Takuhei Shoji

Progressive Macula Vessel Density Loss in Primary Open-Angle Glaucoma: A Longitudinal Study

PURPOSEnTo characterize the rate of macula vessel density loss in primary open-angle glaucoma (POAG), glaucoma-suspect, and healthy eyes.nnnDESIGNnLongitudinal, observational cohort from the Diagnostic Innovations in Glaucoma Study.nnnMETHODSnOne hundred eyes (32 POAG, 30 glaucoma-suspect, and 38 healthy) followed for at least 1 year with optical coherence tomography angiography (OCT-A) imaging on at least 2 visits were included. Vessel density was calculated in the macula superficial layer. The rate of change was compared across diagnostic groups using a multivariate linear mixed-effects model.nnnRESULTSnBaseline macula vessel density was highest in healthy eyes, followed by glaucoma-suspect and POAG eyes (P < .01). The rate of vessel density loss was significantly different from zero in the POAG, but not in the glaucoma-suspect or healthy eyes. The mean rate of change in macula whole en face vessel density was significantly faster in glaucoma eyes (-2.23%/y) than in glaucoma-suspect (0.87%/y, Pxa0= .001) or healthy eyes (0.29%/y, Pxa0= .004). Conversely, the rate of change in ganglion cell complex (GCC) thickness was not significantly different from zero in any diagnostic group, and no significant differences in the rate of GCC change among diagnostic groups were found.nnnCONCLUSIONSnWith a mean follow-up of less than 14xa0months, eyes with POAG had significantly faster loss of macula vessel density than either glaucoma-suspect or healthy eyes. Serial OCT-A measurements also detected glaucomatous change in macula vessel density in eyes without evidence of change in GCC thickness.

Phacoviscocanalostomy versus cataract surgery only in patients with coexisting normal-tension glaucoma: Midterm outcomes

PURPOSE: To compare the midterm efficacy and safety of phacoviscocanalostomy (viscocanalostomy, phacoemulsification, and intraocular lens [IOL] implantation) and cataract surgery (phacoemulsification and IOL implantation) in patients with normal‐tension glaucoma (NTG) and cataract. SETTING: Sensho‐kai Eye Institute, Kyoto, Japan. METHODS: Thirty‐one eyes had phacoviscocanalostomy, and 35 eyes had uncomplicated cataract surgery only. The intraocular pressure (IOP), postoperative antiglaucoma medications, and visual outcomes were compared between groups. RESULTS: The mean follow‐up was 34.9 months ± 19.8 (SD) (range 7 to 78 months). At 36 months, the mean preoperative IOP and postoperative IOP were 17.2 ± 1.5 mm Hg and 14.1 ± 1.6 mm Hg, respectively, in the phacoviscocanalostomy group and 16.7 ± 1.4 mm Hg and 15.6 ± 3.4 mm Hg, respectively, in the cataract surgery only group. The differences between groups were significant at all time points (P<.05). The success probabilities of the phacoviscocanalostomy group achieving 20% and 30% IOP reductions with (or without) medications were 78.5% (67.4%) and 35.5% (37.4%) at 24 months and 58.0% (44.2%) and 28.0% (26.6%) at 48 months, which were significantly better than the probabilities in the cataract surgery only group, which were 16.0% (9.5%) and 5.7% (2.9%) at 24 months (P<.001 for each comparison, Kaplan‐Meier life‐table analysis with log‐rank test). Based on the modified Aulhorn‐Greve classification, the visual acuity and visual fields did not deteriorate in the phacoviscocanalostomy group; the visual fields deteriorated in 6 eyes in the cataract surgery only group during the follow‐up (P = .024). CONCLUSION: Phacoviscocanalostomy lowered IOP and maintained postoperative visual outcomes; it was safe and effective in elderly patients with coexisting NTG and cataract.

Reproducibility of Optical Coherence Tomography Angiography Macular and Optic Nerve Head Vascular Density in Glaucoma and Healthy Eyes

Purpose: Optical coherence tomography angiography (OCT-A) is a noninvasive technology that allows visualization of retinal blood vessels. It is important to determine reproducibility of measurements as low precision can impair its diagnostic capabilities. The purpose of this study is to determine intravisit and intervisit reproducibility of optic nerve head (ONH) and macular vessel density measurements with OCT-A. Patients and Methods: Fifteen healthy volunteers and 14 glaucoma patients completed 2 OCT-A (AngioVue; Optovue Inc.) scanning sessions on each of 2 separate days to assess intravisit and intervisit reproducibility. A series of ONH and macula scans were acquired at each session. Vessel density (%), the proportion of vessel area over the total measurement area was calculated. Reproducibility was summarized using coefficients of variation (CV) and intraclass correlation coefficients calculated from variance component models. Results: In healthy eyes, the CV of intravisit and intervisit global vessel density measures ranged from 1.8% to 3.2% in ONH scans and 2.5% to 9.0% in macular scans. In glaucoma eyes, the CV of intravisit and intervisit global vessel density measures ranged from 2.3% to 4.1% in ONH scans and 3.2% to 7.9% in macular scans. CVs were lower for global than sectorial measures. Global OCT-A ONH intraclass correlation measurements for the retinal nerve fiber layer in healthy eyes were lower (range: 0.65 to 0.85) than in glaucoma eyes (range: 0.89 to 0.94). Scan size did not make large differences in measurement CVs. Conclusions: Reproducibility of OCT-A ONH and macula vessel density measurements is good. Moreover, glaucoma patients have sparser vessel density with poorer reproducibility than healthy subjects.

Modified deep sclerectomy (D-lectomy MMC) for primary open-angle glaucoma: preliminary results.

PurposeTo evaluate the outcome of modified deep sclerectomy [D-lectomy mitomycin C (MMC)] for medically refractory glaucoma patients. MethodsIn a retrospective comparative study, the surgical outcome in 1 eye each of 31 patients who underwent D-lectomy MMC was compared with that of 91 eyes of 91 patients who underwent trabeculectomy with adjunctive MMC. These eyes had a diagnosis of primary open-angle glaucoma or pseudoexfoliation glaucoma, a record of high intraocular pressure (IOP) exceeding 25u2009mm Hg, and planned for surgical intervention. In the D-lectomy MMC cases, a slit incision at the trabecular meshwork and peripheral iridectomy were created. The “lake” and trabeculo-Descemet membrane (“window”) were examined by ultrasound biomicroscope, gonioscopy, and time-domain optical coherence tomography. ResultsPostsurgical IOP at 1, 3, 6, and 12 months after the D-lectomy MMC and trabeculectomy MMC were comparable (P=0.63-0.97). The filtering bleb was noted in 14 (45%) of the 31 D-lectomy MMC eyes at 3 months, and their survival was significantly less than trabeculectomy MMC subjects in which 81 of 91 eyes had the bleb at 3 months (P<0.0001). The lake was noted in 29 of 31 D-lectomy MMC eyes. The sealing of the once penetrated trabecular meshwork was complete at 3 months in 23 of 29 eyes by ultrasound biomicroscopic and/or gonioscopic examinations, whereas that was incomplete in 6 eyes. ConclusionsAddition of a slit incision to the trabecular meshwork and peripheral iridectomy (D-lectomy MMC) improved postsurgical IOP of the deep sclerectomy to the level comparable with trabeculectomy MMC, with a less frequency of the bleb formation.

Risk factors for uncontrolled intraocular pressure after phacoviscocanalostomy.

PurposeTo determine factors affecting the outcome of phacoviscocanalostomy in patients with cataract and primary open-angle glaucoma. MethodsFactors for controlling intraocular pressure (IOP) were investigated in 180 patients using Cox multivariate proportional hazards survival regression. ResultsThe mean preoperative IOP of 20.2±3.8u2009mm Hg decreased significantly (P<0.0001) to 15.3±2.6u2009mm Hg for 5 years postoperatively. The success probabilities defined as an IOP of 17u2009mm Hg or less or a 20% or greater reduction were 47.2% with or without medications and 31.4% without medications at 5 years. Preoperative IOP level [P=0.0013; odds ratio (OR), 1.14] and age (P=0.037; OR, 0.97) were risk factors in the success probability with or without medications. In the analysis without medications, the preoperative IOP (P<0.001; OR, 1.12), the preoperative number of antiglaucoma medications (P=0.033; OR, 1.27), age (P=0.003; OR, 0.96), and IOP spikes (P=0.028; OR, 1.22) were associated with failure. Sex, peeling of juxtacanalicular tissue, ruptured Descemet membrane, fibrin formation, and hyphema did not affect surgical outcomes. ConclusionsHigh preoperative IOP, the number of preoperative medications, postoperative IOP spikes (>30u2009mm Hg) increased the risk of failed IOP control after phacoviscocanalostomy. Increasing patient age decreased the risk of failure.

Macular and Optic Nerve Head Vessel Density and Progressive Retinal Nerve Fiber Layer Loss in Glaucoma

PURPOSEnTo investigate prospectively the relationship between macular and peripapillary vessel density and progressive retinal nerve fiber layer (RNFL) loss in patients with mild to moderate primary open-angle glaucoma.nnnDESIGNnProspective, observational study.nnnPARTICIPANTSnOne hundred thirty-two eyes of 83 patients with glaucoma followed up for at least 2 years (average: 27.3±3.36 months).nnnMETHODSnMeasurements of macular whole image vessel density (m-wiVD) and optic nerve head whole image vessel density (onh-wiVD) were acquired at baseline using OCT angiography. RNFL, minimum rim width (MRW), and ganglion cell plus inner plexiform layer (GCIPL) thickness were obtained semiannually using spectral-domain OCT. Random-effects models were used to investigate the relationship between baseline vessel density parameters and rates of RNFL loss after adjusting for the following confounding factors: baseline visual field mean deviation, MRW, GCIPL thickness, central corneal thickness (CCT), and mean intraocular pressure during follow-up and disc hemorrhage, with or without including baseline RNFL.nnnMAIN OUTCOME MEASURESnEffects of m-wiVD and onh-wiVD on rates of RNFL loss over time.nnnRESULTSnAverage baseline RNFL thickness was 79.5±14.8 μm, which declined with a mean slope of -1.07 μm/year (95% confidence interval, -1.28 to -0.85). In the univariate model, including only a predictive factor and time and their interaction, each 1% lower m-wiVD and onh-wiVD was associated with a 0.11-μm/year (P < 0.001) and 0.06-μm/year (Pxa0= 0.031) faster rate of RNFL decline, respectively. A similar relationship between low m-wiVD and onh-wiVD and faster rates of RNFL loss was found using different multivariate models. The association between vessel density measurements and rate of RNFL loss was weak (r2xa0= 0.125 and r2xa0= 0.033 for m-wiVD and onh-wiVD, respectively). Average CCT also was a predictor for faster RNFL decline in both the univariate (0.11xa0μm/year; P < 0.001) and multivariate models.nnnCONCLUSIONSnLower baseline macular and optic nerve head (ONH) vessel density are associated with a faster rate of RNFL progression in mild to moderate glaucoma. Assessment of ONH and macular vessel density may add significant information to the evaluation of the risk of glaucoma progression and prediction of rates of disease worsening.

Inter-eye Asymmetry of Optical Coherence Tomography Angiography Vessel Density in Bilateral Glaucoma, Glaucoma Suspect, and Healthy Eyes

PURPOSEnTo investigate inter-eye retinal vessel density asymmetry in healthy, glaucoma suspect, and mild-to-moderate glaucoma subjects, and its potential utility for early detection of glaucomatous damage.nnnDESIGNnCross-sectional study.nnnMETHODSnIn 153 subjects including 55 healthy, 32 glaucoma suspect, and 66 glaucoma subjects enrolled in the Diagnostic Innovations in Glaucoma Study (DIGS), vessel density was obtained from optical coherence tomography angiography (OCT-A) macular and optic nerve head scans. Thickness of peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (mGCC) was measured with spectral-domain optical coherence tomography (SD-OCT) scans. Inter-eye asymmetry was calculated by taking the absolute value of difference in vessel density and thickness between the right and left eyes.nnnRESULTSnInter-eye retinal vessel density asymmetry parameters were significantly different among the 3 groups. Glaucoma suspects had significantly higher peripapillary and macular inter-eye vessel density asymmetries compared to healthy groups in univariate (1.1% vs 2.0%, Pxa0= .014 and 1.2% vs 2.5%, Pxa0= .027, respectively) and multivariate analyses (Pxa0= .007 and Pxa0= .038, respectively). No significant differences in asymmetry of thickness parameters were found between glaucoma suspect and healthy groups (all P > .718). However, significant differences in asymmetry of thickness parameters between glaucoma suspects and glaucoma patients (P < .01) were found for all parameters.nnnCONCLUSIONnInter-eye vessel density asymmetry can be quantified by OCT-A measurement. Glaucoma suspects have significantly greater vessel density asymmetry than healthy eyes. Longitudinal studies are needed to better characterize the relationship of vessel density asymmetry with the development and progression of glaucoma.

In vivo crystalline lens measurements with novel swept-source optical coherent tomography: an investigation on variability of measurement

Objective To evaluate the reproducibility of in vivo crystalline lens measurements obtained by novel commercially available swept-source (SS) optical coherence tomography (OCT) specifically designed for anterior segment imaging. Methods and analysis One eye from each of 30 healthy subjects was randomly selected using the CASIA2 (Tomey, Nagoya, Japan) in two separate visits within a week. Each eye was imaged twice. After image scanning, the anterior and posterior lens curvatures and lens thickness were calculated automatically by the CASIA2 built-in program at 0 dioptre (D) (static), −1 D, −3 D and −5 D accommodative stress. The intraobserver and intervisit reproducibility coefficient (RC) and intraclass correlation coefficient (ICC) were calculated. Results The intraobserver and intervisit RCs ranged from 0.824 to 1.254u2009mm and 0.789 to 0.911u2009mm for anterior lens curvature, from 0.276 to 0.299u2009mm and 0.221 to 0.270u2009mm for posterior lens curvature and from 0.065 to 0.094u2009mm and 0.054 to 0.132u2009mm for lens thickness, respectively. The intraobserver and intervisit ICCs ranged from 0.831 to 0.865 and 0.828 to 0.914 for anterior lens curvature, from 0.832 to 0.898 and 0.840 to 0.933 for posterior lens curvature and from 0.980 to 0.992 and 0.942 to 0.995 for lens thickness. High ICC values were observed for each measurement regardless of accommodative stress. RCs in younger subjects tended to be larger than those in older subjects. Conclusions This novel anterior segment SS-OCT instrument produced reliable in vivo crystalline lens measurement with good repeatability and reproducibility regardless of accommodation stress.

Prospective evaluation of factors associated with post-LASIK corneal birefringence with scanning laser polarimetry.

PurposeTo identify factors that affect corneal birefringence, such as the corneal polarization axis (CPA) and corneal polarization magnitude (CPM), after laser in situ keratomileusis (LASIK) using scanning laser polarimetry with a variable corneal polarization compensator. MethodsThe CPA and CPM from 42 patients (42 eyes) who underwent LASIK and 24 normal untreated subjects (24 eyes) were measured 1 week before and 1 week after LASIK. Changes in the CPA and CPM after LASIK were studied using Student t test and Pearson correlation coefficient. ResultsIn the LASIK group, the post-LASIK CPA and CPM significantly changed, whereas both values did not change in normal subjects. Among 5 candidate factors [preoperative CPA (pre-CPA), preoperative CPM (pre-CPM), age, change in corneal curvature, and ablation depth], the change in CPA was significantly correlated with the pre-CPA (r=−0.793) and pre-CPM (r=0.339). The change in CPM was correlated with the pre-CPA (r=−0.455) and pre-CPM (r=−0.411). Over 83% case of postoperative corneal birefringence can be explained by only 2 parameters with regression analysis. ConclusionsThe pre-CPA and pre-CPM are strongly associated with LASIK-induced changes in CPA and CPM. Variations in age, changes in corneal curvature, and ablation depth do not contribute to changes in either parameter.

Optic disc microvasculature dropout in primary open-angle glaucoma measured with optical coherence tomography angiography

Purpose To evaluate microvasculature dropout in the optic disc (Mvd-D) using optical coherence tomography angiography (OCTA) and investigate factors associated with Mvd-D in primary open-angle glaucoma (POAG) eyes. Methods One hundred twenty-three eyes of 123 POAG patients were included from the Diagnostic Innovations in Glaucoma Study. The 3.0×3.0-mm optic nerve head OCTA scans were acquired using a spectral-domain OCT instrument. Images with whole-signal-mode were evaluated. Eyes were classified into 3 categories (Mvd-D, pseudo-Mvd-D, and no Mvd-D). Mvd-D and pseudo-Mvd-D had complete loss of OCTA signals on the temporal side of the optic disc on the en face projection image. They were distinguished base on the visualization of the anterior lamina cribrosa in the horizontal B-scans of that area. No Mvd-D was defined when no complete signal loss of OCTA signals was observed. Covariates including focal lamina cribrosa defects assessed by swept-source OCT and microvasculature dropout in the parapapillary region (Mvd-P) were analyzed. Results Forty-two, 37, and 44 eyes were identified as having Mvd-D, pseudo-Mvd-D, and no Mvd-D, respectively. The eyes with Mvd-D showed significantly lower intraocular pressure, worse visual field mean deviation, larger cup-to-disc ratio, thinner circumpapillary retinal nerve fiber layer (cpRNFL), and lower circumpapillary vessel density within the RNFL than the eyes with pseudo-Mvd-D or the eyes without Mvd-D. Multivariable logistic regression analysis showed significant associations of Mvd-D with larger cup-to-disc ratio (OR, 1.08; P = 0.001), worse visual field mean deviation (OR, 1.09; P = 0.048), higher prevalence of focal lamina cribrosa defect (OR, 9.05; P = 0.002), and higher prevalence of Mvd-P (OR, 10.33; P <0.001). Conclusions OCTA-derived Mvd-D was strongly associated with the presences of Mvd-P and focal lamina cribrosa defects, and these 3 findings were topographically associated with each other.