Vision-Related Quality of Life and Seasonal Affective Disorder in Patients with Glaucoma and Macular Degeneration.

Seasonal affective disorder (SAD) is characterized by depressive episodes related to changes in the seasons. Patients with severe vision loss are at an increased risk of SAD. This study seeks to determine the extent to which patients with moderate vision loss report symptoms of SAD. In this cross-sectional, comparative case series, the Seasonal Pattern Assessment Questionnaire (SPAQ) and the National Eye Institute Visual Function Questionnaire (VFQ-39) were used to screen 111 patients with age-related macular degeneration (AMD) and/or primary open-angle glaucoma (POAG). A multiple regression analysis was performed to create a predictive model for SAD based on the Global Seasonality Score (GSS) using the VFQ-39. Subjects who reported symptoms of SAD (GSS > 8) had lower vision-related quality of life (composite score: 57.2 versus 73.2, p < 0.001). Exploratory factor analysis revealed that the items on the VFQ-39 split into two distinct dimensions that together accounted for 63.2% of the total variance in the GSS. One group of questions addressed vision-related problems; the other group comprised questions related to the quality of life. Whereas this model successfully identified patients with vision loss at risk of SAD, a model restricted to the questions available on the shorter, widely used VFQ-25 instrument did not reliably identify patients at risk of SAD.

Intraocular pressure decreases in eyes with glaucoma-related diagnoses after conversion to aflibercept for treatment-resistant age-related macular degeneration.

OBJECTIVE: To understand intraocular pressure (IOP) response after switching from intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) to intravitreal aflibercept (IVA) for treatment-resistant neovascular age-related macular degeneration (nAMD) in patients with and without coexisting glaucoma-related diagnoses. METHODS: Retrospective, cross-sectional comparative case series of 62 eyes of 58 patients treated with intravitreal injection for nAMD from March 2010 to April 2018. Patients with glaucoma-related diagnoses, defined here as open-angle glaucoma or suspicion of open-angle glaucoma, ocular hypertension, and/or narrow-angle glaucoma, were compared to those without glaucoma. IOP data were collected at baseline, at the three visits where patients received loading doses of IVB/IVR, and at all of the visits following the switch to IVA through the end of follow-up. RESULTS: 19 eyes with pre-existing glaucoma-related diagnoses were compared to 43 eyes without such diagnoses. Baseline IOP was similar for glaucoma and non-glaucoma patients. The loading doses of IVB/IVR did not impact IOP; however, a small, sustained rise in IOP was noted among patients with glaucoma-related diagnoses by the final IVB/IVR injections before the switch to IVA (∆IOP 1.61 ± 0.52 mmHg, P < 0.002). After conversion to IVA, pre-injection IOP declined in eyes both with (-1.59 ± 0.54 mmHg, P < 0.001) and without (-0.99 ± 0.28 mmHg, P < 0.001) glaucoma-related diagnoses. CONCLUSIONS: IOP in patients with glaucoma-related diagnoses appears to be more sensitive to intravitreal injections than it is in patients without glaucoma-related diagnoses. It rises with IVB/IVR and declines after the switch to IVA. Switching patients with nAMD to IVA may present an opportunity to lower IOP in patients with glaucoma.

Quality of referrals for glaucoma assessment: a cross-sectional survey of clinical data and outcomes.

PURPOSE: This study assessed the completeness of clinical information provided by ophthalmological and optometric referrals to glaucoma specialists consulting for open-angle glaucoma (OAG). METHODS: A retrospective, cross-sectional study of 72 internal referrals for evaluation of OAG in a multispecialty group practice was performed. The quality of the referral was assessed based on: (1) the completeness of the clinical triad of intraocular pressure measurement, visual field (VF), and cup-to-disk ratio for each eye; (2) the availability of the data necessary to calculate an ocular hypertension treatment study (OHTS) score; and (3) the presence of retinal nerve fiber layer (RNFL) imaging by mean of optical coherence tomography. RESULTS: The clinical triad was available in 57% of referrals, whereas an OHTS score was calculable in 24% of referrals (p < 0.001); RNLF imaging was available in 51% of referrals (p = 0.859). The completeness of clinical information was similar for ophthalmological and optometric referrals. From the date of referral to the time of the consultation, there was a significant increase in the availability of the clinical triad (57-65%; p = 0.013) and the OHTS score (24-5%; p = 0.004) but not for RNFL imaging (51-56%; p = 0.618). The most common missing clinical information was VF testing, which was absent in 42% of referrals. CONCLUSIONS: Key clinical data necessary for effective diagnosis and staging of OAG was lacking for many patients referred to glaucoma specialists.

An Initiative to Improve Follow-up of Patients with Glaucoma.

Purpose: This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at reducing the number of patients with glaucoma-related diagnoses lost to follow-up (LTF) and reviews its short-term outcomes. Design: Retrospective, comparative case series. Participants: Patients with glaucoma-related diagnoses seen 1 year prior at the Lahey Medical Center and who had not returned within the 6-month period between January 1, 2020, and June 30, 2020, which spanned the outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic in the United States. Methods: An EMR-based tool was designed to identify patients suspected of being LTF with glaucoma-related diagnoses. Providers were enlisted to review the EMR for each of these patients and re-engage them, as appropriate. One month later, the initiative was evaluated by means of a retrospective chart review. Binary logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with being LTF. Main Outcome Measures: Patients who completed a telemedicine or in-person appointment, or had a future scheduled or ordered return appointment, were considered re-engaged. Results: Of the 3551 patients seen during the study period, 384 patients were identified as LTF (11%), with 60 identifying COVID-19 as the reason for canceling their visit (16%). Patients who lived farther from the eye clinic (P < 0.001) or who had a history of canceling or missing an appointment (P < 0.001) were more likely to be LTF. Patients with open-angle glaucoma (P = 0.042) or who had completed a visual field (P < 0.001) or ophthalmic imaging (P < 0.001) within the past year were less likely to be LTF. One month after the re-engagement initiative, 124 LTF patients (32%) had been re-engaged (40% through telemedicine), 238 patients (62%) had future scheduling orders in place, and 22 patients (6%) had no active plan for future follow-up. Conclusions: An EMR-based tool is an effective method for identifying patients at risk of being LTF and provides an opportunity for providers to recall and re-engage patients. Use of telemedicine to recontact LTF patients shows promise of improving the management of glaucoma, enhancing clinical productivity, and documenting treatment plans, thereby potentially reducing medicolegal liability.

Dark Adaptation Survey as a Predictive Tool for Primary Open-Angle Glaucoma.

PURPOSE: To study the extent to which patients with primary open-angle glaucoma (POAG) have subjective difficulties with dark (DA) adaptation and vision under low-luminance conditions and to correlate the reported difficulties with severity of disease, specifically visual field loss. DESIGN: Prospective, comparative case series. PARTICIPANTS: Two hundred twenty patients with and without POAG who sought treatment at an outpatient subspecialty glaucoma clinic between October 2016 and September 2018. METHODS: A questionnaire designed to assess difficulties with DA and vision under low luminance (the DA survey) was developed and given to patients during routine clinical evaluation in a hospital-based eye clinic. Retrospective data related to ocular health and glaucoma severity were abstracted from the medical record. A multiple regression analysis was performed to create a predictive model for POAG. MAIN OUTCOME MEASURES: Severity of glaucoma, specifically visual field loss, and classification of participants as glaucoma patients or control participants. RESULTS: Eighty-five patients with POAG and 127 control participants completed the questionnaire. Exploratory factor analysis of the DA survey using a principal components analysis showed that the items split into 2 dimensions: tasks that involved difficulty with vision under low luminance and those that required DA. Cronbach's α showed a high degree of internal consistency reliability (α = 0.88). Increasing DA survey score correlated with binocular visual field loss among patients with mild, moderate, and advanced POAG (P < 0.001). A model used to differentiate patients with POAG from control participants that included average and intereye difference in cup-to-disc ratio, family history of glaucoma, and DA survey score showed an accuracy, sensitivity, and specificity of 96.7%, 92.9%, and 99.2%, respectively. CONCLUSIONS: This pilot study revealed that problems with DA and vision under low luminance are commonly encountered by patients with POAG. These areas of visual disability are not assessed routinely in glaucoma care. A questionnaire assessing vision under low luminance and light-dark transitions may serve as a proxy for functional impairment in glaucoma. When paired with risk factors such as structural features of the optic nerve and family history, this survey instrument may be suitable to screen for patients with POAG.