Rate of Initial Optic Nerve Head Capillary Density Loss and Risk of Visual Field Progression.

Importance: Rapid initial optic nerve head capillary density loss may be used to assess the risk of glaucoma visual field progression. Objective: To investigate the association between the rate of initial optic nerve head capillary density loss from optical coherence tomography angiography (OCTA) and visual field progression. Design, Setting, Participants: This was a retrospective study of a longitudinal cohort at a glaucoma referral center. A total of 167 eyes (96 with primary open-angle glaucoma and 71 with glaucoma suspect) of 109 patients were monitored for a mean (SD) of 5.7 (1.4) years from January 2015 to December 2022. Data analysis was undertaken in April 2023. Main Outcomes and Measures: The rates of initial capillary density and average retinal nerve fiber layer loss were calculated from the first 3 optic nerve head OCTA and OCT scans, respectively, during the initial follow-up (mean [SD], 2.0 [1.0] years). Based on the median rate, eyes were categorized into fast and slow progressor groups. The association between initial capillary density change or retinal nerve fiber layer thinning and visual field progression was evaluated using linear-mixed and time-varying Cox models. Results: A total of 167 eyes of 109 patients (mean [SD] age, 69.0 [11.1] years; 56 [51.4%] female and 53 [48.6%] male) were assessed. Eighty-three eyes were slow OCTA progressors, while 84 eyes were fast with mean capillary density loss of -0.45% per year and -1.17% per year, respectively (mean difference, -0.72%/year; 95% CI,-0.84 to -0.60; P < .001). Similarly, 83 eyes were slow OCT progressors, while 84 eyes were fast with mean retinal nerve fiber layer thinning of -0.09 µm per year and -0.60 µm per year, respectively (mean difference, -0.51 µm/year; 95% CI,-0.59 to -0.43; P < .001). The fast OCTA and OCT progressors were associated with more rapid visual field loss (mean difference, -0.18 dB/year; 95% CI,-0.30 to -0.06; P = .004 and -0.17 dB/year; 95% CI,-0.29 to -0.06; P = .002, respectively). Fast OCTA progressing eyes were more likely to have visual field progression (hazard ratio, 1.96; 95% CI, 1.04-3.69; P = .04). Seventeen of 52 eyes (32.7%; 95% CI, 32.5-32.8) with fast OCTA and OCT progression developed subsequent visual field likely progression. Conclusion and Relevance: Rapid initial optic nerve head capillary density loss from OCTA was associated with a faster rate of visual field progression and a doubling of the risk of developing event progression in this study. These findings may support clinical use of OCTA and OCT optic nerve head measurements for risk assessment of glaucoma progression.

Smoking Intensity is Associated With Progressive Optic Nerve Head Vessel Density Loss in Glaucoma.

PRCIS: A lifetime history of greater smoking consumption was associated with faster vessel density loss over time. Smoking intensity should be considered when assessing the risk of glaucoma progression, as well as its management. PURPOSE: To investigate the relationship of smoking and smoking intensity, with the rate of optic nerve head (ONH) whole image capillary density (wiCD) loss in primary open angle glaucoma (POAG) and glaucoma suspect patients. METHODS: In this longitudinal study, patients with POAG who had at least 2 years of follow-up and optical coherence tomography angiography (OCTA) performed at a minimum of 4 visits were selected for study. The smoking intensity was calculated as the pack-year at the baseline OCTA. Univariable and multivariable linear mixed models were used to determine the effect of each parameter on the rates of wiCD loss over time. Nonlinear least-squares estimation with piecewise regression model was used to investigate the cutoff point for the relationship between wiCD loss and smoking intensity. RESULTS: One hundred sixty-four eyes (69 glaucoma suspect and 95 POAG) of 110 patients were included with a mean (95% CI) follow-up of 4.0 (3.9 to 4.1) years. Of the 110 patients, 50 (45.5%) had a reported history of smoking. Greater smoking intensity was associated with faster wiCD loss [-0.11 (-0.23 to 0.00)] %/year per 10 pack-year higher; P =0.048) after adjusting for covariates. The wiCD thinning became significantly faster when smoking intensity was greater than 22.2 pack-years. Smoking had no effect on the rate of wiCD thinning in patients who smoked <22.2 pack-years during their lifetime. CONCLUSIONS: A history of greater smoking consumption was associated with faster vessel density loss, suggesting smoking intensity as a potential risk factor for glaucoma.

Retinal Nerve Fiber Layer Optical Texture Analysis and 10-2 Visual Field Assessment in Glaucoma.

PURPOSE: To apply retinal nerve fiber layer (RNFL) optical texture analysis (ROTA) to 1) investigate the association between papillomacular and papillofoveal bundle defects with 10-2 visual field (VF) sensitivity abnormalities, and 2) integrate the information from RNFL bundle defect and 24-2 VF central test locations to determine the likelihood of 10-2 VF sensitivity abnormalities. DESIGN: Cross-sectional. METHODS: A total of 841 eyes (144 healthy, 317 glaucoma suspect, and 380 glaucoma) of 442 participants were included. Eyes underwent 24-2, and 10-2 VF testing and OCT for ROTA. The borders of RNFL defects were delineated from ROTA, and the involvement of the arcuate, papillomacular, and papillofoveal bundles was determined for each eye. Multilevel logistic regression analysis was applied to evaluate the structure-function association. RESULTS: Papillomacular (92.1%) and papillofoveal (37.9%) RNFL bundle defects were prevalent in eyes with glaucoma. A 10-2 VF location that was projected onto a papillomacular or a papillofoveal RNFL bundle defect had a significantly increased likelihood of reduced sensitivity (ORs of 18.61 at PDP < 5%, and 20.17 at TDP < 5%, respectively, P < .001 for both). When predicting the likelihood of VF abnormality in a 10-2 test location, noticeably higher odds ratios were observed when overlapping with an RNFL bundle defect, compared to when an abnormal corresponding 24-2 central point was present. CONCLUSIONS: Papillomacular and papillofoveal RNFL bundle defects are present in a considerable proportion of eyes with glaucoma. When detected, they significantly increase the likelihood of abnormality in the corresponding central VF test locations assessed by the 10-2 test.

Drug Recommendation from Diagnosis Codes: Classification vs. Collaborative Filtering Approaches.

Over time, large amounts of clinical data have accumulated in electronic health records (EHRs), making it difficult for healthcare professionals to navigate and make patient-centered decisions. This underscores the need for healthcare recommendation systems that help medical professionals make faster and more accurate decisions. This study addresses drug recommendation systems that generate an appropriate list of drugs that match patients' diagnoses. Currently, recommendations are manually prepared by physicians, but this is difficult for patients with multiple comorbidities. We explored approaches to drug recommendations based on elderly patients with diabetes, hypertension, and cardiovascular disease who visited primary-care clinics and often had multiple conditions. We examined both collaborative filtering approaches and traditional machine-learning classifiers. The hybrid model between the two yielded a recall at 5 of 76.61%, a precision at 5 of 46.20%, a macro-averaged area under the curve of 74.52%, and an average physician agreement of 47.50%. Although collaborative filtering is widely used in recommendation systems, our results showed that it consistently underperformed traditional classification. Collaborative filtering was sensitive to class imbalances and favored the more popular classes. This study highlighted challenges that need to be addressed when developing recommendation systems in EHRs.

Pars Planectomy: Preliminary Report of a New Glaucoma Filtering Technique in Vitrectomized Eyes.

PURPOSE: To propose a new filtering technique in vitrectomized eyes with glaucoma and report its clinical results and safety. METHODS: The medical records of 13 eyes that developed glaucoma following pars plana vitrectomy and underwent pars planectomy, from 2011 to 2018, at Songklanagarind hospital, Hatyai, Songkhla, Thailand were retrospectively reviewed. The main outcome measures were visual acuity (VA), intraocular pressure (IOP), number of glaucoma medications, and postoperative complications. Surgical success was defined as IOP value at the last visit of 6-21 mmHg, regardless of anti-glaucoma medication usage, and without further glaucoma surgery. RESULTS: The mean follow-up duration was 47.7 ± 32.1 months (range, 0.3-101.1 months). Preoperative BCVA increased from LogMAR 1.01 ± 0.85 to 1.2 ± 0.91 at the last visit (p = 0.233). The mean preoperative IOP was 28.15 ± 9.17 mmHg with an average of 3.46 ± 0.52 anti-glaucoma medications. At the final visit, the mean IOP was 14.08 ± 4.89 mmHg (p = 0.006) and the mean number of anti-glaucoma medications decreased to 1.31 ± 1.38 (p = 0.000). The probability of surgical success was 58.3%, 50%, and 37.5% at 1, 2, and 6 years after pars planectomy, respectively. Postoperative complications included vitreous hemorrhage in 1 eye (7.7%). No retina and pars plicata associated complications were found. CONCLUSION: Pars planectomy is efficient and safe as well as requires a short learning curve. It should be considered as an alternative filtering surgery in glaucoma after vitrectomy, especially with an extensive limbal scar that might be a limitation in trabeculectomy and GDDs techniques and outcomes.

Clinical Prediction Score for Early Neuroimaging in Acquired Isolated Oculomotor Nerve Palsy.

PURPOSE: An immediate neuroimaging investigation in patients with isolated oculomotor nerve palsy (ONP) remains controversial. We aimed to develop a clinical prediction score to determine whether or not acquired isolated ONP patients require prompt imaging. METHODS: A retrospective study was performed. Demographic data and clinical presentations were collected to determine predictive factors favored for early brain imaging using multivariate logistic regression analysis. RESULTS: Ninety-seven eyes of 96 patients diagnosed with isolated ONP were included. Forty-one eyes (42.3%) were caused by ischemia, while the other 56 eyes (57.7%) were caused by non-ischemic etiologies, namely aneurysm (n = 22), trauma (n = 18), inflammation (n = 5), tumor (n = 4), and others (n = 7). Eighty-two eyes (84.5%) had undergone neuroimaging study due to initially suspected non-ischemic causes. Only 36 (43.9%) revealed concordant diagnosis. The potential clinical predictors favored for neuroimaging using multivariate logistic regression analysis were age 10‒50 years (adjusted odds ratio [aOR] 9.01, 95% CI: 1.25‒64.8), age 51‒70 years (aOR 1.71, 95% CI: 0.46‒6.35), history of head trauma (aOR 7.14, 95% CI: 1.19‒42.9), absence of vascular risk factors (aOR 3.85, 95% CI: 1.23‒12.1), and poor pupillary response (aOR 6.96, 95% CI: 1.99‒24.3). The predictor scores with an area under the ROC curve of 0.852 were 4, 1, 4, 3, and 4, respectively. The optimum cut-point was 3 for a sensitivity of 96% and specificity of 44%. CONCLUSION: Patients with acquired isolated ONP should be considered early neuroimaging studies when they are younger than 50 years old, have a history of head trauma, have no history of vascular risk factors, or have poor pupillary reaction.

Clinical Characteristics and Prognostic Factors of Visual Outcomes in Childhood Glaucoma.

PURPOSE: To determine the prognostic factors for poor visual outcomes in childhood glaucoma. METHODS: The medical records of patients with childhood glaucoma diagnosed at age 4 years or younger who were treated surgically from 2002 to 2019 at Songklanagarind Hospital, Hatyai, Thailand, were retrospectively reviewed. Glaucoma subtypes, clinical characteristics, final visual acuity, and etiology of visual impairment were recorded. The generalized estimating equation for logistic regression analysis was used to determine prognostic factors for final visual acuity of worse than 20/200. RESULTS: Forty-five eyes of 31 patients were included (33.3% had primary glaucoma and 66.7% had secondary glaucoma). At the final visit (mean: 6.8 years), 20.5% had good visual acuity (20/50 or better), 15.9% had fair visual acuity (worse than 20/50 to 20/200), and 63.6% had poor visual acuity (worse than 20/200). The major cause of visual impairment (worse than 20/50) was deprivation amblyopia. Prognostic factors for poor final visual acuity (worse than 20/200) were secondary glaucoma, age at diagnosis of younger than 3 months, and interval to surgery of more than 3 months. Eyes with a final visual acuity of better than 20/200 had higher mean intraocular pressure preoperatively that tended to increase postoperatively and every visit afterward compared to the other group. CONCLUSIONS: Two-thirds of eyes with childhood glaucoma ended up with poor final vision. Early surgery to control intraocular pressure, along with amblyopia treatment, should be considered to prevent poor visual outcome. The prognostic factors for poor visual outcome can contribute to parental advice and planning of patient care. [J Pediatr Ophthalmol Strabismus. 2020;57(5):283-291.].

Etiology and management of the hypertensive phase in glaucoma drainage-device surgery.

Insertion of glaucoma drainage devices has become a mainstay in the surgical management of multiple forms of glaucoma, and the indications for this procedure continue to expand. A unique clinical challenge in the postoperative care of these devices is the hypertensive phase, a period of postoperative intraocular pressure elevation in the first three months after surgery. We discuss the influence of a variety of factors on the development of the hypertensive phase after glaucoma drainage implantation, including type of device, device material, and device surface area. Furthermore, several intraoperative and postoperative interventions are investigated as attempts to mitigate this phenomenon. Included among these are the use of antimetabolites, collagen matrix, and a variety of approaches to postoperative inflammation and intraocular pressure control. We provide an overview of our current knowledge of the etiology and management of the hypertensive phase.