Value of 10-2 Visual Field Testing for Detecting Progression in Patients with Glaucoma
Tomita R, Salh D, Dyachok OM, West ME, Sharpe GP, Rafuse PE, Shuba LM, Nicolela MT, Chauhan BC. Ophthalmology. 2026 Jul 6:S0161-6420(26)00463-X. doi: 10.1016/j.ophtha.2026.06.029. Epub ahead of print. PMID: 42409179.
Question
What is the value of the 10-2 test of the Humphrey Field Analyzer in detecting visual field progression in early glaucoma?
Background/Summary of Findings
Most published studies on glaucomatous visual field progression report results from either central 30° or 24° tests of the visual field. Given that almost 40% of retinal ganglion cells are located within the macula and conventional 24-2 testing samples only 12 loci within the central 10°, 24-2 testing potentially under-samples the retinal ganglion cell population. Based on this premise, there has been considerable debate as to whether small paracentral visual field defects are under-detected if more dense ganglion cell sampling by employing specific macular testing is not routinely used, especially in cases of early disease. Few studies on visual field progression comparing 24-2 and 10-2 exist, and few studies purport the superiority of 10-2. Furthermore, the evidence that 10-2 testing is superior to 24-2 testing, and whether the added test burden involved in 10-2 testing can be justified, is limited.
The present study was performed in a cohort of glaucoma patients and aimed to address whether the 10-2 test detected visual field progression in significantly more patients compared to the central points of the 24-2 test, and whether the rates of progression detected by the 10-2 test were faster in global, sectoral, and pointwise analysis.
This was a prospective longitudinal study including patients with open-angle glaucoma as well as healthy control subjects. Participants were examined with the 24-2 and 10-2 tests every 4 months. Only those with ≥5 pairs of tests were included. To analyze the same area as the 10-2, only the central 12 test locations of the 24-2 test—from which global and quadrant mean deviation (MD) slopes—were included, and pointwise total deviation slopes were computed. A range of criteria for progression based on pointwise total deviation slope cut-offs was used. The main outcome measures were the area under the receiver operating characteristics curve (AUC) separating glaucoma patients from healthy controls for global, sectoral, and pointwise analyses, and the overlap in the proportion of patients identified by the 2 tests at matched specificity. One eye from each of 96 glaucoma patients with early visual field damage and from 56 healthy subjects were included in the analysis. The participants were followed for a median of 4.69 and 4.49 years with 13 and 11 pairs of tests, respectively. The AUC of the MD slopes for the 2 tests were not significantly different for global (P = .25) or quadrant (P > .11) analyses. At 90% specificity for global MD slope, the overlap in patients classified as progressing with both tests was 53%, while for the quadrant MD slope, the overlap was less. AUCs were not different for pointwise slope cut-offs >-1.25 dB/y but were significantly higher for the 10-2 test when cut-offs were ≤-1.25 dB/y. Additionally, patients showing progression with only the 10-2 test with steeper pointwise slope cut-offs had a worse baseline 10-2 (but not 24-2) MD.
Clinical Value/Implications
While the authors concluded that their findings did not support the widespread use of the 10-2 test to follow glaucoma patients, they provided evidence that the 10-2 test may be the more appropriate test for following patients with more preferential central visual field loss and for those at higher risk of faster central visual field progression. Given the additional test burden involved when adding 10-2s, it is important that we analyze the specific nature of a patient’s disease to determine what provides the greatest opportunity to understand the rate and subsequently the potential impact of their progression, and to intervene accordingly.
Comparative Five-Year Risks of Systemic Complications with Biologic vs Conventional Therapy in Noninfectious Uveitis.
Chauhan MZ, Muayad J, Surgent-Nahay JL, Shakoor A, Thorne JE, Sallam AB. Ophthalmology. 2026 Jul 6:S0161-6420(26)00464-1. doi: 10.1016/j.ophtha.2026.06.030. Epub ahead of print. PMID: 42409178.
Question
Is there a different 5-year risk of systemic complications in patients with noninfectious uveitis prescribed systemic biologic therapy compared to conventional corticosteroid therapy?
Background/Summary of Findings
Noninfectious uveitis (NIU) is a sight-threatening intraocular inflammatory disease responsible for approximately 10% of blindness in the United States. The risk of vision loss comes from structural damage to the optic nerve and retina, and prevention of damage often requires chronic immunosuppression treatment. First-line therapy for noninfectious uveitis has historically involved corticosteroids. Although topical corticosteroids may be sufficient to manage anterior uveitis, they are inadequate for intermediate, posterior, and panuveitis. To quell inflammation, preserve vision, and prevent recurrence of disease in these cases, expert guidelines recommend initiating systemic corticosteroids, with prompt addition of conventional corticosteroid sparing agents (disease-modifying antirheumatic drugs) to minimize corticosteroid induced systemic complications. Biologic immunomodulators are now standard second-line therapy for NIU that is refractory to disease-modifying antirheumatic drugs or that presents with high-risk systemic associations. Although biologic therapies have improved our ability to control ocular inflammation, serious adverse events have been reported. The purpose of this study was to compare major systemic outcomes across 3 clinically meaningful treatment comparisons in NIU.
Employing a multicenter, retrospective design, the authors used the TriNetX collaborative electronic health record network to identify patients with NIU. They assembled propensity score-matched comparisons: biologic therapy vs no systemic therapy (n = 6896 each) and biologic vs conventional therapy with corticosteroids matched (n = 5994 each) between January 1, 2005, and January 1, 2024. A prespecified subgroup analysis of Analysis 2 restricted to patients receiving combination biologic and conventional therapy vs conventional therapy alone (n = 3653 each) was also conducted. They additionally used time-to-event analyses to identify systemic complications with the main outcome measures including incidence of serious infections, hematologic cytopenias, heart failure, thromboembolic events, diabetes mellitus, malignancy, psychiatric illness, all-cause hospitalization, and all-cause mortality.
After propensity score matching, cohorts were balanced on all measured covariates (all standardized mean differences [SMDs] <0.1). Compared with no systemic therapy, biologic treatment was associated with higher 5-year risks of serious infections, including pneumonia (hazard ratio [HR], 1.41, 95% confidence interval [CI], 1.20–1.67), sepsis (HR, 1.43, 95% CI, 1.16–1.77), and hematologic cytopenias (HR, 1.58, 95% CI, 1.44–1.74), representing 5-year Kaplan-Meier-estimated cumulative incidences of 6.43%, 3.87%, and 30.12%, respectively, in biologic-treated patients. Risks of heart failure, thromboembolic events, psychiatric illness, diabetes, and all-cause mortality did not significantly differ between groups. When compared with conventional immunomodulatory therapy, biologic treatment demonstrated a largely comparable 5-year safety profile, with the primary exceptions of higher rates of hematologic cytopenias (HR, 1.28, 95% CI, 1.16–1.41), psychiatric illness (HR, 1.13, 95% CI, 1.01–1.27), and hospitalization (HR, 1.20, 95% CI, 1.07–1.35).
Clinical Value/Implications
The authors concluded that systemic biologic therapy was associated with higher risks of serious infections and hematologic cytopenias compared with no systemic treatment, while demonstrating a 5-year safety profile broadly comparable to conventional immunomodulatory therapy. They noted that their findings support expert guideline-concordant stepwise immunosuppression and underscore the importance of individualized risk assessment, infection surveillance, and hematologic monitoring for patients requiring systemic therapy.
Geographic Distribution of Access to Diabetic Retinopathy Care in the United States: An American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) Analysis
Singh Parmar UP, Fujita A, Lokhande A, Palia R, Yang E, Lorch A, Singh RP, Gong D, Zebardast N; IRIS® Registry Analytic Center Consortium. Ophthalmology. 2026 Jul 15:S0161-6420(26)00482-3. doi: 10.1016/j.ophtha.2026.07.006. Epub ahead of print. PMID: 42457090.
Question
What is the geographic distribution of access to therapeutic and diagnostic procedures for diabetic retinopathy across the United States?
Background/Summary of Findings
Diabetic retinopathy (DR) is a leading cause of preventable vision loss among adults in the United States. In order to prevent irreversible vision impairment, sustained ophthalmic care is often needed, and outcomes depend heavily on timely diagnosis and intervention. Previous research has shown that patients residing in rural and underserved communities experience lower rates of screening for DR, delayed diagnosis, and reduced adherence to recommended eye care, which reflects structural barriers to accessing care. Broader past analyses of geographic disparities in diabetic eye disease have highlighted how the role of socioeconomic constraints, geographic isolation, and limited specialist availability shapes this lack of access. The article emphasizes that geographic disparities in DR procedural care at the national level remain incompletely characterized. To address this gap, the authors analyzed geographic patterns in therapeutic and diagnostic procedures for DR over 12 years using the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry, characterizing differences in procedure volume, provider subspecialty, and practice-level utilization across urban and nonurban settings.
With a retrospective cohort study using the IRIS® Registry, the authors identified patients with ≥2 International Classification of Disease (ICD) codes for DR between January 1, 2013, and December 31, 2024, excluding those with concurrent ocular conditions that independently require similar treatments. Care was classified as therapeutic (intravitreal injections [IVI], panretinal photocoagulation [PRP], focal laser photocoagulation [FLP], and pars plana vitrectomy [PPV]) or diagnostic (optical coherence tomography [OCT], fundus photography [FP], and fluorescein angiography [FA]) by Current Procedural Terminology (CPT) codes. Urban vs nonurban practice locations were defined using the US Department of Agriculture Rural-Urban Commuting Area codes. Procedure volume, population-adjusted and disease-adjusted rates, physician and practice-level utilization, and physician subspecialty distributions were compared across settings. A sub-analysis examined disease burden, DR care adherence, and DME management among nonurban residents stratified by treating practice urbanization and sociodemographic factors. The main outcome measure was the likelihood of each diagnostic and therapeutic procedure occurring in urban areas.
Singh Parmar et al identified 11,254,015 therapeutic and 35,892,574 diagnostic procedures from 1,142,505 patients with DR. Urban practices performed 95–99% of all procedures, 67–80% after adjusting for population differences, and 65–90% after adjusting for disease burden, with nonurban sitescontributing only 1–35% across categories. In nonurban practices, comprehensive ophthalmologists performed more than 35% of IVI and PRP, whereas in urban practices, they performed roughly 5–7% of these procedures. More than 93% of nonurban residents and over 97% of urban residents received therapeutic procedures in urban practices. The authors found higher odds of all available procedures occurring in urban practice locations. Nonurban residents had a higher proliferative DR prevalence (18.21% vs 16.02%) and higher rates of all therapeutic procedures. Among those receiving care at urban practices, 47.7% had a >1- year OCT gap vs 44.1% at nonurban practices; this increase in discontinuity was disproportionately larger among older, Black patients, and those with lower household incomes.
Clinical Value/Implications
The authors concluded that DR-related diagnostic and therapeutic services were concentrated predominantly in urban practice locations, even after adjustment for population differences and disease burden. These findings signify that we need to improve access to DR care in nonurban communities who may be at a higher risk of visual disability. A shift in policy which incentivizes specialists practicing in nonurban environments, leveraging of tele-retinal infrastructure, and improved partnerships between urban and nonurban practices were all cited by the authors as possible solutions against an increasing gap in ophthalmological care between rural and urban locations.
Toward an Era of Oculomics: Association Between Baseline Diabetic Retinopathy Severity and Mortality Risk in a SOURCE Consortium Cohort
Lee SS, Marwah S, Gaddam S, French DD, Bryar PJ, Andrews CA, Evans CT, Rivera AS, Zhou X, Lavine JA, Stein JD; Collaborative (SOURCE) Consortium. Ophthalmology. 2026 Jul;133(7):852-864. doi: 10.1016/j.ophtha.2026.03.023. Epub 2026 Apr 1. PMID: 41933805.
Question
Is baseline diabetic retinopathy (DR) severity associated with mortality after adjustment for nonclinical and clinical factors?
Background/Summary of Findings
Diabetic retinopathy is a microvascular complication of diabetes mellitus that can cause serious visual sequelae in certain individuals. Beyond its impact on the eye, DR severity has been shown to be a biomarker for serious systemic health problems including, but not limited to, cerebrovascular accidents and mortality.
The field of oculomics is the study of associations between retinal findings and disease, bringing together traditional clinical assessment of retinal pathology with advanced imaging techniques. Although artificial intelligence has been a popular topic in recent years, the foundational principle of oculomics also extends to conventional ophthalmic evaluation of the eye by clinicians.
This large retrospective cohort study evaluated patients with diabetes from 15 tertiary care healthy systems in the Sight Outcomes Research Collaborative (SOURCE) Ophthalmology Big Data consortium. A total of 524687 eligible patients with diabetes mellitus were included in the study. The median follow-up was 4.1 years, and the mean age of the patients was 59.1 years (± 16 years). During follow-up, 36674 (7.0%) of patients died over a mean of 5.4 ± 4.1 years of follow-up. The proportion of Asian, American, Black, White, and Latinx patients who died was 2.2%, 5.7%, 8.8%, and 12.7%.
The study found a strong association between baseline DR severity and all-cause mortality after accounting for demographic factors, nonmedical factors, comordities, and blood sugar control. Compared to patients with diabetes without retinopathy, the hazard for death was increased by 34% in patients with non-proliferative DR without macular edema, 31% in non-proliferative DR with macular edema, 128% in those with proliferative DR without macular edema, and 87% in patients with proliferative DR and macular edema. When focusing on subgroups of patients with non-proliferative DR at baseline, individuals with severe non-proliferative DR had a greater risk of death relative to those with less severe non-proliferative DR.
Nonmedical factors such as older age, male sex, Medicaid health insurance, lower educational status, and living in less affluent communities were all associated with higher all-cause mortality.
Clinical Value/Implications
Patients with non-proliferative DR or proliferative DR, regardless of macular edema presence, were at higher risk for death over an average of 5 years of follow-up. Even after accounting for hemoglobin A1c control, patients with advanced stages of DR maintained substantial mortality risk and may benefit from intensified systemic care beyond glycemic control. These findings support viewing DR not just as an end-organ complication requiring only local ophthalmic treatment, but also as a potential biomarker that can guide comprehensive diabetes management strategies to improve patient outcomes. Eye care professionals should consider communicating DR severity with other providers to identify and address any comorbidities that may increase mortality risk.
Development of Perimetric Glaucoma and Outcomes of Interventions in Pseudoexfoliation Syndrome with and without Ocular Hypertension
Fujita A, Moradi M, Shah R, Elze T, Zebardast N, Friedman DS. Ophthalmology. 2026 Aug;133(8):985-993. doi: 10.1016/j.ophtha.2026.04.010. Epub 2026 Apr 14. PMID: 41985694; PMCID: PMC13118489.
Question
What is the incidence of perimetric glaucoma with pseudoexfoliation syndrome? How effective are interventions in eyes with pseudoexfoliation syndrome with and without ocular hypertension?
Background/Summary of Findings
Pseudoexfoliation syndrome is characterized by fibrillar material accumulation in the anterior segment of the eye, often on the anterior lens capsule and/or pupillary margin. When this material obstructs the trabecular meshwork, intraocular pressure can increase, and glaucoma can develop. Relative to primary open-angle glaucoma, pseudoexfoliative glaucoma is relatively more difficult to manage due to marked pressure spikes, pressure fluctuations, and less response to medical therapy.
This single-center, retrospective cohort study included patients with pseudoexfoliation syndrome at Massachusetts Eye and Ear Infirmary. White patients accounted for 86.5% of the study population, followed by Asian (10.6%) and Black (2.9%) patients. Among 485 eyes from 369 patients, the 4-year cumulative incidence of perimetric glaucoma was 26.5% in eyes without ocular hypertension and 37.5% in those with ocular hypertension. Risk factors for incident glaucoma were older age, higher cup-to-disc ratio, and phakia. Among eyes that developed glaucoma, 87.3% had no documented ocular hypertension at any office visit, suggesting the need to monitor these patients closely even if pressures remain in the normal range. Glaucoma developed in almost 30% of eyes who were treated once ocular hypertension developed, indicating the potential need for more aggressive and proactive treatment. Cataract surgery reduced intraocular pressure by 3 mmHg at one year postoperatively, a significant finding given the high rate of surgical complications with pseudoexfoliation syndrome and the potential intraocular pressure lowering benefit of surgery.
Clinical Value/Implications
This study affirms that once pseudoexfoliation syndrome is diagnosed, patients need to be followed more closely, and clinicians need to be proactive and consider treating the disease more aggressively. Even among patients who were actively being treated for ocular hypertension related to pseudoexfoliation syndrome, progression to glaucoma still occurred and additional intervention was needed. The alarming statistic that 87.3% of eyes that developed glaucoma had no documented ocular hypertension at any office visit suggests that pressure spikes may be missed and that patients should be seen regularly and on a more rigid follow-up schedule, regardless of documented in-office pressures. Furthermore, the study’s findings of phakia being associated with incident glaucoma and standalone lens extraction reducing intraocular pressure by an average of 3 mmHg suggests that earlier cataract surgery referral needs to be strongly considered in patients with pseudoexfoliation syndrome.
Impact of Intravitreal Anti-VEGF Injections on Cataract Development
Choi J, Choi E, Kang SW, Kim SJ, Hwang S, Lee H. Ophthalmology. 2026 Jul;133(7):829-836. doi: 10.1016/j.ophtha.2026.03.009. Epub 2026 Mar 11. PMID: 41825596.
Question
Is there an association between intravitreal anti-VEGF injections and incident cataract surgery?
Background/Summary of Findings
Anti-VEGF therapy has advanced the management of various retinal diseases such as age-related macular degeneration, retinal vein occlusion, and diabetic macular edema. With widespread use of anti-VEGF injections to manage these conditions, concerns over complications such as cataract development secondary to repeated, long-term injections have grown.
In this retrospective cohort study, electronic records were analyzed to compare the incidence of cataract surgery between eyes receiving anti-VEGF treatment and untreated fellow eyes. Overall, 603 patients were followed for a median of 74 months. Patients all had phakic lens status in both eyes at baseline and received 12 or more unilateral anti-VEGF injections. Wet macular degeneration accounted for 79.6% of patients, and macular edema secondary to retinal vein occlusion accounted for 20.4% of included patients. The 10-year cumulative incidence of cataract surgery was 40.7% in injected eyes and 7.2% in fellow untreated eyes. At the time of surgery, all lens opacity grades (nuclear, cortical, and posterior subcapsular) were significantly higher in the eyes receiving anti-VEGF treatment, with the greatest difference observed in posterior subcapsular opacity.
Possible explanations for the increased rate of cataract development include physical trauma to the lens during injection, intraocular inflammation s/p injection, physicochemical stress on lens from anti-VEGF, and oxidative stress from intraocular oxygen gradient disruption.
Clinical Value/Implications
This long-term follow-up study found that eyes receiving repeated intravitreal anti-VEGF therapy were at a significantly higher risk for cataract development than fellow untreated eyes. Clinicians should carefully evaluate the lens for visually significant changes when that eye has undergone repeated anti-VEGF injections. Assessment of anti-VEGF treatment efficacy with regards to best corrected visual acuity should also account for potential cataract development stemming from long-term treatment.
Conflict of Interest
Edward Chu – not applicable
Andrew Rixon – not applicable
Funding Sources
Edward Chu – not applicable
Andrew Rixon – not applicable