Efficiency, Precision, Validity, and Reliability of GlauCAT-Asian Computerized Adaptive Tests in Measuring Glaucoma-Related Quality of Life.

Purpose: To determine the efficiency, precision, and agreement of GlauCAT-Asian and its corresponding validity and reliability. Methods: In this cross-sectional study, 219 participants (mean ± standard deviation age, 66.59 ± 8.61 years; 34% female) across the spectrum of glaucoma severity and 50 glaucoma suspects were recruited from glaucoma clinics in Singapore. Participants answered seven computerized adaptive testing (CAT) evaluations (Ocular Comfort, Activity Limitation, Lighting, Mobility, Concerns, Psychosocial, Glaucoma Management) and underwent eye examinations. Efficiency (mean number of items required for each CAT and time taken for CAT versus full item banks [IBs]), agreement (concordance between CATs and full IB person measures, henceforth referred to as scores), and precision (standard error of measurement [SE]) were evaluated. Other validity and reliability metrics were also assessed. Results: The mean number of items administered ranged from 9 (Mobility/Glaucoma Management) to 12 (Ocular Comfort). Compared to answering the full IBs, CATs provided an average time saving of 38.3% (range, 10% to 70.6% for Lighting and Activity Limitation, respectively). Agreement between scores obtained by CAT versus full IB was high (intracorrelation coefficient ≥0.75), as was precision of score estimates (mean SE range: 0.35 for Psychosocial to 0.29 for Mobility). Scores from Activity Limitation, Mobility, Lighting, and Concerns decreased significantly as glaucoma severity increased (criterion validity; P-trend <0.05). All tests displayed good convergent/divergent validity and test-retest reliability. Conclusions: GlauCAT-Asian provides efficient, precise, accurate, valid, and reliable measurement of the patient-centered impact of glaucoma. Translational Relevance: GlauCAT-Asian may provide a valuable clinical tool for ophthalmologists to monitor impact of disease progression and the effectiveness of therapies.

Measuring glaucoma quality of life in an Asian population using item banking: psychometric evaluation and computerized adaptive testing simulations.

PURPOSE: To assess the psychometric properties of glaucoma-specific health-related quality of life (HRQoL) item banks (IBs), and explore their efficiency using computerized adaptive testing (CAT) simulations. METHODS: In this cross-sectional, clinical study, 300 Asian glaucoma patients answered 221 items within seven IBs: Ocular Comfort Symptoms (OS); Activity Limitation (AL); Lighting (LT); Mobility (MB); Glaucoma Management (GM); Psychosocial (PSY); and Work (WK). Rasch analysis was conducted to assess each IB's psychometric properties (e.g., item "fit" to the construct; unidimensionality) and a set of analytic performance criteria guiding decision making relating to retaining or dropping domains and items was employed. CAT simulations determined the mean number of items for 'high' and 'moderate' measurement precision (stopping rule: SEM 0.3 and 0.387, respectively). RESULTS: Participants' mean age was 67.2 ± 9.2 years (62% male; 87% Chinese). LT, MB, and GM displayed good psychometric properties overall. To optimize AL's psychometric properties, 16 items were deleted due to poor "fit", high missing data, item bias, low discrimination and/or a low clinical/patient importance rating. To resolve multidimensionality in PSY, we rehomed 16 items into a "Concern (CN)" domain. PSY and CN required further amendment, including collapsing of response categories, and removal of poorly functioning items (N = 7). Due to poor measurement precision, low applicability and high ceiling effect, low test information indices, and low item separation index the WK IB was not considered further. In CAT simulations on the final seven IBs (n = 182 items total), an average of 12.1 and 15.7 items per IB were required for moderate and high precision measurement, respectively. CONCLUSIONS: After reengineering our seven IBs, they displayed robust psychometric properties and good efficiency in CAT simulations. Once finalized, GlauCAT™-Asian may enable comprehensive assessment of the HRQoL impact of glaucoma and associated treatments.

The development of a glaucoma-specific health-related quality of life item bank supporting a novel computerized adaptive testing system in Asia.

BACKGROUND: A glaucoma-specific health-related quality of life (HRQoL) item bank (IB) and computerized adaptive testing (CAT) system relevant to Asian populations is not currently available. We aimed to develop content for an IB focusing on HRQoL domains important to Asian people with glaucoma; and to compare the content coverage of our new instrument with established glaucoma-specific instruments. METHODS: In this qualitative study of glaucoma patients recruited from the Singapore National Eye Centre (November 2018-November 2019), items/domains were generated from: (1) glaucoma-specific questionnaires; (2) published articles; (3) focus groups/semi-structured interviews with glaucoma patients (n = 27); and (4) feedback from glaucoma experts. Data were analyzed using the constant comparative method. Items were systematically refined to a concise set, and pre-tested using cognitive interviews with 27 additional glaucoma patients. RESULTS: Of the 54 patients (mean ± standard deviation [SD] age 66.9 ± 9.8; 53.7% male), 67 (62.0%), 30 (27.8%), and 11 (10.2%) eyes had primary open angle glaucoma, angle closure glaucoma, and no glaucoma respectively. Eighteen (33.3%), 11 (20.4%), 8 (14.8%), 12 (22.2%), and 5 (9.3%) patients had no, mild, moderate, severe, or advanced/end-stage glaucoma (better eye), respectively. Initially, 311 items within nine HRQoL domains were identified: Visual Symptoms, Ocular Comfort Symptoms, Activity Limitation, Driving, Lighting, Mobility, Psychosocial, Glaucoma management, and Work; however, Driving and Visual Symptoms were subsequently removed during the refinement process. During cognitive interviews, 12, 23 and 10 items were added, dropped and modified, respectively. CONCLUSION: Following a rigorous process, we developed a 221-item, 7-domain Asian glaucoma-specific IB. Once operationalised using CAT, this new instrument will enable precise, rapid, and comprehensive assessment of the HRQoL impact of glaucoma and associated treatment efficacy.

Investigating the macular choriocapillaris in early primary open-angle glaucoma using swept-source optical coherence tomography angiography.

Introduction: There has been a growing interest in the role of vascular factors in glaucoma. Studies have looked at the characteristics of macular choriocapillaris in patients with glaucoma but with conflicting results. Our study aims to use swept-source optical coherence tomography angiography (SS-OCTA) to evaluate macular choriocapillaris metrics in normal participants and compare them with patients with early primary open-angle glaucoma (POAG) (mean deviation better than -6dB). Methods: In this prospective, observational, cross-sectional study, 104 normal controls (157 eyes) and 100 patients with POAG (144 eyes) underwent 3 mm × 3mm imaging of the macula using the Plex Elite 9000 (Zeiss Meditec, Dublin, CA, USA). Choriocapillaris OCTA images were extracted from the device's built-in review software and were subsequently evaluated for the density and size of choriocapillaris flow deficits. Results: After adjusting for confounding factors, the density of flow deficits was independently higher in those aged 53 years and above (P ≤ 0.024) whereas the average flow deficit size was significantly larger in those aged 69 years and above (95% CI = 12.39 to 72.91; P = 0.006) in both normal and POAG patients. There were no significant differences in the density of flow deficits (P = 0.453) and average flow deficit size (P = 0.637) between normal and POAG participants. Conclusion: Our study found that macular choriocapillaris microvasculature on SS-OCTA is unaltered by subjects with POAG. This suggests that OCTA macular choriocapillaris may not be potentially helpful in differentiating early glaucoma from healthy eyes.

Age-Related Eye Diseases in Individuals With Mild Cognitive Impairment and Alzheimer's Disease.

Introduction: Alzheimer's disease (AD) and age-related eye diseases pose an increasing burden as the world's population ages. However, there is limited understanding on the association of AD/cognitive impairment, no dementia (CIND) with age-related eye diseases. Methods: In this cross-sectional, memory clinic-based study of multiethnic Asians aged 50 and above, participants were diagnosed as AD (n = 216), cognitive impairment, no dementia (CIND) (n = 252), and no cognitive impairment (NCI) (n = 124) according to internationally accepted criteria. Retinal photographs were graded for the presence of age-related macular degeneration (AMD) and diabetic retinopathy (DR) using standard grading systems. Multivariable-adjusted logistic regression models were used to determine the associations between neurological diagnosis and odds of having eye diseases. Results: Over half of the adults had at least one eye disease, with AMD being the most common (60.1%; n = 356), followed by DR (8.4%; n = 50). After controlling for age, sex, race, educational level, and marital status, persons with AD were more likely to have moderate DR or worse (OR = 2.95, 95% CI = 1.15-7.60) compared with NCI. In the fully adjusted model, the neurological diagnosis was not associated with AMD (OR = 0.75, 95% CI = 0.45-1.24). Conclusion: Patients with AD have an increased odds of having moderate DR or worse, which suggests that these vulnerable individuals may benefit from specific social support and screening for eye diseases.

Anterior Segment Optical Coherence Tomography Angiography Following Trabecular Bypass Minimally Invasive Glaucoma Surgery.

Objective: To assess anterior segment optical coherence tomography angiography (AS-OCTA) imaging of the episcleral vessels before and after trabecular bypass minimally invasive glaucoma surgery (MIGS). Design: A prospective, clinical, single-centre, single-arm pilot feasibility study conducted at National University Hospital, Singapore. Subjects: Patients with primary glaucomatous optic neuropathy undergoing Hydrus Microstent (Ivantis Inc., Irvine, CA, USA) implantation, who require at least one intra-ocular pressure-lowering medication. One or two eyes per patient may be enrolled. Methods: We performed AS-OCTA (Nidek RS-3000 Advance 2, Gamagori, Japan) pre- and up to 6 months post-MIGS implantation using a standard protocol in all cornealimbal quadrants, to derive episcleral vessel densities (VD) using a previously described technique. Main Outcome Measures: Episcleral VD pre- and post-surgery, in sectors with and without the implant. Results: We obtained serial AS-OCTA images in 25 eyes undergoing MIGS implantation (23 subjects, mean age 70.3 ± 1.5, 61% female) with mean preoperative intraocular pressure (IOP) of 15.5 mmHg ± 4.0. We observed reductions in postoperative episcleral VD compared to preoperative VD at month 1 (mean difference -3.2, p = 0.001), month 3 (mean difference -2.94, p = 0.004) and month 6 (mean difference -2.19, p = 0.039) in sectors with implants (overall 6 month follow-up, p = 0.011). No significant changes were detected in episcleral VD in the sectors without implants (p = 0.910). Conclusion: In our pilot study, AS-OCTA was able to detect changes in the episcleral VD following trabecular bypass MIGS, which may be a useful modality to evaluate surgical outcomes if validated in future studies.

A multi-regression framework to improve diagnostic ability of optical coherence tomography retinal biomarkers to discriminate mild cognitive impairment and Alzheimer's disease.

BACKGROUND: Diagnostic performance of optical coherence tomography (OCT) to detect Alzheimer's disease (AD) and mild cognitive impairment (MCI) remains limited. We assessed whether compensating the circumpapillary retinal nerve fiber layer (cpRNFL) thickness for multiple demographic and anatomical factors as well as the combination of macular layers improves the detection of MCI and AD. METHODS: This cross-sectional study of 62 AD (n = 92 eyes), 108 MCI (n = 158 eyes), and 55 cognitively normal control (n = 86 eyes) participants. Macular ganglion cell complex (mGCC) thickness was extracted. Circumpapillary retinal nerve fiber layer (cpRNFL) measurement was compensated for several ocular factors. Thickness measurements and their corresponding areas under the receiver operating characteristic curves (AUCs) were compared between the groups. The main outcome measure was OCT thickness measurements. RESULTS: Participants with MCI/AD showed significantly thinner measured and compensated cpRNFL, mGCC, and altered retinal vessel density (p < 0.05). Compensated RNFL outperformed measured RNFL for discrimination of MCI/AD (AUC = 0.74 vs 0.69; p = 0.026). Combining macular and compensated cpRNFL parameters provided the best detection of MCI/AD (AUC = 0.80 vs 0.69; p < 0.001). CONCLUSIONS AND RELEVANCE: Accounting for interindividual variations of ocular anatomical features in cpRNFL measurements and incorporating macular information may improve the identification of high-risk individuals with early cognitive impairment.

Endothelial cell loss associated with minimally invasive glaucoma surgery.

PURPOSE OF REVIEW: Minimally invasive glaucoma surgery (MIGS) represents a safer, albeit moderately effective surgical option for intraocular pressure control. However, the CyPass Micro-Stent (Alcon Laboratories) was withdrawn from the market in 2018 as the COMPASS-XT study demonstrated greater cornea endothelial cell (CEC) loss in patients who received the CyPass Micro-Stent with phacoemulsification compared with phacoemulsification alone. This led to the increased attention on MIGS-associated CEC loss and thus, this review will summarise the recent, available evidence on MIGS-associated CEC loss. RECENT FINDINGS: Prospective clinical trials and retrospective observational studies published between 2011 and 2021 reported a wide range of 12 month CEC loss from 'insignificant', and up to 14.6%, for phacoemulsification combined with various MIGS procedures. Recent clinical trials over the same time period reported CEC loss of 12.8-15.2% associated with phacoemulsification alone. SUMMARY: Apart from the CyPass Micro-Stent clinical trial, no other studies on combined phacoemulsification with MIGS that is 'phaco-plus' procedures have reported a higher short-term CEC loss compared with phacoemulsification alone. However, studies that specifically examine postprocedural CEC loss following phacoemulsification compared to 'phaco-plus' procedures over a longer follow-up period are required.

Multivariate Normative Comparison, a Novel Method for Improved Use of Retinal Nerve Fiber Layer Thickness to Detect Early Glaucoma.

PURPOSE: Detection of early glaucoma remains limited with the conventional analysis of the retinal nerve fiber layer (RNFL). This study assessed whether compensating the RNFL thickness for multiple demographic and anatomic factors improves the detection of glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: Three hundred eighty-seven patients with glaucoma and 2699 healthy participants. METHODS: Two thousand six hundred ninety-nine healthy participants were enrolled to construct and test a multivariate compensation model, which then was applied in 387 healthy participants and 387 patients with glaucoma (early glaucoma, n = 219; moderate glaucoma, n = 97; and advanced glaucoma, n = 71). Participants underwent Cirrus spectral-domain OCT (Carl Zeiss Meditec) imaging of the optic disc and macular cubes. Compensated RNFL thickness was generated based on ethnicity, age, refractive error, optic disc (ratio, orientation, and area), fovea (distance and angle), and retinal vessel density. The RNFL thickness measurements and their corresponding areas under the receiver operating characteristic curve (AUCs) were obtained. MAIN OUTCOME AND MEASURES: Measured and compensated RNFL thickness measurements. RESULTS: After applying the Asian-specific compensation model, the standard deviation of RNFL thickness reduced, where the effect was greatest for Chinese participants (16.9%), followed by Malay participants (13.9%), and Indian participants (12.1%). Multivariate normative comparison outperformed measured RNFL for discrimination of early glaucoma (AUC, 0.90 vs. 0.85; P < 0.001), moderate glaucoma (AUC, 0.94 vs. 0.91; P < 0.001), and advanced glaucoma (AUC, 0.98 vs. 0.96; P < 0.001). CONCLUSIONS: The multivariate normative database of RNFL showed better glaucoma discrimination capability than conventional age-matched comparisons, suggesting that accounting for demographic and anatomic variance in RNFL thickness may have usefulness in improving glaucoma detection.

Combining OCT and OCTA for Focal Structure-Function Modeling in Early Primary Open-Angle Glaucoma.

Purpose: To investigate modeling of the focal visual field (VF) loss by combining structural measurements and vascular measurements in eyes with early primary open-angle glaucoma (POAG). Methods: In this cross-sectional study, subjects with early glaucoma (VF mean deviation, ≥-6 dB) underwent optical coherence tomography (OCT) imaging, optical coherence tomography angiography (OCTA) imaging, and Humphrey 24-2 VF tests. Capillary perfusion densities (CPDs) were calculated after the removal of large vessels in the OCTA images. Focal associations between VF losses at the individual VF test locations, circumpapillary retinal nerve fiber layer (RNFL) thickness measurements from OCT, and CPDs were determined using nerve fiber trajectory tracings. Linear mixed models were used to model focal VF losses at each VF test location. Results: Ninety-seven eyes with early POAG (VF mean deviation, -2.47 ± 1.64 dB) of 71 subjects were included. Focal VF modeling using a combined RNFL-CPD approach resulted in a median adjusted R2 value of 0.30 (interquartile range [IQR], 0.13-0.55), whereas the RNFL-only and CPD-only approaches resulted in median values of 0.22 (IQR, 0.10-0.51) and 0.26 (IQR, 0.10-0.52), respectively. Seventeen VF locations with the combined approach had an adjusted R2 value greater than 0.50. Likelihood testing at each VF test location showed that the combined approach performed significantly better at the superior nasal VF regions of the eyes compared with the univariate approaches. Conclusions: Modeling of focal VF losses showed improvements when structural thickness and vascular parameters were included in tandem. Evaluation of VF defects in early glaucoma may benefit from considering both RNFL and OCTA characteristics.

Developing a normative database for retinal perfusion using optical coherence tomography angiography.

Visualizing and characterizing microvascular abnormalities with optical coherence tomography angiography (OCTA) has deepened our understanding of ocular diseases, such as glaucoma, diabetic retinopathy, and age-related macular degeneration. Two types of microvascular defects can be detected by OCTA: focal decrease because of localized absence and collapse of retinal capillaries, which is referred to as the non-perfusion area in OCTA, and diffuse perfusion decrease usually detected by comparing with healthy case-control groups. Wider OCTA allows for insights into peripheral retinal vascularity, but the heterogeneous perfusion distribution from the macula, parapapillary area to periphery hurdles the quantitative assessment. A normative database for OCTA could estimate how much individual's data deviate from the normal range, and where the deviations locate. Here, we acquired OCTA images using a swept-source OCT system and a 12×12 mm protocol in healthy subjects. We automatically segmented the large blood vessels with U-Net, corrected for anatomical factors such as the relative position of fovea and disc, and segmented the capillaries by a moving window scheme. A total of 195 eyes were included and divided into 4 age groups: < 30 (n=24) years old, 30-49 (n=28) years old, 50-69 (n=109) years old and >69 (n=34) years old. This provides an age-dependent normative database for characterizing retinal perfusion abnormalities in 12×12 mm OCTA images. The usefulness of the normative database was tested on two pathological groups: one with diabetic retinopathy; the other with glaucoma.

Development and Validation of a Preference-Based Glaucoma Utility Instrument Using Discrete Choice Experiment.

IMPORTANCE: A glaucoma-specific instrument for estimating utilities across the spectrum of glaucoma severity is currently lacking, hindering the assessment of the cost-effectiveness of glaucoma treatments. OBJECTIVE: To develop and validate the preference-based Glaucoma Utility Instrument (Glau-U) and to ascertain the association between Glau-U utilities and severity of glaucoma and vision impairment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted in 2 stages at the Singapore National Eye Centre glaucoma clinics. Stage 1 focused on the identification and pretesting of the Glau-U attributes and was carried out between June 2009 and May 2016. Stage 2 involved the development and administration of the discrete choice experiment (DCE) survey and tasks and was conducted between May 7, 2018, and December 11, 2019. Stage 2 participants were English- or Mandarin-speaking Singaporean citizens or permanent residents of Chinese, Malay, or Indian ethnicity who were 40 years or older and had a clinical diagnosis of glaucoma in at least 1 eye. EXPOSURES: Glau-U comprised 6 quality-of-life attributes: activities of daily living, lighting and glare, movement, eye discomfort, other effects of glaucoma, and social and emotional effects. The descriptions or response options for these attributes were no difficulty or never, some difficulty or sometimes, or severe difficulty or often. MAIN OUTCOMES AND MEASURES: Utility weights for Glau-U were developed using a DCE questionnaire, which was interviewer administered to participants. Mixed logit regression determined utility weights for each health state. Glau-U utility weights across better- or worse-eye glaucoma and vision impairment severity were calculated using 1-way analysis of variance. Correlations between Glau-U utilities and better- or worse-eye visual fields and EuroQol 5-Dimension utilities were ascertained to assess convergent and divergent validity. RESULTS: Of the 304 participants (mean [SD] age, 68.3 [8.7] years; 182 men [59.9%]), 281 (92.4%) had no vision impairment in the better eye, 13 (4.3%) had mild impairment, and 10 (3.3%) had moderate to severe vision impairment. Mean (SD) Glau-U utilities decreased as better-eye glaucoma severity increased (none: 0.73 [0.21]; mild: 0.66 [0.21]; moderate: 0.66 [0.20]; severe: 0.60 [0.28]; and advanced or end-stage: 0.22 [0.38]; P < .001), representing reductions of 20.7% to 76.1% in quality-adjusted life-years compared with a health state that included preperimetric glaucoma. Mean (SD) Glau-U utilities also decreased as better-eye vision impairment worsened from 0.67 (0.23) for none to 0.58 (0.32) for mild to 0.46 (0.29) for moderate to severe vision impairment. Glau-U utilities demonstrated moderate correlations with better-eye (r = 0.34; P < .001) and worse-eye (r = 0.33; P < .001) mean deviation scores and low correlations with EuroQol 5-Dimension utilities (r = 0.22; P < .001), supporting convergent and divergent validity. CONCLUSIONS AND RELEVANCE: Use of Glau-U revealed large decrements in utility that were associated with late-stage glaucoma, suggesting that this new instrument may be useful for cost-effectiveness analyses of interventions and informing resource allocation policies for glaucoma and vision loss.

Anterior segment optical coherence tomography angiography for iris vasculature in pigmented eyes.

PURPOSE: To compare anterior segment optical coherence tomography angiography (AS-OCTA) systems in delineating normal iris vessels and iris neovascularisation (NVI) in eyes with pigmented irides. METHODS: Prospective study from January 2019 to June 2019 of 10 consecutive patients with normal pigmented iris, had AS-OCTA scans with a described illumination technique, before using the same protocol in five eyes with NVI (clinical stages 1-3). All scans were sequentially performed using a spectral-domain OCTA (SD-OCTA), and a swept-source OCTA (SS-OCTA, Plex Elite 9000). Images were graded by two masked observers for visibility, artefacts and NVI characteristics. The main outcome measure was iris vessel density measurements comparing SS-OCTA and SD-OCTA systems. RESULTS: The median age of subjects was 28 (20-35) years, and 50% were female. The paired mean difference of iris vessel density measurements was 11.7 (95% CI 14.7 to 8.1; p=0.002), SS-OCTA detecting more vessels than SD-OCTA. The inter-rater reliability for artefact score (κ=0.799, p<0.001) and visibility score (κ=0.722; p<0.001) were substantial. Both AS-OCTA systems were able to detect NVI vessels with a fair agreement (κ=0.588), with clearer NVI characteristics in stage 1/2 compared to stage 3 NVI (mean difference NVI score: 2.7±0.4, p=0.009). CONCLUSION: The SS-OCTA was better able to delineate iris vessels in normal pigmented irides compared to SD-OCTA. Both AS-OCTA systems identified NVI characteristics based on its atypical configuration or location, but further improvements are needed to allow for more accurate objective, serial quantification for clinical use.

Clinical Efficacy and Safety Outcomes of Micropulse Transscleral Diode Cyclophotocoagulation in Patients With Advanced Glaucoma.

PRECIS: Micropulse transscleral cyclophotocoagulation (MPTCP) is only moderately effective in lowering intraocular pressure (IOP) and is useful as an adjunct procedure to other glaucoma surgeries. There was a small risk of loss of vision, prolonged hypotony, and phthisis bulbi. AIM: The aim of this study was to determine the efficacy and safety of a single MPTCP treatment for an Asian population with advanced glaucoma. METHODS: This is a retrospective single-center study of 207 eyes (207 patients) with advanced glaucoma which underwent first-time MPTCP between January 1, 2008, and March 31, 2018. Success was defined as IOP of 6 to 21 mm Hg or ≥20% reduction in IOP without an increase in glaucoma medication from baseline, and without glaucoma reoperation. The IOP, best-corrected visual acuity, and number of glaucoma medications were also analyzed. RESULTS: The mean (SD) age was 64.9±16.9 years. The mean follow-up duration was 18.7±16.2 months. The rate of success at postoperative years 1 and 2 follow-up was 44.1% and 32.6%, respectively. The median survival time of MPTCP was 9.0 months and 85 (40.9%) eyes received reoperation. The mean IOP decreased from 31.5±12.0 mm Hg preoperatively to 22.1±10.3 and 23.8±11.8 mm Hg at postoperative years 1 and 2, respectively (P<0.0001). The mean number of glaucoma medications was reduced from 3.3±1.0 preoperatively to 2.6±1.1 and 2.4±1.1 at postoperative years 1 and 2, respectively (P<0.0001). Significant complications included prolonged hypotony [1 eye (0.5%)], phthisis bulbi [7 eyes (3.4%)], and best-corrected visual acuity reduction [29 eyes (13.9%)]. CONCLUSION: Single first-time MPTCP for advanced glaucoma eyes was moderately effective in lowering IOP but >50% failed by 1 year.

Phacoemulsification vs phacoemulsification with micro-bypass stent implantation in primary angle closure and primary angle closure glaucoma: A randomized single-masked clinical study.

IMPORTANCE: Primary angle closure glaucoma (PACG) is a major cause of irreversible visual impairment in Asia, but there is no published data on the effect of iStent on these patients. BACKGROUND: To compare the efficacy and safety of combined phacoemulsification and iStent implantation with standard phacoemulsification in an Asian population. DESIGN: A prospective, single-masked, randomized study in a public tertiary eye clinic. PARTICIPANTS: Patients with concomitant visually significant cataracts and primary angle closure (PAC) or PACG. METHODS: Patients were randomized and underwent either phacoemulsification alone (phaco) or with concurrent iStent injection (phaco-iStent). Demographic and clinical data were collected. MAIN OUTCOME MEASURES: Complete and qualified success rates at 12 months were compared between both treatment arms. RESULTS: Thirty-two patients were recruited between September 2015 and February 2016. All patients completed 12 months of follow-up. There was no statistically significant difference in preoperative IOP (phaco, 17.5 ± 3.1 mmHg; phaco-iStent, 18.6 ± 4.7 mmHg, P = .65) and 12-months postoperative IOP (phaco, 15.0 ± 2.5 mmHg; phaco-iStent, 14.7 ± 3.1 mmHg, P = .86) between both groups. Complete success rates were 43.8% (95% CI, 19.8-65.6) for the Phaco group and 87.5% (95% CI, 58.6-96.7) for the Phaco-iStent group (P = .01). Thinner preoperative optical coherence tomography (retinal nerve fibre layer) thickness (hazard ratio [HR] = 7.34 [95% CI, 1.53-35.30]) and phacoemulsification alone (HR = 0.93 [95% CI, 0.87-0.02]) were independent factors associated with failure to achieve complete success. CONCLUSIONS AND RELEVANCE: Combined phacoemulsification with iStent implantation is associated with a higher likelihood of complete success compared with phacoemulsification alone in eyes with primary angle closure disease at 12 months postoperatively. Further studies are required to establish the longer term efficacy of iStent implantation and to identify other predictors for surgical success.

Glaucoma screening: where are we and where do we need to go?

PURPOSE OF REVIEW: Current recommendations for glaucoma screening are decidedly neutral. No studies have yet documented improved long-term outcomes for individuals who undergo glaucoma screening versus those who do not. Given the long duration that would be required to detect a benefit, future studies that may answer this question definitively are unlikely. Nevertheless, advances in artificial intelligence and telemedicine will lead to more effective screening at lower cost. With these new technologies, additional research is needed to determine the costs and benefits of screening for glaucoma. RECENT FINDINGS: Using optic disc photographs and/or optical coherence tomography, deep learning systems appear capable of diagnosing glaucoma more accurately than human graders. Eliminating the need for expert graders along with better technologies for remote imaging of the ocular fundus will allow for less expensive screening, which could enable screening of individuals with otherwise limited healthcare access. In India and China, where most glaucoma remains undiagnosed, glaucoma screening was recently found to be cost-effective. SUMMARY: Recent advances in artificial intelligence and telemedicine have the potential to increase the accuracy, reduce the costs, and extend the reach of screening. Further research into implementing these technologies in glaucoma screening is required.

Transscleral cyclophotocoagulation and its histological effects on the conjunctiva.

Micropulse transscleral cyclophotocoagulation (MP-TCP) is increasingly being used as an initial procedure prior to conjunctival filtration surgeries. However, it is uncertain whether MP-TCP may cause inflammation and scarring of the bulbar conjunctiva. Thus, we aimed to study the histological effects of MP-TCP (compared to controls and continuous wave [CW]-TCP) on the conjunctiva. Our study included 10 Dutch Belted Rabbits that underwent TCP in their right eyes (n = 5, MP-TCP; n = 5, CW-TCP), while their left eyes served as controls. The rabbits were euthanised at 4 weeks, and their dissected globes underwent histopathological and immunohistochemical examination. We observed greater conjunctival inflammation in MP-TCP or CW-TCP-treated eyes compared to controls, but not between each other. The majority of the lymphocytic infiltrates were CD4 T-cells. Increased conjunctival fibrosis was evident in MP-TCP or CW-TCP-treated eyes, to similar extents, compared to controls. However, the increased staining for myofibroblasts was not statistically significant in TCP-treated eyes. We concluded that MP-TCP causes significantly greater overall conjunctival inflammation and scarring compared to controls, similar to CW-TCP. As these are risk-factors for fibrosis and failure of the conjunctival bleb, further studies are required to explore the effect, if any, of post-TCP conjunctival changes on future bleb morphology and survival.

Case Series of Combined XEN Implantation and Phacoemulsification in Chinese Eyes: One-Year Outcomes.

PURPOSE: The outcome of XEN implantation in Chinese eyes has not been previously reported. The purpose of our study is to evaluate the efficacy and safety of combined cataract surgery and XEN implantation in Chinese eyes with glaucoma. METHODS: We conducted a prospective study of 31 consecutive Chinese patients who underwent combined phacoemulsification and XEN implantation at the National University Hospital (Singapore) in this study. Patients were assessed preoperatively and postoperatively on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, Snellen visual acuity (VA), and complications were assessed at each visit. The Wilcoxon signed rank test for non-parametric data was used for the analysis of IOP and glaucoma medications at baseline versus 12 months after the procedure. RESULTS: The mean age of the patients was 70 ± 7.9 years and 48.4% were male. Twelve patients (38.7%) were diagnosed with primary open angle glaucoma and 19 patients (61.3%) were diagnosed with primary angle closure glaucoma. There was a significant decrease in IOP at 12 months (12.1 ± 2.6 mmHg) compared with preoperative medicated (15.6 ± 2.7 mmHg, p < 0.0001) and unmedicated IOP (22.1 ± 3.6 mmHg, p < 0.001). as well as a significant reduction in the number of glaucoma medications (1.4 ± 0.6 vs 0.1 ± 0.4, p < 0.0001). The most common complications were transient hypotony (12.9%) and ptosis (12.9%) and there were no sight-threatening intraoperative or postoperative complications. One patient required additional glaucoma surgery for uncontrolled IOP at 8 months after combined phacoemulsification and XEN implantation. CONCLUSION: Combined XEN implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications in Chinese eyes for at least 12 months, with a favorable safety profile.

Glaucoma in myopia: diagnostic dilemmas.

Myopic eyes have an increased risk of glaucoma. However, glaucomatous changes in a myopic eye are often difficult to detect. Classic structural and functional investigations to diagnose glaucoma may be confounded by myopia. Here, we identify some of the common pitfalls in interpreting these structural parameters, and the possible solutions that could be taken to overcome them. For instance, in myopic eyes, we discuss the limitations and potential sources of error when using neuroretinal rim parameters, and retinal nerve fibre layer and ganglion cell-inner plexiform layer thickness measurements. In addition, we also review new developments and potential adjuncts in structural imaging such as the assessment of the retinal nerve fibre layer texture, and the examination of the microcirculation of the optic nerve head using optical coherence tomography angiography. For the functional assessment of glaucoma, we discuss perimetric strategies that may aid in detecting characteristic visual field defects in myopic glaucoma. Ultimately, the evaluation of glaucoma in myopia requires a multimodal approach, to allow correlation between structural and functional assessments. This review provides overview on how to navigate this diagnostic dilemma.