Systemic Medication Associations with Presumed Advanced or Uncontrolled Primary Open-Angle Glaucoma

Association of Systemic Calcium Channel Blocker Use with Visual Field Progression in a Large Real-World Cohort from Glaucoma Clinics

PURPOSE

To test the association between use of calcium channel blocker (CCB) medications and the rate of visual field (VF) progression in a large cohort of patients from 5 glaucoma clinics.

DESIGN

Retrospective longitudinal case-control study.

SUBJECTS

Patients attending 5 glaucoma clinics in the United Kingdom using the same electronic medical record (EMR) system.

METHODS

For the main analysis, we selected 1 eye from patients with at least 5 reliable (false positive errors < 15%) VFs over a period of at least 4 years. The use of systemic medications was derived from the EMR system. Calcium channel blocker users were identified as cases. Propensity score matching (PSM) and multivariable analyses (MVAs) were used to adjust for confounders. A directed acyclic graph of the relevant variables guided the selection of covariates. Linear mixed-effect models (LMMs) were used to test the effect on the rate of VF mean deviation (MD) associated with CCB use and other covariates (for the MV analysis). Sensitivity analyses were conducted with different inclusion criteria and cutoffs on the estimated duration of CCB use.

MAIN OUTCOME MEASURES

The mean difference in the rate of VF MD progression between CCB users and controls.

RESULTS

The main analysis included 14 475 eyes (1942 from CCB users) that met the selection criteria (1 eye per patient). The median (interquartile range) VF series length was 8 (6, 11) tests, with a follow-up of 8.6 (6, 11.5) and 8.2 (5.9, 11.2) years in CCB users and controls, respectively. One-to-one PSM pairing with controls was achieved for all CCB users. The estimated rate of MD progression was -0.31 (-0.33 to -0.28) dB/year (mean [95% confidence intervals]) in the CCB users and -0.35 (-0.37 to -0.33) dB/year in the matched controls (P = 0.016). This significant difference was confirmed with the MV analysis including all controls (P = 0.020). All sensitivity analyses confirmed the main results.

CONCLUSIONS

Calcium channel blocker use was statistically significantly associated with a slower rate of VF deterioration after multivariable adjustment. The estimated difference was small and likely not clinically significant but may be influenced by the limited information on the duration of CCB exposure in this cohort.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Drug-associated glaucoma: A real-world study based on the Food and Drug Administration adverse event reporting system database

BACKGROUND

This study aims to assess the risk of drug-associated glaucoma and track its epidemiological characteristics using real-world data.

METHODS

Adverse event reports from the Food and Drug Administration Adverse Event Reporting System (FAERS) from January 2004 to December 2023 were analysed. Disproportionality analysis and the Bayesian Confidence Propagation Neural Network algorithm were used. The study classified drugs associated with glaucoma, assessed risk levels, and compared drug-induced times across different categories.

RESULTS

Eight hundred and five drugs were linked to glaucoma in the FAERS database. Disproportionality analysis identified 46 drugs with significant risk, mainly adrenergic medications (clobetasol propionate, fluocinolone acetonide), antihypertensives (hydrochlorothiazide), insulin (insulin human), anticholinergics (umeclidinium, darifenacin), VEGF inhibitors (brolucizumab, faricimab), and psychotropics (topiramate, ziprasidone). The top three high-risk drugs were clobetasol propionate, umeclidinium, and fluocinolone acetonide. The shortest drug-induced times were observed with indacaterol, salmeterol, and umeclidinium. Anticholinergic medications had the shortest drug-induced time among all categories. Females (62.5%) and the elderly (average age 63.5 ± 16.8 years) were predominantly affected. Reports of drug-associated glaucoma increased over the years.

CONCLUSION

Preventing drug-associated glaucoma is more effective than treatment. Identifying the risk and drug-induced times of systemic and ophthalmic drugs can reduce occurrence risk. Clinical practitioners should be vigilant and inform patients of these risks.

Associations of different types of statins with the risk of open-angle glaucoma: a systematic review and network meta-analysis

PURPOSE

Previous studies implied that different types of statins may pose divergent impacts on the risk of glaucoma onset. This study aimed to comprehensively evaluate the effects of various statins on the risk of glaucoma occurrence.

METHODS

PubMed, Cochrane CENTRAL, Embase, and Web of Science were searched from February 1994 to February 2024. We included studies that investigated the effects of various types of statins, fibrates, ezetimibe, cholestyramine, niacin, PCSK9 inhibitors, omega-3 fatty acids, and any cholesterol-lowering medications on glaucoma onset or progression. The revised Cochrane risk-of-bias tool for randomized trials (RoB 2.0) and the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-1) tool were used to assess the quality of randomized controlled trials (RCTs) and non-RCTs, respectively. The frequentist network meta-analysis framework was utilized to evaluate the comparative effectiveness, with the random effects model applied.

RESULTS

This network meta-analysis comprised 12 studies, encompassing 262,217 individuals and including cholesterol-lowering medications such as statins, fibrates, ezetimibe, cholestyramine, niacin, and omega-3 fatty acids. Our findings demonstrate that comparing to the placebo, rosuvastatin (risk ratio [RR], 1.23; 95% confidence interval [CI], 1.03 to 1.46), simvastatin (RR, 1.21; 95% CI, 1.02 to 1.43), and pravastatin (RR, 1.20; 95% CI, 1.01 to 1.43) increased the risk of glaucoma onset with statistical significance.

CONCLUSION

Rosuvastatin, simvastatin, and pravastatin were each associated with a significantly increased risk of glaucoma onset. We advise medical practitioners to exercise caution when prescribing these specific statins for patients who are at risk of developing glaucoma.

KEY MESSAGES

What is known Previous studies have suggested a link between statins and the risk of developing glaucoma. However, there is still ongoing debate regarding the specific effects of each type of statin on the onset of glaucoma. What is new This network meta-analysis comprehensively evaluated the effects of various statins on the risk of glaucoma onset. Rosuvastatin, simvastatin, and pravastatin were associated with a significantly increased risk of glaucoma onset.

Change in Systemic Medication and its Influence on Intraocular Pressure - Results From the Gutenberg Health Study

Purpose

The purpose of this study was to investigate the relationship between the change in systemic medication and intraocular pressure (IOP) on a population-based level.

Methods

The Gutenberg Health Study is a population-based prospective observational cohort study in Germany. As part of the baseline examination (2007-2012) and 5-year follow-up examination (2012-2017), IOP was measured by non-contact tonometry. Systemic medication was recorded at both time points. Multivariable regression analyses were carried out to analyze associations. Moreover, we calculated the dose-response relationship for the dosage change of selective beta-blockers with IOP change over 5 years.

Results

The analysis population included 19,161 eyes of 9633 participants. IOP change was lower in participants with new intake of selective beta-blockers (-0.31 mm Hg, P < 0.001) and increased in those with discontinuation of selective beta-blocker intake (+0.28 mm Hg, P = 0.02). Associations between IOP change and statins and calcium channel blockers (CCBs) could be attributed to co-medications. There was a dose-response relationship for change in selective beta-blocker intake and change in IOP (-0.16 mm Hg/100 mg, P = 0.02).

Conclusions

Use of systemic selective beta-blockers is associated with an IOP change on a population level, whereas the association with other systemic medications on IOP change could be explained by co-medication use or change in blood pressure. Patients undergoing IOP monitoring and management should routinely be asked about changes in systemic medications.

Amlodipine increases risk of primary open-angle glaucoma

BACKGROUND

The use of calcium channel blockers is associated with primary open-angle glaucoma (POAG) in a statistically meaningful but minor way. In general, those who had received calcium channel blocker medication were at a 23% increased risk of developing glaucoma in comparison to those who had never taken the antihypertensive drugs. We wished to confirm this association and examine POAG genes that might be involved, since the genetics has not yet been analyzed.

METHODS

We used MedWatch and UK Biobank data to evaluate the effects of amlodipine on POAG and intraocular pressure (IOP). We analyzed three POAG-associated single-nucleotide polymorphisms: rs9913911, an intron variant in growth arrest-specific 7 (GAS7), one of the genes that influences IOP; rs944801, an intron variant within CDKN2B-AS1, and rs2093210, an intron variant within SIX6, known to be associated with vertical cup-disc ratio, an important optic nerve head parameter that is often used to define or diagnose glaucoma.

RESULTS

Amlodipine use in MedWatch doubled the prevalence of POAG, from 0.0805 to 0.177%, a small but significant increase. Multivariate analysis by logistic regression of UK Biobank data revealed that POAG risk was significantly increased with age, male sex, major alleles of rs9913911 (GAS7) and rs944801 (CDKN2B-AS1), and minor allele of rs2093210 (SIX6). Amlodipine increased POAG risk by 16.1% (P = 0.032). Amlodipine has not been associated with increased IOP. We confirmed this lack of association and in addition found that GAS7, associated with IOP, was not associated with POAG risk and amlodipine. But CDKN2B-AS1 and SIX6, POAG genes not associated with IOP, were associated with POAG and amlodipine.

CONCLUSIONS

Amlodipine, a frequently prescribed drug and first line treatment for hypertension, has a potentially hazardous relationship with POAG. Knowledge of this link can guide the prescribing of alternate drugs for hypertensive individuals who have glaucoma or are at risk for it. Diuretics and β-blockers are not associated with POAG or increased IOP and could be substituted for amlodipine in hypertensive patients at risk POAG.

TRIAL REGISTRATION

None.

Long-Term Systemic Use of Calcium Channel Blockers and Incidence of Primary Open-Angle Glaucoma

PURPOSE

To evaluate the association between the systemic use of calcium channel blockers (CCBs) and primary open-angle glaucoma (POAG) using a diverse nationwide dataset.

DESIGN

Retrospective cohort study.

SUBJECTS

213 424 individuals aged 40 years and older in the National Institutes of Health All of Us dataset, notable for its demographic, geographic, and medical diversity and inclusion of historically underrepresented populations. Patients with a diagnosis of POAG prior to use of any kind of antihypertensive medication were excluded.

METHODS

Bivariate and multivariable regression analyses were performed to evaluate associations between CCB use and POAG. Calcium channel blocker use was further divided into exposure to dihydropyridine CCBs and nondihydropyridine CCBs, and subgroup analyses were performed using chi-square and Fisher tests.

MAIN OUTCOME MEASURES

Diagnosis of POAG.

RESULTS

Within our cohort, 2772 participants (1.3%) acquired a diagnosis of POAG, while 210 652 (98.7%) did not. Among patients who developed POAG, the mean age was 73.3 years, 52.5% were female, and 48.2% identified as White. Among patients with POAG, 32.6% used 1 or more CCB, 28.2% used a dihydropyridine CCB, and 2.2% used a nondihydropyridine CCB. In bivariate analysis, use of any CCBs was associated with an increased risk of POAG (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.27-1.31, P < 0.001). In multivariable analysis adjusting for age, gender, race, ethnicity, and comorbidities such as diabetes, hyperlipidemia, and hypertension, use of any CCBs remained associated with an increased risk of developing POAG (OR: 1.52, 95% CI: 1.33-1.74, P < 0.001). When stratified by type of CCB, the use of dihydropyridine CCBs (OR: 1.31, 95% CI: 1.14-1.50, P < 0.001) was associated with increased POAG risk.

CONCLUSIONS

Use of dihydropyridine CCBs was associated with a significantly higher risk of developing POAG, both before and while adjusting for demographic factors and comorbid medical conditions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association of Age of Menopause and Glaucoma Diagnosis in Female Veterans

Purpose

Age of menopause has been associated with the risk of developing glaucoma; however, it is unclear if the onset of menopause is directly associated with the development of glaucoma. Our objective was to determine if there is an association between the age at diagnosis of menopause and glaucoma.

Methods

This retrospective, case-only analysis was performed using the Veterans Affairs (VA) Corporate Data Warehouse of female veterans from 2000 to 2019. Women with both menopause and glaucoma diagnoses were matched based on covariates. The two matched cohorts were early menopause-early comparative (EM-EC; n = 1075) and late menopause-late comparative (LM-LC; n = 1050) women. We used a Pearson correlation to examine the linear relationship between age at diagnosis of menopause and glaucoma. Afterward, we used a multivariate linear regression model with age at diagnosis of glaucoma serving as the outcome variable to account for the covariates.

Results

We found that EM women developed glaucoma 6.0 years (interquartile range [IQR], 5.1-6.5) earlier than the EC group (P < 0.001), and LM women developed glaucoma an average of 5.2 years (IQR, 4.8-5.7) later than the LC group (P < 0.001). There was a modest linear relationship between the age of menopause and glaucoma diagnoses in the EM-EC (r = 0.40) and LM-LC (r = 0.46) cohorts. In our multivariate analysis, age at diagnosis of menopause was the largest factor related to age at diagnosis of glaucoma while accounting for our covariates. Our models predicted a 0.67-year delay in age at diagnosis of glaucoma with each additional premenopausal year.

Conclusions

This case-only analysis elucidates a temporal association between menopause and glaucoma, highlighting the need to characterize the role of menopause in the onset of glaucoma for women.

Amlodipine Attenuates Carrageenan-induced Oxidative Stress Targeting Transsynaptic Neuronal Damage by Promoting Survival of Retinal Ganglion Cells in Adult Zebrafish (Danio rerio)

Background

Transsynaptic degeneration of retinal ganglion cells (RGCs) likely plays a role in progressive loss of vision in glaucoma. Carrageenan (Carr), obtained from seaweed (Rhodophyceae), a sulphated polysaccharide extracted from a species of red algae (Chondrus crispus), is a reversible gel mostly used in eye-drop preparation due to its hydrocolloid nature. But Carr-induced inflammation causing oxidative stress in animals has not yet been evaluated. It was reported that amlodipine (AML) can inhibit inflammatory cytokines by lowering intracellular calcium concentration and increasing antioxidant defences.

Purpose

In this study, we examined the impact of AML administration on Carr-induced oxidative stress, causing free radial-mediated neurodegeneration and behavioural alteration in zebrafish.

Methods

We aimed to evaluate the behavioural alteration in zebrafish using the novel tank diving test (NTDT) and the light-dark preference test (LDPT) as invaluable tools for analysing visual functions. To understand the role of the antioxidant defence system, oxidative stress biomarkers such as lipid peroxidation and CAT activity were analysed. RGCs of the retina of the eye and neurons of the optical tectum (TeO) in the brain were investigated by histopathological studies.

Results

Carr-treated groups swam in random patterns and showed an increased number of transitions and spent more time in alter zones, whereas controls prefer perceived motion. AML significantly attenuates the increased lipid peroxidation level and decreased CAT activity with Carr administration. Histopathological analysis showed an increase in the percentage of pyknotic cell counts after Carr treatment, whereas AML supplementation significantly reduced the pyknotic RGC cell count in the retina and TeO of the brain.

Conclusion

Findings showed the effectiveness of AML as an antioxidant and neuroprotective agent by reducing pyckonsis in developmental RGCs and possible repair mechanisms against Carr-induced oxidative stress. This study may be useful to know the underlying mechanisms of weakening and eliminating central neurons for synaptic connections in the visual system of zebrafish.

Incidence of glaucoma filtration surgery from disease onset of open-angle glaucoma

AIMS

To investigate the rate and risk factors of undergoing glaucoma filtration surgery (GFS) in patients with newly diagnosed open-angle glaucoma (OAG).

METHODS

This is a population-based historic cohort study, consisting of 9420 patients older than 45 years diagnosed with OAG during 1997-2010. Follow-up spanned from 1997 to 2017. We obtained data for trabeculectomy (TRE), deep sclerectomy (DS), and glaucoma drainage implant (GDI) surgeries from national administrative healthcare registers by hospital billing data. We plotted the cumulative incidence of GFS and carried out a multivariate Poisson regression analysis adjusted for age, sex, hospital district, systemic comorbidities, and the number of IOP-lowering drugs. We reported incidence rate ratios (IRR) with 95% confidence intervals (CI) for GFS after the onset of OAG.

RESULTS

The cumulative incidence of GFS at 5 years from OAG onset was 3.1% and at 10 years 5.4%. Age over 80 years at baseline was associated with lower GFS incidence (IRR 0.51, CI 0.31-0.84). The number of IOP-lowering drugs in the first 2 years of treatment correlated with the risk of GFS increasing from (IRR 3.23, CI 2.32-4.50) for two drugs, (IRR 7.44, CI 5.28-10.47) for three and to (IRR 14.95, CI 10.38-21.52) for four drugs.

CONCLUSION

This study characterized the treatment path of OAG from diagnosis to surgical intervention refining the role of GFS among glaucoma therapies.

The Relevance of Arterial Blood Pressure in the Management of Glaucoma Progression: A Systematic Review

BACKGROUND

Glaucoma is one of the leading causes of global blindness and is expected to co-occur more frequently with vascular morbidities in the upcoming years, as both are aging-related diseases. Yet, the pathogenesis of glaucoma is not entirely elucidated and the interplay between intraocular pressure, arterial blood pressure (BP) and ocular perfusion pressure is poorly understood.

OBJECTIVES

This systematic review aims to provide clinicians with the latest literature regarding the management of arterial BP in glaucoma patients.

METHODS

A systematic search was performed in Medline, Embase, Web of Science and Cochrane Library. Articles written in English assessing the influence of arterial BP and systemic antihypertensive treatment of glaucoma and its management were eligible for inclusion. Additional studies were identified by revising references included in selected articles.

RESULTS

80 Articles were included in this systemic review. A bimodal relation between BP and glaucoma progression was found. Both high and low BP increase the risk of glaucoma. Glaucoma progression was, possibly via ocular perfusion pressure variation, strongly associated with nocturnal dipping and high variability in the BP over 24 h.

CONCLUSIONS

We concluded that systemic BP level associates with glaucomatous damage and provided recommendations for the management and study of arterial BP in glaucoma. Prospective clinical trials are needed to further support these recommendations.

Modulation of TRPV4-mediated TNF-α expression in Müller glia and subsequent RGC apoptosis by statins

In addition to regulating cholesterol synthesis, statins have neuroprotective effects. Apoptosis of retinal ganglion cells (RGCs) causes a gradual loss of visual function in glaucoma. This study aimed to investigate the neuroprotective effect of statins on the RGC apoptosis induced by activated Müller glia. Primary Müller cells and RGCs were cultured from the retina of C57BL6 mice. Müller cells were activated with GSK101, a transient receptor potential vanilloid 4 (TRPV4) agonist, and tumor necrosis factor-alpha (TNF-α) released to the medium was measured using an enzyme-linked immunosorbent assay. Cells were pretreated with simvastatin or lovastatin before GSK101. RGCs were treated with conditioned media from Müller glia cultures, and apoptosis was determined using flow cytometry. TRPV4 activation through GSK101 treatment induced gliosis of Müller cells, and the conditioned media from activated Müller cells was potent to induce RGC apoptosis. Statins suppress both gliosis in Müller cells and subsequent RGC apoptosis. TNF-α release to the media was increased in GSK101-treated Müller cells, and TNF-α in the conditioned media was the critical factor causing RGC apoptosis. The increase in TRPV4-mediated TNF-α expression occurred through the nuclear factor kappa-light chain enhancer of activated B cell pathway activation, which was inhibited by statins. Herein, we showed that statins can modulate gliosis and TNF-α expression in Müller cells, protecting RGCs. These data further support the neuroprotective effect of statins, promoting them as a potential treatment for glaucoma.

Proactive Decision Support for Glaucoma Treatment: Predicting Surgical Interventions with Clinically Available Data

A longitudinal ophthalmic dataset was used to investigate multi-modal machine learning (ML) models incorporating patient demographics and history, clinical measurements, optical coherence tomography (OCT), and visual field (VF) testing in predicting glaucoma surgical interventions. The cohort included 369 patients who underwent glaucoma surgery and 592 patients who did not undergo surgery. The data types used for prediction included patient demographics, history of systemic conditions, medication history, ophthalmic measurements, 24-2 VF results, and thickness measurements from OCT imaging. The ML models were trained to predict surgical interventions and evaluated on independent data collected at a separate study site. The models were evaluated based on their ability to predict surgeries at varying lengths of time prior to surgical intervention. The highest performing predictions achieved an AUC of 0.93, 0.92, and 0.93 in predicting surgical intervention at 1 year, 2 years, and 3 years, respectively. The models were also able to achieve high sensitivity (0.89, 0.77, 0.86 at 1, 2, and 3 years, respectively) and specificity (0.85, 0.90, and 0.91 at 1, 2, and 3 years, respectively) at an 0.80 level of precision. The multi-modal models trained on a combination of data types predicted surgical interventions with high accuracy up to three years prior to surgery and could provide an important tool to predict the need for glaucoma intervention.

Deep learning-based identification of eyes at risk for glaucoma surgery

To develop and evaluate the performance of a deep learning model (DLM) that predicts eyes at high risk of surgical intervention for uncontrolled glaucoma based on multimodal data from an initial ophthalmology visit. Longitudinal, observational, retrospective study. 4898 unique eyes from 4038 adult glaucoma or glaucoma-suspect patients who underwent surgery for uncontrolled glaucoma (trabeculectomy, tube shunt, xen, or diode surgery) between 2013 and 2021, or did not undergo glaucoma surgery but had 3 or more ophthalmology visits. We constructed a DLM to predict the occurrence of glaucoma surgery within various time horizons from a baseline visit. Model inputs included spatially oriented visual field (VF) and optical coherence tomography (OCT) data as well as clinical and demographic features. Separate DLMs with the same architecture were trained to predict the occurrence of surgery within 3 months, within 3-6 months, within 6 months-1 year, within 1-2 years, within 2-3 years, within 3-4 years, and within 4-5 years from the baseline visit. Included eyes were randomly split into 60%, 20%, and 20% for training, validation, and testing. DLM performance was measured using area under the receiver operating characteristic curve (AUC) and precision-recall curve (PRC). Shapley additive explanations (SHAP) were utilized to assess the importance of different features. Model prediction of surgery for uncontrolled glaucoma within 3 months had the best AUC of 0.92 (95% CI 0.88, 0.96). DLMs achieved clinically useful AUC values (> 0.8) for all models that predicted the occurrence of surgery within 3 years. According to SHAP analysis, all 7 models placed intraocular pressure (IOP) within the five most important features in predicting the occurrence of glaucoma surgery. Mean deviation (MD) and average retinal nerve fiber layer (RNFL) thickness were listed among the top 5 most important features by 6 of the 7 models. DLMs can successfully identify eyes requiring surgery for uncontrolled glaucoma within specific time horizons. Predictive performance decreases as the time horizon for forecasting surgery increases. Implementing prediction models in a clinical setting may help identify patients that should be referred to a glaucoma specialist for surgical evaluation.

A Systematic Review and Meta-analysis of Systemic Antihypertensive Medications With Intraocular Pressure and Glaucoma

PURPOSE

We synthesized the literature on the association between systemic antihypertensive medications with intraocular pressure (IOP) and glaucoma. Antihypertensive medications included β-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics.

DESIGN

Systematic review and meta-analysis.

METHODS

Databases were searched for relevant articles until December 5, 2022. Studies were eligible if they examined (1) the association between systemic antihypertensive medications with glaucoma or (2) the association between systemic antihypertensive medications with IOP in those without glaucoma or ocular hypertension. The protocol was registered at PROSPERO (International Prospective Register of Systematic Reviews; registration ID: CRD42022352028).

RESULTS

A total of 11 studies were included in the review and 10 studies in the meta-analysis. The 3 studies on IOP were cross-sectional, whereas the 8 studies on glaucoma were primarily longitudinal. In the meta-analysis, β-blockers were associated with a lower odds of glaucoma (odds ratio: 0.83, 95% CI: 0.75-0.92, 7 studies, n = 219,535) and lower IOP (β: -0.53, 95% CI: -1.05 to -0.02, 3 studies, n = 28,683). Calcium channel blockers were associated with a higher odds of glaucoma (odds ratio: 1.13, 95% CI: 1.03-1.24, 7 studies, n = 219,535) but not with IOP (β: -0.11, 95% CI: -0.25 to 0.03, 2 studies, n = 20,620). There were no consistent associations between angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or diuretics with glaucoma or IOP.

CONCLUSIONS

Systemic antihypertensive medications have heterogeneous effects on glaucoma and IOP. Clinicians should be aware that systemic antihypertensive medications may mask elevated IOP or positively or negatively affect the risk of glaucoma.

Calcium Channel Blocker Use and Associated Glaucoma and Related Traits Among UK Biobank Participants

Importance

Calcium channel blocker (CCB) use has been associated with an increased risk of glaucoma in exploratory studies.

Objective

To examine the association of systemic CCB use with glaucoma and related traits among UK Biobank participants.

Design, Setting, and Participants

This population-based cross-sectional study included UK Biobank participants with complete data (2006-2010) for analysis of glaucoma status, intraocular pressure (IOP), and optical coherence tomography (OCT)-derived inner retinal layer thicknesses. Data analysis was conducted in January 2023.

Exposure

Calcium channel blocker use was assessed in a baseline touchscreen questionnaire and confirmed during an interview led by a trained nurse.

Main Outcomes and Measures

The primary outcome measures included glaucoma status, corneal-compensated IOP, and 2 OCT-derived inner retinal thickness parameters (macular retinal nerve fiber layer [mRNFL] and macular ganglion cell-inner plexiform layer [mGCIPL] thicknesses). We performed logistic regression and linear regression analyses to test for associations with glaucoma status and IOP and OCT-derived inner retinal thickness parameters, respectively.

Results

This study included 427 480 adults. Their median age was 58 (IQR, 50-63) years, and more than half (54.1%) were women. There were 33 175 CCB users (7.8%). Participants who had complete data for glaucoma status (n = 427 480), IOP (n = 97 100), and OCT-derived inner retinal layer thicknesses (n = 41 023) were eligible for respective analyses. After adjustment for key sociodemographic, medical, anthropometric, and lifestyle factors, use of CCBs (but not other antihypertensive agents) was associated with greater odds of glaucoma (odds ratio [OR], 1.39 [95% CI, 1.14 to 1.69]; P = .001). Calcium channel blocker use was also associated with thinner mGCIPL (-0.34 μm [95% CI, -0.54 to -0.15 μm]; P = .001) and mRNFL (-0.16 μm [95% CI, -0.30 to -0.02 μm]; P = .03) thicknesses but not IOP (-0.01 mm Hg [95% CI, -0.09 to 0.07 mm Hg]; P = .84).

Conclusions and Relevance

In this study, an adverse association between CCB use and glaucoma was observed, with CCB users having, on average, 39% higher odds of glaucoma. Calcium channel blocker use was also associated with thinner mGCIPL and mRNFL thicknesses, providing a structural basis that supports the association with glaucoma. The lack of association of CCB use with IOP suggests that an IOP-independent mechanism of glaucomatous neurodegeneration may be involved. Although a causal relationship has not been established, CCB replacement or withdrawal may be considered should glaucoma progress despite optimal care.

Effect of antihypertensive medications on the risk of open-angle glaucoma

The purpose of this study was to identify the effect of antihypertensive medication on risks of open-angle glaucoma (OAG) among patients diagnosed with hypertension (HTN). A total of 5,195 patients, who were diagnosed with HTN between January 1, 2006 and December 31, 2015, and subsequently diagnosed with OAG, were selected for analysis. For each OAG patient, 5 non-glaucomatous, hypertensive controls were matched (n = 25,975) in hypertension diagnosis date, residential area, insurance type and economic status. Antihypertensive medications were stratified into 5 types: angiotensin converting enzyme inhibitor (ACEi), angiotensin receptor blockers (ARB), calcium channel blockers (CCB), β-blockers and diuretics. Relative risks were calculated. After adjusting for age, sex, body mass index, lifestyle, comorbidities, blood pressure (BP), follow-up duration, and use of other types of antihypertensive drugs, ARB and CCB were found to slightly increase OAG risks (RR 1.1087 (95% CI 1.0293-1.1942); 1.0694 (1.0077-1.1349), respectively). Combinations of ARB with diuretics (1.0893 (1.0349-1.1466)) and CCB (1.0548 (1.0122-1.0991)) also increased OAG risks. The risks for OAG were found to increase by antihypertensive medication use, but the effects appeared to be small. Further studies are necessary to identify the associations of increased BP, medication and therapeutic effect with OAG.

Association of Systemic Medication Use with Glaucoma and Intraocular Pressure: The European Eye Epidemiology Consortium

PURPOSE

To investigate the association of commonly used systemic medications with glaucoma and intraocular pressure (IOP) in the European population.

DESIGN

Meta-analysis of 11 population-based cohort studies of the European Eye Epidemiology Consortium.

PARTICIPANTS

The glaucoma analyses included 143 240 participants and the IOP analyses included 47 177 participants.

METHODS

We examined associations of 4 categories of systemic medications-antihypertensive medications (β-blockers, diuretics, calcium channel blockers [CCBs], α-agonists, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers), lipid-lowering medications, antidepressants, and antidiabetic medications-with glaucoma prevalence and IOP. Glaucoma ascertainment and IOP measurement method were according to individual study protocols. Results of multivariable regression analyses of each study were pooled using random effects meta-analyses. Associations with antidiabetic medications were examined in participants with diabetes only.

MAIN OUTCOME MEASURES

Glaucoma prevalence and IOP.

RESULTS

In the meta-analyses of our maximally adjusted multivariable models, use of CCBs was associated with a higher prevalence of glaucoma (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.08 to 1.39). This association was stronger for monotherapy of CCBs with direct cardiac effects (OR, 1.96; 95% CI, 1.23 to 3.12). No other antihypertensive medications, lipid-lowering medications, antidepressants, or antidiabetic medications were associated with glaucoma. Use of systemic β-blockers was associated with a lower IOP (β coefficient, -0.33 mmHg; 95% CI, -0.57 to -0.08 mmHg). Monotherapy of both selective systemic β-blockers (β coefficient, -0.45 mmHg; 95% CI -0.74 to -0.16 mmHg) and nonselective systemic β-blockers (β coefficient, -0.54 mmHg; 95% CI, -0.94 to -0.15 mmHg) was associated with lower IOP. A suggestive association was found between use of high-ceiling diuretics and lower IOP (β coefficient, -0.30 mmHg; 95% CI, -0.47 to -0.14 mmHg) but not when used as monotherapy. No other antihypertensive medications, lipid-lowering medications, antidepressants, or antidiabetic medications were associated with IOP.

CONCLUSIONS

We identified a potentially harmful association between use of CCBs and glaucoma prevalence. Additionally, we observed and quantified the association of lower IOP with systemic β-blocker use. Both findings potentially are important, given that patients with glaucoma frequently use systemic antihypertensive medications. Determining causality of the CCB association should be a research priority.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Evaluation of retinal nerve fibre layer thickness as a possible measure of diabetic retinal neurodegeneration in the EPIC-Norfolk Eye Study

BACKGROUND/AIMS

Markers to clinically evaluate structural changes from diabetic retinal neurodegeneration (DRN) have not yet been established. To study the potential role of peripapillary retinal nerve fibre layer (pRNFL) thickness as a marker for DRN, we evaluated the relationship between diabetes, as well as glycaemic control irrespective of diabetes status and pRNFL thickness.

METHODS

Leveraging data from a population-based cohort, we used general linear mixed models (GLMMs) with a random intercept for patient and eye to assess the association between pRNFL thickness (measured using GDx) and demographic, systemic and ocular parameters after adjusting for typical scan score. GLMMs were also used to determine: (1) the relationship between: (A) glycated haemoglobin (HbA1c) irrespective of diabetes diagnosis and pRNFL thickness, (B) diabetes and pRNFL thickness and (2) which quadrants of pRNFL may be affected in participants with diabetes and in relation to HbA1c.

RESULTS

7076 participants were included. After controlling for covariates, inferior pRNFL thickness was 0.94 µm lower (95% CI -1.28 µm to -0.60 µm), superior pRNFL thickness was 0.83 µm lower (95% CI -1.17 µm to -0.49 µm) and temporal pRNFL thickness was 1.33 µm higher (95% CI 0.99 µm to 1.67 µm) per unit increase in HbA1c. Nasal pRNFL thickness was not significantly associated with HbA1c (p=0.23). Similar trends were noted when diabetes was used as the predictor.

CONCLUSION

Superior and inferior pRNFL was significantly thinner among those with higher HbA1c levels and/or diabetes, representing areas of the pRNFL that may be most affected by diabetes.

A medication-wide association study to identify medications associated with incident clinically significant diabetic retinopathy

Background

Diabetic retinopathy, a common microvascular complication of diabetes mellitus, is one of the leading causes of vision loss worldwide. Although some oral drugs have been suggested to affect the risk of diabetic retinopathy, systematic evaluation about the associations between medications and diabetic retinopathy is still absent.

Objective

To comprehensively investigate associations of systemic medications with incident clinically significant diabetic retinopathy (CSDR).

Design

Population-based cohort study.

Methods

From 2006 to 2009, more than 26 000 participants residing in New South Wales were enrolled in the 45 and Up study. Diabetic participants with self-reported physician diagnosis or records of anti-diabetic medication prescriptions were finally included in the current analysis. CSDR was defined as diabetic retinopathy cases requiring retinal photocoagulation recorded in the Medicare Benefits Schedule database from 2006 to 2016. Prescriptions of systemic medication from 5 years to 30 days prior to CSDR were retrieved from the Pharmaceutical Benefits Scheme. The study participants were equally split into training and testing datasets. Logistic regression analyses were performed for the association between each of systemic medication and CSDR in the training dataset. After controlling the false discovery rate (FDR), significant associations were further validated in the testing dataset.

Results

The 10-year incidence of CSDR was 3.9% (n = 404). A total of 26 systemic medications were found to be positively associated with CSDR, among which 15 were validated by the testing dataset. Additional adjustments for pertinent comorbidities suggested that isosorbide mononitrate (ISMN) (OR: 1.87, 95%CI: 1.00-3.48), calcitriol (OR: 4.08, 95% CI: 2.02-8.24), three insulins and analogues (e.g., intermediate-acting human insulin, OR: 4.28, 95% CI: 1.69-10.8), five anti-hypertensive medications (e.g., furosemide, OR: 2.53, 95% CI: 1.77-3.61), fenofibrate (OR: 1.96, 95% CI: 1.36-2.82) and clopidogrel (OR: 1.72, 95% CI: 1.15-2.58) were independently associated with CSDR.

Conclusion

This study investigated the association of a full spectrum of systemic medications with incident CSDR. ISMN, calcitriol, clopidogrel, a few subtypes of insulin, anti-hypertensive and cholesterol-lowering medications were found to be associated with incident CSDR.

[The effect of systemic antihypertensive drugs on the risk of primary open-angle glaucoma]

Primary open-angle glaucoma (POAG) is a common disease. Elevated blood pressure has been reported as a significant risk factor for the development and progression of POAG.

PURPOSE

The goal of the present study was to test the effect of systemic antihypertensive drugs on the risk of POAG using cis-Mendelian randomization (cis-MR) approach.

MATERIAL AND METHODS

The study involved summary statistics from genome-wide association studies (GWAS) for POAG (15229 cases and 177 473 controls) and from GWAS for systolic blood pressure meta-analysis (757 601 individuals). Drug targets for beta-blockers and for calcium channel blockers and genes coding these targets were identified via DrugBank. Genetic variants within the regions of these genes were selected for the Mendelian randomization analysis.

RESULTS

The effect of a 10-mm Hg decrease in systolic blood pressure caused by calcium channel blockers on the risk of POAG amounted to: odds ratio (OR) 0.90 (95% CI 0.63-1.30, p=0.59). For beta blockers the cis-MR estimated effect on the risk of POAG was OR=0.95 (95% CI 0.34-2.70, p=0.92).

CONCLUSION

The results of the present study do not confirm the hypothesis of causal effect of antihypertensive drugs intake on the risk of developing POAG.

Association between statin use and the risks of glaucoma in Australia: a 10-year cohort study

SYNOPSIS

In a cohort of middle-aged and elderly Australians, we found that long-term statin use was associated with a higher risk of glaucoma onset. As to subtypes of statins, the increased risk was only found in rosuvastatin users.

PURPOSE

To investigate the relationship between statin use and glaucoma onset in a 10-year longitudinal study.

METHODS

This nested case-control study was based on data from a large-scale cohort of Australians aged over 45 years old. Medication exposure was identified by claims records from the Pharmaceutical Benefits Scheme during the follow-up period (2009-2016). The onset of glaucoma was defined as the people with at least three claims of antiglaucoma medications. Controls matched by age, gender and cardiovascular diseases were selected from participants without prescription of antiglaucoma medications. A conditional logistic regression model was used to assess the association between statin use and glaucoma onset.

RESULTS

The proportion of statin users was higher in the case group (40.5%) than that in the control group (38.4%). After adjusting for baseline characteristics and longitudinal claims records, statin use was not associated with glaucoma onset (OR 1.04, 95% CI 0.97 to 1.11). However, an increased risk of glaucoma onset was observed in participants with a longer duration of statin use (>3 years vs <1 year: OR 1.12, 95% CI 1.04 to 1.21). With respect to specific types of statins, participants taking rosuvastatin were more likely to suffer from glaucoma (OR 1.11, 95%CI 1.01 to 1.22). The use of other statins was not significantly associated with glaucoma onset.

CONCLUSIONS

Long-term statin use was found to be associated with a higher risk of glaucoma onset in this study. Regarding specific types of statins, the increased risk of glaucoma onset was only observed in users of rosuvastatin.

Ocular and Systemic Factors Associated with Glaucoma

Glaucoma is one of the leading causes of irreversible blindness in the world. Although numerous factors have been implicated in the pathogenesis of glaucoma, the main focus of management still remains lowering the intraocular pressure (IOP) by medical or surgical therapy. However, a major challenge is that many glaucoma patients continue to progress despite good control of IOP. In this regard, the importance of other coexisting factors that may contribute to disease progression needs to be explored. Ophthalmologists need to be aware of ocular risk factors and the impact of systemic diseases and their medications, along with lifestyle modifications on the course of glaucomatous optic neuropathy and adopt a holistic approach in treating the eye as well as the patient to alleviate the suffering from glaucoma in a comprehensive manner.

How to cite this article

Dada T, Verma S, Gagrani M, et al. Ocular and Systemic Factors associated with Glaucoma. J Curr Glaucoma Pract 2022;16(3):179-191.

Statin Use in Relation to Intraocular Pressure, Glaucoma, and Ocular Coherence Tomography Parameters in the UK Biobank

Purpose

The purpose of this study was to evaluate the relationship between statin use and glaucoma-related traits.

Methods

In a cross-sectional study, we included 118,153 UK Biobank participants with data on statin use and corneal-compensated IOP. In addition, we included 192,283 participants (8982 cases) with data on glaucoma status. After excluding participants with neurodegenerative diseases, 41,638 participants with macular retinal nerve fiber layer thickness (mRNFL) and 41,547 participants with macular ganglion cell inner plexiform layer thickness (mGCIPL) were available for analysis. We examined associations of statin use with IOP, mRNFL, mGCIPL, and glaucoma status utilizing multivariable-adjusted regression models. We assessed whether a glaucoma polygenic risk score (PRS) modified associations. We performed Mendelian randomization (MR) experiments to investigate associations with various glaucoma-related outcomes.

Results

Statin users had higher unadjusted mean IOP ± SD than nonusers, but in a multivariable-adjusted model, IOP did not differ by statin use (difference = 0.05 mm Hg, 95% confidence interval [CI] = -0.02 to 0.13, P = 0.17). Similarly, statin use was not associated with prevalent glaucoma (odds ratio [OR] = 1.05, 95% CI = 0.98 to 1.13). Statin use was weakly associated with thinner mRNFL (difference = -0.15 microns, 95% CI = -0.28 to -0.01, P = 0.03) but not with mGCIPL thickness (difference = -0.12 microns, 95% CI = -0.29 to 0.05, P = 0.17). No association was modified by the glaucoma PRS (Pinteraction≥ 0.16). MR experiments showed no evidence for a causal association between the cholesterol-altering effect of statins and several glaucoma traits (inverse weighted variance P ≥ 0.14).

Conclusions

We found no evidence of a protective association between statin use and glaucoma or related traits after adjusting for key confounders.

Associations of statin use with the onset and progression of open-angle glaucoma: A systematic review and meta-analysis

Background

Statins, the first-line therapy for hyperlipidemia, have received considerable attention as candidates for glaucoma treatments given its neuroprotective effects. In this systematic review and meta-analysis, we intended to assess the association of statin use with the onset and progression of open-angle glaucoma (OAG).

Methods

Databases including PubMed, Embase and Web of Science Core Collection were searched for longitudinal studies reporting the association between statin use and OAG onset or progression on Feb 3, 2021. A meta-analysis was performed for the association between statin use and OAG onset. Relative risks (RRs) with 95% confidential intervals (CIs) were retrieved from included studies and pooled using random-effects models. Potential risks of bias were evaluated by the Newcastle-Ottawa Quality Assessment Scale for all eligible studies. This study had been registered on PROSPERO (CRD 42021232172).

Findings

515,788 participants (mean age 68.7 years, 62.3% female) from ten studies were included in the systematic review of the association between statin use and OAG onset, and 26,347 OAG patients (mean age 67.3 years, 52.2% female) from seven studies were included for the association between statin use and OAG progression. Potential risks of bias were detected in 12 studies, which were mainly attributed to selection and confounding bias. In addition, 515,600 participants from eight studies were included in the meta-analysis which collectively showed that statin use was associated with a reduced risk of OAG onset (Pooled RR: 0.95; 95%CI: 0.93-0.98; I2=0.199;). No significant heterogeneity or publication bias was found for studies included in the meta-analysis. There were inconsistent evidences for the association between statin use and OAG progression.

Interpretation

Statin use is associated with a slightly lower risk of OAG onset based on existing evidences from longitudinal observational studies, the association between statin use and OAG progression remains inconclusive. The included evidences were typically weak due to poor study design and under-powered studies. Current findings should be interpreted cautiously and still need to be validated in further research.

Funding

The National Key R&D Program of China (2018YFC0116500), Science and Technology Planning Project of Guangdong Province (2013B20400003), the China Postdoctoral Science Foundation (2019TQ0365), the National Natural Science Foundation of China (82000901 and 82101171).

A Review of Ocular Complications Associated with Medications Used for Anxiety, Depression, and Stress

This review of commonly prescribed psychotropic drugs aims to update the clinician on possible ophthalmic side effects that may include dry eye, diplopia, mydriasis, and cataracts. This review summarizes our current knowledge of known ocular side effects of psychotropic drugs based on reviews, case reports, case-control studies, a case series, and cross-sectional observational studies reported in the recent literature. The review covers disorders related to depression, anxiety, and stress which are commonly encountered within society and can have debilitating impacts on an individual's quality of life that may require chronic therapeutic management. The main medications used in the treatment and management of these conditions typically target receptors, metabolic enzymes, or transport pumps that alter the pre- and/or post-synaptic levels of neurotransmitters such as serotonin, norepinephrine, dopamine, gamma-aminobutyric acid, and opioids to improve mood and/or relieve pain and anxiety. Novel non-therapeutic options are undergoing clinical trials, and some patients may seek alternative therapies or have associated substance abuse issues to alleviate their symptoms. This review summarizes some of the clinical signs of depression and the main therapeutic options and their reported ocular side effects which may be pertinent today given the rise in use of psychotropic medications used to manage depression, anxiety, and stress.

Statin use and the reoperation rates in glaucoma filtration surgery - population-based cohort study

PURPOSE

To examine the association of systemic statin therapy and reoperation rate after glaucoma filtration surgery (GFS).

METHODS

This is a population-based, historic cohort study of 2705 eyes undergoing GFS in Finland between July 2009 and December 2016. GFSs were identified from national administrative healthcare registers. Baseline sociodemographic and health characteristics were documented. Reoperation rates of GFS subgroups were analysed, with statin users compared to non-users. The outcomes were modelled using a Poisson regression model adjusted for age, sex, education, statin use, chronic comorbidities, and cataract surgery with incident rate ratios (IRR) as the main outcome measure.

RESULTS

The cohort contained 2263 subjects with open-angle glaucoma (OAG), 823 men and 1440 women. Surgery was performed on 2705 eyes. First documented procedures: deep sclerectomy (DS) (n = 1601), trabeculectomy (TRE) (799) and glaucoma drainage device (GDD) implantation (305) respectively. In total, 438 secondary operations were performed during the 7.5-year (median 2.25 years) follow-up period. The reoperation rates were 19% after DS, 12% after TRE, and 13% after GDD. Of the surgical procedures, 32% were performed on eyes of patients receiving statin therapy. Statin users showed no difference in reoperation rates (IRR 1.06, CI 0.82-1.37). In subgroups, no difference was observed in the reoperation rates adjusted with statin use after filtration surgery (DS, TRE) (IRR 1.06, CI 0.8-1.40) or GDD implantation (0.57, CI 0.20-1.63).

CONCLUSION

Systemic statin therapy among surgically treated OAG patients had no impact on secondary surgery rates following DS, TRE or GDD implantation.

Retinal Oxygen Delivery and Extraction in Ophthalmologically Healthy Subjects With Different Blood Pressure Status

Purpose

To compare retinal oxygen delivery (DO2) and oxygen extraction (VO2) in ophthalmologically healthy subjects with different blood pressure (BP) status.

Methods

In this case-control study, we prospectively included 93 eyes of 93 subjects (aged 50-65 years) from a Dutch cohort (n = 167,000) and allocated them to four groups (low BP, normal BP [controls], treated arterial hypertension [AHT], untreated AHT). We estimated vascular calibers from fundus images and fractal dimension from optical coherence tomography angiography scans. We combined calibers, fractal dimension, BP, and intraocular pressure measurements in a proxy of retinal blood flow (RBF), using a Poiseuille-based model. We measured arterial and venous oxygen saturations (SaO2, SvO2) with a scanning laser ophthalmoscope. We calculated the DO2 and VO2 from the RBF, SaO2, and SvO2. We compared the DO2 and VO2 between groups and investigated the DO2-VO2 association.

Results

DO2 and VO2 were different between groups (P = 0.009, P = 0.036, respectively). In a post hoc analysis, the low BP group had lower DO2 than the untreated AHT group (P = 4.9 × 10-4). The low BP group and the treated AHT group had a lower VO2 than the untreated AHT group (P = 0.021 and P = 0.034, respectively). There was a significant DO2-VO2 correlation (Robs = 0.65, bobs = 0.51, P = 2.4 × 10-12). After correcting for shared measurement error, the slope was not significant.

Conclusions

The DO2 and VO2 were altered in ophthalmologically healthy subjects with different BP status. Future studies could elucidate whether these changes can explain the increased risk of ophthalmic pathologies in those subjects.

Translational Relevance

Understanding the baseline interplay between BP, retinal perfusion, and oxygenation allows for improved evaluation of retinal disease manifestation.

Multiple Systemic Vascular Risk Factors Are Associated With Low-Tension Glaucoma

PRCIS

Multiple systemic vascular-associated conditions including systemic hypertension and hypotension, diabetes mellitus, migraine headache, peripheral vascular disease, Raynaud syndrome, and anemia were associated with low-tension glaucoma.

PURPOSE

The purpose of this study was to identify systemic risk factors associated with low-tension glaucoma.

PATIENTS AND METHODS

A retrospective case-control study design was employed to identify patients seen at the Mayo Clinic Department of Ophthalmology between 2005 and 2015 with low-tension glaucoma and an age-matched and sex-matched control group, each containing 277 patients.

RESULTS

The low-tension glaucoma group had more myopic refractive errors (-1.6 vs. -1.0 D, P<0.001), lower intraocular pressure (14.2 vs. 15.2 mm Hg, P<0.001), and a higher cup-to-disc ratio (0.7 vs. 0.3, P<0.001). The low-tension glaucoma group was significantly less likely to be obese (body mass index >30, P=0.03). This group had a significantly higher prevalence of systemic hypertension [odds ratio (OR): 1.64, P=0.004], diabetes mellitus (OR: 3.01, P<0.001), peripheral vascular disease (OR: 2.61, P=0.009), migraine headache (OR: 2.12, P=0.02), anemia (OR: 2.18, P=0.003), systemic hypotension (OR: 4.43, P<0.001), Raynaud syndrome (OR: 3.09, P=0.05), and angiotensin-converting enzyme inhibitor (OR: 1.64, P=0.01) or calcium channel blocker use (OR: 1.98, P=0.004). After adjusting for systemic hypertension, calcium channel blocker use remained significant (OR: 1.70, P=0.03). No significant difference was found between groups with respect to hyperlipidemia, obstructive sleep apnea, coronary artery disease, carotid stenosis, stroke, or statin, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta-blocker, or metformin use.

CONCLUSIONS

Multiple vascular-associated conditions were associated with low-tension glaucoma including systemic hypertension, diabetes mellitus, peripheral vascular disease, migraine headache, Raynaud syndrome, anemia, systemic hypotension, and calcium channel blocker use. This study strengthens the evidence for the vascular hypothesis of low-tension glaucoma.

Piezo1 activation induces fibronectin reduction and PGF2α secretion via arachidonic acid cascade

Glaucoma is a neurodegenerative disease that leads to blindness, and lowering intraocular pressure (IOP) is very important in glaucoma treatment. The trabecular meshwork is responsible for aqueous humor outflow, and the accumulation of fibronectin in trabecular meshwork is known to cause ocular hypertension. We have already shown that Piezo1 activation has an IOP lowering effect in mice and suppresses fibronectin expression level in human trabecular meshwork cells (HTMC). In this study, we report the mechanism of the reduction of fibronectin caused by Piezo1 activation. Activation of Piezo1 in HTMC showed increased expression of matrix metalloproteinase-2 (MMP-2) and cyclooxygenase (COX)-2, and decreased fibronectin expression. In addition, Piezo1 activation enhanced phosphorylation of cytosolic phospholipase A2 (cPLA2), and inhibitors targeting cPLA2 and COX-2 suppressed Yoda 1, a Piezo1 agonist, induced fibronectin reduction. These results indicate that the arachidonic acid cascade underlies this reaction, and, in support of this hypothesis, activation of Piezo1 promoted secretion of prostaglandin F2α (PGF2α) in HTMC. These results indicate that the activation of Piezo1 in HTMC promotes the degrading of fibronectin by promoting the arachidonic acid cascade and increasing the expression of PGF2α and MMP-2.

U-Shaped Effect of Blood Pressure on Structural OCT Metrics and Retinal Perfusion in Ophthalmologically Healthy Subjects

Purpose

We wanted to investigate the association of blood pressure (BP) status with the ganglion cell-inner plexiform layer (GCIPL) and retinal nerve fiber layer (RNFL) thickness of nonglaucomatous eyes and to elucidate whether this effect is related to vascular metrics proxying retinal perfusion.

Methods

For this case-control study, we prospectively included 96 eyes of 96 healthy subjects (age 50–65) from a large-scale population-based cohort in the northern Netherlands (n = 167,000) and allocated them to four groups (low BP, normal BP [controls], treated arterial hypertension [AHT], untreated AHT). We measured macular GCIPL and RNFL (mRNFL) and peripapillary RNFL (pRNFL) thicknesses with optical coherence tomography (OCT). We estimated retinal blood flow (RBF), retinal vascular resistance (RVR), and autoregulatory reserve (AR) from quantitative OCT-angiography, fundus imaging, BP, and intraocular pressure. We compared structural and vascular metrics across groups and performed mediation analysis.

Results

Compared to controls, GCIPL was thinner in the low BP group (P = 0.013), treated hypertensives (P = 0.007), and untreated hypertensives (P = 0.007). Treated hypertensives exhibited the thinnest mRNFL (P = 0.001), temporal pRNFL (P = 0.045), and inferior pRNFL (P = 0.034). The association of GCIPL thickness with BP was mediated by RBF within the combined low BP group and controls (P = 0.003), by RVR and AR within the combined treated hypertensives and controls (P = 0.001, P = 0.032), and by RVR within the combined untreated antihypertensives and controls (P = 0.022).

Conclusions

Inner retinal thinning was associated with both tails of the BP distribution and with ineffective autoregulation. Longitudinal studies could clarify whether these defects can explain the reported glaucomatous predisposition of these population groups.

Predictive Analytics for Glaucoma Using Data From the All of Us Research Program

PURPOSE

To (1) use All of Us (AoU) data to validate a previously published single-center model predicting the need for surgery among individuals with glaucoma, (2) train new models using AoU data, and (3) share insights regarding this novel data source for ophthalmic research.

DESIGN

Development and evaluation of machine learning models.

METHODS

Electronic health record data were extracted from AoU for 1,231 adults diagnosed with primary open-angle glaucoma. The single-center model was applied to AoU data for external validation. AoU data were then used to train new models for predicting the need for glaucoma surgery using multivariable logistic regression, artificial neural networks, and random forests. Five-fold cross-validation was performed. Model performance was evaluated based on area under the receiver operating characteristic curve (AUC), accuracy, precision, and recall.

RESULTS

The mean (standard deviation) age of the AoU cohort was 69.1 (10.5) years, with 57.3% women and 33.5% black, significantly exceeding representation in the single-center cohort (P = .04 and P < .001, respectively). Of 1,231 participants, 286 (23.2%) needed glaucoma surgery. When applying the single-center model to AoU data, accuracy was 0.69 and AUC was only 0.49. Using AoU data to train new models resulted in superior performance: AUCs ranged from 0.80 (logistic regression) to 0.99 (random forests).

CONCLUSIONS

Models trained with national AoU data achieved superior performance compared with using single-center data. Although AoU does not currently include ophthalmic imaging, it offers several strengths over similar big-data sources such as claims data. AoU is a promising new data source for ophthalmic research.

Psychopharmacological Treatment, Intraocular Pressure and the Risk of Glaucoma: A Review of Literature

Through the years, the available psychopharmacological treatments have expanded with numerous new drugs. Besides weight gain, gastro-intestinal problems or Parkinson-like symptoms, ocular adverse effects of psychiatric drugs have been reported. These adverse effects are not common, but can be dangerous for the patient. This review summarises the current knowledge on the risk of raised intraocular pressure and glaucoma entailed by psychopharmacological treatment. Also, it provides updated data for clinicians involved in the treatment of patients with glaucoma or glaucoma risk factors. For this purpose, we performed an extensive literature search in the PubMed database using specific terms. Selective serotonin and noradrenaline reuptake inhibitors are the best evidenced as having no association with glaucoma. Antipsychotics, and especially first generation, seem to have no correlation with an increased intraocular pressure and therefore possibly with a risk of glaucoma, although a special attention should be paid when using ziprasidone. Tricyclic antidepressants, benzodiazepines and topiramate should be avoided in patients diagnosed with glaucoma or at risk. Clinicians should be aware of the possible psychotropic drug induced glaucoma and monitor at risk patients closely in order to prevent this condition. Irrespective of the psychopharmacological regimen taken into consideration, the glaucoma patient should be under the strict supervision of the ophthalmologist.

Autonomic Dysfunction and Blood Pressure in Glaucoma Patients: The Lifelines Cohort Study

Purpose

We investigated relationship of glaucoma with measurements related to autonomic dysfunction, including heart rate variability (HRV) and blood pressure (BP).

Methods

Glaucoma was defined using a questionnaire-based algorithm for 86,841 LifeLines Cohort Study participants. Baseline HRV (root mean square of successive differences [RMSSD]) was calculated from resting electrocardiograms; systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) were oscillometric-based measurements. We used a generalized linear mixed model, adjusted for age, age square, sex, body mass index, and familial relationships to assess the relationship of baseline HRV and BP (continuous and quartiles), hypertension, and antihypertensive medication with glaucoma at follow up (median, 3.8 years).

Results

The odds ratio (OR) of glaucoma was 0.95 (95% confidence interval [CI], 0.92-0.99) per unit increase in log-transformed RMSSD (in ms), indicating that autonomous dysfunction (low HRV) is associated with a higher risk of glaucoma. Per 10-mm Hg increase in BP, we found ORs of 1.03 (95% CI, 1.01-1.05; P = 0.015) for SBP, 1.01 (95% CI, 0.97-1.05; P = 0.55) for DBP, 1.03 (95% CI, 1.00-1.06; P = 0.083) for MAP, and 1.04 (95% CI, 1.01-1.07; P = 0.006) for PP. The OR for the lowest versus highest RMSSD quartile was 1.15 (95% CI, 1.05-1.27; P = 0.003). The ORs for the highest versus second quartile were 1.09 (95% CI, 0.99-1.19; P = 0.091) for SBP and 1.13 (95% CI, 1.02-1.24; P = 0.015) for PP. Glaucoma was more common among hypertensives (OR, 1.25; 95% CI, 1.16-1.35; P < 0.001); among those using angiotensin-converting enzyme (ACE) inhibitors (OR, 1.35; 95% CI, 1.18-1.55; P < 0.001); and among those using calcium-channel blockers (OR, 1.19; 95% CI, 1.01-1.40; P = 0.039).

Conclusions

Low HRV, high SBP, high PP, and hypertension were associated with glaucoma. Longitudinal studies may elucidate if autonomic dysregulation and high BP also predict glaucoma incidence.

Balancing treatments for patients with systemic hypertension and glaucoma

INTRODUCTION

Treatment of glaucoma and systemic hypertension requires careful balancing of ophthalmic and systemic medications. This report offers background on various common therapies and considerations to minimize undesirable systemic and ophthalmic outcomes.

AREAS COVERED

Key considerations relating to medical treatments for systemic hypertension and glaucoma chosen from a review of the literature are included. The historic safety of ophthalmic beta blockers and sub-types as well as combination agents are described. The potential role of ocular perfusion pressure in the pathogenesis of glaucoma is reviewed with a discussion of landmark studies, including the Barbados Eye Study and the Early Manifest Glaucoma Trial, with implications for medication choices for hypertension and glaucoma. Systemic antihypertensives are considered with regards to their potential association with glaucoma and its progression, especially in patients with low blood pressure and normal tension glaucoma. Opinions are offered with regard to therapeutic choices and considerations.

EXPERT OPINION

The medical treatment of systemic hypertension and glaucoma carries the potential for drug interactions and significant adverse effects requiring customization for each patient's particular issues. The evolution of new therapies and treatment paradigms, including laser as a first-line treatment, has expanded safe options and minimized potential dangers for high-risk patients.

Screening Medications for Association with Progression to Wet Age-Related Macular Degeneration

PURPOSE

There is an urgent need for treatments that prevent or delay development to advanced age-related macular degeneration (AMD). Drugs already on the market for other conditions could affect progression to neovascular AMD (nAMD). If identified, these drugs could provide insights for drug development targets. The objective of this study was to use a novel data mining method that can simultaneously evaluate thousands of correlated hypotheses, while adjusting for multiple testing, to screen for associations between drugs and delayed progression to nAMD.

DESIGN

We applied a nested case-control study to administrative insurance claims data to identify cases with nAMD and risk-set sampled controls that were 1:4 variable ratio matched on age, gender, and recent healthcare use.

PARTICIPANTS

The study population included cases with nAMD and risk set matched controls.

METHODS

We used a tree-based scanning method to evaluate associations between hierarchical classifications of drugs that patients were exposed to within 6 months, 7 to 24 months, or ever before their index date. The index date was the date of first nAMD diagnosis in cases. Risk-set sampled controls were assigned the same index date as the case to which they were matched. The study was implemented using Medicare data from New Jersey and Pennsylvania, and national data from IBM MarketScan Research Database. We set an a priori threshold for statistical alerting at P ≤ 0.01 and focused on associations with large magnitude (relative risks ≥ 2.0).

MAIN OUTCOME MEASURES

Progression to nAMD.

RESULTS

Of approximately 4000 generic drugs and drug classes evaluated, the method detected 19 distinct drug exposures with statistically significant, large relative risks indicating that cases were less frequently exposed than controls. These included (1) drugs with prior evidence for a causal relationship (e.g., megestrol); (2) drugs without prior evidence for a causal relationship, but potentially worth further exploration (e.g., donepezil, epoetin alfa); (3) drugs with alternative biologic explanations for the association (e.g., sevelamer); and (4) drugs that may have resulted in statistical alerts due to their correlation with drugs that alerted for other reasons.

CONCLUSIONS

This exploratory drug-screening study identified several potential targets for follow-up studies to further evaluate and determine if they may prevent or delay progression to advanced AMD.

Association of Antihypertensive Medication with Retinal Nerve Fiber Layer and Ganglion Cell-Inner Plexiform Layer Thickness

PURPOSE

To evaluate the association between different classes of antihypertensive medication with retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GC-IPL) thickness in a nonglaucomatous multiethnic Asian population.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 9144 eyes for RNFL analysis (2668 Malays, 3554 Indians, and 2922 Chinese) and 8549 eyes for GC-IPL analysis (2460 Malays, 3230 Indians, and 2859 Chinese) aged 44 to 86 years.

METHODS

Participants underwent standardized systemic and ocular examinations and interviewer-administered questionnaires for collection of data on medication and other variables. Intraocular pressure (IOP) readings were obtained by Goldmann applanation tonometry before pupil dilation for fundoscopy and OCT imaging. Blood pressure (BP) was measured with an automatic BP monitor. Mean arterial pressure (MAP) was defined as diastolic BP plus 1/3 (systolic BP - diastolic BP). Regression models were used to investigate the association of antihypertensive medication with OCT measurements of RNFL and GC-IPL.

MAIN OUTCOME MEASURES

Average and sectoral RNFL and GC-IPL thickness.

RESULTS

After adjusting for age, gender, ethnicity, MAP, IOP, body mass index (BMI), and presence of diabetes, we found that participants taking any type of antihypertensive medication (β = -0.83; 95% confidence interval [CI], -1.46 to -0.02; P = 0.01), specifically angiotensin-converting enzyme inhibitors (ACEIs) (β = -1.66; 95% CI, -2.57 to -0.75; P < 0.001) or diuretics (β = -1.38; 95% CI, -2.59 to -0.17; P < 0.05), had thinner average RNFL in comparison with participants who were not receiving antihypertensive treatment. Use of a greater number of antihypertensive medications was significantly associated with thinner average RNFL (P for trend = 0.001). This association was most evident in the inferior RNFL quadrant in participants using ACEIs (β = -2.44; 95% CI, -3.99 to -0.89; P = 0.002) or diuretics (β = -2.76; 95% CI, -4.76 to -0.76; P = 0.007). A similar trend was noted in our analysis of macular GC-IPL thickness.

CONCLUSIONS

Use of 2 or more antihypertensive medications, ACEI, and diuretics were associated with a loss of structural markers of retinal ganglion cell health in a multiethnic Asian population.

Machine learning applied to retinal image processing for glaucoma detection: review and perspective

INTRODUCTION

This is a systematic review on the main algorithms using machine learning (ML) in retinal image processing for glaucoma diagnosis and detection. ML has proven to be a significant tool for the development of computer aided technology. Furthermore, secondary research has been widely conducted over the years for ophthalmologists. Such aspects indicate the importance of ML in the context of retinal image processing.

METHODS

The publications that were chosen to compose this review were gathered from Scopus, PubMed, IEEEXplore and Science Direct databases. Then, the papers published between 2014 and 2019 were selected . Researches that used the segmented optic disc method were excluded. Moreover, only the methods which applied the classification process were considered. The systematic analysis was performed in such studies and, thereupon, the results were summarized.

DISCUSSION

Based on architectures used for ML in retinal image processing, some studies applied feature extraction and dimensionality reduction to detect and isolate important parts of the analyzed image. Differently, other works utilized a deep convolutional network. Based on the evaluated researches, the main difference between the architectures is the number of images demanded for processing and the high computational cost required to use deep learning techniques.

CONCLUSIONS

All the analyzed publications indicated it was possible to develop an automated system for glaucoma diagnosis. The disease severity and its high occurrence rates justify the researches which have been carried out. Recent computational techniques, such as deep learning, have shown to be promising technologies in fundus imaging. Although such a technique requires an extensive database and high computational costs, the studies show that the data augmentation and transfer learning techniques have been applied as an alternative way to optimize and reduce networks training.

Primary Open Angle Glaucoma and Vascular Risk Factors: A Review of Population Based Studies from 1990 to 2019

Glaucoma is one of the leading causes of blindness worldwide, and as the proportion of those over age 40 increases, so will the prevalence of glaucoma. The pathogenesis of primary open angle glaucoma (POAG) is unclear and multiple ocular risk factors have been proposed, including intraocular pressure, ocular perfusion pressure, ocular blood flow, myopia, central corneal thickness, and optic disc hemorrhages. The purpose of this review was to analyze the association between systemic vascular risk factors (including hypertension, diabetes, age, and migraine) and POAG, based on major epidemiological studies. Reports presenting the association between POAG and systemic vascular risk factors included a total of over 50,000 patients. Several epidemiological studies confirmed the importance of vascular risk factors, particularly hypertension and blood pressure dipping, in the pathogenesis and progression of glaucomatous optic neuropathy. We found that diabetes mellitus is associated with elevated intraocular pressure, but has no clear association with POAG. No significant correlation between migraine and POAG was found, however, the definition of migraine varied between studies.

Machine Learning-Based Predictive Modeling of Surgical Intervention in Glaucoma Using Systemic Data From Electronic Health Records

PURPOSE

To predict the need for surgical intervention in patients with primary open-angle glaucoma (POAG) using systemic data in electronic health records (EHRs).

DESIGN

Development and evaluation of machine learning models.

METHODS

Structured EHR data of 385 POAG patients from a single academic institution were incorporated into models using multivariable logistic regression, random forests, and artificial neural networks. Leave-one-out cross-validation was performed. Mean area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy, and Youden index were calculated for each model to evaluate performance. Systemic variables driving predictions were identified and interpreted.

RESULTS

Multivariable logistic regression was most effective at discriminating patients with progressive disease requiring surgery, with an AUC of 0.67. Higher mean systolic blood pressure was associated with significantly increased odds of needing glaucoma surgery (odds ratio [OR] = 1.09, P < .001). Ophthalmic medications (OR = 0.28, P < .001), non-opioid analgesic medications (OR = 0.21, P = .002), anti-hyperlipidemic medications (OR = 0.39, P = .004), macrolide antibiotics (OR = 0.40, P = .03), and calcium blockers (OR = 0.43, P = .03) were associated with decreased odds of needing glaucoma surgery.

CONCLUSIONS

Existing systemic data in the EHR has some predictive value in identifying POAG patients at risk of progression to surgical intervention, even in the absence of eye-specific data. Blood pressure-related metrics and certain medication classes emerged as predictors of glaucoma progression. This approach provides an opportunity for future development of automated risk prediction within the EHR based on systemic data to assist with clinical decision-making.

A review of systemic medications that may modulate the risk of glaucoma

With increasing longevity, patients are developing more and more chronic diseases that require treatment with medications. Yet, it is not fully understood the extent by which these systemic medications affect ocular structures and whether they may increase or decrease the risk of sight-threatening ocular diseases. This review provides a summary of reported associations between different systemic medications and the risk of developing glaucoma or experiencing disease progression. Medication classes covered in this review that are known to or may modulate the risk of open-angle glaucoma include corticosteroids, beta blockers, calcium channel blockers, metformin, statins, selective serotonin reuptake inhibitors, bupropion, postmenopausal hormones, and cannabinoids. Medication classes addressed in this review that may increase the risk of angle closure glaucoma include anticholinergics, adrenergic agonists, certain classes of antidepressants, sulfonamides, and topiramate.

Effect of systemic antihypertensives on change in intraocular pressure after initiating topical prostaglandins for primary open-angle glaucoma

Purpose

There is a limited understanding of factors that influence the efficacy of topical glaucoma medication. Our study is a long-term, case–control analysis of how systemic antihypertensive (anti-HTN) medications influence the change in IOP after initiating prostaglandin (PG) drop therapy.

Materials and methods

A retrospective chart review of 3,781 patients was performed on patients with a diagnosis of glaucoma suspect that progressed to primary open-angle glaucoma (POAG) by ICD-9 codes over a 10-year period. Inclusion criteria consisted of the following: 1) progression from preglaucoma to glaucoma diagnosis in a time span of ≥6 months; 2) two visual fields recorded between these dates; 3) initial average IOP of both eyes of ≥21 mmHg; and 4) initiation of topical PG therapy alone. IOP (in mmHg) was measured at initiation of PG drops and at next visit.

Results

One hundred eleven patients were qualified for analysis. Patients not on anti-HTN agents had an average IOP decrease of 6.38±0.56 mmHg. Comparatively, patients on anti-HTN agents had an average IOP decrease of 6.66±0.48 mmHg (P=0.61). In addition, there was no statistical difference between IOP decrease between patients on single vs multiple systemic anti-HTN agents (P=0.85). There were eight nonresponders to PGs on no anti-HTN medications and 12 nonresponders on anti-HTN medication (P=0.55).

Conclusion

Systemic anti-HTN medication use did not significantly impact IOP reduction after topical PG initiation for POAG. Additionally, nonresponse to PG therapy was not correlated to systemic anti-HTN use.

Blood pressure and glaucoma: At the crossroads between cardiology and ophthalmology

Glaucoma is an optic nerve neuropathy of undetermined cause. Although many mechanisms are thought to be involved in the development and progression of the disease, only an increased intraocular pressure has been established as a clinically significant modifiable risk factor. Nevertheless, up to 40% of patients develop glaucoma without evidence of increased intraocular pressure. Ample evidence suggests that alterations in the control of arterial blood might negatively affect optic nerve function. However, evidence-based guidelines on the management of arterial blood pressure in glaucoma patients are lacking. Regrettably, intraocular pressure is generally not included as a secondary end-point in clinical trials on arterial hypertension. Considering the relative simplicity of intraocular pressure measurements and large number of patients included in hypertension studies, the benefits of including intraocular pressure as a secondary end-point could be of a great value for improving care for glaucoma patients. Therefore, closer collaboration between cardiologists and ophthalmologists is needed.

The risk of glaucoma and serotonergic antidepressants: A systematic review and meta-analysis

BACKGROUND

The aim of current study was to conduct a systematic review and meta-analysis to explore the relationship between antidepressant use and glaucoma.

METHODS

Eight major electronic databases were searched from inception until March 19th, 2018 to obtain relevant studies that evaluated associations of antidepressants [including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)] treatment and the risk of primary open-angle glaucoma (POAG) or primary angle-closure glaucoma (PACG) as well as intraocular pressure (IOP), and related anterior chamber parameters compared to participants not exposed to antidepressant treatment. A random-effects meta-analysis was conducted.

RESULTS

Six case-control studies and one cohort study were eligible (N = 801,754). The use of SSRIs was not associated with a higher risk of glaucoma (k = 7, pooled adjusted odds ratio (pAOR) = 0.956, 95% confidence interval (CI) = 0.807 to 1.133, p = 0.604). In addition, IOP was lower in participants exposed to antidepressants (SSRIs and SNRIs) (k = 4, Hedges' g = -0.519, 95% CI = -0.743 to -0.296, p < 0.001). Finally, pupillary diameter was higher in participants exposed to antidepressant treatment (k = 4, Hedges' g = 0.681, 95% CI = 0.462 to 0.900, p < 0.001).

LIMITATIONS

High heterogeneity of included studies limit the establishment of causal inferences.

CONCLUSIONS

This meta-analysis indicates that a putative association between the use of SSRIs and a higher risk of glaucoma remains to be proven. However, antidepressant drug treatment may be associated with significantly lower IOP and higher pupillary diameter. The mechanisms underpinning these associations deserve further investigation.