Factors associated with loss to follow-up in patients with advanced age-related macular degeneration: A telehealth recall initiative.

INTRODUCTION: Patients with advanced age-related macular degeneration (AMD) frequently experience loss to follow-up (LTFU), heightening the risk of vision loss from treatment delays. This study aimed to identify factors contributing to LTFU in patients with advanced AMD and assess the effectiveness of telephone-based outreach in reconnecting them with eye care. METHODS: A custom reporting tool identified patients with advanced AMD who had not returned for eye care between 31 October 2021 and 1 November 2022. Potentially LTFU patients were enrolled in a telephone outreach programme conducted by a telehealth extender to encourage their return for care. Linear regression analysis identified factors associated with being LTFU and likelihood of accepting care post-outreach. RESULTS: Out of 1269 patients with advanced AMD, 105 (8.3%) did not return for recommended eye care. Patients LTFU were generally older (89.2 ± 8.9 years vs. 87.2 ± 8.5 years, p = 0.02) and lived farther from the clinic (25 ± 43 miles vs. 17 ± 30 miles, p = 0.009). They also had a higher rate of advanced dry AMD (26.7% vs. 18.5%, p = 0.04) and experienced worse vision in both their better-seeing (0.683 logMAR vs. 0.566 logMAR, p = 0.03) and worse-seeing (1.388 logMAR vs. 1.235 logMAR, p = 0.04) eyes. Outreach by a telehealth extender reached 62 patients (59%), 43 through family members or healthcare proxies. Half of the cases where a proxy was contacted revealed that the patient in question had died. Among those contacted directly, one third expressed willingness to resume eye care (20 patients), with 11 scheduling appointments (55%). Despite only two patients returning for in-person eye care through the intervention, the LTFU rate halved to 4.4% by accounting for those patients who no longer needed eye care at the practice. CONCLUSIONS: There is a substantial risk that older patients with advanced AMD will become LTFU. Targeted telephone outreach can provide a pathway for vulnerable patients to return to care.

Targeted Telephone-Based Outreach Reconnects Glaucoma Patients With Subspecialty Care.

PRCIS: A personalized telephone-based intervention is a cost-effective method to return overdue patients with open angle glaucoma (OAG) to subspecialty care. Patients who accepted care overwhelmingly preferred in-person appointments with their provider instead of hybrid visits with telehealth. PURPOSE: To evaluate the effectiveness of a telephone-based outreach strategy to reconnect OAG patients with subspeciality care. PATIENTS AND METHODS: Established patients with OAG who were seen before March 1, 2021, but had not returned for care in the following year were contacted via a telephone-based intervention. Patients lost to follow-up (LTF) were offered the option of an in-person visit or a hybrid telehealth visit, which combined in-office testing of vision, intraocular pressure, and optic nerve imaging with a virtual consultation with their glaucoma specialist on a separate date. RESULTS: Of 2727 patients with OAG, 351 (13%) had not returned for recommended care. Outbound calls reached 176 of those patients (50%). Nearly half of all patients contacted readily accepted care, with 71 scheduling in-person appointments (93%) and 5 selecting hybrid visits (6.6%). Medication refills were requested by 17 of those 76 patients, representing nearly a third of the 56 patients who were treated with topical glaucoma medications. Assessment of the program 90 days later found that 40 patients had returned for care, 100 patients had transferred or declined further care, and 40 patients were identified as deceased, lowering the LTF rate to 6.4%, with 15 patients still scheduled for future visits. On the basis of an average call duration of 2.8±2.0 minutes, the added cost of returning a patient with OAG to care by the program was $28.11. CONCLUSIONS: Providing targeted outreach by telephone is an effective and cost-efficient strategy to reconnect OAG patients LTF with subspecialty care.

Telehealth improves follow-up and monitoring of age-related macular degeneration during the COVID-19 pandemic.

PURPOSE: To prevent vision loss, it is important to monitor patients with age-related macular degeneration (AMD) for the development of choroidal neovascularization. The coronavirus disease 2019 (COVID-19) pandemic caused many patients to miss or delay visits. To offset those gaps in care, providers utilized telehealth (TH) to evaluate patients for symptoms of disease progression and provide health education on the importance of continuous monitoring. METHODS: This study evaluates the impact of TH encounters on the rate of return for recommended in-person examinations for 1103 patients with non-neovascular (dry) AMD seen in an outpatient ophthalmology clinic in 2019 and due for return evaluation after the outbreak of COVID-19 in 2020. Logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with TH utilization and in-person return. RESULTS: 422 patients (38%) utilized TH during the study period. Patients who completed a TH encounter were more likely to return for an in-person examination as compared with those who did not receive TH (OR: 1.8, CI 95%: 1.4-2.3, P < 0.001). Completing a TH visit was associated with the detection of new wet AMD (OR: 3.3, 95% CI 1.04-10.6, P = 0.043), as well as with an earlier return for those patients who were found to have disease progression (62 ± 54 days vs. 100 ± 57 days, P = 0.049). CONCLUSION: Completing a TH visit increased the rate at which patients with dry AMD returned for recommended in-person eye examinations. In many cases, this permitted the earlier detection of wet AMD, which is linked with achieving better outcomes.

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting.

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Effectiveness and Financial Viability of Telehealth Physician Extenders for Re-Engagement of Patients with Diabetic Retinopathy.

Purpose: To assess the effectiveness and financial implications of employing a telehealth physician extender program to re-engage patients with diabetic retinopathy (DR) who are lost to follow-up (LTF). Methods: Established patients with DR unevaluated in the prior 12 months were identified as LTF, and randomized to receive a recall intervention or standard operating procedure (SOP). For the intervention, a telehealth physician extender performed outbound calls, offering each patient a symptom screening questionnaire following a physician-directed escalation pathway and assistance in scheduling a return appointment. All patients retained the ability to schedule an appointment by means of SOP. Appointment schedule and adherence rates were assessed 30 days after a 6-week intervention period. Call times were digitally measured to estimate intervention labor cost. Results: Four hundred twenty-five of 2,514 established patients with DR were LTF (17%). One hundred fifty-seven patients were assigned to the intervention group; the remaining 268 formed the SOP group. Sixty-six outbound calls reached patients (42%). At the time of program assessment, the intervention group demonstrated a higher rate of appointment scheduling (31% vs. 14%, p < 0.001) and adherence (14% vs. 7%, p = 0.020). The measured call duration was 2.3 ± 1.9 min, yielding an estimated cost of US$4.70 per appointment scheduled. Conclusion: Re-engagement by a telehealth physician extender improves the rate at which patients with DR return for eye care, and can be done at a reasonable cost. This method of improving adherence with follow-up should be readily translatable to other health care settings.

Assessing optometric care delivered by telehealth during the COVID-19 public health emergency.

Background: The emergence of coronavirus disease 2019 (COVID-19) forced many eye care providers to implement telehealth services while in-person visits were reserved for essential and/or emergency eye care. Objective: This study documents how an optometry group successfully implemented telehealth to care for patients during the outbreak of the COVID-19 pandemic in the United States. Design: Retrospective, comparative case series. Methods: Records were reviewed for patients seen in an academic optometry clinic from 23 March through 7 April 2020, the period of the Massachusetts stay-at-home advisory issued in response to COVID-19. Patients who completed telehealth visits were compared with those who received in-person care. Services delivered by telehealth included a check of symptoms, medication refills, health education, and assurance of future follow up. The study took into account the reason for each visit, as well as the rate of scheduled and completed follow-up appointments. Patient satisfaction with in-person care was evaluated by Press Ganey patient experience surveys. Results: Out of 855 patients scheduled, 421 patients completed telehealth encounters (49%), and 46 patients completed in-clinic visits (5.4%). A further 272 patients canceled appointments (32%), 123 patients were unable to be contacted (14%), and 8 patients declined care offered by telehealth (0.94%). Most patients who were cared for by telehealth returned to see optometrists (88%). By contrast, most patients who required in-person visits during this period were subsequently seen by ophthalmologists (58%, p < 0.001). Patient satisfaction remained high for in-person visits that took place during the COVID-19-related emergency, with improvements noted in patient satisfaction regarding 'information about delays' (47 % versus 100%, p = 0.007) and 'concern for questions or worries' (76% versus 100%, p = 0.037) compared with the same period 1 year prior. Conclusion: Optometrists rapidly embraced telehealth to deliver eye care to their patients during the COVID-19 public health emergency. Most eye issues were able to be addressed through telehealth; urgent eye problems were triaged and referred to the optometry clinic, when appropriate.

Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19. Methods: This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed. Results: The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ 2=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ 2=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ 2=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ 2=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model. Conclusion: Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

An initiative to improve follow-up of patients with diabetic retinopathy.

BACKGROUND: This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at identifying and reducing the number of patients with diabetic retinopathy (DR) lost to follow-up (LTF). METHOD: Providers were enlisted to review the EMRs and re-engage patients with DR seen 1 year prior and who had not returned for care within the past 6 months. Binary logistic regression analysis was used to identify demographic, clinical and sociomedical factors associated with being LTF, as well as those predictive of re-engagement. RESULTS: Out of 673 patients with DR, 78 (12%) were identified as LTF. Patients LTF were more likely to be younger (p = 0.001) and have poorly controlled haemoglobin A1c (HbA1c ≥ 8%, p = 0.04) and cholesterol (LDL ≥ 100 mg/dL, p < 0.001) levels. These patients were also more likely to have completed fewer ophthalmology appointments (p < 0.001), and less likely to have had retinal imaging within the last year (p < 0.001). Charts reviewed 1 month after the EMR-based initiative revealed that 22 patients (28%) had been successfully re-engaged by providers, while 56 patients (72%) remained LTF. History of prior treatment for DR was associated with re-engagement by providers (p = 0.04). One month following the provider-based intervention, the LTF rate dropped to 8.3%, and by 1 year only 3.6% of the patients remained LTF. CONCLUSIONS: Electronic medical record-based tools can successfully identify DR patients as being LTF, offering an opportunity for providers to re-engage patients in a timely manner. Future studies are needed to determine the long-term impact of patient re-engagement on DR outcomes and efficiency of clinical practice.

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.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System.

PURPOSE: We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes. METHODS: A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations. RESULTS: Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973-0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47-2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13-2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89-7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73-35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations. CONCLUSION: Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

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.

Modeling the impact of COVID-19 on Retina Clinic Performance.

BACKGROUND: COVID-19, a highly contagious respiratory virus, presents unique challenges to ophthalmology practice as a high-volume, office-based specialty. In response to the COVID-19 pandemic, many operational changes were adopted in our ophthalmology clinic to enhance patient and provider safety while maintaining necessary clinical operations. The aim of this study was to evaluate how measures adopted during the pandemic period affected retina clinic performance and patient satisfaction, and to model future clinic flow to predict operational performance under conditions of increasing patient and provider volumes. METHODS: Clinic event timestamps and demographics were extracted from the electronic medical records of in-person retina encounters from March 15 to May 15, 2020 and compared with the same period in 2019 to assess patient flow through the clinical encounter. Patient satisfaction was evaluated by Press Ganey patient experience surveys obtained from randomly selected outpatient encounters. A discrete-events simulation was designed to model the clinic with COVID-era restrictions to assess operational performance under conditions of increasing patient and provider volumes. RESULTS: Retina clinic volume declined by 62 % during the COVID-19 health emergency. Average check-in-to-technician time declined 79 %, total visit length declined by 46 %, and time in the provider phase of care declined 53 %. Patient satisfaction regarding access nearly doubled during the COVID-period compared with the prior year (p < 0.0001), while satisfaction with overall care and safety remained high during both periods. A model incorporating COVID-related changes demonstrated that wait time before rooming reached levels similar to the pre-COVID era by 30 patients-per-provider in a 1-provider model and 25 patients-per-provider in a 2-provider model (p < 0.001). Capacity to maintain distancing between patients was exceeded only in the two 2-provider model above 25 patients-per-provider. CONCLUSIONS: Clinic throughput was optimized in response to the COVID-19 health emergency. Modeling these clinic changes can help plan for eventual volume increases in the setting of limits imposed in the COVID-era.

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.

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.

A 3-month clinical trial comparing the IOP-lowering efficacy of bimatoprost and latanoprost in patients with normal-tension glaucoma.

This multicenter, randomized, double-blind clinical trial was undertaken to compare the intraocular pressure (IOP)-lowering efficacy and safety of topical bimatoprost 0.03% with that of latanoprost 0.005% for the treatment of patients with normal-tension glaucoma. After washout of all ocular hypotensive medications, patients with normal-tension glaucoma (n=60) were randomly assigned to oncedaily bimatoprost 0.03% or latanoprost 0.005% for 3 mo. Diurnal IOP measurements were taken at each study visit. Primary outcome measures consisted of mean change from baseline IOP (8 AM, Noon, 4 PM) and change in visual field. Secondary measures included mean IOP, ophthalmologic examination findings, results of clinical evaluation, and adverse events. Mean change from baseline IOP at each study visit was statistically significant at all diurnal measurements for patients taking bimatoprost and for those taking latanoprost (P<.001). The 8 AM mean change from baseline IOP measurement showed a significant between-group difference (P< or =.033) in favor of bimatoprost at both follow-up visits. After 3 mo of treatment, mean IOP reductions from baseline ranged from 2.8 to 3.8 mm Hg (17.5%-21.6%) with bimatoprost and from 2.1 to 2.6 mm Hg (12.7%-16.2%) with latanoprost. Overall mean reduction in IOP after 3 mo of treatment was 3.4 mm Hg (19.9% rpar; with bimatoprost and 2.3 mm Hg (14.6%) with latanoprost (P=.035). No significant between-group differences were observed in incidence of adverse events, clinical success, or demographic variables. Bimatoprost was found to be more effective than latanoprost in lowering IOP in the patient with normal-tension glaucoma. Both drugs were efficacious and well tolerated.