Artificial intelligence-derived macular thinning patterns were associated with central visual field progression in glaucoma and outperformed global thickness metrics in predicting progression across disease severities. To provide spatial patterns of ganglion cell complex thickness and assess their associations with central visual field progression in glaucoma. Macular patterns from the ganglion cell complex were determined using an artificial intelligence algorithm termed archetypal analysis (AA). The diagnostic accuracy of spatial patterns for detecting 10-2 central visual field progression in eyes with at least five 10-2 visual field tests was calculated and compared with the mean global ganglion cell complex thickness. Eyes with progression on either of 2 trend-based methods (significant MD slope less than -0.5dB/y or clustered pointwise linear regression) were classified as "progressors." A total of 4031 macular scans of 1093 eyes (611 patients) were included, with a mean (SD) age of 67.8 (12.7) years. Eleven distinct spatial patterns were identified. While the macular vulnerable zone was preferentially affected in 4 patterns, most of the less vulnerable zones were preserved. The AA models at baseline achieved AUROC [0.73 (95% CI, 0.62-0.84)] and outperformed global ganglion cell complex thickness [0.55 (95% CI, 0.46-0.61), P =0.01] for predicting central VF progression in eyes with early disease at baseline. The AA models AUROC [0.70 (95% CI, 0.59-0.80)] also outperformed ganglion cell complex thickness [0.55 (95% CI, 0.48-0.60), P =0.02] for predicting central VF progression across all severities. Using unsupervised artificial intelligence, characteristic patterns of macular thinning were identified and associated with progression in the central visual field. Spatial macular pattern analysis may enhance individualized care and improve risk stratification for those at risk of central VF damage.

Précis:This is a retrospective observational study investigating the congruity between numerical and clinical hypotony and the risk factors for clinical manifestations of hypotony after trabeculectomy.Purpose:To identify risk factors associated with clinically meaningful hypotony after trabeculectomy.Design:Retrospective cohort study.Methods:Patients who underwent trabeculectomy with mitomycin-C (MMC) were included. Clinical hypotony was defined as the presence (≥ 3 wk after surgery) of choroidal detachment, hypotony keratopathy, hypotony maculopathy, or shallow anterior chamber or the need for trabeculectomy revision to resolve the hypotony at any time after surgery. Numerical hypotony was defined as intraocular pressure (IOP) ≤5 mmHg in 2 or more consecutive visits, at least one of them ≥ 3 weeks after surgery. Baseline, intraoperative, and postoperative characteristics were evaluated as potential risk factors. Univariable and multivariable analyses were conducted to assess the association between each characteristic and the presence of clinical hypotony.Results:Nine hundred ninety-two eyes were included. Two hundred eighty-four eyes (28.6%) met the criteria for numerical hypotony, 222 of which (79.9%) did not show any clinical sequelae of hypotony. 99 eyes (10%) met our criteria for clinical hypotony, whereas 42 of them (42.4%) did not have numerical hypotony. The most frequent manifestation of hypotony was serous choroidal effusion (54 eyes, 5.4%) followed by shallow anterior chamber (28 eyes, 2.8%). Thirty-four eyes (3.4%) underwent trabeculectomy revision to treat the hypotony. Asian ethnicity mitigated against the development of clinical hypotony (OR: 0.29, CI: 0.10–0.72, P=0.015) and the requirement for suture lysis postoperatively was associated with a lower risk of clinical hypotony (OR: 0.49, CI: 0.29–0.81, P=0.006).Conclusions:A minority of eyes (20.1%) with numerical hypotony showed clinical manifestations of low IOP. Asian ethnicity and eyes that required suture lysis postoperatively tended to have less incidence of clinical sequelae of hypotony after trabeculectomy.

Analysis of 1175 Korean adults in the 2019 KNHANES study found that sensitization to house dust mites and birch pollen significantly increased glaucoma risk, while oak pollen sensitization showed a protective effect. The relationship between allergen sensitization and glaucoma remains poorly understood. This study investigated the association between specific allergen sensitization patterns and glaucoma risk using data from the 2019 Korea National Health and Nutrition Examination Survey. In this population-based cross-sectional study, we analyzed 1175 adult participants (≥19y) who completed ophthalmologic examinations and allergen sensitization assessments. Glaucoma diagnosis was based on International Society of Geographical and Epidemiological Ophthalmology criteria. Specific IgE antibodies against 7 common allergens were measured using ImmunoCAP assays, with significant sensitization defined as IgE ≥3.5kU/L. We employed the Synthetic Minority Over-sampling Technique to address class imbalance. Multiple logistic regression models were employed to evaluate associations between allergen sensitization and glaucoma, adjusting for demographic and clinical factors. Among the participants, 50 (4.3%) were diagnosed with glaucoma. Analysis of allergen sensitization patterns revealed house dust mites as the most prevalent allergen (11.7% overall), with comparable rates between the glaucoma (12.0%) and non-glaucoma groups (11.7%). Birch pollen sensitization followed at 4.1% and 4.0% in the glaucoma and non-glaucoma groups, respectively. Multivariate logistic regression analysis, after adjusting for confounders, identified house dust mite sensitization as having the strongest positive association with glaucoma (OR: 3.08, 95% CI: 1.40-6.77, P =0.005), followed by birch pollen (OR: 2.69, 95% CI: 1.02-7.12, P =0.046). Interestingly, oak pollen sensitization demonstrated a protective effect (OR: 0.24, 95% CI: 0.07-0.81, P =0.022). Our findings suggest a complex relationship between allergen sensitization and glaucoma, with different allergens showing varying associations with disease risk.

GATT significantly reduced intraocular pressure and reduced medication use in POAG and PXG patients over 5 years, with high success rates. Previous glaucoma surgeries and early intraocular pressure spikes were risk factors for failure. To evaluate the long-term outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in managing primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG) over 5 years. This retrospective study involved 51 eyes of 42 patients who underwent GATT using prolene suture by a single surgeon with a follow-up duration of at least 5 years. Mean follow-up duration was 69.0±12.1 months. Mean intraocular pressure (IOP) significantly reduced in POAG patients (n=26), from 27.4±5.6mmHg to 14.5±1.9mmHg ( P <0.001), and in PXG patients (n=25), from 26.4 ± 6.6mmHg to 13.3±2.1mmHg ( P <0.001) at the final visit. Correspondingly, the average number of antiglaucomatous medications decreased from 3.2±0.7 to 2.1±1.5 in POAG ( P =0.019) and from 3.5±0.7 to 1.5±1.4 in PXG ( P <0.001). The qualified cumulative surgical success rates at a target IOP ≤18mmHg were 83.1% (95% CI: 72.5%-93.7%) for POAG and 91.2% (95% CI: 84.7%-97.7%) for PXG, and at a target IOP ≤15mmHg were 68.2% (95% CI: 55.0%-81.4%) and 83.5% (95% CI: 74.4%-92.7%), respectively. Factors such as prior incisional glaucoma surgery and higher IOP levels during the first postoperative week were identified as risks for surgical failure. GATT showed promising long-term efficacy and safety in POAG and PXG patients followed for 5 years, achieving significant reductions in IOP and medication dependence. Prior incisional glaucoma surgery and early postoperative IOP elevations were identified as risk factors for failure.

This study revealed the prevalence of paracentral scotoma in highly myopic eyes with early open angle glaucoma, and highlighted structural and vascular parameters associated with paracentral scotoma, which may facilitate the assessment of central visual function. To investigate the prevalence and associated factors of paracentral scotoma in patients with high myopia and early open angle glaucoma (OAG). In this cross-sectional study, myopic eyes with early OAG (mean deviation of visual field > -6dB) were categorized into the high myopia group and the low-to-moderate myopia group. Paracentral scotoma was defined as a visual field defect in one hemifield within 10 degrees of fixation. The prevalence of paracentral scotoma was compared between the 2 groups. Association between structural and vascular factors and paracentral scotoma was investigated by logistic regression analysis. A total of 220 myopic eyes with early OAG were enrolled, including 136 highly myopic eyes, and 84 low-to-moderate myopic eyes. Paracentral scotoma was more prevalent in the high myopia group (39.7% vs. 22.6%, P = 0.012). Multivariate logistic regression analysis showed that thinner circumpapillary retinal nerve fiber layer (cpRNFL) thickness in inferior-temporal and temporal-upper sectors, thinner inferior ganglion cell complex (GCC) thickness, lower radial peripapillary capillary (RPC) vessel density in inferior-temporal and temporal-lower sectors, and lower inferior perifoveal vessel density were significantly associated with paracentral scotoma in highly myopic eyes with early OAG (all P < 0.05). Compared with low-to-moderate myopia, highly myopic eyes with early OAG were more likely to develop paracentral scotoma. The measurement of cpRNFL thickness and RPC vessel density in the temporal and inferior-temporal sectors, GCC thickness, and perifoveal vessel density in the inferior sector may help assessment of central visual function in highly myopic eyes with early OAG.

This chapter reviews the current recommendations on screening for open angle glaucoma in Black and Hispanic populations. Strategies for increasing case-finding and decreasing cost, with emphasis on evolving technologies, are presented. To address the current recommendations on primary open angle glaucoma screening in high-risk minority populations and to discuss potential strategies to improve the screening of glaucoma in these populations. A literature review was performed by searching PubMed, EMBASE, and Google Scholar. All English-language papers that resulted from the search terms from January 1980 to October 2023 were reviewed. In the next few decades, the societal burden of glaucoma will increase because of the demographic shift to an older and more diverse US population, including Black and Hispanic populations, which have been shown to have a higher prevalence of the disease. The current (2022) conclusion of the US Preventive Services Task Force is that the evidence to assess the balance of benefits and harms of screening for glaucoma in adults is insufficient to recommend widespread screening. The Preferred Practice Pattern guideline similarly states that screening for glaucoma in the general population is not cost-effective. However, the guidelines state that screening is more useful and cost-effective when it is targeted at populations at high risk for glaucoma, such as older adults, those with a family history of glaucoma, and Black and Hispanic individuals. Strategies for improving the effectiveness of glaucoma screening must increase case finding and decrease cost. New screening technologies, such as telemedicine and artificial intelligence, are expanding access for underserved populations. There is still no clear consensus on the effectiveness of glaucoma screening for the general population. However, glaucoma screening may be useful and cost-effective when it is targeted at populations at high risk for glaucoma, particularly using emerging technologies that improve access and case-finding.

Cost of disposable ophthalmic equipment. The authors performed a cost analysis comparing the use of disposable and reusable tonometry equipment and gonioscopy lenses. All adult patient (≥16y of age) visits in a 1-year period were included. Scenario analysis was employed to calculate the cost of disposable [Goldmann applanation tonometry (GAT) tips, rebound tonometry tips, and gonioscopy lenses] and reusable equipment (GAT tips and gonioscopy lenses) as well as sanitization over 2, 5, and 10 years at a single institution. To account for variability in scenario modeling, a sensitivity analysis was additionally performed. The main outcome measure was cost differences for disposable equipment compared with reusable equipment with sanitization. The total volume included was 80,356 patient visits. Accounting for variable costs, the additional cost associated with disposable tonometry (GAT or rebound tonometry tips) instead of reusable GAT was $118,723 over 2 years and $603,924 over 10 years. Assuming a gonioscopy frequency of 3.2%, the additional cost associated with disposable gonioscopy lenses was $171,100 at 5 years and $361,237 at 10 years. At a gonioscopy frequency of 10%, the additional cost associated with disposable lenses was $1,208,096 without inflation at 10 years. Overall, the total additional cost associated with disposable tonometry tips and gonioscopy lenses over reusable versions of this equipment was $965,161 over 10 years at a single institution. A widespread transition from reusable to disposable tonometry and gonioscopy equipment was associated with an additional cost of $965,161 over a 10-year period at a single institution.

Intraluminal stent-removal post-PGI surgery significantly reduces IOP with high success rates but carries the risk of hypotony and complications, for example, suprachoroidal hemorrhage. Long-term management often requires the eventual addition of IOP-lowering therapy despite initial efficacy. To report outcomes after intraluminal stent removal following PAUL Glaucoma Implant (PGI) surgery from a single-center cohort. Retrospective review of patients undergoing intraluminal prolene removal following PGI surgery at the University Eye Hospital, Bonn, Germany, from April 2021 to November 2023. Seventy eyes of 68 patients were included. Qualified and complete success rates (95% CI) were 92.9% and 55.7% after 1 year and 88.6% (81.4% to 95.7%) and 50% (37.1% to 62.9%) at the last follow-up time point for IOP ≤18mm Hg and 81.4% and 54.3% and 70% and 42.9% IOP ≤15mm Hg, respectively. Mean IOP decreased from 23.93 to 12.07mm Hg after 12 months, 11.32mm Hg after 24 months, and 10.41mm Hg after 36 months. The mean number of IOP-lowering eye drops was zero before and immediately after removal and increased to 1.57 (0 to 2) at 12 months, 1.15 (0 to 4) at 24 months, and 1.12 (0 to 4) at 36 months. Postoperative complications occurred in 5 eyes (7.1%). Two eyes had suprachoroidal hemorrhage, with one needing vitrectomy and one external tube ligation; one required PGI explantation for persistent hypotony. Removal of the prolene stent following PGI surgery effectively lowers IOP in the short term, with a moderate increase in IOP and need for pressure-lowering therapy over time. However, it can also lead to adverse outcomes, such as hypotony and suprachoroidal hemorrhage, especially in patients with systemic risk factors or those undergoing early removal.

In our study of the factors predictive of latanoprost response, we found that normotensive subjects with higher intraocular pressure, lower uveoscleral outflow, and higher body mass index had a greater response to 1-week treatment. To evaluate relationships between variable intraocular pressure (IOP) responses to latanoprost and participant characteristics, baseline values and changes in aqueous humor dynamics (AHD) parameters. We assessed 226 eyes from 113 healthy participants. AHD parameters measured at baseline and after 1-week treatment with latanoprost included: IOP by pneumatonometry, episcleral venous pressure (EVP) by venomanometry, aqueous humor flow rate by fluorophotometry, outflow facility by 2-minute pneumatonography, and uveoscleral outflow calculated using the modified Goldmann equation. IOP responses were categorized into 4 groups: nonresponders (<10% reduction), all-responders (≥10% reduction), medium-responders (10%-20% reduction), and high-responders (≥20% reduction). Generalized estimating equation models were used to analyze treatment effects and compare groups. Baseline IOP was higher in high-responders than medium-responders and nonresponders ( P =0.007 and P <0.001, respectively). Body mass index (BMI) was significantly higher in high-responders and all-responders compared with nonresponders ( P =0.02 and P =0.03, respectively). Responders had lower baseline uveoscleral outflow ( P =0.03). There were no significant differences in other baseline characteristics including EVP, outflow facility, and aqueous flow rate between the 4 groups. IOP decreased while outflow facility and uveoscleral outflow increased after latanoprost treatment in all responder groups but did not change in nonresponders. EVP and aqueous flow rate did not change significantly in any group. The change in uveoscleral outflow was greater in high-responders than in nonresponders ( P =0.004). In healthy subjects, higher baseline IOP, lower uveoscleral outflow and higher BMI are predictors of a greater IOP reduction by latanoprost. A greater increase in uveoscleral outflow is responsible for this larger response.