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Imaging can elucidate visual prognosis and disease progression risk.

OCT biomarkers associated with advanced age-related macular degeneration

The expanse of land that the Ohio State School for the Blind (OSSB) in Columbus lies on is teeming with life, bringing serenity and peace of mind to its students. With both OSSB moving and the Ohio School for the Deaf (OSD) expanding to its location on Morse Road in 1953, the schools reside less than 2 miles apart from each other, with Bill Moose Run splitting the middle of the land as a protected nature preserve.

Gregory Hopkins, OD, MS, FAAO, extern coordinator at OSSB and clinical associate professor of practice for The Ohio State University College of Optometry in Columbus, said he finds that the nature surrounding the school and the students have more in common than they have differences. “When I’m up there, there’s always wildlife around, and you can hear the birds chirping. They have a sensory garden out in the front,” he said. “It’s interesting to be out there because it’s very immersive. I think of each of these kids being like a rare bird.”

It is the broad diversity of OSSB students’ eye conditions that makes each patient who Hopkins serves unique, he said. Every Wednesday, he leads optometry students in eye examinations of no more than 6 patients a day to ensure that each of the approximately 100 OSSB students receives routine eye examinations or complete workups when necessary. He estimates that of these students, approximately a quarter have conditions caused by early birth, such as retinopathy of prematurity, and another quarter have some form of optic nerve atrophy.

“That leads half of them to [have] a complete and total grab bag of different conditions, and some of them have very important systemic implications,” Hopkins said. Some of these rare conditions and diseases include choroideremia, syndromic retinitis pigmentosa, albinism, and Leber congenital amaurosis.

Although each student’s visual acuity and eye condition may be different, Hopkins said it is nearly impossible to assume what each student’s visual acuity may be from a glance. “The difficulty with vision impairment, just like other conditions, is [that] it’s a spectrum,” he said. “The irony is that their visual acuity is invisible to onlookers. I can look at 2 kids’ class photos from OSSB in the yearbook and not know which of them can see better than the other just from that, so this requires very individualized care.”

In order to keep medical records fresh for quality patient care and help secure federal quota funding, Hopkins said each student at the school has a comprehensive eye examination at least every 3 years. These examinations are done to the level of the patients’ visual ability (eg, if a patient has had an eye removed, infections and allergies can still be checked for). For new students who transfer in, Hopkins said these examinations are usually longer, running from 1.5 to 2 hours. He estimates that the average visual acuity of OSSB students is 20/200.

Hopkins said a part of the routine care that he provides to his patients also includes conversations about their conditions for the sake of transparency and planning for the future. “Some of the work I do there is talking to the kids about what the odds are that they may get some genetic therapy or cures in their life. Or sometimes there’s a kid who was mainstreamed and [had] some kind of trauma or tragic loss of vision, and now they’re just trying to completely retool,” Hopkins said.

Examinations for nonspeaking and blind or deaf students can prove to be a challenge but are made easier by the proximity of OSD, according to Hopkins. “Being so close to [OSD] and having developed a reputation for doing decent work, I get more patients coming over from there, and to do an examination through an American Sign Language interpreter [for] a kid who has impaired vision is probably one of the hardest styles of examinations that you can attempt to do,” he said.

Additionally, because students either live on campus or take the bus to school every day, Hopkins said providing comprehensive care without the parents present is also challenging, despite efforts to connect via Zoom. “Imagine if I sent one of my kids into the doctor’s office and they had to rely on them for everything. It’s tough, so I try to get around that by getting access to the medical records at children’s hospitals,” he said.

Ultimately, Hopkins said that these efforts to provide individualized care contribute to OSSB’s ability to put its students at ease and help them feel welcome. “For each kid, the determination is made that this would be the least restrictive learning environment for them, and a lot of them are super happy to be there because they don’t have to explain themselves to other people 10 times a day,” he said. “Everyone there just gets it.”

OSSB is the oldest school for blind individuals in the nation and is just one of the more than 50 schools and agencies in the US registered as members of the Council of Schools and Services for the Blind that serve children with visual impairment. According to a 2023 annual report from the American Printing House, almost 55,000 students with blindness or low vision were registered under the annual Federal Quota Census, with 4539 (8%) registered through schools for the blind.

 This percentage has remained steady since 2016.

As far as employment rate after completing school, findings from one study in 2019 estimated that approximately 44% of the population with a visual impairment are employed and that 10% of people with a visual impairment who are in the labor force are unemployed.5 Hopkins said that although OSSB provides a postsecondary program to help with the transition into the workplace with internships and vocational classes, it can still prove difficult for alumni to find their footing. He added that having OSSB on their transcript may even work as a detriment to finding adequate, full-time work. “Most of them are unfortunately not being offered full employment at the level that they would hope, so that’s why we try and have these safety nets,” Hopkins said.

Set up for success at Cleveland Sight Center

With a small portion of students with visual impairments enrolled in schools for blind individuals, the large majority experience a different learning environment through the public school system. More than 43,000 students with visual impairments were registered through public schools in 2023.

 As many as 90% of high school students with blindness or low vision attend their neighborhood’s public school, according to Mobility International USA.

For young children entering the public school system, the transition can prove difficult for both them and their family. To help ease this transition, Cleveland Sight Center (CSC) in Ohio is one of the country’s nonprofit organizations that provides early intervention services for children from birth to the age of 3 years. According to Laurie Zebrasky, MSW, manager of early childhood services at CSC, the organization has 5 staff members who provide direct services at home for approximately 250 families across 7 counties every year.

Because CSC is involved in these children’s lives during some of their most formative years, Zebrasky said their care plans are constantly changing to best fit their needs. “[Early intervention specialists are] giving that parent information, the knowledge, the tools, the skills that they need to be an advocate for their own child, to help them understand their own child’s diagnosis better,” Zebrasky said. “All that preparation that we’re doing over those couple of years, if we have them that long in early intervention, is also helping to shape them and prepare them for what we call that transition to preschool.”

Zebrasky added that this also includes a timeline for how long resources and support are provided to a given family through CSC. “If the child turns 3 [years] in May, they’re not going to get special education preschool services until September, and they’re a child [with] very high need[s], we can still go out and make a couple of visits over the summer,” Zebrasky said.

Optimizing the child’s living space depends on many different factors, including reducing visual clutter and determining the physical location for light sources, according to Barbara Williams, MEd, CSC’s early intervention specialist and team lead. Improving a child’s ability to navigate their living space also requires an assessment for the child, which includes functional vision assessments and evaluating orientation and mobility. “When we’re assessing, we really tease out, how does the child respond to things like color and complexity, and do they respond more on one side than the other?... It’s a matter of observing the child, interacting with the child, and getting information from the parent or caregiver, because they’re the ones who know the child the best,” Williams said. To better understand a child’s visual acuity, Williams said CSC also works with an optometrist to walk the team through eye reports and specific visual conditions.

In terms of referrals, Zebrasky said the organization is working to improve their relationships with local eye care providers to help streamline the process. She emphasized that children do not need to have no light perception or have legal blindness to benefit from early intervention services. “Doctors generally only make referrals for the most severe cases,” Zebrasky said. “I would love to be able to grow the communication.”

History. Ohio School for the Deaf. Accessed August 15, 2024. 

About us. Ohio State School for the Blind. Accessed August 15, 2024. 

. American Printing House. Accessed August 15, 2024. 

https://www.aph.org/app/uploads/2024/02/APH-Annual-Report_FY2023-accessible-UA.pdf

The Year of Braille: Annual Report, Fiscal Year 2016

https://www.aph.org/app/uploads/2018/09/APH-Annual-Report-FY16-1.pdf

McDonnall MC, Sui Z. Employment and unemployment rates of people who are blind or visually impaired: estimates from multiple sources. 

High school placements for blind and low vision students. Mobility International USA. Accessed August 16, 2024. 

https://www.miusa.org/resource/tip-sheets/highschoolplacements/

From schools for blind individuals to early intervention services, families have options to help prepare their children with visual impairments for adulthood.

Eye care takes the forefront for students with visual impairments

Visionix USA has announced the launch of its VX 610 non-mydriatic automated fundus camera.

 The device features auto alignment, auto focus, and auto capture functions for retinal imaging, according to a news release.

“Our goal is to continuously advance eye care technology, enhance the patient experience, and improve the productivity of eye care professionals,” said Peter Wyles, CEO of Visionix USA, in a statement. “The VX 610 fundus camera demonstrates this commitment with its clear images, compact design, and automated capture features, ensuring precision and efficiency in screening and diagnostics.”

The VX 610 utilizes cross-polarized light technology, which allows for image clarity without the need for pupil dilation.

Images filters include vascular, choroidal, nerve fibre, and red free, in addition to cup-to-disc ratio for glaucoma screening.

 The device also has a 45-degree field of view and 90-degree mosaic function, with a retinal resolution of 14 microns. In addition to a secured, cloud-based storage ability and automatic database backup, VX 610 also includes a fundus adapter to transfer images to a local PC.

The device will be featured at Vision Expo West, being held from September 18-21 at the Venetian Expo in Las Vegas, Nevada. At Visionix’s booth #F10065, attendees will be able to experience a live demo of VX 610, in addition to viewing the company’s Optovue OCTs and OCTAs and Briot/Weco lens finishing platforms.

Visionix unveils the VX 610 automated fundus camera. News release. Visionix USA. August 21, 2024. Accessed August 22, 2024.

Visionix VX 610. Visionix USA. Accessed August 22, 2024. 

https://www.visionix.com/us/product/vx-610-automated-fundus-camera/

The device features cross-polarized light technology, allowing for image clarity without the need for pupil dilation.

Visionix USA announces US launch of VX 610 fundus camera

As the most common cause of irreversible blindness worldwide, glaucomatous optic neuropathy is well known to optometrists, and clinicians are comfortable diagnosing and managing it.

For years, the standard algorithm has changed little: treat patients with topical medications until the disease becomes severe enough to consider incisional surgery.

In the past decade, however, this strategy has been dramatically upended by the introduction of several new medications, a new understanding of the role of lasers, and the rapid growth of low-risk microsurgeries.

 of glaucoma has only advanced modestly in recent years, the 

 of the disease has undergone a transformation. In particular, management has shifted toward intervention that is earlier, safer, and often more surgical.

This 2-part series will review the new landscape of glaucoma management: part 1 will cover new medications and the use of lasers, and part 2 will focus on the minimally invasive glaucoma surgery (MIGS).


Glaucoma is a chronic progressive optic neuropathy that causes irreversible peripheral and/or central vision loss and may ultimately lead to blindness. 

Approximately 76 million individuals have glaucoma worldwide, a number that will increase over the next 2 decades.

 Risk factors for glaucoma include older age, a family history of glaucoma, non-White race, thinner corneas, and elevated intraocular pressure (IOP).

Podcast: Mark Dunbar, OD, FAAO dives into glaucoma, part 1

There are many subtypes of glaucoma, a topic beyond the scope of this article. The only modifiable risk factor for most subtypes is elevated IOP, and almost all existing treatments are aimed at lowering IOP.

Glaucoma management is notoriously difficult to standardize, and treatment decisions are highly personal to each patient. Many factors must be considered, including pretreatment IOP, the severity of glaucomatous damage, the rate of progression, and the patient’s life expectancy. 

Generally, a more aggressive treatment is recommended for younger individuals, those with severe disease or a fast rate of progression, those with low unmanaged IOP, and those with additional risk factors.

Many doctors choose to set a target IOP for each eye; this number can then guide treatment, as it is considered to be the highest acceptable IOP that is still likely to prevent or slow further vision loss.

Target IOP can be determined based on a percentage reduction from pretreatment IOP or on the stage of glaucoma (


As the glaucoma armamentarium becomes more varied and powerful, many doctors are realizing that improving patient care means managing glaucoma 

. Selective laser trabeculoplasty (SLT) illustrates this point.

SLT is a 532-nm Q-switched, frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG) laser that delivers very short pulses of energy to pigmented trabecular meshwork (TM) cells. 


No structural or coagulative damage has been found in the TM after treatment, the procedure is painless, and it results on average in a decline in IOP of 17% to 30%. SLT is indicated for mild to moderate cases of open angle, pigment dispersion, or pseudoexfoliative glaucoma.

Since the introduction of SLT in 2001, doctors in the US have tended to regard the use of SLT as a secondary attempt after maximum drop therapy has failed, usually just before incisional surgery becomes necessary.

This changed recently with the publication of the LiGHT study (NCT03395535) in 2019, in which investigators showed definitively that SLT was superior to topical medications in efficacy, safety, and cost, and strongly recommended considering SLT before starting any drops.

As the conclusions of this landmark study reverberate through the profession, optometrists and ophthalmologists have adjusted their treatment algorithm. A diagnosis of glaucoma now frequently triggers using SLT first, instead of topical medications. 

Patient satisfaction with SLT is higher than with drops, and adherence is no longer an issue. SLT can be repeated as frequently as needed, and repeated SLT often results in greater effectiveness.

Interestingly, investigators have uncovered suggestions that the current protocol of maximum-power SLT performed as needed might be inferior to low-power SLT performed annually.

 This inquiry has given rise to a large clinical trial whose results, once released, might change once again the use of this therapy.


Historically, topical medications have been considered the first-line treatment for patients with glaucoma. There are now 5 major categories of IOP-lowering eye drops: prostaglandin analogues, ρ-kinase inhibitors, β-blockers, α-agonists, and carbonic anhydrase inhibitors.

How one OD encouraged glaucoma medication adherence

Prostaglandin analogues (PGAs) reduce IOP by decreasing outflow resistance within the uveoscleral pathway. PGAs have been the first-line drops for many years, and despite the recent introduction of several more potent medications, they maintain that status due to their effectiveness, once-daily dosing, affordability, and low risk of adverse effects. 

The use of PGAs has been correlated with a decrease in the number of trabeculectomies performed.

 PGAs commonly produce a 25% to 33% reduction in IOP, although the effect is more pronounced in patients with higher baseline IOPs.

 The PGAs can produce adverse effects of hyperemia, hypertrichosis, and periorbital fat atrophy.


The FDA recently approved 3 new glaucoma topical medications that have had a large impact on prescribing patterns. The first of these, latanoprostene bunod (Vyzulta, Bausch + Lomb), was released in 2017. Latanoprostene bunod combines the known agent latanoprost with nitric oxide. 

Nitric oxide increases aqueous outflow by relaxing chronic TM contraction. This provides an IOP reduction of 1 to 2 mmHg more than a PGA alone while maintaining the same dosing schedule.

Netarsudil 0.2% (Rhopressa, Aerie Pharmaceuticals), a ρ-kinase (ROCK) inhibitor, also was introduced in 2017. The ρ-kinase enzyme promotes contraction of TM cells and matrix, so inhibition of the enzyme by this drug increases the outflow of aqueous fluid through the TM. 

The use of netarsudil produces conjunctival hyperemia in 50% of patients—a significant adverse effect. Like the PGAs, Netarsudil is dosed once daily at bedtime. On average, it results in a 25% to 30% drop from baseline IOP.

Netarsudil has been combined with latanoprost to create Rocklatan (Aerie), an effective combination medication. Rocklatan offers the highest average IOP reduction of any single glaucoma medication: 30% to 36% from baseline.

The instillation regimen is identical to the PGAs, latanoprostene bunod, and netarsudil: once daily at bedtime. It is important to discuss the significant adverse effects of conjunctival hyperemia and corneal verticillata prior to starting this drop, in addition to the adverse effects linked to the latanoprost moiety.

The introduction of netarsudil and nitric oxide has affected the treatment algorithm significantly. Whereas many doctors continue to start any topical therapy with a PGA, if this drug proves insufficiently potent, they may consider switching to Vyzulta or Rocklatan. 

The instillation burden for these medications is no greater than that of the original PGA, and most patients will see a further reduction in their IOPs.


Older topical medications can still play a helpful role in the reduction of IOP. These include β-blockers, α-agonists, and carbonic anhydrase inhibitors.

By decreasing aqueous production, β-blockers reduce IOP. They are less likely to cause ocular surface issues; however, cardiac or respiratory adverse effects may occur.

 These should be avoided in patients with bradycardia, hypotension, asthma, and obstructive pulmonary disease.

 Patients who are already using systemic β-blockers should be carefully monitored when taking topical β-blockers.

Carbonic anhydrase inhibitors and α-agonists are commonly used second-line agents. These can be added to a patient’s regimen when a monotherapy is not sufficient. The α-agonists frequently cause conjunctival hyperemia.

Unfortunately, increasing the number of drops used daily negatively affects patient adherence to therapy.

 According to some studies, fewer than 50% of patients continue adhering to therapy beyond the first year.

Look beyond IOP in treating glaucoma patients


Combination therapies may help patient adherence and reduce exposure to preservatives. In cases of more severe disease and when a significant decrease in IOP is needed, a combination drop is preferred, as it will simplify the administration schedule and provide greater IOP reduction. 

The list of combination drops available in the US includes timolol plus brimonidine (Combigan, Allergan), timolol plus dorzolamide (Cosopt/Cosopt PF, Akorn), brimonidine plus brinzolamide (Simbrinza, Alcon), and Rocklatan.


The largest factor interfering with the success of medical glaucoma treatment is patient inability to adhere to topical therapy as prescribed.

 Challenges with drop adherence include difficulty with drop administration, adverse effects, and the expense of medications.

Thorough patient education regarding the severity and permanence of potential vision loss might seem like a powerful way to address poor adherence but is actually surprisingly ineffective.

It may not be the lack of education that precludes patients from taking their glaucoma medication, but rather various aspects of their lifestyles, such as level of busyness, time away from home, or forgetfulness.

This is supported by the fact that younger patients have higher nonadherence rates, despite having better access to information about glaucoma.

Medications with the easiest administration, such as once-daily regimens, should be strongly considered as first line treatments. The more complex the medication regimen, the lower the rate of adherence to therapy.

Utilizing treatment modalities that are not reliant on constant patient cooperation will result in better continuity of care. This includes SLT, surgeries, and sustained-release implants.


Sustained-release medications may soon become a highly effective option for managing glaucoma. The only device approved for use at this point is the bimatoprost intracameral implant Durysta (Allergan). 

The solid, biodegradable, rod-shaped implant is placed in the anterior chamber angle and then slowly releases a prostaglandin analog as its copolymer matrix degrades. The intracameral implant is capable of delivering medication for up to 6 months but is not yet approved for repeat use.


We are in the midst of a paradigm shift in the management of glaucoma. Our management of this disease has shifted towards intervention that is earlier, safer, and often more surgical. 

We now know that a large proportion of patients do not use their eye drops as prescribed, and the wave of new once-daily drops and the increased use of SLT laser as a first-line treatment are powerful strategies to produce more consistent results.

Another powerful strategy has been the increased use of MIGS, which will be treated in the second part of this 2-part series.

The field of glaucoma has recently become significantly more exciting, and is evolving quickly. As optometrists master the new options, we will be able to offer our patients a higher standard of care, which can result in significantly less vision lost to this disease.


1. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040. 

. 2014;121(11):2081-2090. doi:10.1016/j.ophtha.2014.05.013

2. Hollands H, Johnson D, Hollands S, Simel DL, Jinapriya D, Sharma S. Do findings on routine examination identify patients at risk for primary open-angle glaucoma? 

. 2013;309(19):2035-2042. doi:10.1001/jama.2013.5099

3. Villasana GA, Bradley C, Ramulu P, Unberath M, Yohannan J. The effect of achieving target intraocular pressure on visual field worsening. 

. Published online September 8, 2021. doi:10.1016/j.ophtha.2021.08.025

4. Leahy KE, White AJR. Selective laser trabeculoplasty: current perspectives. 

. 2015;9:833-841. doi:10.2147/OPTH.S53490

5. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516. doi:10.1016/S0140-6736(18)32213-X

6. Garg A, Vickerstaff V, Nathwani N, et al. Efficacy of repeat selective laser trabeculoplasty in medication-naïve open-angle glaucoma and ocular hypertension during the LiGHT trial. 

. 2020;127:467-476. doi:10.1016/j.ophtha.2019.10.023

7. Gandolfi SA, Ungaro N, Varan I, Saccà S. Low power selective laser trabeculoplasty (SLT) repeated yearly as primary treatment in open angle glaucoma: long-term comparison with conventional SLT and ALT. 

8. Realini T, Gazzard G, Latina M, Kass M. Low-energy selective laser trabeculoplasty repeated annually: rationale for the COAST trial. 

 2021;30(7):545-551. doi:10.1097/IJG.0000000000001788

9. Rachmiel R, Trope GE, Chipman ML, Gouws P, Buys YM. Effect of medical therapy on glaucoma filtration surgery rates in Ontario. 

 2006;124(10):1472-1477. doi:10.1001/archopht.124.10.1472

10. Aspberg J, Heijl A, Johannesson G, et al. Intraocular pressure lowering effect of latanoprost as first-line treatment for glaucoma. 

. 2018;27(11):976-980. doi:10.1097/IJG.0000000000001055

11. Alm A. Latanoprost in the treatment of glaucoma. 

 2014;8:1967-1985. doi:10.2147/OPTH.S59162

12. Weinreb RN, Ong T, Sforzolini S, et al; VOYAGER Study Group. A randomised, controlled comparison of latanoprostene bunod and latanoprost 0.005% in the treatment of ocular hypertension and open angle glaucoma: the VOYAGER study. 

Advancements in medications and lasers bring better adherence and outcomes.

Birva Shah, OD

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