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Lowering of intraocular pressure is currently the only therapeutic measure for Glaucoma management. Many longterm, randomized trials have shown the efficacy of lowering IOP, either by a percentage of baseline, or to a specified level. This has lead to the concept of 'Target\" IOP, a range of IOP on therapy, that would stabilize the Glaucoma/prevent further visual field loss, without significantly affecting a patient's quality of life. A clinical staging of Glaucoma by optic nerve head evaluation and perimetric parameters, allows a patient's eye to be categorized as having - mild, moderate or severe Glaucomatous damage. An initial attempt should be made to achieve the following IOP range for both POAG or PACG after an iridotomy. In mild glaucoma the initial target IOP range could be kept as 15-17 mmHg, for moderate glaucoma 12-15 mmHg and in the severe stage of glaucomatous damage 10-12 mmHg. Factoring in baseline IOP, age, vascular perfusion parameters, and change on perimetry or imaging during follow up, this range may be reassessed over 6 months to a year. \"Target\" IOP requires further lowering when the patient continues to progress or develops a systemic disease such as a TIA. Conversely, in the event of a very elderly or sick patient with stable nerve and visual field over time, the target IOP could be raised and medications reduced. An appropriate use of medications/laser/surgery to achieve such a \"Target\" IOP range in POAG or PACG can maintain visual fields and quality of life, preventing Glaucoma blindness.

AimsTo assess peripapillary perfused capillary density (PCD) in primary open-angle glaucoma (POAG) across stage of disease.MethodsIn this observational, cross-sectional study, 60 eyes with varying stages of POAG and 24 control eyes were imaged on a spectral domain optical coherence tomography angiography system (AngioVue, Optovue, Fremont, California, USA) generating images centred on the optic nerve head. Major blood vessels were removed using custom automated software. PCD was calculated as a percentage as the ratio of pixels associated with perfused capillaries to the total number of pixels in the corresponding region-of-interest (ROI). Analysis of covariance was used to compare PCD among the subject groups and control for possible covariates. Area under the receiver operating characteristic curve (AROC) and sensitivity at 95% specificity were calculated to assess the capability of PCD to distinguish mild glaucoma from control. The Pearson's product-moment correlation coefficient was used to assess correlations between PCD and circumpapillary retinal nerve fibre layer thickness (cpRNFLT) and visual field mean deviation (MD).ResultsPCD demonstrated a progressive stepwise decrease from control eyes throughout worsening POAG stage at all ROIs. PCD demonstrated AROC and sensitivity values comparable to cpRNFLT and visual field parameters and exhibited significant correlations with cpRNFLT and MD at all corresponding ROIs.ConclusionsPCD displayed significant correlations with morphological and functional indices and exhibited diagnostic capabilities comparable to currently employed clinical variables. Our preliminary results suggest that PCD analysis may prove to be a useful tool in monitoring POAG across stage and identifying early POAG.

The purpose of this study is to examine if aqueous autotaxin (ATX) and TGF-β levels could be used for differentiating glaucoma subtypes. This prospective observational study was performed using aqueous humor samples obtained from 281 consecutive patients. Open angle glaucoma patients were classified into three groups: primary open-angle glaucoma (POAG), secondary open-angle glaucoma (SOAG), and exfoliation glaucoma (XFG). Aqueous levels of ATX and TGF-βs were quantified. The AUC as well as sensitivity and specificity for the classification into normal and glaucoma subtypes using four indicators-ATX, TGF-β1, TGF-β2, and TGF-β3, upon the application of three machine learning methods. ATX, TGF-β1, and TGF-β3 were positively correlated with IOP, and ATX was significantly and negatively correlated with the mean deviation. From least absolute shrinkage and selection operator regression analysis, the AUC values to distinguish each subgroup [normal, POAG, SOAG, and XFG] ranged between 0.675 (POAG vs. normal) and 0.966 (XFG vs. normal), when four variables were used. High AUC values were obtained with ATX for discriminating XFG from normal eyes and with TGF-β3 for discriminating XFG from normal eyes, POAG, or SOAG. Aqueous TGF-β and ATX exhibited high diagnostic performance in detecting glaucoma subtypes, and could be promising biomarkers for glaucoma.

AimsTo evaluate the relationship between macular vessel density (mVD) and central visual field sensitivity (cVFS) at different stages of glaucoma and to compare this relationship with that between the thickness of the macular ganglion cell-inner plexiform layer (mGCIPLT) and cVFS.MethodsThe mVD and mGCIPLT were measured by optical coherence tomography angiography in 139 patients with glaucoma. The cVFS was defined as the average of 12 central points on 24-2 visual field (VF) testing. Vasculature–function and structure–function relationships were analysed by comparing mVD and mGCIPLT with cVFS in eyes with early and moderate-to-advanced glaucoma.ResultsGlobal and regional mVD–cVFS associations were statistically significant in eyes with moderate-to-advanced (all p<0.05), but not early stage (all p>0.05) glaucoma. The global association between average mVD and cVFS was significantly stronger than that between average mGCIPLT and cVFS in eyes with moderate-to-advanced glaucoma (p=0.049). Reduced mVD was independently associated with cVFS loss after adjusting for age and mGCIPLT in eyes with moderate-to-advanced glaucoma.ConclusionsThe macular vasculature–function relationship using mVD was stronger than the structure–function relationship using mGCIPLT in eyes with moderate-to-advanced glaucoma. The mVD may be useful in monitoring cVFS in advanced glaucoma.

Background and Objectives: Open-angle glaucoma subtypes share a structural phenotype but differ in pathophysiology: pseudoexfoliative glaucoma (PXG) involves vascular endothelial dysfunction associated with deposition of exfoliative material, whereas normal-tension glaucoma (NTG) reflects primary vascular dysregulation in the absence of elevated intraocular pressure. We characterized subtype-specific OCT angiography (OCTA) profiles obtained from a 3 × 3 mm macular scan and evaluated their discriminatory power for pairwise subtype classification. Materials and Methods: This was a single-center, cross-sectional study of 304 eyes: 198 glaucomatous eyes—primary open-angle glaucoma (POAG, glaucoma simplex in our clinical nomenclature), n = 102; PXG (glaucoma capsulare), n = 68; NTG (glaucoma sine tensio), n = 28—and 106 healthy controls. The Cirrus HD-OCT 5000 AngioPlex 3 × 3 mm OCTA protocol was used to assess vessel density (VD), perfusion density, foveal avascular zone (FAZ) morphology, ganglion cell complex (GCC), and retinal nerve fiber layer (RNFL) thickness. Analyses included Kruskal–Wallis tests with Bonferroni post hoc correction, ROC analysis with DeLong comparison of combined versus structural-only models, multivariate regression, and an exploratory XGBoost classifier with SHAP-based interpretation. Results: VD Inner and Perfusion Inner were lower in PXG (16.37 ± 3.33%; 0.31 ± 0.05) than in POAG (18.73 ± 3.41%; 0.34 ± 0.05; both p < 0.001); Perfusion Inner was also lower than in NTG (p < 0.05). FAZ Area was largest in NTG (0.27 ± 0.11 mm2) and greater than in PXG (0.19 ± 0.08; p < 0.01); FAZ Circularity differed across subtypes (p < 0.001). Combined OCTA–structural models outperformed structural-only models for POAG vs. PXG (DeLong p = 0.002) and for PXG vs. NTG (AUC = 0.770; p = 0.010). Sector-resolved Spearman analysis revealed subtype-specific coupling: in NTG, VD Inner and Perfusion Inner correlated with the inferior RNFL (r = 0.53 and r = 0.52; both p < 0.01); in PXG, coupling shifted nasally (r = 0.41 and r = 0.46; both p < 0.001). The exploratory XGBoost classifier separated glaucoma from controls with an internal cross-validated AUC of 0.975 ± 0.008 (5-fold CV; not externally validated); FAZ Circularity (mean |SHAP| = 0.418) and FAZ Area (0.411) were the top inter-subtype features, supported by case-level SHAP. RNFL avg and average GCC independently predicted MD across subtypes; in PXG, Perfusion Inner also predicted MD (β = −32.78; p = 0.032). Conclusions: In this single-center, cross-sectional cohort, OCTA revealed subtype-associated macular microvascular profiles that are complementary to structural OCT. Reduced vessel and perfusion density characterized PXG, whereas FAZ enlargement and reduced circularity distinguished NTG and PXG. Vascular–structural coupling was nasal-predominant in PXG and inferior-predominant in NTG. Combined multimodal models outperformed structural-only approaches. Macular perfusion additionally predicted MD in PXG. The XGBoost/SHAP analysis is exploratory; prospective and externally validated studies are required before clinical deployment.

To evaluate the Childhood Glaucoma Research Network (CGRN) classification system and describe the prevalence of each subtype according to this classification. Retrospectively, the medical records of 205 consecutive childhood glaucoma and glaucoma suspect patients at an urban tertiary care center were reviewed. The initial diagnosis and new diagnosis according to CGRN classification were recorded. All patients fit one of the seven categories of the new classification. Seventy-one percent of diagnoses were changed upon reclassification. Twenty-three percent of patients had primary glaucoma (juvenile open-angle glaucoma and primary congenital glaucoma [PCG]); 36% had secondary glaucoma (glaucoma associated with nonacquired ocular anomalies; glaucoma associated with nonacquired systemic disease or syndrome; glaucoma associated with acquired condition; and glaucoma following cataract surgery); and 39% were glaucoma suspect. Of the patients diagnosed with glaucoma, PCG was the most common diagnosis, seen in 32% of patients. The CGRN classification provides a useful method of classifying childhood glaucoma.

To evaluate choroidal structural changes in glaucoma using choroidal vascularity index (CVI) compared to healthy subjects. This retrospective study included 56 patients with open angle glaucoma (OAG), 50 patients with preperimetric glaucoma (PPG) and 50 age-matched healthy eyes. Choroidal images were binarized into luminal area (LA) and stromal area. CVI was defined as the ratio of LA to total circumscribed choroid area (TCA). Mean choroidal thickness (CT) and mean CVI between glaucoma patients and healthy subjects were compared. OAG and PPG eyes showed smaller LA (0.45 ± 0.13 ㎟ vs. 0.47 ± 0.11 ㎟, p = 0.04). In multivariate regression analysis, CVI of both OAG (64.34±0.19%, p = 0.001) and PPG (65.37±0.15%, p = 0.001) were significantly lower than healthy eyes (68.81±0.14%). Eyes with glaucoma demonstrated reduced CVI compared with healthy eyes. CVI may be a potential noninvasive tool for studying vascular dysfunction in glaucoma.

To investigate the plasma lipoprotein subclasses in patients with primary open-angle glaucoma (POAG), a total of 20 Chinese POAG patients on intraocular pressure (IOP)-lowering treatment and 20 age-matched control subjects were recruited. Based on the levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C), the study subjects were divided into elevated- and normal-level subgroups. The plasma lipoprotein, lipoprotein subclasses, and oxidized LDL (oxLDL) levels were quantitatively measured. The discrimination potential of the lipoproteins was evaluated using the area under the receiver operating characteristic curve (AUC), and their correlation with clinical parameters was also evaluated. Compared to the control subjects with elevated TC and/or LDL-C levels, the levels of TC, LDL-C, non-high-density lipoprotein cholesterol (non-HDL), LDL subclass LDL3 and small dense LDL (sdLDL), and oxLDL were significantly higher in POAG patients with elevated TC and/or LDL-C levels. No differences in any lipoproteins or the subclasses were found between the POAG patients and control subjects with normal TC and LDL-C levels. Moderate-to-good performance of TC, LDL-C, non-HDL, LDL3, sdLDL, and oxLDL was found in discriminating between the POAG patients and control subjects with elevated TC and/or LDL-C levels (AUC: 0.710–0.950). Significant negative correlations between LDL3 and sdLDL with retinal nerve fiber layer (RNFL) thickness in the superior quadrant and between LDL3 and average RNFL thickness were observed in POAG patients with elevated TC and/or LDL-C levels. This study revealed a significant elevation of plasma lipoproteins, especially the LDL subclasses, in POAG patients with elevated TC and/or LDL-C levels, providing insights on monitoring specific lipoproteins in POAG patients with elevated TC and/or LDL-C.

Background Glaucoma is the leading cause of irreversible blindness worldwide. There tends to be a lower reporting of glaucoma in Africa compared to other blinding conditions in global burden data. Research findings of glaucoma in Nigeria will significantly increase our understanding of glaucoma in Nigeria, in people of the West African diaspora and similar population groups. We determined the prevalence and types of glaucoma in Nigeria from the Nigeria National Blindness and Visual Impairment cross-sectional Survey of adults aged ≥40 years. Methods Multistage stratified cluster random sampling with probability-proportional-to-size procedures were used to select a nationally representative sample of 15,027 persons aged ≥40 years. Participants had logMAR visual acuity measurement, FDT visual function testing, autorefraction, A-scan biometry and optic disc assessment. Participants with visual acuity of worse than 6/12 or suspicious optic discs had detailed examination including Goldmann applanation tonometry, gonioscopy and fundus photography. Disc images were graded by Moorfields Eye Hospital Reading Centre. Glaucoma was defined using International Society of Geographical and Epidemiological Ophthalmology criteria; and classified into primary open-angle or primary angle-closure or secondary glaucoma. Diagnosis of glaucoma was based on ISGEO classification. The type of glaucoma was determined by gonioscopy. Results A total of 13,591 participants in 305 clusters were examined (response rate 90.4 %). Optic disc grading was available for 25,289 (93 %) eyes of 13,081 (96 %) participants. There were 682 participants with glaucoma; a prevalence of 5.02 % (95 % CI 4.60–5.47). Among those with definite primary glaucoma that had gonioscopy ( n  = 243), open-angle glaucoma was more common (86 %) than angle-closure glaucoma (14 %). 8 % of glaucoma was secondary with the commonest causes being couching (38 %), trauma (21 %) and uveitis (19 %). Only 5.6 % (38/682) of participants with glaucoma knew they had the condition. One in every 5 persons with glaucoma (136;20 %) was blind i.e., visual acuity worse than 3/60. Conclusion Nigeria has a high prevalence of glaucoma which is largely open-angle glaucoma. A high proportion of those affected are blind. Secondary glaucoma was mostly as a consequence of procedures for cataract. Public health control strategies and high quality glaucoma care service will be required to reduce morbidity and blindness from glaucoma.

Glaucoma is a group of progressive optic neuropathies that have in common characteristic optic nerve head changes, loss of retinal ganglion cells and visual field defects. Among the large family of glaucomas, primary open-angle glaucoma (POAG) is the most common type, a complex and heterogeneous disorder with environmental and genetic factors contributing to its pathogenesis. Approximately 5% of POAG is currently attributed to single-gene or Mendelian forms of glaucoma. Genetic linkage analysis and genome-wide association studies have identified various genomic loci, paving the path to understanding the pathogenesis of this enigmatic, blinding disease. In this review we summarize the most common variants reported thus far and their possible clinical correlations.