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.

Predicting the Prognosis of Fuchs Endothelial Corneal Dystrophy by Using Scheimpflug Tomography.

PURPOSE: To determine if Scheimpflug tomography pachymetry map and posterior elevation map patterns, central corneal thickness (CCT), and corneal backscatter can predict the prognosis of Fuchs endothelial corneal dystrophy (FECD). DESIGN: Cross-sectional study with follow-up of outcomes. PARTICIPANTS: Ninety-six eyes (56 subjects) with a range of severity of FECD. METHODS: Corneas were graded by cornea specialists according to the area and confluence of guttae and the presence of clinically definite edema. Masked and randomized Scheimpflug imaging pachymetry map and posterior elevation map patterns were assessed by 1 observer for loss of regular isopachs, displacement of the thinnest point of the cornea, and the presence of posterior surface depression. The prognosis of eyes over a 5-year (median) follow-up period was determined based on FECD progression (new onset of clinically definite edema or ≥5% increase in CCT) or intervention by endothelial keratoplasty. Cumulative probabilities of progression and intervention were estimated from survival analyses, with risk factors determined by using Cox proportional hazards models. MAIN OUTCOME MEASURES: Pachymetry map and posterior elevation map patterns, corneal backscatter, and CCT (ultrasonic pachymetry). RESULTS: In univariate analyses, loss of regular isopachs (hazard ratio [HR], 18.00) displacement of the thinnest point (HR, 11.53), focal posterior surface depression (HR, 10.21), and anterior corneal backscatter (HR, 1.22, per 1-grayscale unit increment), were risk factors for progression or intervention (P < 0.001), whereas CCT (HR, 1.30, per 25-µm increment) was not (P = 0.15). In multivariate analyses, loss of regular isopachs (HR, 11.57; P < 0.001) and displacement of the thinnest point (HR, 5.61; P = 0.02) were independent and clinically important risk factors for progression and intervention. The 5-year cumulative risk of disease progression and intervention was 7%, 48%, and 89% when none, 1 or 2, and all 3 pachymetry map and posterior elevation map parameters were present, respectively (P <0.001). The 4-year cumulative risk of disease progression and intervention after uncomplicated cataract surgery was 0%, 50%, and 75% when none, 1 or 2, and all 3 pachymetry map and posterior elevation map parameters were present, respectively (P < 0.001). CONCLUSIONS: Three Scheimpflug tomography pachymetry map and posterior elevation map patterns can predict FECD prognosis independent of CCT. The risk of FECD progression and intervention, including after uncomplicated cataract surgery, increases according to the number of parameters present.

Non-contact tests for identifying people at risk of primary angle closure glaucoma.

BACKGROUND: Primary angle closure glaucoma (PACG) accounts for 50% of glaucoma blindness worldwide. More than three-quarters of individuals with PACG reside in Asia. In these populations, PACG often develops insidiously leading to chronically raised intraocular pressure and optic nerve damage, which is often asymptomatic. Non-contact tests to identify people at risk of angle closure are relatively quick and can be carried out by appropriately trained healthcare professionals or technicians as a triage test. If the test is positive, the person will be referred for further specialist assessment. OBJECTIVES: To determine the diagnostic accuracy of non-contact tests (limbal anterior chamber depth (LACD) (van Herick test); oblique flashlight test; scanning peripheral anterior chamber depth analyser (SPAC), Scheimpflug photography; anterior segment optical coherence tomography (AS-OCT), for identifying people with an occludable angle. SEARCH METHODS: We searched the following bibliographic databases 3 October 2019: CENTRAL; MEDLINE; Embase; BIOSIS; OpenGrey; ARIF and clinical trials registries. The searches were limited to remove case reports. There were no date or language restrictions in the searches. SELECTION CRITERIA: We included prospective and retrospective cross-sectional, cohort and case-control studies conducted in any setting that evaluated the accuracy of one or more index tests for identifying people with an occludable angle compared to a gonioscopic reference standard. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and quality assessment using QUADAS2 for each study. For each test, 2 x 2 tables were constructed and sensitivity and specificity were calculated. When four or more studies provided data at fixed thresholds for each test, we fitted a bivariate model using the METADAS macro in SAS to calculate pooled point estimates for sensitivity and specificity. For comparisons between index tests and subgroups, we performed a likelihood ratio test comparing the model with and without the covariate. MAIN RESULTS: We included 47 studies involving 26,151 participants and analysing data from 23,440. Most studies were conducted in Asia (36, 76.6%). Twenty-seven studies assessed AS-OCT (analysing 15,580 participants), 17 studies LACD (7385 participants), nine studies Scheimpflug photography (1616 participants), six studies SPAC (5239 participants) and five studies evaluated the oblique flashlight test (998 participants). Regarding study quality, 36 of the included studies (76.6%) were judged to have a high risk of bias in at least one domain.The use of a case-control design (13 studies) or inappropriate exclusions (6 studies) raised patient selection concerns in 40.4% of studies and concerns in the index test domain in 59.6% of studies were due to lack of masking or post-hoc determination of optimal thresholds. Among studies that did not use a case-control design, 16 studies (20,599 participants) were conducted in a primary care/community setting and 18 studies (2590 participants) in secondary care settings, of which 15 investigated LACD. Summary estimates were calculated for commonly reported parameters and thresholds for each test; LACD ≤ 25% (16 studies, 7540 eyes): sensitivity 0.83 (95% confidence interval (CI) 0.74, 0.90), specificity 0.88 (95% CI 0.84, 0.92) (moderate-certainty); flashlight (grade1) (5 studies, 1188 eyes): sensitivity 0.51 (95% CI 0.25, 0.76), specificity 0.92 (95% CI 0.70, 0.98) (low-certainty); SPAC (≤ 5 and/or S or P) (4 studies, 4677 eyes): sensitivity 0.83 (95% CI 0.70, 0.91), specificity 0.78 (95% CI 0.70, 0.83) (moderate-certainty); Scheimpflug photography (central ACD) (9 studies, 1698 eyes): sensitivity 0.92 (95% CI 0.84, 0.96), specificity 0.86 (95% CI 0.76, 0.93) (moderate-certainty); AS-OCT (subjective opinion of occludability) (13 studies, 9242 eyes): sensitivity 0.85 (95% CI 0.76, 0.91); specificity 0.71 (95% CI 0.62, 0.78) (moderate-certainty). For comparisons of sensitivity and specificity between index tests we used LACD (≤ 25%) as the reference category. The flashlight test (grade 1 threshold) showed a statistically significant lower sensitivity than LACD (≤ 25%), whereas AS-OCT (subjective judgement) had a statistically significant lower specificity. There were no statistically significant differences for the other index test comparisons. A subgroup analysis was conducted for LACD (≤ 25%), comparing community (7 studies, 14.4% prevalence) vs secondary care (7 studies, 42% prevalence) settings. We found no evidence of a statistically significant difference in test performance according to setting. Performing LACD on 1000 people at risk of angle closure with a prevalence of occludable angles of 10%, LACD would miss about 17 cases out of the 100 with occludable angles and incorrectly classify 108 out of 900 without angle closure. AUTHORS' CONCLUSIONS: The finding that LACD performed as well as index tests that use sophisticated imaging technologies, confirms the potential for this test for case-detection of occludable angles in high-risk populations. However, methodological issues across studies may have led to our estimates of test accuracy being higher than would be expected in standard clinical practice. There is still a need for high-quality studies to evaluate the performance of non-invasive tests for angle assessment in both community-based and secondary care settings.

Number, frequency and time interval of examinations under anesthesia in bilateral retinoblastoma.

PURPOSE: Current practice in retinoblastoma (Rb) has transformed this malignancy into a curable disease. More attention should therefore be given to quality of life considerations, including measures related to examinations under anesthesia (EUAs). We aimed to investigate EUA measures in bilateral Rb patients and compare the findings to EUAs in unilateral Rb. METHODS: A retrospective analysis of bilateral Rb patients that presented to the London Rb service from 2006 to 2013, were treated and had long-term follow-up. RESULTS: A total of 62 Rb patients, 15 (24.2%) of which had International Intraocular Retinoblastoma Classification (IIRC) group A/B/no Rb at presentation, 26 (41.9%) C/D, and 21 (33.9%) were E in at least one eye. The mean number of EUAs was 35.8 ± 21.5, mean time from first to last EUA was 50.6 ± 19.9 months, and mean EUA frequency was 0.715 ± 0.293 EUAs/month. IIRC group was found not to correlate with any of the EUA measures. Age at presentation inversely correlated with time interval from first to last EUA and to EUA frequency (p ≤ 0.029). Rb family history correlated with the latter measure (p = 0.005) and intraophthalmic artery chemotherapy and brachytherapy correlated with all EUA measures (p ≤ 0.029). Mean follow-up time was 80.1 ± 24.3 months. When compared with a previously reported cohort of unilateral Rb, the present group underwent 3× more EUAs (p < 0.001) over nearly double the time (p < 0.001). CONCLUSIONS: Families should be counselled on anticipated EUA burden associated with bilateral Rb. In this respect, age at presentation and family history were found to have a predictive role, whereas IIRC group did not.

Transcultural validation of the 5-Item Dry Eye Questionnaire for the Mexican population.

PURPOSE: To translate and validate a Spanish-language adaptation of the 5-Item Dry Eye Questionnaire for the Mexican population. METHODS: Based on the MAPI Institute guidelines, the linguistic validation procedures consisted of four steps. Every step was reviewed by the committee. The translated validated questionnaire was applied to 25 Mexican subjects. The questionnaires were completed by the same subjects at three time points, 8 h apart on the same day and then 3 days later. Sensitivity and specificity of the DEQ-5 to predict DE signs was subsequently estimated in 200 patients see in the Asociación para Evitar la Ceguera ophthalmology clinic. RESULTS: During the forward translation step analysis, the committee decided to change the severity scale, as the words "constantly" and "frequently" are synonymous in Spanish, so it was modified by changing "constantly" to "always" for better understanding. Overall, the intra-test intra-class correlation coefficient from tests administered on the same day was 0.9 (95% CI 0.77-0.95, p = 0.0005). The intra-test intra-class correlation coefficient from tests administered 3 days apart was 0.9 (95% CI 0.88-0.97, p = 0.0005). When applying the questionnaire to 200 patients seen in an eye clinic, we found a sensitivity of 76% and a specificity of 31% for a DEQ-5 score of ≥ 6, against 2 or more positive signs of dry eye. CONCLUSION: MAPI methodology proved to be a reliable strategy for the transcultural Dry Eye Questionnaire for translation from English to Spanish for the Mexican population.

Routine colonoscopy, diabetic eye care, mammogram and pap smear screening in vascular surgery patients.

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

Survey of Ophthalmologists Regarding Practice Patterns for Dry Eye and Sjogren Syndrome.

OBJECTIVE: To survey ophthalmologists about current practice patterns regarding the evaluation of dry eye patients and referrals for a Sjogren syndrome (SS) workup. METHODS: An online survey was sent to ophthalmologists affiliated with the Scheie Eye Institute or Wills Eye Hospital using REDCap in August 2015. Descriptive statistics were used to summarize the data. RESULTS: Four hundred seventy-four survey invitations were sent out and 101 (21%) ophthalmologists completed the survey. The common traditional dry eye test performed was corneal fluorescein staining (62%) and the most common newer dry eye test performed was tear osmolarity (18%). Half of respondents (51%) refer fewer than 5% of their dry eye patients for SS workups, with 18% reporting that they never refer any patients. The most common reasons for referrals included positive review of systems (60%), severe dry eye symptoms (51%) or ocular signs (47%), or dry eye that is refractory to treatment (42%). The majority (83%) felt that there is a need for an evidence-based standardized screening tool for dry eye patients to decide who should be referred for evaluation for SS. CONCLUSIONS: Ophthalmologists continue to prefer the use of traditional dry eye tests in practice, with the most common test being corneal fluorescein staining. There is an underreferral of dry eye patients for SS workups, which is contributing to the continued underdiagnosis of the disease. Most respondents felt that there was a need for an evidence-based standardized screening tool to decide which dry eye patients should be referred for SS evaluations.

Lack of consensus on consensual response.

The pupillary light reflex (PLR) is a routinely utilized clinical test to quickly assess integrity of subcortical light perception pathways in patients. While interpretation is simple for ophthalmologists, interestingly discrepancy occurs in annotation of the test results, especially for the consensual response. An email survey sent to diplomates of either the American or European Colleges of Veterinary Ophthalmologists (ACVO and ECVO, respectively), requesting use of a 'direct/consensual' annotation convention, showed 58% of respondents preferred one convention while 39% preferred a different convention. The majority preferred convention was different between ACVO and ECVO respondents. Standardization of PLR annotation convention across specialists is recommended for clarity in medical record keeping and communication among colleagues.

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.

[A 20-year prospective follow-up study to evaluate the development of retinopathy and nephropathy after the onset of type 1 diabetes mellitus: Contribution of glycemic control and metabolic memory]. / Prospektivnoe 20-letnee nabliudenie, otsenivaiushchee razvitie retinopatii i nefropatii ot momenta debiuta sakharnogo diabeta 1-go tipa: vklad kontrolia glikemii i 'metabolicheskoi pamiati'.

AIM: To assess the time course of changes in the level of glycated hemoglobin (HbA1c) for 20 years after the onset of type 1 diabetes mellitus (T1DM) and to compare its correlation with the development of microvascular complications, such as diabetic retinopathy (DR) and diabetic nephropathy (DN). SUBJECTS AND METHODS: A total of 187 children with new-onset T1DM were registered in Moscow in 1994. During the 20-year follow-up study, these patients underwent regular check-ups at the Endocrinology Research Center, Ministry of Health of the Russian Federation, which included assessment of physical data, HbA1c 2-4 times a year, biochemical blood and albuminuria tests (once per year), and ophthalmologic examination (twice a year). A total of 155 people fully completed the 20-years follow-up study. RESULTS: During the 20-year follow-up period after the onset of T1DM, 86 of the 155 patients developed microvascular complications: DR and DN in 86 (55.5%) and 24 (15.5%) cases, respectively; while DR concurrent with DN were noted in 20 patients. By the time of their last visit, 69 (44.5%) patients had no evidence suggesting the presence of microvascular complications. The level of HbA1c at the onset of the disease in patients who later developed the complications was higher than in those without complications (10.2±0.6 and 8.5±0.2%, respectively (p = 0.003). The statistically significant differences in HbA1c levels between the groups persisted during subsequent 15 years of follow-up, averaging 9.2±1.5, 9.7±0.9, and 8.1±0.7% after 5, 10, and 15 years, respectively, in the complication group and 7.1±0.3, 8.1±0.4, and 7.2±0.2% in the non-complication group (p < 0.01). Over the last 5 years of the follow-up, the mean HbA1c level between the groups was not significantly different, which at the end of the 20-year follow-up period was 7.8±0.3 and 7.4±0.6%, respectively (p > 0.05). The mean duration of T1DM, in which DR developed, was 9.6±6.2, 11.0±2.0, and 13.6±4.6 years for the non-proliferative, pre-proliferative, and proliferative stages, respectively. That of T1DM, in which DN developed, was 11.8±0.6 years for microalbuminuria and 16.1±1.3 years for macroalbuminuria. CONCLUSION: The 20-year clinical follow-up of patients who had fallen ill with T1DM in childhood showed that diabetic microangiopathies developed with the long-term preservation of poor blood glucose control (BGC) starting at the onset of the disease. At the same time, the complications progressed to more severe stages, despite a clear trend toward better BGC. This may be suggestive of the negative metabolic memory phenomenon, which necessitates stable BGC, starting at the onset of the disease, for the prevention of microvascular complications.

Geographic Variation in the Use of Diagnostic Testing of Patients with Newly Diagnosed Open-Angle Glaucoma.

PURPOSE: To determine the extent of geographic variation in the proportion of patients with newly diagnosed open-angle glaucoma (OAG) undergoing visual field (VF) testing, fundus photography (FP), and other ocular imaging (OOI) among patients residing in different US communities. DESIGN: Retrospective, longitudinal cohort study. PARTICIPANTS: All enrollees with newly diagnosed OAG enrolled in a managed care network between 2001 and 2014. METHODS: We identified all persons in the plan with incident OAG residing in 201 communities across the United States. All communities contributed ≥20 enrollees. The proportion of enrollees undergoing ≥1 VF test, FP, OOI, and no testing of any type in the 2 years after first OAG diagnosis was determined for each community, and comparisons were made to assess the extent of variation in use of diagnostic testing among patients residing in the different communities. MAIN OUTCOME MEASURES: Receipt of VF testing, FP, OOI, or none of these tests in the 2 years after initial OAG diagnosis. RESULTS: Of the 56675 enrollees with newly diagnosed OAG, the mean proportion of patients undergoing VF testing within 2 years of initial diagnosis was 74%±7%, ranging from as low as 51% in Rochester, Minnesota, to as high as 95% in Lancaster, Pennsylvania. The mean proportion undergoing OOI was 63%±10% and varied from 34% in Palm Springs/Rancho Mira, California, to 85% in Charleston, South Carolina. The mean proportion receiving FP was 26%±10% and ranged from as low as 3% in Fresno, California, to as high as 57% in Harlingen, Texas. The proportion undergoing no glaucoma testing ranged from 0% in Binghamton, New York, to as high as 35% in 2 other communities. CONCLUSIONS: In many US communities, a high proportion of patients are undergoing testing according to established practice guidelines. However, in several communities, less than 60% of patients with newly diagnosed OAG are undergoing VF testing in the 2 years after initial OAG diagnosis, and in a few communities >1 in 4 patients have no record of glaucoma diagnostic testing of any type. Additional research is needed to understand factors driving this variation in practice patterns and its impact on patient outcomes.

Knowledge, Beliefs and Practices of Patients with Diabetic Retinopathy at the University Hospital of the West Indies, Jamaica.

To determine the knowledge, beliefs and practices of patients with diabetic retinopathy attending the Retina Eye Clinic at the University Hospital of the West Indies. A prospective study was done using a questionnaire with a sample population of 150 patients. The questions included their knowledge about the frequency of their eye examination, the relevance of exercise and a healthy diet, the role of the ophthalmologist and their views on the importance of compliance with medications for diabetes and hypertension. One hundred and fifty patients were recruited. Sixty six percent (99/150) were females and 34 % (51/150) males. The ages ranged from 29 to 83 years (mean ± SD, 56.1 ± 10.3) years. Type II diabetes was more common; 63 and 79 % of females and males respectively. A minority (19.8 %) obtained tertiary education. The mean % knowledge scores were 86 ± 14 for males and 82.8 ± 16.4 for females (p = 0.260). Prior to attending the retina clinic, 50 % were unaware of the need for annual eye examinations. Compliance with medication, exercise and a special diet was seen in 73, 40.3 and 49.7 % respectively. Current knowledge scores were good. However, knowledge about the timing and frequency of eye examinations prior to attending the retina clinic was inadequate. Correct knowledge and beliefs did not correspond to a high level of compliant practices.

Determinants of Eye Care Utilization in Rural South-eastern Nigeria.

To determine the barriers and incentives to eye care utilization (ECU) in Abagana, a rural south-eastern Nigerian community. The study was a population-based cross-sectional mixed method (quantitative and qualitative) survey of adult inhabitants of Abagana, in July-August, 2011. Data on respondents' socio-demographics, barriers and incentives to ECU were collected, and analysed using descriptive and comparative statistics. A p < 0.05 was considered statistically significant. Qualitative data were obtained from focus group discussions and in-depth interviews and analyzed using ATLAS.ti software. The 549 respondents (males 224) were aged 49.8 ± 15.9 SD years (range 18-93 years). Overall, orthodox eye care had ever been sought by 42.4%, and 46.4% of those who reported change in vision. Lack of awareness-31.8%, cost-18.0%, and fatalistic attitudes-15.9% were the main ECU barriers. Possession of health insurance (OR 11.49; 95% CI 4.21-31.34; p = 0.001), family history of eye disorder (OR 3.27, 95% CI 2.03-5.26; p = 0.001), noticed change in vision (OR 11.30; 95% CI 1.42-90.09; p = 0.022), current eye disease (OR 4.06; 95% CI 2.29-7.19; p = 0.001) and systemic co-morbidity (OR 4.33; 95% CI 2.67-7.02; p = 0.001) were the incentives to ECU. To enhance the low ECU in Abagana community, educational interventions on eye health maintenance and eye health seeking behaviours, and measures to reduce eye care cost are recommended.

A survey of current and anticipated use of standard and specialist equipment by UK optometrists.

PURPOSE: To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT. METHODS: An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members. RESULTS: Four hundred and thirty-two responses were received (response rate = 35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12 months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern. CONCLUSION: UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.

Pegylated interferon-associated retinopathy is frequent in hepatitis C virus patients with hypertension and justifies ophthalmologic screening.

UNLABELLED: Treatment with pegylated interferon alpha (PegIFNα) and ribavirin is still regarded as the standard of care for chronic hepatitis C virus (HCV). Retinopathy has been occasionally described but prospective, longitudinal data are lacking. We investigated the frequency and clinical significance of retinopathy during therapy with PegIFNα and ribavirin in 97 consecutive HCV patients. In all, 54 (55.7%) and 43 (44.3%) patients were treated with PegIFNα 2a and PegIFNα 2b, respectively. Ophthalmologic examination was performed before therapy (baseline), at 3 and 6 months (3T and 6T, respectively) of therapy, and 3 months after the end of therapy (3ET). All patients underwent the baseline and 3T examination, 95.9% and 90.7% of patients underwent 6T and 3ET examination, respectively. Overall, 30.9% of patients developed retinopathy, as defined by the presence of cotton wool spots and/or retinal hemorrhages. Variables significantly associated with retinopathy during treatment were age (P = 0.004), metabolic syndrome (P = 0.05), hypertension (P < 0.0001), cryoglobulinemia (P = 0.05), and preexisting intraocular lesions at baseline (P = 0.01). By multivariate analysis, the only variable independently associated with PegIFNα-associated retinopathy was hypertension (hazard ratio [HR] = 4.99, 95% confidence interval [CI] 2.29-10.89). The frequency of retinopathy was significantly higher in hypertensive patients versus those without hypertension at all timepoints (18.5% versus 5.7% at baseline, P = 0.05; 48.1% versus 15.7% at 3T, P = 0.0009; 68.0% versus 19.1% at 6T, P < 0.0001; 32.0% versus 6.2%, P = 0.0005 at 3ET). In one (1.1%) hypertensive patient, who developed bilateral branch retinal vein occlusion at 6T, the therapy was discontinued. A cost analysis showed that screening for PegIFNα-associated retinopathy was cost-effective as compared with thyroid-stimulating hormone screening. CONCLUSION: Retinopathy is frequent during treatment with PegIFNα and ribavirin, especially in hypertensive patients, who may develop serious complications. Screening for PegIFNα-associated retinopathy should be recommended for HCV patients with hypertension.

Comparison of standardized clinical classification with fundus photograph grading for the assessment of diabetic retinopathy and diabetic macular edema severity.

PURPOSE: To compare evaluation by clinical examination with image grading at a reading center for the classification of diabetic retinopathy and diabetic macular edema. METHODS: Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Family Investigations of Nephropathy in Diabetes (FIND) had similar methods of clinical and fundus photograph evaluation. For analysis purposes, the photographic grading scales were condensed to correspond to the clinical scales, and agreement between clinicians and reading center classification were compared. RESULTS: Six thousand nine hundred and two eyes of ACCORD participants and 3,638 eyes of FIND participants were analyzed for agreement (percent, kappa) on diabetic retinopathy on a 5-level scale. Exact agreement between clinicians and reading center on diabetic retinopathy severity category was 69% in ACCORD and 74% in FIND (kappa 0.42 and 0.65). Sensitivities of the clinical grading to identify the presence of mild nonproliferative retinopathy or worse were 0.53 in ACCORD and 0.84 in FIND. Specificities were 0.97 and 0.96, respectively. Diabetic macular edema agreement in 6,649 eyes of ACCORD participants and 3,366 eyes of FIND participants was similar (kappa 0.35 and 0.41). Sensitivities of the clinical grading to identify diabetic macular edema were 0.44 and 0.53 and specificities were 0.99 and 0.94, respectively. CONCLUSION: The results support the use of clinical information for defining broad severity categories but not for documenting small-to-moderate changes in diabetic retinopathy over time.

Self-reported racial discrimination in health care and diabetes outcomes.

BACKGROUND: Self-reported racial discrimination in healthcare has been associated with negative health outcomes, but little is known about its association with diabetes outcomes. METHODS: We used data from the Behavioral Risk Factor Surveillance System to investigate associations between self-reported healthcare discrimination and the following diabetes outcomes: (1) quality of care, (2) self-management and (3) complications. RESULTS: In unadjusted logistic regression models, significant associations were found between self-reported healthcare discrimination and most measures of quality of care [diabetes-related primary care visits odds ratio (OR), 0.38; 95% confidence interval (CI), 0.21-0.66), HbA1c testing (OR, 0.42; 95%CI, 0.21-0.82), and earlier eye examination interval (OR, 0.48; 95% CI, 0.24-0.93)] and health outcomes [foot disorders (OR, 2.32, 95%CI: 1.15, 4.68) and retinopathy (OR, 2.26; 95%CI, 1.24-4.12)], but not the number of provider foot examinations (P=0.48) or diabetes self-management (self glucose monitoring, P=0.42; self foot examinations, P=0.74; diabetes class participation, P=0.37). The effects of self-reported discrimination were attenuated or eliminated after controlling for sociodemographics, health status, and access to care. CONCLUSIONS: Self-reported racial/ethnic discrimination in healthcare was associated with worse diabetes care and more diabetes complications, but not self-care behaviors, suggesting that factors beyond patients' own behaviors may be the main source of differential outcomes. The relationships between self-reported discrimination and diabetes outcomes were eliminated once adjusting for sociodemographics, health status, and access to care. Our findings suggest that other factors (ie, race, insurance, health status) may play equally or more important roles in determining diabetes health disparities, and that a comprehensive strategy is needed to effectively address health disparities.

Reasons for not seeking eye care among adults aged ≥40 years with moderate-to-severe visual impairment--21 States, 2006-2009.

In 2000, an estimated 3.4 million U.S. residents aged ≥40 years were blind or visually impaired. Vision problems place a substantial burden on individuals, caregivers, health-care payers, and the U.S. economy, with the total cost estimated at $51.4 billion annually. Although regular comprehensive eye examinations are essential for timely treatment of eye disease to maintain vision health, a previous study has shown that substantial percentages of persons do not seek eye care, despite having visual impairment. To ascertain why adults aged ≥40 years with moderate-to-severe visual impairment did not seek eye care in the preceding year, CDC analyzed data for 21 states from 2006-2009 Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which found that eye-care cost or lack of insurance (39.8%) and perception of no need (34.6%) were the most common reasons given for not seeking eye care. Among those aged 40-64 years, cost or lack of health insurance was the most common reason (42.8%); among those aged ≥65 years, the most common reason was no need (43.8%). Identifying the reasons for unmet eye-care needs might enable development of targeted interventions to improve vision health among those with moderate-to-severe visual impairment.