Glaucoma Fellows-in-Training Recent Surgery Trends.

PURPOSE: The volume of microinvasive glaucoma surgery (MIGS) has increased dramatically in recent years, from 31 059 in 2013 to 69 420 in 2018. We investigated the impact of this trend on trainees by determining the proportion of glaucoma surgeries performed by fellows-in-training comprised by MIGS, trabeculectomies, and aqueous shunts. DESIGN: Retrospective analysis. PARTICIPANTS: Fellows-in-training at Glaucoma Fellowship Programs certified by the Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO-FCC) METHODS: We analyzed aggregate summaries of surgeries performed by fellows as reported to the AUPO-FCC from the academic years (AYs) beginning in 2014 through AY 2020. Each report lists the average number of procedures performed per surgery type per fellow. We combined these averages to create a sum "average number surgeries performed" across glaucoma surgeries and computed the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of surgeries performed per year. MAIN OUTCOME MEASURES: Average number of procedures performed for each surgery type as well as the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of procedures performed per year. RESULTS: Average number of MIGS performed is significantly greater in later years compared with earlier years (P < 0.001). The average number of trabeculectomies performed between AYs 2014 and AY 2020 ranged from 21.8 to 31.9 and decreased, on average, by - 0.80 year-to-year. The average number of aqueous shunts performed between AY 2014 and AY 2020 ranged from 44.7 to 49.5, with an average increase of + 0.8 year-to-year. The total average number of procedures performed (across all 3 surgical subtypes) increased on average by + 4.8 procedures each year. CONCLUSIONS: Since 2014, fellows are performing increasing numbers of MIGS procedures, whereas the total number of trabeculectomies and aqueous shunt surgeries performed each year remain similar, resulting in a net increase in total number of procedures performed per fellow each year. This suggests the increase in MIGS is not associated with a substantial decline in trabeculectomies or aqueous shunts performed by glaucoma fellows. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Systematic analysis of levels of evidence supporting American Academy of Ophthalmology Preferred Practice Pattern guidelines, 2012-2021.

BACKGROUND: Despite the increased emphasis on evidence-based medicine, the current state of evidence behind ophthalmology clinical practice guidelines is unknown. The purpose of this systematic analysis was to understand the levels of evidence (LOE) supporting American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) guidelines, assess changes over time, and compare LOE across ophthalmology subspecialties. METHODS: All current PPP guidelines and their immediate predecessors were comprehensively reviewed to identify all recommendations with LOE provided (I [randomized controlled trials], II [case-control or cohort studies], and III [nonanalytic studies]). RESULTS: Twenty-three out of 24 current PPPs had a prior edition. Among the PPPs with a prior edition, the number of recommendations with LOE decreased from 1254 in prior PPPs to 94 in current PPPs. The number of recommendations with LOE I decreased from 114 to 83, LOE II decreased from 147 to 2, and LOE III decreased from 993 to 9. However, the proportion of LOE I recommendations increased from 9 to 88%, driven by a disproportionate decrease in reporting of evidence lower than LOE I. Subgroup analysis by subspecialty showed similar trends (LOE I recommendations in prior PPPs vs current PPPs: retina: 57 [12%] vs 19 [100%]; cornea: 33 [5%] vs 24 [100%]; glaucoma: 9 [23%] vs 17 [100%]; cataract: 13 [17%] vs 18 [100%]). CONCLUSIONS: Trends in LOE reporting in PPP guidelines indicate an increasing emphasis on evidence from randomized controlled trials from 2012 to 2021. The decline in the number of recommendations with LOE reported suggests an area for improvement in future guidelines as the presence of LOE is crucial to facilitate interpretation of clinical practice guidelines.

How Medication Adherence Affects Disease Management in Veterans with Glaucoma: Lessons Learned from a Clinical Trial.

INTRODUCTION: We conducted a secondary, real-world clinical assessment of a randomized controlled trial to determine how a glaucoma medication adherence intervention impacted the clinical outcomes of participants at 12 months post-randomization. Participants included veterans at a VA eye clinic with medically treated glaucoma who reported poor adherence and their companions, if applicable. METHODS: The treatment group received a glaucoma education session with drop administration instruction and virtual reminders from a "smart bottle" (AdhereTech) for their eye drops. The control group received a general eye health class and the smart bottle with the reminder function turned off. Medical chart extraction determined if participants in each group experienced visual field progression, additional glaucoma medications, or a recommendation for surgery or laser due to inadequate intraocular pressure control over the 12 months following randomization. The main outcome measure was disease progression, defined as visual field progression or escalation of glaucoma therapy, in the 12 months following randomization. RESULTS: Thirty-six versus 32% of the intervention (n = 100) versus control (n = 100) groups, respectively, experienced disease intensification. There was no difference between the intervention and control groups in terms of intensification (intervention vs. control group odds ratio: 1.20; 95% confidence interval: [0.67, 2.15]), including when age, race, and disease severity were accounted for in the logistic regression model. Those whose study dates included time during the COVID-19 pandemic were evenly distributed between groups. CONCLUSIONS: A multifaceted intervention that improved medication adherence for glaucoma for 6 months did not affect the clinical outcomes measured at 12 months post-randomization. Twelve months may not be long enough to see the clinical effect of this intervention or more than 6 months of intervention are needed.

Evaluation of the IOP-Lowering Effect of a Multi-Pressure Dial at Different Negative Pressure Settings.

Purpose: To evaluate the intraocular pressure (IOP)-lowering effect of a multi-pressure dial (MPD) at targeted negative pressure settings. Methods: Prospective, intrasubject controlled study of 65 healthy subjects randomized to receive no negative pressure for 60 minutes or negative pressure application at designated levels of 25%, 50%, and 75% of baseline IOP for 20 minutes each. The main outcome measure was mean IOP with application of negative pressure. Results: In the study eye group, from a baseline IOP of 15.8 ± 3.6 mm Hg, the mean IOP was 13.5 ± 3.4, 11.5 ± 3.1, and 10.2 ± 2.7 mm Hg with negative pressure settings of 25%, 50% and 75%, respectively. In the control eye group, from a baseline IOP of 15.5 ± 3.0 mm Hg, the mean IOP values at the same time points, without negative pressure, were 15.6 ± 3.0, 15.5 ± 2.5 and 15.3 ± 2.4 mm Hg. The difference between the mean IOPs of the two groups was significantly different at all negative pressure settings (P < 0.001) in comparison with baseline. There was one minor adverse event, a corneal abrasion, that was unrelated to device wear. Conclusions: Negative pressure application to the periocular space with a multi-pressure dial can produce titratable IOP reduction while the device is worn with active negative pressure. To our knowledge, this technology represents the first nonpharmacologic, nonlaser, nonsurgical method for IOP reduction. Translational Relevance: This represents the first study demonstrating the IOP-lowering ability of the multi-pressure dial, a device that uses a novel IOP-lowering strategy by delivering negative pressure to the periocular region.

Treatment Outcomes Following Resident Performed Nonvalved (Baerveldt 350) Glaucoma Drainage Device Implantation.

PRECIS: When compared with outcomes by glaucoma specialists in several prospective studies, residents at the Durham Veterans Affairs Medical Center achieved comparable reductions in intraocular pressure (IOP) and failure rates during the year following Baerveldt drainage device implantation. PURPOSE: To review the outcomes of resident performed Baerveldt implantation through 1 year of postoperative management in a resident-run clinic. MATERIALS AND METHODS: The medical records of all veterans at the Durham Veterans Affairs Medical Center were searched to identify those with Baerveldt implantation by resident physicians from July 1, 2007 to June 30, 2017. Exclusion criteria include previous glaucoma tube or concurrent surgical intervention, including cataract extraction. All postoperative visits were reviewed and clinical data were collected. Failure was defined as 2 consecutive visits, starting at postoperative month (POM) 3, with IOP ≤5 mm Hg, or with IOP >21 mm Hg or <20% IOP reduction from baseline, reoperation for glaucoma, or loss of light perception. RESULTS: A total of 48 eyes were included with mean (SD) IOP and number of medications: baseline, 23.1 (6.7) mm Hg on 3.7 (1.0) medications; postoperative day 1, 20.5 (11.7) mm Hg on no medications; postoperative week 1, 14.3 (6.9) mm Hg and 1.9 (1.7) medications; POM1, 16.7 (6.4) mm Hg and 2.2 (1.5) medications; POM3, 15.1 (5.2) mm Hg and 2.1 (1.6) medications; POM6 12.8 (4.9) mm Hg and 2.8 (1.3) medications; POM12, 13.0 (4.0) mm Hg and 2.8 (1.4) medications. IOP decreased at all time intervals (P<0.01) but postoperative day 1 (P=0.15) while medication burden was reduced at every visit (P<0.01). Through 12 months, 8 patients (17%) failed with a time to failure of 9.2 (0.3) months. No patients underwent additional glaucoma surgical interventions or lost light perception. CONCLUSIONS: Residents can safely and efficaciously perform Baerveldt implantation, providing reassurance regarding the autonomy afforded residents in the operating room and clinic.

A randomized controlled trial of an online educational video intervention to improve glaucoma eye drop technique.

OBJECTIVE: To determine the effectiveness of an online video intervention in improving self-efficacy and eye drop application technique in glaucoma patients. METHODS: We randomized ninety-two patients with primary open-angle glaucoma, all who self-administer their eye drops, to either watch the 4-minute Meducation® eye drop technique video in the intervention group, or a nutrition video in the control group. We assessed five eye drop technique steps using objective video recordings at baseline, immediately after watching the video, and 1 month later. We used linear regression models to determine whether the intervention group had better self-efficacy and technique than the control group. RESULTS: Adjusted for baseline technique and other covariates, eye drop technique averaged 0.73 steps better in intervention patients than controls immediately after the video (p = 0.003) and 0.63 steps better at 1 month (p = 0.01). Adjusted for baseline self-efficacy, intervention patients had better eye drop technique self-efficacy than controls immediately after the video (p = 0.02) and at 1 month (p = 0.02). CONCLUSION: A short educational video can significantly improve glaucoma patients' short-term self-efficacy and eye drop technique. PRACTICE IMPLICATIONS: Videos may provide an inexpensive, convenient way to deliver eye drop technique education in any provider's office or online.

Identifying risk factors for blindness from primary open-angle glaucoma by race: a case-control study.

PURPOSE: To examine the factors associated with blindness from primary open-angle glaucoma (POAG) among black and white patients at our institution. PATIENTS AND METHODS: For this retrospective, case-control study, patients legally blind from POAG ("cases") were matched on age, race, and gender with non-blind POAG patients ("controls"). Thirty-seven black case-control pairs and 19 white case-control pairs were included in this study. Clinical variables were compared at initial presentation and over the course of follow-up. RESULTS: Black case-control pairs and white case-control pairs had similar characteristics at presentation, including cup-to-disc ratio and number of glaucoma medications. However, over the course of follow-up, black cases underwent significantly more glaucoma surgeries than matched controls (2.4 versus 1.2, p=0.001), whereas white cases and controls had no significant difference in glaucoma operations (0.9 versus 0.6, p=0.139). Our analysis found that glaucoma surgery is associated with blindness in black patients (odds ratio [OR] 1.6, 95% CI 1.1-2.2) but not in white patients (OR 1.5, 95% CI 0.7-3.2). CONCLUSION: Black and white case-control pairs with POAG shared similar risk factors for blindness at presentation. However, over the follow-up period, black cases required significantly more glaucoma surgeries compared to black controls, whereas there was no significant difference in surgery between white cases and controls. There was no difference in medication changes in either case-control set.

Risk Factors for Earlier Reexposure of Glaucoma Drainage Devices.

PURPOSE: The purpose of this study was to investigate factors associated with a second exposure of a glaucoma drainage device (GDD) following repair of an initial GDD exposure. MATERIALS AND METHODS: This IRB-approved retrospective cohort study examined the incidence of a second exposure of a GDD following initial repair for exposure. Logistic regression was performed to assess the relationship between demographic and clinical characteristics and a second exposure of the GDD. Kaplan-Meier survival curves were plotted and Cox regression was performed to examine factors impacting the time to a second GDD exposure. RESULTS: Ninety-four eyes of subjects that underwent initial revision for GDD exposure were reviewed. Approximately 44% (N=41/94) of subjects underwent surgical revision for a second exposure. Factors associated with reexposure in multivariate logistic regression included caucasian race (odds ratio, 2.99; P=0.02) and use of a nonscleral patch graft (odds ratio, 2.93; P=0.019). Time from revision of the initial exposure to reexposure was significantly shorter for those with a nonscleral patch graft (hazard ratio, 2.23; P=0.01) and caucasian race (hazard ratio, 2.08; P=0.04). CONCLUSIONS: Caucasian race and use of a nonscleral patch graft during revision surgery was associated with a higher risk of experiencing a sooner reexposure of the GDD following revision of an initial exposure. Future studies should examine whether particular graft materials increase the risk of GDD reexposure.

Eye Care Professionals' Perspectives on Eye Donation and an Eye Donation Registry for Research: A Single-Institution, Cross-Sectional Study.

PURPOSE: A centralized eye donation registry for research could help to bridge the gap between patients interested in donating their eyes to science and scientists who conduct research on human eye tissue. Previous research has demonstrated patient and family support for such a registry. In this study, we assessed the views that eye care professionals have toward an eye donation registry for research. MATERIALS AND METHODS: Surveys were distributed to all 46 clinical faculty members of the Duke University Eye Center. In addition to collecting demographic information, the surveys assessed clinicians' experience with discussing eye donation with patients, described the proposed eye donation registry for research and asked how the registry would affect the clinicians' practice. RESULTS: A total of 21 eye care professionals returned the survey. Thirty-three percent reported discussing eye donation with patients, and 43% reported that a patient has asked about donating their eyes for research on their disease. Eighty-six percent of eye care professionals reported that a centralized registry would improve the way they work with patients who express a desire to donate their eyes for research. CONCLUSIONS: The majority of eye care professionals at our academic institution indicated that an eye donation registry for research would improve how they work with patients who are interested in donating their eyes for research on their disease. Future research should examine how best to communicate this registry to ophthalmic patients.

Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence.

OBJECTIVE: To examine the associations of provider-patient communication, glaucoma medication adherence self-efficacy, and outcome expectations with glaucoma medication adherence. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Two hundred seventy-nine patients with glaucoma who were newly prescribed or taking glaucoma medications were recruited at 6 ophthalmology clinics. METHODS: Patients' visits were video recorded and communication variables were coded using a detailed coding tool developed by the authors. Adherence was measured using Medication Event Monitoring Systems for 60 days after their visits. MAIN OUTCOME MEASURES: The following adherence variables were measured for the 60-day period after their visits: whether the patient took 80% or more of the prescribed doses, percentage of the correct number of prescribed doses taken each day, and percentage of the prescribed doses taken on time. RESULTS: Higher glaucoma medication adherence self-efficacy was associated positively with better adherence with all 3 measures. Black race was associated negatively with percentage of the correct number of doses taken each day (ß = -0.16; P < 0.05) and whether the patient took 80% or more of the prescribed doses (odds ratio, 0.37; 95% confidence interval, 0.16-0.86). Physician education about how to administer drops was associated positively with percentage of the correct number of doses taken each day (ß = 0.18; P < 0.01) and percentage of the prescribed doses taken on time (ß = 0.15; P < 0.05). CONCLUSIONS: These findings indicate that provider education about how to administer glaucoma drops and patient glaucoma medication adherence self-efficacy are associated positively with adherence.

Risk factors for exposure of glaucoma drainage devices: a retrospective observational study.

OBJECTIVES: The purpose of this study was to identify risk factors for exposure of glaucoma drainage devices (GDD). SETTING: This retrospective, observational study was conducted in the eye clinic of an academic medical centre. PARTICIPANTS: Participants included 1073 consecutive adults who underwent GDD surgery between 1 January 2005 and 1 January 2011. Participants were included if chart review indicated GDD surgery during the study period and excluded if at least 12 months of clinical follow-up was not available in the medical record. PRIMARY OUTCOME MEASURE: The primary outcome measure was exposure of the GDD occurring at least 1 month after implant surgery. The characteristics of participants who experienced exposure of the implant were compared to the characteristics of participants who did not experience exposure. RESULTS: Of the 1073 participants having undergone GDD surgery, 67 experienced exposure of the device. Neither the type of GDD, type of patch graft (eye bank sclera, Tutoplast sclera and Tutoplast pericardium), surgeon, location of GDD, number of GDD previously implanted into the eye, nor history of diabetes or uveitis were associated with likelihood of exposure. Women were more likely than men to experience exposure of the GDD (OR 2.004 (95% CI1.170 to 3.431)) in both univariable (p=0.011) and multivariable (p=0.013) analyses. In survival analysis, exposure of the GDD occurred earlier for women than for men (58 vs 61 months; p=0.024).White race (vs black) was also associated with increased risk of GDD exposure (OR 1.693 (95% CI 1.011 to 2.833)) in univariable (p=0.044) and multivariable (p=0.046) analyses. CONCLUSIONS: Women are two times more likely to experience GDD exposure than men, independent of age. White race is also a risk factor for exposure.

Provider use of collaborative goal setting with glaucoma patients.

PURPOSE: The purpose of this preliminary study was to describe the extent to which providers used collaborative goal setting and individualized assessment with patients who were newly prescribed glaucoma medications. METHODS: English-speaking glaucoma suspect patients from six ophthalmology clinics who were newly prescribed glaucoma medications had their medical visits videotaped and were interviewed after the visits. The videotapes were transcribed and coded to examine provider use of collaborative goal setting and individualized assessment. RESULTS: Fifty-one patients seeing 12 ophthalmologists participated. Providers gave patients glaucoma treatment options during 37% of the visits; only five providers gave patients treatment options Providers asked for patient treatment preferences in less than 20% of the visits; only two providers asked for patient treatment preferences. Providers were significantly more likely to ask African American patients for their preferences or ideas concerning treatment than non-African American patients (Pearson χ² = 4.1, p = 0.04). Providers were also significantly more likely to ask African American patients about their confidence in using glaucoma medication regularly than non-African American patients (Pearson χ² = 8.2, p = 0.004). Providers asked about patient views about glaucoma in less than 20% of the visits; five providers asked patients their views on glaucoma and its treatment. Providers were significantly more likely to ask African American patients about their views on glaucoma than non-African American patients (Pearson χ² = 5.62, p = 0.02). CONCLUSIONS: Eye care providers often did not use collaborative goal setting or conduct individualized assessments of patient views on glaucoma when prescribing treatment for the first time.

Acquired central corneal thickness increase following removal of childhood cataracts.

PURPOSE: To evaluate central corneal thickness (CCT) in children with congenital/developmental cataracts before and after cataract removal, to correlate CCT with corneal diameters before cataract surgery in this same group, and to evaluate CCT over time in a separate group of children who were already aphakic or pseudophakic at study entry. DESIGN: Longitudinal study. METHODS: Children with cataract (Group 1, with pre-cataract-removal CCT) and aphakia/pseudophakia (Group 2, presenting after cataract removal) were included. CCT measurements were performed using ultrasound pachymetry. Normal fellow eyes of unilaterally affected cases served as controls. In bilateral cases, right eyes were used for analyses. RESULTS: Group 1 comprised 66 children. Before cataract surgery, unilateral cases (n = 31) showed similar CCT and strong association between the affected and fellow eyes (552.0 ± 32.9 µm vs 550.9 ± 40.4 µm, respectively; r(2) = 0.71, P = .0001). After cataract surgery, affected eyes (n = 13) showed mean CCT increase of 29.7 ± 43.1 µm (P = .03) while fellow eyes remained unchanged. Similarly, before cataract surgery, bilateral cases (n = 35) showed similar CCT between the right and left eyes. After cataract surgery, mean CCT increase was 27.4 ± 39.4 µm for first operated eyes of bilateral cases (n = 17, P = .01). Group 2 comprised 50 aphakic/pseudophakic children lacking pre-cataract-removal CCT. CCT was higher in eyes with glaucoma vs those without, at both first and last measurements (ΔCCT 58.9 ± 27.0 µm at first examination, P = .034, and 56.4 ± 27.1 µm at last examination, P = .043, respectively). There was no statistically significant CCT change over the study interval (median 28 months) for either Group 2 eyes with or those without glaucoma. CONCLUSIONS: CCT in children with cataracts increases after cataract surgery while the fellow eye remains stable. This increase seems to occur early after surgery, likely remaining stable thereafter, though glaucoma can accentuate the increase.

Health literacy and ophthalmic patient education.

In 1997, Ebrahimzadeh, Davalos, and Lee wrote in this journal that only 32% of the ophthalmic patient educational materials reviewed were written at or below the recommended eighth-grade reading level. Since that time, the National Assessment of Adult Literacy found that more than one-third of adult Americans possess only basic or below basic health literacy skills, defined as the ability to understand written information in a healthcare setting. Subsequently, investigators have shown that poor health literacy skills are associated with poor prescription medication adherence, increased hospital admissions, and increased mortality. We review the readability of currently available ophthalmic educational materials, with particular attention to the health literacy status of the patient population for which the materials are intended. Examples of prose at various readability levels are provided. Optimizing patient education and improving clinical outcomes requires understanding the attributes that the patient brings to the patient-physician relationship, including health literacy.

Combined fluocinolone acetonide intravitreal insertion and glaucoma drainage device placement for chronic uveitis and glaucoma.

PURPOSE: To determine whether a fluocinolone acetonide sustained-release intravitreal drug delivery system can be implanted safely at the same time that a glaucoma drainage device is placed for eyes with uveitis and elevated intraocular pressure (IOP) receiving maximum tolerated IOP-lowering therapy. DESIGN: Retrospective, observational case series. METHODS: Subjects had chronic noninfectious intermediate or posterior uveitis and elevated IOP while receiving maximum tolerated medical therapy. Fluocinolone acetonide implantation and glaucoma tube shunt placement were performed in a single surgical session. The main outcome measures were inflammatory recurrences, visual acuity (VA), use of adjunctive anti-inflammatory therapy, IOP, and adverse events. RESULTS: Seven eyes of 5 patients were studied. The average number of recurrences 12 months before implantation was 3 episodes per eye; of the 3 eyes followed up for more than 30 months, none had an inflammatory recurrence within 30 months after implantation. The mean Snellen visual acuity 12 months after the combined surgery was 20/114, compared with 20/400 at baseline. Adjunctive steroid use decreased. Average IOP decreased from 27.3 mm Hg at baseline to 14.6 mm Hg 12 months after the combined surgery (P = .019). CONCLUSIONS: The favorable results observed in all eyes suggest that fluocinolone acetonide implantation can be safely combined with glaucoma tube shunt placement in a single surgical session in eyes with uveitis and elevated IOP receiving maximum tolerated IOP-lowering therapy. Uveitis recurrences decreased, visual acuity improved, and IOP decreased. There were no adverse events during insertion of the fluocinolone acetonide implant and placement of the glaucoma tube shunt.