A Comparison of Artificial Intelligence and Human Diabetic Retinal Image Interpretation in an Urban Health System.

INTRODUCTION: Artificial intelligence (AI) diabetic retinopathy (DR) software has the potential to decrease time spent by clinicians on image interpretation and expand the scope of DR screening. We performed a retrospective review to compare Eyenuk's EyeArt software (Woodland Hills, CA) to Temple Ophthalmology optometry grading using the International Classification of Diabetic Retinopathy scale. METHODS: Two hundred and sixty consecutive diabetic patients from the Temple Faculty Practice Internal Medicine clinic underwent 2-field retinal imaging. Classifications of the images by the software and optometrist were analyzed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and McNemar's test. Ungradable images were analyzed to identify relationships with HbA1c, age, and ethnicity. Disagreements and a sample of 20% of agreements were adjudicated by a retina specialist. RESULTS: On patient level comparison, sensitivity for the software was 100%, while specificity was 77.78%. PPV was 19.15%, and NPV was 100%. The 38 disagreements between software and optometrist occurred when the optometrist classified a patient's images as non-referable while the software classified them as referable. Of these disagreements, a retina specialist agreed with the optometrist 57.9% the time (22/38). Of the agreements, the retina specialist agreed with both the program and the optometrist 96.7% of the time (28/29). There was a significant difference in numbers of ungradable photos in older patients (≥60) vs younger patients (<60) (p=0.003). CONCLUSIONS: The AI program showed high sensitivity with acceptable specificity for a screening algorithm. The high NPV indicates that the software is unlikely to miss DR but may refer patients unnecessarily.

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre.

OBJECTIVES: To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia. DESIGN: Retrospective chart review. PARTICIPANTS: Patients from a community glaucoma screening program. METHODS: Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence. RESULTS: A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence. CONCLUSIONS: The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.

Primary Open-Angle African American Glaucoma Genetics (POAAGG) Study: gender and risk of POAG in African Americans.

The purpose of this study was to investigate the association between gender and primary open-angle glaucoma (POAG) among African Americans and to assess demographic, systemic, and behavioral factors that may contribute to differences between genders. The Primary Open-Angle African American Glaucoma Genetics (POAAGG) study had a case-control design and included African Americans 35 years and older, recruited from the greater Philadelphia, Pennsylvania. Diagnosis of POAG was based on evidence of both glaucomatous optic nerve damage and characteristic visual field loss. Demographic and behavioral information, history of systemic diseases and anthropometric measurements were obtained at study enrollment. Gender differences in risk of POAG were examined using multivariate logistic regression. A total of 2,290 POAG cases and 2,538 controls were included in the study. The percentage of men among cases was higher than among controls (38.6% vs 30.3%, P<0.001). The subjects' mean age at enrollment was significantly higher for cases compared to controls (70.2±11.3 vs. 61.6±11.8 years, P<0.003). Cases had lower rates of diabetes (40% vs. 46%, P<0.001), higher rates of systemic hypertension (80% vs. 72%, P<0.001), and lower body mass index (BMI) (29.7±6.7 vs. 31.9±7.4, P<0.001) than controls. In the final multivariable model, male gender was significantly associated with POAG risk (OR, 1.64; 95% CI, 1.44-1.87; P<0.001), after adjusting for age, systemic hypertension, diabetes, and BMI. Within the POAAGG study, men were at higher risk of having POAG than women. Pending genetic results from this study will be used to better understand the underlying genetic variations that may account for these differences.

A Pilot Study on the Effect of Alternate Nostril Breathing and Foot Reflexology on Intraocular Pressure in Ocular Hypertension.

The purpose of this study is to investigate the effects of alternate nostril breathing (ANB) and foot reflexology (FR) on lower intraocular pressure (IOP) in patients with ocular hypertension (OHTN). This prospective pilot study recruited 11 patients from 2014 to 2016 from Temple opthamology outpatient clinic. Patients had OHTN with ages of 48-78 years. Patients were excluded if they currently performed ANB or FR, were unable to perform the task, had previous eye surgery or laser, were receiving other complementary and alternative medicine for OHTN, or were unable to complete drug washout period. After a 30-day drug washout, patients were randomly assigned to complete either ANB or FR for 5 min. After instruction, patients completed either ANB or FR, and completed the alternate task 2 weeks later. IOP was measured before the task, immediately after the task, and then every 30 min for 2 h. Decrease in IOP compared with baseline IOP was significant for ANB and FR at all time points. Baseline IOP was 25.86 ± 3.19 mmHg for ANB and 25.41 ± 3.54 mmHg for FR (N = 22 eyes). There was only one significant difference between IOP for the right and left eyes for FR at 120 min. Otherwise, there was no difference between eyes for both ANB and FR. There was a significant decrease in IOP at 30 min post task with IOP decrease of 1.98 ± 1.70 mmHg for ANB and 3.59 ± 1.89 mmHg for FR (both p < 0.0001) and at 60 min post task with IOP decrease of 2.39 ± 2.05 mmHg for ANB and 3.86 ± 1.89 mmHg for FR (both p < 0.0001). The decrease in IOP at 90 and 120 min post task was less but remained significant (p < 0.0001). Both FR and ANB had a small but significant IOP lowering effect. These alternative therapies could serve as possible adjunctive treatments for lowering IOP.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Intraocular Pressure Measurements Found in a Population at High Risk for Glaucoma.

PRECIS: Intraocular pressure (IOP) measurements, when used during telemedicine eye screening alongside nonmydriatic fundus photography, were shown to improve the likelihood of accurate glaucoma and glaucoma-related diagnoses at the follow-up eye examination. PURPOSE: To determine if IOP measurements, used as an adjunct to nonmydriatic fundus photography, are useful in glaucoma telemedicine screening. MATERIALS AND METHODS: A total of 902 high-risk individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening at visit 1 included fundus photography, assessing family history of glaucoma, and IOP measurements using a hand-held rebound tonometer. Participants with suspicious nerve findings for glaucoma, IOP>21 mm Hg or other ocular pathologies were invited for a follow-up appointment with an ophthalmologist (visit 2). RESULTS: Of the 902 individuals screened at visit 1, 19.6% (n=177/902) had elevated IOP (>21 mm Hg). Fifteen participants were found to have an IOP>30 mm Hg at visit 1, including 2 with an IOP of >40 mm Hg. Among all who attended visit 2 (n=347), 10.9% had glaucoma and 7.2% had ocular hypertension. For participants having both suspicious nerve findings and IOP>21 mm Hg compared with those with neither, the odds ratio (OR) of being diagnosed with glaucoma was 4.48 (95% CI, 1.50-13.93; P=0.007), whereas for participants with suspicious discs and IOP≤21 mm Hg the OR was 2.04 (95% CI, 0.83-5.53; P=0.15). CONCLUSIONS: In this telemedicine vision screening setting, having a higher IOP at the screening visit increased the likelihood of receiving a final diagnosis of glaucoma. Therefore, this study supports incorporating IOP measurements, using a portable tonometer, into vision screening programs in high-risk populations.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: confirmation between eye screening and comprehensive eye examination diagnoses.

AIMS: To evaluate agreement between ocular findings of a telemedicine eye screening (visit 1) with diagnoses of a comprehensive eye examination (visit 2). METHODS: A primary care practice (PCP)-based telemedicine screening programme incorporating fundus photography, intraocular pressure (IOP) and clinical information was conducted. Eligible individuals were African American, Hispanic/Latino or Asian over the age of 40; Caucasian individuals over age 65; and adults of any ethnicity over age 40 with a family history of glaucoma or diabetes. Participants with abnormal images or elevated IOP were invited back for a complete eye examination. Both visit 1 and visit 2 were conducted at participants' local PCP. Ocular findings at visit 1 and eye examination diagnoses at visit 2 are presented, including a cost analysis. RESULTS: Of 906 participants who attended visit 1, 536 were invited to visit 2 due to ocular findings or unreadable images. Among the 347 (64.9%) who attended visit 2, 280 (80.7%) were diagnosed with at least one ocular condition. Participants were predominately women (59.9%) and African American (65.6%), with a mean age (±SD) of 60.6±11.0 years. A high diagnostic confirmation rate (86.0%) was found between visit 1 and visit 2 for any ocular finding. Of 183 with suspicious nerves at visit 1, 143 (78.1%) were diagnosed as glaucoma or glaucoma suspects at visit 2. CONCLUSIONS: This screening model may be adapted and scaled nationally and internationally. Referral to an ophthalmologist is warranted if abnormal or unreadable fundus images are detected or IOP is >21 mm Hg. TRIAL REGISTRATION NUMBER: NCT02390245.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Analysis of Unreadable Fundus Images.

PURPOSE: The purpose of this study was to ascertain determinants of unreadable fundus images for participants enrolled in the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. METHODS: Individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening (visit 1) included fundus photography, assessing family history of glaucoma, and intraocular pressure (IOP) measurements. Participants with an unreadable image in at least one eye were deemed unreadable and invited to return for a confirmatory eye examination (visit 2). RESULTS: A total of 906 participants completed the visit 1 eye screening and 17.1% (n=155/906) were "unreadable." In the multivariable logistic regression analysis, older age, male sex, smoking, and worse visual acuity were significantly associated with an unreadable fundus image finding at the eye screening (P<0.05). Of the 89 participants who were invited for the confirmatory eye examination solely for unreadable images and attended visit 2, 58 (65.2%) were diagnosed with at least one ocular pathology. The most frequent diagnoses were cataracts (n=71; 15 visually significant, 56 nonvisually significant), glaucoma suspects (n=27), and anatomical narrow angle (n=10). CONCLUSIONS: Understanding the causes of unreadable fundus images will foster improvements in telemedicine techniques to optimize the predictive accuracy, efficiency, and cost in ophthalmology. A high proportion of participants with unreadable images (65.2%) in our study were diagnosed with some ocular pathology, indicating that the finding of an unreadable fundus image warrants a referral for a comprehensive follow-up eye examination.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results.

PURPOSE: To describe methodology and screening results from the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. DESIGN: Screening program results for a prospective randomized clinical trial. METHODS: Individuals were recruited who were African-American, Hispanic/Latino, or Asian over age 40 years; white individuals over age 65 years; and any ethnicity over age 40 years with a family history of glaucoma or diabetes. Primary care offices and Federally Qualified Health Centers were used for telemedicine (Visit 1). Two posterior fundus photographs and 1 anterior segment photograph were captured per eye in each participant, using a nonmydriatic, autofocus, hand-held fundus camera (Volk Optical, Mentor, Ohio, USA). Medical and ocular history, family history of glaucoma, visual acuity, and intraocular pressure measurements using the ICare rebound tonometer (ICare, Helsinki, Finland) were obtained. Images were read remotely by a trained retina reader and a glaucoma specialist. RESULTS: From April 1, 2015, to February 6, 2017, 906 individuals consented and attended Visit 1. Of these, 553 participants were female (61.0%) and 550 were African-American (60.7%), with a mean age of 58.7 years. A total of 532 (58.7%) participants had diabetes, and 616 (68%) had a history of hypertension. During Visit 1, 356 (39.3%) participants were graded with a normal image. Using image data from the worse eye, 333 (36.8%) were abnormal and 155 (17.1%) were unreadable. A total of 258 (28.5%) had a suspicious nerve, 62 (6.8%) had ocular hypertension, 102 (11.3%) had diabetic retinopathy, and 68 (7.5%) had other retinal abnormalities. CONCLUSION: An integrated telemedicine screening intervention in primary care offices and Federally Qualified Health Centers detected high rate of suspicious optic nerves, ocular hypertension, and retinal pathology.

Association of Football Subconcussive Head Impacts With Ocular Near Point of Convergence.

IMPORTANCE: An increased understanding of the relationship between subconcussive head impacts and near point of convergence (NPC) ocular-motor function may be useful in delineating traumatic brain injury. OBJECTIVE: To investigate whether repetitive subconcussive head impacts during preseason football practice cause changes in NPC. DESIGN, SETTING, AND PARTICIPANTS: This prospective, observational study of 29 National Collegiate Athletic Association Division I football players included baseline and preseason practices (1 noncontact and 4 contact), and postseason follow-up and outcome measures were obtained for each time. An accelerometer-embedded mouthguard measured head impact kinematics. Based on the sum of head impacts from all 5 practices, players were categorized into lower (n = 7) or higher (n = 22) impact groups. EXPOSURES: Players participated in regular practices, and all head impacts greater than 10g from the 5 practices were recorded using the i1Biometerics Vector mouthguard (i1 Biometrics Inc). MAIN OUTCOMES AND MEASURES: Near point of convergence measures and symptom scores. RESULTS: A total of 1193 head impacts were recorded from 5 training camp practices in the 29 collegiate football players; 22 were categorized into the higher-impact group and 7 into the lower-impact group. There were significant differences in head impact kinematics between lower- and higher-impact groups (number of impacts, 6 vs 41 [lower impact minus higher impact = 35; 95% CI, 21-51; P < .001]; linear acceleration, 99g vs 1112g [lower impact minus higher impact= 1013; 95% CI, 621 - 1578; P < .001]; angular acceleration, 7589 radian/s2 vs 65 016 radian/s2 [lower impact minus higher impact= 57 427; 95% CI , 31 123-80 498; P < .001], respectively). The trajectory and cumulative burden of subconcussive impacts on NPC differed by group (F for group × linear trend1, 238 = 12.14, P < .001 and F for group × quadratic trend1, 238 = 12.97, P < .001). In the higher-impact group, there was a linear increase in NPC over time (B for linear trend, unstandardized coefficient [SE]: 0.76 [0.12], P < .001) that plateaued and resolved by postseason follow-up (B for quadratic trend [SE]: -0.06 [0.008], P < .001). In the lower-impact group, there was no change in NPC over time. Group differences were first observed after the first contact practice and remained until the final full-gear practice. No group differences were observed postseason follow-up. There were no differences in symptom scores between groups over time. CONCLUSIONS AND RELEVANCE: Although asymptomatic, these data suggest that repetitive subconcussive head impacts were associated with changes in NPC. The increase in NPC highlights the vulnerability and slow recovery of the ocular-motor system following subconcussive head impacts. Changes in NPC may become a useful clinical tool in deciphering brain injury severity.

The value of intraocular pressure asymmetry in diagnosing glaucoma.

PURPOSE: To investigate the amount of intraocular pressure (IOP) asymmetry in a large group of ethnically diverse patients with and without glaucoma, and to delineate the risk for glaucoma which increasing amounts of IOP asymmetry confer upon the patient. PATIENTS AND METHODS: Collaborative retrospective study of 326 glaucoma patients and 326 controls. Former Wills Eye Institute fellows collected single pre-treatment measurements of IOP on patients diagnosed as having definite glaucoma based on characteristic optic nerve damage and confirmatory visual field damage. Patients with a normal eye examination who had normal-appearing optic discs and no apparent glaucoma, or who had a normal eye examination in association with refractive error or cataract, were used as controls. RESULTS: Intraocular pressure asymmetry is a significant risk factor for having glaucoma (odds ratio, 2.14; 95% confidence interval, 1.86-2.47; P<0.001). Absence of IOP asymmetry between the fellow eyes is associated with a 1% probability of having glaucoma. A difference of 3 mm Hg is associated with a 6% probability of having glaucoma, and a difference of >6 mm Hg with a 57% probability of having glaucoma. The association between IOP asymmetry and glaucoma status is significant for subjects with both elevated IOP (P=0.014) and statistically normal IOP (maximum IOP ≤ 21 mm Hg; P<0.001). CONCLUSIONS: Inter-eye asymmetry of IOP is a common finding in patients with glaucoma. There is a direct relationship between the amount of IOP asymmetry between the fellow eyes and the likelihood of having glaucoma.

Agreement of visual field interpretation among glaucoma specialists and comprehensive ophthalmologists: comparison of time and methods.

AIMS: To evaluate interobserver agreement and interpretation time for three clinically available formats of visual field presentation: serial Humphrey visual field (HVF), STATPAC2 and PROGRESSOR. METHODS: 40 field series from the Advanced Glaucoma Intervention Study were presented to eight glaucoma specialists and eight comprehensive ophthalmologists to determine whether each field series was stable or progressive. Interobserver agreement and agreement with Hodapp-Parrish-Anderson criteria were evaluated using κ statistics, and the interpretation time was compared. RESULTS: For glaucoma specialists, median κ values for interobserver agreement were 0.47, 0.60 and 0.43 for HVF, STATPAC2 and PROGRESSOR, respectively. Respective κ values for comprehensive ophthalmologists were 0.43, 0.43 and 0.35. For glaucoma specialists, median κ values for agreement with Hodapp-Parrish-Anderson criteria were 0.52, 0.67 and 0.52 for HVF, STATPAC2 and PROGRESSOR, respectively. Respective κ values for comprehensive ophthalmologists were 0.41, 0.47 and 0.33. For glaucoma specialists, the mean±SD interpretation time for the series of 40 fields was 63.4±35.9, 57.1±23.1 and 41.1±15.3 min using HVF, STATPAC2 and PROGRESSOR, respectively. Respective interpretation times for comprehensive ophthalmologists were 72.9±38.3, 68.6±30.6 and 51±24.1 min. Interpretation time was decreased when STATPAC2 or PROGRESSOR was used rather than HVF. Time reduction was significant for glaucoma specialists using PROGRESSOR (p=0.02). CONCLUSIONS: For glaucoma specialists, interobserver agreement and agreement with HPA criteria were moderate to substantial. For comprehensive ophthalmologists, interobserver agreement and agreement with HPA criteria were fair to moderate. Field interpretation time may be reduced clinically when using STATPAC2 or PROGRESSOR rather than HVF.

Knowledge about glaucoma and barriers to follow-up care in a community glaucoma screening program.

OBJECTIVE: To assess perceived barriers to glaucoma follow-up care, including the lack of glaucoma knowledge and the lack of health care access, among participants in a community glaucoma screening program. DESIGN: Community survey. PARTICIPANTS: Two hundred forty-three consecutive participants in a series of free glaucoma screenings between November 2002 and August 2003. METHODS: The survey consisted of 20 questions designed to elicit knowledge of glaucoma and perception of potential barriers to follow-up care. Our aim was to find correlations between patient demographics and knowledge of glaucoma as well as perceived potential barriers to follow-up care. The data were analyzed using SPSS, v. 10.1. RESULTS: The average age of the respondents was 70 years, and females predominated (66%). About half of the respondents knew of an eye doctor in their neighborhood, and 60% had had an eye examination in the past year. Two hundred twenty-two (91%) indicated they could get to an eye doctor if the screening examination indicated they needed a follow-up examination. Two hundred twenty (90.5%) had medical insurance. One hundred seventy-eight (73%) of the participants had heard of glaucoma; 71 (29%) identified an accurate definition of glaucoma. The level of education and the language spoken at home were correlated with both glaucoma awareness (p < 0.001; p < 0.001) and knowledge of an accurate definition of glaucoma (p < 0.001; p < 0.025). CONCLUSIONS: In this population, a lack of adequate education about glaucoma may be more significantly associated with poor follow-up rates than a lack of access to care in those identified as glaucoma suspects.

Comparison of single thickness and double thickness processed pericardium patch graft in glaucoma drainage device surgery: a single surgeon comparison of outcome.

PURPOSE: To compare the incidence of conjuctival erosions with single thickness versus double thickness allograft processed pericardium used in mitomycin-C (MMC) augmented glaucoma drainage device (GDD) sugery. PATIENTS AND METHODS: In a retrospective comparative case series, medical records of 84 consecutive glaucoma patients who underwent GDD surgery between July 1996 to December 2004 were reviewed. All surgeries were done by one glaucoma surgeon (M.R.M.). MMC was adminstered in all cases over the plate area and either single thickness processed pericardium patch graft (STPP) or double thickness processed pericardium patch graft (DTPP) was used to cover the external silicone tube of the glaucoma device at the limbus. The principal outcome measure was the incidence of conjunctival erosions associated with GDD surgery. RESULTS: Eighty-four patients (90 eyes) who met the eligibility criteria were enrolled in the study. Thirty-one consecutive eyes received a STPP, and 59 consecutive eyes received a DTPP. Five eyes (16.0%) in the STPP group developed conjunctival erosion. None of the eyes in DTPP group developed conjunctival erosion. The Mann-Whitney U test difference in the rate of conjunctival erosion was statistically significant between 2 groups (P=0.002). For the STPP group, the average time to conjunctival erosion was 9 months (range, 4 to 14 mo). All erosions were surgically corrected using DTPP and followed up for a mean of 8.6 months after repair with no additional conjunctival erosions. CONCLUSIONS: DTPP placed over the silicone tube significantly reduced the incidence of conjunctival erosion after MMC augmented GDD surgery.

Improvement in colour vision parameters following successful trabeculectomy.

PURPOSE: To determine whether colour vision improves following reduction of intraocular pressure (IOP) in glaucoma patients. METHODS: The medical records of 29 glaucoma patients (41 eyes) were reviewed. Inclusion criteria required subjects to have made more than four visits to the Glaucoma Service Laboratory and to undergo a thorough eye examination including a Farnsworth-Munsell 100-hue colour vision test and Goldmann tonometry before and after pressure lowering. Colour vision parameters of total error score (TES), yellow-blue score (YBS) and red-green score (RGS) were measured. The study group consisted of 21 eyes of glaucoma patients who underwent uncomplicated trabeculectomy with an IOP reduction of >/= 20% from baseline. The control group consisted of 21 eyes of glaucoma patients matched for age and colour vision, who received medication and/or underwent surgery with a post-intervention IOP reduction of < 20% from baseline. The primary outcome was a comparison of pre- and post-intervention colour vision parameters between the two groups. RESULTS: There was a statistically significant improvement in TES (43 +/- 44, p < 0.001), RGS (19 +/- 27, p = 0.0077) and YBS (23 +/- 29, p = 0.0007) in the study group compared with the control group. The improvement in TES (r = 0.52, p < 0.001), RGS (r = 0.55, p < 0.001) and YBS (r = 0.40, p = 0.008) was correlated with the percentage of IOP reduction. There was no statistically significant difference between improvement in Y-B and R-G scores in the study group. CONCLUSION: Intraocular pressure reduction of >/= 20% post-trabeculectomy was associated with an improvement in colour vision. Colour vision tests may be useful as an adjunctive outcome measure for therapeutic interventions.

Clinical predictors of latanoprost treatment effect.

PURPOSE: To determine the relationship between latanoprost efficacy and clinical features of glaucoma. PATIENTS AND METHODS: Study design was retrospective, observational case series. The charts of all patients who underwent a one-eyed therapeutic trial of latanoprost during the course of their clinical care between 1997 and 2001 were reviewed. Intraocular pressures of both eyes prior to and one month after initiation of latanoprost were recorded. Latanoprost treatment effect was calculated by subtracting the change in intraocular pressure (IOP) in the fellow eye from the change in the treated eye. The effect of optic disc stage, age, race, sex, diagnosis, involved eye, type and number of other glaucoma medications, pattern of cupping (concentric, focal, or indeterminate), and pre-treatment IOP was correlated with the treatment effect. The stage of glaucoma was determined by determining the disc damage likelihood scale (DDLS) stage. RESULTS: One hundred eighty-six cases were included. Latanoprost treatment effect was 4.5 +/- 5.7 mm Hg, was moderately correlated with pre-treatment IOP (Pearson's r = 0.527, P < 0.01), and was weakly inversely correlated with advancing disc stage (Pearson's r = -0.194, P < 0.01) and age (Pearson's r = -0.175, P < 0.05). It was independent of the other variables studied (P > 0.05). CONCLUSION: Most clinical parameters examined in this study were not correlated with latanoprost treatment response. A moderate direct correlation was noted with pre-treatment IOP and a weak inverse correlation was noted with optic disc stage and age.

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg.

PURPOSE: To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt) for patients with IOP over 30 mm Hg. STUDY DESIGN: Prospective interventional case series. METHODS: Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP > 30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test. RESULTS: Mean pretreatment IOP was 37.5 +/- 1.0 mm Hg. Baseline posttreatment IOP was 18.4 +/- 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 +/- 0.9 mm Hg and the peak, 17.6 +/- 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis. CONCLUSIONS: Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.

Knowledge of chronology of optic disc stereophotographs influences the determination of glaucomatous change.

PURPOSE: To determine the influence of knowledge of the chronology with which stereoscopic photographs of the optic disc were obtained on how the photographs are interpreted. DESIGN: Case series. PARTICIPANTS: Disc photographs of patients enrolled in the Advanced Glaucoma Intervention Study and Collaborative Initial Glaucoma Treatment Study studies from Wills Eye Hospital. METHODS: Two sets of interpretable optic disc stereo slides were included for evaluation. All patients had a follow-up of at least 5 years with baseline and follow-up photographs. Three observers (1 glaucoma attending physician and 2 glaucoma fellows) evaluated the stereophotographs in chronological order to identify the clinical impression of glaucomatous change (glaucomatous deterioration or improvement) based on information such as neuroretinal rim width, nerve fiber layer defects, rim color, peripapillary atrophy, disc hemorrhages, and blood vessel alterations. Three months later, the slide pairs were shuffled so the observers were masked to the chronological sequence. The photographs were reevaluated to determine if there was glaucomatous change. MAIN OUTCOME MEASURES: Agreement between the 2 readings was measured for each observer individually and for the 3 observers collectively. The difference between the number of photographic pairs identified as worse when chronological order was known versus unknown was evaluated using a chi-square test. Intraobserver and interobserver agreement were assessed in terms of kappa values. RESULTS: Intraobserver agreement between chronologically masked and unmasked readings was 61%, 64%, and 71% for the 3 observers, respectively. Average intraobserver agreement between masked and unmasked readings was 65% (kappa, 0.35). Agreement in identifying change (either deterioration or improvement) was 59%, 70%, and 68%, respectively, for each observer. Agreement in identifying stability was 63%, 62%, and 73%, respectively. The number of cases identified as having deteriorated was significantly higher (101 vs. 54) when the observer knew the chronological order with which the photographs were taken (P=0.007). Interobserver agreement was higher when the chronology of photographs was known (kappa, 0.68+/-0.05 for unmasked evaluation; kappa, 0.30+/-0.05 for masked evaluation). CONCLUSIONS: When disc photographs are read with knowledge of the chronology with which they were obtained, the observations differ considerably from when the readings are made without this knowledge.

Pupil dilation with intracameral 1% lidocaine during glaucoma filtering surgery.

PURPOSE: To evaluate pupil dilation from intracameral injection of nonpreserved 1% lidocaine. DESIGN: Observational case series of 25 consecutive phakic trabeculectomies. METHOD: Patients were evaluated in the operating room setting and given one drop of topical tetracaine preoperatively. Nonpreserved 1% lidocaine (0.1 cc) was injected intracameraly into the anterior chamber through a paracentesis site at the corneal limbus. Pupil diameter was measured after instillation of topical tetracaine, before injection of intracameral lidocaine. Postinjection measurements were made at 1, 3, and 5 minutes. RESULTS: The mean male pupil diameter was significantly greater than female dilation at every time point. The mean blue iris diameter was greater than brown at 1 and 3 minutes, but there was no difference at 5 minutes or more. There was no racial difference in the pupil dilation response to intracameral lidocaine. CONCLUSIONS: Nonpreserved intracameral 1% lidocaine produces immediate pupil dilation in previously undilated phakic patients during trabeculectomy surgery.

Reliability of the disk damage likelihood scale.

PURPOSE: To report the reliability of the glaucoma disk damage likelihood scale (DDLS) in comparison to the Armaly cup/disk ratio by determining the interobserver and intraobserver agreement for optic disk stereo photographs and the interobserver agreement for in vivo patient measurements of the optic disk. DESIGN: Observational case series. METHODS: Optic disk photographs: 48 stereo pairs of optic nerve photographs were selected from patients with a spectrum of glaucomatous visual field loss. Two masked observers graded the optic disk photographs three times according to the DDLS and Armaly cup/disk ratio. Interobserver and intraobserver agreements were calculated using the test-retest method. Patient measurements: three observers performed in vivo patient measurements on 34 eyes of glaucoma clinic patients and made a single determination of the DDLS stage and Armaly cup/disk ratio, based on the indirect biomicroscopic examination. Level of interobserver agreement was tabulated. RESULTS: Optic disk photographs: interobserver and intraobserver agreement for the vertical DDLS measurement was greater than for two determinations (clinical impression and measured) of the vertical Armaly cup/disk ratio (interobserver: 85% vs 68% and 74%, respectively; intraobserver grader 1: 97% vs 89% and 80%, grader 2: 99% vs 95% and 89%, respectively). In vivo patient measurements: the interobserver agreement for the DDLS and Armaly cup/disk ratio was similar (70.1% vs 67.6%, respectively). CONCLUSIONS: For the stereo optic disk photographs, the inter- and intra-observer agreement for the DDLS is greater than the Armaly cup/disk ratio. For the in vivo patient measurements, the level of agreement for the DDLS and the Armaly cup/disk ratio is similar.