Referral outcomes from a vision screening program for school-aged children.

OBJECTIVE: To assess ocular diagnoses and follow-up patterns of children referred for a comprehensive eye examination after a school-based vision screening program. DESIGN: Retrospective chart review. PARTICIPANTS: Students in grades K-5 from the School District of Philadelphia public schools screened by The Wills Eye Vision Screening Program for Children between January 2014 and June 2015. METHODS: Children with subnormal best-corrected visual acuity or other ocular conditions were referred to the Wills Eye pediatric ophthalmology service. A social worker assisted parents/guardians of referred children in scheduling an appointment and navigating insurance/payment issues. Measured outcomes included demographic information, ocular diagnoses, treatments, and follow-up patterns. RESULTS: Of 10 726 children screened, 509 (5%) were referred for a follow-up eye examination. Of these 509 children, only 127 (25%) completed a referral eye examination with parental consent. Most children (58%) were diagnosed with more than one eye condition, including refractive error (76%), amblyopia (43%), strabismus (16%), and anisometropia (13%). Other conditions included macular hypoplasia, ptosis, and other congenital anomalies. CONCLUSIONS: This program discovered and addressed potentially vision-threatening conditions in underserved children susceptible to amblyopia by offering social worker services and financial support to enable referred children to complete an eye examination. Contact by the social worker required consent. Obtaining such consent proved to be a barrier to connecting children with the recommended consultation.

Depression and quality of life in a community-based glaucoma-screening project.

OBJECTIVE: To identify the prevalence and risk factors of depression among individuals given a glaucoma-related diagnosis at a screening program. DESIGN: Cross-sectional community-based in a university hospital. PARTICIPANTS: Volunteers from a community glaucoma-screening program. METHODS: After collecting sociodemographic information, participants were administered the Geriatric Depression Scale-15 (GDS-15) and the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25). RESULTS: Participants were predominantly African American (73.5%), older than 65 years (65.7%), single (75.4%), and female (66.8%). Among 268 participants, 89 were diagnosed with glaucoma and 179 as glaucoma suspects. The frequency of depression among the glaucoma and glaucoma suspect participants was 18% and 16.2%, respectively. The mean GDS-15 score was 2.4 ± 2.7 with no difference between glaucoma and glaucoma suspect groups, p = 0.654. The mean VFQ-25 score was 78.6 ± 15.9 and was lower in glaucoma (74.7 ± 19.7) than glaucoma suspect participants (80.4 ± 13.6), p = 0.003. Risk factors for depression included difficulties with paying expenses (p = 0.017), Asian race (p < 0.001), and poorer scores on the VFQ-25 subscales of "General Health" (p < 0.001), "Distance Activities" (p = 0.024), and "Dependency" (p = 0.001). CONCLUSIONS: Prevalence of depression in those diagnosed with glaucoma or glaucoma suspect was higher than previous estimates of the general population. Glaucoma-screening programs might benefit from including depression-screening protocols along with referral services or low-cost treatments of depression.

Adherence to Follow-up Recommendations Among Individuals in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To evaluate rates of adherence to free follow-up eye exam appointments among participants in the Philadelphia Glaucoma Detection and Treatment Project. PATIENTS AND METHODS: Ophthalmologists and testing equipment were brought directly to participants at risk for glaucoma at 43 community sites in Philadelphia. Those diagnosed with glaucoma-related pathology were recommended to return for follow-up to be reexamined on site. Rates of adherence and clinical and demographic risk factors for adherence were evaluated. RESULTS: Five hundred thirty-one participants were diagnosed with glaucoma-related conditions and recommended to attend community-based follow-up exams. Follow-up adherence rate was 61.2% (n=325/531). Significant factors associated with greater eye exam appointment adherence, based on our univariable analysis, included final diagnosis of glaucoma (risk ratio [RR]=1.33; 95% confidence interval [CI], 1.13-1.57), male sex (RR=1.19; 95% CI, 1.04-1.36), white race (RR=1.26; 95% CI, 1.08-1.48), age (RR=1.17; 95% CI, 1.00-1.37) recommendation for glaucoma medication (RR=1.52; 95% CI, 1.35-1.71), recommendation for laser peripheral iridotomy (RR=1.18; 95% CI, 1.02-1.35), diagnosis of age-related macular degeneration (RR=1.42; 95% CI, 1.13-1.77) and an increased intraocular pressure (>22 mm Hg in the worse eye) (RR=1.23; 95% CI, 1.06-1.42). On the basis of our multivariable model, diagnosis, sex, and recommended glaucoma medications were significantly associated with follow-up adherence. CONCLUSIONS: This study demonstrates that individuals living in underserved urban communities would take advantage of free eye exams in community sites and return for follow-up eye exams in these same settings. Future studies could investigate interventions to improve eye exam appointment adherence in community-based settings to detect glaucoma-eye conditions.

Improving Follow-Up Adherence in a Primary Eye Care Setting.

Lack of patient adherence with eye appointments can decrease ocular outcomes. This prospective, randomized, single-blinded controlled study assessed the effectiveness of multiple interventions in improving follow-up adherence to recommended eye appointments. Patients due for follow-up appointments were randomly assigned to usual care, automated intervention, or personal intervention. Automated-intervention patients and personal-intervention patients received a call one month prior to the recommended follow-up date, and a mailed appointment reminder letter. The call was automated for automated-intervention patients and personalized for personal-intervention patients. The primary outcome was adherence to the follow-up appointment. The secondary outcome was rate of appointment scheduling. Patients in the personal-intervention group had greater adherence to follow-up recommendations (38%) than patients in the usual care group (28%) and the automated-intervention group (30%). Personal intervention significantly increased appointment scheduling (51%) over usual care (32%) and automated intervention (36%). These results support systems-level changes to improve patient follow-up adherence in urban primary eye care settings.

Impossibility to eliminate observer effect in the assessment of adherence in clinical trials.

PURPOSE: To utilize the Travoprost Dosing Aid (DA) in the assessment of patient medication adherence, while also determining whether or not altering the functionality of the DA in three randomized subject groups can reduce observer effect. METHODS: Forty-five subjects were randomized into three groups: two with monitored DAs and one without monitoring. One group of subjects was given a DA that both monitored drop usage and had visual and audible alarms, while the other monitored group included subjects given a DA that had no alarms but continued to monitor drop usage. The third group was given a DA that had no alarm reminders or dose usage monitoring. Subjects were informed that some monitors would not be functional, in an attempt to reduce observer effect, or the effect of being monitored on subject behavior and adherence. A six-item questionnaire was also utilized to assess how the subjects felt about their adherence and DA use. RESULTS: The overall adherence rates were found to be 78% in the fully functional group (95% confidence interval: 70-88) and 76% in the no alarms group (95% confidence interval: 65-89). No association was seen between questionnaire response and medication adherence. The patients in the DA group without alarms had a significantly higher odds ratio of medication adherence if they reported on the questionnaire that using the DA did affect how much they used their drops. CONCLUSION: Though the use of DA was expected to reveal different rates of adherence depending on the functionality of the DA between groups, patients with a nonfunctioning DA did not have a significant difference in medication adherence compared to those given a fully functional DA. This supports that an observer effect was not reduced despite these interventions, and that the subjects adhered to taking their medications as if they had a functioning DA and were being monitored.

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

PURPOSE: To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University. MATERIALS AND METHODS: Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App. RESULTS: Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs $3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App. CONCLUSIONS: Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend $3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients' level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.

Bilateral Same-day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To report the outcomes of bilateral, same-day laser peripheral iridotomy (LPI) in the Philadelphia Glaucoma Detection and Treatment Project. METHODS: The Philadelphia Glaucoma Detection and Treatment Project was a community-based initiative aimed to improve detection, management, treatment, and follow-up care of individuals at high risk for glaucoma. This novel project performed LPI, where 2 eyes received laser therapy on the same day. Of the 1649 patients examined between January 1, 2013 and May 31, 2014, patients who underwent bilateral, same-day LPI were included in our analysis. Main outcome measures were visual acuity, intraocular pressure (IOP), and postoperative complication rates. RESULTS: A total of 132 eyes of 66 patients underwent bilateral, same-day LPI. Mean visual acuity remained unchanged following treatment (P=0.85). Eight patients (12.1%) had IOP spikes >5 mm Hg following treatment, and 4 patients (6.1%) spiked >10 mm Hg. IOP returned to normal in all but 1 patient, who was diagnosed with chronic angle-closure glaucoma. Hyphema was reported in 2 patients (3%) and glare in 1 patient (1.5%). Thirteen patients (19.7%) had repeat LPI treatment. All patients successfully tolerated LPI treatment without serious complications. CONCLUSIONS: Performing bilateral, same-day LPI was well tolerated in a large community-based, glaucoma detection and treatment project. Applying this treatment strategy may be considered in similar settings, where patients' access to eye care is limited and it may be a cost-effective strategy.

Evaluation of Nonmydriatic Hand-held Optic Disc Photography Grading in the Philadelphia Glaucoma Detection and Treatment Project.

PURPOSE: To determine the reproducibility of optic disc photograph grading obtained by a hand-held fundus camera and to determine the diagnostic value of these photographs in detecting patients with glaucoma in a community-based glaucoma-detection program. MATERIALS AND METHODS: Patients underwent slit-lamp examination by an ophthalmologist who graded each patient's optic discs using 2 methods: cup-to-disc ratio (CDR) and disc damage likelihood scale (DDLS). After a comprehensive glaucoma evaluation, patients were diagnosed as having "glaucoma," "glaucoma suspect," or "no glaucoma." Nonmydriatic, monoscopic optic disc photographs were then taken with a portable digital imaging device. On a different day, the same examiner and a second observer graded the disc photographs in a masked manner and determined a diagnostic impression based only on the disc photographs. RESULTS: Of the 1649 patients examined, 119 subjects were randomly selected according to 3 groups of diagnoses: "glaucoma" (n=36), "glaucoma suspect" (n=50), and "no glaucoma" (n=33). For CDR, the intraobserver agreement was 0.71 and the interobserver agreement was 0.69. For disc DDLS, the intraobserver agreement was 0.65 and the interobserver agreement was 0.67. The area under the receiver-operating characteristic distinguishing between normal and glaucoma was 0.88 and 0.86 for CDR and disc DDLS, respectively. CONCLUSIONS: Nonmydriatic, monoscopic disc photographs obtained by a hand-held camera had only moderate disc grading reproducibility. This could be due to a reduced quality of images, making interpretation more challenging, due to taking photographs through small pupils by a hand-held camera and the high percentage of patients with significant cataracts.

An Education- and Telephone-Based Intervention to Improve Follow-up to Vision Care in Patients With Diabetes: A Prospective, Single-Blinded, Randomized Trial.

The aim was to evaluate the effectiveness of a multipronged intervention on diabetic dilated fundus examination (DFE) adherence. In a prospective trial, 521 patients with diabetes who were due for follow-up DFEs were randomized to usual care or the intervention group. Usual care received a form letter reminder to schedule and an automated reminder phone call prior to their appointment. Intervention participants received an educational brochure about diabetic eye disease and a personalized letter reminder to schedule. A research assistant called intervention participants to help schedule the appointment, and they received a reminder letter and an automated phone call prior to the scheduled visit. Patients in the intervention group were significantly more likely to schedule (63% vs 40%; P < .0001) and complete their appointment (48% vs 30%; P < .0001) compared with usual care. A multipronged intervention, including an educational mailing and telephone assistance with scheduling an appointment, significantly improved diabetic DFE adherence.

Trabeculectomy in Patients With Glaucoma Over 80 Years of Age: Relatively Short-term Outcomes.

PURPOSE: To compare the surgical outcomes of trabeculectomy performed in elderly patients (above 80 y) with those of younger controls. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent trabeculectomy from January 1, 2009 through April 30, 2011 at the Wills Eye Hospital. Patients over 80 years of age were compared with younger controls. Outcome measures included intraocular pressure (IOP), visual acuity, number of glaucoma medications, surgical complications, and surgical failure. Surgical failure was defined as when IOP>21 mm Hg or <20% reduction below baseline or IOP<5 mm Hg or reoperation for glaucoma, or loss of light perception. RESULTS: Eighty-six eyes of patients over 80 years of age (range, 81 to 94 y) were compared with 86 eyes of younger controls (range, 22 to 79 y). Mean follow-up time was 23.9±8.0 and 25.1±8.0 months for each group, respectively. After 1 year, the failure rate was 31.3% in the elderly group, compared with 29.5% in the control group (P=0.98). At last follow-up visit, the rate of failure between the groups was similar (P=0.35). Postoperative complications were similar between the groups (P=0.25). CONCLUSIONS: The surgical outcomes of trabeculectomy in patients older than 80 years were found to be similar to those of younger controls. Taking into consideration elderly glaucoma patients' general health condition and life expectancy, age alone may not be a barrier to performing glaucoma filtration surgery.