Delisted routine eye examinations for nonrefractive eye conditions: a comparative analysis.

BACKGROUND: In 2004, Ontario delisted routine eye examinations for people aged 20-64 years, potentially encouraging patients seeking eye care to visit government-insured primary care providers (PCPs) rather than optometrists whose services had been deinsured. We investigated if utilization of PCP services for nonrefractive eye conditions increased after 2004 among Ontarians who were affected by the delisting. METHODS: We conducted a comparative analysis of the utilization of PCP services for nonrefractive eye conditions in Ontario using administrative data from 2000 to 2014. We included participants without a visit to government-insured optometrists or ophthalmologists in the year before the study year; we excluded participants with existing diabetes. Changes in utilization before and after delisting were statistically assessed using segmented regression analysis in subgroups stratified by age, sex, rurality and neighbourhood income. RESULTS: A significant increase in utilization of PCP services for nonrefractive ocular diagnoses after 2004 was documented among people affected by the delisting: 17.8% (95% confidence interval [CI] 17.0% to 18.7%) for people aged 20-39 years and 11.6% (95% CI 10.6% to 12.5%) for people aged 40-64 years. This corresponds to an increase in the number of patients who visited PCPs for nonrefractive ocular diagnoses of 10 690 (95% CI 321 to 21 059) for people aged 20-39 years and 20 682 (95% CI -94 to 41 457) for people aged 40-64 years. Among people aged 65 years and older (an age group not affected by the delisting), utilization of PCP services for nonrefractive ocular diagnoses was stable (p = 0.95) throughout the study period. Changes in utilization of PCP services for nonocular diagnoses were nonsignificant among people aged 0-19, 40-64 and 65 years and older. INTERPRETATION: After delisting, utilization of the services of government-funded PCPs for nonrefractive ocular diagnoses significantly increased among Ontarians affected by the delisting. The impact on ocular outcomes and the cost-effectiveness of increased use of PCPs for ocular management warrants further investigation and policy-makers' consideration.

Eye care utilisation in Newfoundland and Labrador: access barriers and vision health outcomes.

OBJECTIVE: Our prior study revealed significantly lower use of eye care providers in Newfoundland and Labrador (NFLD). This study reports factors associated with this low use and related vision health outcomes. DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 14 925 Caucasian respondents to the Canadian Community Health Survey - Healthy Aging 2008/2009 aged ≥65 years. METHODS: Univariate and multivariate analyses were performed using self-reported survey data. RESULTS: NFLD, along with 3 other provinces, does not insure seniors for routine eye examinations. Among seniors without self-reported glaucoma, cataracts, and diabetes, the use of eye care providers in NFLD (36.3%) is the lowest compared with provinces with (50.7%, p < 0.05) and without (42.2%, p > 0.05) government-insured eye examinations. Among seniors with known eye disease insured for eye care in all provinces, eye care utilisation in NFLD (63.1%) is still the lowest across all provinces (69.4%-71.3%, p > 0.05). Compared with the national average, NFLD seniors have significantly higher proportions of low income (61.7% vs 47.4%), no postsecondary education (53.6% vs 42.2%), and rural residency (40.6% vs 18.9%). These factors are all associated with low levels of eye care utilisation. Compared with insured provinces, NFLD has a significantly lower prevalence of self-reported cataracts (16.7% vs 23.1) and glaucoma (3.8% vs 7.0%), and a slightly higher prevalence of presenting visual impairment (4.0% vs 3.5%). CONCLUSIONS: Lack of government insurance, low socioeconomic status, and living in nonurbanised areas all contribute to the underutilisation of eye care providers in NFLD. This underutilisation appears to be associated with reduced detection of eye diseases.

Gender gap and declining surgical activity among new graduates: cataract surgery in Ontario.

OBJECTIVE: To investigate the proportion of ophthalmologists performing cataract surgery; the volume performed; and the influence of career stage, sex, and trends over time. DESIGN: Population-based study of cataract surgical practice patterns among all ophthalmologists in Ontario, Canada, from April 1999 to March 2013. PARTICIPANTS: All active ophthalmologists in Ontario, Canada, providing government health care for the provincial population of approximately 13 million. METHODS: The IntelliHealth database operated by the Ministry of Health and Long Term Care, which has excellent accuracy for procedure performance, was used to obtain anonymized physician services. RESULTS: The percentage of ophthalmologists performing cataract surgery decreased (68% to 64%), but the yearly mean number of cataract surgeries performed per person increased 1.5 times (307.7 to 470.2). The percentage of early-career ophthalmologists performing cataract surgery declined from 85% to 62%, and this was accompanied by a decline in the median number of cases performed per early-career surgeon (from 243.0 to 169.5). This decline in surgical activity among new graduates was accompanied by growth in the percentage of high-volume and late-career surgeons. In each of the years studied, males performed more surgeries per person than their female counterparts, and this gap grew from 1.4 times to 1.7 times more cataract surgery from 2000 to 2013. CONCLUSIONS: Early-career ophthalmologists are becoming less active with cataract surgery, which may be explained by the increasing surgical activity among late-career and high-volume ophthalmologists. A large sex and volume gap exists among cataract surgeons, which continues to increase.

Wait times and volume of cataract surgery in Ontario: 2000-2012.

OBJECTIVE: To review cataract surgery trends and wait times in Ontario. DESIGN: Retrospective analysis of health records. METHODS: Ontario Health Insurance Plan billing service claims between 2000 and 2012 were analyzed for the yearly number of cataract surgeries, alone and in combination with other procedures. The number of Ontarians with cataracts was estimated by applying composite prevalence curves derived from published population data. This was then used to calculate the yearly number of procedures per 1000 Ontarians with cataracts. RESULTS: Per 1000 people with cataract, the rate of cataract extraction increased 18.9% overall from 2000 to 2012, increasing by 38.3% from 2000 to 2006 and decreasing by 14.6% from 2006 to 2012. Mean wait times for cataract surgery decreased by 45.8% from 2006 to 2009 and increased 28.5% from 2009 to 2013. The proportion of surgeries that were same-day bilateral cataract extraction increased 2.21-fold from 2000 to 2012 but represented only 0.82% of total cataract surgeries in 2012. In 2000, 3% of cataract surgeries were combined with other procedures, and this decreased to 1.8% in 2012. Of these combinations, the rates of combined glaucoma filtration procedures decreased by 44.3%, anterior vitrectomy decreased by 32.5%, posterior vitrectomy increased by 58.3%, and corneal transplantation decreased by 10.7% during this time period. CONCLUSIONS: The yearly rate of cataract surgery has decreased since 2006, and wait times have increased from 2009. Same-day bilateral cataract extraction represented less than 1% of the total cataract surgical volume. Rates of cataract combined with posterior vitrectomy have increased (58%), whereas anterior vitrectomy at the time of cataract surgery decreased (33%).

Trends in glaucoma surgical procedures in Ontario: 1992-2012.

OBJECTIVE: To analyze trends in the surgical management of glaucoma in Ontario over the past 2 decades. DESIGN: Retrospective analysis of health records. METHODS: Ontario Health Insurance Plan billing service claims between 1992 and 2012 were analyzed for the yearly number of glaucoma laser and incisional surgical procedures. The yearly number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS: Per 1000 people with POAG, laser trabeculoplasty (LT) rates increased nearly 2-fold (185%) from 1992 to 2012, with the rates stabilizing between 2008 and 2012, and total glaucoma filtration procedure (GFP) rates (trabeculectomy, aqueous shunts, and combined GFP and cataract extraction) in 2012 were similar to those in 1992, with a peak rate noted in 1996. Shunts represented 0.9% of GFP in 1992 and 33% in 2012. Data for combination codes billed on the same day for the same patient were available from 2000. From 2000 to 2012 the rates of trabeculectomy alone remained unchanged, the number of aqueous shunts alone increased more than 5-fold, combined trabeculectomy and cataract extraction decreased 81%, whereas combined shunts and cataract extraction increased from 6 in 2000 to 420 in 2012. Combined aqueous shunts and cataract extraction represented 0.4% of combined cataract extractions in 2000 and 26.3% in 2012. CONCLUSIONS: Over the past 2 decades there was an overall increase in the rate of LT, no change in the rate of trabeculectomies, and a significant increase in aqueous shunt surgery.

Does government assistance improve utilization of eye care services by low-income individuals?

OBJECTIVE: To examine whether government-funded, low-income vision care programs improve use of eye care services by low-income individuals in Canada. DESIGN: Cross-sectional survey. PARTICIPANTS: 27,375 white respondents to the Canadian Community Health Survey (CCHS) Healthy Aging 2008/2009. METHODS: Government-funded, low-income vision care programs were reviewed. The amount of assistance provided was compared with professional fee schedules for general/routine eye examinations and market prices for eyeglasses. The utilization of eye care providers was derived from the CCHS. RESULTS: To receive low-income vision care assistance, individuals must be in receipt of social assistance. Criteria for receiving social assistance are stringent. The Canadian Financial Capability Survey revealed that 7.9% of Canadians aged 45 to 64 years and 5.5% aged ≥65 years received social assistance in 2009. The CCHS found in 2008/2009 that 12.5% of citizens aged 45 to 64 years and 13.2% of those aged ≥65 years had difficulty paying for basic expenses such as food. In 5 provinces, low-income vision care assistance fully covers a general/routine eye examination. In the remainder, the assistance provided is insufficient for a general/routine eye examination. The assistance for eyeglasses is inadequate in 5 provinces, requiring out-of-pocket copayments. Among middle-aged whites who self-reported not having glaucoma, cataracts, diabetes, or vision problems not corrected by lenses, utilization of eye care providers was 28.1% among those with financial difficulty versus 41.9% among those without (p < 0.05), giving a prevalence ratio 0.68 (95% CI 0.57-0.80) adjusted for age, sex and education. CONCLUSIONS: Despite government assistance, low-income individuals use vision care services less often than wealthy individuals.

De-insurance in Ontario has reduced use of eye care services by the socially disadvantaged.

OBJECTIVE: Effective November 1, 2004, the Ontario Ministry of Health and Long-Term Care de-insured, or delisted, routine eye examinations for Ontarians aged 20 to 64 years. We examined whether this delisting reduced Ontarians' access to eye care providers (ophthalmologists and optometrists). DESIGN: Cross-sectional survey. PARTICIPANTS: Ontario respondents to the Canadian Community Health Survey in 2000/2001 (n = 39 234 before delisting) and 2007/2008 (n = 43 835 after delisting). METHODS: We compared utilization rates of eye care providers by Ontarians in a 12-month period in 2000/2001 to utilization rates in 2007/2008 using self-reported data. RESULTS: Among Ontarians aged 40 to 64 years, utilization was significantly reduced (-7.2%, p < 0.05) after delisting by those who did not have a secondary school graduation certificate. This was compared to a slight reduction (-0.7%, p > 0.05) by those who had completed secondary school or higher education. A reduction of -5.4% was observed among Ontarians in the lowest income quintile in contrast to increased utilization in all other income groups (p > 0.05). Before delisting, the gap in utilization between people with and without a secondary school graduation certificate was 4.7%. This gap doubled to 11.2% after delisting (p < 0.05). The disparity in utilization between those in the highest and lowest income quintile was 4.5% before delisting and 12.0% after delisting (p > 0.05). Cost was the likely barrier that resulted in this finding. CONCLUSIONS: The use of eye care providers among socially disadvantaged Ontarians decreased significantly after vision care services were delisted. The effects of delisting appear to have caused an inequity in access to eye care providers, and that contradicts the objectives of the Canada Health Act.

Survey of complementary and alternative medicine use in glaucoma patients.

PURPOSE: To determine the prevalence, types, and associated factors of complementary and alternative medicine (CAM) use in glaucoma patients. PATIENTS AND METHODS: Prospective, multicenter, cross-sectional survey. A total of 1516 consecutive patients attending 2 tertiary glaucoma clinics were surveyed on CAM use. Information gathered on standardized data collection sheets included demographic variables, ophthalmic history, glaucoma treatment history, and details of CAM use. RESULTS: The response rate was 92.5%. A total of 166 patients (10.9%) reported current use of CAM therapy specifically for glaucoma whereas 41 patients (2.7%) reported past use of CAM. Of the patients who reported CAM use, 62.5% had not disclosed the use of CAM to their ophthalmologist and 40.5% believed that the treatments were helping their glaucoma. The most commonly used types of CAM were herbal medications (34.5%), dietary modifications (22.7%), and vitamin/mineral supplements (18.8%). Of the 207 patients who reported current or past CAM use for their glaucoma, 3 (1.4%) indicated that they used conventional glaucoma treatments < prescribed because of their CAM use. CONCLUSIONS: Approximately 1 in 9 glaucoma patients use CAM for their disease. Many of these patients do not disclose the use of CAM to their ophthalmologist, but the vast majority report that they still take conventional glaucoma medications as prescribed.

Comparison of newly diagnosed ocular hypertension and open-angle glaucoma: ocular variables, risk factors, and disease severity.

Purpose. To describe the distribution of ocular variables, risk factors, and disease severity in newly diagnosed ocular hypertension (OH) or open-angle glaucoma (OAG). Methods. Eligible subjects underwent a complete history and examination. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) obtained from multiple logistic regression models were used to compare OAG to OH and advanced to early/moderate OAG. Results. 405 subjects were enrolled: 292 (72.1%) with OAG and 113 (27.9%) with OH. 51.7% had early, 27.1% moderate, and 20.9% advanced OAG. The OR for OAG versus OH was 8.19 (P < 0.0001) for disc notch, 5.36 (P < 0.0001) for abnormal visual field, 1.45 (P = 0.001) for worsening mean deviation, 1.91 (P < 0.0001) for increased cupping, 1.03 for increased age (P = 0.030), and 0.36 (P = 0.010) for smoking. Conclusions. Increased age was a risk for OAG, and smoking decreased the risk of OAG compared to OH. Almost half of the OAG subjects had moderate/advanced disease at diagnosis.

Disc photography and Heidelberg retinal tomography documentation of reversal of cupping following trabeculectomy.

BACKGROUND: Reversal of cupping is a widely recognized phenomenon. However, whether or not functional improvement is associated with reversal of cupping is controversial. There has not been any documentation in the literature of reversal of cupping with accompanying Heidelberg Retinal Tomograph (HRT) images and visual field (VF) changes at each time point. METHODS: Case report based on one patient. RESULTS: Reversible cupping was seen following a dramatic reduction of IOP post-trabeculectomy, which was associated with an improved HRT but unchanged VF. CONCLUSIONS: This case documents reversal of cupping with VF and HRT testing accompanying the disc photos at each time point. Despite improvement in disc appearance and on structural testing, functional testing was unchanged.

Digital ocular massage for hypertensive phase after Ahmed valve surgery.

PURPOSE: To examine the role of ocular massage during the hypertensive phase after Ahmed valve surgery METHODS: Nonrandomized prospective study. RESULTS: Eighteen patients with intraocular pressure (IOP) above target 1 to 8 weeks after Ahmed glaucoma drainage device surgery underwent digital ocular massage. The mean IOP 1 hour after massage was 4.3 mm Hg lower than before massage (18.8%, P=0.0008). We used a 20% reduction in IOP at 1-hour postmassage to differentiate responders from nonresponders and by this definition 50% responded to ocular massage. One patient (5.6%) responded well but was unable to perform massage at home. The remaining 8 patients (44.4%) performed regular digital massage and the 20% drop in IOP was maintained at the 2-week, 6-week, and 6-month review, although by 6 months 50% required glaucoma drops to achieve target IOP. There were no massage-associated complications in this series. CONCLUSIONS: Digital ocular massage has a useful role to play in the management of the hypertensive phase after Ahmed glaucoma drainage device surgery. In this series 50% of patients achieved a 20% drop in IOP with massage.

Effect of local anesthesia on trabeculectomy success.

PURPOSE: To compare the long-term results of trabeculectomy surgery with subconjunctival anesthesia versus topical lidocaine 2% jelly. METHODS: A retrospective review of the long-term intraocular pressure (IOP) of 57 trabeculectomies previously enrolled in a prospective study comparing subconjunctival anesthesia to topical lidocaine 2% jelly. Baseline data included patient demographics, diagnosis, and ophthalmic history. Postoperative data included IOP, glaucoma therapy, and any interventions. Follow-up was conducted by reviewing the medical charts from July 2002 to August 2007. Differences between the groups were statistically assessed by the Student t test, chi(2) test, Fisher exact test, and Kaplan-Meier survival analysis. RESULTS: Data were available for 57 of the 58 original study patients, with a median age of 65 years. The median follow-up time was 4.2 years for both groups (range: 0.1 to 4.8). There were no statistically significant differences in baseline characteristics and follow-up observations. At the 4-year follow-up, 29.5% of the subconjunctival anesthesia patients versus 39.5% of the topical lidocaine 2% jelly patients were complete success (IOP between 6 to 21 mm Hg and 20% reduction without glaucoma therapy or repeat filtration surgery, P=0.15) and 82.7% of the subconjunctival anesthesia patients versus 95.8% for the topical lidocaine 2% jelly patients were qualified success (above with or without glaucoma therapy, P=0.39). CONCLUSIONS: Though small numbers observed, the 2 anesthetic techniques did not seem to influence the long-term success of trabeculectomy surgery. Further studies with more patients are warranted.

Finger massage versus a novel massage device after trabeculectomy.

BACKGROUND: Ocular massage is a common technique employed after trabeculectomy to aid filtration. This pilot study compares a novel ocular massage device (MD) with finger massage (FM) after trabeculectomy. The device provides the patient with audio feedback about correctly applied force, and the force applied can be customized for each patient. METHODS: A prospective, randomized study was performed comparing the effects of FM versus MD on intraocular pressure (IOP) and complication rates. All patients were given a standardized tutorial in ocular massage. The efficiency of their massage technique was evaluated at 1 week by having the patient perform the massage in front of the ophthalmologist, with IOP measurements taken before and after massage. Information on bleb morphology, IOP, ocular medications, and complications were recorded on a weekly basis. The patient perspective was recorded by questionnaire at 1 week, 1 month, and 3 months after initiation of the massage. RESULTS: Twenty-five patients were enrolled in the study, 12 randomly assigned to the FM and 13 to the MD groups. Patients in the MD group were much more confident that they were doing the massage correctly (p = 0.009) and reported a greater ease of use and lower pain scores. The mean difference in IOP in the 2 groups was not statistically significant in the first 3 weeks, and IOP after 3 months was statistically similar in both groups. Laser suture lysis was performed in 8 patients (66%) in the FM versus 6 (46%) in the MD group (p = 0.42). Wound leaks developed in 4 patients (3 in the FM group vs. 1 in the MD group, p = 0.32). INTERPRETATION: The massage device shows promise as an adjunctive tool in the postoperative management of trabeculectomies.