Predicting Visual Field Worsening with Longitudinal OCT Data Using a Gated Transformer Network

Detecting glaucoma worsening using optical coherence tomography derived visual field estimates

Multiple glaucoma studies have attempted to generate visual field (VF) mean deviation (MD) estimates using cross-sectional optical coherence tomography (OCT) data. However, whether such models offer any value in detecting longitudinal VF progression is unclear. We address this by developing a machine learning (ML) model to convert OCT data to MD and assessing its ability to detect longitudinal worsening. In this study, we created a model dataset of 70,575 paired OCT/VFs to train an ML model to convert OCT to VF-MD. We created a separate progression dataset of 4,044 eyes with ≥ 5 paired OCT/VFs to assess the ability of OCT-derived MD to detect worsening. The progression dataset eyes had 2 additional unpaired VFs (≥ 7 total) to establish a "ground truth" rate of progression defined by MD slope. We used the ML model to generate longitudinal OCT-MD estimates for each OCT scan for progression dataset eyes. We calculated MD slopes after substituting/supplementing VF-MD with OCT-MD and measured the ability to detect progression. We labeled true progressors using a ground truth MD slope < 0.5 dB/year calculated from ≥ 7 VF-MD measurements. We compared the area under the curve (AUC) of MD slopes calculated using both VF-MD (with < 7 measurements) and OCT-MD. Because we found OCT-MD substitution had a statistically inferior AUC to VF-MD, we simulated the effect of reducing OCT-MD mean absolute error (MAE) on the ability to detect worsening. Our model's OCT-MD estimates had an MAE of 1.62 dB (better than that of any previously published models). However, we found the AUC of MD slopes with partial OCT-MD substitution was significantly worse than the VF-MD slope. Supplementing VF-MD with OCT-MD also did not improve AUC, regardless of MAE. We found that OCT-MD estimates needed an MAE ≤ 1.00 dB before AUC was statistically similar to VF-MD alone. Overall, our ML model converting OCT data to VF-MD had error levels lower than those published in prior work and was inferior to VF-MD data for detecting trend-based VF progression. Our data suggest that future models converting OCT data to VF-MD must achieve better prediction errors (MAE ≤ 1 dB) to be clinically valuable at detecting VF worsening.

Characterizing Longitudinal Changes in Fear of Falling and Quality of Life in Patients with Varying Levels of Visual Field Damage

PURPOSE

To investigate the relationship between baseline visual field (VF) severity and rates of visual field loss with changes in quality of life (QoL) and fear of falling (FoF) in adults with glaucoma.

METHODS

Prospective cohort study, including participants from the Falls In Glaucoma Study. Quality of life and FoF were assessed annually using the Glaucoma Quality of Life-15 Questionnaire, and the University of Illinois at Chicago FoF Questionnaire, respectively, with higher Rasch-analyzed scores (in logits) indicating better QoL and greater FoF. Mean deviation (MD) values of each eye were collected, with better-eye MD taken as the primary exposure. Change rates in better-eye MD, QoL, and FoF were computed using linear regression. Separate regression models were employed to explore the relationship between baseline better-eye MD and its rate of change with rates of change in QoL and FoF.

RESULTS

The mean (standard deviation) rate of change in better-eye MD was -0.08 dB/year (0.5), rate of QoL change was -0.08 logits/year (0.4), and rate of FoF change was 0.16 logits/year (0.7). At baseline, better-eye MD (per dB worse) was significantly associated with worse baseline QoL (β = -0.10 logits [95% confidence interval [CI]: -0.13, -0.08]) and greater FoF (β = 0.06 logits [95% CI: 0.01, 0.10]). Baseline better-eye MD was associated with no significant change in QoL ( -0.004 logits/year, 95% CI: -0.02, 0.01) or FoF (-0.0001 logits/year, 95% CI: -0.02, 0.02) over time. Change rates in better-eye MD showed significant associations with faster increases in FoF over time (β = 0.26 logits/year [95% CI: 0.06, 0.45]; per dB loss/year), but not with changes in QoL (P = 0.79).

CONCLUSIONS

Patients with glaucoma generally showed worsening of QoL and FoF over time, though the degree of change was modest and not related to the degree of damage at baseline. Faster rates of better-eye MD change alone were associated with faster increases in FoF. Further studies are needed to evaluate the reasons (visual and nonvisual) for changes in QoL and functionality over time and find ways in which QoL and mobility can be improved for those with VF damage.

FINANCIAL DISCLOSURES

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

The AI revolution in glaucoma: Bridging challenges with opportunities

Recent advancements in artificial intelligence (AI) herald transformative potentials for reshaping glaucoma clinical management, improving screening efficacy, sharpening diagnosis precision, and refining the detection of disease progression. However, incorporating AI into healthcare usages faces significant hurdles in terms of developing algorithms and putting them into practice. When creating algorithms, issues arise due to the intensive effort required to label data, inconsistent diagnostic standards, and a lack of thorough testing, which often limits the algorithms' widespread applicability. Additionally, the "black box" nature of AI algorithms may cause doctors to be wary or skeptical. When it comes to using these tools, challenges include dealing with lower-quality images in real situations and the systems' limited ability to work well with diverse ethnic groups and different diagnostic equipment. Looking ahead, new developments aim to protect data privacy through federated learning paradigms, improving algorithm generalizability by diversifying input data modalities, and augmenting datasets with synthetic imagery. The integration of smartphones appears promising for using AI algorithms in both clinical and non-clinical settings. Furthermore, bringing in large language models (LLMs) to act as interactive tool in medicine may signify a significant change in how healthcare will be delivered in the future. By navigating through these challenges and leveraging on these as opportunities, the field of glaucoma AI will not only have improved algorithmic accuracy and optimized data integration but also a paradigmatic shift towards enhanced clinical acceptance and a transformative improvement in glaucoma care.

Detecting Glaucoma Worsening Using Optical Coherence Tomography Derived Visual Field Estimates

Objective

Multiple studies have attempted to generate visual field (VF) mean deviation (MD) estimates using cross-sectional optical coherence tomography (OCT) data. However, whether such models offer any value in detecting longitudinal VF progression is unclear. We address this by developing a machine learning (ML) model to convert OCT data to MD and assessing its ability to detect longitudinal worsening.

Design

Retrospective, longitudinal study.

Participants

A model dataset of 70,575 paired OCT/VFs to train an ML model converting OCT to VF-MD. A separate progression dataset of 4,044 eyes with ≥ 5 paired OCT/VFs to assess the ability of OCT-derived MD to detect worsening. Progression dataset eyes had two additional unpaired VFs (≥ 7 total) to establish a "ground truth" rate of progression defined by MD slope.

Methods

We trained an ML model using paired VF/OCT data to estimate MD measurements for each OCT scan (OCT-MD). We used this ML model to generate longitudinal OCT-MD estimates for progression dataset eyes. We calculated MD slopes after substituting/supplementing VF-MD with OCT-MD and measured the ability to detect progression. We labeled true progressors using a ground truth MD slope <0.5 dB/year calculated from ≥ 7 VF-MD measurements. We compared the area under the curve (AUC) of MD slopes calculated using both VF-MD (with <7 measurements) and OCT-MD. Because we found OCT-MD substitution had a statistically inferior AUC to VF-MD, we simulated the effect of reducing OCT-MD mean absolute error (MAE) on the ability to detect worsening.

Main Outcome Measures

AUC.

Results

OCT-MD estimates had an MAE of 1.62 dB. AUC of MD slopes with partial OCT-MD substitution was significantly worse than the VF-MD slope. Supplementing VF-MD with OCT-MD also did not improve AUC, regardless of MAE. OCT-MD estimates needed an MAE ≤ 1.00 dB before AUC was statistically similar to VF-MD alone.

Conclusion

ML models converting OCT data to VF-MD with error levels lower than published in prior work (MAE: 1.62 dB) were inferior to VF-MD data for detecting trend-based VF progression. Models converting OCT data to VF-MD must achieve better prediction errors (MAE ≤ 1 dB) to be clinically valuable at detecting VF worsening.

Self-supervised learning-enhanced deep learning method for identifying myopic maculopathy in high myopia patients

Accurate detection and timely care for patients with high myopia present significant challenges. We developed a deep learning (DL) system enhanced by a self-supervised learning (SSL) approach to improve the automatic diagnosis of myopic maculopathy (MM). Using a dataset of 7,906 images from the Shanghai High Myopia Screening Project and a public validation set of 1,391 images from MMAC2023, our method significantly outperformed conventional techniques. Internally, it achieved 96.8% accuracy, 83.1% sensitivity, and 95.6% specificity, with AUC values of 0.982 and 0.999. Externally, it maintained 89.0% accuracy, 71.7% sensitivity, and 87.8% specificity, with AUC values of 0.978 and 0.973. The model's Cohen's kappa values exceeded 0.8, indicating substantial agreement with retinal experts. Our SSL-enhanced DL approach offers high accuracy and potential to enhance large-scale myopia screenings, demonstrating broader significance in improving early detection and treatment of MM.

Novel Technologies in Artificial Intelligence and Telemedicine for Glaucoma Screening

PURPOSE

To provide an overview of novel technologies in telemedicine and artificial intelligence (AI) approaches for cost-effective glaucoma screening.

METHODS/RESULTS

A narrative review was performed by summarizing research results, recent developments in glaucoma detection and care, and considerations related to telemedicine and AI in glaucoma screening. Telemedicine and AI approaches provide the opportunity for novel glaucoma screening programs in primary care, optometry, portable, and home-based settings. These approaches offer several advantages for glaucoma screening, including increasing access to care, lowering costs, identifying patients in need of urgent treatment, and enabling timely diagnosis and early intervention. However, challenges remain in implementing these systems, including integration into existing clinical workflows, ensuring equity for patients, and meeting ethical and regulatory requirements. Leveraging recent work towards standardized data acquisition as well as tools and techniques developed for automated diabetic retinopathy screening programs may provide a model for a cost-effective approach to glaucoma screening.

CONCLUSION

Leveraging novel technologies and advances in telemedicine and AI-based approaches to glaucoma detection show promise for improving our ability to detect moderate and advanced glaucoma in primary care settings and target higher individuals at high risk for having the disease.

Detecting Visual Field Worsening From Optic Nerve Head and Macular Optical Coherence Tomography Thickness Measurements

Purpose

Compare the use of optic disc and macular optical coherence tomography measurements to predict glaucomatous visual field (VF) worsening.

Methods

Machine learning and statistical models were trained on 924 eyes (924 patients) with circumpapillary retinal nerve fiber layer (cp-RNFL) or ganglion cell inner plexiform layer (GC-IPL) thickness measurements. The probability of 24-2 VF worsening was predicted using both trend-based and event-based progression definitions of VF worsening. Additionally, the cp-RNFL and GC-IPL predictions were combined to produce a combined prediction. A held-out test set of 617 eyes was used to calculate the area under the curve (AUC) to compare cp-RNFL, GC-IPL, and combined predictions.

Results

The AUCs for cp-RNFL, GC-IPL, and combined predictions with the statistical and machine learning models were 0.72, 0.69, 0.73, and 0.78, 0.75, 0.81, respectively, when using trend-based analysis as ground truth. The differences in performance between the cp-RNFL, GC-IPL, and combined predictions were not statistically significant. AUCs were highest in glaucoma suspects using cp-RNFL predictions and highest in moderate/advanced glaucoma using GC-IPL predictions. The AUCs for the statistical and machine learning models were 0.63, 0.68, 0.69, and 0.72, 0.69, 0.73, respectively, when using event-based analysis. AUCs decreased with increasing disease severity for all predictions.

Conclusions

cp-RNFL and GC-IPL similarly predicted VF worsening overall, but cp-RNFL performed best in early glaucoma stages and GC-IPL in later stages. Combining both did not enhance detection significantly.

Translational Relevance

cp-RNFL best predicted trend-based 24-2 VF progression in early-stage disease, while GC-IPL best predicted progression in late-stage disease. Combining both features led to minimal improvement in predicting progression.

A multi-label transformer-based deep learning approach to predict focal visual field progression

PURPOSE

Tracking functional changes in visual fields (VFs) through standard automated perimetry remains a clinical standard for glaucoma diagnosis. This study aims to develop and evaluate a deep learning (DL) model to predict regional VF progression, which has not been explored in prior studies.

METHODS

The study included 2430 eyes of 1283 patients with four or more consecutive VF examinations from the baseline. A multi-label transformer-based network (MTN) using longitudinal VF data was developed to predict progression in six VF regions mapped to the optic disc. Progression was defined using the mean deviation (MD) slope and calculated for all six VF regions, referred to as clusters. Separate MTN models, trained for focal progression detection and forecasting on various numbers of VFs as model input, were tested on a held-out test set.

RESULTS

The MTNs overall demonstrated excellent macro-average AUCs above 0.884 in detecting focal VF progression given five or more VFs. With a minimum of 6 VFs, the model demonstrated superior and more stable overall and per-cluster performance, compared to 5 VFs. The MTN given 6 VFs achieved a macro-average AUC of 0.848 for forecasting progression across 8 VF tests. The MTN also achieved excellent performance (AUCs ≥ 0.86, 1.0 sensitivity, and specificity ≥ 0.70) in four out of six clusters for the eyes already with severe VF loss (baseline MD ≤  - 12 dB).

CONCLUSION

The high prediction accuracy suggested that multi-label DL networks trained with longitudinal VF results may assist in identifying and forecasting progression in VF regions.

Big data for imaging assessment in glaucoma

Glaucoma is the leading cause of irreversible blindness worldwide, with many individuals unaware of their condition until advanced stages, resulting in significant visual field impairment. Despite effective treatments, over 110 million people are projected to have glaucoma by 2040. Early detection and reliable monitoring are crucial to prevent vision loss. With the rapid development of computational technologies, artificial intelligence (AI) and deep learning (DL) algorithms are emerging as potential tools for screening, diagnosing, and monitoring glaucoma progression. Leveraging vast data sources, these technologies promise to enhance clinical practice and public health outcomes by enabling earlier disease detection, progression forecasting, and deeper understanding of underlying mechanisms. This review evaluates the use of Big Data and AI in glaucoma research, providing an overview of most relevant topics and discussing various models for screening, diagnosis, monitoring disease progression, correlating structural and functional changes, assessing image quality, and exploring innovative technologies such as generative AI.

The Impact of Social Vulnerability on Structural and Functional Glaucoma Severity, Worsening, and Variability

PURPOSE

To determine the associations between social vulnerability index (SVI) and baseline severity, worsening, and variability of glaucoma, as assessed by visual field (VF) and OCT.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Adults with glaucoma or glaucoma suspect status in 1 or both eyes. Visual fields were derived from 7897 eyes from 4482 patients, while OCTs were derived from 6271 eyes from 3976 patients. All eyes had a minimum of 5 tests over follow-up using either the Humphrey Field Analyzer or the Cirrus HD-OCT.

METHODS

Social vulnerability index, which measures neighborhood-level environmental factors, was linked to patients' addresses at the census tract level. Rates of change in mean deviation (MD) and retinal nerve fiber layer (RNFL) thickness were computed using linear regression. The slope of the regression line was used to assess worsening, while the standard deviation of residuals was used as a measure of variability. Multivariable linear mixed-effects models were used to investigate the impact of SVI on baseline, worsening, and variability in both MD and RNFL. We further explored the interaction effect of mean intraocular pressure (IOP) and SVI on worsening in MD and RNFL.

MAIN OUTCOME MEASURES

Glaucoma severity defined based on baseline MD and RNFL thickness. Worsening defined as MD and RNFL slope. Variability defined as the standard deviation of the residuals obtained from MD and RNFL slopes.

RESULTS

Increased (worse) SVI was significantly associated with worse baseline MD (β = -1.07 dB, 95% confidence interval [CI]: [-1.54, -0.60]), thicker baseline RNFL (β = 2.46 μm, 95% CI: [0.75, 4.17]), greater rates of RNFL loss (β = -0.12 μm, 95% CI: [-0.23, -0.02]), and greater VF variability (β = 0.16 dB, 95% CI: [0.07, 0.24]). Having worse SVI was associated with worse RNFL loss with increases in IOP (βinteraction = -0.07, 95% CI: [-0.12, -0.02]).

CONCLUSIONS

Increased SVI score is associated with worse functional (VF) loss at baseline, higher rates of structural (OCT) worsening over time, higher VF variability, and a greater effect of IOP on RNFL loss. Further studies are needed to enhance our understanding of these relationships and establish their cause.

FINANCIAL DISCLOSURE(S)

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

Application of artificial intelligence in glaucoma care: An updated review

The application of artificial intelligence (AI) in ophthalmology has been increasingly explored in the past decade. Numerous studies have shown promising results supporting the utility of AI to improve the management of ophthalmic diseases, and glaucoma is of no exception. Glaucoma is an irreversible vision condition with insidious onset, complex pathophysiology, and chronic treatment. Since there remain various challenges in the clinical management of glaucoma, the potential role of AI in facilitating glaucoma care has garnered significant attention. In this study, we reviewed the relevant literature published in recent years that investigated the application of AI in glaucoma management. The main aspects of AI applications that will be discussed include glaucoma risk prediction, glaucoma detection and diagnosis, visual field estimation and pattern analysis, glaucoma progression detection, and other applications.

Artificial intelligence for glaucoma: state of the art and future perspectives

PURPOSE OF REVIEW

To address the current role of artificial intelligence (AI) in the field of glaucoma.

RECENT FINDINGS

Current deep learning (DL) models concerning glaucoma diagnosis have shown consistently improving diagnostic capabilities, primarily based on color fundus photography and optical coherence tomography, but also with multimodal strategies. Recent models have also suggested that AI may be helpful in detecting and estimating visual field progression from different input data. Moreover, with the emergence of newer DL architectures and synthetic data, challenges such as model generalizability and explainability have begun to be tackled.

SUMMARY

While some challenges remain before AI is routinely employed in clinical practice, new research has expanded the range in which it can be used in the context of glaucoma management and underlined the relevance of this research avenue.

Advancing Glaucoma Care: Integrating Artificial Intelligence in Diagnosis, Management, and Progression Detection

Glaucoma, the leading cause of irreversible blindness worldwide, comprises a group of progressive optic neuropathies requiring early detection and lifelong treatment to preserve vision. Artificial intelligence (AI) technologies are now demonstrating transformative potential across the spectrum of clinical glaucoma care. This review summarizes current capabilities, future outlooks, and practical translation considerations. For enhanced screening, algorithms analyzing retinal photographs and machine learning models synthesizing risk factors can identify high-risk patients needing diagnostic workup and close follow-up. To augment definitive diagnosis, deep learning techniques detect characteristic glaucomatous patterns by interpreting results from optical coherence tomography, visual field testing, fundus photography, and other ocular imaging. AI-powered platforms also enable continuous monitoring, with algorithms that analyze longitudinal data alerting physicians about rapid disease progression. By integrating predictive analytics with patient-specific parameters, AI can also guide precision medicine for individualized glaucoma treatment selections. Advances in robotic surgery and computer-based guidance demonstrate AI's potential to improve surgical outcomes and surgical training. Beyond the clinic, AI chatbots and reminder systems could provide patient education and counseling to promote medication adherence. However, thoughtful approaches to clinical integration, usability, diversity, and ethical implications remain critical to successfully implementing these emerging technologies. This review highlights AI's vast capabilities to transform glaucoma care while summarizing key achievements, future prospects, and practical considerations to progress from bench to bedside.

Multi-Dataset Comparison of Vision Transformers and Convolutional Neural Networks for Detecting Glaucomatous Optic Neuropathy from Fundus Photographs

Glaucomatous optic neuropathy (GON) can be diagnosed and monitored using fundus photography, a widely available and low-cost approach already adopted for automated screening of ophthalmic diseases such as diabetic retinopathy. Despite this, the lack of validated early screening approaches remains a major obstacle in the prevention of glaucoma-related blindness. Deep learning models have gained significant interest as potential solutions, as these models offer objective and high-throughput methods for processing image-based medical data. While convolutional neural networks (CNN) have been widely utilized for these purposes, more recent advances in the application of Transformer architectures have led to new models, including Vision Transformer (ViT,) that have shown promise in many domains of image analysis. However, previous comparisons of these two architectures have not sufficiently compared models side-by-side with more than a single dataset, making it unclear which model is more generalizable or performs better in different clinical contexts. Our purpose is to investigate comparable ViT and CNN models tasked with GON detection from fundus photos and highlight their respective strengths and weaknesses. We train CNN and ViT models on six unrelated, publicly available databases and compare their performance using well-established statistics including AUC, sensitivity, and specificity. Our results indicate that ViT models often show superior performance when compared with a similarly trained CNN model, particularly when non-glaucomatous images are over-represented in a given dataset. We discuss the clinical implications of these findings and suggest that ViT can further the development of accurate and scalable GON detection for this leading cause of irreversible blindness worldwide.

Optical Coherence Tomography and Optical Coherence Tomography Angiography: Essential Tools for Detecting Glaucoma and Disease Progression

Early diagnosis and detection of disease progression are critical to successful therapeutic intervention in glaucoma, the leading cause of irreversible blindness worldwide. Optical coherence tomography (OCT) is a non-invasive imaging technique that allows objective quantification in vivo of key glaucomatous structural changes in the retina and the optic nerve head (ONH). Advances in OCT technology have increased the scan speed and enhanced image quality, contributing to early glaucoma diagnosis and monitoring, as well as the visualization of critically important structures deep within the ONH, such as the lamina cribrosa. OCT angiography (OCTA) is a dye-free technique for noninvasively assessing ocular microvasculature, including capillaries within each plexus serving the macula, peripapillary retina and ONH regions, as well as the deeper vessels of the choroid. This layer-specific assessment of the microvasculature has provided evidence that retinal and choroidal vascular impairments can occur during early stages of glaucoma, suggesting that OCTA-derived measurements could be used as biomarkers for enhancing detection of glaucoma and its progression, as well as to reveal novel insights about pathophysiology. Moreover, these innovations have demonstrated that damage to the macula, a critical region for the vision-related quality of life, can be observed in the early stages of glaucomatous eyes, leading to a paradigm shift in glaucoma monitoring. Other advances in software and hardware, such as artificial intelligence-based algorithms, adaptive optics, and visible-light OCT, may further benefit clinical management of glaucoma in the future. This article reviews the utility of OCT and OCTA for glaucoma diagnosis and disease progression detection, emphasizes the importance of detecting macula damage in glaucoma, and highlights the future perspective of OCT and OCTA. We conclude that the OCT and OCTA are essential glaucoma detection and monitoring tools, leading to clinical and economic benefits for patients and society.