. Mixed-model linear regression analysis shows that the duration of the test was significantly influenced by the severity of glaucoma in group 1, which is further predisposed by false negatives (FN; β = 0.06, p < 0.0001, R 2 61.7%)., Conclusion: The video with verbal instruction can minimize the number of repeated tests compared with only verbal or only video instruction medium. The video as well as the combined video/verbal instructions have a practical influence of obtaining more reliable fields compared with only verbal instruction.

Purpose: To determine rate of change over time on scanning laser ophthalmoscopy, HRT, compared to perimetry, and to determine incidence, parametric changes, and risk factors for progression in primary open angle glaucoma (POAG) and chronic primary angle closure angle glaucoma (CPACG) eyes., Methods: Prospective clinical study of 116 POAG eyes and 129 CPACG eyes of different severities of glaucoma. Standard automated perimetry and optic nerve head topography were studied at baseline and thereafter every 6 months. Changes in HFA and HRT parameters, in response to IOP, were compared over at least 5 years., Results: Fourteen POAG eyes (12.1%) and 20 CPACG eyes (15.5%) showed progression on SAP over time. Percentage drop of IOP was similar in eyes that progressed and in stable eyes. The change in MD in CPACG eyes was 1.8 dB/year on SAP and 1.36 dB/year in POAG eyes, P = 0.1. Twenty-nine eyes showed progression on HRT with 24 confirmed on SAP. Trend analysis picked up progression more frequently than other HRT parameters. Eyes that progressed in both groups, in all severities of glaucoma, had intermittent fluctuations of ≥ 4 mmHg over mean IOP on ≥3 follow up visits, P ≤ 0.001., Conclusion: IOP fluctuations of ≥ 4 mmHg over the mean IOP and duration of disease were associated with progression in POAG and CPACG eyes.

Purpose of the Study: The purpose of the study was to evaluate retinal vessel diameter in age-matched normal tension glaucoma (NTG) and primary open angle glaucoma (POAG) eyes with hemifield involvement., Methods: Fundus photographs of patients with hemifield defect, good visibility of retinal nerve fiber layer defect, and vessels were compared with 30 controls. One eye of each patient (28 NTG and 30 POAG) was randomly chosen for analysis using Image J software by different clinicians at 2 levels. The structural parameters analyzed included retinal nerve fiber layer defect width, diameter of vessels (superotemporal or inferotemporal artery and superotemporal or inferotemporal vein)., Results: The average superotemporal artery diameter was similar in NTG (71±16.8 µm), POAG (79±26.6 µm), and controls (82±14.1 µm), P=0.2 with similar pattern seen for other vessels. The affected quadrant in all eyes and those with disc hemorrhage (n=8) did not have significantly different arteries and veins diameter as compared with the unaffected quadrant in that eye. No relation of artery or vein diameter with retinal nerve fiber layer defect width or clinical variables in NTG or POAG eyes was seen on multivariate regression analysis., Conclusions: The vessel diameter was not significantly different in the affected and unaffected quadrants of age and severity-matched NTG and POAG eyes with hemifield structural and functional defect as reported in earlier studies. These results point toward the possibility that vascular diameter changes may not be the cause for glaucomatous changes.

Objective: To compare the variability of central field index (CFI) versus visual field index (VFI) in stable glaucoma with central fixation involvement., Materials and Methods: For this retrospective study, we identified multiple visual fields (VFs) of patients with repeatable central fixation involvement on Humphrey VFs (24-2 and 10-2 program) which were stable (clinically and on VFs) over a very short period of 2 to 3 months. The VFI and CFI were calculated as described in earlier reports. We graded the fields as early [mean deviation (MD)>-6 dB], moderate (-6.1 to -12 dB), and severe glaucoma (<-12 dB) based on MD on 24-2 program. The variability of CFI and VFI between visits and across different severity of glaucoma was compared. Relation of the divergence to field indices and clinical parameters were assessed., Results: The intervisit difference for VFI was greater than CFI ranging from -4% to 9% versus -1% to 8% in early (P=0.9), -13% to 18% versus -6% to 17% (P=0.056) in moderate, and -21% to 19% versus -9% to 9% (P<0.001) in severe glaucoma. The CFI within each group had narrower range than VFI with maximum range in severe glaucoma (33% to 95%). The divergence of CFI from VFI started at MD 24-2 beyond (worse) -10 dB. This difference between CFI and VFI was associated significantly with number of points with P<1% on 24-2 (R=80.3%)., Conclusions: CFI is less variable than VFI in stable eyes with fixation involvement especially in severe glaucoma indicating need for incorporating CFI calculation for monitoring advanced disease in eyes with central defects.

Purpose: To evaluate structural alterations and healing responses in the trabecular meshwork region with optical coherence tomography (AS-OCT) following after gonioscopy assisted transluminal trabeculotomy (GATT) and microincisional trabeculectomy (MIT). Methods: 73 eyes of 67 patients (M:F = 45:22) with ≥6 months of follow-up after MIT (n = 41) or GATT (n = 32) with or without combined cataract surgery were included for this prospective study. The angle as seen on AS-OCT at 1, 3, 6 months after surgery were evaluated for structural alterations like peripheral anterior synechiae (PAS), hyphema, and hyperreflective scarring responses. The scarring was graded according to the linear extent measured from the centre of the trabecular meshwork (TM) gutter to the sclera/cornea as mild (<250μ), moderate (250–500μ), and severe(˃500μ), while the pattern of scarring was graded as open saucer/gutter, closed gutter, and trench pattern. The association of the need for medication or surgical outcome and clinical variables and AS-OCT parameters including the pattern and severity of scarring were analysed using multivariate regression. Results: All eyes achieved significant reduction of IOP and number of medications with a final IOP of 15±3.2mm Hg at a mean follow-up of 8±32. months. While mild scarring was seen more common in MIT, severe scarring was seen in >65% of GATT eyes compared to 31% of MIT eye, p<0.001. An open saucer was equally seen in MIT and GATT while the trench pattern was more commonly seen in GATT eyes (>50%). Severe scarring in a trench pattern seemed to predict the need for medications for IOP control, though they independently did not seem to influence the final IOP or surgical outcome. Conclusion: A severe form of scarring in a trench pattern on AS-OCT predicted the need for glaucoma medications after MIGS surgery. Regular monitoring of the scarring responses by AS-OCT and clinical examination are necessary to identify those at need for medications after MIGS. [ABSTRACT FROM AUTHOR]

Purpose: To report the histopathologic correlates of trabecular meshwork (TM) specimens procured by microincisional trabeculectomy (MIT) for different severities of glaucoma (early glaucoma: visual field mean deviation [MD] <−6 dB, moderate glaucoma: MD from − 6 to − 12 dB, and advanced glaucoma: MD <−12 dB). Methods: TM specimens from four patients undergoing MIT with or without cataract surgery were analyzed by routine histopathology for structural changes. The number of cells, the number of cells with spindle-shaped nuclei suggestive of epithelial–mesenchymal transformation (EMT), and the distance between the trabecular beams were calculated using different tools on freely available ImageJ software using the line or pint/count tool. Results: The TM specimens procured from two early and two advanced glaucoma cases showed decreasing cellularity and decreased compact arrangement of the trabecular beams in severe disease stages. The number of cells and preserved architecture in all four specimens were evident, with > 50 cells being present per section in all four cases despite the glaucoma being of advanced disease stage in two patients. Conclusion: The TM specimens obtained from MIT can be utilized for downstream analysis using different molecular methods for studying the molecular events in the tissue from early to severe glaucoma. [ABSTRACT FROM AUTHOR]

Purpose: To compare visual field progression in severity-matched pseudoexfoliation glaucoma (XFG) and primary glaucoma after intraocular pressure (IOP) reduction by filtering surgery.Methods: Patients with XFG (n=32), primary open-angle glaucoma (POAG, n=33) or primary angle closure glaucoma (PACG, n=28) that underwent routine cataract and glaucoma filtering surgery by the same surgeon (APR) between May 2017 and September 2021, were included for this prospective study. Rate of progression (ROP) was determined using guided progression analysis and compared between XFG and primary glaucoma. Multivariate regression was done to analyse the factors responsible for progression in each group.Results: Visual field progression after surgery was noted in 48 eyes (n=11 XFG, 18 POAG and 19 PACG eyes) at a mean follow-up of 10± 5.6 months after surgery with RVI seen in 18 of 48 eyes. The final IOP (p=0.8) and mean ROP (p=0.09) were not significantly different between XFG and primary glaucoma. The XFG eyes had a greater number of eyes (36%) showing an ROP worse than − 5dB/yr, with 45% of eyes showing an IOP spike > 5mm Hg, and a higher mean IOP spike between visits. The ROP in eyes with RVO and > 5mm Hg IOP spikes was greater in XFG than in POAG or PACG. In the multivariate analysis, higher IOP fluctuations > 5mm Hg, and associated retinal vein occlusions (RVO) were significant factors for visual progression greater than − 5dB/year (R2=53.5%) in POAG and XFG eyes. Age, gender, baseline MD, and number of medications before surgery or at final follow-up did not influence visual progression rates in either group.Conclusion: A higher IOP fluctuation > 5mm Hg and associated RVO were the significant factors predicting visual field progression after filtering surgery in XFG and POAG eyes. Control of both IOP-dependent and -independent mechanisms of VF progression is therefore essential in these eyes. [ABSTRACT FROM AUTHOR]

Purpose: Pseudoexfoliation glaucoma (XFG) is often associated with a higher rate of intraoperative complications and failure. This study aims to compare the long-term clinical and surgical outcomes of cataract surgery alone versus combined surgery in XFG. This was a retrospective comparative case series. Methods: All patients with XFG who underwent either cataract surgery alone [group 1: either phacoemulsification, PHACO/small-incision cataract surgery (SICS), n = 35] or combined surgery (group 2: phacotrabeculectomy, PHACOT or SICS + trabeculectomy, n = 46) from 2013 to 2018 by a single trained surgeon were screened and recalled for a detailed clinical examination, including Humphrey visual field analysis at 3-monthly intervals for a minimum of 3 years. Surgical success (intraocular pressure, IOP, <21 mm Hg and >6 mm Hg with (qualified success) or without medicines, complete success, survival rates, visual field changes, and need for additional procedures/medicines for IOP control were compared between groups. Results: A total of 81 eyes of 68 patients with XFG were included in this study (groups 1–35 eyes and groups 2–46 eyes each). Both groups achieved 27–40% IOP reduction from preoperative IOP levels, P < 0.001. Surgical success rates were similar in both groups (complete success 66% vs 55%, P = 0.4), qualified success 17% vs 24%, P = 0.8, in groups 1 and 2). Kaplan–Meier analysis showed a marginally better survival rate for group 1, 75% (55–87%), than group 2, 66% (50–78%), at 3 and 5 years which was not significantly different. The number of eyes that progressed at 5 years after surgery (5–6%) was similar in both groups. Conclusion: Cataract surgery can be as effective as combined surgery in XFG eyes with regards to final visual acuity, long-term IOP profile, and visual field progression, and complications/survival rates are comparable between the two procedures. [ABSTRACT FROM AUTHOR]

Glaucoma represents one of the most important ocular diseases causing irreversible ganglion cell death. It is one of the most common causes of visual impairment and morbidity in the elderly population. There are various tests for measuring visual function in glaucoma. While visual field remains the undisputed method for screening, diagnosis, and monitoring disease progression, other tests have been studied for their utility in glaucoma practice. This review discusses some of the commonly used tests of visual function that can be routinely used in clinics for glaucoma management. Among the various modalities of testing visual function in glaucoma, this review highlights the tests that are most clinically relevant. [ABSTRACT FROM AUTHOR]

Purpose To evaluate first and second order responses on multifocal electroretinogram (mfERG) and with retinal nerve fibre layer thickness (RNFL) on Cirrus spectral domain optical coherence tomography (SD-OCT) in glaucoma. Methods Patients (old and new) diagnosed with primary open angle glaucoma, primary angle closure glaucoma or normal tension glaucoma attending glaucoma services from November 2012 to January 2013 were screened. Ninety-seven eyes fulfilling inclusion criteria were evaluated by Humphrey visual field, Cirrus SD-OCT imaging and mfERG (Veris Science 5.1.10X; EDI, Redwood City, California, USA) for this observational cross-sectional study. The global and averaged quadrant-wise peak-to-trough amplitudes and peak implicit times of the first trough (N1), the first peak (P1) and the second trough (N2) of the mfERG were compared with average RNFL-full circle (FC) or quadrant RNFL thickness in early (mean deviation (MD) >-6 dB), moderate (MD -6 to -12 dB) and advanced glaucoma (MD <-12 dB). Results The RNFL-FC correlated with P1N2 amplitude on univariate analysis (r=0.7, p=0.004) and N2 amplitude (r=-0.4, p<0.001). Comparing relationships in different stages of glaucoma, P1N2 amplitude correlated significantly with RNFL-FC and superotemporal quadrant, RNFL-superior temporal (ST), in early and moderate glaucoma only. In contrast, the implicit time of P1N2 correlated significantly with RNFL-FC and RNFL-ST only in severe glaucoma while in earlier stages, this relationship did not hold true. On multivariate analysis, P1N2 amplitude correlated with age (β=-0.2, p<0.001), RNFL-FC (β=0.05, p=0.05), RNFL-ST (β=0.06, p=0.01) and cup-disc ratio (β=-3.2, p=0.006). Conclusions Of all responses on mfERG, P1N2 amplitude correlates well with RNFL-FC and RNFL-ST on SD-OCT and can be used for monitoring early and moderate glaucoma. Diffuse structural changes may best be reflected by changes in P1N2 implicit time owing to ceiling effect of the amplitude in all regions in severe glaucoma. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate optic nerve characteristics independent of systemic factors predisposing to parafoveal scotoma in normal tension glaucoma. Methods: We included 40 patients with bilateral normal tension glaucoma with parafoveal scotoma (visual field defect in one hemifield within 10° of fixation with at least one point at p<1% lying at the two innermost paracentral points) in only one eye (Parafoveal group, PF, n = 40) identified from the hospital database in this observational cross sectional study. The other eye with no parafoveal scotoma constituted the control group (n = 32). Red free fundus photographs were evaluated using Image J software analyzing parameters including vertical and horizontal disc diameter, disc haemorrhage, location and angular width of the retinal nerve fibre layer depth and displacement of the central vessel trunk, CVT (vertical and horizontal). Clinical characteristics and disc parameters were compared in the two groups. Results: The PF group had lower mean deviation(MD) and visual field index (VFI) and higher pattern standard deviation (PSD) than control group (p≤0.001) for similar untreated IOP, (p = 0.9). Disc haemorrhages were more frequent in the PF group, p = 0.01. The PF group had greater width of nerve fibre layer defects, p = 0.05 and greater vertical displacement of the central vessel trunk, p = 0.001. On multivariate logistic regression, parafoveal scotoma was significantly associated with increased vertical distance of the CVT, p = 0.0001. Conclusion: Increased vertical displacement of the CVT is associated with parafoveal scotoma in normal tension glaucoma. Localising the vessel trunk may help clinicians in identifying patients at risk for parafoveal involvement. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate gonioscopic features and relate them to clinical characteristics in eyes with juvenile-onset primary open-angle glaucoma (JOAG). Methods: Goniophotographs of unrelated JOAG patients, presenting between 10-40 years of age, were evaluated and compared with 60 healthy subjects in the same age group. Age of onset, family history of glaucoma, highest untreated IOP and visual field defect (mean deviation) were analyzed and correlated with the gonioscopic features among JOAG patients. Results: Of 126 patients included in the study, 44 (34 %) had a normal open angle (group 1), while 82 (66 %) had developmental anomalies (group 2). Developmental anomalies of the angle were classified as: high iris insertion with or without prominent iris processes ( n = 42), a featureless angle ( n = 30), and those with prominent iris processes alone ( n = 10). There was no difference in age of onset (group 1, 30.5 ± 7 years and group 2, 26.3 ± 9.6 years) ( p = 0.07) or the untreated IOP at presentation (group 1; 36 ± 12.5 mmHg and group 2, 38.8 ± 12.3 mmHg; p = 0.37) between the groups. However, those with angle anomalies presented with a greater visual field defect (MD −23.5 ± 10.5 vs −14.8 ± 13 dB; p = 0.02) compared to those with normal appearing angle. Conclusions: While two thirds of JOAG patients present with developmental anomalies of the angle, one third have normal appearing angles. High insertion of the iris is the most common form of gonio dysgenesis observed. Those with angle dysgenesis are more likely to present with severe disease. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the long-term outcomes of laser peripheral iridotomy (LPI) in primary angle closure disease. Methods: We retrospectively reviewed the medical records of all Indian subjects of primary angle closure (PAC) and primary angle closure glaucoma (PACG) who underwent LPI between 2003 and 2004. Subjects requiring additional treatment in the form of antiglaucoma medications or trabeculectomy during the follow-up were identified. Baseline factors predicting the need for additional treatment following LPI in primary angle closure disease (PAC+PACG) were analyzed. Results: 84 eyes (PAC:PACG = 16:68) of 47 subjects had undergone LPI during the study period. Over a mean follow-up of 50 ± 22.7 months, 68 eyes (PAC:PACG = 9:59) required additional treatment, of which 26 eyes (PAC:PACG=2:24) subsequently underwent trabeculectomy. Over the initial 20 months of follow-up after LPI, the cumulative probability of requiring no additional treatment was similar between PAC [63.6% (95% CI: 29.7-84.5)] and PACG eyes [64.0% (95% CI: 44.5-78.3)]. Subsequently, the cumulative probability of requiring no additional treatment in PACG eyes dropped to 24.8% (9.7-43.5) at 4 years and 9.9% (1.8-26.7) at 7 years. Presenting IOP (p = 0.01) and highest recorded IOP before LPI (p = 0.03) were the most significant predictors of the need for additional treatment after LPI. Extent of synechial angle closure (p = 0.04) and the cup to disc ratio (p = 0.05) significantly predicted the need for trabeculectomy subsequently in PACG eyes. Conclusions: The majority of angle closure eyes required additional treatment after LPI. Eyes with a higher presenting IOP were more likely to require additional treatment and those with a greater amount of synechial angle closure and larger cup disc ratio at presentation were more likely to require surgery over the follow-up. [ABSTRACT FROM AUTHOR]

Objective: To evaluate long-term structural and functional changes of the optic nerve head in medically and surgically treated juvenile-onset primary open-angle glaucoma (JOAG). Methods: Forty-two eyes of 42 consecutive primary JOAG patients presenting between January 2000 and January 2003. Results were analysed for long-term intra-ocular pressure (IOP) control, IOP fluctuation, disc characteristics on a Heidelberg Retinal Tomograph II and for visual field changes over a 5-year period. The parameters were compared between medically and surgically treated eyes. Results: The average age of the patients was 26.8 ± 6.1 years. The average baseline IOP was 35.3 ± 14.9 mm Hg. An IOP control <18 mm Hg was achieved in 84% of eyes that underwent filtering surgery (n = 17), compared to 63% on medical therapy alone (n = 25) at the end of 5 years; log rank test p = 0.38. Over 5 years, 4 eyes showed progression (9.5%) of which 3 had been medically treated and 1 had failed surgery (p = 0.45). Conclusion: A tenth of JOAG eyes showed progression over 5 years, and this was more common in those treated medically. Aggressive IOP lowering may thus be needed in eyes with JOAG. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]