Glaucoma and Driving License: How to Identify Patients at Risk of Revocation.

Aim: To identify clinical criteria that are easily achievable with follow-up tests and can identify subjects not suitable for driving. Patients and methods: We recruited 194 subjects with a clear diagnosis of glaucoma, with no other conditions that could affect the visual field (VF), and who performed a reliable VF examination. All patients underwent a full ophthalmologic evaluation and a questionnaire considering driving habits. An integrated visual field (IVF) was built using both monocular VF charts; the number of missed points (NoMP) within the central 20°, the average sensitivity (AS), and the better eye mean deviation (BEMD) were evaluated. Results: A total of 128 subjects showed a valid driving license (DL); 61.7% of drivers did not show missed points within the central 20° of the IVF, 27.4% presented one to three missed points, and 10.9% had four or more missed points. Best corrected visual acuity (BCVA) was highly above the legal criteria.Stratifying drivers by their BEMD (-7, -10, and -14 dB), we confirmed that the BEMD decrease corresponds to an increased NoMP and a decreased AS. Conclusion: Better eye mean deviation can be useful in clinical practice to identify patients at increased risk of being unsuitable for driving. Nevertheless, it is important to set specific cut-offs based on on-road driving performance. IVF evaluation may also be implemented in perimeter analysis software so that the composition of IVF, the BEMD, and the AS could directly describe the patient's binocular VF, excluding recourse to the Esterman visual field test (EVFT). Clinical significance: This new methodology will allow every physician-not just ophthalmologists-even if not an expert in evaluating a VF test, in assessing the ability to drive of glaucomatous patients. How to cite this article: Landini L, Donati S, Digiuni M, et al. Glaucoma and Driving License: How to Identify Patients at Risk of Revocation. J Curr Glaucoma Pract 2022;16(2):117-123.

Direct Versus Indirect Corneal Neurotization for the Treatment of Neurotrophic Keratopathy: A Multicenter Prospective Comparative Study.

PURPOSE: To analyze the comparative safety and efficacy of two techniques of corneal neurotization (CN) (direct corneal neurotization [DCN] vs indirect corneal neurotization [ICN]) for the treatment of neurotrophic keratopathy (NK). DESIGN: Multicenter interventional prospective comparative case series. METHODS: This study took place at ASST Santi Paolo e Carlo University Hospital, Milan; S.Orsola-Malpighi University Hospital, Bologna; and Santa Maria alle Scotte University Hospital, Siena, Italy. The study population consisted of consecutive patients with NK who underwent CN between November 2014 and October 2019. The intervention procedures included DCN, which was was performed by transferring contralateral supraorbital and supratrochlear nerves. ICN was performed using a sural nerve graft. The main outcome measures included NK healing, corneal sensitivity, corneal nerve fiber length (CNFL) measured by in vivo confocal microscopy (IVCM), and complication rates. RESULTS: A total of 26 eyes in 25 patients were included: 16 eyes were treated with DCN and 10 with ICN. After surgery, NK was healed in all patients after a mean period of 3.9 months without differences between DCN and ICN. Mean corneal sensitivity improved significantly 1 year after surgery (from 3.07 to 22.11 mm; P < .001) without differences between the 2 groups. The corneal sub-basal nerve plexus that was absent before surgery in all patients, except 4, become detectable in all cases (mean CNFL: 14.67 ± 7.92 mm/mm2 1 year postoperatively). No major complications were recorded in both groups. CONCLUSIONS: CN allowed the healing of NK in all patients as well as improvement of corneal sensitivity in most of them thanks to nerve regeneration documented by IVCM. One year postoperatively, DCN and ICN showed comparable outcomes.

Evidence for alterations in fixational eye movements in glaucoma.

BACKGROUND: Fixation changes in glaucoma are generally overlooked, as they are not strikingly evident as in macular diseases. Fundus perimetry might give additional insights into this aspect, along with traditional perimetric measures. In this work we propose a novel method to quantify glaucomatous changes in fixation features as detected by fundus perimetry and relate them to the extent of glaucomatous damage. METHODS: We retrospectively analysed fixation data from 320 people (200 normal subjects and 120 with glaucoma) from the Preferred Retinal Locus (PRL) detection of a Compass perimeter. Fixation stability was measured as Bivariate Contour Ellipse Area (BCEA), and using two novel metrics: (1) Mean Euclidean Distance (MED) from the Preferred Retinal Locus, and (2) Sequential Euclidean Distance (SED) of sequential fixation locations. These measures were designed to capture the spread of fixation points, and the frequency of position changes during fixation, respectively. RESULTS: In the age corrected analysis, SED was significantly greater in glaucomatous subjects than controls (P = 0.002), but there was no difference in BCEA (P = 0.15) or MED (P = 0.054). Similarly, SED showed a significant association with Mean Deviation (P <  0.001), but neither BCEA nor MED were significantly correlated (P > 0.14 for both). CONCLUSION: Changes in the scanning pattern detected by SED are better than traditional measures of fixation spread (BCEA) for describing the changes in fixation stability observed in glaucoma.

Compass fundus automated perimetry.

BACKGROUND: Compass (CenterVue, Padova, Italy) is a fundus automated perimeter which has been introduced in the clinical practice for glaucoma management in 2014. The aim of the article is to review Compass literature, comparing its performances against Humphrey Field Analyzer (Zeiss Humphrey Systems, Dublin, CA, USA). RESULTS: Analyses on both normal and glaucoma subjects agree on the fact that Humphrey Field Analyzer and Compass are interchangeable, as the difference of their global indices is largely inferior than test -retest variability for Humphrey Field Analyzer. Compass also enables interesting opportunities for the assessment of morphology, and the integration between morphology and function on the same device. CONCLUSION: Visual field testing by standard automated perimetry is limited by a series of intrinsic factors related to the psychophysical nature of the examination; recent papers suggest that gaze tracking is closely related to visual field reliability. Compass, thanks to a retinal tracker and to the active dislocation of stimuli to compensate for eye movements, is able to provide visual fields unaffected by fixation instability. Also, the instrument is a true colour, confocal retinoscope and obtains high-quality 60° × 60° photos of the central retina and stereo-photos details of the optic nerve. Overlapping the image of the retina to field sensitivity may be useful in ascertaining the impact of comorbidities. In addition, the recent introduction of stereoscopic photography may be very useful for better clinical examination.

Comparison of Compass and Humphrey perimeters in detecting glaucomatous defects.

PURPOSE: To compare the performance of Compass fundus automated perimetry (FAP) and Humphrey Field Analyzer (HFA) in glaucoma patients. METHODS: A total of 120 patients with glaucoma underwent 1 FAP and 1 HFA perimetric test over the central 24° on one eye. The chosen eye and sequence were randomized and only reliable examinations were considered for analysis. Mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and the area of absolute scotoma were compared between perimeters. Glaucoma Staging System (GSS2) data were analyzed by means of k test. RESULTS: Mean sensitivity difference (FAP-HFA) was -1.0 ± 2.81 dB (p<0.001, 95% confidence interval [CI] -1.61, -0.60 dB), MD difference was +0.27 ± 2.84 dB (p = 0.36, 95% CI -5.30, 5.83 dB), PSD difference was +0.48 ± 1.95 dB (p = 0.0075, 95% CI -3.37, 4.33 dB), and VFI difference was +2.4% ± 8.4% (p = 0.003, 95% CI -14.0%, +18.8% dB). Weighted kappa for GSS2 was 0.87. Points with null sensitivities were 9.9 ± 10.2 with FAP and 8.2 ± 8.9 with HFA (difference: 1.7 ± 4.0 points, p = 0.013). CONCLUSIONS: Mean sensitivity with FAP is 1 dB lower than HFA, a finding due to different threshold strategies. Differences of global indices for FAP and HFA are small, which makes the 2 perimeters equivalent in the clinical setting. However, FAP seems more severe in evaluating glaucomatous damage, with absolute scotoma areas larger than with HFA. We raise the hypothesis that such difference may be the result of the active compensation of eye movements available with FAP.

Blindness and Glaucoma: A Multicenter Data Review from 7 Academic Eye Clinics.

PURPOSE: To evaluate frequency, conversion rate, and risk factors for blindness in glaucoma patients treated in European Universities. METHODS: This multicenter retrospective study included 2402 consecutive patients with glaucoma in at least one eye. Medical charts were inspected and patients were divided into those blind and the remainder ('controls'). Blindness was defined as visual acuity≤0.05 and/or visual field loss to less than 10°. RESULTS: Unilateral and bilateral blindness were respectively 11.0% and 1.6% at the beginning, and 15.5% and 3.6% at the end of the observation period (7.5±5.5 years, range:1-25 years); conversion to blindness (at least unilateral) was 1.1%/year. 134 eyes (97 patients) developed blindness by POAG during the study. At the first access to study centre, they had mean deviation (MD) of -17.1±8.3 dB and treated intraocular pressure (IOP) of 17.1±6.6 mmHg. During follow-up the IOP decreased by 14% in these eyes but MD deteriorated by 1.1±3.5 dB/year, which was 5-fold higher than controls (0.2±1.6 dB/year). In a multivariate model, the best predictors for blindness by glaucoma were initial MD (p<0.001), initial IOP (p<0.001), older age at the beginning of follow-up (p<0.001), whereas final IOP was found to be protective (p<0.05). CONCLUSIONS: In this series of patients, blindness occurred in about 20%. Blindness by glaucoma had 2 characteristics: late diagnosis and/or late referral, and progression of the disease despite in most cases IOP was within the range of normality and target IOP was achieved; it could be predicted by high initial MD, high initial IOP, and old age.

Repeatability and reproducibility of applanation resonance tonometry: a cross-sectional study.

BACKGROUND: To assess repeatability (intra-observer variability) and reproducibility (inter-operator variability) of intraocular pressure (IOP) measurements with servo-controlled Bioresonator Applanation Resonance Tonometry (ART) and to evaluate possible influential factors. METHODS: The study included 178 patients (115 glaucoma and 63 controls; one eye per subject). IOP was measured once with a Goldmann applanation tonometer (GAT) and twice by ART (ART1, ART2), in randomized sequence, by a single operator to assess intra-operator variability. Each ART measurement consisted on 3 readings. To assess inter-operator variability 2 evaluators performed 2 measurements each (in random order) on the same patient. Repeatability and reproducibility were assessed by the coefficient of variation (CoV) and intraclass correlation coefficient (ICC). RESULTS: In the entire cohort, ART1 was 0.4 ± 2.2 mmHg (-7.0 to 5.7 mmHg) higher than ART2 (p = 0.03) regardless of test order. Intra-operator CoV was 7.0% ± 6.3%, and ICC was 0.80-0.92. Inter-operator CoV ranged between 5.7% ± 6.1% and 8.2% ± 7.2%, and ICC between 0.86 and 0.97. ART1 and 2 were respectively 1.7 ± 3.1 and 1.3 ± 3.1 mmHg higher than GAT (p < 0.01). Test-retest difference with ART fell within ±1 mmHg in 41% of cases, within ±2 mmHg in 70%, within ±3 mmHg in 85%. 15% had a test-retest difference higher than ± 3 mmHg; Bland-Altman 95% intervals of confidence were -3.9 and +4.6 mmHg. Results were unaffected by age, diagnosis, central corneal thickness, keratometry, operator, randomization sequence. CONCLUSIONS: In most cases ART repeatability and reproducibility were high, with no differences due to patients' characteristics. ART measurements overestimated GAT by a mean of 1.3-1.7 mmHg.

Compass: clinical evaluation of a new instrument for the diagnosis of glaucoma.

AIMS: To evaluate Compass, a new instrument for glaucoma screening and diagnosis that combines scanning ophthalmoscopy, automated perimetry, and eye tracking. MATERIALS AND METHODS: A total of 320 human subjects (200 normal, 120 with glaucoma) underwent full ophthalmological evaluation and perimetric evaluation using the Humphrey SITA standard 24° test (HFA), and the Compass test that consisted of a full-threshold program on the central 24° with a photograph of the central 30° of the retina. A subgroup of normal subjects and glaucoma patients underwent a second Compass test during the same day in order to study test-retest variability. After exclusion of 30 patients due to protocol rules, a database was created to compare the Compass to the HFA, and to evaluate retinal image quality and fixation stability. RESULTS: The difference in mean sensitivity between Compass and HFA was -1.02 ± 1.55 dB in normal subjects (p<0.001) and -1.01 ± 2.81 dB in glaucoma (p<0.001). Repeatability SD for the average sensitivity was 1.53 for normal subjects and 1.84 for glaucoma. Test time with the Compass was 634±96 s (607±78 for normals, 678±108 for glaucoma). Compass analysis showed the percentage of fixation within the central 1° was 86.6% in normal subjects, and 79.3% in glaucoma patients. Color image quality was sufficient for diagnostic use in >65% of cases; Image-based diagnosis was in accordance with the initial diagnosis in 85% of the subjects. CONCLUSIONS: Based on preliminary results, Compass showed useful diagnostic characteristics for the study of glaucoma, and combined morphological information with functional data.

An evaluation of therapeutic noninferiority of 0.005% latanoprost ophthalmic solution and xalatan in patients with glaucoma or ocular hypertension.

PURPOSE: To assess the therapeutic noninferiority of 0.005% latanoprost ophthalmic solution versus Xalatan in the treatment of patients with primary open-angle glaucoma or ocular hypertension. PATIENTS AND METHODS: This was a double-masked, randomized, multicenter study. A total of 184 patients with a diagnosis of unilateral or bilateral primary open-angle glaucoma or ocular hypertension were randomly assigned to either 0.005% latanoprost ophthalmic solution or Xalatan for 12 weeks. The primary end-point was the change in intraocular pressure (IOP) at 12 weeks in the 2 groups. Noninferiority was reached if the 2-sided 95% confidence intervals (CI) for the difference between adjusted treatment means were entirely within the interval from -1.5 to +1.5 mm Hg. RESULTS: The difference between treatments in the change of IOP from baseline to the end of treatment was 0.12 mm Hg (95% CI: -0.47, 0.71) in the intention-to-treat population and 0 mm Hg (95% CI: -0.58, 0.57) in the per protocol population. There was no statistically significant difference between the 2 groups in terms of drug-related adverse events. The most commonly reported drug-related local adverse events were: ocular hyperemia, eyelashes growth, and eye irritation. CONCLUSIONS: This study demonstrates that 0.005% latanoprost ophthalmic solution is noninferior to Xalatan in lowering IOP and is generally well tolerated.

Short-term changes in intraocular pressure after phacoemulsification in glaucoma patients.

PURPOSE: To evaluate short-term intraocular pressure (IOP) changes after phacoemulsification in glaucoma and normal patients and the effect of oral acetazolamide (Diamox) to control IOP in these patients. METHODS: 120 patients undergoing cataract surgery were included in this prospective multicenter study involving 6 University Eye Clinics: 60 patients with well-controlled primary open-angle glaucoma (POAG) and 60 controls. Half of the study participants received oral acetazolamide, 250 mg, 1 and 6 h after surgery. The treated and untreated groups were matched for age and density of cataract. All patients underwent a standard phacoemulsification procedure and were checked for IOP with Goldmann tonometry in the morning before surgery and then at 3, 6, 21 and 24 h postoperatively by a masked evaluator. RESULTS: The group with POAG showed a significant postsurgical increase in IOP (p < 0.001) at all time points. Six of thirty (20%) untreated POAG patients showed at least 1 IOP reading above 30 mm Hg whereas acetazolamide significantly reduced postoperative IOP at all time points (p < 0.01) and in no case was IOP >30 mm Hg. The control group had high IOP during the first 6 h (p < 0.01), but normal values thereafter. CONCLUSION: A significant short-term IOP increase may be found after phacoemulsification both in POAG and normal patients; this is not dangerous in normal subjects, but can be potentially dangerous in POAG patients. The use of systemic acetazolamide provided significant control of IOP and could be considered a 'possible standard' management of cataract surgery in POAG patients.

A review of the use of latanoprost for glaucoma since its launch.

INTRODUCTION: Prostaglandins are increasingly used as first choice treatment for glaucoma because they are highly effective, lack relevant systemic side effects and require just once-daily administration. Latanoprost is an ester prodrug analog of prostaglandin F2α, which reduces intraocular pressure (IOP) by increasing uveoscleral outflow. Latanoprost 0.005% has received European and US approval as the first-line drug for reducing IOP in patients with open-angle glaucoma or ocular hypertension. Following the recent patent expiry for Xalatan®, a number of latanoprost generics have entered the glaucoma market. AREAS COVERED: This review, achieved through PubMed and Medline research methods, describes the composition, pharmacokinetics, mode of action, efficacy, side effects and safety profile of latanoprost. EXPERT OPINION: Latanoprost was the first prostaglandin analog introduced in glaucoma management and it dramatically changed the market of the disease thanks to its efficacy and safety. Conjunctival hyperemia, which is commonly found after latanoprost use, is associated with a minor efficacy and duration of trabeculectomy; yet, from the ophthalmologist's perspective, this side effect seems largely counterbalanced by the high efficacy and safety of this compound. It is always advisable to consider the pro-inflammatory mode of action of latanoprost because this may have negative effects in particular patients (i.e., those with uveitis and cystoid macular edema) for whom caution and close follow-up is necessary.