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To examine the performance of self-reported visual difficulty (VD) in predicting objective visual impairment (VI) in older adults and explore factors that influence discordance. Cross-sectional analysis of the National Health and Aging Trends Study (2022). Participants reporting blindness or difficulties with distance or near vision were characterized as having VD. Presenting binocular distance visual acuity (VA), near VA, and contrast sensitivity (CS) were assessed. Objective VI was defined as having VI in distance VA (worse than 20/40), near VA (worse than 20/40), or CS (worse than 1.55 logCS). Receiver operating characteristic analysis was used to compare performance of VD in predicting VI. To investigate factors that influence discordance, we limited our sample to adults with VI and used a multivariable logistic regression model to identify factors associated with not reporting VD. Similar analyses were performed to explore factors associated with reporting VD in adults without VI. Discordance factors. Four thousand nine hundred ninety-nine adults were included in the 2022 cohort. Visual difficulty achieved an area under the curve (AUC) of 56.0 (95% confidence interval [CI], 55.2–56.9) in predicting VI, with a sensitivity of 15.8 (95% CI, 14.2–17.5) and specificity of 96.3 (95% CI, 95.5–96.9). Characteristics associated with not reporting VD in adults with VI included female gender (odds ratio [OR], 0.64 [95% CI, 0.42–0.99]), Hispanic ethnicity (OR, 0.49 [95% CI, 0.31–0.78), higher income (≥75 000, OR, 1.99 [95% CI, 1.14–3.45]), ≥4 comorbidities (OR, 0.46 [95% CI, 0.29–0.72]), and depressive symptoms (OR, 0.49 [95% CI, 0.25–0.93]). Factors associated with self-reporting VD in the absence of VI included Hispanic ethnicity (OR, 2.11 [95% CI, 1.15–3.86]), higher income (≥$75 000, OR, 0.27 [95% CI, 0.12–0.63]), and anxiety symptoms (OR, 3.05 [95% CI, 1.56–5.97]). Self-reported VD is a distinct measure assessing disability and has limited ability in predicting objective VI. Caution is advised when using self-reported VD as a surrogate measure for objective VI in epidemiological studies, although it may still be an effective way to capture risk of current or future disability. Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

The article reports on a study which shows the decline in number of glaucoma surgical and laser procedures among Medicare beneficiaries in the U.S. from 1994 to 2012. Topics discussed include the increasing number of Medicare beneficiaries due to a growing aging population in the country, the increase in endoscopic cyclophotocoagulation (ECP) and canaloplasty, and the identified reasons for the decrease.

To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population. Retrospective, longitudinal study. Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery. Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis. The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery. There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n = 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3–1.7), 1.1 (95% CI, 1.0–1.2), and 0.8 (95% CI, 0.8–0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P = 0.002) and combined surgery (aOR 1.8, P = 0.047). The other risk factor for both stand-alone (aOR 1.1, P = 0.001) and combined (aOR 1.06, P = 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P = 0.004) and male gender (1.46, P = 0.001) were significant risk factors for combined cataract and glaucoma surgeries. Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

To examine the association of physical activity (PA) with glaucoma and related traits, to assess whether genetic predisposition to glaucoma modified these associations, and to probe causal relationships using Mendelian randomization (MR). Cross-sectional observational and gene–environment interaction analyses in the UK Biobank. Two-sample MR experiments using summary statistics from large genetic consortia. UK Biobank participants with data on self-reported or accelerometer-derived PA and intraocular pressure (IOP; n = 94 206 and n = 27 777, respectively), macular inner retinal OCT measurements (n = 36 274 and n = 9991, respectively), and glaucoma status (n = 86 803 and n = 23 556, respectively). We evaluated multivariable-adjusted associations of self-reported (International Physical Activity Questionnaire) and accelerometer-derived PA with IOP and macular inner retinal OCT parameters using linear regression and with glaucoma status using logistic regression. For all outcomes, we examined gene–PA interactions using a polygenic risk score (PRS) that combined the effects of 2673 genetic variants associated with glaucoma. Intraocular pressure, macular retinal nerve fiber layer (mRNFL) thickness, macular ganglion cell–inner plexiform layer (mGCIPL) thickness, and glaucoma status. In multivariable-adjusted regression models, we found no association of PA level or time spent in PA with glaucoma status. Higher overall levels and greater time spent in higher levels of both self-reported and accelerometer-derived PA were associated positively with thicker mGCIPL (P < 0.001 for trend for each). Compared with the lowest quartile of PA, participants in the highest quartiles of accelerometer-derived moderate- and vigorous-intensity PA showed a thicker mGCIPL by +0.57 μm (P < 0.001) and +0.42 μm (P = 0.005). No association was found with mRNFL thickness. High overall level of self-reported PA was associated with a modestly higher IOP of +0.08 mmHg (P = 0.01), but this was not replicated in the accelerometry data. No associations were modified by a glaucoma PRS, and MR analyses did not support a causal relationship between PA and any glaucoma-related outcome. Higher overall PA level and greater time spent in moderate and vigorous PA were not associated with glaucoma status but were associated with thicker mGCIPL. Associations with IOP were modest and inconsistent. Despite the well-documented acute reduction in IOP after PA, we found no evidence that high levels of habitual PA are associated with glaucoma status or IOP in the general population. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

Purpose To describe the prevalence of vertical cup-to-disc ratio (vCDR) asymmetry in U.S. adults and assess the utility of vCDR asymmetry in the diagnosis of glaucoma. Design Cross-sectional study. Participants A total of 5359 subjects aged ≥40 years from the 2005–2008 National Health and Nutrition Examination Survey (NHANES). Methods Subjects completed retinal photography and had vCDR determined in both eyes, with vCDR asymmetry calculated as the absolute value of the difference between the 2 eyes. Frequency Doubling Technology perimetry was used to assess for visual field (VF) defects. Subjects were categorized as having “disc defined glaucoma” if either disc demonstrated glaucomatous features, and VF data were combined with optic disc grading to determine “disc plus field defined glaucoma.” Main Outcome Measures Association between vCDR asymmetry and disc plus field defined glaucoma. Results In U.S. adults without glaucoma, the 50th, 97.5th, and 99.5th percentiles of vCDR asymmetry are 0.05, 0.19, and 0.26, respectively. Vertical cup-to-disc ratio asymmetry ≥0.20 occurs in 2.1% of U.S. adults without glaucoma. The prevalence of vCDR asymmetry ≥0.20 among white, black, and Hispanic adults without glaucoma is 2.4%, 0.7%, and 1.8%, respectively. The odds of vCDR asymmetry ≥0.20 are 1.44 times higher per 10-year increase in age (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.20–1.72; P < 0.01). Each 0.10 increase in vCDR asymmetry was associated with a 2.57 times higher adjusted odds of disc plus field defined glaucoma (OR, 2.57; 95% CI, 1.43–4.61; P < 0.01). The sensitivity and specificity of vCDR asymmetry ≥0.20 for disc plus field defined glaucoma are 22.7% and 97.7%, respectively, whereas the positive likelihood ratio is 9.9 and the positive predictive value (PPV) is 7.0%. At a higher vCDR asymmetry cutoff of ≥0.30, the PPV increases to 37.7%. Conclusions Vertical cup-to-disc ratio asymmetry is predictive of prevalent glaucoma, but the PPV remains low even at high degrees of asymmetry. Vertical cup-to-disc ratio asymmetry should initiate a more comprehensive glaucoma workup, especially in individuals with additional risk factors, but it is not appropriate as a screening metric for glaucoma. [ABSTRACT FROM AUTHOR]

To identify visual field (VF) worsening from longitudinal OCT data using a gated transformer network (GTN) and to examine how GTN performance varies for different definitions of VF worsening and different stages of glaucoma severity at baseline. Retrospective longitudinal cohort study. A total of 4211 eyes (2666 patients) followed up at the Johns Hopkins Wilmer Eye Institute with at least 5 reliable VF results and 1 reliable OCT scan within 1 year of each reliable VF test. For each eye, we used 3 trend-based methods (mean deviation [MD] slope, VF index slope, and pointwise linear regression) and 3 event-based methods (Guided Progression Analysis, Collaborative Initial Glaucoma Treatment Study scoring system, and Advanced Glaucoma Intervention Study [AGIS] scoring system) to define VF worsening. Additionally, we developed a "majority of 6" algorithm (M6) that classifies an eye as worsening if 4 or more of the 6 aforementioned methods classified the eye as worsening. Using these 7 reference standards for VF worsening, we trained 7 GTNs that accept a series of at least 5 as input OCT scans and provide as output a probability of VF worsening. Gated transformer network performance was compared with non–deep learning models with the same serial OCT input from previous studies—linear mixed-effects models (MEMs) and naive Bayes classifiers (NBCs)—using the same training sets and reference standards as for the GTN. Area under the receiver operating characteristic curve (AUC). The M6 labeled 63 eyes (1.50%) as worsening. The GTN achieved an AUC of 0.97 (95% confidence interval, 0.88–1.00) when trained with M6. Gated transformer networks trained and optimized with the other 6 reference standards showed an AUC ranging from 0.78 (MD slope) to 0.89 (AGIS). The 7 GTNs outperformed all 7 MEMs and all 7 NBCs accordingly. Gated transformer network performance was worse for eyes with more severe glaucoma at baseline. Gated transformer network models trained with OCT data may be used to identify VF worsening. After further validation, implementing such models in clinical practice may allow us to track functional worsening of glaucoma with less onerous structural testing. Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

Glaucoma is a leading cause of irreversible blindness, and its worsening is most often monitored with visual field (VF) testing. Deep learning models (DLM) may help identify VF worsening consistently and reproducibly. In this study, we developed and investigated the performance of a DLM on a large population of glaucoma patients. We included 5099 patients (8705 eyes) seen at one institute from June 1990 to June 2020 that had VF testing as well as clinician assessment of VF worsening. Since there is no gold standard to identify VF worsening, we used a consensus of six commonly used algorithmic methods which include global regressions as well as point-wise change in the VFs. We used the consensus decision as a reference standard to train/test the DLM and evaluate clinician performance. 80%, 10%, and 10% of patients were included in training, validation, and test sets, respectively. Of the 873 eyes in the test set, 309 [60.6%] were from females and the median age was 62.4; (IQR 54.8–68.9). The DLM achieved an AUC of 0.94 (95% CI 0.93–0.99). Even after removing the 6 most recent VFs, providing fewer data points to the model, the DLM successfully identified worsening with an AUC of 0.78 (95% CI 0.72–0.84). Clinician assessment of worsening (based on documentation from the health record at the time of the final VF in each eye) had an AUC of 0.64 (95% CI 0.63–0.66). Both the DLM and clinician performed worse when the initial disease was more severe. This data shows that a DLM trained on a consensus of methods to define worsening successfully identified VF worsening and could help guide clinicians during routine clinical care. [ABSTRACT FROM AUTHOR]

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. Cross-sectional study. Adults diagnosed with glaucoma or suspicion of glaucoma (controls). 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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

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. Prospective cohort study. Older adults diagnosed with glaucoma or suspected glaucoma. 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. Activity fragmentation and amount of activity (steps) over the course of the day. 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. 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. [ABSTRACT FROM AUTHOR]

To determine the association between physical activity levels and the rate of visual field (VF) loss in glaucoma. Longitudinal, observational study. Older adults with suspect or manifest glaucoma. Participants wore accelerometers for 1 week to define average steps per day, minutes of moderate-to-vigorous activity, and minutes of nonsedentary activity. All available VF measurements before and after physical activity assessment were retrospectively analyzed to measure rates of VF loss. Pointwise changes in VF sensitivity associated with physical activity measures. A total of 141 participants (mean age, 64.9±5.8 years) were enrolled. Eye mean deviation (MD) at the time of physical activity assessment was −6.6 decibels (dB), and average steps per day were 5613±3158. The unadjusted average rate of VF loss as measured by pointwise VF sensitivity was 0.36 dB/year (95% confidence interval, −0.37 to −0.35). In multivariable models, slower VF loss was observed for patients demonstrating more steps (+0.007 dB/year/1000 daily steps, P < 0.001), more moderate-to-vigorous activity (+0.003 dB/year/10 more minutes of moderate-to-vigorous activity per day, P < 0.001), and more nonsedentary activity (+0.007 dB/year/30 more minutes of nonsedentary time per day, P = 0.005). Factors associated with a faster rate of VF loss included older age, non-white race, glaucoma surgery, cataract surgery, and moderate baseline VF damage (–6 dB ≥ MD >–12 dB) as opposed to mild VF damage (MD >–6 dB). Similar associations between baseline accelerometer-measured physical activity and rates of VF loss were observed over other time periods (e.g., within 1, 3, and 5 years of activity assessment). Increased walking, greater time spent doing moderate-to-vigorous physical activity, and more time spent in nonsedentary activity were associated with slower rates of VF loss in a treated population of patients with glaucoma, with an additional 5000 daily steps or 2.6 hours of nonsedentary physical activity decreasing the average rate of VF loss by approximately 10%. Future prospective studies are needed to determine if physical activity can slow VF loss in glaucoma or if progressive VF loss results in activity restriction. If the former is confirmed, this would mark physical activity as a novel modifiable risk factor for preventing glaucoma damage. [ABSTRACT FROM AUTHOR]

Purpose To demonstrate the effects of prolonged silent reading on tear film and ocular surface parameters. Design Prospective, observational clinical study. Participants A total of 177 patients with dry eye and 34 normal controls aged 50 years and older. Methods After evaluating symptoms using the Ocular Surface Disease Index (OSDI) questionnaire, the following tests were performed in consecutive order: automated noninvasive tear break-up time (TBUT), surface asymmetry and regularity indices, Schirmer’s testing without anesthesia, corneal staining using fluorescein, and conjunctival staining using lissamine green. The participants were then asked to read a 30-minute validated passage silently. The tests were repeated after the reading task. Main Outcome Measures Changes in tear film and ocular surface parameters after reading. Results All parameters, with the exception of surface asymmetry index, worsened after the reading task in patients with dry eye and in controls. The worsening reached a statistical significance for corneal and conjunctival staining in the dry eye group (P < 0.001) and for corneal staining in the control group (P < 0.01). At baseline, OSDI scores correlated only with corneal and conjunctival staining scores (r = 0.19, P = 0.006 and r = 0.27, P < 0.001). Among postreading measurements, baseline OSDI scores correlated with TBUT (r = −0.15, P = 0.03) in addition to corneal and conjunctival staining (r = 0.25, P < 0.001 and r = 0.22, P = 0.001). Changes in TBUT and Schirmer’s test correlated significantly with their respective baseline values (r = −0.61, P < 0.001 and r = −0.44, P < 0.001), indicating that the more unstable the tear film and the lower the aqueous tear secretion, the worse they became after the prolonged reading task. Worsening in corneal staining directly correlated with the baseline conjunctival staining (r = 0.17, P = 0.02) and surface regularity index (r = 0.21, P = 0.01). Conclusions Evaluating tear film and ocular surface parameters at rest may miss clinical findings brought about by common everyday tasks such as reading, leading to discordance between patient-reported symptoms and clinician-observed signs. Quantifying dry eye after visually straining activities such as prolonged silent reading may help better understand patient symptomatology. [ABSTRACT FROM AUTHOR]

Purpose To determine whether laser peripheral iridotomy (LPI) location affects postoperative dysphotopsia symptoms. Design Multicenter, randomized, prospective, single-masked trial. Participants Five hundred fifty-nine South Indian patients 30 years of age or older diagnosed as primary angle-closure suspects (PACSs) or with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) in both eyes. Methods Patients were randomized to either bilateral superior or bilateral nasal/temporal LPI. Occurrence of new visual disturbances was evaluated before and 2 weeks after LPI using a questionnaire based on the 7-item dysphotopsia symptoms described by Spaeth et al. Main Outcome Measures New-onset dysphotopsia symptoms. Results Superior LPI (n = 285) and nasal/temporal LPI (n = 274) patients were matched for age ( P = 0.6), gender ( P = 0.7), and distribution of PACS versus PAC or PACG ( P = 0.7). Similar initial laser energy settings were used in both groups ( P = 0.3), although superior LPIs required more shots ( P = 0.006) and greater total energy ( P < 0.001) than nasal/temporal LPIs. No significant differences in postoperative anterior chamber reaction ( P = 0.7) or LPI area ( P = 0.9) were noted between the 2 groups. No group differences were noted regarding the proportion of patients demonstrating 1 or more dysphotopsia symptoms before LPI (15.8% for superior vs. 13.9% for nasal/temporal; P = 0.1) or any individual dysphotopsia symptom ( P > 0.2 for all). After LPI, 8.9% of all patients reported 1 or more new symptoms, the most common consisting of linear dysphotopsias, glare, and blurring in 2.7%, 4.3%, and 4.3% of patients, respectively. Patients undergoing superior LPI were not more likely to describe the new onset of 1 or more dysphotopsia symptoms as compared with patients undergoing nasal/temporal LPI (8.4% vs. 9.5%; P = 0.7), nor did the frequency of any new individual symptoms differ by group ( P ≥ 0.3 for all). In multivariate logistic regression analysis, neither LPI location nor LPI area nor total laser energy predicted higher odds of new postoperative dysphotopsias ( P > 0.1 for all). Conclusions Laser peripheral iridotomy likely is safe with respect to visual dysphotopsias regardless of location, LPI size, and amount of laser energy used. [ABSTRACT FROM AUTHOR]

Purpose Assess the impact of false-positives (FP), false-negatives (FN), fixation losses (FL), and test duration (TD) on visual field (VF) reliability at different stages of glaucoma severity. Design Retrospective. Participants A total of 10 262 VFs from 1538 eyes of 909 subjects with suspect or manifest glaucoma and ≥5 VF examinations. Methods Predicted mean deviation (MD) was calculated with multilevel modeling of longitudinal data. Differences between predicted and observed MD (ΔMD) were calculated as a reliability measure. The impact of FP, FN, FL, and TD on ΔMD was assessed using multilevel modeling. Main Outcome Measures ΔMD associated with a 10% increment in FP, FN, and FL, or a 1-minute increase in TD. Results FL had little impact on ΔMD (<0.2 decibels [dB] per 10% abnormal catch trials), and no level of FL produced ≥1 dB of ΔMD at any disease stage. FP yielded greater than expected MD, with a 10% increment in abnormal catch trials associated with a ΔMD = 0.42, 0.73, and 0.66 dB in mild (MD >−6 dB), moderate (−6 ≤MD <−12 dB), and severe (−12 ≤MD ≤−20 dB) disease, respectively, up to 20% abnormal catch trials, and a ΔMD = 1.57, 2.06, and 3.53 dB beyond 20% abnormal catch trials. FNs generally produced observed MDs below expected MDs. FN were minimally impactful up to 20% abnormal catch trials (ΔMD per 10% increment >−0.14 dB at all levels of severity). Beyond 20% abnormal catch trials, each 10% increment in abnormal catch trials was associated with a ΔMD = −1.27, −0.53, and −0.51 dB in mild, moderate, and severe disease, respectively. |ΔMD| ≥1 dB occurred with 22% FP and 26% FN in early, 14% FP and 34% FN in moderate, and 16% FP and 51% FN in severe disease. A 1-minute increment in TD produced ΔMDs between −0.35 and −0.40 dB. Conclusions FL have little impact on reliability in patients with established glaucoma. FP, and to a lesser extent FNs and TD, significantly affect reliability. The impact of FP and FN varies with disease severity and over the range of abnormal catch trials. On the basis of our findings, we present evidence-based, severity-specific standards for classifying VF reliability for clinical or research applications. [ABSTRACT FROM AUTHOR]

Objective To characterize fall-related hazards in the homes of persons with suspected or diagnosed glaucoma, and to determine whether those with worse visual field (VF) damage have fewer home hazards. Design Cross-sectional study using baseline (2013–2015) data from the ongoing Falls in Glaucoma Study (FIGS). Participants One-hundred seventy-four of 245 (71.0%) FIGS participants agreeing to the home assessment. Methods Participants' homes were assessed using the Home Environment Assessment for the Visually Impaired (HEAVI). A single evaluator assessed up to 127 potential hazards in 8 home regions. In the clinic, binocular contrast sensitivity (CS) and better-eye visual acuity (VA) were evaluated, and 24-2 VFs were obtained to calculate average integrated VF (IVF) sensitivity. Main Outcome Measures Total number of home hazards. Results No significant visual or demographic differences were noted between participants who did and did not complete the home assessment ( P > 0.09 for all measures). Mean age among those completing the home assessment (n = 174) was 71.1 years, and IVF sensitivity ranged from 5.6 to 33.4 dB (mean = 27.2 dB, standard deviation [SD] = 4.0 dB). The mean number of items graded per home was 85.2 (SD = 13.2), and an average of 32.7 (38.3%) were identified as hazards. IVF sensitivity, CS, and VA were not associated with total home hazards or the number of hazards in any given room ( P > 0.06 for all visual measures and rooms). The bathroom contained the greatest number of hazards (mean = 7.9; 54.2% of graded items classified as hazardous), and the most common hazards identified in at least 1 room were ambient lighting <300 lux and exposed light bulbs. Only 27.9% of graded rooms had adequate lighting. IVF sensitivity, CS, and VA were not associated with home lighting levels ( P > 0.18 for all), but brighter room lighting was noted in the homes of participants with higher median income ( P < 0.001). Conclusions Multiple home fall hazards were identified in the study population, and hazard numbers were not lower for persons with worse VF damage, suggesting that individuals with more advanced glaucoma do not adapt their homes for safety. Further work should investigate whether addressing home hazards is an effective intervention for preventing falls in this high-risk group. [ABSTRACT FROM AUTHOR]

Purpose To compare anterior segment optical coherence tomography (ASOCT) angle morphology before and after laser peripheral iridotomy (LPI) in a cohort of South Indian subjects with primary angle-closure suspect (PACS) or primary angle-closure/primary angle-closure glaucoma (PAC/PACG) and to examine baseline parameters associated with angle widening. Design Prospective observational study. Participants A total of 244 subjects aged ≥30 years with PACS or PAC/PACG in at least 1 eye. Methods The ASOCT images and angle gonioscopic grades were analyzed for all subjects at baseline and 2 weeks after LPI. Multivariable linear and logistic regression models were used to determine predictors of angle widening (change in mean angle opening distance [AOD750]) and angle opening (all 4 quadrants with trabecular meshwork [TM] visible on gonioscopy after LPI). Main Outcome Measures Change in ASOCT parameters with LPI and baseline predictors of angle widening. Results Laser peripheral iridotomy resulted in angle widening on ASOCT with significant increases in AOD750, angle recess area, and trabecular iris surface area ( P < 0.05 for all). Gonioscopically, 44.7% of all subjects had open angles in all 4 quadrants after LPI, with a greater percentage of angles open in the PACS group compared with the PAC/PACG group (52.4% vs. 36.4%; P = 0.01). In multivariable regression analyses, greater postoperative angle widening as defined by change in AOD750 was associated with shorter baseline AOD750 and axial length, and greater baseline anterior chamber depth, iris curvature, and lens vault ( P ≤ 0.002 for all). Gonioscopic angle opening after LPI was more common with wider baseline angle width (modified Shaffer grade) and lower cup-to-disc ratio ( P < 0.001 for both). Conclusions In a South Indian population with PACS or PAC/PACG, LPI results in significant anterior chamber angle widening seen on both ASOCT and gonioscopy, although some degree of persistent iridotrabecular contact was present in approximately half of PACS eyes and approximately two thirds of PAC/PACG eyes on gonioscopy. The greatest widening by ASOCT was observed in eyes with features most consistent with greater baseline pupillary block. [ABSTRACT FROM AUTHOR]

Purpose To compare reduction in intraocular pressure (IOP) and change in anterior chamber angle configuration between eyes undergoing phacoemulsification versus those undergoing manual small-incision cataract surgery (MSICS). Design Prospective, randomized, double-masked, parallel assignment clinical trial. Participants Five hundred eyes of 500 participants 40 to 70 years of age with normal IOP, gonioscopically open angles, and age-related cataract. Methods Eyes underwent phacoemulsification or MSICS after a 1:1 randomization and allocation code. Best-corrected vision, IOP, comprehensive slit-lamp evaluation, and anterior segment (AS) optical coherence tomography (OCT) were performed at baseline and at 1, 3, and 6 months follow-up. Main Outcome Measures Change in IOP (ΔIOP) and AS OCT parameters between baseline and 6 months after surgery. Results Six months, similar IOP reduction was observed in eyes undergoing phacoemulsification (ΔIOP = 2.7±2.9 mmHg) and MSICS (ΔIOP = 2.6±2.6 mmHg; P = 0.70). Widening of the angle opening distance (AOD) 500 μm from the scleral spur (median ΔAOD500 = 103 μm; interquartile range = 39–179 μm) was also similar in both groups ( P = 0.28). Multivariate linear regression analysis showed that eyes with higher baseline IOP experienced significantly greater reduction in IOP at 6 months (ΔIOP = 0.46-mmHg reduction for every 1-mmHg increment in baseline IOP; 95% confidence interval [CI], 0.4–0.5 mmHg; P < 0.001). After adjusting for covariates, the magnitude of widening of AOD500 was not associated significantly with reduction in IOP (1.33-mmHg reduction for every 1-mm increment in AOD500; P = 0.07). Baseline AOD500 (β = −0.60-mm change/1-mm increment of baseline AOD; 95% CI, −0.67 to −0.53 mm) and anterior chamber depth (β = 0.07-mm change/1-mm increment of baseline anterior chamber depth; 95% CI, 0.04–0.1 mm) were significant predictors of AOD500 widening at 6 months. Conclusions Both phacoemulsification and MSICS led to significant and similar IOP reductions 6 months after surgery, and both surgeries produced similar changes in anterior chamber and angle parameters. Higher baseline IOP was associated with greater IOP reduction; IOP reduction also can be attributed partly to changes in angle and anterior chamber configuration, although these parameters were unable to predict significantly predict IOP drop at 6 months. [ABSTRACT FROM AUTHOR]

Rho kinase inhibitors, such as netarsudil, are a relatively new class of medications recently introduced into the market for the treatment of glaucoma, the leading cause of irreversible blindness in the world. Previous clinical trials have studied netarsudil's efficacy when used as a first- or second-line agent but limited studies have investigated its effectiveness in the real world where it is more commonly used as a third, fourth, or fifth agent in combination with other topical medications. Equally important, prior studies have not compared its effectiveness to its peer medications in these settings. To compare intraocular pressure (IOP) lowering after initiation of netarsudil or brimonidine therapy in patients with glaucoma using >2 medications for IOP management. A chart review of 369 eyes from 279 patients followed at a single academic tertiary practice was performed with an institutional review board waiver of consent to compare IOP lowering after prescription of netarsudil (n = 176) versus brimonidine (n = 193) as a third, fourth, or fifth IOP-lowering agent. Patients were identified by querying the electronic medical record for those with a glaucoma-related diagnosis who were prescribed either medication. Five sequential IOP measurements were obtained to determine the mean change in IOP before and after treatment (ΔIOP = mean IOP 4,5 – mean IOP 1,2,3). A multilevel linear mixed-effects model assessed the influence of medication (independent variable) on ΔIOP (dependent variable). Additional independent variables of interest included the number of glaucoma medications at baseline, age, sex, glaucoma type and severity, race, and pretreatment IOP. Bootstrap analysis was performed to remove sampling bias and confirm mixed-effects model findings. Kaplan-Meier survival analysis evaluated the probability of requiring additional intervention within 3 years following the date of medication prescription. The unadjusted mean (SD) ΔIOP for netarsudil and brimonidine was −2.20 (4.11) mm Hg and −2.21 (3.25) mm Hg, respectively (P = 0.484). The adjusted linear mixed-effects models and bootstrap analysis demonstrated that there was no statistical difference in IOP-lowering effectiveness between the medications. Netarsudil and brimonidine failed to adequately control IOP at similar rates with 42% and 47% probabilities of survival respectively by the 3-year follow-up (P = 0.520). When escalating pharmacologic therapy, the IOP-lowering effect of netarsudil appeared to be similar to that produced by brimonidine. (Curr Ther Res Clin Exp. 2023; 84:XXX–XXX) [ABSTRACT FROM AUTHOR]

Purpose To determine the accuracy of patient–physician communication regarding topical ophthalmic medication use based on bottle cap color, particularly among individuals who may have acquired color vision deficiency from glaucoma. Design Cross-sectional, clinical study. Participants Patients aged ≥18 years with primary open-angle, primary angle-closure, pseudoexfoliation, or pigment dispersion glaucoma, bilateral visual acuity of ≥20/400, and no concurrent conditions that may affect color vision. Methods A total of 100 patients provided color descriptions of 11 distinct medication bottle caps. Color descriptors were then presented to 3 physicians. Physicians matched each color descriptor to the medication they thought the descriptor was describing. Main Outcome Measures Frequency of patient–physician agreement, occurring when all 3 physicians accurately matched the color descriptor to the correct medication. Multivariate regression models evaluated whether patient–physician agreement decreased with degree of better-eye visual field (VF) damage, color descriptor heterogeneity, or color vision deficiency, as determined by the Hardy–Rand–Rittler (HRR) score and Lanthony D15 color confusion index (D15 CCI). Results Subjects had a mean age of 69 (±11) years, with VF mean deviation of −4.7 (±6.0) and −10.9 (±8.4) decibels (dB) in the better- and worse-seeing eyes, respectively. Patients produced 102 unique color descriptors to describe the colors of the 11 bottle caps. Among individual patients, the mean number of medications demonstrating agreement was 6.1/11 (55.5%). Agreement was less than 15% for 4 medications (prednisolone acetate [generic], betaxolol HCl [Betoptic; Alcon Laboratories Inc., Fort Worth, TX], brinzolamide/brimonidine [Simbrinza; Alcon Laboratories Inc.], and latanoprost [Xalatan; Pfizer, Inc., New York, NY]). Lower HRR scores and higher D15 CCI (both indicating worse color vision) were associated with greater VF damage ( P < 0.001). Extent of color vision deficiency and color descriptor heterogeneity significantly predicted agreement in multivariate models (odds of agreement = 0.90 per 1 point decrement in HRR score, P < 0.001; odds of agreement = 0.30 for medications exhibiting high heterogeneity [≥11 descriptors], P = 0.007). Conclusions Physician understanding of patient medication use based solely on bottle cap color is frequently incorrect, particularly in patients with glaucoma who may have color vision deficiency. Errors based on communication using bottle cap color alone may be common and could lead to confusion and harm. [ABSTRACT FROM AUTHOR]

Purpose Determine how procedural treatments for glaucoma have changed between 1994–2012. Design Retrospective, observational analysis. Participants Medicare Part B beneficiaries. Methods We analyzed Medicare fee-for-service paid claims data between 1994–2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year. Main Outcome Measures Number of glaucoma-related procedures performed. Results Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994–2003, but then decreased 48% from 11 018 to 5728 between 2003–2012. Mini-shunts done via an external approach (including ExPRESS [Alcon Inc, Fort Worth, TX]) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005–2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994–2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994–2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively. Conclusions Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure–lowering procedures highlights the need for well-designed clinical trials comparing these procedures. [ABSTRACT FROM AUTHOR]

Purpose To compare the effects of uncorrected refractive error (URE) and nonrefractive visual impairment (VI) on performance and disability measures. Design Cross-sectional, population-based study. Participants A total of 2469 individuals with binocular presenting visual acuity (PVA) of ≥20/80 who participated in the first round of the Salisbury Eye Evaluation study. Methods The URE was defined as binocular PVA of ≤20/30, improving to >20/30 with subjective refraction. The VI was defined as post-refraction binocular best-corrected visual acuity (BCVA) of ≤20/30. The visual acuity decrement due to VI was calculated as the difference between BCVA and 20/30, whereas visual acuity due to URE was taken as the difference between PVA and BCVA. Multivariable regression analyses were used to assess the disability impact of (1) vision status (VI, URE, or normal vision) using the group with normal vision as reference and (2) a 1-line decrement in acuity due to VI or URE. Main Outcome Measures Objective measures of visual function were obtained from timed performance of mobility and near vision tasks, self-reported driving cessation, and self-reported visual difficulty measured by the Activities of Daily Vision (ADV) scale. The ADV responses were analyzed using Rasch analysis to determine visual ability. Results Compared with individuals with normal vision, subjects with VI (n = 191) had significantly poorer objective and subjective visual functioning in all metrics examined ( P < 0.05), whereas subjects with URE (n = 132) demonstrated slower walking speeds, slower near task performance, more frequent driving cessation, and lower ADV scores ( P < 0.05), but did not demonstrate slower stair climbing or descent speed. For all functional metrics evaluated, the impact of VI was greater than the impact of URE. The impact of a 1-line VA decrement due to VI was associated with greater deficits in mobility measures and driving cessation when compared with a 1-line VA decrement due to URE. Conclusions Visual impairment is associated with greater disability than URE across a wide variety of functional measures, even in analyses adjusting for the severity of vision loss. Refractive and nonrefractive vision loss should be distinguished in studies evaluating visual disability and be understood to have differing consequences. [ABSTRACT FROM AUTHOR]

PURPOSE: To identify predictors of visual outcomes following Boston type 1 Keratoprosthesis (KPro) implantation. DESIGN: Retrospective chart review. METHODS: Data regarding preoperative clinical and demographic characteristics and postoperative course were collected. PATIENTS: Fifty-nine eyes of 59 adult patients who underwent KPro implantation between January 2006 and March 2012 at a single tertiary care center. MAIN OUTCOME MEASURES: Preoperative factors associated with all-cause and glaucoma-related loss of visual acuity from the best postoperative visual acuity noted. RESULTS: Fifty-two of 59 eyes (88%) achieved improved vision post implantation, with 7 eyes failing to gain vision as a result of pre-existing glaucoma (n = 4) or retino-choroidal disease (n = 3). Twenty-one eyes (21/52, 40%) maintained their best-ever visual acuity at last visit (mean follow-up period was 37.8 months). The likelihood of maintaining best-ever vision was 71% at 1 year, 59% at 2 years, and 48% at 3 years. Primary KPro implantation was associated with a higher likelihood of losing best-ever vision as compared to KPro implantation as a repeat corneal procedure (hazard ratio [HR] = 3.06; P = 006). The main reasons for postimplantation vision loss was glaucoma (12/31, 39%), and the risk of glaucomatous visual acuity loss was 15% at 2 years and 27% at 3 years. Prior trabeculectomy was associated with a higher rate of vision loss from glaucoma (HR = 3.25, P = .04). CONCLUSION: Glaucoma is the primary reason for loss of visual acuity after KPro implantation. Conditions necessitating primary KPro surgery are associated with more frequent all-cause vision loss. Prospective trials are necessary to better determine which clinical features best predict KPro success. [ABSTRACT FROM AUTHOR]