A Randomized Trial to Improve Adherence to Follow-up Eye Examinations Among People With Glaucoma.

INTRODUCTION: Appointment nonadherence is common among people with glaucoma, making it difficult for eye care providers to monitor glaucoma progression. Our objective was to determine whether the use of patient navigators, in conjunction with social worker support, could increase adherence to recommended follow-up eye appointments. METHODS: A randomized, controlled trial evaluated the effectiveness of an intervention that used patient navigators and social workers to improve patient adherence to follow-up eye care compared with usual care. Participants with glaucoma and other eye diseases (N = 344) were identified at primary care clinics in community settings through telemedicine screening of imaging and then randomized to enhanced intervention (EI) or usual care (UC). Data on participants' visits with local ophthalmologists were collected for up to 3 years from randomization. Groups were compared for timely attendance at the first visit with the local ophthalmologist and adherence to recommended follow-up visits. RESULTS: Timely attendance at the first visit was higher for EI than UC (74.4% vs 39.0%; average relative risk [aRR] = 1.85; 95% CI, 1.51-2.28; P < .001). Rates of adherence to recommended annual follow-up during year 1 were 18.6% in the EI group and 8.1% in the usual care group (aRR = 2.08; 95% CI, 1.14-3.76; P = .02). The aRR across years 2 and 3 was 3.92 (95% CI, 1.24-12.43; P = .02). CONCLUSION: An intervention using patient navigators and social workers doubled the rate of adherence to annual recommended follow-up eye care compared with usual care in community settings, and was effective at increasing connections with local ophthalmologists. Interventions to further improve long-term adherence are needed.

Reversible structural and functional changes after intraocular pressure reduction in patients with glaucoma.

PURPOSE: The aim of this study was to evaluate structural and functional improvement following intraocular pressure (IOP) reduction in patients with glaucoma using Spectral Domain Optical Coherence Tomography (SD-OCT), Visual Field (VF) testing, and Visual Evoked Potentials (VEP). METHODS: A total of 76 eyes from 61 patients underwent SD-OCT, VF and VEP testing. Sixty-two eyes were put in either an acutely high (group 1, IOP > 32 mmHg) or mildly high (group 2, IOP between 22 and 31 mmHg) IOP group and underwent a pressure-lowering intervention. Fourteen eyes with stable glaucoma were controls (group 3, IOP < 22 mmHg). SD-OCT, VF and VEP testing were subsequently performed on all patients at three follow-up visits. Results from these follow-up periods were analyzed for signs of functional and structural improvement. RESULTS: Both group 1 and group 2 patients demonstrated significant decrease in the average cup to disc ratio (p < 0.05) following the intervention. Post-interventional reduction of cup volume was also significant for group 2 patients (p < 0.05). RNFL thickness changes were insignificant. Qualitative grading of VFs by two observers showed improvement in group 1 patients' VFs (p = 0.021). VEP measurements were mostly insignificant, with the exception of High Contrast Latency (LHC) deteriorating for group 2 patients in the first follow-up visit (p = 0.025). CONCLUSIONS: This study provides evidence for structural disc cupping reversal following IOP lowering interventions. These changes were not related to the amount of pressure lowering. While there was evidence of functional improvement as measured by VF testing, VEP was unable to detect any reversible changes.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Intraocular Pressure Measurements Found in a Population at High Risk for Glaucoma.

PRECIS: Intraocular pressure (IOP) measurements, when used during telemedicine eye screening alongside nonmydriatic fundus photography, were shown to improve the likelihood of accurate glaucoma and glaucoma-related diagnoses at the follow-up eye examination. PURPOSE: To determine if IOP measurements, used as an adjunct to nonmydriatic fundus photography, are useful in glaucoma telemedicine screening. MATERIALS AND METHODS: A total of 902 high-risk individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening at visit 1 included fundus photography, assessing family history of glaucoma, and IOP measurements using a hand-held rebound tonometer. Participants with suspicious nerve findings for glaucoma, IOP>21 mm Hg or other ocular pathologies were invited for a follow-up appointment with an ophthalmologist (visit 2). RESULTS: Of the 902 individuals screened at visit 1, 19.6% (n=177/902) had elevated IOP (>21 mm Hg). Fifteen participants were found to have an IOP>30 mm Hg at visit 1, including 2 with an IOP of >40 mm Hg. Among all who attended visit 2 (n=347), 10.9% had glaucoma and 7.2% had ocular hypertension. For participants having both suspicious nerve findings and IOP>21 mm Hg compared with those with neither, the odds ratio (OR) of being diagnosed with glaucoma was 4.48 (95% CI, 1.50-13.93; P=0.007), whereas for participants with suspicious discs and IOP≤21 mm Hg the OR was 2.04 (95% CI, 0.83-5.53; P=0.15). CONCLUSIONS: In this telemedicine vision screening setting, having a higher IOP at the screening visit increased the likelihood of receiving a final diagnosis of glaucoma. Therefore, this study supports incorporating IOP measurements, using a portable tonometer, into vision screening programs in high-risk populations.

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre.

OBJECTIVES: To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia. DESIGN: Retrospective chart review. PARTICIPANTS: Patients from a community glaucoma screening program. METHODS: Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence. RESULTS: A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence. CONCLUSIONS: The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: confirmation between eye screening and comprehensive eye examination diagnoses.

AIMS: To evaluate agreement between ocular findings of a telemedicine eye screening (visit 1) with diagnoses of a comprehensive eye examination (visit 2). METHODS: A primary care practice (PCP)-based telemedicine screening programme incorporating fundus photography, intraocular pressure (IOP) and clinical information was conducted. Eligible individuals were African American, Hispanic/Latino or Asian over the age of 40; Caucasian individuals over age 65; and adults of any ethnicity over age 40 with a family history of glaucoma or diabetes. Participants with abnormal images or elevated IOP were invited back for a complete eye examination. Both visit 1 and visit 2 were conducted at participants' local PCP. Ocular findings at visit 1 and eye examination diagnoses at visit 2 are presented, including a cost analysis. RESULTS: Of 906 participants who attended visit 1, 536 were invited to visit 2 due to ocular findings or unreadable images. Among the 347 (64.9%) who attended visit 2, 280 (80.7%) were diagnosed with at least one ocular condition. Participants were predominately women (59.9%) and African American (65.6%), with a mean age (±SD) of 60.6±11.0 years. A high diagnostic confirmation rate (86.0%) was found between visit 1 and visit 2 for any ocular finding. Of 183 with suspicious nerves at visit 1, 143 (78.1%) were diagnosed as glaucoma or glaucoma suspects at visit 2. CONCLUSIONS: This screening model may be adapted and scaled nationally and internationally. Referral to an ophthalmologist is warranted if abnormal or unreadable fundus images are detected or IOP is >21 mm Hg. TRIAL REGISTRATION NUMBER: NCT02390245.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Ocular Findings at Two Health Centers.

Blindness from glaucoma can be prevented by early detection and treatment. Telemedicine improves access to treatment in high-risk populations that face barriers to receiving adequate ophthalmic care. We used a practice-based telemedicine screening model at two health centers. Telemedicine imaging of the fundus and optic nerve, followed by a complete eye exam at the same location for participants with abnormal findings, unreadable images, or ocular hypertension (OHTN), was performed. A total of 182 participants were screened, of whom 108 qualified for a complete eye exam. Of these, 62 (34.1%) had abnormal images, 12 (6.6%) had OHTN, and 34 (18.7%) had unreadable images. Eighty-nine of the 108 (82%) returned for the complete eye exam. Predominantly, participants were African American with glaucoma suspect and cataract. Screening location was an important factor for follow-up. Assessment of the fundus and optic disc using telemedicine resulted in early detection of glaucoma and other ocular pathology.

Visual Field Changes in Professional Wind versus Non-wind Musical Instrument Players in the Philadelphia Orchestra.

PURPOSE: We compare the prevalence of glaucoma in professional wind versus non-wind instrument players in the Philadelphia Orchestra. Visual field changes in individuals with glaucoma and glaucoma suspects were evaluated, and the results were correlated with cumulative practice time. METHODS: In this cross-sectional, observational study, fifty-one Philadelphia Orchestra musicians were enrolled and categorized as wind or non-wind instrument players. All study participants underwent screening fundus photography. Participants with optic discs suspicious for glaucoma underwent further evaluation, including standard automated visual field perimetry and a comprehensive eye examination by a glaucoma specialist. RESULTS: Of the 51 musicians enrolled, 9 of the 21 wind instrument players (43%) and 8 of the 30 non-wind instrument players (27%) were suspected of developing glaucoma in at least one eye (P = 0.25), with examinations performed on 12 of the 17 returning musicians (71%) for further confirmation. Wind instrument players exhibited significantly higher Octopus visual field mean defect scores (1.08 ± 1.5 dB) than non-wind instrument players (-0.43 ± 0.7 dB; P < 0.001). There was a significant association between cumulative hours playing wind instruments and visual field mean defect (P < 0.001). CONCLUSION: Among members of the Philadelphia Orchestra, the difference in prevalence of glaucoma suspicious optic discs between wind and non-wind instrument players was not significant. The clinical significance of the greater visual field mean defect found in wind instrument players, and the association between the degree of visual field mean defect and the cumulative practice-time of playing wind instruments, needs further investigation.

Short-duration transient visual evoked potentials and color reflectivity discretization analysis in glaucoma patients and suspects.

AIM: To evaluate the use of short-duration transient visual evoked potentials (VEP) and color reflectivity discretization analysis (CORDA) in glaucomatous eyes, eyes suspected of having glaucoma, and healthy eyes. METHODS: The study included 136 eyes from 136 subjects: 49 eyes with glaucoma, 45 glaucoma suspect eyes, and 42 healthy eyes. Subjects underwent Humphrey visual field (VF) testing, VEP testing, as well as peripapillary retinal nerve fiber layer optical coherence tomography imaging studies with post-acquisition CORDA applied. Statistical analysis was performed using means and ranges, ANOVA, post-hoc comparisons using Turkey's adjustment, Fisher's Exact test, area under the curve, and Spearman correlation coefficients. RESULTS: Parameters from VEP and CORDA correlated significantly with VF mean deviation (MD) (P<0.05). In distinguishing glaucomatous eyes from controls, VEP demonstrated area under the curve (AUC) values of 0.64-0.75 for amplitude and 0.67-0.81 for latency. The CORDA HR1 parameter was highly discriminative for glaucomatous eyes vs controls (AUC=0.94). CONCLUSION: Significant correlations are found between MD and parameters of short-duration transient VEP and CORDA, diagnostic modalities which warrant further consideration in identifying glaucoma characteristics.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results.

PURPOSE: To describe methodology and screening results from the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. DESIGN: Screening program results for a prospective randomized clinical trial. METHODS: Individuals were recruited who were African-American, Hispanic/Latino, or Asian over age 40 years; white individuals over age 65 years; and any ethnicity over age 40 years with a family history of glaucoma or diabetes. Primary care offices and Federally Qualified Health Centers were used for telemedicine (Visit 1). Two posterior fundus photographs and 1 anterior segment photograph were captured per eye in each participant, using a nonmydriatic, autofocus, hand-held fundus camera (Volk Optical, Mentor, Ohio, USA). Medical and ocular history, family history of glaucoma, visual acuity, and intraocular pressure measurements using the ICare rebound tonometer (ICare, Helsinki, Finland) were obtained. Images were read remotely by a trained retina reader and a glaucoma specialist. RESULTS: From April 1, 2015, to February 6, 2017, 906 individuals consented and attended Visit 1. Of these, 553 participants were female (61.0%) and 550 were African-American (60.7%), with a mean age of 58.7 years. A total of 532 (58.7%) participants had diabetes, and 616 (68%) had a history of hypertension. During Visit 1, 356 (39.3%) participants were graded with a normal image. Using image data from the worse eye, 333 (36.8%) were abnormal and 155 (17.1%) were unreadable. A total of 258 (28.5%) had a suspicious nerve, 62 (6.8%) had ocular hypertension, 102 (11.3%) had diabetic retinopathy, and 68 (7.5%) had other retinal abnormalities. CONCLUSION: An integrated telemedicine screening intervention in primary care offices and Federally Qualified Health Centers detected high rate of suspicious optic nerves, ocular hypertension, and retinal pathology.

Bilateral Same-day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To report the outcomes of bilateral, same-day laser peripheral iridotomy (LPI) in the Philadelphia Glaucoma Detection and Treatment Project. METHODS: The Philadelphia Glaucoma Detection and Treatment Project was a community-based initiative aimed to improve detection, management, treatment, and follow-up care of individuals at high risk for glaucoma. This novel project performed LPI, where 2 eyes received laser therapy on the same day. Of the 1649 patients examined between January 1, 2013 and May 31, 2014, patients who underwent bilateral, same-day LPI were included in our analysis. Main outcome measures were visual acuity, intraocular pressure (IOP), and postoperative complication rates. RESULTS: A total of 132 eyes of 66 patients underwent bilateral, same-day LPI. Mean visual acuity remained unchanged following treatment (P=0.85). Eight patients (12.1%) had IOP spikes >5 mm Hg following treatment, and 4 patients (6.1%) spiked >10 mm Hg. IOP returned to normal in all but 1 patient, who was diagnosed with chronic angle-closure glaucoma. Hyphema was reported in 2 patients (3%) and glare in 1 patient (1.5%). Thirteen patients (19.7%) had repeat LPI treatment. All patients successfully tolerated LPI treatment without serious complications. CONCLUSIONS: Performing bilateral, same-day LPI was well tolerated in a large community-based, glaucoma detection and treatment project. Applying this treatment strategy may be considered in similar settings, where patients' access to eye care is limited and it may be a cost-effective strategy.

Evaluation of Nonmydriatic Hand-held Optic Disc Photography Grading in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To determine the reproducibility of optic disc photograph grading obtained by a hand-held fundus camera and to determine the diagnostic value of these photographs in detecting patients with glaucoma in a community-based glaucoma-detection program. MATERIALS AND METHODS: Patients underwent slit-lamp examination by an ophthalmologist who graded each patient's optic discs using 2 methods: cup-to-disc ratio (CDR) and disc damage likelihood scale (DDLS). After a comprehensive glaucoma evaluation, patients were diagnosed as having "glaucoma," "glaucoma suspect," or "no glaucoma." Nonmydriatic, monoscopic optic disc photographs were then taken with a portable digital imaging device. On a different day, the same examiner and a second observer graded the disc photographs in a masked manner and determined a diagnostic impression based only on the disc photographs. RESULTS: Of the 1649 patients examined, 119 subjects were randomly selected according to 3 groups of diagnoses: "glaucoma" (n=36), "glaucoma suspect" (n=50), and "no glaucoma" (n=33). For CDR, the intraobserver agreement was 0.71 and the interobserver agreement was 0.69. For disc DDLS, the intraobserver agreement was 0.65 and the interobserver agreement was 0.67. The area under the receiver-operating characteristic distinguishing between normal and glaucoma was 0.88 and 0.86 for CDR and disc DDLS, respectively. CONCLUSIONS: Nonmydriatic, monoscopic disc photographs obtained by a hand-held camera had only moderate disc grading reproducibility. This could be due to a reduced quality of images, making interpretation more challenging, due to taking photographs through small pupils by a hand-held camera and the high percentage of patients with significant cataracts.

Improving Access to Eye Care among Persons at High-Risk of Glaucoma in Philadelphia--Design and Methodology: The Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: The Wills Eye Glaucoma Research Center initiated a 2-year demonstration project to develop and implement a community-based intervention to improve detection and management of glaucoma in Philadelphia. METHODS: The glaucoma detection examination consisted of: ocular, medical, and family history; visual acuity testing; corneal pachymetry; biomicroscopy of the anterior segment; intraocular pressure (IOP) measurement; gonioscopy; funduscopy; automated visual field testing; and fundus-color photography. Treatment included laser surgery and/or IOP-lowering medication. A cost analysis was conducted to understand resource requirements. Outcome measures included; prevalence of glaucoma-related pathology and other eye diseases among high-risk populations; the impact of educational workshops on level of knowledge about glaucoma (assessed by pre- and post-test evaluation); and patient satisfaction of the glaucoma detection examinations in the community (assessed by satisfaction survey). Treatment outcome measures were change in IOP at 4-6 weeks and 4-6 months following selective laser trabeculoplasty treatment, deepening of the anterior chamber angle following laser-peripheral iridotomy treatment, and rate of adherence to recommended follow-up examinations. Cost outcomes included total program costs, cost per case of glaucoma detected, and cost per case of ocular disease detected. RESULTS: This project enrolled 1649 participants (African Americans aged 50+ years, adults 60+ years and individuals with a family history of glaucoma). A total of 1074 individuals attended a glaucoma educational workshop and 1508 scheduled glaucoma detection examination appointments in the community setting. CONCLUSIONS: The Philadelphia Glaucoma Detection and Treatment Project aimed to improve access and use of eye care and to provide a model for a targeted community-based glaucoma program.

The impact of educational workshops on individuals at risk for glaucoma in the Philadelphia Glaucoma Detection and Treatment Project.

OBJECTIVES: The purpose of this study was to investigate the impact of educational workshops, led by community health educators, on the level of knowledge, perceived risk of glaucoma, and rate of attendance in a subsequent glaucoma detection examination. METHODS: Participants attended an educational workshop about glaucoma and completed an 8-question pre- and post-test to assess knowledge. A paired samples t-test assessed mean differences in composite pre- and post-test scores, correct responses for each question, and perceived risk of glaucoma after the workshop. RESULTS: Seven hundred and seven (707) pre- and post-test surveys were completed. There was a significant increase in the level of knowledge about glaucoma as reflected in the pre- and post-test composite scores (M=3.86, SD=1.95 vs. M=4.97, SD=1.82, P<0.001). In the 5 largest community sites, 44% (n=221/480) of the participants who attended an educational workshop scheduled a glaucoma detection examination appointment and 76% (n=160/211) of these participants completed this eye examination in the community setting. CONCLUSIONS: Educational workshops increased knowledge and awareness about glaucoma and were helpful in recruiting patients for community-based glaucoma detection examinations. PRACTICE IMPLICATIONS: We recommend including educational workshops when conducting community-based outreach programs.

Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial.

PURPOSE: To compare outcomes of selective laser trabeculoplasty (SLT) with drug therapy for glaucoma patients in a prospective randomized clinical trial. PATIENTS AND METHODS: Sixty-nine patients (127 eyes) with open-angle glaucoma or ocular hypertension were randomized to SLT or medical therapy. Target intraocular pressure (IOP) was determined using the Collaborative Initial Glaucoma Treatment Study formula. Patients were treated with SLT (100 applications 360 degrees) or medical therapy (prostaglandin analog). Six visits over 1 year followed initial treatment. If target IOP range was not attained with SLT, additional SLT was the next step, or in the medical arm additional medications were added. PRIMARY OUTCOME: IOP; secondary: number of steps. RESULTS: Sixty-nine patients were treated. Data collection terminated with 54 patients reaching 9 to 12-months follow-up. Twenty-nine patients were in the SLT group, 25 patients in the medical group. Baseline mean IOP for all eyes was 24.5 mm Hg in the SLT group, 24.7 mm Hg in the medical group. Mean IOP (both eyes) at last follow-up was 18.2 mm Hg (6.3 mm Hg reduction) in the SLT arm, 17.7 mm Hg (7.0 mm Hg reduction) in the medical arm. By last follow-up, 11% of eyes received additional SLT, 27% required additional medication. There was not a statistically significant difference between the SLT and medication groups. CONCLUSIONS: IOP reduction was similar in both arms after 9 to 12-months follow-up. More treatment steps were necessary to maintain target IOP in the medication group, although there was not a statistically significant difference between groups. These results support the option of SLT as a safe and effective initial therapy in open-angle glaucoma or ocular hypertension.