Grace M. Richter

Risk Factors for Cortical, Nuclear, Posterior Subcapsular, and Mixed Lens Opacities: The Los Angeles Latino Eye Study

PURPOSE To identify sociodemographic and biological risk factors associated with having cortical, nuclear, posterior subcapsular (PSC), and mixed lens opacities. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 5945 Latinos aged ≥ 40 years from 6 census tracts in Los Angeles, California. METHODS Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II. Univariate and stepwise logistic regression analyses were used to identify independent risk factors associated with each type of lens opacity. MAIN OUTCOME MEASURES Odds ratios for sociodemographic and biological risk factors associated with cortical only, nuclear only, PSC only, and mixed lens opacities. RESULTS Of the 5945 participants with gradable lenses, 468 had cortical only lens opacities, 217 had nuclear only lens opacities, 27 had PSC only opacities, and 364 had mixed lens opacities. Older age, higher hemoglobin A(1c), and history of diabetes mellitus were independent risk factors for cortical only lens opacities. Older age, smoking, and myopic refractive error were independent risk factors for nuclear only lens opacities. Higher systolic blood pressure and history of diabetes were independent risk factors for PSC lens opacities. Older age, myopic refractive error, history of diabetes, higher systolic blood pressure, female gender, and presence of large drusen were independent risk factors for mixed lens opacities. CONCLUSIONS The modifiable and non-modifiable risk factors identified in this study provide insight into the mechanisms related to the development of lens opacification. Improved glycemic control, smoking cessation and prevention, and blood pressure control may help to reduce the risk of having lens opacities and their associated vision loss.

Minimally invasive glaucoma surgery: current status and future prospects.

Minimally invasive glaucoma surgery aims to provide a medication-sparing, conjunctival-sparing, ab interno approach to intraocular pressure reduction for patients with mild-to-moderate glaucoma that is safer than traditional incisional glaucoma surgery. The current approaches include: increasing trabecular outflow (Trabectome, iStent, Hydrus stent, gonioscopy-assisted transluminal trabeculotomy, excimer laser trabeculotomy); suprachoroidal shunts (Cypass micro-stent); reducing aqueous production (endocyclophotocoagulation); and subconjunctival filtration (XEN gel stent). The data on each surgical procedure for each of these approaches are reviewed in this article, patient selection pearls learned to date are discussed, and expectations for the future are examined.

Optical coherence tomography angiography: A comprehensive review of current methods and clinical applications

ABSTRACT OCT has revolutionized the practice of ophthalmology over the past 10–20 years. Advances in OCT technology have allowed for the creation of novel OCT‐based methods. OCT‐Angiography (OCTA) is one such method that has rapidly gained clinical acceptance since it was approved by the FDA in late 2016. OCTA images are based on the variable backscattering of light from the vascular and neurosensory tissue in the retina. Since the intensity and phase of backscattered light from retinal tissue varies based on the intrinsic movement of the tissue (e.g. red blood cells are moving, but neurosensory tissue is static), OCTA images are essentially motion‐contrast images. This motion‐contrast imaging provides reliable, high resolution, and non‐invasive images of the retinal vasculature in an efficient manner. In many cases, these images are approaching histology level resolution. This unprecedented resolution coupled with the simple, fast and non‐invasive imaging platform have allowed a host of basic and clinical research applications. OCTA demonstrates many important clinical findings including areas of macular telangiectasia, impaired perfusion, microaneurysms, capillary remodeling, some types of intraretinal fluid, and neovascularization among many others. More importantly, OCTA provides depth‐resolved information that has never before been available. Correspondingly, OCTA has been used to evaluate a spectrum of retinal vascular diseases including diabetic retinopathy (DR), retinal venous occlusion (RVO), uveitis, retinal arterial occlusion, and age‐related macular degeneration among others. In this review, we will discuss the methods used to create OCTA images, the practical applications of OCTA in light of invasive dye‐imaging studies (e.g. fluorescein angiography) and review clinical studies demonstrating the utility of OCTA for research and clinical practice. HIGHLIGHTSOCTA images provide reliable, high resolution, and non‐invasive images of retinal vascular tissue in a clinically feasible manner.OCTA demonstrates clinically significant features of diabetic retinopathy, retinal vein occlusion, macular degeneration, and glaucoma.Quantitative OCTA metrics show good correlation with clinical severity of diabetic retinopathy, retinal venous occlusion, and uveitis.Current FDA approved SD‐OCTA systems have limited resolution underneath the RPE and a field‐of‐view that is limited to the macula.Current OCTA methods display and interpret data in a 2D manner. Advances in 3D rendering and wide‐field metrics will provide more information.

Risk Factors for Incident Cortical, Nuclear, Posterior Subcapsular, and Mixed Lens Opacities

PURPOSE To identify sociodemographic and biological risk factors associated with the 4-year incidence of nuclear, cortical, posterior subcapsular (PSC), and mixed lens opacities. DESIGN Population-based, longitudinal study. PARTICIPANTS We included 4658 Latinos ≥40 years from 6 census tracts in Los Angeles, California. METHODS Participants underwent an interview and detailed eye examination, including best-corrected visual acuity and slit-lamp assessment of lens opacities using the Lens Opacities Classification System II (LOCS II) at baseline and again 4 years later. Each opacity type was defined in persons with a LOCS II score of ≥2. Univariate and forward stepwise logistic regression analyses were used to identify independent baseline risk factors associated with 4-year incidence of nuclear only, cortical only, PSC only, and mixed (when >1 opacity type developed in a person) lens opacities. These comprised 4 mutually exclusive groups, and were based on person rather than eye. MAIN OUTCOME MEASURES Odds ratios for independent risk factors associated with 4-year incidence of nuclear-only, cortical-only, PSC-only, and mixed lens opacities. RESULTS Of the 3471 participants with gradable lenses in the same eye at baseline and 4-year follow-up, 200 (5.8%) had incident nuclear-only opacities, 151 (4.1%) had incident cortical-only opacities, 16 (0.5%) had incident PSC-only lens opacities, and 88 (2.5%) had mixed lens opacities. Independent baseline risk factors for incident nuclear-only lens opacities included older age, current smoking, and presence of diabetes. Independent risk factors for incident cortical-only lens opacities included older age and having diabetes at baseline. Female gender was an independent risk factor for incident PSC-only lens opacities. Older age and presence of diabetes at baseline examination were independent risk factors for incident mixed lens opacities. Specifically, in diabetics, higher levels of hemoglobin A1c was associated with greater risk for 4-year incident nuclear-only, cortical-only and mixed lens opacities. CONCLUSIONS Improved diabetic control and smoking prevention may reduce the risk of developing lens opacities. Understanding both modifiable and nonmodifiable risk factors provides insight into the development of lens opacification.

Prevalence of Visually Significant Cataract and Factors Associated with Unmet Need for Cataract Surgery: Los Angeles Latino Eye Study

PURPOSE To estimate the prevalence of visually significant cataract in a US Latino population and to report predisposing, enabling, need, and health behavior characteristics associated with the unmet need for cataract surgery (UNCS). DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 6142 Latinos 40 years and older from 6 census tracts in Los Angeles County, California. METHODS Participants completed an in-home interview and a comprehensive eye examination that included assessment of lens opacification, using the slit lamp-based Lens Opacities Classification System II (LOCS II), and best-corrected visual acuity. Visually significant cataract was defined by any LOCS II grading >or=2, best-corrected visual acuity <20/40, cataract as the primary cause of vision impairment, and self-reported vision of fair or worse. Because cataract surgery is not needed in all persons, participants with a visually significant cataract or prior cataract surgery in at least 1 eye composed the at-risk cohort needing cataract surgery. Unmet need for cataract surgery was defined as any person in the at-risk cohort who had at least 1 eye with a visually significant cataract. Univariate and stepwise logistic regression analyses were used to identify predisposing, enabling, need, and health behavior characteristics associated with UNCS. MAIN OUTCOME MEASURES Prevalence of visually significant cataract and odds ratios (ORs) for factors associated with UNCS. RESULTS Of 6142 participants who completed the interview and clinical examination, 118 (1.92%) had visually significant cataract in at least 1 eye. Of the 344 participants who have needed cataract surgery, 118 (34.3%) had UNCS. Independent factors associated with UNCS included health behavior: having last eye examination >or=5 years ago compared with <1 year ago (OR, 3.76; 95% confidence interval [CI], 1.71-8.25), and enabling factors: being uninsured (OR, 2.79; CI, 1.30-5.19), income less than

Four-year incidence and progression of lens opacities: the Los Angeles Latino Eye Study.

20,000 (OR, 2.60; CI, 1.40-5.56), and self-reported barriers to eye care (OR, 2.41; CI, 1.14-5.13). CONCLUSIONS Latinos in our study had a substantial UNCS. Because Latinos with specific health behavior and enabling characteristics were more likely to have UNCS, interventions aimed at modifying these characteristics may be beneficial in reducing the unmet need and thus reducing the burden of visual impairment related to cataract in the United States.

Ocular Determinants of Refractive Error and Its Age- and Sex-Related Variations in the Chinese American Eye Study.

PURPOSE To estimate the 4-year incidence and progression of lens opacities. DESIGN Population-based longitudinal study. METHODS A total of 4658 adult Latinos from Los Angeles County were examined at baseline and 4-year follow-up. Examination included assessment of lens opacities using the Lens Opacities Classification System II (LOCS II). Incidences of cortical, nuclear, and posterior subcapsular opacities (with LOCS II scores >or=2) were defined as opacity development in persons without that opacity at baseline. Single and mixed opacities were defined in persons without any opacity at baseline. Incidence of all lens changes included development of at least 1 opacity or cataract surgery among those without any opacity at baseline. Four-year progressions were defined as increase of >or=2 in LOCS II score. RESULTS The 4-year incidence of all lens opacities was 14.2%. Four-year incidence of cataract surgery was 1.48%. The incidences were 4.1% for cortical-only, 5.8% for nuclear-only, 0.5% for PSC-only, and 2.5% for mixed. The incidences for any opacities were 7.5% for cortical, 10.2% for nuclear, and 2.5% for PSC. Incidence increased with age (P < .0001 for all). The progressions were 8.5% for cortical, 3.7% for nuclear, and 2.9% for PSC opacities. CONCLUSIONS Our Latino population had a higher incidence of nuclear than cortical opacities, but a greater progression of cortical than nuclear opacities. Incidence and progression of PSC was low. Additional understanding of the natural history and progression of various lens opacities will give us a better understanding of the pathogenesis and management of lens opacities.

The Promise of Optical Coherence Tomography Angiography in Glaucoma

Importance Uncorrected refractive error (RE) is a leading cause of visual impairment, and variations in ocular anatomy determine RE. The unique ocular determinants of RE in Chinese American individuals have not been studied previously. Objective To report ocular determinants of RE in a Chinese American population 50 years and older in Monterey Park, California. Design, Setting, and Participants The Chinese American Eye Study, a population-based, cross-sectional study, was conducted from February 1, 2010, through October 31, 2013, in Monterey Park, with this particular data analysis performed from January 1 through December 31, 2016. This study included data from 4582 participants who underwent an eye examination to obtain axial length (AL), central corneal thickness, vitreous chamber depth (VCD), anterior chamber depth (ACD), lens thickness (LT), corneal power (CP), noncycloplegic subjective refraction, and lens nuclear opalescence (NOP) grading. Data from the right phakic eye of each participant were used. Multiple regression models (standardized regression coefficients [SRCs] and semipartial correlation coefficients squared [SPCCs2]) identified key determinants of RE. Main Outcomes and Measures Ocular determinants of RE. Results Among the 4071 participants eligible for analysis (1496 men [36.7%] and 2575 women [63.3%]; mean [SD] age, 60.5 [8.1] years), mean (SD) RE was −0.52 (2.95) diopters (D), with no sex-related difference. A hyperopic shift occurred in women from −0.62 (2.95) D at 50 to 59 years to 0.60 (1.62) D at 80 years or older and in men from −0.69 (3.00) D at 50 to 59 years to 0.40 (2.29) D at 80 years or older (P < .001 for both). Compared with men, women had shorter AL (mean [SD], 23.62 [1.34] vs 24.14 [1.27] mm; P = .006), shorter ACD (mean [SD], 3.33 [0.34] vs 3.44 [0.34] mm; P < .001), and steeper CP (mean [SD], 43.50 [1.52] vs 42.88 [1.45] D; P = .02), after adjusting for age and height. No sex differences were found in VCD, LT, and NOP after height adjustment. Compared with younger individuals, older individuals had shallower ACD, thicker LT, and more NOP compared with younger individuals (P < .001 for both), even after adjustment for height. Axial length was the strongest determinant of RE (SRC = −0.92; SPCC2 = 0.55), followed by CP (SRC = −0.43; SPCC2 = 0.15). When individual components of AL were evaluated, VCD had the greatest contributing effect (SRC = −0.99; SPCC2 = 0.52), followed by CP (SRC = −0.47; SPCC2 = 0.15) and LT (SRC = −0.29; SPCC2 = 0.06). Conclusions and Relevance These data suggest that Chinese American individuals have longer AL and greater contribution of AL to RE than do Latino and other Chinese populations. Future studies should explore risk factors for increased AL in Chinese Americans and potential interventions that may ultimately prevent myopia-related disease.

Macular Microcysts In Schwartz–matsuo Syndrome

Optical coherence tomography angiography (OCTA) studies in primary open-angle glaucoma have consistently demonstrated reduced microcirculation in the superficial optic nerve, peripapillary retina, and the macula of glaucoma patients. These studies clearly demonstrate the superior resolution of OCTA compared with prior methods that were used to measure ocular blood flow (OBF) or its surrogates. How will OCTA help the glaucoma clinician now and in the future? What else must we learn before achieving more practical usefulness from OCTA for glaucoma? First, OCTA will supplement current glaucoma diagnostic tools to aid in the early detection of glaucoma. Diagnostic accuracy of OCTA vessel density measurements from small studies to date support its promise in this role, and this surely will be enhanced with ongoing improvements to OCTA hardware and software. Currently, peripapillary retinal nerve fiber layer (RNFL) and inner macula thickness measurements by OCT are routine tools to aid in the detection of glaucoma and its progression, but these are

Comparison of surgical outcomes of trabeculectomy, Ahmed shunt, and Baerveldt shunt in uveitic glaucoma

Purpose: To describe a case of macular microcysts associated with advanced secondary glaucoma from Schwartz–Matsuo syndrome. Methods: Clinical presentation, color fundus photography, optic disk photography, visual fields, and optical coherence tomography are presented. Results: A 32-year-old woman presented with advanced, unilateral secondary glaucoma associated with a macula-on rhegmatogenous retinal detachment. She was diagnosed with Schwartz–Matsuo syndrome. Spectral domain optical coherence tomography showed macular microcystic changes in the paracentral retina at the level of the inner nuclear layer. Conclusion: Macular microcystic changes in the paracentral inner nuclear layer on spectral domain optical coherence tomography have been described in eyes with optic atrophy associated with a variety of diseases. This is the first described case of macular microcysts associated with advanced secondary glaucoma from Schwartz–Matsuo syndrome and may offer insights into the pathogenesis of these microcysts.