Longitudinal Changes in Visual Acuity and Contrast Sensitivity and Incident Dementia.

PURPOSE: To evaluate the impact of baseline and change in vision on the risk of developing dementia. DESIGN: Retrospective cohort study. METHODS: This longitudinal analysis utilized data from the 2021 and 2022 National Health and Aging Trends Study. Binocular presenting vision was assessed, including distance (DVA) and near (NVA) visual acuity, and contrast sensitivity (CS). Dementia status was defined based on: (1) medical diagnosis of dementia, (2) dementia score, or (3) poor cognitive test performance. RESULTS: Of the 2,159 adults included in this study, weighted mean (SD) age was 77.9 years (5.2), with the majority being female (weighted: 54%), and White (88%). The baseline median (interquartile range [IQR]) DVA was 0.08 (0-0.20) logMAR, NVA was 0.17 (0.09-0.26) logMAR, and CS was 1.80 (1.65-1.85) logCS. Over the 1-year follow up period, 192 (6.6%) adults developed dementia. In time-to-event analyses, baseline DVA (HR: 1.08 [95% CI: 1.02-1.14], per 0.1 logMAR), NVA (HR: 1.07 [95% CI: 1.01-1.13], per 0.1 logMAR), and CS (HR: 1.09 [95% CI: 1.03-1.15], per 0.1 logCS) were associated with greater likelihood of incident dementia. Further, change in CS (HR: 1.14 [95% CI: 1.04-1.25], per 0.1 logCS worse/year), but not VA, was associated with greater likelihood of incident dementia. CONCLUSIONS: Worse baseline VA and CS are associated with greater likelihood of incident dementia. Further, worsening CS over time, but not VA, was associated with higher likelihood of incident dementia. Future work is needed to study interventions targeted at improving vision deficits and examine their impact on decreasing dementia risk.

Concordance Between Self-Reported Visual Difficulty and Objective Visual Impairment: The National Health and Aging Trends Study.

OBJECTIVE: To examine the performance of self-reported visual difficulty (VD) in predicting objective visual impairment (VI) in older adults and explore factors that influence discordance in these classifications. DESIGN: Cross-sectional analysis of the National Health and Aging Trends Study (2022). METHODS: Participants reporting blindness or difficulties with distance or near vision were characterized as having VD. Presenting binocular distance visual acuity (VA), near VA, and contrast sensitivity (CS) were assessed. Objective VI was defined as having VI in either distance VA (worse than 20/40), near VA (worse than 20/40), or CS (worse than 1.55 logCS). Receiver operating characteristic analysis was used to compare performance of VD in predicting objective VI. To investigate factors that influence discordance, we limited our sample to adults with objective VI and employed a multivariable logistic regression model to identify factors associated with not reporting VD. Similar analyses were performed to explore factors associated with reporting VD in adults without objective VI. RESULTS: 4,999 adults were included in the 2022 cohort. VD achieved an area under the curve (AUC) of 56.0 (95% CI: 55.2, 56.9) in predicting objective VI, with a sensitivity of 15.8 (95% CI: 14.2, 17.5) and specificity of 96.3 (95% CI: 95.5, 96.9). Characteristics associated with not reporting VD in adults with objective VI included: female gender (odds ratio [OR]: 0.64 [95% CI: 0.42, 0.99]), Hispanic ethnicity (OR: 0.49 [95% CI: 0.31, 0.78), higher income (≥75k, OR: 1.99 [95% CI: 1.14, 3.45]), having ≥4 comorbidities (OR: 0.46 [95% CI: 0.29, 0.72]), and having depressive symptoms (OR: 0.49 [95% CI: 0.25, 0.93]). Meanwhile, factors associated with self-reporting VD in the absence of objective VI included Hispanic ethnicity (OR: 2.11 [95% CI: 1.15, 3.86]), higher income (≥75k, OR: 0.27 [95% CI: 0.12, 0.63]), and having anxiety symptoms (OR: 3.05 [95% CI: 1.56, 5.97]). CONCLUSIONS: Self-reported visual difficulty is a distinct measure assessing disability and has limited ability in predicting objective VI. Caution is advised when utilizing self-reported visual difficulty as a surrogate measure for objective VI in epidemiological studies, though it may still be an effective way to capture risk of current or future disability.

The Quantitative Impact of Visual Function on Accelerometer-measured Physical Activity in Older United States Adults: A Nationwide Cross-sectional Analysis.

Purpose: To explore the impact of objective vision measures on novel metrics of objectively-measured physical activity (PA) in a nationally representative sample of United States (US) older adults. Design: Cross-sectional analysis using data from the National Health and Aging Trends Study. Participants: Adults had their distance and near visual acuity (VA) and contrast sensitivity (CS) tested. Any objective vision impairment (VI), defined as any VI in distance VA, near VA, or CS, was the primary exposure. Physical activity data were collected using the Actigraph CentrePoint Insight Watch worn for 7 days. Methods: Multivariable regression models were used to investigate the association between vision and PA measures. All analyses accounted for the survey design and models were adjusted for age, sex, race, living arrangement, education, and comorbidities. Main Outcome Measures: Physical activity metrics included (1) total daily activity (active minutes per day, number of active bouts, and mean length of active bouts), (2) activity fragmentation, and (3) time until 75% activity. An active bout was defined as ≥ 1 consecutive active minute. Activity fragmentation was defined as the probability of an active minute being followed by a sedentary minute, with higher values indicating more fragmented activity. Time until 75% activity was defined as the time taken to complete 75% of daily PA starting from their first active bout. Results: Among 723 participants, sampled from 10 443 338 older adults in the US, 30% had any objective VI. Any objective VI was significantly associated with lower number of active minutes per day (7.8% fewer [95% confidence interval {CI}: -13.6% to -1.7%]), shorter active bouts (7.0% shorter [95% CI: -12.3% to -1.4%]), and greater activity fragmentation (2.5% [95% CI: 0.8% to 4.2%]), while no associations were found with number of active bouts. Time until 75% activity did not significantly differ between adults with any objective VI and those without (P = 0.34). Conclusions: Older US adults with any objective VI displayed lower total daily activity, as well as more fragmented, shorter periods of PA, despite having a similar number of active bouts compared to their normally sighted counterparts. Implementing interventions that increase bout duration may help promote PA in adults with VI. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Visual Impairment and Real-World Home Physical Activity With Home Environment in an Older Population.

Importance: Physical activity levels are lower in visual impairment. However, additional factors, such as home environmental features, which can modify physical activity in this group, are unknown. Objective: To investigate the association between home environment features and home physical activity in patients with visual impairment. Design, Setting, and Participants: This cross-sectional study of clinical patients included participants with glaucoma suspect and primary glaucoma who were 60 years or older with varying degrees of visual field damage. Study participants were recruited from the Johns Hopkins Wilmer Eye Institute Glaucoma Clinic, Baltimore, Maryland, from September 2013 through March 2015. Data were analyzed from December 19, 2022, through December 25, 2022. Main Outcomes and Measures: Total in-home steps taken per day was the primary outcome measure; time in daily home physical activity and nonsedentary activity were secondary outcomes. Results: A total of 153 participants were included in analyses with mean age of 71 (SD, 7.8) years and 71 were female (46%). Sixty percent had more than 1 comorbid illness, about one-third took 5 or more prescription drugs, and median daily home steps were 1137. Median integrated visual field sensitivity was 28 dB. Better-eye median visual acuity in logMAR was 0.05 (20/22 Snellen equivalent). For every 0.1-log unit increment in average measured home lighting, participants took 5% more daily steps (rate ratio [RR], 1.05; 95% CI, 1.00-1.10; P = .04) and had a 3% faster average daily peak cadence (RR, 1.03; 95% CI, 1.01-1.05; P = .01). The average number of nonsedentary activity minutes (RR, 1.04; 95% CI, 1.00-1.07; P = .06), average bout duration (ß = 0.03; 95% CI, 0.00-.07; P = .06), and activity fragmentation (ß = -0.06; 95% CI, -0.13 to 0.00; P = .06) showed associations with home lighting. The number of hazards was not associated with any activity metric (steps: RR, 1.14; 95% CI, 0.96-1.34; P = .13; peak cadence: RR, 1.00; 95% CI, 0.93-1.08; P = .98; and nonsedentary time: RR, 1.11; 95% CI, 0.98-1.26; P = .11), nor was the frequency of hazards. Conclusions and Relevance: In this study, results demonstrated that home environment features, particularly lighting, may influence home activity metrics in older adults with visual impairment. Further prospective studies would be needed to confirm if home modifications can improve at-home activity.

A Comparative Analysis of Intraocular Pressure Measurement Accuracy With Reused iCare Probes.

PURPOSE: To assess the accuracy of reused iCare probes after disinfection with 70% isopropyl alcohol and ethylene oxide gas compared to new iCare probes and Goldmann applanation tonometry (GAT). DESIGN: Prospective comparative analysis. PARTICIPANTS: A total of 118 eyes from 59 patients recruited from the Aravind Eye Hospital glaucoma clinic in Tirupati, South India. METHODS: Intraocular pressure (IOP) was measured on each eye using a new iCare tonometer probe, an iCare probe previously used and disinfected 1 time prior (once used probe) and 5 times prior (multiply used probe), as well as with GAT. Probes were disinfected after each use with 70% isopropyl alcohol swabs and ethylene oxide sterilization. MAIN OUTCOME MEASURES: Agreement demonstrated with intraclass correlation coefficients (ICCs), mean difference in IOP values with limits of agreement, and Bland-Altman plots among IOP measurement approaches. RESULTS: Compared to new iCare probes, both once used probes (ICC = 0.989, 95% confidence interval [CI] 0.985-0.993) and multiply used probes (ICC = 0.989, 95% CI 0.984-0.992) showed excellent agreement, and the mean difference in IOP was minimal for both once used probes (0.70 mmHg, 95% CI 0.29-1.11) and multiply used probes (0.75 mmHg, 95% CI 0.66-0.82) compared to new probes. Bland-Altman plots demonstrated minimal differences between new and reused probes across the spectrum of IOP. When comparing multiply used probes to once used probes, there was a high level of agreement (0.993) (95% CI 0.990-0.995) and negligible mean IOP difference 0.04 mmHg (95% CI 0.32-0.40). Additionally, ICC values for new probes (0.966, 95% CI 0.951-0.976), once used probes (0.958, 95% CI 0.940-0.971), and multiply used probes (0.957, 95% CI 0.938-0.970) compared to GAT were similar and all showed excellent agreement. Both new and reused iCare probes underestimated IOP by 2 to 3 mmHg compared to GAT. CONCLUSIONS: In this prospective comparative analysis, we found that reusing iCare probes up to 5 times does not compromise the accuracy of IOP measurements when disinfected with 70% isopropyl alcohol swabs and ethylene oxide. Reusing iCare probes has the potential to transform care by reducing cost, decreasing environmental waste, and allowing for glaucoma screening camps and increased glaucoma monitoring in low resource settings leading to earlier identification and treatment of glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Vision Impairment and Psychosocial Function in US Adults.

Importance: Vision impairment and psychosocial function, including symptoms of depression and anxiety and social isolation, are a major cause of morbidity in the US. However, there is a lack of nationally representative studies assessing associations between both objective and subjective vision impairment with psychosocial function following the COVID-19 pandemic. Objective: To provide updated national estimates on the associations of vision impairment with depressive and anxiety symptoms and social isolation in US adults 65 years and older. Design, Setting, and Participants: This was a cross-sectional analysis of the National Health and Aging Trends Study round 9 (2019) and 11 (2021), a nationally representative sample of Medicare beneficiaries aged 65 years and older. Binocular distance visual acuity, near visual acuity, and contrast sensitivity were tested. Objectively measured vision impairment was defined as having vision impairment in either distance visual acuity (worse than 20/40), near visual acuity (worse than 20/40), or contrast sensitivity (worse than 1.55 logCS). Self-reported vision impairment was defined based on participants' report on their vision status. Data were analyzed in May 2023. Main Outcomes and Measures: Depressive and anxiety symptoms assessed via the Patient Health Questionnaire. Social isolation was defined based on living arrangement, communication frequency, and activity participation responses. Results: Among 2822 community-dwelling adults sampled from a population of 26 182 090, the mean (SD) age was 78.5 (5.6) years; 1605 individuals (54.7%) were female; 1077 (32.3%) had objectively measured vision impairment, and 203 (6.4%) had self-reported vision impairment. In adjusted models, all outcomes were significantly associated with objectively measured vision impairment, including depressive symptoms (odds ratio [OR], 1.81; 95% CI, 1.26-2.58), anxiety symptoms (OR, 1.74; 95% CI, 1.13-2.67), and severe social isolation (OR, 2.01; 95% CI, 1.05-3.87). Similarly, depressive symptoms (OR, 2.37; 95% CI, 1.44-3.88) and anxiety symptoms (OR, 2.10; 95% CI, 1.09-4.05) but not severe social isolation symptoms (OR, 2.07; 95% CI, 0.78-5.49) were significantly associated with self-reported vision impairment. Conclusions and Relevance: In this study, vision impairment was associated with several psychosocial outcomes, including symptoms of depression and anxiety and social isolation. These findings provide evidence to support prioritizing research aimed at enhancing the health and inclusion of people with vision impairment.

Utilizing visual symptoms to distinguish dry eye from glaucoma, cataract, and suspect glaucoma patients: a cross-sectional study.

BACKGROUND: The diagnosis of dry eye and other common ophthalmological conditions can be supported using patient reported symptoms, which is increasingly useful in contexts such as telemedicine. We aim to ascertain visual symptoms that differentiate dry eye from cataract, glaucoma, or glaucoma suspects. METHODS: Adults with dry eye, glaucoma, cataract, and suspected glaucoma (controls) completed a questionnaire to rate the frequency and severity of 28 visual symptoms. Univariate, followed by multivariable logistic regression with backward stepwise selection (p < 0.05), determined the individual symptoms and set of symptoms best distinguishing dry eye from each of the other conditions. RESULTS: Mean age of 353 patients (94 glaucoma suspect controls, 79 glaucoma, 84 cataract, and 96 dry eye) was 64.1 years (SD = 14.1); 67% were female and 68% White. Dry eye patients reported more frequent light sensitivity (OR = 15.0, 95% CI = 6.3-35.7) and spots in vision (OR = 2.8, 95% CI = 1.2-6.3) compared to glaucoma suspect controls. Compared to glaucoma patients, dry eye patients experienced more frequent light sensitivity (OR = 9.2, 95% CI = 2.0-41.7), but less frequent poor peripheral vision (OR = 0.2, 95% CI = 0.06-0.7), difference in vision between eyes (OR = 0.09, 95% CI = 0.01-0.7), and missing patches of vision (OR = 0.06, 95% CI = 0.009-0.3). Compared to cataract patients, dry eye patients reported more frequent spots in vision (OR = 4.5, 95% CI = 1.5-13.4) and vision variability across the week (OR = 4.7, 95% CI = 1.2-17.7) and were less likely to report worsening vision (OR = 0.1, 95% CI = 0.03-0.4) and blindness (OR = 0.1, 95% CI = 0.02-0.8). CONCLUSION: Visual symptoms may serve as a complementary tool to distinguish dry eye from various ocular conditions, though the symptoms that best distinguish dry eye differ across comparisons. Differentiating how patients visually perceive common eye diseases may be used in a variety of clinical settings to rule out specific conditions.

Early Endophthalmitis Incidence and Risk Factors after Glaucoma Surgery in the Medicare Population from 2016 to 2019.

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

How much does cataract surgery contribute to intraocular pressure lowering?

PURPOSE OF REVIEW: To review the literature evaluating the effect of cataract surgery on intraocular pressure (IOP) in patients with glaucoma. RECENT FINDINGS: Recent high-quality secondary analyses of large and primary trials continue to show IOP lowering following cataract surgery. Likewise, cataract surgery remains a key treatment for angle closure glaucoma. Some micro-invasive glaucoma surgeries (MIGS) have strong evidence to be performed at the time of cataract surgery. Data clarifying when these surgeries should be combined with cataract surgery is emerging. The mechanism underlying IOP lowering after cataract surgery remains unclear. SUMMARY: Patients who are glaucoma suspects with visually significant cataracts would benefit from cataract surgery alone. Those with mild-moderate damage on 1-2 classes of medications would most likely benefit from additional MIGS. Patients with advanced disease would benefit from cataract surgery and a choice of additional surgery, which depends on disease status and patient factors. Clear lens extraction is becoming a more accepted practice as a primary procedure for patients with angle closure and high IOP or glaucoma. The role of additional MIGS in angle closure needs further study.

The Impact of Achieving Target Intraocular Pressure on Glaucomatous Retinal Nerve Fiber Layer Thinning in a Treated Clinical Population.

PURPOSE: To estimate the effect of being below and above the clinician-set target intraocular pressure (IOP) on rates of glaucomatous retinal nerve fiber layer (RNFL) thinning in a treated real-world clinical population. DESIGN: Retrospective cohort study. METHODS: A total of 3256 eyes (1923 patients) with ≥5 reliable optical coherence tomography scans and 1 baseline visual field test were included. Linear mixed-effects modeling estimated the effects of the primary independent variables (mean target difference [measured IOP - target IOP] and mean IOP, mm Hg) on the primary dependent variable (RNFL slope, µm/y) while accounting for additional confounding variables (age, biological sex, race, baseline RNFL, baseline pachymetry, and disease severity). A spline term accounted for differential effects when above (target difference >0 mm Hg) and below (target difference ≤0 mm Hg) target pressure. RESULTS: Eyes below and above target had significantly different mean RNFL slopes (-0.44 vs -0.71 µm/y, P < .001). Each 1 mm Hg increase above target had a 0.143 µm/y faster rate of RNFL thinning (P < .001). Separating by disease severity, suspect, mild, moderate, and advanced glaucoma had 0.135 (P = .002), 0.116 (P = .009), 0.203 (P = .02), and 0.65 (P = .22) µm/y faster rates of RNFL thinning per 1 mm Hg increase, respectively. CONCLUSIONS: Being above the clinician-set target pressure is associated with more rapid RNFL thinning in suspect, mild, and moderate glaucoma. Faster rates of thinning were also present in advanced glaucoma, but statistical significance was limited by the lower sample size of eyes above target and the optical coherence tomography floor effect.

The Association of Physical Activity with Glaucoma and Related Traits in the UK Biobank.

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

Distinguishing Glaucoma, Cataract, and Glaucoma Suspect Based on Visual Symptoms.

PRCIS: Cataract, glaucoma, and glaucoma suspect patients report differing visual symptoms. Asking patients about their visual symptoms may provide useful diagnostic information and inform decision-making in patients with comorbid conditions. PURPOSE: To compare visual symptoms in glaucoma, glaucoma suspect (controls), and cataract patients. METHODS: Glaucoma, cataract, and glaucoma suspect patients at Wilmer Eye Institute responded to a questionnaire rating the frequency and severity of 28 symptoms. Univariate and multivariable logistic regression determined the symptoms that best differentiate each disease pair. RESULTS: In all, 257 patients (mean age: 67.4 ± 13.4 y; 57.2% female; 41.2% employed), including 79 glaucoma, 84 cataract, and 94 glaucoma suspect patients, participated. Compared with glaucoma suspects, glaucoma patients were more likely to report poor peripheral vision (OR 11.29, 95% CI: 3.73-34.16), better vision in 1 eye (OR 5.48, 95% CI: 1.33-22.64), and light sensitivity (OR 4.85, 95% CI: 1.78-13.24), explaining 40% of the variance in diagnosis (ie, glaucoma vs. glaucoma suspect). Compared with controls, cataract patients were more likely to report light sensitivity (OR 3.33, 95% CI: 1.56-7.10) and worsening vision (OR 12.20, 95% CI: 5.33-27.89), explaining 26% of the variance in diagnosis (ie, cataract vs. glaucoma suspect). Compared with cataract patients, glaucoma patients were more likely to report poor peripheral vision (OR 7.24, 95% CI: 2.53-20.72) and missing patches (OR 4.91, 95% CI: 1.52-15.84), but less likely to report worsening vision (OR 0.08, 95% CI 0.03-0.22), explaining 33% of the variance in diagnosis (ie, glaucoma vs. cataract). CONCLUSIONS: Visual symptoms distinguish disease state to a moderate degree in glaucoma, cataract, and glaucoma suspect patients. Asking about visual symptoms may serve as a useful diagnostic adjunct and inform decision-making, for example, in glaucoma patients considering cataract surgery.

Using Objective Vision Measures to Explore the Association of Vision Impairment With Cognition Among Older Adults in the United States.

PURPOSE: To evaluate the association between vision impairment (VI) and cognitive function using objective measures. DESIGN: Cross-sectional analysis with a nationally representative sample. METHODS: The association between VI and dementia was investigated in a US population-based, nationally representative sample of Medicare beneficiaries, the National Health and Aging Trends Study (NHATS), a nationally representative sample of Medicare beneficiaries aged ≥65 years, using objective vision measures. Exposures included distance VI (>20/40), near VI (>20/40), contrast sensitivity impairment (CSI) (<1.55), any objective VI (distance and near visual acuity, or contrast), and self-reported VI. The main outcome measure was dementia status defined based on survey reports, interviews, and cognitive tests. RESULTS: A total of 3026 adults were included in this study; the majority were female (55%) and White (82%). The weighted prevalence rates were 10% for distance VI, 22% for near VI, 22% for CSI, 34% for any objective VI, and 7% for self-reported VI. Across all measures of VI, dementia was more than twice as prevalent in adults with VI compared to their peers without (P < .001 for all). In adjusted models, all measures of VI were associated with higher odds of dementia (distance VI: OR 1.74, 95% CI 1.24-2.44; near VI: OR 1.68, 95% CI 1.29-2.18; CSI: OR 1.95, 95% CI 1.45-2.62; any objective VI: OR 1.83, 95% CI 1.43-2.35; self-reported VI: OR 1.86, 95% CI 1.20-2.89). CONCLUSIONS: In a nationally representative sample of older US adults, VI was associated with increased odds of dementia. These results suggest that maintaining good vision and eye health may help preserve cognitive function in older age, although more research is needed to investigate the potential benefits of interventions that focus on vision and eye health on cognitive outcomes.

Predicting Visual Field Worsening with Longitudinal OCT Data Using a Gated Transformer Network.

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

Association of Optic Nerve Head and Macular Optical Coherence Tomography Measures With Glaucoma-Related Disability.

PRCIS: Optical coherence tomography (OCT) estimated retinal nerve fiber layer (RNFL) thickness associated with glaucoma-related disability independent of the visual field (VF) damage and thus may provide additional patient-relevant disability information beyond what is captured by standard VF testing. PURPOSE: To examine whether OCT metrics [peripapillary RNFL thickness and macular ganglion cell/inner plexiform layer (GCIPL) thickness] are associated with quality of life (QoL) measures and additional disability metrics, and whether these associations are independent of VF damage. METHODS: In this cross-sectional study, 156 patients with glaucoma or suspected glaucoma received VF testing and OCT scans to measure RNFL and GCIPL thickness. QoL was assessed using the Glaucoma Quality-of-Life 15 and additional disability measures including fear of falling, reading speed, and steps per day were assessed. Multivariable regression models adjusting for relevant covariates tested whether RNFL or GCIPL thickness from the less-impaired eye were associated with disability measures and whether associations were independent of VF damage. RESULTS: Greater VF damage is associated with worse QoL (95% CI=0.4-1.4; P <0.001) and slower reading speed (CI=-0.06 to -0.02; P <0.001). Lower RNFL and GCIPL thicknesses were associated with lower QoL scores, but not with QoL scores or other disability metrics after correcting for VF damage. However, post hoc analyses in patients with better eye thicknesses between 55 and 75 µm demonstrated associations between lower RNFL thickness and worse QoL (CI=-2.2 to -0.1; P =0.04) and greater fear of falling (CI=-6.1 to -0.4; P =0.03) even after accounting for VF damage. No such associations were observed for GCIPL thickness. CONCLUSIONS: OCT RNFL, but not GCIPL, thickness is associated with multiple disability measures independent of VF damage severity.

The Impact of Social Determinants of Health on Vision Loss From Cataracts and Cataract Surgery Utilization in the United States-A National Health Interview Survey Analysis.

PURPOSE: To investigate the association of social determinants of health (SDOH) factors and cataract-related outcomes disparities. DESIGN: Cross-sectional, with a nationally representative sample. METHODS: We used publicly available data from the 2008, 2016, and 2017 National Health Interview Survey data sets. Outcome measures included self-reported prevalence for ever been diagnosed with cataract, vision loss secondary to cataracts, and the likelihood of undergoing cataract surgery. Survey-weighted, multivariable logistic regression models, adjusted for age, race and ethnicity, and other relevant covariates, were used to examine the association between SDOH factors and cataract-related outcomes. RESULTS: A total of 81,551 participants were included, who were predominantly between 18 and 44 years of age (49.6%), female (51.7%), and White (74.8%). Multivariable regression models with age as a covariate showed that individuals who were not working were more likely to report having cataracts than those who were working (P < .001). Those who needed but could not afford medical care in the past year were more likely to report vision loss secondary to cataracts than their counterparts (P < .001). Uninsured participants were less likely to report undergoing cataract surgery than those with private insurance (P = .03). Individuals with higher income (poverty-income ratio: 1.00-2.99 vs <1.00) were more likely to report undergoing cataract surgery (P = .04). CONCLUSIONS: Several SDOH factors were associated with disparities in rates of cataract-related outcomes. These findings highlight the importance of ophthalmologists screening for social risks in patients with cataract, as these social factors are important barriers for access to care.

Associations of Midlife and Late-Life Blood Pressure Status With Late-Life Retinal OCT Measures.

Purpose: To explore the relationship of long-term blood pressure (BP) patterns with late-life optical coherence tomography (OCT) structural measures reflecting optic nerve health. Methods: Participants in this community-based cohort study of black and white individuals were part of the Atherosclerosis Risk in Communities study and the nested Eye Determinants of Cognition (EyeDOC) study. Participants had BP measured six times from 1987 to 2017 and were categorized into five BP patterns: sustained normotension; midlife normotension, late-life hypertension (systolic BP [SBP] >140 mmHg or diastolic BP [DBP] >90 mmHg or antihypertensive medication use); sustained hypertension; midlife normotension, late-life hypotension (SBP <90 mmHg or DBP <60 mmHg); and midlife hypertension, late-life hypotension. Multivariable linear regression modeling was used to evaluate associations between BP patterns and late-life OCT ganglion cell complex (GCC) and peripapillary retinal nerve fiber layer (RNFL) thickness. Results: In total, 931 eyes of 931 participants (mean age at EyeDOC visit = 80 years; 63% female; 45% black) were included. Mean GCC and RNFL thicknesses in the sustained normotension pattern were 90.8 ± 10.3 µm and 89.9 ± 11.2 µm versus 89.4 ± 11.9 µm and 90.1 ± 12.2 µm in the sustained hypertension pattern (P > 0.05). Compared to the sustained normotension pattern, no significant differences in GCC or RNFL thickness were found for any anomalous BP pattern. Conclusions: Assessment of long-term BP status showed no significant associations with late-life OCT structural measures. Translational Relevance: OCT imaging results in our population-based sample suggest that neither hypertension, even when present in midlife, nor late-life hypotension are significant risk factors for late-life optic nerve damage.

Five-Year Visual Field Outcomes of the HORIZON Trial.

PURPOSE: To compare visual field (VF) progression between glaucoma patients receiving cataract surgery alone (CS) or with a Hydrus microstent (CS-HMS). DESIGN: Post hoc analysis of VF data from the HORIZON multicenter randomized controlled trial. METHODS: A total of 556 patients with glaucoma and cataract were randomized 2:1 to either CS-HMS (369) or CS (187) and followed up for 5 years. VF was performed at 6 months and then every year after surgery. We analyzed data for all participants with at least 3 reliable VFs (false positives < 15%). Average between-group difference in rate of progression (RoP) was tested using a Bayesian mixed model and a 2-sided Bayesian P value <.05 (main outcome). A multivariable model measured the effect of intraocular pressure (IOP). A survival analysis compared the probability of global VF sensitivity dropping by predefined cutoffs (2.5, 3.5, 4.5, and 5.5 dB) from baseline. RESULTS: Data from 352 eyes in the CS-HMS arm and 165 in the CS arm were analyzed (2966 VFs). The mean RoP was -0.26 dB/y (95% credible interval -0.36, -0.16) for CS-HMS and -0.49 dB/y (95% credible interval -0.63, -0.34) for CS. This difference was significant (P = .0138). The difference in IOP only explained 17% of the effect (P < .0001). Five-year survival analysis showed an increased probability of VF worsening by 5.5 dB (P = .0170), indicating a greater proportion of fast progressors in the CS arm. CONCLUSIONS: CS-HMS has a significant effect on VF preservation in glaucoma patients compared with CS alone, reducing the proportion of fast progressors.

A deep learning model incorporating spatial and temporal information successfully detects visual field worsening using a consensus based approach.

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