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1.
JAMA ; 325(2): 164-174, 2021 01 12.
Artículo en Inglés | MEDLINE | ID: mdl-33433580

RESUMEN

Importance: Glaucoma is the most common cause of irreversible blindness worldwide. Many patients with glaucoma are asymptomatic early in the disease course. Primary care clinicians should know which patients to refer to an eye care professional for a complete eye examination to check for signs of glaucoma and to determine what systemic conditions or medications can increase a patient's risk of glaucoma. Open-angle and narrow-angle forms of glaucoma are reviewed, including a description of the pathophysiology, risk factors, screening, disease monitoring, and treatment options. Observations: Glaucoma is a chronic progressive optic neuropathy, characterized by damage to the optic nerve and retinal nerve fiber layer, that can lead to permanent loss of peripheral or central vision. Intraocular pressure is the only known modifiable risk factor. Other important risk factors include older age, nonwhite race, and a family history of glaucoma. Several systemic medical conditions and medications including corticosteroids, anticholinergics, certain antidepressants, and topiramate may predispose patients to glaucoma. There are 2 broad categories of glaucoma, open-angle and angle-closure glaucoma. Diagnostic testing to assess for glaucoma and to monitor for disease progression includes measurement of intraocular pressure, perimetry, and optical coherence tomography. Treatment of glaucoma involves lowering intraocular pressure. This can be achieved with various classes of glaucoma medications as well as laser and incisional surgical procedures. Conclusions and Relevance: Vision loss from glaucoma can be minimized by recognizing systemic conditions and medications that increase a patient's risk of glaucoma and referring high-risk patients for a complete ophthalmologic examination. Clinicians should ensure that patients remain adherent with taking glaucoma medications and should monitor for adverse events from medical or surgical interventions used to treat glaucoma.


Asunto(s)
Glaucoma , Presión Intraocular , Adulto , Progresión de la Enfermedad , Ojo/anatomía & histología , Glaucoma/complicaciones , Glaucoma/diagnóstico , Glaucoma/fisiopatología , Glaucoma/terapia , Humanos , Tamizaje Masivo , Pronóstico , Factores de Riesgo , Trastornos de la Visión/etiología , Trastornos de la Visión/prevención & control
2.
Cochrane Database Syst Rev ; 2: CD010746, 2017 02 23.
Artículo en Inglés | MEDLINE | ID: mdl-28231380

RESUMEN

BACKGROUND: Glaucoma is the international leading cause of irreversible blindness. Intraocular pressure (IOP) is the only currently known modifiable risk factor; it can be reduced by medications, incisional surgery, or laser trabeculoplasty (LTP). LTP reduces IOP by 25% to 30% from baseline, but early acute IOP elevation after LTP is a common adverse effect. Most of these IOP elevations are transient, but temporarily elevated IOP may cause further optic nerve damage, worsening of glaucoma requiring additional therapy, and permanent vision loss. Antihypertensive prophylaxis with medications such as acetazolamide, apraclonidine, brimonidine, dipivefrin, pilocarpine, and timolol have been recommended to blunt and treat the postoperative IOP spike and associated pain and discomfort. Conversely, other researchers have observed that early postoperative IOP rise happens regardless of whether people receive perioperative glaucoma medications. It is unclear whether perioperative administration of antiglaucoma medications may be helpful in preventing or reducing the occurrence of postoperative IOP elevation. OBJECTIVES: To assess the effectiveness of medications administered perioperatively to prevent temporarily increased intraocular pressure (IOP) after laser trabeculoplasty (LTP) in people with open-angle glaucoma (OAG). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), MEDLINE Ovid (1946 to 18 November 2016), Embase.com (1947 to 18 November 2016), PubMed (1948 to 18 November 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 18 November 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com); last searched 17 September 2013, ClinicalTrials.gov (www.clinicaltrials.gov); searched 18 November 2016 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 18 November 2016. We did not use any date or language restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which participants with OAG received LTP. We included trials which compared any antiglaucoma medication with no medication, one type of antiglaucoma medication compared with another type of antiglaucoma medication, or different timings of medication. DATA COLLECTION AND ANALYSIS: Two review authors independently screened records retrieved by the database searches, assessed the risk of bias, and abstracted data. We graded the certainty of the evidence using GRADE. MAIN RESULTS: We included 22 trials that analyzed 2112 participants and identified no ongoing trials. We performed several comparisons of outcomes: one comparison of any antiglaucoma medication versus no medication or placebo, three comparisons of one antiglaucoma medication versus a different antiglaucoma mediation, and one comparison of antiglaucoma medication given before LTP to the same antiglaucoma medication given after LTP. Only one of the included trials used selective laser trabeculoplasty (SLT); the remaining trials used argon laser trabeculoplasty (ALT). Risk of bias issues were primarily in detection bias, reporting bias, and other potential bias due to studies funded by industry. Two potentially relevant studies are awaiting classification due to needing translation.In the comparison of any medication versus no medication/placebo, there was moderate-certainty evidence that the medication group had a lower risk of IOP increase of 10 mmHg or greater within two hours compared with the no medication/placebo group (risk ratio (RR) 0.05, 95% confidence interval (CI) 0.01 to 0.20). This trend favoring medication continued between two and 24 hours, but the evidence was of low and very low-certainty for an IOP increase of 5 mmHg or greater (RR 0.17, 95% CI 0.09 to 0.31) and 10 mmHg or greater (RR 0.22, 95% CI 0.11 to 0.42). Medication was favored over placebo/no medication with moderate-certainty in reducing IOP from the pre-LTP measurements for both within two hours and between two and 24 hours. At two hours, the mean difference (MD) in IOP between the medication group and the placebo/no medication group was -7.43 mmHg (95% CI -10.60 to -4.27); at between two and 24 hours, the medication group had a mean reduction in IOP of 5.32 mmHg more than the mean change in the placebo/no medication group (95% CI -7.37 to -3.28). Conjunctival blanching was an ocular adverse effect that was more common when brimonidine was given perioperatively compared with placebo in three studies.In our comparison of brimonidine versus apraclonidine, neither medication resulted in a lower risk of increased IOP of 5 mmHg or greater two hours of surgery; however, we were very uncertain about the estimate. There may be a greater mean decrease in IOP within two hours after LTP. We were unable to perform any meta-analyses for other review outcomes for this comparison.In our comparison of apraclonidine versus pilocarpine, we had insufficient data to perform meta-analyses to estimate effects on either of the primary outcomes. There was moderate-certainty evidence that neither medication was favored based on the mean change in IOP measurements from pre-LTP to two hours after surgery.In the comparison of medication given before LTP versus the same medication given after LTP, we had insufficient data for meta-analysis of IOP increase within two hours. For the risk of IOP increase of 5 mmHg or greater and 10 mmHg or greater at time points between two and 24 hours, there was no advantage of medication administration before or after LTP regarding the proportion of participants with an IOP spike (5 mmHg or greater: RR 0.82, 95% CI 0.25 to 2.63; 10 mmHg or greater: RR 1.55, 95% CI 0.19 to 12.43). For an IOP increase of 10 mmHg or greater, we had very low-certainty in the estimate, it would likely change with data from new studies. AUTHORS' CONCLUSIONS: Perioperative medications are superior to no medication or placebo to prevent IOP spikes during the first two hours and up to 24 hours after LTP, but some medications can cause temporary conjunctival blanching, a short-term cosmetic effect. Overall, perioperative treatment was well tolerated and safe. Alpha-2 agonists are useful in helping to prevent IOP increases after LTP, but it is unclear whether one medication in this class of drugs is better than another. There was no notable difference between apraclonidine and pilocarpine in the outcomes we were able to assess. Future research should include participants who have been using these antiglaucoma medications for daily treatment of glaucoma before LTP was performed.


Asunto(s)
Antihipertensivos/uso terapéutico , Glaucoma de Ángulo Abierto/cirugía , Presión Intraocular/efectos de los fármacos , Hipertensión Ocular/prevención & control , Complicaciones Posoperatorias/prevención & control , Trabeculectomía/efectos adversos , Agonistas de Receptores Adrenérgicos alfa 2/uso terapéutico , Antihipertensivos/efectos adversos , Tartrato de Brimonidina/uso terapéutico , Clonidina/análogos & derivados , Clonidina/uso terapéutico , Conjuntiva/efectos de los fármacos , Humanos , Pilocarpina/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto
3.
BMC Ophthalmol ; 17(1): 269, 2017 Dec 29.
Artículo en Inglés | MEDLINE | ID: mdl-29284445

RESUMEN

BACKGROUND: To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals. METHODS: Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported. RESULTS: International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates. CONCLUSIONS: Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of "best practices" to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.


Asunto(s)
Benchmarking/organización & administración , Oftalmopatías/terapia , Hospitales Especializados , Oftalmología , Evaluación de Resultado en la Atención de Salud/métodos , Calidad de Vida , Oftalmopatías/epidemiología , Salud Global , Humanos , Morbilidad/tendencias
4.
J Glaucoma ; 33(1): 24-27, 2024 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-37671557

RESUMEN

PRCIS: Drive-through intraocular pressure (IOP) measurement using iCare tonometry is a promising method of low-contact, high-throughput IOP monitoring. However, owing to its vulnerability to variable measurement technique and local air currents, the iCare may overestimate IOPs. PURPOSE: During the COVID-19 pandemic, a drive-through IOP measurement protocol using the iCare tonometer was established to facilitate low-contact monitoring of select glaucoma patients. As the iCare may be prone to error due to variable measurement technique and local air currents, we endeavored to assess the reliability of drive-through IOP measurements by comparing them with recent measurements taken in clinic settings. METHODS: Inclusion criteria were patients with drive-through IOP measurements performed from April 28 to October 11, 2020; exclusion criteria were pre-drive-through IOPs >21 mmHg. Drive-through IOP measurements were compared with the closest previous and/or subsequent in-clinic IOP measurements. Data were gathered using the Sight Outcomes Research Collaborative (SOURCE) data repository. RESULTS: The post-exclusion study group consisted of 314 patients receiving a total of 868 drive-through IOP measurements, all of whom had prior in-clinic measurements, and 56.8% of whom had subsequent in-clinic measurements. Drive-through IOPs were, on average, +2.4 mmHg (+14.5%; SD 4.9) higher than in-clinic IOPs. Further sub-analysis of the data showed a difference of +2.1 mmHg OD and +2.6 mmHg OS. Compared with the closest previous in-clinic visit, the difference was +2.4 mmHg OU (+2.1 mmHg OD, +2.7 mmHg OS); compared with the closest subsequent in-clinic visit, the difference was +2.3 mmHg OU (+2.1 mmHg OD, +2.5 mmHg OS). 68.6% of all drive-through IOPs were higher than corresponding in-clinic IOPs; 21.1% were lower. 25.9% of drive-through IOPs were higher by more than 5 mmHg, whereas 3.9% of drive-through IOPs were lower by more than 5 mmHg. DISCUSSION: As teleophthalmology becomes an ever more important tool in glaucoma patient care, drive-through or walk-through IOP monitoring methods are likely to play an increasing role. However, our data reveals potential inaccuracies in drive-through iCare IOP measurements which tended to overestimate IOP. It is advisable to confirm large changes in IOP with in-clinic measurement before making management decisions. CONCLUSION: With better optimization of accuracy and reliability of measurements, drive-through tonometry is a promising, high-throughput, low-contact method of measuring IOP.


Asunto(s)
Glaucoma , Hipertensión Ocular , Oftalmología , Telemedicina , Humanos , Presión Intraocular , Hipertensión Ocular/diagnóstico , Reproducibilidad de los Resultados , Pandemias , Glaucoma/diagnóstico , Tonometría Ocular/métodos , Manometría
5.
Ophthalmology ; 119(2): 304-7, 2012 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-22115714

RESUMEN

OBJECTIVE: To test for differences in reliability and performance between traditional, isolated perimetry and simultaneous testing with 2 patients in the same room. DESIGN: Comparative case series. PARTICIPANTS: A total of 471 eyes of 261 subjects. METHODS: Consecutive patients undergoing Humphrey visual field (VF) testing in the Kellogg Eye Center glaucoma clinic were screened. Patients who underwent VF testing with another patient in the same room ("double field") during the screening interval were included as subjects if a comparison isolated VF from the same patient ("single field") was obtainable from the clinic's records. An individual subject's performance and reliability on his/her double and single fields were compared using a paired t test. In addition, the double fields were stratified by technician-to-patient ratio, and their VF indices were compared using an independent 2-sample t test. MAIN OUTCOME MEASURES: False negatives, false positives, fixation losses, mean deviation, pattern standard deviation, VF index, VF duration, and technician-to-patient ratio. RESULTS: No significant differences between single and double fields were found in the reliability or performance parameters. Test duration was longer in double fields than in single fields (6.1 vs. 5.9 minutes, P < 0.001). There were no significant differences found in reliability or performance indices when the double-field data were stratified by technician-to-patient ratio (1:2 vs. 2:2). CONCLUSIONS: There is no decrement in VF performance or reliability when patients undergo simultaneous testing with another patient in the same room. Busy clinical practices may be able to minimize costs and maximize efficiency by having 1 technician simultaneously supervise more than 1 test-taker in the same space.


Asunto(s)
Trastornos de la Visión/diagnóstico , Pruebas del Campo Visual/normas , Campos Visuales/fisiología , Anciano , Reacciones Falso Negativas , Femenino , Glaucoma/diagnóstico , Humanos , Masculino , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos
6.
J Glaucoma ; 30(3): 223-226, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33273284

RESUMEN

PRECIS: A drive-through clinic was created to obtain intraocular pressure measurements before a virtual visit with their provider, in order to provide care for patients in the Kellogg Glaucoma Clinic while minimizing risk of COVID-19 transmission. PURPOSE: The aim of this study was to establish a drive-through clinic model to provide glaucoma care for patients while minimizing the risk of COVID-19 transmission. PATIENTS AND METHODS: A drive-through clinic was created by adapting a 1-lane, 1-way driveway adjacent to the Kellogg Eye Center building entrance. Patients were physicianselected from the Glaucoma Clinic at Kellogg Eye Center as existing patients who required intraocular pressure (IOP) checks and therapeutic management and were chosen based on their ability to be managed with an IOP measurement primarily. The entrance was otherwise closed to the public, allowing staff to utilize an adjacent vestibule with glass walls and sliding doors as a staffroom. Patients were instructed to arrive within a 15-minute time window at which time they would drive through the lane and stop their cars under an awning over the driveway. Ophthalmic technicians wearing appropriate personal protective equipment then approached each car, confirmed patient information, and measured IOP. Once the data were recorded using a mobile workstation, the physician was able to complete each visit by discussing the findings and therapeutic plan with the patient, either in-person in real time or virtually by phone or video visit at a later time. RESULTS: A total of 241 visits were completed over 14 half day clinic sessions, with number of drive-through visits ranging from 5 to 45 per session. CONCLUSIONS: It is possible to institute a drive-through model of IOP checks for glaucoma patients which is efficient and minimizes the risk of exposure to COVID-19 for patients and staff.


Asunto(s)
COVID-19/epidemiología , Transmisión de Enfermedad Infecciosa/prevención & control , Glaucoma/diagnóstico , Presión Intraocular/fisiología , Pandemias , Tonometría Ocular/métodos , COVID-19/transmisión , Comorbilidad , Glaucoma/epidemiología , Glaucoma/fisiopatología , Humanos , SARS-CoV-2
7.
JAMA Ophthalmol ; 138(9): 974-980, 2020 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-32678424

RESUMEN

Importance: During the coronavirus disease 2019 (COVID-19) pandemic, eye care professionals caring for patients with sight-threatening diseases, such as glaucoma, have had to determine whether some patient appointments could safely get postponed, weighing the risk that the patient's glaucoma could worsen during the interim vs the morbidity risk of acquiring COVID-19 while seeking ophthalmic care. They also need to prioritize appointment rescheduling during the ramp-up phase (when pandemic-associated service reductions are eased). Objective: To describe a flexible and scalable scoring algorithm for patients with glaucoma that considers glaucoma severity and progression risk vs the presence of high-risk features for morbidity from COVID-19, using information from a large data repository. Design, Setting, and Participants: In this cross-sectional study, patients with upcoming clinic appointments for glaucoma from March 16, 2020, to April 16, 2020, at an academic institution enrolled in the Sight Outcomes Research Collaborative (SOURCE) Ophthalmology Electronic Health Record Data Repository were identified. A risk stratification tool was developed that calculated a glaucoma severity and progression risk score and a COVID-19 morbidity risk score. These scores were summed to determine a total score for each patient. Main Outcomes and Measures: Total scores and percentages of clinic appointments recommended for rescheduling. Results: Among the 1034 patients with upcoming clinic appointments for glaucoma, the mean (SD) age was 66.7 (14.6) years. There were 575 women (55.6%), 733 White individuals (71%), and 160 Black individuals (15.5%). The mean (SD) glaucoma severity and progression risk score was 4.0 (14.4) points, the mean (SD) COVID-19 morbidity risk score was 27.2 (16.1) points, and the mean (SD) total score was 31.2 (21.4) points. During pandemic-associated reductions in services, using total score thresholds of 0, 25, and 50 points would identify 970 appointments (93.8%), 668 appointments (64.6%), and 275 appointments (26.6%), respectively, for postponement and rescheduling. The algorithm-generated total scores also helped prioritize appointment rescheduling during the ramp-up phase. Conclusions and Relevance: A tool that considers the risk of underlying ophthalmic disease progression from delayed care receipt and the morbidity risk from COVID-19 exposure was developed and implemented, facilitating the triage of upcoming ophthalmic appointments. Comparable approaches for other ophthalmic and nonophthalmic care during the COVID-19 pandemic and similar crises may be created using this methodology.


Asunto(s)
Citas y Horarios , Betacoronavirus , Infecciones por Coronavirus/epidemiología , Glaucoma/terapia , Evaluación de Resultado en la Atención de Salud , Neumonía Viral/epidemiología , Triaje , Anciano , Anciano de 80 o más Años , Instituciones de Atención Ambulatoria , COVID-19 , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oftalmología , Pandemias , SARS-CoV-2
8.
J Glaucoma ; 16(8): 700-3, 2007 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-18091458

RESUMEN

PURPOSE: To determine if ocular pulse amplitude (OPA) as measured by dynamic contour tonometry (DCT) is related to severity of glaucoma, and if intraocular pressure (IOP) as measured by DCT is related to central corneal thickness (CCT). METHODS: Patients were selected from the Duke Eye Center glaucoma clinic. Fifty-five eyes of 32 patients were included; right and left eyes were analyzed separately. CCT, OPA, DCT IOP, Goldmann applanation tonometry (GAT), Tonopen applanation tonometry (TAT), and systemic blood pressure were measured. Advanced Glaucoma Intervention Study score and mean deviation of visual field, and vertical and horizontal cup-disc ratios were recorded in a masked manner. Descriptive statistics were obtained, and OPA, DCT IOP, GAT, and TAT underwent univariate analyses to assess for relationships with predictor variables. RESULTS: OPA, DCT IOP, GAT, and TAT were positively associated with CCT and with having no surgical intervention for right and left eyes, and were negatively associated with vertical and horizontal cup-disc ratios. CONCLUSIONS: Increased OPA seems to correlate with less severe glaucoma and with increased CCT. DCT IOP seems to be affected by CCT along with GAT and TAT.


Asunto(s)
Córnea/diagnóstico por imagen , Ojo/irrigación sanguínea , Glaucoma/diagnóstico , Glaucoma/fisiopatología , Presión Intraocular , Pulso Arterial , Tonometría Ocular/métodos , Anciano , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Tonometría Ocular/normas , Ultrasonografía
9.
Am J Ophthalmol ; 179: 145-150, 2017 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-28483494

RESUMEN

PURPOSE: Improving adherence to practice guidelines can improve patient safety and quality of care. We sought to establish a regional glaucoma physician collaborative to evaluate and improve adherence to the American Academy of Ophthalmology's Primary Open-angle Glaucoma (POAG) Preferred Practice Pattern (PPP) guidelines. DESIGN: Prospective interventional study. METHODS: The collaborative consisted of 13 glaucoma specialists from 3 practices in Michigan. All consecutive POAG new patient visits were reviewed from each study site to determine physician adherence to the 13 major examination elements of the PPP. In phase 1 of the study, physician adherence rates for each of the recommended examination elements were combined and averaged for all groups. Averages for the collaborative were reported to each site, and each physician received his or her individual adherence rates. Physicians discussed strategies to improve overall adherence to the PPP. Adherence rates were collected in phase 2 to determine if feedback and sharing of strategies resulted in improved adherence. RESULTS: A total of 274 new POAG patient visits from phase 1 and 280 visits from phase 2 were reviewed. After accounting for multiple comparisons, overall improvement approached statistical significance for the evaluation of visual function (91.2% to 96.1%, P < .02) and target intraocular pressure determination (73.7% to 83.2%, P < .01). Improvement for other measures that had a high rate of adherence at baseline (eg, ocular history, pupil examination, and central corneal thickness measurement) was not statistically significant. CONCLUSIONS: It is feasible to establish a regional glaucoma physician collaborative to improve standardization of care for patients with newly diagnosed POAG.


Asunto(s)
Glaucoma de Ángulo Abierto/terapia , Adhesión a Directriz/tendencias , Oftalmología/normas , Pautas de la Práctica en Medicina/normas , Mejoramiento de la Calidad , Humanos , Presión Intraocular , Michigan , Estudios Prospectivos
10.
J Glaucoma ; 25(3): 285-90, 2016 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-25144212

RESUMEN

PURPOSE: To evaluate eyes with preexisting scleral buckles (SBs) that underwent placement of a 250 mm Baerveldt glaucoma drainage device (GDD). PATIENTS AND METHODS: Records of all patients with a preexisting SB who underwent 250 mm Baerveldt GDD placement at the Kellogg Eye Center between January 1, 2005 and September 30, 2012 were reviewed. Outcome measures included visual acuity (VA), intraocular pressure (IOP), and number of glaucoma medications prescribed. RESULTS: Seventeen eyes of 17 patients were analyzed. Mean follow-up was 23.9 months. Twelve eyes (70.6%) achieved successful control of IOP (<22 mm Hg, not requiring additional IOP reduction procedures, and no devastating complications). Preoperatively, mean IOP was 25.5 mm Hg, mean number of glaucoma medications was 3.5, and mean logMAR VA was 1.1 (Snellen equivalent 20/200). At 1 and 2 years postoperatively, mean IOP was 9.2 and 8.8 mm Hg (P<0.001), and mean number of glaucoma medications was 0.9 and 0.3 (P<0.001), respectively. There were no statistically significant changes in logMAR VA at 1 and 2 years postoperatively (P=0.45 and 0.99, respectively). Complications included conjunctival dehiscence (4 eyes, 24%), wound leak (2 eyes, 12%), tube and plate exposure requiring removal of drainage device (2 eyes, 12%), phthisis (2 eyes, 12%), and hemorrhagic choroidal detachment (1 eye, 6%). CONCLUSIONS: In eyes with preexisting SBs, the Baerveldt 250 mm GDD effectively lowers IOP and reduces the number of glaucoma medications. Complications related to conjunctival dehiscence are not uncommon in these eyes with significantly scarred conjunctiva.


Asunto(s)
Implantes de Drenaje de Glaucoma , Glaucoma de Ángulo Abierto/cirugía , Curvatura de la Esclerótica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Femenino , Glaucoma de Ángulo Abierto/etiología , Glaucoma de Ángulo Abierto/fisiopatología , Humanos , Presión Intraocular/fisiología , Masculino , Persona de Mediana Edad , Implantación de Prótesis , Desprendimiento de Retina/complicaciones , Desprendimiento de Retina/fisiopatología , Desprendimiento de Retina/cirugía , Estudios Retrospectivos , Tonometría Ocular , Agudeza Visual/fisiología
11.
Appl Clin Inform ; 7(4): 930-945, 2016 10 12.
Artículo en Inglés | MEDLINE | ID: mdl-27730248

RESUMEN

OBJECTIVES: To understand the attitudes and perceptions of ophthalmologists toward an electronic health record (EHR) system, before and after its clinical implementation. METHODS: Ophthalmologists at a single large academic ophthalmology department were surveyed longitudinally before and after implementation of a new EHR system. The survey measured ophthalmologists' attitudes toward implementation of a new EHR. Questions focused on satisfaction, efficiency, and documentation. All attending physicians (between 56 and 61 at various time points) in the University of Michigan Department of Ophthalmology and Visual Sciences were surveyed. We plotted positive responses to survey questions and assessed whether perceptions followed a J-curve with an initial decrease followed by an increase surpassing pre-implementation levels. RESULTS: Survey responses were received from 32 (52%) ophthalmologists pre-implementation, and 28 (46%) at 3 months, 35 (57%) at 7 months, 40 (71%) at 13 months and 39 (67%) at 24 months post-implementation. After EHR implementation respondents were more likely to express concerns about their ability to create high-quality documentation (p<0.01) and the impact of an electronic health record on meaningful patient interaction (p<0.01). Physicians did not report a significant change in the amount of time spent documenting outside of regular clinical work hours (p=0.54) or on their clinic efficiency and workflow (p=0.97). There was no significant change in overall job satisfaction during the study period (p=0.69). We did not observe a J-curve for any of the survey responses analyzed. CONCLUSIONS: As ophthalmology practices continue to transition to EHRs, adapting them to their specific culture and needs is important to maintain efficiency and user satisfaction. This study identifies areas of concern to ophthalmologists that may be addressed through education of physicians and customization of software as other practices move forward with EHR implementation.


Asunto(s)
Actitud del Personal de Salud , Registros Electrónicos de Salud , Oftalmólogos/psicología , Adulto , Anciano , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios
12.
Ophthalmic Surg Lasers Imaging ; 36(4): 346-7, 2005.
Artículo en Inglés | MEDLINE | ID: mdl-16156156

RESUMEN

The development of Lisch nodules in an eye that had undergone trabeculectomy with mitomycin C is described. Complete ophthalmologic examinations and genetic testing of a 12-year-old boy were performed. Lisch nodules can develop after trabeculectomy without the systemic manifestations of neurofibromatosis type 1.


Asunto(s)
Glaucoma de Ángulo Abierto/cirugía , Neoplasias del Iris/etiología , Neurofibromatosis 1/etiología , Trabeculectomía/efectos adversos , Niño , Terapia Combinada , Glaucoma de Ángulo Abierto/tratamiento farmacológico , Humanos , Masculino , Mitomicina/administración & dosificación
13.
Am J Ophthalmol ; 160(2): 275-282.e4, 2015 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-25935096

RESUMEN

PURPOSE: To evaluate use of medical, laser, or incisional surgical interventions for glaucoma after laser peripheral iridotomy (LPI). DESIGN: Retrospective longitudinal cohort study. METHODS: All enrollees aged ≥21 years in a US managed-care network who underwent bilateral LPIs in 2001-2011 were identified. The mean numbers of pre- and post-LPI glaucoma medication classes prescribed and the proportion of enrollees requiring cataract or glaucoma surgery within 2 years after the LPIs were determined. Multivariable logistic regression assessed factors associated with enrollees' prescription of ≥1 glaucoma medication class after bilateral LPIs. RESULTS: Of the 1660 patients undergoing bilateral LPIs, 1280 (77.1%) had no pre- or post-LPI prescriptions for any glaucoma medication class. Of the remaining patients, 251 (66.1%) required more glaucoma medication classes after than before the procedures, whereas 44 (11.6%) used fewer after the procedures; 85 (22.4%) were prescribed the same number before and after the LPIs. A total of 167 patients (10.1%) underwent cataract surgery and 79 (4.8%) received glaucoma surgery over the 2-year follow-up. Black patients had a 130% increased odds for glaucoma medication-class prescriptions after bilateral LPIs, compared with white patients (P = .02). The odds of post-LPI glaucoma medication use increased by 21% for every additional 5 years of age (P < .0001). CONCLUSION: Most patients undergoing bilateral LPIs received no pre- or post-LPI glaucoma medication-class prescriptions and had no cataract or additional glaucoma surgery within 2 years after LPIs. Clinicians should alert black or older patients and those already taking glaucoma medications before the procedure of their higher odds of requiring medications afterward.


Asunto(s)
Glaucoma de Ángulo Cerrado/cirugía , Presión Intraocular , Iridectomía/normas , Iris/cirugía , Terapia por Láser/normas , Procedimientos Quirúrgicos Oftalmológicos/normas , Guías de Práctica Clínica como Asunto , Femenino , Estudios de Seguimiento , Glaucoma de Ángulo Cerrado/fisiopatología , Humanos , Iridectomía/métodos , Terapia por Láser/métodos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Oftalmológicos/métodos , Estudios Retrospectivos , Estados Unidos
14.
Arch Ophthalmol ; 122(1): 17-21, 2004 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-14718289

RESUMEN

OBJECTIVE: To determine if central corneal thickness (CCT) is related to the level of glaucoma severity at the initial examination. METHODS: The initial visit to a glaucoma specialist by consecutive patients with primary open-angle glaucoma from 1997 to 2002 was reviewed retrospectively. Each patient's age, sex, race, family history of glaucoma, number of glaucoma medications, visual acuity, spherical equivalent, intraocular pressure, CCT, visual field data, and vertical and horizontal cup-disc ratios were analyzed. RESULTS: Three hundred fifty eyes of 190 patients met the inclusion and exclusion criteria. Central corneal thickness was significantly lower in blacks (mean, 537 microm) than in whites (mean, 556 microm). Lower CCT was significantly associated with worsened Advanced Glaucoma Intervention Study score, worsened mean deviation of visual field, increased vertical and horizontal cup-disc ratios, and increased number of glaucoma medications. In multivariate analysis, lower CCT was significantly associated with worsened Advanced Glaucoma Intervention Study score, worsened mean deviation of visual field, and increased vertical and horizontal cup-disc ratios. CONCLUSIONS: Central corneal thickness is a powerful clinical factor in determining glaucoma severity at the initial examination by a specialist. Measuring CCT may aid the ophthalmologist in identification of glaucoma patients at high risk for progression.


Asunto(s)
Córnea/patología , Glaucoma de Ángulo Abierto/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Población Negra , Pesos y Medidas Corporales , Córnea/diagnóstico por imagen , Técnicas de Diagnóstico Oftalmológico , Femenino , Glaucoma de Ángulo Abierto/etnología , Humanos , Presión Intraocular , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Ultrasonografía , Campos Visuales , Población Blanca
15.
Am J Ophthalmol ; 136(5): 814-9, 2003 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-14597031

RESUMEN

PURPOSE: To review our initial experience with radial optic neurotomy as treatment for retinal vein occlusion. DESIGN: Interventional case series. PATIENT POPULATION: five patients (four with central retinal vein occlusion and one with hemiretinal vein occlusion). INTERVENTION: Pars plana vitrectomy with radial optic neurotomy was performed in each case. MAIN OUTCOME MEASURES: Best-corrected visual acuity, presence of macular edema, perfusion status, and time to venous phase of the angiogram were reviewed retrospectively. RESULTS: Mean preoperative visual acuity was 4/200. Preoperatively, the vein occlusion was perfused in one (20%), nonperfused in one (20%), and indeterminate in three (60%). Mean follow-up time was 4.5 months. Mean postoperative visual acuity was 20/400 at last follow-up. Four patients (80%) had improvement in visual acuity and one (20%) worsened. Two patients (40%) improved to 20/80 postoperatively. In four cases (80%), disk congestion improved and intraretinal hemorrhage reabsorbed more quickly than would be expected without treatment. Time to the venous phase of fluorescein angiography improved slightly in three cases (60%) postoperatively. Perfusion status as determined by fluorescein angiography was not significantly altered postoperatively. One patient (20%) had resolution of macular edema postoperatively as shown by volumetric optical coherence tomography. One patient developed choroidovitreal neovascularization and one developed iris neovascularization postoperatively, both of which responded to panretinal photocoagulation. CONCLUSIONS: Radial optic neurotomy may improve visual acuity in eyes with central retinal vein occlusion, although choroidovitreal neovascularization from the neurotomy site can occur. Further study is needed to determine its role in the management of central vein occlusion.


Asunto(s)
Síndromes Compartimentales/cirugía , Descompresión Quirúrgica/métodos , Nervio Óptico/cirugía , Oclusión de la Vena Retiniana/cirugía , Anciano , Síndromes Compartimentales/complicaciones , Síndromes Compartimentales/fisiopatología , Femenino , Angiografía con Fluoresceína , Humanos , Masculino , Vena Retiniana/fisiología , Oclusión de la Vena Retiniana/etiología , Oclusión de la Vena Retiniana/fisiopatología , Tomografía de Coherencia Óptica , Agudeza Visual , Vitrectomía
16.
Ophthalmic Surg Lasers Imaging ; 34(4): 350-2, 2003.
Artículo en Inglés | MEDLINE | ID: mdl-12875471

RESUMEN

A 58-year-old hypertensive man with a perfused central retinal vein occlusion of 21 days' duration received 50 microg of intravitreal recombinant tissue plasminogen activator in 0.1 cc. Best-corrected visual acuity improved 2 weeks after the injection. Optical coherence tomography and fluorescein angiography demonstrated resolution of cystoid macular edema and improvement of venous outflow. Intravitreal tissue plasminogen activator may be a useful treatment for central retinal vein occlusion with a duration of 21 days or less.


Asunto(s)
Oclusión de la Vena Retiniana/tratamiento farmacológico , Activador de Tejido Plasminógeno/administración & dosificación , Angiografía con Fluoresceína , Fondo de Ojo , Humanos , Edema Macular/complicaciones , Masculino , Persona de Mediana Edad , Oftalmoscopía , Óptica y Fotónica , Oclusión de la Vena Retiniana/complicaciones , Oclusión de la Vena Retiniana/diagnóstico , Oclusión de la Vena Retiniana/fisiopatología , Tomografía , Agudeza Visual , Cuerpo Vítreo
17.
Can J Ophthalmol ; 49(2): 205-9, 2014 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-24767230

RESUMEN

OBJECTIVE: To report baseline characteristics and surgical outcomes of placement of simultaneous glaucoma drainage devices (GDDs) in eyes with considerably elevated intraocular pressure (IOP) despite maximal medical therapy. DESIGN: Retrospective case series. PARTICIPANTS: Twelve eyes of 12 patients underwent simultaneous placement of a Baerveldt 350 GDD and an Ahmed S3 GDD in the same eye. METHODS: The medical records were reviewed of consecutive patients who underwent simultaneous placement of a Baerveldt 350 GDD and an Ahmed S3 GDD in the same eye at the University of Michigan Kellogg Eye Center from 2006 to 2009. Baseline characteristics, preoperative and postoperative IOP, number of glaucoma medications, visual acuity, and complications were recorded. RESULTS: Mean follow-up time was 28.6 ± 22.8 months. The mean baseline cup/disc ratio was recorded at 0.94 ± 0.07 horizontally and 0.92 ± 0.09 vertically. The mean baseline IOP of 38.8 ± 6.2 mm Hg was significantly reduced at all time points postoperatively, and the mean IOP at last follow-up was 15.1 ± 4.9 mm Hg (p ≤ 0.0001). Mean number of glaucoma medications was significantly lower at last follow-up than preoperatively (1.4 ± 1.3 vs 3.2 ± 0.8; p = 0.001). There was no difference in mean logMAR visual acuity from before surgery to last follow-up (1.14 vs 1.12; p = 0.933). CONCLUSIONS: Simultaneous placement of 2 GDDs effectively reduces IOP in the immediate postoperative period and long-term, and may be useful in glaucomatous eyes with advanced disease and considerably elevated preoperative IOP.


Asunto(s)
Implantes de Drenaje de Glaucoma , Glaucoma/cirugía , Implantación de Prótesis , Adulto , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Femenino , Estudios de Seguimiento , Glaucoma/fisiopatología , Humanos , Presión Intraocular/fisiología , Complicaciones Intraoperatorias , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Tonometría Ocular , Resultado del Tratamiento , Agudeza Visual/fisiología , Adulto Joven
19.
Semin Ophthalmol ; 28(3): 191-201, 2013 May.
Artículo en Inglés | MEDLINE | ID: mdl-23697623

RESUMEN

Adherence to prescribed glaucoma medications is often poor, and proper adherence can be challenging for patients. We systematically reviewed the literature and identified eight studies using educational interventions to improve glaucoma medication adherence. Overall, five of the eight studies found that educational interventions lead to a significant improvement in medication adherence, and two additional studies found a trend towards improvement. Using information from this systematic review and Health Behavior Theory, we constructed a conceptual framework to illustrate how counseling and education can improve glaucoma medication adherence. More rigorous studies grounded in Health Behavior Theory with adequately powered samples and longer follow-up are needed.


Asunto(s)
Antihipertensivos/uso terapéutico , Glaucoma/tratamiento farmacológico , Cumplimiento de la Medicación/estadística & datos numéricos , Educación del Paciente como Asunto , Humanos , Aceptación de la Atención de Salud
20.
Br J Ophthalmol ; 97(12): 1549-53, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24123909

RESUMEN

OBJECTIVE: To design and implement a quality improvement (QI) programme in an academic department of ophthalmology. DESIGN: The six core competencies of the Accreditation Council for Graduate Medical Education serve as the model for this programme in an institutional practice. The authors review departmental rates of postoperative infections, unplanned reoperations, intraoperative complications, specific subspecialty postoperative complications and successes, and patient and staff compliments and complaints. RESULTS: The authors describe the structure and evolution of the QI programme in our ophthalmology department. CONCLUSIONS: It is possible to implement a structured QI programme in an academic department of ophthalmology. With healthcare oversight increasing, physician self-monitoring of quality of care measures will become even more important.


Asunto(s)
Acreditación/organización & administración , Educación de Postgrado en Medicina/organización & administración , Educación de Postgrado en Medicina/normas , Oftalmología/educación , Oftalmología/normas , Mejoramiento de la Calidad/organización & administración , Centros Médicos Académicos/organización & administración , Competencia Clínica/normas , Educación Basada en Competencias/organización & administración , Educación Basada en Competencias/normas , Humanos , Procedimientos Quirúrgicos Oftalmológicos/normas , Desarrollo de Programa , Infección de la Herida Quirúrgica/prevención & control
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