Clinical outcome measures in vision and eye care.

Traditionally, clinical outcome assessments have focused on the patient's perspective through patient-reported outcome assessments; however, given the complexity, integration, and interactions of various participants within the clinical ophthalmology setting, we propose that additional diverse clinical perspectives should be explored in order to appreciate fully the value of care provided to patients. In this review we introduce a framework by which clinical outcome assessments (COAs) can be organized. Our COA framework is composed of five outcome measurements that encompass the perspectives of each player in a patient's care: clinical data-reported outcomes, patient-reported outcomes, clinician-reported outcomes, observer-reported outcomes, and reviewer-reported outcomes. By establishing a standard for evaluating patient care, we hope to address gaps in expectations of patient care and encourage more thoughtful patient-clinician relationships.

Significance of Social Determinants of Health in Tumor Presentation, Hospital Readmission, and Overall Survival in Ocular Oncology.

PURPOSE: To evaluate the association between social determinants of health (SDH) with presentation and outcomes in patients with ocular cancer. METHODS: The National Cancer Database was queried for primary clinical tumor (cT) classifications of T1 to T4 N0M0 uveal melanoma, conjunctival melanoma, or retinoblastoma diagnosed between January 2006 and December 2017. Pearson χ2 analysis assessed differences in SDH-related characteristics between cancer cohorts. Binary logistic regression with adjusted odds ratios (aORs) and multivariate Cox proportional hazards ratios (HRs) with 95% confidence intervals (CIs) were performed. DESIGN: Cross-sectional with a nationally representative sample. RESULTS: Three thousand nine hundred sixty-eight uveal melanoma cases, 352 conjunctival melanoma cases, and 480 retinoblastoma cases were included. Differences in race, primary payer status, income quartile, population density, facility location, Charlson-Deyo comorbidity score, history of malignancy, cT classification at presentation, surgical treatment, radiotherapy, chemotherapy, 30-day readmission, and overall survival (OS) were observed among the cancers. Female sex (aOR 0.819 [95% CI 0.689-0.973]) and top income quartile (aOR 0.691 [95% CI 0.525-0.908]) had decreased likelihood of advanced cT classification at presentation. No insurance (aOR 1.736 [95% CI 1.159-2.601]) and Medicaid primary payer status (aOR 1.875 [95% CI 1.323-2.656]) had increased likelihood of advanced cT classification. Patients in rural areas (aOR 7.157 [95% CI 1.875-27.320]) were more likely to be readmitted within 30 days after initial treatment. Increased age was associated with decreased 5-year OS (HR 1.040 [95% CI 1.033-1.047]). CONCLUSIONS: SDH may influence advanced cT classification at presentation and 30-day readmission compared with OS in patients with ocular cancer, highlighting the need for ophthalmologists and public health efforts to address disparities in SDH.

Eye Disease Prevalence and VF-14 Validation Among Patients Experiencing Homelessness and Presenting for Ophthalmic Examination in Baltimore, Maryland.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic is projected to drive 1.5 million Americans toward homelessness, adding to the 3.5 million currently affected. Homelessness poses both socioeconomic and public health challenges because housing status is a social determinant of health. Given ophthalmic health's importance in daily functioning, we characterized ophthalmic disease and vision-related quality of life (VRQOL) among a population experiencing homelessness in Baltimore, Maryland. Methods: Questionnaires, including a Visual Function Index-14 (VF-14) for measuring VRQOL, were administered among patients seeking eye examinations at Health Care for the Homeless (HCH) from October 2018 to March 2020. Results: One hundred sixty-two participants were enrolled in this study. The average age was 53 years. Participants' most common vision concerns were blurry vision (70%) and desire for glasses (52%). Best corrected visual acuity (BCVA) measurements revealed significant vision loss (18%, P < 0.001). Physicians mostly diagnosed refractive error (77%), cataracts (36%), glaucoma/glaucoma suspect (25%), and dry eye (24%). Nearly half were referred to additional ophthalmic care (46%). VRQOL trends reflected functional vision categories (P = 0.042 and P = 0.021). The 1:1 VRQOL and BCVA comparison showed correlation (rho = -0.3, P < 0.001). Cronbach's alpha demonstrated VF-14 reliability (alpha = 0.92). Conclusions: We find high ophthalmic disease prevalence within a population experiencing homelessness. Comparison to studies worldwide reveals healthcare disparities despite healthcare system differences, suggesting a need for more targeted solutions. VF-14 is valid and reliable in assessing those experiencing homelessness. Intragroup VRQOL comparisons may reveal subgroup needs. It is imperative that future studies continue monitoring those experiencing homelessness. Translational Relevance: Validation of VF-14 will allow future studies to utilize this patient-oriented metric within populations experiencing homelessness.

Characterizing industry payments to ophthalmologists before and after onset of the COVID-19 pandemic.

Purpose: The COVID-19 pandemic had profound effects on many different aspects of our healthcare system and the relationship between industry and physicians was no exception. The present database study evaluates industry payments to ophthalmologists in order to identify whether there are significant differences in industry payments to ophthalmologists before and after onset of the pandemic. Methods: The Centers for Medicare & Medicaid Services Open Payments Database was queried for all ophthalmologists who received industry payments between 2018 and 2021. Pre-Covid was defined as 2018-2019 while post-Covid was defined as 2020-2021. Payment date, value, type, company making payment, and state of recipient were recorded. The top ten companies and states in terms of payment value were included in analysis. Generalized Estimating Equations (GEE) modeling was used to assess significance. Results: There were 729,263 industry payments to 20,832 ophthalmologists totaling $817,892,867.54 included for analysis in this study. We found that there was a significant increase in the mean value of research payments and a significant decrease in the mean value of general payments after the onset of the pandemic (both p < 0.001). We also report significant changes in industry payments to ophthalmologists based on the company making the payment and the state in which the ophthalmologist practices. Conclusions: Our results suggest that significant differences exist in industry payment patterns to ophthalmologists following onset of the COVID-19 pandemic. Understanding underlying reasons for the observed differences may improve our understanding of the relationship between industry and clinical ophthalmology.

Impact of Gap Years Following Medical School Graduation on Resident Research Productivity in Ophthalmology.

Background Gap years following medical school graduation have become more common, but research into their tangible career benefit is lacking. Examining the impact of gap years on resident scholarly productivity in ophthalmology may provide insight generalizable to all specialties. Objective To evaluate whether a gap year following medical school graduation significantly predicts scholarly productivity during ophthalmology residency. Methods In December 2021, residents were recorded from 110 publicly available American ophthalmology residency program webpages. They were included if educational history was listed on publicly accessible academic and social media profiles. Residents were then stratified into gap year and nongap year cohorts. Publication data were recorded from Scopus and PubMed. Pearson's chi-square, independent sample t -tests, and multivariable regression were performed. Results A total of 1,206 residents were analyzed, with 1,036 (85.9%) residents taking no gap year and 170 (14.1%) residents with at least one gap year. Gap year residents were predicted to have increase in the likelihoods of publishing at least one, two, or five total articles during residency, in addition to at least one article in a high-impact journal. There was no significant relationship between gap years and publications with senior authors affiliated with either the resident's medical school or residency program. Conclusion Residents taking gap years following graduation may publish more during residency, but these publications are not associated with senior authors at their institutions. Future investigations should continue to evaluate the significance of gap years in medical education.

Referral to Vision Rehabilitation Services for Uveitis Patients: Referral Criteria and Barriers.

PURPOSE: Despite the benefits of vision rehabilitation services (VRS) for uveitis patients, limited literature has examined issues in VRS access within uveitis. We surveyed American Uveitis Society members regarding VRS referral practices, criteria, and barriers. METHODS: Survey responses were collected from November 2022 to January 2023. Analysis summarized responses and compared response patterns of frequently-referring and infrequently-referring providers through Fisher's exact tests and logistic regression. RESULTS: Most of the 33 respondents completed 1 to 5 monthly referrals using criteria of visual acuity loss, visual field loss, and difficulty performing vision-related activities. Key referral barriers included cost of services and insufficient patient-provider communication regarding vision loss. The practice of speaking to patients about vision loss during clinic visits was correlated with higher VRS referral rates (P = 0.047). CONCLUSIONS: Greater patient-provider communication about vision loss may represent an opportunity to increase access to VRS.

Maternity and family leave experiences among female ophthalmologists in the United States.

OBJECTIVE: To evaluate family and maternity leave policies and examine the social and professional impacts on female ophthalmologists. PARTICIPANTS: Participants were recruited through the Women in Ophthalmology online list-serv to complete a survey evaluating maternity leave policies and their impacts. Survey questions were repeated for each birth event after medical school for up to five birth events. RESULTS: The survey was accessed 198 times, and 169 responses were unique. Most participants were practicing ophthalmologists (92%), with a minority in residency (5%), in fellowship (1.2%), on disability/leave (0.6%), or retired (0.6%). Most participants (78%) were within their first ten years of practice. Experiences were recorded for each leave event, with 169 responses for the first leave, 120 for the second, 28 for the third, and 2 for the fourth. Nearly half of participants reported the information they received about maternity leave to be somewhat or extremely inadequate (first: 50%; second: 42%; third: 41%). Many reported a greater sense of burnout after returning to work (first: 61%, second: 58%, third: 46%). A minority of participants received full pay during the first through third maternity leave events, 39%, 27%, and 33%, respectively. About a third of participants reported being somewhat or very dissatisfied with their maternity leave experience (first: 42%, second: 35%; third: 27%). CONCLUSIONS: Female ophthalmologists have varying experiences with maternity leave, but many encounter similar challenges. This study demonstrates that many women receive inadequate information about family leave, desire more weeks of leave, experience a wide variation in pay practices, and lack support for breastfeeding. Understanding the shared experiences of women in ophthalmology identifies areas where improvements are needed in maternity leave practices within the field to create a more supportive environment for physician mothers.

Predictors of intraocular pressure reduction after femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: a prospective trial.

PURPOSE: To evaluate the association between postoperative intraocular pressure (IOP) reduction and phacoemulsification parameters in patients who underwent both conventional phacoemulsification surgery (CPS) and femtosecond laser-assisted cataract surgery (FLACS). METHODS: This was a prospective multicenter comparative study that enrolled 90 participants who underwent cataract surgery at the University of Maryland Medical System and the Wilmer Eye Institute. Patients underwent FLACS in one eye and CPS in the fellow eye. IOP was measured prior to surgery and monitored through six months postoperatively. Demographic, clinical, biometric, and intraoperative variables including cumulative dissipated energy (CDE), aspiration time, and phacoemulsification time were analyzed for any significant association with postoperative IOP. Postoperative IOP reduction was the primary outcome variable. A secondary goal of the study was to determine differences in postoperative IOP reduction between CPS and FLACS cohorts. RESULTS: In total, 157 non-glaucomatous eyes were included. Using multivariable analysis, we found preoperative IOP to be consistently associated with postoperative IOP reduction in the entire cohort. At the 6-month follow-up visit, there was a 12.4% reduction in IOP (-2.2 ± 3.4 mm Hg) seen, with no statistically significant difference between FLACS and CPS (12.3% ± 19.4% vs 12.5% ± 19.3%, respectively, p = 0.32). FLACS reduced the CDE required for phacoemulsification (6.6 ± 4.4%-seconds vs 8.6 ± 6.9%-seconds, respectively, p < 0.05). CDE was a predictor of IOP response at 6 months, but subgroup analysis revealed that this trend was driven by seven eyes requiring high CDE, and for the majority of eyes, CDE did not influence the size of the decrease. The seven eyes experiencing highest CDE were less likely to show IOP reduction at 6 months. CONCLUSION: Both FLACS and CPS resulted in similar and significant IOP reductions through 6 months after surgery. Preoperative IOP was significantly associated with IOP reduction, and CDE generally did not influence the size of the decrease.

Barriers to Care in the Treatment of Glaucoma: Socioeconomic Elements That Impact the Diagnosis, Treatment, and Outcomes in Glaucoma Patients.

Purpose of Review: This article reviews socioeconomic elements that impact the access to glaucoma care, early intervention in susceptible patients, and longevity of treatment and patient compliance in various demographic groups. Recent Findings: Socioeconomic factors such as insurance eligibility, education, income, marital status, and access to technology can deeply impact the diagnosis and long-term treatment of glaucoma patients. Depending on the severity, and/or urgency of care, many individuals who face these barriers forgo annual eye exams, leading to a higher incidence of untreated glaucoma. Summary: Early intervention and regular follow-up are essential for patient compliance in the management of glaucoma. Routine eye care leads to earlier detection and can improve management options and reduce the severity of disease burden.

Postoperative complications of Ab-Interno XEN implantation in primary angle closure glaucoma.

The XEN Gel Stent offers a unique Ab-interno approach for managing glaucoma and has shown a favorable risk profile relative to traditional trabeculectomy. XEN implantation has almost exclusively been reported in patients with open angle glaucoma and data in patients with angle closure glaucoma is limited. We report a postoperative complication of the XEN Gel Stent in a patient with primary angle closure glaucoma. An 86-year-old man with primary angle closure glaucoma underwent combined phacoemulsification and XEN implantation. After approximately two months, intraocular pressure was elevated and the stent was occluded by iris pigmentary deposits, traversing from the proximal to the distal conjunctival ends of the stent. Using an Ab-interno approach, the implant was successfully explanted, and the patient's intraocular pressure was notably lowered.

Characteristics of Glaucoma Patients Attending a Vision Rehabilitation Service.

PURPOSE: In this study, we describe common demographic and clinical characteristics of the glaucoma patient population attending vision rehabilitation. DESIGN: Cross-sectional study. PARTICIPANTS: Patients attending a hospital-based vision rehabilitation center with a primary ocular diagnosis of glaucoma. METHODS: Participants' charts were retrospectively reviewed. Data extracted from medical records included demographics, referring physician, ocular history, glaucoma diagnosis, past ocular surgery, intraocular pressure, optic nerve findings, results of a functional intake assessing activities of daily living, depression, visual hallucinations, best-corrected visual acuity (BCVA), mean deviation (MD) scores on visual field testing, and log contrast sensitivity (CS). MAIN OUTCOME MEASURES: Participant demographic information, ocular history, self-reported difficulty with activities of daily living, depression, visual hallucinations, BCVA, visual field, and CS. RESULTS: The mean age of patients in this study was 77 years and ranged from 8 to 103 years. Ninety percent of patients were referred to vision rehabilitation by an ophthalmologist. Median BCVA was 20/50. Fifty-five percent of patients were functionally monocular, and for all patients, there was a median 9-line difference in BCVA between eyes. Median MD score was -13.95 decibels (dB). Median CS was 1.05. Patients reported having the greatest difficulty with reading (88%), writing (72%), and mobility (67%). Seventy-eight percent of patients stopped driving, and 12% reported difficulty driving. Among those experiencing depression, there was a 4:1 ratio of depressed patients having difficulty with mobility. One-third of patients experienced visual hallucinations. CONCLUSIONS: Most glaucoma patients attending vision rehabilitation are not legally blind, but many are functionally monocular. This may cause greater difficulty performing functions that require the use of binocularity. Increasing the referral of younger glaucoma patients to vision rehabilitation may help patients learn to cope with the loss of visual function that occurs over time.

Topical mydriatics as adjunctive therapy for traumatic iridocyclitis.

BACKGROUND: Traumatic eye complaints account for 3% of all hospital emergency department visits. The most common traumatic injury to the eye is blunt trauma, which accounts for 30% of these visits. Blunt trauma frequently leads to traumatic iridocyclitis, thus causing anterior uveitis. Iridocyclitis frequently causes tearing, photophobia, eye pain, and vision loss. These symptoms are a result of the inflammatory processes and ciliary spasms to iris muscles and sphincter. The inflammatory process is usually managed with topical corticosteroids, while the ciliary spasm is blunted by dilating the pupils with topical mydriatic agents, an adjuvant therapy. However, the effectiveness of mydriatic agents has not been quantified in terms of reduction of ocular pain and visual acuity loss. OBJECTIVES: To evaluate the effectiveness and safety of topical mydriatics as adjunctive therapy to topical corticosteroids for traumatic iridocyclitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane Eyes and Vision Trials Register (2019, issue 6); Ovid MEDLINE; Embase.com; Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus; PubMed; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 12 June 2019. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) that compared topical mydriatic agents in conjunction with topical corticosteroid therapy versus topical corticosteroids alone, in participants with traumatic iridocyclitis. DATA COLLECTION AND ANALYSIS: Two review authors (JH, MK) independently screened titles and abstracts, then full-text reports, against eligibility criteria. We planned to have two authors independently extract data from included studies. We resolved differences in opinion by discussion. MAIN RESULTS: There were no eligible RCTs that compared the interventions of interest in people with traumatic iridocyclitis. AUTHORS' CONCLUSIONS: We did not find any evidence from RCTs about the efficacy of topical mydriatic agents as an adjunctive therapy with topical corticosteroids for treating traumatic iridocyclitis. In the absence of these types of studies, we cannot draw any firm conclusions. Controlled trials that compare the combined use of topical mydriatic agents and corticosteroid drops against standard corticosteroid drops alone, in people with traumatic iridocyclitis are required. These may provide evidence about the efficacy and risk of topical mydriatic drops as adjuvant therapy for traumatic iridocyclitis.

Measurement of Retinal Microvascular Blood Velocity Using Erythrocyte Mediated Velocimetry.

Changes in retinal blood flow may be involved in the pathogenesis of glaucoma and other ocular diseases. Erythrocyte mediated velocimetry (EMV) is a novel technique where indocyanine green (ICG) dye is sequestered in erythrocyte ghosts and autologously re-injected to allow direct visualization of erythrocytes for in vivo measurement of speed. The purpose of this study is to determine the mean erythrocyte speed in the retinal microvasculature, as well as the intravisit and intervisit variability of EMV. Data from 23 EMV sessions from control, glaucoma suspect, and glaucoma patients were included in this study. In arteries with an average diameter of 43.11 µm ± 6.62 µm, the mean speed was 7.17 mm/s ± 2.35 mm/s. In veins with an average diameter of 45.87 µm ± 12.04 µm, the mean speed was 6.05 mm/s ± 1.96 mm/s. Intravisit variability, as measured by the mean coefficient of variation, was 3.57% (range 0.44-9.68%). Intervisit variability was 4.85% (range 0.15-8.43%). EMV may represent reliable method for determination of retinal blood speed, potentially allowing insights into the effects of pharmacologic agents or pathogenesis of ocular diseases.

Anterior segment ultrasound biomicroscopy image analysis using ImageJ software: Intra-observer repeatability and inter-observer agreement.

PURPOSE: In this novel study, we demonstrate a standardized imaging and measurement protocol of anterior segment (AS) structures with reliability analysis using ultrasound biomicroscopy (UBM) and ImageJ software. METHODS: Ten pediatric and young adult patients undergoing examination under anesthesia for AS pathology were imaged using UBM. Four trained observers analyzed 20 images using ImageJ. Forty-five structural parameters were measured. Those that relied on the trabecular-iris angle (TIA) as a reference landmark were labeled TIA-dependent (TD) and all others were labeled non-TIA dependent (NTD). Intra-observer repeatability (IOR) and inter-observer agreement (IOA) of measurements were determined using coefficient of variation (CV) and intra-class correlation (ICC) followed by assessment of Bland-Altman plots (BAP) for each pair of observers, respectively. RESULTS: For NTD parameters, non-ciliary body (CB) related measurements showed CV range 0.60-16.22% and ICC range 0.84-0.89, whereas CB-related parameters showed CV range 2.86-23.40% and ICC range 0.29-0.92. For TD parameters, parameters < 2 degrees removed from reference showed CV range 0.02-5.40% and ICC range 0.89-1.00, whereas parameters > 1 degree removed showed CV range 0.63-27.44% and ICC range 0.22-1.00. No systematic proportional bias was detected by BAPs. CONCLUSIONS: Preplaced landmarks yielded good IOR and IOA in quantitative assessment of AS structures that were NTD and non-CB-related or less removed from the reference. CB-related NTD measurements varied greatly in IOR and IOA, indicating protocol modifications or CB qualitative assessments needed to improve accuracy. Variability in TD measurements increased the further removed from the reference, which supports implementation of a reliable reference landmark to minimize variation.

Referral to Low Vision Services for Glaucoma Patients: Referral Criteria and Barriers.

PURPOSE: To determine what criteria are being used by glaucoma specialists to refer patients to low vision services (LVS) and to identify potential barriers to LVS referral. METHODS: A survey was emailed to members of the American Glaucoma Society (AGS). The number and percentage of responses to each survey question were examined. RESULTS: Reported criteria for referral included difficulty performing activities related to vision (78%), degree of visual field loss (63%), and difficulty with orientation and mobility (27%). Reported barriers to LVS referral included patients not expressing difficulty with activities related to vision (34%), not having enough time to counsel patients during clinic visits (32%), and perceiving that patients would not be able to afford LVS even if they were referred (31%). CONCLUSIONS: Among glaucoma specialists, patient-reported difficulties with vision-related activities were the most common criteria used for LVS referral. Reported barriers to LVS referral, including perceived patient economic restraints and insufficient time to counsel patients during clinic visits, need to be addressed through appropriate interventions.

Referral to Low Vision Services for Glaucoma Patients: Referral Patterns and Characteristics of Those Who Refer.

PURPOSE: To identify characteristics of ophthalmologists and practices who refer glaucoma patients to low vision services (LVS). MATERIALS AND METHODS: An online survey was distributed to members of the American Glaucoma Society. The survey queried demographics of responders and their clinical practices, criteria and barriers to referral to LVS. Survey responders were categorized as high referrers if they reported referring >5 patients to LVS and low referrers if they referred ≤5. χ and Fischer exact tests were used to compare characteristics between high and low referrers. Logistic regression analyses were used to calculate odds ratios and 95% confidence intervals and determine factors associated with referrer status. RESULTS: High referrers to LVS tended to have >10 patients per month who had already seen a low vision provider (53% vs. 10%, P<0.001), reported following the American Academy of Ophthalmology's Preferred Practice Pattern (PPP) recommendations for LVS referrals (38% vs. 18%, P=0.011), and expressed satisfaction with their current referral practices (86% vs. 70%, P=0.049). In the fully adjusted model those who followed PPP were 2.5 times more likely to report being a high referrer as compared with a low referrer (95% confidence interval, 1.1-5.3). However, only 22% of ophthalmologists reported following these guidelines in their practice. The number of years in practice, practice location or type, volume of patients seen each week, and distance to a low vision clinic were not associated with referral. CONCLUSIONS: Familiarity with PPP guidelines may positively influence LVS referral practices.

Microinvasive Glaucoma Surgery: An Evidence-Based Assessment.

INTRODUCTION: The advent of Microinvasive Glaucoma Surgery (MIGS) offers a novel approach in the treatment of glaucoma with the number of procedures developing at an exciting pace. AREAS COVERED: MIGS procedures aim to lower intraocular pressure (IOP) via four mechanisms: (1) increasing trabecular outflow, (2) increasing outflow via suprachoroidal shunts, (3) reducing aqueous production, and (4) subconjunctival filtration. A comprehensive search for published studies for each Microinvasive Glaucoma Surgery (MIGS) device or procedure was undertaken using the electronic database PubMed. Search terms included 'minimally invasive glaucoma surgery', 'microincisional glaucoma surgery', and 'microinvasive glaucoma surgery'. A manual search for each device or procedure was also performed. After review, randomized control trials and prospective studies were preferentially included. EXPERT OPINION: These procedures offer several benefits: an improved safety profile allowing for intervention in earlier stages of glaucoma, combination with cataract surgery, and decreased dependence on patient compliance with topical agents. Established MIGS procedures have proven efficacy and more recent devices and procedures show promising results. Despite this, further study is needed to assess the long term IOP-lowering effectiveness of these procedures. Particularly, rigorous study with more randomized control trials and head-to-head comparisons would allow for better informed clinical and surgical decision-making. MIGS offers new solutions for glaucoma treatment.