Interprofessional Electronic Consultations for the Diagnosis and Management of Neuro-Ophthalmic Conditions.

BACKGROUND: Interprofessional electronic consultation (eConsult) is a telemedicine modality in which consulting providers review outside records and provide recommendations without in-person consultation. The purpose of this study was to describe the utilization of eConsults in the management of neuro-ophthalmic conditions. METHODS: Retrospective cohort study of all patients who received an eConsult for a neuro-ophthalmic condition at a single quaternary referral center from 2018 to 2020. Main outcome measures included proportion of eConsults in which sufficient data were provided to the neuro-ophthalmologist to generate a definitive management decision, proportion of patients for whom an in-person neuro-ophthalmology evaluation was recommended, and the eConsult's impact on patient care. RESULTS: Eighty eConsults were conducted on 78 patients during the 3-year study period. Forty-eight (60.0%) subjects were female, mean age was 54 years, and 65 (81.3%) were White. The median time from eConsult request to completion was 4 days (range: 0-34 days). The most frequent eConsult questions were vision/visual field disturbances in 28 (35.0%) cases, optic neuropathies in 22 (27.5%), and optic disc edema in 17 (21.3%). At the time of eConsult, sufficient prior information was provided in 35 (43.8%) cases for the neuro-ophthalmologist to provide a definitive management decision. In 45 (56.3%) eConsults, further diagnostic testing was recommended. In-person neuro-ophthalmology consultation was recommended in 24 (30.0%) cases. Sixty-one (76.3%) eConsults provided diagnostic and/or treatment direction, and 12 (15.0%) provided reassurance. CONCLUSION: eConsults increase access to timely neuro-ophthalmic care and provide diagnostic and treatment direction to non-neuro-ophthalmology providers when sufficient information is provided at the time of eConsult.

Long-Term Visual Outcomes in Exudative Age-Related Macular Degeneration Patients With Unanticipated Gaps in Therapy.

BACKGROUND AND OBJECTIVES: This study's objective was to describe long-term visual outcomes of patients with age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor injections who were lost to follow-up and then resumed treatment with anti-vascular endothelial growth factor injections. MATERIALS AND METHODS: This was a retrospective cohort study of eyes with at least 7 years of follow-up following the initiation of treatment for wet AMD with and without gaps in therapy. RESULTS: The baseline mean logMAR visual acuity was 0.65 ± 0.5 (Snellen acuity 20/89) in eyes with gaps in therapy and 0.53 ± 0.3 (20/68) in eyes without gaps. In the initial 7-year follow-up period, the eyes with gaps in therapy had significantly worse visual acuity (P < .001) and this remained significant when accounting for baseline visual acuity (P < .001). CONCLUSIONS: Gaps in intravitreal injection therapy for exudative AMD were negatively associated with visual acuity. Adherence to therapy is important to address in the care of patients with exudative AMD. [Ophthalmic Surg Lasers Imaging Retina 2022;53:481-489.].

Characterization and Utility of Remote Interpretation of Visual Field Diagnostic Testing in an Academic Center.

BACKGROUND: The use of remote interpretation of data has risen in neuro-ophthalmology to increase efficiency and maintain social distancing due to the coronavirus disease-19 pandemic. The purpose of this study is to characterize the use and efficiency of remote interpretation of visual fields (VFs) in an academic center and to determine how often the VF interpretation was consistent with the patient's clinical history and imaging at the time of the consult. METHODS: This is a retrospective study at a single academic center that enrolled all patients receiving a remote interpretation of VF from January 1, 2012, through December 31, 2012. Data were collected regarding the referring department, indication for the VF, interpretation of the VF and comparison with any prior VFs, any associated interventions with the VF, and available follow-up VFs. The main outcome measures included 1) characterizing the use of remote VF interpretations and 2) how many remote VF interpretation results were consistent with the referring diagnosis based on the patient's clinical history and imaging. RESULTS: One hundred eighty patients received remote interpretation of VFs. The most frequent referring departments were endocrinology (79; 44%), neurology (51; 28%), and neurosurgery (43; 24%). The VF indications included parasellar lesion (107; 59%), seizure disorder (26; 14%), meningioma (19; 11%), vascular lesion (11; 6%), and others (17; 9%). There were 78 patients (43%) that had an intervention before the VF, whereas 49 (27%) were preoperative VFs. Eighty-seven (48%) of the VFs were interpreted as abnormal. Of all the 180 remote interpretation of VFs, 156 (87%) had VF interpretations that were consistent with the clinical question posed by the referring provider based on clinical history and imaging. Among the other 24 remote VF interpretations (13% of total remote VF interpretations), there was no clear interpretation because of either additional unexpected VF defects (n = 5, 21%), VF defect mismatch (n = 6, 25%), or unreliable VFs (n = 13, 54%). The median wait time for patients receiving remote VF interpretations was 1 day. CONCLUSIONS: Remote interpretation of VFs was most often requested by endocrinology, neurology, and neurosurgery and could be performed very quickly. The most common indications were parasellar lesions, and just less than half of patients receiving remote VF interpretations had a prior intervention. A majority of remote VF interpretations were able to answer the clinical question, given the patient's clinical history and imaging. Remote interpretation of VFs may thus offer referring departments a more efficient method of obtaining VF interpretations than in-office neuro-ophthalmology examinations.

Need for Additional Glaucoma Surgery and Complications Following Glaucoma Drainage Device Surgery.

PRCIS: In this longitudinal study of patients with open-angle (OAG), pseudoexfoliative (PXE), or neovascular glaucoma (NVG) receiving glaucoma drainage devices (GDD), posttube cumulative rates of reoperation, corneal graft, and visually threatening complications (VT-complications) increased beyond 5 years and were not significantly affected by glaucoma type. PURPOSE: To study the need for additional glaucoma surgery and development of complications after first GDD surgery in eyes with primary OAG, PXE, or NVG glaucoma. PATIENTS AND METHODS: There were 306 eyes with OAG (n=185), PXE (n=60), or NVG (n=61) glaucoma who received a first GDD between 1996 and 2017. Outcomes including glaucoma reoperation, corneal graft procedure, and VT-complications after GDD were measured. Kaplan-Meier analysis was used to compare cumulative rate of reaching outcomes over time after GDD placement among the 3 glaucoma groups. RESULTS: When comparing the OAG, PXE, and NVG groups, there were no significant differences in post-GDD cumulative rates of reoperation (P=0.33), corneal graft (P=0.26), or VT-complications (P=0.65) over time. For all eyes, the overall cumulative rates for each outcome measure increased beyond 5 years, and specific Kaplan-Meier rates (5-y, 10-y) included: reoperation (16%, 25%), corneal graft (6%, 12%), VT-complications (9%, 14%). When comparing specific GDDs, the Ahmed FP7 had a higher cumulative reoperation rate over time compared with the Baerveldt 350 (P=0.019). CONCLUSION: Glaucoma type did not significantly affect post-GDD cumulative rates of reoperation, corneal graft, and VT-complication among the OAG, PXE, and NVG groups. For all eyes, cumulative rates of reoperation, corneal graft, and VT-complications increased beyond 5 years. The Ahmed FP7 had a significantly higher cumulative reoperation rate compared with the Baerveldt 350 over time.

Long-Term Follow-up of Patients with Exudative Age-Related Macular Degeneration Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

PURPOSE: To determine the long-term visual outcomes and intravitreal injection burden of patients with exudative age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with exudative AMD treated with intravitreal anti-VEGF injections with annual office visits for at least 7 years. METHODS: Snellen visual acuity was measured at baseline and then annually until the last year of follow-up. The number of injections was recorded on an annual basis during each year of follow-up. MAIN OUTCOME MEASURES: The change in the frequency of injections over time along with the change in visual acuity each year from the baseline visit through 7 years. RESULTS: During this period, 533 eyes of 429 patients were treated for exudative AMD. Of these, 391 eyes (73%) met the inclusion criteria of annual office visits and received a mean of 5.8 ± 2.5 intravitreal injections per year. The baseline mean visual acuity was 0.6 ± 0.5 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/80), and the 7-year visual acuity was 0.8 ± 0.6 logMAR (Snellen equivalent, 20/126; P < 0.0001). When compared with the 142 eyes that did not undergo an office visit for a continuous 12-month period, eyes with annual office visits showed similar baseline mean visual acuity (0.7 logMAR vs. 0.6 logMAR; P = 0.2102), but more injections per year (P < 0.0001). Of the 533 total eyes, 124 eyes (23%) maintained better than 20/40 visual acuity at 7 years. These eyes received more injections overall per year (6.5 vs. 5.5 injections per year; P = 0.0007). CONCLUSIONS: In a real-world setting, eyes that maintained consistent, long-term follow-up received significantly more intravitreal injections per year than eyes with inconsistent follow-up. Eyes with 20/40 or better vision at study conclusion received more injections per year than eyes with worse than 20/40 vision.

TEN-YEAR FOLLOW-UP OF PATIENTS WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION TREATED WITH INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS.

PURPOSE: To identify the visual acuity outcomes of patients with age-related macular degeneration treated with intravitreal anti-vascular endothelial growth factor injections over a 10-year period. METHODS: This was a retrospective, cohort study of eyes with exudative age-related macular degeneration that received ≥2 intravitreal anti-vascular endothelial growth factor injections and had at least 10 years of follow-up after the initiation of treatment. Snellen visual acuity was recorded at baseline and then annually until the last year of follow-up. Optical coherence tomography data were collected at the time of treatment initiation and at the last examination visit. A subanalysis was performed on patients who continued to receive anti-vascular endothelial growth factor therapy using a modified treat and extend protocol versus those who discontinued treatment for longer than 1 year. RESULTS: One hundred thirty eyes of 115 patients met the inclusion criteria. The mean follow-up after treatment initiation was 11.1 ± 0.7 years. Eyes received an average of 45.1 ± 32.3 intravitreal injections in total and a mean of 5 to 7 injections per year. The baseline mean logMAR visual acuity was 0.61 ± 0.5 (Snellen acuity 20/81), and the final mean logMAR visual acuity was 0.88 ± 0.7 (20/152, P value = <0.0001). There were 40 eyes that received at least one injection every year. These eyes did not have a significant change in visual acuity between the baseline and final examinations 0.47 ± 0.4 (20/59 vs. 0.58 ± 0.5 [20/76, P = 0.28]), whereas the eyes that did not receive at least one injection every year saw a significant decline in visual acuity 0.67 ± 0.5 (20/94 vs. 1.01 ± 0.7 [20/205, P < 0.0001]). CONCLUSION: Eyes with exudative age-related macular degeneration that received intravitreal injections every year had stable visual acuity over a 10-year period. Continuous intravitreal anti-vascular endothelial growth factor therapy may stabilize visual acuity for 10 years and potentially longer.