Development of Portable Electronic Health Record Based Algorithms to Identify Individuals with Diabetic Retinopathy.

Objectives: To develop, validate and implement algorithms to identify diabetic retinopathy (DR) cases and controls from electronic health care records (EHR)s. Methods : We developed and validated EHR-based algorithms to identify DR cases and individuals with type I or II diabetes without DR (controls) in three independent EHR systems: Vanderbilt University Medical Center Synthetic Derivative (VUMC), the VA Northeast Ohio Healthcare System (VANEOHS), and Massachusetts General Brigham (MGB). Cases were required to meet one of three criteria: 1) two or more dates with any DR ICD-9/10 code documented in the EHR, or 2) at least one affirmative health-factor or EPIC code for DR along with an ICD9/10 code for DR on a different day, or 3) at least one ICD-9/10 code for any DR occurring within 24 hours of an ophthalmology exam. Criteria for controls included affirmative evidence for diabetes as well as an ophthalmology exam. Results: The algorithms, developed and evaluated in VUMC through manual chart review, resulted in a positive predictive value (PPV) of 0.93 for cases and negative predictive value (NPV) of 0.97 for controls. Implementation of algorithms yielded similar metrics in VANEOHS (PPV=0.94; NPV=0.86) and lower in MGB (PPV=0.84; NPV=0.76). In comparison, use of DR definition as implemented in Phenome-wide association study (PheWAS) in VUMC, yielded similar PPV (0.92) but substantially reduced NPV (0.48). Implementation of the algorithms to the Million Veteran Program identified over 62,000 DR cases with genetic data including 14,549 African Americans and 6,209 Hispanics with DR. Conclusions/Discussion: We demonstrate the robustness of the algorithms at three separate health-care centers, with a minimum PPV of 0.84 and substantially improved NPV than existing high-throughput methods. We strongly encourage independent validation and incorporation of features unique to each EHR to enhance algorithm performance for DR cases and controls.

Visual function and mobility after multifocal versus monofocal intraocular lens implantation.

Clinical relevance: Mobility and fall risk may be important considerations in choosing between intraocular lenses.Background: Fall risk in older adults increases when wearing multifocal spectacles, but little is known about mobility among individuals with different types of intraocular lenses. This study compared visual function, fall risk and balance control following bilateral implantation of monofocal or multifocal intraocular lenses.Methods: This was a non-randomised, cross-sectional study involving adults with bilateral intraocular lenses. Participants completed questionnaires concerning physical functioning, fall history and balance-related confidence. Binocular visual acuity, contrast sensitivity (Pelli-Robson chart and computerized testing), depth perception and glare sensitivity were assessed. Physical performance measures included the Sensory Organization Test, preferred gait speed, Dynamic Gait Index and wayfinding in a virtual environment.Results: Fifteen participants (mean ± standard deviation, 67.1 ± 6.8 years) had monofocal intraocular lenses and 14 participants (68.1 ± 6.1 years) had multifocal intraocular lenses. Contrast sensitivity in the monofocal group was significantly better than that in the multifocal group (p = 0.02) at intermediate and high spatial frequencies. Contrast sensitivity of the monofocal group also was less affected by glare than the contrast sensitivity of the multifocal group, at an intermediate spatial frequency (p = 0.02). However, the multifocal group had significantly better Dynamic Gait Index scores (p = 0.04), even after controlling for perceived physical function.Conclusions: The participants with monofocal intraocular lenses generally had better contrast sensitivity than did those with multifocal intraocular lenses. However, the scores on a mobility test that is associated with fall risk were worse for those with monofocal lenses.

A Survey of Glaucoma Surgery Practice Patterns in the Veterans Health Administration.

INTRODUCTION: Glaucoma surgical practice patterns are not well described in the United States (US). This study aims to evaluate the indications for and potential barriers to glaucoma surgery in the Veterans Health Administration (VHA). MATERIALS AND METHODS: An anonymous 10-question survey using REDCap (Nashville, TN) software was sent by mail (with web link) and email to ophthalmology chiefs at the 86 academically affiliated Veterans Affairs Medical Centers (VAMCs). Academic-affiliated VAMCs were selected because of their patient range and role in ophthalmic education. Non-responders received two reminder e-mails and two phone calls; the survey was closed after 6 weeks. The data were analyzed using descriptive statistics. RESULTS: The response rate was 45% (39/86). Most respondents (92%) worked in an integrated eye clinic with both ophthalmology and optometry services. Almost half of the respondents (49%; 19/39) believed that laser trabeculoplasty (LTP) was an option for initial glaucoma therapy. Noncompliance was a commonly reported indication for LTP (95%), tube shunt procedures (65%), micro-invasive glaucoma surgery (59%), and trabeculectomy (48.7%). One third of the respondents believed that there were delays in glaucoma care. The respondents noted that significant barriers in access to surgery included lack of transportation (69%), scheduling challenges (62%), and delayed referral (62%). CONCLUSION: This survey of glaucoma surgery practice patterns highlights the growing role of LTP and suggests that non-compliance and access remain significant barriers to glaucoma surgical care within the VHA.

Diagnostic Accuracy of Technology-based Eye Care Services: The Technology-based Eye Care Services Compare Trial Part I.

PURPOSE: Ophthalmologic telemedicine has the ability to provide eye care for patients remotely, and many countries have used screening tele-ophthalmology programs for several years. One such initiative at the Veterans Affairs (VA) Healthcare System is Technology-based Eye Care Services (TECS). The TECS services are located in primary care clinics and provide basic screening eye care, including vision, refraction, and retinal photography. Eye care providers ("readers") review the clinical data and recommend appropriate follow-up. One of the most common referrals from TECS has been for glaucoma, and this study was powered for glaucoma/glaucoma suspect detection. The current study was undertaken to identify aspects of the protocol that could be refined to enhance accuracy. DESIGN: Prospective comparison between the standard TECS protocol versus a face-to-face (FTF) examination on 256 patients, all of whom had no known history of significant ocular disease. PARTICIPANTS: Patients with no known ocular disease who were scheduled for an in-person eye appointment at the Atlanta VA. Patients underwent screening through the TECS protocol and received an FTF examination on the same day (gold standard). The TECS readers were masked to the results of the FTF examination. MAIN OUTCOME MEASURES: Percent agreement, kappa, sensitivity, and specificity were calculated for the TECS readers' interpretations versus the FTF examination. RESULTS: The TECS readers showed substantial agreement for cataract (κ ≥ 0.71) and diabetic retinopathy (κ ≥ 0.61) and moderate to substantial agreement for glaucoma/glaucoma suspect (κ ≥ 0.52) compared with an FTF examination. Age-related macular degeneration (AMD) showed moderate agreement (κ ≥ 0.34). Percent agreement with the TECS protocol was high (84.3%-98.4%) for each of the disease categories. Overall sensitivity and specificity were ≥75% and ≥55%, respectively, for any diagnosis resulting in referral. Inter-reader and intra-reader agreement was substantial for most diagnoses (κ > 0.61) with percent agreements ranging from 66% to 99%. CONCLUSIONS: Our results indicate that the standard TECS protocol is accurate when compared with an FTF examination for the detection of common eye diseases. The inclusion of additional testing such as OCT could further enhance diagnostic capability.

The Impact of OCT on Diagnostic Accuracy of the Technology-Based Eye Care Services Protocol: Part II of the Technology-Based Eye Care Services Compare Trial.

PURPOSE: Ophthalmologic telemedicine programs help to address the growing demand for eye care and lessen healthcare disparities for patients. One example is Technology-Based Eye Care Services (TECS), implemented in the Veteran Affairs Healthcare System in 2015. Accuracy and quality data for TECS both have been reported, and data suggest that although the TECS examination is comparable with an in-person examination, sensitivity for glaucoma and glaucoma suspect detection is less than that for other diseases, such as macular degeneration. Several articles suggest that OCT can improve disease detection for glaucoma. Therefore, this study was undertaken to test the impact of OCT on the accuracy of the TECS protocol. This article reports the data from part II of the TECS Compare trial; results from part I are discussed in a previous article. DESIGN: Prospective comparison between the TECS protocol with OCT versus a face-to-face (FTF) examination for 256 patients. PARTICIPANTS: An eligible patient was defined as a patient with no known ocular disease who desired a routine eye examination. METHODS: Patient underwent the TECS protocol workup and OCT nerve, OCT macula, and FTF examination on the same day. MAIN OUTCOME MEASURES: Percent agreement, κ values, sensitivity, and specificity were calculated for nonexpert readers after OCT interpretation of the TECS protocol using the FTF examination as the clinical gold standard. RESULTS: OCT did not improve the diagnostic accuracy of the TECS protocol when compared with an FTF examination. In most cases, OCT had no impact, and in the case of reader 2, OCT actually reduced the κ value from moderate agreement to agreement equal to chance while lowering the percent agreement by 10%. OCT also did not impact inter- or intrareader variability parameters. CONCLUSIONS: In this study, OCT did not seem to improve the accuracy of glaucoma or retinal disease detection when added to the standard TECS protocol. In one case, OCT worsened the agreement of the reader compared with the FTF. Further study is necessary to confirm these findings, and results may change if the readers are glaucoma or retina specialists instead of nonexpert OCT readers, comprehensive and anterior segment specialists.

Diagnosis of retinal detachments by a tele-ophthalmology screening program.

In 2015, a tele-ophthalmology program was undertaken at the Atlanta Veterans Affairs Medical Center to provide screening eye care for veterans in their primary care clinics. Though this program was developed as a screening tool, the availability of these services in primary care clinics has enabled triage of certain acute eye complaints. These case reports describe two patients who were diagnosed with retinal detachments through this program, although their primary care providers had triaged them as requiring non-urgent referrals to the eye clinic. Although many patients are seen for acute ocular complaints in primary care clinics and emergency departments, providers in such settings may lack the ability to adequately examine eyes and thus triage ocular complaints. These cases demonstrate the ability of tele-ophthalmology to assist in diagnosing urgent ocular conditions in primary care clinics. Though tele-ophthalmology has been accepted in some parts of the world, in the United States of America it remains widely underutilized. These cases highlight the ability of tele-ophthalmology to close the gap in acute eye care coverage that exists in the USA, most prominently in rural regions.

Differences in Tertiary Glaucoma Care in the Veterans Affairs Health Care System.

Importance: Glaucoma is a common cause of visual impairment in the Veterans Affairs (VA) health care system, but to our knowledge, no data exist concerning tertiary glaucoma care (ie, laser and filtering surgery). Objective: To determine whether the rate of tertiary glaucoma care differs among veterans cared for through the 4 different eye care delivery models that are present in the VA: optometry-only clinics, ophthalmology-only clinics, clinics with optometry and ophthalmology functioning as a single integrated clinic with ophthalmology as the lead, and clinics with optometry and ophthalmology functioning as separate clinics. Design, Setting, and Participants: In this retrospective review of the Veterans Health Administration Support Service Center database, 490 926 veterans with a glaucoma-related diagnosis received care from 136 VA medical centers during fiscal year 2016. Demographic and baseline clinical factors, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, and Current Procedural Terminology codes, and the rates of glaucoma surgery procedures were extracted from the database. The organizational structure of each VA eye clinic was obtained. Univariate and multivariate regression analyses were performed for log percent for laser peripheral iridotomy (LPI), laser trabeculoplasty (LTP), and filtering surgery. Main Outcomes and Measures: Rates of LPI, LTP, and filtering surgery. Results: Of the 490 926 veterans with a glaucoma-related diagnosis, 465 842 (94.9%) were male, 309 677 (63.1%) were white, and 203 243 (41.4%) were aged 65 to 74 years. The rate of LPI was 0.30%, 0.28%, 0.67%, and 0.69% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of LTP was 0.31%, 1.06%, 0.93%, and 0.92% in care delivery models that included optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). The rate of filtering surgery was 0.32%, 0.51%, 0.69%, and 0.60% in optometry-only clinics, ophthalmology-only clinics, integrated clinics, and separated clinics, respectively (P < .001). Multivariate regression analyses showed that these differences remained significantly different even after adjusting for potential confounders. Conclusions and Relevance: Disparities exist in the use of tertiary glaucoma services within the VA, and different care delivery models may play a role. Outcomes of glaucoma care for the different models of eye care delivery were not analyzed in this study.

Remote eye care screening for rural veterans with Technology-based Eye Care Services: a quality improvement project.

CONTEXT: Veterans are at high risk for eye disease because of age and comorbid conditions. Access to eye care is challenging within the entire Veterans Hospital Administration's network of hospitals and clinics in the USA because it is the third busiest outpatient clinical service and growing at a rate of 9% per year. ISSUE: Rural and highly rural veterans face many more barriers to accessing eye care because of distance, cost to travel, and difficulty finding care in the community as many live in medically underserved areas. Also, rural veterans may be diagnosed in later stages of eye disease than their non-rural counterparts due to lack of access to specialty care. In March 2015, Technology-based Eye Care Services (TECS) was launched from the Atlanta Veterans Affairs (VA) as a quality improvement project to provide eye screening services for rural veterans. LESSONS LEARNED: By tracking multiple measures including demographic and access to care metrics, data shows that TECS significantly improved access to care, with 33% of veterans receiving same-day access and >98% of veterans receiving an appointment within 30 days of request. TECS also provided care to a significant percentage of homeless veterans, 10.6% of the patients screened. Finally, TECS reduced healthcare costs, saving the VA up to US$148 per visit and approximately US$52 per patient in round trip travel reimbursements when compared to completing a face-to-face exam at the medical center. Overall savings to the VA system in this early phase of TECS totaled US$288,400, about US$41,200 per month. Other healthcare facilities may be able to use a similar protocol to extend care to at-risk patients.

Early Experience with Technology-Based Eye Care Services (TECS): A Novel Ophthalmologic Telemedicine Initiative.

PURPOSE: The aging population is at risk of common eye diseases, and routine eye examinations are recommended to prevent visual impairment. Unfortunately, patients are less likely to seek care as they age, which may be the result of significant travel and time burdens associated with going to an eye clinic in person. A new method of eye-care delivery that mitigates distance barriers and improves access was developed to improve screening for potentially blinding conditions. We present the quality data from the early experience (first 13 months) of Technology-Based Eye Care Services (TECS), a novel ophthalmologic telemedicine program. DESIGN: With TECS, a trained ophthalmology technician is stationed in a primary care clinic away from the main hospital. The ophthalmology technician follows a detailed protocol that collects information about the patient's eyes. The information then is interpreted remotely. Patients with possible abnormal findings are scheduled for a face-to-face examination in the eye clinic. PARTICIPANTS: Any patient with no known ocular disease who desires a routine eye screening examination is eligible. METHODS: Technology-Based Eye Care Services was established in 5 primary care clinics in Georgia surrounding the Atlanta Veterans Affairs hospital. MAIN OUTCOME MEASURES: Four program operation metrics (patient satisfaction, eyeglass remakes, disease detection, and visit length) and 2 access-to-care metrics (appointment wait time and no-show rate) were tracked. RESULTS: Care was rendered to 2690 patients over the first 13 months of TECS. The program has been met with high patient satisfaction (4.95 of 5). Eyeglass remake rate was 0.59%. Abnormal findings were noted in 36.8% of patients and there was >90% agreement between the TECS reading and the face-to-face findings of the physician. TECS saved both patient (25% less) and physician time (50% less), and access to care substantially improved with 99% of patients seen within 14 days of contacting the eye clinic, with a TECS no-show rate of 5.2%. CONCLUSIONS: The early experience with TECS has been promising. Tele-ophthalmology has the potential to improve operational efficiency, reduce cost, and significantly improve access to care. Although further study is necessary, TECS shows potential to help prevent avoidable vision loss.

Eye Care Productivity and Access in the Veterans Affairs Health Care System.

OBJECTIVES: Eye care in the Veterans Affairs Health Care System is challenged with increasing demand and higher prevalence of patients with complex ocular conditions. Understanding factors that impact eye care productivity and access is necessary for appropriate allocation of resources. The purpose of this study was to determine the impact of various eye clinic personnel on eye care provider productivity and patient access. METHODS: Utilizing data from the Veterans Health Administration National Data Warehouse, workload and level of staffing were analyzed. Trends in the data were analyzed using descriptive and regression analyses employing both linear and curve fitting modeling methods. RESULTS: There was a significant positive correlation between ophthalmology technicians and ophthalmologist productivity (p < 0.001), number of unique patients seen per year per provider (p = 0.047), and total yearly number of office visits per provider (p < 0.001). Similarly, there was a significant positive correlation between number of ophthalmology residents and productivity (p = 0.046) and number of clinic visits per provider (p < 0.001) but not the number of unique patients seen. Positive correlation was found between optometry technicians and the number of unique patients' seen by optometrists (p = 0.041) and total number of clinic visits per provider (p < 0.001) but not optometrist productivity. No significant correlations were present for nurses, nurse practitioners, physician assistants, or clerical staff. CONCLUSION: Eye care technicians provide a cost-effective multiplier effect for provider productivity, especially in ophthalmology clinics, allowing significant increases in total clinic visits and number of unique patients seen per year.

Retrospective Evaluation of a Teleretinal Screening Program in Detecting Multiple Nondiabetic Eye Diseases.

BACKGROUND: Diabetic teleretinal screening programs have been utilized successfully across the world to detect diabetic retinopathy (DR) and are well validated. Less information, however, exists on the ability of teleretinal imaging to detect nondiabetic ocular pathology. INTRODUCTION: This study performed a retrospective evaluation to assess the ability of a community-based diabetic teleretinal screening program to detect common ocular disease other than DR. MATERIALS AND METHODS: A retrospective chart review of 1,774 patients who underwent diabetic teleretinal screening was performed. Eye clinic notes from the Veterans Health Administration's electronic medical record, Computerized Patient Record System, were searched for each of the patients screened through teleretinal imaging. When a face-to-face examination note was present, the physical findings were compared to those obtained through teleretinal imaging. Sensitivity, specificity, and positive and negative predictive values were calculated for suspicious nerve, cataract, and age-related macular degeneration. RESULTS: A total of 903 patients underwent a clinical examination. The positive predictive value was highest for cataract (100%), suspicious nerve (93%), and macular degeneration (90%). The negative predictive value and the percent agreement between teleretinal imaging and a clinical examination were over 90% for each disease category. DISCUSSION: A teleretinal imaging protocol may be used to screen for other common ocular diseases. CONCLUSION: It may be feasible to use diabetic teleretinal photographs to screen patients for other potential eye diseases. Additional elements of the eye workup may be added to enhance accuracy of disease detection. Further study is necessary to confirm this initial retrospective review.

Toric Intraocular Lens Outcomes in Patients With Glaucoma.

PURPOSE: To report the outcomes of toric intraocular lens implantation in patients with glaucoma and corneal astigmatism. METHODS: One hundred twenty-six eyes of 87 patients with glaucoma and corneal astigmatism that underwent cataract surgery with an AcrySof toric intraocular lens (Alcon Laboratories, Inc., Fort Worth, TX) implant were selected for this single-center, retrospective case series. Corrected distance visual acuity, intraocular pressure, and refractive astigmatism were measured in each eye preoperatively and postoperatively. Uncorrected distance visual acuity and toric alignment were measured postoperatively. RESULTS: The uncorrected distance visual acuity was 0.04 ± 0.08 logMAR (20/22 Snellen) for all eyes. Ninety-eight percent of all eyes achieved an uncorrected distance visual acuity of 20/40 or better, with 76% achieving 20/25 or better and 47% achieving 20/20. The corrected distance visual acuity for all eyes was 0.01 ± 0.03 logMAR (20/20.5 Snellen) postoperatively. The refractive cylinder improved from 1.47 ± 1.10 diopters preoperatively to 0.31 ± 0.37 diopters postoperatively. The residual refractive cylinder was 1.00 diopter or less in 97% of eyes, 0.75 diopters or less in 90% of eyes, and 0.50 diopters or less in 83% of eyes. Mean misalignment was 4.4° ± 5.1°. Intraocular pressure decreased by a mean of 2.3 ± 3.3 mm Hg following the surgery. CONCLUSION: Toric intraocular lenses can reliably reduce astigmatism and improve uncorrected vision in eyes with cataract and glaucoma.

Reduced intraocular pressure after cataract surgery in patients with narrow angles and chronic angle-closure glaucoma.

PURPOSE: To evaluate the effect of cataract surgery on intraocular pressure (IOP) in patients with narrow angles and chronic angle-closure glaucoma (ACG) and to determine whether the change in IOP was correlated with the preoperative pressure, axial length (AL), and anterior chamber depth (ACD). SETTING: Private practice, Atlanta, Georgia, USA. DESIGN: Retrospective case series. METHODS: Charts of patients with narrow angles or chronic ACG who had cataract surgery were reviewed. All eyes had previous laser iridotomies. Data recorded included preoperative and postoperative IOP, AL, and ACD. The preoperative IOP was used to stratify eyes into 4 groups. RESULTS: The charts of 56 patients (83 eyes) were reviewed. The mean reduction IOP in all eyes was 3.28 mm Hg (18%), with 88% having a decrease in IOP. There was a significant correlation between preoperative IOP and the magnitude of IOP reduction (r = 0.68, P < .001). The mean decrease in IOP was 5.3 mm Hg in eyes with a preoperative IOP above 20 mm Hg, 4.6 mm Hg in the over 18 to 20 mm Hg group, 2.5 mm Hg in the over 15 to 18 mm Hg group, and 1.4 mm Hg in the 15 mm Hg or less group. The mean follow-up was 3.0 years ± 2.3 (SD). CONCLUSIONS: Cataract surgery reduced IOP in patients with narrow angles and chronic ACG. The magnitude of reduction was highly correlated with preoperative IOP and weakly correlated with ACD. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Lens-based glaucoma surgery: using cataract surgery to reduce intraocular pressure.

UNLABELLED: Cataract surgery has been demonstrated to lower intraocular pressure (IOP) in eyes with glaucoma. The evidence is strong in angle-closure patients that cataract surgery improves IOP and dramatically reduces the future risk for IOP spikes and acute attacks. Randomized controlled trials (RCTs) have shown that cataract surgery may be preferable to laser iridotomy or phacotrabeculectomy. The data are so convincing that an RCT has been undertaken to assess whether clear lens extraction may be appropriate following acute attacks and in cases of uncontrolled IOP. The case favoring cataract surgery in open-angle glaucoma (OAG) is more controversial. Impressive IOP reduction has been shown in OAG patients when the patients are stratified by preoperative IOP. The patients with the highest preoperative IOPs have pressure reductions up to 8.5 mm Hg. However, these findings have been criticized for methodological weaknesses. Combining cataract surgery with microinvasive glaucoma surgery in phaco-plus procedures provides further options for lens-based glaucoma surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.