Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): optometric exam improves access and utilization of eye care services.

PURPOSE: To describe the benefits of optometric evaluation for detection of vision-affecting conditions in the context of community-based eye health screenings and identify factors associated with having a recent dilated eye exam. METHODS: Enrolled participants were age 40 and older, living independently in affordable housing developments in New York City. Eye health screening failure and criteria for seeing the on-site study optometrist were defined as visual acuity 20/40 or worse in either eye, intraocular pressure 23-29 mmHg, or an unreadable fundus image. The optometrist conducted a manifest refraction using loose lenses and used a portable slit lamp and ophthalmoscope to perform a non-dilated anterior and posterior segment ocular health evaluation. Demographics, social determinants of health, eye health screening results, and rates of suspected ophthalmic conditions were recorded. To determine factors associated with having a recent dilated eye exam, which was the main outcome for this statistical analysis, a stepwise multivariate logistic regression was performed. RESULTS: A total of 708 participants were screened, 308 attended the optometric exam; mean age 70.7 ± 11.7 [standard deviation (SD)] years. Among this subgroup, 70.1% identified as female, 54.9% self-identified as African American, 39% as Hispanic/Latino, and 26.6% Dominican ethnicity; 78.2% (241/308) had not undergone a dilated eye exam within the last year, 71.4% reported they did not have an eye care provider. Stepwise multivariate logistic regression analysis indicated that participants who self-reported having cataracts (odds ratio (OR) 2.15; 95% confidence interval (CI) 1.03-4.47; p = 0.041), self-reported having glaucoma/glaucoma suspect (OR 5.60; 95% CI 2.02-15.43; p = 0.001), or spoke Spanish as their primary language (OR 3.25; 95% CI 1.48-7.11; p = 0.003) had higher odds of having a recent dilated eye exam. CONCLUSIONS: This community-based screening initiative demonstrated the effectiveness of optometric exams in detecting vision-affecting conditions and identified factors associated with having a recent dilated eye exam. Optometrists play a vital role in increasing access to eye care for high-risk, underserved populations. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04271709).

Manhattan Vision Screening and Follow-Up Study: (NYC-SIGHT)Tele-Retinal Image Findings and Importance of Photography.

Purpose: To describe tele-retinal abnormality image findings from the Manhattan Vision Screening and Follow-up Study (NYC-SIGHT), which aims to investigate whether community-based eye health outreach strategies using telemedicine can improve visual outcomes among at-risk populations in Upper Manhattan. Methods: A 5-year prospective, cluster-randomized clinical trial was conducted. Eligible individuals aged 40 years and older were recruited from affordable housing developments and senior centers in New York City. Participants underwent on-site eye health screening (best-corrected visual acuity, intraocular pressure [IOP] measurements, and fundus photography). Fundus images were graded via telemedicine by a retina specialist. Multivariate logistic regression modeling was used to assess the factors associated with abnormal retinal findings requiring referral to ophthalmology. Results: Participants with a retinal abnormality on fundus photography (n = 157) were predominantly older adults, with a mean age of 68.4 ± 11.1 years, female (63.7%), African American (50.3%), and Hispanic (43.3%). A total of 32 participants in our study passed the vision and IOP screening but had an abnormal retinal image and ocular pathology that would have been missed without fundus photography. Individuals who self-identified as having preexisting glaucoma (odds ratio [OR] = 3.749, 95% confidence interval [CI] = 1.741-8.074, p = 0.0001) and had severe vision impairment (OR = 4.1034, 95% CI = 2.0740-8.1186, p = 0.000) at the screening had significantly higher odds of having an abnormal retinal image. Conclusion: This community-based study targeted populations at-risk for eye disease, improved access to eye care, detected a significant number of retinal image abnormalities requiring follow-up by using telemedicine, and provided evidence of the importance of fundus photography during eye health screenings. CTR number: NCT04271709.

Identifying Rapid Glaucoma Progression Using Hemifield Rates of Progression.

PRCIS: Hemifield rates of progression are more sensitive to focal progression (or faster progression) than global rates. This can aid in tailoring management and treatment decisions. PURPOSE: To determine if the rate of progression (ROP) of each hemifield of the 24-2 visual field (VF) aids in the detection of rapidly progressing eyes. METHODS: In this retrospective longitudinal study, we evaluated 1658 eyes of 1658 consecutive glaucoma patients with global mean deviation (MD) VF loss between -3 and -15 dB at baseline and ≥8 reliable VF tests (Swedish Interactive Thresholding Algorithm 24-2) with over ≥3 years of follow-up. The ROP (dB/year) based on global MD, superior hemifield MD, and inferior hemifield MD was calculated. The worst hemifield ROP (ROPworst) and hemifield ROP absolute difference (ROPdiff) were determined for each eye. Eyes were categorized based on the ROP from each metric as slow (-0.5 dB/year or better), rapid (worse than -0.5 dB/year), very rapid (worse than -1.0 dB/year), and catastrophic (worse than -2.0 dB/year) progression. The rate of significant asymmetric hemifield progression rate (ROPdiff ≥0.5 dB/year) was also evaluated. RESULTS: On average, ROPworst was faster than ROPglobal by 0.25±0.3 dB/year ( P <0.001). Based on ROPworst, 422 eyes (25%) were classified as progressing more rapidly than the ROPglobal classification. Over 40% (153/339) of the eyes classified as rapid progressors by ROPglobal were classified as very rapid or catastrophic progressors based on ROPworst. Eyes that progressed more rapidly based on ROPworst also had a higher rate of asymmetric progression. CONCLUSION: Hemifield ROPs are more sensitive to focal progression (or faster progression) than global rates and can aid in tailoring management and treatment decisions.

Improving glaucoma staging in clinical practice by combining the ICD-10 glaucoma severity classification system and optical coherence tomography.

OBJECTIVE: The International Classification of Disease, 10th revision (ICD-10) codes used for glaucoma severity classification are based on the 24-2 visual-field (VF) test. This study aim was to assess the added value of providing clinicians with optical coherence tomography (OCT) data, in addition to functional data, for glaucoma staging in clinical practice. EXPOSURE: Disease classification was determined for 54 glaucoma eyes, according to the principles of the ICD-10 guidelines. Eyes were independently graded in a masked fashion using the 24-2 VF test and 10-2 VF test, with and without OCT information. The reference standard (RS) for severity was determined using a previously published automated structure-function topographic agreement for glaucomatous damage using all available information. RESULTS: The RS classified eyes as mild, moderate and advanced in 3, 16 and 35 cases, respectively. Individual and combined 24-2 and 10-2 based gradings were significantly different from the RS (all P < 0.005), with Kappa agreements of 0.26, 0.45 and 0.42 respectively (P < 0.001). Classifications using OCT combined with either of the VF were not-significantly different from the RS (P > 0.3) with Kappa agreements of 0.56 and 0.57 respectively (P < 0.001). Combining 24-2 with OCT had less severity overestimations while 10-2 with OCT had fewer underestimations. CONCLUSION: Combining OCT and VF data provides better staging of glaucoma severity than VF data alone. The 24-2 and OCT combination seems most appropriate given the high concordance with the RS and less overestimation of severity. Incorporating structural information into disease stages allows clinicians to set more appropriate severity-based treatment targets for individual patients.

Association of Psychosocial Factors with Activation Among Patients with Glaucoma.

OBJECTIVE: To investigate the association of psychosocial factors with health self-management behaviors and beliefs among patients with primary open-angle glaucoma (POAG). DESIGN: Prospective cross-sectional cohort study. PARTICIPANTS: Patients (n = 202) with mild, moderate, or advanced bilateral POAG. METHODS: Patients (N = 1164) were identified from electronic medical records at a single academic medical center. Letters soliciting participation were mailed to 591 randomly selected potential participants. Psychometric measures and a social determinants of health questionnaire were administered by phone to 202 study participants. MAIN OUTCOME MEASURES: The National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ), the Multidimensional Health Locus of Control (MHLC), the Perceived Medical Condition Self-Management Scale-4, the Patient Health Questionnaire-9 (PHQ), the Patient Activation Measure-13 (PAM), a health literacy question, and a social determinants of health questionnaire. RESULTS: For each increase in level of POAG severity, there was a decrease in mean NEI-VFQ score (P < 0.001). For each unit increase in NEI-VFQ item 1, self-rated vision, mean PAM score increased (R2 = 5.3%; P = 0.001; 95% confidence interval [CI], 0.077-0.276). For each unit increase in "Internal" on the MHLC, mean PAM score increased (R2 = 19.3%; 95% CI, 0.649-1.166; P < 0.001). For each unit increase in "Doctors" on the MHLC, mean PAM score increased (R2 = 11.0%; 95% CI, 1.555-3.606; P < 0.001). For each unit increase in "Chance" on the MHLC, mean PAM score decreased (R2 = 2.6%; 95% CI, -0.664 to -0.051; P = 0.023). On multivariate analysis, adjusting for age, sex and race, for each unit increase in PHQ, mean PAM score decreased (95% CI, 0.061-1.35; P = 0.032); for each unit increase in MHLC "Doctors", mean PAM score increased (95% CI, -1.448 to 3.453; P < 0.001); for each unit increase in MHLC "Internal", mean PAM score increased (95% CI, 0.639-1.137; P < 0.001); for each unit increase in MHLC "Chance", mean PAM score decreased (95% CI, -0.685 to -0.098; P = 0.009). CONCLUSIONS: We identified modifiable behavioral factors that could increase patients' self-perceived ability and confidence to manage their own eye care. Locus of control (MHLC), level of depression (PHQ), and self-rated functional vision (NEI-VFQ) were each associated with patient behaviors, attitudes, and beliefs needed for health self-management (activation, assessed by the PAM) and may be important determinants of adherence behaviors. Targeting change in patients' care beliefs and behaviors may improve activation and treatment outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Detecting Established Glaucoma Using OCT Alone: Utilizing an OCT Reading Center in a Real-World Clinical Setting.

Purpose: We evaluated the ability of an optical coherence tomography (OCT)-based reading center for glaucoma (ORG) to detect established glaucoma using OCT alone. Methods: This study included eyes from 70 consecutive patients with established glaucoma (i.e. moderate or severe glaucoma according to the International Classification of Diseases [ICD]-10 guidelines) and 20 consecutive healthy subjects, who had no evidence of glaucomatous optic neuropathy (GON) or visual field (VF) loss in either eye. Using a standardized ORG quality assessment, 33 eyes were excluded due to media opacity (12), poor image quality (13), or epiretinal membrane (8). Of the remaining 147 eyes, 86 had established glaucoma and 36 were from healthy controls (total n = 122). Based on the OCT report alone and applying a previously described evaluation method, the presence of GON in each eye was determined by two masked ORG graders. The main outcome measures were sensitivity and specificity for detection of eyes with established glaucoma. Results: Of the 86 eyes with established glaucoma (average mean deviation [MD] = -10.9 ± 7.7 dB, range = -0.5 to -31.5 dB), only one eye (MD = -0.46) was missed (sensitivity = 98.8%). However, the other eye of this patient was correctly classified as GON. Therefore, at a patient level, sensitivity was 100%. None of the 36 healthy eyes was classified as GON by the ORG (specificity = 100%). Conclusions: An OCT-based reading center is able to identify eyes with established glaucoma using OCT alone with high sensitivity and specificity. Translational Relevance: Our study validates the use of a systematic OCT-based approach for glaucoma detection in a real-world setting.

Manhattan Vision Screening and Follow-up Study (NYC-SIGHT): Vision and refractive error results.

CLINICAL RELEVANCE: Optometrists can play a key role in providing access to eye care in underserved populations by organising community-based eye health screenings that include optometric exams to detect vision impairment and uncorrected refractive error. BACKGROUND: Community-based eye health screenings and optometric exams were conducted in the NYC-SIGHT Study. METHODS: A sub-analysis of vision impairment and refractive error results within a 5-year prospective, cluster-randomised clinical trial. Eligible individuals (age ≥40 years) were recruited from 10 affordable housing developments in Upper Manhattan. Developments were randomised into usual care (received glasses prescription only) and intervention (free glasses) groups. Participants with 6/12 visual acuity or worse, intraocular pressure 23-29 mmHg, or an unreadable fundus image were scheduled with the study optometrist for refraction and a non-dilated exam. Visual improvement data were obtained by comparing the presenting acuity at screening compared to the best corrected acuity after refraction by the optometrist. Chi-square, two-sample t-tests, and a stepwise multivariate logistic regression model were used to determined factors associated with improvable visual impairment. RESULTS: Seven hundred and eight participants completed screening, 308 received an optometric exam. Those with improvable vision impairment (n = 251), mean age: 69.8 years, 70.5% female, 53% African American, 39.8% Hispanic, >95% had health insurance. Refractive error diagnosed in 87.8% of the participants; lines of improvement: 2 lines (n = 59), 3 to 5 lines (n = 120), and ≥6 lines (n = 72). Stepwise multivariate logistic regression analysis showed that participants with visual acuity 6/12 or worse (odds ratio 16.041, 95% confidence interval 6.009 to 42.822, p = 0.000) or a normal fundus image (odds ratio 2.783, 95% confidence interval 1.001 to 7.740, p = 0.05) had significantly higher odds of improvable vision impairment. CONCLUSION: This innovative, targeted community-based study included an optometrist who detected high rates of refractive error and improvable vision impairment in an underserved population living in New York City.

Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): Subanalysis of Referral to Ophthalmology.

PURPOSE: The Manhattan Vision Screening and Follow-up Study aims to provide access to eye care for underserved populations, detect native rates of ocular pathology, and refer participants with eye disease to ophthalmology. This subanalysis describes the reasons for referral to ophthalmology and identifies risk factors associated with being referred. METHODS: Enrolled participants were aged ≥40 years, living independently in public housing developments and able to provide consent for eye health screenings. Those with habitual visual acuity 20/40 or worse, intraocular pressure (IOP) 23-29 mmHg, or an unreadable fundus image failed and were scheduled with the on-site optometrist. The optometric exam determined whether further referral to ophthalmology for a clinic exam was warranted. Those with an abnormal image or IOP ≥30 mmHg were referred directly to ophthalmology. Main outcome was factors associated with referral to ophthalmology. RESULTS: A total of 708 individuals completed the eye health screening over 15 months. A total of 468 participants were referred to ophthalmology (250 had an abnormal image and 218 were referred by the optometrist). Those referred were predominantly older adults (mean age 70.0 ± 11.4 years), female (66.7%), African American (55.1%) and Hispanic (39.5%). Seventy percent of participants had not had a recent eye exam. Stepwise multivariate logistic regression analysis showed that participants with pre-existing glaucoma (OR 3.14, 95% CI 1.62 to 6.08, p = 0.001), an IOP ≥23 mmHg (OR 5.04, 95% 1.91 to 13.28, p = 0.001), or vision impairment (mild) (OR 2.51, 95% CI 1.68 to 3.77, p = 0.001) had significantly higher odds of being referred to ophthalmology. CONCLUSION: This targeted community-based study in Upper Manhattan provided access to eye care and detected a significant amount of ocular pathology requiring referral to ophthalmology in this high-risk population.

Manhattan Vision Screening and Follow-up Study (NYC-SIGHT): a nested cross-sectional assessment of falls risk within a cluster randomised trial.

BACKGROUND: To investigate the feasibility of using the Stopping Elderly Accidents, Deaths and Injuries (STEADI) Falls Risk Tool Kit during community-based eye health screenings to assess falls risk of participants enrolled in the Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT). METHODS: Cross-sectional analysis of data from a 5-year prospective, cluster-randomised clinical trial conducted in affordable housing developments in New York City in adults age 40 years and older. Prescreening questions determined whether participants were at risk of falling. STEADI tests classified participants at low, moderate or high risk of falling. Multivariate logistic regression determined odds of falls risk of all enrolled participants. RESULTS: 708 participants completed the eye health screening; 351 (49.6%) performed STEADI tests; mean age: 71.0 years (SD±11.3); 72.1% female; 53.6% Black, non-Hispanic, 37.6% Hispanic/Latino. Level of falls risk: 32 (9.1%) low, 188 (53.6%) moderate and 131 (37.3%) high. Individuals age >80 (OR 5.921, 95% CI (2.383 to 14.708), p=0.000), had blurry vision (OR 1.978, 95% CI (1.186 to 3.300), p=0.009), high blood pressure (OR 2.131, 95% CI (1.252 to 3.628), p=0.005), arthritis (OR 2.29876, 95% CI (1.362 to 3.875), p=0.002) or foot problems (OR 5.239, 95% CI (2.947 to 9.314), p=0.000) had significantly higher odds of falling, emergency department visits or hospitalisation due to falling. CONCLUSION: This study detected a significant amount of falls risk in an underserved population. The STEADI Falls Risk screening questions were easy for eye care providers to ask, were highly predictive of falls risk and may be adequate for referral to occupational health and/or physical therapy.

Manhattan Vision Screening and Follow-up Study (NYC-SIGHT): Baseline Results and Costs of a Cluster-Randomized Trial.

PURPOSE: To describe the 15-month baseline results and costs of the Manhattan Vision Screening and Follow-up Study, which aims to investigate whether innovative community-based eye health screening can improve early detection and management of glaucoma and other eye diseases among high-risk populations. DESIGN: Five-year prospective, cluster-randomized controlled trial. METHODS: Individuals aged 40+ years were recruited from public housing buildings in New York City for an eye health screening (visual acuity (VA) with correction, intraocular pressure measurements (IOP), and fundus photography). Participants with VA 20/40 or worse, IOP 23-29 mm Hg, or an unreadable fundus image failed the screening and were scheduled for an optometric examination at the same location; those with an abnormal image were referred to ophthalmology. A cost analysis was conducted alongside the study. RESULTS: A total of 708 participants were screened; mean age 68.6±11.9 years, female (65.1%), African American (51.8%) and Hispanic (42%). 78.4% (n = 555) failed the eye health screening; 35% (n= 250) had an abnormal image and were also referred to ophthalmology. 308 participants attended the optometric exam; 218 were referred to ophthalmology. Overall, 66.1% were referred to ophthalmology. The cost per participant to deliver the eye health screening and optometric examination was $180.88. The cost per case of eye disease detected was $273.64. CONCLUSIONS: This innovative study in public housing developments targeted high-risk populations, provided access to eye-care, and improved early detection of ocular diseases in New York City. The study has identified strategies to overcoming barriers to eye care to reduce eye health disparities.

Rationale and Development of an OCT-Based Method for Detection of Glaucomatous Optic Neuropathy.

A specific, sensitive, and intersubjectively verifiable definition of disease for clinical care and research remains an important unmet need in the field of glaucoma. Using an iterative, consensus-building approach and employing pilot data, an optical coherence tomography (OCT)-based method to aid in the detection of glaucomatous optic neuropathy was sought to address this challenge. To maximize the chance of success, we utilized all available information from the OCT circle and cube scans, applied both quantitative and semiquantitative data analysis methods, and aimed to limit the use of perimetry to cases where it is absolutely necessary. The outcome of this approach was an OCT-based method for the diagnosis of glaucomatous optic neuropathy that did not require the use of perimetry for initial diagnosis. A decision tree was devised for testing and implementation in clinical practice and research that can be used by reading centers, researchers, and clinicians. While initial pilot data were encouraging, future testing and validation will be needed to establish its utility in clinical practice, as well as for research.

The ICD-10 Glaucoma Severity Score Underestimates the Extent of Glaucomatous Optic Nerve Damage.

PURPOSE: To evaluate the International Classification of Disease, Tenth Revision (ICD-10) codes used for glaucoma severity classification, which are based on the location of visual field (VF) defects; given the known poor sensitivity of the 24-2 visual field test to early disease and macular damage, we hypothesized that the ICD-10 codes would not accurately reflect the extent of glaucomatous damage. DESIGN: Retrospective validity and reliability analysis. METHODS: We evaluated 80 eyes with glaucomatous optic neuropathy (GON). Masked reviewers assigned an ICD-10 severity grade based on 24-2 VF. Two additional masked examiners determined the presence of optical coherence tomography (OCT) structural damage in each hemifield and/or central 5 degrees to define an OCT-based equivalent ICD-10 classification. RESULTS: A total of 80 eyes with GON were classified as mild, moderate and advanced in 15, 23, and 42 cases, respectively, based on the 24-2 VF, and in 6, 7, and 67 cases, respectively, based on OCT. The OCT classifications were more severe in 29 of 80 cases (36%). In 33 cases (41.3%), macular damage detected by OCT was missed by the 24-2. In 4 of 80 cases (5%), the VF overestimated the severity, likely due to variability of the 24-2 test. CONCLUSIONS: The ICD-10 system relies solely on damage seen on the 24-2 and as provides a 24-2 functional score rather than a "glaucoma" severity score. OCT revealed wide variation of damage across grades, with a significant proportion of the eyes showing macular structural damage missed with the 24-2 VF. Adding OCT information to the ICD-10 system would help it to more accurately reflect the extent of glaucomatous damage.

A Prospective Randomized Trial of Ahmed Glaucoma Drainage Device Implantation with or without Ologen Collagen Matrix.

PURPOSE: The purpose of this study is to evaluate the effectiveness of Ologen collagen matrix (OCM; Aeon Astron Corporation) in the prevention of the postoperative hypertensive phase and on long-term intraocular pressure (IOP) control after Ahmed glaucoma valve (AGV; New World Medical) implantation. DESIGN: This is a prospective, randomized, controlled study of 26 patients treated at a tertiary care center, with 13 eyes assigned to each treatment arm. PARTICIPANTS: Consecutive patients with refractory glaucoma requiring AGV implantation were enrolled. Refractory glaucoma was defined as IOP >21 mmHg on maximum tolerated glaucoma medications or progressive visual field and optic nerve head changes despite maximal tolerated medical therapy. METHODS: In Ologen eyes, a round 12 × 1-mm OCM segment was placed flush over the AGV-FP7 plate immediately before conjunctival closure. Control eyes received conventional AGV surgery without OCM implantation. MAIN OUTCOME MEASURES: The primary outcomes were postoperative IOP and requirement of pressure-lowering medications. On the basis of these measures, the rates of complete and qualified success over the course of follow-up were calculated. Complete success was defined as IOP ≤21 mmHg without antihypertensive medications. Qualified success was defined as IOP ≤21 mmHg with or without medications. Frequency of hypertensive phase was also determined. RESULTS: Patients receiving Ologen-augmented AGV surgery exhibited significantly lower IOPs compared with control subjects at the 1-, 2-, and 3-month time points (P < 0.04). Maximum mean IOP postoperatively was 25.2 ± 7.4 for control eyes and 16.8 ± 8.9 for Ologen eyes, peaking at month 2 for both groups and stabilizing by month 6. No differences in average number of pressure-lowering medications were detected between groups. There were no statistically significant differences in complete or qualified success rates at 6 and 12 months. The frequency of hypertensive phase was 61.5% in control eyes and 38.5% in OCM-implanted eyes. CONCLUSIONS: Ologen collagen matrix-augmented AGV surgery may provide better IOP control in the intermediate postoperative period and blunt the hypertensive phase compared with AGV implantation alone.

Patient Concerns Regarding Suspended Ophthalmic Care Due to COVID-19.

PURPOSE: The temporary cessation and profound changes in ophthalmic care delivery that occurred as a result of the coronavirus disease 2019 (COVID-19) pandemic have yet to be fully understood. Our objective is to assess patients' self-reported impact of health care lockdown measures on their fears and anxieties during the crisis period of the COVID-19 pandemic in New York City. METHODS: We conducted a digital, self-reported, patient care survey distributed by an e-mail at Columbia University's Department of Ophthalmology outpatient faculty practice. Inclusion criteria were age greater than or equal to 18 years, a diagnosis of either retinal disease or glaucoma, and a canceled or rescheduled ophthalmology established patient appointment during the acute phase of the COVID-19 pandemic in New York City. Patients without an e-mail address listed in their electronic medical records were excluded. The survey occurred between March 2, 2020, to May 30, 2020. Primary measures were survey responses to assess key areas of patient anxiety or concern during the pandemic including the safety of care delivery in a COVID pandemic, difficulties contacting or being seen by their ophthalmologist, concern of vision loss or disease progression, and concern over missed or access to treatments. Secondary measures were correlating survey response to factors such as visual acuity, intraocular pressure, diagnosis, disease severity, follow-up urgency, recent treatments, and diagnostic testing data. RESULTS: Of the 2594 surveys sent out, 510 (19.66%) were completed. Over 95% of patients were at least as concerned as in normal circumstances about their ocular health during the peak of the pandemic. Overall, 76% of respondents were more concerned than normal that they could not be seen by their ophthalmologist soon enough. Increased concern over ocular health, disease progression, and access to care all showed positive correlations (P<0.05) with worse disease severity as measured with testing such as visual fields and optical coherence tomography. In addition, 55% of patients were afraid of contracting COVID-19 during an office visit. CONCLUSION AND RELEVANCE: We found a majority of our patients were concerned about limitations in access to ophthalmic care and were fearful of disease progression. In addition, we found a number of demographic and clinical factors that correlated with increased anxiety in our patients.

Corneal laceration by sharp objects in children seven years of age and younger.

PURPOSE: Young children are prone to develop amblyopia after penetrating injury. We sought to evaluate the management of penetrating corneal injury without intraocular foreign body (IOFB) in children 18 months. Data retrieved included all details from the initial examination, surgical procedures, amblyopia prevention measures, and final visual acuity. RESULTS: Twenty children eligible for the study were identified. The mean age was 4.3 years, and mean follow-up time was 58 months. The corneal wound size range was 1-10 mm, with 8 eyes having wounds >or=6 mm. All patients required primary surgical management. Traumatic cataract extraction was performed at the primary operation in 6 eyes, with intraocular lens (IOL) implantation in 4 eyes. Additional surgical procedures were performed in 12 eyes. Yttrium-Aluminum-Garnet (YAG) capsulotomy was performed in 3 eyes with secondary cataract. Twelve patients required spectacle or contact lens correction, and 11 patients had patching for amblyopia prevention. At the end of follow-up, visual acuity was 20/40 or better in 14 eyes, 20/50 to 20/100 in 4 eyes, no light perception (NLP) in 1 eye, and unknown in 1 eye. CONCLUSIONS: Proper management of penetrating corneal injury in young children can result in excellent visual rehabilitation. Major measures include prompt traumatic cataract extraction with either primary or secondary IOL implantation, opening of posterior capsular opacification with YAG laser, correction of refractive errors, and patching for amblyopia prevention.

Penetrating keratoplasty with pars plana glaucoma drainage devices.

PURPOSE: To study the outcome of penetrating keratoplasty (PK) in eyes undergoing simultaneous insertion or repositioning of a glaucoma drainage device (GDD) through the pars plana. METHODS: The medical records of all patients who underwent PK and primary placement or repositioning of a GDD through the pars plana from April 1, 1997, through December 1, 2005, were reviewed. Intraocular pressure (IOP) control was defined as maintenance of IOP > or = 5 and < or = 21 mm Hg (without loss of light perception vision or needing further glaucoma surgery). Kaplan-Meier life table survival analysis was used to estimate the success of graft survival (clarity) and glaucoma control. RESULTS: Eighty-three eyes of 80 patients (34 men and 46 women) were identified. Mean follow-up was 16 months (range, 6-96 months). PK and pars plana vitrectomy were performed with primary pars plana GDD insertion (57 eyes) or tube repositioning from the anterior chamber to pars plana (26 eyes). Grafts remained clear in 93% of eyes (76/83) at 6 months, 87% (56/66) at 1 year, and 59% (19/32) at 2 years. IOP was controlled in 87% (72/83) of eyes at 6 months, 95% (57/63) at 1 year, and 83% (20/24) at 2 years. CONCLUSIONS: PK with simultaneous pars plana GDD repositioning or placement showed comparable short- and long-term IOP control to that of previous studies with limbal-based GDD. The rate of corneal graft failure and the rate of immunologic rejection were comparable to or lower than those reported in other series with primary limbal-based GDD.

The ISNT rule and differentiation of normal from glaucomatous eyes.

OBJECTIVE: To determine whether the ISNT rule (that normal eyes show a characteristic configuration for disc rim thickness of inferior > or = superior > or = nasal > or = temporal), widely used for clinical evaluation of the optic nerve head, can differentiate normal from glaucomatous eyes. METHODS: All subjects underwent complete eye examination, including achromatic automated perimetry, simultaneous stereoscopic disc photography, and confocal scanning laser ophthalmoscopy. Subjects with normal eyes had no evidence of glaucoma or ocular hypertension and had normal perimetry measurements. Subjects with glaucoma had a reproducible visual field defect. One eye from each subject was randomly enrolled. The ISNT rule was assessed by masked evaluation of disc photographs at the 3, 6, 9, and 12 o'clock positions. RESULTS: Sixty-six subjects with normal eyes (33 black and 33 white individuals) and 43 with open-angle glaucoma (15 black and 28 white individuals) were enrolled. The ISNT rule was intact in 52 (79%) of 66 normal eyes and 12 (28%) of 43 glaucomatous eyes (P<.001). Multiple logistic regression indicated that the odds ratio for glaucoma associated with violation of the ISNT rule was 6.04 (95% confidence interval, 1.74-20.95) after adjustment for age; race was not a confounder of this association. CONCLUSION: The ISNT rule is useful in differentiating normal from glaucomatous optic nerves and is unaffected by race.

Measurements of optic disk size with HRT II, Stratus OCT, and funduscopy are not interchangeable.

PURPOSE: To assess the interchangeability of optic disk size measurements using slit-lamp funduscopy, optical coherence tomography (OCT-3), and confocal scanning laser ophthalmoscopy (HRT-II) in clinical practice. DESIGN: Prospective nonrandomized clinical study. METHODS: Measurements of vertical disk diameter (VDD) were obtained with the three methods. Disk area was obtained from OCT and HRT printouts. True agreement between methods in measuring VDD was assessed using Bland-Altman graphs and 95% limits of agreement (LoA). Disks were classified as small, average, or large, and agreement between methods in this classification was assessed using kappa statistics. RESULTS: Forty-eight patients were enrolled (mean age 53.4 +/- 14.3 years). VDD (mean +/- SD) was 1.58 +/- 0.15, 1.70 +/- 0.22, and 1.90 +/- 0.24 mm with funduscopy, HRT, and OCT, respectively. Very large LoA were observed: -0.29 to 0.70 mm for OCT and HRT, -0.07 to 0.71 mm for OCT and funduscopy, and -0.29 to 0.53 mm for HRT and funduscopy. There was poor agreement (kappa < 0.4) in classification of disk size as small, average, or large whether disk diameter or area was compared and using two definitions of disk size. CONCLUSIONS: We observed a large range of differences in estimating disk size with HRT, OCT, and funduscopy. This precludes interchangeable use of these measurements in clinical practice, and does not allow simple conversion formulas to be proposed. In addition, there is poor agreement between these methods in classifying disk size as small, average, or large. At present, estimation of both absolute and relative disk size can only be defined separately for each measurement modality.

Assessment of a race-specific normative HRT-III database to differentiate glaucomatous from normal eyes.

PURPOSE: To determine if a new, normative, race-specific database enhances the ability of confocal scanning laser ophthalmoscopy to differentiate normal from glaucomatous eyes. METHODS: One eye of eligible normal and glaucoma patients was enrolled. All subjects underwent a complete ophthalmologic examination, standard achromatic perimetry (SITA-SAP, 24-2), and confocal scanning laser ophthalmoscopy [Heidelberg retinal tomograph (HRT-II)] within 1 month of enrollment. Racial groups were defined by self-report. Glaucoma was defined by the existence of reproducible SAP loss (pattern standard deviation <5% and/or Glaucoma Hemifield Test outside normal limits) on 2 consecutive fields. Normal subjects had 2 normal visual fields (pattern standard deviation >5% and Glaucoma Hemifield Test within 97% normal limits) and a normal clinical examination. HRT-II examinations were exported to the HRT-III software, which includes a large race-specific normative database consisting of 733 white and 215 black eyes. Moorfields regression analysis (MRA) for the most abnormal optic disc sector was compared between the HRT-II (MRA2) and the HRT-III software before (MRA3-B) and after (MRA3-A) adjustment for race. Sectors outside the 99.9% confidence interval limits ("outside normal limits") were determined to be abnormal. RESULTS: We enrolled 124 black (52 glaucoma, 72 normal) and 96 white (32 glaucoma, 64 normal) subjects. Mean age was 51+/-13 years and 50+/-16 years for blacks and whites, respectively (P = 0.45). Visual field mean deviation was -7.3+/-6.7 db for glaucomatous eyes and -0.4+/-1.1 db for normal eyes (P < 0.001). Sensitivity and specificity for the HRT-II was 71.9% and 95.3%, respectively, for white subjects and 50.0% and 98.6%, respectively, for black subjects. Using the expanded HRT-III database, analysis yielded a sensitivity of 81.3% and specificity of 93.8% for whites and a sensitivity of 71.2% and specificity of 86.1% for blacks. After an adjustment for black ethnicity was made in the HRT-III program, the sensitivity and specificity for blacks was 65.4% and 90.3%, respectively. CONCLUSIONS: A new, larger, race-specific HRT-III database increases sensitivity while maintaining specificity for whites and increases sensitivity but decreases specificity for blacks. New software and databases based on race require careful scrutiny before use in clinical practice.

Donor scleral patch for treating hypotony due to leaking and/or overfiltering blebs.

OBJECTIVE: To report a modified technique of bleb revision with the use of a donor scleral patch in cases in which scleral melting did not allow effective suturing and closure of the aqueous leak. The suturing technique ensures tight adaptation of the scleral patch over the leaky region, and allows better-controlled aqueous flow with loose suturing of the posterior edge of the scleral patch. METHODS: Records of patients who underwent bleb revision with donor scleral graft from 1997 to 2003 were reviewed retrospectively. Chart information including demographic and clinical data was recorded preoperatively and 1 day, 1 week, 1 month, 6 months, and at final follow-up. RESULTS: Fifteen patients underwent this surgical procedure for bleb revision. The mean follow-up time was 22.0 +/- 24.0 months (median = 8.0 months). The mean preoperative visual acuity was 20/50 and the mean intraocular pressure (IOP) was 2.9 +/- 2.3 mm Hg, which improved to 20/30 and 14.1 +/- 3.3 mm Hg respectively, on last follow-up. CONCLUSIONS: The scleral patch with 4-nylon sutures should be proposed in cases in which a macerated scleral bed is revealed during the revision. The loose suturing of the scleral patch at its posterior border was found to prevent intraocular pressure spikes.