Telemedicine in long-term care of glaucoma patients.

Introduction: This manuscript describes data from an original study, simulating a tele-glaucoma programme in an established clinic practice with an interdisciplinary team. This is a 'real life' trial of a telemedicine approach to see a follow-up patient. The goal is to evaluate the accuracy of such a programme to detect worsening and/or unstable disease. Such a programme is attractive since in-clinic time could be reduced for both the patient and provider. This study evaluates agreement between in-person and remote assessment of glaucoma progression. Methods: A total of 200 adult glaucoma patients were enrolled at a single institution. The in-person assessment by an optometrist or glaucoma specialist at time of enrolment was used as the gold standard for defining progression. Collated clinical data were then reviewed by four masked providers who classified glaucoma as progression or non-progression in each eye by comparing data from enrolment visit to data from the visit immediately prior to enrolment. Agreement of glaucoma progression between the masked observer and the in-person assessment was determined using Kappa statistics. Intra-observer agreement was calculated using Kappa to compare in-person to remote assessment when both assessments were performed by the same provider (n = 279 eyes). Results: A total of 399 eyes in 200 subjects were analysed. Agreement between in-person versus remote assessment for the determination of glaucoma progression was 63%, 62%, 69% and 68% for each reader 1­4 (kappa values = 0.19, 0.20, 0.35 and 0.33, respectively). For intra-observer agreement, reader 1 agreed with their own in-person assessment for 65% of visits (kappa = 0.18). Discussion: Intra-observer agreement was similar to the agreement for each provider who did not see the patient in person. This similarity suggests that telemedicine may be equally effective at identifying glaucomatous disease progression, regardless of whether the same provider performed both in-clinic and remote assessments. However, fair agreement levels highlight a limitation of using only telemedicine data to determine progression compared with clinical detail available during in-patient assessment.

Provider Agreement in the Assessment of Glaucoma Progression Within a Team Model.

PURPOSE: Glaucoma specialists and optometrists who work in a team model at a single institution utilize a common definition of glaucoma progression and treatment algorithm. The purpose of this study was to assess the consistency of agreement in identifying glaucoma progression among glaucoma specialists and optometrists of 1 team. METHODS: In total, 399 eyes of 200 patients age 18 or older with glaucoma were enrolled over 2 years. Clinical data, disc photographs, optical coherence tomography (OCT), and visual fields were independently reviewed by 2 masked optometrists and 2 masked fellowship-trained glaucoma specialists. Each eye was judged as progression or no progression of glaucomatous disease. The following were assessed: (1) agreement among optometrists; (2) agreement among glaucoma specialists; and (3) agreement among optometrists and glaucoma specialists. The frequency of use of testing modality to determine progression was also studied. κ statistics were used to evaluate agreements. RESULTS: Optometrists agreed with each other for 74.2% of the eyes assessed (κ=0.42), whereas glaucoma specialists agreed with each other for 78.7% of eyes (κ=0.39). All 4 providers agreed with each other for 54.4% of the eyes evaluated (κ=0.37). Providers had the highest agreement when the progression decision was based on disc hemorrhage (92%) and the lowest agreement when based on OCT progression analysis (36%). Compared with optometrists, glaucoma specialists used OCT (P≤0.01) more frequently to determine disease progression. CONCLUSIONS: Fair to moderate agreement levels were found among providers in their assessment of glaucoma progression, suggesting that a team approach to glaucoma management may be effective. Further work is needed to investigate ways to optimize consistency within the glaucoma team.

The Risk of Primary Open-Angle Glaucoma Following Vitreoretinal Surgery-A Population-based Study.

PURPOSE: To determine the risk of primary open-angle glaucoma (POAG) following vitreoretinal surgery. DESIGN: Retrospective, population-based cohort study. METHODS: All residents of Olmsted County, Minnesota, undergoing scleral buckle and/or vitrectomy between 2004 and 2015 were included in the operative cohort. The fellow nonoperative eyes were included in the comparison cohort. The study and comparison cohorts consisted of 344 and 277 eyes, respectively. The main outcome measure was the development of POAG. Secondary glaucomas were excluded. The probability of glaucoma in operative eyes and nonoperative fellow eyes was compared. The observed rate of POAG in the operative eyes was also compared to the rate of POAG in the population of Olmsted County. RESULTS: The mean age was 64.7 years and the median follow-up period was 4.9 years. There were 58, 57, and 229 study eyes in the scleral buckle, scleral buckle with vitrectomy, and vitrectomy only cohorts, respectively. The 10-year cumulative probability of developing glaucoma was significantly greater in the operative group (8.9%, 95% confidence interval [CI] 3.8%-14%) compared to the nonoperative group (1.0%, 95% CI 0-2.4%; P = .02). None of the eyes in the scleral buckle group developed glaucoma. The 10-year probability of POAG was 17.5% (95% CI 0-34.9%) and 10.0% (95% CI 3.0%-17.0%) in the scleral buckle with vitrectomy and vitrectomy alone cohorts, respectively. The rates of POAG in operative eyes undergoing scleral buckle with vitrectomy and vitrectomy alone were significantly greater than the rate of POAG for the Olmsted County general population (1.0%, P < .001). CONCLUSIONS: The risk of POAG is increased after vitrectomy.

Comparison of refractive assessment by wavefront aberrometry, autorefraction, and subjective refraction.

PURPOSE: To compare refractive assessment results obtained with an aberrometer, an autorefractor, and manual subjective refraction (SR) in a healthy population with optimal visual potential. METHODS: Sixty adults aged 18-59 years with visual acuity of 20/25 or better, no media opacity, and no known corneal or retinal abnormalities were recruited during the course of routine eye examination. Refractive error in both eyes of each patient was assessed by 3 methods: manual SR, a Nidek 530-A autorefractor (AR), and a Nidek OPD-II Scan wavefront aberrometer (OPD). The order of testing was randomized. One technician collected all OPD and AR measurements, and 1 optometrist performed manual SR. Refractive measurements were converted from spherocylindrical prescriptions to power vectors and compared between methods by 2-factor repeated measures and Bland-Altman analysis. RESULTS: Analysis of the power vectors followed by a log transformation showed no significant difference in refractive results between AR, OPD, and SR (P=.63). Bland-Altman analysis identified mean differences (95% CI of limits of agreement) of -0.06 (-0.67 to 0.55) for OPD vs SR, 0.001 (-0.522 to 0.524) for AR vs SR, and 0.06 (-0.541 to 0.662) for AR vs OPD. CONCLUSION: Agreement between all refractive assessments was comparable to previously reported agreement between repeated measures of SR. Agreement between AR and SR was slightly stronger than between OPD and SR. Although both the OPD and AR results, in general, showed a high level of agreement with SR, results beyond ±0.50D (5.8% for AR, 10% for OPD) would discourage prescribing spectacles directly from either instrument.

Comparison of refractive assessment by wavefront aberrometry, autorefraction, and subjective refraction / Comparación de la evaluación refractiva mediante aberrometría por frente de onda, autorefractómetro y refracción subjetiva

Purpose: To compare refractive assessment results obtained with an aberrometer, an autorefractor, and manual subjective refraction (SR) in a healthy population with optimal visual potential. Methods: Sixty adults aged 18---59 years with visual acuity of 20/25 or better, no media opacity, and no known corneal or retinal abnormalities were recruited during the course of routine eye examination. Refractive error in both eyes of each patient was assessed by 3 methods: manual SR, a Nidek 530-A autorefractor (AR), and a Nidek OPD-II Scan wavefront aberrometer (OPD). The order of testing was randomized. One technician collected all OPD and AR measurements, and 1 optometrist performed manual SR. Refractive measurements were converted from spherocylindrical prescriptions to power vectors and compared between methods by 2-factor repeated measures and Bland---Altman analysis. Results: Analysis of the power vectors followed by a log transformation showed no significant difference in refractive results between AR, OPD, and SR (P = .63). Bland---Altman analysis identified mean differences (95% CI of limits of agreement) of −0.06 (−0.67 to 0.55) for OPD vs SR, 0.001 (−0.522 to 0.524) for AR vs SR, and 0.06 (−0.541 to 0.662) for AR vs OPD. Conclusion: Agreement between all refractive assessments was comparable to previously reported agreement between repeated measures of SR. Agreement between AR and SR was slightly stronger than between OPD and SR. Although both the OPD and AR results, in general, showed a high level of agreement with SR, results beyond ±0.50D (5.8% for AR, 10% for OPD) would discourage prescribing spectacles directly from either instrument (AU)

Objetivo: Comparar los resultados de la evaluación refractiva obtenidos mediante aberrómetro, autorefractómetro y refracción subjetiva manual (RS) en una población sana con un potencial visual óptimo. Métodos: Se reclutó a sesenta adultos de edades comprendidas entre 18 y 59 años, con agudeza visual de 20/25 o superior, sin opacidad de medios, y sin anomalías retinianas o corneales, en el curso de un examen ocular rutinario. Se evaluó el error refractivo en los dos ojos de cada paciente mediante tres métodos: RS manual, un autorrefractómetro (AR) Nidek 530-A, y un aberrómetro por frente de onda Nidek OPD-II Scan (OPD). El orden de las pruebas fue aleatorio. Un técnico recolectó todas las mediciones de OPD y AR, y un optometrista llevó a cabo la RS manual. Las mediciones refractivas se transformaron de prescripciones esferocilíndricas en vectores de potencia, comparándose entre sí los tres métodos mediante mediciones repetidas de dos factores y análisis de Bland---Altman. Resultados: El análisis de los vectores de potencia, seguido de una transformación logarítmica, no reflejó ninguna diferencia significativa de los resultados refractivos entre AR, OPD, y RS (P = 0,63). El análisis de Bland---Altman identificó diferencias medias (95% de IC de los límites de acuerdo) de---0,06 (---0,67-0,55) D para OPD frente a RS, 0,001 (---0,522-0.524) D para AR frente a RS, y 0,06 (---0,541-0,662) D para AR frente a OPD. Conclusión: La concordancia entre todas las evaluaciones refractivas fue comparable a la concordancia previamente reportada entre las mediciones repetidas de RS. La concordancia entre AR y RS fue ligeramente superior que entre OPD y RS. Aunque en general los resultados de OPD y AR reflejaron un elevado nivel de concordancia con RS, los resultados que exceden la diferencia de ±0.50D (5.8% para AR, 10% para OPD) no permiten realizar la prescripción de gafas con cualquiera de ambos instrumentos (AU)