Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan.

PURPOSE: To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Relationship between Unstable Housing, Food Insecurity, and Vision Status in the MI-SIGHT Community Eye Disease Screening Program.

PURPOSE: Assess rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical shop. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA] ≤ 20/50, best corrected visual acuity [BCVA] ≥ 20/40), URE without VI (PVA ≥ 20/40, had ≥ 2 lines of improvement to BCVA), and no or adequately corrected RE (PVA ≥ 20/40, < 2 line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared between groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, the average age was 55.1 years (standard deviation = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 (10.3%); 96 had VI from URE (8.2%), 168 (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI from URE reported having a college degree and a larger percentage reported income < $10 000 compared to participants with no or adequately corrected RE (3.2% versus 14.2%, P = 0.02; 45.5% versus 21.6%, respectively, P < 0.0001. Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (VFQ9 composite score 67.3 ± 19.6 versus 77.0 ± 14.4 versus 82.2 ± 13.3, respectively; P < 0.0001). 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical shop with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

NO EFFECT OF REAL-WORLD UNIVERSAL FACE MASKING ON POST-INTRAVITREAL INJECTION ENDOPHTHALMITIS RATE AT A SINGLE TERTIARY ACADEMIC CENTER.

PURPOSE: To determine whether universal masking during COVID-19 altered rate and outcomes of postinjection endophthalmitis. METHODS: Retrospective, single-site, comparative, cohort study. Eyes diagnosed with endophthalmitis within 4 weeks of intravitreal injection at the University of Michigan from August 1, 2012, to November 15, 2022, were identified. Cases were considered "masking" between March 15, 2020, and November 15, 2022. Endophthalmitis rate, visual acuity, and microbial spectrum were investigated. RESULTS: There were 20 postinjection endophthalmitis cases out of 72,194 injections (0.028%; one in 3,571 injections) premasking and 10 of 38,962 with universal masking (0.026%; one in 3,846 injections; odds ratio 0.9; 95% [confidence interval]: 0.4-2.0). Referral from the community was unchanged with 32 cases referred premasking (0.35 cases/month) and 10 cases with masking (0.31 cases/month). Presenting mean the logarithm of the minimum angle of resolution visual acuity with masking of all postinjection endophthalmitis cases trended worse (2.35 ± 0.40) compared with premasking (2.09 ± 0.48; P = 0.05) with light perception visual acuity more common with masking (31.6% vs. 10.9%, P = 0.06). There was no delay in time from procedure to initial treatment ( P = 0.36), no difference in the rate of initial treatment with tap and inject (T/I), and similar positive-culture rates ( P = 0.77) between the cohorts. Visual acuity after 30 days of follow-up was clinically unchanged (∼20/500 vs. 20/400; P = 0.59). CONCLUSION: Universal masking had no effect on postinjection endophthalmitis rate or on the rate of culture-positive cases. Although presenting visual acuity appeared worse with masking, this was not statistically significant, and current treatment paradigms resulted in similar visual outcomes.

Social Deprivation and the Risk of Screening Positive for Glaucoma in the MI-SIGHT Telemedicine-Based Glaucoma Detection Program.

PURPOSE: To assess whether increased poverty is associated with increased risk of screening positive for glaucoma or suspected glaucoma in a large public screening and intervention program. DESIGN: Cross-sectional study from 2020 to 2022. PARTICIPANTS: Adults ≥ 18 years old without acute ocular symptoms. METHODS: Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program participants' sociodemographic characteristics and area deprivation index (ADI) values were summarized from the clinical sites, which included a free clinic and a Federally Qualified Health Center (FQHC). The ADI, a composite measure of neighborhood deprivation (range, 1-10; 10 is worst deprivation), was assigned on the basis of the participants' addresses. Group comparisons were performed via 2-sample t tests or Wilcoxon Mann-Whitney tests for continuous measures and chi-square tests or Fisher exact tests with Monte Carlo simulation for categorical measures; Holm adjustment was used for multiple comparisons. MAIN OUTCOME MEASURES: Risk factors for screening positive for glaucoma or suspected glaucoma. RESULTS: Of the 1171 enrolled participants, 1165 (99.5%) completed the screening: 34% at the free clinic and 66% at the FQHC. Participants were on average aged 55.1 ± 14.5 years, 62% were women, 54% self-reported as Black/African-American, 34% White, 10% Hispanic or Latino, and 70% earned < $30 000 annually. The mean ADI was 7.2 ± 3.1. The FQHC had higher (worse) ADI than the free clinic (free clinic: 4.5 ± 2.9, FQHC: 8.5 ± 2.1, P < 0.0001). One-quarter (24%) of participants screened positive for glaucoma or suspected glaucoma. Screening positive for glaucoma or suspected glaucoma was associated with being older (P = 0.01), identifying as Black/African-American (P = 0.0001), having an established eyecare clinician (P = 0.0005), and not driving a personal vehicle to the appointment (P = 0.001), which is a proxy for increased poverty. Participants who screened positive had worse ADI than those who screened negative (7.7 ± 2.8 vs. 7.0 ± 3.2, P = 0.002). A larger percentage of White participants screened positive at the FQHC compared with White participants at the free clinic (21.3% vs. 12.3%, P = 0.01). FQHC White participants had worse ADI than free clinic White participants (7.5 ± 2.5 vs. 3.7 ± 2.7, P < 0.0001). CONCLUSIONS: Personal poverty, assessed as not driving a personal vehicle to the appointment, and neighborhood-level poverty were both associated with increased rates of screening positive for glaucoma or suspected glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Support, Educate, Empower personalized glaucoma coaching trial design.

BACKGROUND: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. METHODS/DESIGN: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. DISCUSSION: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India.

PURPOSE: To assess whether routine fundus photography (RFP) to screen for posterior segment disease at community eye clinics (vision centers [VCs]) in India increases referral to centralized ophthalmolic care. DESIGN: Stepped-wedge, cluster-randomized trial. PARTICIPANTS: Patients aged 40 to 75 years and those aged 20 to 40 years with a known history of hypertension or diabetes mellitus presenting to 4 technician-run VCs associated with the Aravind Eye Care System in India. METHODS: VCs (clusters) were randomized to standard care or RFP across five 2-week study periods (steps). Patients in each cluster received standard care initially. At the start of each subsequent step, a randomly chosen cluster crossed over to providing RFP to eligible patients. All clusters took part in RFP during the last step. Standard care involved technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist. RFP involved eye exams, dilation and 40-degree fundus photography, and teleconsultation with an ophthalmologist. MAIN OUTCOME MEASURES: Standard care and RFP clusters were compared by the proportion of patients referred for in-person evaluation by an ophthalmologist because of fundus photography findings and urgency of referral (urgently in ≤ 2 weeks vs. nonurgently in > 2 weeks). Generalized linear mixed models adjusting for cluster and step were used to estimate the odds of referral due to fundus photography findings compared with standard care. RESULTS: A total of 1447 patients were enrolled across the VCs, including 737 in the standard care group and 710 in the RFP group. Compared with standard care, the RFP group had a higher proportion of referrals due to fundus photography findings (11.3% vs. 4.4%), nonurgent referrals due to fundus photography (9.3% vs. 3.3%), and urgent referrals due to fundus photography (1.8% vs. 1.1%). The RFP intervention was associated with a 2-fold increased odds of being referred because of photography findings compared with standard care (odds ratio, 2.07; 95% confidence interval, 0.98-4.40; P = 0.058). CONCLUSIONS: Adding RFP to community eye clinics was associated with an increased odds of referral compared with standard care. This increase in referral was mostly due to nonurgent posterior segment disease.

The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study.

PURPOSE: To evaluate the relationship between medication adherence and visual field progression in participants randomized to the medication arm of the Collaborative Initial Glaucoma Treatment Study (CIGTS). DESIGN: The CIGTS was a randomized, multicenter clinical trial comparing initial treatment with topical medications to trabeculectomy for 607 participants with newly diagnosed glaucoma. PARTICIPANTS: Three hundred seven participants randomized to the medication arm of the CIGTS. METHODS: Participants were followed up at 6-month intervals for up to 10 years. Self-reported medication adherence and visual fields were measured. Medication adherence was assessed by telephone from responses to the question, "Did you happen to miss any dose of your medication yesterday?" The impact of medication adherence on mean deviation (MD) over time was assessed with a linear mixed regression model adjusting for the effects of baseline MD and age, cataract extraction, interactions, and time (through year 8, excluding time after crossover to surgery). Medication adherence was modeled as a cumulative sum of the number of prior visits where a missed dose of medication was reported. MAIN OUTCOME MEASURE: Mean deviation over time. RESULTS: Three hundred seven subjects (306 with adherence data) were randomized to treatment with topical medications and followed up for an average of 7.3 years (standard deviation, 2.3 years). One hundred forty-two subjects (46%) reported never missing a dose of medication over all available follow-up, 112 patients (37%) reported missing medication at up to one third of visits, 31 patients (10%) reported missing medication at one third to two thirds of visits, and 21 patients (7%) reported missing medication at more than two thirds of visits. Worse medication adherence was associated with loss of MD over time (P = 0.005). For subjects who reported never missing a dose of medication, the average predicted MD loss over 8 years was 0.62 dB, consistent with age-related loss (95% confidence interval [CI], 0.17-1.06; P = 0.007); subjects who reported missing medication doses at one third of visits had a loss of 1.42 dB (95% CI, 0.86-1.98; P < 0.0001); and subjects who reported missing medication doses at two thirds of visits showed a loss of 2.23 dB (95% CI, 1.19-3.26; P < 0.0001). CONCLUSIONS: This longitudinal assessment demonstrated a statistically and clinically significant association between medication nonadherence and glaucomatous vision loss.

Testability Study of the Titmus V3 Test in Pre-school Children.

SIGNIFICANCE: Vision screening can identify people who have vision problems requiring a comprehensive examination. When children are screened, the most prevalent serious problem is amblyopia secondary to uncorrected ametropia. Screening also identifies strabismus, which can lead to loss of binocularity. Early diagnosis permits treatment with restoration of balanced vision and binocularity. PURPOSE: The study evaluated the testability of the Titmus V3 Vision Screener as a method to screen vision and strabismus in pre-school children. METHODS: Pre-school children between 36 and 66 months of age underwent vision screening in six Michigan counties. The State of Michigan screening consists of the LEA Symbols test for visual acuity and the stereo butterfly for near-strabismus testing. The proposed Titmus V3 screening tests were the LEA Symbols slide for vision and near-strabismus test slide. Primary and secondary objectives of this study were to evaluate the percentage of pre-school children who completed the Titmus V3 screening tests for vision and near strabismus and factors associated with an inability to complete the tests, contrasting the pass/fail results between the state and Titmus V3 results. RESULTS: Two-hundred sixty-three children were tested. The percentages of children unable to score on the Titmus V3 instrument versus the state's LEA Symbols test were 16.0% and 5.3%, respectively. The percentage of children unable to score on the Titmus V3 near-strabismus test slide was 6.9 versus 3.4% on the State of Michigan stereo butterfly test. Younger age at testing was the most important factor associated with the inability to complete testing. CONCLUSIONS: Because of testability limitations and higher failure rates relative to the State of Michigan testing methods, the Titmus V3 screening device is not a feasible alternative to the standard methods used by the State of Michigan for vision and near-strabismus screening among the pre-school subjects we tested.

Eye Symptom Questionnaire to Evaluate Anterior Eye Health.

OBJECTIVES: Ophthalmologists assess eye complaints with a careful history and eye examination; however, other types of physicians have limited tools to evaluate anterior segment (AS) eye diseases. We identified the eye symptom questions that providers should ask to help determine the presence and urgency of AS eye diseases. METHODS: Persons with and without AS disease completed a self-report eye symptom questionnaire (ESQ) based on the National Institutes of Health Toolbox symptom items in an academic center's corneal and comprehensive eye clinics. Gold standard ophthalmic examination determined the presence and urgency of AS disease. The association between reported symptom severity and the probability of AS disease, or urgent AS disease, was evaluated using logistic regression models, and sensitivity and specificity of the ESQ were also calculated. RESULTS: A total of 324 eyes of 162 subjects were included in the study. Of these, AS disease was present in 255 eyes (79%); of which, 111 eyes showed urgent disease. Increasing symptom severity for eye pain (odds ratio [OR]=2.58; P<0.001), glare (OR=2.61; P=0.001), and blurry vision (OR=1.98; P<0.001) were associated with increased odds of AS disease. Increasing symptom severity for eye pain (OR=2.02; P<0.001), eye redness (OR=1.69; P=0.02), and blurry vision (OR=1.41, P=0.01) were associated with increased odds of urgent AS disease. For the primary analysis with mild symptoms considered relevant, the sensitivity of the ESQ to detect AS disease was 83% and to detect urgent AS disease was 92%. CONCLUSION: Symptoms of eye pain, glare, redness, and blurry vision indicate the presence and urgency of AS disease.

Large Disparities in Receipt of Glaucoma Care between Enrollees in Medicaid and Those with Commercial Health Insurance.

PURPOSE: To determine whether the type of health insurance a patient possesses and a patient's race/ethnicity affect receipt of common tests to monitor open-angle glaucoma (OAG). DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: A total of 21 766 persons aged ≥40 years with newly diagnosed OAG between 2007 and 2011 enrolled in Medicaid or a large United States managed care network. METHODS: We determined the proportion of patients with newly diagnosed OAG who underwent visual field (VF) testing, fundus photography (FP), other ocular imaging (OOI), or none of these tests within the first 15 months after initial OAG diagnosis. Multivariable logistic regression was used to assess the extent by which health insurance type and race/ethnicity affected the odds of undergoing glaucoma testing. MAIN OUTCOME MEASURES: Odds ratios (OR) of undergoing VF testing, FP, OOI, or none of these tests in the 15 months after initial OAG diagnosis with 95% confidence intervals (CI). RESULTS: A total of 18 372 persons with commercial health insurance and 3394 Medicaid recipients met the study inclusion criteria. The proportions of persons with commercial health insurance with newly diagnosed OAG who underwent VF, FP, and OOI were 63%, 22%, and 54%, respectively, whereas the proportions were 35%, 19%, and 30%, respectively, for Medicaid recipients. Compared with those with commercial health insurance, Medicaid recipients were 234% more likely to not receive any glaucoma testing in the 15 months after initial diagnosis (OR = 3.34; 95% CI, 3.07-3.63). After adjustment for confounders, whites with OAG enrolled in Medicaid had 198% higher odds of receiving no glaucoma testing compared with whites possessing commercial health insurance (OR = 2.98; 95% CI, 2.66-3.33). Blacks with Medicaid insurance demonstrated 291% higher odds (OR = 3.91; 95% CI, 3.40-4.49) of not receiving any glaucoma testing compared with blacks with commercial health insurance. CONCLUSIONS: Irrespective of race/ethnicity, Medicaid recipients with OAG are receiving substantially less glaucoma testing compared with persons with commercial health insurance. Disparities in testing are observed across all races/ethnicities but were most notable for blacks. These findings are particularly disconcerting because blacks are more likely than whites to go blind from OAG and there are disproportionately more blacks in Medicaid. Efforts are needed to improve the quality of glaucoma care for Medicaid recipients, especially racial minorities.

Binocular Measures of Visual Acuity and Visual Field versus Binocular Approximations.

PURPOSE: To assess the relationship of binocular visual function tests with binocular approximations using data from the Collaborative Initial Glaucoma Treatment Study (CIGTS). DESIGN: Case series based on existing data from a clinical trial. PARTICIPANTS: Six hundred seven patients with newly diagnosed open-angle glaucoma from the CIGTS. METHODS: Monocular visual field (VF) and visual acuity (VA) tests were performed at baseline and every 6 months thereafter. Binocular tests of visual function (Esterman VF score, binocular VA) were added to the CIGTS protocol 3 years into the study. The binocular approximations of binocular visual function were better or worse eye, average eye, better or worse location, and binocular summation or pointwise binocular summation. Associations between binocular tests and binocular approximations to represent binocular visual function were assessed with Pearson's correlations (r), as was the relationship between vision-related quality of life (VR QOL; Visual Activities Questionnaire [VAQ] and the 25-item National Eye Institute Visual Function Questionnaire [NEI VFQ-25]) and binocular tests or binocular approximations of visual function. MAIN OUTCOME MEASURES: Binocular visual function (VF and VA) and VR QOL. RESULTS: Five hundred seventy-five patients underwent at least 1 binocular visual function test. The Esterman score was correlated significantly with all binocular approximations of VF, with r values ranging from 0.31 (worse-eye mean deviation [MD]) to 0.42 (better-eye MD; P < 0.0001 for all). Binocular VA showed stronger correlations with binocular approximations, with r values ranging from 0.65 (worse-eye VA) to 0.80 (binocular summation; P < 0.0001 for all). Correlations between the VAQ and Esterman score were stronger in 7 of 9 subscales (r = -0.14 to -0.25; P < 0.05 for all) than correlations with all 7 binocular approximations. In contrast, correlations between the VAQ and binocular VA (r = -0.07 to -0.21) were weaker in all subscales than those with better-eye, average-eye, and binocular summation of VA (r = -0.12 to -0.25), but not different from worse-eye values. These trends also were found in relevant subscales of the NEI VFQ-25. CONCLUSIONS: We found limited benefit in binocular testing of VA in the clinical setting as a means of approximating a patient's reported visual functioning. In contrast, we found some benefit in performing binocular VF testing, because the results correlated more closely with reported functioning than binocular approximations.

Perioperative medications for preventing temporarily increased intraocular pressure after laser trabeculoplasty.

BACKGROUND: Glaucoma is the international leading cause of irreversible blindness. Intraocular pressure (IOP) is the only currently known modifiable risk factor; it can be reduced by medications, incisional surgery, or laser trabeculoplasty (LTP). LTP reduces IOP by 25% to 30% from baseline, but early acute IOP elevation after LTP is a common adverse effect. Most of these IOP elevations are transient, but temporarily elevated IOP may cause further optic nerve damage, worsening of glaucoma requiring additional therapy, and permanent vision loss. Antihypertensive prophylaxis with medications such as acetazolamide, apraclonidine, brimonidine, dipivefrin, pilocarpine, and timolol have been recommended to blunt and treat the postoperative IOP spike and associated pain and discomfort. Conversely, other researchers have observed that early postoperative IOP rise happens regardless of whether people receive perioperative glaucoma medications. It is unclear whether perioperative administration of antiglaucoma medications may be helpful in preventing or reducing the occurrence of postoperative IOP elevation. OBJECTIVES: To assess the effectiveness of medications administered perioperatively to prevent temporarily increased intraocular pressure (IOP) after laser trabeculoplasty (LTP) in people with open-angle glaucoma (OAG). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), MEDLINE Ovid (1946 to 18 November 2016), Embase.com (1947 to 18 November 2016), PubMed (1948 to 18 November 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 18 November 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com); last searched 17 September 2013, ClinicalTrials.gov (www.clinicaltrials.gov); searched 18 November 2016 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 18 November 2016. We did not use any date or language restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which participants with OAG received LTP. We included trials which compared any antiglaucoma medication with no medication, one type of antiglaucoma medication compared with another type of antiglaucoma medication, or different timings of medication. DATA COLLECTION AND ANALYSIS: Two review authors independently screened records retrieved by the database searches, assessed the risk of bias, and abstracted data. We graded the certainty of the evidence using GRADE. MAIN RESULTS: We included 22 trials that analyzed 2112 participants and identified no ongoing trials. We performed several comparisons of outcomes: one comparison of any antiglaucoma medication versus no medication or placebo, three comparisons of one antiglaucoma medication versus a different antiglaucoma mediation, and one comparison of antiglaucoma medication given before LTP to the same antiglaucoma medication given after LTP. Only one of the included trials used selective laser trabeculoplasty (SLT); the remaining trials used argon laser trabeculoplasty (ALT). Risk of bias issues were primarily in detection bias, reporting bias, and other potential bias due to studies funded by industry. Two potentially relevant studies are awaiting classification due to needing translation.In the comparison of any medication versus no medication/placebo, there was moderate-certainty evidence that the medication group had a lower risk of IOP increase of 10 mmHg or greater within two hours compared with the no medication/placebo group (risk ratio (RR) 0.05, 95% confidence interval (CI) 0.01 to 0.20). This trend favoring medication continued between two and 24 hours, but the evidence was of low and very low-certainty for an IOP increase of 5 mmHg or greater (RR 0.17, 95% CI 0.09 to 0.31) and 10 mmHg or greater (RR 0.22, 95% CI 0.11 to 0.42). Medication was favored over placebo/no medication with moderate-certainty in reducing IOP from the pre-LTP measurements for both within two hours and between two and 24 hours. At two hours, the mean difference (MD) in IOP between the medication group and the placebo/no medication group was -7.43 mmHg (95% CI -10.60 to -4.27); at between two and 24 hours, the medication group had a mean reduction in IOP of 5.32 mmHg more than the mean change in the placebo/no medication group (95% CI -7.37 to -3.28). Conjunctival blanching was an ocular adverse effect that was more common when brimonidine was given perioperatively compared with placebo in three studies.In our comparison of brimonidine versus apraclonidine, neither medication resulted in a lower risk of increased IOP of 5 mmHg or greater two hours of surgery; however, we were very uncertain about the estimate. There may be a greater mean decrease in IOP within two hours after LTP. We were unable to perform any meta-analyses for other review outcomes for this comparison.In our comparison of apraclonidine versus pilocarpine, we had insufficient data to perform meta-analyses to estimate effects on either of the primary outcomes. There was moderate-certainty evidence that neither medication was favored based on the mean change in IOP measurements from pre-LTP to two hours after surgery.In the comparison of medication given before LTP versus the same medication given after LTP, we had insufficient data for meta-analysis of IOP increase within two hours. For the risk of IOP increase of 5 mmHg or greater and 10 mmHg or greater at time points between two and 24 hours, there was no advantage of medication administration before or after LTP regarding the proportion of participants with an IOP spike (5 mmHg or greater: RR 0.82, 95% CI 0.25 to 2.63; 10 mmHg or greater: RR 1.55, 95% CI 0.19 to 12.43). For an IOP increase of 10 mmHg or greater, we had very low-certainty in the estimate, it would likely change with data from new studies. AUTHORS' CONCLUSIONS: Perioperative medications are superior to no medication or placebo to prevent IOP spikes during the first two hours and up to 24 hours after LTP, but some medications can cause temporary conjunctival blanching, a short-term cosmetic effect. Overall, perioperative treatment was well tolerated and safe. Alpha-2 agonists are useful in helping to prevent IOP increases after LTP, but it is unclear whether one medication in this class of drugs is better than another. There was no notable difference between apraclonidine and pilocarpine in the outcomes we were able to assess. Future research should include participants who have been using these antiglaucoma medications for daily treatment of glaucoma before LTP was performed.

CLINICAL EVALUATION OF THE RAPID ACCESS VITREAL INJECTION GUIDE: A Handheld Instrument for Assisting Intravitreal Injections.

PURPOSE: The Rapid Access Vitreal Injection (RAVI) guide combines the function of an eyelid speculum and measuring caliper into a single instrument for assisting intravitreal injections. This study clinically evaluated the RAVI guide with respect to patient acceptance, complication rates, and operative goals. METHODS: A prospective study was performed on 54 patients undergoing intravitreal injections using the RAVI guide (n = 32) or the speculum/caliper (n = 22). Device-related pain was assessed using the Wong-Baker scoring system, scaled from 0 (no pain) to 10 (agonizing pain). RESULTS: Mean device-related pain score did not differ significantly between the 2 groups, with scores of 0.6 and 0.7 for the RAVI guide and speculum groups, respectively. The rate of significant pain (score of ≥2) was twice as high in the speculum group (7 of 22, 32%) compared with the RAVI guide group (5 of 32, 16%), but this difference was not statistically significant (P = 0.19, Fisher's exact test). Operative goals of avoiding needle touch to lashes/lids and guiding needle insertion to the intended site were achieved in all patients. CONCLUSION: The RAVI guide appeared equivalent to the eyelid speculum in achieving operative goals, with similarly low pain scores. It has the potential for facilitating efficient, accurate, and safe intravitreal injections.

Thyroid-Related Orbital Decompression Surgery: A Multivariate Analysis of Risk Factors and Outcomes.

PURPOSE: Despite the number of publications on orbital decompression surgery for thyroid eye disease, there are few comparative studies and most studies are underpowered. The goal of the study is to use multivariable analysis to identify independent patient and disease-related predictors of response to decompression surgery and of need for secondary decompressions. METHODS: The authors retrospectively reviewed all patients who underwent transorbital thyroid-related orbital decompression surgery at the Kellogg Eye Center of the University of Michigan between 1999 and 2014. Demographic, medical, and surgical covariates were collected. Decompression techniques included medial, lateral, and balanced decompressions, with or without orbital fat removal. Main outcomes included proptosis reduction and secondary decompressions, both analyzed at the orbital level. Univariate and multivariable analyses (with adjustment for interorbit correlation) were conducted to determine predictors of the outcomes of interest. RESULTS: Mean proptosis reduction was 3.8 ± 2.4 mm (mean ± standard deviation, N = 420 orbits). The secondary decompression rate was 13.8% (82/594). On multivariable mixed linear regression, larger preoperative proptosis (p < 0.0001), balanced decompression (p = 0.0002), thyroid eye disease duration < 4 years (p = 0.0093), and history of orbital radiation (p = 0.0111) were all predictive of greater proptosis reduction. On multivariable survival modeling, factors associated with increased hazard for secondary decompression include younger age (p = 0.0434), larger preoperative proptosis (p = 0.0001), unilateral decompression (p = 0.0272), preoperative steroid treatment (p = 0.0200), and normal thyroid function (p = 0.0148). Factors associated with decreased hazard include adjunctive fat decompression (p = 0.0004), balanced decompression (vs. lateral, p = 0.0039), and African-American ethnicity (p = 0.0076). CONCLUSIONS: Despite a diverse study cohort, the authors have identified factors associated with clinically relevant outcomes of decompression surgery for thyroid eye disease, including proptosis reduction and incidence of secondary decompression. Randomized controlled trials of different treatment algorithms for TED are needed to devise optimized guidelines for individualizing surgical care.

Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern(®) Guidelines.

UNLABELLED: COMPREHENSIVE ADULT MEDICAL EYE EVALUATION® PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern® (PPP) guidelines, discussing the rationale and components of an ophthalmic evaluation for adult patients with and without risk factors.

Assessing Geographic Variation in Strabismus Diagnosis among Children Enrolled in Medicaid.

PURPOSE: To determine how strabismus diagnosis varies within a given community and across communities among children with Medicaid health insurance. DESIGN: Retrospective cohort analysis. PARTICIPANTS: Children aged ≤10 years enrolled in Medicaid in Michigan or North Carolina during 2009. METHODS: Children who met the study inclusion criteria were identified from the Medicaid Analytic Extract database, which includes claims data for all children enrolled in Medicaid throughout the United States. Residential location was determined by the last known 5-digit ZIP code for each child, which was linked to the centroid of a ZIP Code Tabulation Area (ZCTA) for geo-referencing and spatial analyses. International Classification of Diseases, 9th Revision, Clinical Modification billing codes were used to identify children diagnosed with strabismus (code 378.xx). Bayesian hierarchical intrinsic conditional autoregressive spatial probit models were used to determine the risk of a child receiving a strabismus diagnosis in communities throughout Michigan and North Carolina. Maps display communities (ZCTAs) where the 95% credible intervals for the spatial random effects estimates do not cross zero, allowing for identification of locations with increased and decreased strabismus diagnosis risk relative to other communities in the states. MAIN OUTCOME MEASURES: Likelihood of receiving a diagnosis of strabismus. RESULTS: In 2009, among 519 212 eligible children in Michigan, 7535 (1.5%) received ≥1 strabismus diagnosis, and in North Carolina, 5827 of 523 886 eligible children (1.1%) were diagnosed with strabismus. In both states, the proportion receiving a strabismus diagnosis among black (0.9% in Michigan; 0.7% in North Carolina) and Hispanic (1.1% in Michigan; 0.8% in North Carolina) children was lower than the proportion for white children (1.8% in Michigan; 1.6% in North Carolina). Children living in poorer communities in both states were less likely to be diagnosed with strabismus independent of their race/ethnicity. CONCLUSIONS: A child's likelihood of being diagnosed with strabismus is associated with characteristics of the residential community where he or she resides. The findings of this study highlight the importance of ensuring that children who live in less affluent communities have access to the necessary services and eye care professionals to properly diagnose and treat them for this condition.

Evaluation of Screening for Retinopathy of Prematurity by ROPtool or a Lay Reader.

PURPOSE: To determine if (1) tortuosity assessment by a computer program (ROPtool, developed at the University of North Carolina, Chapel Hill, and Duke University, and licensed by FocusROP) that traces retinal blood vessels and (2) assessment by a lay reader are comparable with assessment by a panel of 3 retinopathy of prematurity (ROP) experts for remote clinical grading of vascular abnormalities such as plus disease. DESIGN: Validity and reliability analysis of diagnostic tools. PARTICIPANTS: Three hundred thirty-five fundus images of prematurely born infants. METHODS: Three hundred thirty-five fundus images of prematurely born infants were obtained by neonatal intensive care unit nurses. A panel of 3 ROP experts graded 84 images showing vascular dilatation, tortuosity, or both and 251 images showing no evidence of vascular abnormalities. These images were sent electronically to an experienced lay reader who independently graded them for vascular abnormalities. The images also were analyzed using the ROPtool, which assigns a numerical value to the level of vascular abnormality and tortuosity present in each of 4 quadrants or sectors. The ROPtool measurements of vascular abnormalities were graded and compared with expert panel grades with a receiver operating characteristic (ROC) curve. Grades between human readers were cross-tabulated. The area under the ROC curve was calculated for the ROPtool, and sensitivity and specificity were computed for the lay reader. MAIN OUTCOME MEASURES: Measurements of vascular abnormalities by ROPtool and grading of vascular abnormalities by 3 ROP experts and 1 experienced lay reader. RESULTS: The ROC curve for ROPtool's tortuosity assessment had an area under the ROC curve of 0.917. Using a threshold value of 4.97 for the second most tortuous quadrant, ROPtool's sensitivity was 91% and its specificity was 82%. Lay reader sensitivity and specificity were 99% and 73%, respectively, and had high reliability (κ, 0.87) in repeated measurements. CONCLUSIONS: ROPtool had very good accuracy for detection of vascular abnormalities suggestive of plus disease when compared with expert physician graders. The lay reader's results showed excellent sensitivity and good specificity when compared with those of the expert graders. These options for remote reading of images to detect vascular abnormalities deserve consideration in the quest to use telemedicine with remote reading for efficient delivery of high-quality care and to detect infants requiring bedside examination.