Purpose To investigate patients' perception of glaucomatous VF loss and its association with glaucoma severity using the Amsler grid test. Methods In this prospective cross-sectional study, glaucoma patients with abnormal 10–2 Humphrey Swedish Interactive Threshold Algorithm-standard VF tests were enrolled consecutively. All patients underwent a black-on-white Amsler grid test for each eligible eye. They were asked to outline any perceived scotomas (areas with abnormal grid lines) on the grid and then describe verbally their perception of the scotomas. Examiners asked patients to clarify their descriptions. All descriptions used by patients were recorded in their own words, which were then sorted into descriptor categories according to similar themes. The number of descriptor categories was counted for each eye. 10–2 VF mean deviation (MD) was compared among eyes that reported different number of descriptor categories. The mean 10–2 VF MD values were compared among different descriptor categories. Results Fifty glaucoma patients (88 eyes) were included. Patients used a total of 44 different descriptors for their scotomas. Patients' descriptors were classified into categories that incorporated similar themes, resulting in 4 overarching descriptor categories: Missing/White, Blurry/Gray, Black, and Not Aware. Fifty-two eyes reported one descriptor category and 19 eyes reported two descriptor categories (mean number of descriptor categories = 1.27±0.45). Eyes that reported two descriptor categories had worse VF MD than those that reported one (-17.86±10.31 dB vs. -12.08±7.53 dB; p = 0.012). When eyes were organized according to its combination of descriptor categories, each eye naturally sorted into one of the following 5 groups, in frequency order: Missing/White (27 eyes; 31%), Blurry/Gray (21 eyes; 24%), combined Missing/White and Blurry/Gray (19 eyes; 21%), Not Aware (17 eyes; 19%), and Black (4 eyes; 5%). The mean 10–2 VF MD severity order was Black (-21.18±10.59 dB), combined Missing/White and Blurry/Gray (-17.86±10.31 dB), Missing/White (-11.92±6.76 dB), Blurry/Gray (-10.55±7.03 dB), and Not Aware (-3.91±4.05 dB) (p<0.001). Conclusion Paracentral vision loss in glaucoma is perceived by patients. As the perception of scotomas and the variety of terms to describe scotomas are related to glaucoma severity, clinicians should pay attention to patients' subjective descriptions of their glaucomatous VF loss. The historical notion that glaucoma patients lose their peripheral vision first and eventually look through a black tunnel needs to be updated to reflect the true perception of glaucoma.

Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study (GWAS) followed by replication in a combined total of 10,503 PACG cases and 29,567 controls drawn from 24 countries across Asia, Australia, Europe, North America, and South America. We observed significant evidence of disease association at five new genetic loci upon meta-analysis of all patient collections. These loci are at EPDR1 rs3816415 (odds ratio (OR) = 1.24, P = 5.94 × 10(-15)), CHAT rs1258267 (OR = 1.22, P = 2.85 × 10(-16)), GLIS3 rs736893 (OR = 1.18, P = 1.43 × 10(-14)), FERMT2 rs7494379 (OR = 1.14, P = 3.43 × 10(-11)), and DPM2-FAM102A rs3739821 (OR = 1.15, P = 8.32 × 10(-12)). We also confirmed significant association at three previously described loci (P < 5 × 10(-8) for each sentinel SNP at PLEKHA7, COL11A1, and PCMTD1-ST18), providing new insights into the biology of PACG.

PURPOSE:To investigate the efficacy of the Amsler grid test in detecting central visual field (VF) defects in glaucoma. DESIGN:Prospective, cross-sectional study. PARTICIPANTS:Patients with glaucoma with reliable Humphrey 10-2 Swedish Interactive Threshold Algorithm standard VF on the date of enrollment or within the previous 3 months. METHODS:Amsler grid tests were performed for each eye and were considered "abnormal" if there was any perceived scotoma with missing or blurry grid lines within the central 10 degrees ("Amsler grid scotoma"). An abnormal 10-2 VF was defined as ≥3 adjacent points at P < 0.01 with at least 1 point at P < 0.005 in the same hemifield on the pattern deviation plot. Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area were calculated with the 10-2 VF as the clinical reference standard. Among eyes with an abnormal 10-2 VF, regression analyses were performed between the Amsler grid scotoma area and the 10-2 VF parameters (mean deviation [MD], scotoma extent [number of test points with P < 0.01 in total deviation map] and scotoma mean depth [mean sensitivity of test points with P < 0.01 in total deviation map]). MAIN OUTCOME MEASURES:Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area. RESULTS:A total of 106 eyes (53 patients) were included (mean ± standard deviation age, 24-2 MD and 10-2 MD = 66±12 years, -9.61±8.64 decibels [dB] and -9.75±9.00 dB, respectively). Sensitivity, specificity, and positive and negative predictive values of the Amsler grid test were 68%, 92%, 97%, and 46%, respectively. Sensitivity was 40% in eyes with 10-2 MD better than -6 dB, 58% in eyes with 10-2 MD between -12 and -6 dB, and 92% in eyes with 10-2 MD worse than -12 dB. The area under the receiver operating characteristic curve of the Amsler grid scotoma area was 0.810 (95% confidence interval, 0.723-0.880, P < 0.001). The Amsler grid scotoma area had the strongest relationship with 10-2 MD (quadratic R(2)=0.681), followed by 10-2 scotoma extent (quadratic R(2)=0.611) and 10-2 scotoma mean depth (quadratic R(2)=0.299) (all P < 0.001). CONCLUSIONS:The Amsler grid can be used to screen for moderate to severe central vision loss from glaucoma.

Purpose To compare anterior segment parameters in Chinese and Japanese subjects using anterior segment optical coherence tomography (ASOCT) and to determine if the associations between these parameters and angle closure vary between the two ethnic groups. Methods We conducted a case-control study among 117 Japanese and 102 Chinese patients with primary angle closure (PAC) or primary angle closure glaucoma (PACG); and 117 Japanese and 176 Chinese controls. All participants underwent A-scan biometry and ASOCT imaging (Visante, Carl Zeiss Meditec, Dublin, Ca). ASOCT-derived biometric parameters were compared between groups. Multivariate analysis was performed to determine predictors of angle opening distance at 750µm from the scleral spur (AOD750). Results Japanese were older (p<0.001) and consisted of more females (p<0.001). Age and gender adjusted analysis of covariance showed that Japanese eyes with angle closure had a significantly shallower anterior chamber depth (p=0.015), shorter axial length (p<0.001), greater lens thickness (p<0.001), lens vault (LV) (p=0.001) and iris curvature (I-Curv) (p<0.001), and a smaller anterior chamber area (p=0.044) and volume (p=0.028); but no significant difference was noted for anterior chamber width (ACW). In Japanese, the predictors of AOD750 were LV (p=0.004), ACW (p=0.049) and ICurv (p=0.017); in Chinese, only the LV (p<0.001) was a determinant factor. Conclusion Japanese eyes with angle closure were smaller, with thicker lenses. LV is an important factor for angle closure in both races. These results suggest differing mechanisms of angle closure pathogenesis between the two ethnic groups.

Purpose: To determine the effectiveness of argon laser peripheral iridoplasty (ALPI) in primary angle closure (PAC) and primary angle-closure glaucoma (PACG).Design: Randomized controlled trial.Participants: Eighty PAC or PACG subjects who underwent laser iridotomy (LI) and had at least 180 degrees of persistent appositional angle closure and intraocular pressure (IOP) of more than 21 mmHg were enrolled.Methods: Subjects were randomized to receive either 360 degrees ALPI (Visulas 532s; Carl Zeiss Meditec, Jena, Germany) or medical therapy (Travoprost 0.004%; Alcon-Couvreur, Puurs, Antwerp, Belgium). Repeat ALPI was performed if the IOP reduction was less than 20% from baseline along with inadequate angle widening at the month 1 or month 3 visit. Intraocular pressure was controlled with systematic addition of medications when required.Main Outcome Measures: The primary outcome measure was success rates after ALPI at 1 year. Complete success was defined as an IOP of 21 mmHg or less without medication, and qualified success was defined as an IOP of 21 mmHg or less with medication. Failure was defined as an IOP more than 21 mmHg despite additional medications or requiring glaucoma surgery.Results: Forty subjects (51 eyes) were randomized to ALPI and 40 subjects (55 eyes) were randomized to medical therapy. Complete success (IOP <= 21 mmHg without medication) was achieved in 35.0% eyes of the ALPI group compared with 85.0% of eyes in the prostaglandin analog (PGA) group (P < 0.001), and qualified success (IOP <= 21 mmHg with medication) was achieved in 35.0% and 7.5%, respectively (P = 0.003). The IOP decreased by 4.9 mmHg (95% confidence interval [CI], 3.5-6.3 mmHg) in the ALPI group (P < 0.001) and by 6.1 mmHg (95% CI, 5.1-7.1 mmHg) in the medication group (P < 0.001). A failure rate of 30.0% was noted in the ALPI group compared with 7.5% in the medication group (P = 0.01). No treatment-related complications were recorded in either group.Conclusions: After 1 year, ALPI was associated with higher failure rates and lower IOP reduction compared with PGA therapy in eyes with persistent appositional angle closure and raised IOP after LI. (C) 2016 by the American Academy of Ophthalmology.

Primary open angle glaucoma (POAG), a major cause of blindness worldwide, is a complex disease with a significant genetic contribution. We performed Exome Array (Illumina) analysis on 3504 POAG cases and 9746 controls with replication of the most significant findings in 9173 POAG cases and 26 780 controls across 18 collections of Asian, African and European descent. Apart from confirming strong evidence of association at CDKN2B-AS1 (rs2157719 [G], odds ratio [OR] = 0.71, P = 2.81 × 10−33), we observed one SNP showing significant association to POAG (CDC7–TGFBR3 rs1192415, ORG-allele = 1.13, Pmeta = 1.60 × 10−8). This particular SNP has previously been shown to be strongly associated with optic disc area and vertical cup-to-disc ratio, which are regarded as glaucoma-related quantitative traits. Our study now extends this by directly implicating it in POAG disease pathogenesis.

IMPORTANCE Selective laser trabeculoplasty (SLT) should be explored as a therapeutic option in eyes with angle closure. OBJECTIVE To assess the intraocular pressure (IOP)-lowering efficacy of SLT in eyes with primary angle closure (PAC) and PAC glaucoma (PACG). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at tertiary eye care institutions of 100 patients diagnosed as having PAC or PAC glaucoma in which the angles had opened at least 180° (visible posterior trabecular meshwork on gonioscopy) after laser iridotomy. Recruitment and baseline were completed from June 2009 to April 2012 and 6-month follow-up was completed from December 2009 to November 2012. INTERVENTIONS Eligible patients with a baseline IOP greater than 21 mm Hg were randomized to either SLT or prostaglandin analog (PGA; travoprost, 0.004%). The SLT was repeated if the IOP reduction was less than 20.0% from baseline at the 1- or 3-month follow-up visit. MAIN OUTCOMES AND MEASURES The primary outcome measure was the change in IOP from baseline to the final follow-up visit (at 6 months). The frequency of additional postoperative treatments and complications were secondary outcomes. RESULTS Fifty patients (96 eyes) were randomized to SLT and 50 patients (99 eyes) to PGA medical therapy. At 6 months, 49 patients in the SLT group and 47 in the PGA group completed follow-up. Analysis was based on intent to treat. At 6 months, IOP decreased by 4.0 mm Hg (95% CI, 3.2-4.8) in the SLT group (P < .001) and by 4.2 mm Hg (95% CI, 3.5-4.9) in the PGA group (P < .001). There were no differences between the SLT and PGA groups in the absolute mean reduction of IOP (4.0 vs 4.2 mm Hg, respectively; P = .78) or in the percentage of reduction in IOP (16.9% vs 18.5%, respectively; P = .52). Complete success (IOP ≤21 mm Hg without medications) was achieved in 60.0% eyes of the SLT group, compared with 84.0% of eyes in the PGA group (P = .008). No patients required glaucoma surgery. Additional medications were required in 22.0% of patients in the SLT group compared with 8.0% in the PGA group (P = .05). One patient in the SLT group (2.0%) had a transient posttreatment IOP spike greater than 5 mm Hg. The mean endothelial cell count showed a significant decrease from baseline in the SLT arm (4.8% decrease; P = .001). No other events such as persistent uveitis or increase in peripheral anterior synechiae were noted in eyes that underwent SLT. Two patients in the PGA group exited owing to drug-related complications (1 patient with uveitis and 1 with allergic conjunctivitis). CONCLUSIONS AND RELEVANCE Eyes with PAC or PACG respond to SLT in the short term, but the overall long-term therapeutic effectiveness needs further evaluation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01004900.

Purpose:To determine the agreement between intraocular pressure (IOP) measurements using conventional Goldmann applanation tonometry (GAT) and Tonosafe disposable prisms, and also to provide a comprehensive cost analysis of the use of both types of prisms Methods:In this prospective observational study, 198 eyes of 100 glaucoma patients had their IOPs measured by 5 consultant ophthalmologists. Data were analyzed using the Bland-Altman method of differences, and correlation was measured using the Pearson coefficient. An analysis of the cost incurred using the 2 methods over a 6-month period was performed. Results:The majority were Chinese (82%), with a male preponderance (57%). The range of IOPs as measured by GAT was 4 to 34 mm Hg. Using the Bland-Altman method to compare GAT and disposable prisms, the bias was 0.2 mm Hg. Tonosafe overestimated the IOP by 0.2 mm Hg in the right eye and underestimated it by 0.2 mm Hg in the left eye. The Tonosafe IOP correlated well with GAT, with a Pearson coefficient of correlation(r) of 0.91 (P<0.0005) for the right eye and 0.92 (P<0.0005) for the left eye, respectively. For those with GAT IOP≥21 mm Hg (n=26), Tonosafe underestimated the IOP by 0.35 mm Hg. The cost incurred by Tonosafe prisms was approximately 8 times that of GAT, but the cost differential reverses when GAT had to be replaced after every 100 cycles of disinfection. Conclusions:We found a good correlation between Tonosafe prisms and conventional GAT in measuring the IOP. Tonosafe prisms may be of use, especially if the risk of transmission of infection is high. However, cost may limit its more widespread use.

OBJECTIVE:To evaluate the association between focal, structural defects of the lamina cribrosa (LC) and glaucomatous visual field (VF) progression. DESIGN:Retrospective, observational study. PARTICIPANTS:A total of 169 patients with glaucoma (169 eyes) with a range of glaucomatous damage. METHODS:Serial horizontal and vertical enhanced-depth imaging optical coherence tomography (EDI OCT) B-scans of the optic nerve head were obtained from patients with glaucoma with 5 or more prior Humphrey 24-2 VFs (Carl Zeiss Meditec, Inc, Dublin, CA). The EDI OCT scans were reviewed for the presence of focal LC defects (laminar holes or disinsertions with a diameter >100 μm). The VF progression was defined as having ≥ 2 significantly progressing test points (with a slope calculated using pointwise linear regression [PLR], worse than -1.0 dB/year at P<0.01). Age, intraocular pressure (IOP), baseline VF mean deviation (MD), disc hemorrhage, and central corneal thickness (CCT) were recorded. MAIN OUTCOME MEASURES:The relationship between focal LC defects and the rate and risk of VF progression. RESULTS:Mean age and VF MD at the time of EDI OCT were 69 ± 12 years and -11.49 ± 6.87 dB, respectively. Sixty eyes (36%) progressed according to PLR criteria. Progression was more common in eyes with, rather than without, focal LC defects (38/81 eyes [47%] vs. 22/88 eyes [25%], P = 0.003). Among the evaluated parameters, the presence of focal LC defects, disc hemorrhage, higher mean follow-up IOP, greater number of VFs, and longer follow-up period were significantly associated with VF progression in the multivariable analyses (odds ratios, 2.90, 4.66, 1.22, 1.25, and 1.27, respectively; P = 0.010, P = 0.002, P = 0.002, P<0.001, and P<0.001, respectively). The mean global progression rate was significantly faster in the group with focal LC defect than in the group with no focal LC defect (-0.54 ± 0.99 dB/year vs. -0.28 ± 0.52 dB/year; P = 0.031). Among the 60 progressing eyes, despite no significant difference in the mean number of progressing VF points per eye (6.7 ± 7.0 vs. 6.5 ± 4.4; P = 0.899), the mean localized progression rate was significantly faster in the eyes with focal LC defects than in the eyes with no focal LC defects (-2.85 ± 1.85 dB/year vs. -1.75 ± 0.56 dB/year; P = 0.009). CONCLUSIONS:Focal LC defects are strongly associated with glaucomatous VF progression, and eyes with focal LC defects tend to progress faster than those without.

Anterior chamber depth (ACD) is a key anatomical risk factor for primary angle closure glaucoma (PACG). We conducted a genome-wide association study (GWAS) on ACD to discover novel genes for PACG on a total of 5,308 population-based individuals of Asian descent. Genome-wide significant association was observed at a sequence variant within ABCC5 (rs1401999; per-allele effect size =  -0.045 mm, P = 8.17 × 10(-9)). This locus was associated with an increase in risk of PACG in a separate case-control study of 4,276 PACG cases and 18,801 controls (per-allele OR = 1.13 [95% CI: 1.06-1.22], P = 0.00046). The association was strengthened when a sub-group of controls with open angles were included in the analysis (per-allele OR = 1.30, P = 7.45 × 10(-9); 3,458 cases vs. 3,831 controls). Our findings suggest that the increase in PACG risk could in part be mediated by genetic sequence variants influencing anterior chamber dimensions.

Objective: To compare the performance of 10-2 versus 24-2 visual fields (VFs) in detecting progression of initial parafoveal scotoma (IPFS) in glaucomatous eyes.Design: Retrospective, observational study.Participants: Glaucoma patients with the following criteria: (1) an IPFS (>= 3 adjacent points with P<0.05 within the central 10 degrees degrees of fixation, 1 point or more with P<0.01 lying at the innermost paracentral points, and no scotoma outside the central 10 degrees) in either hemifield based on 2 reliable Humphrey 24-2 Swedish interactive threshold algorithm standard VFs, and (2) 5 or more 10-2 and 24-2 VFs.Methods: Based on threshold map sensitivities, VF progression, defined as having 1 or more significantly progressing point(s) with a slope of sensitivity of less than -1.0 dB/year at P<0.01, was evaluated using pointwise linear regression.Main Outcome Measures: The number of progressing eyes in 10-2 and 24-2 VF analyses.Results: Fifty eyes (50 patients) were included (mean age +/- standard deviation, 62 +/- 9 years). Mean follow-up period (5.7 vs. 5.6 years) and number of VFs (7.6 vs. 7.8) were similar between 10-2 and 24-2 analyses (all P>0.3). Significantly more progressing eyes were detected in 10-2 than in 24-2 analyses (24 vs. 11 eyes; P = 0.007). This difference became greater within the central 10 degrees (24 vs. 4 eyes; P<0.001). Four of the 11 progressing eyes in 24-2 analysis were missed in 10-2 analysis, whereas 17 of the 24 progressing eyes in 10-2 analysis were missed in 24-2 analysis. The 4 progressing eyes missed in 10-2 analysis had progressing point(s) only outside the central 10 degrees in 24-2 analysis. The other 3 eyes with progressing point(s) only outside the central 10 degrees in 24-2 analysis were detected as progressing in 10-2 analysis. Similar results were obtained when more stringent criteria (at least 2 significantly progressing points within the same hemifield) were used for VF progression.Conclusions: The 10-2 VF detects more progressing eyes than the 24-2 VF in glaucoma patients with IPFS, suggesting that closer surveillance of the central VF using testing algorithms with closely spaced grids is warranted in eyes with parafoveal scotomas. (c) 2013 by the American Academy of Ophthalmology.

OBJECTIVE:To assess the value of enhanced depth imaging optical coherence tomography (EDI OCT) in diagnosing and evaluating optic nerve head drusen (ONHD) compared with conventional diagnostic methods.DESIGN:Prospective, comparative, cross-sectional study.PARTICIPANTS:Thirty-four patients with clinically visible or suspected ONHD in either eye based on dilated optic disc examination or optic disc stereophotography and without ocular comorbidity.METHODS:Spectral-domain OCT of the optic nerve head in both conventional (non-EDI) and EDI modes, ultrasound B-scan, and standard automated perimetry were performed on both eyes of all participants.MAIN OUTCOME MEASURES:Detection and findings of ONHD between EDI OCT and conventional diagnostic methods.RESULTS:Sixty-eight eyes were clinically classified into 3 groups: 32 eyes with definite ONHD, 25 eyes with suspected ONHD, and 11 normal-appearing fellow eyes. In the definite ONHD group, EDI OCT, non-EDI OCT, and ultrasound B-scan were positive for ONHD in all eyes and visual field (VF) was abnormal in 24 eyes. In the suspected ONHD group, EDI OCT, non-EDI OCT, ultrasound B-scan, and VF were positive in 17, 14, 7, and 3 eyes, respectively; 8 eyes had no evidence of ONHD in any of the tests. In normal-appearing fellow eyes, EDI OCT, non-EDI OCT, ultrasound B-scan, and VF were positive in 3, 1, 1, and 0 eyes, respectively; 4 eyes had no evidence of ONHD in any of the tests. Enhanced depth imaging OCT had a significantly higher ONHD detection rate than ultrasound B-scan in all eyes (52/68 eyes vs. 40/68 eyes; P<0.001), in eyes with clinically suspected ONHD or normal-appearing fellow eyes (20/36 eyes vs. 8/36 eyes; P<0.001), and in eyes with clinically suspected ONHD (17/25 eyes vs. 7/25 eyes; P = 0.002). Enhanced depth imaging OCT-detected ONHD appeared as signal-poor regions surrounded by short, hyper-reflective bands or isolated/clustered hyper-reflective bands without a signal-poor core. In non-EDI OCT, posterior surfaces of the ONHD and deep-seated hyper-reflective bands were invisible or less clear than in EDI OCT.CONCLUSIONS:Enhanced depth imaging OCT detects lesions likely representing ONHD more often and better assesses their shape and structure than conventional tests.

PURPOSE:To assess factors associated with focal lamina cribrosa (LC) defects in glaucoma.METHODS:Serial enhanced depth imaging (EDI) optical coherence tomography (OCT) B-scans of the optic nerve head were obtained from glaucoma patients. EDI OCT scans were reviewed for focal LC defects (laminar holes or disinsertions). Evaluated clinical factors included age, central corneal thickness, visual field (VF) mean deviation (MD), exfoliation syndrome, normal-tension glaucoma (NTG), disc hemorrhage, and intraocular pressure (IOP) during past follow-up.RESULTS:One hundred forty-eight glaucomatous eyes (148 patients; mean age, 68 ± 12 years; mean VF MD, -11.63 ± 6.96 dB) were included. Sixty-seven (45%) eyes had focal LC defects and 81 (55%) did not. Eyes with focal LC defects had a higher prevalence of both disc hemorrhage (25% vs. 6%) and NTG (33% vs. 9%) and worse VF MD (-14.12 vs. -9.58 dB) than those without focal LC defects (P = 0.002, P < 0.001, and P < 0.001, respectively). In the multivariate logistic regression analysis, higher frequency of disc hemorrhage detection (odds ratio [OR], 3.63; P = 0.032), a diagnosis of NTG (OR, 4.23; P = 0.005), and worse VF MD (OR, 1.11; P < 0.001) were significant factors associated with the presence of focal LC defects. Disc hemorrhage developed in the same half of the disc as the largest or the second largest focal LC defect in 15 of 17 eyes (88.2%).CONCLUSIONS:Disc hemorrhage, a diagnosis of NTG, and more advanced glaucoma status are associated with focal LC defects. Future studies are needed to elucidate the cause-and-effect relationships between focal LC defects and these factors.

IMPORTANCE:Considering the potential clinical importance of focal lamina cribrosa (LC) defects as a characteristic structural feature in glaucoma and a risk factor for glaucomatous visual field progression, it may be helpful to know the structure of focal LC defects and the spatial relationship between them and glaucomatous optic disc changes such as neuroretinal rim thinning/notching and acquired pits of the optic nerve (APON).OBJECTIVE:To investigate structural and spatial relationships between focal LC defects and glaucomatous neuroretinal rim thinning/notching and APON.DESIGN:In a cross-sectional analysis of data from an ongoing, prospective, longitudinal study, serial enhanced-depth imaging (EDI) optical coherence tomographic (OCT) images of the optic nerve head were obtained from patients with glaucoma and reviewed for focal LC defects (laminar holes or disinsertions). Anterior laminar insertion points and edges of laminar holes or disinsertions were marked in EDI-OCT images, reconstructed 3-dimensionally, and superimposed on optic disc photographs.SETTING:A glaucoma referral practice.PARTICIPANTS:Two hundred thirty-nine eyes (120 patients) were examined. Fifty-four eyes were excluded because of an incomplete horizontal or vertical set of serial EDI-OCT images or poor-quality EDI-OCT images owing to media opacity, irregular tear film, or poor patient cooperation. Among the remaining 185 eyes, 40 (from 31 patients) had laminar holes or disinsertions and were included for analysis.MAIN OUTCOME MEASURES:Presence, extent, and location of laminar holes or disinsertions.RESULTS:Among 185 eyes, 11 laminar holes and 36 laminar disinsertions were found in 40 eyes. Superimposed images of the 3-dimensionally reconstructed focal LC defects and disc photographs showed that the outline of the LC defect corresponded almost precisely to that of clinical APON for 6 laminar holes and that the LC defect was much larger than and enclosed APON for 10 laminar disinsertions. The remaining 5 laminar holes and 26 laminar disinsertions corresponded to focal neuroretinal rim loss, with no evidence of APON in disc photographs.CONCLUSIONS AND RELEVANCE:Focal LC defects (laminar holes or disinsertions) are associated with neuroretinal rim loss and APON. The extent of LC defects can be visualized more effectively on EDI-OCT images than by clinical examination.

Ningli Wang, Tin Aung and colleagues report genome-wide association analyses for primary angle closure glaucoma, a major cause of blindness worldwide. They identify three loci newly associated with this disease. Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study including 1,854 PACG cases and 9,608 controls across 5 sample collections in Asia. Replication experiments were conducted in 1,917 PACG cases and 8,943 controls collected from a further 6 sample collections. We report significant associations at three new loci: rs11024102 in PLEKHA7 (per-allele odds ratio (OR) = 1.22; P = 5.33 × 10−12), rs3753841 in COL11A1 (per-allele OR = 1.20; P = 9.22 × 10−10) and rs1015213 located between PCMTD1 and ST18 on chromosome 8q (per-allele OR = 1.50; P = 3.29 × 10−9). Our findings, accumulated across these independent worldwide collections, suggest possible mechanisms explaining the pathogenesis of PACG.

OBJECTIVE:To characterize the progression pattern of initial parafoveal scotomas (IPFSs) using cross-sectional and longitudinal 10-2 visual field (VF) data. DESIGN:Retrospective, observational study. PARTICIPANTS:Glaucoma patients with an IPFS in either hemifield based on 2 reliable 24-2 Swedish interactive threshold algorithm standard VFs (≥3 adjacent points with P<0.05 within the central 10° of fixation, 1 point or more with P<0.01 lying at the innermost paracentral points, and no scotoma outside the central 10°) and at least 2 10-2 VFs (first and last VFs 1 year or more apart). METHODS:To simulate a cohort with an extended follow-up, eyes with an IPFS were divided into subgroups based on the severity of glaucoma using their 10-2 VF pattern standard deviation (PSD). Cross-sectional data were used to create an average pattern deviation map that was generated by averaging pattern deviation map values of 10-2 VF point-by-point within each subgroup. Longitudinal data (eyes with 5 or more 10-2 VFs) was used to perform pointwise linear regression analysis of pattern deviation values. Patterns of IPFS progression were identified from these cross-sectional and longitudinal assessments. MAIN OUTCOME MEASURES:Average pattern deviation maps (cross-sectional) and maps of progression rates (longitudinal) in different disease severity subgroups. RESULTS:Eighty eyes (80 patients) and 40 eyes (40 patients) with an IPFS were included for cross-sectional and longitudinal analyses, respectively. The mean age ± standard deviation, 24-2 VF mean deviation, and 24-2 VF PSD for all eyes were 63±10 years, -3.27±2.18 dB, and 5.46±2.40 dB, respectively. Based on maps generated in both cross-sectional and longitudinal analyses, IPFS in the superior hemifield had an arcuate pattern initially that later deepened approximately 3° to 5° above fixation. The scotoma then elongated toward the physiologic blind spot and spread toward the nasal periphery, sparing the area corresponding to the papillomacular bundle. The IPFS in the inferior hemifield had a similar pattern, but was slightly farther from fixation. CONCLUSIONS:Superior and inferior IPFS have a similar characteristic pattern of progression, although the latter tend to be farther from fixation. Understanding these patterns should help in the management of such patients and in improving VF testing algorithms.