Self-Reported Driving Difficulty, Avoidance, and Negative Emotion With On-Road Driving Performance in Older Adults With Glaucoma.

PURPOSE: To investigate the relationship between self-perceived driving difficulty, driving avoidance, and negative emotion about driving with glaucoma severity and on-road driving performance. DESIGN: Cohort study. METHODS: Glaucoma patients (n = 111), aged 55 to 90 years, with mild, moderate, and advanced glaucoma in the better-eye based on the Glaucoma Staging System, and age-matched controls (n = 47) were recruited from a large tertiary academic center. Self-reported questionnaires were administered by a trained occupational therapist followed by a standardized on-road driving evaluation (pass vs "at-risk" score) with a masked and certified driving rehabilitation specialist. RESULTS: Compared to controls, glaucoma participants reported greater driving difficulty with as early as mild glaucoma (P = .0391) and negative emotion about driving starting with moderate glaucoma (P = .0042). Glaucoma participants reporting at least 1 driving difficulty and negative emotion had a 3.3-fold (adjusted odds ratio [OR] = 3.3; 95% CI = 1.24-8.52; P = .0163) and 4.2-fold (adjusted OR = 4.2; 95% CI = 1.5-12.2; P = .0078) greater odds, respectively, of an at-risk score on the on-road test. Self-reported driving difficulty in "difficult" conditions (P = .0019), rain (P = .0096), interstates (P = .0378), and high traffic (P = .0076), driving avoidance on sunny (P = .0065) and cloudy (P = .0043) days, and driving fewer days per week (P = .0329) were also associated with at-risk driving. CONCLUSIONS: Screening tools that assess self-perceived driving difficulty and driving avoidance in specific conditions, negative emotion about driving, and driving exposure may help identify unsafe drivers with glaucoma. Some of these drivers, particularly those with modest glaucoma, may benefit from a driving evaluation and early referral to resources that could enable them to continue driving safely and confidently.

Compositional Analysis of Extracellular Aggregates in the Eyes of Patients With Exfoliation Syndrome and Exfoliation Glaucoma.

Purpose: Exfoliation syndrome (XFS) is a condition characterized by the production of insoluble fibrillar aggregates (exfoliation material; XFM) in the eye and elsewhere. Many patients with XFS progress to exfoliation glaucoma (XFG), a significant cause of global blindness. We used quantitative mass spectrometry to analyze the composition of XFM in lens capsule specimens and in aqueous humor (AH) samples from patients with XFS, patients with XFG and unaffected individuals. Methods: Pieces of lens capsule and samples of AH were obtained with consent from patients undergoing cataract surgery. Tryptic digests of capsule or AH were analyzed by high-performance liquid chromatography-mass spectrometry and relative differences between samples were quantified using the tandem mass tag technique. The distribution of XFM on the capsular surface was visualized by SEM and super-resolution light microscopy. Results: A small set of proteins was consistently upregulated in capsule samples from patients with XFS and patients with XFG, including microfibril components fibrillin-1, latent transforming growth factor-ß-binding protein-2 and latent transforming growth factor-ß-binding protein-3. Lysyl oxidase-like 1, a cross-linking enzyme associated with XFS in genetic studies, was an abundant XFM constituent. Ligands of the transforming growth factor-ß superfamily were prominent, including LEFTY2, a protein best known for its role in establishing the embryonic body axis. Elevated levels of LEFTY2 were also detected in AH from patients with XFG, a finding confirmed subsequently by ELISA. Conclusions: This analysis verified the presence of suspected XFM proteins and identified novel components. Quantitative comparisons between patient samples revealed a consistent XFM proteome characterized by strong expression of fibrillin-1, lysyl oxidase-like-1, and LEFTY2. Elevated levels of LEFTY2 in the AH of patients with XFG may serve as a biomarker for the disease.

Rate of Falls, Fear of Falling, and Avoidance of Activities At-Risk for Falls in Older Adults With Glaucoma.

PURPOSE: To determine the relationship between glaucoma severity and rate of falls, fear of falling, and avoidance of activities at-risk for falls. DESIGN: Cross-sectional study. METHODS: Patients with glaucoma (n = 138) 55 to 90 years of age with mild (n = 61), moderate (n = 54), or advanced (n = 23) glaucoma in the better eye based on the Glaucoma Staging System and age-matched control subjects (n = 50) were recruited from the Eye Clinics at Washington University, St. Louis, MO. Participants completed questionnaires regarding falls, the fear of falling, and the avoidance of activities at-risk for falls. RESULTS: Of the glaucoma participants, 36% reported ≥1 fall in the previous 12 months compared with 20% of control subjects (adjusted odds ratio [OR] 2.7 [95% confidence interval {CI} 1.18-6.17]; P = .018). Compared with control subjects, the mild glaucoma group trended toward a higher fall risk (adjusted OR 2.43 [95% CI 0.97-6.08]; P = .059) and the advanced group had the highest fall risk (adjusted OR 7.97 [95% CI 2.44-26.07]; P = .001). A greater risk of a high fear of falling and high avoidance of at-risk activities occurred at the moderate stage of glaucoma compared with control subjects (adjusted OR 4.66 [95% CI 1.24-17.49]; P = .023 and adjusted OR 4.49 [95% CI 1.34-15.05]; P = .015, respectively). CONCLUSIONS: Patient education, interventions, and appropriate referrals to minimize falls should be considered in older adults with early glaucoma and continue with advancing disease. Minimizing a patient's fall risk may decrease their fear of falling and avoidance of at-risk activities. Reducing falls, the fear of falling, and the avoidance of at-risk activities may lower morbidity and mortality and improve emotional and social well-being of patients with glaucoma. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

PANRETINAL PHOTOCOAGULATION VERSUS RANIBIZUMAB FOR PROLIFERATIVE DIABETIC RETINOPATHY: Comparison of Peripapillary Retinal Nerve Fiber Layer Thickness in a Randomized Clinical Trial.

PURPOSE: Compare changes in retinal nerve fiber layer (RNFL) thickness between eyes assigned to intravitreous ranibizumab or panretinal photocoagulation and assess correlations between changes in RNFL and visual field sensitivity and central subfield thickness. METHODS: Eyes with proliferative diabetic retinopathy were randomly assigned to ranibizumab or panretinal photocoagulation. Baseline and annual follow-up spectral domain optical coherence tomography RNFL imaging, optical coherence tomography macular imaging, and automated static perimetry (Humphrey visual field 60-4 algorithm) were performed. RESULTS: One hundred forty-six eyes from 120 participants were analyzed. At 2 years, for the ranibizumab (N = 74) and panretinal photocoagulation (N = 66) groups, respectively, mean change in average RNFL thickness was -10.9 ± 11.7 µm and -4.3 ± 11.6 µm (difference, -4.9 µm; 95% confidence interval [-7.2 µm to -2.6 µm]; P < 0.001); the correlation between change in RNFL thickness and 60-4 Humphrey visual field mean deviation was -0.27 (P = 0.07) and +0.33 (P = 0.035); the correlation between change in RNFL thickness and central subfield thickness was +0.63 (P < 0.001) and +0.34 (P = 0.005), respectively. CONCLUSION: At 2 years, eyes treated with ranibizumab had greater RNFL thinning than eyes treated with panretinal photocoagulation. Correlations between changes in RNFL thickness, visual field, and central subfield thickness suggest that the decrease in RNFL thickness with ranibizumab is likely due to decreased edema rather than loss of axons.

Glaucoma and quality of life: fall and driving risk.

PURPOSE OF REVIEW: Numerous population-based studies suggest that glaucoma is an independent risk factor for falling and motor vehicle collisions, particularly for older adults. These adverse events lead to increased healthcare expenditures and decreased quality of life. Current research priorities, therefore, include identifying factors that predispose glaucoma patients to falling and unsafe driving, and developing screening strategies and targeted rehabilitation. The purpose of this article is to review recent studies that address these priorities. RECENT FINDINGS: Studies continue to support that glaucoma patients, particularly those with advanced disease, have an increased risk of falling or unsafe driving. Risk factors, however, remain variable and include severity and location of visual field defects, contrast sensitivity, and performance on divided attention tasks. Such variability is likely because of the multifactorial nature of ambulating and driving and compensatory strategies used by patients. SUMMARY: Falls and unsafe driving remain a serious public health issue for older adults with glaucoma. Ambulation and driving are complex tasks and there is no consensus yet, regarding the best methods for risk stratification and targeted interventions to increase safety. Therefore, comprehensive and individualized assessments are recommended to most effectively evaluate a patient's risk for falling or unsafe driving.

On-road Driving Performance of Patients With Bilateral Moderate and Advanced Glaucoma.

PURPOSE: To compare on-road driving performance of patients with moderate or advanced glaucoma to controls and evaluate factors associated with unsafe driving. DESIGN: Case-control pilot study. METHODS: A consecutive sample of 21 patients with bilateral moderate or advanced glaucoma from Washington University, St Louis, Missouri and 38 community-dwelling controls were enrolled. Participants, aged 55-90 years, underwent a comprehensive clinical evaluation by a trained occupational therapist and an on-road driving evaluation by a masked driver rehabilitation specialist. Overall driving performance of pass vs marginal/fail and number of wheel and/or brake interventions were recorded. RESULTS: Fifty-two percent of glaucoma participants scored a marginal/fail compared to 21% of controls (odds ratio [OR], 4.1; 95% CI, 1.30-13.14; P = .02). Glaucoma participants had a higher risk of wheel interventions than controls (OR, 4.67; 95% CI, 1.03-21.17; P = .046). There were no differences detected between glaucoma participants who scored a pass vs marginal/fail for visual field mean deviation of the better (P = .62) or worse (P = .88) eye, binocular distance (P = .15) or near (P = .23) visual acuity, contrast sensitivity (P = .28), or glare (P = .88). However, glaucoma participants with a marginal/fail score performed worse on Trail Making Tests A (P = .03) and B (P = .05), right-sided Jamar grip strength (P = .02), Rapid Pace Walk (P = .03), Braking Response Time (P = .03), and identifying traffic signs (P = .05). CONCLUSIONS: Patients with bilateral moderate or advanced glaucoma are at risk for unsafe driving-particularly those with impairments on psychometric and mobility tests. A comprehensive clinical assessment and on-road driving evaluation is recommended to effectively evaluate driving safety of these patients.

Effect of endoscopic cyclophotocoagulation on refractive outcomes when combined with cataract surgery.

OBJECTIVE: To determine the difference between predicted and actual refractive outcomes after combined endoscopic cyclophotocoagulation and cataract surgery (phaco-ECP) in patients with open-angle glaucoma (OAG). DESIGN: Retrospective case-control study of patients with OAG who underwent phaco-ECP compared with cataract surgery alone. PARTICIPANTS: Eighty-three patients with OAG, aged 55 to 91 years, who underwent a combined phaco-ECP procedure and 58 biometry- and age-matched control patients with OAG who underwent cataract surgery alone. METHODS: Patient records were retrospectively reviewed at the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis (St. Louis, Mo.). The primary outcome was the difference in predicted and actual refractive outcomes in patients undergoing either phaco-ECP or standard cataract surgery. RESULTS: Compared with phaco alone, the difference in predicted versus actual postoperative results was more myopic in the phaco-ECP group (0.029, -0.110, and -0.095 vs -0.169, -0.325, and -0.312 [p < 0.05] for Sanders, Retzlaff, Kraff/Theoretical, Hoffer Q, and Holladay, respectively). Moreover, the F test for variability showed significantly more variability in refractive outcomes in the phaco-ECP group compared with standard cataract surgery. CONCLUSIONS: Patients undergoing phaco-ECP may have postoperative refractive errors that may vary from that predicted preoperatively more so than in cataract surgery alone. Surgeons may consider analyzing their results to determine whether any adjustment should be made to lens power selection when performing phaco-ECP.

Differences in vision between clinic and home and the effect of lighting in older adults with and without glaucoma.

IMPORTANCE: Patients often report greater visual difficulties at home than expected from vision testing in the clinic. Such discordance may be owing to worse vision in the home than measured in clinic. OBJECTIVE: To compare vision measured between the clinic and home and evaluate factors, including lighting, associated with these differences. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study conducted from 2005-2009 involved 126 patients with glaucoma and 49 without glaucoma recruited from the Glaucoma and Comprehensive Eye Clinics at Washington University, St Louis, Missouri. Patients underwent clinic and home visits, were aged 55 to 90 years, were consecutively recruited, and met inclusion criteria for this study. A total of 166 eligible patients refused participation. EXPOSURE: Participants underwent clinic and home visits randomized to order of completion. At each visit, masked and certified examiners measured binocular distance visual acuity (DVA) with a nonbacklit chart, near visual acuity (NVA), contrast sensitivity (CS), CS with glare, and lighting. MAIN OUTCOMES AND MEASURES: Differences in vision between the clinic and home. RESULTS: The mean scores for all vision tests were significantly better in the clinic than home for participants with and without glaucoma (P < .05, matched-pair t tests). For DVA, 29% of participants with glaucoma read 2 or more lines better in the clinic than home and 39% with advanced glaucoma read 3 or more lines better. For the entire sample, 21% of participants read 2 or more lines better in the clinic than home for NVA and 49% read 2 or more triplets better in the clinic for CS with glare. Lighting was the most significant factor associated with differences in vision between the clinic and home for DVA, NVA, and CS with glare testing (P < .05, multiple regression model). Median home lighting was 4.3 times and 2.8 times lower than clinic lighting in areas tested for DVA and NVA, respectively. Home lighting was below that recommended in 85% or greater of participants. CONCLUSIONS AND RELEVANCE: Vision measured in the clinic is generally better than vision measured at home, with differences mainly owing to poor home lighting. Knowledge that vision discrepancies between patient report and clinical testing may be owing to home lighting may initiate clinician-patient discussions to optimize home lighting and improve the vision of older adults in their homes.

Effect of measurement order between right and left eyes on intraocular pressure measurement.

OBJECTIVE: To determine whether the order of intraocular pressure (IOP) measurement between right and left eyes affects IOP measurement. METHODS: A total of 105 healthy volunteers from the eye clinics and staff at Washington University were randomized into 2 groups. Group 1 underwent 3 sets of 2 IOP measurements per eye, starting with the right eye (right eye twice, left eye twice, right eye twice). Group 2 underwent similar measurements starting with the left eye. After 2 weeks the order of IOP measurements were reversed between groups. A mixed-model repeated-measures analysis of variance analyzed the association of IOP measurement with the order measured (1) between first and second eyes, (2) between first and second visits, (3) between right and left eyes, and (4) with ocular squeezing. RESULTS: Intraocular pressure measured higher in first eyes compared with fellow eyes regardless of whether right or left eyes were measured first (P = .002). Intraocular pressure measurements decreased between the first and second visits (P < .001). No difference was found in IOP measurements between right and left eyes (P = .41). Moderate and severe ocular squeezing were associated with higher IOP measurements (P < .001) and occurred more during earlier than later IOP measurements within a set (P < .001) and between sets (P < .001 to P = .03). CONCLUSIONS: Intraocular pressure measured in the first eye, whether right or left, is higher than IOP measured in the fellow eye; this may be partially because of ocular squeezing. Measurements of IOP decrease between first and second visits. Multiple IOP measurements at multiple visits are necessary to accurately diagnose and treat patients with glaucoma and ocular hypertension.

Effect of cataract and its removal on signal strength and peripapillary retinal nerve fiber layer optical coherence tomography measurements.

PURPOSE: To assess the effect of cataract on optical coherence tomography (OCT), signal strength (SS), and peripapillary retinal nerve fiber layer (RNFL) thickness measurements. METHODS: Peripapillary RNFL thickness measurements were obtained by Stratus OCT scans using the Fast RNFL thickness (3.4) acquisition protocol before and after cataract extraction in 45 patients with cataract, including 23 glaucoma patients. Cataracts were graded according to the Lens Opacities Classification System III. RESULTS: The postoperative RNFL thickness and SS were 9.3% (P=0.001) and 24.1% (P<0.001) higher than before surgery, respectively. There was greater postoperative change in RNFL thickness measurements in patients with lower preoperative RNFL measurements (r=-0.63, P<0.001) and SS (r=-0.59, P<0.001). Eyes with preoperative SS more than 6 had no significant difference between precataract and postcataract surgery RNFL thickness (P=0.14). There was no significant difference in RNFL thickness change between eyes with cataract only (10.9±20.8 µm) and those with cataract and glaucoma (7.0±14.7 µm; P=0.81). CONCLUSIONS: Cataracts may decrease peripapillary RNFL thickness measurements and the SS on OCT scans. Thinning of the peripapillary RNFL suggestive of glaucomatous progression may be the result of artifact from advancing cataract rather than actual structural changes in the peripapillary RNFL. Peripapillary RNFL thickness measurements should be interpreted with caution in glaucomatous eyes with significant cataract, particularly if the SS is attenuated.

The utility of the monocular trial: data from the ocular hypertension treatment study.

OBJECTIVE: To determine whether adjusting the intraocular pressure (IOP) change of the trial eye for the IOP change of the fellow eye (i.e., monocular trial) is a better assessment of medication response than testing each eye independently. DESIGN: Analysis of data from a prospective, randomized, clinical trial. PARTICIPANTS: Two hundred six participants with ocular hypertension randomized to the observation group and later started on a topical prostaglandin analog (PGA). METHODS: Participants were started on a topical PGA in 1 eye and returned in approximately 1 month to determine medication response. The IOP response of the trial eye was determined by the IOP change between baseline and 1 month in the trial eye alone (unadjusted method) and by adjusting for the IOP change in the fellow eye between the same visits (adjusted method). Our "gold standard" for medication response was the IOP change in the trial eye between up to 3 pre- and 3 posttreatment visits on the same medication. Pearson correlation was used to compare the gold standard with the unadjusted and adjusted methods. In addition, symmetry of IOP response between trial and fellow eyes to the same medication was determined by correlating the trial eye IOP change between up to 3 pre- and 3 posttreatment visits to the fellow eye IOP change between the same visits. MAIN OUTCOME MEASURES: Correlations of IOP change of the trial eye using the gold standard to the IOP change of the trial eye using the unadjusted and adjusted methods. RESULTS: The correlations of IOP change using the gold standard to the IOP change using the unadjusted and adjusted methods were r = 0.40 and r = 0.41, respectively. The correlation of IOP change of both eyes between the same pre- and posttreatment visits was r = 0.81. CONCLUSIONS: The monocular trial (i.e., adjusted method) appears equivalent to testing each eye independently (i.e., unadjusted method); however, neither method is adequate to determine medication response to topical PGAs. Both eyes have a similar IOP response to the same PGA. Further studies to understand IOP fluctuation are necessary to improve current methods of assessing medication response. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Non-Invasive Couching Technique to Treat a Morgagnian Cataract Causing Bullous Keratopathy.

A case is described in which a non-invasive couching technique was used to relieve bullous keratopathy caused by a dislocated Morgagnian cataract. This technique involved applying digital pressure to the inferior cornea to push the dislocated nucleus through the pupil and into the posterior segment. This technique may be useful in cases where relief or prevention of eye pain is the primary goal.

The monocular trial controversy: a critical review.

PURPOSE OF REVIEW: The utility of the monocular trial to determine the response to topical ocular hypotensive medications has been recently debated. This review provides a critical evaluation of recent studies and discusses factors that affect the accurate determination of medication response. RECENT FINDINGS: Recent concerns about the validity of the monocular trial arise from studies reporting a low-to-moderate correlation of intraocular pressure (IOP) response between the first and second eyes to the same topical ocular hypotensive medication. Few studies, however, have addressed the classic monocular trial that adjusts IOP in the trial eye based on IOP change in the fellow eye. Conflicting results from prior studies are due to differences in study question, study design, and method of analysis. Factors such as variability of IOP, diurnal variation, and regression to the mean further complicate the understanding of whether monocular trials or binocular simultaneous trials (i.e. testing each eye separately) are better for determining medication effect. SUMMARY: The issue of whether or not to use the monocular trial remains controversial. A more clear understanding of factors such as nontherapeutic variability of IOP within the same eye and between eyes may elucidate the answer to this question. Further studies of monocular and binocular trials are needed to clarify which method better estimates medication response.

Variability of intraocular pressure measurements in observation participants in the ocular hypertension treatment study.

PURPOSE: To describe variability of intraocular pressure (IOP) measurements within the same eye and between right and left eyes over a 60-month period in participants in the Ocular Hypertension Treatment Study. DESIGN: Analysis of data from a prospective, randomized clinical trial. PARTICIPANTS: Eight hundred ten participants randomized to the observation group. METHODS: Intraocular pressure measurements were obtained at the baseline visit and every 6 months thereafter. Pearson correlation coefficients were calculated for IOP measurements in the same eye between visits and for IOP measurements between right and left eyes of participants at each visit. Differences in IOP measurements between visits are reported in percent change (>15%, >20%, and >30%) and in millimeters of mercury (<3 mmHg, 3-5 mmHg, and >5 mmHg). The effects of regression to the mean, consistency in time of day, and sequence of IOP measurement of right and left eyes were examined. MAIN OUTCOME MEASURES: Correlation of IOP measurements between consecutive 6-month visits. RESULTS: The correlation of IOP measurements within the same eye between consecutive visits was r = 0.62, whereas the correlation of IOP measurements between right and left eyes at the same visit was r = 0.72. Thirteen percent of eyes had >20% change in IOP between consecutive visits. Sixty-six percent of eyes had a change in IOP within 3 mmHg, and 10% of eyes had a change in IOP >5 mmHg between visits. Eyes with a higher baseline IOP had a lower IOP at 6 months. There was a stronger correlation of IOP measured within 2 hours of the time of day between visits (r = 0.56) than >2 hours apart (r = 0.39). IOP of the right eye, which was measured first, was 0.3+/-2.8 mmHg higher than the left eye. CONCLUSIONS: The variability of IOP measurements in the same eye between consecutive visits is moderate and is greater than the variability of IOP measurements between right and left eyes at the same visit. Factors affecting the variability of IOP measurement include regression to the mean, time of day, and measurement order. Knowledge of variability in IOP and its measurements may help clinicians establish a more accurate baseline IOP, target IOP, and assessment of medication effect.

Urban African American Pre-Adolescent Social Problem Solving Skills: Family Influences and Association with Exposure to Situations of Sexual Possibility.

The results of two studies focusing on the social problem solving skills of African American preadolescent youth are detailed. In the first study data from a sample of 150 African American children, ages 9 to 11 years, was used to examine the association between type of youth social problem solving approaches applied to hypothetical risk situations and time spent in unsupervised peer situations of sexual possibility. Findings revealed that children with more exposure to sexual possibility situations generated a wider range of social problem solving strategies, but these approaches tended to be unrealistic and ambiguous. Further, there was a positive association between the amount of time spent unsupervised and youth difficulty formulating a definitive response to hypothetical peer pressure situations. Children with less exposure to sexual possibility situations tended to be more aggressive when approaching situations of peer pressure. In the second study, data from a non-overlapping sample of 164 urban, African American adult caregivers and their 9 to 11 year old children was examined in order to explore the associations between child gender, family-level factors including family communication frequency and intensity, time spent in situations of sexual possibility, and youth social problem solving approaches. Results revealed that children were frequently using constructive problem solving and help seeking behaviors when confronted by difficult social situations and that there was a significant relationship between the frequency and intensity of parent child communication and youth help seeking social problem solving approaches. Implications for research and family-based interventions are highlighted.