Outcomes of microPulse transscleral laser therapy in eyes with prior glaucoma aqueous tube shunt.

PURPOSE: To evaluate the outcomes of micropulse transscleral laser therapy (MP-TLT) in patients with uncontrolled glaucoma and prior glaucoma aqueous tube shunt. METHODS: In this single­center, retrospective, interventional case series, eyes that underwent MP-TLT and had prior glaucoma aqueous tube shunt surgeries were included. The Cyclo Glaucoma Laser System (IRIDEX Corporation, Mountain View, CA, USA) with the MicroPulse P3 probe (version 1) was used. Post­operative data were collected at day 1, week 1, and months 1, 3, 6, 12, 18, 24, 30 and 36. RESULTS: A total of 84 eyes (84 patients) with mean age of 65.8 ± 15.2 years and with advanced glaucoma (baseline mean deviation -16.25 ± 6.80 dB and best-corrected visual acuity 0.82 ± 0.83 logMar) were included in the study. Baseline mean IOP was 19.95 ± 5.6 mm Hg with a mean number of medications 3.39 ± 1.02. There were statistically significant differences in IOP between baseline and all follow-up visits (p < 0.01 for all). The mean percentage of IOP reduction between baseline and different follow-up visits ranged from 23.4% to 35.5% (p < 0.01). There was a significant reduction of visual acuity (≥ 2-lines) at 1 year (30.3%) and 2 years (76.78%). There was a statistically significant reduction in the number of glaucoma medications between baseline and all follow-up visits after postoperative week 1 (p < 0.05 for all). No severe complications including persistent hypotony and related complications were observed. At the last follow-up visit, only 24 (28%) eyes out of 84 eyes remained in the study. CONCLUSION: MP-TLT is an effective treatment for reducing IOP and decreasing the number of medications in patients with advanced glaucoma and prior glaucoma aqueous tube shunt.

Risk Factors and Long-Term Outcomes in Patients with Low Intraocular Pressure after Trabeculectomy.

PURPOSE: To examine risk factors for low intraocular pressure (IOP) after trabeculectomy and to describe long-term outcomes in these eyes. DESIGN: Retrospective case-control study. PARTICIPANTS: Cases with low IOP included all patients with IOP ≤5 mmHg on 3 or more consecutive visits 3 months or later after trabeculectomy. Control patients without low IOP after trabeculectomy were randomly selected at a 1:2 case-to-control ratio. METHODS: A case-control study was performed of patients undergoing trabeculectomy at the Stein Eye Institute. Covariates included demographics, history of cataract surgery, refractive error, number of glaucoma medications, family history of glaucoma, diabetes, hypertension, visual acuity (VA), IOP, number of sutures in the scleral flap, laser suture lysis, surgeon, and laterality of surgery. Logistic regression modeling was used to examine associations between each covariate and low IOP. Postoperative outcomes that were examined included reoperation, vision loss, and surgical failure. The time between trabeculectomy and each outcome was compared between cases and controls with Cox proportional hazards regression modeling. MAIN OUTCOME MEASURES: Low IOP after trabeculectomy, reoperation, vision loss, and surgical failure. RESULTS: Of 3659 total trabeculectomies performed by 5 surgeons between 1990 and 2013, 64 eyes had low IOP (1.7%), which were compared with 130 control eyes. Fifteen of the 64 eyes with low IOP had hypotony maculopathy (23.4%). After accounting for differences in baseline IOP, laser suture lysis was negatively correlated with low IOP after trabeculectomy (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87); surgeon was correlated with high vs. low IOP after trabeculectomy (OR, 5.32; 95% CI, 1.53-18.52). There were no statistically significant associations between low IOP and time to reoperation (hazard ratio [HR], 0.73; 95% CI, 0.32-1.68), vision loss (HR, 1.77; 95% CI, 0.81-3.88) or surgical failure (HR, 1.14; 95% CI, 0.62-2.11). In patients with low IOP, there was a higher unadjusted incidence of bleb revision in patients who had maculopathy (7.6 vs. 1.9 revisions/100 person-years; for maculopathy versus no maculopathy P = 0.008). CONCLUSIONS: The absence of laser suture lysis and surgeon are factors potentially associated with low IOP after trabeculectomy. Numeric hypotony does not necessarily represent clinical failure after trabeculectomy.

Aqueous shunts for glaucoma.

BACKGROUND: Aqueous shunts are employed to control intraocular pressure (IOP) for people with primary or secondary glaucomas who fail or are not candidates for standard surgery. OBJECTIVES: To assess the effectiveness and safety of aqueous shunts for reducing IOP in glaucoma compared with standard surgery, another type of aqueous shunt, or modification to the aqueous shunt procedure. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 8), MEDLINE Ovid (1946 to August 2016), Embase.com (1947 to August 2016), PubMed (1948 to August 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to August 2016), ClinicalTrials.gov (www.clinicaltrials.gov); searched 15 August 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 15 August 2016. We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 August 2016. We also searched the reference lists of identified trial reports and the Science Citation Index to find additional trials. SELECTION CRITERIA: We included randomized controlled trials that compared various types of aqueous shunts with standard surgery or to each other in eyes with glaucoma. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results for eligibility, assessed the risk of bias, and extracted data from included trials. We contacted trial investigators when data were unclear or not reported. We graded the certainty of the evidence using the GRADE approach. We followed standard methods as recommended by Cochrane. MAIN RESULTS: We included 27 trials with a total of 2099 participants with mixed diagnoses and comparisons of interventions. Seventeen studies reported adequate methods of randomization, and seven reported adequate allocation concealment. Data collection and follow-up times varied.Four trials compared an aqueous shunt (Ahmed or Baerveldt) with trabeculectomy, of which three reported one-year outcomes. At one-year, the difference in IOP between aqueous shunt groups and trabeculectomy groups was uncertain (mean difference (MD) 2.55 mmHg, 95% confidence interval (CI) -0.78 to 5.87; 380 participants; very low-certainty evidence). The difference in logMAR visual acuity was also uncertain (MD 0.12 units, 95% CI -0.07 to 0.31; 380 participants; very low-certainty evidence). In two trials, the difference in visual field score was uncertain (MD -0.25, 95% CI -1.91 to 1.40; 196 participants; very low-certainty evidence). The mean number of antiglaucoma medications was higher in the aqueous shunt group than the trabeculectomy group in one trial (MD 0.80, 95% CI 0.48 to 1.12; 184 participants; low-certainty evidence). The effect on needing additional glaucoma surgery was uncertain between groups in two trials (risk ratio (RR) 0.24, 95% CI 0.04 to 1.36; 329 participants; very low-certainty evidence). In one trial, fewer total adverse events were reported in the aqueous shunt group than the trabeculectomy group (RR 0.59, 95% CI 0.43 to 0.81; 212 participants; very low-certainty evidence). No trial reported quality-of-life outcomes at one-year follow-up.Two trials that compared the Ahmed implant with the Baerveldt implant for glaucoma found higher mean IOP in the Ahmed group at one-year follow-up (MD 2.60 mmHg, 95% CI 1.58 to 3.62; 464 participants; moderate-certainty evidence). The difference in logMAR visual acuity was uncertain between groups (MD -0.07 units, 95% CI -0.27 to 0.13; 501 participants; low-certainty evidence). The MD in number of antiglaucoma medications was within one between groups (MD 0.35, 95% CI 0.11 to 0.59; 464 participants; moderate-certainty evidence). More participants in the Ahmed group required additional glaucoma surgery than the Baerveldt group (RR 2.77, 95% CI 1.02 to 7.54; 514 participants; moderate-certainty evidence). The two trials reported specific adverse events but not overall number of adverse events. Neither trial reported visual field or quality-of-life outcomes at one-year follow-up.One trial compared the Ahmed implant with the Molteno implant for glaucoma over two-year follow-up. Mean IOP was higher in the Ahmed group than the Molteno group (MD 1.64 mmHg, 95% CI 0.85 to 2.43; 57 participants; low-certainty evidence). The differences in logMAR visual acuity (MD 0.08 units, 95% CI -0.24 to 0.40; 57 participants; very low-certainty evidence) and mean deviation in visual field (MD -0.18 dB, 95% CI -3.13 to 2.77; 57 participants; very low-certainty evidence) were uncertain between groups. The mean number of antiglaucoma medications was also uncertain between groups (MD -0.38, 95% CI -1.03 to 0.27; 57 participants; low-certainty evidence). The trial did not report the proportion needing additional glaucoma surgery, total adverse events, or quality-of-life outcomes.Two trials compared the double-plate Molteno implant with the Schocket shunt for glaucoma; one trial reported outcomes only at six-month follow-up, and the other did not specify the follow-up time. At six-months, mean IOP was lower in the Molteno group than the Schocket group (MD -2.50 mmHg, 95% CI -4.60 to -0.40; 115 participants; low-certainty evidence). Neither trial reported the proportion needing additional glaucoma surgery, total adverse events, or visual acuity, visual field, or quality-of-life outcomes.The remaining 18 trials evaluated modifications to aqueous shunts, including 14 trials of Ahmed implants (early aqueous suppression versus standard medication regimen, 2 trials; anti-vascular endothelial growth factor agent versus none, 4 trials; corticosteroids versus none, 2 trials; shunt augmentation versus none, 3 trials; partial tube ligation versus none, 1 trial; pars plana implantation versus conventional implantation, 1 trial; and model M4 versus model S2,1 trial); 1 trial of 500 mm2 Baerveldt versus 350 mm2 Baerveldt; and 3 trials of Molteno implants (single-plate with oral corticosteroids versus single-plate without oral corticosteroids, 1 trial; double-plate versus single-plate, 1 trial; and pressure-ridge versus double-plate with tube ligation, 1 trial). AUTHORS' CONCLUSIONS: Information was insufficient to conclude whether there are differences between aqueous shunts and trabeculectomy for glaucoma treatment. While the Baerveldt implant may lower IOP more than the Ahmed implant, the evidence was of moderate-certainty and it is unclear whether the difference in IOP reduction is clinically significant. Overall, methodology and data quality among existing randomized controlled trials of aqueous shunts was heterogeneous across studies, and there are no well-justified or widely accepted generalizations about the superiority of one surgical procedure or device over another.

Surgical interventions for vertical strabismus in superior oblique palsy.

BACKGROUND: Superior oblique palsy is a common cause of vertical strabismus in adults and children. Patients may be symptomatic from binocular vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo strabismus surgery, but the optimal surgical treatment for vertical strabismus in people with superior oblique palsy is unknown. OBJECTIVES: To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for vertical strabismus in people with superior oblique palsy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. DATA COLLECTION AND ANALYSIS: Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. MAIN RESULTS: We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion).We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence).Both trials also reported the average postoperative reduction in vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence).Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another strabismus surgery during the postoperative period. AUTHORS' CONCLUSIONS: The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for vertical strabismus in this disorder.

Cataract Surgery and Mortality in the United States Medicare Population.

PURPOSE: To determine the association between cataract surgery and all-cause mortality in United States Medicare patients with cataract. DESIGN: Retrospective cohort study. PARTICIPANTS: A 5% random sample of United States Medicare beneficiaries with a diagnosis of cataract from the 2002 through 2012 Denominator and Physician/Supplier Part B files. METHODS: The exposure of interest was cataract surgery and the outcome of interest was all-cause mortality. Baseline characteristics that were examined included demographics, systemic comorbidities, and ocular comorbidities. Cox proportional hazards regression modeling was used to assess the association between cataract surgery and mortality. Additional subgroup analyses were performed in propensity score deciles and within strata of age, gender, region, systemic disease burden, and in patients with versus without severe cataract subtypes. MAIN OUTCOME MEASURES: All-cause mortality. RESULTS: The 5% Medicare sample included 1 501 420 patients with cataract, of whom 544 984 (36.3%) underwent cataract surgery. Patients with cataract surgery were followed up for a mean of 11.4 quarters (standard deviation [SD], 10.8 quarters; range, 0.0-44.0 quarters), whereas patients without cataract surgery were followed up for a mean of 12.9 quarters (SD, 12.2 quarters; range, 0.0-44.0 quarters). Mortality incidence was 2.78 deaths per 100 person-years in patients with cataract surgery and 2.98 deaths per 100 person-years in patients without surgery (P < 0.0001). Overall, patients with cataract surgery had a lower adjusted hazard of mortality compared with patients without surgery (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.72-0.74). The strongest associations were observed in patients with a high propensity score decile (HR, 0.52; 95% CI, 0.50-0.54), patients 80 to 84 years of age (HR, 0.63; 95% CI, 0.62-0.65), women (HR, 0.69; 95% CI, 0.68-0.70), patients in the western United States (HR, 0.52; 95% CI, 0.32-0.86), patients with a moderate systemic disease burden (HR, 0.71; 95% CI, 0.69-0.72), and patients with severe cataract (HR, 0.68; 95% CI, 0.66-0.70). CONCLUSIONS: In a national cohort of United States Medicare beneficiaries with cataract, cataract surgery was associated with decreased all-cause mortality. Further studies are needed to examine mechanisms surrounding the association between cataract surgery and mortality.

Geographic Trends in Ophthalmology Resident Physician Compensation and Cost-of-Living Expenses.

Importance: Given that resident physician financial strain has been associated with poor outcomes, objective metrics to forecast financial well-being may be useful to (1) applicants when evaluating ophthalmology residency programs and (2) programs when determining resident benefits. Objectives: To determine and compare the relative value of ophthalmology resident stipends plus benefits when adjusted for cost-of-living expenses and to analyze program characteristics associated with greater resident net incomes. Design, Setting, and Participants: In this cross-sectional study, the American Medical Association's Fellowship and Residency Electronic Interactive Database was used to identify US Accreditation Council for Graduate Medical Education-accredited ophthalmology residency programs. Resident physician stipends and stipends plus benefits as well as residency program characteristics from the 2023-2024 academic year were noted for all eligible programs. The Massachusetts Institute of Technology's Living Wage Calculator's required annual income (RAI) was selected as a surrogate to approximate cost-of-living expenses. Exposure: Residency program characteristics, including affiliation, size, ranking, presence of housing benefit, and training year. Main Outcomes and Measures: The primary outcome was the annual stipend plus benefits income surplus (SPBIS) for each residency program, defined as the resident's stipend plus benefits (SPB) minus the RAI for the county in which the residency program is located. Secondary outcomes included income surplus variation by program characteristics. Results: Of 116 ophthalmology residency programs analyzed, 37 (31.9%) were located in the Northeast, 36 (31.0%) in the South, 29 (25.0%) in the Midwest, and 14 (12.1%) in the West. The mean (SD) postgraduate year 1 resident annual SPB was $65 397 ($8205), and the median (IQR) was $63 986 ($59 992-$69 698). After adjusting for the cost of living, the mean (SD) SPBIS was $27 459 ($5734) and the median (IQR) was $27 380 ($23 625-$31 796). Annual cost-of-living expenses varied by as much as $8628 (95% CI, $6310-$10 947) and SPBIS varied by as much as $6283 (95% CI, $3367-$9198) between regions. Resident SPB increased by a mean (SD) of 3.97% (0.98%) for each subsequent training year (range, 0.93%-7.26%). Annual SPBIS increased by a mean (SD) of 9.48% (3.60%) for each subsequent training year. Conclusions and Relevance: After adjusting for living costs, intraregional and interregional differences in SPBIS among ophthalmology residents can vary by thousands of dollars, impacting residents' financial security. Further discussion regarding compensation may lead to innovative strategies that aim to improve resident well-being and performance.

Prevalence and Severity of Glaucoma in the California Medicare Population.

PURPOSE: To examine the prevalence of glaucoma by type and severity in the 2019 California (CA) Medicare population, and to identify associated demographic and systemic factors. DESIGN: Retrospective cross-sectional design. METHODS: The study population included all 2019 CA Medicare beneficiaries ≥65 years of age with Part A and Part B coverage. Outcomes included prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma (ACG). Covariates included age, sex, race and ethnicity, Charlson Comorbidity Index (CCI) score, pseudophakia, and age-related macular degeneration. Logistic regression modeling was used to examine multivariable predictors of each type of glaucoma. RESULTS: Of 5,856,491 beneficiaries in the 2019 California Medicare population, there were 220,662 (3.8%) with any glaucoma, 171,988 (2.9%) with POAG, 8,827 (0.2%) with SOAG, and 12,978 (0.2%) with ACG. The largest proportion of beneficiaries had moderate to severe glaucoma (68,553 of 220,662 [31.0%] for any glaucoma moderate stage, 3,168 of 12,978 [24.4%] for ACG severe stage). Multivariable predictors of any glaucoma included age ≥85 years vs 65 to 69 years (adjusted odds ratio [aOR] = 2.03, 95% CI = 2.00, 2.06), female vs male sex (aOR = 1.03, 95% CI = 1.02, 1.04), Black vs non-Hispanic White race and ethnicity (aOR = 1.70, 95% CI = 1.67, 1.73), and CCI ≥5 vs 0 (aOR = 5.59, 95% = 5.51, 5.67). CONCLUSIONS: In the 2019 CA Medicare population, multiple demographic and systemic factors were associated with increased likelihood of glaucoma, and beneficiaries with glaucoma had a high prevalence of moderate to severe disease. Strategies are needed to improve early screening and diagnosis for elderly individuals at risk for glaucoma in California.

Racial and ethnic differences in the prevalence and treatment patterns for neovascular glaucoma in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

PURPOSE: To examine racial and ethnic differences in the prevalence and treatment patterns for neovascular glaucoma (NVG) in at-risk individuals in the American Academy of Ophthalmology (Academy) IRIS® Registry (Intelligent Research in Sight). PARTICIPANTS: Eyes in the IRIS Registry with a retinal ischemia based on a history of proliferative diabetic retinopathy (PDR), retinal vein occlusion (RVO), and/or ocular ischemic syndrome (OIS). METHODS: Race and ethnicity was defined as Asian, Black, Hispanic/Latino, Non-Hispanic White, and Other/Unknown. In eyes with retinal ischemia, the outcome was neovascular glaucoma (NVG). In eyes with NVG, outcomes included treatment of retinal ischemia with pan-retinal photocoagulation (PRP), and surgery to lower intraocular pressure (IOP) with trabeculectomy, tube shunt, and cyclophotocoagulation (CPC). Covariates included age, sex, region of residence, insurance type, smoking status, and systemic and ocular comorbidities. Cox proportional hazards regression was used to examine adjusted associations between race and ethnicity and NVG and each type of NVG treatment. MAIN OUTCOME MEASURES: Incidence of NVG, PRP, trabeculectomy, tube shunt, CPC, and any IOP-lowering surgery RESULTS: Of 312,106 eyes with retinal ischemia, there were 5,885 (1.9%) with NVG. Compared to eyes of individuals who identified as Non-Hispanic White, eyes of individuals who were Black and Hispanic/Latino had higher hazards of NVG in adjusted analyses (hazards ratio [HR]=1.28, 95% confidence interval [CI]=1.15, 1.43 for Black; HR=1.32, 95% CI=1.17, 1.47 for Hispanic/Latino). Compared to eyes of individuals who were Non-Hispanic White, there was higher hazards of trabeculectomy in eyes of individuals who were Hispanic/Latino (adjusted HR=1.91, 95% CI=1.08, 3.39) and higher hazards of tube shunt (adjusted HR=1.35, 95% CI=1.07, 1.69) and of any IOP-lowering surgery (adjusted HR=1.29, 95% CI=1.09, 1.53) in eyes of individuals who were Black. There were no statistically significant differences in the hazards of PRP or CPC. CONCLUSIONS: Eyes of Black and Hispanic/Latino individuals with retinal ischemia in the IRIS Registry had higher likelihood of NVG and of IOP-lowering surgery for NVG. Further study is needed to examine the medical and social factors that preclude optimal management of diabetic eye disease, in order to prevent its blinding complications.

Predictors of Glaucomatous Progression in Individuals with Small and Large Optic Discs.

PURPOSE: To identify factors associated with glaucomatous progression in individuals with small and large optic discs. DESIGN: Retrospective review. SUBJECTS: 4505 individuals with glaucoma at UCLA; 233 (59.7%) with small discs, 157 (40.3%) with large discs. METHODS: Small and large disc sizes were defined by OCT or Heidelberg Retinal Tomography as disc area ≤ 5% (≤ 1.3 mm2) and ≥ 95% (≥ 2.9 mm2), respectively. Medical records were reviewed for demographics, systemic comorbidities, glaucoma type, ocular comorbidities, and ocular surgery. Logistic regression was used to identify predictors of visual field (VF) progression in individuals with small and large discs and predictors of large versus small discs. MAIN OUTCOME MEASURES: The VF deterioration with mean deviation, pointwise linear regression, and glaucoma rate index (GRI); large vs. small disc. RESULTS: In individuals with small discs, Asian versus non-Hispanic White ethnicity was associated with increased progression (adjusted odds ratio [aOR] = 4.05; 95% confidence interval [CI] = 1.12-14.59 for GRI). Higher intraocular pressure (IOP) range and peak were associated with increased progression in individuals with both small discs (aOR = 1.12; 95% CI = 1.00-1.27 and aOR = 1.05; 95% CI = 1.00-1.10 per 1 mmHg for range and peak with GRI) and large discs (aOR = 1.35; 95% CI = 1.12-1.66 and aOR = 1.11; 95% CI = 1.03-1.20 per 1 mmHg for range and peak with GRI). Multivariable predictors of having large vs. small discs included vasospastic phenotype (aOR = 2.58; 95% CI = 1.35-5.19) and Black (aOR = 20.46; 95% CI = 8.33-61.84), Hispanic/Latino (aOR = 9.65; 95% CI = 4.14-25.39), Asian (aOR = 4.87; 95% CI = 2.96-8.1), and other (aOR = 2.79; 95% CI = 1.69-4.63) versus non-Hispanic White ethnicity. CONCLUSIONS: Increased odds of glaucomatous progression were associated with Asian vs. non-Hispanic White ethnicity in glaucoma patients with small optic discs, as well as with increased IOP range and peak in those with small and large discs. Individuals with a vasospastic phenotype and those from racial and ethnic minority backgrounds had increased odds of having large vs. small optic discs. Further characterization of discernible phenotypes would improve disease prognostication and help individualize glaucoma treatment. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Population-Level Associations Between Visual Impairment and Functional Difficulties in California.

PURPOSE: The prevalence of visual impairment is increasing, and there is a need to understand the functional implications. Using the American Community Survey (ACS) data, this study examined the relationship between visual impairment and functional difficulties in California. METHODS: Using the 2010-2014 and 2015-2019 ACS 5-year estimates from the U.S. Census, data were obtained for visual impairment and functional difficulties including hearing, cognitive, ambulatory, self-care, and independent living difficulties. The prevalence of vision impairment and each functional difficulty was calculated on the Medical Service Study Area (MSSA) level in California. Unadjusted and adjusted linear regression models were performed to estimate the association between visual impairment and each functional difficulty, adjusting for age, sex, race and ethnicity, education level, English-speaking ability, poverty status, health insurance status, and urbanity of residence location. RESULTS: The prevalence of visual impairment in California was 2.3% (659,502 of 28,794,572) in 2010-2014 and 2.3% (709,353 of 30,231,767) in 2015-2019 among the population ≥ 18 years old. There were statistically significant associations between the prevalence of vision impairment and increased prevalence of all functional difficulties, with the most positive correlation observed with ambulatory difficulty (slope estimate 0.58 ± 0.072 for 2010-2014 and 0.78 ± 0.082 for 2015-2019 for ambulatory difficulty). CONCLUSIONS: There may be population-level impacts of functional consequences from vision impairment, suggesting the need for neighborhood-level investigation and policy-based interventions to address the burden of vision impairment on the population level.

Disparities in Glaucoma Surgery: A Review of Current Evidence and Future Directions for Improvement.

There is a need to understand existing disparities in glaucoma surgery and to create strategies to eliminate these disparities. Disparities can exist in several aspects of glaucoma surgical management, including patient selection and timing of surgery, type of surgery performed, intra-operative and postoperative surgical complications, follow-up surgical care, and long-term surgical outcomes. Additionally, multiple types of disparities can exist within each of these realms, including disparities by race and ethnicity, age, gender, insurance type, people with disabilities, and other social, economic, and demographic factors. Disparities in glaucoma surgery have been examined in large scale datasets, retrospective clinical studies, and clinical trials, and several studies have identified likely racial and ethnic disparities in glaucoma surgical incidence and outcomes. We present existing literature on disparities in glaucoma surgery, analyze the advantages and limitations of various study designs for the investigation of these disparities, and propose directions for future research and interventions to identify and eliminate disparities in surgical glaucoma care.

Social Vulnerability, Prevalence of Glaucoma, and Incidence of Glaucoma Surgery in the California Medicare Population.

PURPOSE: To examine associations of Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) scores with prevalence of glaucoma and incidence of glaucoma surgery in 2019 California Medicare beneficiaries. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: 2019 California Medicare beneficiaries ≥ 65 years old with part A and part B coverage. METHODS: The exposure of interest was SVI score, which was assessed overall and by themes. Outcomes included prevalence of glaucoma in the study population and incidence of glaucoma surgery in beneficiaries with glaucoma. Logistic regression modeling was performed to assess associations between quartiles of each type of SVI score, prevalence of glaucoma, and incidence of glaucoma surgery, controlling for age, sex, race/ethnicity, Charlson Comorbidity Index score, pseudophakia, and age-related macular degeneration. MAIN OUTCOME MEASURES: Prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma in all beneficiaries. Incidence of any glaucoma surgery, trabeculectomy, tube shunt, minimally invasive glaucoma surgery (MIGS), and cyclophotocoagulation (CPC) in beneficiaries with glaucoma. RESULTS: Of 5 725 245 beneficiaries in the total study population, there were 215 814 (3.8%) with any glaucoma, and of those with glaucoma, 10 135/215 814 (4.7%) underwent glaucoma surgery. In adjusted analyses for overall SVI score, where higher levels of SVI refer to higher levels of social vulnerability, there were decreased odds of any glaucoma (adjusted odds ratio [aOR] = 0.83; 95% confidence interval [CI] = 0.82, 0.84 for Q4 vs. Q1), POAG (aOR = 0.85; 95% CI = 0.84, 0.87 for Q4 vs. Q1), and SOAG (aOR = 0.59; 95% CI = 0.55, 0.63 for Q4 vs. Q1) in higher (Q4) vs. lower (Q1) SVI quartile. There were increased odds of any glaucoma surgery (aOR = 1.19; 95% CI = 1.12, 1.26 for Q4 vs. Q1), MIGS (aOR = 1.24; 95% CI = 1.15, 1.33 for Q4 vs. Q1), and CPC (aOR = 1.49; 95% CI = 1.29, 1.76 for Q4 vs. Q1) for higher (Q4) vs. lower (Q1) SVI quartile. CONCLUSIONS: In the 2019 California Medicare population, there were variable associations between SVI score, prevalence of glaucoma, and incidence of glaucoma surgery. Further investigation is needed to understand the role of social, economic, and demographic factors in glaucoma care on the individual and structural levels. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association Between Myopia and Primary Open-Angle Glaucoma by Race and Ethnicity in Older Adults in the California Medicare Population.

Importance: Racial and ethnic differences in the association between myopia and primary open-angle glaucoma (POAG) are not well understood. Objective: To investigate the association between myopia and POAG in the 2019 California Medicare population and to investigate whether there was evidence of effect measure modification of this association by race and ethnicity. Design, Setting, and Participants: This cross-sectional study used administrative claims data from 2019 California Medicare beneficiaries 65 years or older with California residence and active coverage with Medicare parts A and B. Analysis took place between October 2021 and October 2023. Exposures: The primary exposure was myopia, which was defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. Main Outcomes and Measures: The outcome of interest was POAG, which was defined by ICD-10-CM code. Results: Of 2 717 346 California Medicare beneficiaries in 2019, 1 440 769 (53.0%) were aged 65 to 74 years, 1 544 479 (56.8%) identified as female, 60 211 (2.2%) had myopia, and 171 988 (6.3%) had POAG. Overall, 346 723 individuals (12.8%) identified as Asian, 117 856 (4.3%) as Black, 430 597 (15.8%) as Hispanic, 1 705 807 (62.8%) as White, and 115 363 (4.2%) as other race and ethnicity. In adjusted logistic regression analyses, beneficiaries with myopia had higher odds of POAG compared with beneficiaries without myopia (odds ratio [OR], 2.41; 95% CI, 2.35-2.47). In multivariable models stratified by race and ethnicity, the association between myopia and POAG was stronger in Asian (OR, 2.74; 95% CI, 2.57-2.92), Black (OR, 2.60; 95% CI, 2.31-2.94), and Hispanic (OR, 3.28; 95% CI, 3.08-3.48) beneficiaries compared with non-Hispanic White beneficiaries (OR, 2.14; 95% CI, 2.08-2.21). Conclusions and Relevance: In the 2019 California Medicare population, myopia was associated with greater adjusted odds of POAG. This association was stronger among Asian, Black, and Hispanic beneficiaries compared with non-Hispanic White beneficiaries. These findings suggest possible disparities in glaucoma risk by race and ethnicity in individuals with myopia and may indicate greater need for glaucoma screening in individuals with myopia from racial and ethnic minority backgrounds.

Access to Eye Care Providers and Glaucoma Severity in the National Institutes of Health All of Us Research Program.

PRCIS: In the "All of Us (AoU) Research Program," individuals with access to vision care were more likely to have mild, moderate, or severe glaucoma and undergo incisional surgery compared with those without vision care access. PURPOSE: To examine the associations between access to eye care, glaucoma severity, and incisional glaucoma surgery using data from the National Institute of Health AoU Research Program. MATERIALS AND METHODS: Individuals with International Classification of Diseases Ninth or 10th Revision codes and who answered the survey question about eye care access in AoU were included in the study. The exposure variable was access to eye care services, with outcome variables (1) glaucoma severitys and (2) likelihood of incisional surgery. Unadjusted multinomial logistic regression compared access to eye care services and glaucoma severity. In addition, unadjusted logistic regression models compared access to eye care and the likelihood of incisional surgery. These were repeated using adjusted analyses, controlling for sex assigned at birth, race and ethnicity, and age. RESULTS: Compared with individuals without access to eye care services, those with access were more likely to have all levels of glaucoma severity [mild adjusted odds ratio (aOR): 5.81, 95% CI: 3.15-10.73, moderate aOR: 4.44, 95% CI: 2.45-8.02, severe aOR: 6.95, 95% CI: 2.69-17.93, and unspecified aOR: 3.06, 95% CI: 2.72, 3.45]. Access to eye care was associated with increased odds of any incisional glaucoma surgery (aOR: 3.00, 95% CI: 1.24-9.90) and of trabeculectomy (aOR: 3.30, 95% CI: 1.02-20.28) but not of tube shunt procedures (aOR: 2.65, 95% CI: 0.80-16.38). CONCLUSIONS: This study demonstrated that access to eye care services was associated with a higher prevalence of all levels of glaucoma severity; those with access to eye care services were more likely to undergo incisional surgery than those without access. Future research should focus on methods to best encourage eye care to limit glaucoma progression.

Evaluating Discrepancies in Self-Reported Glaucoma and Electronic Health Records in the National Institutes of Health All of Us Database.

PURPOSE: Patient understanding of glaucoma diagnosis is critical for disease management and it is unclear if there are racial/ethnic differences in this regard. The purpose of this study was to determine the level of agreement between glaucoma diagnosis by self-report and electronic health record (EHR) data using the National Institute of Health's "All of Us (AoU)" database and to examine the association between race/ethnicity and discordance of glaucoma diagnosis between self-report and EHR data. DESIGN: Cross-sectional study. PARTICIPANTS: Individuals in AoU who answered a survey question about glaucoma diagnosis and had EHR data availability. METHODS: The agreement between self-reported glaucoma and EHR data was estimated using Cohen's κ coefficient. Multivariable logistic regression was performed, adjusting for age, sex, education level, income, and health care literacy, to examine the associations between race/ethnicity and discordance between self-reported glaucoma and EHR diagnosis. MAIN OUTCOME MEASURES: Agreement between self-reported glaucoma and EHR diagnosis. RESULTS: Of all 87 782 individuals, 1985 (2.26%) had both self-reported and EHR glaucoma, 81 781 (92.16%) had no glaucoma, 2022 (2.31%) individuals had EHR-only glaucoma, and 1994 (2.27%) had self-report-only glaucoma (Cohen's κ = 0.47). In the multivariable regression, Black or African American (adjusted odds ratio [aOR], 1.67; 95% confidence interval [CI], 1.40-1.98), Asian (aOR, 2.63; 95% CI, 1.97-3.44), and Hispanic or Latino (aOR, 1.63; 95% CI, 1.33-1.99) individuals were more likely to have EHR-only glaucoma than White individuals. Additionally, Black or African American (aOR, 2.30; 95% CI, 1.97-2.67) and Hispanic or Latino individuals (aOR,1.47; 95% CI, 1.21-1.79) were more likely to have self-report-only glaucoma compared with White individuals. CONCLUSIONS: In the AoU database, we found that Black or African American and Hispanic or Latino individuals had higher odds of discordance between glaucoma diagnosis by self-report and EHR. Future studies are needed to examine the issues leading to this discordance, such as a lack of patient understanding regarding their diagnosis or a lack of culturally appropriate physician explanation/teaching. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Associations Between Niacin Intake and Glaucoma in the National Health and Nutrition Examination Survey.

PRCIS: This study examined the association between dietary niacin intake and glaucoma in the 2005-2008 National Health and Nutrition Examination Survey (NHANES). Increased niacin intake was associated with lower odds of glaucoma overall and among women. PURPOSE: To examine the association between dietary niacin intake and glaucoma in the 2005-2008 NHANES. MATERIALS AND METHODS: This cross-sectional study included adult participants of the 2005-2008 NHANES. The exposure was dietary niacin intake, which was examined as a continuous and categorical variable. The outcome was glaucoma as defined by regraded disc images. Covariates included age, sex, race/ethnicity, education level, income, body mass index, smoking status, alcohol use, cardiovascular disease, diabetes mellitus, daily energy intake, vitamin B2 and B6 consumption, and macular degeneration. Adjusting for all covariates, logistic regression was performed to examine the association between niacin intake and glaucoma in the overall population and stratified by sex. RESULTS: The weighted population included 5371 individuals (109,734,124 weighted), of whom 55 (1.0%) had glaucoma. Each 1 mg increase in niacin intake was associated with a 6% decreased odds of glaucoma odds [adjusted odds ratio (aOR) = 0.94, 95% CI = 0.90, 0.98]. Among women, increased niacin intake was associated with decreased odds of glaucoma both with niacin as a continuous (aOR = 0.89, 95% CI = 0.80, 0.99 per 1 mg increase in niacin intake) and binary variable (aOR = 0.35, 95% CI = 0.14, 0.90 for higher vs lower niacin intake). CONCLUSIONS: In the 2005-2008 NHANES population, higher levels of niacin intake were associated with decreased odds of glaucoma overall and in women. Further studies are needed to examine the potential protective effects of niacin on glaucoma risk.