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A single-center prospective cohort study was conducted to investigate whether intraocular pressure (IOP)-related 24-h contact lens sensor (CLS) profile parameters can help predict glaucoma progression in patients with normal-tension glaucoma (NTG). CLS measurements (Triggerfish; SENSIMED, Etagnières, Switzerland) at baseline without medication were performed for 24 h in one eye, following diurnal IOP measurements using Goldmann applanation tonometry at 3-h intervals. Glaucoma progression during the follow-up period of ≥ 2 years was determined based on the Guided Progression Analysis of Humphrey visual fields and/or structural progression using fundus photographs. Among 79 patients (mean values: follow-up periods, 48.1 months; age, 51.5 years; baseline IOP, 14.0 mmHg; mean deviation, - 6.04 dB), 23 showed glaucoma progression. A smaller standard deviation of nocturnal ocular pulse amplitude in the CLS profile, a larger range of diurnal IOP at baseline, and the presence of optic disc hemorrhage (DH) during the study period were significant risk factors for glaucoma progression in the multivariate Cox proportional hazards model (hazard ratio, 0.30/mVeq, 1.23/mmHg, and 4.37/presence of DH; P = 0.016, 0.017, and 0.001, respectively). CLS measurements may be useful for assessing the risk of future glaucoma progression in patients with NTG, providing supplementary information to routine IOP measurements., (© 2024. The Author(s).)

Background/objectives: We aimed to measure cerebrospinal fluid (CSF) flow rates in the subarachnoid space (SAS) of the optic nerve (ON) by applying non-invasive diffusion-weighted MRI in patients with normal tension glaucoma (NTG) compared to age-matched controls., Subjects/methods: In this prospective study, an analysis of diffusion-weighted images of 26 patients with NTG (49ONs) and age-matched volunteers (52ONs) was conducted. Subjects were classified into 4 groups: group I (50-59 y., n = 12 eyes), group II (60-69 y., n = 16 eyes), group III (70-79 y., n = 18 eyes) and group IV ( > 80 y., n = 6 eyes) for NTGs and healthy volunteers, respectively. The flow-range ratio (FRR) between the frontal lobe SAS and the SAS of the ON was calculated for each age category group and then compared between age-categories as well as between NTGs and controls., Results: The mean FRR for age groups were (I) 0.54 ± 0.06 and 0.62 ± 0.03 (p < 0.05), (II) 0.56 ± 0.08 and 0.63 ± 0.03 (p < 0.05), (III) 0.54 ± 0.06 and 0.62 ± 0.02 (p < 0.001) as well as (IV) 0.61 ± 0.03 and 0.61 ± 0.04, for NTGs and controls, respectively. Using pooled data, the difference between the FRR in NTGs and controls was statistically significant (p < 0.0001). There were no statistically significant differences within the age categories of the control group. When comparing the FRR of NTGs by age categories, no statistically significant difference was found between the subgroups., Conclusions: FRR was significantly reduced in NTGs compared to age-matched controls without any significant differences within the age groups themselves. Given the physiological importance of CSF for the integrity of neurons, axons and glial cells, reduced CSF flow dynamics might be part of the underlying neurodegenerative process of NTG., (© 2024. The Author(s).)

Purpose: To observe the rate of progressive retinal nerve fiber layer (RNFL) thinning in the unaffected eyes of patients with unilateral normal-tension glaucoma (NTG), in comparison with that of healthy subjects, and to identify the factors associated with progressive RNFL thinning., Design: Retrospective, longitudinal, observational study., Participants: Ninety-five patients with unilateral NTG and 61 healthy controls., Methods: This study included unilateral NTG and healthy control subjects who were followed up for longer than 4 years and in whom at least 5 reliable retinal nerve fiber layer thickness (RNFLT) measurements were performed using OCT. Factors associated with the rate of thinning of the unaffected eyes of unilateral patients with NTG were identified using regression analysis., Main Outcome Measures: The rate of progressive RNFL thinning and the associated factors., Results: Retinal nerve fiber layer thickness decreased significantly in both the unaffected eyes of unilateral patients with NTG and the healthy eyes (both P < 0.001). The RNFL thinning was significantly faster in the unaffected eyes of unilateral patients with NTG than in the healthy eyes (P < 0.001), specifically in the temporal-inferior (TI) sector (P = 0.003). Factors associated with faster RNFL thinning in the unaffected eyes of unilateral patients with NTG were thicker baseline RNFL of the unaffected eyes (P = 0.002) and a worse visual field (VF) mean deviation (MD) in the NTG eyes (P = 0.040). In the healthy controls, the rate of RNFL thinning in the contralateral eyes was the only factor associated with faster thinning (P = 0.007)., Conclusions: The unaffected eyes of unilateral patients with NTG showed faster RNFL thinning than healthy control eyes, more obviously in the TI sector, and were likely to progress faster when they had a thicker baseline RNFL, and when the NTG eyes had a worse VF MD. In unilateral patients with NTG, initiation of prophylactic treatment could be considered for the unaffected eyes when they are accompanied by a risk of developing glaucoma., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: This systematic review and meta-analysis quantitatively examines the efficacy of angle-based minimally invasive glaucoma surgery (MIGS) in normal tension glaucoma (NTG)., Methods: A literature search was performed on Medline, Embase, PubMed, CINAHL and Cochrane Library from inception until 20 December 2022. Pilot, cohort, observational studies and randomised controlled trials including at least 5 subjects undergoing angle-based MIGS (trabecular-bypass devices, excisional trabeculotomy, goniotomy and ab-interno canaloplasty) for NTG, with or without cataract surgery, were included. Meta-analysis of continuous outcome using the meta routine in R version 2022.12.0+353 was performed to determine mean intraocular pressure (IOP) and anti-glaucoma medication (AGM) reduction post-operatively., Results: Of the 846 studies initially identified, 15 studies with a pooled total of 367 eyes which underwent combined phacoemulsification and angle-based MIGS were included for final meta-analysis. Outcomes of the iStent were reported in 5 studies, iStent inject in 7 studies, Hydrus Microstent in 1 study, Kahook Dual Blade in 3 studies, and Trabectome in 2 studies. There was significant reduction in both IOP and AGM post-operatively at 6 months (2.44 mmHg, 95%CI: 1.83-3.06; 1.21 AGM, 95%CI: 0.99-1.44), 12 months (2.28 mmHg, 95%CI: 1.71-2.84; 1.18 AGM, 95%CI: 0.90-1.47), 24 months (2.10 mmHg, 95%CI: 1.51-2.68; 1.26 AGM, 95%CI: 0.85-1.68) and 36 months (2.43 mmHg, 95%CI: 1.71-3.15, 0.87 AGM, 95%CI: 0.21-1.53) (all p < 0.05). Subgroup analysis on combined phacoemulsification-iStent inject surgery demonstrated a reduction in both IOP (2.31 mmHg, 95%CI: 1.07-3.56, p < 0.001) and AGM (1.07 AGM, 95%CI: 0.86-1.29, p < 0.001) at 12 months post-operatively., Conclusions: Angle-based MIGS combined with phacoemulsification effectively reduces IOP and AGM in NTG eyes for up to 36 months after surgery., (© 2024 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: To investigate the predictive capabilities of peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thinning to detect visual field (VF) progression in normal-tension glaucoma patients with an initial parafoveal scotoma (IPFS) or nasal step (INS)., Design: Retrospective cohort study., Methods: A total of 185 early-stage glaucoma eyes, followed for 10 years, were retrospectively stratified into IPFS and INS groups. Progressive pRNFL and mGCIPL thinning were assessed using spectral-domain optical coherence tomography and VF progression using both event- or trend-based analysis. Kaplan-Meier survival analysis compared VF survival in each VF phenotype with or without progressive pRNFL and mGCIPL thinning. Cox proportional regression analysis identified VF progression factors., Results: VF progression was detected in 42 IPFS (n = 86) and 47 INS (n = 99) eyes. Among VF progressors, pRNFL thinning was significantly faster in INS group compared to IPFS group (P < .01), while mGCIPL thinning was similar (P = .16). At 5 years, eyes with progressive mGCIPL thinning showed significantly lower VF survival in both VF phenotypes (all P < .05). Progressive pRNFL thinning showed significantly lower VF survival only in INS eyes (P = .015). Cox multivariate regression revealed that mGCIPL thinning predicted subsequent VF progression in IPFS eyes, while mGCIPL and pRNFL thinning had significant associations with VF progression in INS eyes., Conclusions: mGCIPL outperforms pRNFL at early follow-up in detecting VF progression in IPFS eyes but not INS eyes. Appropriate selection of structural parameters (mGCIPL vs. pRNFL) maximizes early VF progression detection according to initial VF defect location., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the structural, microvascular, and functional progression of normal tension glaucoma (NTG) with or without high myopia by examining longitudinal changes in optical coherence tomography angiography (OCTA) and visual field (VF) parameters., Methods: We evaluated 61 NTG eyes and classified 25 of the eyes with axial lengths (ALs) of ≥26 mm as highly myopic. We assessed the rate of change in OCTA parameters, namely radial peripapillary capillary (RPC) vessel density (VD), parafovea VD, deep parafovea VD, retinal nerve fibre layer (RNFL) thickness, and ganglion cell complex thickness. We evaluated the correlation of the rate of change in OCTA parameters with VF loss and AL., Results: Among the 61 NTG eyes, rates of loss of RPC VD, parafovea VD, deep parafovea VD, and RNFL thickness were significantly different from zero despite the nonsignificant rate of change in VF mean deviation (MD). Changes in these OCTA parameters did not differ significantly in highly myopic NTG eyes. The rate of change in VF MD was significantly correlated with the rate of change in parafovea VD in highly myopic and non-highly myopic NTG eyes. In highly myopic NTG eyes, AL was negatively correlated with the rates of loss of RNFL thickness, VF MD, and VF PSD., Conclusion: NTG eyes with a relatively stable VF exhibited loss of VD and RNFL thickness. VF progression in NTG was correlated with decreasing parafovea VD, indicating a structure-function correlation. Greater AL may indicate faster VF loss and RNFL thinning in highly myopic NTG eyes., (© 2024 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To explore the association between progressive peripapillary capillary vessel density (pcVD) reduction and the progression of visual field (VF) impairment in individuals with normal tension glaucoma (NTG)., Design: Prospective cohort study., Methods: The study enrolled 110 participants with one eye each, totalling 110 NTG eyes. VF defects were evaluated using standard automated perimetry mean deviation (MD), while pcVD measurements were obtained using optical coherence tomography angiography throughout the follow-up period. Estimates of VF progression were determined by event-based and trend-based analyses. Fast VF progression was defined as an MD slope steeper than -0.5 dB/year, while the slow progression or stable VF was defined as an MD slope better or equal to -0.25 dB/year. Linear mixed-effects models were employed to analyse the rates of change in pcVD reduction and VF MD decline over time. Additionally, univariable and multivariable linear models were used to examine the relationship between pcVD changes and VF loss rates in NTG., Results: Slow VF progression or stable VF was observed in 45% of subjects, while 25% had moderate progression and 30% showed fast progression. Patients with VF progression exhibited faster rate of pcVD reduction in peripapillary global region (-0.73 ± 0.40%/year vs. -0.56 ± 0.35%/year, p = 0.022). Moreover, this rate positively correlated with VF MD decline in NTG (estimate 0.278, 95% CI 0.122-0.433, p = 0.001)., Conclusion: In individuals with NTG, faster VF progression was linked to a quicker reduction in pcVD, suggesting a positive correlation between pcVD decline and VF deterioration., (© 2024 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Optineurin (OPTN) is a gene associated with familial normal tension glaucoma (NTG). While NTG involves intraocular pressure (IOP)-independent neurodegeneration of the visual pathway that progresses with age, how OPTN dysfunction leads to NTG remains unclear. Here, we generated an OPTN knockout mouse (Optn -/ - ) model to test the hypothesis that a loss-of-function mechanism induces structural and functional eye deterioration with aging. Eye anatomy, visual function, IOP, retinal histology, and retinal ganglion cell survival were compared to littermate wild-type (WT) control mice. Consistent with OPTN's role in NTG, loss of OPTN did not increase IOP or alter gross eye anatomy in young (2-3 months) or aged (12 months) mice. When retinal layers were quantitated, young Optn -/ - mice had thinner retina in the peripheral regions than young WT mice, primarily due to thinner ganglion cell-inner plexiform layers. Despite this, visual function in Optn -/ - mice was not severely impaired, even with aging. We also assessed relative abundance of retinal cell subtypes, including amacrine cells, bipolar cells, cone photoreceptors, microglia, and astrocytes. While many of these cellular subtypes were unaffected by Optn deletion, more dopaminergic amacrine cells were observed in aged Optn -/ - mice. Taken together, our findings showed that complete loss of Optn resulted in mild retinal changes and less visual function impairment, supporting the possibility that OPTN-associated glaucoma does not result from a loss-of-function disease mechanism. Further research using these Optn mice will elucidate detailed molecular pathways involved in NTG and identify clinical or environmental risk factors that can be targeted for glaucoma treatment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Topic: To investigate differences in peripapillary choroidal thickness (PPCT) between primary open-angle glaucoma (POAG), normal tension glaucoma (NTG), and healthy eyes, additionally comparing differences between POAG and NTG eyes., Clinical Relevance: Peripapillary choroidal thickness is a well-established OCT parameter in eyes with glaucoma and other ocular pathologies. The relationship between PPCT and glaucoma, if better understood, may facilitate the development of PPCT as a potential diagnostic and monitoring metric for glaucoma. In particular, there has yet to be a synthesis that directly compares PPCT between POAG eyes and NTG eyes., Methods: A comprehensive literature search was performed on PubMed, EMBASE, and Cochrane Library, identifying studies from inception to December 2022. We included studies that measured PPCT using OCT in POAG, NTG, and healthy eyes. Mean difference (MD) among groups was calculated. Statistical analysis was performed using R version 4.2.0. Risk of bias of included studies was assessed using the Newcastle Ottawa Scale (NOS)., Results: Eighteen studies were included in this meta-analysis, with a pooled total of 935 healthy control eyes, 446 NTG eyes, and 934 POAG eyes. There was a significant reduction of PPCT in POAG eyes compared with healthy eyes [MD = -16.32; 95% confidence interval (CI) (-27.55 to -5.09)]. Reduction in PPCT was also significant in NTG eyes compared with healthy eyes [MD = -34.96; 95% CI (-49.97 to -19.95)]. NTG eyes had significantly reduced PPCT compared with POAG eyes [MD = -26.64; 95% CI (-49.00 to -4.28)]., Conclusions: Glaucomatous eyes appear to have significantly reduced PPCT compared with normal healthy eyes. In addition, PPCT in NTG eyes appear significantly thinner compared with that in POAG eyes., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Equol is metabolized by intestinal bacteria from soy isoflavones and is chemically similar to estrogen. Dietary habits, such as consumption of soy products, influence equol production. A relationship between glaucoma and estrogen has been identified; here, we investigated the relationship between equol production status and glaucoma in Japan., Methods: We recruited 68 normal-tension glaucoma (NTG) patients (male to female ratio 26:42, average age 63.0 ± 7.6 years) and 31 controls (male to female ratio 13:18, average age 66.0 ± 6.3 years) from our hospital. All women included were postmenopausal. Urinary equol concentration was quantified with the ELISA method. MD was calculated based on the Humphrey visual field. The association between MD and equol was analyzed with Spearman's rank correlation coefficient. The Mann-Whitney U test was used to compare the equol-producing (> 1 μM) and non-producing (< 1 μM) subjects. We also investigated the association between equol and glaucoma with a logistic regression analysis., Results: There was a significant association between equol and MD (r = 0.36, P < 0.01) in the NTG patients. Glaucoma, represented by MD, was significantly milder in the equol-producing subjects than the non-equol producing subjects (P = 0.03). A multivariate analysis revealed the independent contributions of equol, cpRNFLT, and IOP to MD (P = 0.03, P = 0.04, and P < 0.01, respectively)., Conclusion: Our results suggest that equol, acting through estrogen receptor-mediated neuroprotective effects, might be involved in suppressing the progression of NTG. This result also adds to evidence that glaucoma may be influenced by lifestyle., (© 2024. The Author(s).)

Background: Minimally invasive bleb surgery using the XEN-45 gel stent has not been established for the treatment of normal-tension glaucoma (NTG). The main objective of this study was to evaluate the long-term treatment efficacy and safety of XEN-45 in eyes with uncontrolled NTG., Methods: A retrospective analysis of patients with NTG who underwent XEN-45 gel stent implantation at university hospital Tuebingen between 2016 and 2021. The primary outcome measure was surgical success after three years defined as lowering of intraocular pressure (IOP) of ≥ 20%, with target IOP between 6 and 15 mmHg. Success was complete without and qualified irrespective of topical antiglaucoma medication use. The need for further glaucoma surgery, except for needling, was regarded as a failure. The secondary outcome measures included changes in mean IOP, number of antiglaucoma medications, and needling and complication rates., Results: Twenty-eight eyes from 23 patients were included in the final analysis. Complete and qualified success rates were 56.5% and 75% after three years, respectively. Mean postoperative IOP ± standard deviation decreased significantly after three years from 19.3 ± 2.0 mmHg at baseline to 13.7 ± 4.2 mmHg (n = 22; p < 0.0001). The median number of antiglaucoma medications decreased from 2 (range 0-4) to 0 after three years (range 0-3; p < 0.0001). Sixteen eyes (57%) required a median of 1 (range 1-3) needling procedures. One eye required further glaucoma surgery. No sight-threatening complications were observed., Conclusion: The XEN-45 stent is effective and safe for the long-term treatment of NTG. However, needling was frequently required to improve outcomes., (© 2024. The Author(s).)

Background/aims: To assess the performance of deep-learning (DL) models for prediction of conversion to normal-tension glaucoma (NTG) in normotensive glaucoma suspect (GS) patients., Methods: Datasets of 12 458 GS eyes were reviewed. Two hundred and ten eyes (105 eyes showing NTG conversion and 105 without conversion), followed up for a minimum of 7 years during which intraocular pressure (IOP) was lower than 21 mm Hg, were included. The features of two fundus images (optic disc photography and red-free retinal nerve fibre layer (RNFL) photography) were extracted by convolutional auto encoder. The extracted features as well as 15 clinical features including age, sex, IOP, spherical equivalent, central corneal thickness, axial length, average circumpapillary RNFL thickness, systolic/diastolic blood pressure and body mass index were used to predict NTG conversion. Prediction was performed using three machine-learning classifiers (ie, XGBoost, Random Forest, Gradient Boosting) with different feature combinations., Results: All three algorithms achieved high diagnostic accuracy for NTG conversion prediction. The AUCs ranged from 0.987 (95% CI 0.978 to 1.000; Random Forest trained with both fundus images and clinical features) and 0.994 (95% CI 0.984 to 1.000; XGBoost trained with both fundus images and clinical features). XGBoost showed the best prediction performance for time to NTG conversion (mean squared error, 2.24). The top three important clinical features for time-to-conversion prediction were baseline IOP, diastolic blood pressure and average circumpapillary RNFL thickness., Conclusion: DL models, trained with both fundus images and clinical data, showed the potential to predict whether and when normotensive GS patients will show conversion to NTG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Backgroud: The aim of this study was to investigate the associations between fluctuation in blood pressure (BP), ocular perfusion pressure (OPP) and visual field (VF) progression in normal-tension glaucoma (NTG)., Methods: This prospective, longitudinal study included 44 patients with NTG. Only newly diagnosed NTG patients who had not been treated with a glaucoma medication were included. Patients were examined every year for 7 years. Intraocular pressure (IOP), heart rate (HR), systolic BP (SBP), diastolic BP (DBP), ocular perfusion pressure (OPP), and diastolic ocular perfusion pressure (DOPP) were measured at the same time. Ophthalmic examinations, including perimetry, were performed also. Initial VF were compared with follow-up data after 7 years., Results: After 7 years of follow-up, 9 of the 44 patients showed VF progression. The standard deviation (SD) of SBP and OPP were significantly associated with VF progression (P = 0.007, < 0.001, respectively). Multiple regression analysis showed that VF progression was significantly associated with SD of OPP (odds ratio, OR = 2.012, 95% CI = 1.016-3.985; P = 0.045)., Conclusions: Fluctuation in OPP was associated with VF progression in patients with NTG., (© 2024. The Author(s).)

Purpose: To retrospectively evaluate the 3-year efficacy and safety of single-agent omidenepag isopropyl in patients with normal tension glaucoma (NTG)., Study Design: Retrospective., Methods: One hundred patients (100 eyes) who had newly been administered omidenepag isopropyl were enrolled in this study. Intraocular pressure (IOP) was compared at baseline and 6, 9, 12, 18, 24, 30, and 36 months after administration. The mean deviation values at baseline and 12, 24, and 36 months measured using the Humphrey visual field test (30-2 Swedish Interactive Threshold Algorithm standard) were compared. Adverse reactions and dropouts were assessed., Results: IOP significantly decreased from 15.5±2.7 mmHg at baseline to 13.8 ±2.3 mmHg after 6 months, 13.9± 2.3 mmHg after 12 months, 13.9±2.3 mmHg after 18 months, 13.8±2.1 mmHg after 24 months, 13.9±2.0 mmHg after 30 months, and 13.6±1.7 mmHg after 36 months (P < 0.0001). There was no significant difference in the mean deviation values at baseline (-3.66±3.49 dB), 12 months (-3.41±3.80 dB), 24 months (-3.13±3.81 dB), and 36 months (-3.06±3.30 dB). Adverse reactions occurred in 11 patients (11.0%), including conjunctival hyperemia in 6 patients. Fifty-two patients (52.0%) were excluded from the analysis because they discontinued treatment either due to IOP measurement by NCT or the use of additional drugs., Conclusion: After the administration of omidenepag isopropyl, IOP in patients with NTG decreased within 3 years, visual fields were maintained, and safety was satisfactory. Thus, omidenepag isopropyl can be used as the first-line treatment for patients with NTG., (© 2024. Japanese Ophthalmological Society.)

Objectives: To review the current literature related to the correlation between translaminar pressure difference (TLPD) and glaucoma., Materials and Methods: In this article, we conducted a literature review using MEDLINE via PubMed, Cochrane Eyes and Vision, and Google Scholar from 01/01/2010 to 31/12/2022. Search terms included "glaucoma", "intraocular pressure", "translaminar cribrosa pressure gradient/difference", "intracranial pressure", and "cerebrospinal fluid pressure". Of 471 results, 8 articles were selected for the meta-analysis., Results: Our meta-analysis demonstrated significantly higher intraocular pressure, lower cerebrospinal fluid pressure (CSFp), and greater TLPD in high-tension and normal-tension glaucoma groups compared to healthy groups., Conclusion: The differences in CSFp and TLPD between glaucoma and healthy people detected in current studies suggests a potential relationship between TLPD and glaucoma., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

Purpose: Many studies have examined the ocular pulse amplitude (OPA) to better understand its physiology and clinical relevance, but the papers are scattered, not consistently indexed, and sometimes difficult to locate. We aimed to identify and summarize the relevant published evidence on OPA and, in a meta-analysis, outline specific differences of this parameter between healthy individual, primary open-angle glaucoma, normal-tension glaucoma, ocular hypertension, and cataract patients., Design: Systematic review and meta-analysis., Methods: A thorough literature search and data extraction were conducted by 2 reviewers independently. Reports on OPA measured by the dynamic contour tonometry in conjunction with different ocular and systemic diseases or potential influencing factors were included., Results: Of the 527 initially found reports, 97 met the inclusion criteria assessing 31 clinical conditions. A meta-analysis based on 6850 eyes and 106 study arms (68.8%) revealed differences in mean OPA values in millimeters of mercury between various entities. Among healthy eyes, the OPA was 2.58 mm Hg (95% CI: 2.45-2.71), whereas OPA values were higher in glaucoma (unspecified glaucoma 2.73 mm Hg, 95% CI: 2.38-3.08; normal-tension glaucoma 2.66 mm Hg, 95% CI: 2.36-2.97; and primary open-angle glaucoma 2.92 mm Hg, 95% CI: 2.75-3.08). Although ocular hypertension showed the highest OPA values (3.53 mm Hg, 95% CI: 3.05-4.01), the lowest values were found in cataract eyes (2.26 mm Hg, 95% CI: 1.57-2.94)., Conclusion: We found different OPA values characteristic of different clinical entities, with above-normal values in glaucoma and ocular hypertension and lower values in cataract patients. Our work is intended for clinicians and researchers who want to get a quick overview of the available evidence or who need statistical data on OPA distributions in individual diseases., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to investigate whether the lamina cribrosa (LC) curve changes in response to intraocular pressure (IOP) reduction following administration of topical ocular hypotensive eye drops in eyes with normal tension glaucoma (NTG)., Methods: Ninety-three eyes of 93 patients with treatment naïve NTG at initial examination and with ≥20% reduction from baseline IOP following administration of topical ocular hypotensive eye drops were included. Serial horizontal B-scan images of the optic nerve head (ONH) were obtained from each eye using enhanced depth imaging spectral domain optical coherence tomography (OCT) before and 1 year after IOP-lowering treatment. The LC curvature in each eye was assessed by measuring the LC curvature index (LCCI) in horizontal OCT B-scan images obtained at three (superior, central, and inferior) locations spaced equidistantly across the vertical optic disc diameter before and after IOP-lowering treatment. We evaluated the OCT detectible change in the LC curvature based on the interval change of LCCI to exceed the intersession standard deviation of 1.96 times and factors associated with the magnitude of the LCCI change in the eyes showing significant LC change., Results: IOP decreased from 15.7 ± 2.5 mm Hg at baseline to 11.2 ± 1.7 mm Hg after topical glaucoma medication. Among the 93 subjects, 62 (66.7%) eyes showed the significant reduction of the LCCI (interssetional change over 1.5) after the treatment; greater interssessional change of the LCCI after IOP reduction was associated with younger age (P = 0.020) and larger baseline LCCI (P < 0.001)., Conclusions: The OCT detectible changes in LC curvature occurred in response to a modest decrease in the IOP in the naïve NTG eyes. The therapeutic benefit of these changes need to be assessed in longitudinal studies.

Purpose: This study aimed to investigate the effect of nimodipine on peripapillary and macular capillary vessel density (VD) in patients with normal-tension glaucoma (NTG) using optical coherence tomography angiography (OCTA)., Methods: Sixty mg nimodipine was administered to 20 enrolled NTG patients for 3 months. Patients were treated with glaucoma medication simultaneously. The macular and peripapillary VD were measured automatically by OCTA at baseline, 1.5 h after administering nimodipine, and after 3 months of administering the drug. The retinal nerve fibre layer (RNFL), ganglion cell complex thickness, visual field (VF) testing, intraocular pressure (IOP), blood pressure and pulse rate in each subject were assessed during each follow-up., Results: Compared with the baseline, the parafovea VD was higher (50.89 ± 4.26 versus 46.80 ± 5.40, P = .044) 1.5 h after administration of nimodipine. After administration of nimodipine for 3 months, the parafovea VD was obviously increased (51.14 ± 5.68 versus 46.80 ± 5.40, P = .039), while IOP, systolic blood pressure, mean arterial pressure and mean ocular perfusion pressure were decreased compared to baseline (all P < .05). No significant differences were found between the radial peripapillary capillary and disc VD. The parafovea VD was positively correlated with the administration of nimodipine (β = 0.39, P = .004), RNFL thickness (β = 0.49, P = .022), and VF mean deviation (β = 0.4, P = .040) in the multivariate analysis., Conclusions: Nimodipine effectively increased superficial macular capillary VD, but did not affect peripapillary capillary VD in patients with NTG. This finding indicates that patients with NTG may benefit from the administration of nimodipine.

The visual acuity is very important for glaucoma patients in their lives. The purpose of this study was to examine about the correlation of visual acuity and visual field (VF) parameters or optical coherence tomography (OCT) parameters in patients with glaucoma. We evaluated 210 eyes of 210 patients (110 men and 100 women; mean age, 69.6 ± 9.6 years) with open-angle glaucoma and 68 eyes of healthy controls. In glaucomatous eyes including healthy eyes, correlation between visual acuity and each of the VF parameters or each of the OCT parameters was estimated using regression analyses. The average visual acuity of control group was - 0.08, and that of glaucoma group was - 0.06 (early stage), - 0.03 (moderate stage), and 0.08 (severe stage), respectively. Regression analyses including healthy eyes and glaucomatous eyes revealed significant correlations between visual acuity and mean deviation (MD) of 30-2 Humphrey VF ( rs  = - 0.44), MD of 10-2 VF ( rs  = - 0.45), total deviation in central 10-2 VF ( rs  = - 0.42), ganglion cell complex thickness (macula, rs  = - 0.33; superior, rs  = - 0.33; inferior, rs  = - 0.35; and global, rs  = - 0.34), and circumpapillary retinal nerve fiber layer ( rs  = - 0.38). The visual acuity of glaucomatous eyes correlated with VF parameters and OCT parameters. The visual acuity decreased as glaucoma progressed.

Purpose : Maintaining visual acuity in glaucoma patients is an important part of preventing the deterioration of quality of vision. We identified specific areas of the papillomacular bundle (PMB) that were strongly associated with visual acuity, based on en-face images derived from optical coherence topography (OCT) wide scans. Methods : The study recruited 23 eyes of 21 glaucoma patients (age: 61.3 ± 13.0 years, M: F = 9:12, Humphrey field analyzer-measured mean deviation: -19.9 ± 6.5 dB) with good best-corrected visual acuity (20/20 or more) and a remaining PMB with a maximum width no more than half that of the vertical disc diameter. En-face images were derived from 12 × 9 mm wide-scan images made with DRI-OCT (Triton, Topcon). Averaged en-face images were created by identifying the disc center and fovea line (DFL) and aligning it between images. We then measured the frequency of remaining PMB at 10 µm intervals along a vertical line intersecting the DFL at its midpoint. Finally, we used a logistic analysis in a much larger group of patients to identify cases of glaucoma with low BCVA (<20/20). Results : In the averaged en-face image, the residual PMB area appeared as a high-intensity region above the DFL. Analysis showed that residual PMB was most common in an area 830-870 µm above the DFL. The correlation coefficient of residual PMB in this area to BCVA was -0.57 ( p < .01), and among OCT parameters in this residual PMB area, the AUC to identify decreased BCVA was highest for ganglion cell complex thickness (0.85, p < .01), with a cutoff of 87.5 µm. Conclusions : This study identified specific areas of the PMB that were associated with BCVA in wide-scan, en-face OCT images from glaucoma patients. This suggests that it may be possible to identify visual impairment during glaucoma treatment by measuring this area.

This study investigated the predicted risk factors for the development of normal-tension glaucoma (NTG) in NTG suspects. A total of 684 eyes of 379 NTG suspects who were followed-up for at least 5 years were included in the study. NTG suspects were those having (1) intraocular pressure within normal range, (2) suspicious optic disc (neuroretinal rim thinning) or enlarged cup-to-disc ratio (≥ 0.6), but without definite localized retinal nerve fiber layer (RNFL) defects on red-free disc/fundus photographs, and (3) normal visual field (VF). Demographic, systemic, and ocular characteristics were determined at the time of the first visit via detailed history-taking and examination of past medical records. Various ocular parameters were assess using spectral-domain optical coherence tomography and Heidelberg retinal tomography. Conversion to NTG was defined either by the presence of a new localized RNFL defect at the superotemporal or inferotemporal region on disc/fundus red-free photographs, or presence of a glaucomatous VF defect on pattern standard deviation plots on two consecutive tests. Hazard ratios were calculated with the Cox proportional hazard model. In total, 86 (12.6%) of the 684 NTG suspects converted to NTG during the follow-up period of 69.39 ± 7.77 months. Significant (P < 0.05, Cox regression) risk factors included medication for systemic hypertension, longer axial length, worse baseline VF parameters, thinner baseline peripapillary RNFL, greater disc torsion, and lamina cribrosa (LC) thickness < 180.5 μm (using a cut-off value obtained by regression analysis). Significant (P < 0.05, Cox regression) risk factors in the non-myopic NTG suspects included medication for systemic hypertension and a LC thinner than the cut-off value. Significant (P < 0.05, Cox regression) risk factors in the myopic NTG suspects included greater disc torsion. The results indicated that 12.6% of NTG suspects converted to NTG during the 5-6-year follow-up period. NTG suspects taking medication for systemic hypertension, disc torsion of the optic disc in the inferotemporal direction, and thinner LC of the optic nerve head at baseline were at greater risk of NTG conversion. Related baseline risk factors were different between myopic and non-myopic NTG suspects., (© 2021. The Author(s).)

Purpose: To investigate the relationship between pulse wave velocity (PWV) and retinal vessel density (VD) measured by optical coherence tomography angiography (OCTA) in patients with normal-tension glaucoma (NTG)., Methods: This retrospective study included 103 patients with NTG and 109 healthy controls who underwent glaucoma examination and PWV measurements. Each group was classified into two subgroups according to a brachial-ankle PWV of 1400 cm/s. NTG was diagnosed when the maximum untreated intraocular pressure was < 21 mmHg on three repeated measurements obtained at different times in the presence of glaucomatous optic discs (neuroretinal rim thinning and excavation), peripapillary retinal nerve fiber layer defects, and glaucomatous visual field defects. Healthy controls did not have glaucomatous optic discs or visual field defects and exhibited normal retinal nerve fiber layer thickness. The interval between glaucoma examination and PWV measurements did not exceed six months. Univariate and multivariate logistic regression analyses were performed to identify factors associated with high PWV., Results: PWV was higher in the NTG group than in the control group, while peripapillary VD and macular VD (mVD) were lower (all P < 0.05). Stepwise logistic regression analysis revealed that high PWV was significantly associated with age, mean arterial pressure (MAP), and mVD in the NTG group. Meanwhile, high PWV was significantly associated with age, MAP, and low-density lipoprotein cholesterol levels in healthy controls., Conclusions: High PWV is associated with decreased mVD in NTG patients, suggesting that systemic arterial stiffness might be involved in the pathogenesis of NTG.

Purpose: To examine feasibility of phase-contrast magnetic resonance imaging (PCMRI) and to assess blood flow rate in the ophthalmic artery (OA) in patients with normal tension glaucoma (NTG) compared with healthy controls., Methods: Sixteen patients with treated NTG and 16 age- and sex-matched healthy controls underwent PCMRI using a 3-Tesla scanner and ophthalmological examinations. OA blood flow rate was measured using a 2D PCMRI sequence with a spatial resolution of 0.35 mm 2 ., Results: The blood flow rate in the NTG group was 9.6 ± 3.9 ml/min [mean ± SD] compared with 11.9 ± 4.8 ml/min in the control group. Resistance Index (RI) and Pulsatility Index (PI) were 0.73 ± 0.08 and 1.36 ± 0.29, respectively, in the NTG group and 0.68 ± 0.13 and 1.22 ± 0.40, respectively, in the healthy group. The mean visual field index (VFI) was 46% ± 25 for the worse NTG eyes. The measured differences observed between the NTG group and the control group in blood flow rate (p = 0.12), RI (p = 0.18) and PI (p = 0.27) were non-significant., Conclusions: This case-control study, using PCMRI, showed a slight, but non-significant, reduction in OA blood flow rate in the NTG patients compared with the healthy controls. These results indicate that blood flow may be of importance in the pathogenesis of NTG. Considering that only a limited portion of the total OA blood flow supplies the ocular system and the large inter-individual differences, a larger study or more advanced PCMRI technique might give the answer., (© 2020 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To investigate whether the position of the central retinal vascular trunk (CRVT), as a surrogate of lamina cribrosa (LC) offset, was associated with the presence of glaucoma in normal-tension glaucoma (NTG) patients., Methods: The position of the CRVT was measured as the deviation from the center of the Bruch's membrane opening (BMO), as delineated by spectral-domain optical coherence tomography imaging. The offset index was calculated as the distance of the CRVT from the BMO center relative to that of the BMO margin. The angular deviation of CRVT was measured with the horizontal nasal midline as 0° and the superior location as a positive value. The offset index and angular deviation were compared between glaucoma and fellow control eyes within individuals., Results: NTG eyes had higher baseline intraocular pressure (P = 0.001), a larger β-zone parapapillary atrophy area (P = 0.013), and a larger offset index (P<0.001). In a generalized linear mixed-effects model, larger offset index was the only risk factor of NTG diagnosis (OR = 31.625, P<0.001). A generalized estimating equation regression model revealed that the offset index was larger in the NTG eyes than in the control eyes for all ranges of axial length, while it was the smallest for the axial length of 23.4 mm (all P<0.001)., Conclusions: The offset index was larger in the unilateral NTG eyes, which fact is suggestive of the potential role of LC/BMO offset as a loco-regional susceptibility factor., Competing Interests: The authors have declared that no competing interests exist.

Direct comparison data on spatial patterns of visual field (VF) defects among primary angle-closure glaucoma (PACG), high-tension glaucoma (HTG) and normal-tension glaucoma (NTG) are not available. We aimed to compare the intraocular asymmetry of VF loss among patients with PACG, NTG and HTG across different severity levels. A total of 162 eyes of 114 patients with PACG, 111 eyes of 74 patients with HTG and 148 eyes of 102 patients with NTG were included. VF defects were categorized into 3 stages (early, moderate, and advanced), and each hemifield was divided into 5 regions according to the Glaucoma hemifield test (GHT). The mean total deviation (TD) of each GHT region was calculated. In the early stage, the paracentral, peripheral arcuate 1 and peripheral arcuate 2 regions in the superior hemifield in the NTG group had significantly worse mean TDs than their corresponding regions in the inferior hemifield. In the advanced stage, the central region in the superior hemifield in the PACG group had a significantly worse mean TD than that in the inferior hemifield. There was no significant difference in the mean TD for any of the five regions between hemifields across all severity levels in the in the HTG group. The superior hemifield was affected more severely than the inferior hemifield in all three subtypes of primary glaucoma. This asymmetric tendency was more pronounced in NTG than in PACG and HTG.

We investigated the characteristics of localized vessel density defects (VD) either in the deep or superficial vascular layer of normal-tension glaucoma patients using optical coherence tomography angiography (OCTA). In this retrospective, cross-sectional study, 74 eyes with localized retinal nerve fiber layer (RNFL) defect were included. The relationships between the widths of the VD in the superficial and deep layer and ocular factors were evaluated. Eyes with greater deep VD were significantly older (P = 0.023). The IOP measured at OCTA exam was significantly related to the width of the deep VD (P = 0.009). By contrast, average ganglion cell inner plexiform layer thickness (GCIPLT) was substantially related to the width of the superficial VD (P = 0.004). In logistic regression analysis, aging was noticeably associated with wider deep VD, whereas worse mean deviation (MD) had a significant association with wider superficial VD (P = 0.001, P = 0.003, respectively). In sum, while changes of the superficial layer seemed an overall ramification of glaucomatous damages, the deep layer was more likely to be affected by factors related to ocular microcirculation, such as IOPs and older age. Thus, looking into the deep vascular layer using OCTA could identify risk factors related to the disturbance in ocular microcirculation.

Background/aims: To investigate whether the association of long-term intraocular pressure (IOP) fluctuation with the rate of progression of normal-tension glaucoma (NTG) differs between myopia and non-myopia., Methods: The medical records of 65 myopic NTG (axial length (AL) > 24.0 mm) and 64 non-myopic NTG eyes (AL < 24.0 mm), who had been treated with topical medications for more than 5 years, were reviewed. Multiple linear regression models were fitted to analyse the relationships of the slope of mean deviation (MD) or visual field index (VFI) with the clinical factors, including the interactions with myopia., Results: The average follow-up period was 8.3 years. Twenty-two (22) non-myopic eyes (34.4%) and 27 myopic eyes (41.5%) showed NTG progression (p=0.511). The interaction of myopia with IOP fluctuation was a significant factor regarding both MD and VFI slope (p=0.002, 0.024, respectively); stratified analyses suggested that the risk effect of IOP fluctuation was significant only in myopic NTG in terms of both MD (β= -1.27, p=0.003) and VFI slope (β=-2.32, p=0.011)., Conclusion: Long-term IOP fluctuation was significantly related to faster visual field progression in myopic NTG eyes, compared with non-myopic NTG eyes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

This study assesses the safety and efficacy of microinvasive glaucoma surgery (MIGS) with cataract extraction in patients with normal-tension glaucoma (NTG). In our sample of 45 NTG patients, mean intraocular pressure (IOP) decreased from 13.7 to 12.3 mmHg at 2.5 years, and mean medication burden decreased from 2.0 to 1.1 at 1.5 years. For success defined as IOP reduction ≥ 30% from baseline IOP with medication burden reduction from preoperative levels, success probability was 5.4% at 1.5 years. For success defined as medication burden reduction with an IOP reaching goal IOP as determined by the glaucoma specialist, success probabilities were 67.2% at 1.5 years and 29.4% at 2.5 years. At the last follow-up visit, eyes with two MIGS procedures with different mechanisms of action achieved successful medication reduction 68.8% of the time versus 35.7% achieved by a single MIGS procedure (p = 0.052). At their last visit, visual acuity was unchanged or improved in all eyes (100%). MIGS with cataract surgery results in modest reductions in IOP and medication burden in NTG patients, which may lead to lower costs and better therapeutic compliance. A combination of two MIGS procedures with different mechanisms of action may potentially be more effective in reducing medication burden than a single MIGS procedure in NTG patients. Further research is necessary to ascertain whether MIGS for NTG patients may help decrease medication burden while helping achieve goal IOP.

Purpose: To investigate the association between peripheral vasospasm and the visual field (VF) progression rate in patients with normal-tension glaucoma (NTG) with low-teen intraocular pressure (IOP)., Methods: The finger temperature of 113 NTG patients was measured before and after exposure to ice water using a Temperature gun (cold pressor test). These patients had confirmed VF progression, despite a low-teen IOP during a follow-up period of >5 years. VF progression rates were calculated as the slope of the visual field index (VFI) and mean deviation (MD) over time. Demographic, systemic, and ocular factors and VF progression rates were compared, based on the cold pressor test results. A regression analysis was used to investigate the factors affecting VF progression rates., Results: Mean age, initial IOP, mean IOP during the follow-up period, and initial VF MD were 57.1 years, 15.8 mmHg, 12.0 mmHg, and -5.2 dB, respectively. When patients were divided into two groups (less vasospasm and more vasospasm) according to changes in temperature after exposure to ice water, the VF progression rate was significantly faster in the group with more vasospasm. In a multiple regression analysis, older age, worse initial VF MD, and greater decrease in finger temperature after ice water exposure were significantly associated with faster VF progression rates., Conclusion: An excessive drop in finger temperature after exposure to ice water was significantly associated with faster VF progression in patients with low-teen NTG. This suggests that the blood flow in the optic nerve head may also be disturbed by peripheral vasospasm, accelerating glaucomatous damage regardless of IOP., Competing Interests: The authors have declared that no competing interests exist.

Background: We know little about the changes of brain activity in patients with normal-tension glaucoma (NTG)., Purpose: To investigate the altered spontaneous brain activity in patients with NTG through the resting state functional magnetic resonance imaging-fractional amplitude of low-frequency fluctuation (rsfMRI-fALFF) technique, and to explore the relationship with optical coherence tomography (OCT) and field of vision., Material and Methods: Twenty patients with NTG and 20 healthy controls (HCs) (matched for sex, age, and level of education) were enrolled. Spontaneous cerebral activity variations were investigated using the rsfMRI-fALFF technique in all individuals. The average fALFF values of patients with NTG and HCs were compared., Results: Compared with HCs, patients with NTG had significantly lower fALFF values in the right angular gyrus and precuneus; however, higher fALFF values in the brain regions were not observed. The values showed statistically significant negative correlation with those of the retinal nerve fiber layer (right angular gyrus: r = -0.607, P  = 0.010; right precuneus: r = -0.504, P  = 0.020). There was no significant correlation between the fALFF value and cup-disc ratio (right angular gyrus: r = 0.158, P  = 0.494; right precuneus: r = -0.087, P  = 0.706), mean deviation (right angular gyrus: r = 0.096, P  = 0.468; right precuneus: r = 0.026, P  = 0.845), and pattern SD value (right angular gyrus: r = 0.064, P  = 0.626; right precuneus: r = -0.145, P  = 0.268)., Conclusion: Abnormal spontaneous activities were detected in numerous brain regions of patients with NTG, which may provide useful information for understanding the dysfunction in NTG. These activity changes in brain regions may be used as effective clinical indicators for NTG.

Choroidal microvasculature dropout (CMvD) implies compromised optic nerve head perfusion in glaucoma patients. However, there are conflicting findings whether office-hour systemic blood pressure (BP) is related to the presence of CMvD. The present study investigated which systemic BP parameters, derived from 24-h ambulatory BP monitoring (ABPM), are associated with CMvD as assessed by optical coherence tomography angiography (OCT-A) in normal-tension glaucoma (NTG). This study included 88 eyes of 88 NTG patients who underwent 24-h ABPM and OCT-A imaging. Various systemic BP parameters associated with the presence of CMvD were evaluated using logistic regression analyses. CMvD was detected in 38 NTG eyes (43.2%). NTG eyes with CMvD had nighttime diastolic BP (DBP) dip of greater magnitude and longer duration than eyes without CMvD. In multivariate logistic regression, worse VF mean deviation (MD) (odds ratio [OR] 0.786; P = 0.001), greater nighttime DBP dip "%" (OR 1.051; P = 0.034), and higher daytime peak IOP (OR 1.459; P = 0.013) were significantly associated with the presence of CMvD. Based on our findings that the eyes with CMvD are closely associated with having nighttime DBP dip, NTG patients with CMvD should be recommended to undergo 24-h ABPM.

Aims: To evaluate the associations between retinal blood flow (RBF) and optical coherence tomography (OCT) structural measurements in normal-tension glaucoma (NTG) eyes with single-hemifield visual field (VF) damage by the Doppler OCT., Methods: The Doppler OCT was used to measure temporal artery (TA) RBF and temporal vein (TV) RBF. Retinal nerve fibre layer thickness (RNFLT) was measured by spectral-domain OCT., Results: Forty-three consecutive eyes of 43 patients with NTG with VF defect confined to a single hemifield and 24 eyes of 24 age-matched healthy subjects were studied. TA and TV RBF and RNFLT were reduced in the damaged hemisphere compared with the normal hemisphere (mean (SD), 3.61 (1.68) vs 5.86 (2.59) µL/min, p<0.001; 5.61 (2.51) vs 6.94 (2.83) µL/min, p=0.010; 69.0 (19.7) vs 99.7 (22.8) µm, p<0.001). Those values in the normal hemisphere of NTG eyes also decreased compared with the healthy hemisphere of the healthy eyes (8.40 (3.36) µL/min, p<0.001; 9.28 (4.47) µL/min, p<0.002; 122.8 (20.2) µm, p<0.001). Multivariate model showed that normal and damaged hemispheres and RNFLT were associated with RBF reduction. In addition, the RBF in the normal hemisphere was lower than that in the healthy hemisphere even after adjusting for RNFLT., Conclusion: In NTG eyes with single-hemifield damage, the RBF was significantly reduced in the damaged hemisphere compared with the normal one. The RBF decreased in the normal and damaged hemispheres of NTG eyes compared with the healthy hemisphere independent from RNFLT., Competing Interests: Competing interests: Akitoshi Yoshida has a patent for the Doppler OCT system., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : The purpose of this pilot study was to investigate the differences in neurovascular coupling between Caucasian patients with normal tension glaucoma (NTG) and healthy subjects (HS) with laser speckle flowgraphy (LSFG). Methods : Measurement of optic nerve head blood flow was performed with LSFG. The mean blur rate of the whole optic nerve head (MA), of the big retinal vessels (MV) and of the microvasculature (MT) was analysed during continuous flicker light stimulation for four minutes. Results : We included 12 eyes from 12 Caucasian patients with a diagnosis of normal tension glaucoma and 12 eyes from 12 age- and sex-matched healthy individuals. MA, MV and MT all increased significantly in both groups during the observation period with no difference between the groups. Conclusion : Neurovascular coupling is detectable in NTG patients. Flicker light stimulation leads to a comparable increase in ocular blood flow in glaucoma patients and healthy individuals.

Purpose: To investigate 24-hour nyctohemeral intraocular pressure (IOP)-related patterns with contact lens sensors (CLSs) in eyes with primary open-angle glaucoma (POAG) with normal baseline IOP (i.e., normal-tension glaucoma [NTG]) and healthy controls., Design: Prospective, case-control study., Participants: Thirty eyes of 30 patients with NTG, who had had a wash-out period for their IOP-lowering treatment, and 20 eyes of 20 healthy volunteer subjects., Methods: Patients and subjects were hospitalized for the purposes of 24-hour CLS (SENSIMED Triggerfish; Sensimed AG, Lausanne, Switzerland) measurement. The IOP-related patterns during wake and sleep times over the course of the 24 hours were compared between the 2 groups. The 24-hour ambulatory blood pressure and posture were monitored simultaneously. A generalized linear model was used to find the factors associated with NTG., Main Outcome Measures: The IOP-related patterns, including mean and standard deviation (SD) of measurements, amplitude of cosine-fit curve, acrophase (signal peak), and bathyphase (signal trough) values (millivolt equivalents [mVEq])., Results: The SDs of the 24-hour CLS measurements were significantly greater in NTG eyes than in healthy controls (112.51±26.90 vs. 85.18±29.61 mVEq, P = 0.002). The amplitudes of cosine-fit curve (141.88±39.96 vs. 106.08±41.49 mVEq, P = 0.004) and acrophase values (277.74±129.80 vs. 190.58±127.88 mVEq, P = 0.024), mostly measured during nocturnal period, were significantly greater in NTG eyes than in healthy controls. The NTG subjects slept longer in the lateral decubitus posture than the healthy controls (199.1±137.8 vs. 113.2±86.2 minutes, P = 0.009). In the multivariable generalized linear model, the greater amplitude of cosine-fit curve (β = 0.218, P = 0.012) and greater time of decubitus posture during sleep (β = 0.180, P = 0.004) were found to be significantly associated with NTG., Conclusions: Continuous monitoring of 24-hour IOP-related values with CLS can be useful for assessment of glaucoma risk, especially for patients with NTG whose IOP appears to be in the normal range. Fluctuation of 24-hour IOP-related values and posture during sleep time might be associated with NTG., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background/aims: To compare intraocular pressure (IOP) measurements using a prototype smartphone tonometer with other tonometers used in clinical practice., Methods: Patients from an academic glaucoma practice were recruited. The smartphone tonometer uses fixed force applanation and in conjunction with a machine-learning computer algorithm is able to calculate the IOP. IOP was also measured using Goldmann applanation tonometry (GAT) in all subjects. A subset of patients were also measured using ICare, pneumotonometry (upright and supine positions) and Tono-Pen (upright and supine positions) and the results were compared., Results: 92 eyes of 81 subjects were successfully measured. The mean difference (in mm Hg) for IOP measurements of the smartphone tonometer versus other devices was +0.24 mm Hg for GAT, -1.39 mm Hg for ICare, -3.71 mm Hg for pneumotonometry and -1.30 mm Hg for Tono-Pen. The 95% limits of agreement for the smartphone tonometer versus other devices was -4.35 to 4.83 mm Hg for GAT, -6.48 to 3.70 mm Hg for ICare, -7.66 to -0.15 mm Hg for pneumotonometry and -5.72 to 3.12 mm Hg for Tono-Pen. Overall, the smartphone tonometer results correlated best with GAT (R 2 =0.67, p<0.001). Of the 92 videos, 90 (97.8%) were within ±5 mm Hg of GAT and 58 (63.0%) were within ±2 mm Hg of GAT., Conclusions: Preliminary IOP measurements using a prototype smartphone-based tonometer was grossly equivalent to the reference standard., Competing Interests: Competing interests: AYL has received grant support from Novartis and Carl Zeiss Meditec. AYL has received honoraria from Topcon and Verana Health. JCW has a patent pending US20170215728A1. None of the other authors have any competing interests related to this study., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

PRéCIS:: Our study demonstrated that in low-tension glaucoma (LTG) patients, Microperimeter-3 (MP-3)-derived and Humphrey Field Analyzer (HFA)-derived retinal sensitivities were similar and strongly correlated, allowing the respective data to be interrelated., Purpose: To compare and correlate retinal sensitivities obtained by Nidek MP-3 with those obtained from the HFA in eyes with LTG., Materials and Methods: In this prospective comparative study, 45 eyes of 24 LTG patients underwent retinal sensitivity assessments using the MP-3 (Nidek Technologies) and the HFA (Carl Zeiss Meditec) at the UCLA-Doheny Eye Center. Global and pointwise retinal sensitivity measurements were compared and correlated between the 2 devices., Results: No statistically significant differences (P=0.85) were noted between the mean retinal sensitivities determined by each device (MP-3: 26.33±4.31 dB; range, 13.05 to 31.60 vs. HFA: 26.42±3.98 dB; range, 17.17 to 30.96), and a strong correlation (r=0.66, P<0.001) was noted for retinal sensitivity measurements. In addition, moderate to strong correlations were observed between the mean retinal sensitivity derived by MP-3 versus HFA-derived mean deviation (r=0.57, P<0.001), as well as, the pattern standard deviation (r=0.67, P<0.001). The intraclass correlation coefficient was excellent (ICC=0.80, 95% confidence interval, 0.63-0.89), while the Bland-Altman analysis showed good agreement between the 2 devices with respect to retinal sensitivity., Conclusion: Retinal sensitivity measurements obtained by the MP-3 microperimetry instrument and the standard automated HFA perimeter were similar and highly correlated in patients with LTG. Given the potential benefits of microperimetry technology such as auto-eye-tracking and potentially more precise structure-function correlations, the use of microperimetry to monitor visual function in glaucoma management warrants further consideration.

Aim of the Study: The purpose of the present study was to determine if swept-source optical coherence tomography angiography (OCTA) of the superficial plexus in the macular region can detect differences between high-tension open-angle glaucoma (HTG) and normal-tension glaucoma (NTG)., Materials and Methods: In this prospective study 60 eyes from 60 patients (40 HTG; 20 NTG) underwent fovea centred 3 × 3 mm cube macula OCTA imaging by a swept-source OCTA device (Plex Elite, Zeiss, Jena, Germany). Quantitative analysis of the vasculature at the superficial plexus was performed by assessing the Perfusion Density (PD), defined as the total area of perfused vasculature per unit area in a region of measurement, for each group, respectively. Besides, macular ganglion cell layer thickness and mean deviation from visual field testing was assessed and correlated with PD., Results: Average superficial PD of the measured 3 × 3 mm field was comparable between HTG and NTG ( P = .567). In both groups a significant relation of PD and age (HTG: r = -0.48, p = .002; NTG: r = -0.615; p = .004) was shown, indicating reduced PD with increasing age. For both groups a positive correlation between PD and mean deviation (MD) (HTG: r = 0.492, p = .003; NTG: r = 0.530, p = .029) as well as PD and GCL thickness was shown (r = 0.486, p = .002 vs. r = 0.389; p = .09). However, the latter did not reach statistical significance in the NTG group., Conclusion: PD at the central 3 mm around the fovea is comparable between HTG and NTG. Significant correlation with age and MD was shown in both groups.

Purpose: To investigate the structural characteristics of the posterior sclera around the optic nerve head (ONH) in patients with normal-tension glaucoma (NTG) and myopia with central visual field (VF) defect., Design: Cross-sectional study., Methods: Ninety-seven eyes of 97 NTG patients with myopia were included in this study. Swedish interactive thresholding algorithm (SITA) 24-2 and 10-2 were both performed to compare the central VF with peripheral VF. Optic disc torsion, tilt, and peripapillary atrophy area were calculated in 2-dimensional disc photographs. The most posterior point-that is, the deepest point of the eye (DPE)-was identified in 3-dimensional en face optical coherence tomography results and related measurements were calculated using built-in software., Results: Forty-two eyes had worse SITA 10-2 mean deviation (MD) than SITA 24-2 MD and they were assigned to the central dominant VF defect group. The central dominant VF defect group had larger disc torsion and ONH tilt angle and shallower disc-DPE depth than the peripheral dominant VF defect group. According to logistic regression analysis, large ONH tilt angle and shallow disc-DPE depth were significant factors associated with central visual function impairment., Conclusions: Subjects with worse central VF than peripheral showed greater peripapillary scleral deformation, such as in torsion and tilt. Their posterior scleral deformation appeared to be closer to the ONH. Scleral deformation around the ONH may be associated with papillomacular bundle and central VF defects., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aim: The aim of the study was to determine the frequency of pathologies which can mimic normal-tension glaucoma (NTG), observed in neuroimaging of NTG patients, and to evaluate the frequency of pathologies in determined additional indications for neuroimaging. Material and Methods . The studied group consisted of 126 NTG patients who met at least one of the following criteria: unilateral NTG, damage in the visual field (VF) inconsistent with optic disc appearance, fast VF progression, worsening of visual acuity, predominant optic disc pallor rather than optic disc excavation, diagnosis under the age of 50, and scotoma in VF restricted by a vertical line. The patients included in the research underwent MRI scans of the brain and both orbits., Results: After neuroimaging, the results of 29 (23%) patients were qualified as positive; 18 (14.2%) of the identified pathologies were found to clinically affect the visual pathway. The most frequent brain pathology was intracranial meningiomas, observed in 4 patients (3.1%), followed by optic nerve sheath meningiomas diagnosed in 3 cases (2.4%), and brain glioma in 1 patient (0.8%). Pituitary gland adenomas were described in 6 patients (4.5%); 3 of the tumours were in contact with the optic chiasm. 53 (40%) patients had minimal ischemic changes in different regions of the brain. In the case of worsening BCVA or fast VF progression, the frequency of positive results was the highest (50% and 40%), whereas in the case of diagnosis at a young age and unilateral involvement, neuropathology was the rarest (0% and 6.9%)., Conclusions: In the case of NTG, the decision to perform neuroimaging should be made after a detailed assessment of clinical status, rather in the event of finding the signs of possible compressive optic neuropathy than as an obligatory procedure for every patient., Competing Interests: All authors declare no conflict of interests., (Copyright © 2020 Ewa Kosior-Jarecka et al.)

Purpose: This study aimed to compare the clinical characteristics of patients who showed structural progression in the peripapillary retinal nerve fiber layer (RNFL) first against those who showed progression in the macular ganglion cell-inner plexiform layer (GCIPL) first and to investigate clinical parameters that help determine whether a patient exhibits RNFL or GCIPL damage first., Methods: A retrospective review of medical records of patients diagnosed with early-stage normal-tension glaucoma was performed. All eyes underwent intraocular pressure measurement with Goldmann applanation tonometer, standard automated perimetry, and Cirrus optical coherence tomography at 6-month intervals. Structural progression was determined using the Guided Progression Analysis software. Blood pressure was measured at each visit., Results: Forty-one eyes of 41 patients (mean age, 52.6 ± 16.7 years) were included in the study. In 21 eyes, structural progression was first detected in the RNFL at 54.2 ± 14.8 months, while structural progression was first observed at the macular GCIPL at 40.5 ± 11.0 months in 20 eyes. The mean intraocular pressure following treatment was 13.1 ± 1.8 mmHg for the RNFL progression first group and 13.4 ± 1.8 mmHg for the GCIPL progression first group ( p = 0.514). The GCIPL progression first group was older ( p = 0.008) and had thinner RNFL at baseline ( p = 0.001). The logistic regression analyses indicated that both age and follow-up duration until first progression predicted the region of structural progression (odds ratio, 1.051; 95% confidence interval, 1.001-1.105; p = 0.046 for age; odds ratio, 0.912; 95% confidence interval, 0.840-0.991; p = 0.029 for time until progression)., Conclusions: Age of glaucoma patients and time until progression are associated with the region of the first structural progression in normal-tension glaucoma. Further studies exploring the association between glaucomatous progression and the location of damage are needed., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2020 The Korean Ophthalmological Society.)

Purpose: The differential diagnosis of superior segmental optic hypoplasia (SSOH) and normal-tension glaucoma (NTG) is an issue in the ophthalmologic field. To date, several modalities have been developed to solve this issue; however, no standard methods have been established. Recently, optical coherence tomography angiography (OCTA) has been introduced to better evaluate the volumetric angiography images. Therefore, in this study, we investigated the usefulness of OCTA in differentiating between SSOH and NTG., Materials and Methods: In this retrospective study, we included 26 patients with SSOH who had definite visual field defects and 40 patients with NTG who had only inferior visual field defects. Age, sex, intraocular pressure, refractive error, retinal nerve fiber layer thickness, and visual field defects were compared between the groups. In addition, we analyzed and compared the peripapillary vessel density (VD) measured on OCTA between the groups. The area under the receiver operating characteristic curves were obtained for each parameter., Results: On Cirrus HD-OCT, the retinal nerve fiber layer in patients with SSOH was thinner in the superonasal segment and thicker in the superotemporal segment compared with patients with NTG. In the analysis of OCTA, the peripapillary VD of the superonasal segment was significantly lower in the SSOH group than in the NTG group, while it was significantly higher in the superotemporal segment in the SSOH group than in the NTG group. The optimal superonasal-to-superotemporal ratio cutoff was 0.8828, with a sensitivity of 95% and specificity of 92.3%, for the diagnosis of SSOH (area under the receiver operating characteristic curve=0.962)., Conclusions: Our findings suggest that the superonasal-to-superotemporal VD ratio measured on OCTA may be used to distinguish between SSOH and NTG. However, further large-scale studies are required to verify our findings.

Precis: The surgical outcome of iStent inject devices is associated with device protrusion within the anterior chamber. Schlemm canal (SC) dilatation has a prognostic value. iStent inject devices do not move within the first year after implantation., Introduction: The iStent inject is a device designed to be implanted ab-interno through the trabecular meshwork. The present study follows up on our preliminary report, using successive in vivo anterior segment optical coherence tomography (AS-OCT) imaging to analyze the associations between stent positioning, iridocorneal angle structures, and surgical outcomes., Methods: In total, 54 eyes of 42 patients (73.3±7.4 y) with cataract and mild-to-moderate open-angle glaucoma were examined in this prospective study. All patients underwent implantation of 2 iStent inject devices combined with phacoemulsification. Patients were followed up over a 12-month period. AS-OCT was performed after 3 and 12 months. Thirty unoperated fellow eyes served as control eyes., Results: Intraocular pressure (IOP) decreased from 16.5±4.2 mm Hg at baseline to 15.1±3.7 mm Hg at 12 months (-8.7%; P=0.004), while medications decreased from 1.8±1.0 to 0.5±0.9 (-72.2%; P<0.001). Unmedicated IOP≤18 mm Hg was achieved in 58.8% of operated eyes. No sight-threatening complications were reported. On AS-OCT, 44.9% of devices were buried within the trabeculum. Device position was unchanged between scans. Regression analysis elicited significant predictors: SC dilatation effect [risk ratio (RR)=0.230; P=0.003], greatest SC diameter (RR=0.991; P=0.049), extrusion of the most anterior device (RR=0.993; P=0.012), gonioscopically visible devices (RR=0.406; P=0.040), baseline treatments (RR=2.214; P=0.001), and baseline IOP (RR=0.184; P=0.006). Endothelial cell density decreased by 14.6% at 12 months (P<0.001)., Conclusions: This study demonstrates the IOP-lowering and medication-lowering potential of iStent inject surgery in primary open-angle and pseudoexfoliative glaucoma. It confirms that surgical outcomes are positively associated with device protrusion within the anterior chamber, and suggests SC dilatation effect as a favorable prognostic indicator. It shows that stents are stable in time, highlighting the importance of the initial implantation location.

Background: Intraocular lens fixation surgery is associated with fluctuations in intraocular pressure. This may be significantly relevant in glaucoma patients., Objectives: To assess short- and medium-term intraocular pressure control after trans-scleral intraocular lens fixation surgery in glaucoma patients., Methods: The charts of all glaucoma patients who underwent trans-scleral intraocular lens fixation surgery with at least 6 months follow-up by a single surgeon between the years 2004 and 2017 were reviewed. Primary outcomes were intraocular pressure at 1 day and 6 months after surgery. Secondary outcome measures were hypotensive medication use and the need for further intraocular pressure lowering interventions., Results: Eleven eyes of 10 patients were included in the analysis. Mean follow-up post intraocular lens fixation surgery was 54.6 months. Mean intraocular pressure before, 6 months, and last follow-up after intraocular lens fixation surgery was 15.8 ± 5.3 mmHg (range 10.6-25.3), 13.5 ± 3.8 mmHg (range 8-21, p = 0.2), and 11.8 ± 5.6 (range 6-21, p = 0.09) on a mean of 2.3 ± 1.6, 2 ± 1.6 (p = 0.23), and 1.7 ± 1.5 (p = 0.08) hypotensive medications, respectively. A pressure spike was noted in 5 of the 11 eyes on the first post-operative day (mean spike 15.2 mmHg, range 6-23). Four of 11 eyes in the study (36%) needed additional interventions to control intraocular pressure by the 6-month point. One eye required the addition of two classes of topical medications, one eye required laser trabeculoplasty, and two eyes required trabeculectomy., Conclusion: Over a third of glaucomatous eyes required a change in the management of their disease in the early post-operative period. Close follow-up of patients undergoing trans-scleral intraocular lens fixation surgery is warranted.

PRéCIS:: Four parameters of the noninvasive, portable RETeval electroretinogram (ERG) system were found to correlate with visual field mean deviation and optical coherence tomography (OCT) thickness parameters, and may therefore be suitable for glaucoma detection., Purpose: To investigate the RETeval full-field ERG parameters for accuracy of separating glaucoma and normal eyes, and correlation with glaucoma severity., Patients and Methods: Sixty-two eyes of 62 primary open-angle glaucoma patients [visual field mean deviation (MD) range: -0.44 to -31.15 dB] and 39 eyes of 39 healthy controls underwent one RETeval test (photopic negative response protocol), OCT imaging, and Humphrey 30-2 visual field testing. The glaucoma patients were divided into early (MD≥-6dB, n=33) and moderate-to-advanced (MD<-6 dB, n=29) groups., Results: Significant correlations were found between the best-performing 4 RETeval ERG parameters and the glaucoma severity measures (MD and OCT thickness parameters) for all eyes, all glaucoma eyes and the moderate-to-advanced glaucoma eyes [photopic negative response amplitude at 72 ms (PhNR 72) and MD: r=-0.333, -0.414, and -0.485, respectively, P≤0.008; PhNR 72 and average circumpapillary retinal nerve fiber layer thickness; r=-0.429, -0.450, and -0.542, respectively, P≤0.002]. Except for P-ratio, there was no significant difference between the area under the receiver-operating characteristic (AUROC) values of the OCT thickness parameters (range: 0.927 to 0.938) and the 4 best-performing RETeval ERG parameters (range: 0.839 to 0.905) in the early glaucoma versus control separation. For differentiating the control and the moderate-to-advanced glaucoma eyes, the AUROC values of the 4 best-performing RETeval ERG parameters ranged between 0.924 and 0.958, and no significant difference was found between them and those of the OCT parameters., Conclusions: The noninvasive, portable RETeval full-field ERG device may be useful to detect glaucoma in moderate-to-advanced stages.

Purpose: To compare lamina cribrosa (LC) morphology between eyes with nonarteritic anterior ischemic optic neuropathy (NAION) and eyes with normal tension glaucoma (NTG) in the Korean population., Methods: This retrospective study included 48 eyes with NAION, 48 eyes with NTG, and 48 healthy control eyes matched by age, intraocular pressure, axial length, and optic disc area. Eyes with NAION and NTG were also matched by retinal nerve fiber layer (RNFL) thickness in the affected sector. Optic nerve heads were scanned using enhanced depth imaging spectral-domain optical coherence tomography. LC depth (LCD) and the LC curvature index (LCCI) were measured at seven locations spaced equidistantly across the vertical optic disc diameter. LCD and the LCCI were compared in the three groups., Results: RNFL thicknesses of the matched affected sectors did not differ between the NAION and NTG groups (P = 0.347). LCD and the LCCI were significantly larger in the NTG group than in the NAION and healthy control groups at all seven planes (P < 0.001 each), but were comparable in the NAION and healthy control groups. The LCCI was larger in the affected than in the unaffected sector of NTG eyes (P = 0.010) but did not differ in NAION eyes (P = 1.000). LCD did not differ between affected and unaffected sectors in either NAION (P = 0.600) or NTG (P = 0.098) eyes., Conclusions: LC morphology differed in eyes with NAION and NTG, despite a similar degree of RNFL damage. Evaluation of LC morphology may help to understand the distinctive pathophysiology of NAION and to differentiate NAION from NTG eyes.

Purpose: Selective laser trabeculoplasty (SLT) is a common treatment option for managing glaucoma and ocular hypertension. We assessed the real-world effectiveness of SLT and baseline factors associated with treatment success in the United Kingdom., Design: Retrospective observational study of de-identified electronic medical records (Medisoft Glaucoma module [Medisoft Ltd, Leeds, UK]) from 5 UK ophthalmology teaching centers., Participants: Adult patients undergoing their first recorded SLT. For bilateral SLT (same day), analyses included 1 randomly selected eye., Methods: Patient demographics, procedure details, and clinical outcomes data were extracted. Factors associated with treatment success were assessed using multivariable Cox regression., Main Outcome Measures: Change from baseline in intraocular pressure (IOP) and glaucoma medication use at 12 to 18 and 24 to 36 months post-SLT. A Kaplan-Meier survival analysis was also conducted. Failure of SLT was defined as any further glaucoma procedure post-SLT or any of the following at 2 consecutive visits: IOP >21 mmHg, IOP reduction <20% from baseline, or increase in glaucoma medications from baseline., Results: A total of 831 SLT-treated eyes (mean baseline IOP 22.0 mmHg) of 831 patients were analyzed. At 12 to 18 and 24 to 36 months post-SLT, respectively, significant reductions in IOP (-4.2 [95% confidence interval {CI}, -4.7 to -3.7] and -3.4 [95% CI, -4.1 to -2.7] mmHg; both P < 0.0001) and significant increases in the number of glaucoma medications (0.13 [95% CI, 0.04-0.23], P = 0.007, and 0.20 [95% CI, 0.06-0.33], P = 0.005) were observed. Survival analysis demonstrated treatment success in 70%, 45%, and 27% of eyes at 6, 12, and 24 months post-SLT, respectively. Higher baseline IOP was strongly associated with treatment success (hazard ratio [HR], 0.67 for baseline IOP >21 mmHg vs. ≤21 mmHg, 95% CI, 0.57-0.80; P < 0.001). Selective laser trabeculoplasty success was not significantly associated with age (P = 0.78), baseline visual field mean deviation (P = 1.00), or concurrent use of IOP-lowering medication (P = 0.52)., Conclusions: Most patients initially responded to SLT, but the majority failed within 1 year. Efficacy of SLT was better in patients with higher baseline IOP but did not differ by glaucoma severity or concurrent use of IOP-lowering medication. These findings may help inform which patients are suitable for SLT therapy., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background/aims: To investigate (1) the effect of reading or writing on a smartphone in terms of intraocular pressure (IOP) change in eyes with glaucoma, and (2) to determine whether previous glaucoma filtering surgery can affect IOP fluctuation during such work., Methods: Forty eyes of 40 medically well IOP-controlled normal-tension glaucoma (NTG) patients and 38 eyes of 38 NTG patients who had undergone successful trabeculectomy (TLE) were enrolled. The participants were instructed to read a sample text and to then type it on a smartphone under low-light [100 lux] conditions. Three IOP measurements were obtained: baseline; during smartphone work (5, 15 and 25 min); post-work (5 and 15 min)., Results: Baseline IOP did not significantly differ between the two groups (medication group: 13.9±1.6 mm Hg; TLE group: 13.6±1.7 mm Hg; p=0.426). After 5 min of smartphone work, the medication group showed significantly elevated mean IOP (15.5±1.8 mm Hg;+11.5%; p<0.001), along with further increases over the course of 25 min (17.5±2.2 mm Hg;+25.9%; p<0.001). 5 min after halting work, IOP dropped below the baseline (13.1±1.7 mm Hg; p<0.001). For the TLE group, IOP also was elevated after 5 min (14.9±1.7 mm Hg;+9.4%; p<0.001); however, it did not show further increase over the course of 25 min of work (15.0±1.6 mm Hg;+10.3%). At 5 min after cessation of work, IOP had restored to the pre-work level (14.0±1.9 mm Hg;+2.8%; p=0.053)., Conclusion: Working on a smartphone under low-light condition can incur IOP elevation in treated NTG patients. However, among the participants in this study, IOP fluctuation was much smaller in those who had undergone TLE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)