The Ophthalmology Surgical Competency Assessment Rubric for Trabeculectomy.

PURPOSE: To produce an internationally valid tool to assess skill in performing trabeculectomy surgery. METHODS: A panel of 5 experts developed a tool for assessing trabeculectomy surgery by using a modified Dreyfus scale of skill acquisition and providing descriptors for each level of skill for each category. The tool was then reviewed by a panel of 10 international content experts for their constructive comments, which were incorporated into the final rubric tool. RESULTS: A final rubric, incorporating the suggestions of the international panel, published here as the ICO-OSCAR: Trabeculectomy. CONCLUSIONS: The tool ICO-OSCAR: Trabeculectomy has content and face validity. It can be used internationally to assess trabeculectomy surgery skill. Predictive and construct validity, and reliability are yet to be determined.

Incidence and management of elevated intraocular pressure with antivascular endothelial growth factor agents.

PURPOSE: To review recent literature regarding ocular hypertension following intravitreal antivascular endothelial growth factors (anti-VEGF). METHOD: An electronic literature search was performed using MEDLINE, OVID, and PubMed. Key search terms were elevated IOP, anti-VEGF, sustained IOP elevation in anti-VEGF, chronic intraocular pressure elevation in anti-VEGF, high IOP with anti-VEGF, acute elevation in intraocular pressure with anti-VEGF, glaucoma and anti-VEGF. RESULT: Transient elevation of intraocular pressure after intravitreal anti-VEGF injection is due to temporary increase in volume, and the acute spike generally does not affect a healthy eye. Caution should be taken in a glaucomatous eye, and pretreatment with an IOP-lowering medication is recommended. Persistent elevation of intraocular pressure is more common than previously thought and may be correlated to several factors including increased number of intravitreal injections. CONCLUSION: Persistent ocular hypertension may be associated with intravitreal anti-VEGF injections. Physicians should be aware of this condition and monitor their patients for persistent ocular hypertension, especially in eyes with preexisting glaucoma. Prompt diagnosis and treatment can prevent potential loss of vision.

Comparison of intraocular pressure measurements and assessment of intraobserver and interobserver reproducibility with the portable ICare rebound tonometer and Goldmann applanation tonometer in glaucoma patients.

PURPOSE: The goals of our study were to analyze the correlation of rebound tonometer (RBT) and Goldmann applanation tonometer (GAT), assess the intraobserver and interobserver reproducibility of these tonometers, and investigate the influence of central corneal thickness (CCT) on intraocular pressure (IOP) measurements recorded with both tonometers in glaucoma patients under treatment. METHODS: In a prospective study of 65 eyes with glaucoma, IOP was measured using RBT and GAT, followed by measurements of CCT. RESULTS: A clear correlation between RBT and GAT was found (r=0.89, P<0.001). Bland-Altman analysis showed a mean difference of measurements by GAT and RBT of 2.45 mm Hg with 2 SD=4.24 mm Hg. Both tonometers were affected by CCT. High intraobserver correlation coefficients were found with both tonometers (0.981 and 0.979 for RBT for examiner 1 and examiner 2, respectively, and 0.989 for GAT for both examiners). Interobserver agreement appeared to be better with GAT when compared with RBT (variation coefficients were 4.6% for GAT and 7.1% for RBT). CONCLUSIONS: RBT may have a potential role and use in routine evaluation and management of glaucoma patients given its high correlation with GAT and high reproducibility in IOP measurements. As with GAT, measurements obtained with RBT are affected by CCT, reinforcing the role of pachymetry in glaucoma management.

Influence of pupil size and other test variables on visual function assessment using visual evoked potentials in normal subjects.

The purpose of this study was to assess the influence of pupil size and optical blur on measurements obtained with isolated-check visual evoked potential (icVEP). Two stimulus conditions of icVEP, +15 and -15% contrasts, were studied in normal subjects with normal (N), miotic (M), and dilated (D) pupils. The effects of optical blur were studied in subjects with normal pupil. Response to visual stimuli was quantified by a signal-to-noise (SNR) ratio. In 30 normal subjects, the mean age was 26.0 +/- 3.4 years. Mean pupil diameters were N = 4.2 +/- 0.6 mm, M = 2.7 +/- 0.6 mm, and D = 7.3 +/- 0.9 mm. For both +15 and -15% contrast levels, mean SNR values were reduced for dilated and constricted pupils when compared with normal pupils. Mean SNR values for optical blur with a +2 or +3 diopter lens placed over the distance correction were reduced when compared with SNR measurements obtained with best-corrected visual acuity under both +15 and -15% contrast levels. Statistical significance was found in comparisons of N versus M (P < 0.001) and N versus D (P = 0.002) for +15 and -15% contrast conditions, respectively. No statistical difference was seen for M versus D (P = -0.435). The effect of optical blur was statistically significant when compared to the normal pupils with best-corrected vision (P < 0.001). No statistically significant difference was found comparing +2 and +3 diopters lenses for optical blur testing. Visual evoked potential values are influenced by pupillary constriction and dilation, as well as optical blur. When obtaining icVEP measurements, the influence of pupil size and optical blur should be kept in mind for accurate interpretations.

Assessment of the Student Sight Savers Program methods for glaucoma screening.

PURPOSE: To assess methods used for glaucoma screening in the Student Sight Savers Program (SSSP), an initiative of the Friends of the Congressional Glaucoma Caucus Foundation that has screened individuals for glaucoma in the United States since 2001. METHODS: This was a prospective, case-control, clinic-based study (total N = 70). Patients with primary open-angle glaucoma and age- and sex-matched controls with no evidence of glaucoma or other ocular disease were evaluated with the SSSP screening method. Primary outcome measures were sensitivity, specificity, and positive predictive power for both low- and high-prevalence populations. RESULTS: Sensitivity and specificity values of the individual tests were 48.6% and 68.6% for family history of glaucoma, 22.1% and 78.6% for intraocular pressure (IOP), and 58.1% and 98.6% for frequency doubling technology (FDT) visual field (P = 0.03, chi-square). Specificity of FDT was significantly better than IOP (P < 0.001) and the questionnaire (P < 0.01) by z-test. When analyzing the overall screening criteria (positive screen was >or= 1 positive in the three tests), the sensitivity increased to 88.6% with reduction in specificity to 57.1%. The positive predictive power (PPP) for high-prevalence population was low for the overall screening criteria (15.4%) and highest for FDT as an individual (34.0%) or combined (41.0% to 45.3%) test. The medical student education and community awareness aspects of the program were not assessed. CONCLUSIONS: Of different methods used in the SSSP, FDT was the best single screening test, demonstrating high specificity but only moderate sensitivity. Use of multiple screening criteria resulted in slightly increased sensitivity and PPP over FDT, but decreased specificity.

Assessment of optic nerve cup-to-disk ratio changes in patients receiving multiple intravitreal injections of antivascular endothelial growth factor agents.

PURPOSE: To assess whether the transient intraocular pressure rise, frequent intraocular pressure fluctuations, or antivascular endothelial growth factor (VEGF) effects of repeated intravitreal injection of anti-VEGF agents can lead to changes in the optic nerve vertical cup-to-disk ratio (C/D). METHODS: Patients with a known history of glaucoma and those receiving triamcinolone acetonide were excluded from the study. Fundus photographs were cropped to optic disk images only, which were then randomized and independently graded by two glaucoma specialists. In patients who received treatments in only one eye, the fellow eye was used as a control. RESULTS: Twenty-three eyes of 21 patients met inclusion criteria. The mean change in C/D was -0.012 (95% confidence interval [CI], -0.053 to 0.029) for the treated group and -0.006 (95% CI, -0.106 to 0.095) for the control group, with no statistically significant difference (P = 0.90). The mean change in C/D for eyes receiving < or =5 injections (n = 9) was 0.003 (95% CI, -0.089 to 0.095) in the treated group and 0.054 (95% CI, -0.033 to 0.142) in the control group, with no statistically significant difference (P = 0.33). In eyes receiving >5 injections (n = 14), the mean change in C/D was -0.021 (95% CI, -0.095 to 0.052) in the treated group and -0.057 (95% CI, -0.231 to 0.116) in the control group, with no statistically significant difference (P = 0.70). CONCLUSION: There was no statistically significant change in the vertical C/D of optic nerves in patients receiving multiple intravitreal injections of anti-VEGF agents, regardless of whether they received fewer or more than five total injections. This suggests that the short-term intraocular pressure rise and frequent intraocular pressure fluctuation, as well as the anti-VEGF properties of these drugs, do not adversely change the optic nerve C/D. Additional prospective studies are warranted to confirm these conclusions.