Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States.

PURPOSE: To assess patterns in gonioscopy during initial glaucoma evaluations in the United States. DESIGN: Retrospective, case-control study. METHODS: Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics DataMart. Initial evaluation was defined as follows: (1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; (2) continuously observable during a 36-month lookback period; (3) no history of glaucoma medications, laser, or surgical procedures; and (4) optical coherence tomography (OCT) or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes. RESULTS: Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (P < .001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared with Asians. Age ≥60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (P < .001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (P < .01). CONCLUSIONS: More than 70% patients undergoing initial glaucoma evaluation in the United States do not have a record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.

Practice Patterns and Sociodemographic Disparities in the Clinical Care of Anatomical Narrow Angles in the United States.

PURPOSE: To assess treatment and visit patterns among patients with newly diagnosed anatomical narrow angle (ANA) and identify sociodemographic factors associated with disparities in care. DESIGN: Retrospective practice pattern evaluation study. METHODS: A total of 263,422 patients diagnosed with ANA between 2007 and 2019 were identified in the Optum Clinformatics Data Mart. Inclusion was limited to newly diagnosed ANA, defined as (1) continuous enrollment during a 2-year lookback period and 1-year study period from first diagnosis; (2) diagnosis by an ophthalmologist or optometrist; and (3) no history of pseudophakia, ANA treatments, or prior primary angle closure glaucoma diagnosis. Outcome measures were treatment with laser peripheral iridotomy (LPI), cataract surgery, or intraocular pressure-lowering medications and number of eye care visits. Logistic and Poisson regression were performed to assess factors associated with treatment and eye care visits, respectively. RESULTS: Among 52,405 eligible cases, 27.7% received LPI, 13.9% received drops, and 15.1% received cataract surgery. Odds of LPI were higher in Asians and Hispanics (odds ratio [OR] ≥ 1.16, P < .001). Non-Whites had higher odds of drops (OR ≥ 1.19, P < .001), but Hispanics had lower odds of cataract surgery (OR = 0.79, P < .001). The mean number of eye care visits was 2.6±2.1 including the day of diagnosis. Older age and treatment were associated with higher rates of eye care visits (rate ratio > 1.15, P < .001). CONCLUSION: More than a quarter of patients with newly diagnosed ANA receive treatment with LPI. Racial minorities are more likely to receive ANA-specific treatments but less likely to receive cataract surgery. These differences may reflect racial differences in disease severity and the need for clearer practice guidelines in ANA care.

P-ANCA Vasculitis Presenting with Orbital Infiltration.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) may affect the eye or orbit, and ophthalmic manifestations of AAV are associated with higher mortality than other inflammatory eye diseases. Perinuclear ANCA (p-ANCA) vasculitis is an uncommon cause of orbital inflammation. A 70-year-old woman with chronic kidney disease presented with a 1-year history of orbital mass and edema around her OD. Fundoscopy revealed 360° optic disc elevation OD. MRI orbits showed an infiltrative, intra- and extraconal lesion extending through the right orbital apex to the cavernous sinus. Labwork and orbital biopsy were consistent with p-ANCA vasculitis, and the patient's ocular symptoms improved after methylprednisolone. Diagnosis of AAV is complicated by a wide diversity of symptoms, and this case highlights an unusual presentation of p-ANCA vasculitis in the orbit. Ophthalmologists have an important role in diagnosing systemic conditions such as AAV by initiating the proper inflammatory workup.

Identifying, Understanding, and Addressing Disparities in Glaucoma Care in the United States.

Glaucoma is the leading cause of irreversible blindness worldwide, currently affecting around 80 million people. Glaucoma prevalence is rapidly rising in the United States due to an aging population. Despite recent advances in the diagnosis and treatment of glaucoma, significant disparities persist in disease detection, management, and outcomes among the diverse patient populations of the United States. Research on disparities is critical to identifying, understanding, and addressing societal and healthcare inequalities. Disparities research is especially important and impactful in the context of irreversible diseases such as glaucoma, where earlier detection and intervention are the primary approach to improving patient outcomes. In this article, we first review recent studies identifying disparities in glaucoma care that affect patient populations based on race, age, and gender. We then review studies elucidating and furthering our understanding of modifiable factors that contribute to these inequities, including socioeconomic status (particularly age and education), insurance product, and geographic region. Finally, we present work proposing potential strategies addressing disparities in glaucoma care, including teleophthalmology and artificial intelligence. We also discuss the presence of non-modifiable factors that contribute to differences in glaucoma burden and can confound the detection of glaucoma disparities. Translational Relevance: By recognizing underlying causes and proposing potential solutions, healthcare providers, policymakers, and other stakeholders can work collaboratively to reduce the burden of glaucoma and improve visual health and clinical outcomes in vulnerable patient populations.

A Longitudinal Analysis of Gene x Environment Interaction on Verbal Intelligence Across Adolescence and Early Adulthood.

The Scarr-Rowe hypothesis proposes that the heritability of intelligence is higher in more advantaged socioeconomic contexts. An early demonstration of this hypothesis was Rowe and colleagues (Rowe et al., Child Dev 70:1151-1162, 1999), where an interaction between the heritability of verbal intelligence and parental education was identified in adolescent siblings in Wave I of the National Longitudinal Study of Adolescent to Adult Health. The present study repeated their original analysis at Wave I using contemporary methods, replicated the finding during young adulthood at Wave III, and analyzed the interaction longitudinally utilizing multiple measurements. We examined parental education, family income, and peer academic environment as potential moderators. Results indicated increased heritability and decreased shared environmental variance of verbal intelligence at higher levels of parental education and peer academic environment in adolescence. Moreover, moderation by peer academic environment persisted into adulthood with its effect partially attributable to novel gene-environment interactions that arose in the process of cognitive development.

Rates and Patterns of Diagnostic Conversion from Anatomical Narrow Angle to Primary Angle-Closure Glaucoma in the United States.

PURPOSE: To assess rates of diagnostic conversion from anatomical narrow angle (ANA) to primary angle-closure glaucoma (PACG) in the United States and identify factors associated with diagnostic conversion. DESIGN: Retrospective case-control study. PARTICIPANTS: Patients diagnosed with ANA between the years 2007 and 2019 were identified based on International Classification of Diseases (ICD) codes in the Optum Clinformatics Data Mart Database. Inclusion was limited to newly diagnosed ANA, defined as the following: (1) continuous enrollment during a 2-year look back period and 6-year study period from index (first) date of ANA diagnosis; (2) diagnosis by an ophthalmologist or optometrist and record of gonioscopy; and (3) no history of intraocular pressure (IOP)-lowering drops, laser peripheral iridotomy (LPI), or intraocular surgery. METHODS: Cox proportional hazards models were developed to assess factors associated with diagnostic conversion, defined as a change in ICD code from ANA to PACG. MAIN OUTCOME MEASURES: New diagnosis of PACG within the 6-year study period recorded after an index diagnosis of ANA. RESULTS: Among 3985 patients meeting inclusion criteria, 459 (11.52%) had detected diagnostic conversion to PACG within the study period. The conversion rate was stable at 3.54% per year after the first 6 months of ANA diagnosis. In the Cox proportional hazards model, age > 70 years and early (within 6 months of ANA diagnosis) need for LPI or IOP-lowering drops were positively associated with diagnostic conversion (hazard ratio [HR] > 1.59; P < 0.02). Cataract surgery at any time and late (after 6 months of ANA diagnosis) need for IOP-lowering drops appeared protective against diagnostic conversion (HR < 0.46; P < 0.004). CONCLUSIONS: Annual risk of diagnostic conversion from ANA to PACG is relatively low overall; elderly patients are at higher risk whereas patients receiving cataract surgery are at lower risk. The utility of long-term monitoring seems low for most patients with ANA, highlighting the need for improved clinical methods to identify patients at higher risk for PACG. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.