Relationship Between Blood Pressure and Rates of Glaucomatous Visual Field Progression: The Vascular Imaging in Glaucoma Study.

PURPOSE: To examine the relationship between systemic arterial blood pressure (BP) and the rate of change in standard automated perimetry (SAP) in eyes with glaucoma and glaucoma suspects. DESIGN: Prospective cohort study. PARTICIPANTS: 124 eyes (91 glaucoma, 33 suspects) of 64 subjects (mean age 68.4±7.6 years) followed at the Bascom Palmer Eye Institute, Palm Beach Gardens, FL. METHODS: Participants underwent ophthalmic examination, BP measurement, and SAP at 4-month intervals. 24-hour ambulatory blood pressure monitoring (ABPM) was acquired at the baseline visit. Linear mixed models (adjusted for inclusion of both eyes, age, gender, race, intraocular pressure, baseline severity, and central corneal thickness) were used to investigate the effect of BP on the rates of SAP mean deviation (MD) change over time. MAIN OUTCOME MEASURES: Effect of baseline 24-hour and follow-up mean arterial (MAP), systolic (SBP), and diastolic blood pressure (DBP) on change in SAP MD. RESULTS: Eyes had an average of 8.9±1.5 SAP exams over 28.3±6.0 months of follow-up. The median rate of MD change was 0.14dB/year (range -1.21 to 0.96dB/year) with 9 (7%) eyes presenting moderate to fast progression (MD change ≤ -0.50 dB/year). Each 10mmHg lower in 24-hour average MAP and SBP were associated with -0.171 dB/year (P=0.045) and -0.137 dB/year (P=0.023) faster rates of MD loss. Lower mean SBP during follow up was significantly (P = 0.003) associated with MD progression. CONCLUSIONS: Lower baseline 24-hour ABPM measurements, as well as low SBP during follow-up, were significantly associated with faster rates of glaucomatous SAP progression and may be used as a predictor of risk of glaucomatous progression.

A Hybrid Deep Learning Classification of Perimetric Glaucoma Using Peripapillary Nerve Fiber Layer Reflectance and Other OCT Parameters from Three Anatomy Regions.

Précis: A hybrid deep-learning model combines NFL reflectance and other OCT parameters to improve glaucoma diagnosis. Objective: To investigate if a deep learning model could be used combine nerve fiber layer (NFL) reflectance and other OCT parameters for glaucoma diagnosis. Patients and Methods: This is a prospective observational study where of 106 normal subjects and 164 perimetric glaucoma (PG) patients. Peripapillary NFL reflectance map, NFL thickness map, optic head analysis of disc, and macular ganglion cell complex thickness were obtained using spectral domain OCT. A hybrid deep learning model combined a fully connected network (FCN) and a convolution neural network (CNN) to develop to combine those OCT maps and parameters to distinguish normal and PG eyes. Two deep learning models were compared based on whether the NFL reflectance map was used as part of the input or not. Results: The hybrid deep learning model with reflectance achieved 0.909 sensitivity at 99% specificity and 0.926 at 95%. The overall accuracy was 0.948 with 0.893 sensitivity and 1.000 specificity, and the AROC was 0.979, which is significantly better than the logistic regression models (p < 0.001). The second best model is the hybrid deep learning model w/o reflectance, which also had significantly higher AROC than logistic regression models (p < 0.001). Logistic regression with reflectance model had slightly higher AROC or sensitivity than the other logistic regression model without reflectance (p = 0.024). Conclusions: Hybrid deep learning model significantly improved the diagnostic accuracy, without or without NFL reflectance. Hybrid deep learning model, combining reflectance/NFL thickness/GCC thickness/ONH parameter, may be a practical model for glaucoma screen purposes.

A Gateway Framework to Guide Major Health System Changes Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

Recent events - on both a global scale and within individual countries - including the lockdowns associated with COVID-19 pandemic, inflation concerns, and political tensions, have increased pressure to reconfigure social services for ongoing sustainability. Healthcare services across the world are undergoing major system change (MSC). Given the complexity and different contextual drivers across healthcare systems, there is a need to use a variety of perspectives to improve our understanding of the processes for MSC. To expand the knowledge base and develop strategies for MSC requires analysing change projects from different perspectives to distil the elements that drove the success. We offer the Gateway Framework as a collaborative transformational system tool to assess and reorganise operations, services, and systems of healthcare organisations. This framework and guiding questions, accounts for past events whilst being proactive, future orientated, and derived from externally defined and a standardised requirements to promote safe, high-quality care.

Acute serous and hemorrhagic choroidal effusion associated with topical dorzolamide therapy.

Purpose: To report a case of acute onset unilateral hemorrhagic and serous choroidal effusion associated with dorzolamide administration and antiplatelet use that recurred in a patient who experienced a dorzolamide-induced choroidal effusion ten years prior to presentation. Observations: A 78-year-old male with a history of POAG in both eyes presented with sudden onset decreased vision and flashes of light in the left eye two days after escalating from timolol maleate 0.5% twice daily in both eyes to fixed combination dorzolamide-timolol 22.3-6.8 mg/mL twice daily in both eyes. Systemic medication included daily aspirin 81 mg for primary prevention of cardiovascular disease. Dilated fundus examination and B-scan ultrasound of the left eye revealed a hemorrhagic choroidal effusion in the nasal retinal periphery and low lying serous choroidal effusion in the temporal periphery. Complete resolution of the choroidal detachment was achieved in four days following prompt cessation of dorzolamide, and treatment with topical prednisolone acetate 1% four times daily and atropine 1% two times daily. Conclusions and importance: Topical dorzolamide may induce an idiosyncratic reaction leading to serous and hemorrhagic choroidal effusion, which can be exacerbated by antiplatelet use. Prompt recognition and management of drug-induced choroidal effusion can lead to improved visual outcomes and prevent long-term sequelae.

Direct Costs of Second Aqueous Shunt Implant Versus Transscleral Cyclophotocoagulation (The Assists Trial).

PRCIS: The cost of cyclophotocoagulation is less than the cost of a second glaucoma drainage device. PURPOSE: To compare the total direct costs of implantation of a second glaucoma drainage device (SGDD) with transscleral cyclophotocoagulation (CPC) for patients with inadequately controlled intraocular pressure (IOP) reduction, despite the presence of a preexisting glaucoma drainage device in the ASSISTS clinical trial. METHODS: We compared the total direct cost per patient, including the initial study procedure, medications, additional procedures, and clinic visits during the study period. The relative costs for each procedure during the 90-day global period and the entire study period were compared. The cost of the procedure, including facility fees and anesthesia costs, were determined using the 2021 Medicare fee schedule. Average wholesale prices for self-administered medications were obtained from AmerisourceBergen.com. The Wilcoxon rank sum test was used to compare costs between procedures. RESULTS: Forty-two eyes of 42 participants were randomized to SGDD (n=22) or CPC (n=20). One CPC eye was lost to follow-up after initial treatment and was excluded. The mean (±SD, median) duration of follow-up was 17.1 (±12.8, 11.7) months and 20.3 (±11.4, 15.1) months for SGDD and CPC, respectively ( P =0.42, 2 sample t test). The mean total direct costs (±SD, median) per patient during the study period were $8790 (±$3421, $6805 for the SGDD group) and $4090 (±$1424, $3566) for the CPC group ( P <0.001). Similarly, the global period cost was higher in the SGDD group than in the CPC group [$6173 (±$830, $5861) vs. $2569 (±$652, $2628); P <0.001]. The monthly cost after the 90-day global period was $215 (±$314, $100) for SGDD and $103 (±$74, $86) for CPC ( P =0.31). The cost of IOP-lowering medications was not significantly different between groups during the global period ( P =0.19) or after the global period ( P =0.23). CONCLUSION: The total direct cost in the SGDD group was more than double that in the CPC group, driven largely by the cost of the study procedure. The costs of IOP-lowering medications were not significantly different between groups. When considering treatment options for patients with a failed primary GDD, clinicians should be aware of differences in costs between these treatment strategies.

Implementing health system improvement: resources and strategies for interprofessional teams.

Health system improvement (HSI) is focused on systematic changes to organisational processes and practices to improve the efficient delivery of safe care and quality outcomes. Guidelines that specify how interprofessional teams conduct HSI and knowledge translation are needed. We address this urgent requirement providing health professional teams with resources and strategies to investigate, analyse and implement system-level improvements. HSI encompasses similar, yet different, inter-related activities across a continuum. The continuum spans three categories of activities, such as quality improvement, health management research and translational health management research. A HSI decision making guide and checklist, comprising six-steps, is presented that can be used to select and plan projects. This resource comprises six interconnected steps including, defining the activity, project outcome, aim, use of evidence, appropriate methodology and implementation plan. Each step has been developed focusing on an objective, actions and resources. HSI activities provide a foundation for interprofessional collaboration, allowing multiple professions to create, share and disseminate knowledge for improved healthcare. When planned and executed well, HSI projects assist clinical and corporate staff to make evidence-informed decisions and directions for the benefit of the service, organisation and sector.