PURPOSE:To evaluate the effect of a single intraoperative dose of intravitreal bevacizumab (Avastin) on surgical success after trabeculectomy with mitomycin-C (MMC) over 3 years. DESIGN:Single-center, parallel, double-masked, randomized, placebo-controlled trial. The setting was a single ophthalmic outpatient referral center within a tertiary teaching hospital. PARTICIPANTS:Patients requiring primary or redo trabeculectomy or phacotrabeculectomy for progressing glaucoma. Patients were randomized to a single intraoperative intravitreal injection of Avastin (1.25 mg in 0.05 mL) or placebo (balanced salt solution 0.05 mL). MAIN OUTCOME MEASURE:The primary outcome was treatment success, which was defined by "complete success" when intraocular pressure (IOP) remained less than a predefined target IOP without the requirement of topical medication or "qualified success" when topical medication was required to meet the predefined target IOP threshold. RESULTS:From a total of 131 patients randomized to bevacizumab (Avastin; n = 65) or placebo (n = 66), 111 patients completed 36 months of follow-up (85%). At 36 months, trabeculectomy survival was higher in the bevacizumab cohort (hazard ratio [complete success] = 0.17, P = 0.002; [qualified success] = 0.07, P = 0.03). Within the placebo cohort, the requirement for topical therapy was higher at 3 months (P = 0.008), 6 months (P = 0.009), 12 months (P = 0.007), and 36 months (P < 0.005). CONCLUSIONS:Bevacizumab was given as a single intravitreal dose during trabeculectomy with MMC resulting in improved surgical success at 36 months postoperatively. FINANCIAL DISCLOSURE(S):The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Glaucoma is the leading cause of irreversible blindness; vision loss is preventable with timely treatment, but early detection is challenging, leaving ∼50% undiagnosed, highlighting the need for improved risk assessment tools. We developed a polygenic risk score (PRS) using data from >6 million individuals. PRS performance was exceptional in European ancestries; top 10% PRS individuals had 10-fold increased risk (OR=10.0) relative to the remainder. Performance remained good across all major ancestry groups; high-PRS individuals were at high absolute risk, especially Africans. High-risk individuals (top 10% PRS) developed glaucoma up to 25 years earlier than those in the lowest 10% and were at 100 times the risk. The PRS also predicted need for treatment escalation in early glaucoma and both prevalent and incident surgery. Risk profiling with this PRS which is clinically available, enables earlier identification and more timely treatment of high-risk individuals for preventable vision loss, with a reduced screening and monitoring burden for those at low-risk. Glaucoma is the leading cause of irreversible blindness worldwide. Early detection is essential because current treatments cannot restore lost vision. Population-wide screening using conventional risk factors for glaucoma (such as elevated intraocular pressure) is not currently cost-effective, though a better stratification method could improve early diagnosis rates and reduce over-monitoring of lower risk cases. Glaucoma is one of the most heritable common complex diseases, suggesting that genetics-based approaches could revolutionize risk stratification. Previous polygenic risk scores (PRS) indexing glaucoma genetic risk were limited by restricted applicability outside European ancestry populations, small discovery sample sizes, modest predictive power, poor clinical availability. The inability to cover a broad range of ancestries limited the practical clinical application of earlier versions of glaucoma PRS for risk stratification and patient management. A novel PRS, trained on >6 million individuals, has significantly improved glaucoma risk prediction across major ancestry groups, identifying high-risk individuals (top 10% of risk versus remainder) with odds ratios up to 10 in Europeans and 3.4–7.5 in non-Europeans (larger than for any other common complex disease). The excellent PRS risk stratification remained after adjusting for intraocular pressure; adding PRS to a prediction model with age, sex and intraocular pressure increased the Area Under the Curve for predicting glaucoma status from 0.63 to 0.82. High-risk individuals (top 10% PRS) developed glaucoma up to 25 years earlier than those in the lowest 10% and were at 100 times greater risk. The PRS also predicted structural progression, the need for treatment initiation and escalation in early glaucoma, both prevalent and incident incisional surgery for glaucoma, and the likelihood of glaucoma being present in first-degree relatives. These improvements impart strong clinical utility for population risk stratification, and the personalised management of individuals with clinical features suggestive of early stage glaucoma. This clinically available, enhanced PRS enables accurate identification of both high- and low-risk individuals across diverse populations, supporting earlier diagnosis, targeted monitoring, and timely treatment. It provides a clinical tool which can be applied for precision prevention and management of glaucoma, enabling cost-effective, equitable, genetically-informed glaucoma risk stratification across the entire population.

Background Despite several studies suggesting a potential oligogenic risk model in amyotrophic lateral sclerosis (ALS), case–control statistical evidence implicating oligogenicity with disease risk or clinical outcomes is limited. Considering its direct clinical and therapeutic implications, we aim to perform a large-scale robust investigation of oligogenicity in ALS risk and in the disease clinical course. Methods We leveraged Project MinE genome sequencing datasets (6711 cases and 2391 controls) to identify associations between oligogenicity in known ALS genes and disease risk, as well as clinical outcomes. Results In both the discovery and replication cohorts, we observed that the risk imparted from carrying multiple ALS rare variants was significantly greater than the risk associated with carrying only a single rare variant, both in the presence and absence of variants in the most well-established ALS genes. However, in contrast to risk, the relationships between oligogenicity and ALS clinical outcomes, such as age of onset and survival, did not follow the same pattern. Conclusions Our findings represent the first large-scale, case–control assessment of oligogenicity in ALS and show that oligogenic events involving known ALS risk genes are relevant for disease risk in ~6% of ALS but not necessarily for disease onset and survival. This must be considered in genetic counselling and testing by ensuring to use comprehensive gene panels even when a pathogenic variant has already been identified. Moreover, in the age of stratified medication and gene therapy, it supports the need for a complete genetic profile for the correct choice of therapy in all ALS patients.

OBJECTIVE:Pigment dispersion syndrome (PDS) is a known risk factor for glaucoma, with at least 1 in 10 patients with PDS developing glaucoma. There are no standardized clinical tools to stratify the risk of glaucoma onset or progression in the context of PDS. This study investigated whether multitrait polygenic risk scores (PRSs) built from variants collectively associated with open-angle glaucoma, intraocular pressure (IOP), and vertical cup:disc ratio (VCDR) could stratify individuals with PDS for their risk of glaucoma development. DESIGN:Cross-sectional study of 2 independent PDS cohorts: the Australian and New Zealand Registry of Advanced Glaucoma (ANZRAG, n = 264), and the Glaucoma Services at the University of Iowa Carver College of Medicine (n = 203). PARTICIPANTS:Participants of European ancestry with PDS were classified as PDS-Glaucoma (n = 288), PDS-Glaucoma Suspect (n = 110), or PDS-No Glaucoma (n = 69). METHODS:Previously published and validated PRS for open-angle glaucoma, IOP, and VCDR were expressed as a percentile or quintile of an ancestrally matched normal population. Multivariable logistic and linear regressions and survival analyses were performed. MAIN OUTCOME MEASURES:Odds of pigmentary glaucoma and odds of clinically relevant outcomes. RESULTS:Participants from ANZRAG with PDS in the top quintile of an open-angle glaucoma-PRS had greater odds of glaucoma diagnosis compared with the bottom quintile (adjusted odds ratio [OR], 5.29; 95% confidence interval [CI], 1.57-21.28; P = 0.011). This observation was replicated among participants with PDS from the University of Iowa (adjusted OR, 4.07; 95% CI, 1.24-13.85; P = 0.021). Among those with PDS-Glaucoma across both cohorts combined, participants in the top quintile of glaucoma-PRS compared with the bottom quintile were diagnosed 8 years earlier (95% CI, 5.17-10.41; P < 0.001), recorded a maximum IOP 8 mmHg higher (95% CI, 2.89-11.95; P = 0.001), were at greater risk of escalation to incisional surgery (adjusted OR, 1.37; 95% CI, 1.03-1.87; P = 0.038), and were at greater risk of additional incisional surgeries to the same eye (adjusted OR, 1.27; 95% CI, 1.08-1.52; P = 0.006). A PRS for IOP also differentiated pigmentary glaucoma status; a PRS for VCDR did not. CONCLUSIONS:A multitrait PRS for open-angle glaucoma stratifies risk of glaucoma onset and disease severity among individuals with PDS. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

ABSTRACT Objective Most antiseizure medications (ASMs) are prescribed off label for neonates. Lacosamide's efficacy in infants and availability in intravenous formulation suggest potential utility for neonates. We evaluated the safety and efficacy of lacosamide for neonatal seizures. Methods This 10‐center, retrospective study of neonates with seizures and lacosamide treatment initiated by ≤ 48 weeks postmenstrual age collected clinical data from medical records and electroencephalogram recordings. Lacosamide efficacy was determined by changes in seizure burden with lacosamide treatment and seizure cessation by hospital discharge. Potential adverse events were reviewed. Results Among 62 eligible neonates, 33 had acute provoked seizures while 29 had neonatal‐onset epilepsy; there was no difference in seizure type or baseline seizure severity between groups. There were high rates of pretreatment status epilepticus (48%) and treatment‐resistant seizures, with 93% receiving ≥ 3 ASMs before lacosamide. Most received intravenous lacosamide, with a median loading dose of 5.0 mg/kg and median daily dose of 7.3 mg/kg. Seizure cessation occurred in 37% of neonates; 21% had no additional ASM administered after lacosamide. Seizure burden, measured in seizure minutes per hour, was lower at both 4 h and 7 days following lacosamide administration. In addition, there was a median reduction in seizure frequency of 30 seizures per day at 7 and 30 days posttreatment ( p < .05). Lacosamide was continued at discharge in most neonates (72%). Seventy adverse events were reported in 35 (56%) neonates. Four transient events with possible or unknown relationship to lacosamide were likely multifactorial in origin; none were cardiac arrhythmias. Summary Despite high rates of treatment‐resistant seizures in this neonatal cohort, 37% experienced seizure cessation and most remained on lacosamide at hospital discharge. Most adverse events were not attributed to lacosamide. These results favor use of lacosamide and provide a rationale for future prospective studies.

PURPOSE:Pseudoexfoliation syndrome (PEX) is a known risk factor for glaucoma, but its individual clinical course ranges from no glaucoma to total blindness. This study investigated whether polygenic risk scores (PRSs) built from variants collectively associated with open-angle glaucoma, intraocular pressure (IOP), and vertical cup-to-disc ratio (VCDR) can stratify individuals with pseudoexfoliation for the risk of glaucoma development. DESIGN:Retrospective multicohort study of 2 glaucoma registries and 1 population-based cohort. PARTICIPANTS:For the primary analysis, participants (n = 828) were classified as having PEX with glaucoma, PEX with suspected glaucoma, or PEX with no glaucoma. For the secondary analysis, a cohort of participants (n = 2460) were classified as having PEX with glaucoma, having PEX with no glaucoma, and being unaffected, and an independent cohort of participants (n = 3372) were classified as having primary open-angle glaucoma (POAG) or suspected POAG. METHODS:Previously published and validated PRSs for open-angle glaucoma, IOP, and VCDR were expressed as a percentile, decile, or tertile of an ancestrally matched healthy population. Multivariable logistic and linear regressions and survival analyses were performed. MAIN OUTCOME MEASURES:The main outcome measures were odds of pseudoexfoliative glaucoma (PEX-G) and odds of clinically relevant outcomes. RESULTS:Participants in the top tertile of the glaucoma PRS showed greater odds of receiving a PEX-G diagnosis (adjusted odds ratio [aOR], 4.22; 95% confidence interval [CI], 2.62-6.88; P < 0.001), greater odds of bilateral central vision loss (aOR, 3.43; 95% CI, 1.49-8.99; P = 0.007), and greater odds of bilateral incisional surgery (aOR, 3.35; 95% CI, 1.33-10.24; P = 0.018). Age at PEX-G diagnosis was 1 year younger with each increasing glaucoma PRS decile (1.06 years; 95% CI, 0.59-1.53 years; P < 0.001). Participants with manifest glaucoma and pseudoexfoliation showed a comparatively lower glaucoma PRS than counterparts with POAG. CONCLUSIONS:The PRSs for open-angle glaucoma, IOP, and VCDR stratify risk of glaucoma development and disease severity among individuals with PEX. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Microglia play a pivotal role in neurodegenerative disease pathogenesis, but the mechanisms underlying microglia dysfunction and toxicity remain to be elucidated. To investigate the effect of neurodegenerative disease-linked genes on the intrinsic properties of microglia, we studied microglia-like cells derived from human induced pluripotent stem cells (iPSCs), termed iMGs, harboring mutations in profilin-1 (PFN1) that are causative for amyotrophic lateral sclerosis (ALS). ALS-PFN1 iMGs exhibited evidence of lipid dysmetabolism, autophagy dysregulation and deficient phagocytosis, a canonical microglia function. Mutant PFN1 also displayed enhanced binding affinity for PI3P, a critical signaling molecule involved in autophagic and endocytic processing. Our cumulative data implicate a gain-of-toxic function for mutant PFN1 within the autophagic and endo-lysosomal pathways, as administration of rapamycin rescued phagocytic dysfunction in ALS-PFN1 iMGs. These outcomes demonstrate the utility of iMGs for neurodegenerative disease research and implicate microglial vesicular degradation pathways in the pathogenesis of these disorders.

Sex is an important covariate in all genetic and epigenetic research due to its role in the incidence, progression and outcome of many phenotypic characteristics and human diseases. Amyotrophic lateral sclerosis (ALS) is a motor neuron disease with a sex bias towards higher incidence in males. Here, we report for the first time a blood-based epigenome-wide association study meta-analysis in 9274 individuals after stringent quality control (5529 males and 3975 females). We identified a total of 226 ALS saDMPs (sex-associated DMPs) annotated to a total of 159 unique genes. These ALS saDMPs were depleted at transposable elements yet significantly enriched at enhancers and slightly enriched at 3'UTRs. These ALS saDMPs were enriched for transcription factor motifs such as ESR1 and REST. Moreover, we identified an additional 10 genes associated with ALS saDMPs through chromatin loop interactions, suggesting a potential regulatory role for these saDMPs on distant genes. Furthermore, we investigated the relationship between DNA methylation at specific CpG sites and overall survival in ALS using Cox proportional hazards models. We identified two ALS saDMPs, cg14380013 and cg06729676, that showed significant associations with survival. Overall, our study reports a reliable catalogue of sex-associated ALS saDMPs in ALS and elucidates several characteristics of these sites using a large-scale dataset. This resource will benefit future studies aiming to investigate the role of sex in the incidence, progression and risk for ALS.

ABSTRACT Objective Genetic variation in the neurofilament heavy chain gene ( NEFH ) has been convincingly linked to the pathogenesis of multiple neurodegenerative diseases, however, the relationship between NEFH mutations and ALS susceptibility has not been robustly explored. We therefore wanted to determine if genetic variants in NEFH modify ALS risk. Methods We performed fixed and random effects model meta-analysis of published case-control studies reporting NEFH variant frequencies using next-generation sequencing, microarray or PCR-based approaches. Comprehensive screening and rare variant burden analysis of NEFH variation in the Project MinE ALS whole-genome sequencing data set was also conducted. Results We identified 12 case-control studies that reported NEFH variant frequencies, for a total of 9,496 samples (4,527 ALS cases and 4,969 controls). Fixed effects meta-analysis found that rare (MAF<1%) missense variants in the tail domain of NEFH increase ALS risk (OR 4.56, 95% CI 2.13-9.72, p<0.0001). A total of 591 rare NEFH variants, mostly novel (78.2%), were found in the Project MinE dataset (8,903 samples: 6,469 cases and 2,434 controls). Burden analysis showed ultra-rare (MAF <0.1%) pathogenic missense variants in the tail domain are associated with ALS (OR 1.94, 95% CI 0.86-4.37, Madsen-Browning p=0.039), replicating and confirming the meta-analysis finding. High-frequency rare (MAF 0.1-1%) tail in-frame deletions also confer susceptibility to ALS (OR 1.18, 95% CI 0.67-2.07, SKAT-O p=0.03), which supports previous findings. Interpretation This study shows that NEFH tail domain variants are a risk factor of ALS and supports the inclusion of missense and in-frame deletion NEFH variants in ALS genetic screening panels.

Repeat expansions in the C9orf72 gene are the most common genetic cause of (ALS) and frontotemporal dementia (FTD). Like other genetic forms of neurodegeneration, pinpointing the precise mechanism(s) by which this mutation leads to neuronal death remains elusive, and this lack of knowledge hampers the development of therapy for C9orf72-related disease. We used an agnostic approach based on genomic data (n = 41,273 ALS and healthy samples, and n = 1,516 C9orf72 carriers) to overcome these bottlenecks. Our drug-repurposing screen, based on gene- and expression-pattern matching and information about the genetic variants influencing onset age among C9orf72 carriers, identified acamprosate, a γ-aminobutyric acid analog, as a potentially repurposable treatment for patients carrying C9orf72 repeat expansions. We validated its neuroprotective effect in cell models and showed comparable efficacy to riluzole, the current standard of care. Our work highlights the potential value of genomics in repurposing drugs in situations where the underlying pathomechanisms are inherently complex. VIDEO ABSTRACT.

Recently, large-scale case-control analyses have been prioritized in the study of ALS. Yet the same effort has not been put forward to investigate additive moderate phenotypic effects of genetic variants in genes driving ALS risk, despite case-level evidence suggesting a potential oligogenic risk model. Considering its direct clinical and therapeutic implications, a large-scale robust investigation of oligogenicity in ALS is greatly needed. Here, we leveraged the Project MinE ALS Sequencing Consortium genome sequencing datasets of individuals with ALS (n = 6711) and controls (n = 2391) to identify signals of association between oligogenicity in known ALS genes (n=26) and disease risk, as well as clinical outcomes. Applying regression models to a discovery and replication cohort, we observed that the risk imparted from carrying rare variants in multiple known ALS genes was significant and was greater than the risk associated with carrying only a single rare variant, both in the presence and absence of variants in the most well-established ALS genes, such as C9orf72 . However, in contrast to risk, the relationships between oligogenicity and ALS clinical outcomes, such as age of onset and survival, might not follow the same pattern as we did not observe any associations. Our findings represent the first large-scale, case-control assessment of oligogenic associations in ALS to date and confirm that oligogenic events involving known ALS risk genes are indeed relevant for the risk of disease in approximately 6% of ALS but not necessarily for disease onset and survival. This must be considered in genetic counselling and testing by ensuring the use of comprehensive gene panels even when a potential pathogenic variant has already been identified. Moreover, in the age of stratified medication and gene therapy, it supports the need of a complete genetic profile for the correct choice of therapy in all ALS patients. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This is an EU Joint Programme Neurodegenerative Disease Research (JPND) project. The project is supported through the following funding organizations under the aegis of JPND http://www.neurodegenerationresearch.eu/ [United Kingdom, Medical Research Council (MR/L501529/1 and MR/R024804/1) and Economic and Social Research Council (ES/L008238/1)]. AAC is a NIHR Senior Investigator. AAC receives salary support from the National Institute for Health and Care Research (NIHR) Dementia Biomedical Research Unit at South London and Maudsley NHS Foundation Trust and King's College London. The work leading up to this publication was funded by the European Community's Health Seventh Framework Program (FP7/2007 2013; grant agreement number 259867) and Horizon 2020 Program (H2020-PHC-2014-two-stage; grant agreement number 633413). This project has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 Research and Innovation Programme (grant agreement no. 772376 EScORIAL. This study represents independent research part funded by the NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, King's College London, or the Department of Health and Social Care. AAD is supported by the Canadian Institute of Health Research Banting Postdoctoral Fellowship Program. AI is funded by South London and Maudsley NHS Foundation Trust, MND Scotland, Motor Neurone Disease Association, National Institute for Health and Care Research, Spastic Paraplegia Foundation, Rosetrees Trust, Darby Rimmer MND Foundation, the Medical Research Council (UKRI) and Alzheimer's Research UK. SMKF is supported by grants from ALS Canada, Brain Canada, the Michael J. Fox Foundation, and the Montreal Neurological Institute Hospital. Project MinE Belgium was supported by a grant from IWT (n 140935), the ALS Liga Belgie, the National Lottery of Belgium and the KU Leuven Opening the Future Fund. AAK is funded by the ALS Association Milton Safenowitz Research Fellowship, The Motor Neurone Disease Association (MNDA) Fellowship, The Darby Rimmer Foundation, and The NIHR Maudsley Biomedical Research Centre. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Individual whole-genome sequencing data are available and can be requested through Project MinE (<https://www.projectmine.com/research/data-sharing/>). A data access committee controls access to raw data, ensuring a FAIR data setup (<https://www.datafairport.org>). Details on the frequencies and gene burden test results are available on the ProjectMinE databrowser [29][1] (<http://databrowser.projectmine.com>). [1]: #ref-29