Detecting Fast Progressors: Comparing a Bayesian Longitudinal Model to Linear Regression for Detecting Structural Changes in Glaucoma.

PURPOSE: Demonstrate that a novel Bayesian hierarchical spatial longitudinal (HSL) model identifies macular superpixels with rapidly deteriorating ganglion cell complex (GCC) thickness more efficiently than simple linear regression (SLR). DESIGN: Prospective cohort study. SETTING: Tertiary Glaucoma Center. SUBJECTS: One hundred eleven eyes (111 patients) with moderate to severe glaucoma at baseline and ≥4 macular optical coherence tomography scans and ≥2 years of follow-up. OBSERVATION PROCEDURE: Superpixel-patient-specific GCC slopes and their posterior variances in 49 superpixels were derived from our latest Bayesian HSL model and Bayesian SLR. A simulation cohort was created with known intercepts, slopes, and residual variances in individual superpixels. MAIN OUTCOME MEASURES: We compared HSL and SLR in the fastest progressing deciles on (1) proportion of superpixels identified as significantly progressing in the simulation study and compared to SLR slopes in cohort data; (2) root mean square error (RMSE), and SLR/HSL RMSE ratios. RESULTS: Cohort- In the fastest decile of slopes per SLR, 77% and 80% of superpixels progressed significantly according to SLR and HSL, respectively. The SLR/HSL posterior SD ratio had a median of 1.83, with 90% of ratios favoring HSL. Simulation- HSL identified 89% significant negative slopes in the fastest progressing decile vs 64% for SLR. SLR/HSL RMSE ratio was 1.36 for the fastest decile of slopes, with 83% of RMSE ratios favoring HSL. CONCLUSION: The Bayesian HSL model improves the estimation efficiency of local GCC rates of change regardless of underlying true rates of change, particularly in fast progressors.

A Bayesian Hierarchical Spatial Longitudinal Model Improves Estimation of Local Macular Rates of Change in Glaucomatous Eyes.

Purpose: Demonstrate that a novel Bayesian hierarchical spatial longitudinal (HSL) model improves estimation of local macular ganglion cell complex (GCC) rates of change compared to simple linear regression (SLR) and a conditional autoregressive (CAR) model. Methods: We analyzed GCC thickness measurements within 49 macular superpixels in 111 eyes (111 patients) with four or more macular optical coherence tomography scans and two or more years of follow-up. We compared superpixel-patient-specific estimates and their posterior variances derived from the latest version of a recently developed Bayesian HSL model, CAR, and SLR. We performed a simulation study to compare the accuracy of intercept and slope estimates in individual superpixels. Results: HSL identified a significantly higher proportion of significant negative slopes in 13/49 superpixels and a significantly lower proportion of significant positive slopes in 21/49 superpixels than SLR. In the simulation study, the median (tenth, ninetieth percentile) ratio of mean squared error of SLR [CAR] over HSL for intercepts and slopes were 1.91 (1.23, 2.75) [1.51 (1.05, 2.20)] and 3.25 (1.40, 10.14) [2.36 (1.17, 5.56)], respectively. Conclusions: A novel Bayesian HSL model improves estimation accuracy of patient-specific local GCC rates of change. The proposed model is more than twice as efficient as SLR for estimating superpixel-patient slopes and identifies a higher proportion of deteriorating superpixels than SLR while minimizing false-positive detection rates. Translational Relevance: The proposed HSL model can be used to model macular structural measurements to detect individual glaucoma progression earlier and more efficiently in clinical and research settings.

Comparing Rates of Change in Moderate to Advanced Glaucoma: Retinal Nerve Fiber Layer Versus Bruch Membrane Opening-Minimum Rim Width.

PURPOSE: To compare rates of change (RoC) of peripapillary retinal nerve fiber layer (RNFL) and Bruch membrane opening-based minimum rim width (BMO-MRW) thickness in moderate-to-advanced glaucoma. DESIGN: Prospective cohort study. METHODS: Longitudinal optical coherence tomography (OCT) optic nerve head volume scans of 113 eyes of 113 glaucoma patients with moderate-to-advanced or central damage were exported. This study estimated and compared global and sectoral RoC with linear mixed effects models and simple linear regression (SLR) of RNFL and BMO-MRW thickness. Permutation analyses were used to test significance of RoC in the SLR model. It also compared longitudinal signal-to-noise ratios (LSNR) defined as RoC divided by residual standard deviation (SD) between the two groups. RESULTS: Mean (SD) follow-up and median (IQR) OCT scan sessions were 5.2 (1.3) years and 10 (8-11), respectively. Baseline average (SD) visual field mean deviation was -9.2 (5.8) dB. Based on SLR, a higher proportion of significant negative RNFL RoC was observed compared to BMO-MRW in the inferotemporal (35% vs 20%; P = .015) and inferonasal (42% vs 17%; P < .001) sectors. Permutation analyses also demonstrated a higher proportion of worsening RNFL RoC than BMO-MRW in the inferotemporal (P = .026) and inferonasal (P < .001) sectors along with overall lower positive RoC. Longitudinal signal-to-noise ratios for RNFL were significantly more negative than for BMO-MRW globally, and in the inferotemporal, inferonasal, and superonasal sectors (P ≤ .01). CONCLUSIONS: Longitudinal RNFL OCT measurements are more likely to detect structural change and demonstrate better LSNR compared with BMO-MRW in eyes with central or moderate-to-advanced glaucoma damage at baseline.

One-year outcomes of combined phacoemulsification and viscogoniosynechialysis with and without endoscopic cyclophotocoagulation in primary angle-closure glaucoma.

PURPOSE: To compare the outcomes of combined phacoemulsification and viscogoniosynechialysis (VGSL) with and without endoscopic cyclophtocoagulation (ECP) in primary angle-closure glaucoma (PACG). METHODS: In this prospective interventional case series 52 eyes of 50 patients were enrolled. Twenty-seven eyes underwent combined phacoemulsification and VGSL (PV group) and 25 eyes underwent the same procedure plus circumferential ECP (PVE group). All eyes were followed 1 day, 1 week, 3 months, 6 months, and 1 year after the procedure. Intraocular pressure and antiglaucoma medications were compared between and within groups using generalized estimating equations. Kaplan-Meier survival analysis was carried out to compare intensity to failure between groups. RESULTS: The mean ± SD age was 63.23 ± 6.87 years and 50% of the cases were male in the entire group. Intraocular pressure (IOP) and antiglaucoma medications were significantly reduced at all time points in comparison with the baseline in both groups (p < 0.05). There was no significant difference between groups in either IOP or medications at specific time points (p > 0.05). One eye in each group developed a fibrinous reaction in the postoperative period. There was no statistically significant difference between groups regarding the intensity to failure (P = 0.169). CONCLUSION: There were no significant differences in IOP and medication reduction between groups. Also, the complications were comparable between groups.

Differentiating Glaucomatous Optic Neuropathy From Non-glaucomatous Optic Neuropathies Using Deep Learning Algorithms.

PURPOSE: A deep learning framework to differentiate glaucomatous optic disc changes due to glaucomatous optic neuropathy (GON) from non-glaucomatous optic disc changes due to non-glaucomatous optic neuropathies (NGONs). DESIGN: Cross-sectional study. METHOD: A deep-learning system was trained, validated, and externally tested to classify optic discs as normal, GON, or NGON, using 2183 digital color fundus photographs. A Single-Center data set of 1822 images (660 images of NGON, 676 images of GON, and 486 images of normal optic discs) was used for training and validation, whereas 361 photographs from 4 different data sets were used for external testing. Our algorithm removed the redundant information from the images using an optic disc segmentation (OD-SEG) network, after which we performed transfer learning with various pre-trained networks. Finally, we calculated sensitivity, specificity, F1-score, and precision to show the performance of the discrimination network in the validation and independent external data set. RESULTS: For classification, the algorithm with the best performance for the Single-Center data set was DenseNet121, with a sensitivity of 95.36%, precision of 95.35%, specificity of 92.19%, and F1 score of 95.40%. For the external validation data, the sensitivity and specificity of our network for differentiating GON from NGON were 85.53% and 89.02%, respectively. The glaucoma specialist who diagnosed those cases in masked fashion had a sensitivity of 71.05% and a specificity of 82.21%. CONCLUSIONS: The proposed algorithm for the differentiation of GON from NGON yields results that have a higher sensitivity than those of a glaucoma specialist, and its application for unseen data thus is extremely promising.

Association of Blood Pressure With Rates of Macular Ganglion Cell Complex Thinning in Patients With Glaucoma.

Importance: There are scarce data on the association of blood pressure measures with subsequent macular structural rates of change in patients with glaucoma. Objective: To investigate the association of baseline blood pressure measures with rates of change of the macular ganglion cell complex in patients with central or moderate to advanced glaucoma damage at baseline. Design, Setting, and Participants: This prospective cohort study, conducted from August 2021 to August 2022, used data from patients in the Advanced Glaucoma Progression Study at the University of California, Los Angeles. Participants were between 39 and 80 years of age and had more than 4 macular imaging tests and 2 or more years of follow-up. Exposures: A diagnosis of glaucoma with either central damage or a visual field mean deviation worse than -6 dB. Main Outcomes and Measures: The main outcome was the association of blood pressure measures with ganglion cell complex rates of change. Macular ganglion cell complex thickness rates of change were estimated with a bayesian hierarchical model. This model included relevant demographic and clinical factors. Blood pressure measures, intraocular pressure, and their interactions were added to the model to assess the association of baseline blood pressure measures with global ganglion cell complex rates of change. Results: The cohort included 105 eyes from 105 participants. The mean (SD) age, 10-2 visual field mean deviation, and follow-up time were 66.9 (8.5) years, -8.3 (5.3) dB, and 3.6 (0.4) years, respectively, and 67 patients (63.8%) were female. The racial and ethnic makeup of the cohort was 15 African American (14.3%), 23 Asian (21.9%), 12 Hispanic (11.4%), and 55 White (52.4%) individuals based on patient self-report. In multivariable analyses, female sex, history of taking blood pressure medications, higher intraocular pressure, thicker central corneal thickness, shorter axial length, higher contrast sensitivity at 12 cycles per degree, and higher baseline 10-2 visual field mean deviation were associated with faster ganglion cell complex thinning. Lower diastolic blood pressure was associated with faster rates of ganglion cell complex thinning at higher intraocular pressures. For intraocular pressures of 8 and of 16 mm Hg (10% and 90% quantiles, respectively), every 10 mm Hg-lower increment of diastolic blood pressure was associated with 0.011 µm/y slower and -0.130 µm/y faster rates of ganglion cell complex thinning, respectively. Conclusions and Relevance: In this cohort study, a combination of lower diastolic blood pressure and higher intraocular pressure at baseline was associated with faster rates of ganglion cell complex thinning. These findings support consideration of evaluating and addressing diastolic blood pressure as a therapeutic measure in patients with glaucoma if supported by appropriate clinical trials.

Comparison of Ganglion Cell Layer and Inner Plexiform Layer Rates of Change in Suspected and Established Glaucoma.

PURPOSE: We compared ganglion cell layer (GCL) and inner plexiform layer (IPL) rates of change (RoC) in patients with glaucoma suspect (GS) and established glaucoma (EG) to test the hypothesis that IPL thickness changes would occur earlier than GCL changes in eyes with early damage. DESIGN: Prospective, cohort study. METHODS: A total of 64 GS eyes (46 patients) and 112 EG eyes (112 patients) with ≥2 years of follow-up and ≥3 macular optical coherence tomography scans were included. GCL and IPL superpixel thickness measurements were exported. A Bayesian hierarchical model with random intercepts/slopes and random residual variances was fitted to estimate RoC in individual superpixels. Normalized RoC and proportions of superpixels with significantly negative and positive GCL and IPL RoC were compared within the groups. RESULTS: The average (SD) follow-up time and number of scans were 3.5 (0.7) years and 4.2 (1.0), respectively, in the GS group and 3.6 (0.4) years and 7.3 (1.1) in the EG group. Mean (SD) normalized RoC was faster for GCL than IPL (-0.69 [0.05] vs -0.33 [0.04]) in the GS group, whereas it was faster for IPL (-0.47 [0.03] vs -0.28 [0.02]) in EG eyes. GCL RoC were significantly negative in 24 of 36 superpixels compared with 8 of 36 for IPL (P < .001) in GS eyes. In the EG group, 23 of 36 superpixels had significant negative IPL RoC compared with 13 of 36 superpixels for GCL (P = .006). CONCLUSIONS: GCL thickness is more likely to demonstrate change over time compared with IPL in glaucoma suspects. There is no evidence of preferential IPL thinning in eyes with suspected early glaucoma damage.

Measurement of the Inner Macular Layers for Monitoring of Glaucoma: Confounding Effects of Age-Related Macular Degeneration.

OBJECTIVE: To investigate the confounding effect of nonexudative age-related macular degeneration (AMD), specifically drusen and outer retinal atrophy, on the architecture and automated segmentation of the inner retinal layers as measured with OCT. DESIGN: Observational cross-sectional study. SUBJECTS: Two hundred sixty-three consecutive eyes with nonexudative AMD were identified through a retrospective chart review. Exclusion criteria were a diagnosis of glaucoma or glaucoma suspect, other retinal pathology affecting the macula, axial length > 26.5 mm or spherical equivalent less than -6 diopters, any other optic nerve or neurologic disorders, or poor image quality. METHODS: Drusen were automatically segmented on macular OCT B-scans with a publicly available and validated deep learning approach. Automated segmentation of the inner plexiform layer (IPL)/inner nuclear layer (INL) boundary was carried out with the device's proprietary software. MAIN OUTCOME MEASURES: Quality of segmentation of the IPL/INL boundary as a function of drusen size and presence of inner retinal layer displacement in the area of macular pathology (drusen or atrophy). RESULTS: One hundred twenty-five eyes (65 patients) met the inclusion criteria. Drusen size varied between 16 and 272 µm (mean, 118 µm). Automated segmentation had a 22% chance of failure if the drusen height was between 145 and 185 µm and was most likely to fail with drusen heights above 185 µm. When drusen height was normalized by total retinal thickness, segmentation failed 36% of the time when the drusen to total retinal thickness ratio was 0.45 or above. Images were likely to show displacement of inner retinal layers with drusen heights above 176 µm and a normalized drusen height ratio of 0.5 or higher. Eighty-seven percent of images with outer retinal atrophy displayed incorrect segmentation. CONCLUSIONS: Outer retinal diseases can alter the retinal topography and affect the segmentation accuracy of the inner retinal layers. Large drusen may cause segmentation error and compression of the inner macular layers. Geographic atrophy confounds automated segmentation in a high proportion of eyes. Clinicians should be cognizant of the effects of outer retinal disease on the inner retinal layer measurements when interpreting the results of macular OCT imaging in patients with glaucoma.

Six-month outcomes of combined conventional needle goniotomy and phacoemulsification in eyes with early to moderate primary open-angle and pseudoexfoliation glaucoma and ocular hypertension.

Purpose: Angle-based surgeries for the treatment of open-angle glaucoma have gained popularity in recent years. This study aimed to evaluate the efficacy of combined phacoemulsification and goniotomy in primary open-angle and pseudoexfoliation glaucoma (POAG and PXG) and ocular hypertension (OHTN). Methods: In this interventional case series in the setting of the Glaucoma Service at the Farabi Eye Hospital, 32 eyes of 30 patients with early-to-moderate POAG and PXG and OHTN were enrolled. All eyes underwent combined phacoemulsification and needle goniotomy. Intraocular pressure (IOP) and the number of antiglaucoma medications as well as demographic data were recorded at baseline and one day, one week, one month, three months, and six months after the surgery. Generalized Estimating Equation (GEE) was used to compare the values of IOP and the number of medications at different time points. Kaplan-Meier graph was used to demonstrate the survival status of the eyes. Results: Mean IOP at baseline was 21.8 ± 4.6 mmHg on mean 1.2 ± 1.5 topical medications. There was a 25.2% (16.3 ± 4.5 mmHg) and 32.1% (14.8 ± 3.9 mmHg) reduction in IOP at three and six months after procedure, respectively (P < 0.001). Meanwhile, the decline in medications was 66.7% (0.4 ± 0.9) and 50.0% (0.6 ± 1.1) at the same time points (P = 0.002 and P = 0.048, respectively). Post-operative complications were clot hyphema (n = 1, 3.1%), fibrinous inflammation (n = 1, 3.1%) and distorted pupil (n = 2, 6.3%). Conclusion: Combined phacoemulsification and needle goniotomy as a procedure for mild and moderate POAG and PXG and OHTN is as effective as other modified goniotomies in the setting of minimally invasive glaucoma surgeries (MIGS).

Comparison of Vascular Density and Structural Patterns Between Primary Open Angle Glaucoma and Primary Angle Closure Glaucoma.

PURPOSE: To compare the pattern of vascular density and structural damage in primary open angle glaucoma (POAG) with primary angle closure glaucoma (PACG) using optical coherence tomography (OCT) and OCT angiography (OCTA) in the optic nerve head, circumpapillary, and macular regions, respectively. MATERIALS AND METHODS: One hundred thirty-one eyes of 82 patients (53 eyes with PACG and 78 eyes with POAG) were enrolled in this study. The patients underwent complete ophthalmic examination, Bruch membrane opening minimum rim width, circumpapillay retinal nerve fiber layer (cpRNFL), and macular ganglion cell complex (GCC) measurements and vascular density determination of the peripapillary and macular area with OCT and OCTA. A linear mixed model was used for the statistical analysis. RESULTS: There was no significant difference between the 2 groups in terms of age ( P =0.94) and visual field mean deviation ( P =0.78). Female-to-male ratio was higher in PACG patients than the POAG group ( P =0.02), and AL was shorter in PACG eyes ( P <0.001). cpRNFL and GCC were not different between the 2 groups (all P values>0.05, except for nasal segment cpRNFL). Vessel densities in the peripapillary and macular areas were comparable between the 2 groups (all P values>0.05). Although Bruch membrane opening minimum rim width was thicker in PACG eyes on univariate analysis, the multivariable analysis showed no significant difference between the 2 groups ( P >0.05). CONCLUSIONS: PACG and POAG eyes with similar visual field damages have comparable structural damage patterns in the peripapillary and inner macular thickness and vessel density measurements.

The role of optical coherence tomography angiography in moderate and advanced primary open-angle glaucoma.

PURPOSE: To evaluate the relationship between structure and function in moderate and advanced primary open-angle glaucoma (POAG) and to determine the accuracy of structure and vasculature for discriminating moderate from advanced POAG. METHODS: In this cross-sectional study, 25 eyes with moderate and 40 eyes with advanced POAG were enrolled. All eyes underwent measurement of the thickness of circumpapillary retinal nerve fiber layer (cpRNFL) and macular ganglion cell complex (GCC), and optical coherence tomography angiography (OCTA) of the optic nerve head (ONH) and macula. Visual field (VF) was evaluated by Swedish interactive threshold algorithm and 24-2 and 10-2 patterns. The correlation between structure and vasculature and the mean deviation (MD) of the VFs was evaluated by a partial correlation coefficient. The area under the receiver operating characteristic curve (AUC) was applied for assessing the power of variables for discrimination moderate from advanced POAG. RESULTS: Including all eyes, whole image vessel density (wiVD) of the ONH area, and vessel density (VD) in the inferior quadrant of perifovea were the parameters with significant correlation with the mean deviation (MD) of the VF 24-2 in OCTA of the ONH and macula (r = .649 and .397; p < .05). The greatest AUCs for discriminating moderate and advanced POAG belonged to VD of the inferior hemifield of ONH area (.886; 95% CI (.805, .967)), and VD in the inferior quadrant of perifovea (.833; 95% CI (.736, .930)) without statistically significant difference (.886 Versus .833; p = .601). CONCLUSION: Among vascular parameters of the ONH area, wiVD had the strongest correlation with the MD of the VF 24-2 while VD of the inferior hemifield of the ONH area had the greatest AUC for discriminating moderate and advanced POAG. Vessel density in the inferior quadrant of perifovea had a significant correlation with the MD of VF 24-2 and also the greatest AUC for discriminating moderate and advanced POAG.

Evaluation of Anterior Segment Parameters in Pseudoexfoliation Disease Using Anterior Segment Optical Coherence Tomography.

PURPOSE: To compare anterior segment and angle parameters between pseudoexfoliation syndrome (PEX) and PEX glaucoma (PEXG) and normal control subjects using anterior segment optical coherence tomography (AS-OCT) imaging. DESIGN: Cross-sectional study. METHODS: One hundred and two subjects with PEXG, PEX, and normal eyes as the control group were recruited from an academic referral institution. All subjects underwent a complete ophthalmologic examination, axial length measurement, and AS-OCT imaging. Anterior segment and angle parameters were evaluated. RESULTS: After excluding 4 eyes because of poor imaging of the scleral spur, data from 34 eyes with PEXG, 33 eyes with PEX, and 31 eyes of normal control subjects were analyzed. Anterior chamber depth was significantly shallower in eyes with PEXG compared with eyes of control subjects (P < .001). The differences in anterior chamber angle parameters (AOD500, AOD750, TISA500,and TISA750) were significant among study groups, with lower values in the PEXG group compared with the PEX and control subject groups. Lens vault (mean [mm]±SD) was higher in the PEXG (0.46 ±0.21) and PEX (0.427 +0.28) groups compared with the control group (0.305+ 0.20). CONCLUSIONS: PEXG eyes have the narrowest anterior chamber angle parameters. There is a progressive decrease in angle parameters from control subjects to the PEX group to the PEXG group. Narrow anterior chamber angle and anterior chamber depth may have a role in the progression of PEX to PEXG. Detection of narrow angle in these patients may help clinicians manage the disease more properly.

The Effect of Acute Rises in Intraocular Pressure after Intravitreal Bevacizumab Injection on the Peripapillary Retinal Nerve Fiber Layer Thickness and the Role of Anterior Chamber Paracentesis.

PURPOSE: To evaluate acute changes in intraocular pressure (IOP) and their short-term effects on the peripapillary retinal nerve fiber layer (RNFL) thickness after intravitreal bevacizumab (IVB) injection. METHODS: Fifty-eight eyes of 37 patients with treatment-naïve diabetic macular edema or exudative age-related macular degeneration were included in the study. Patients were divided into two groups, and the participants of each group received 3 monthly injections of IVB. IOP was measured right before the injection, immediately after the injection, and 5 min and 20 min after each injection. Peripapillary, RNFL thickness was measured before the injection and 1 month after the third injection. In the second group, anterior chamber (AC) paracentesis was performed before IVB injection. RESULTS: IOP values after injection in all sessions were significantly higher in the first group (P < 0.001). The peripapillary RNFL thickness changes 1 month after the third injection was not statistically significantly different in each group (P = 0.816 and 0.773 for the first and second groups, respectively). CONCLUSION: AC paracentesis is an effective modality to reduce the acute rise in IOP. The effect of acute IOP elevation on the peripapillary RNFL thickness was not statistically significant.

Changes in anterior segment optical coherence tomography following pars plana vitrectomy without tamponade.

BACKGROUND: To evaluate changes in anterior segment morphology on anterior segment optical coherence tomography (AS-OCT) following pars plana vitrectomy (PPV) without tamponade. METHODS: Patients who underwent PPV without tamponade for epiretinal membrane were evaluated. Eligible patients underwent intraocular pressure (IOP) measurement and AS-OCT preoperatively as well as 1 month and 6 months post-operatively. Anterior chamber width (ACW), anterior chamber depth (ACD), trabecular iris angle (TIA), angle opening distance at 500 and 750 µm (AOD), and trabecular iris space area at 500 and 750 µm (TISA) at four quadrants were recorded and analyzed. Additionally, the mean values of TIA (MTIA), AOD (MAOD), and TISA (MTISA) for each eye (mean of four quadrants) were analyzed. RESULTS: 23 patients completed the study. The mean age of participants was 56.4 ± 3.6 years of age and 13/23 (56%) were female. Mean IOP of patients was 18.1 ± 1.1, 18.3 ± 1.1, and 18.1 ± 1.2 preoperatively,1 month post-operatively, and 6 months post-operatively, respectively. (p = 0.83). No difference was detected post-operatively in measurements of ACW, ACD, MTIA, MAOD500, MAOD750, MTISA500, and MTISA750. CONCLUSION: Pars plana vitrectomy without tamponade was not associated with changes in anterior chamber morphology.

Ahmed glaucoma valve implantation with and without subconjunctival bevacizumab in refractory glaucoma.

PURPOSE: To evaluate the effects of subconjunctival bevacizumab injection on intraocular pressure (IOP), hypertensive phase, and failure and success rates of Ahmed Glaucoma Valve (AGV) implantation. METHODS: A total of 63 eyes of 63 patients (30 cases in control and 33 cases in bevacizumab group) were included in this randomized masked prospective clinical trial. Pre- and postoperative BCVA, IOP, number of medications, complications and success rates were compared between AGV + bevacizumab and AGV alone group. RESULTS: Both groups showed statistically significant reductions in IOP in all their follow-up visits (P < 0.05). The mean IOP was lower in the AGV + Bevacizumab group than AGV group in all follow-up visits. However, the difference was only significant at the 3rd month (17.3 ± 6.2 vs. 20.7 ± 4.6, p = 0.04). The number of medications was not differed significantly between the two groups at their last visit (p value = 0.84) Complete success rate was higher in AGV + Bevacizumab. However, the difference was not significant (p = 0.73). The qualified and overall success rate, failure rate and the need for second tube were not statistically different between the two groups. The hypertensive phase was not statistically significant between the 2 groups (33.3% in AGV + Bevacizumab group and 50% in AGV group, p = 0.06) CONCLUSION: Adjunctive use of Bevacizumab during AGV implantation is beneficial in controlling hypertensive phase and IOP control and may lead to higher success rates and lower failure rates after AGV implantation. However, whether it's clearly beneficial or its exact role remains to be investigated.

Bilateral spontaneous filtering blebs.

PURPOSE: To report a case of bilateral spontaneous filtering bleb, scleral thinning, microspherophakia, and mild craniofacial dysmorphism. OBSERVATIONS: An 18-year-old girl was referred to our clinic for evaluation of bilateral spontaneous filtering blebs. Her corrected distance visual acuity (CDVA) was 20/400 in the right eye (RE) and 20/100 in the left eye (LE). She had superior scleral thinning, multicystic filtering bleb, and microspherophakia bilaterally. The IOP was 9 mmHg in the RE and 8 mmHg in the LE. A mild craniofacial dysmorphism including downward slanting of palpebral fissures and malar hypoplasia was present. There was no sign of corneal ectasia in tomography. Anterior segment optical coherence tomography revealed the filtering blebs as subconjunctival low reflective fluid-filled spaces. Due to severe scleral thinning un the RE we performed a tectonic scleral patch graft. 6 months after surgery the depth of the anterior chamber increased and CDVA improved. CONCLUSION AND IMPORTANCE: This case indicated that the formation of spontaneous filtering blebs may occur in a syndromic condition. In any case with this symptom, special attention should be paid to craniofacial features, sclera, crystalline lens, and IOP. Tectonic scleral patch graft could be a valuable option in selected patients.

Prevalence and risk factors of glaucoma in an adult population from Shahroud, Iran.

PURPOSE: To determine the prevalence of glaucoma and its risk factors in a 40- to 64-year-old Iranian population. METHODS: In this cross-sectional study, 6311 individuals between the ages of 40-64 years old in Shahroud, a northeastern city in Iran, were selected through multistage cluster sampling. All participants underwent eye exams, optometry, and imaging. They had stereoscopic optic disc photography, visual field evaluation, and their intraocular pressure (IOP) was measured by ophthalmologists before pupil dilation. Glaucoma was defined by the standardized criteria, offered by the International Society for Geographical and Epidemiological Ophthalmology (ISGEO). RESULTS: Of the 5190 people who participated in the study (82.2%), data from 4637 people were used in the analysis. The prevalence of glaucoma was 1.92% [95% confidence intervals (CI): 1.53-2.31]; 1.4% (95% CI: 0.96-1.84) in women and 2.62% (95% CI: 1.95-3.28) in men. Glaucoma prevalence was 0.9% in the 40-44 years age group, and significantly increased to 3.55% in the 60-64 years age group. In the multiple logistic regression model, age [odds ratio (OR) = 1.08, 95% CI: 1.05-1.12], IOP (OR = 1.04, 95% CI: 1.01-1.06), axial length (OR = 1.34, 95% CI: 1.1-1.63), corneal radius of curvature (OR = 2.76, 95% CI: 1.26-6.06), and corneal diameter (OR = 0.63, 95% CI: 0.46-0.87) showed significant statistical association with glaucoma. CONCLUSIONS: The prevalence of glaucoma was considerably high at older ages. Major risk factors confirmed by this study included older age and high IOP. Certain ocular biometric components such as the axial length and the corneal radius of curvature must be noted as important glaucoma risk factors at younger ages.

Lamina Cribrosa and Choroid Features and Their Relationship to Stage of Pseudoexfoliation Glaucoma.

Purpose: To better understand the relationship of lamina cribrosa (LC) and choroid features to the severity of pseudoexfoliation glaucoma (PXG). Methods: In this cross-sectional study, 137 eyes of 122 subjects (47 eyes with moderate/advanced PXG [mean deviation (MD), -15.0 ± 7.7 dB], 34 eyes with mild PXG [MD, -2.7 ± 1.5 dB], 32 aged-matched pseudoexfoliation syndrome [PXS] eyes, and 24 aged-matched control eyes) were investigated. Optic discs, LC thickness, and anterior LC depth (ALD; midsuperior, center, and midinferior) as well as peripapillary choroidal thickness were determined. Linear mixed modeling was used to adjust for age, sex, and axial length. Results: A progressive decrease in LC thickness was found when comparing controls (271.9 ± 61.3 µm), PXS (212.6 ± 51.5 µm), mild PXG (180.8 ± 24.6 µm), and moderate/advance PXG (138.9 ± 37.5 µm) (P < 0.001). ALD was greater (P < 0.001) in moderate/advance glaucoma (306.7 ± 105.3 µm) and mild PXG (209.5 ± 79.7 µm) compared with PXS (155 ± 86.7 µm) and healthy controls (149.2 ± 103 µm). Although eyes with moderate/advance PXG had the thinnest choroid (117.2 ± 36.6 µm), choroidal thickness was comparable in mild PXG, PXS, and controls (150.0 ± 46.1, 159.7 ± 65.5, and 157.5 ± 51.1 µm, respectively; P = 0.002). Worse MD was the only factor associated with thinner LC (ß = 2.344, P < 0.001) and choroid (ß = 1.717, P = 0.009 µm) in PXG eyes. Higher IOP (ß = 4.305, P = 0.013) and worse MD (ß = -6.390, P < 0.001) were associated with deeper ALD in PXG. Conclusions: In pseudoexfoliation, LC thinning is an early sign, and there is progressive thinning with advancing glaucoma. Choroidal thinning is observable only with moderate/advanced glaucoma. In PXG eyes, LC thickness, depth, and peripapillary choroidal thickness are associated with glaucoma severity.

Classification of primary angle closure spectrum with hierarchical cluster analysis.

PURPOSE: To classify subjects with primary angle closure into clusters based on features from anterior segment optical coherence tomography (ASOCT) imaging and to explore how these clusters correspond to disease subtypes, including primary angle closure suspect (PACS), primary angle closure glaucoma(PACG), acute primary angle closure (APAC) and fellow eyes of APAC and reveal the factors that become more predominant in each subtype of angle closure. METHOD: A cross-sectional study of 248 eyes of 198 subjects(88 PACS eyes, 53 PACG eyes, 54 APAC eyes and 53 fellow eyes of APAC) that underwent complete examination including gonioscopy, A-scan biometry, and ASOCT. An agglomerative hierarchical clustering method was used to classify eyes based on ASOCT parameters. RESULTS: Statistical clustering analysis produced three clusters among which the anterior segment parameters were significantly different. Cluster 1(43 eyes) had the smallest anterior chamber depth(ACD) and area, as well as the greatest lens vault (p<0.001 for all). Cluster 2(113 eyes) had the thickest iris at 2000 microns(p = 0.048), and largest iris area(p<0.001), and the deepest ACD (p<0.001). Cluster 3(92 eyes) was characterized by elements of both clusters 1 and 2 and a higher iris curvature(p<0.001). There was a statistically significant difference in the distribution of clusters among subtypes of angle closure eyes(p<0.001). Although the patterns of clusters were similar in PACS and PACG eyes, with the majority of the eyes classified into cluster 2(55%, and 62%, respectively), the highest proportion of APAC and fellow eyes were assigned to clusters 1(44%) and 3 (51%), respectively. CONCLUSION: Hierarchical cluster analysis identified three clusters with different features. Predominant anatomical components are different among subtypes of primary angle closure.