Uncorrected Refractive Error in the African American Eye Disease Study.

Importance: Refractive error remains the largest cause of correctable visual impairment in the US. Correction of refractive error will reduce visual impairment and its associated morbidity but also improve quality of life and productivity. Objective: To determine the burden of and risk factors (RFs) associated with any uncorrected refractive error (UCRE) and unmet refractive need (URN) in a population-based sample of African American adults. Design, Setting, and Participants: This cross-sectional study, conducted from April 2014 to April 2018, included a population-based sample of self-identified African American participants 40 years and older from 30 contiguous census tracts in Inglewood, California. Participants underwent a complete ophthalmic examination and an in-home-administered questionnaire to assess sociodemographic, lifestyle, biological, medical, and health care and eye care usage RFs associated with UCRE and URN. Measurements of visual acuity (VA) were performed using a standard Early Treatment Diabetic Retinopathy Study protocol. Noncycloplegic automated refraction with supplemental subjective refraction was performed. UCRE was defined as an improvement of 2 or more lines with refraction in the better-seeing eye. URN was defined as an improvement of 2 or more lines with refraction in the better-seeing eye in those persons who were visually impaired. Sex- and age-specific burden of UCRE and URN were calculated, and multiple regression analyses were used to identify independent RFs. Study data were analyzed from May 2018 to December 2023. Exposures: Presence or absence of correctable refractive error. Main Outcomes and Measures: Self-reported sex- and age-specific prevalence of and risk indicators of UCRE and URN. Results: Of the 7957 eligible participants in the African American Eye Disease Study (AFEDS), 6347 (80%) completed both the in-home interview and the clinical examination. Of these, 6337 participants (mean [SD] age, 61 [11] years; 3997 female [63%]) with complete refractive error data were included in the analysis. Refractive error-related correctable visual impairment was present in over two-thirds of participants with visual impairment (68.7%). The overall prevalence of any UCRE was 14.6% (925 of 6337), and the overall prevalence of any URN was 5.4% (URN1 [those with presenting VA of worse than 20/40 in the better-seeing eye but who could achieve 20/40 or better with correction], 157 of 2893; URN2 [those with presenting VA of worse than 20/40 in the better-seeing eye but who could achieve an improvement of 2 or more lines with refractive correction], 155 of 2891). Conclusions and Relevance: Results of this cross-sectional study suggest a high burden of refractive error-associated correctable refractive error in African American adults, making it the leading cause of visual impairment in this population. Providing universal coverage for vision care and prescription glasses is an affordable and achievable health care intervention that could reduce the burden of visual impairment in African American adults by over two-thirds and likely raise the quality of life and work productivity, especially in this vulnerable minority population.

Prevalence of Comprehensive Eye Examination in Preschool Children With Eye Conditions.

Introduction: The purpose of this study is to assess the prevalence of comprehensive eye examinations in multiethnic preschool children, including children with visually significant eye conditions, and identify factors associated with comprehensive eye examinations. Methods: A sample of 9,197 African American, Hispanic, Asian American, and non-Hispanic White children aged 6-72 months was recruited for the Multi-Ethnic Pediatric Eye Disease Study from 2003 to 2011. Logistic regression performed in 2022 identified independent factors associated with parent-reported history of comprehensive eye examinations. The proportion of children with previous comprehensive eye examinations and the proportion with undetected amblyopia or strabismus were measured. Results: The prevalence of comprehensive eye examinations was 6.3% overall and 38.3%, 24.8%, 19.1%, 15.1%, and 9.8% among children with strabismus, amblyopia, significant anisometropia, hyperopia, and astigmatism, respectively. Children without prior comprehensive eye examinations were more likely to have undetected amblyopia or strabismus than those with comprehensive eye examination history (ps<0.001). The prevalence of comprehensive eye examinations was higher among older children. Prevalence varied by race/ethnicity, with 8.1%, 7.9%, 6.3%, and 4.9% of non-Hispanic White, Asian American, African American, and Hispanic children having had prior comprehensive eye examinations, respectively; however, the differences did not remain after adjusting for other associated factors. Older age, a primary caregiver with a college/university degree or higher, having vision insurance, gestational age <33 weeks, neurodevelopmental disorder diagnosis, strabismus, and ocular disease history were all statistically significantly associated with a relatively higher prevalence of comprehensive eye examinations in multivariable analyses. Conclusions: Comprehensive eye examinations were uncommon among preschool children, including those with treatable vision disorders. Interventions, such as parent education and vision insurance, are needed to imaprove comprehensive eye examination access and utilization for at-risk preschool children.

Retinal perfusion is linked to cognition and brain MRI biomarkers in Black Americans.

INTRODUCTION: We investigated whether retinal capillary perfusion is a biomarker of cerebral small vessel disease and impaired cognition among Black Americans, an understudied group at higher risk for dementia. METHODS: We enrolled 96 Black Americans without known cognitive impairment. Four retinal perfusion measures were derived using optical coherence tomography angiography. Neurocognitive assessment and brain magnetic resonance imaging (MRI) were performed. Multiple linear regression analyses were performed. RESULTS: Lower retinal capillary perfusion was correlated with worse Oral Symbol Digit Test (P < = 0.005) and Fluid Cognition Composite scores (P < = 0.02), but not with the Crystallized Cognition Composite score (P > = 0.41). Lower retinal perfusion was also correlated with higher free water and peak width of skeletonized mean diffusivity, and lower fractional anisotropy (all P < 0.05) on MRI (N = 35). DISCUSSION: Lower retinal capillary perfusion is associated with worse information processing, fluid cognition, and MRI biomarkers of cerebral small vessel disease, but is not related to crystallized cognition.

Use of the Spanish English Neuropsychological Assessment Scale in older adult Latines and those at risk for autosomal dominant Alzheimer's disease.

OBJECTIVE: The Spanish English Neuropsychological Assessment Scale (SENAS) is a cognitive battery with English and Spanish versions for use with persons for whom either language is predominant. Few studies have examined its utility outside the normative sample. The current study examined SENAS performance in samples of older adult Latines and Latines with or at risk for autosomal dominant Alzheimer's disease (ADAD) mutations. METHOD: The SENAS was administered to 202 older adults from the Los Angeles Latino Eye Study (LALES) and 29 adults with (carriers) or without (non-carriers) mutations causing ADAD. We examined associations between SENAS, age, education, and language (LALES) and between SENAS, estimated years from familial age of dementia diagnosis, education, language, and acculturation (ADAD). Partial correlations were used to examine differences in correlational strength between estimated years from familial age of dementia diagnosis and SENAS scores among ADAD carriers compared to chronological age and SENAS in the LALES sample. Exploratory t-tests were performed to examine SENAS performance differences between ADAD carriers and non-carriers. RESULTS: In an older adult sample (LALES), increased age correlated with worse verbal delayed recall; English fluency and higher education correlated with better naming and visuospatial subtest performance. Among ADAD carriers, verbal and nonverbal delayed recall and object naming subtest performance worsened as they approached their familial age of dementia diagnosis. English fluency and higher U.S.-acculturation were related to better SENAS performance among carriers and non-carriers. Tests of verbal delayed recall and object naming best distinguished ADAD carriers from their familial non-carrier counterparts. CONCLUSIONS: Verbal delayed recall and object naming measures appear to be most sensitive to age-related changes in older adult samples and mutation-related changes in distinguishing ADAD carriers from non-carriers. Future research should examine the sensitivity of SENAS in other samples, such as larger samples of symptomatic ADAD carriers and other AD subtypes.

Classification of Angle Closure Severity by Hierarchical Cluster Analysis of Ocular Biometrics in the Dark and Light.

Purpose: The purpose of this study was to investigate the classification of angle closure eyes based on hierarchical cluster analysis of ocular biometrics measured in the dark and light using anterior segment optical coherence tomography (AS-OCT). Methods: Participants of the Chinese American Eye Study received complete eye examinations to identify primary angle closure suspects (PACS) and primary angle closure without/with glaucoma (PAC/G). AS-OCT was performed in the dark and light. Biometric parameters describing the angle, iris, lens, and anterior chamber were analyzed. Hierarchical clustering was performed using Ward's method. Post hoc logistic regression models were developed to identify biometric predictors of angle closure staging. Results: Analysis of 159 eyes with PACS (N = 120) or PAC/G (N = 39) produced 2 clusters in the dark and light. In both analyses, cluster 1 (N = 132 in the dark and N = 126 in the light) was characterized by smaller angle opening distance (AOD)750 and trabecular iris space area (TISA)750, greater iris curvature (IC), and greater lens vault (LV; P < 0.001) than cluster 2. The proportion of PAC/PACG to PACS eyes was significantly higher in cluster 1 than 2 in the light (36:90 and 3:30, respectively; P = 0.02), but not the dark (36:96 and 3:24, respectively; P = 0.08). On multivariable regression analyses, smaller TISA750 (odds ratio [OR] = 0.84 per 0.01 mm2) and AOD750 (OR = 0.93 per 0.01 mm) in the light and smaller TISA750 (OR = 0.86 per 0.01 mm2) in the dark conferred higher risk of PAC/G (P ≤ 0.02). Conclusions: Unsupervised cluster analysis of ocular biometrics can classify angle closure eyes by severity. Static biometrics measured in the light and dark are both predictive of PAC/G. Translational Relevance: Clustering of biometrics measured in the light could provide an alternative source of information to risk-stratify angle closure eyes for more severe disease.

Racial and Ethnic Differences in the Roles of Myopia and Ocular Biometrics as Risk Factors for Primary Open-Angle Glaucoma.

Purpose: Assess how the roles of refractive error (RE) and ocular biometrics as risk factors for primary open-angle glaucoma (POAG) differ by race and ethnicity. Methods: Data from the Los Angeles Latino Eye Study (LALES) and the Chinese American Eye Study (CHES), two population-based epidemiological studies, were retrospectively analyzed. Multivariable logistic regression and interaction term analyses were performed to assess relationships between POAG and its risk factors, including RE and axial length (AL), and to assess effect modification by race/ethnicity. Results: Analysis included 7601 phakic participants of LALES (47.3%) and CHES (52.7%) with age ≥ 50 years. Mean age was 60.6 ± 8.3 years; 60.9% were female. The prevalence and unadjusted risk of POAG were higher in LALES than CHES (6.0% and 4.0%, respectively; odds ratio [OR] = 1.55; P < 0.001). In the multivariable analysis, significant risk factors for POAG included Latino ethnicity (OR = 2.25; P < 0.001), refractive myopia (OR = 1.54 for mild, OR = 2.47 for moderate, OR = 3.94 for high compared to non-myopes; P ≤ 0.003), and longer AL (OR = 1.37 per mm; P < 0.001). AL (standardized regression coefficient [SRC] = 0.3) was 2.7-fold more strongly associated with POAG than high myopia status (SRC = 0.11). There was no modifying effect by race/ethnicity on the association between RE (per diopter) or AL (per millimeter) and POAG (P = 0.49). Conclusions: Although the POAG risk conferred by myopic RE and longer AL is similar between Latino and Chinese Americans, the difference in POAG prevalence between the two groups is narrowed by higher myopia prevalence among Chinese Americans. Racial/ethnic populations with higher myopia incidence may become disproportionately affected by POAG in the context of the global myopia epidemic.

Refractive Error and Anterior Chamber Depth as Risk Factors in Primary Angle Closure Disease: The Chinese American Eye Study.

PRCIS: The risk of primary angle closure disease (PACD) rises rapidly with greater hyperopia while remaining relatively low for all degrees of myopia. Refractive error (RE) is useful for angle closure risk stratification in the absence of biometric data. PURPOSE: To assess the role of RE and anterior chamber depth (ACD) as risk factors in PACD. METHODS: Chinese American Eye Study participants received complete eye examinations including refraction, gonioscopy, amplitude-scan biometry, and anterior segment ocular coherence tomography imaging. PACD included primary angle closure suspect (≥3 quadrants of angle closure on gonioscopy) and primary angle closure/primary angle closure glaucoma (peripheral anterior synechiae or intraocular pressure >21 mm Hg). Logistic regression models were developed to assess associations between PACD and RE and/or ACD adjusted for sex and age. Locally weighted scatterplot smoothing curves were plotted to assess continuous relationships between variables. RESULTS: Three thousand nine hundred seventy eyes (3403 open angle and 567 PACD) were included. The risk of PACD increased with greater hyperopia [odds ratio (OR) = 1.41 per diopter (D); P < 0.001] and shallower ACD (OR = 1.75 per 0.1 mm; P < 0.001). Hyperopia (≥ + 0.5 D; OR = 5.03) and emmetropia (-0.5 D to +0.5 D; OR = 2.78) conferred a significantly higher risk of PACD compared with myopia (≤0.5 D). ACD (standardized regression coefficient = -0.54) was a 2.5-fold stronger predictor of PACD risk compared with RE (standardized regression coefficient = 0.22) when both variables were included in one multivariable model. The sensitivity and specificity of a 2.6 mm ACD cutoff for PACD were 77.5% and 83.2% and of a +2.0 D RE cutoff were 22.3% and 89.1%. CONCLUSION: The risk of PACD rises rapidly with greater hyperopia while remaining relatively low for all degrees of myopia. Although RE is a weaker predictor of PACD than ACD, it remains a useful metric to identify patients who would benefit from gonioscopy in the absence of biometric data.

Generalisability and performance of an OCT-based deep learning classifier for community-based and hospital-based detection of gonioscopic angle closure.

PURPOSE: To assess the generalisability and performance of a deep learning classifier for automated detection of gonioscopic angle closure in anterior segment optical coherence tomography (AS-OCT) images. METHODS: A convolutional neural network (CNN) model developed using data from the Chinese American Eye Study (CHES) was used to detect gonioscopic angle closure in AS-OCT images with reference gonioscopy grades provided by trained ophthalmologists. Independent test data were derived from the population-based CHES, a community-based clinic in Singapore, and a hospital-based clinic at the University of Southern California (USC). Classifier performance was evaluated with receiver operating characteristic curve and area under the receiver operating characteristic curve (AUC) metrics. Interexaminer agreement between the classifier and two human examiners at USC was calculated using Cohen's kappa coefficients. RESULTS: The classifier was tested using 640 images (311 open and 329 closed) from 127 Chinese Americans, 10 165 images (9595 open and 570 closed) from 1318 predominantly Chinese Singaporeans and 300 images (234 open and 66 closed) from 40 multiethnic USC patients. The classifier achieved similar performance in the CHES (AUC=0.917), Singapore (AUC=0.894) and USC (AUC=0.922) cohorts. Standardising the distribution of gonioscopy grades across cohorts produced similar AUC metrics (range 0.890-0.932). The agreement between the CNN classifier and two human examiners (Ò =0.700 and 0.704) approximated interexaminer agreement (Ò =0.693) in the USC cohort. CONCLUSION: An OCT-based deep learning classifier demonstrated consistent performance detecting gonioscopic angle closure across three independent patient populations. This automated method could aid ophthalmologists in the assessment of angle status in diverse patient populations.

Ocular and systemic determinants of perifoveal and macular vessel parameters in healthy African Americans.

PURPOSE: To determine the relationship of various systemic and ocular characteristics with perifoveal and macular vessel density in healthy African American eyes. DESIGN: A population-based cross-sectional study of prospectively recruited African Americans ≥40 years of age. Participants underwent 3×3 mm and 6×6 mm macula scans using spectral-domain optical coherence tomography angiography (OCTA), clinical examinations and clinical questionnaires. Participants with glaucoma, severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy and macular oedema were excluded. Custom MATLAB based software quantified vessel area density (VAD) and vessel skeleton density (VSD) in the superficial retinal layer of the macula. Multivariable regression analysis, controlling for inter-eye correlation, was performed to determine systemic and ocular determinants of macular vessel metrics using stepwise selection. Candidate variables included: age, gender, body mass index, history of smoking, history of diabetes, diabetes duration, history of stroke or brain haemorrhage, systolic blood pressure, diastolic blood pressure (DBP), pulse pressure, mean arterial pressure, central subfield thickness (CSFT), visual field mean deviation, intraocular pressure, axial length (AL), mean ocular perfusion pressure and signal strength (SS). RESULTS: A total of 2221 OCTA imaged eyes from 1472 participants were included in this study. Reduced perifoveal and macular VAD and VSD were independently associated with longer AL, reduced SS, reduced CSFT and older age. Male gender and lower DBP were also associated with reduced perifoveal and macular VSD. CONCLUSIONS: When interpreting OCTA images in a clinical setting, it is important to consider the effects ocular and systemic characteristics may have on the macular microcirculation.

Anterior segment biometric measurements explain misclassifications by a deep learning classifier for detecting gonioscopic angle closure.

BACKGROUND/AIMS: To identify biometric parameters that explain misclassifications by a deep learning classifier for detecting gonioscopic angle closure in anterior segment optical coherence tomography (AS-OCT) images. METHODS: Chinese American Eye Study (CHES) participants underwent gonioscopy and AS-OCT of each angle quadrant. A subset of CHES AS-OCT images were analysed using a deep learning classifier to detect positive angle closure based on manual gonioscopy by a reference human examiner. Parameter measurements were compared between four prediction classes: true positives (TPs), true negatives (TNs), false positives (FPs) and false negatives (FN). Logistic regression models were developed to differentiate between true and false predictions. Performance was assessed using area under the receiver operating curve (AUC) and classifier accuracy metrics. RESULTS: 584 images from 127 participants were analysed, yielding 271 TPs, 224 TNs, 77 FPs and 12 FNs. Parameter measurements differed (p<0.001) between prediction classes among anterior segment parameters, including iris curvature (IC) and lens vault (LV), and angle parameters, including angle opening distance (AOD). FP resembled TP more than FN and TN in terms of anterior segment parameters (steeper IC and higher LV), but resembled TN more than TP and FN in terms of angle parameters (wider AOD). Models for detecting FP (AUC=0.752) and FN (AUC=0.838) improved classifier accuracy from 84.8% to 89.0%. CONCLUSIONS: Misclassifications by an OCT-based deep learning classifier for detecting gonioscopic angle closure are explained by disagreement between anterior segment and angle parameters. This finding could be used to improve classifier performance and highlights differences between gonioscopic and AS-OCT definitions of angle closure.

Optimal number and orientation of anterior segment OCT images to measure ocular biometric parameters in angle closure eyes: the Chinese American Eye Study.

PURPOSE: To assess the optimal number and orientation of anterior segment optical coherence tomography (AS-OCT) images for accurately measuring ocular biometric parameters in angle closure eyes. METHODS: Subjects with angle closure, defined as >3 quadrants of non-visible pigmented trabecular meshwork on static gonioscopy, were selected from the Chinese American Eye Study. Mean angle opening distance (AOD500) was calculated using four images (0°-180°, 45°-225°, 90°-270° and 135°-315° meridians) from one eye per subject. Ten eyes from each quartile of AOD500 measurements were randomly selected for detailed 32-image analysis of 10 biometric parameters, including AOD500, iris curvature (IC), anterior chamber depth (ACD), lens vault (LV), and anterior chamber area (ACA). Mean and range of measurements from 1, 2, 4, 8 or 16 images were compared with 32-image values for all parameters. RESULTS: 40 out of 335 eyes with angle closure were selected for 32-image analysis. Deviation from the 32-image mean was between 0.44% and 19.31% with one image, decreasing to 0.08% to 4.21% with two images for all parameters. Deviation from the 32-image range of measurements was between 54.67% to 88.94% with one image, decreasing to <7.00% with eight images for all parameters except ACD and ACA. Orienting the first image analysed along the 25°-205° meridian better approximated the range of measurements when four or fewer images were analysed. CONCLUSIONS: Sectoral anatomical variations in angle closure eyes are easily misrepresented based on current AS-OCT imaging conventions. A revised multi-image approach can better capture the mean and range of biometric measurements.

Effective refractive error coverage in adults aged 50 years and older: estimates from population-based surveys in 61 countries.

BACKGROUND: In 2021, WHO Member States endorsed a global target of a 40-percentage-point increase in effective refractive error coverage (eREC; with a 6/12 visual acuity threshold) by 2030. This study models global and regional estimates of eREC as a baseline for the WHO initiative. METHODS: The Vision Loss Expert Group analysed data from 565 448 participants of 169 population-based eye surveys conducted since 2000 to calculate eREC (met need/[met need + undermet need + unmet need]). A binary logistic regression model was used to estimate eREC by Global Burden of Disease (GBD) Study super region among adults aged 50 years and older. FINDINGS: In 2021, distance eREC was 79·1% (95% CI 72·4-85·0) in the high-income super region; 62·1% (54·7-68·8) in north Africa and Middle East; 49·5% (45·0-54·0) in central Europe, eastern Europe, and central Asia; 40·0% (31·7-48·2) in southeast Asia, east Asia, and Oceania; 34·5% (29·4-40·0) in Latin America and the Caribbean; 9·0% (6·5-12·0) in south Asia; and 5·7% (3·1-9·0) in sub-Saharan Africa. eREC was higher in men and reduced with increasing age. Global distance eREC increased from 2000 to 2021 by 19·0%. Global near vision eREC for 2021 was 20·5% (95% CI 17·8-24·4). INTERPRETATION: Over the past 20 years, distance eREC has increased in each super region yet the WHO target will require substantial improvements in quantity and quality of refractive services in particular for near vision impairment. FUNDING: WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation.

Visual Field Loss Impacts Vision-Specific Quality of Life by Race and Ethnicity: The Multiethnic Ophthalmology Cohorts of California Study.

PURPOSE: To assess the impact of visual field loss (VFL) on vision-specific quality of life (VSQOL) by race, ethnicity, and age. DESIGN: Pooled analysis of cross-sectional data from 3 population-based, prospective cohort studies. PARTICIPANTS: The Multiethnic Ophthalmology Cohorts of California Study (MOCCaS) participants included 6142 Latinos, 4582 Chinese Americans, and 6347 Black Americans from Los Angeles County. METHODS: A total of 17 071 adults aged 40 years and older completed comprehensive interviews and ophthalmic examinations from 2000 to 2018. VFL was measured using the Humphrey Swedish Interactive Threshold Algorithm Standard 24-2 test as decibels (dB) of mean deviation (MD). Multivariable linear regression was used to evaluate the impact of VFL in the better-seeing eye on self-reported VSQOL scores, adjusting for sociodemographic and clinical covariables. Hierarchical modeling was performed to determine the best-fit model after considering main effects and interactions by race, ethnicity, and age. MAIN OUTCOME MEASURES: The VSQOL scores were measured using the 25 Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Item response theory was used to model vision-related task and well-being composite scores, and classical test theory was used to calculate 11 vision subscales. RESULTS: The impact of VFL on VSQOL varied by race and ethnicity. Five-point reductions in task and well-being scores were reached after mild-to-moderate VFL for Latinos (6.7 dB and 7.5 dB), mild-to-moderate VFL for Chinese Americans (7.0 dB and 8.7 dB), and moderate-to-severe VFL for Black Americans (10.1 dB and 12.9 dB), respectively. Differences met statistical significance when comparing Latinos and Black Americans (P < 0.001). Visual field loss had the largest effect on driving among all participants. Driving difficulties were the only VSQOL outcome modified by age; participants aged 65 years and older scored 0.487 lower points per MD of VFL (P < 0.001). Subscales most affected by VFL included role function, mental health, and dependency. CONCLUSIONS: Race and ethnicity modified the impact of VFL on VSQOL, even after adjusting for sociodemographic covariates. In MOCCaS, Latinos and Chinese Americans reported a greater change in VSQOL than Black Americans for the same level of VFL. Future work should assess whether findings were due to socioeconomic or cultural differences in perception of visual function.

Ocular Biometric Determinants of Dark-to-Light Change in Angle Width: The Chinese American Eye Study.

PURPOSE: To assess ocular biometric determinants of dark-to-light change in anterior chamber angle width and identify dynamic risk factors in primary angle closure disease (PACD). DESIGN: Population-based cross-sectional study. METHODS: Chinese American Eye Study (CHES) participants underwent anterior segment optical coherence tomography imaging in the dark and light. Static dark and light biometric parameters, including angle opening distance, 750 µm (AOD750), anterior chamber width (ACW), lens vault (LV), and pupillary diameter (PD) were measured, and dynamic dark-to-light changes were calculated. Contributions by static and dynamic parameters to dark-to-light changes in AOD750 were assessed using multivariable linear regression models with standardized regression coefficients (SRCs) and semipartial correlation coefficients squared (SPCC2). PACD was defined as ≥3 quadrants of gonioscopic angle closure. RESULTS: The analysis included 1011 participants. All biometric parameters differed between dark and light (P < .05). On multivariable regression analysis, change in ACW (SRC = -0.35, SPCC2 = 0.081) and PD (SRC = -0.46, SPCC2 = 0.072) were the strongest determinants of dark-to-light change in AOD750 (overall R2 = 0.40). Dark-to-light increase in AOD750 was less in eyes with than without PACD (0.081 mm and 0.111 mm, respectively; P < .001). ACW increased in eyes with PACD and decreased in eyes without PACD from dark to light (P < .025), whereas change in PD was similar (P = .28). CONCLUSIONS: Beneficial angle widening effects of transitioning from dark to light are attenuated in eyes with PACD, which appears related to aberrant dark-to-light change in ACW. These findings highlight the importance of assessing the angle in both dark and light to identify potential dynamic mechanisms of angle closure.

Longer Axial Length Potentiates Relationship of Intraocular Pressure and Peripapillary Vessel Density in Glaucoma Patients.

Purpose: The purpose of this study was to investigate how axial length (AL) changes the relationship of intraocular pressure (IOP) with peripapillary vessel density (pVD) in glaucoma versus non-glaucomatous eyes. Methods: A population-based, cross-sectional study of 2127 African Americans aged 40 years and older in Inglewood, California, were imaged with 6 × 6-mm optic disc optical coherence tomography angiography scans. There were 1028 healthy subjects (1539 eyes) and 65 subjects with glaucoma (86 eyes) who met inclusion criteria. A multivariable linear mixed effects regression model investigated the relationship of IOP on pVD after controlling for signal strength, retinal nerve fiber layer thickness, and age. These results were stratified by AL groups. Results: Higher IOP was a significant predictor of lower pVD among subjects with glaucoma (P = 0.009), but not among healthy subjects (P = 0.26). After stratifying by the sample median AL (23.46 mm), higher IOP was associated with lower pVD among subjects with glaucoma with longer AL (≥ 23.46 mm, P = 0.005), but not among those in the shorter AL (< 23.46 mm, P = 0.45). IOP was not significantly associated with pVD among healthy subjects in either AL stratum. Conclusions: Among subjects with glaucoma with longer AL, IOP was significantly associated with pVD. This relationship was not seen among subjects with glaucoma with shorter AL or non-glaucomatous subjects in either AL group. These findings support the hypothesis that disturbed retinal autoregulation may be present in subjects with glaucoma with longer AL. Longitudinal studies are needed to further investigate whether axial elongation increases glaucoma risk by compromising retinal autoregulation.

Hemiretinal Asymmetry in Peripapillary Vessel Density in Healthy, Glaucoma Suspect, and Glaucoma Eyes.

PURPOSE: To investigate hemiretinal asymmetry in radial peripapillary capillary vessel area density (VAD) of healthy, glaucoma suspect, and glaucoma eyes of varying severity and its diagnostic utility for glaucoma. DESIGN: Population-based, cross-sectional study. METHODS: Optic disc scans (6 × 6 mm) were collected on optical coherence tomography angiography (OCTA) to obtain VAD and on optical coherence tomography (OCT) to measure circumpapillary retinal nerve fiber layer (RNFL) thickness. Hemiretinal difference in VAD (hdVAD) was defined as the absolute difference between superior and inferior hemiretinal VAD. Age-adjusted multivariable linear regression of hdVAD on glaucoma severity was performed. Areas under curves (AUCs) were calculated from predicted probabilities generated by multiple logistic regression of glaucoma severity on age-adjusted single and combined parameters. RESULTS: A total of 1,043 eyes of 1,043 participants (587 healthy, 270 suspect, 67 mild, 54 moderate, 65 severe glaucoma) were included. After age adjustment, mean hdVAD was similar between healthy and suspect (P = .225), higher in mild vs suspect (P < .001), and higher in moderate vs mild (P = .018), but lower in severe vs moderate (P = .001). AUCs of hdVAD were highest for discriminating mild (0.685) and moderate (0.681) glaucoma from healthy. Combining hdVAD and global RNFL (gRNFL) yielded the highest AUCs of all parameters for mild (0.818) and any POAG (0.859) and resulted in significantly better diagnostic accuracy than either hdVAD or gRNFL alone (P < .05 for all comparisons). CONCLUSIONS: hdVAD is higher in early glaucoma and may help with early detection when damage is focal, but its diagnostic ability appears less robust in advanced glaucoma when damage is diffuse.

Glaucoma Expert-Level Detection of Angle Closure in Goniophotographs With Convolutional Neural Networks: The Chinese American Eye Study.

PURPOSE: To compare the performance of a novel convolutional neural network (CNN) classifier and human graders in detecting angle closure in EyeCam (Clarity Medical Systems, Pleasanton, California, USA) goniophotographs. DESIGN: Retrospective cross-sectional study. METHODS: Subjects from the Chinese American Eye Study underwent EyeCam goniophotography in 4 angle quadrants. A CNN classifier based on the ResNet-50 architecture was trained to detect angle closure, defined as inability to visualize the pigmented trabecular meshwork, using reference labels by a single experienced glaucoma specialist. The performance of the CNN classifier was assessed using an independent test dataset and reference labels by the single glaucoma specialist or a panel of 3 glaucoma specialists. This performance was compared to that of 9 human graders with a range of clinical experience. Outcome measures included area under the receiver operating characteristic curve (AUC) metrics and Cohen kappa coefficients in the binary classification of open or closed angle. RESULTS: The CNN classifier was developed using 29,706 open and 2,929 closed angle images. The independent test dataset was composed of 600 open and 400 closed angle images. The CNN classifier achieved excellent performance based on single-grader (AUC = 0.969) and consensus (AUC = 0.952) labels. The agreement between the CNN classifier and consensus labels (κ = 0.746) surpassed that of all non-reference human graders (κ = 0.578-0.702). Human grader agreement with consensus labels improved with clinical experience (P = 0.03). CONCLUSION: A CNN classifier can effectively detect angle closure in goniophotographs with performance comparable to that of an experienced glaucoma specialist. This provides an automated method to support remote detection of patients at risk for primary angle closure glaucoma.

Impact of Visual Field Loss on Vision-Specific Quality of Life in African Americans: The African American Eye Disease Study.

PURPOSE: To elucidate how visual field loss (VFL) impacts self-reported vision-specific quality of life (VSQOL) in African Americans, who experience a disproportionate burden of visual impairment. DESIGN: Cross-sectional, population-based cohort. METHODS: Eligible participants (n = 7,957) were recruited who self-identified as African American, were aged 40 years or older, and resided in Inglewood, California, USA. A total of 6,347 participants (80.0%) completed clinical eye examinations. Total mean deviation (MD) of VFL was measured bilaterally as decibels (dB) using the Humphrey SITA Standard 24-2 test. VSQOL was measured using the National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) and scored using item response theory (IRT). RESULTS: Participants with reliable data (n = 5,121) had a mean age of 60.7 years (standard deviation 11.0); those with worse VFL were older; had more comorbidities, lower income, less education, and worse visual acuity; and were more likely to be unemployed and depressed. Using IRT analysis, a change in VF of 6.2 (95% confidence interval [CI]: 5.3, 7.7) dB and 9.2 (95% CI: 7.5, 11.9) dB was necessary to observe a meaningful (5-point) difference in vision-related task and emotional well-being scores, respectively. VFL had the greatest impact on self-reported driving ability (6.0 dB [95% CI: 5.2, 7.1]), followed by satisfaction with general vision, near vision, vision-related mental health, and peripheral vision. CONCLUSIONS: The strongest impact of VFL reported by African Americans was on their ability to complete visual tasks, especially for driving. An effect of VFL on emotional well-being also was observed, but the magnitude of association was about 50% lower for well-being compared to that of task.

Influence of Distance and Near Visual Impairment on Self-Reported Near Visual Functioning in a Multinational Study.

PURPOSE: To assess the influence of distance and near visual impairment on self-reported near visual functioning (VF) in a multinational study. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Participants aged 35 years or older were selected randomly with cluster sampling at 7 sites: rural sites in Nepal (Kaski) and India (Madurai), a semirural site in China (Shunyi), semiurban sites in South Africa (Durban) and Niger (Dosso), and urban sites in the United States (Los Angeles) and China (Guangzhou). METHODS: Binocular presenting distance and near visual acuity (VA) were measured with a logarithm of the minimum angle of resolution tumbling E chart at 4 m and 40 cm, respectively. A 12-item near VF questionnaire interview was administered by trained local interviewers, with responses scored from 100 to 0 as visual disability increased. Multiple linear regression was used to investigate the association of age, gender, education, and VA with overall eyesight, difficulty with activities, and social functioning subscale scores. MAIN OUTCOME MEASURES: Visual functioning subscale scores. RESULTS: The study sample consisted of 6851 questionnaire respondents. The VF subscale scores decreased significantly with worse distance and near VA, and even mildly impaired VA could result in reduced VF. Lower VF subscale scores were associated with older age at 4 sites, female gender at 3 sites, and greater education at 2 sites. The influence of near VA was greater than distance VA at 3 sites, and at 1 site, distance VA was more influential than near VA. With study site included in the regression modeling, lower scores for the overall eyesight subscale (compared with the Shunyi reference site) were found in Guangzhou, Kaski, and Durban; lower difficulty in activities scores were found in Kaski and Durban, but better scores were found in Guangzhou and Madurai; and social functioning scores were lower in Kaski, Durban, and Dosso. CONCLUSIONS: Along the entire VA spectrum, lower levels of distance and near VA led to significant reductions in VF subscale scores, with wide variation both within and between study sites. The impact of near vision on VF should receive greater emphasis with further investigation in various socioeconomic and cultural settings.

FACTORS ASSOCIATED WITH PREVALENT LENS OPACITIES IN CHINESE AMERICAN ADULTS: THE CHINESE AMERICAN EYE STUDY.

PURPOSE: To identify risk factors associated with lens opacities in Chinese Americans. METHODS: A cross-sectional population-based study of 4,582 Chinese Americans ≥50 years residing in Monterey Park, California. Participants completed a comprehensive clinical examination with lens assessment using the Lens Opacities Classification System II, with lens opacities defined by a grade ≥2 in either eye. Participants were considered to have nuclear-only, cortical-only, or posterior subcapsular (PSC)-only if that was the only type of opacity present in both eyes. RESULTS: Cortical-only opacity was associated with older age, diabetes mellitus (OR 1.5, 95%CI 1.1-2.1), and family history of cataracts (OR 1.5, 95%CI 1.2-1.9). Nuclear-only opacity was associated with older age, diabetes mellitus (OR 1.4, 95%CI 1.1-1.9), greater waist-to-hip ratio (OR 1.2, 95%CI 1.1-1.4), and high-density lipoprotein (OR 1.1, 95%CI 1.02-1.2). Mixed-type opacities were associated with older age, greater waist-to-hip ratio (OR 1.3, 95%CI 1.1-1.6), and higher HbA1 c (OR 1.3, 95%CI 1.1-1.4). Taller height (OR 0.7, 95%CI 0.6-0.8), greater weight (OR 0.98, 95%CI 0.97-0.99), and higher diastolic pressure (OR 0.98, 95%CI 0.96-0.99) were protective. CONCLUSION: CHES identified a strong, dose-response association between age and all types of prevalent lens opacities, which suggests an increasing cataract burden in Chinese Americans based on aging populations. CHES results demonstrate general consistency with previous population-based studies in regard to more sedentary lifestyle exposures (e.g., Westernized lifestyle) and prevalent cortical-only, nuclear-only, and mixed-type opacities, yet also identified further sedentary lifestyle exposures associated with prevalent lens opacities. Improved glycemic control and a more active lifestyle that minimizes factors contributing to metabolic syndrome may help reduce the burden of vision loss associated with lens opacities.