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.

Remote Screening for Optic Nerve Cupping Using Smartphone-based Nonmydriatic Fundus Photography.

PRECIS: Evaluation of nonmydriatic fundus photographs captured with a low-cost, smartphone-based camera facilitated remote screening of patients for enlarged optic nerve cup-to-disc ratio in the Independent Nation of Samoa, an underserved setting with one full-time ophthalmologist in the entire country. PURPOSE: To investigate factors that impact inter-rater agreement of glaucoma suspect optic disc status using a low-cost, handheld nonmydriatic fundus camera. METHODS: Color fundus photographs were obtained using the PanOptic iExaminer attached to an iPhone 6S by a lay examiner on 206 participants in the Independent Nation of Samoa. Images were remotely graded by an ophthalmologist and optometrist, and images from participants identified as at-risk for glaucoma were escalated to a glaucoma subspecialist for review. Fundus photo brightness, contrast, and focus were measured using the cup, rim, and temporal regions of the disc. Stereoscopic image pairs were subsequently generated from a subset of individual nonmydriatic photographs. RESULTS: Features suggestive of glaucoma based on optic disc cupping were identified in 16.0% (33/206) of participants. There was moderately strong agreement between graders (90.3%) with κ=0.53 [95% confidence interval (CI)=0.33-0.73]. The intraclass correlation coefficients for the cup-to-disc ratio (CDR) and its difference were 0.84 (95% CI=0.81-0.87) and 0.68 (95% CI=0.59-0.75). Of the 33 participants identified, 94% had clinical risk criteria for potential glaucoma when reviewed by a subspecialist. Color fundus photograph cup brightness was significantly associated with cup-to-disc (CDR) grade, R2=0.36 (P<0.001), in which a brighter disc yielded a higher CDR. CONCLUSIONS: Smartphone-based screening is a simple, low-cost method capable of measuring the CDR of the optic nerve. When combined with testing for other glaucoma risk factors such as intraocular pressure, this method of measuring CDR may help identify those patients who should be referred for further ophthalmologic assessment. We are currently conducting studies to assess the sensitivity and specificity of smart phone-based remote screening.

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.

Posterior Surgical Revision of Failed Fornix-based Trabeculectomy.

PURPOSE: To evaluate outcomes after revision of failed fornix-based trabeculectomy using a posterior conjunctival incision and mitomycin C. METHODS: Cases were identified using Current Procedural Terminology codes. Information from clinical records was analyzed retrospectively. Complete success was defined as intraocular pressure (IOP) ≤16 mm Hg with no glaucoma medications and IOP reduction of >20% from preoperative levels. Qualified success was defined as IOP≤16 with or without medications and IOP reduction of >20%. Secondary outcomes included IOP, number of glaucoma medications used, visual acuity, and complications. RESULTS: Sixty eyes of 56 patients underwent surgical revision of failed trabeculectomy. The complete success rate at 1 year was 43.7%, declining to 41.7% at 2 years and all time points up to 5 years; qualified success rates were 68.9% at 1 year and at all subsequent time points. Mean IOP declined from 21.2±7.7 (SD) mm Hg preoperatively to 10.9±4.3 mm Hg at 1 year, to 10.5±3.8 mm Hg at 2 years, and to 9.9±4.6 mm Hg at 3 years. The mean number of glaucoma medications used fell from 2.5±0.5 preoperatively to 1.0±0.4 at 1 year, 0.9±0.4 at 2 years, and 0.9±0.4 at 3 years. Complications included bleb leak in 3 eyes (5.0%), hypotony with choroidal detachment in 3 eyes (5.0%) and hyphema in 1 eye (1.7%). Eight eyes required additional glaucoma surgery. CONCLUSIONS: Surgical bleb revision with mitomycin C using a posterior incision in cases of failed fornix-based trabeculectomy can provide effective control of IOP. This conjunctiva-sparing procedure should be considered as a viable alternative to a tube shunt or repeat trabeculectomy.

Randomized comparison of 1-Site and 2-Site phacotrabeculectomy with 3-year follow-up.

PURPOSE: To compare intraocular pressure (IOP) control and other clinical outcomes after 1-site fornix-based and 2-site limbus-based phacotrabeculectomy. DESIGN: Prospective randomized controlled trial. PARTICIPANTS: A total of 90 eyes of 76 patients with cataract and glaucoma were treated. METHODS: Forty-four eyes were assigned randomly to receive a 1-site phacotrabeculectomy with a fornix-based conjunctival flap, and 46 eyes were assigned randomly to receive a 2-site phacotrabeculectomy with a limbus-based conjunctival flap. All operations were performed with mitomycin C. MAIN OUTCOME MEASURES: Intraocular pressure and number of antiglaucoma medications were recorded at baseline and during a 3-year follow-up period. RESULTS: Mean preoperative IOP was 20.1+/-3.8 mmHg in the 1-site group and 19.5+/-5.3 mmHg in the 2-site group (P = 0.56) using a mean of 2.3+/-0.9 and 2.5+/-0.9 antiglaucoma medications, respectively (P = 0.27). After 3 years of follow-up, the mean IOP was 12.6+/-4.8 mmHg in the 1-site group and 11.7+/-4.0 mmHg in the 2-site group (P = 0.40), receiving a mean of 0.3+/-0.7 and 0.4+/-0.9 medications, respectively (P = 0.59). At the end of the study, 73% of 1-site eyes and 78.4% of 2-site eyes had IOPs of less than 18 mmHg while receiving no antiglaucoma medications (P = 0.59). Visual acuity was similar for both groups at 3 months after surgery. There were no significant differences in the need for digital pressure, postoperative bleb needling with 5-fluorouracil, or number of postoperative visits. There were 2 major complications in each group during follow-up. Early leaks of the conjunctival wound closure occurred in 6 eyes in the 1-site group and in 0 eyes in the 2-site group (P = 0.03). Operating time (in minutes) was less in the 1-site surgery group (P<0.0001). Day one postoperative IOP was higher in the 2-site group (P = 0.0.01). CONCLUSIONS: One-site fornix-based and 2-site limbus-based phacotrabeculectomy were similarly effective in lowering IOP and reducing the need for antiglaucoma medications over a 3-year follow-up period.