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PRCIS: Primary open angle glaucoma and pseudoexfoliation glaucoma showed different progression patterns of the retinal nerve fiber layer and ganglion cell-inner plexiform layer thinning in OCT-guided progression analysis. PURPOSE: To compare the patterns of progression of retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning by guided progression analysis (GPA) of optical coherence tomography (OCT) in primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG). MATERIALS AND METHODS: The progression of RNFL and GCIPL thinning was assessed by the GPA of Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA). By overlaying the acquired images of the RNFL and GCIPL thickness-change maps, the topographic patterns of progressive RNFL and GCIPL thinning were evaluated. The rates of progression of RNFL and GCIPL thinning were analyzed and compared between patients with POAG and those with PXG. RESULTS: Of the 248 eyes of 248 patients with POAG (175 eyes of 175 patients) or PXG (73 eyes of 73 patients) enrolled, 156 POAG eyes and 48 PXG eyes were included. Progressive RNFL thinning was significantly more common in PXG than in POAG ( P =0.005). According to the RNFL progression-frequency maps, progression appeared mainly in the superotemporal and inferotemporal areas in POAG, whereas it had invaded more into the temporal area in PXG. According to the GCIPL maps, progression was most common in the inferotemporal area in both POAG and PXG. The average progression rate of GCIPL thinning was faster in PXG than in POAG ( P =0.013), and when analyzed in 2 halves (superior/inferior), the progression rate of the inferior half was faster in PXG than in POAG ( P =0.011). CONCLUSIONS: OCT GPA showed progression patterns of RNFL and GCIPL thinning in POAG and PXG. Understanding the specific patterns of progressive RNFL and GCIPL thinning according to glaucoma type may prove helpful to glaucoma-patient treatment and monitoring.

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We investigated the internal morphology of filtration blebs after XEN gel stent implantation using anterior segment optical coherence tomography (AS-OCT) and identified factors related to intraocular pressure (IOP) postoperatively. Eighteen eyes of 18 patients who had undergone XEN gel stent implantation were analyzed. Blebs were imaged using Visante OCT (Carl Zeiss Meditec AG, Germany) at 6 months and 1 year after surgery and evaluated for quantitative parameters including bleb height, maximum height of internal cavity, maximum bleb wall thickness, and maximum bleb epithelial thickness. Subjects were classified into two groups according to the presence or absence of a definite internal cavity between the conjunctiva and sclera using AS-OCT imaging. Nine eyes (50%) were assigned to the internal cavity group and 9 (50%) to the uniform group. Postoperative IOP was significantly lower in the internal cavity group than in the uniform group both at 6 months and 1 year after surgery (p = 0.024 and p = 0.040). Postoperative IOP showed statistically significant negative correlations with bleb height and the height of the internal cavity (Spearman correlation coefficient r = -0.518, p = 0.028 and r = -0.453, p = 0.034, respectively). AS-OCT facilitates analysis of bleb morphology after XEN gel stent implantation. A larger height of the internal cavity of the bleb appeared to correlate with lower IOP after XEN implantation.

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PURPOSE: The purpose of this study was to report a case with bilateral paravascular inner retinal defects (PIRDs) enlarging with progressive myopia, which had different structural characteristics from the glaucomatous retinal nerve fiber layer (RNFL) defect. PATIENTS AND METHODS: A 10-year-old girl with high myopia was referred to a glaucoma clinic for evaluation of RNFL defects shown in color fundus photographs. Fundus photographs and optical coherence tomography examinations were serially reviewed to examine the changes in the RNFL. RESULTS: Cleavage of inner retinal layers involving the layers deeper than the RNFL was identified in optical coherence tomography, which appeared and enlarged in both eyes along with progressive myopia and axial elongation during the follow-up period of 8 years. CONCLUSIONS: PIRD developed and enlarged with progressive myopia and axial elongation in childhood. It should be differentiated from the widening of RNFL defect shown with glaucoma progression.

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Purpose: To predict demographic characteristics from anterior segment optical coherence tomography (AS-OCT) images of eyes using a Vision Transformer (ViT) model. Methods: A total of 2970 AS-OCT images were used to train, validate, and test a ViT to predict age and sex, and 2616 images were used for height, weight, and body mass index (BMI). The main outcome measure was the area under the receiver operating characteristic curve (AUC) of the ViT. Results: The ViT achieved the largest AUC (0.910) for differentiating age ≤75 versus >75 years, followed by age ≤60 versus 60-75 versus >75 years (AUC, 0.844), and for discriminating sex (AUC, 0.665). The prediction abilities for the other demographic characteristics were lower: an AUC of 0.521 for classifying height ≤170 versus >170 cm in males and ≤155 versus >155 cm in females; 0.522 for weight <70 versus ≥70 kg in males and 0.503 for <55 versus ≥55 kg in females, and 0.517 for BMI <23 versus 23-25 versus ≥25 kg/m2. Heatmaps highlighted the area of the iridocorneal angle for its contribution to the prediction of age ≤75 versus >75 years. Conclusions: Although the ViT demonstrated a good ability to classify age from AS-OCT images, it performed poorly for sex, height, weight, and BMI. The heatmap obtained of the prediction will provide clues to understanding the age-related anterior segment changes in eyes. Translational Relevance: The ViT can determine age-related anterior segment structural changes using AS-OCT images, which will aid clinicians in the management of ocular diseases.

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PRCIS: Optic coherence tomography imaging in preperimetric open angle glaucoma (OAG) differed between young-age-onset and old-age-onset eyes. Inferior and superior quadrants were thinner in young and old-age-onset eyes, respectively. Understanding the specific patterns of early glaucomatous damage based on age-at-onset may improve glaucoma diagnosis and monitoring. PURPOSE: To investigate the patterns of retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning in preperimetric OAG by optical coherence tomography based on age at onset ("young-age onset (<40 y)" vs. "old-age onset (≥40 y)". MATERIALS AND METHODS: The RNFL and GCIPL deviation images were acquired by Cirrus HD-optical coherence tomography, and overlaid, thus converted to a "deviation frequency map", respectively. The topographic thinning patterns and parameters of RNFL and GCIPL thickness measurements were compared. RESULTS: A total of 194 eyes of 194 patients with preperimetric OAG and 97 eyes of 97 age-matched normal subjects were analyzed. Young-age-onset eyes of preperimetric OAG mainly had RNFL defects inferotemporally (264-296 degrees) with GCIPL defects in the inferior region (213-357 degrees). Old-age-onset preperimetric OAG eyes had RNFL defects inferotemporally (266-294°) and superotemporally (33-67 degrees), with GCIPL defects in the inferior and superior regions (206-360 degrees, 0-22 degrees). The inferior quadrant of RNFL and GCIPL thicknesses were significantly thinner in young-age-onset eyes compared with old-age-onset eyes ( P =0.012, 0.016), while the superior quadrant of those were significantly thinner in the old-age-onset eyes ( P =0.003, 0.005). CONCLUSION: Young-age-onset and old-age-onset eyes of preperimetric OAG present different specific patterns of RNFL and GCIPL thinning.

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Purpose: To compare the clinical outcomes of maximum tolerated medical therapy (MTMT) in patients with penetrating keratoplasty (PKP) with those of Ahmed glaucoma valve (AGV) implantation. Methods: The medical records were retrospectively reviewed in patients who had undergone PKP for bullous keratopathy and were treated with MTMT or AGV implantation for the management of glaucoma. A total of 18 bullous keratopathic patients were investigated between January 2010 and February 2017: 9 patients treated with MTMT and 9 patients treated with AGV implantation. Non-corrected visual acuity (NCVA), intraocular pressure (IOP), endothelial cell density (ECD), hexagonality, coefficient of variation (CV), central corneal thickness (CCT), median survival time of the graft, and the presence of epithelial keratopathy were compared between the groups at each time point or between baseline and after treatment of glaucoma in each group. Results: There were no significant differences in the visual acuity and corneal thickness between the two groups or within each group over time. Both groups showed a significant reduction in IOP compared with the baseline IOP, and IOP reductions were greater in the AGV group than in the MTMT group (p = 0.040). Significant ECD reductions were found in each group between the baseline and 6 months (p = 0.008 in the MTMT group, p = 0.015 in the AGV group); however, no differences were found between the two groups until 12 months. The significant hexagonality reduction was found in the AGV group between the baseline and 12 months (p = 0.018). The median survival time showed no significant difference in the survival analysis. Conclusions: Maximum tolerated medical therapy in penetrating keratoplasty for bullous keratopathy seems to similarly affect the endothelial cell density or graft survival when compared with at least 12 month-followed Ahmed glaucoma valve implantation.

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PURPOSE: Development and validation of a decision tree model (DTM) for prediction of mental health status in Korean caregivers of children with glaucoma. DESIGN: Cross-sectional study. METHODS: Caregivers of children younger than 18 years with diagnosed primary childhood glaucoma (n = 42), secondary childhood glaucoma (n = 51), and glaucoma suspect (GS; n = 36) were prospectively enrolled at Seoul National University Children's Hospital, Seoul, Korea. The participants completed 2 questionnaires, the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7) Assessment. A DTM analysis for discrimination of those with moderate-to-severe depressive (PHQ-9 score ≥10) and anxiety (GAD-7 score ≥11) symptoms was performed with recursive partitioning algorithms based on the obtained clinical, demographic, and socioeconomic data. RESULTS: The mean PHQ-9 and GAD-7 scores did not significantly differ among the 3 groups (P = .823 for PHQ-9 score; P = .730 for GAD-7 score). The DTM's balanced accuracies were 0.875 (95% CI = 0.778-0.972) for the PHQ-9 score and 0.880 (95% CI = 0.800-0.960) for theGAD-7 score. The DTM of the PHQ-9 revealed that in caregivers of children with glaucoma, depressive symptoms should be strongly suspected when (1) the child has undergone more than 2 glaucoma surgeries; or (2) the visual acuity (VA, converted to logarithm of minimum angle of resolution [logMAR]) in the better eye is worse than 0.4 if the child has had only 1 or no surgery. CONCLUSIONS: Evaluation of the number of glaucoma surgeries and VA in the better eye can be a useful decision support tool in predicting mental illness in caregivers of children with glaucoma.

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Rho-associated coiled-coil kinase (ROCK) signaling can affect glaucoma risk by regulating trabecular meshwork outflow. We investigated the effect of ROCK gene polymorphism on the risks of primary open-angle glaucoma (POAG) and POAG-related phenotypes including intraocular pressure (IOP) in a Korean population. A total of 24 single-nucleotide polymorphisms (SNPs) from ROCK1 and ROCK2 were selected and genotyped for 363 POAG patients and 213 healthy controls. Among the 363 POAG patients, 282 were normal-tension glaucoma (NTG, baseline IOP ≤ 21 mmHg) and 81 were high-tension glaucoma (HTG, baseline IOP > 21 mmHg). The SNPs rs288979, rs1006881, rs35996865, rs10083915, and rs11873284 in ROCK1 (tagged to each other, r2 = 1) were nominally associated with risk of HTG (OR = 0.52, p = 0.045). However, there were no SNPs that were significantly associated with the risk of NTG. In the genotype-phenotype correlation analysis, the SNPs rs2230773 and rs3771106 in ROCK2 were significantly correlated with central corneal thickness (CCT)-adjusted IOP (p = 0.024) and axial length (AXL; p = 0.024), respectively. The present data implicated the role of ROCK in POAG development, and as such, can serve as a good reference for upcoming Rho/ROCK-pathway-related studies on POAG.

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PURPOSE: We sought to compare the efficacy as well as the safety of two maximum medical therapy combinations applied to lower the intraocular pressure (IOP) in different primary open-angle glaucoma (POAG) age groups. METHODS: This was a retrospective, consecutive case series study that included 60 eyes of 60 subjects with POAG, specifically 20 subjects aged 40 to 54 years, 21 aged 55 to 69 years, and 19 aged 70 years or older. All had been treated for at least 12 months with triple maximum medical therapy (TMT; dorzolamide/timolol, brimonidine, and latanoprost) to lower their IOP, which subsequently was changed to double maximum medical therapy (DMT, fixed drug combinations of tafluprost/timolol and brinzolamide/brimonidine). The rate of IOP change and adverse drug reactions were compared amongst the three age groups. RESULTS: The mean IOP change at three months after converting from TMT to DMT was -0.65 ± 1.42 mmHg (-3.84% ± 9.31%) among the overall study group, but this finding was not statistically significant (p = 0.108). In the 40 to 54 years and 55 to 69 years groups, the mean IOP change rates were +0.29 ± 0.96 mmHg (+2.40% ± 6.85%, p = 0.087) and -0.50 ± 0.99 mmHg (-3.05% ± 6.40%, p = 0.084) respectively. In the 70 years or older group, the mean IOP change, interestingly, was -1.80 ± 1.46 mmHg (-11.29% ± 9.31%, p < 0.001) and nine (47.4%) of the 19 subjects showed additional IOP reductions of 10% or more after converting from TMT to DMT. In all three age groups, the incidence rate of dry eye was significantly lower for DMT than for TMT (p = 0.031). CONCLUSIONS: In POAG patients, DMT was proven to be both effective and safe for lowering the IOP, especially in those 70 years or older group, when compared with the TMT protocol.

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