Pilot study comparing a new virtual reality-based visual field test to standard perimetry in children.

PURPOSE: To assess the feasibility and performance of Vivid Vision Perimetry (VVP), a new virtual reality (VR)-based visual field platform. METHODS: Children 7-18 years of age with visual acuity of 20/80 or better undergoing Humphrey visual field (HVF) testing were recruited to perform VVP, a VR-based test that uses suprathreshold stimuli to test 54 field locations and calculates a fraction seen score. Pearson correlation coefficients were calculated to evaluate correlation between HVF mean sensitivity and VVP mean fraction seen scores. Participants were surveyed regarding their experience. RESULTS: A total of 37 eyes of 23 participants (average age, 12.9 ± 3.1 years; 48% female) were included. All participants successfully completed VVP testing. Diagnoses included glaucoma (12), glaucoma suspect (7), steroid-induced ocular hypertension (3), and craniopharyngioma (1). Sixteen participants had prior HVF experience, and none had prior VVP experience, although 7 had previously used VR. Of the 23 HVF tests performed, 9 (39%) were unreliable due to fixation losses, false positives, or false negatives. Similarly, 35% of VVP tests were unreliable (as defined by accuracy of blind spot detection). Excluding unreliable HVF tests, the correlation between HVF average mean sensitivity and VVP mean fraction seen score was 0.48 (P = 0.02; 95% CI, 0.09-0.74). When asked about preference for the VVP or HVF examination, all participants favored the VVP, and 70% were "very satisfied" with VVP. CONCLUSIONS: In our cohort of 23 pediatric subjects, VVP proved to be a clinically feasible VR-based visual field testing, which was uniformly preferred over HVF.

Visual Field Testing Frequency and Associations in Children with Glaucoma.

PRCIS: Children with glaucoma had an average of 1.3 visual field tests per year. Self-reported black and multiracial patients had lower visual field testing rates, while older children with better visual acuity had more frequent testing. PURPOSE: To evaluate frequency of visual field (VF) testing in children with glaucoma and identify characteristics associated with VF frequency. METHODS: Retrospective cohort study of 82 children aged 6-18 years with glaucoma seen between August 2018-May 2023. Patients were divided into those who had ≥1 VF test (303 VF tests of 61 children) and 0 VFs (21 children). Eyes were excluded if best corrected visual acuity (BCVA) was counting fingers or worse. Characteristics obtained included age, self-reported race and ethnicity, sex, primary language, glaucoma diagnosis, distance to provider, office visit frequency, follow-up compliance, insurance type, and BCVA. The main outcome measure was VF testing frequency. RESULTS: Among children with ≥1 VF test, mean age at first VF was 11.8±2.8 years, mean number of VF/year was 1.3±0.8, and 44.9% of all VFs were reliable. 39.3% of patients underwent <1 VF/year, 45.9% ≥1 to <2 VFs/year, and 14.8% ≥2 VF/year. Children that were Black or multiracial had significantly lower VF testing frequency (estimated difference (ED) -1.2 [95% CI -2.0 to -0.4, P=0.002] and ED -1.3 [CI -2.2 to -0.3, P=0.008], respectively). Better visual acuity and greater office visit frequency were significantly associated with higher VF testing frequency (ED 0.052 [95% CI 0.001 to 0.103, P=0.045] and ED 0.2 [95% CI 0.1 to 0.3, P<0.001], respectively). CONCLUSIONS: Most children had between 1-2 VF/year, though less than half of all VFs were reliable. Ophthalmologists should consider barriers to care in glaucoma monitoring.

Factors Associated With Visual Field Testing Reliability in Children With Glaucoma or Suspected Glaucoma.

PURPOSE: To evaluate Humphrey Visual Field (HVF) test reliability and its associated risk factors in children with glaucoma or glaucoma suspect. DESIGN: Retrospective cohort study. METHODS: None. SETTING: Single-center childhood glaucoma clinic. PATIENT POPULATION: One hundred thirty-six patients aged ≤18 years with glaucoma/glaucoma suspect, and least 1 completed 24 to 2 HVF test between 2018 and 2023. OBSERVATION PROCEDURE: Demographic and clinical characteristics including age, primary language, visual acuity (VA), and glaucoma diagnosis were extracted from electronic health records. MAIN OUTCOME MEASURES: HVF 24 to 2 testing metrics, including FP, FN, and FL. Tests were defined as reliable using manufacturer guidelines of ≤33% FP, ≤33% FN, and ≤20% FL. For each patient, a reliability score was calculated as the percentage of reliable tests among all tests completed. A multivariable logistic regression model was used to determine factors associated with test-level reliability (yes/no). A multivariable linear regression model was used to determine factors associated with patient-level reliability score. RESULTS: Among 634 HVFs from 136 patients (Mean ± SD age at first test 12.0 ± 3.2 years, 47.8% female), 51.3% were reliable. Older age, better baseline VA, and English as primary language were associated with greater odds of test-level reliability (P < .04). Mean ± SD patient-level reliability score was 51.7 ± 38.1%. Older age at first clinic visit, better baseline VA, and English as primary language were associated with higher reliability scores (all P < .02), and number of prior VF tests was not (P = .56). CONCLUSIONS: Younger age, worse visual acuity, and non-English as primary language were associated with decreased reliability and should be considered when interpreting VF testing in children. A significant learning effect was not observed with repeated testing.

Probing versus primary nasal endoscopy for the treatment of congenital dacryocystoceles.

PURPOSE: To compare outcomes and complications of three surgical techniques for the treatment of congenital dacryocystoceles: nasolacrimal probing and irrigation (P+I), P+I plus nasal endoscopy (NE) with intranasal cyst marsupialization, and primary NE with intranasal cyst marsupialization. METHODS: The medical records of children ≤2 years of age at a single academic center with a diagnosis of dacryocystocele from 2012 to 2022 were retrospectively identified and reviewed. The primary outcome was resolution of the dacryocystocele (ie, elimination of the medial canthal mass and resolution of tearing or discharge) after a single procedure ("primary success"). Surgical techniques were compared using exact logistic regression. RESULTS: Of 54 patients, 21 (39%) underwent P+I, 23 (43%) underwent P+I plus nasal endoscopy, and 10 (18%) underwent primary NE. Primary success was 76% for P+I and 100% for the other two cohorts. Most patients (89%) who underwent P+I received general anesthesia compared with none who underwent primary nasal endoscopy. Most complications were related to the use of general anesthesia, with a complication rate of 10% for P+I, 48% for P+I plus NE, and 0% for primary NE. Most P+I procedures required hospital admission compared to half of primary NE procedures. CONCLUSIONS: In our study cohort, primary NE provided good outcomes and was associated with a lower complication rate than P+I with or without NE.

Genetic changes and testing associated with childhood glaucoma: A systematic review.

Many forms of childhood glaucoma have been associated with underlying genetic changes, and variants in many genes have been described. Currently, testing is variable as there are no widely accepted guidelines for testing. This systematic review aimed to summarize the literature describing genetic changes and testing practices in childhood glaucoma. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) 2020 guidelines and registered with Prospero (ID CRD42023400467). A comprehensive review of Pubmed, Embase, and Cochrane databases was performed from inception through March 2, 2023 using the search terms: (glaucoma) AND (pediatric OR childhood OR congenital OR child OR infant OR infantile) AND (gene OR genetic OR genotype OR locus OR genomic OR mutation OR variant OR test OR screen OR panel). Information was extracted regarding genetic variants including genotype-phenotype correlation. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1,916 records screened, 196 studies met inclusion criteria and 53 genes were discussed. Among study populations, mean age±SD at glaucoma diagnosis was 8.94±9.54 years and 50.4% were male. The most common gene discussed was CYP1B1, evaluated in 109 (55.6%) studies. CYP1B1 variants were associated with region and population-specific prevalence ranging from 5% to 86% among those with primary congenital glaucoma. MYOC variants were discussed in 31 (15.8%) studies with prevalence up to 36% among patients with juvenile open angle glaucoma. FOXC1 variants were discussed in 25 (12.8%) studies, which demonstrated phenotypic severity dependent on degree of gene expression and type of mutation. Overall risk of bias was low; the most common domains of bias were selection and comparability. Numerous genes and genetic changes have been associated with childhood glaucoma. Understanding the most common genes as well as potential genotype-phenotype correlation has the potential to improve diagnostic and prognostic outcomes for children with glaucoma.

A Prospective Study of the Effects of General Anesthesia on Intraocular Pressure in Healthy Children.

Purpose: To determine the effect of general anesthesia on intraocular pressure (IOP) in children with no intraocular pathology and determine which postanesthetic time point is most predictive of preinduction IOP. Design: Prospective observational study. Participants: Children with no intraocular pathology ≤ 18 years scheduled for general anesthesia as part of their routine care followed by a pediatric ophthalmologist at Nanjing Medical University. Methods: Participants underwent a standardized general anesthetic protocol using a mask induction with sevoflurane and propofol maintenance. Intraocular pressure was measured at the following 7 time points: preinduction (taken in the preoperative area), postinduction minutes 1, 3, and 5, and postairway placement minutes 1, 3, and 5 for a total time period of 10 minutes after induction. A generalized estimating equation was used to evaluate the effect of anesthesia on IOP and the effect of patient factors (age, gender, vital signs, and airway type) on preanesthetic and postanesthetic IOP. An IOP prediction model was developed using the postanesthesia IOP measurements for predicting preinduction IOP. Main Outcome Measures: Intraocular pressure and change in IOP at prespecified time points. Results: Eighty-five children were enrolled with a mean ± standard deviation (SD) age of 7.5 ± 2.9 years. Mean ± SD preinduction IOP was 20.1 ± 3.7 mmHg. Overall, IOP was lowest at 3 minutes postinduction, decreased to a mean of 13.4 ± 3.7 mmHg (P < 0.001). After this, IOP rose 5 minutes postinduction to 16.5 ± 4.2 mmHg, which did not reach preinduction IOP levels (P < 0.001). The IOP prediction model showed that combining 1 minute postinduction and 3 minutes postairway was most predictive (R2 = 0.13), whereas 1 minute postairway was least predictive of preinduction IOP (R2 = 0.01). Conclusions: After the induction of general anesthesia in children, IOP temporarily decreases with a trough at 3 minutes postinduction before increasing and remaining stable just below preinduction levels. Intraocular pressure measurements taken 1 minute after induction with 3 minutes after airway placement are most predictive of preinduction IOP, though predictive value is relatively low. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

In Silico Identification of a Potential TNF-Alpha Binder Using a Structural Similarity: A Potential Drug Repurposing Approach to the Management of Alzheimer's Disease.

Introduction: Alzheimer's disease (AD) is a neurodegenerative disorder with no conclusive remedy. Yohimbine, found in Rauwolfia vomitoria, may reduce brain inflammation by targeting tumour necrosis factor-alpha (TNFα), implicated in AD pathogenesis. Metoserpate, a synthetic compound, may inhibit TNFα. The study is aimed at assessing the potential utility of repurposing metoserpate for TNFα inhibition to reduce neuronal damage and inflammation in AD. The development of safe and effective treatments for AD is crucial to address the growing burden of the disease, which is projected to double over the next two decades. Methods: Our study repurposed an FDA-approved drug as TNFα inhibitor for AD management using structural similarity studies, molecular docking, and molecular dynamics simulations. Yohimbine was used as a reference compound. Molecular docking used SeeSAR, and molecular dynamics simulation used GROMACS. Results: Metoserpate was selected from 10 compounds similar to yohimbine based on pharmacokinetic properties and FDA approval status. Molecular docking and simulation studies showed a stable interaction between metoserpate and TNFα over 100 ns (100000 ps). This suggests a reliable and robust interaction between the protein and ligand, supporting the potential utility of repurposing metoserpate for TNFα inhibition in AD treatment. Conclusion: Our study has identified metoserpate, a previously FDA-approved antihypertensive agent, as a promising candidate for inhibiting TNFα in the management of AD.

Effect of Lens Status on the Outcomes of Glaucoma Drainage Device Implantation.

PURPOSE: To assess the effect of lens status and cataract surgery on glaucoma drainage device (GDD) efficacy. DESIGN: Retrospective cohort study. PARTICIPANTS: Two hundred and forty-three eyes of 216 patients that underwent GDD implantation with ≥1 follow-up visit within 3 years postoperatively. Exclusion criteria included GDD combined with other ophthalmic procedures. 90%-94% of GDDs were Ahmed implants; 83%-90% had adjunctive mitomycin-C. METHODS: Outcomes were compared between phakic eyes (group A), eyes phakic at time of implantation but subsequently underwent cataract surgery within 3 years (group B), and pseudophakic eyes (group C). Outcomes were measured at 1, 3, 6, 12, 24, and 36 months after tube shunt implantation. Multivariable regression models were performed, adjusting for baseline characteristics. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) after GDD implantation. Secondary outcomes included change in visual acuity (VA), number of glaucoma eye drops, and rate of failure, defined as additional glaucoma surgery, vision decrease to no light perception, or IOP persistently ≤ 5 mmHg or > 21 mmHg or not reduced from baseline by 20%. RESULTS: There were 65 eyes in group A, 52 in group B, and 126 in group C. Within group B, cataract surgery was performed at a mean of 1.3 ± 0.7 years after GDD implantation. There were no statistically significant differences in mean IOP or medications between the 3 groups at all time points up to 3 years postoperatively. Significant improvement in VA was noted in groups A and B compared to group C at 6 months, 1 year, and 2 years after implantation; however, by postoperative year 3, change in VA was similar across groups. There were no significant differences in the failure rate amongst groups (P = 0.68). IOP and medications up to 12 months after cataract surgery were similar compared to preoperative baseline. Group B had significantly more short-term (P = 0.02) and long-term (P < 0.001) postoperative complications than groups A or C, driven primarily by hypotony. CONCLUSIONS: There were no differences in IOP, glaucoma medications, or rate of failure 3 years after GDD implantation based on lens status or after undergoing subsequent cataract surgery. These results may inform the management of patients with co-existing glaucoma and cataract. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Anterior Segment OCT for Detection of Narrow Angles: A Community-Based Diagnostic Accuracy Study.

PURPOSE: To assess the diagnostic accuracy of anterior segment OCT (AS-OCT) screening for detecting gonioscopically narrow angles. DESIGN: Population-based cross-sectional study. PARTICIPANTS: A stratified random sample of individuals aged ≥ 60 years, selected from a door-to-door census performed in low-lying Nepal. TESTING: Participants underwent AS-OCT, posterior segment OCT, and intraocular pressure (IOP) testing in the community. Those meeting referral criteria in either eye were invited to have a comprehensive eye examination including gonioscopy. Referral criteria included (i) the lowest 2.5% of AS-OCT measurements, (ii) retinal OCT results suggestive of glaucomatous optic neuropathy, diabetic retinopathy, or age-related macular degeneration, and (iii) elevated IOP. MAIN OUTCOME MEASURES: Sensitivity and specificity of 5 semiautomated AS-OCT parameters relative to gonioscopically narrow angles, defined as the absence of visible trabecular meshwork for ≥ 180° on nonindentation gonioscopy. RESULTS: Of 17 656 people aged ≥ 60 years enumerated from 102 communities, 12 633 (71.6%) presented for AS-OCT testing. Referral was recommended for 697 participants based on AS-OCT criteria and 2419 participants based on other criteria, of which 858 had gonioscopy performed by a glaucoma specialist. Each of the 5 AS-OCT parameters offered good diagnostic information for predicting eyes with gonioscopically narrow angles, with areas under the receiver operating characteristic curve ranging from 0.85 to 0.89. The angle opening distance at 750 µm from the scleral spur (AOD750) provided the most diagnostic information, providing an optimal sensitivity of 87% (95% confidence interval [CI], 75%-96%) and specificity of 77% (71%-83%) at a cutpoint of 367 µm, and a sensitivity of 65% (95% CI, 54%-74%) when specificity was constrained to 90% (cutpoint, 283 µm). CONCLUSIONS: On AS-OCT, the AOD750 parameter detected approximately two-thirds of cases of gonioscopically narrow angles when test specificity was set to 90%. Although such a sensitivity may not be sufficient when screening solely for narrow angles, AS-OCT requires little additional effort if posterior segment OCT is already being performed and thus could provide incremental benefit when performing OCT-based screening. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Anterior chamber fluorescein leakage in a child with intraocular pressure elevation and vitreous hemorrhage.

Purpose: To report a case of a child with neovascular and ghost cell glaucoma in the setting of previously treated vitreous hemorrhage with unique fluorescein leakage from abnormal iris vessels ultimately preventing successful fluorescein angiography. Observations: A 3-year-9-month-old female with a medical history of very high-risk B-cell acute lymphoblastic leukemia presented with eye pain and was noted to have a complete vitreous hemorrhage and intraocular pressure elevation in the right eye which was refractory to maximum medical therapy and vitrectomy. Following vitreous hemorrhage resolution, an examination under anesthesia with fluorescein angiography was found to have diffuse leakage of fluorescein into the anterior chamber, presumably due to the active iris neovascularization. This anterior chamber fluorescein signal prevented visualization of the retinal vasculature. The patient was diagnosed with mixed mechanism glaucoma (neovascular and ghost cell) due to a resolved vitreous hemorrhage in the setting of a presumed prior ischemic event. Conclusions and Importance: We report a case of an unsuccessful fluorescein angiogram in the setting of anterior chamber fluorescein leakage due to active iris neovascularization, and review considerations for the differential diagnosis and useful diagnostic tests in this clinical scenario.

Relationship Between Intraocular Pressure and Age: A Population-Based Study in Nepal.

PRCIS: Intraocular pressure (IOP) decreased with age in a population-based study in Nepal, from a mean of 14.1 mm Hg among those 60-64 years old to 13.0 mm Hg among those 80 years old or older. PURPOSE: Few studies have assessed the distribution of IOP from the Indian subcontinent, despite its large population and high burden of glaucoma. The objective of this study was to assess the distribution of IOP measurements from adults living in a lowland region of Nepal. METHODS: In a population-based cross-sectional study, all individuals aged 60 years and older from an area of lowland Nepal were invited for an IOP assessment with a rebound tonometer. RESULTS: Of 160 communities (28,672 people aged ≥60 y) enrolled, 79 (13,808 people aged ≥60 y) were randomly selected for IOP testing. Of those eligible, 10,017 (72.5%) individuals underwent tonometry. Mean IOP decreased monotonically over 5-year age groups, from 14.1 mm Hg (SD: 3.6) among those aged 60-64 years to 13.0 mm Hg (SD: 4.2) among those 80 years or older. The 97.5th percentile IOP measurement was 21.0 mm Hg for all age groups. In adjusted analyses, younger age, self-reported diabetes, and higher population density were each associated with higher IOP, and self-reported cataract surgery was associated with lower IOP. CONCLUSIONS: Mean IOP was lower among older individuals in Nepal, consistent with many studies from East Asia and in contrast to many studies from western populations. These results suggest that ethnic background might be a consideration when diagnosing ocular hypertension.

Bilateral Nasolacrimal Duct Obstruction Managed With Probing and Irrigation in a Patient With FGF10-Associated Lacrimo-auriculo-dento-digital Syndrome.

The authors report a case of lacrimo-auriculo-dento-digital syndrome in a 16-month-old boy with punctal agenesis, upper canalicular dysgenesis and polydactyly, presenting as bilateral congenital nasolacrimal duct obstruction and unilateral acute dacryocystitis. Genetic sequencing revealed a novel mutation in fibroblast growth factor 10. [J Pediatr Ophthalmol Strabismus. 2023;60(4):e38-e40.].

Barriers in Ophthalmology Residency Applications for Students Identifying as Underrepresented in Medicine: A San Francisco Match Analysis.

OBJECTIVE: There is a significant lack of ophthalmologists who self-identify as underrepresented in medicine (URiM) in the physician workforce. Prior literature has revealed bias in traditional metrics for selection relied on by resident programs such as United States Medical Licensing Examination (USMLE) scores, letters of recommendation (LOR), and induction into medical honors societies such as Alpha Omega Alpha (AOA). The purpose of this study was to elucidate race-based differences in word usage within ophthalmology residency letters of recommendation that may disproportionately affect URiM applicants. DESIGN: This was a retrospective, cohort study. SETTING: This was a multicenter study across the Wilmer Eye Institute at Johns Hopkins, the University of California San Francisco, and the University of North Carolina at Chapel Hill. PARTICIPANTS: San Francisco (SF) Match applications submitted to three ophthalmology residency programs between 2018 and 2020 were reviewed. URiM status, USMLE Step 1 score, and AOA membership were recorded. Letters of recommendation were analyzed using text analysis software. T-tests and chi-squared or Fisher's exact tests were used to compare continuous and categorical variables, respectively. Frequency of word/summary term usage in letters of recommendation were the main outcome measures. RESULTS: Relative to non-URiM applicants, URiM applicants had lower USMLE Step 1 scores (mean difference=7.0; p<0.001). Non-URiM letters of recommendation were more likely to describe applicants as "dependable" (p=0.009) and highlight "research" (p=0.046). URiM letters were more likely to describe applicants as "warm" (p=0.02) and "caring" (p=0.02). CONCLUSIONS: This study identified potential barriers for URiM ophthalmology residency applicants which can help guide future interventions to increase workforce diversity.

Efficacy of Ahmed and Baerveldt glaucoma drainage device implantation in the pediatric population: A systematic review and meta-analysis.

Glaucoma drainage devices (GDD) are increasingly utilized in the management of childhood glaucoma. This systematic review and meta-analysis assesses the efficacy of first-time Ahmed or Baerveldt implantation in children. PubMed, Embase, and Cochrane Library were searched for relevant English-language, peer-reviewed literature. Postoperative outcomes were pooled using random effects regression models with restricted maximum likelihood estimation. Thirty-two studies (1,221 eyes, 885 children) were included. Mean ± standard deviation preoperative IOP was 31.8 ± 3.4 mm Hg. Pooled mean IOP at 12 and 24 months postoperatively were 16.5 mm Hg (95% CI, 15.5-17.6) and 17.6 mm Hg (95% CI, 16.4-18.7), respectively. Pooled proportions of success were 0.87 (95% CI, 0.83-0.91) at 12 months, 0.77 (95% CI, 0.71-0.83) at 24 months, 0.54 (95% CI, 0.44-0.65) at 48 months, 0.60 (95% CI, 0.48-0.71) at 60 months, and 0.37 (95% CI, 0.32-0.42) at 120 months. There were no differences in proportion of success at 12 and 24 months among eyes that received Ahmed and Baerveldt tube shunts, nor between eyes with primary glaucoma, glaucoma following cataract surgery, or other secondary glaucoma. Our findings show that Ahmed and Baerveldt shunts substantially reduced IOP for at least 24 months in childhood glaucoma, with similar findings among device types and glaucoma etiologies.

Diagnostic Accuracy of Frequency-Doubling Technology and the Moorfields Motion Displacement Test for Glaucoma.

PURPOSE: Portable perimetric testing could be useful for community-based glaucoma screening programs. Frequency-doubling technology (FDT) and the Moorfields motion displacement test (MDT) are portable perimeters that have shown promise as potential screening tools for glaucoma. This study's goal was to determine the diagnostic accuracy of FDT and MDT for visual field defects and glaucoma. DESIGN: Prospective, cross-sectional, diagnostic accuracy study. PARTICIPANTS: A consecutive series of patients aged ≥ 50 years who presented to a glaucoma clinic in South India and had never undergone Humphrey field analyzer (HFA) visual field testing in the past. METHODS: Participants underwent 24-2 Swedish Interactive Thresholding Algorithm (SITA) Standard HFA perimetry, FDT perimetry, MDT perimetry, and iPad perimetry using visualFields Easy in random order. Ophthalmologist grades of HFA and optic nerve head photographs were used as reference standards for glaucoma and field defect presence. Receiver operating characteristic curves were constructed to assess the diagnostic accuracy of various parameters for each test. MAIN OUTCOME MEASURES: Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). RESULTS: Overall, 292 eyes from 173 participants were included, with 112 eyes classified as moderate or worse glaucoma. For moderate or worse glaucoma detection, the best parameter on FDT was mean deviation (MD) (AUROC, 0.84; 95% confidence interval [CI], 0.79-0.89) and the best parameter on MDT was global probability of true damage (GPTD) (AUROC, 0.87; 95% CI, 0.82-0.91). When specificity was set to 90%, the sensitivity for detection of moderate or worse glaucoma was 55% (95% CI, 39%-68%) for FDT MD and 62% (95% CI 52%-71%) for MDT GPTD. CONCLUSIONS: Frequency-doubling technology and MDT perimetry had fair diagnostic accuracy for glaucoma detection when administered to naïve test takers in this South Indian population. Although not appropriate for use as a sole glaucoma screening test, these perimetric tests may be useful as ancillary tests. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Randomized Trial to Evaluate the Efficacy of the Nanodropper Device for Pupillary Dilation and Cycloplegia in Children.

PURPOSE: We evaluated the noninferiority of 10.4 µl of eye drops eluted with a commercially available eye drop adapter, the Nanodropper (Nanodropper, Inc), on pupillary dilation and cycloplegia in children compared with the standard of care (SOC), 50 µl of eye drops. DESIGN: Prospective randomized trial. PARTICIPANTS: Pediatric patients scheduled for routine pupillary dilation at the University of California, San Francisco, at the Pediatric Ophthalmology Clinic were enrolled. Each participant provided 1 eye for the intervention group (Nanodropper) and 1 eye for the control group (SOC). METHODS: Participants were randomized to receive small-volume dilating drops in 1 eye (Nanodropper) and SOC dilating drops in the other eye. Dilation was performed using 1 drop each of 1% cyclopentolate, 1% tropicamide, and 2.5% phenylephrine. Refraction and pupillometry were obtained before and 30 minutes after dilation. A noninferiority analysis was performed to assess change from before to after dilation in spherical equivalent and in pupil constriction percentage and maximum pupil diameter after dilation. MAIN OUTCOME MEASURES: Spherical equivalent, maximum pupil diameter, and pupil constriction percentage. RESULTS: One hundred eyes of 50 patients were included, with a mean ± standard deviation age of 9 ± 3 years. After controlling for baseline measurements, the spherical equivalent after dilation was 0.05 diopter (D) more (95% confidence interval [CI], -0.28 to 0.37 D) in the Nanodropper arm, which did not achieve noninferiority. Maximum pupil diameter after dilation was lower in the Nanodropper group (mean, -0.01 mm; 95% CI, -0.20 to -0.03), which did achieve noninferiority. Constriction percentage after dilation was 0.57 percentage points more (95% CI, -1.38 to 2.51 percentage points) in the Nanodropper group, which did not achieve noninferiority. CONCLUSIONS: Administration of eye drops using a small-volume adapter demonstrated similar efficacy to SOC in a pediatric population. Strict noninferiority was met only for pupillary dilation and not for cycloplegia or constriction percentage; however, the small differences in the effect of the Nanodropper versus SOC on all primary outcomes were not clinically significant. We conclude that small-volume eye drops have the potential to decrease unnecessary medical waste and medication toxicity while maintaining therapeutic effect. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.