Impact of Natural Blind Spot Location on Perimetry.

We study the spatial distribution of natural blind spot location (NBSL) and its impact on perimetry. Pattern deviation (PD) values of 11,449 reliable visual fields (VFs) that are defined as clinically unaffected based on summary indices were extracted from 11,449 glaucoma patients. We modeled NBSL distribution using a two-dimensional non-linear regression approach and correlated NBSL with spherical equivalent (SE). Additionally, we compared PD values of groups with longer and shorter distances than median, and larger and smaller angles than median between NBSL and fixation. Mean and standard deviation of horizontal and vertical NBSL were 14.33° ± 1.37° and -2.06° ± 1.27°, respectively. SE decreased with increasing NBSL (correlation: r = -0.14, p \u3c 0.001). For NBSL distances longer than median distance (14.32°), average PD values decreased in the upper central (average difference for significant points (ADSP): -0.18 dB) and increased in the lower nasal VF region (ADSP: 0.14 dB). For angles in the direction of upper hemifield relative to the median angle (-8.13°), PD values decreased in lower nasal (ADSP: -0.11 dB) and increased in upper temporal VF areas (ADSP: 0.19 dB). In conclusion, we demonstrate that NBSL has a systematic effect on the spatial distribution of VF sensitivity

An Artificial Intelligence Approach to Detect Visual Field Progression in Glaucoma Based on Spatial Pattern Analysis.

Purpose: To detect visual field (VF) progression by analyzing spatial pattern changes. Methods: We selected 12,217 eyes from 7360 patients with at least five reliable 24-2 VFs and 5 years of follow-up with an interval of at least 6 months. VFs were decomposed into 16 archetype patterns previously derived by artificial intelligence techniques. Linear regressions were applied to the 16 archetype weights of VF series over time. We defined progression as the decrease rate of the normal archetype or any increase rate of the 15 VF defect archetypes to be outside normal limits. The archetype method was compared with mean deviation (MD) slope, Advanced Glaucoma Intervention Study (AGIS) scoring, Collaborative Initial Glaucoma Treatment Study (CIGTS) scoring, and the permutation of pointwise linear regression (PoPLR), and was validated by a subset of VFs assessed by three glaucoma specialists. Results: In the method development cohort of 11,817 eyes, the archetype method agreed more with MD slope (kappa: 0.37) and PoPLR (0.33) than AGIS (0.12) and CIGTS (0.22). The most frequently progressed patterns included decreased normal pattern (63.7%), and increased nasal steps (16.4%), altitudinal loss (15.9%), superior-peripheral defect (12.1%), paracentral/central defects (10.5%), and near total loss (10.4%). In the clinical validation cohort of 397 eyes with 27.5% of confirmed progression, the agreement (kappa) and accuracy (mean of hit rate and correct rejection rate) of the archetype method (0.51 and 0.77) significantly (P \u3c 0.001 for all) outperformed AGIS (0.06 and 0.52), CIGTS (0.24 and 0.59), MD slope (0.21 and 0.59), and PoPLR (0.26 and 0.60). Conclusions: The archetype method can inform clinicians of VF progression patterns

The Effect of Patient Characteristics and Sleep Quality on Visual Field Performance Reliability

Purpose. To investigate the association of automated visual field (VF) reliability indices (false positive [FP], false negative [FN], and fixation loss [FL]) and sleep quality, VF experience, and age. Methods. Prospective, cross-sectional study. Adult patients (age ≥ 18 years) completing automated VF testing were invited to participate. Baseline participant characteristics were obtained, and all participants were asked to complete the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Nonparametric Spearman correlations and logistical regression models were performed. Results. 63 patients were enrolled. Lower PSQI score was correlated with higher percentage (%) FL in the right eye (p=0.03). Fewer prior VF was significantly correlated with higher %FP in the right eye (p=0.008). Older age was significantly correlated with higher %FN in the left eye (p=0.01). Greater mean deviation (MD) and pattern standard deviation (PSD) were strongly correlated with higher %FN in the right (p=0.02 and 0.002, resp.) and left eyes (p=0.01 and 0.02, resp.). Conclusion. In this prospective, cross-sectional study, worse MD and PSD are strongly correlated with increased FN in both eyes. Increased FN in the left eye associated with older age might be attributable to test fatigue. Worse sleep quality is associated with decreased FL in the right eye

Barriers to Glaucoma Medication Compliance Among Veterans: Dry Eye Symptoms and Anxiety Disorders

To identify barriers to compliance of medical treatment for glaucoma among veterans. Patients with glaucoma from the Miami Veterans Affairs Eye Clinic (n=74) filled out a 63-question survey regarding dry eye symptoms, concurrent systemic disease, and medications. The association between glaucoma medical compliance was defined as self-reported adherence to drop regimens greater than 75% of the time. Eighty percent of veterans (n=59) reported compliance with glaucoma therapy. Dry eye symptoms (as defined by Dry Eye Questionnaire 5 score ≥6) were reported by 39% (n=29), and their presence was associated with decreased compliance (63% vs. 89%, P=0.007). Anxiety and posttraumatic stress syndrome (PTSD) were also associated with significant noncompliance (64% vs. 83%, P=0.05 and 58% vs. 84%, P=0.02, respectively). Other studied factors including demographics, depression (P=0.11), and glaucoma regimens did not play a significant role in glaucoma medication compliance. Dry eye symptoms, PTSD, and anxiety were associated with decreased compliance to medical treatment of glaucoma. Identifying and treating underlying ocular surface disease and anxiety disorders may lead to increased adherence to glaucoma treatment

Relationship between central corneal thickness and hypotony-related complications after glaucoma surgery

To examine the hypothesis that patients with increased central corneal thickness may have an overestimation of Goldmann applanation tension and a predisposition to hypotony-related complications. A case-control analysis of patients with an intraocular pressure of 7 mm Hg or less on two consecutive postoperative visits following glaucoma filtration or drainage implant surgery was performed. Forward stepwise multiple logistic regression was used to determine the model that best predicted hypotony-related complications defined as choroidal effusion or hypotony maculopathy. Forty-three eyes (17 with hypotony-related complications and 26 controls) of 43 patients were enrolled. Eyes with pseudophakia (P = .006) and lower postoperative intraocular pressure (P = .013) were significantly more likely to develop hypotony-related complications. Mean central corneal thickness was similar in eyes with hypotony-related complications (519 +/- 32 microm) and controls (525 +/- 37 microm) and was not a significant predictor of hypotony-related complications in the multivariate model (P = .90). Increased central corneal thickness does not represent a risk factor for hypotony-related complications following glaucoma surgery

Brimonidine allergy presenting as vernal-like keratoconjunctivitis

To report a brimonidone-induced allergic reaction that mimicked a limbal form of vernal keratoconjunctivitis in the setting of background ocular surface toxicity. A 78-year-old male with a history of primary open angle glaucoma presented with symptoms of unilateral blurry vision, irritation, and redness shortly after starting brimonidine exclusively in the right eye. Examination revealed injected palpebral and bulbar conjunctiva, diffuse punctate epithelial erosion and discrete, non-staining corneal limbal infiltrates superiorly. Given the unilateral presentation, the patient was diagnosed with an allergic limbal keratoconjunctivitis secondary to bromonidine. Shortly after discontinuing the brimonidine, there was full resolution of the corneal limbal infiltrates. The punctate epithelial erosions and tear film abnormalities remained. Direct medication allergy and ocular surface disease are two distinct entities that often co-exist. Distinguishing between the two entities, sometimes by trial and error, is critical in the management of these patients

Naturally occurring insulin autoantibodies in neonates of normal pregnancies and their relationship to insulinemia and birth weight

OBJECTIVE: The objectives of this study were to determine whether insulin autoantibodies are present in umbilical cord blood from normal pregnancies, determine whether cord blood insulin autoantibody levels correlate with respective maternal levels at delivery, determine whether cord blood insulin autoantibody levels are related to cord blood or maternal insulin levels, and to determine what relationship neonatal birth weight has with either cord blood insulin autoantibody and insulin levels or maternal insulin autoantibody and insulin levels. STUDY DESIGN: Paired umbilical cord and maternal serum samples were taken from 70 normal subjects at delivery. Measurements of serum insulin autoantibody (competitive charcoal radiobinding assay) and insulin (radioimmune inhibition assay) levels were performed. Multiple linear regression analysis and paired t tests were used for data analyses. RESULTS: Neonatal insulin autoantibody levels (120 nU/ml) were more than two times higher than maternal levels (49 nU/ml) ( p < 0.001). No correlation was observed between neonatal and maternal insulin autoantibody levels ( r = 0.14, p = 0.25). A positive correlation of both neonatal and maternal insulin with birth weight was observed ( r = 0.28, p < 0.02; and r = 0.36, p < 0.01, respectively). CONCLUSIONS: These results suggest that the insulin autoantibody levels in fetal cord blood are not related to maternal levels in normal uncomplicated pregnancies. In addition, insulin levels in both maternal and neonatal circulations were positively correlated with increased birth weight in the normal pregnancies studied

Dry Eye Symptoms and Ocular Pain in Veterans with Glaucoma

Dry eye and glaucoma are two frequently encountered ocular conditions, which can lead to substantial morbidity and decreased quality of life. Patients on topical glaucoma medications are known to be at greater risk for ocular surface symptoms. Veterans seen in the eye clinics at the Miami Veterans Affairs Hospital from January to July 2016 completed surveys assessing dry eye and ocular pain symptoms, including the five item Dry Eye Questionnaire (DEQ5). A total of 62 patients with glaucoma completed the survey. Of those, 52 were on glaucoma medications at the time of the survey, with the majority requiring more than one medication to control intraocular pressure. The frequency of mild or greater dry eye symptoms (defined as DEQ5 &gt;6) tended to increase with increasing medication burden, and patients on brimonidine were more likely to report a DEQ5 &gt;6. Patients on three or more glaucoma medications were more likely to report symptoms of shooting pain, dryness, and itchiness. Patients using timolol were more likely to report throbbing and pain by light, while those on latanoprost reported stinging. Our data support an association between increasing number of glaucoma medications and worsening of dry eye symptoms. Patient and medication-associated symptoms can be used to tailor individual medication regimens

The influence of etiology on surgical outcomes in neovascular glaucoma

The authors sought to evaluate visual outcomes in patients with varying etiologies of neovascular glaucoma (NVG), who were treated with glaucoma drainage devices (GDD). This was a retrospective case series of patients at a large academic teaching institution who had surgical intervention for neovascular glaucoma between September 2011 and May 2019. Eyes were included if there was documented neovascularization of the iris/angle with an intraocular pressure (IOP) > 21 mmHg at presentation. Eyes must also have been treated with surgical intervention that included a GDD. Primary outcome measure was visual acuity at the 1-year post-operative visit. Secondary outcome measure was qualified success after surgery defined by: pressure criteria (5 mmHg < IOP ≤ 21 mmHg), no re-operation for elevated IOP, and no loss of LP vision. One hundred twenty eyes met inclusion criteria. 61.7% had an etiology of proliferative diabetic retinopathy (PDR), 23.3% had retinal vein occlusions (RVO), and the remaining 15.0% suffered from other etiologies. Of patients treated with GDD, eyes with PDR had better vision compared to eyes with RVO at final evaluation (p = 0.041). There was a statistically significant difference (p = 0.027) in the mean number of glaucoma medications with Ahmed eyes (n = 70) requiring 1.9 medications and Baerveldt eyes (n = 46) requiring 1.3 medications at final evaluation. In our study, many patients with NVG achieved meaningful vision, as defined by World Health Organization (WHO) guidelines, and IOP control after GDD. Outcomes differed between patients with PDR and RVO in favor of the PDR group. Different GDD devices had similar performance profiles for VA and IOP outcomes. Direct prospective comparison of Baerveldt, Ahmed, and cyclophotocoagulation represents the next phase of discovery