Assessment of visual field progression in glaucoma.

PURPOSE OF REVIEW: Perimetry plays an important role in the diagnosis and management of glaucoma. This article discusses the assessment of visual field progression in patients with glaucoma. RECENT FINDINGS: Selecting the best visual field test strategy and establishing a baseline of visual fields will assist clinicians in the detection of glaucomatous progression. Repeat testing serves to confirm or refute changes on visual field testing. More frequent testing after initial diagnosis is recommended to establish a baseline and to identify patients with rapid progression who may need more aggressive management. Statistically significant changes on event analysis can prompt examination of a patient's trend analysis to determine whether clinically significant deterioration may be occurring. Future applications of machine learning can complement existing methods of visual field interpretation. SUMMARY: Many treated patients with glaucoma will experience visual field progression. Optimal utilization of visual field testing strategy and analytical software can help clinicians identify patients with glaucomatous progression likely to cause functional visual disability.

Myopia and glaucoma: sorting out the difference.

PURPOSE OF REVIEW: The aim of the present review was to summarize the evidence implicating the association between myopia and glaucoma, the possible underlying mechanisms for this relation, and the controversies surrounding detection of glaucomatous changes in coexisting myopia. RECENT FINDINGS: Numerous studies have shown that increasing categories of myopia are associated with a higher risk for optic neuropathy and glaucoma-like visual field defects. Recently, some high-resolution imaging modalities have been developed that aid further detection of the microanatomical changes of the optic nerve head and thus may provide a new insight to explain the association between myopia and glaucoma. Although the highly myopic eye usually shows many structural and functional defects that are difficult to distinguish from those caused by glaucoma, some new methods have been introduced to better differentiate between these changes. SUMMARY: The interaction of myopia with glaucoma risk remains complex, largely because of the retinal and nerve fiber layer damage that occurs in myopia alone. Whether to treat for glaucoma relies on the suspicion level of the clinician who must consider other risk factors for vision loss. Ultimately, it is the progression of glaucoma-like findings that determines whether a myopic patient has glaucoma.

Effect of COVID-19 Shelter-In-Place Orders on Visual Outcomes of Ophthalmic Surgical Emergencies.

PURPOSE: To compare the outcomes of ophthalmic surgical emergencies during shelter-in-place (SIP) order with the corresponding period in 2019. METHODS: This retrospective cohort study compared patients presenting to the Bascom Palmer Eye Institute (BPEI) emergency department (ED) who underwent urgent surgery during the SIP period (March 23-May 17, 2020), compared to the same weeks in 2019 (non-SIP). Main outcome measures included symptom-to-ED time, ED-to-surgical decision time, surgical decision-to-operating room (OR) time, ED-to-OR time, and postoperative follow-up time. Secondary outcome measures included travel distance, visual acuity (VA), intraocular pressure (IOP), and number of glaucoma medications. RESULTS: Seventy-six and 148 patients presented with ophthalmic surgical emergencies in the SIP and non-SIP study periods, respectively. Retinal detachment (RD), acute glaucoma, and open globe injury were the most common diagnoses in both periods. Symptom-to-ED and surgical decision-to-OR times were shorter during the SIP period. SIP patients had comparable preoperative VA but worse postoperative VA compared to non-SIP patients. During the SIP period, RD patients experienced postoperative VA reduction rather than improvement (+0.09 vs. -0.23 logMAR, p = 0.03); glaucoma patients were less likely to reach surgical decision within 24 h (OR 0.16 [95% CI 0.03-0.95]); and globe injuries had longer ED-to-surgical decision time and ED-to-OR time compared to the non-SIP period. Other outcomes were similar between both study periods. CONCLUSION: There was reduced volume of ophthalmic surgical emergencies and worse postoperative vision during SIP compared to the non-SIP period, despite shorter symptom-to-ED and surgical decision-to-OR times suggesting minimal delays in seeking or receiving care.

Gonioscopy-Assisted Transluminal Trabeculotomy and Goniotomy, With or Without Concomitant Cataract Extraction, in Steroid-Induced and Uveitic Glaucoma: 24-Month Outcomes.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) and goniotomy with Kahook Dual Blade both achieved sustained reductions in intraocular pressure (IOP) and medication burden in eyes with steroid-induced or uveitic glaucoma at 24 months. Both procedures had favorable safety profiles. PURPOSE: To characterize the 24-month surgical outcomes of GATT and excisional goniotomy in eyes with steroid-induced or uveitic glaucoma. PATIENTS AND METHODS: A retrospective chart review was performed of eyes with steroid-induced or uveitic glaucoma that underwent GATT or excisional goniotomy, either standalone or combined with phacoemulsification cataract surgery, by a single surgeon at the Cole Eye Institute. IOP, number of glaucoma medications, and steroid exposure were recorded preoperatively and at multiple postoperative timepoints up to 24 months. Surgical success was defined as at least 20% IOP reduction or IOP <12, 15, or 18 mm Hg (Criterion A, B, or C). Surgical failure was defined as need for additional glaucoma surgery or loss of light perception vision. Intraoperative and postoperative complications were reported. RESULTS: Forty eyes of 33 patients underwent GATT, and 24 eyes of 22 patients underwent goniotomy, of which 88% and 75%, respectively, had 24-months' follow-up. Concomitant phacoemulsification cataract surgery was performed in 38% (15/40) GATT eyes and 17% (4/24) goniotomy eyes. IOP and number of glaucoma medications were reduced at all postoperative timepoints in both groups. At 24 months, GATT eyes had mean IOP 12.9±3.5 mm Hg on 0.9±1.2 medications, and goniotomy eyes had mean IOP 14.3±4.1 mm Hg on 1.8±1.3 medications. Surgical failure was 8% for GATT and 14% for goniotomy at 24 months. Transient hyphema and transient IOP elevation were the most common complications, and 10% GATT eyes required surgical evacuation of hyphema. CONCLUSIONS: Both GATT and goniotomy demonstrate favorable efficacy and safety in steroid-induced and uveitic glaucoma eyes. Both procedures achieved sustained reductions in IOP and glaucoma medication burden at 24 months.

Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices.

BACKGROUND AND OBJECTIVE: The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations. PATIENTS AND METHODS: This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed. RESULTS: A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005). CONCLUSIONS: This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].

Acute retinal necrosis following recombinant subunit varicella-zoster virus vaccine.

PURPOSE: Previously, secondary prevention of herpes zoster required live-attenuated vaccination, which is contraindicated in immunocompromised populations. More recently, a recombinant subunit vaccine (Shingrix, GlaxoSmithKline, Research Triangle Park, North Carolina) was approved by the Food and Drug Administration. Iatrogenic varicella-zoster virus (VZV) infection is theoretically impossible as it does not contain a live virus. We present a case of acute retinal necrosis (ARN) and disseminated zoster after receiving the recombinant subunit vaccine. OBSERVATIONS: A 65-year-old woman with past medical history of multiple myeloma treated with a previous autologous hematopoietic stem cell transplant and now with daratumumab and pomalidomide developed disseminated zoster and subsequently acute retinal necrosis weeks after receiving the zoster subunit vaccine. Molecular testing confirmed the presence of VZV, and the absence of herpes simplex virus, cytomegalovirus, and toxoplasmosis. The VZV was found to be genotypically wildtype and not related to the Oka strain used in the live-attenuated zoster vaccine. She was treated with systemic valacyclovir and intravitreal foscarnet. CONCLUSIONS AND IMPORTANCE: This is the first report of VZV infection following the zoster subunit vaccine. The Advisory Committee on Immunization Practices (ACIP) has recommended the recombinant subunit vaccine over the live-attenuated vaccine due to its superior efficacy. The off-label use of the subunit vaccine in immunocompromised populations has been supported up to this point by studies demonstrating its relative safety. Though post-vaccination VZV infection or reactivation appears to be rare, clinicians should be aware of this potential complication to the recombinant subunit vaccine.

Association between light-to-dark changes in angle width and iris parameters in light, dark and changes from light-to-dark conditions.

BACKGROUND/AIMS: To evaluate the association between light-to-dark changes in angle width parameters and iris parameters in light, dark and changes from light-to-dark conditions. METHODS: In this prospective, cross-sectional study, anterior segment optical coherence tomography images, obtained under light and dark conditions, were analysed to determine angle opening distance measured at 500 µm from the scleral spur (AOD500), trabecular-iris space area at 500 µm from the scleral spur (TISA500), iris thickness measured at 750 µm from the scleral spur (IT750), iris thickness measured at 2000 µm from the scleral spur (IT2000), iris area (IArea) and pupil diameter (PD). Multivariable linear mixed-effect regression models were used to evaluate the association between light-to-dark changes in angle width parameters (AOD500, TISA500) and iris parameters (IT750, IT2000, IArea, PD) in light, dark and changes from light-to-dark conditions. RESULTS: 534 eyes from 314 non-glaucomatous subjects were analysed. IT750, IT2000, IArea and PD in light conditions were significantly associated with light-to-dark changes in AOD500 (p<0.05). IT750, IT2000 and IArea in light conditions were significantly associated with light-to-dark changes in TISA500 (p<0.05). IT750 in dark conditions was significantly associated with light-to-dark changes in AOD500 and TISA500 (p<0.05). Light-to-dark changes in IT2000, IArea and PD were significantly associated with light-to-dark changes in AOD500 (p<0.05). Light-to-dark changes in IArea were significantly associated with light-to-dark changes in TISA500 (p<0.05). CONCLUSIONS: Evaluation of iris parameters in light, dark and changes from light-to-dark conditions demonstrated that IT750, IT2000, IArea and PD in light conditions are significant predictors of light-to-dark changes in angle width.

Association Between Trabecular Meshwork Anteroposterior Length and Anterior Chamber Angle Width.

PURPOSE: To investigate the association between trabecular meshwork anteroposterior length and anterior chamber angle width in nonglaucomatous subjects. DESIGN: Prospective, cross-sectional study. METHODS: Time-domain and spectral-domain anterior segment optical coherence tomography images for 561 eyes from 366 nonglaucomatous subjects were analyzed to determine trabecular meshwork anteroposterior length and 3 anterior chamber angle width parameters measured at different distances from the scleral spur: angle opening distance at 250 µm (AOD250), 500 µm (AOD500), and 750 µm (AOD750) from the scleral spur; trabecular-iris space area at 500 µm (TISA500) and 750 µm (TISA750) from the scleral spur; angle recess area at 750 µm (ARA750) from the scleral spur. Univariable and multivariable linear mixed-effect regression models, the latter adjusting for age, sex, ethnicity, axial length, and the use of both eyes in the same subject, were used to evaluate the association between trabecular meshwork anteroposterior length and anterior chamber angle width parameters. RESULTS: Mean trabecular meshwork anteroposterior length was 824.86 ± 181.77 µm. Univariate regression analyses showed a significant positive association between trabecular meshwork anteroposterior length and all anterior chamber angle width parameters: AOD250 (P < .001; ß = 335.13), AOD500 (P < .001; ß = 271.84), AOD750 (P < .001; ß = 202.56), TISA500 (P < .001; ß = 780.78), TISA750 (P < .001; ß = 449.17), ARA750 (P < .001; ß = 381.39). Multivariate regression analyses showed a significant positive association between trabecular meshwork anteroposterior length and all anterior chamber angle width parameters: AOD250 (P = .005; ß = 294.02), AOD500 (P = .036; ß = 172.94), AOD750 (P = .049; ß = 125.58), TISA500 (P = .004; ß = 611.51), TISA750 (P = .011; ß = 333.96), ARA750 (P < .0001; ß = 309.12). CONCLUSIONS: Wider anterior chamber angle is associated with greater trabecular meshwork anteroposterior length.

The Effect of Cumulative Dissipated Energy on Changes in Intraocular Pressure After Uncomplicated Cataract Surgery by Phacoemulsification.

PURPOSE: To investigate the association between ultrasound energy, expressed as cumulative dissipated energy (CDE), and changes in intraocular pressure (IOP) after uncomplicated cataract surgery by phacoemulsification. METHODS: In this prospective study, nonglaucomatous subjects underwent cataract surgery by phacoemulsification. IOP was compared by clustered linear regression at 4 separate time-points: preoperative, 1 day, 1 month, and 3 months after cataract surgery. Changes in the IOP were evaluated as a function of CDE using univariate and multivariate clustered linear regression models, which adjusted for sex, ethnicity, age, axial length, spherical equivalent, mean preoperative Shaffer gonioscopy grade of all 4 quadrants, cataract grade, preoperative IOP, central corneal thickness, and use of both eyes in the same subject. RESULTS: One hundred sixty-one eyes (89 Asian, 49 white, 12 African, and 11 Hispanic) from 116 nonglaucomatous subjects were analyzed. The 161 eyes included 81 right and 80 left eyes. The 89 Asian eyes included 46 Chinese, 35 Filipino, and 8 Vietnamese. Preoperative IOP was 14.9±3.2 mm Hg. Postoperative IOP significantly increased to 16.0±4.9 mm Hg at 1 day (P=0.037) and decreased to 12.4±3.1 and 12.3±3.0 mm Hg at 1 and 3 months, respectively (both P<0.0001). IOP changes at 1 day, 1 month, and 3 months did not demonstrate significant associations with CDE measurements in either univariate or multivariate clustered linear regression analyses (all P>0.05). CONCLUSIONS: The amount of ultrasound energy delivered to the eye during phacoemulsification, expressed as CDE, was not associated with postoperative changes in IOP.

Lens Position Parameters as Predictors of Intraocular Pressure Reduction After Cataract Surgery in Glaucomatous Versus Nonglaucomatous Eyes.

PURPOSE: To evaluate the relationship between lens position parameters and intraocular pressure (IOP) reduction after cataract surgery in patients with primary open-angle glaucoma (POAG) and in nonglaucomatous patients. METHODS: The main outcomes of this prospective study were percent and absolute IOP change, which were calculated using the preoperative IOP and the IOP 4 months after cataract surgery in POAG and nonglaucomatous eyes. Lens position (LP), defined as anterior chamber depth (ACD) + one-half lens thickness (LT), was assessed preoperatively using parameters from optical biometry. Preoperative IOP, axial length (AL), ACD, LT, relative lens position (RLP), and the ratio of preoperative IOP to ACD (PD ratio) were also evaluated as potential predictors of IOP change. RESULTS: Four months postoperatively, the average IOP reduction was 2.80 ± 3.83 mm Hg (15.79%) from the preoperative mean of 14.73 ± 2.89 mm Hg for nonglaucomatous eyes. The average IOP reduction was 2.66 ± 2.07 mm Hg (16.98%) from the preoperative mean of 14.86 ± 2.97 mm Hg for POAG eyes. Preoperative IOP, sex, AL, ACD, PD ratio, and LP predicted IOP change in nonglaucomatous eyes. Preoperative IOP and PD ratio predicted IOP change in POAG eyes. CONCLUSIONS: Intraocular pressure reduction after phacoemulsification cataract surgery in nonglaucomatous eyes is significantly greater in more anteriorly positioned lenses. Though it did not reach statistical significance in patients with glaucoma, the association of LP with IOP reduction is in the same direction as in nonglaucomatous patients where smaller LP appears to predict greater IOP reduction. Lens position is a simple, easily calculable, accurate, and widely available parameter, which clinicians can potentially utilize in managing glaucoma.

Ethnic differences in trabecular meshwork height by optical coherence tomography.

IMPORTANCE: Differences in ocular anatomy may contribute to ethnic differences in glaucoma risk. Because the trabecular meshwork (TM) plays an important role in aqueous outflow, its anatomy in relation to at-risk populations may provide insight into a potential contributor to elevated intraocular pressure and thus to probability of glaucoma development. OBJECTIVE: To investigate whether differences exist in TM height between ethnic groups. DESIGN, SETTING, AND PARTICIPANTS: This prospective study took place from January 1, 2012, to December 31, 2013. Adult patients who self-reported as being of white, Asian, Hispanic, or African American ethnicity were recruited from ophthalmology clinics at the University of California, San Francisco. The TM height was assessed using spectral-domain anterior segment optical coherence tomography. MAIN OUTCOMES AND MEASURES: Trabecular meshwork height was measured from the scleral spur to the Schwalbe line. We hypothesized that ethnicities with a higher prevalence of glaucoma would tend to have shorter TM heights. RESULTS: We collected data from 460 eyes of 291 participants after excluding 34 optical coherence tomographic scans owing to poor image quality. The final sample was 32.2% white, 45.1% Asian, 10.5% African American, and 12.1% Hispanic. There were 64.2% women, and the mean age was 68.1 years. The mean (SD) TM height among all eyes included in the study was 836 (131) µm. The mean (SD) TM height was characterized among white (851 [131] µm), Asian (843 [126] µm), Hispanic (822 [147] µm), and African American (771 [118] µm) persons. Ethnicity was not associated with TM height overall (P = .23, linear mixed regression model). However, the TM heights of African American participants (771 µm) were shorter than those of white (851 µm; adjusted difference 95% CI, -119.8 to -8.1; P = .02) and Asian (843 µm; adjusted difference 95% CI, -117.4 to -10.8; P = .02) participants. CONCLUSIONS AND RELEVANCE: Although TM height is not associated with ethnicity overall, African American individuals have shorter TM heights compared with Asian and white persons. Trabecular meshwork size may play a role in ethnic differences of glaucoma risk and be a new risk factor to consider in primary open-angle glaucoma.