Reusing Surgical Materials for Cataract Surgery: An Assessment of Potential Contamination.

PURPOSE: To evaluate microbiological cultures of cataract surgical devices and products that were reused for multiple cases. SETTING: Aravind Eye Hospital, Pondicherry, Tamil Nadu, India. DESIGN: Prospective cohort study. METHODS: Samples from multiple surgical instruments and products that were reused for consecutive cataract surgeries underwent bacterial and fungal cultures and were monitored alongside positive controls for 7 days. This included instruments that were processed using immediate use steam sterilization (IUSS) between cases (e.g., surgical cannulas, syringes, phacoemulsification and coaxial/bimanual irrigation and aspiration (IA) tips, phacoemulsification and IA sleeves) (Group 1), instruments that were used without sterilization between cases (e.g., phacoemulsification tubing/handpieces, coaxial IA handpieces) (Group 2) and the residual (unused) fluid from balanced salt solution bags after being used for multiple patients (Group 3). RESULTS: 3,333 discrete samples were collected from all 3 product groups that were reused across multiple patients. In all collected samples, no bacterial or fungal growth was observed. Of the 3,241 cataract surgeries that utilized reused and IUSS-sterilized instruments alongside instrument sets cultured on the same day and balanced salt solution bags shared across multiple patients, no eyes developed endophthalmitis over a 6-week follow-up period. CONCLUSION: Bacterial or fungal growth was not found in extensive microbiological cultures of IUSS-sterilized ophthalmic surgical instruments, and cataract surgical products that were reused in multiple patients. This microbiological data complements clinical endophthalmitis data from 2 million consecutive cases at the Aravind Eye Hospital, suggesting that their instrument and surgical supply processing practices may allow for safe and sustainable ophthalmic care.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery.

PURPOSE: To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE). DESIGN: Retrospective, sequential, clinical registry study. METHODS: 85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR. RESULTS: Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups. CONCLUSIONS: Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Reducing topical drug waste in ophthalmic surgery: multisociety position paper.

This position article on reducing topical drug waste with ophthalmic surgery was written by the Ophthalmic Instrument Cleaning and Sterilization Task Force, comprising representatives of the ASCRS, American Academy of Ophthalmology, American Glaucoma Society, and Outpatient Ophthalmic Surgery Society. Drug waste significantly increases the costs and carbon footprint of ophthalmic surgery. Surgical facilities should be permitted to use topical drugs in multidose containers on multiple patients until the manufacturer's labeled date of expiration, if proper guidelines are followed. Surgical patients requiring a topical medication not used for other patients should be allowed to bring that partially used medication home for postoperative use. These recommendations are based on published evidence and clarification of policies from multiple regulatory and accrediting agencies with jurisdiction over surgical facilities. Surveys suggest that most ambulatory surgery centers and hospitals performing cataract surgery are wasting topical drugs unnecessarily.

Incidence and Outcomes of Suprachoroidal Hemorrhage Following Aurolab Aqueous Drainage Implant in Adult and Pediatric Glaucoma.

PRCIS: Postoperative suprachoroidal hemorrhage (PSCH) is an infrequent but devastating complication after nonvalved aqueous drainage implant surgery and demonstrated a bimodal distribution. The final outcomes of either conservative management or surgical drainage of the hemorrhage remained poor. PURPOSE: The aim was to report the incidence and outcomes of eyes developing PSCH after undergoing Aurolab aqueous drainage implant (AADI) surgery for adult and pediatric refractory glaucomas. MATERIALS AND METHODS: In this retrospective series, case files of all patients who underwent AADI between May 2012 and December 2019 were retrieved from an electronic database. A PSCH was defined as the presence of hemorrhagic choroidal detachment, confirmed by ultrasound B scan, occurring in a closed system in the postoperative period. RESULTS: Of the 986 eyes that underwent AADI during the study period, 7 (0.7%), developed PSCH (95% confidence interval=0.3-1.6%). There were no differences in the preoperative parameters between those with and without PSCH. Of these, 4 were seen in pediatric eyes (4/288, 1.4%) and 3 in adult eyes (3/698, 0.4%) (P<0.01). Four eyes (57%) had PSCH in the immediate postoperative period (ie, between 24 and 48 h of AADI surgery), while the remaining 3 had onset ranging from 6 to 7 weeks after surgery. Anatomic risk factors were present in all eyes including hypotony (n=4), myopia (n=3), microcornea (n=2), microphthalmos (n=1), postvitrectomy (n=1), and staphyloma (n=1). Visual acuity improved in only 1 (14%) eye while 3 (43%) eyes developed phthisis bulbi, all in the pediatric age group. CONCLUSIONS: PSCH is a rare complication following AADI and is seen in <1% eyes. The incidence is higher in the pediatric age group. Visual and anatomic outcomes are dismal following PSCH with globe salvage possible in only about half these eyes.

Comparison of outcomes between Aurolab aqueous drainage implant placed in the superotemporal versus inferonasal quadrant.

AIM: To determine the outcomes of Aurolab aqueous drainage implant (AADI) placed in the superotemporal versus the inferonasal quadrant in adult eyes with refractory glaucoma. METHODS: This was a retrospective study of eyes that had AADI placement and completed a minimum of 2-year follow-up. The choice of the quadrant was at the surgeon's discretion and mainly depended on the amount of scarring and conjunctival mobility. The cumulative failure rate of the AADI was defined as intraocular pressure (IOP) >21 mm Hg or not reduced by 20% below baseline on two consecutive follow-up visits after 3 months, IOP ≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for glaucoma or a complication, or loss of light perception vision. RESULTS: We included 84 eyes with AADI in the inferonasal quadrant versus 69 eyes in the superotemporal quadrant. A significant drop in IOP was seen in both groups (18.4±10.4 mm Hg in the inferonasal group vs 17.7±11.1 mm Hg in the superotemporal group; p=0.63) at 3-month follow-up and this was maintained until last follow-up. Best-corrected visual acuity, IOP, number of IOP-lowering medications and complications were similar between the two groups at all time points. The cumulative success rate at 2-year follow-up without IOP-lowering medications was 57.1% (47.1%-68.1%) in the inferonasal group and 50.7% (39.8%-63.1%) in the superotemporal group (p=0.47). CONCLUSIONS: Inferonasal AADI placement appears to be an equally safe and effective surgical option compared with superotemporal AADI placement and may be helpful in certain clinical situations.

The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings.

PURPOSE: We compared rates of intraocular lens (IOL) decentration, neodymium-doped yttrium aluminum garnet capsulotomy for posterior capsule opacification (PCO), and visual acuity (VA) in eyes with and without pseudoexfoliation (PEX) 5 years after undergoing cataract surgery. DESIGN: Prospective comparative interventional study. METHODS: This multicenter study population included 1 eye of both 930 cataract patients with and 470 cataract patients without uncomplicated PEX (no small pupils or phacodonesis) all undergoing phacoemulsification by experienced Aravind Eye Care System surgeons. Eyes were randomized to either 1- or 3-piece intraocular lenses (IOLs). PEX eyes were also randomized to either receive or not receive a capsule tension ring. The main outcome measures included IOL decentration and PCO. Secondary outcomes included postoperative best-corrected VA. RESULTS: Follow-up was 86.2% in the PEX group and 86.7% in the control group at 5 years. The PEX group was older (P < .001) and had more men (P = .01). IOL decentration at 5 years was equally prevalent in PEX and control eyes (1.0% vs 1.1%, respectively, P = .8). Neodymium-doped yttrium aluminum garnet posterior capsulotomy rates for PCO were similar in the PEX group when compared with control subejcts (5.3% compared with 3.2%, respectively, P = .07). Best corrected VA was better at baseline and years 2 and 3 in the control group (P = .0001, P = .0005, and P = .02); however, there was no difference in BCVA at years 1, 4, and 5 between the PEX and control groups (P = .09, P = .29, and P = .5). CONCLUSION: In a large-scale, long-term, prospective comparative study of cataract surgery in eyes with uncomplicated PEX, the risks of IOL decentration and PCO were low and comparable to that in control subjects. When approaching cataract surgery in eyes with relatively uncomplicated PEX, neither IOL choice (1- vs 3-piece acrylic IOL) nor the presence/absence of a capsule tension ring affects outcomes at 5 years.

Intermediate-term outcomes of Aurolab aqueous drainage implant in refractory paediatric glaucoma.

AIM: To report the intermediate-term outcomes of Aurolab aqueous drainage implant (AADI) surgery in paediatric eyes with refractory glaucoma. METHODS: Case records of patients below 18 years, who underwent AADI surgery between 2012 and 2015 with >2 years follow-up, were analysed. The intraocular pressure (IOP), visual acuity, number of antiglaucoma medications, complications and resurgery if any were recorded at baseline, day 1and then at months 1, 3, 6, 9, 12, 18, 24 and at the last visit. Failure was defined as IOP >18 mm Hg or not reduced by at least 30% below baseline, IOP ≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for a complication or loss of light perception vision. RESULTS: 101 eyes of 101 patients were included with a mean age of 10.4±4.7 years at the time of surgery and a mean follow-up of 40.9±15.1 months. Glaucoma following cataract surgery was the most common type of glaucoma (n=31, 30%), followed by primary congenital glaucoma (n=29, 29%). The cumulative probability of failure was 15.8% (95% CI 10.1% to 24.5%) at 1 year, 22.7% (95% CI 15.7% to 32.2%) at 2 years, 42.5% (95% CI 32.6% to 53.9%) at 3 years and 62.1% (95% CI 49.5% to 74.8%) at the 4 years time point. CONCLUSION: The AADI showed excellent success until 2 years after surgery in paediatric eyes after which failure rates increased. Further prospective studies with longer follow-up are required to evaluate the long-term success of the AADI for paediatric glaucomas.

Rho-Associated Kinase Inhibitors: Evolving Strategies in Glaucoma Treatment.

Glaucoma, a group of progressive optic neuropathies with similar patterns of tissue loss, is primarily treated with medical therapy, followed by laser therapy and, later, incisional surgery. Aside from the introduction of prostaglandin analogs, topical carbonic anhydrase inhibitors, and topical alpha-agonists in the 1990s, no new pharmaceutical agents to lower intraocular pressure (IOP) have been introduced for approximately 20 years. The Rho kinase inhibitors represent a new class of glaucoma medications that inhibit the downstream pathway of the Rho family of small G-proteins to increase outflow from the conventional (trabecular) outflow pathway in the eye. Several of these Rho kinase inhibitors, ripasudil and netarsudil, have recently reached the market and are used in clinical practice in several countries. A fixed-dose combination of latanoprost and netarsudil was also very recently approved (2019) by the US FDA. Several other novel agents are undergoing clinical trials. These drugs are poised to act as adjuncts to already established medical therapy for further lowering of IOP in the treatment of glaucoma.

The Aravind Pseudoexfoliation Study: Surgical and First-Year Postoperative Results in Eyes without Phacodonesis and Nonmiotic Pupils.

PURPOSE: To compare intraoperative complication rates, 1-year visual outcomes, and postoperative complication rates over the first postoperative year in eyes with and without pseudoexfoliation undergoing cataract surgery. DESIGN: Prospective, comparative, interventional study. PARTICIPANTS: Nine hundred thirty eyes with cataract and uncomplicated pseudoexfoliation (without phacodonesis, clinically shallow anterior chambers, or pupil size <4 mm) and 476 controls with cataract but without pseudoexfoliation recruited from 4 centers of the Aravind Eye Care System in Southern India. The 2 groups were randomized separately to receive either a single-piece acrylic intraocular lens (IOL; SA60AT; Alcon Laboratories, Fort Worth, TX) or a 3-piece acrylic IOL (MA60AS; Alcon Laboratories). The pseudoexfoliation group also was randomized to receive or not receive a capsular tension ring. METHODS: All eyes underwent phacoemulsification with IOL implantation and were followed up at 1 day, 1 month, 3 months, and 1 year after surgery. MAIN OUTCOME MEASURES: Association of pseudoexfoliation status with intraoperative complication rates, 1-year best-corrected visual acuity, and any other complications. RESULTS: Mean ages were 63.0±6.9 years and 57.9±7.3 years in the pseudoexfoliation and control groups, respectively (P < 0.001). Pseudoexfoliation patients were more likely to be men (P = 0.014), to have a nuclear opalescence grade of more than 4 (P = 0.001), and to have a pupil size of less than 6 mm (P < 0.001) when compared with controls. Intraoperative complication rates were 2.9% and 1.9% in the pseudoexfoliation and control groups, respectively (P = 0.29). One-year postoperative best-corrected visual acuity was comparable (P = 0.09). Complication rates at 1 year were 2.7% and 2.5% in the pseudoexfoliation and control groups, respectively (P = 0.82). Average endothelial cell loss was 14.7% in the pseudoexfoliation group and 12.7% in the control group at 1 year (P = 0.066) when adjusting for age and nuclear opacity. CONCLUSIONS: Pseudoexfoliation eyes without shallow anterior chamber, small pupils, or apparent zonulopathy may represent eyes with lower risks of complications. Despite smaller pupils and denser cataracts, pseudoexfoliation eyes without clinically apparent preoperative zonulopathy were not at a higher risk of intraoperative or postoperative complications or worse visual outcomes after cataract surgery.

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.

Waste generated during glaucoma surgery: A comparison of two global facilities.

PURPOSE: We measured waste from glaucoma surgeries at an eye care facility in Southern India and compared these results to a community hospital in the United States. METHODS: The waste produced in the glaucoma operating room at Aravind Eye Hospital, Madurai, India from June 22 to July 15, 2015 was weighed and compared to the waste produced in the glaucoma surgical clinic in a Baltimore-area community hospital from one day of surgeries in August 2015. RESULTS: The average waste produced per trabeculectomy at Aravind was 0.5 ±â€¯0.2 kg, compared to an average of 1.4 ±â€¯0.4 kg per trabeculectomy (p < 0.05) at the Baltimore-area hospital. Waste from device surgeries and trabeculectomy with phacoemulsification was also quantified at Aravind, with averages of 0.4 ±â€¯0.2 kg and 0.7 ±â€¯0.2 kg respectively. CONCLUSIONS AND IMPORTANCE: The amount of waste per trabeculectomy at the Aravind Eye Hospital was significantly lower than the waste per trabeculectomy in the Baltimore-area hospital, even though the used and the apparent complication rates between Aravind and American eye hospital are comparable. Given efforts to decrease the environmental impact of health care, it is necessary to examine the waste produced from surgeries to determine if policy and legal changes in the United States could decrease surgical waste while not affecting the surgical complication rate.

A Worldwide Price Comparison of Glaucoma Medications, Laser Trabeculoplasty, and Trabeculectomy Surgery.

Importance: Medical and surgical interventions for glaucoma are effective only if they are affordable to patients. Little is known about how affordable glaucoma interventions are in developing and developed countries. Objective: To compare the prices of topical glaucoma medications, laser trabeculoplasty, and trabeculectomy relative with median annual household income (MA-HHI) for countries worldwide. Design, Setting and Participants: Cross-sectional observational study. For each country, we obtained prices for glaucoma medications, laser trabeculoplasty, and trabeculectomy using government pricing data, drug databases, physician fee schedules, academic publications, and communications with local ophthalmologists. Prices were adjusted for purchasing power parity and inflation to 2016 US dollars, and annual therapy prices were examined relative to the MA-HHI. Interventions costing less than 2.5% of the MA-HHI were considered affordable. Main Outcomes and Measures: Daily cost for topical glaucoma medications, cost of annual therapy with glaucoma medications, laser trabeculoplasty, and trabeculectomy relative to MA-HHI in each country. Results: Data were obtained from 38 countries, including 17 developed countries and 21 developing countries, as classified by the World Economic Outlook. We observed considerable variability in intervention prices compared with MA-HHI across the countries and across interventions, ranging from 0.1% to 5% of MA-HHI for timolol, 0.1% to 27% for latanoprost, 0.2% to 17% for laser trabeculoplasty, and 0.3% to 42% for trabeculectomy. Timolol was the most affordable medication in all countries studied and was 2.5% or more of MA-HHI in only 2 countries (5%). The annual cost of latanoprost was 2.5% or more of MA-HHI in 15 countries (41%) (15 developing countries [75%] and no developed countries). The cost of laser trabeculoplasty was 2.5% or more of the MA-HHI in 15 countries (44%) (11 developing countries [65%] and 4 developed countries [24%]). The cost of trabeculectomy was 2.5% or more of the MA-HHI in 28 countries (78%) (18 developing countries [95%] and 10 developed countries [59%]). In 18 countries (53%), laser trabeculoplasty cost less than a 3-year latanoprost supply. Conclusions and Relevance: For many patients worldwide, the costs of medical, laser, and incisional surgical interventions were 2.5% or more of the MA-HHI. Successfully reducing global blindness from glaucoma requires addressing multiple contributing factors, including making glaucoma interventions more affordable.

Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility.

PURPOSE: To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting. SETTING: Two tertiary care centers of the Aravind Eye Care System in southern India. DESIGN: Observational case series. METHODS: Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents). RESULTS: Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions. CONCLUSIONS: Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.

New pharmacotherapy for the treatment of glaucoma.

INTRODUCTION: Glaucoma is the second leading cause of blindness in the world and current pharmacotherapies for glaucoma have remained relatively unchanged (with the exception of fixed combinations of previously available medications) since the mid-1990s with the development of prostaglandin analogues. Now, with both new formulations and new classes of medications with novel mechanisms of action, the medical therapy of glaucoma may be heralding a new dawn in medical management. Areas covered: This review outlines new topical therapies for intraocular pressure (IOP) lowering treatment, in addition to new formulations, preservative-free options, and advances in glaucoma medical therapy delivery. We performed a comprehensive search for published studies for glaucoma medical therapy using the electronic database PubMed. A manual search for each therapy or delivery system was also performed. Expert commentary: These advances in glaucoma therapy have the potential to overcome many barriers to glaucoma's medical care, particularly in terms of adherence. However, both time and research are needed to prove the relative efficacy and safety of these new pharmacotherapies and products, helping us decide their role in the treatment of elevated intraocular pressure. We are hopeful that these new developments in therapy may bring more options for glaucoma medical therapy.

Glaucoma Screening in Nepal: Cup-to-Disc Estimate With Standard Mydriatic Fundus Camera Compared to Portable Nonmydriatic Camera.

PURPOSE: To compare cup-to-disc ratio (CDR) measurements from images taken with a portable, 45-degree nonmydriatic fundus camera to images from a traditional tabletop mydriatic fundus camera. DESIGN: Prospective, cross-sectional, comparative instrument validation study. METHODS: Setting: Clinic-based. STUDY POPULATION: A total of 422 eyes of 211 subjects were recruited from the Tilganga Institute of Ophthalmology (Kathmandu, Nepal). Two masked readers measured CDR and noted possible evidence of glaucoma (CDR ≥ 0.7 or the presence of a notch or disc hemorrhage) from fundus photographs taken with a nonmydriatic portable camera and a mydriatic standard camera. Each image was graded twice. MAIN OUTCOME MEASURES: Effect of camera modality on CDR measurement; inter- and intraobserver agreement for each camera for the diagnosis of glaucoma. RESULTS: A total of 196 eyes (46.5%) were diagnosed with glaucoma by chart review; 41.2%-59.0% of eyes were remotely diagnosed with glaucoma over grader, repeat measurement, and camera modality. There was no significant difference in CDR measurement between cameras after adjusting for grader and measurement order (estimate = 0.004, 95% confidence interval [CI], 0.003-0.011, P = .24). There was moderate interobserver reliability for the diagnosis of glaucoma (Pictor: κ = 0.54, CI, 0.46-0.61; Topcon: κ = 0.63, CI, 0.55-0.70) and moderate intraobserver agreement upon repeat grading (Pictor: κ = 0.63 and 0.64, for graders 1 and 2, respectively; Topcon: κ = 0.72 and 0.80, for graders 1 and 2, respectively). CONCLUSIONS: A portable, nonmydriatic, fundus camera can facilitate remote evaluation of disc images on par with standard mydriatic fundus photography.

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy.

PURPOSE: To analyze predictors of image quality for a handheld nonmydriatic fundus camera used for screening of vision-threatening diabetic retinopathy. METHODS: An ophthalmic photographer at an Aravind Eye Hospital obtained nonmydriatic and mydriatic fundus images from 3 fields in 275 eyes of 155 participants over 13 months using a Smartscope camera (Optomed, Oulu, Finland) and a Topcon tabletop fundus camera (Topcon, Tokyo, Japan). Two fellowship-trained retina specialists graded the images. Repeated-measures logistic regression assessed predictors of the main outcome measure: gradability of the fundus images. RESULTS: Of 2,475 images, 76.2% of the Smartscope nonmydriatic images, 90.1% of the Smartscope mydriatic images, and 92.0% of the Topcon mydriatic images were gradable. Eyes with vitreous hemorrhage (OR = 0.24, p < 0.0001) or advanced cataract (OR = 0.08, p < 0.0001) had decreased odds of image gradability. Excluding eyes with cataract or vitreous hemorrhage, nonmydriatic macular image gradability improved from 68.4% in the first set of 55 eyes to 94.6% in the final set of 55 eyes. CONCLUSION: With sufficient training, paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera, particularly in patients with clear lenses and clear ocular media.