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The human papillomavirus (HPV) causes largely preventable cancers by completing a vaccination series. However, pediatric HPV vaccination rates remain low. Current evidence indicates that integrating five factors creates a high-quality recommendation associated with higher HPV vaccination rates. This quality improvement project aimed to evaluate the impact of an educational intervention to improve the quality of providers' recommendations and subsequent vaccination rates.Using the Squire 2.0 Guidelines, clinical staff were observed during well-child visits (aged 11-12 years) before and after the intervention across three Plan-Do-Study-Act cycles.Thirty-nine encounters with mostly (n = 31; 80%) families of color. The quality of vaccine recommendations was improved after the intervention; however, vaccination rates did not increase for the 39 patients. Providers' delivery approach (presumptive vs. conversational) did increase vaccination rates.Providers' delivery style appears to be important when making HPV vaccine recommendations.

For optimal drug delivery, dry powder inhalers (DPIs) depend on the patient’s peak inspiratory flow (PIF) and the internal resistance of the device to create turbulent energy and disaggregate the powder. A suboptimal PIF may lead to ineffective drug inhalation into the lungs. Our objective was to report the prevalence of suboptimal PIF in patients with COPD hospitalized for any reason using 1 or more DPIs. In this real-world, observational, single‑site, retrospective study, PIF was measured for each DPI using the In-Check™ DIAL set to match the resistance of the DPI used by each patient. PIFs

Previous studies have shown that cannabis consumers are willing to pay more money for higher-quality products; however, the definition of “quality” cannabis has not been defined. Despite the known health risks of THC overuse, THC potency has been adopted as the primary market-driving feature of cannabis products. The purpose of this study was to objectively identify features of cannabis that contribute to its appealing subjective effects. In the course of conducting cannabis competitions, commercially available cannabis inflorescences were distributed to healthy volunteers (“judges”) in a randomized, double-blind fashion. Anonymous online survey data about the subjective effects of each cannabis sample were analyzed independently, by researchers not involved with the competitions. Pleasant subjective aroma (but not terpene expression, THC potency, or THC dose) was positively correlated with pleasant subjective effects. There was also a moderate but significant negative association between the amount of cannabis consumed and subjective appeal. These results suggest that, unlike THC potency, pleasant aroma is predictive of pleasant subjective effects. Similar to other agricultural commodities such as coffee and tea, aroma appears to be a robust indicator of the quality of cannabis inflorescence. These findings have wide-reaching public health implications, given the well-established health risks of THC overuse.

Background Glucagon-like peptide-1 receptor agonists (GLP-1 agonists) are effective hemoglobin A1c (HbA1c) and weight-lowering agents. The treatment effect is unknown in patients with HbA1c of 9% or greater. Objective The purpose of this study was to evaluate glycemic control and weight loss after adding a GLP-1 agonist in patients with a baseline HbA1c of 9% (75 mmol/mol) or greater. Methods A single-health system retrospective chart review screened adults with type 2 diabetes mellitus with a baseline hemoglobin A1c of 9% (75 mmol/mol) or greater and were prescribed a GLP-1 agonist for eligibility. The primary outcome assessed was the change in HbA1c from baseline to the first HbA1c check. Secondary outcomes included change in weight (kg) from baseline to the first HbA1c check. Results Three hundred sixty-two patients were screened of which 151 (41.7%) were included in the final analysis. The mean change in HbA1c from baseline to first HbA1c check for all participants was −2.1% (95% CI: −2.3% to −1.8%; P < .001; −23 mmol/mol [95% CI: −25 to −20 mmol/mol]). The mean change in weight from baseline to first HbA1c check was −2.0 kg (95% CI: −2.6 kg to −1.4 kg; P < .001). Conclusion In patients with type 2 diabetes mellitus with a baseline HbA1c ≥ 9%, GLP-1 agonist initiation resulted in a significant reduction of both HbA1c and weight compared to baseline. Large, prospective, multisite studies are needed to confirm findings of this retrospective study.

Background: People with diabetes-related ulcers may benefit from hyperbaric oxygen (HBO2) therapy and from continuous glucose monitors (CGM). Although blood glucose (BG) meters based on glucose oxidase (GO) report erroneously low values at high pO2, BG meters based on glucose dehydrogenase (GD) do not. We therefore examined the performance of a GO-based CGM system in comparison to GO-based and GD-based BG systems in normobaric air (NBAir), hyperbaric air (HBAir), and HBO2 environments. Materials and Methods: Twenty-six volunteers without diabetes mellitus (DM) wore Dexcom G6 CGM systems and provided periodic blood samples before, during, and after a standard HBO2 treatment consisting of three 30-min intervals of HBO2 separated by two 5-min intervals of HBAir. Accuracy of the CGM and GO-based BG meter were assessed by comparisons with the GD-based values. Results: The mean absolute relative difference for the CGM system was 15.96% and for the GO-based meter was 8.52%. Compared to NBAir, HBO2 exposure resulted in significantly higher CGM values (+3.76 mg/dL, P

Purpose This study evaluated the ability of topographically correspondent (TC) minimum rim width (MRW) and peripapillary retinal nerve fiber layer thickness (pRNFLT) criteria to detect optical coherence tomography (OCT) structural abnormality in glaucoma (GL) and glaucoma suspect (GLS) eyes. Design Retrospective cross-sectional study. Methods A total of 196 GL eyes, 150 GLS eyes, and 303 heathy eyes underwent pRNFL and 24 radial optic nerve head OCT imaging and manual correction of the internal limiting membrane, Bruch's membrane opening (BMO), and outer pRNFL segmentations. MRW and pRNFLT were quantified in 6 Garway-Heath or 12 30-degree (clock-hour) sectors. OCT abnormality for each parameter was defined to be less than the 5th percentile of the healthy eye distribution. OCT abnormality for individual eyes was defined using global, sectoral, and combined parameter criteria that achieved ≥95% specificity in the healthy eyes. TC combination criteria required the sectoral location of MRW and pRNFLT abnormality to be topographically aligned and included comMR (a previously reported TC combination consisting of MRW and pRNFLT parameter: [MRW + pRNFLT × (average MRW healthy eyes/average pRNFLT healthy eyes) MRW]. Results TC sectoral criteria (1 Garway-Heath MRW + corresponding Garway-Heath RNFLT), (one 30-degree MRW + any 1 corresponding or adjacent 30-degree pRNFLT), 30-degree and Garway-Heath comMR-TI and global comMR were the best performing criteria, demonstrating (96%-99% specificity), 86%-91% sensitivity for GL, 80%-84% sensitivity for early GL (MD ≥ −4.0 dB) and 93%-96% sensitivity for moderate-to-advanced GL (MD Conclusions Clinically intuitive TC MRW and pRNFLT combination criteria identified the sectoral location of OCT abnormality in GL eyes with high diagnostic precision.

Introduction: Focused Cardiac Ultrasound (FoCUS) is a relatively new technology that requires training and mentoring. The use of a FoCUS simulator is a novel training method that may prompt greater adoption of this technology by physicians at different levels of training and experience. The objective of this study was to determine if simulation training using an advanced echo simulator (Real Ultrasound®) is a feasible means of delivering training in FoCUS. Methods: Twenty-five residents and attending physicians participated in this study. After performing a pretest, training on the Real Ultrasound® was administered. Improvement was assessed immediately after simulator training. Additionally, some participants were retested six months after training to determine whether learned skills were retained. Results: Of the 25 participants recruited, all completed the pretest phase, and 17 completed the training and immediate posttest assessment. At pretest, the median angular deviation of acquired images from anatomically correct was 37°, which improved to 30° after training (p

PRéCIS:: There are errors in automated segmentation of the retinal nerve fiber layer (RNFL) in glaucoma suspects or patients with mild glaucoma that appear to persist over time; however, automated segmentation has greater repeatability than manual segmentation.To identify whether optical coherence tomography (OCT) segmentation errors in RNFL thickness measurements persist longitudinally.This was a cohort study. We used spectral domain OCT (Spectralis) to measure RNFL thickness in a 6-degree peripapillary circle, and exported the native "automated segmentation only" results. In addition, we exported RNFL thickness results after "manual refinement" to correct errors in the automated segmentation, and used the differences in these measurements as "error" in segmentation. We used Bland-Altman plots and linear regression to determine the magnitude, location, and repeatability of RNFL thickness error in all twelve 30-degree sectors and compared the error at baseline to follow-up time points at 6 months, 2 years, 3 years, and 4 years.We included 406 eyes from 213 participants. The 95% confidence interval for errors at baseline was -6.5 to +13.2 μm. The correlation between the baseline error and the errors in the follow-up time periods were high (r0.5, P0.001 for all). Automated segmentation had a smaller SD of residuals from the longitudinal trend line when compared to manual refinement (1.56 vs. 1.80 μm, P0.001), and a higher ability (P=0.009) to monitor progression using an analysis of a longitudinal signal-to-noise ratio.Errors in automated segmentation remain relatively stable, and baseline error is highly likely to persist in the same direction and magnitude in subsequent time periods. However, automated segmentation (without manual refinement) is more repeatable and may be more sensitive to glaucomatous progression. Future segmentation algorithms could exploit these findings to improve automated segmentation in the future.

PURPOSE: To assess glaucoma specialists’ detection of optic nerve head (ONH) rim tissue that is thin by optical coherence tomography (OCT) criteria. DESIGN: Reliability analysis METHODS: 5 clinicians marked the disc margin (DM) and rim margin (RM) on stereo-photos of 151 glaucoma or glaucoma suspect eyes obtained within 3 months of OCT imaging. The photo and OCT infrared image for each eye were colocalized and regionalized into twelve sectors relative to the axis between Bruch’s membrane opening (BMO) centroid and the fovea. For each clinician, the distance from BMO centroid to their DM (DM radius) and RM (RM radius) was used to generate sectoral rim width (RW) (DM radius – RM radius) and cup-to-disc ratio (CDR) (RM radius / DM radius) estimates. OCT minimum rim width (MRW) was determined by sector. Among all eyes, for each OCT MRW suspicious sector (< 5% of OCT normative data base), we determined each clinician’s detection (clinician CDR ≥ 0.7). RESULTS: Clinicians most commonly failed to detect OCT suspicious rim tissue in the nasal sectors. Among 502 sectors with suspicious OCT MRW all 5 clinicians rated CDR ≥ 0.7 in only 29.5% and all 5 clinicians rated CDR < 0.7 in 21%. OCT suspicious rim thickness was most common (32% of eyes) in the nasal and inferior sectors. MRW vs clinician RW discordance was greatest nasally, while BMO vs clinician DM discordance was greatest temporally. CONCLUSIONS: Clinicians most commonly failed to detect OCT suspicious rim thickness nasally where suspicious rim tissues were also most common.

Background The Centers for Disease Control and Prevention lists accidents (unintentional injuries) as the fifth leading cause of infant mortality. Data analysis from a multihospital system of inpatient family birth centers revealed fluctuations in newborn birth admission falls rates at times above the benchmark reported in the literature. Purpose We describe a multipronged approach to address an identified safety concern. The aim of the project was to decrease the rate of newborn falls during birth hospitalization. Despite applying multiple interventions described in the literature, newborn falls were not eliminated. Study design and methods In this quality improvement project, a nursing leadership team was convened to review the literature, identify current and ideal states, obtain stakeholder input, identify contributing factors, and agree on standardized interventions to prevent newborn falls. The project received exempt status from the institutional review board. Results Since we started the project in 2016, there was a downward trend in newborn birth admission falls in 2017; however, based on our variable data over the last 5 years and small numbers of falls, it is difficult to conclude that any one strategy or combination of strategies has been successful. Because falls from bed with the new mother were the most common types of newborn falls, interventions were focused; however, our falls rate for newborns never fell below comparable rates in the literature. Clinical implications More data are needed on effective interventions that can reduce the rate of newborn falls, especially those from bed while with the new mother. A comprehensive approach based on analysis of events and review of existing evidence are necessary first steps.

PURPOSE: To compare the frequency of observing optic nerve head (ONH) prelaminar schisis by optical coherence tomography (OCT) in glaucoma and glaucoma suspect (GL/S) eyes versus healthy control (HC) eyes and to assess its association other markers of glaucoma severity. METHODS: This cross-sectional study included 298 eyes of 150 GL/S patients and 88 eyes of 44 HC. OCT scans were obtained by SPECTRALIS (Heidelberg Engineering GmbH), including 24 radial B-scans, each comprised of 768 A-lines spanning 15°, centered on the ONH. Two reviewers masked to all other clinical, demographic and ocular information, independently graded the OCT scans for the presence of ONH prelaminar schisis on a 4-point scale: 0 (none) to 3 (severe). The probability of ONH schisis was compared between groups and against demographic and ocular factors, including structural and functional measures of glaucoma severity. RESULTS: The frequency and severity of ONH prelaminar schisis were greater in GL/S than in HC (p=0.009). Among the GL/S group, 165 eyes (55.4%) had no visible schisis (Grade-0), 71 (23.8%) had Grade-1, 46 (15.4%) had Grade-2 and 16 (5.4%) had Grade-3 schisis. Among HC eyes, 59 (67.0%) had Grade-0, 24 (27.3%) had Grade-1, 5 (5.7%) had Grade-2, none had Grade-3. ONH schisis was more common in eyes with thinner MRW and a deeper cup. CONCLUSIONS: ONH prelaminar schisis may be a sign of glaucomatous deformation and reflect ongoing pathophysiological damage. ONH prelaminar schisis can impact OCT image segmentation and diagnostic parameters, resulting in substantial overestimation of the true rim tissue thickness and underestimation of cup depth.

Purpose To use optical coherence tomography (OCT) to 3-dimensionally characterize the optic nerve head (ONH) in peripapillary scleral bowing in non-highly myopic healthy eyes. Design Cross-sectional, multicenter study. Methods A total of 362 non-highly myopic (+6 diopters [D] > spherical equivalent > −6D) eyes of 362 healthy subjects from 20-90 years old underwent OCT ONH radial B-scan imaging. Bruch's membrane (BM), BM opening (BMO), anterior scleral canal opening (ASCO), and the peripapillary scleral surface were segmented. BMO and ASCO planes were fit, and their centroids, major axes, ovality, areas and offsets were determined. Peripapillary scleral bowing was characterized by 2 parameters: peripapillary scleral slope (ppSS) of 3 anterior peripapillary scleral segments (0-300, 300-700, and 700-1,000 μm from the ASCO centroid); and ASCO depth relative to a peripapillary scleral reference plane (ASCOD-ppScleral). Peripapillary choroidal thickness (ppCT) was calculated relative to the ASCO as the minimum distance between the anterior scleral surface and BM. Results Both ppSS and ASCOD-ppScleral ranged from slightly inward through profoundly outward in direction. Both parameters increased with age and were independently associated with decreased ppCT. Conclusions In non-highly myopic healthy eyes, outward peripapillary scleral bowing achieved substantial levels, was markedly increased with age, and was independently associated with decreased peripapillary choroidal thickness. These findings provide a normative foundation for characterizing this anatomy in cases of high myopia and glaucoma and in eyes with optic disc tilt, torsion, and peripapillary atrophy.

PURPOSE: To quantify the variability of 5 glaucoma specialists’ optic disc margin (DM), rim margin (RM) and rim width (RW) estimates. DESIGN: Inter-Observer Reliability analysis. METHODS: Clinicians viewed stereo-photos from 214 subjects with glaucoma or ocular hypertension and digitally marked the DM and RM. For each photo, the centroid of each clinician’s DM was calculated, and an averaged DM(centroid) was determined. The axis between the DM(centroid) and the fovea was used to establish twelve 30° sectors. Measurements from the DM centroid to each clinician’s DM (DM(radius)) and RM (RM(radius)) were used to generate a RW (DM(radius) – RM(radius)) and cup disc ratio (CDR) (RM(radius)/DM(radius)) by sector. Parameter means, standard deviations and coefficient of variations (COVs) were calculated across all clinicians for each eye. Parameter means for each clinician, and intra-class correlation coefficients (ICC), were calculated across all eyes by sector. RESULTS: Among all eyes, the median COV by sector ranged from 3–5% for DM(radius), 20–25% for RM(radius), and 26–30% for RW. Sectoral ICCs for CDR ranged from 0.566 to 0.668. Sectors suspicious for rim thinning by one clinician were frequently overlooked by others. Among 1724 sectors in which at least one clinician was suspicious for rim thinning, (CDR ≥ 0.7), all 5 clinicians’ CDRs were ≥ 0.7 in only 499 (29%) and 2 of the 5 clinicians failed to detect rim thinning (CDR < 0.7) in 442 (26%). CONCLUSION: In this study, glaucoma specialist RM, DM and RW discordance was frequent and substantial even in sectors that were suspicious for rim thinning.

We investigated the proportion of encounters that were interrupted during family-centered rounds in the pediatric intensive care unit (PICU) to determine whether the use of a physician assistant (PA) significantly affected the proportion of interrupted encounters.We evaluated 2,657 rounding encounters in our 24-bed regional referral unit. The duration of each rounding encounter and total rounding duration were recorded. The presence or absence of a PA during each rounding encounter, the occurrence of an interruption, and other potential predictors of interruptions were recorded.The presence of a PA during PICU rounds was significantly associated (P.001) with a 35.4% lower likelihood of an interruption.Family-centered rounds in the PICU are less likely to be interrupted when a PA is present. PAs help physicians and improve rounding efficiency by safely and effectively handling certain interruptions.

PurposeTo determine the frequency with which retinal tissues other than the nerve fibre layer, hereafter referred to as protruded retinal layers (PRL), are a component of optical coherence tomography (OCT) neuroretinal rim measurements.MethodsNinety healthy (30 White, Black and Japanese, respectively) subjects were included in the study. A radial scan pattern (24 B-scans centred on Bruch's membrane opening [BMO]) was used. For each of the 48 minimum rim width (MRW) measurement points, we determined whether PRL were present, absent or indeterminate. When present, the proportion of PRL within the MRW was quantified.ResultsProtruded retinal layers were present in 503 (11.6%), absent in 3805 (88.1%) and indeterminate in 12 (0.3%) measurement points. Overall, 69 (76.6%) subjects had ≥1 points with PRL, with White subjects having the highest frequency and Japanese the lowest (29 [97%] and 18 [60%], respectively; p&nbsp

Objective Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors. Study Design Observational analytic case-control study in a tertiary referral center. Methods Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro-ophthalmologist), and a psychologist clinician-investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis-Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction. Results There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug-induced Parkinson-like syndrome and idiopathic progressive neurological degenerative process. Conclusions Components of the Millon Behavioral Medicine Diagnostic, PHQ-9 and GAD-7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities that could confound outcomes. The identification of these comorbid psychological as well as other neurological degenerative disease processes led to alternate clinical management pathways for these patients. Level of Evidence 2b.

Purpose Various global indices are available to summarize results from standard automated perimetry. This study asks which index can detect significant deterioration earliest, for a fixed specificity. Design Comparison of prognostic indices. Methods Two cohorts were tested. A test-retest cohort contained 5 reliable visual fields, within a short interval, from 45 eyes of 23 participants with glaucoma and/or likelihood of developing glaucoma. A separate longitudinal cohort contained 508 eyes from 330 participants, tested on average 13 times. Three global indices were extracted: mean deviation (MD), pattern standard deviation (PSD), and visual field index (VFI). For each index we defined a critical P value Crit Index , such that 5% of test-retest series showed significant deterioration with P Index , using artificial "test dates" in random order. Therefore these criteria have 95% specificity over series of 5 tests. The times to detect significant deterioration in the longitudinal cohort were compared using a survival analysis model. Results The median time to detect significant deterioration with MD was 7.3 years (95% confidence interval [CI] 6.8–7.9 years). For VFI, the median was 8.5 years (95% CI 7.9–9.0 years); this comparison had P = .088. For PSD, the median was 10.5 years (95% CI 9.3–11.7 years), slower than MD with P P = .0013) and 107 for PSD ( P = .029). Conclusions MD detected significant deterioration sooner than VFI or PSD. In particular, MD detected more eyes in the first 5 years of their follow-up, which were presumably undergoing more rapid progression.

OBJECTIVE: We determined the differential aging effects of the inner six layers of the macula in contrast to the minimum neuroretinal rim width (MRW) and peripapillary retinal nerve fibre layer (RNFL) thickness. DESIGN: Cross-sectional, multi-centre study. PARTICIPANTS: Approximately equal number of White subjects with a normal ocular and visual field examination in each decade group from 20-90 years. METHODS: Optical coherence tomography of the macula, optic nerve head and peripapillary retina. MAIN OUTCOME MEASURES: (i) Sectoral measurements of the inner six layers of the macula; (ii) age-related decline of each of these layers; (iii) strength of the associations with age of the macular parameters, MRW and peripapillary RNFL thickness; (iv) association between ganglion cell layer (GCL) thickness and MRW and peripapillary RNFL thickness. RESULTS: The study sample comprised one eye of 246 subjects with median (range) age of 52.9 (19.8 – 87.3) years. Of the six layers, there was a statistically significant decline with age of only the GCL, inner plexiform layer and inner nuclear layer thickness with rates of −0.11 μm/y, −0.07 μm/y and −0.03 μm/y, respectively. These rates corresponded to 2.92%, 2.15% and 0.88% loss per decade, respectively, and were generally uniform across sectors. The rate of loss of MRW and peripapillary RNFL thickness was −1.22 μm/y and −0.20 μm/y, corresponding to 3.63% and 2.04% loss per decade. However, the association of GCL thickness change with age (R(2) = 0.28) was approximately twice that of MRW and RNFL thickness (R(2) = 0.14 for each). CONCLUSIONS: In concordance with histopathological studies showing age-related loss of retinal ganglion cell axons, we showed a significant decline in GCL thickness, as well as MRW and peripapillary RNFL thickness. The stronger relationship between aging and GCL thickness compared to the rim or peripapillary RNFL may indicate that GCL thickness could be better suited to measure progression of structural glaucomatous loss.

Author(s): Yang, Hongli; Luo, Haomin; Gardiner, Stuart K; Hardin, Christy; Sharpe, Glen P; Caprioli, Joseph; Demirel, Shaban; Girkin, Christopher A; Liebmann, Jeffrey M; Mardin, Christian Y; Quigley, Harry A; Scheuerle, Alexander F; Fortune, Brad; Chauhan, Balwantray C; Burgoyne, Claude F | Abstract: Purpose:To quantify peripapillary choroidal thickness (PCT) and the factors that influence it in healthy participants who represent the racial and ethnic composition of the U.S. population. Methods:A total of 362 healthy participants underwent optical coherence tomography (OCT) enhanced depth imaging of the optic nerve head with a 24 radial B-scan pattern aligned to the fovea to Bruch's membrane opening axis. Bruch's membrane, anterior scleral canal opening (ASCO), and the anterior scleral surface were manually segmented. PCT was measured at 100, 300, 500, 700, 900, and 1100 μm from the ASCO globally and within 12 clock-hour sectors. The effects of age, axial length, intraocular pressure, ethnicity, sex, sector, and ASCO area on PCT were assessed by ANOVA and univariable and multivariable regressions. Results:Globally, PCT was thicker further from the ASCO border and thinner with older age, longer axial length, larger ASCO area, European descent, and female sex. Among these effectors, age and axial length explained the greatest proportion of variance. The rate of age-related decline increased further from the ASCO border. Sectorally, the inferior-temporal sectors were thinnest (10.7%-20.0% thinner than the thickest sector) and demonstrated a higher rate of age-related loss (from 15.6% to 20.7% faster) at each ASCO distance. Conclusions:In healthy eyes, PCT was thinnest in the inferior temporal sectors and thinner PCT was associated with older age, European descent, longer axial length, larger ASCO area, and female sex. Among these associations, age had the strongest influence, and its effect was greatest within the inferior temporal sectors.

PurposeTo assess anterior scleral canal opening (ASCO) offset relative to Bruch's membrane opening (BMO) (ASCO/BMO offset) so as to determine neural canal direction, obliqueness, and minimum cross-sectional area (NCMCA) in 362 healthy eyes.DesignCross-sectional study.MethodsAfter optical coherence tomography optic nerve head and retinal nerve fiber layer thickness (RNFLT) imaging, BMO and ASCO were manually segmented. Planes, centroids, size, and shape were calculated. Neural canal direction was defined by projecting the neural canal axis vector (connecting BMO and ASCO centroids) onto the BMO plane. Neural canal obliqueness was defined by the angle between the neural canal axis and the BMO plane perpendicular vector. NCMCA was defined by projecting BMO and ASCO points onto a neural canal axis perpendicular plane and measuring the area of overlap. The angular distance between superior and inferior peak RNFLT was measured, and correlations between RFNLT, BMO, ASCO, ASCO/BMO offset, and NCMCA were assessed.ResultsMean (SD) NCMCA was significantly smaller than either the BMO or ASCO area (1.33 (0.42), 1.82 (0.38), 2.22 (0.43) mm2, respectively), and most closely correlated to RNFLT (P < .001, R2= 0.158). Neural canal direction was most commonly superior-nasal (55%). Mean neural canal obliqueness was 39.4° (17.3°). The angular distance between superior and inferior peak RNFLT correlated to neural canal direction (P ≤ .008, R2= 0.093).ConclusionsASCO/BMO offset underlies neural canal direction, obliqueness, and NCMCA. RNFLT is more strongly correlated to NCMCA than to BMO or ASCO, and its peripapillary distribution is influenced by neural canal direction.

In clinic, “deep” vs. “shallow” cupping is well established in human glaucoma. Our central hypothesis is that the “shallow” or senile sclerotic cupping of aged eyes is a manifestation of their stiffer connective tissues. We predicted that there are age-related differences in structure/function relationships. The relationship between the magnitude of laminar deformation and visual field loss will be different in young (“compliant”) eyes compared to old (“stiff”) eyes.

PURPOSE To determine the association of vision-related quality of life (QoL) to demographic factors and visual function in glaucoma suspect or early glaucoma patients. MATERIALS AND METHODS We administered the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) on the same day as a comprehensive ocular examination to participants either with glaucoma or at high risk for developing glaucoma. Regression models were used to determine the association between VFQ-25 composite and subscale scores, visual field status, logMAR equivalent visual acuity (VA), age, and sex. In all analyses we used data from the eye with the best mean deviation (MD), best pattern SD, and best VA. RESULTS Data from 198 participants were analyzed. The mean best MD (±SD) was 0.02±1.52 dB (range, -5.11 to 2.63 dB) and the mean best pattern SD was 1.75±1.03 dB (range, 0.91 to 8.36 dB). The mean VFQ-25 composite score was 91.6±6.7 (range, 54.5 to 100.0). Composite score and the Distance Activities, Color Vision subscale scores were associated with best MD (P≤0.05). The General Vision and Driving subscale scores were associated with best VA (P≤0.03). The composite score and the Distance Activities, Driving, and Color Vision subscale scores were associated with age (P≤0.05). Finally, the Distance Activities, Driving, and Peripheral Vision subscale scores were associated with sex (P≤0.04). CONCLUSIONS Vision-related QoL is associated with visual field status even in early and suspected glaucoma. It is also associated with VA, age, and sex. Particular decreases in QoL are related to distance activities, driving, and color vision.

PURPOSE We determined whether longitudinal changes in retinal nerve fiber layer (RNFL) reflectance provide useful prognostic information about longitudinal changes in function in glaucoma. METHODS The reflectance intensity of each pixel within spectral-domain optical coherence tomography (SD-OCT) circle scans was extracted by custom software. A repeatability cohort comprising 53 eyes of 27 participants (average visual field mean deviation [MD] -1.65 dB) was tested five times within a few weeks. To minimize test-retest variability in their data, a reflectance intensity ratio was defined as the mean reflectance intensity of pixels within the RNFL divided by the mean between the RNFL and RPE. This was measured in a separate longitudinal cohort comprising 310 eyes of 205 participants tested eight times at 6-month intervals (average MD, -0.99 dB; median rate of change, -0.09 dB/y). The rate of change of this ratio, together with the rate of RNFL thinning, and their interaction, were used to predict the rate of change of MD. RESULTS In univariate analyses, the rate of RNFL thinning was predictive of the rate of MD change (P < 0.0001), but the rate of change of reflectance intensity ratio was not (P = 0.116). However, in a multivariable model, the interaction between these two rates significantly improved upon predictions of the rate of functional change made using RNFL thickness alone (P = 0.038). CONCLUSIONS For a given rate of RNFL thinning, a reduction in the RNFL reflectance intensity ratio is associated with more rapid functional deterioration. Incorporating SD-OCT reflectance information may improve the structure-function relation in glaucoma.

Purpose We compared the accuracy of orbital volume correction between the transorbital and transantral reconstructive techniques. Materials and Methods A retrospective cohort study was performed of patients who had undergone repair of isolated, unilateral orbital floor blowout fractures at Legacy Emanuel Hospital from 2013 to 2018. A total of 21 patients were identified and included in the predictor variable cohorts of the transorbital versus transantral repair technique. The outcome variable of orbital volume correction was evaluated by comparing the volume of the postoperative repaired orbits with that of the contralateral noninjured orbits. Additional ordinal variables analyzed included the preoperative orbital defect size and analysis of the transantral cohort stratified by the plating technique used. Data were assessed using analysis of variance and paired t tests. Results A transantral approach was used for orbital repair in 9 patients. In these patients, the postoperative orbital volume in the injured orbit was 2.69% greater than that in the uninjured orbit. The 12 patients who had undergone transantral repair had a postoperative orbital volume in the injured orbit that was 0.56% smaller than that of the uninjured orbit (P = .033). Division of the transantral cohort into 2 different plating techniques identified a less than 1% difference in mean orbital volume correction between the 2 techniques (P = .104). The average defect volume before transorbital repair was 4.87 cm3 compared with 5.22 cm3 for transantral repair (P = .907). Conclusions The results from the present study have shown that the accuracy of orbital volume correction using the transantral approach will be comparable to that of the transorbital approach, as shown by a small, but statistically significant, increased accuracy in the volume correction with the transantral approach. Additional investigation to establish clinical correlations with these findings should be conducted.

Purpose:To quantify the influence of ocular and demographic factors on central laminar depth (LD) in healthy participants. Methods:A total of 362 normal subjects underwent optical coherence tomography (OCT) enhanced depth imaging of the optic nerve head (ONH) with a 24 radial B-scan pattern aligned to the fovea-to-Bruch's membrane opening (BMO) axis. BMO, anterior lamina, anterior scleral canal opening (ASCO), Bruch's membrane (BM), and the peripapillary scleral surface were manually segmented. The extent of laminar segmentation was quantified within 72 ASCO subsectors. Central LD was quantified relative to four reference planes: BMO, ASCO, BM, and scleral. The effects of age, sex, ethnicity, IOP, BMO area, ASCO area, and axial length on LD were assessed. Results:Laminar visibility was most consistent within the central ASCO (median 89%, range, 69%-95%). LDBMO and LDBM were significantly shallower in eyes with greater age, BMO area, and axial length and in females. LDASCO was shallower in eyes with greater ASCO area and axial length and in European and Hispanic descent compared to African descent eyes. LDSclera behaved similarly, but was not associated with axial length. BMO and ASCO area were not different between African descent and European descent eyes. Conclusions:Central LD was deeper in African descent eyes and influenced least by age, axial length, and sex, but more by ASCO area, when measured relative to the ASCO and sclera. However, the magnitude of these effects for all four reference planes was small, and their clinical importance in the detection of glaucoma and its progression remains to be determined.

Background Randomized trials on clinical outcomes of music are conflicting, with few performed in the postoperative pediatric population. We aimed to determine if there was a benefit of a live, customized bedside music delivery program (MyMusicRx®) for children hospitalized after pediatric surgery. We present our perspective on the utility of music medicine, review others’ work in this area, and discuss future directions. Methods All admitted postsurgical patients aged between 5 and 18 years were considered. One live, customized music session was delivered by a MyMusicRx® music specialist to intervention participants, and compared with matched controls who did not receive music intervention. Pain, cumulative analgesia dosage, and vital signs within 12 h after unit arrival were compared between groups. Results Thirty-two participants (16 intervention, 16 controls; 8:8 females:males per group) were enrolled. No differences in age, surgery length, or duration of music intervention were found between groups. No differences in pain scores (p = 0.73), heart rate (p = 0.82), respirations (p = 84), narcotic (p = 0.92) or non-narcotic medication usage (p = 0.88, 0.86, 0.95; ibuprofen, acetaminophen, and ketorolac, respectively), or time to first narcotic dose (p = 0.64) were found. Conclusion A single music intervention in the acute postoperative period did not appear to be adequate to augment traditional methods of pain and hemodynamic control. Prior studies have similar outcome measures but conflicting results. We did not evaluate psychological well-being, patient engagement, or family perception in this pilot study. Future directions include developing and validating a tool that explores the observable impact of music medicine on children’s emotions and behaviors.

BACKGROUND AND OBJECTIVE: The incorporation of family-centered rounds has become standard in PICUs across the United States. We compared rounding times in our institution, with and without family members present, to determine the effect on total rounding time and work flow. METHODS: This observational study of a convenience sample was conducted over a 17-month period (May 2014–October 2015), accounting for typical seasonal variation in the PICU. The individual patient rounding times for 2657 encounters were recorded. The presence of family members, intubation status, physician assistant participation, interruptions during rounds, attending physician’s full- or part-time status, and patient census were documented. The effect of family presence on per-patient rounding time was analyzed, while controlling for influential variables. RESULTS: Family members were present during 1743 of 2657 (66%) rounding encounters. The average per-patient rounding time with and without family members present was 8.6 minutes and 7.3 minutes, respectively, a difference of 1.3 minutes per patient. In statistical models that accounted for other influential variables, the presence of family members was associated with a highly significant (20.4%, P < .001) increase in the per-patient rounding time. CONCLUSIONS: The presence of family members increases per-patient rounding times in the PICU. Family presence on rounds may have benefits that outweigh the additional time required to complete each patient interaction.

Objective Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors. Study Design Observational analytic case‐control study in a tertiary referral center. Methods Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro‐ophthalmologist), and a psychologist clinician‐investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ‐9) and Generalized Anxiety Disorder Screener (GAD‐7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis‐Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction. Results There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug‐induced Parkinson‐like syndrome and idiopathic progressive neurological degenerative process. Conclusions Components of the Millon Behavioral Medicine Diagnostic, PHQ‐9 and GAD‐7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities that could confound outcomes. The identification of these comorbid psychological as well as other neurological degenerative disease processes led to alternate clinical management pathways for these patients. Level of Evidence 2b.

Visual field testing uses high-contrast stimuli in areas of severe visual field loss. However, retinal ganglion cells saturate with high-contrast stimuli, suggesting that the probability of detecting perimetric stimuli may not increase indefinitely as contrast increases. Driven by this concept, this study examines the lower limit of perimetric sensitivity for reliable testing by standard automated perimetry.Evaluation of a diagnostic test.A total of 34 participants with moderate to severe glaucoma; mean deviation at their last clinic visit averaged -10.90 dB (range, -20.94 to -3.38 dB). A total of 75 of the 136 locations tested had a perimetric sensitivity of ≤ 19 dB.Frequency-of-seeing curves were constructed at 4 nonadjacent visual field locations by the Method of Constant Stimuli (MOCS), using 35 stimulus presentations at each of 7 contrasts. Locations were chosen a priori and included at least 2 with glaucomatous damage but a sensitivity of ≥ 6 dB. Cumulative Gaussian curves were fit to the data, first assuming a 5% false-negative rate and subsequently allowing the asymptotic maximum response probability to be a free parameter.The strength of the relation (R(2)) between perimetric sensitivity (mean of last 2 clinic visits) and MOCS sensitivity (from the experiment) for all locations with perimetric sensitivity within ± 4 dB of each selected value, at 0.5 dB intervals.Bins centered at sensitivities ≥ 19 dB always had R(2) 0.1. All bins centered at sensitivities ≤ 15 dB had R(2) 0.1, an indication that sensitivities are unreliable. No consistent conclusions could be drawn between 15 and 19 dB. At 57 of the 81 locations with perimetric sensitivity19 dB, including 49 of the 63 locations ≤ 15 dB, the fitted asymptotic maximum response probability was80%, consistent with the hypothesis of response saturation. At 29 of these locations the asymptotic maximum was50%, and so contrast sensitivity (50% response rate) is undefined.Clinical visual field testing may be unreliable when visual field locations have sensitivity below approximately 15 to 19 dB because of a reduction in the asymptotic maximum response probability. Researchers and clinicians may have difficulty detecting worsening sensitivity in these visual field locations, and this difficulty may occur commonly in patients with glaucoma with moderate to severe glaucomatous visual field loss.

There are currently several functional and structural assessments used clinically to assist with the diagnosis and management of patients with glaucoma. However, none of these tests have sufficiently good diagnostic performance (sensitivity and specificity) to be relied upon in isolation. Identifying structural features that change concurrently with functional measures could indicate a causal relationship, shedding light on the pathophysiological processes leading to vision loss. Moreover, relating structural and functional findings in eyes that are developing, or that have developed glaucoma, provides an opportunity to improve our understanding of this disease. This in turn may lead to the development of better diagnostic tools and better methods for monitoring change over time. It may also allow structural measures that have fewer drawbacks than perimetry (e.g. better repeatability1, 2, shorter test times, better patient acceptance3) to be used as surrogates for function. One additional benefit to understanding structure-function relationships is that differences in the strength of correlation between function and structural tests that all purport to measure the same anatomical feature can be used to make conclusions about the relative ‘noisiness’ of the different structural tests. An improvement in correlation strength brought about by using a different structural test or a better model of the structure-function relation (i.e. exponential vs linear) would imply that variability has been reduced. Even with these enhancements, the correlation between structure and function will almost certainly never reach 1.0 due to factors such as inter-subject variability and temporal disconnects between structural and functional change. Functional deficits are related to decreases in the density of retinal ganglion cells and a corresponding thinning of the retinal nerve fiber layer (RNFL) in experimental models of glaucoma.4 Even though both structural and functional measures describe important aspects of the glaucomatous disease process, and they should certainly be related, some patients display seemingly conflicting results: loss in one, and no loss in the other. One reason for discrepancies between structure and function is variability both between and within patients.5 A second reason is the reliance of different structural measures on distinct theoretical underpinnings. This results in different definitions of the term RNFL, each referring to the presence, or estimated integrity, of different underlying structures. A third reason is that functional testing (such as SAP) typically only assesses a small portion of the retina, in particular the central 25 to 30°. In contrast, most structural measures assess the entire optic nerve head (ONH) or the vast majority of the axons within the RNFL. As a result, there are portions of the ONH and peripapillary RNFL that are not represented within the most commonly used visual field patterns. Three techniques are commonly used in clinical practice to obtain objective measurements of the ‘thickness’ of the peripapillary RNFL. Of these, only one directly measures RNFLT: optical coherence tomography (OCT) measures the distance between the vitreoretinal boundary at the inner limiting membrane (ILM) and the anterior border of the retinal ganglion cell layer (RGCL).6 Scanning laser polarimetry (SLP) measures the relative phase retardance of a scanning laser beam as its polarization state is varied over 360 deg at each double pass traverse through the tissue.7 Normal retardance of the RNFL is known to be dependent on the integrity of the axonal cytoskeleton.8, 9 The retardance measurement is then typically converted to RNFLT by assuming a linear relation between them.7, 10 Confocal scanning laser tomography (CSLT) calculates the average height of the peripapillary retinal surface around the disc margin relative to a reference plane and uses this as its measure of RNFLT. The indirect measures of RNFLT produced by SLP and CSLT do not preclude their ability to provide an important structural measure that correlates with function. For the sake of simplicity, all three estimates (from spectral domain [SD] OCT, SLP and CSLT) will be referred to as ‘RNFLT’ for the remainder of this manuscript. The literature contains studies that employ a range of techniques to analyze structure-function relations. This has resulted in many structure-function relations that are difficult to compare due to differences in study design. In order to determine the strongest structure-function relation among several techniques, it is necessary to study the same cohort, preferably acquiring multiple structural and/or functional measures on the same day. One such study by Bowd et al (2006)11 assessed the relation between SAP and three measures of RNFLT (SLP, time domain [TD] OCT and CSLT as measured by GDxVCC, Stratus OCT, and HRT II respectively). SAP hemifield sensitivity was better correlated with the corresponding sectors of the peripapillary RNFLT measured with TDOCT than with SLP or CSLT. This was true both when assuming linear or logarithmic relations between RNFLT and visual function. A secondary analysis of global RNFLT versus mean visual field sensitivity found that TDOCT produced the strongest association and CSLT the weakest. Since the Bowd et al study was performed, newer forms of OCT and SLP have become available. SDOCT has greater axial resolution and faster scanning times (with potentially less eye movement artifact) than TDOCT. For SLP, the introduction of enhanced corneal compensation (GDx ECC) has reduced the number of patients who manifest an atypical retardation pattern, which were difficult to interpret when using variable corneal compensation (GDx VCC).12 Since these advancements have been made, no studies have compared correlations of these three structural measures to visual function. The current study was designed to determine which of three estimates of RNFLT (SDOCT, SLP and CSLT) correlated best with SAP in a cohort of participants who were either high-risk ocular hypertensives or who had non-endstage glaucoma.

Glaucoma is a chronic, progressive and potentially blinding condition. Predicting which patients will experience significant progression is recognized as a crucially needed development in the management of this disease. Application of the CART (Classification And Regression Trees) methodology has demonstrated that certain patterns of visual field findings may convey greater predictive information for glaucoma progression. However, the current standard classification tree method was developed for uncorrelated data. In this article a classification tree method is extended to correlated binary data. The robust Wald test statistic from generalized estimating equations (GEE) is used to measure the between-node difference while adjusting for correlation between the eyes of a patient. The proposed method is assessed through simulations conducted under a variety of model configurations and is used to analyze the perimetry and psychophysics in glaucoma (PPIG) study data. Employing an amalgamation algorithm from the result of a best-sized tree, each eye is classified to one of two prognosis categories (less likely, or more likely, to progress). Receiver operating characteristics (ROC) and area under the curve (AUC) indicate that the proposed method, applied to data from both eyes of the same patient, provides much improved prediction accuracy compared with application of standard CART method to the same PPIG data.

PURPOSE To determine the clinical features of optic disc progression in patients with ocular hypertension and early glaucoma. PATIENTS A total of 336 eyes of 168 patients with ocular hypertension or early glaucoma. METHODS Two glaucoma specialists independently graded the baseline and most recent optic disc photographs for optic disc progression. Optic disc progression was defined as: new or increased neuroretinal rim thinning (2 or more clock hours), notching (1 clock hour or less of thinning of the neuroretinal rim), excavation (undermining of the neuroretinal rim or disc margin), and nerve fiber layer defect(s). They also determined the location of these changes. RESULTS Ninety-two of 336 eyes (27.4%) showed optic disc progression after a median of 6.1 years. Of those with progression, excavation occurred in 89% of eyes; rim thinning occurring in 54%; and notching occurring in 16%. Fifty-six percent (56%) had 2 or more features of progression. The inferotemporal quadrant was the most common location for progression, but more than 1 location of progression occurred in at least 30% of eyes with progression. CONCLUSIONS Optic disc progression occurred frequently in this cohort of ocular hypertension and early glaucoma patients. When evaluating the optic disc for glaucomatous progression, eye care providers should pay particular attention to increased excavation and neuroretinal rim thinning-especially in the inferotemporal quadrant.

To characterize the error of optical coherence tomography (OCT) measurements of retinal nerve fiber layer (RNFL) thickness when using automated retinal layer segmentation algorithms without manual refinement.Cross-sectional study.This study was set in a glaucoma clinical practice, and the dataset included 3490 scans from 412 eyes of 213 individuals with a diagnosis of glaucoma or glaucoma suspect. We used spectral domain OCT (Spectralis) to measure RNFL thickness in a 6-degree peripapillary circle, and exported the native "automated segmentation only" results. In addition, we exported the results after "manual refinement" to correct errors in the automated segmentation of the anterior (internal limiting membrane) and the posterior boundary of the RNFL. Our outcome measures included differences in RNFL thickness and glaucoma classification (i.e., normal, borderline, or outside normal limits) between scans with automated segmentation only and scans using manual refinement.Automated segmentation only resulted in a thinner global RNFL thickness (1.6 μm thinner, P.001) when compared to manual refinement. When adjusted by operator, a multivariate model showed increased differences with decreasing RNFL thickness (P.001), decreasing scan quality (P.001), and increasing age (P.03). Manual refinement changed 298 of 3486 (8.5%) of scans to a different global glaucoma classification, wherein 146 of 617 (23.7%) of borderline classifications became normal. Superior and inferior temporal clock hours had the largest differences.Automated segmentation without manual refinement resulted in reduced global RNFL thickness and overestimated the classification of glaucoma. Differences increased in eyes with a thinner RNFL thickness, older age, and decreased scan quality. Operators should inspect and manually refine OCT retinal layer segmentation when assessing RNFL thickness in the management of patients with glaucoma.

To test the hypothesis that development of glaucomatous visual fields can be predicted several years earlier from prior visual field information. One-hundred and seven eyes with glaucomatous optic neuropathy (n = 47 eyes) or which were suspicious for glaucoma (n = 60) were prospectively enrolled in a longitudinal study. Visual fields were evaluated on an annual basis using standard automated perimetry (SAP), the original version of frequency doubling technology (FDT) perimetry, and a custom version of FDT that used the 24-2 stimulus pattern. All SAP fields were within normal limits at the initial visit. When the SAP glaucoma hemifield test was ‘outside normal limits’ or the pattern standard deviation probability was worse than the lower 5th percentile or more than two clustered locations at the p

Purpose To determine how well rates of localized retinal nerve fiber layer thickness (RNFLT) change correlate with rates of sensitivity change at corresponding locations in the visual field in glaucoma. Design Retrospective cohort study. Methods Three hundred and sixty-four eyes of 191 participants with suspected or confirmed glaucoma, as judged by experienced clinicians, were tested every 6 months with perimetry and optical coherence tomography (OCT). For each 24-2 visual field location, the corresponding sectoral peripapillary RNFLT was defined using a 30-degree sector, centered on the angle of nerve fiber entry into the optic nerve head. Rates of change of pointwise sensitivity and sectoral RNFLT were calculated over the last 8 visits at which reliable data were obtained. Passing-Bablok regression was used to predict the rate of pointwise sensitivity change from the rate of sectoral RNFLT change, for each location. Results Rates of sectoral RNFLT change were significantly predictive of rates of pointwise sensitivity change at all locations in the field. Correlations were modest, averaging 0.15, ranging from 0.03 to 0.25 depending on the location. A 1 μm/y more rapid thinning in corresponding sectors was associated with 0.3 dB/y more rapid loss in the superior visual field but less than 0.1 dB/y more rapid loss at many locations in the inferior visual field. Conclusions Localized RNFL thinning is associated with sensitivity loss at corresponding locations in the visual field, and their rates of change are significantly correlated. Peripapillary RNFLT may be used to monitor localized changes caused by glaucoma that have measurable consequences for a patient's vision.

Glaucoma is the third leading cause of blindness in the USA, and the second leading cause worldwide.1 Whether a patient’s vision will deteriorate rapidly, slowly or remain relatively stable is one of the most important questions in glaucoma management.2 It has been estimated that 15% of patients with glaucoma will have visual fielddamage within their lifetime that is so severe that it falls outside the dynamic range of automated perimetry.3 However, predicting the rate of progression remains challenging. This is partly because little is known about the exact course of the disease over time, due to there being limited information from well-controlled longitudinal studies, and due to the variability of currently available testing methods. Individuals progress differently, and diagnostic test procedures are constantly being refined. While glaucoma is commonly diagnosed and followed using a combination of structural and functional tests, the most important practical issue for patients is loss of visual function and its impact on their quality of life and activities of daily living.4, 5 Therefore, predicting the rate of functional change remains a high priority. The most widely used functional test for glaucoma is Standard Automated Perimetry (SAP), in which contrast sensitivities for small white stimuli displayed on a uniform white background are measured at numerous locations throughout the visual field.6 Various factors have been reported to be associated with an increased probability of future progression, and/or the rate of future progression. These include higher Intraocular Pressure (IOP),2, 7–10 IOP fluctuation,7, 11 increased age 3, 7–10 and being of a certain race,3, 9, 12 although some of these factors have been disputed.2, 10, 12, 13 It has also been reported that structural damage is often detectable before functional loss with the tools currently available,14 so it may be predictive of future functional change (although it has also been reported that for other patients functional loss is detectable first15). Given that measurements of structure are generally better tolerated by patients than visual field testing,16 it is appealing to use such tests as part of a prognostic evaluation. However, the agreement between structural and functional measures of progression is relatively weak,15, 17, 18 and individual patients can follow very different disease courses. Neuroretinal rim area in particular has been shown to be both globally and topographically correlated with retinal nerve fiber layer thickness and with function,19–21 and has been reported to be the structural parameter from Confocal Scanning Laser Ophthalmoscopy (CSLO) that is best related to current functional status.22 However, its usefulness as a predictor of subsequent functional progression is uncertain. The CSLO Ancillary Study to the Ocular Hypertension Treatment Study (OHTS) found that a decreased rim area, among other CSLO parameters, was predictive of reaching a primary open angle glaucoma endpoint.23 However, the study incorporated not only functional but also structural endpoints (determined using the examination of stereophotographs). Perhaps more importantly, such an endpoint-based analysis is dependent not only on the stage of disease, but also on the exact endpoint used, and provides only limited information about the rate at which functional progression may occur. Therefore we aim to determine the utility of CSLO parameters to predict the rate of subsequent functional change. In this study, we examine the relations between CSLO parameters and both the current functional status and the rate of subsequent functional change. Although clinical decisions are unlikely to be made based on the value of one index at a single time point, assessing the predictive strength of a measure can remove much of the uncertainty caused by confounding factors, and would be expected to be indicative of the utility of that measure in a more complete predictive model. Such a predictive model may be helpful in the management of patients over time.

Currently, global indices that summarize the visual field combine sensitivities on a logarithmic (decibel) scale. Recent structure–function models for glaucoma suggest that contrast sensitivity should be converted to a linear scale before averaging across visual field locations, to better relate sensitivity with the number of surviving retinal ganglion cells (RGCs). New indices designed to represent the number of RGCs already lost are described. At least one was found to be a significantly better predictor of subsequent rate of change than traditional Mean Deviation (p=0.014) in participants with glaucomatous optic neuropathy. Issues concerning the creation of optimal global indices are discussed.

Purpose: To determine whether the hill of vision for Short-Wavelength Automated Perimetry (SWAP) is shallower for women who consume phyto-oestrogen-rich foods than for women who do not. Methods: Visual field data were compared for two groups of healthy amenorrhoeic women 48–69 years-old with normal vision and not using hormone replacement: (1) 24 subjects who reported consuming soy and/or flax products and (2) 20 subjects who reported not consuming these products. Two types of 24-2 visual fields were measured: (1) Full Threshold SWAP and (2) a white-on-white (W/W) field obtained using a Swedish Interactive Threshold Algorithm (SITA Standard). Results: The reduction of SWAP sensitivity from the centre of the field (4 loci, mean eccentricity = 4.2°) to the periphery (20 loci, mean eccentricity = 21.9°) was less for soy/flax consumers than for nonconsumers, both with age-referencing (mean difference = 1.7 dB, p = 0.018) and without (p = 0.012). Corresponding distinctions existed for the SWAP – W/W difference, and there was minimal effect for W/W fields alone. The peripheral age-referenced SWAP sensitivities averaged 2.5 dB higher for consumers than nonconsumers (p = 0.022). Conclusion: The between-group distinctions are consistent with the possibility (derived from the women’s health literature) that phyto-oestrogens may counteract a decline of short-wavelength-sensitive cone-mediated response among postmenopausal women. These results suggest another potential application for SWAP outside its original intended purpose as a glaucoma test. Future studies should assess whether phyto-oestrogen consumption is most beneficial for women who are sufficiently young and/or not too far beyond menopause.

Purpose To examine demographic and clinical factors associated with glaucomatous peripapillary retinoschisis (PPRS) and assess its association with glaucoma progression. Methods Using a case control study design and longitudinal data from a cohort of 166 subjects with a diagnosis of glaucoma or glaucoma suspect, we compared functional, structural, clinical, and demographic characteristics between PPRS cases and controls. Results The frequency of PPRS was 6.0% (12 eyes from 10/166 subjects) with two eyes having PPRS in different sectors for a total of 15 retinoschisis events. There were no significant differences (P > 0.05) in age, sex, visual acuity, central corneal thickness, intraocular pressure, or presence of vitreous adhesion between PPRS and controls. However, eyes with PPRS tended to have a higher cup-to-disc ratio (P = 0.06), thinner RNFL (P = 0.02), and worse visual field mean deviation (MD, P = 0.06) than controls. The rate of RNFL thinning was faster in PPRS (average: -2.8%/year; range: -7.4% to 0.0%/year) than controls (-1.3%/year; range: -4.4% to 0.6%/year; P = 0.021). The rate of visual field MD change was faster in PPRS (-0.49 dB/year; range: -2.0 to 0.9 dB/year) than controls (-0.06 dB/year; range: -0.8 to 0.3 dB/year; P = 0.030). OCT scans showed hyperreflective structures spanning the PPRS whose morphology and spacing (50 ± 7 μm) are consistent with Muller glia, causing signal attenuation casting "shadows" onto distal retina. Conclusions This is the first report showing that glaucomatous PPRS is associated with a faster overall rate of RNFL thinning and visual field deterioration and to specifically identify OCT signs of Muller cell involvement.

Purpose To evaluate the reproducibility of the Heidelberg retina tomograph (HRT) Glaucoma Probability Score (GPS) and assess its potential for monitoring progression. Design Evaluation of diagnostic tests in a randomized, controlled clinical trial. Participants For reproducibility, we included 43 ocular hypertensive (OHT) and 31 glaucoma subjects. For progression, we included 198 OHT and 21 control subjects. Methods To study reproducibility, global GPS values were generated for HRT images acquired in a test–retest study. Images were acquired at 2 visits within 6 weeks of each other, by 2 different observers. To study progression, GPS values were generated for HRT images acquired prospectively (1993–2001). Linear regression of GPS against time was performed, with progression defined as a significant negative slope ( P Main Outcome Measures Reproducibility of GPS was assessed using Bland–Altman analysis (mean difference, 95% limits of agreement). Progression was assessed by the number of OHT subjects identified as progressing, and by agreement with VF progression. Results Reproducibility of GPS was better at its extremes (−0.01±0.20 for GPS 0–0.30, and 0.02±0.09 for GPS 0.78–1.00) than in its mid range (0.07±0.54 for GPS 0.30–0.78). Estimated criterion specificity ranged from 95.2% (95% confidence interval, 76.1%–99.9%) to 96.8% (93.2%–98.5%). Twenty-five OHT subjects (12.6%) progressed by GPS, with 11 of the 25 (5.6%) also progressing by VF; 26 subjects (13.1%) progressed by VF alone. Conclusions Changes in HRT GPS values between 0.30 and 0.78 should be interpreted with caution because the index has poorer reproducibility in this range. The global GPS progression algorithm performs at least as well as previously described rim area-based HRT progression strategies. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.