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PURPOSE: To evaluate the ability of macular and multifocal (mf) pattern electroretinogram (PERG) to differentiate preperimetric glaucoma (PG) and glaucoma with hemifield loss (GHL) from controls, to compare the discrimination ability of PERG and fourier-domain optical coherence tomography (FD-OCT), and to assess the relationship between measurements. PATIENTS AND METHODS: Standard automated perimetry, steady-state and transient PERG and mfPERG measurements were obtained from PG (n=14, 24 eyes), GHL (n=5, 7 eyes), and controls (n=19, 22 eyes). Circumpapillary retinal nerve fiber layer (cpRNFL), full-thickness macula, and segmented macular layer thicknesses on FD-OCT were investigated. Measurements were compared using mixed effects linear models. The relationships between measurements and the diagnostic performance of each technology were assessed. RESULTS: Compared with controls, average P50 peak time transient PERG responses were reduced in PG and GHL, whereas average latency and amplitude steady-state and mfPERG responses were abnormal only in GHL. cpRNFL and macular thickness measurements in PG and GHL differed significantly from controls. A significant relationship was found between PERG and most FD-OCT or SAP parameters. Partial least squares discriminant analysis revealed that OCT parameters, along with mfPERG and transient PERG parameters had similar ability to discriminate PG and GHL from healthy controls. CONCLUSIONS: PERG and OCT parameters may be abnormal, with significant correlations between measurements, in PG eyes. Both technologies may be useful for detection of early glaucoma.

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PURPOSE: To investigate the effects of the foveal position relative to the optic disc on the 10-2 visual field (VF) results of glaucoma patients with localized inferotemporal neuroretinal rim defects (ITD). DESIGN: Cross-sectional study. PARTICIPANTS: Fifty-seven eyes of 35 open-angle glaucoma (OAG) patients were included and divided into two groups based upon the presence (18 eyes) or not (39 eyes) of ITD. METHODS: Three different parameters obtained from a spectral domain optic coherence tomography (sdOCT) [disc-fovea angle (DFA), fovea vertical deviation (FVD) from midline, and the angular difference between the ITD border and the DFA (DAD)] were tested for their relationship with four 10-2 VF sectors: superior hemifield, superior edge, nasal edge, and superonasal arcuate. These relationships were tested with regression analyses with linear mixed effects models and random intercepts. MAIN OUTCOME MEASURES: Influences of DFA, FVD, and DAD on 10-2 VF sectors. RESULTS: Mean (±SD) values of DFA, FVD, and DAD were respectively: -5.05° ± 4.40°, -1346.6 um ± 1609.0 um, and 43.30° ± 17.33°. After adjustment for multiple comparisons, both FVD and DAD, but not DFA, were significantly associated with the severity of defects on the predefined VF sectors. Larger DAD values (third tertile: 54°-77°) showed higher coefficient estimate for the nasal edge sector sensitivities. CONCLUSIONS: The vertical foveal location and its position relative to the ITD was associated with loss of sensitivity at 10-2 VF locations in the superior hemifield. This association was significant but weak and was not seen using other conventional parameters that describe foveal position relative to the optic disc on sdOCT.

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PURPOSE: The purpose of this is to test the hypothesis the intraocular pressure (IOP) peaks during a stress test [the water drinking test (WDT)] can estimate the risk of future visual field progression in treated primary open-angle glaucoma (POAG) patients. PATIENTS AND METHODS: Design: Prospective, longitudinal study. SETTING: Clinical practice. STUDY POPULATION: Treated POAG patients whose IOP was ≤18 mm Hg and who had no IOP-lowering interventions between the date of the WDT and the last eligible visual field. INTERVENTION: At baseline examination, patients underwent the WDT and were then followed at regular intervals with office-based IOP measurements and visual field testing. MAIN OUTCOME MEASURE: Cox-proportional hazards survival analysis testing the predictive value of IOP peaks during the WDT versus IOP measurements during office hours on visual field progression. RESULTS: A total of 144 eyes of 96 patients with baseline visual field damage ranging from mild to severe followed for a mean of 28 months were analyzed. In the multivariable analysis adjusting for potential confounders, higher IOP peaks during the WDT were predictive of future visual field progression (hazard ratio=1.11; 95% confidence interval, 1.02 to 1.21; P=0.013). The average and peak IOP during office hours over the same follow-up period were not significantly associated with progression (P=0.651 and 0.569, respectively). CONCLUSIONS: IOP peaks detected with the WDT were predictive of future visual field progression in a treated POAG population. This stress test could be a useful tool for risk assessment in daily practice.

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PURPOSE: To classify the appearance of the optic disc seen on fundus photographs of healthy subjects and patients with or suspected glaucoma whose diagnosis was based upon visual fields (VFs) and spectral-domain optical coherence tomography (sdOCT) results. PATIENTS AND METHODS: One eye of 100 patients with or suspected glaucoma and 62 healthy subjects were prospectively tested with 24-2 and 10-2 VF and macular and disc sdOCT cube scans. All eyes with or suspected glaucoma had a 24-2 mean deviation better than -6.0 dB and an abnormal appearing disc on stereophotographs. The retinal ganglion cell plus inner plexiform layer (RGC+) from the macular scans and the retinal nerve fiber layer (RNFL) from the macular and disc scans were segmented and converted to probabilities plots. An eye was considered "glaucoma" if the sdOCT probability plots showed an abnormality in a region that corresponded to a defect seen on the 24-2 and/or 10-2 VF total deviation plot. Similarly, an eye was considered "suspect" only if both the sdOCT and VF plots were normal. Healthy subjects (normal VFs and sdOCT) were classified as "controls" and used as reference for comparisons. Glaucoma specialists reviewed the stereophotographs and classified eyes based on the presence of signs suggestive of glaucomatous optic neuropathy. RESULTS: The pattern of clinical signs of glaucomatous optic neuropathy seen on stereophotographs was statistically different between glaucoma (P<0.001) and suspects (P<0.001) vs. controls and explained up to 68% of the total variance of the diagnosis based upon sdOCT and VFs. Vertical cup-to-disc>0.6, focal neuroretinal rim thinning, focal RNFL loss, and violation of the ISNT rule had the best performance to differentiate glaucoma and suspects from controls. Compared with the suspect group, glaucoma eyes (abnormal sdOCT and VF tests) were more likely to have vertical cup-to-disc>0.6 (92% vs. 69%, P=0.003), diffuse rim (53% vs. 9%, P<0.001) and RNFL (61% vs. 26%, P<0.001) thinning, and ß-zone parapapillary atrophy (68% vs. 17%, P<0.001). CONCLUSIONS: Focal and diffuse signs of glaucoma damage seen on stereophotographs often match damage shown on VFs and sdOCT. In addition, damage shown on VFs and sdOCT is often missed during clinical evaluation. Longitudinal studies ought to differentiate focal signs of glaucoma damage seen on stereophotography from false-positives or very early loss.

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IMPORTANCE: There is an increasing need to prolong trabeculectomy success rates with minimally invasive procedures. OBJECTIVE: To investigate the safety and efficacy of Nd:YAG laser goniopuncture (LGP) in lowering intraocular pressure (IOP) in eyes having late bleb failure following trabeculectomy with mitomycin C administration. DESIGN, SETTING, AND PARTICIPANTS: Prospective, noncomparative, interventional cohort at a referral glaucoma practice, including 19 eyes of 19 patients with uncontrolled glaucoma after failed trabeculectomy. INTERVENTIONS: All eyes had ischemic nonfunctioning blebs with patent internal ostia and underwent Nd:YAG LGP, followed by a 5-fluorouracil injection. MAIN OUTCOMES AND MEASURES: The IOP and the number of antiglaucoma medications before and after the procedure, as well as presurgical and postsurgical appearance of the blebs, using the Indiana Bleb Appearance Grading Scale classification. RESULTS: The mean (SD) time of LGP after trabeculectomy was 35.7 (32.3) months, and the mean (SD) follow-up period after LGP was 6.0 (1.1) months (range, 4.4-8.4 months). The mean (SD) IOP had decreased from 20.9 (4.5) mm Hg (range, 15.5-29.0 mm Hg) to 11.9 (4.1) mm Hg (range, 5.0-21.0 mm Hg) (P < .001). The only complications observed after LGP were 2 cases of hypotony, which resolved spontaneously. Compared with baseline Indiana Bleb Appearance Grading Scale classifications, 2 eyes showed an increase in bleb height and 10 eyes showed an increase in bleb extension. None of the eyes had a positive Seidel test result. The mean (SD) number of hypotensive agents per eye had decreased from 0.7 (1.1) to 0.3 (0.7) after the procedure. At the last follow-up visit, 15 eyes (79%) had achieved an IOP of 15 mm Hg or less, with a minimum IOP reduction of 20% from baseline without medication use. CONCLUSIONS AND RELEVANCE: The Nd:YAG LGP is a safe and effective procedure for lowering IOP in eyes with ischemic nonfunctioning blebs and patent trabeculectomy ostia. This is a promising solution to rescue failed trabeculectomies and can potentially prolong trabeculectomy success rates.

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BACKGROUND: The water-drinking test has been used as a stress test to evaluate the drainage system of the eye. However, in order to be clinically applicable,a test must provide reproducible results with consistent measurements. This study was performed to verify the reproducibility of intraocular pressure peaks and fluctuation detected during the water-drinking test in patients with ocular hypertension and open-angle glaucoma. DESIGN: A prospective analysis of patients in a tertiary care unit for glaucoma treatment. PARTICIPANTS: Twenty-four ocular hypertension and 64 open-angle glaucoma patients not under treatment. METHODS: The water-drinking test was performed in 2 consecutive days by the same examiners in patients not under treatment. Reproducibility was assessed using the intraclass correlation coefficient. MAIN OUTCOME MEASURES: Peak and fluctuation of intraocular pressure obtained with the water-drinking test were analysed for reproducibility. RESULTS: Eighty-eight eyes from 24 ocular hypertension and 64 open-angle glaucoma patients not under treatment were evaluated. Test and retest intraocular pressure peak values were 28.38 ± 4.64 and 28.38 ± 4.56 mmHg, respectively (P = 1.00). Test and retest intraocular pressure fluctuation values were 5.75 ± 3.9 and 4.99 ± 2.7 mmHg, respectively (P = 0.06). Based on intraclass coefficient, reproducibility was excellent for peak intraocular pressure (intraclass correlation coefficient = 0.79) and fair for intraocular pressure fluctuation (intraclass correlation coefficient = 0.37). CONCLUSION: Intraocular pressure peaks detected during the water-drinking test presented excellent reproducibility, whereas the reproducibility of fluctuation was considered fair.

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BACKGROUND: To investigate the association between corneal biomechanics and optic nerve head morphology in newly diagnosed primary open-angle glaucoma patients. DESIGN: Hospital based prospective study. PARTICIPANTS: Forty-two untreated newly diagnosed primary open-angle glaucoma patients. METHODS: Patients underwent corneal hysteresis measurement using the Ocular Response Analyzer and confocal scanning laser ophthalmoscopy for optic nerve head topography evaluation. One eye was selected randomly for analysis. Data collected included age, race, gender, intraocular pressure and central corneal thickness. MAIN OUTCOME MEASURES: Multiple regression analysis (controlling for baseline intraocular pressure and disc area) was used to investigate factors associated with the following optic nerve head topographic parameters: linear cup-to-disc ratio and mean cup depth. RESULTS: Mean age of participants was 66.7 ± 11.8 years. Corneal hysteresis was the only factor significantly associated with both mean cup depth (correlation coefficient [r] = -0.34, P = 0.03) and cup-to-disc ratio (r = -0.41, P = 0.01). Central corneal thickness was significantly associated with mean cup depth (r = -0.35, P = 0.02), but not with cup-to-disc ratio (r = -0.25, P = 0.13). Although a trend towards a positive association between age and cup-to-disc ratio was identified (r = 0.26, P = 0.08), age was not significantly associated with mean cup depth (r = 0.06, P = 0.72). When comparing fellow eyes of patients with bilateral glaucoma, the eye with higher corneal hysteresis had smaller cup-to-disc ratio in 75% of the cases. CONCLUSIONS: In untreated newly diagnosed primary open-angle glaucoma patients, those with thinner corneas and mainly lower corneal hysteresis values had a larger cup-to-disc ratio and deeper cup, independently of intraocular pressure values and disc size.

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Although glaucoma is a multifactorial disease, elevated intraocular pressure (IOP) remains the most important known risk factor. Different systemic and local factors are thought to influence an individual's IOP. There can be a clinically significant rise in IOP when going from upright to horizontal or inverted body positions. Although there is a significant interindividual variability, the magnitude of the IOP change is greater in glaucomatous eyes. As patients usually spend a significant portion of their lives in the horizontal position, mainly during sleep, this is highly relevant. In this review we discuss the relationship between postural changes and IOP fluctuation, including changes in both body and head position. The possible mechanisms involved and the main implications for glaucomatous eyes are discussed. Finally, considerations with regard to sleep position in glaucoma patients are made based on evidence in the literature.

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