Reduced Mammography Screening for Breast Cancer among Women with Visual Impairment.

PURPOSE: Timely mammography to screen for breast cancer in accordance with the United States Preventive Services Task Force (USPSTF) recommendations can reduce morbidity and mortality substantially. This study assessed whether the odds of undergoing screening mammography are similar for women with and without visual impairment (VI). DESIGN: Retrospective, longitudinal cohort study. PARTICIPANTS: Women aged 65 to 72 years enrolled in fee-for-service Medicare from January 1, 2008, through December 31, 2015. METHODS: Patients with no vision loss (NVL), partial vision loss (PVL), and severe vision loss (SVL) were matched 1:1:1 based on age, race, time in Medicare, urbanicity of residence, and overall health. Women with pre-existing breast cancer were excluded. Multivariable conditional logistic regression modeling compared the odds of undergoing screening mammography within a 2-year follow-up period among the 3 groups. MAIN OUTCOMES MEASURES: Proportion of participants undergoing mammography and adjusted odds ratios (ORs) of undergoing mammography within 2 years of follow-up. RESULTS: A total of 1044 patients were matched (348 in each group). The mean ± standard deviation age at the index date was 69.0 ± 1.5 years for all 3 groups. The proportion of women undergoing 1 mammography screening or more within the 2-year follow-up was 69.0% (n = 240), 56.9% (n = 198), and 56.0% (n = 195) for the NVL, PVL, and SVL groups, respectively (P = 0.0005). The mean ± standard deviation number of mammography screenings undergone per patient during the 5-year period (3-year look-back plus 2-year follow-up) was 3.1 ± 2.0, 2.5 ± 2.0, and 2.3 ± 2.1 for the NVL, PVL, and SVL groups, respectively (P < 0.0001). Women with SVL had 42% decreased odds (OR, 0.58; 95% CI, 0.37-0.90; P = 0.01), and those with PVL had 44% decreased odds (OR, 0.56; CI, 0.36-0.87; P = 0.009) of undergoing mammography during follow-up compared with those with NVL. CONCLUSIONS: Women with VI were significantly less likely to undergo mammography screening for breast cancer than women without VI. Clinicians should look for ways to help ensure that patients with VI undergo mammography and other preventive screenings as recommended by the USPSTF.

Inhibition of p53 attenuates steatosis and liver injury in a mouse model of non-alcoholic fatty liver disease.

BACKGROUND & AIMS: p53 and its transcriptional target miRNA34a have been implicated in the pathogenesis of fatty liver. We tested the efficacy of a p53 inhibitor, pifithrin-α p-nitro (PFT) in attenuating steatosis, associated oxidative stress and apoptosis in a murine model of non-alcoholic fatty liver disease (NAFLD). METHODS: C57BL/6 mice were fed a high-fat (HFD) or control diet for 8 weeks; PFT or DMSO (vehicle) was administered three times per week. Markers of oxidative stress and apoptosis as well as mediators of hepatic fatty acid metabolism were assessed by immunohistochemistry, Western blot, real-time PCR, and biochemical assays. RESULTS: PFT administration suppressed HFD-induced weight gain, ALT elevation, steatosis, oxidative stress, and apoptosis. PFT treatment blunted the HFD-induced upregulation of miRNA34a and increased SIRT1 expression. In the livers of HFD-fed, PFT-treated mice, activation of the SIRT1/PGC1α/PPARα axis increased the expression of malonyl-CoA decarboxylase (MLYCD), an enzyme responsible for malonyl-CoA (mCoA) degradation. Additionally, the SIRT1/LKB1/AMPK pathway (upstream activator of MLYCD) was promoted by PFT. Thus, induction of these two pathways by PFT diminished the hepatic mCoA content by enhancing MLYCD expression and function. Since mCoA inhibits carnitine palmitoyltransferase 1 (CPT1), the decrease of hepatic mCoA in the PFT-treated, HFD-fed mice increased CPT1 activity, favored fatty acid oxidation, and decreased steatosis. Additionally, we demonstrated that PFT abrogated steatosis and promoted MLYCD expression in palmitoleic acid-treated human HepaRG cells. CONCLUSIONS: The p53 inhibitor PFT diminished hepatic triglyceride accumulation and lipotoxicity in mice fed a HFD, by depleting mCoA and favoring the ß-oxidation of fatty acids.

Racial Disparities Affecting Black Patients In Glaucoma Diagnosis And Management.

Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.

Racial Disparities Affecting Black Patients in Glaucoma Diagnosis and Management.

Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.

Steroid Response Following Dropless Cataract Surgery Using Subconjunctival Triamcinolone.

Purpose: To assess the rates of postoperative steroid response following dropless cataract surgery using a subconjunctival depot of triamcinolone versus conventional cataract surgery using topical prednisolone. Patients and Methods: We reviewed consecutive cataract surgery cases performed by a single surgeon to determine the likelihood of steroid response, defined as intraocular pressure (IOP) 50% above baseline or IOP > 24 mmHg postoperatively, excluding the first 72 hours. Logistic regression models were performed including baseline characteristics as exposures in the model and steroid response as the outcome. Main outcome measures were the proportion of eyes developing steroid response, risk factors for developing steroid response, and duration of steroid response. Results: Of the 150 dropless and 218 conventional cases, 26 eyes developed steroid response (15 dropless and 11 conventional cases [10% vs 5%, P=0.096]). Risk factors for steroid response included dropless surgery (OR=2.43, 95% CI=1.03-6.02], P=0.046) and prior diagnosis of glaucoma (OR=7.18, 95% CI=2.66-19.22], P<0.001). Baseline IOP, age, sex, race, and axial length did not increase risk for steroid response. Of the eyes with steroid response, more dropless cases had an IOP elevation ≥30 days (9/15 eyes vs 1/11 eyes; P=0.008), including one patient with refractory IOP elevation in the dropless group who required urgent bilateral trabeculectomy for IOP control. Conclusion: Dropless cataract surgery increases the risk of prolonged steroid response postoperatively. Patients with glaucoma have an increased risk of steroid response and may not be good candidates for dropless cataract surgery with subconjunctival triamcinolone.

Potentially Missed Opportunities in Prevention of Acute Angle-Closure Crisis.

Importance: If an anatomic narrow angle is not appropriately diagnosed and treated, it can result in acute angle-closure crisis (AACC) and lead to substantial vision loss. Objective: To identify patients who presented with AACC and assess for factors that may have been associated with risk of developing it. Design, Setting, and Participants: This population-based retrospective cohort study conducted from January 1, 2001, to December 31, 2015, included a 20% nationwide sample of 1179 Medicare beneficiaries. Patients aged 40 years or older with AACC were identified with billing codes. A 2-year lookback period from the date of initial presentation of AACC was used to identify patients who had at least 1 eye care visit, received a diagnosis of open-angle glaucoma (OAG) or suspected OAG, or received at least 1 medication associated with risk of AACC. Of the patients who had at least 1 eye care visit, those who underwent gonioscopy, received a diagnosis of an anatomic narrow angle before developing AACC, or both were identified. Main Outcomes and Measures: Proportions of patients who had at least 1 eye care visit, had OAG or suspected OAG, received at least 1 medication associated with risk of AACC, underwent gonioscopy, or received a diagnosis of an anatomic narrow angle before development of AACC. Results: A total of 1179 patients had a confirmed diagnosis of AACC. The mean (SD) age of patients with AACC was 66.7 (11.8) years (range, 40-96 years), 766 were women (65.0%), 57 were Asian (4.8%), 109 were Black (9.2%), 126 were Latino (10.7%), 791 were White (67.1%), and 96 were other race and ethnicity (8.1%). Of these patients, only 796 (67.5%) consulted an optometrist or ophthalmologist at least once during the 2-year lookback period. A total of 464 individuals (39.4%) had OAG or suspected OAG, and 414 (35.1%) had received at least 1 medication associated with increased risk of AACC before developing it. Of the 796 patients who consulted an optometrist or ophthalmologist in the lookback period, less than one-third underwent gonioscopy in the 2 years before developing AACC (n = 264 [33.2%]), and less than one-half of all patients undergoing gonioscopy received a diagnosis of an anatomic narrow angle (n = 113 [42.8%]). Most patients underwent gonioscopy in the 1 to 4 weeks preceding the AACC. Conclusions and Relevance: In this group of Medicare patients, there appear to have been multiple opportunities for interventions that may have averted AACC. Interventions aimed at addressing risk factors associated with AACC and improving performance of gonioscopy might be associated with reduced risk for ocular morbidity.

SEROLOGY NEGATIVE BARTONELLA NEURORETINITIS IN AN IMMUNOCOMPROMISED PATIENT.

BACKGROUND/PURPOSE: To report a case of serology-negative severe disseminated Bartonella neuroretinitis in an immunocompromised patient in which diagnosis was made by detection of B. henselae DNA by universal polymerase chain reaction of brain tissue. METHODS: Case report. RESULTS: A 57-year-old man with immunoglobulin A vasculitis on immunosuppressive therapy presented with lethargy, weight loss, and bilateral decreased vision. Fundus examination revealed bilateral mild vitritis, marked optic disc edema, vascular sheathing, and numerous white inner retinal and preretinal lesions. Brain magnetic resonance imaging revealed multiple foci of restricted diffusion and a ring-enhancing focus in the left parietal lobe. Serologies, cerebrospinal fluid, and vitreous biopsies were all negative for Bartonella. A brain biopsy was performed and B. henselae DNA was detected by universal polymerase chain reaction of the specimen. The patient demonstrated resolution of fundus findings with antibiotic treatment. Repeat serological testing demonstrated seroconversion. CONCLUSION: In immunocompromised patients, infection by Bartonella henselae can present as severe disseminated disease. Establishing the diagnosis can be challenging as serologic testing is often unrevealing in the setting of a blunted immune response. Polymerase chain reaction has been used in select cases to establish the diagnosis.

Two pediatric cases of reticular corneal epithelial edema associated with netarsudil.

Purpose: To report two pediatric cases of reticular corneal epithelial edema associated with the use of netarsudil ophthalmic solution 0.02%. Observations: In Case 1, a six-year-old male with glaucoma following cataract surgery was treated with netarsudil for thirteen months and developed diffuse reticular corneal epithelial edema on post-operative day one after undergoing transscleral diode cyclophotocoagulation for persistently elevated intraocular pressures. In Case 2, a three-month-old male with bilateral ocular hypertension developed unilateral inferior reticular corneal epithelial edema five weeks after initiation of netarsudil, which had been discontinued in the fellow eye two weeks prior. In both cases, the reticular epithelial edema resolved following cessation of netarsudil. Conclusions and Importance: Netarsudil-associated reticular corneal epithelial edema can occur in infants and young children.

Subjective outcome and quality of life following external dacryocystorhinostomy.

Purpose: : To assess the patient reported outcome and quality of life in post external dacryocystorhinostomy operated patients. Methods: A prospective questionnaire based study was carried out on 112 patients diagnosed with chronic dacryocystitis who underwent external dacryocystorhinostomy in the department of Orbit and Oculoplasty at a tertiary eye hospital in South India. Results: We included 112 cases in our study. Mean (SD) of the age of patients was 48.03 (12.79) years and ranged from 7 to 72 years of age. 44 (39.3%) patients were males and 68 (60.7%) were females. All cases had subjective symptoms of tearing, pain and swelling at baseline which were relieved by post-operative 3 in all cases. The mean (SD) best corrected visual acuity was 0.28 (0.39) at baseline and 0.25 (0.37) at postoperative 3 (p < 0.001). All four parameters studied in the GBI questionnaire - total mean GBI (32.22 vs 48.86, P < 0.001), general subscale (31.21 vs 44.08, P < 0.001), social health (46.28 vs 61.01, P < 0.001), physical outcome (22.17 vs 55.80, P = 0.0001) scores showed significant improvement from 1 vs 3 months post DCR. Conclusion: : The GBI questionnaire is an effective tool for assessing patients' quality of life following DCR. External DCR can not only produce a successful anatomical outcome but also bring about a measurable improvement in subjective symptoms and quality of life among patients with symptomatic NLDO.

The use of bevacizumab and ranibizumab for branch retinal vein occlusion in medicare beneficiaries.

PURPOSE: To describe the frequency and variation of intravitreal bevacizumab and ranibizumab use for branch retinal vein occlusion (BVO) in the United States (US). METHODS: We obtained a 5% random sample of Medicare beneficiaries from the Medicare Denominator and Physician/Supplier Part B claims files from 2010 to 2013 and identified all beneficiaries with an ICD-9-CM code for branch retinal vein occlusion (BVO, 362.36). Patient age, gender, race, state of residence and Charlson Comorbidity Index (CCI) scores were collected. Healthcare Common Procedure Coding System (HSCPS) codes for bevacizumab (J3590, J9035, and J3490) and for ranibizumab (J2778) were used to identify the mode of treatment for each patient. Patients who met the following criteria were excluded from this study: (1) under 65 years of age; (2) residence outside of the 50 United States or the District of Columbia; (3) no Part-B coverage or with HMO coverage that was not processed by Centers for Medicare & Medicaid Services (CMS); (4) concomitant diagnosis of diabetic edema (ICD-9: 362.07) or central retinal vein occlusion (ICD-9: 362.35); and (5) received both or none of the above two treatments. Geographic variation was examined by comparing injection frequencies across the nine US census divisions using Chi-squared analysis. RESULTS: During 2010-2013, a majority of the 3944 BVO patients who met the inclusion criteria received bevacizumab compared to ranibizumab (76.7% vs 23.3%). Most patients were aged 75-79 (22.0%) or 80-84 (22.0%), female (61.5%), white (88.3%), and had a CCI score of 1-2 (39.8%). The frequencies of bevacizumab and ranibizumab injections for BVO varied significantly between the US census divisions (p < 0.0001). The highest frequencies of bevacizumab use were in the Mountain (90.6%) and Pacific (82.7%) divisions while the highest frequencies of ranibizumab use were in the West North Central (37.9%) and Mid Atlantic (32.7%) divisions. CONCLUSIONS AND IMPORTANCE: A majority of Medicare beneficiaries with BVO received bevacizumab compared to ranibizumab from 2010 to 2013, with significant geographic variation in the use of the two anti-VEGF agents. Future research into factors driving geographic variation in the use of these agents may help direct cost-effective strategies for the management of BVO.

Frequency of a diagnosis of glaucoma in individuals who consume coffee, tea and/or soft drinks.

AIMS: To evaluate the association between consumption of coffee, tea or soft drinks, and glaucoma in the participants of the 2005-2006 National Health and Nutrition Examination Survey (NHANES). METHODS: The exposures of interest of this retrospective cross-sectional study were caffeinated and decaffeinated coffee, iced tea, hot tea and soft drinks. The outcome of interest was a clinical diagnosis of glaucoma based on the Rotterdam criteria. Analysis of the correlation between the frequency of consumption of each type of beverage and glaucoma was performed using logistic regression modelling while controlling for age, body mass index, gender, ethnicity, smoking status and diabetes. Data were weighted using the multistage NHANES sampling design. RESULTS: Among a total of 1678 survey participants, the overall prevalence of glaucoma was 5.1% (n=84). Most participants were non-Hispanic white (n=892; 53.2%). There were no statistically significant associations between consumption of caffeinated and decaffeinated coffee, iced tea and soft drinks, and glaucoma. Participants who consumed at least one cup of hot tea daily had a 74% decreased odds of having glaucoma compared with those who did not consume hot tea (adjusted OR=0.26, 95% CI 0.09 to 0.72, P=0.004 for trend); however, no statistically significant association existed for decaffeinated hot tea and glaucoma. CONCLUSION: In NHANES, participants who consumed hot tea daily were less likely to have glaucoma than those who did not consume hot tea. No significant associations were found between the consumption of coffee, iced tea, decaffeinated tea and soft drinks, and glaucoma risk. This study is limited by its cross-sectional design and use of multiple statistical testing, and larger prospective studies are needed to investigate the proposed association between tea consumption and decreased glaucoma risk.

Frequency of Bevacizumab and Ranibizumab Injections for Diabetic Macular Edema in Medicare Beneficiaries.

BACKGROUND AND OBJECTIVE: To describe the frequency and variation of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) and ranibizumab (Lucentis; Genentech, South San Francisco, CA) use for diabetic macular edema (DME) in the United States. PATIENTS AND METHODS: The authors obtained a 5% sample of Medicare beneficiaries from the Medicare Part B claims files from 2010 to 2013 and identified beneficiaries with DME using the ICD-9-CM code (362.07). Geographic variation was examined by comparing injection frequencies of bevacizumab and ranibizumab across U.S. census divisions using Chi-squared analysis. RESULTS: The sample included 5,290 Medicare beneficiaries with DME. Overall, there was greater bevacizumab use (86.4%) compared to ranibizumab use (13.6%). Frequency of bevacizumab use was highest in the Mountain division (92.2%) and lowest in the Mid-Atlantic (76.0%). The total number of bevacizumab and ranibizumab injections for DME varied significantly between U.S. census divisions (P < .0001). CONCLUSION: Bevacizumab is used more frequently than ranibizumab for the treatment of DME among Medicare beneficiaries, with significant geographic variation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:241-244.].

Characteristics Associated With Receiving Cataract Surgery in the US Medicare and Veterans Health Administration Populations.

Importance: Considerable variation exists with respect to the profiles of patients who receive cataract surgery in the United States. Objective: To identify patient characteristics associated with receiving cataract surgery within the US Medicare and Veterans Health Administration (VHA) populations. Design, Setting, and Participants: In this population-based retrospective cohort study of 3 073 465 patients, Medicare and VHA patients with a cataract diagnosis between January 1, 2002, and January 1, 2012, were identified from the 2002-2012 Medicare Part B files (5% sample) and the VHA National Patient Care Database. Patient age, sex, race/ethnicity, region of residence, Charlson Comorbidity Index (CCI) scores, and comorbidities were recorded. Cataract surgery at 1 and 5 years after diagnosis was identified. Data analysis was performed from July 1, 2016, to July 1, 2017. Main Outcomes and Measures: Odds ratios (ORs) of cataract surgery for selected patient characteristics. Results: The study sample included 1 156 211 Medicare patients (mean [SD] age, 73.7 [7.0] years) and 1 917 254 VHA patients (mean [SD] age, 66.8 [10.2] years) with a cataract diagnosis. Of the 1 156 211 Medicare patients, 407 103 (35.2%) were 65 to 69 years old, 683 036 (59.1%) were female, and 1 012 670 (87.6%) were white. Of the 1 917 254 VHA patients, 905 455 (47.2%) were younger than 65 years, 1 852 158 (96.6%) were male, and 539 569 (28.1%) were white. A greater proportion of Medicare patients underwent cataract surgery at 1 year (Medicare: 213 589 [18.5%]; VHA: 120 196 [6.3%]) and 5 years (Medicare: 414 586 [35.9%]; VHA: 240 884 [12.6%]) after diagnosis. Factors associated with the greatest odds of surgery at 5 years were older age per 5-year increase (Medicare: OR, 1.24 [95% CI, 1.23-1.24]; VHA: OR, 1.18 [95% CI, 1.17-1.18]), residence in the southern United States vs eastern United States (Medicare: OR, 1.38 [95% CI, 1.36-1.40]; VHA: OR, 1.40 [95% CI, 1.38-1.41]), and presence of chronic pulmonary disease (Medicare: OR, 1.26 [95% CI, 1.24-1.27]; VHA: OR, 1.40 [95% CI, 1.38-1.41]). Within Medicare, female sex was associated with greater odds of surgery at 5 years (OR, 1.14; 95% CI, 1.13-1.15). Higher CCI scores (CCI score ≥3 vs 0-2) were associated with increased odds of surgery among VHA but not Medicare patients at 5 years (Medicare: OR, 0.94 [95% CI, 0.92-0.95]; VHA: OR, 1.24 [95% CI, 1.23-1.36]). Black race vs white race was associated with decreased odds of cataract surgery 5 years after diagnosis (Medicare: OR, 0.79 [95% CI, 0.78-0.81]; VHA: OR, 0.75 [95% CI, 0.73-0.76]). Conclusions and Relevance: Within both groups, older age, residence in the southern United States, and presence of chronic pulmonary disease were associated with increased odds of cataract surgery. Findings from this study suggest that few disparities exist between the types of patients receiving cataract surgery who are in Medicare vs the VHA, although it is possible that a smaller proportion of VHA patients receive surgery compared with Medicare patients.

Student-Driven Approaches to Undergraduate Medical Research: A Peer-Led Symposium.

Exposure to research early in medical school facilitates the development of physician-scientists and competent clinicians. In the last decade, institutions have established programs and policies to address the physician- scientist shortage. However, student-led initiatives to promote medical student engagement in research remain unexplored. This paper presents the design and results of the third iteration of a symposium in which senior medical students provided guidance and advice to preclinical students interested in research. It also reviews the lessons learned from three years of conducting the symposium. [Full article available at http://rimed.org/rimedicaljournal-2016-08.asp, free with no login].

An Appraisal of Clinical Practice Guidelines for Diabetic Retinopathy.

The objective is to evaluate the methodological quality of clinical practice guidelines (CPGs) published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS), and Royal College of Ophthalmologists (RCO) for diabetic retinopathy. Four evaluators independently appraised the CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which covers 6 domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence). Scores ranged from 35% to 78% (AAO), 60% to 92% (COS), and 35% to 82% (RCO). Intraclass correlation coefficients for the reliability of mean scores were 0.78, 0.78, and 0.79, respectively. The strongest domains were Scope and Purpose, and Clarity of Presentation (COS). The weakest were Stakeholder Involvement (AAO), Rigor of Development (AAO, RCO), Applicability, and Editorial Independence (RCO). Diabetic retinopathy practice guidelines can be improved by targeting Stakeholder Involvement, Rigor of Development, Applicability, and Editorial Independence.

An evaluation of cataract surgery clinical practice guidelines.

PURPOSE: This study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument to evaluate the methodological quality of clinical practice guidelines (CPG) published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS) and Royal College of Ophthalmologists (RCO) for the management of cataract in adults. STUDY DESIGN: An evaluation of the AAO, COS and RCO CPGs using a reliable and validated instrument. METHODS: Four evaluators independently appraised the three CPGs using the AGREE II Instrument, which covers six domains (Scope and Purpose, Stakeholder Involvement, Rigour of Development, Clarity of Presentation, Applicability and Editorial Independence). The AGREE II includes an Overall Assessment summarising guideline methodological rigour across all domains, using a 7-point scale where perfect adherence equals a score of 7. RESULTS: Scores ranged from 36% to 75% for the AAO guideline; 45% to 94% for the COS guideline and 23% to 85% for the RCO guideline. Intraclass correlation coefficients for the reliability of mean scores for the AAO, COS, and RCO were 0.78, 0.74 and 0.80; 95% CIs (0.60 to 0.90), (0.45 to 0.88) and (0.53 to 0.91), respectively. The strongest domains were Scope and Purpose (COS, RCO), Clarity of Presentation (COS, RCO) and Editorial Independence (AAO, COS). The weakest were Stakeholder Involvement (AAO), Applicability (AAO, COS) and Editorial Independence (RCO). CONCLUSIONS: Cataract surgery practice guidelines can be improved by targeting stakeholder involvement, applicability and editorial independence.

Critical Appraisal of Clinical Practice Guidelines for Age-Related Macular Degeneration.

Purpose. To evaluate the methodological quality of age-related macular degeneration (AMD) clinical practice guidelines (CPGs). Methods. AMD CPGs published by the American Academy of Ophthalmology (AAO) and Royal College of Ophthalmologists (RCO) were appraised by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which comprises six domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence), and an Overall Assessment score summarizing methodological quality across all domains. Results. Average domain scores ranged from 35% to 83% for the AAO CPG and from 17% to 83% for the RCO CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO and RCO CPGs were 0.74 and 0.88, respectively. The strongest domains were Scope and Purpose and Clarity of Presentation. The weakest were Stakeholder Involvement (AAO) and Editorial Independence (RCO). Conclusions. Future AMD CPGs can be improved by involving all relevant stakeholders in guideline development, ensuring transparency of guideline development and review methodology, improving guideline applicability with respect to economic considerations, and addressing potential conflict of interests within the development group.

Evaluation of primary open-angle glaucoma clinical practice guidelines.

OBJECTIVE: To evaluate the methodologic quality of 3 primary open-angle glaucoma (POAG) clinical practice guidelines (CPGs). DESIGN: The CPGs were assessed with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. PARTICIPANTS: Four authors (A.M.W., C.M.W., B.K.Y., D.J.W.) performed independent assessments of POAG CPGs. METHODS: POAG CPGs published by the American Academy of Ophthalmology (AAO), Canadian Ophthalmological Society (COS), and National Institute for Health and Care Excellence (NICE) were appraised using the AGREE II instrument's 6 domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence) and Overall Assessment score summarizing guideline quality across all domains. RESULTS: Scores ranged from 28% to 85% for the AAO CPG, 51% to 96% for the COS CPG, and 55% to 97% for the NICE CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO, COS, and NICE CPGs were 0.89, 0.86, and 0.74; 95% CIs were 0.80 to 0.95, 0.74 to 0.93, and 0.51 to 0.87, respectively. The strongest domains were Scope and Purpose (AAO, COS, NICE) and Clarity of Presentation (COS, NICE). The weakest domains were Stakeholder Involvement (AAO, COS) and Editorial Independence (AAO, COS, NICE). CONCLUSIONS: Future POAG CPGs can be improved by addressing potential conflicts of interest within the development group, ensuring transparency of guideline development methodology, and involving all relevant stakeholders in guideline development and review.