Incident glaucoma and ocular hypertension after periocular and intravitreal steroid injections: a claims-based analysis.

BACKGROUND/AIMS: This study aims to determine the incidence and risk of open-angle glaucoma or ocular hypertension (OHT) following ocular steroid injections using healthcare claims data. METHODS: We retrospectively reviewed deidentified insurance claims data from the IBM MarketScan Database to identify 19 156 adult patients with no prior history of glaucoma who received ocular steroid injections between 2011 and 2020. Patient demographics and steroid treatment characteristics were collected. Postinjection glaucoma/OHT development was defined as a new diagnosis of glaucoma/OHT, initiation of glaucoma drops, and/or surgical or laser glaucoma treatment. Cox proportional hazards models were used to determine the risk of glaucoma/OHT development within 5 years after first steroid injection. RESULTS: Overall, 3932 (20.5%) patients were diagnosed with new glaucoma/OHT, 3345 (17.5%) started glaucoma drops and 435 (2.27%) required a laser or surgical glaucoma procedure within 5 years of first steroid injection. Triamcinolone subconjunctival injections were associated with a lower risk of glaucoma/OHT development than retrobulbar or intravitreal steroid injections (p<0.001, HR 0.68, 95% CI 0.59 to 0.79), whereas the 0.59 mg fluocinolone acetonide intravitreal implant had the highest risk of glaucoma/OHT development (p=0.001, HR 2.01, 95% CI 1.34 to 3.02). The risk of glaucoma/OHT development was also higher for patients receiving multiple steroid injections (p<0.001), with the largest increase in risk occurring after three total steroid injections. CONCLUSION: Patients receiving ocular steroid injections are at risk of developing glaucoma/OHT, even with no prior glaucoma/OHT diagnosis or treatment. Patients should be closely monitored for the development of glaucoma following ocular steroid injections, particularly in the setting of intravitreal and/or repeated steroid administration.

Perceptions of Respect From Clinicians by Patients in Racial and Ethnic Minority Groups With Eye Disease.

IMPORTANCE: The perception of being treated with respect by clinicians may be a driver of disparities in individuals in racial and ethnic minoritie groups with eye diseases. Understanding these drivers may help identify potential interventions to reduce eye health disparities to prevent vision loss and blindness. OBJECTIVE: To evaluate the association between racial and ethnic minority status and the perception of being treated with respect by clinicians. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis of a nationally representative cohort study using data from the National Health Interview Survey (NHIS) included participants in the 2017 survey with complete data on outcomes, associated factors, and covariates. Data analysis took place from January 2021 to February 2021. Using a population-based survey conducted in the US in 2017 by the US census bureau on behalf of the National Center for Health Statistics, NHIS study participants (age ≥18 years) who self-reported having an eye disease (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included, and patients who self-reported as Black, Asian, other/multiple races, or Hispanic ethnicity were considered to be in racial and ethnic minority groups. MAIN OUTCOMES AND MEASURES: Multivariable logistic regression models were used to evaluate the association of minority status with self-reported "always" being treated with respect by clinicians and self-reported "always" being asked about opinions/beliefs about medical care. RESULTS: Participants in racial and ethnic minority groups had 23% lower odds of reporting being treated with respect compared with non-Hispanic White patients (adjusted odds ratio [AOR], 0.77; 95% CI, 0.61-0.97; P = .03). A minority of participants had 66% higher odds of reporting being asked about their beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). For all patients, being asked about opinions/beliefs by their clinician was associated with a 5.8 times higher odds of reporting being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001). CONCLUSIONS AND RELEVANCE: In this nationally representative US population of patients with eye diseases, being a patient in a racial or ethnic minority group was associated with feeling less respected by health care professionals compared with non-Hispanic White patients. Asking about opinions and beliefs, regardless of race or ethnicity, is associated with patients feeling that they are treated with respect.

Netarsudil Improves Trabecular Outflow Facility in Patients with Primary Open Angle Glaucoma or Ocular Hypertension: A Phase 2 Study.

PURPOSE: Intraocular pressure (IOP) reduction is key to controlling primary open angle glaucoma (POAG). Pharmacotherapies for POAG or ocular hypertension (OHT) commonly lower IOP by increasing uveoscleral outflow or decreasing aqueous humor production. Netarsudil (Rhopressa), a Rho kinase inhibitor, reduces IOP by improving trabecular outflow facility, which is reduced in POAG. We investigated the effects of netarsudil on aqueous humor dynamics in patients with POAG or OHT. DESIGN: Double-masked, randomized, vehicle-controlled, Phase 2 trial. METHODS: Netarsudil 0.02% was instilled in 1 eye and vehicle into the contralateral eye of 20 patients once daily in the morning for 7 days. The primary endpoint was change in mean diurnal outflow facility on day 8 versus that on day 1 (baseline). Outflow facility was measured by using Schiøtz tonography, IOP by pneumotonometry, and episcleral venous pressure (EVP) by automated venomanometry. RESULTS: Eighteen patients (90%) completed the study. Mean diurnal outflow facility increased 0.039 versus 0.007 µL/min/mm Hg from baseline in the netarsudil- and the vehicle-treated groups, respectively (P < .001 vs. baseline for netarsudil), a treatment difference of 0.03 µL/min/mm Hg (P ≤ .001). Mean diurnal IOP change from baseline at day 8 was -4.52 mm Hg for netarsudil versus -0.98 mm Hg for vehicle, a treatment difference of -3.54 mm Hg (P < .0001). Mean diurnal EVP change from baseline was -0.79 mm Hg in the netarsudil-treated group versus 0.10 mm Hg for vehicle, a treatment difference of -0.89 mm Hg (P < .001). All patients reporting an adverse event reported conjunctival hyperemia of mild or moderate severity. CONCLUSIONS: Netarsudil acts on the conventional outflow pathway, both proximal and distal, to significantly reduce IOP in POAG and OHT by improving trabecular outflow facility and decreasing EVP.

The Use of eHealth Practices by United States Patients with Self-Reported Glaucoma.

PURPOSE: Patient-oriented eHealth practices (e.g., scheduling appointments on the Internet, communicating with providers online) are an integral part of modern healthcare delivery. It is not known what proportion of United States patients with glaucoma use eHealth and how this use compares with those without glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: Participants in the 2016 through 2017 National Health Interview Survey (NHIS), a cross-sectional survey regarding health topics that is administered annually to a nationally representative sample of noninstitutionalized adults in the United States. METHODS: Based on the NHIS complex survey design, we calculated the proportion of participants with and without glaucoma who used 5 different eHealth practices (looking up health information on the Internet, requesting or ordering a prescription medication on the Internet, scheduling a medical appointment on the Internet, communicating with healthcare provider online, and using online groups to learn about health topics) during the 12 months before the survey. We performed univariate and multivariate logistic regression to evaluate the association between self-reported glaucoma diagnosis and use of the eHealth practices. MAIN OUTCOME MEASURES: Proportion using eHealth practices and odds ratios (ORs). RESULTS: Forty thousand four hundred sixty-five survey participants were included in the analysis; 1932 had self-reported glaucoma and 38 533 did not. For those with glaucoma, 46.2% (95% confidence interval [CI], 43.3%-49.0%) used at least one of the eHealth practices in the 12 months before the survey compared with 52.5% (95% CI, 51.5%-53.5%) of those without glaucoma (P < 0.001). After adjusting for confounders, participants with glaucoma were more likely to report use of at least 1 of the eHealth practices compared with those without glaucoma (adjusted OR, 1.22; 95% CI, 1.06-1.40; P = 0.005). CONCLUSIONS: In this nationally representative United States population, nearly half of people with glaucoma reported using eHealth practices. Although a lower proportion of people with glaucoma used eHealth practices compared with those without glaucoma, this relationship actually reversed after adjusting for confounders. Because many patients with glaucoma are capable of and already using e-Health, further investment in these technologies may be beneficial.

Cost-Related Medication Nonadherence in a Nationally Representative US Population with Self-Reported Glaucoma.

PURPOSE: To determine the rates of cost-related nonadherence to medications among US adults with glaucoma and to determine if participants with glaucoma have more cost-related medication nonadherence than those without glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: Participants in the 2016-2017 National Health Interview Survey (NHIS), a cross-sectional survey regarding health topics that is administered annually to a nationally representative sample of noninstitutionalized adults in the United States. METHODS: We calculated proportions of NHIS participants with and without self-reported glaucoma who reported cost-related nonadherence over the previous 12 months. We analyzed responses to 7 survey items that dealt with medication cost-related issues to any/all of a participants' medication: couldn't afford a prescribed medication; skipped medication doses to save money; took less medicine to save money; delayed filling a prescription to save money; asked doctor for lower cost medication to save money; bought prescription drugs from another country to save money; used alternative therapies to save money. We performed univariable and multivariable logistic regression to evaluate the association between self-reported glaucoma diagnosis and responses to these selected questions. MAIN OUTCOME MEASURES: Proportion of participants with and without self-reported glaucoma who reported cost-related nonadherence. RESULTS: Participants with glaucoma reported they could not afford prescribed medication more frequently than participants without glaucoma (8.2% vs. 6.4% P = 0.024). Adjusted predicted proportions from a multivariable model demonstrated that participants with glaucoma responded that they had greater cost-related barriers to medication access. CONCLUSIONS: In this nationally representative sample of the US population, after adjustment for confounding variables, participants with glaucoma more frequently reported cost-related nonadherence to medications compared with participants without glaucoma. Providers prescribing medication to patients with glaucoma should be aware of these findings and consider the impact of medication cost on their patients' ability to adhere to therapy.

Treatment Patterns and Outcomes in Bleb-Related Endophthalmitis: A 9-Year Analysis at a Tertiary Eye Center.

Purpose: Clinical presentation, treatment choices, and outcomes in cases of bleb-related endophthalmitis (BRE) at a tertiary care center over a 9-year period are described. Methods: A retrospective review was conducted of patients diagnosed with BRE at Duke Eye Center (Durham, North Carolina) from January 1, 2009 to January 1, 2018, with at least 6 months of follow-up, assessing demographic data, initial management, and visual acuity (VA). Results: Twenty eyes of 20 patients with BRE were identified. Median time from surgery to presentation was 6.53 years. Presenting VA of light perception only was significantly associated with the decision to pursue pars plana vitrectomy (PPV) as initial treatment (odds ratio 59.4, 95% CI, 2.1-1670.8, P = .016). Twelve eyes (60%) had culture-proven infectious endophthalmitis. Eleven eyes (55%) underwent PPV during treatment; 5 eyes underwent PPV on presentation, and 6 eyes underwent PPV after initial presentation. Compared with pre-endophthalmitis VA, 6 eyes that underwent subsequent PPV had greater VA loss at 6 months than cases not undergoing subsequent PPV (Early Treatment Diabetic Retinopathy Study line loss of 14 vs 4 lines, respectively; P = .044). Conclusions: BRE eyes presenting with light-perception VA were more likely to undergo initial PPV; yet many eyes in this study required PPV during treatment. Visual outcomes are often poor in BRE despite intensive management. There was greater VA loss from pre-endophthalmitis VA levels at 6 months in eyes undergoing PPV after initial treatment. Prospective studies are needed to assess the optimal role of PPV in patients with BRE.

Evolution of a Glaucoma Fellow's Surgical Training: Improvements in Tube Shunt Case Times during the Academic Year.

Purpose The aim of the study is to report changes in tube shunt placement surgical case times for glaucoma fellows during the course of the academic year. Patients and Methods Electronic health records were retrospectively reviewed to determine patient demographics, surgical case times (defined as procedure start time to procedure end time), and glaucoma fellow involvement. Only cases with a glaucoma fellow as the primary surgeon were included. Operative case times were compared by first and second halves of the academic year (beginning in July and ending in June) using a two-tailed t -test. Results Five hundred and seventy-three individual tube shunt surgeries (385 Ahmed, 188 Baerveldt) performed by 28 glaucoma fellows (17 females, 11 males) at Duke University Eye Center and University of North Carolina Medical Center were included. Overall, case times were significantly shorter in the second half of the academic year as compared with the first (55.3 ± 17.1 minutes vs. 61.0 ± 17.4 minutes, p <0.001). Both male (57.3 ± 16.8 minutes vs. 63.2 ± 18.6 minutes, p = 0.008) and female (53.5 ± 17.3 minutes vs. 59.3 ± 16.4 minutes, p = 0.003) fellows demonstrated shorter case times over the academic year; additionally, female fellows trended toward shorter case times than male fellows in both the first half ( p = 0.072) and second half ( p = 0.053) of the academic year. Fellows also exhibited shorter case times with both Ahmed implants (54.1 ± 16.2 minutes vs. 59.3 ± 15.8 minutes, p = 0.002) and Baerveldt implants (57.8 ± 18.9 minutes vs. 64.2 ± 20.0 minutes, p = 0.025) cases over the academic year. Baerveldt case times were significantly longer than Ahmed cases in the first half ( p = 0.028) and trended toward being longer than Ahmed cases in the second half ( p = 0.070). Conclusion Across 5 years at two academic institutions, glaucoma fellows had shorter primary tube shunt surgical case times in the second half of the academic year. These findings reflect improvement in surgical efficiency throughout glaucoma fellowship. These findings should be taken into consideration when scheduling trainee surgeries at academic medical centers at different points in the academic year.

Granulomatosis with polyangiitis-associated ischemic optic neuropathy in a previously healthy 50-year-old female.

PURPOSE: To describe a case of anterior ischemic optic neuropathy as a presenting sign of granulomatosis with polyangiitis. OBSERVATIONS: A previously healthy 50-year-old female developed right eye, then left eye, redness and pruritis and was diagnosed with allergic versus viral conjunctivitis. Five days later, she noted an acute decline in vision in the right eye, corresponding with a decrease on Snellen testing from 20/30 to 20/100 with correction. She was noted to have a right relative afferent pupillary defect, 2+ pallid disc edema, and OCT (Spectralis, Heidelberg Engineering, Carlsbad, CA) findings of significant retinal nerve fiber thickening. Review of systems revealed a three-month history fatigue, right-sided headaches, jaw claudication, bronchitis, cough without hemoptysis, and epistaxis, as well as interval development of a petechial rash across her body, migratory polyarthralgias, fevers, and tachycardia. ESR and CRP were markedly elevated, and the patient was admitted to the hospital for a systemic vasculitis workup. She was started on IV methylprednisolone. Her vision improved dramatically with steroids, measuring 20/50 with correction in the right eye after 24 hours and returning to baseline after five days. An extensive workup including imaging, bloodwork, and biopsies led to a diagnosis of granulomatosis with polyangiitis, with PR3-positive ANCA. CONCLUSIONS: Ocular findings, including anterior ischemic optic neuropathy, may be the presenting signs for patients with granulomatosis with polyangiitis. Prompt recognition and treatment with high-dose steroids and immunomodulatory therapy is important for visual recovery. IMPORTANCE: Prompt recognition of potential vasculitis-related vision loss can lead to timely initiation of vision-saving treatment.

Impact of Video Education on Patient Knowledge, Anxiety, and Satisfaction in Selective Laser Trabeculoplasty: A Pilot Study.

PRéCIS:: In patients undergoing selective laser trabeculoplasty, preoperative video education did not improve patient knowledge regarding the procedure, decrease anxiety, or increase satisfaction, as these metrics were already favorable across all patients in this study. PURPOSE: To assess the effect of an educational video on patient knowledge, anxiety, and satisfaction at a selective laser trabeculoplasty (SLT) procedure visit. MATERIALS AND METHODS: This is a prospective, randomized trial. Patients at a single academic medical center completed a survey at their procedure visit for SLT; patients were randomized to view an educational video or no video before survey administration. Knowledge was assessed with a 10-item questionnaire. The 6-item State-Trait Anxiety Inventory scale (STAI-6) assessed anxiety (score >40 defined significant anxiety). Perceptions of visit quality were assessed using a Likert scale. RESULTS: Twenty-two patients were randomized into video (n=11) and control (n=11) groups. No difference in knowledge was observed between groups (83.6% control vs. 82.7% video group, P=0.635). No patient had significant anxiety (STAI-6 range, 20 to 40, average 29) and scores were similar between groups (P=0.385). Overall, patients had positive perceptions of visit quality, and there was no significant difference between groups (P=0.999). CONCLUSION: Patients undergoing SLT had high levels of knowledge, low levels of anxiety, and high levels of satisfaction. In this clinical setting, an educational video seemed to have no additional benefit on these metrics and thus, may be omitted. Further research may be directed toward optimizing patient education regarding SLT, particularly in settings with poor health literacy, limited resources, or limited access to glaucoma specialists.

Association of Open-Angle Glaucoma with Non-Alzheimer's Dementia and Cognitive Impairment.

PURPOSE: To compare the odds of central neurodegenerative diseases in patients with open-angle glaucoma (OAG) with the odds in patients without glaucoma (control patients). DESIGN: Cross-sectional study. PARTICIPANTS: Patients 18 years of age or older who visited Duke University Health System between January 1, 2000, and July 31, 2015. METHODS: An electronic query of patient records at Duke University Health System was performed to identify patients with and without diagnoses of OAG, amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), vascular dementia (VD), senile dementia (SD), mild cognitive impairment (MCI), and other neurodegenerative diseases. Univariate logistic regression analyses were performed to calculate unadjusted odds ratios (OR). Age group, race, and gender were included as covariates in multiple logistic regression analyses to calculate adjusted ORs. MAIN OUTCOME MEASURES: Odds ratios comparing the odds of each neurodegenerative disease in OAG patients with the odds in control patients. RESULTS: A total of 1 511 602 patients were included in this study: 24 892 OAG patients and 1 484 790 control patients. Mean age was 58.9 ± 14.0 years for OAG patients and 44.9 ± 14.1 years for control patients. After adjusting for age, race, and gender, the OR comparing the odds of each neurodegenerative disease in OAG patients with the odds in control patients were as follows: for AD: adjusted OR, 0.84; 95% confidence interval (CI), 0.77-0.93; for ALS: adjusted OR, 0.28; 95% CI, 0.14-0.49); for PD: adjusted OR, 1.00; 95% CI, 0.89-1.13; for VD: adjusted OR, 1.11; 95% CI, 0.99-1.25; for SD: adjusted OR, 1.30; 95% CI, 1.19-1.41; for MCI: adjusted OR, 2.00; 95% CI, 1.79-2.22; and for other neurodegenerative disease: adjusted OR, 1.79; 95% CI, 1.51-2.10. CONCLUSIONS: Open-angle glaucoma patients may have increased odds of SD, MCI, and other neurodegenerative diseases. Further work is necessary to identify potential causal relationships. A negative correlation exists between OAG and ALS diagnosis that is likely related to limited life expectancy and physical limitations in ALS patients. A weak negative correlation exists between OAG and AD diagnosis. No correlation exists between OAG and PD or VD.

Reticular Bullous Epithelial Edema in Corneas Treated with Netarsudil: A Case Series.

PURPOSE: To describe the patient characteristics and the clinical course of an unusual reticular pattern of bullous epithelial corneal edema in a series of patients treated with netarsudil. DESIGN: Retrospective case series. METHODS: Case series at a single academic center where treatment with netarsudil produced a particular pattern of bullous epithelial corneal edema. RESULTS: Six episodes of reticular bullous epithelial corneal edema were identified in 5 eyes of 5 patients treated with netarsudil. A total of 4 of 5 patients had a history of corneal edema in the affected eye, and the fifth patient had risk factors for corneal edema including a history of anterior uveitis and an anterior chamber glaucoma drainage device. In 4 of 6 episodes, corneal edema was present, typically in the corneal stroma at the time of netarsudil initiation. In 5 of 6 cases, visual acuity worsened with onset of bullous epithelial edema, and in all cases, visual acuity stabilized or improved following discontinuation of netarsudil. In all cases, the reticular bullous epithelial edema improved or resolved after discontinuation of netarsudil. CONCLUSIONS: The patient characteristics and natural history of a particular pattern of reticular bullous epithelial edema in a series of patients treated with netarsudil once daily is reported. Most patients had a history of corneal edema or predisposing risk factors for corneal edema. All patients demonstrated improvement in bullous epithelial edema after netarsudil discontinuation. Visual acuity improved in most patients within weeks after discontinuation of netarsudil, although 2 patients also underwent surgical interventions that might have contributed to improved visual acuity.

Prospective Studies of Minimally Invasive Glaucoma Surgeries: Systematic Review and Quality Assessment.

Glaucoma is a common blinding disease; while there is no cure, effective treatments include medications, laser, and incisional surgery. There is significant interest from patients and doctors to develop safer surgical options throughout the spectrum of disease, to minimize treatment burden in mild glaucoma patients and to minimize risk of complications in patients needing more aggressive treatment. Surgical procedures called Minimally or Micro-Invasive Glaucoma Surgery (MIGS) are growing in popularity. Eighty-seven prospective studies on MIGS were identified and assessed for quality. Most (74%) did not have a control group. Twelve of the highest quality were reviewed. MIGS procedures appeared to have fewer complications, and lowered intraocular pressure, and reduced medication use. Studies were limited by small sample size, narrow spectrum of glaucomatous disease, and/or conflicts of interest. There is a need for high quality, independently funded and performed, comparative studies on the MIGS to help make treatment decisions.

PENETRATING INJURY FROM PLASTIC AIRSOFT PELLET SHOWS BEAM-HARDENING ARTIFACT ON COMPUTER TOMOGRAPHY.

PURPOSE: To describe a case of left eye corneal perforation, cataract, hyphema, and intraocular foreign body after airsoft pellet injury. METHODS: The authors reviewed the medical history and diagnostic imaging of a 12-year-old boy injured by a pellet from an airsoft gun. Typically, plastic airsoft pellets cause blunt trauma to the globe, which can lead to visual disability from corneal abrasion or hyphema. Initial computed tomography of the left orbit showed a 6.1 mm × 7.6-mm radiodense foreign body with beam-hardening artifact, a radiographic feature associated with metallic objects. RESULTS: The patient was taken to the operating room for globe repair, lensectomy, vitrectomy, and removal of intraocular foreign body. The removed foreign body was a plastic airsoft pellet. CONCLUSION: This is the first report of a plastic intraocular foreign body showing beam-hardening artifact. This finding may have implications in the diagnosis and management of retained intraocular or intraorbital plastic foreign bodies.

Cytokine biomarkers in tear film for primary open-angle glaucoma.

PURPOSE: To determine the utility of tear film cytokines as biomarkers for early primary open-angle glaucoma (POAG). METHODS: Patients without POAG and eye drop-naïve patients with newly diagnosed POAG were recruited from an academic hospital-based glaucoma practice. Tear films of recruited patients were obtained and analyzed using a multiplex, high-sensitivity electrochemiluminescent enzyme-linked immunosorbent assay for proinflammatory cytokines (IFNγ, IL-10, IL-12p70, IL-13, IL-1ß, IL-2, IL-4, IL-6, IL-8, and TNFα). RESULTS: Mean concentrations of tear film cytokines were lower in the glaucoma group for 8 of 10 cytokines tested. IL-12p70 (3.94±2.19 pg/mL in control vs 2.31±1.156 pg/mL in POAG; P=0.035) was significantly lower in the tear film of patients with newly diagnosed POAG. CONCLUSION: Proinflammatory cytokines were lower in eye drop-naïve newly diagnosed glaucoma patients. Tear film cytokine profiles may be used as biomarkers of early POAG.

Malignant Peripheral Nerve Sheath Tumor of the Lower Eyelid: Case Presentation and Literature Review.

Solitary benign neurogenic tumors are common in the orbit, but only rarely arise from peripheral nerves in the eyelids. In contrast, malignant tumors of neural or nerve sheath elements are exceedingly rare in the orbit and, to date, have never been reported in the lower eyelid. The authors report a 55-year-old man with multiple recurrent lower eyelid masses initially treated as chalazia then misdiagnosed as neurotropic malignant melanoma on pathology. Diagnosis of malignant peripheral nerve sheath tumor was ultimately confirmed histopathologically after surgical resection. The patient has since undergone multiple resections and adjuvant radiotherapy. Twenty-two months since the last procedure, the patient remains disease-free.