Khanna, Cheryl L.

Background This study aimed to provide methodology to create a facial contour-informed normative 60-4 visual field and to apply the reference field to a glaucoma cohort to derive facial contour-informed 60-4 global indices. Methods Participant recruitment was completed at a tertiary medical centre. 60 eyes from 30 participants with no ocular pathology by clinical exam or optical coherence tomography were recruited for the healthy cohort. For the glaucoma cohort, 86 eyes from 43 patients diagnosed with glaucoma by clinical exam were recruited, with 30-2 visual field mean deviation used to stratify glaucoma severity. Results The median (range) age of the healthy participants was 33 (24–61) years old. A facial contour-informed 60-4 visual field reference field was developed. 43 glaucoma patients were recruited with a resulting median (range) age of 65 (30–84). Three algorithms compensating for facial contour were used for the derivation of 60-4 mean deviation and pattern SD. All mean deviation algorithms correlated with 30-2 mean deviation severity (ρ≤−0.62, p<0.0001) and retinal nerve fibre layer thickness (ρ≥0.36, p<0.05). For pattern SD, consideration of inferior nasal defects allowed correlation with both 30-2 mean deviation severity (ρ≥0.49, p<0.001) and retinal nerve fibre layer thickness (ρ≤−0.47, p<0.01). Conclusion This study provides methodology for deriving a facial contour-informed 60-4 reference field and illustrates the feasibility of applying facial contour information to refine global indices of the 60-4 visual field. Obtained metrics compensated for facial contour and correlated with functional and structural disease metrics.

Précis: Using a CNN-enhanced platform, 60-4 visual fields identified peripheral glaucomatous defects missed by central testing in mild cases; facial contour correction showed these defects occurred exclusively outside the temporal visual field. Purpose: To develop a methodology to separate facial contour-induced visual field defects from defects related to glaucoma in patients with peripheral field defects. Methods: Ninety-seven eyes from 50 patients previously diagnosed with glaucoma were enrolled in the study. Thirty-one (62%) participants were male, and 86% were white. The study involved patients with glaucoma who underwent visual field testing using standard automated perimetry, including 10-2, 24-2, 30-2, and 60-4 visual fields. A convolutional neural network (CNN)-enhanced platform, previously developed to identify facial contour-dependent defects in healthy subjects, was used to analyze the visual field data. Patients: The study included 97 eyes from 50 patients with glaucoma, with the majority having primary open angle glaucoma. Results: In 90 out of 97 eyes, there were 60-4 visual field defects. However, 20 (22%) of these eyes did not have glaucomatous defects on the 10-2 or 30-2 visual fields. All patients with 60-4 defects in the absence of more central defects had mild glaucoma, and these eyes comprised 38% of the mild glaucoma group. 60-4 visual field increased the sensitivity of identifying glaucoma in mild disease. Without facial contour, the 60-4 visual field mean threshold summation was 1099.6±346.6 dB, and decreased to 1057±331 dB when accounting for facial contour, which affected 8.03%±4.02% of test points. Facial contour-dependent visual field defects were exclusively found outside the temporal visual field. Conclusion: The study demonstrated the potential utility of 60-4 visual fields for identifying early functional glaucomatous changes that may not be detected by more central visual field tests (10-2 or 30-2). It may be important to consider peripheral visual field defects, which can be affected by facial contour, in the diagnosis and monitoring of glaucoma, particularly in mild cases.

AbstractAxenfeld‐Rieger Syndrome (ARS) type 1 is a rare autosomal dominant condition characterized by anterior chamber anomalies, umbilical defects, dental hypoplasia, and craniofacial anomalies, with Meckel's diverticulum in some individuals. Here, we describe a clinically ascertained female of childbearing age with ARS for whom clinical targeted sequencing and deletion/duplication analysis followed by clinical exome and genome sequencing resulted in no pathogenic variants or variants of unknown significance in PITX2 or FOXC1. Advanced bioinformatic analysis of the genome data identified a complex, balanced rearrangement disrupting PITX2. This case is the first reported intrachromosomal rearrangement leading to ARS, illustrating that for patients with compelling clinical phenotypes but negative genomic testing, additional bioinformatic analysis are essential to identify subtle genomic abnormalities in target genes.

Précis: Damage to disposable selective laser trabeculoplasty (SLT) lenses correlated with the amount of total laser energy. Furthermore, greater lens damage was associated with diminished patient treatment response. Purpose: Disposable SLT lenses have been observed to be damaged during use by laser, potentially affecting therapeutic response. This study sought to identify factors associated with the magnitude of lens damage and its effect on treatment outcomes. Patient and Methods: We analyzed 113 eyes from 82 patients who underwent SLT between 2020 and 2021 at an American academic medical center. For each procedure, we recorded baseline patient characteristics, procedure settings, physician age (as a possible factor causing laser defocus due to accommodation), and area of lens damage. Treatment response was calculated as the difference between preoperative and postoperative intraocular pressure (IOP). Results: Area of lens damage was associated with greater total laser energy (r=0.34, P<0.001) and greater mean energy per application (r=0.37, P<0.001). IOP reduction decreased with increasing lens damage (r=−0.19, P=0.022). Lens damage was not associated with patient characteristics indicative of glaucoma severity or user settings (physician age and slit lamp used). Greater IOP reduction was associated with higher preop IOP (r=0.46, P<0.001) and a smaller cup-to-disc ratio (r=0.22, P=0.036). IOP reduction was not associated with retinal nerve fiber layer thickness, patient age, or the number of glaucoma medications. Conclusions: Increased laser damage to disposable SLT lenses was associated with diminished treatment effect. The amount of damage was correlated with total and average laser energy, but not patient or physician factors. Overall, these findings call for reconsideration of using disposable SLT lenses as part of routine practice.

Précis: When comparing patients on systemic immunosuppressive therapy to those without, there was no difference in intraocular pressure (IOP) early after SLT; however, at 1 year following SLT, IOP was higher in the immunosuppression group compared with controls. Purpose: To determine whether patients taking systemic immunosuppressive medications have a different IOP-lowering response to selective laser trabeculoplasty (SLT) compared with a control group of patients. Methods: All patients who underwent SLT at Mayo Clinic 2017–2021 were identified. Patients on systemic immunosuppressive medications at the time of SLT were compared with control patients not receiving systemic immunosuppressive medications. The primary endpoints of this study were the percentage IOP reduction at 1 to 2, 3 to 6, and 12 months. Additional analyses included the percentage of patients who did not require additional therapy at each time point. Results: There were 108 eyes of 72 patients that underwent SLT in the immunosuppressed group and 1997 eyes of 1417 patients in the control group. There was no significant difference in age-adjusted change in IOP between groups at the first postoperative visit 1 to 2 months following SLT (−18.8±20.7% vs. −16.0±16.5%, P=0.256) or 3–6 months following SLT (−15.2±21.6% vs. −18.3±23.2%, P=0.062). However, at 12 months following SLT, the IOP reduction in the immunosuppressive therapy group was significantly less compared with the control group (−15.1±21.2% vs. −20.3±22.9%, P=0.045). There was no difference between groups in the number of additional treatments during the study intervals. Conclusion: Patients in the systemic immunosuppressive therapy group showed equivalent early IOP-lowering after SLT compared with a control group, but the treatment response was diminished at 1 year. Further studies investigating IOP regulation after SLT in immunosuppressed patients are needed.

AbstractPurpose: Evaluation of an adjustable chin rest apparatus for visual field machine.Methods: The HFA 60‐4 visual field test was performed in the primary position and then repeated in the optimum head turn angle using an adjustable chin rest to maximize a visual field for each subject. The optimum head turn angle was calculated using a 3D face model. A 3D model of the face of the subjects was reconstructed using a single facial photo and a Convolutional Neural Networks (CNN), which is a deep learning algorithm. The angles between visual axis and all points around it on the face surface were calculated and the points on the 3D face model with the angle less than 60 degrees was used to predict the optimal head turn angle. A chin rest apparatus for a visual field system was made by 3D printing. The chin rest apparatus includes a moveable chin rest insert coupled to the base and configured to be adjusted to one of a plurality of head turn angles.Results: Three eyes from three healthy subjects (2 female and 1 male) with the mean age of 27.33, CI: 7.37 were enrolled. The visual field defects cause by the facial contour of the subject was decreased by turning the subject's head relative to a vertical axis away from (nasally) the eye being tested using a visual field system with the adaptive chin rest. The mean threshold of the visual field tests of all eyes in the primary angle and optimized angle was 1496, CI: 380.22 and 1567.67, CI: 295.37 respectively. Mean of the degree of head turn to maximize the visual field for all individuals was 6.67 degrees, CI: 2.88.Conclusions: The described adaptive chin rest can be used to position a subject's head at an optimal head turn angle that minimizes the visual field defects caused by the facial contours and maximizes the measured visual field of the subject. This technology can be used in far peripheral visual field tests for early detection of glaucoma as well as accurate follow up of disease progression.

Background Despite, the potential clinical utility of 60–4 visual fields, they are not frequently used in clinical practice partly, due to the purported impact of facial contour on field defects. The purpose of this study was to design and test an artificial intelligence-driven platform to predict facial structure-dependent visual field defects on 60–4 visual field tests. Methods Subjects with no ocular pathology were included. Participants were subject to optical coherence tomography, 60–4 Swedish interactive thresholding algorithm visual field tests and photography. The predicted visual field was compared with observed 60–4 visual field results in subjects. Average and point-specific sensitivity, specificity, precision, negative predictive value, accuracy, and F1-scores were primary outcome measures. Results 30 healthy were enrolled. Three-dimensional facial reconstruction using a convolution neural network (CNN) was able to predict facial contour-dependent 60–4 visual field defects in 30 subjects without ocular pathology. Overall model accuracy was 97%±3% and 96%±3% and the F1-score, dependent on precision and sensitivity, was 58%±19% and 55%±15% for the right eye and left eye, respectively. Spatial-dependent model performance was observed with increased sensitivity and precision within the far inferior nasal field reflected by an average F1-score of 76%±20% and 70%±29% for the right eye and left eye, respectively. Conclusions This pilot study reports the development of a CNN-enhanced platform capable of predicting 60–4 visual field defects in healthy controls based on facial contour. Further study with this platform may enhance understanding of the influence of facial contour on 60–4 visual field testing.

Précis: Surgical and clinical success rates were similar among Ahmed FP7, and Baerveldt 250 and 350 glaucoma drainage devices at three years. Purpose: To compare rates of surgical and clinical success in patients with Ahmed FP7 (FP7), Baerveldt 250 (B250), or Baerveldt 350 (B350) glaucoma drainage devices (GDDs). Design: A retrospective cohort study. Methods: A total of 157 eyes of 129 adult patients with FP7, B250, B350 GDDs, and 190 eyes of 99 medically controlled glaucoma patients were enrolled at a tertiary care institution from August 2017 through July 2019. They were followed through April 2020. The main outcome measures included surgical and clinical failure. Surgical failure was defined as intraocular pressure (IOP) outside 5–21 mm Hg, IOP reduced <20% below baseline, additional glaucoma surgery, GDD removal, or no light perception. Eyes that did not meet their goal IOP ranges or required secondary glaucoma interventions were deemed clinical failures. Results: A total of 43 (12.4%) FP7, 36 (10.4%) B250, 78 (22.5%) B350, and 190 (54.8%) medically treated control eyes were enrolled. By the postoperative year 3 visit, 10 (23.2%) FP7, 11 (30.6%) B250, and 32 (41.0%) B350 eyes had met a surgical failure criterion (P=0.127). There were no significant differences in the numbers of eyes meeting their IOP target ranges (P=0.510), and rates of secondary glaucoma surgeries (P=0.270). Overall clinical success was attained among 83.3% FP7, 81.8% B250, and 68.0% B350 eyes (P=0.447). Conclusions: The GDD groups were similar in their rates of success, based on both the surgical and clinical success definitions.

Purpose: New-onset persistent diplopia has become a common complication after glaucoma drainage device (GDD) placement. Understanding the orbital anatomy of such patients may provide information regarding risk of diplopia, GDD selection, and post-operative management. The purpose of this study was to examine the orbital anatomic differences in diplopic and non-diplopic patients after GDD implantation using high-resolution MRI. Methods: Seven eyes ( N = 4 with diplopia and N = 3 without diplopia after GDD placement) of seven patients that had undergone placement of Baerveldt 250 (B250), Baerveldt 350 (B350), or Ahmed FP7 (FP7) GDD were prospectively enrolled at a single institution. All patients underwent a 3.0T orbital MRI with 3D volumetric T1 and T2 weighted sequence. Images were analyzed for orbital volume, axial length, orbital distances, presence of superior rectus-lateral rectus (SR-LR) band, position of GDD, and SR-LR angles. Results: Patients with diplopia had smaller mean ± SD orbital axial (911.5 ± 111.8 mm 3 vs 931.7 ± 79.7 mm 3 ) and coronal volumes (1162.5 ± 145.5 mm 3 vs 1180 ± 34.6 mm 3 ) compared to non-diplopic patients. Average orbital rim distances were larger for the diplopic group. The SR-LR displacement angle for diplopic patients was larger (101.6° ± 8.1 vs 94.7° ± 17.6) while the SR-LR quadrantic angle (86.6° ± 4.2 vs 89.1° ± 4.3) was smaller. SR-LR band was present and intact in all patients. GDD malpositioning was not evident in any patient. Conclusion: The decreased orbital axial and coronal volumes as well as increased orbital rim distances in diplopic patients suggests the need for further studies to understand the role of orbital anatomy in occurrence of diplopia. Dynamic MRI imaging may be helpful in identifying differences in extraocular muscle function that reveal an etiology of diplopia in patients with GDD implantation.