British Journal of Ophthalmology

This prospective, multicenter, real-world evidence study evaluates the 12-month safety and effectiveness of standalone cyclodialysis with AlloFlo cleft reinforcement for intraocular pressure (IOP) reduction in open-angle glaucoma (OAG). AlloFlo represents the worlds first acellular, allogenic scleral tissue implant, and data from this CREST Study cohort (NCT05506423) contribute critical long-term safety and effectiveness knowledge to the field of extracellular matrix biomaterials research, in addition to describing a novel procedure for surgical management of OAG. Eyes with investigator-confirmed inadequately controlled OAG were treated with standalone cyclodialysis using a microsurgical cannula (CycloPen), followed by uveoscleral cleft reinforcement with AlloFlo. Eyes were followed prospectively for 12 months. Key outcomes included changes in medicated IOP, number of glaucoma medications, adverse events, and progression to subsequent glaucoma procedures. Forty-one eyes of 38 patients were included. Most eyes (66%) were considered treatment-refractory, defined as having any of: failed [&ge;] 1 incisional surgery or cilioablative procedure; condition in which incisional surgery would be more likely to fail than in eyes with uncomplicated OAG. At 12 months, mean IOP decreased 31% to 14.7 {+/-} 6.9 mmHg (within the normal IOP range of 10-20 mmHg, p < 0.001); mean number of glaucoma medications decreased 32% to 1.9 {+/-} 1.6 (p < 0.001). Seventy-one percent of eyes achieved [&ge;] 20% IOP reduction (a clinically meaningful benchmark set by the FDA). More than half of eyes (53%) achieved [&ge;] 20% IOP reduction without increasing medication. Three eyes (7.2%) progressed to incisional glaucoma surgery. Postoperative IOP elevations [&ge;] 10 mmHg occurred in 17% of eyes, most of which resolved within 30 days of the procedure. No persistent inflammation, implant rejection, clinically significant hyphema, or scaffold migration occurred. These findings suggest that uveoscleral outflow enhancement with AlloFlo provides a safe, conjunctiva-sparing option for IOP reduction in OAG, including eyes with prior surgical interventions.

BackgroundAchieving precise postoperative refractive outcomes remains a significant challenge in cataract surgery. While advanced intraocular lens (IOL) power calculation formulas exist, they are constrained by their singular algorithmic structures. This study investigated whether a stacking ensemble machine learning approach could overcome these limitations. MethodsA dataset of 1,710 eyes from patients who underwent cataract surgery with monofocal IOL implantation (Vivinex or SA60AT) was utilized. Following rigorous preprocessing and feature engineering, a stacking ensemble architecture was developed comprising three diverse base learners (Multi-Layer Perceptron, Support Vector Regressor with RBF kernel, and SplineTransformer with Linear Regression) and a Ridge Regressor meta-learner. The model was trained on 80% of the data using 5-fold cross-validation and evaluated on an independent 20% test set (n=341). Performance was compared against six standard IOL formulas. ResultsThe stacking ensemble model demonstrated excellent predictive accuracy, achieving a Mean Absolute Error (MAE) of 0.272 D on the independent test set (n=341). The model achieved lower MAE compared to all six standard IOL formulas, including Kane (MAE 0.295 D) and Barrett Universal II (MAE 0.318 D). Clinically, 85.1% of eyes achieved predictions within {+/-}0.50 D, compared to 82.5% for Kane formula and 81.8% for Barrett Universal II. ConclusionThe stacking ensemble machine learning model significantly enhances postoperative refraction prediction accuracy compared to established IOL calculation formulas. By leveraging algorithmic diversity and data-driven learning, this approach represents a promising advancement toward reducing refractive surprises and improving patient satisfaction in cataract surgery. External validation on independent datasets is required to confirm generalizability.

PurposeTo demonstrate that the total loss of astigmatism as a consequence of misalignment or rotation of a toric intraocular lens (tIOL) can occur much earlier than the widely believed and taught 30 degrees. To give a precise surgically useful estimate of that value. To clarify the role of mismatch and misalignment of toric intraocular lenses in cataract surgery beyond what is commonly recognized in the literature and make corresponding surgical recommendations. SettingPrivate Practice and Research Center. The EYE Center. Champaign, IL, USA. DesignFormal Analytical Study MethodsThe astigmatism addition approach is used in its simplest form along with analytical tools to derive new results concerning mismatch, misalignment and rotation of toric intraocular lenses. ResultsThe often stated results of total loss of astigmatic correction by 30-degree rotation and 3.3 % loss per degree represent a usually poor approximation to realistic surgical cases. We show how they constitute a very special case in the context of a more general framework relevant to procedures performed by refractive cataract surgeons dealing with the surgical correction of astigmatism with tIOLs. Total loss of astigmatic correction can occur with as little as 20 degrees of misalignment and less than 10 degrees of tIOL rotation. A practical approximation for that angle of doom, {Delta}, in the surgically relevant range can be expressed by{Delta} {approx} 30 - 15{omega} degrees, where [Formula] is the fractional overcorrection of L, the cylinder of the tIOL, and A, the astigmatism to be corrected. Similarly for undercorrection we show that{Delta} {approx} 30 + 15 u degrees where [Formula] represents the corresponding fractional undercorrection. That is to say the angle of doom is extended beyond the 30 degrees for cases of undercorrection of the astigmatism. We also demonstrate that overcorrection of astigmatism results in a significantly faster decline in astigmatism correction per degree of misalignment/rotation. The significant clinical implications and surgical recommendations, including for optimal degree of overcorrection, are a natural consequence of these novel results. ConclusionsTotal loss of astigmatism correction can occur at a significantly smaller angle than commonly believed and overcorrected astigmatism residual rises with tIOL misalignment or rotation significantly faster than undercorrected astigmatism. We provide the methodology and explicit solution for determining this behavior.

PurposeTo compare the efficacy of Ex-PRESS implantation to trabeculectomy with mitomycin C, for maintaining low target intraocular pressure (IOP) in patients with open angle glaucoma. Materials and MethodsPatients were randomly assigned to receive Ex-PRESS implantation or trabeculectomy. Patients with IOP [&ge;] 15 mmHg were included in this study. Surgical success was defined according to three target mean IOP ranges (5 mmHg [&le;] IOP [&le;]18 mmHg [criterion A], 5 mmHg [&le;] IOP [&le;]15 mmHg [criterion B], and 5 mmHg [&le;] IOP [&le;]12 mmHg [criterion C]) representing reductions of at least 20% below baseline on two consecutive follow-up visits 3 months post surgery. ResultsA total of 73 patients, including 30 in the Ex-PRESS implantation group and 43 in the trabeculectomy group, were included in the study. The baseline IOP was 20.4 {+/-} 4.9 mmHg in the Ex-PRESS implantation group and 21.9 {+/-} 7.9 mmHg in the trabeculectomy group. There were no significant differences in baseline ocular or demographic characteristics between the two groups. There was no statistical difference in IOP every 6 months. After the 3-year follow-up, success rates were A) 60.0% and 60.2%, B) 45.7% and 58.1%, and C) 31.5% and 40.5% for the Ex-PRESS implantation and trabeculectomy groups, respectively. A greater number of glaucoma medications before surgery was associated with a higher failure rate in the trabeculectomy group but not the Ex-PRESS implantation group. ConclusionsBoth procedures resulted in similar IOP reductions and success rates for low target IOP. The number of preoperative glaucoma medications was a risk factor for trabeculectomy failure.

PurposeInvestigate the effects of myopia and glaucoma in the prelaminar neural canal and anterior lamina cribrosa using 1060-nm swept-source optical coherence tomography DesignRetrospective, cross-sectional study MethodsO_ST_ABSSettingC_ST_ABSClinical practice Patient or study population19 controls (38 eyes); 38 glaucomatous subjects (63 eyes). Inclusion criteria for glaucomatous subjects: i) optic disc neural rim loss; ii) peripapillary nerve fibre layer (NFL) loss on spectral domain optical coherence tomography (SD-OCT); iii) glaucomatous visual field defect with an abnormal pattern standard deviation (P<.05); iv) stable SD-OCT, visual field, and optic disc clinical examination for 6 or more months. Inclusion criteria for control subjects: no evidence of retinal or optic nerve pathology. Exclusion criteria: i) retinal diseases or optic neuropathy other than primary open-angle glaucoma; ii) intraocular pressure less than 10 mmHg or higher than 20 mmHg; iii) ocular media opacities; iv) any surgery-related complication deemed inappropriate for the study. Intervention or observation proceduresSwept-source optical coherence tomography Main Outcome Measure(s)Bruchs membrane opening (BMO) and anterior laminar insertion (ALI) dimension, prelaminar neural canal dimension, anterior lamina cribrosa surface (ALCS) depth ResultsGlaucomatous eyes had more bowed and nasally rotated BMO and ALI, more horizontally skewed prelaminar neural canal, and deeper ALCS than the control eyes. Increased axial length was associated with a wider, longer, and more horizontally skewed neural canal, and decrease in the ALCS depth and curvature. ConclusionOur findings suggest that glaucomatous posterior bowing or cupping of lamina cribrosa can be significantly confounded by the myopic expansion of the neural canal. This may be related to higher glaucoma risk associated with myopia from decreased compliance and increased susceptibility to IOP-related damage of LC being pulled taut.

PurposeTo compare the accuracy of 9 intraocular lens (IOL) power calculation formulas (SRK/T, Hoffer Q, Holladay 1, Haigis, Barrett Universal II, Kane, EVO 2.0, Ladas Super formula and Hill-RBF 3.0) using partial coherence interferometry (PCI). MethodsData from patients having uncomplicated cataract surgery with the insertion of 1 of 3 IOL types were included. All preoperative biometric measurements were performed using PCI. Prediction errors (PE) were deduced from refractive outcomes evaluated 3 months after surgery. The mean prediction error (ME), mean absolute prediction error (MAE), median absolute prediction error (MedAE), and standard deviation of prediction error (SD) were calculated, as well as the percentage of eyes with a PE within {+/-}0.25, {+/-}0.50, {+/-}0.75 and {+/-}1.00D for each formula. ResultsIncluded in the study were 126 eyes of 126 patients. Kane achieved the lowest MAE and SD across the entire sample as well as the highest percentage of PE within {+/-}0.50D, and was proven to be more accurate than Haigis and Hoffer Q (P <.001). For an axial length of more than 26.0 mm, EVO 2.0 and Barrett obtained the lowest MAEs, with EVO 2.0 and Kane showing a higher percentage of prediction at {+/-}0.50D compared to old generation formulas except for SRK/T (P =.04). ConclusionAll investigated formulas achieved good results; there was a tendency towards better outcomes with new generation formulas, especially in atypical eyes.

ObjectiveTo perform a systematic review and meta-analysis of the clinical evidence of the treatment effect of surgical cyclodialysis in the management of intraocular (IOP) in patients with glaucoma. MethodsA comprehensive literature review was conducted of peer-reviewed interventional studies from the PubMed, Cochrane, Web of Science and EMBASE databases of surgical cyclodialysis treatment for the lowering of intraocular pressure in patients with glaucoma. Key outcome measures of treatment success were long-term IOP control, as well as IOP-lowering medication burden and the incidence of intraoperative and postoperative adverse events. The meta-analysis was registered with Prospero ID CRD42025632759 ResultsA total of 40 studies spanning a publication period of more than 100 years of surgical cyclodialysis treatment encompassing data from over 4,082 eyes were included in the analysis. Clinical evidence comprised observational, non-randomized studies, 75% of which involved an ab-externo approach and 25% comprised an ab-interno cyclodialysis intervention. Given the natural evolution of the clinical paradigm over the years, changes in surgical technique, instrumentation and addressable population, the overall analysis was constructed to account for the significant variability in outcomes reporting. Across the final evaluable dataset, the clinical performance of cyclodialysis surgery was characterized by overall qualified success rates of 72.3% on average (range 33%-97%) over a postoperative follow-up period ranging from 6 to 132 months. Depending on surgical technique and disease severity, reported success rates indicate slightly increased efficacy and lower rate of complications with ab-interno intervention. Durability of the cyclodialysis procedure varied significantly, with higher rates of failure in patients with advanced and refractory glaucoma. Specific complications such as persistent hyphema, hypotony and vision loss were reported infrequently. All outcomes, including IOP reduction, ocular safety, and durability, showed significant improvement with the newer interventional ab-interno surgical techniques. ConclusionCyclodialysis remains an enduring surgical intervention and one of the few available surgical options for uveoscleral outflow enhancement in glaucoma patients. The IOP lowering effect of the procedure can be significant, albeit variable, with better clinical performance in mild and moderate glaucoma and with advanced interventional ab-interno surgical approaches. SynopsisResults of a meta-analysis comprising more than 4,000 glaucoma cases of cyclodialysis surgery for the lowering of intraocular pressure demonstrate significant and sustained efficacy of one of the few surgical interventions for uveoscleral outflow enhancement.

PurposeTo evaluate if an intraoperative OCT (iOCT) optimized surgical protocol without prolonged overpressure is non-inferior to a standard protocol during Descemet membrane endothelial keratoplasty (DMEK). DesignA multicenter international prospective non-inferiority randomized control trial SubjectsSixty-five pseudophakic eyes of 65 patients with corneal endothelial dysfunction resulting from Fuchs endothelial corneal dystrophy were enrolled in 3 corneal centers in The Netherlands and Belgium. MethodsThe study was powered to include 63 patients scheduled for routine DMEK. Subjects were randomized to the control arm (n=33) without iOCT-use and raising the intraocular pressure above normal physiological limits for 8 minutes (i.e., overpressure) or the intervention arm (n=32) with OCT-guidance to assess graft orientation and adherence while refraining from prolonged raising the intraocular pressure. The RD and 95% confidence intervals (95% CI) were calculated from a logistic regression model using 1,000 bootstrap samples. Secondary outcomes included the incidence of graft detachment, surgeon-reported iOCT-aided surgical decision making, surgical time, endothelial cell density (ECD), and corrected distance visual acuity (CDVA). Main Outcome MeasuresThe primary outcome was the incidence of postoperative surgery-related adverse events, defined as rebubbling, graft failure, and iatrogenic acute glaucoma. The non-inferiority margin was set at a risk difference (RD) of 10%. ResultsIn the control group, 13 adverse events were recorded in 10 subjects compared to 13 adverse events in 12 subjects in the intervention group. The mean unadjusted RD measured 0.38% (95%CI: - 9.64-10.64) and the RD adjusted for study site measured -0.32% (95%CI: -10.29-9.84). No significant differences in ECD and CDVA were found between the two groups 3 and 6 months postoperatively. Surgeons reported that iOCT aided surgical decision-making in 40% of cases. Surgical- and graft unfolding time were, respectively, 13% and 27% shorter in the iOCT-group. ConclusionsiOCT-guided DMEK surgery with refraining from prolonged over-pressuring was non-inferior compared to conventional treatment. Surgery times were reduced considerably, and surgeons reported the iOCT aided surgical decision-making in 40% of cases. Refraining from prolonged overpressure did not affect postoperative ECD or CDVA.

ObjectiveTo determine clinical predictors of surgical failures following horizontal strabismus surgery for esotropia, in order to estimate the optimal surgical strategy. DesignRetrospective pooled observational case series of published cases. SubjectsPatients having horizontal strabismus surgery for esotropia, published between 1940 and 2025, with known preoperative deviation, surgical approach, and outcome. MethodsClinical data from individual patients having strabismus surgery for esotropia was recorded from published case series, and analyzed using multivariable logistic regression to predict over- and under-correction. Main Outcome MeasureSurgical failure, as determined by reoperation, suture adjustment, or postoperative strabismus of 10 prism diopters or more. ResultsWe abstracted individual patient data for 3518 surgeries from 163 publications. Binocular (as compared with monocular) surgery was associated with fewer under-corrections (odds ratio [OR] 0.75, 95% CI 0.61 to 0.92, p=0.005) and more over-corrections (OR 1.87, 95% CI 1.26 to 2.79, p=0.002, n=3266). Increasing preoperative deviation was associated with more under-corrections (OR 1.06/{degrees}, 95% CI 1.05/{degrees} to 1.07/{degrees}, p<0.0001) and fewer overcorrections (OR 0.97/{degrees}, 95% CI 0.95/{degrees} to 0.99/{degrees}, p=0.001, n=3266). Increasing surgical dose was associated with fewer under-corrections (OR 0.95/mm, 95% CI 0.91/mm to 0.99/mm, p=0.01), and more over-corrections (OR 1.08/mm, 95% CI 1.01/mm to 1.16/mm, p=0.02, n=3266). The failure rate was minimized with a large per-muscle surgical dose. As the preoperative deviation increases, one progresses from unilateral recessions, to unilateral recession-resections, and then bi-medial recessions. Under a range of assumptions, bi-medial recessions of 6 mm are optimal for preoperative deviations of 45 to 50 prism diopters. ConclusionsLarger doses for esotropia surgery do produce a larger response. Most models predicted the lowest failure rates with large recessions or resections, with additional muscles operated for larger preoperative deviations. Thus, the analysis supports the approach of Scobee (1951) over that of Parks (1975). The preferred surgical strategy depends on multiple factors.

PurposeTo show current approaches for overcorrecting astigmatism and "flipping" its axis need be reconsidered in light of methods we introduce that take into account both mismatch and misalignment of the toric intraocular lens (tIOL) with respect to the astigmatism to be corrected at the time of cataract surgery. SettingPrivate Practice and Research Center. The EYE Center. Champaign, IL, USA. DesignFormal Analytical Study MethodsIn the most common surgical situation where both mismatch and misalignment exist, we present an analysis of the point at which overcorrection and undercorrection residuals coincide, yielding a simple but powerful methodology to predict the optimal degree of overcorrection with a tIOL. The method is illustrated for tIOLs used in surgical practice. ResultsThe minimum astigmatism appropriate to overcorrect with a tIOL is given by, [Formula],where m is the midpoint threshold used by "split-the-difference" algorithms and{chi} is the estimate of tIOL misalignment due to all causes. Correspondingly, the maximum overcorrection, {Omega}max, that should be attempted is [Formula] where [Formula] is the dioptric step at the corneal plane, with {sigma} = H - B, where H = n {sigma} is the cylinder of the overcorrecting tIOL and B = (n - 1){sigma} is the cylinder of the undercorrecting tIOL, both at the IOL plane,{tau} is the toricity ratio and{gamma} relates to the angle of misalignment{chi} by [Formula] which can be approximated by [Formula]. {Omega} maxfactors elegantly in the product of [Formula], the (ideal) midpoint correction for perfect alignment, by the bracketed term, representing the percent reduction of the ideal value in a realistic surgical situation with estimated misalignment{chi} . To illustrate: an eye of average dimensions [Formula] and tIOLs from major manufacturers [Formula], with A = 2.35 D dictating n = 5. For a misalignment of 10{degrees}{Omega}max{cong} 0.10 D is the maximum overcorrection that should be accepted, significantly smaller than the midpoint [Formula] D, recommended by many current tIOL calculators. ConclusionAn optimal method is presented for the selection of an overcorrecting tIOL at the time of refractive cataract surgery with improvement over current tIOL calculators methods.

PurposeTo compare 3 automated devices for measuring the horizontal corneal diameter [white-to-white (WTW) distance]. SettingFundacion Oftalmologica Los Andes, Santiago, Chile. Study DesignRetrospective. MethodsIn 65 eyes of 38 patients, the WTW distance was measured independently using Orbscan IIz tomography system (Bausch & Lomb), IOLMaster 700 (Carl Zeiss Meditec) and OPD Scan III (NIDEK). We tested for systematic differences in measurements and estimated the limits of agreement (LoA) using linear mixed effects models. ResultsThe mean WTW distance was 11.8 {+/-} 0.40 mm with Orbscan IIz, 12.1 {+/-} 0.5 mm with IOLMaster 700 and 12.0 {+/-} 0.4 mm with OPD Scan III. The mean difference between IOLMaster 700 and Orbscan IIz was 0.33 (95% CI 0.28;0.38) (p<0.001), between OPD Scan III and Orbscan IIz was 0.24 mm (95% CI 0.21;0.28) (p<0.001), and between IOL Master 700 and OPD Scan III was 0.09 (95% CI 0.05;0.12) (p<0.001). The 95% LoA for Orbscan IIz versus IOLMaster 700 was -0.69 mm to 0.03 mm, Orbscan IIz versus OPD Scan III was -0.52 mm to -0.03 mm, and OPD versus IOLMaster 700 was -0.39 mm to 0.22 mm. Switching to IOLMaster 700 or OPD Scan III measurements led to a selection of a longer phakic IOL length (Visian ICL, STAAR) in 34% and 33% of the cases, respectively compared to Orbscan IIz. ConclusionsThe data suggests that these devices are not interchangeable for usual clinical practice. Adjustments based on mean differences was not enough to compensate for inter-instrument discrepancy in WTW measurements.

BackgroundThis systematic review and meta-analysis aim to evaluate the efficacy and safety of the PAUL(R) Glaucoma Implant in reducing intraocular pressure and number of anti-glaucoma medication use in both adult and paediatric populations. MethodsA systematic review was conducted following the PRISMA guidelines. The databases PubMed, Ovid-Embase and Scopus were searched to include studies published between January 2017 and September 2025. Studies were stratified by age and risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and ROBUST-RCT for randomized trials. Primary outcomes were intraocular pressures and number of glaucoma medications at each follow-up visits. Random effects meta-analyses were performed. Secondary outcome was complications. ResultsTwenty-four studies (twenty adults, four paediatric) comprising 836 eyes were included in our review and meta-analysis. Both adult and paediatric patients showed significant IOP reduction post-surgery, with a mean difference of 17.48 mmHg (95% CI: 14.59, 20.37) and 20.31 mmHg (95% CI: 7.80, 32.82) at 1 week, respectively, and sustained reductions at 12 months. The reduction in glaucoma medications was 79.2% for adults and 71.4% for children at 12 months. Subgroup analyses demonstrated greater IOP reduction in studies conducted in the Middle East. The uses of Mitomycin C did not significantly affect outcomes. ConclusionThe PAUL(R) glaucoma implant showed significant and sustained IOP reductions with reduced need for glaucoma medications. The PAUL(R) glaucoma implant is a promising surgical option for glaucoma management in both adults and children. Further long-term prospective comparative studies are needed to assess long-term efficacies and allow direct comparisons with other glaucoma drainage devices.

PO_SCPLOWURPOSEC_SCPLOWTo determine if lamina cribrosa (LC) depth and curvature predict visual field (VF) progression rate in the African Descent and Glaucoma Evaluation Study (ADAGES) cohort in patients with primary open angle glaucoma (POAG). SO_SCPLOWUBJECTSC_SCPLOWParticipants, and/or Controls. Three eyes from three research-consented brain-dead organ donors. MO_SCPLOWETHODSC_SCPLOWAnterior laminar cribrosa surface depth (ALCSD) and LC curvature index (LCCI) were defined from 24 radial B-scan spectral domain optic coherence tomographic (SDOCT) images of each image. All scans were processed using a deep learning software to perform the segmentation and optic nerve health (ONH) layers. Univariable and multivariable linear mixed effects models were used to test associations between VF progression rate, ALCSD, and other demographic and clinical characteristics and known risk factors for progressive POAG. Additionally, the variable selection in the final multivariable model was reached using the Akaike information criterion index (AICc) and clinical utility. MO_SCPLOWEASURESC_SCPLOWIOP change with exposure to NP. MO_SCPLOWAINC_SCPLOW OO_SCPLOWUTCOMEC_SCPLOWThe associations between ALCSD and LCCI with the rate of VF progression. RO_SCPLOWESULTSC_SCPLOWThere was a statistically significant relationship between faster VF progression rates, and a deeper ALCSD (-0.02 dB/year/50 microns, p<0.001) and LCCI (-0.01unit/dB/year, p<0.001). There was also increasing progression seen in both models for with increasing age (-0.025dB/year/10 years, p<0.007), intraocular pressure (IOP) (-0.011dB/year per 2 mmHg, p=0.021), and disease severity (0.017dB/year per dB, p<0.001). The rate of progression was faster in the ED cohort (-0.056 dB/year, p=0.006) following propensity matching for disease severity and age. CO_SCPLOWONCLUSIONSC_SCPLOWIn the ADAGES cohort, there is a statistically significant association between VF progression rate and ALCSD and curvature (LCCI). A 50 um deeper LC at baseline had a similar effect of VF progression as being 10 years of age older. These data suggest that morphologic change in the ONH due to glaucomatous and age-related remodeling may induce greater vulnerability to develop progressive disease. Thus, LC depth and curvature may inform the likelihood and rate of glaucoma progression and are promising candidates for mechanistic biomarkers.

ObjectiveTo assess the correlation between glaucoma incidence and optic disc parameters obtained through an automated deep learning (DL) algorithm segmentation. Methods and AnalysisWe obtained eligible fundus photographs and corresponding participant data from the UK Biobank. To accurately assess the optic disc parameters and their relationship with glaucoma incidence using Cox proportional hazard regression models, we developed a DL algorithm that automatically segmented the optic disc and cup and calculated various parameters including the vertical cup-to-disc ratio (VCDR), ovality index, cup-to-disc area ratio, rim area, disc area, and disc rotation from the fundus photos. We performed two logistic regression models, with model A comprising sociodemographic and health covariates and model B including additional ophthalmic features. Receiver operating characteristic curves (ROC) and areas under the curve (AUC) were plotted and calculated for each model to evaluate their performance. ResultsA total of 44,376 subjects with fundus photos were included in our study. After a median follow-up of 10.1 years, 354 incident glaucoma were documented. Subjects with larger VCDR had a higher risk of incident glaucoma; the HR (95% CI) was 2.05 (1.57-2.66) in the multivariable-adjusted model (p<0.001). The results remain significant in the sensitivity analysis that excluded fundus photographs with "Reject" quality. After adding the optic disc parameters into the regression model A, the AUC increased by 4.2% to 78.6%. ConclusionThe VCDR calculated by automatic optic disc segmentation model shows potential as a biomarker for evaluating the risk of glaucoma. What is already known on this topicGlaucoma is a worldwide leading cause of irreversible vision loss, and its early diagnosis is of great necessity. What this study addsData from the UK Biobank shows the optic disc parameters and their relationship with glaucoma incidence. We develop a DL-based algorithm for optic disc segmentation in Color fundus photos and validate its efficacy in glaucoma prediction. How this study might affect research, practice or policyThe VCDR calculated using an automatic optic disc segmentation based on a DL model can serve as a biomarker to predict the incidence of glaucoma.

PurposeTo evaluate the performance of a large language model (LLM) in identifying medication non-adherence, visit non-adherence, and family history of glaucoma (FHoG) in clinical notes from the electronic health record (EHR). MethodsWe extracted clinical notes of 1,250 glaucoma-related encounters between 2014 and 2024 and structured EHR family history field data from the Bascom Palmer Ophthalmic Repository, with 125 randomly selected notes (10%) used for prompt development and excluded from analysis. Two fellowship-trained glaucoma specialists labeled notes for evidence of non-adherence and FHoG. We utilized MedGemma-27B-text-it, a specialized medical LLM, to identify medication non-adherence, visit non-adherence, and FHoG. We calculated accuracy, sensitivity, and specificity of LLM performance for each task, Jaccard index for FHoG, and mean squared error (MSE) of number of family members with glaucoma. ResultsPrevalence of medication non-adherence, visit non-adherence, and FHoG were 7.3%, 4.7%, and 29.2%, respectively. LLM accuracy was 0.91 (sensitivity: 0.96; specificity: 0.91) for medication non-adherence and 0.96 (sensitivity: 0.97; specificity: 0.94) for visit non-adherence. For FHoG, LLM accuracy was 0.98 (sensitivity: 0.99; specificity: 0.99) with Jaccard index of 0.99, while EHR family history field accuracy and Jaccard index were 0.49 and 0.75, respectively. LLM and EHR MSE in quantifying the number of relatives with glaucoma were 0.05{+/-}0.56 and 0.85{+/-}1.80, respectively (p<0.001). ConclusionsLLMs identified non-adherence to medication and visit schedules as well as degree of FHoG in clinical notes with high accuracy. Translational RelevanceLocal LLM pipelines can enable large-scale research into glaucoma risk factors that are unavailable in discrete EHR fields.

PurposeTo evaluate clinical and sociodemographic factors associated with selecting treatments in glaucoma patients with rapid visual field (VF) progression. DesignRetrospective cohort study Participants2,782 eyes from 1,812 adults with 5 or more 24-2 visual fields over five years and at least one optical coherence tomography (OCT) scan. MethodsRapid progressors were defined by mean deviation (MD) slopes worse than -1 dB/year. Demographic (age, gender, race), clinical (intraocular pressure (IOP), VF metrics, OCT measures), and socioeconomic (social vulnerability index, or SVI) variables were collected. Patients were categorized based on the most intensive treatment received in the first seven years: medical management, minimally invasive procedures (e.g., minimally invasive glaucoma surgery or laser), or aggressive procedures (e.g., filtering surgery or external ciliodestruction). Logistic regression was performed to identify demographic, clinical, and socioeconomic factors associated with treatment intensity. Main Outcome MeasuresOdds of treatment selection based on rapid VF progression ResultsRapid progressors had significantly higher odds of receiving aggressive procedures (odds ratio [OR] 3.83, 95% confidence interval [CI] 2.56-5.74, p < 0.001) and any procedure (OR 3.15, 95% CI 2.28-4.35, p < 0.001), yet only 23% of rapid progressors underwent aggressive procedures in the first seven years. Among rapid progressors, worse MD and smaller rim area predicted aggressive procedures and higher IOP predicted any procedure. Higher SVI was associated with a reduced likelihood of receiving minimally invasive procedures among rapid progressors (OR 0.05, 95% CI 0.00-0.76, p = 0.031). ConclusionAlthough rapid progression was a strong predictor of aggressive procedures, fewer than one in four underwent aggressive IOP-lowering interventions. Baseline IOP and structural severity appeared to supersede VF progression in clinical decisions. Patients in areas of higher socioeconomic vulnerability were also less likely to receive less invasive procedures. Better integrating rates of functional decline and addressing socioeconomic barriers may help optimize care for rapidly progressing glaucoma patients.

PurposeTo examine the influence of patient demographic characteristics and ophthalmic practice composition on access to cataract surgery in the United States as measured by preoperative best-corrected visual acuity (BCVA). Patient and methodsThis retrospective cohort study analyzed data from the IRIS(R) Registry (Intelligent Research in Sight) for patients age > 50 who had at least one BCVA measurement in the six months preceding cataract surgery performed between January 1, 2016, and December 31, 2020. We used a mixed-effects model to estimate the relationship between individual-level demographic factors and practice-level composition factors and preoperative BCVA. Results2,387,045 individuals met inclusion criteria. The mean BCVA prior to surgery was 0.23 (SD: 0.32) logMAR. The worst pre-operative BCVA was observed in patients with Hispanic race and ethnicity while White patients had the best [0.34 (SD: 0.43), 0.21(SD: 0.30); p<0.001]. Grouping patients in terms of percentage of BCVA worse than 20/50 prior to surgery, Hispanic patients, active smokers, and uninsured patients had higher percentages of worse preoperative vision (33.7%, 23.5%, 34.9%). Analysis of compositional effects of race and ethnicity, smoking and insurance status showed that, regardless of an individual patients demographic, patients treated at practices serving higher proportions of White patients showed better BCVA (b = -.008 per 10 percentage points, P < .001) while patients at practices with higher percentages of actively smoking patients showed worse BCVA (b=-0.016 per 10 percentage points active smoking patients, P < .001). There was no compositional effect of insurance status. Conclusions and RelevanceOverall differences exist with regard to the visual acuity at which cataract surgery is initiated at both the level of the individual patient and the composition of practice in which they are treated. Plain Language SummaryDemographic disparities and geographic variation in access to cataract surgery in the United States have been previously described in large national studies of insurance data. Smaller studies of single institutions expanded upon these studies by showing differences in preoperative visual acuity- an important measure of access to cataract surgery- based on factors such as race and insurance status but were limited by the size and scope of their study patients. The IRIS(R) Registry (Intelligent Research in Sight) is the nations first comprehensive ophthalmic clinical registry with data from both individual patients as well as ophthalmic group practices. Using data from this registry, we show differences in preoperative visual acuity prior to cataract surgery at both the level of the patient and the practice in which they are treated.

PurposeTo compare 2-year results of a filtering trabeculotomy (FTO) to conventional trabeculectomy (TE) in open-angle glaucoma by exact matching. Methods110 patients received an FTO and 86 a TE. FTO avoided the need for an iridectomy due to a preserved trabeculo-Descemet window anterior to the scleral flap. TE employed a trabecular block excision and iridectomy. Mitomycin C was used in both. FTO and TE were exact-matched by baseline intraocular pressure (IOP) and the number of glaucoma medications. Complete and qualified success (IOP [&le;]18 mmHg and IOP reduction [&ge;] 30%, with or without medication) were primary endpoints. IOP, visual acuity (BCVA), complications and intervention were secondary endpoints. Results44 FTO were exact-matched to 44 TE. The IOP baseline in both groups was 22.5{+/-}4.7 mmHg on 3{+/-}0.9 medications. At 24 months, complete success was reached by 59% in FTO and 66% in TE and qualified success by 59% in FTO and 71% in TE. In FTO, IOP was reduced to 12.4{+/-}4.3 mmHg at 12 months and 13.1{+/-}4.1 mmHg at 24 months. In TE, IOP was 11.3{+/-}2.2 mmHg at 12 months and 12.0{+/-}3.5 mmHg at 24 months. Medications could be reduced at 24 months to 0.6{+/-}1.3 in FTO and 0.2{+/-}0.5 in TE. There were no significant differences between the two groups in IOP, medications, complications or interventions at any point. ConclusionModifying aqueous flow through a limited trabeculotomy in FTO yielded clinical outcomes similar to traditional TE but allowed to avoid an iridectomy.

PurposeTo develop a method for predicting postoperative anterior chamber depth (ACD) in cataract surgery patients based on preoperative biometry, demographics, and intraocular lens (IOL) power. MethodsPatients who underwent cataract surgery and had both preoperative and postoperative biometry measurements were included. Patient demographics and IOL power were collected from the Sight Outcomes Research Collaborative (SOURCE) database. A gradient boosting decision tree model was developed to predict the postoperative ACD. The mean absolute error (MAE) and median absolute error (MedAE) were used as evaluation metrics. The performance of the proposed method was compared to five existing formulas. Results847 patients were assigned randomly in a 4:1 ratio to a training/validation set (678 patients) and a testing set (169 patients). Using preoperative biometry and patient sex as predictors, the presented method achieved an MAE of 0.106 {+/-} 0.098 (SD) on the testing set, and a MedAE of 0.082. MAE was significantly lower than that of the five existing methods (p < 0.01). When keratometry was excluded, our method attained an MAE of 0.123 {+/-} 0.109, and a MedAE of 0.093. When IOL power was used as an additional predictor, our method achieved an MAE of 0.105 {+/-} 0.091 and a MedAE of 0.080. ConclusionsThe presented machine learning method achieved accuracy surpassing that of previously reported methods in the prediction of postoperative ACD. Translational RelevanceIncreasing accuracy of postoperative ACD prediction with the presented algorithm has the potential to improve refractive outcomes in cataract surgery.

PurposeTo achieve a highly balanced comparison of trabecular bypass stenting (IS2, iStent inject)with ab interno trabeculectomy (T, Trabectome) by exact matching. In a similar study, IS1 (1st generation iStent) had shown a loss of effect at 6 months. Methods53 IS2 eyes were matched to 3446 T eyes. Patients were matched using exact matching by baseline IOP, the number of glaucoma medications, and glaucoma type and using nearest neighbor matching by age. Individuals without a close match were excluded. All surgeries were combined with phacoemulsification. ResultsA total of 78 eyes (39 in each group) could be matched as exact pairs with a baseline IOP of 18.3{+/-}5.1 mmHg and glaucoma medications of 2.7{+/-}1.2 in each. IOP in IS2 was reduced to 14.6{+/-}4.2 mmHg at 3 months and in T to a minimum of 13.1{+/-}3.2 mmHg at 1 month. In IS2, IOP began to rise again at 6 months, eventually exceeding baseline. At 24 months, IOP in IS2 was 18.8{+/-}9.0 mmHg and in T 14.2{+/-}3.5 mmHg. IS2 had a higher average IOP than T at all postoperative visits (p<0.05 at 1, 12, 18 months). Glaucoma medications decreased to 2.0{+/-}1.5 in IS2 and to 1.5{+/-}1.4 in T. ConclusionT resulted in a larger and sustained IOP reduction compared to IS2 where a rebound occurred after six months to slightly above preoperative values. This time course fits bioreactivity data of the IS1.