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The newly released Swedish Interactive Thresholding Algorithm (SITA)-Faster (SFR) has significantly shorter testing durations compared with older SITA algorithms, but its variability is uncertain. This study quantified and established threshold limits of test–retest variability across the 24-2 test grid using SFR. Cross-sectional study with prospective longitudinal arm. 1426 eyes of 787 patients with healthy, suspected glaucoma, or manifest glaucoma eyes from hospital- and university- eye clinics. Two SFR tests per eye at a baseline visit and at two follow-up visits. Pointwise variability measured by test–retest difference in pointwise sensitivity between tests one and two, mean global variability (test–retest variance) measured by average of pointwise variability for each participant, global sensitivity, and reliability indices of each eye. Of the 1426 eyes, 540 eyes (37.9%) had a diagnosis of glaucoma, 753 eyes (52.8%) were suspected of having glaucoma, and the remaining 133 eyes (9.3%) were healthy. Of 74 152 pointwise sensitivities obtained, the mean test–retest difference was 2.17 ± 2.9 dB, whereas the mean test–retest variance for each participant was 2.17 ± 1.2 dB. Pointwise and global variability increased with worsening threshold sensitivity and (MD), respectively, and was greater for peripheral compared with central test locations. In the longitudinal cohort, no significant difference in mean test-retest variance was found across the 3 visits (mean variability, 2.10 dB vs. 2.16 dB vs. 2.16 dB at visits F0 vs. F1 vs. F2; P = 0.53, repeated-measures analysis of variance). Baseline MD (–0.19 dB; 95% CI, –0.22 to 0.16 dB; P < 0.0001) and abnormally high sensitivity on glaucoma hemifield test (1.14 dB; 95% CI, 0.78–1.51 dB; P < 0.0001) were significantly associated with increased variability. Finally, test–retest MD showed minimal change around the recommended 15% false-positive cutoff threshold. The variability of SFR increases with worsening threshold sensitivity, is stable over time, and is greater for peripheral compared with central test locations. Worse baseline MD and abnormally high sensitivity are significant predictors of increased variability. A cutoff of 15% in false-positive results may be inappropriate as a threshold for judging test reliability in SFR. The author(s) have no proprietary or commercial interest in any materials discussed in this article. [ABSTRACT FROM AUTHOR]

Glaucoma is the leading cause of irreversible blindness worldwide. As a chronic disease, glaucoma presents a significant burden to the individual, health‐care provider and the health‐care system. Currently, strategies for treating glaucoma are focused on lowering intraocular pressure, which is aimed at slowing or arresting disease progression over time. This is the only current accepted therapeutic strategy for glaucoma, and can be achieved using topical drugs, laser trabeculoplasty, filtration surgery or cyclodestructive techniques. The lowering of intraocular pressure has been well‐supported by numerous large‐scale seminal clinical trials in primary open‐angle glaucoma, in both its early and advanced stages. Although such guidance remains current, in the last 10-years, there has been a significant evolution in preferred first‐line therapies in the treatment of open‐angle glaucoma with a resultant shift in practice patterns, particularly early in the course of the disease. These changes reflect both from the perspective of the doctor – in titrating the most effective and least risky treatment modality – and the perspective of the patient, in consenting to a treatment that preserves vision and results in minimal negative impact on quality of life. In this review, the most recent evidence regarding treatment modalities for early primary open‐angle glaucoma is presented and an updated framework for management guidance is proposed. [ABSTRACT FROM AUTHOR]

A 69-year-old woman developed severe right suprabulbar pain with blurred right-sided vision. There were no haloes around lights, photophobia, nausea or vomiting. Investigations in the emergency department excluded a posterior communicating/internal carotid artery aneurysm. However, she did not have an ophthalmological assessment and the initial diagnosis was of sinusitis-related headache. An urgent ear, nose and throat assessment found no abnormality, but a local ophthalmologist subsequently diagnosed and managed the patient's acute angle closure crisis. Periocular pain always deserves detailed assessment with an accurate history, visual acuity assessment and intraocular pressure measurement. [ABSTRACT FROM AUTHOR]

Abstract: Cellular responses to changes in pressure are implicated in numerous disease processes. In glaucoma apoptosis of retinal ganglion cells (RGCs) is associated with elevated intra-ocular pressure, however, the exact cellular mechanisms remain unclear. We have previously shown that pressure can induce apoptosis in B35 and PC12 neuronal cell lines, using an in vitro model for pressure elevation. A novel RGC line allows us to study the effects of pressure on retinal neurons. ‘RGC-5’ cultures were subjected to elevated ambient hydrostatic pressure conditions in our model. Experimental pressure conditions were 100mm Hg and 30mm Hg, representing acute (high) and chronic (lower-pressure) glaucoma, and 15mm Hg for normal intra-ocular pressure, set above atmospheric pressure for 2h. Negative controls were treated identically except for the application of pressure, while positive controls were generated by treatment with a known apoptotic stimulus. Apoptosis was determined by a combination of cell morphology and specific TUNEL and Annexin V fluorescent markers. These were assessed simultaneously by laser scanning cytometry (LSC), which also enabled quantitative marker analysis. RGC-5 neurons showed a significantly increased proportion of apoptotic cells compared with controls; maximal at 100mm Hg, moderate at 30mm Hg and not statistically significant at 15mm Hg. This graded response, proportionate to the level of pressure elevation, is representative of the severity of analogous clinical settings (acute, chronic glaucoma and normal). These results complement earlier findings of pressure-induced apoptosis in other neuronal cultures. They suggest the possibility of novel mechanisms of pressure-related mechanotransduction and cell death, relevant to the pathogenesis of diseases such as glaucoma. [Copyright &y& Elsevier]

Highlights from the article: It is instructive that 2 American glaucomatologists, Allan E. Kolker and John Hetherington Jr., were the first to write about corneal indentation (CI) in Becker-Schaffer's Diagnosis and Therapy of the Glaucomas, published by C. V. Mosby, in St Louis, Missouri in 1976.[2] Their seminal article demonstrated a success rate for CI of 71.4%.[6] Currently, in the hands of the authors, CI normalizes the intraocular pressures in PACD patients in over 90% of cases. 7 M.R. Razeghinejad, J.S. Myers, Contemporary approach to the diagnosis and management of primary angle-closure disease, Surv Ophthalmol, 63, 6 2018, 754-768.

Purpose Methods Results Conclusions To utilise ganglion cell‐inner plexiform layer (GCIPL) measurements acquired using widefield optical coherence tomography (OCT) scans spanning 55° × 45° to explore the link between co‐localised structural parameters and clinical visual field (VF) data.Widefield OCT scans acquired from 311 healthy, 268 glaucoma suspect and 269 glaucoma eyes were segmented to generate GCIPL thickness measurements. Estimated ganglion cell (GC) counts, calculated from GCIPL measurements, were plotted against 24‐2 SITA Faster visual field (VF) thresholds, and regression models were computed with data categorised by diagnosis and VF status. Classification of locations as VF defective or non‐defective using GCIPL parameters computed across eccentricity‐ and hemifield‐dependent clusters was assessed by analysing areas under receiver operating characteristic curves (AUROCCs). Sensitivities and specificities were calculated per diagnostic category.Segmented linear regression models between GC counts and VF thresholds demonstrated higher variability in VF defective locations relative to non‐defective locations (mean absolute error 6.10–9.93 dB and 1.43–1.91 dB, respectively). AUROCCs from cluster‐wide GCIPL parameters were similar across methods centrally (p = 0.06–0.84) but significantly greater peripherally, especially when considering classification of more central locations (p < 0.0001). Across diagnoses, cluster‐wide GCIPL parameters demonstrated variable sensitivities and specificities (0.36–0.93 and 0.65–0.98, respectively), with the highest specificities observed across healthy eyes (0.73–0.98).Quantitative prediction of VF thresholds from widefield OCT is affected by high variability at VF defective locations. Prediction of VF status based on cluster‐wide GCIPL parameters from widefield OCT could become useful to aid clinical decision‐making in appropriately targeting VF assessments. [ABSTRACT FROM AUTHOR]

This systematic review examined geographical and temporal trends in medical school ophthalmology education in relationship to course and student outcomes. Evidence suggesting a decline in ophthalmology teaching in medical schools is increasing, raising concern for the adequacy of eye knowledge across the rest of the medical profession. Systematic review of Embase and SCOPUS, with inclusion of studies containing data on medical school ophthalmic course length; 1 or more outcome measures on student ophthalmology knowledge, skills, self-evaluation of knowledge or skills, or student course appraisal; or both. The systematic review was registered prospectively on the International Prospective Register of Systematic Reviews (identifier, CRD42022323865). Results were aggregated with outcome subgroup analysis and description in relationship to geographical and temporal trends. Descriptive statistics, including nonparametric correlations, were used to analyze data and trends. Systematic review yielded 4596 publication titles, of which 52 were included in the analysis, with data from 19 countries. Average course length ranged from 12.5 to 208.7 hours, with significant continental disparity among mean course lengths. Africa reported the longest average course length at 103.3 hours, and North America reported the shortest at 36.4 hours. On average, course lengths have been declining over the last 2 decades, from an average overall course length of 92.9 hours in the 2000s to 52.9 hours in the 2020s. Mean student self-evaluation of skills was 51.3%, and mean student self-evaluation of knowledge was 55.4%. Objective mean assessment mark of skills was 57.5% and that of knowledge was 71.7%, compared with an average pass mark of 66.7%. On average, 26.4% of students felt confident in their ophthalmology knowledge and 34.5% felt confident in their skills. Most evidence describes declining length of courses devoted to ophthalmology in the last 20 years, significant student dissatisfaction with courses and content, and suboptimal knowledge and confidence. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

The presence or absence of spontaneous retinal venous pulsations (SVP) provides clinically significant insight into the hemodynamic status of the optic nerve head. Reduced SVP amplitudes have been linked to increased intracranial pressure and glaucoma progression. Currently, monitoring for the presence or absence of SVPs is performed subjectively and is highly dependent on trained clinicians. In this study, we developed a novel end-to-end deep model, called U3D-Net, to objectively classify SVPs as present or absent based on retinal fundus videos. The U3D-Net architecture consists of two distinct modules: an optic disc localizer and a classifier. First, a fast attention recurrent residual U-Net model is applied as the optic disc localizer. Then, the localized optic discs are passed on to a deep convolutional network for SVP classification. We trained and tested various time-series classifiers including 3D Inception, 3D Dense-ResNet, 3D ResNet, Long-term Recurrent Convolutional Network, and ConvLSTM. The optic disc localizer achieved a dice score of 95% for locating the optic disc in 30 milliseconds. Amongst the different tested models, the 3D Inception model achieved an accuracy, sensitivity, and F1-Score of 84 ± 5%, 90 ± 8%, and 81 ± 6% respectively, outperforming the other tested models in classifying SVPs. To the best of our knowledge, this research is the first study that utilizes a deep neural network for an autonomous and objective classification of SVPs using retinal fundus videos. [ABSTRACT FROM AUTHOR]

Frontloading SITA-Faster (SFR) visual fields (2 tests per eye on the same visit) has been shown to provide repeatable perimetric data at minimal time cost. This study reports the outcomes of using frontloaded SFR in the evaluation of pointwise visual field (VF) defects in a cohort of patients with glaucoma when transitioned from SITA-Standard (SS). Prospective, cross-sectional study. A total of 144 eyes of 91 patients with confirmed or suspected glaucoma who had an SS test on a previous visit. Two SFR tests (T1, T2) per eye on the same visit. Global sensitivity, reliability indices, and pointwise deviation map probability scores from the pattern deviation grid of each patient were compared across the 3 sequential tests to evaluate the consistency of VF defects. The mean age was 68.6 years, and 79.2% of patients had a diagnosis of glaucoma. There was no significant difference in mean deviation (MD) across the 3 tests (–5.83 decibels [dB], –5.28 dB, and –5.71 dB in SS, SFR1, and SFR2, respectively, repeated-measures analysis of variance [ANOVA], P = 0.48). The frontloaded SFR tests provided repeatable VFs that confirmed existing pointwise data on the SS in 4661 (62.3%) locations, reversed an SS defect in 614 (8.2%) locations, and demonstrated a new repeatable defect in 406 (5.4%) locations of the pattern deviation grid. A new defect of at least 3 contiguous points was identified in 20.1% of eyes. The non-repeatable points on the 2 SFR tests displayed no significant difference in the distribution of defect/nondefect points based on test order or peripheral versus central locations. There was no significant difference in the rate of obtaining at least 1 reliable test result between SS and the frontloaded SFR T1 and T2 (P = 0.77). Test duration significantly decreased from SS to SFR1/2 (379 vs. 160 vs. 158 seconds, P < 0.0001). Frontloading SFR tests can provide repeatable data for the evaluation of the consistency of pattern deviation defects in glaucoma, with no observable decline in performance from test fatigue. This is achieved at equivalent duration and reliability as a single SS test. Frontloading SFR may be helpful in increasing testing frequency/quantity to meet recommended guidelines for progression analysis. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

An awareness of a patient's risk profile for glaucoma and the importance of early detection can help prevent vision loss that is irreversible once it occurs. Knowledge of the algorithms guiding glaucoma treatment options, the medications used and factors leading to nonadherence, as well as the increasing interest in laser therapy and lifestyle and nutrition interventions, can further aid disease management. [ABSTRACT FROM AUTHOR]

The presence or absence of spontaneous retinal venous pulsations (SVP) provides clinically significant insight into the hemodynamic status of the optic nerve head. Reduced SVP amplitudes have been linked to increased intracranial pressure and glaucoma progression. Currently, monitoring for the presence or absence of SVPs is performed subjectively and is highly dependent on trained clinicians. In this study, we developed a novel end-to-end deep model, called U3D-Net, to objectively classify SVPs as present or absent based on retinal fundus videos. The U3D-Net architecture consists of two distinct modules: an optic disc localizer and a classifier. First, a fast attention recurrent residual U-Net model is applied as the optic disc localizer. Then, the localized optic discs are passed on to a deep convolutional network for SVP classification. We trained and tested various time-series classifiers including 3D Inception, 3D Dense-ResNet, 3D ResNet, Long-term Recurrent Convolutional Network, and ConvLSTM. The optic disc localizer achieved a dice score of 95% for locating the optic disc in 30 milliseconds. Amongst the different tested models, the 3D Inception model achieved an accuracy, sensitivity, and F1-Score of 84 ± 5%, 90 ± 8%, and 81 ± 6% respectively, outperforming the other tested models in classifying SVPs. To the best of our knowledge, this research is the first study that utilizes a deep neural network for an autonomous and objective classification of SVPs using retinal fundus videos. [ABSTRACT FROM AUTHOR]

To assess the association between a glaucoma polygenic risk score (PRS) and treatment outcomes in primary open-angle glaucoma. Prospective, observational cohort study. Participants from the Progression Risk of Glaucoma: Relevant SNPs with Significant Association Study were divided into a cohort with suspect glaucoma who were treatment naive at enrollment and one with early manifest and suspect glaucoma receiving treatment at enrollment. A per-allele weighted glaucoma PRS was calculated for 1107 participants. Multivariable mixed-effects Cox proportional regression analysis assessed the association between PRS and time to commencement of intraocular pressure (IOP)-lowering therapy in 416 patients with suspect glaucoma who were treatment naive at study enrollment. Secondary analysis evaluated the association between PRS and escalation of IOP-lowering therapy among 691 patients with suspect and early manifest glaucoma who were receiving IOP-lowering therapy at enrollment. Commencement or escalation of IOP-lowering therapy. A higher PRS was associated with a greater risk of commencing IOP-lowering therapy within 5 years (hazard ratio [HR], 1.45 per 1 standard deviation [/SD]; 95% confidence interval [CI], 1.27–1.62; P < 0.001). Participants in the upper population-based quintile showed a 3.3 times greater risk of commencing therapy by 5 years than those in the lowest quintile (HR, 3.30; 95% CI, 1.63–6,70; P < 0.001) and a 5.4 times greater risk of commencing IOP-lowering therapy by 2 years than the those in the lowest quintile (HR, 5.45; 95% CI, 2.08–14.25; P < 0.001). A higher PRS was associated with a greater risk of treatment escalation among patients receiving treatment at enrollment (HR, 1.19/SD; 95% CI, 1.09–1.31; P < 0.001). In combined analysis of all participants, participants in the top population-based quintile were at 2.3 times greater risk of requiring initiation or escalation of IOP-lowering therapy than those in the lowest quintile (HR, 2.33; 95% CI, 1.75–3.01; P < 0.001). This study demonstrated novel associations between glaucoma polygenic risk and risk of commencement or escalation of IOP-lowering therapy, building on previous work highlighting the potential clinical usefulness of genetic risk stratification in glaucoma. Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

Many ophthalmologists preform clinical refactions, although little is known of the perceptions and practise of refraction by ophthalmologists and key barriers preventing this aspect of ophthalmic practice. Although there are numerous studies on visual acuity in ophthalmology, there is no study to date on the practice of refraction by ophthalmologists. This study evaluates the practice patterns of ophthalmologists in current practice. It specifically addresses perceptions of ophthalmologists about (a) the importance of refraction in clinical practice, and (b) barriers to performing refraction. The methodology and frequency of performing refraction by ophthalmologists is also assessed. This cross-sectional study was conducted at the Annual Scientific Congress of the Royal Australian and New Zealand College of ophthalmologists in 2017, held in Perth, Australia. All attending ophthalmologists and ophthalmology trainees were invited to participate. Participants completed a 17-variable questionnaire on the perceptions of practitioners about refraction and their practice of it. Data were analysed using Microsoft Excel and IBM SPSS Version 24. At this Congress, 213 attendees completed the survey, with most being consultant general ophthalmologists (85%). Twenty-six percent of participants either 'really loved' or 'liked' refracting patients. Those who reported feeling competent with refraction were more likely to perform it themselves (p = 0.001). Individuals most commonly reported taking 3-5 minutes to refract a patient (38%). Participants under the age of 65, and participants practising paediatric ophthalmology, were more likely to perform a refraction. The literature indicates that this is the first study to describe the practice patterns of refraction by ophthalmologists. Although ophthalmologists found refraction important, the majority preferred patients to be refracted by others. Key barriers to ophthalmologists performing refraction included the time required to perform the refraction, a busy clinic, and the availability of alternative providers. [ABSTRACT FROM AUTHOR]

Background: Glaucoma, the leading cause of irreversible blindness, is classified as a neurodegenerative disease, and its incidence increases with age. Pathophysiological changes, such as the deposition of amyloid-beta plaques in the retinal ganglion cell layer, as well as neuropsychological changes, including cognitive decline, have been reported in glaucoma. However, the association between cognitive ability and retinal functional and structural measures in glaucoma, particularly glaucoma subtypes, has not been studied. We studied the association between cognitive ability and the visual field reliability indices as well as the retinal ganglion cell (RGC) count estimates in a cohort of glaucoma patients. Methods: A total of 95 eyes from 61 glaucoma patients were included. From these, 20 were normal-tension glaucoma (NTG), 25 were primary open-angle glaucoma (POAG), and 16 were glaucoma suspects. All the participants had a computerised Humphrey visual field (HVF) assessment and optical coherence tomography (OCT) scan and were administered the written Montreal Cognitive Assessment (MoCA) test. RGC count estimates were derived based on established formulas using the HVF and OCT results. A MoCA cut-off score of 25 and less was designated as cognitive impairment. Student's t-test was used to assess differences between the groups. The Pearson correlation coefficient was used to assess the association between MoCA scores and retinal structural and functional measures. Results: Significant associations were found between MoCA scores and the false-negative and pattern standard deviation indices recorded on the HVF (r = −0.19, r = −0.22, p < 0.05). The mean IOP was significantly lower in the cognitively impaired group (i.e., MOCA ≤ 25) (13.7 ± 3.6 vs. 15.7 ± 4.5, p < 0.05). No significant association was found between RGC count estimates and MoCA scores. Analysis of these parameters in individual glaucoma subtypes did not reveal any group-specific significant associations either. [ABSTRACT FROM AUTHOR]

Abstract: MYOC gene variants are associated with autosomal dominant primary open angle glaucoma (POAG). In this study, we describe a previously unreported MYOC variant segregating with a POAG phenotype in an Australian family. Two individuals affected with POAG and three unaffected individuals from the same family were recruited through the Australian and New Zealand Registry of Advanced Glaucoma (ANZRAG). Direct sequencing of all MYOC coding exons identified the novel heterozygous single nucleotide transition MYOC:c.1119G>A, p.(Trp373*), predicted to encode an aberrant truncated MYOC protein in two affected siblings. Two unaffected siblings and an unaffected niece were negative for the MYOC sequence variant. [Copyright &y& Elsevier]

Thus, it is difficult to evaluate the difference that the cataract risk stratification made, considering that only 20 cases out of 500 were redistributed away from 100 cases performed by the Registrars.1 It was instructive to examine the visual outcomes (VOs)2 of Han et al's SP 1 sp patient cohort. 4 Lundström M, Barry P, Henry Y, Rosen P, Stenevi U. Visual outcome of cataract surgery: study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. [Extracted from the article]

To investigate corneal stiffness parameters (SPs) as predictors of future progression risk in glaucoma suspect eyes. Prospective, longitudinal study. Three hundred seventy-one eyes from 228 primary open-angle glaucoma suspects, based on optic disc appearance, with normal baseline Humphrey Visual Field (HVF; Carl Zeiss Meditec) results. Baseline corneal SPs were measured using Corvis ST (Oculus Optikgeräte GmbH). Participants were followed up every 6 months with clinical examination, HVF testing, and OCT. The baseline SP at first applanation (SP-A1) and highest concavity predicted the prospective outcome measures. Structural progression was measured by the OCT rate of thinning of the retinal nerve fiber layer (RNFL) and ganglion cell–inner plexiform layer (GCIPL). Functional progression was assessed by permutation analysis of pointwise linear regression criteria on HVF testing. Stiffness parameters correlated positively with central corneal thickness (CCT), which was adjusted for in all analyses. A higher SP-A1, suggestive of a stiffer cornea, was associated with a faster rate of RNFL thinning (P < 0.001), synergistic with thinner CCT (P = 0.004) over a mean follow-up of 4.2 years. Eyes with higher SP-A1 and thinner CCT (thin and stiff corneas) showed accelerated RNFL thinning by 0.72 μm/year relative to eyes with lower SP-A1 and thicker CCT (95% confidence interval [CI], 0.17–1.28; P = 0.011) and were at 2.9-fold higher likelihood of fast RNFL progression of more than 1 μm/year (95% CI, 1.4–6.1; P = 0.006). Consistent results also were observed with GCIPL thinning. Furthermore, a higher SP-A1 was associated with a greater risk of visual field progression (P = 0.002), synergistic with thinner CCT (P = 0.010). Eyes with higher SP-A1 and thinner CCT were at 3.7-fold greater risk of visual field progression relative to eyes with thicker CCT and lower SP-A1 (95% CI, 1.3–10.5; P = 0.014). Glaucoma suspect eyes with higher corneal SPs and lower CCT, suggestive of thin and stiff corneas, are at greater risk of progression. Corneal SPs seem to act synergistically with CCT as risk factors for glaucoma progression. [ABSTRACT FROM AUTHOR]

The document is a collection of letters published in the Journal of Cataract & Refractive Surgery. The first letter discusses the importance of considering automated refraction as a starting point for subjective refraction and the risks of inappropriate evaluation and treatment. The authors suggest that subjective refraction should always be included in discussions of refractive results with multifocal and EDOF IOLs. The second letter congratulates Kugler et al. on their study on the safety of office-based lens surgery, but raises concerns about delays in accessing emergency eyecare in office-based centers. The authors emphasize the need for robust methods for early detection and prompt management of complications in office-based settings. [Extracted from the article]

Glaucoma, a leading cause of blindness, is a multifaceted disease with several patho-physiological features manifesting in single fundus images (e.g., optic nerve cupping) as well as fundus videos (e.g., vascular pulsatility index). Current convolutional neural networks (CNNs) developed to detect glaucoma are all based on spatial features embedded in an image. We developed a combined CNN and recurrent neural network (RNN) that not only extracts the spatial features in a fundus image but also the temporal features embedded in a fundus video (i.e., sequential images). A total of 1810 fundus images and 295 fundus videos were used to train a CNN and a combined CNN and Long Short-Term Memory RNN. The combined CNN/RNN model reached an average F-measure of 96.2% in separating glaucoma from healthy eyes. In contrast, the base CNN model reached an average F-measure of only 79.2%. This proof-of-concept study demonstrates that extracting spatial and temporal features from fundus videos using a combined CNN and RNN, can markedly enhance the accuracy of glaucoma detection. [ABSTRACT FROM AUTHOR]

To investigate the association between cardiovascular disease and baseline structural defects and disease progression in glaucoma. Prospective, longitudinal study of preperimetric and perimetric glaucoma. Two thousand six hundred twenty-eight eyes from 1314 participants recruited to the Progression Risk of Glaucoma: Relevant SNPs with Significant Association (PROGRESSA) study were evaluated for baseline and longitudinal structural thinning using spectral-domain OCT and for visual field progression on Humphrey visual field (HVF) assessment. Patients were classified as either predominantly macula ganglion cell–inner plexiform layer (mGCIPL), predominantly peripapillary retinal nerve fiber layer (pRNFL), or both mGCIPL and pRNFL structural change at enrollment, and then evaluated for longitudinal OCT or HVF progression. Cardiovascular disease and medication characteristics of the participants were compared with a reference group of stable patients. OCT and HVF baseline status and longitudinal progression. After accounting for age and cardiovascular characteristics, patients with predominantly mGCIPL thinning at baseline showed a higher prevalence of hypertension (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.66–4.41; P < 0.001), antihypertensive use (OR, 2.03; 95% CI, 1.20–3.46; P = 0.008), and statin use (OR, 1.98; 95% CI, 1.07–3.66; P = 0.029) than reference patients. Patients with predominantly pRNFL thinning exhibited a comparable prevalence of cardiovascular disease or medication with reference patients. Review of longitudinal OCT and HVF data (mean follow-up, 5.34 ± 1.29 years) showed that hypertension was associated with an increased risk of both OCT (OR, 1.79; 95% CI, 1.17–2.75; P = 0.006) and HVF progression (OR, 1.92; 95% CI, 1.18–3.15; P = 0.013). A 1-standard deviation (approximately 21 mmHg) increase in systolic blood pressure at baseline was associated with a greater risk of OCT progression (OR, 1.27; 95% CI, 1.01–1.63; P = 0.041) and HVF progression (OR, 1.32; 95% CI, 1.01–1.73; P = 0.043). The association between systolic blood pressure and structural progression was comparable to that observed between intraocular pressure and structural progression (OR, 1.30; 95% CI, 1.01–1.67; P = 0.039). Cardiovascular disease is an important risk factor for glaucoma progression. [ABSTRACT FROM AUTHOR]

Background: In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.Methods: Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.Results: Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ2 test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).Conclusion: Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics. [ABSTRACT FROM AUTHOR]

To examine the combined effects of common genetic variants associated with intraocular pressure (IOP) on primary open-angle glaucoma (POAG) phenotype using a polygenic risk score (PRS) stratification. Cross-sectional study. For the primary analysis, we examined the glaucoma phenotype of 2154 POAG patients enrolled in the Australian and New Zealand Registry of Advanced Glaucoma, including patients recruited from the United Kingdom. For replication, we examined an independent cohort of 624 early POAG patients. Using IOP genome-wide association study summary statistics, we developed a PRS derived solely from IOP-associated variants and stratified POAG patients into 3 risk tiers. The lowest and highest quintiles of the score were set as the low- and high-risk groups, respectively, and the other quintiles were set as the intermediate risk group. Clinical glaucoma phenotype including maximum recorded IOP, age at diagnosis, number of family members affected by glaucoma, cup-to-disc ratio, visual field mean deviation, and treatment intensity. A dose–response relationship was found between the IOP PRS and the maximum recorded IOP, with the high genetic risk group having a higher maximum IOP by 1.7 mmHg (standard deviation [SD], 0.62 mmHg) than the low genetic risk group (P = 0.006). Compared with the low genetic risk group, the high genetic risk group had a younger age of diagnosis by 3.7 years (SD, 1.0 years; P < 0.001), more family members affected by 0.46 members (SD, 0.11 members; P < 0.001), and higher rates of incisional surgery (odds ratio, 1.5; 95% confidence interval, 1.1–2.0; P = 0.007). No statistically significant difference was found in mean deviation. We further replicated the maximum IOP, number of family members affected by glaucoma, and treatment intensity (number of medications) results in the early POAG cohort (P ≤ 0.01). The IOP PRS was correlated positively with maximum IOP, disease severity, need for surgery, and number of affected family members. Genes acting via IOP-mediated pathways, when considered in aggregate, have clinically important and reproducible implications for glaucoma patients and their close family members. [ABSTRACT FROM AUTHOR]

Importance Cataract and primary open‐angle glaucoma (POAG) commonly co‐exist, and cataract surgery is thought to reduce intraocular pressure (IOP), the major modifiable risk factor of POAG. Background: Previous studies exploring the effect of cataract surgery on IOP are limited by retrospective design, lack of a control group, medication use and washout and loss to follow up. Design Prospective, multicentre, matched case‐control Australian study. Participants: 171 eyes of 108 POAG patients who underwent cataract surgery, matched to 171 control eyes. Methods: Serial longitudinal IOP measurements were compared before and after cataract surgery, and relative to the controls. A mixed‐effect model was used for the longitudinal data. Main Outcome Measures: Change in IOP. Results: The mean follow‐up time was 4.8 (1.4) years. Cataract surgery reduced mean IOP by 2.22 mmHg (95% confidence interval: 1.93‐2.52 mmHg, P <.001) with 59 eyes (34%) achieving at least 3 mmHg reduction. Compared to matched controls, the mean reduction in IOP was 1.75 mmHg (95% confidence interval 1.15‐2.33 mmHg; P <.001). Higher preoperative IOP and being on fewer topical glaucoma medications preoperatively were strongly predictive of a larger IOP reduction in a multivariable model. Anterior chamber depth was not associated with IOP reduction. Eyes with preoperative IOP ≥24 mmHg had a mean IOP reduction of 4.03 mmHg with 81% experiencing at least 3 mmHg reduction. Sub‐analysis of medication naïve and pseudoexfoliation patients showed similar results. Conclusions and Relevance: Cataract surgery has a confirmed effect in reducing IOP in a "real world" setting of early glaucoma patients. [ABSTRACT FROM AUTHOR]

Saccades are a key component for the assessment and diagnosis of Neuro-ophthalmological disorders. Traditionally, clinicians have been taught to use large amplitude saccades (LAS) to assess saccadic velocity (SV), when small amplitude saccades (SAS) may be more effective. This study aimed to evaluate the advantages of SAS over LAS by presenting a video to 108 clinicians where both methods were used to assess a patient with a unilateral partial 6th nerve palsy. SAS was the preferred method in identifying the 6th nerve palsy by 43/55 (78.2%) of Neurologists, and 36/53 (67.9%) of Ophthalmologists. These findings indicate that SAS may be a more effective method than LAS for determining SV. [ABSTRACT FROM AUTHOR]

Compression of anterior visual pathway (AVP) structures by intracranial arteries is observed not infrequently on neuroimaging. Whether or not such compression results in damage to these structures, however, remains unclear. This information is important to define as AVP compression by intracranial arteries may be a causative factor in patients with otherwise unexplained visual dysfunction. In a single centre, 37 patients with evidence of intracranial artery AVP compression demonstrated on magnetic resonance imaging were identified by retrospective review of case records over the period 2011–2017. Variables were collected, including patient demographics, visual acuity, visual fields, pupillary reactions and optic disc appearance for patients in the case series. Visual field deficits correlated with compression sites in the 37 patients examined. Internal carotid artery-optic nerve compression was the most frequent (unilateral compression n = 9, bilateral compression n = 14), followed by chiasmal compression by the anterior cerebral artery (n = 8) and a combination of optic nerve and chiasmal compression (n = 5). Visual acuity and visual fields were stable on follow-up (mean 4 years) in 24 of 26 cases (93%). We conclude that AVP compression by intracranial arteries may be a causative factor in unexplained visual dysfunction. The visual defects are largely non-progressive. [ABSTRACT FROM AUTHOR]

To investigate which clinical measures influence whether an individual demonstrates earliest glaucomatous structural progression on peripapillary retinal nerve fiber layer (pRNFL) or macular ganglion cell–inner plexiform layer (mGCIPL). Prospective, longitudinal cohort study. Two hundred seventy-one eyes from 207 individuals with statistically significant evidence of glaucomatous progression on OCT Guided Progression Analysis (GPA) software were drawn from a total of 1271 eyes from 686 individuals categorized as glaucoma suspect or having early manifest glaucoma undergoing glaucoma surveillance. Individuals demonstrating earliest evidence of longitudinal progression on mGCIPL GPA event analysis were compared with individuals demonstrating evidence of earliest longitudinal progression on pRNFL GPA event analysis. Correlation of OCT event change analysis with intraocular pressure (IOP), clinical variables, and baseline thickness of the pRNFL and mGCIPL. Intraocular pressure, baseline pRNFL thickness, baseline mGCIPL thickness, and systemic hypertension were associated with location of first progression. Eyes demonstrating earliest longitudinal progression on mGCIPL had significantly lower maximum-recorded pretreatment IOP (mean difference, 3.90 mmHg; 95% confidence interval [CI], 2.37–5.43 mmHg; P < 0.001). The interval between progression on pRNFL and progression on mGCIPL increased by 12.4 months for every 5-mmHg increase in IOP (95% CI, 10.32–15.72 months). Eyes demonstrating earliest longitudinal progression on mGCIPL showed significantly lower baseline average pRNFL thickness than eyes progressing on pRNFL first (mean difference, 7.07 μm; 95% CI, 4.38–9.77 μm; P < 0.001). Eyes progressing first on mGCIPL parameters were 3.03 times more likely to demonstrate a new paracentral field defect than eyes progressing first on pRNFL parameters (odds ratio, 3.03; 95% CI, 1.26–7.28; P = 0.01). Clinical features, particularly pretreatment IOP, influence whether structural glaucoma progression is detected earlier with mGCIPL or pRNFL imaging. These data support the usefulness of mGCIPL imaging in addition to pRNFL analysis for detection of glaucoma progression, particularly in patients with normal IOP. [ABSTRACT FROM AUTHOR]

Purpose: The ganglion cell analysis (GCA) of the CIRRUSTM HD-OCT (Carl Zeiss, Meditec; Dublin, CA) provides measurement of the macular ganglion cell-inner plexiform layer (GCIPL) thickness. This study determined the frequency of scan artefacts and errors in GCIPL imaging in individuals undergoing HD-OCT surveillance for glaucoma. Method: A total of 1439 eyes from 721 subjects enrolled in a prospective study assessing predictors of glaucoma progression underwent macular GCIPL imaging with the CIRRUS HD-OCT at recruitment. The prevalence of acquisition errors, segmentation errors, and co-morbid macular pathology was determined. Results: A total of 87 (6.0%) of the 1439 scans had either acquisition errors, segmentation artefacts, or other macular pathology. The most common co-morbid macular pathology was epiretinal membrane in 2.2% of eyes. Conclusion: The macular GCIPL scan was artefact free in 94% of eyes. However, epiretinal membrane and high myopia can cause scan artefact and should be considered when interpreting the results. [ABSTRACT FROM AUTHOR]

Importance Worldwide, ophthalmology teaching is being reduced or eliminated from medical school curricula. The current state of ophthalmic teaching in Australia is unknown. Background: To evaluate the perceptions of junior medical officers (JMOs) and medical students on ophthalmology teaching in Australian medical schools. Design: Survey‐based cross‐sectional study. Participants: A total of 838 JMOs and medical students from across Australia. Methods: Fifty‐six hospitals and 20 medical schools across Australia were contacted. Hardcopy and online surveys were distributed to participants at consenting institutions, evaluating the characteristics of ophthalmology teaching received during medical school and participant confidence in basic ophthalmological clinical skills and knowledge. Factor analysis was performed on confidence scores. Main outcome measures: Likert scale confidence ratings, teaching methods encountered versus preferred. Results: Four hundred and thirty‐two (51.6%) surveys were received from JMOs and 406 (48.4%) from medical students. The most common form of teaching received were lectures (71.3% JMOs, 65.5% medical students), while the most preferred type were hospital tutorials (37.7% JMOs, 61.6% medical students). Mean confidence in ophthalmology‐specific skills and knowledge topics were not high for medical students (skills: 2.66/5, 95% confidence interval [CI] = 2.55–2.76; knowledge: 2.88/5, 95% CI = 2.80–2.96) and JMOs (skills: 2.52/5, 95% CI = 2.43–2.60; knowledge: 2.84/5, 95% CI = 2.77–2.91). Many participants voiced the need for more ophthalmology teaching, particularly clinically oriented opportunities. Conclusions and relevance: JMOs and medical students do not show high levels of confidence in basic ophthalmological clinical skills and knowledge, and report inadequate emphasis on ophthalmology during medical school. [ABSTRACT FROM AUTHOR]

Background To compare the agreement between peak intraocular pressures measured through the water drinking test and the supine test, in patients with primary open angle glaucoma. Design Consecutive, prospective, blinded. Participants Twenty-one patients from the Glaucoma Unit, Prince of Wales Hospital, Sydney, Australia. Methods For the supine test, intraocular pressure was recorded immediately after the patient had lain down and at 20 and 40 min. At the second evaluation, intraocular pressure was measured in each patient after drinking 10 mL/kg body weight of water for the water drinking test. Again, all patients had their intraocular pressure measured at 20 and 40 min ( t = 20 and t = 40, respectively). Patients were excluded from the study if they had pre-existing cardiac, renal or pulmonary complications or had concurrent ocular disease or an anatomical abnormality (including angle recession, peripheral anterior synechiae and developmental anomalies of the angle) that may have influenced intraocular pressure. Main Outcome Measure Bland-Altman analysis. Results Bland-Altman analysis indicated an overall excellent agreement in terms of mean difference between methods (1.0, −1.0 and −0.90 mmHg, at 0, 20 and 40 min, respectively). Further, with the exception of t = 40, all measured time points had 95% confidence intervals within 6.5 mmHg of their mean difference on the Bland-Altman plot. Conclusions There was close agreement between the intraocular pressure values of the supine test and water drinking test. However, as the water drinking test may be uncomfortable and potentially hazardous, there is potential that the supine test may be a safer and more comfortable alternative. [ABSTRACT FROM AUTHOR]

Background To identify and classify materials in the vitreous observed during phacoemulsification cataract surgery (phaco). Design Prospective, consecutive, observational case series at one ophthalmic day surgery in Sydney, Australia. Participants A total of 767 consecutive phaco cases. Cases were excluded if there was posterior capsule rupture or vitreous loss intraoperatively. Methods For each patient, age, gender, baseline corrected distance visual acuity, presence of pseudoexfoliation, nuclear sclerosis grade and phacoemulsification ultrasound time were recorded. The relationship between these variables and materials in the vitreous was evaluated with regression analysis. Two patients with materials in the vitreous developed an acute intraoperative rock-hard eye syndrome. In these two patients, pars plana needle aspiration of retrolenticular fluid was performed to re-establish normal intraocular pressure. Histology was undertaken to compare this fluid with known lens material retrieved from the Fluid Management System bags in two unrelated cases. Main Outcome Measurements Presence of materials in the vitreous during phaco. Results Materials in the vitreous were observed in either Berger's space or the anterior vitreous in 386 eyes (50.3% of cases); the majority was putatively lens material (46.5% of all cases). Pigment and ophthalmic viscoelastic device were seen in the anterior vitreous in 9.8% and 1.7% of cases, respectively. Logistic regression analysis demonstrated that higher nuclear sclerosis grade ( P = 0.025), male gender ( P = 0.003) and greater age ( P = 0.016) were predictive of the presence of materials in the vitreous. Histological assessment with light microscopy and birefringence techniques identified the materials in the vitreous as lens material. Conclusion Materials in the vitreous were seen in 50.3% of phaco cases. It has been histologically demonstrated that lens materials can be introduced into the anterior vitreous during phaco. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the influence of different clinical examination techniques, including optic nerve head ( ONH) photography, visual field tests, and adjunct imaging on the diagnosis of glaucoma by Australian and New Zealand optometrists. The effect of a short-term, didactic teaching module on these is also explored. Methods Clinical data of 30 patients previously seen at the Centre for Eye Health was collected and compiled into glaucoma diagnostic assessment modules. Each of six modules contained different combinations of clinical examination results and required a classification of the cases as normal, suspicious or glaucoma. A cohort of 54 Australian and New Zealand optometrists were recruited for the study and allocated into two cohorts. The intervention group completed a glaucoma training course prior to the assessment while the control group completed the assessment without additional training. Diagnostic accuracy was compared between modules and optometrist groups. Results High false negative rates were observed with ONH photography, which were drastically reduced with the addition of visual field, albeit at the cost of increased false positive rates. Addition of adjunct imaging techniques partially compensated for the increase in the false positive rate from the visual field, but had limited effect on false negative rate. Educational intervention resulted in larger improvement in the diagnostic ability when multiple imaging modalities were provided. Conclusion The study highlighted the importance of combining both structural and functional assessments in glaucoma. Current imaging technology demonstrated limited usefulness for event diagnosis due to the persistent difficulties of defining structural and functional loss in glaucoma, thus highlighting the need for new glaucoma assessment techniques. Short-term didactic teaching programs may only result in limited improvement of glaucoma diagnostic ability in optometrists, and hence, it may need to be combined with long-term and/or non-didactic training components to obtain a greater effect. [ABSTRACT FROM AUTHOR]

Background. This study evaluated the effectiveness of managing posterior blepharitis (PB) using a novel Posterior Blepharitis Management Protocol (PBMP). Design. Prospective, consecutive case series with 100% followup to one month. Participants. 27 patients (54 eyes) with PB from an Ophthalmology practice in Sydney, Australia. Methods. Each patient’s PB was assessed by grading the nature and expressibility of the central lower lid tarsal gland secretions on Compression Of The Eyelid (COTE). Patients were then instructed in detail to undertake daily PB management sessions at home using our modified PBMP. Main Outcome Measures. On a subjective scale, patients compared their symptoms at one month with baseline. COTE scores were reevaluated to assess the objective effectiveness of each individual’s PBMP. COTE scoring was described as grades 1 (clear oil), 2 (pus, liquid), 3 (toothpaste-like secretions), and 4 (complete tarsal gland obstruction). Results. Patients reported a mean 77.8% ± 13.5% subjective improvement in symptoms. There was a trend towards improvement in COTE grading at one month compared with baseline: grades 1 (0 to 7.4%), 2a (22.2 to 16.6%), 2b (7.4 to 3.7%), 3 (18.5 to 27.7%), and 4 (51.8 to 44%). Conclusions. PBMP provided a rapid, inexpensive, simple, effective, and safe method of treating PB. [ABSTRACT FROM AUTHOR]

Background Optimizing patient management will reduce unnecessary vision loss in glaucoma through early detection. One method is the introduction of collaborative care schemes between optometrists and ophthalmologists. Design We conducted a retrospective study to evaluate the impact of the Centre for Eye Health ( CFEH) on glaucoma patient outcomes and management in primary optometric care. Participants Patients referred to CFEH by optometrists for a glaucoma assessment were eligible for this study if written consent was provided (500 participants were randomly chosen). Methods Clinical data were classified according to disease risk and implemented patient care and analysed against the original diagnosis and patient parameters, followed by statistical analysis. Main Outcome Measures Two main parameters were evaluated; suitable referral of patients for glaucoma condition assessment and appropriate implementation of follow-up care. Results The majority of patients referred for glaucoma assessment (86.2%) were classified as glaucoma suspects or likely to have glaucoma, indicating suitable referral of patients for a CFEH evaluation. Further, the involvement of CFEH resulted in a false positive rate of 7.8% for those patients who proceeded to ophthalmological care. However, long-term optometric patient care was not maintained for up to a third of primarily lower risk patients. Conclusions The investigated collaborative eye health-care model led to a substantial improvement in appropriate referrals of glaucoma patients to ophthalmologists and could be suitable for optimizing patient care and utilization of resources. Improvement in follow-up of patients by optometrists is required to minimize inappropriately discontinued patient care. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the use of pars plana needle aspiration of retrolenticular fluid in the immediate management of an acute intraoperative rock-hard eye syndrome (AIRES). Setting: Private practice, Sydney, Australia. Design: Retrospective case series. Methods: Data over an 18-month period were collected to evaluate efficacy, complications, and visual outcomes in patients who had pars plana needle aspiration for management of AIRES, which is an acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification cataract surgery but without evidence of a choroidal hemorrhage. Preoperative and postoperative (1 day, 1 week, and 1 month) data were evaluated. Resolution of AIRES and postoperative posterior segment status, IOP, and corrected distance visual acuity (CDVA) were the main outcome measures. Results: Acute intraoperative rock-hard eye syndrome occurred in 6 (1.45%) of 413 surgeries. All 6 patients were women with a mean age of 81 years. Four patients had dense nuclear cataracts. In each case, the anterior chamber depth and IOP normalized immediately after pars plana needle aspiration and the procedure concluded uneventfully. Mild vitreous hemorrhage was observed in 1 patient postoperatively. At 1 month, the IOP was normal in 5 of 6 cases, while the CDVA was 20/12 in 5 of 6 cases. Conclusion: Although the etiology of AIRES is iatrogenic, immediate resolution was achieved uneventfully with pars plana needle aspiration, which appears to be a safe management technique with satisfactory outcomes. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

A letter to the editor is presented related to the role of clear lens extraction in adult angle closure disease.

A letter to the editor is presented in response to the article "Novel grading system for pupillary ruff changes and associated features," by T. Wong and colleagues in the July 2012 issue.

The authors enjoyed the case report by Singh et al of a low-flow carotid cavernous fistula producing defective abduction in one eye.[1] 1 Singh S, Curragh DS, Davis G, Selva D. Persistent isolated abducens nerve palsy in a successfully embolized low-flow carotid cavernous fistula. [Extracted from the article]

We describe the use of a Steri-Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Hydrogel Sealant Versus Sutures to Prevent Fluid Egress After Cataract Surgery" in the 2016 issue.

A letter to the editor is presented related to the deficiency of carnitine palmitoyl transferase II with reference to normal pressure glaucoma.

A letter to the editor related to improved measurement of optic nerve height using red-free light in dynamic disc dimensioning is presented.