Trabecular Procedures Combined with Cataract Surgery for Open-Angle Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To determine the intraocular pressure (IOP) reduction of various trabecular procedures (a form of minimally invasive glaucoma surgery [MIGS]) combined with cataract surgery compared with cataract surgery alone, to compare the safety of the various trabecular procedures, and to highlight patient characteristics that may favor one trabecular procedure over another. METHODS: A search of English-language peer-reviewed literature in the PubMed database was initially conducted in February 2021 and updated in April 2023. This yielded 279 articles. Twenty studies met initial inclusion and exclusion criteria and were assessed for quality by the panel methodologist. Of these, 10 were rated level I, 3 were rated level II, and 7 were rated level III. Only the 10 level I randomized controlled trials (RCTs) were included in this assessment, and all were subject to potential industry-sponsorship bias. RESULTS: The current analysis focuses on the amount of IOP reduction (in studies that involved medication washout) and on IOP reduction with concurrent medication reduction (in studies that did not involve medication washout). Based on studies that performed a medication washout, adding a trabecular procedure to cataract surgery provided an additional 1.6 to 2.3 mmHg IOP reduction in subjects with hypertensive, mild to moderate open-angle glaucoma (OAG) at 2 years over cataract surgery alone, which itself provided approximately 5.4 to 7.6 mmHg IOP reduction. In other words, adding a trabecular procedure provided an additional 3.8% to 8.9% IOP reduction over cataract surgery alone, which itself provided 21% to 28% IOP reduction. There was no clear benefit of one trabecular procedure over another. Patient-specific considerations that can guide procedure selection include uveitis predisposition, bleeding risk, metal allergy, and narrowing of Schlemm's canal. There are no level I data on the efficacy of trabecular procedures in subjects with pretreatment IOP of 21 mmHg or less. CONCLUSIONS: Trabecular procedures combined with cataract surgery provide an additional mild IOP reduction over cataract surgery alone in hypertensive OAG subjects. Additional research should standardize outcome definitions, avoid industry sponsorship bias, and study the efficacy of these procedures in normotensive OAG. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Central Visual Field Testing in Early Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate the current published literature on the utility of the 10-2 visual field (VF) testing strategy for the evaluation and management of early glaucoma, defined here as mean deviation (MD) better than -6 decibels (dB). METHODS: A search of the peer-reviewed literature was last conducted in June 2023 in the PubMed database. Abstracts of 986 articles were examined to exclude reviews and non-English-language articles. After inclusion and exclusion criteria were applied, 26 articles were selected, and the panel methodologist rated them for strength of evidence. Thirteen articles were rated level I, and 8 articles were rated level II. The 5 level III articles were excluded. Data from the 21 included articles were abstracted and reviewed. RESULTS: The central 12 locations on the 24-2 VF test grid lie within the central 10 degrees covered by the 10-2 VF test. In early glaucoma, defects detected within the central 10 degrees generally agree between the 2 tests. Defects within the central 10 degrees of the 24-2 VF test can predict defects on the 10-2 VF test, although the 24-2 may miss defects detected on the 10-2 VF test. In addition, results from the 10-2 VF test show better association with findings from OCT scans of the macular ganglion cell complex. Modifications of the 24-2 test that include extra test locations within the central 10 degrees improve detection of central defects found on 10-2 VF testing. CONCLUSIONS: Evidence to date does not support routine testing using 10-2 VF for patients with early glaucoma. However, early 10-2 VF testing may provide sufficient additional information for some patients, particularly those with a repeatable defect within the central 12 locations of the standard 24-2 VF test or who have inner retinal layer thinning on OCT scans of the macula. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Aqueous Shunts with Extraocular Reservoir for Open-Angle Adult Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate the recently published literature on the efficacy and safety of the use of aqueous shunts with extraocular reservoir for the management of adult open-angle glaucomas (OAGs). METHODS: A search of peer-reviewed literature was last conducted in April 2023 of the PubMed database and included only articles published since the last aqueous shunt Ophthalmic Technology Assessment, which assessed articles published before 2008. The abstracts of these 419 articles were examined, and 58 studies were selected for full-text analysis. After inclusion and exclusion criteria were applied, 28 articles were selected and assigned ratings by the panel methodologist according to the level of evidence. Twenty-five articles were rated level I and 3 articles were rated level II. There were no level III articles. RESULTS: Implantation of aqueous shunts with extraocular reservoir can lower intraocular pressure (IOP) by between one-third and one-half of baseline IOP, depending on whether it is undertaken as the primary or secondary glaucoma surgery. Success rates for aqueous shunts were found to be better than for trabeculectomies in eyes with prior incisional surgery. Conversely, in eyes without prior incisional surgery, implantation of aqueous shunts was found to have an overall lower success rate as the primary glaucoma procedure compared with trabeculectomy. Although both valved and nonvalved aqueous shunts with extraocular reservoir were effective, the nonvalved device generally achieved slightly lower long-term IOPs with fewer glaucoma medications and less need for additional glaucoma surgery. Both devices slow the rates of visual field progression with efficacy comparable with that of trabeculectomy. Early aqueous humor suppression after aqueous shunt implantation is recommended for the management of the postoperative hypertensive phase and long-term IOP control. No strong evidence supports the routine use of mitomycin C with aqueous shunt implantation for OAG. CONCLUSIONS: Implantation of aqueous shunts with extraocular reservoir, including valved or nonvalved devices, has been shown to be an effective strategy to lower IOP. Strong level I evidence supports the use of aqueous shunts with extraocular reservoir by clinicians for the management of adult OAG. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011. METHODS: Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies. RESULTS: Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT. CONCLUSIONS: Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Corneal Hysteresis for the Diagnosis of Glaucoma and Assessment of Progression Risk: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature on the utility of corneal hysteresis (CH) to assist the clinician in the diagnosis of glaucoma or in the assessment of risk for disease progression in existing glaucoma patients. METHODS: Searches of the peer-reviewed literature in the PubMed database were performed through July 2022. The abstracts of 423 identified articles were examined to exclude reviews and non-English articles. After inclusion and exclusion criteria were applied, 19 articles were selected, and the panel methodologist rated them for level of evidence. Eight articles were rated level I, and 5 articles were rated level II. The 6 articles rated level III were excluded. RESULTS: Corneal hysteresis is lower in patients with primary open-angle glaucoma, primary angle-closure glaucoma, pseudoexfoliative glaucoma, and pseudoexfoliation syndrome compared with normal subjects. Interpretation of low CH in patients with high intraocular pressure (IOP) or on topical hypotensive medications is complicated by the influence of these parameters on CH measurements. However, CH is also lower in treatment-naïve, normal-tension glaucoma patients compared with normal subjects who have a similar IOP. In addition, lower CH is associated with an increased risk of progression of glaucoma based on visual fields or structural markers in open-angle glaucoma patients, including those with apparently well-controlled IOP. CONCLUSIONS: Corneal hysteresis is lower in glaucoma patients compared with normal subjects, and lower CH is associated with an increased risk of disease progression. However, a causal relationship remains to be demonstrated. Nevertheless, measurement of CH complements current structural and functional assessments in determining disease risk in glaucoma suspects and patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Comparison of surgical outcomes of trabeculectomy, Ahmed shunt, and Baerveldt shunt in uveitic glaucoma.

BACKGROUND: Uveitis is defined as a collection of syndromes involving intraocular inflammation which can lead to pain, tissue damage, and vision loss. Ophthalmic surgery in uveitis patients can be challenging due to inflammation-induced fibrosis and scarring. Trabeculectomy and implantation of glaucoma drainage devices (aqueous shunts) have been used in surgical management of uveitic glaucoma, however there is a paucity of literature examining the comparative results of these entities in this unique setting. The purpose of this retrospective comparative study is to compare clinical outcomes of trabeculectomy with MMC, Ahmed shunt, and Baerveldt shunt surgery specifically in uveitic glaucoma. RESULTS: Median IOP, IOP reduction, glaucoma medication use, and visual acuity at 6- and 12-month follow-up were similar across groups. Postoperative hypotony rate was significantly different across trabeculectomy (53%), Baerveldt (24%), and Ahmed (18%) groups (p = 0.027); other complication rates were similar. Baerveldt eyes had a lower failure rate compared to trabeculectomy (p = 0.0054) and Ahmed (p = 0.0008) eyes. CONCLUSIONS: While there was no difference in IOP reduction between trabeculectomy, Ahmed, and Baerveldt, Baerveldt eyes had the lowest failure rate.

MACULAR MICROCYSTS IN SCHWARTZ-MATSUO SYNDROME.

PURPOSE: To describe a case of macular microcysts associated with advanced secondary glaucoma from Schwartz-Matsuo syndrome. METHODS: Clinical presentation, color fundus photography, optic disk photography, visual fields, and optical coherence tomography are presented. RESULTS: A 32-year-old woman presented with advanced, unilateral secondary glaucoma associated with a macula-on rhegmatogenous retinal detachment. She was diagnosed with Schwartz-Matsuo syndrome. Spectral domain optical coherence tomography showed macular microcystic changes in the paracentral retina at the level of the inner nuclear layer. CONCLUSION: Macular microcystic changes in the paracentral inner nuclear layer on spectral domain optical coherence tomography have been described in eyes with optic atrophy associated with a variety of diseases. This is the first described case of macular microcysts associated with advanced secondary glaucoma from Schwartz-Matsuo syndrome and may offer insights into the pathogenesis of these microcysts.

Minimally invasive glaucoma surgery: current status and future prospects.

Minimally invasive glaucoma surgery aims to provide a medication-sparing, conjunctival-sparing, ab interno approach to intraocular pressure reduction for patients with mild-to-moderate glaucoma that is safer than traditional incisional glaucoma surgery. The current approaches include: increasing trabecular outflow (Trabectome, iStent, Hydrus stent, gonioscopy-assisted transluminal trabeculotomy, excimer laser trabeculotomy); suprachoroidal shunts (Cypass micro-stent); reducing aqueous production (endocyclophotocoagulation); and subconjunctival filtration (XEN gel stent). The data on each surgical procedure for each of these approaches are reviewed in this article, patient selection pearls learned to date are discussed, and expectations for the future are examined.

Risk factors for incident cortical, nuclear, posterior subcapsular, and mixed lens opacities: the Los Angeles Latino eye study.

PURPOSE: To identify sociodemographic and biological risk factors associated with the 4-year incidence of nuclear, cortical, posterior subcapsular (PSC), and mixed lens opacities. DESIGN: Population-based, longitudinal study. PARTICIPANTS: We included 4658 Latinos ≥40 years from 6 census tracts in Los Angeles, California. METHODS: Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II (LOCS II) at baseline and again 4 years later. Each opacity type was defined in persons with a LOCS II score of ≥2. Univariate and forward stepwise logistic regression analyses were used to identify independent baseline risk factors associated with 4-year incidence of nuclear only, cortical only, PSC only, and mixed (when >1 opacity type developed in a person) lens opacities. These comprised 4 mutually exclusive groups, and were based on person rather than eye. MAIN OUTCOME MEASURES: Odds ratios for independent risk factors associated with 4-year incidence of nuclear-only, cortical-only, PSC-only, and mixed lens opacities. RESULTS: Of the 3471 participants with gradable lenses in the same eye at baseline and 4-year follow-up, 200 (5.8%) had incident nuclear-only opacities, 151 (4.1%) had incident cortical-only opacities, 16 (0.5%) had incident PSC-only lens opacities, and 88 (2.5%) had mixed lens opacities. Independent baseline risk factors for incident nuclear-only lens opacities included older age, current smoking, and presence of diabetes. Independent risk factors for incident cortical-only lens opacities included older age and having diabetes at baseline. Female gender was an independent risk factor for incident PSC-only lens opacities. Older age and presence of diabetes at baseline examination were independent risk factors for incident mixed lens opacities. Specifically, in diabetics, higher levels of hemoglobin A1c was associated with greater risk for 4-year incident nuclear-only, cortical-only and mixed lens opacities. CONCLUSIONS: Improved diabetic control and smoking prevention may reduce the risk of developing lens opacities. Understanding both modifiable and nonmodifiable risk factors provides insight into the development of lens opacification.

Risk factors for cortical, nuclear, posterior subcapsular, and mixed lens opacities: the Los Angeles Latino Eye Study.

PURPOSE: To identify sociodemographic and biological risk factors associated with having cortical, nuclear, posterior subcapsular (PSC), and mixed lens opacities. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 5945 Latinos aged ≥ 40 years from 6 census tracts in Los Angeles, California. METHODS: Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II. Univariate and stepwise logistic regression analyses were used to identify independent risk factors associated with each type of lens opacity. MAIN OUTCOME MEASURES: Odds ratios for sociodemographic and biological risk factors associated with cortical only, nuclear only, PSC only, and mixed lens opacities. RESULTS: Of the 5945 participants with gradable lenses, 468 had cortical only lens opacities, 217 had nuclear only lens opacities, 27 had PSC only opacities, and 364 had mixed lens opacities. Older age, higher hemoglobin A(1c), and history of diabetes mellitus were independent risk factors for cortical only lens opacities. Older age, smoking, and myopic refractive error were independent risk factors for nuclear only lens opacities. Higher systolic blood pressure and history of diabetes were independent risk factors for PSC lens opacities. Older age, myopic refractive error, history of diabetes, higher systolic blood pressure, female gender, and presence of large drusen were independent risk factors for mixed lens opacities. CONCLUSIONS: The modifiable and non-modifiable risk factors identified in this study provide insight into the mechanisms related to the development of lens opacification. Improved glycemic control, smoking cessation and prevention, and blood pressure control may help to reduce the risk of having lens opacities and their associated vision loss.

Four-year incidence and progression of lens opacities: the Los Angeles Latino Eye Study.

PURPOSE: To estimate the 4-year incidence and progression of lens opacities. DESIGN: Population-based longitudinal study. METHODS: A total of 4658 adult Latinos from Los Angeles County were examined at baseline and 4-year follow-up. Examination included assessment of lens opacities using the Lens Opacities Classification System II (LOCS II). Incidences of cortical, nuclear, and posterior subcapsular opacities (with LOCS II scores >or=2) were defined as opacity development in persons without that opacity at baseline. Single and mixed opacities were defined in persons without any opacity at baseline. Incidence of all lens changes included development of at least 1 opacity or cataract surgery among those without any opacity at baseline. Four-year progressions were defined as increase of >or=2 in LOCS II score. RESULTS: The 4-year incidence of all lens opacities was 14.2%. Four-year incidence of cataract surgery was 1.48%. The incidences were 4.1% for cortical-only, 5.8% for nuclear-only, 0.5% for PSC-only, and 2.5% for mixed. The incidences for any opacities were 7.5% for cortical, 10.2% for nuclear, and 2.5% for PSC. Incidence increased with age (P < .0001 for all). The progressions were 8.5% for cortical, 3.7% for nuclear, and 2.9% for PSC opacities. CONCLUSIONS: Our Latino population had a higher incidence of nuclear than cortical opacities, but a greater progression of cortical than nuclear opacities. Incidence and progression of PSC was low. Additional understanding of the natural history and progression of various lens opacities will give us a better understanding of the pathogenesis and management of lens opacities.

Diagnostic performance of a telemedicine system for ophthalmology: advantages in accuracy and speed compared to standard care.

Telemedicine has potential to improve quality and delivery of medical care, particularly in image-oriented specialties where decisions are based on appearance of morphological features during examination. In the ophthalmology domain, nearly all published telemedicine studies have measured accuracy against a gold standard of ophthalmoscopic examination. The purposes of this study are to examine difficulties in defining an absolute gold standard and to compare diagnostic speed in a representative disease, retinopathy of prematurity. We compare results from ophthalmoscopic and telemedicine examinations by the same physicians. In 180 (86.5%) of 208 eyes, the two examinations produced the same diagnosis. In some discrepancies, there was rationale suggesting that telemedicine may have provided a more accurate diagnosis than ophthalmoscopic examination. The quantity and nature of these disagreements has important implications for evaluation of telemedicine systems in image-based specialties, and for the definition of gold standards in future studies.

Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery: Los Angeles Latino Eye Study.

PURPOSE: To estimate the prevalence of visually significant cataract in a US Latino population and to report predisposing, enabling, need, and health behavior characteristics associated with the unmet need for cataract surgery (UNCS). DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 6142 Latinos 40 years and older from 6 census tracts in Los Angeles County, California. METHODS: Participants completed an in-home interview and a comprehensive eye examination that included assessment of lens opacification, using the slit lamp-based Lens Opacities Classification System II (LOCS II), and best-corrected visual acuity. Visually significant cataract was defined by any LOCS II grading >or=2, best-corrected visual acuity <20/40, cataract as the primary cause of vision impairment, and self-reported vision of fair or worse. Because cataract surgery is not needed in all persons, participants with a visually significant cataract or prior cataract surgery in at least 1 eye composed the at-risk cohort needing cataract surgery. Unmet need for cataract surgery was defined as any person in the at-risk cohort who had at least 1 eye with a visually significant cataract. Univariate and stepwise logistic regression analyses were used to identify predisposing, enabling, need, and health behavior characteristics associated with UNCS. MAIN OUTCOME MEASURES: Prevalence of visually significant cataract and odds ratios (ORs) for factors associated with UNCS. RESULTS: Of 6142 participants who completed the interview and clinical examination, 118 (1.92%) had visually significant cataract in at least 1 eye. Of the 344 participants who have needed cataract surgery, 118 (34.3%) had UNCS. Independent factors associated with UNCS included health behavior: having last eye examination >or=5 years ago compared with <1 year ago (OR, 3.76; 95% confidence interval [CI], 1.71-8.25), and enabling factors: being uninsured (OR, 2.79; CI, 1.30-5.19), income less than $20,000 (OR, 2.60; CI, 1.40-5.56), and self-reported barriers to eye care (OR, 2.41; CI, 1.14-5.13). CONCLUSIONS: Latinos in our study had a substantial UNCS. Because Latinos with specific health behavior and enabling characteristics were more likely to have UNCS, interventions aimed at modifying these characteristics may be beneficial in reducing the unmet need and thus reducing the burden of visual impairment related to cataract in the United States.

Speed of telemedicine vs ophthalmoscopy for retinopathy of prematurity diagnosis.

PURPOSE: To compare the speed of retinopathy of prematurity (ROP) diagnosis using standard indirect ophthalmoscopy with that of telemedicine. DESIGN: Prospective, comparative study. METHODS: Three study examiners (2 pediatric retinal specialists [R.V.P.C., T.C.L.] and 1 pediatric ophthalmologist [M.F.C.]) conducted ROP diagnosis via standard indirect ophthalmoscopy and telemedicine. Each examiner performed: 1) standard ophthalmoscopy on 72 to 150 consecutive infants at his respective institution and 2) telemedical diagnosis on 125 consecutive deidentified retinal image sets from infants from an at-risk population. Time for ophthalmoscopic diagnosis was measured in 2 ways: 1) time spent by the examiner at the infant's bedside and 2) mean total time commitment per infant. Time for telemedicine diagnosis was recorded by computer time stamps in the web-based system. For each examiner, nonparametric statistical analysis (Mann-Whitney U test) was used to compare the distribution of times for examination by ophthalmoscopy vs telemedicine. RESULTS: Mean (+/- standard deviation [SD]) times for ophthalmoscopic diagnosis ranged from 4.17 (+/- 1.34) minutes to 6.63 (+/- 2.28) minutes per infant. Mean (+/- SD) times for telemedicine diagnosis ranged from 1.02 (+/- 0.27) minutes to 1.75 (+/- 0.80) minutes per infant. Telemedicine was significantly faster than ophthalmoscopy (P < .0001). The total time commitment by ophthalmologists performing bedside ophthalmoscopy for ROP diagnosis, including travel and communication with families and hospital staff, was 10.08 (+/- 2.53) minutes to 14.42 (+/- 2.64) minutes per infant. CONCLUSIONS: The ophthalmologist time requirement for telemedical ROP diagnosis is significantly less than that for ophthalmoscopic diagnosis. Additional time requirements associated with bedside ROP diagnosis increased this disparity. Telemedicine has potential to alleviate the time commitment for ophthalmologists who manage ROP.