Relationship between Blood Pressure and Rates of Glaucomatous Visual Field Progression: The Vascular Imaging in Glaucoma Study.

PURPOSE: To examine the relationship between systemic arterial blood pressure (BP) and the rate of change in standard automated perimetry (SAP) in eyes with glaucoma and suspected glaucoma. DESIGN: Prospective cohort study. PARTICIPANTS: One hundred twenty-four eyes (91 eyes with glaucoma, 33 eyes with suspected glaucoma) of 64 patients (mean age, 68.4 ± 7.6 years) followed up at the Bascom Palmer Eye Institute, Palm Beach Gardens, Florida. METHODS: Participants underwent ophthalmic examination, BP measurement, and SAP at 4-month intervals. At the baseline visit, 24-hour ambulatory blood pressure monitoring (ABPM) was acquired. Linear mixed models (adjusted for inclusion of both eyes, age, sex, race, intraocular pressure, baseline severity, and central corneal thickness) were used to investigate the effect of BP on the rates of SAP mean deviation (MD) change over time. MAIN OUTCOME MEASURES: Effect of baseline 24-hour and follow-up mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP on change in SAP MD. RESULTS: Eyes underwent an average of 8.9 ± 1.5 SAP examinations over 28.3 ± 6.0 months of follow-up. The median rate of MD change was 0.14 dB/year (range, -1.21 to 0.96 dB/year) with 9 eyes (7%) showing moderate to fast progression (MD change, ≤ -0.50 dB/year). Each 10 mmHg lower in 24-hour average MAP and SBP were associated with -0.171 dB/year (P = 0.045) and -0.137 dB/year (P = 0.023) faster rates of MD loss. Lower mean SBP during follow-up was associated significantly (P = 0.003) with MD progression. CONCLUSIONS: Lower baseline 24-hour ABPM measurements, as well as low SBP during follow-up, were associated significantly with faster rates of glaucomatous SAP progression and may be used as a predictor of risk of glaucomatous progression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Hybrid Deep Learning Classification of Perimetric Glaucoma Using Peripapillary Nerve Fiber Layer Reflectance and Other OCT Parameters from Three Anatomy Regions.

Précis: A hybrid deep-learning model combines NFL reflectance and other OCT parameters to improve glaucoma diagnosis. Objective: To investigate if a deep learning model could be used combine nerve fiber layer (NFL) reflectance and other OCT parameters for glaucoma diagnosis. Patients and Methods: This is a prospective observational study where of 106 normal subjects and 164 perimetric glaucoma (PG) patients. Peripapillary NFL reflectance map, NFL thickness map, optic head analysis of disc, and macular ganglion cell complex thickness were obtained using spectral domain OCT. A hybrid deep learning model combined a fully connected network (FCN) and a convolution neural network (CNN) to develop to combine those OCT maps and parameters to distinguish normal and PG eyes. Two deep learning models were compared based on whether the NFL reflectance map was used as part of the input or not. Results: The hybrid deep learning model with reflectance achieved 0.909 sensitivity at 99% specificity and 0.926 at 95%. The overall accuracy was 0.948 with 0.893 sensitivity and 1.000 specificity, and the AROC was 0.979, which is significantly better than the logistic regression models (p < 0.001). The second best model is the hybrid deep learning model w/o reflectance, which also had significantly higher AROC than logistic regression models (p < 0.001). Logistic regression with reflectance model had slightly higher AROC or sensitivity than the other logistic regression model without reflectance (p = 0.024). Conclusions: Hybrid deep learning model significantly improved the diagnostic accuracy, without or without NFL reflectance. Hybrid deep learning model, combining reflectance/NFL thickness/GCC thickness/ONH parameter, may be a practical model for glaucoma screen purposes.

Acute serous and hemorrhagic choroidal effusion associated with topical dorzolamide therapy.

Purpose: To report a case of acute onset unilateral hemorrhagic and serous choroidal effusion associated with dorzolamide administration and antiplatelet use that recurred in a patient who experienced a dorzolamide-induced choroidal effusion ten years prior to presentation. Observations: A 78-year-old male with a history of POAG in both eyes presented with sudden onset decreased vision and flashes of light in the left eye two days after escalating from timolol maleate 0.5% twice daily in both eyes to fixed combination dorzolamide-timolol 22.3-6.8 mg/mL twice daily in both eyes. Systemic medication included daily aspirin 81 mg for primary prevention of cardiovascular disease. Dilated fundus examination and B-scan ultrasound of the left eye revealed a hemorrhagic choroidal effusion in the nasal retinal periphery and low lying serous choroidal effusion in the temporal periphery. Complete resolution of the choroidal detachment was achieved in four days following prompt cessation of dorzolamide, and treatment with topical prednisolone acetate 1% four times daily and atropine 1% two times daily. Conclusions and importance: Topical dorzolamide may induce an idiosyncratic reaction leading to serous and hemorrhagic choroidal effusion, which can be exacerbated by antiplatelet use. Prompt recognition and management of drug-induced choroidal effusion can lead to improved visual outcomes and prevent long-term sequelae.

Direct Costs of Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation (The Assists Trial).

PRCIS: The cost of cyclophotocoagulation is less than the cost of a second glaucoma drainage device. PURPOSE: To compare the total direct costs of implantation of a second glaucoma drainage device (SGDD) with transscleral cyclophotocoagulation (CPC) for patients with inadequately controlled intraocular pressure (IOP) reduction, despite the presence of a preexisting glaucoma drainage device in the ASSISTS clinical trial. METHODS: We compared the total direct cost per patient, including the initial study procedure, medications, additional procedures, and clinic visits during the study period. The relative costs for each procedure during the 90-day global period and the entire study period were compared. The cost of the procedure, including facility fees and anesthesia costs, were determined using the 2021 Medicare fee schedule. Average wholesale prices for self-administered medications were obtained from AmerisourceBergen.com. The Wilcoxon rank sum test was used to compare costs between procedures. RESULTS: Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). One CPC eye was lost to follow-up after initial treatment and was excluded. The mean (±SD, median) duration of follow-up was 17.1 (±12.8, 11.7) months and 20.3 (±11.4, 15.1) months for SGDD and CPC, respectively ( P =0.42, 2 sample t test). The mean total direct costs (±SD, median) per patient during the study period were $8790 (±$3421, $6805 for the SGDD group) and $4090 (±$1424, $3566) for the CPC group ( P <0.001). Similarly, the global period cost was higher in the SGDD group than in the CPC group [$6173 (±$830, $5861) vs. $2569 (±$652, $2628); P <0.001]. The monthly cost after the 90-day global period was $215 (±$314, $100) for SGDD and $103 (±$74, $86) for CPC ( P =0.31). The cost of IOP-lowering medications was not significantly different between groups during the global period ( P =0.19) or after the global period ( P =0.23). CONCLUSION: The total direct cost in the SGDD group was more than double that in the CPC group, driven largely by the cost of the study procedure. The costs of IOP-lowering medications were not significantly different between groups. When considering treatment options for patients with a failed primary GDD, clinicians should be aware of differences in costs between these treatment strategies.

Outcomes of the Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation Treatment Study: A Randomized Comparative Trial.

PRCIS: Short-term overall success rates were high with either SGDD or CPC. However, SGDD was associated with more clinic visits and an increased risk of additional glaucoma surgery. Both treatments were reasonable options for eyes with inadequately controlled IOP after a single GDD. PURPOSE: The purpose of this study is to compare the implantation of a second glaucoma drainage device (SGDD) and transscleral cyclophotocoagulation (CPC) in eyes with inadequately controlled intraocular pressure (IOP), despite the presence of a preexisting glaucoma drainage device. METHODS: Patients with inadequately controlled IOP, despite the medical therapy and a preexisting glaucoma drainage device, were enrolled at 14 clinical centers and randomly assigned to treatment with a SGDD or CPC. MAIN OUTCOME MEASURES: Surgical failure was defined as: (1) IOP ≤5 mm Hg or >18 mm Hg or <20% reduction below baseline on maximum tolerated topical ocular hypotensive therapy, (2) reoperation for glaucoma, or (3) loss of light perception. The primary outcome measure was overall success with or without adjunctive medical therapy. RESULTS: Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). Mean duration of follow-up was 18.6 (±12.1; range: 1.1-38.6) months. The cumulative success rate was 79% for SGDD and 88% for CPC at 1 year ( P =0.63). Although the study was underpowered, no significant differences in IOP, postoperative number of IOP-lowering medications, or adverse events were observed. The number of additional glaucoma surgeries ( P =0.003), office visits during the first 3 months ( P <0.001), and office visits per month after month 3 ( P <0.001) were greater in the SGDD group. CONCLUSIONS: Short-term overall success rates were high with either SGDD or CPC. However, SGDD was associated with more clinic visits and an increased risk of additional glaucoma surgery.

Comparison of Outcomes From Delayed-Onset Bleb-Related Endophthalmitis Treated With Pars Plana Vitrectomy Versus Vitreous Biopsy.

PRCIS: Bleb-related endophthalmitis (BRE) is a serious complication of glaucoma filtration surgery. The current study reports similar visual and intraocular pressure (IOP) outcomes in eyes treated with pars plana vitrectomy (PPV) compared with vitreous biopsy and injection of intravitreal antibiotics (TI). PURPOSE: The purpose of this study was to investigate the isolated organisms, visual acuity (VA), and IOP outcomes associated with delayed-onset BRE in eyes treated with PPV versus TI. PATIENTS AND METHODS: A retrospective chart review was conducted at the Bascom Palmer Eye Institute (Miami, Florida) and the University of Florida (Gainesville, FL) identifying patients treated for BRE with at least 1 month of follow-up from the inception of an electronic health record (2014 and 2011, respectively) through 2021. All patients had undergone bleb-forming glaucoma surgery at least 1 month before endophthalmitis diagnosis. RESULTS: Thirty-nine eyes from 39 patients (33 from Bascom Palmer, 6 from University of Florida) were included. Trabeculectomy was performed in 34 of 39 eyes (87.2%). Streptococcus species (9 eyes, 23.1%) and Staphylococcus species (8 eyes, 20.5%) were the most common isolated organisms and were similar in both treatment groups ( P =0.49). Baseline VA was worse in the PPV group (logarithm of the minimum angle of resolution: 2.51 vs. 2.16, P =0.04), but VA at last follow-up was similar ( P =0.48) in both groups. After recovery from BRE, the average IOP in the PPV group was 15.1 mm Hg on 0.9 IOP-lowering medications compared with 12.6 mm Hg on 1.2 medications in the TI group (IOP: P =0.56; medications: P =0.80). Additional glaucoma surgery was performed in 44.4% of the PPV eyes and 16.7% of the TI eyes ( P =0.09). CONCLUSION: In eyes with delayed-onset BRE, isolated organisms, visual outcomes, and IOP control were similar after initial PPV compared with TI.

Trends in Glaucoma Surgeries Performed by Glaucoma Subspecialists versus Nonsubspecialists on Medicare Beneficiaries from 2008 through 2016.

PURPOSE: To characterize the use of laser and incisional glaucoma surgeries among Medicare beneficiaries from 2008 through 2016 and to compare the use of these surgeries by glaucoma subspecialists versus nonsubspecialists. DESIGN: Retrospective, observational analysis. PARTICIPANTS: Medicare beneficiaries (n = 1 468 035) undergoing ≥1 laser or incisional glaucoma surgery procedure during 2008 through 2016. METHODS: Claims data from a 20% sample of enrollees in fee-for-service Medicare throughout the United States were analyzed to identify all laser and incisional glaucoma surgeries performed from 2008 through 2016. We assessed use of traditional incisional glaucoma surgery techniques (trabeculectomy and glaucoma drainage implant [GDI] procedure) and microinvasive glaucoma surgery (MIGS). Enrollee and procedure counts were multiplied by 5 to estimate use throughout all of Medicare. Linear regression was used to compare trends in use of glaucoma surgeries between ophthalmologists who could be characterized as glaucoma subspecialists versus nonsubspecialists. MAIN OUTCOME MEASURES: Numbers of laser and incisional glaucoma surgeries performed overall and stratified by glaucoma subspecialist status. RESULTS: The number of Medicare beneficiaries undergoing any glaucoma therapeutic procedure increased by 10.6%, from 218 375 in 2008 to 241 565 in 2016. The total number of traditional incisional glaucoma surgeries decreased by 11.7%, from 37 225 to 32 885 (P = 0.02). The total number of MIGS procedures increased by 426% from 13 705 in 2012 (the first year MIGS codes were available) to 58 345 in 2016 (P = 0.001). Throughout the study period, glaucoma subspecialists performed most of the trabeculectomies (76.7% in 2008, 83.1% in 2016) and GDI procedures (77.7% in 2008, 80.6% in 2016). Many MIGS procedures were performed by nonsubspecialists. The proportions of endocyclophotocoagulations, iStent (Glaukos; San Clemente, CA) insertions, goniotomies, and canaloplasties performed by glaucoma subspecialists in 2016 were 22.0%, 25.2%, 56.9%, and 62.8%, respectively. CONCLUSIONS: From 2008 through 2016, a large shift in practice from traditional incisional glaucoma surgeries to MIGS procedures was observed. Although glaucoma subspecialists continue to perform most traditional incisional glaucoma surgeries, many MIGS procedures are performed by nonsubspecialists. These results highlight the importance of training residents in performing MIGS procedures and managing these patients perioperatively. Future studies should explore the impact of this shift in care on outcomes and costs.

Secondary open-angle glaucoma and serous macular detachment associated with pulmonary hypertension.

PURPOSE: We describe a patient with secondary open-angle glaucoma and serous macular detachment associated with pulmonary hypertension. OBSERVATIONS: A 59 year-old male with pulmonary hypertension presented with vision loss and was noted to have bilateral engorged epibulbar vessels, blood in Schlemm's canal, elevated intraocular pressure, retinal venous tortuosity and serous retinal detachments. Enhanced depth optical coherence tomography (ED-OCT) showed bilateral serous macular detachments with marked choroidal thickening. Fluorescein angiography and indocyanine green angiography revealed choroidal vascular congestion and engorgement. Improvement of subretinal fluid was achieved with systemic control of his venous hypertension, and the intraocular pressure responded to medical anti-glaucoma therapy. CONCLUSIONS: Pulmonary hypertension may be associated with secondary open-angle glaucoma, choroidal engorgement and serous macular detachment, and should be considered in the differential diagnosis of elevated episcleral venous pressure. Management of ocular complications is challenging and requires a multi-disciplinary approach.

Efficacy and safety of ultrasonic circular cyclocoagulation with second-generation probe in glaucoma: A retrospective study.

BACKGROUND: To assess the efficacy and safety of the second-generation probe of ultrasonic circular cyclocoagulation (UC3) in naive or refractory glaucoma, with a 6-month follow-up. METHODS: A retrospective consecutive case-series study included patients having a UC3 procedure with the second-generation probe of the EyeOP1 device, intraocular pressure (IOP) ≥ 21 mmHg and under maximum tolerated medical treatment, with or without previous glaucoma surgery. Surgical success was defined at the 6-month post-operative visit as IOP > 5 and ≤ 21 mmHg with IOP reduction ≥ 20% from baseline, without any reoperation, and visual acuity better than negative light perception. RESULTS: 100 patients were included and 97 (97.0%; 97 eyes) attended the 6-month follow-up. At 6 months, surgical success was obtained in 48 eyes (49.5%). Intraocular pressure was reduced from a mean ± SD preoperative value of 28.0 ± 5.6 mmHg to 19.3 ± 7.1 mmHg at 6 months (p<0.0001). The proportion of eyes requiring oral acetazolamide decreased from 57.0% to 30.0% between baseline and 6 months after surgery (p = 0.0007). We observed 15 (15.0%) cases of postsurgical macular edema, 8 (8.0%) of hypotony, and 20 (20.0%) of visual acuity loss > 2 Snellen lines. Postsurgical macular edema was associated with a history of epiretinal membranes, uveitis or retinal detachment. Risk factors for hypotony were a history of diabetes or trabeculectomy. CONCLUSIONS: The second-generation UC3 probe significantly reduced IOP in eyes with naive and refractory glaucoma but severe post-operative complications were often observed. Further studies are needed to better identify responders and decrease the high risk for complications associated with the procedure.

Estimating Visual Field Mean Deviation using Optical Coherence Tomographic Nerve Fiber Layer Measurements in Glaucoma Patients.

To construct an optical coherence tomography (OCT) nerve fiber layer (NFL) parameter that has maximal correlation and agreement with visual field (VF) mean deviation (MD). The NFL_MD parameter in dB scale was calculated from the peripapillary NFL thickness profile nonlinear transformation and VF area-weighted averaging. From the Advanced Imaging for Glaucoma study, 245 normal, 420 pre-perimetric glaucoma (PPG), and 289 perimetric glaucoma (PG) eyes were selected. NFL_MD had significantly higher correlation (Pearson R: 0.68 vs 0.55, p < 0.001) with VF_MD than the overall NFL thickness. NFL_MD also had significantly higher sensitivity in detecting PPG (0.14 vs 0.08) and PG (0.60 vs 0.43) at the 99% specificity level. NFL_MD had better reproducibility than VF_MD (0.35 vs 0.69 dB, p < 0.001). The differences between NFL_MD and VF_MD were -0.34 ± 1.71 dB, -0.01 ± 2.08 dB and 3.54 ± 3.18 dB and 7.17 ± 2.68 dB for PPG, early PG, moderate PG, and severe PG subgroups, respectively. In summary, OCT-based NFL_MD has better correlation with VF_MD and greater diagnostic sensitivity than the average NFL thickness. It has better reproducibility than VF_MD, which may be advantageous in detecting progression. It agrees well with VF_MD in early glaucoma but underestimates damage in moderate~advanced stages.

Malignant Glaucoma After Laser Peripheral Iridotomy.

PURPOSE: We describe a patient with primary angle-closure glaucoma who developed malignant glaucoma following laser peripheral iridotomy. METHODS: A 58-year-old male presented with peripheral and central anterior chamber shallowing following an uncomplicated Nd: YAG laser peripheral iridotomy. Intraocular pressure (IOP) and B-scan echography were normal, and there was -1.5 Ddiopter asymmetric myopia. Despite treatment with aqueous suppression and cycloplegia for 7 months, the patient developed progressive myopic shift and anterior chamber shallowing. RESULTS: The patient underwent 23-G pars plana vitrectomy and lensectomy using a standard 3-port technique, and sulcus posterior chamber intraocular lens implantation in the left eye. Twelve months postoperatively, the anterior chamber has remained deep, best-corrected visual acuity is 20/15, and the IOP is 11 mm Hg. CONCLUSIONS: Malignant glaucoma is a rare complication of laser iridotomy and should be considered in eyes with progressive anterior chamber shallowing and myopia despite normal IOP.

Predictive Factors for the Rate of Visual Field Progression in the Advanced Imaging for Glaucoma Study.

PURPOSE: To investigate predictive factors associated with the rate of visual field (VF) loss in open-angle glaucoma. DESIGN: Prospective multicenter cohort study. METHODS: Perimetric glaucoma patients of the Advanced Imaging for Glaucoma study were selected for analysis if they had 9 completed visits. Confirmed rapid significant progression (CRSP) of VF was defined as a significant (P < 0.05) negative VF index (VFI) slope of -1%/year or a mean deviation slope of -0.5 dB/year, confirmed at 2 consecutive follow-up visits. Slow progression was defined as VFI slope greater than -0.5%/year or a mean deviation slope of -0.25 dB/year. Fourier-domain optical coherence tomography (FD-OCT) measured optic disc, peripapillary retinal nerve fiber layer (NFL), and macular ganglion cell complex (GCC) thicknesses. Logistic regression was used to identify baseline predictors for CRSP and slow progression. Linear regression was used to identify baseline predictors for the VFI and mean deviation slope. RESULTS: Eyes (n = 150) of 103 participants were included. Slow progression was observed in 80 eyes (53.3%) and CRSP in 23 eyes (15.3%). Larger NFL and GCC baseline focal loss volume (FLV), thinner central corneal thickness, and lower VFI were significant (P < 0.05) baseline predictors of more rapid progression on univariate analysis. The predictor with the highest odds ratio (OR) was NFL-FLV, which was also the most significant non-VF predictor in the multivariate analysis. Eyes with NFL-FLV >8.5% had an OR of 2.67 for CRSP and 0.42 for slow progression. Disc hemorrhage during the follow-up was also important, with an OR of 2.61 for CRSP and 0.23 for slow progression for each occurrence. CONCLUSIONS: Focal loss measured by FD-OCT or VF along with CCT are strong baseline predictors for the rate of glaucoma progression.

A Comparison of Resource Use and Costs of Caring for Patients With Exfoliation Syndrome Glaucoma Versus Primary Open-Angle Glaucoma.

PURPOSE: To characterize differences in resource utilization and cost of managing enrollees with exfoliation glaucoma (XFG) compared to primary open-angle glaucoma (POAG). DESIGN: Retrospective utilization and cost comparison using Medicare claims data. METHODS: We identified Medicare beneficiaries with XFG or POAG and ≥5 years of continuous enrollment from January 2008 to December 2014. We distinguished newly diagnosed cases from those with preexisting disease. We compared ophthalmic resource utilization and costs over 2 years of follow-up for persons with newly diagnosed and preexisting XFG vs those with POAG. Main outcome measures were number of clinic visits, diagnostic procedures, medication fills, laser and incisional surgery, and mean eye care costs per beneficiary. RESULTS: Among 192 eligible enrollees (median age 77.6 years) with newly diagnosed XFG and 7339 enrollees (median age 77.3 years) with newly diagnosed POAG, those with XFG had more office visits (mean, 9.1 vs 7.9; P = .001), cataract surgery (34.9% vs 19.0%; P < .0001), and glaucoma surgery (28.7% vs 19.7%, P = .002). They also experienced 27% higher mean total eye care costs ($3260 vs $2562, P = .0001) over 2 years of follow-up. Among 2745 enrollees (median age 80.5 years) with preexisting XFG and 89 036 persons (median age 79.5) with preexisting POAG, persons with XFG had more office visits (mean 9.3 vs 7.3; P < .0001), perimetry (85.3% vs 79.8%; P < .0001), cataract surgery (23.4% vs 12.3%; P < .0001), laser trabeculoplasty (18.6% vs 9.6%; P < .0001), and trabeculectomy (8.1 vs 1.8%; P < .0001) and experienced 37% higher total mean eye care costs ($3764 vs $2739; P < .0001). CONCLUSIONS: Healthcare resource utilization and costs are substantially higher for managing patients with XFG compared to POAG.

Detecting Glaucoma Progression Using Guided Progression Analysis with OCT and Visual Field Assessment in Eyes Classified by International Classification of Disease Severity Codes.

PURPOSE: To compare the detection and rates of progressive retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL) loss with spectral-domain (SD) OCT and visual field (VF) loss using Guided Progression Analysis (GPA; Carl Zeiss Meditec, Dublin, CA) in glaucomatous eyes classified using International Classification of Diseases (ICD) diagnosis codes. DESIGN: Retrospective cohort study. PARTICIPANTS: Glaucoma patients with at least 3 years of follow-up and a minimum of 4 SD OCT and 5 reliable VF examinations. METHODS: Glaucoma severity was classified using ICD, 10th Edition, Clinical Modification, diagnosis codes. Rates of RNFL, macular GCIPL, and VF loss were calculated, and progression estimates were compared using generalized estimating equations and McNemar's tests. MAIN OUTCOME MEASURES: Progressive RNFL, GCIPL, and VF loss assessed by GPA criteria. RESULTS: A total of 147 eyes of 116 patients (mean age, 69.9±8.5 years) were included with mean follow-up of 69.67±18.64 months. Overall, 38 of 147 eyes (25.9%) showed RNFL progression, 35 eyes (23.8%) showed GCIPL progression, and 20 eyes (13.6%) showed VF progression. Progression by all 3 methods was noted in 10 eyes (7.0%). Eyes with mild (n = 62) and severe (n = 46) glaucoma showed significantly more progression on SD OCT compared with VF (P < 0.001 and P = 0.004). Retinal nerve fiber layer, GCIPL, and VF progressors showed faster rates of loss in average RNFL, GCIPL, and VF mean deviation compared with nonprogressors (mean ± standard error: -1.47±0.30 µm/year vs. -0.03±0.12 µm/year [P = 0.0001], -1.68±0.34 µm/year vs. -0.29±0.07 µm/year [P = 0.0001], and -1.07±0.20 dB/year vs. -0.19±0.04 dB/year [P = 0.0001], respectively). CONCLUSIONS: Spectral-domain OCT progression was significantly more common than VF progression in glaucomatous eyes classified with mild and severe disease. Structure and function should be monitored closely across the entire spectrum of glaucoma severity.

Non-Synonymous variants in premelanosome protein (PMEL) cause ocular pigment dispersion and pigmentary glaucoma.

Pigmentary glaucoma (PG) is a common glaucoma subtype that results from release of pigment from the iris, called pigment dispersion syndrome (PDS), and its deposition throughout the anterior chamber of the eye. Although PG has a substantial heritable component, no causative genes have yet been identified. We used whole exome sequencing of two independent pedigrees to identify two premelanosome protein (PMEL) variants associated with heritable PDS/PG. PMEL encodes a key component of the melanosome, the organelle essential for melanin synthesis, storage and transport. Targeted screening of PMEL in three independent cohorts (n = 394) identified seven additional PDS/PG-associated non-synonymous variants. Five of the nine variants exhibited defective processing of the PMEL protein. In addition, analysis of PDS/PG-associated PMEL variants expressed in HeLa cells revealed structural changes to pseudomelanosomes indicating altered amyloid fibril formation in five of the nine variants. Introduction of 11-base pair deletions to the homologous pmela in zebrafish by the clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 method caused profound pigmentation defects and enlarged anterior segments in the eye, further supporting PMEL's role in ocular pigmentation and function. Taken together, these data support a model in which missense PMEL variants represent dominant negative mutations that impair the ability of PMEL to form functional amyloid fibrils. While PMEL mutations have previously been shown to cause pigmentation and ocular defects in animals, this research is the first report of mutations in PMEL causing human disease.

Safety and Efficacy of Diode Laser Transscleral Cyclophotocoagulation in Eyes With Good Visual Acuity.

BACKGROUND/AIMS: The main aim of this study was to evaluate the safety and efficacy of diode laser transscleral cyclophotocoagulation (TSCPC) in eyes with good visual acuity. PATIENTS AND METHODS: A retrospective chart review identified patients who underwent TSCPC for uncontrolled intraocular pressure (IOP) from 2014 to 2016. Enrollment criteria included pretreatment best-corrected visual acuity (BCVA) of 20 of 40 or better, and a minimum of 6 months of postoperative follow-up. RESULTS: Thirty-three eyes of 33 patients(mean age, 72.1±16.0 y) were enrolled (mean follow-up 12.6±6.1 mo). The mean (SD) IOP was reduced 48.3% from 27.1 mm Hg (7.8) at baseline to 13.1 mm Hg (4.2) at last follow-up. Reduction of ≥1 glaucoma medications was achieved in 17 eyes (51.5%) at last follow-up. The cumulative probability of complete success (BCVA loss <2 Snelling lines, 20% reduction IOP, no reoperation for glaucoma, no IOP<5 mm Hg) was 78.8% and 50% at months 6 and 12, respectively. The cumulative probability of qualified success (BCVA≥2 lines with ≥20% reduction IOP, no reoperation for glaucoma, no IOP<5 mm Hg) was 90.1% and 81.3% at month 6 and 1 year, respectively. Significant vision loss, defined as BCVA≥2 lines, occurred in 33% of patients. The most common complications were postoperative iritic (56.3%) and cystoid macular edema (12.5%). CONCLUSIONS: TSCPC demonstrates a strong reduction in IOP and glaucoma medication use. However, with significant vision loss in 33% of patients, future prospective studies with a comparison group receiving traditional glaucoma surgery are needed to determine comparative safety and efficacy.

Is Obstructive Sleep Apnea Associated With Progressive Glaucomatous Optic Neuropathy?

PURPOSE: The purpose of this study was to evaluate the relationship between obstructive sleep apnea syndrome (OSAS) and glaucoma progression, and to examine the correlation between OSAS severity and rate of visual field (VF) loss. METHODS: Patients with concurrent diagnoses of open-angle glaucoma and OSAS between 2010 and 2016 were identified. Enrollment criteria consisted of glaucomatous optic neuropathy and VF loss, ≥5 reliable VFs, ≥2 years of follow-up, and polysomnography (PSG) within 12 months of final VF. PSG parameters including apnea-hypopnea index (AHI) and oxygen saturation (SpO2) were collected. Eyes were classified as "progressors" or "nonprogressors" based upon event analysis using Glaucoma Progression Analysis criteria. Two-tailed t test comparisons were performed, and correlations between rates of VF loss and PSG parameters were assessed. RESULTS: A total of 141 patients with OSAS and glaucoma were identified. Twenty-five patients (age 67.9±7.6 y) with OSAS (8 mild, 8 moderate, 9 severe) were enrolled. Eleven eyes (44%) were classified as progressors, and had more severe baseline VF loss (P=0.03). Progressors and nonprogressors had nonsignificantly different (P>0.05) age (69.9±8.7 vs. 66.4±6.6 y), follow-up (4.4±0.7 vs. 4.3±1.0 y), intraocular pressure (13.1±2.8 vs. 14.9±2.5 mm Hg), mean ocular perfusion pressure (49.7±5.5 vs. 48.8±9.0 mm Hg), AHI (31.3±18.6 vs. 26.4±24.0), body-mass index (27.8±5.5 vs. 28.8±5.6), and SpO2 (94.1±1.6% vs. 94.0±1.6%). AHI was not correlated with slopes of VF mean deviation (r, -0.271; P, 0.190) or pattern standard deviation (r, 0.211; P, 0.312), and no substantial increase in risk of progression was found with increase in AHI. CONCLUSIONS: This study does not support a relationship between OSAS and glaucomatous progression. No correlation was observed between OSAS severity and rate of VF loss.