Publications by authors named "Jonathan S Myers"

100 Publications

Variability and Power to Detect Progression of Different Visual Field Patterns.

Ophthalmol Glaucoma 2021 Apr 10. Epub 2021 Apr 10.

Bernard and Shirlee Brown Glaucoma Research Laboratory, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, NY. Electronic address:

Purpose: To compare the variability and ability to detect visual field progression of 24-2, central 12 locations of the 24-2 and 10-2 visual field (VF) tests in eyes with abnormal VFs.

Design: Retrospective, multisite cohort.

Participants: A total of 52,806 24-2 and 11,966 10-2 VF tests from 7,307 eyes from the Glaucoma Research Network database were analyzed. Only eyes with ≥ 5 visits and ≥ 2 years of follow-up were included.

Methods: Linear regression models were used to calculate the rates of MD (Mean Deviation) change (slopes) while their residuals were used to assess variability across the entire MD range. Computer simulations (n=10,000) based upon real MD residuals of our sample were performed to estimate power to detect significant progression (P < 5%) at various rates of MD change.

Main Outcome Measures: Time required to detect progression.

Results: For all 3 patterns, the MD variability was highest within the -5 to -20 dB range and consistently lower with the 10-2 compared to 24-2 or Central 24-2. Overall, time to detect confirmed significant progression at 80% power was the lowest with 10-2 VF, with a decrease of 14.6% to 18.5% when compared to 24-2 and a decrease of 22.9% to 26.5% when compared to Central 24-2.

Conclusion: Time to detect central VF progression was reduced with 10-2 MD compared with 24-2 and C24-2 MD in glaucoma eyes in this large dataset, in part because 10-2 tests had lower variability. These findings contribute to current evidence of the potential value of 10-2 testing in the clinical management of glaucoma patients and in clinical trial design.
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http://dx.doi.org/10.1016/j.ogla.2021.04.004DOI Listing
April 2021

In-vivo imaging of the conventional aqueous outflow system.

Curr Opin Ophthalmol 2021 May;32(3):275-279

Wills Eye Hospital, Glaucoma Service, Philadelphia, Pennsylvania, USA.

Purpose Of Review: The aim of this study was to provide a comprehensive summary of in-vivo imaging techniques of the aqueous outflow system and discuss its role in improving our understanding of glaucoma pathogenesis and management.

Recent Findings: Our understanding of the aqueous outflow system is largely derived from ex-vivo studies. Recent innovations in imaging technology and techniques enable in-vivo evaluation of the conventional outflow system in real-time. Optical coherence tomography allows for noninvasive, high-resolution, volumetric imaging of ocular tissues. Dynamic structural changes have been observed at the trabecular meshwork and Schlemm's canal. In parallel, aqueous angiography using injected tracers show a similar dynamism with variable and pulsatile flow signals.

Summary: In-vivo imaging enable real-time evaluation of the conventional aqueous outflow pathway. This emerging field shows great promise to expand our understanding of the pathogenesis and treatment of glaucoma.
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http://dx.doi.org/10.1097/ICU.0000000000000751DOI Listing
May 2021

Effect of shunt type on rates of tube-cornea touch and corneal decompensation after tube shunt surgery in uveitic glaucoma.

Graefes Arch Clin Exp Ophthalmol 2021 Jan 30. Epub 2021 Jan 30.

Wills Eye Hospital, Glaucoma Research Center, 840 Walnut Street, Suite 1140, Philadelphia, PA, 19107, USA.

Purpose: To evaluate the effect of tube shunt type [Ahmed (AGV) versus Baerveldt (BGI)] on the frequency of tube-cornea touch and corneal decompensation after tube shunt surgery.

Methods: This retrospective comparative study included 145 eyes of 130 patients with uveitic glaucoma who underwent AGV (75 eyes) or BGI (70 eyes) implantations. Electronic medical records were reviewed to document demographic factors, intraocular pressure (IOP) reduction, frequency of tube-cornea touch, corneal decompensation, and need for subsequent corneal transplantation.

Results: The mean follow-up was 27.7±3.3 months for AGV and 32.8±3.8 months for BGI (p=0.30). Tube-cornea touch was observed in 5 eyes after BGI and 1 eye in the AGV group (p=0.08). The BGI group reported a significantly higher rate of corneal decompensation (9 versus 0; p=0.001) and transplantation (6 versus 0; p=0.01) compared to the AGV group. Previous trabeculectomy was a significant risk factor for corneal complications in eyes undergoing BGI implantation (odds ratio [OR]= 8.17, 95% confidence interval [CI]=1.78-37.45, p=0.007).

Conclusion: Similar rates of tube-cornea touch were observed in both shunt types; BGI shunts were associated with a greater incidence of corneal complications and transplantation as compared to AGV in this retrospective series of uveitic glaucoma cases.
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http://dx.doi.org/10.1007/s00417-021-05095-2DOI Listing
January 2021

Surgical Cancellations in Glaucoma Practice: Causes, Delays, and Effect on Patient Care and Revenue.

Ophthalmol Glaucoma 2020 Dec 16. Epub 2020 Dec 16.

Glaucoma Service, Wills Eye Hospital, Philadelphia, Pennsylvania; Thomas Jefferson University, Philadelphia, Pennsylvania. Electronic address:

Purpose: To assess the incidence of glaucoma surgery cancellations, as well as their characteristics, underlying reasons, resultant surgical delay, and estimated lost potential reimbursement, at a tertiary eye hospital.

Design: Retrospective observational study of planned surgical procedures of 4 glaucoma specialists at a tertiary eye center over a 2-year period (May 2017-May 2019). An additional prospective survey of patients was conducted.

Participants: Patients who canceled glaucoma surgeries.

Methods: Demographics and clinical information were recorded from the electronic medical record. A brief phone survey was implemented to determine the reason for cancellation and whether the patient rescheduled. Lost reimbursement was estimated assuming Medicare reimbursement rates for each procedure based on facility fee, surgeon fee, and anesthesia fee.

Main Outcome Measures: Reasons for surgical cancellation, delay related to surgical cancellations, and annual lost reimbursement potential.

Results: One hundred twenty-three of 1384 glaucoma surgeries (8.9%) to be performed by 4 glaucoma specialists at Wills Eye Hospital during the 2-year study period were canceled. Among those canceled, the mean age ± standard deviation (SD) of the patients was 70.3 ± 14.4 years and 51% were men. Of the cancellations, 56.9% were made within 1 day of the planned date of surgery and 96.7% were canceled within 7 days. Of the reasons for surgical cancellation, 28% were considered preventable, 50% were considered unpreventable, and 23% were categorized as "no reason given." Most of the surgeries eventually were performed-to-date (64.2%); the mean ± SD delay in surgery was 63.4 ± 68.6 days. The 3 most common preventable reasons for cancellation were lack of transportation (34%), lack of timely clearance (26%), and insurance-related issues (14%). Assuming Medicare reimbursement rates, the estimated annual lost potential reimbursement from surgical cancellations of the 4 glaucoma specialists was $208 306.

Conclusions: This study highlights a significant number of cancellations in a glaucoma practice, most of which occurred within 1 day of planned surgery. Minimizing preventable causes of cancellations could decrease the likelihood of surgical delays as well as lost reimbursement. Further comparison with patients who successfully underwent surgery performed without delay may identify predictive factors or interventions that could decrease the number of surgical cancellations.
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http://dx.doi.org/10.1016/j.ogla.2020.12.006DOI Listing
December 2020

Reoperation for Complications Within 90 Days of Minimally Invasive Glaucoma Surgery.

J Cataract Refract Surg 2020 Dec 9. Epub 2020 Dec 9.

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, PA, USA.

Objective: To describe reoperations that occurred within 90 days of minimally invasive glaucoma surgery (MIGS) at a single institution over a 30-month period.

Setting: Tertiary care hospital.

Design: Retrospective case series.

Methods: Charts of adult patients who underwent trabecular microbypass stents, gel microstents, and goniotomy procedures (including gonioscopy-assisted transluminal trabeculotomy) from October 1, 2017 to March 15, 2020 at Wills Eye Hospital were examined. Outcome measures were unanticipated reoperations within the first 90 days after MIGS procedures and the complications that led to these reoperations.

Results: 448 MIGS procedures were performed on 436 eyes of 348 patients over a 30-month period by 6 glaucoma surgeons. Of these, 206 (46.0 %) were trabecular microbypass stents (198 iStent/iStent inject, 8 Hydrus), 152 (33.9%) were gel microstents, 90 (20.1%) were goniotomy procedures. Combined phacoemulsification took place in 256 (58.7%) of eyes. Reoperation within 90 days took place in 23/436 eyes (5.3%), including 16/152 eyes in the gel microstent group (10.5%), 4/198 eyes in iStent/iStent inject group (2.0%), 3/90 eyes in the goniotomy group (3.3%). Indications for reoperation were elevated intraocular pressure (IOP) in 16/23 eyes (69.6%), gel microstent tip exposure with wound leakage in 3/23 eyes (13%), and early gel microstent encapsulation without elevated IOP in 1/23 eye (4.3%). 2/23 eyes (8.7%) required reoperation for lens complications while 1/23 eye (4.3%) had elevated IOP and aphakia requiring reoperation.

Conclusions: The rate of reoperation within the first 90 days after MIGS was low. Elevated IOP and complications associated with gel microstents were the main indications for reoperation.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000545DOI Listing
December 2020

Predicting Global Test-Retest Variability of Visual Fields in Glaucoma.

Ophthalmol Glaucoma 2020 Dec 11. Epub 2020 Dec 11.

Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: To model the global test-retest variability of visual fields (VFs) in glaucoma.

Design: Retrospective cohort study.

Participants: Test-retest VFs from 4044 eyes of 4044 participants.

Methods: We selected 2 reliable VFs per eye measured with the Humphrey Field Analyzer (Swedish interactive threshold algorithm 24-2) within 30 days of each other. Each VF had fixation losses (FLs) of 33% or less, false-negative results (FNRs) of 20% or less, and false-positive results (FPRs) of 20% or less. Stepwise linear regression was applied to select the model best predicting the global test-retest variability from 3 categories of features of the first VF: (1) base parameters (age, mean deviation, pattern standard deviation, glaucoma hemifield test results, FPR, FNR, and FL); (2) total deviation (TD) at each location; and (3) computationally derived archetype VF loss patterns. The global test-retest variability was defined as root mean square deviation (RMSD) of TD values at all 52 VF locations.

Main Outcome Measures: Archetype models to predict the global test-retest variability.

Results: The mean ± standard deviation of the root mean square deviation was 4.39 ± 2.55 dB. Between the 2 VF tests, TD values were correlated more strongly in central than in peripheral VF locations (intraclass coefficient, 0.66-0.89; P < 0.001). Compared with the model using base parameters alone (adjusted R = 0.45), adding TD values improved prediction accuracy of the global variability (adjusted R = 0.53; P < 0.001; Bayesian information criterion [BIC] decrease of 527; change of >6 represents strong improvement). Lower TD sensitivity in the outermost peripheral VF locations was predictive of higher global variability. Adding archetypes to the base model improved model performance with an adjusted R of 0.53 (P < 0.001) and lowering of BIC by 583. Greater variability was associated with concentric peripheral defect, temporal hemianopia, inferotemporal defect, near total loss, superior peripheral defect, and central scotoma (listed in order of decreasing statistical significance), and less normal VF results and superior paracentral defect.

Conclusions: Inclusion of archetype VF loss patterns and TD values based on first VF improved the prediction of the global test-retest variability than using traditional global VF indices alone.
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http://dx.doi.org/10.1016/j.ogla.2020.12.001DOI Listing
December 2020

Inter-Eye Association of Visual Field Defects in Glaucoma and Its Clinical Utility.

Transl Vis Sci Technol 2020 11 17;9(12):22. Epub 2020 Nov 17.

Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.

Purpose: To investigate intereye associations of visual field (VF) defects.

Methods: We selected 24-2 VF pairs of both eyes from 63,604 patients tested on the same date with mean deviation (MD) ≥ -12 dB. VFs were decomposed into one normal and 15 defect patterns previously identified using archetypal analysis. VF pattern weighting coefficients were correlated between the worse and better eyes, as defined by MD. VF defect patterns (weighting coefficients > 10%) in the better eye were predicted from weighting coefficients of the worse eye by logistic regression models, which were evaluated by area under the receiver operating characteristic curve (AUC).

Results: Intereye correlations of archetypal VF patterns were strongest for the same defect pattern between fellow eyes. The AUCs for predicting the presence of 15 defect patterns in the better eye based on the worse eye ranged from 0.69 (superior nasal step) to 0.92 (near total loss). The AUC for predicting superior paracentral loss was 0.89. Superior paracentral loss in the better eye was positively correlated with coefficients of superior paracentral loss, central scotoma, superior altitudinal defect, nasal hemianopia, and inferior paracentral loss in the worse eye, and negatively correlated with coefficients of the normal VF, superior peripheral defect, concentric peripheral defect, and temporal wedge. The parameters are presented in the descending order of statistical significance.

Conclusions: VF patterns of the worse eye are predictive of VF defects in the better eye.

Translational Relevance: Our models can potentially assist clinicians to better interpret VF loss under measurement uncertainty.
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http://dx.doi.org/10.1167/tvst.9.12.22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683854PMC
November 2020

Marijuana and Glaucoma: A Social Media Content Analysis.

Ophthalmol Glaucoma 2020 Nov 24. Epub 2020 Nov 24.

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, Pennsylvania; Thomas Jefferson University, Philadelphia, Pennsylvania. Electronic address:

Purpose: This study analyzes the content quality and characteristics of the most popular and highly ranked search results on the internet related to glaucoma and medical cannabis (MC).

Design: Internet-based, cross-sectional study.

Participants: Not applicable.

Methods: Google and 2 social media platforms (Facebook, YouTube) were used to identify online information most accessible to patients. Search criteria included "glaucoma" AND "marijuana" or "cannabinoid" or "CBD." The top 20 Google search and YouTube results for each search term and the posts from the top 9 patient-based glaucoma Facebook groups were aggregated and analyzed using the search criteria.

Main Outcome Measures: The quality of the content was graded by 2 independent graders using a previously validated Sandvik score and previously reported risk score. The differing values were resolved by a final grader. Additional analysis included whether the source was professional (by physician or medical organization) or shared an opinion on MC (pro, mixed, or against) use in glaucoma.

Results: This search resulted in an aggregate of 51 websites on Google, 126 posts from Facebook groups, and 37 videos on YouTube. The mean (± standard deviation) Sandvik score and risk score were 11.0 (±2.23), 10.2 (±1.12), 10.6 (±1.89) and 0.27 (±0.49), 0.46 (±0.62), 0.97 (±0.90) for Google, Facebook, and YouTube, respectively. Analysis of variance showed statistically significant differences in Sandvik (P = 0.01) and risk (P < 0.0001) scores across the 3 platforms. A significant portion of online material was pro-MC use in the setting of glaucoma (24% of Google, 59% of YouTube, and 21% of Facebook results). Professional content had a significantly higher content quality score and a lower risk score, and was less likely to recommend MC use in glaucoma.

Conclusions: Despite American Academy of Ophthalmology, Canadian Ophthalmological Society, and American Glaucoma Society statements against MC use in patients with glaucoma, a significant portion of online material recommends its use. With the wide variation in quality and content of online information, it is important for physicians to be aware of the different platforms and opinions that are readily available to patients.
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http://dx.doi.org/10.1016/j.ogla.2020.11.004DOI Listing
November 2020

Early Experience with Netarsudil in Pediatric Patients: A Retrospective Case Series.

Ophthalmol Glaucoma 2021 Mar-Apr;4(2):232-234. Epub 2020 Oct 14.

Glaucoma Service, Wills Eye Hospital, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.ogla.2020.10.005DOI Listing
October 2020

Netarsudil's Effect in Eyes with a History of Selective Laser Trabeculoplasty.

Ophthalmol Glaucoma 2020 Jul - Aug;3(4):306-308. Epub 2020 Jan 22.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ogla.2020.01.005DOI Listing
January 2020

Outcomes of Valved and Nonvalved Tube Shunts in Neovascular Glaucoma.

Ophthalmol Glaucoma 2021 Mar-Apr;4(2):182-192. Epub 2020 Sep 18.

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, Pennsylvania. Electronic address:

Purpose: To determine the outcomes of Ahmed glaucoma valve (AGV; New World Medical Inc) and Baerveldt glaucoma implant (BGI; Advanced Medical Optics) surgery in the setting of neovascular glaucoma (NVG).

Design: Single-center, retrospective study.

Participants: Consecutive patients who underwent AGV or BGI surgery for the treatment of NVG and had ≥6 months of follow-up.

Methods: Chart review of AGV and BGI surgical outcomes in patients with NVG.

Main Outcome Measures: Progression to no light perception (NLP) vision and 6-month surgical failure, which was defined as intraocular pressure (IOP) >21 mmHg with medications or <5 mmHg at 2 consecutive visits, or glaucoma reoperation.

Results: A total of 152 eyes (91 AGV, 61 BGI) were included with an average follow-up of 29.6 ± 25.8 months. Baseline demographics and clinical characteristics were comparable between groups. At month 6, failure was similar between AGV and BGI eyes (21.6% vs. 25.9%; P = 0.552), but glaucoma medication use was lower in BGI eyes (P < 0.001). At the final visit, 18.7% of AGV and 14.8% of BGI eyes progressed to NLP vision (P = 0.530), and medication use was lower in BGI eyes (P < 0.0001). Multivariate analysis identified lower preoperative visual acuity (VA) (P = 0.001), failure to receive panretinal photocoagulation within 2 weeks of surgery (P = 0.003), and bilaterality of the underlying ischemic retinal pathology (P = 0.026) as the strongest predictors of NLP outcome. Age, sex, race, NVG etiology, tube type, preoperative IOP, extent of synechial angle closure preoperatively, preoperative hyphema, IOP at the first NLP visit, and final IOP were not significant predictors of NLP vision.

Conclusions: Eyes with AGV and BGI had comparable outcomes in NVG, although fewer medications were required in BGI eyes to control IOP. Progression to NLP vision was associated with poor baseline VA, delayed retinal treatment, and bilaterality of the underlying ischemic retinal pathology.
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http://dx.doi.org/10.1016/j.ogla.2020.09.010DOI Listing
September 2020

Transscleral Cyclophotocoagulation for Glaucoma in the Setting of Uveal Melanoma.

Ophthalmol Glaucoma 2020 Sep 19. Epub 2020 Sep 19.

Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ogla.2020.09.011DOI Listing
September 2020

Preliminary Report on a Novel Virtual Reality Perimeter Compared With Standard Automated Perimetry.

J Glaucoma 2021 Jan;30(1):17-23

Glaucoma Service, Wills Eye Hospital, Philadelphia, PA.

Precis: The VisuALL head-mounted perimetry in normal subjects and glaucoma patients had a moderate to strong correlation with the Humphrey Field Analyzer (HFA).

Purpose: Visual field testing has a vital role in diagnosing and managing glaucoma. The current clinical practice relies on large, table-based testing units. This study investigated the performance of a novel virtual reality head-mounted visual perimetry device (VisuALL), in normal and glaucoma patients.

Methods: This prospective observational study was conducted on 50 eyes of 25 healthy subjects (normal group) and 52 eyes of 26 patients with a controlled mild or moderate stage of glaucoma (glaucoma group). All participants had visual field testing with VisuALL and the HFA (24-2, Swedish Interactive Threshold Algorithm). The mean sensitivity of the whole visual field and each quadrant were compared between both machines and the receiver operating characteristic was used to compare the diagnostic abilities and the Bland-Altman plot to evaluate the agreement of the 2 perimeters.

Results: The global mean sensitivity of the VisuALL and the HFA correlated significantly in both normal (r=0.5, P=0.001) and glaucoma (r=0.8, P<0.001) groups. The mean sensitivity of all quadrants also correlated significantly in both groups. The VisuALL mean sensitivity had a greater (0.98) receiver operating characteristic curve than HFA (0.93) mean sensitivity (P=0.06) in discriminating normal versus glaucoma.

Conclusion: There was an excellent correlation between the VisuALL and the Standard Automated Perimetry in normal and glaucoma patients and VisuALL showing high diagnostic performance.
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http://dx.doi.org/10.1097/IJG.0000000000001670DOI Listing
January 2021

Surgical Approaches for Implanting Xen Gel Stent without Conjunctival Dissection.

Clin Ophthalmol 2020 17;14:2361-2371. Epub 2020 Aug 17.

Department of Ophthalmology, University of Toronto, Toronto, Canada.

The XEN Gel Stent (Allergan Inc., an Abbvie company) is an implant that lowers intraocular pressure by creating a filtration pathway from the anterior chamber to the subconjunctival space, using the same pathway as trabeculectomy. While the primary method for implantation is via ab interno approach, it is also possible to implant the device ab externo. This technique paper details the surgical steps for closed conjunctival implantation of the Gel Stent and provides surgical pearls for enhancing outcomes.
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http://dx.doi.org/10.2147/OPTH.S265695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445523PMC
August 2020

Balancing treatments for patients with systemic hypertension and glaucoma.

Expert Opin Pharmacother 2020 Dec 24;21(18):2225-2230. Epub 2020 Aug 24.

Wills Eye Hospital, Glaucoma Research Center , Philadelphia, PA, USA.

Introduction: Treatment of glaucoma and systemic hypertension requires careful balancing of ophthalmic and systemic medications. This report offers background on various common therapies and considerations to minimize undesirable systemic and ophthalmic outcomes.

Areas Covered: Key considerations relating to medical treatments for systemic hypertension and glaucoma chosen from a review of the literature are included. The historic safety of ophthalmic beta blockers and sub-types as well as combination agents are described. The potential role of ocular perfusion pressure in the pathogenesis of glaucoma is reviewed with a discussion of landmark studies, including the Barbados Eye Study and the Early Manifest Glaucoma Trial, with implications for medication choices for hypertension and glaucoma. Systemic antihypertensives are considered with regards to their potential association with glaucoma and its progression, especially in patients with low blood pressure and normal tension glaucoma. Opinions are offered with regard to therapeutic choices and considerations.

Expert Opinion: The medical treatment of systemic hypertension and glaucoma carries the potential for drug interactions and significant adverse effects requiring customization for each patient's particular issues. The evolution of new therapies and treatment paradigms, including laser as a first-line treatment, has expanded safe options and minimized potential dangers for high-risk patients.
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http://dx.doi.org/10.1080/14656566.2020.1810235DOI Listing
December 2020

Pooled Efficacy and Safety Profile of Netarsudil Ophthalmic Solution 0.02% in Patients With Open-angle Glaucoma or Ocular Hypertension.

J Glaucoma 2020 10;29(10):878-884

Aerie Pharmaceuticals Inc., Durham, NC.

Precis: In pooled phase III analyses, once-daily netarsudil 0.02% resulted in intraocular pressure (IOP) reduction that was noninferior to twice-daily timolol 0.5%, with minimal treatment-related serious or systemic adverse events (AEs). Ocular AEs were generally tolerable.

Purpose: The purpose of this study was to assess the efficacy and safety of the Rho kinase inhibitor netarsudil in patients with open-angle glaucoma or ocular hypertension.

Patients And Methods: Pooled analysis of data from the ROCKET-1 to 4 phase III studies of once-daily (PM) netarsudil or twice-daily timolol in patients with open-angle glaucoma or ocular hypertension. The primary efficacy measure was mean IOP at 8:00 AM, 10:00 AM, and 4:00 PM at week 2, week 6, and month 3 in patients with baseline IOP <25 mm Hg.

Results: In the pooled primary efficacy population (netarsudil, n=494; timolol, n=510), once-daily netarsudil was noninferior to twice-daily timolol at all 9 timepoints through month 3. Mean treated IOP ranged from 16.4 to 18.1 mm Hg among netarsudil-treated patients and 16.8 to 17.6 mm Hg among timolol-treated patients. In the pooled safety population (n=839 in each treatment group), treatment-related serious AEs occurred at similar frequencies in each treatment group (netarsudil, 0.1%; timolol, 0%). The most common ocular AE, conjunctival hyperemia (netarsudil, 54.4%; timolol, 10.4%), was graded as mild in 77.6% (354/456) of affected netarsudil-treated patients.

Conclusions: Once-daily netarsudil resulted in IOP lowering that was noninferior to twice-daily timolol, with tolerable ocular AEs that were generally mild and self-resolving. As a first-in-class agent in the United States, with a novel mechanism of action, netarsudil may provide a useful therapeutic option for patients who would benefit from IOP lowering.
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http://dx.doi.org/10.1097/IJG.0000000000001634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647436PMC
October 2020

Beliefs and Attitudes of Ophthalmologists Regarding SLT as First Line Therapy for Glaucoma.

J Glaucoma 2020 10;29(10):851-856

Glaucoma Research Center.

Precis: Targeted educational interventions for physicians may be useful in increasing adoption of selective laser trabeculoplasty (SLT) as first line therapy for the treatment of glaucoma.

Purpose: SLT is a safe and effective first line treatment for glaucoma, however, it is underutilized. To evaluate barriers for the widespread adoption of this procedure, we assessed the beliefs and attitudes of ophthalmologists. We developed an educational intervention directed to physicians to increase the consideration of SLT earlier in the glaucoma treatment paradigm.

Subjects And Methods: In this prospective study, an online survey and educational slide presentation was sent to a group of comprehensive ophthalmologists, ophthalmology residents, and glaucoma specialists. Subjects were asked to respond to questions regarding their beliefs and attitudes towards SLT before and after watching the educational slide presentation.

Results: A total of 53 subjects were enrolled. Before watching the slide presentation, 85% of subjects stated they offer SLT to newly diagnosed patients, although only 28% preferred it over medications. While 52% of physicians reported between 0% and 10% of their newly diagnosed patients receive laser therapy, 47% said they would use it as a first line therapy for all or most newly diagnosed glaucoma patients. Most subjects (94%) stated the educational slide presentation convinced them that SLT is appropriate as a first line therapy for treatment of open angle glaucoma.

Conclusions: A better understanding of the barriers for utilizing SLT as a first line therapy provides valuable information to help increase the adoption of this safe and effective procedure. A targeted educational intervention may improve acceptance of SLT as first line therapy for open angle glaucoma.
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http://dx.doi.org/10.1097/IJG.0000000000001615DOI Listing
October 2020

In Reply: A Novel Surgical Technique for Ahmed Glaucoma Valve Implantation Without Plate Sutures.

J Glaucoma 2020 09;29(9):e108-e109

Glaucoma Research Center Wills Eye Hospital Philadelphia, PA.

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http://dx.doi.org/10.1097/IJG.0000000000001603DOI Listing
September 2020

Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study.

J Glaucoma 2020 09;29(9):750-755

Wills Eye Hospital, Glaucoma Research Center.

Precis: Baerveldt glaucoma drainage device demonstrated a greater reduction in intraocular pressure (IOP) than Ahmed in patients with uveitic glaucoma. The most common cause of failure was uncontrolled IOP in Ahmed and hypotony in the Baerveldt group.

Purpose: To compare the efficacy and safety of Ahmed and Baerveldt glaucoma drainage devices in uveitic glaucoma.

Materials And Methods: The retrospective comparative study included patients with uveitic glaucoma who underwent Ahmed or Baerveldt glaucoma drainage device implantation with a minimum follow-up of 3 months. Success was defined as IOP ≥6 and ≤21 mm Hg and >20% reduction on 2 consecutive visits after the third month with (qualified success) or without (complete success) medications and no further glaucoma surgery or loss of vision. IOP, number of medications, visual acuity, complications, and interventions were compared between groups.

Results: In total, 137 eyes of 122 patients (67 Ahmed, 70 Baerveldt) were included. The preoperative IOP and number of medications in the Ahmed group (32.7±10.3 mm Hg; 4.1±1.3) were similar to Baerveldt (32.1±10.2 mm Hg; 4.3±1.3; P=0.73, 0.35). These at the last follow-up were (18.1±9.8 mm Hg; 2.1±1) in Ahmed and (12.7±6.9 mm Hg; 1.3±1.3) in Baerveldt groups (P=0.04, 0.01). The Baerveldt had greater IOP reduction (60.3% vs. 44.5%) and complete success rate (30% vs. 9%) with higher complication rate (51.4% vs. 20.9%) (all P≤0.05). The de novo glaucoma reoperation rate was 19% in the Ahmed group and 4% in the Baerveldt group (P=0.006). Hypotony resulted in failure in 7 eyes (10%) in the Baerveldt group and none in the Ahmed group (P=0.013).

Conclusions: Higher complete success rate and significantly greater reduction in mean IOP and number of medications were observed in the Baerveldt group, but with a higher rate of complications including hypotony.
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http://dx.doi.org/10.1097/IJG.0000000000001583DOI Listing
September 2020

Monitoring Glaucomatous Functional Loss Using an Artificial Intelligence-Enabled Dashboard.

Ophthalmology 2020 09 10;127(9):1170-1178. Epub 2020 Mar 10.

Wilmer Eye Institute and Division of Health Sciences Informatics, Johns Hopkins University, Baltimore, Maryland.

Purpose: To develop an artificial intelligence (AI) dashboard for monitoring glaucomatous functional loss.

Design: Retrospective, cross-sectional, longitudinal cohort study.

Participants: Of 31 591 visual fields (VFs) on 8077 subjects, 13 231 VFs from the most recent visit of each patient were included to develop the AI dashboard. Longitudinal VFs from 287 eyes with glaucoma were used to validate the models.

Method: We entered VF data from the most recent visit of glaucomatous and nonglaucomatous patients into a "pipeline" that included principal component analysis (PCA), manifold learning, and unsupervised clustering to identify eyes with similar global, hemifield, and local patterns of VF loss. We visualized the results on a map, which we refer to as an "AI-enabled glaucoma dashboard." We used density-based clustering and the VF decomposition method called "archetypal analysis" to annotate the dashboard. Finally, we used 2 separate benchmark datasets-one representing "likely nonprogression" and the other representing "likely progression"-to validate the dashboard and assess its ability to portray functional change over time in glaucoma.

Main Outcome Measures: The severity and extent of functional loss and characteristic patterns of VF loss in patients with glaucoma.

Results: After building the dashboard, we identified 32 nonoverlapping clusters. Each cluster on the dashboard corresponded to a particular global functional severity, an extent of VF loss into different hemifields, and characteristic local patterns of VF loss. By using 2 independent benchmark datasets and a definition of stability as trajectories not passing through over 2 clusters in a left or downward direction, the specificity for detecting "likely nonprogression" was 94% and the sensitivity for detecting "likely progression" was 77%.

Conclusions: The AI-enabled glaucoma dashboard, developed using a large VF dataset containing a broad spectrum of visual deficit types, has the potential to provide clinicians with a user-friendly tool for determination of the severity of glaucomatous vision deficit, the spatial extent of the damage, and a means for monitoring the disease progression.
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http://dx.doi.org/10.1016/j.ophtha.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483368PMC
September 2020

iStent inject trabecular micro-bypass stents with topical prostaglandin as standalone treatment for open-angle glaucoma: 4-year outcomes.

Clin Exp Ophthalmol 2020 08 12;48(6):767-774. Epub 2020 May 12.

Minnesota Eye Consultants, Minneapolis, Minnesota, USA.

Importance: Long-term data are needed regarding effective and safe glaucoma treatment modalities.

Background: This study evaluated 4-year outcomes of second-generation trabecular micro-bypass stent implantation (iStent inject) combined with topical travoprost in open-angle glaucoma (OAG).

Design: Prospective, non-randomized, multi-surgeon study at a tertiary care ophthalmology centre.

Participants: OAG subjects with preoperative intraocular pressure (IOP) 18 to 30 mmHg on two medications and 22 to 38 mmHg post-washout.

Methods: Subjects (n = 53) underwent standalone iStent inject implantation and started travoprost on postoperative Day 1. Measures included IOP, medications, comprehensive ophthalmic examinations and testing, and adverse events (AEs). Annual medication washouts were performed.

Main Outcome Measures: Mean medicated and unmedicated IOP; and proportions of eyes with IOP ≤18mmHg, ≤15 mmHg, or ≥20% reduced while on travoprost vs screening IOP on two medications.

Results: At 48 months postoperative, 85% of eyes reduced IOP ≥20% on travoprost vs screening IOP on 2 medications; 92% of eyes had IOP ≤18 mmHg on travoprost; and 83% had IOP ≤15 mmHg on travoprost. At Month 49 (post-washout), 90% of eyes reduced IOP ≥20% vs preoperative washout IOP. Throughout follow-up, mean IOP on travoprost was 11.9 to 13.0 mmHg (34%-40% reduced vs 19.7 mmHg on 2 medications preoperatively; P < .0001 throughout), and post-washout IOP was 16.5 to 17.7 mmHg (28%-34% reduced vs 24.9 mmHg preoperatively; P < .0001 throughout). Favourable safety included minimal AEs; stable visual acuity, cup-to-disc ratio and visual fields; and no secondary surgeries.

Conclusions And Relevance: Combining iStent inject implantation with topical prostaglandin produced significant and safe 4-year IOP and medication reductions in OAG.
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http://dx.doi.org/10.1111/ceo.13763DOI Listing
August 2020

Fixed-combination topical anti-hypertensive ophthalmic agents.

Expert Opin Pharmacother 2020 Jul 31;21(10):1269-1282. Epub 2020 Mar 31.

Glaucoma Service, Wills Eye Hospital , Philadelphia, PA, USA.

Introduction: Fixed-combination glaucoma medications have altered the paradigm of ocular hypertension and glaucoma treatment and are in widespread use today. A comprehensive review of fixed-combination medications will help educate and inform providers for optimal patient care.

Areas Covered: In this review, the authors describe the composition, mechanism of action, efficacy, side effects, and safety profile of fixed-combination agents for the treatment of ocular hypertension and glaucoma as well as comparisons between the most frequently prescribed medications.

Expert Opinion: Fixed-combination therapeutics provide an effective and efficient means of lowering intraocular pressure with comparable side effects and outcomes to constituent parts with lower patient exposure to preservatives and improvement in compliance.
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http://dx.doi.org/10.1080/14656566.2020.1743264DOI Listing
July 2020

Artificial Intelligence Classification of Central Visual Field Patterns in Glaucoma.

Ophthalmology 2020 06 12;127(6):731-738. Epub 2019 Dec 12.

Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts; Complex Structures in Biology and Cognition, Max Planck Institute for Mathematics in the Sciences, Leipzig, Germany. Electronic address:

Purpose: To quantify the central visual field (VF) loss patterns in glaucoma using artificial intelligence.

Design: Retrospective study.

Participants: VFs of 8712 patients with 13 951 Humphrey 10-2 test results from 13 951 eyes for cross-sectional analyses, and 824 patients with at least 5 reliable 10-2 test results at 6-month intervals or more from 1191 eyes for longitudinal analyses.

Methods: Total deviation values were used to determine the central VF patterns using the most recent 10-2 test results. A 24-2 VF within a 3-month window of the 10-2 tests was used to stage eyes into mild, moderate, or severe functional loss using the Hodapp-Anderson-Parrish scale at baseline. Archetypal analysis was applied to determine the central VF patterns. Cross-validation was performed to determine the optimal number of patterns. Stepwise regression was applied to select the optimal feature combination of global indices, average baseline decomposition coefficients from central VFs archetypes, and other factors to predict central VF mean deviation (MD) slope based on the Bayesian information criterion (BIC).

Main Outcome Measures: The central VF patterns stratified by severity stage based on 24-2 test results and a model to predict the central VF MD change over time using baseline test results.

Results: From cross-sectional analysis, 17 distinct central VF patterns were determined for the 13 951 eyes across the spectrum of disease severity. These central VF patterns could be divided into isolated superior loss, isolated inferior loss, diffuse loss, and other loss patterns. Notably, 4 of the 5 patterns of diffuse VF loss preserved the less vulnerable inferotemporal zone, whereas they lost most of the remaining more vulnerable zone described by the Hood model. Inclusion of coefficients from central VF archetypical patterns strongly improved the prediction of central VF MD slope (BIC decrease, 35; BIC decrease of >6 indicating strong prediction improvement) than using only the global indices of 2 baseline VF results. Eyes with baseline VF results with more superonasal and inferonasal loss were more likely to show worsening MD over time.

Conclusions: We quantified central VF patterns in glaucoma, which were used to improve the prediction of central VF worsening compared with using only global indices.
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http://dx.doi.org/10.1016/j.ophtha.2019.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246163PMC
June 2020

Pathophysiology and management of glaucoma and ocular hypertension related to trauma.

Surv Ophthalmol 2020 Sep - Oct;65(5):530-547. Epub 2020 Feb 11.

Glaucoma Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Ocular trauma is a significant cause of blindness worldwide, particularly if associated with glaucoma. Direct damage from blunt or penetrating trauma, bleeding, inflammation, lens-related problems, orbital and brain vascular pathologies related to trauma, and chemical injuries may increase intraocular pressure and lead to traumatic glaucoma. Treatment may be as simple as eliminating the underlying cause in some conditions or management can be challenging, depending on the mechanism of damage. If proper management is not undertaken, visual outcomes can be poor. We discuss a broad spectrum of trauma-related mechanisms of intraocular pressure elevation, as well as their management.
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http://dx.doi.org/10.1016/j.survophthal.2020.02.003DOI Listing
February 2020

Characterization of Central Visual Field Loss in End-stage Glaucoma by Unsupervised Artificial Intelligence.

JAMA Ophthalmol 2020 02;138(2):190-198

Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston.

Importance: Although the central visual field (VF) in end-stage glaucoma may substantially vary among patients, structure-function studies and quality-of-life assessments are impeded by the lack of appropriate characterization of end-stage VF loss.

Objective: To provide a quantitative characterization and classification of central VF loss in end-stage glaucoma.

Design, Setting, And Participants: This retrospective cohort study collected data from 5 US glaucoma services from June 1, 1999, through October 1, 2014. A total of 2912 reliable 10-2 VFs of 1103 eyes from 1010 patients measured after end-stage 24-2 VFs with a mean deviation (MD) of -22 dB or less were included in the analysis. Data were analyzed from March 28, 2018, through May 23, 2019.

Main Outcomes And Measures: Central VF patterns were determined by an artificial intelligence algorithm termed archetypal analysis. Longitudinal analyses were performed to investigate whether the development of central VF defect mostly affects specific vulnerability zones.

Results: Among the 1103 patients with the most recent VFs, mean (SD) age was 70.4 (14.3) years; mean (SD) 10-2 MD, -21.5 (5.6) dB. Fourteen central VF patterns were determined, including the most common temporal sparing patterns (304 [27.5%]), followed by mostly nasal loss (280 [25.4%]), hemifield loss (169 [15.3%]), central island (120 [10.9%]), total loss (91 [8.3%]), nearly intact field (56 [5.1%]), inferonasal quadrant sparing (42 [3.8%]), and nearly total loss (41 [3.7%]). Location-specific median total deviation analyses partitioned the central VF into a more vulnerable superonasal zone and a less vulnerable inferotemporal zone. At 1-year and 2-year follow-up, new defects mostly occurred in the more vulnerable zone. Initial encroachments on an intact central VF at follow-up were more likely to be from nasal loss (11 [18.4%]; P < .001). One of the nasal loss patterns had a substantial chance at 2-year follow-up (8 [11.0%]; P = .004) to shift to total loss, whereas others did not.

Conclusions And Relevance: In this study, central VF loss in end-stage glaucoma was found to exhibit characteristic patterns that might be associated with different subtypes. Initial central VF loss is likely to be nasal loss, and 1 specific type of nasal loss is likely to develop into total loss.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.5413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990977PMC
February 2020

A Novel Surgical Technique for Ahmed Glaucoma Valve Implantation Without Plate Sutures.

J Glaucoma 2020 03;29(3):161-167

Glaucoma Research Center.

PRéCIS:: A modification to the surgical technique of Ahmed glaucoma valve (AGV) implantation without plate sutures or surgical glue products has a similar safety and efficacy profile than the standard procedure, in the short and mid-term follow-up.

Purpose: The purpose of this study was to assess the safety and efficacy of a modified AGV implantation technique without plate sutures.

Methods: A retrospective case-control study including patients seen in the Glaucoma service of an academic institution. Patients that underwent a modified AGV implantation without plate sutures were included as cases and patients that underwent standard AGV implantation, as controls. Success was defined as intraocular pressure (IOP) reduction >20%, IOP >5 and <21 without the need for additional surgical intervention, and maintenance of light perception.

Results: A total of 170 eyes were included. Mean (range) follow-up was 11.2±7.39 (3 to 24) months. There was no statistically significant difference in visual acuity and IOP between the groups during the postoperative period. In a univariate analysis, there was a larger decrease in IOP for the no plate suture group at the 6 months (-15.6±11.6 vs. -11.5±10.5, P=0.04) and 1 year (-16.4±10.4 vs. -11.1±10.4, P=0.02) visits. There was also a larger decrease in number of medications in the no plate suture group in the 3 months (-1.65±1.5 vs. -1.13±1.22, P=0.02), 6 months (-1.55±1.44 vs. -0.98±1.3, P=0.01) and 1 year (-1.70±1.5 vs. -1.04±1.2, P=0.04) visits. However, those differences were not confirmed by a multivariable model after adjusting for glaucoma type and number of previous glaucoma surgeries. No differences in the trajectory of the survival curves were noted between groups (P=0.36).

Conclusion: The comparison of short and mid-term outcomes of patients undergoing AGV implantation using both techniques showed similar outcomes and success rates.
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http://dx.doi.org/10.1097/IJG.0000000000001428DOI Listing
March 2020

Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons.

J Cataract Refract Surg 2019 12;45(12):1704-1710

Wills Eye Hospital, Philadelphia, Pennsylvania, USA.

Purpose: To determine the efficacy, safety, and surgical outcomes of trabecular microbypass stent (iStent) surgery performed by resident trainees and attending surgeons.

Setting: Wills Eye Hospital, Philadelphia, Pennsylvania, USA.

Design: Retrospective case series.

Methods: Records of all patients who had microbypass stent surgery by a resident at Wills Eye Hospital were retrospectively reviewed. The attending-performed group included any patient who had a microbypass stent implanted by an attending surgeon on the same day a resident case was performed.

Results: Between 2016 and 2018, 31 microbypass stents were implanted by a resident supervised by an attending and 93 microbypass stents were implanted by an attending surgeon on the day a resident case was performed. The mean follow-up was 16.2 months ± 17.9 (SD). The mean intraocular pressure (IOP) decreased from 16.0 ± 4.6 mm Hg at baseline to 14.0 ± 3.1 mm Hg at most recent follow-up visit in the resident group (P = .02) and from 17.5 ± 4.8 mm Hg to 15.1 ± 4.3 mm Hg, respectively, in the attending group (P < .001). The final mean IOP and mean number of hypotensive medications were similar between the 2 groups (P = .83 and P = .12, respectively). Self-resolving hyphema occurred in 1 resident case and 2 attending cases. The resident group had 1 case of iridodialysis, which did not require additional surgery. One eye in the attending group ultimately required a trabeculectomy.

Conclusion: Microbypass stent implantation by resident trainees with attending supervision had similar efficacy and safety as surgery performed by attending surgeons.
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http://dx.doi.org/10.1016/j.jcrs.2019.07.021DOI Listing
December 2019

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre.

Can J Ophthalmol 2019 12 19;54(6):717-722. Epub 2019 Sep 19.

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, PA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Objectives: To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia.

Design: Retrospective chart review.

Participants: Patients from a community glaucoma screening program.

Methods: Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence.

Results: A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence.

Conclusions: The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.
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http://dx.doi.org/10.1016/j.jcjo.2019.03.003DOI Listing
December 2019

Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study: Cataract Classifications Following Eye Screening.

Telemed J E Health 2020 08 13;26(8):992-1000. Epub 2019 Nov 13.

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, Pennsylvania, USA.

Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study p pp
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http://dx.doi.org/10.1089/tmj.2019.0170DOI Listing
August 2020

Baseline Age and Mean Deviation Affect the Rate of Glaucomatous Vision Loss.

J Glaucoma 2020 01;29(1):31-38

Bernard and Shirlee Brown Glaucoma Research Laboratory, Edward S. Harkness Eye Institute, Columbia University Medical Center.

Purpose: The purpose of this study was to assess the relationship between the rate of the glaucomatous visual field (VF) worsening and baseline age and baseline VF mean deviation (MD).

Design: This study was a retrospective, multisite cohort.

Participants: A total of 84,711 reliable Swedish Interactive Thresholding Algorithm 24-2 VF tests from 8167 eyes from 5644 patients with ≥6 VF tests, ≥5 years of follow-up, baseline age 18 years or above and baseline MD ≥-10 dB, and at least 2 abnormal VF tests were included from the Glaucoma Research Network Database.

Methods: The global mean deviation rates (MDRs) and pointwise total deviation rates (TDRs) of VF progression (dB/y) were calculated for each eye using linear regression. The relationships between MDR and baseline age and MD were determined using linear mixed-effects models and logistic regression, with rapid progression defined as an MDR≤-1.0 dB/y. The relationships between TDR and baseline age and baseline MD were determined using linear mixed-effects models.

Main Outcome Measures: Coefficients of the regression models.

Results: In individual mixed-effects models both baseline age (β=-0.0079 dB/y; P<0.001) and baseline MD (β=0.012/y; P<0.001) were associated with faster progression. All parameters were statistically significant in the full model with both parameters and their interaction (β=0.00065; P=0.0017) as covariates. With logistic regression, each year increase in baseline age increased the odds of belonging to the rapid-progressing group by a factor of 1.033, and each unit increase in baseline MD (less severe visual loss) decreased the odds by a factor of 0.8821. The mean pointwise TDR ranged from -0.21 to -0.55 dB/y, with the most rapid pointwise progression observed in the nasal and paracentral regions of the field.

Conclusions: Older age and worse MD at baseline are associated with more rapid VF progression in this large dataset. The effect of age on MDR is influenced by baseline MD severity, supporting the importance of early detection and more aggressive therapy in older patients with worse VF damage. The pointwise rate of VF loss varies across the VF, providing a means for physicians to more effectively monitor progression.
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http://dx.doi.org/10.1097/IJG.0000000000001401DOI Listing
January 2020