Limited English Proficiency Is Associated With Diabetic Retinopathy in Patients Presenting for Cataract Surgery.

Purpose: To investigate the relationship between limited English proficiency (LEP) and diabetic retinopathy (DR) in patients presenting for cataract surgery. Methods: This is a retrospective observational study of patients who underwent cataract surgery between January 2014 and February 2020. Patients who self-identified as needing or preferring an interpreter were defined as having LEP. Differences in demographics, characteristics, and outcomes including history of type 2 diabetes (T2DM), DR, preoperative best corrected visual acuity (BCVA), macular edema, and anti-vascular endothelial growth factor injections were analyzed. Statistical comparisons were assessed using logistic regression with generalized estimating equations. Results: We included 13,590 eyes. Of these, 868 (6.4%) were from LEP patients. Patients with LEP were more likely to be Hispanic (P < 0.001), female sex (P = 0.008), or older age (P = 0.003) and have worse mean BCVA at presentation (P < 0.001). Patients with LEP had a significantly higher rate of T2DM (P < 0.001), macular edema (P = 0.033), and DR (18.1% vs. 5.8%, P < 0.001). Findings remained significant when controlling for age, sex, race/ethnicity, and type of health insurance. Patients with LEP and DR were more likely to have had later stages of DR (P = 0.023). Conclusions: Patients with LEP presenting for cataract surgery had a higher rate of DR and associated complications compared to patients with English proficiency. Further studies are needed to understand how language disparities influence health and what measures could be taken to improve healthcare in this vulnerable population. Translational Relevance: Our study highlights healthcare disparities within ophthalmology and emphasizes the importance of advocating for improved healthcare delivery for patients with LEP.

Reduction of Eyedrop Volume for Topical Ophthalmic Medications with the Nanodropper Bottle Adaptor.

Purpose: To determine the drop volume and total number of dispensed drops using the Nanodropper eyedrop bottle adaptor (Nanodropper, Inc.) compared to drops dispensed from stock bottles to potentially limit ocular toxicity of these eyedrops and prolong bottle use. Patients and Methods: Six topical ocular hypotensive medications (5 solutions, 1 suspension), one steroid (suspension) and two artificial tears emulsions were selected for this study. An analytical balance was used to determine the mass per 10 drops with and without the volume-reducing adaptor and repeated until the bottles were completely emptied. The density of each product was determined using the calculated density. The average drop volume and number of drops per bottle for the nine medications were compared with and without the adaptor with paired t-testing. Results: When all medications were assessed, the drops delivered with the adaptor were 62.1% smaller than eyedrops administered from standard bottles. Compared to stock bottle eyedrops, which had a mean volume of 39.8 ± 2.1 µL, the adaptor resulted in drops with a mean volume of 15.1 ± 1.0 µL, p<0.0001. The adaptor delivered 2.6x the number of drops dispensed from a standard 2.5 mL bottle (184.1 ± 15.1 drops with adaptor and 69.8 ± 4.9 drops from stock bottle, p<0.0001). Conclusion: The Nanodropper eyedrop bottle adaptor can significantly reduce drop volume and increase the overall number of drops dispensed compared with stock eyedrop bottles. Further studies are needed to elucidate the clinical impact of utilizing decreased drop volume with direct comparison to current standards of care.

Disparities in eye clinic patient encounters among patients requiring language interpreter services.

BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Comparison of cataract surgery outcomes in English proficient and limited English proficiency patients.

PURPOSE: To determine differences in cataract surgery outcomes between English proficient (EP) and limited English proficiency (LEP) patients. SETTING: Sue Anschutz-Rodgers Eye Center, Aurora, Colorado. DESIGN: Retrospective. METHODS: Patients who underwent phacoemulsification at the Sue Anschutz-Rogers Eye Center between January 2014 and February 2020 were included. Patients who self-identified as needing or preferring an interpreter in medical encounters were defined as LEP. Differences in surgical characteristics and outcomes including cataract maturity, surgical complexity, and surgical complications were analyzed. RESULTS: 868 eyes (6.4%) were identified from LEP patients. LEP patients were more likely to have mature cataracts (5.1% vs 2.3%, P < .0001). LEP patients' surgeries were more likely to be considered complex (27.8% vs 15.3%, P < .0001) and use higher cumulative dissipated energy (mean of 9.5 [SD = 9.5] vs 7.2 [SD = 7.1], P < .0001). Preoperative visual acuity was worse in LEP patients (logMAR 0.566 [SD = 0.64] vs 0.366 [SD = 0.51], P < .0001) but showed greater improvement after surgery (logMAR 0.366 [SD = 0.54] vs 0.254 [SD = 0.41], P < .0001). There were no significant differences in operative time, intraoperative or postoperative complications. More LEP patients were on steroids 4 weeks postoperatively when compared with EP patients (14.6% vs 10.1%, P < .0002). LEP patients were less likely to undergo subsequent YAG capsulotomy (7.3% vs 12.8%, P < .0001). CONCLUSIONS: Disparities in cataract outcomes between EP and LEP patients was demonstrated. Further research into ophthalmic health disparities for LEP patients is needed to understand the root causes and how they can be addressed.

Subjective and Objective Measurement of Sleep Quality and Activity in Glaucoma.

PRCIS: Glaucoma patients exhibit worse indices of sleep function by both objective and subjective metrics compared with controls. PURPOSE: The purpose of this study is to characterize the sleep parameters and physical activity levels of glaucoma patients compared with controls. PATIENTS AND METHODS: A total of 102 patients with a diagnosis of glaucoma in at least 1 eye and 31 control subjects were enrolled in the study. Participants completed the Pittsburgh Sleep Quality Index (PSQI) during enrollment and then wore wrist actigraphs for 7 consecutive days to characterize circadian rhythm, sleep quality, and physical activity. The primary outcomes of the study were subjective and objective metrics of sleep quality using the PSQI and actigraphy devices, respectively. The secondary outcome was physical activity, measured by the actigraphy device. RESULTS: From the PSQI survey, glaucoma patients had higher (worse) scores compared with controls for sleep latency, sleep duration, and subjective sleep quality, whereas scores for sleep efficiency were lower (better), suggesting more time spent in bed asleep. By actigraphy, time in bed was significantly higher in glaucoma patients as was time awake after sleep onset. Interdaily stability, quantifying the synchronization to the 24-hour light-dark cycle, was lower in glaucoma patients. There were no other significant differences between glaucoma and control patients with regard to rest-activity rhythms or physical activity metrics. In contrast to the survey data, findings from the actigraphy demonstrated that there were no significant associations between the study group and controls regarding sleep efficiency, onset latency, or total sleep time. CONCLUSIONS: In this study, patients with glaucoma demonstrated several subjective and objective differences in sleep function when compared with controls, whereas physical activity metrics were similar.

Comparison of Outcomes of Phacoemulsification Combined with Endoscopic Cyclophotocoagulation, iStent, or Both in the Management of Open-Angle Glaucoma.

INTRODUCTION: To compare outcomes of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco/ECP), first generation iStent implantation (phaco/iStent), or both (phaco/iStent/ECP) in patients with open-angle glaucoma. METHODS: A retrospective chart review was performed on patients at the University of Colorado Department of Ophthalmology. Outcomes included intraocular pressure (IOP), medication use, best corrected visual acuity (BCVA), and surgical complications were analyzed. Success was defined as IOP reduction of ≥ 20% and/or reduction by at least one glaucoma medication. RESULTS: A total of 394 eyes were included in the study. There were 170 eyes (43.1%) in the phaco/ECP group, 175 eyes (44.4%) in the phaco/iStent group, and 49 eyes (12.4%) in the phaco/iStent/ECP group. The mean pre-operative IOP was 15.9 mmHg for phaco/ECP, 15.8 mmHg for phaco/iStent, and 15.2 mmHg for phaco/iStent/ECP. At 24 months, the mean IOP was 13.7 mmHg (p < 0.0001), 14.2 mmHg (p = 0.0001), and 13.0 mmHg (p = 0.0007), respectively. The mean pre-operative number of glaucoma medications was 2.0 for phaco/ECP, 1.4 for phaco/iStent, and 2.2 for phaco/iStent/ECP and at 24 months post-surgery decreased to, 1.8 (p = 0.011), 0.9 (p < 0.0001), and 1.7 (p = 0.01), respectively. The success rate at 24 months was 54.4% for phaco/ECP, 75.3% for phaco/iStent, and 55.6% for phaco/iStent/ECP. CONCLUSION: Phacoemulsification when combined with ECP, iStent, or both, lowered IOP and glaucoma medication reliance at 24 months. The success rate for phaco/iStent was significantly higher than phaco/ECP. When iStent was added to phaco/ECP, the success rate was higher at earlier postoperative visits compared to the phaco/ECP alone.

Surgical outcomes of excisional goniotomy using the kahook dual blade in severe and refractory glaucoma: 12-month results.

OBJECTIVES: To describe the efficacy and safety of goniotomy with trabecular meshwork excision using the Kahook Dual Blade (KDB, New World Medical Inc., Rancho Cucamonga, CA) in patients with severe or refractory glaucoma. METHODS: This retrospective multicentre case series reports on 40 eyes with severe or refractory open-angle glaucoma that underwent standalone or combined KDB goniotomy and were followed for 12 months post-operatively in the United-States, Mexico and Switzerland. Surgical success was defined as an intraocular pressure (IOP) reduction ≥20% from baseline at 12 months, with fewer medications than preoperatively. Mean IOP and antiglaucoma medication reduction, probabilities of achieving an IOP ≤16 or 18 mmHg, and adverse events were also analysed. RESULTS: Mean IOP decreased from 18.1 ± 5.0 mmHg at baseline to 14.8 ± 3.7 mmHg at 12 months (18.2% reduction, P < 0.001). Concomitantly, the mean number of glaucoma medications decreased from 2.5 ± 1.4 to 1.7 ± 1.2 (32% reduction, P = 0.002). The proportion of eyes achieving an IOP reduction of more than 20% from baseline was 37.5% (n = 15) at 12 months. At 12 months, 67.5% and 82.5% achieved a medicated IOP ≤ 16 and ≤18 mmHg, respectively. No severe complications were reported. CONCLUSION: Excisional goniotomy with KDB achieves a statistically significant IOP and antiglaucoma medication reduction in severe or refractory glaucoma over a period of 12 months. While its efficacy decreases with time, its favourable safety profile makes it a potentially useful primary or adjunctive procedure in high-risk eyes.

Comparison of intraocular pressure readings with Perkins, Tonopen, iCare 200, and iCare Home to manometry in cadaveric eyes.

AIM: To compare intraocular pressure (IOP) readings obtained with Perkins tonometry, iCare Home, iCare 200, and Tonopen to IOP readings obtained with the manometer of a perfusion system to assess the accuracy and reproducibility of each method of tonometry at set pressures. METHODS: The IOP of human cadaveric eyes (n=2) was measured using a manometer inserted into the eye through the optic nerve. IOP measurements were obtained using a Perkins tonometer, iCare Home, iCare 200, and Tonopen. These measurements were compared to set point IOP measurements of a manometer to determine accuracy and reproducibility of each device. RESULTS: Mean IOP readings obtained with the Perkins tonometer compared to manometer readings demonstrated a difference of -1.0±5.0 mm Hg (P=0.45), indicating a lower reading on average than manometery although not significant. Mean IOP difference between iCare 200 and manometer was 5.3±2.2 mm Hg (P<0.0001). Mean difference in IOP between iCare Home and manometer was 3.5±2.4 mm Hg (P=0.0004). Mean IOP difference compared to manometer was 4.6±4.0 mm Hg for the Tonopen (P<0.0001). IOP measurements obtained with the Perkins tonometer demonstrated a standard deviation of 5.0 mm Hg while the Tonopen measurements demonstrated a 4.0 mm Hg standard deviation. In comparison, iCare 200 and iCare Home demonstrated 2.2 and 2.4 mm Hg standard deviation, respectively. CONCLUSION: Applanation tonometry produces more accurate IOP readings than rebound tonometry or Tonopen, however it demonstrates greater variability than the other forms of tonometry. Rebound tonometry is more reproducible but tends to over-estimate IOP.

Outcomes of Kahook Dual Blade Goniotomy for Uveitis Associated Open Angle Glaucoma or Ocular Hypertension.

PRCIS: Kahook Dual Blade (KDB) goniotomy can successfully lower intraocular pressure in some patients with uveitis-associated ocular hypertension or glaucoma. PURPOSE: The purpose of this study was to report a case series of patients that underwent KDB goniotomy at a single institution for uveitis-associated ocular hypertension or glaucoma with an open angle. METHODS: We performed a retrospective chart review of all patients with uveitis-associated ocular hypertension or glaucoma who underwent KDB goniotomy with trabecular meshwork excision alone or in combination with phacoemulsification cataract surgery at a single center between August 2017 and February 2020. The case series included 45 eyes of 37 patients. All eyes developed ocular hypertension refractory to maximum-tolerated medical therapy and required surgical intervention. Two eyes were excluded as they were lost to follow-up before 5 months postoperatively. Surgical success was defined as reaching the goal intraocular pressure or lower for each patient, including ongoing medical therapy. RESULTS: At most recent follow-up, 25 (55.6%) of 45 eyes had an intraocular pressure that was at goal. Mean follow-up time was 15.2±12.1 months ranging from 0.5 to 36 months postoperatively, considering that patients were eliminated from the data analysis once they required a second surgery. The mean number of preoperative medications, including oral carbonic anhydrase inhibitors was 3.7±1.2 medications. The mean number of postoperative medications through the last clinic visit was 2.5±1.9 medications for a mean reduction of 1.2±1.6 medications ( P -value <0.0001*). CONCLUSIONS: This larger case series shows that some patients with uveitis-associated ocular hypertension or glaucoma with an open angle may have success with KDB goniotomy.

Selective Laser Trabeculoplasty and Outcomes of Subsequent Phacoemulsification Combined with Kahook Dual Blade Goniotomy.

INTRODUCTION: To investigate the relationship between intraocular pressure (IOP)-lowering success of selective laser trabeculoplasty (SLT) and combined phacoemulsification/Kahook Dual Blade (phaco/KDB) goniotomy in eyes with mild to severe open angle glaucoma (OAG). METHODS: Eyes undergoing combined phaco/KDB goniotomy and that had previously undergone SLT were analyzed. Data collected included demographics, glaucoma type and severity, IOP, and topical IOP-lowering medications before and after both procedures. Eyes were divided into two groups based on success of SLT, defined as IOP reduction of at least 20% maintained on at least two consecutive follow-up visits without any subsequent medication additions or interventions. Phaco/KDB goniotomy success was defined as IOP reduction of at least 20% and/or reduction in the number of IOP-lowering medications of at least one up to 12 months of follow-up. RESULTS: Overall, SLT was successful in 20 of 43 eyes (46.5%), of which 63.6% (7/11) had successful phaco/KDB goniotomy at 12 months follow-up. Among eyes with unsuccessful SLT, 60.0% (9/15) had successful phaco/KDB at 12 months follow-up. Phaco/KDB success rate was similar in patients regardless of their previous response to SLT at all postoperative time points up to 12 months follow-up (p = 0.87). CONCLUSIONS: The presence or lack of IOP-lowering response to SLT did not influence the success rate of subsequent phaco/KDB goniotomy in eyes with mild to severe OAG. Patients who did not respond to SLT still benefited from phaco/KDB goniotomy at a later date.

Association between axial length and toric intraocular lens rotation according to an online toric back-calculator.

AIM: To assess the relationship between axial length (AL) and intraocular lens (IOL) rotation among eyes receiving a toric IOL and subsequently entered into an online toric back-calculator database. METHODS: Retrospective analysis of data collected online via astigmatismfix.com, a freely available online toric back-calculator where surgeons enter pre- and post-operative information to help manage residual postoperative astigmatism. Included records were deemed valid with entry of AL and IOL orientation between January 2017 and March 2019. Rotation was determined by a difference of ≥5° between pre-operative intended IOL orientation and actual post-operative IOL orientation. Frequency and magnitude of rotation are presented with means and associated standard deviation (SD). Linear regression models of this association are presented. RESULTS: Records of 6752 eyes were included in the analysis, of which 74.8% were determined to have a rotated IOL. The magnitude of rotation increased with each millimeter (mm) increase in AL with a mean rotation of 13.3° (SD: 12.8°) for eyes with AL 20-20.9 mm and a maximum mean rotation of 30.6° (SD: 30.3°) among eyes with AL 29-29.9 mm. General linear modeling demonstrated a significant association (P<0.0001) with a parameter estimate of 1.19 (standard error: 0.159) and R 2 of 0.0083. CONCLUSION: Analysis from an online database indicates that toric IOLs inserted into eyes with longer AL are more likely to rotate and to rotate more degrees from the target axis. The findings from this study are clinically relevant for surgeons implanting toric IOLs.

Clinical Outcomes of Ahmed ClearPath Implantation in Glaucomatous Eyes: A Novel Valveless Glaucoma Drainage Device.

PRCIS: Designed with novel features to facilitate implantation and improve safety, the Ahmed ClearPath (ACP) glaucoma drainage device (GDD) provided intraocular pressure (IOP) reduction comparable with other GDDs in eyes with refractory glaucoma in a multicenter retrospective study. PURPOSE: To present clinical outcomes with a novel valveless GDD (ACP, New World Medical). The 250 and 350 mm2 models feature a contoured plate for optimal globe apposition, anteriorized suture points to facilitate suturing to the globe, and a prethreaded 4-0 polypropylene ripcord suture. METHODS: This was a multicenter retrospective analysis of eyes with medically and/or surgically uncontrolled glaucoma implanted with the 250 or 350 mm2 ACP either as a standalone procedure or in combination with other procedures. Pre-, intra-, and postoperative data through 6 months were collected. RESULTS: A total of 104 eyes (100 subjects) received the ACP by 10 US surgeons, 63.5% of which had primary open-angle glaucoma and 62.5% had severe glaucoma. Mean baseline IOP was 26.3 (9.0) mm Hg and mean medication use was 3.9 (1.3). Through 6 months' follow-up, mean IOP ranged from 13.6 to 16.7 mm Hg and mean medication use from 0.9 to 1.9 medications (P<0.0001 at all timepoints for each outcome measure). At 6 months, mean IOP was 13.7 mm Hg (-13.0 mm Hg, 43.0%, P<0.0001) and mean medication use was 1.9 medications per eye (-2.1, 47.7%, P<0.0001). Common adverse events included anterior chamber inflammation (16.3%), hyphema (15.4%), and hypotony (6.7%). CONCLUSION: The new ACP appears to be safe and efficacious as a standalone procedure or in combination with other procedures for uncontrolled glaucoma, and may be considered as a GDD option for patients in whom its unique design may facilitate the implantation process.

Physician burnout in ophthalmology: U.S. survey.

PURPOSE: To determine the prevalence of physician burnout among ophthalmologists in the United States and identify associated risks. SETTING: All practice types within the United States. DESIGN: Cross-sectional study. METHODS: A survey was distributed through email listservs to several national ophthalmology societies. Participants completed a modified Mini Z Burnout Survey, a 10-item questionnaire measured in 5-point Likert scales, followed by demographic questions. The Mini Z Burnout survey assessed 3 main outcomes: stress, burnout, and work satisfaction. The percentage of subgroups experiencing burnout were presented and comparisons made with odds ratios from logistic regression modeling. RESULTS: Of the 592 ophthalmologists responding to the survey, 37.8% (224) self-reported symptoms of burnout with a low of 30.8% (12/39) for vitreoretinal specialists to a high of 45.4% (30/66) for uveitis specialists. Most of those reporting burnout were categorized as mild (65.2% [146/224]), followed by moderate (29.5% [66/224]) and severe (5.4% [12/224]). Women had almost twice the odds of reporting burnout (odds ratio [OR] = 1.9 [95% CI: 1.3-2.7]; P = .0005). Physicians employed in academic (OR = 2.0 [95% CI: 1.2-3.2]; P = 0.007) and hospital facilities (OR = 2.4 [95% CI: 1.3-4.6]; P = .008) reported higher rates of burnout compared with those in large private groups. Burnout was associated with self-reported low work control, insufficient time for documentation, and misalignment with departmental leaders (P < .0001). CONCLUSIONS: Ophthalmologists exhibited a high degree of self-reported burnout in the U.S. This study highlights sex, employment autonomy, and practice type as major factors associated with burnout.

The Utility of iCare HOME Tonometry for Detection of Therapy-Related Intraocular Pressure Changes in Glaucoma and Ocular Hypertension.

PURPOSE: To assess whether iCare HOME rebound tonometry can detect therapy-related changes during self-monitoring of intraocular pressure (IOP). DESIGN: Prospective clinical trial. PARTICIPANTS: A total of 43 eyes (n = 27 subjects) with open-angle glaucoma or ocular hypertension were enrolled during standard-of-care clinic visits. Participants were grouped into control eyes managed on stable therapy (n = 18 eyes) or therapy change eyes undergoing selective laser trabeculoplasty (SLT, n = 8 eyes), initiating topical therapy (n = 8 eyes), or adding a second medication to existing monotherapy (n = 9 eyes). METHODS: Subjects recorded IOP 4 times daily for 1 week using iCare HOME tonometry. Upon tonometer return, subjects underwent SLT or new medication start; an additional week of iCare HOME measurements was collected after 4 to 6 weeks. Control subjects recorded an additional week of measurements after 6 weeks. Measurements were grouped into 4 time periods (5-10 am, 10 am to 3 pm, 3-8 pm, 8 pm to 1 am). Goldmann applanation tonometry (GAT) was performed at each study visit for comparison. MAIN OUTCOME MEASURES: Detection of therapy response defined as an IOP reduction of ≥20%. RESULTS: For eyes that demonstrated a therapy response by GAT (n = 11), iCare HOME detected a therapy response in 90.9% of eyes in ≥1 time period and 45.5% of eyes in all 4 time periods. In eyes without a GAT-measured therapy response (n = 14), iCare HOME detected a response for 71.4% (n = 10) of eyes in ≥1 time period and for 7.1% of eyes (n = 1) at all 4 time periods. In treatment eyes, intraday and interday average minimum and maximum IOP, as well as interday IOP range, were significantly reduced after therapy without a significant change in intraday IOP range. Control group eyes did not demonstrate a significant change in average IOP minimum, maximum, or range between study weeks. CONCLUSIONS: Home tonometry with iCare HOME reliably detects therapy-related IOP changes in patients with glaucoma and ocular hypertension. Treatment responses correlated well with in-office GAT and may detect treatment responses missed by GAT. Intraocular pressure measurements via home tonometry provide additional clinical information regarding intraday and interday IOP fluctuation beyond standard of care in office GAT measurements. The iCare HOME is a valuable tool to monitor therapeutic efficacy in patients with glaucoma.

A Comparison of Clinical Outcomes After XEN Gel Stent and EX-PRESS Glaucoma Drainage Device Implantation.

PRECIS: Although the XEN stent offers a lower risk of hypotony and choroidal effusions with fewer clinic visits postoperatively, its surgical success rate was inferior to the EX-PRESS shunt. PURPOSE: To compare the clinical efficacy and safety outcomes of the XEN stent and EX-PRESS glaucoma drainage device in glaucomatous eyes. MATERIALS AND METHODS: One hundred eyes from 88 patients underwent ab interno XEN stent or EX-PRESS shunt implantation (52 XEN and 48 EX-PRESS) for uncontrolled glaucoma at the University of Colorado Eye Center. The primary outcome was surgical success defined as intraocular pressure (IOP) ≥6 and ≤18 mm Hg, without reoperation for uncontrolled glaucoma, loss of light perception, or use of glaucoma medications (complete success). Secondary outcomes were the same requirements allowing for medications (qualified success), mean IOP, medication use, adverse events, and number of postoperative clinic visits in the first 3 months. RESULTS: Baseline characteristics including glaucoma type and severity were similar between groups, with the exception of XEN patients having fewer men (17% vs. 46%), older patients (median age, 78 vs. 68), and a higher percentage of white patients (89% vs. 69%). Adjusted hazard ratio of failure of XEN relative to EX-PRESS was 3.94 (95% confidence interval, 1.73-9.00, P=0.001) for complete success and 1.61 (95% confidence interval, 0.40-6.38, P=0.501) for qualified success. There were significantly fewer postoperative clinic visits during the first 3 months in the XEN group (5.3 vs. 9.1 visits, P<0.001). The incidence of serous choroidal effusions and hypotony was significantly less after XEN compared with EX-PRESS (1 vs. 9, P=0.02 and 15 vs. 25, P=0.023, respectively). Three XEN stents (5.8%) required removal. CONCLUSIONS: In this population, although the XEN stent offers a better safety profile and fewer postoperative clinic visits, complete surgical success was inferior to the EX-PRESS shunt.

Iris manipulation during phacoemulsification: intraoperative and postoperative complications.

AIM: To quantify intraoperative and postoperative complications in complex phacoemulsification cataract extraction (phacoemulsification) with iris manipulation compared to non-complex and complex phacoemulsification without iris manipulation. METHODS: All phacoemulsification cases at the University of Colorado between January 1, 2014, and June 30, 2017 were included. Exclusion criteria for the primary outcome of intraoperative complications were planned combination surgery and eyes with less than 28d follow-up. Exclusion criteria for the secondary outcomes of postoperative complications were unplanned additional surgery, and chronic steroid eye drop use prior to surgery. Data including sex, race/ethnicity, surgery length, visual acuity, intraoperative and postoperative complications, and intraocular pressures (IOP) were collected and analyzed utilizing general linear and Logistic regression modeling. RESULTS: The medical records of 5772 eyes were reviewed (500 complex without iris manipulation, 367 with iris manipulation). The number of any intraoperative complication in the complex with iris manipulation and complex without iris manipulation groups was 15 (4.1%) and 26 (5.2%), respectively, compared to 41 (0.8%) in the non-complex group. Postoperative inflammation was found in 135 (2.8%) non-complex cases, 20 (4.1%) complex cases without iris manipulation, and 20 (5.6%) complex cases with iris manipulation. The adjusted odds ratio of postoperative inflammation in phacoemulsification with iris manipulation compared to non-complex was 2.3 (95%CI: 1.3-4.0, P=0.005). The rate of IOP spikes >10 mm Hg was significantly greater in cases with iris manipulation (P=0.001). CONCLUSION: Complex cases have more intraoperative complications. However, only complex cases with iris manipulation led to increase rates of postoperative inflammation and IOP spikes >10 mm Hg.

Hypotony maculopathy captured with vertical rasters on optical coherence tomography (OCT) imaging.

PURPOSE: To remind eye care providers of the importance of obtaining vertical rasters in OCT evaluation of patients with suspected hypotony maculopathy. OBSERVATIONS: OCT with vertical rasters may identify chorioretinal folds that are missed by ophthalmoscopic examination, fundus photography, and traditional OCT with horizontal rasters alone. CONCLUSIONS AND IMPORTANCE: In patients with low IOP and decreased vision, OCT imaging with horizonal and vertical rasters should be obtained to diagnose hypotony maculopathy and monitor response to treatment.

Attitudes and Perceptions Toward Virtual Health in Eye Care During Coronavirus Disease 2019.

Purpose: To evaluate attitudes and perceptions toward virtual health (VH) and its usage among eye care providers before, during, and after the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: In April and May 2020, an online survey comprised of questions regarding past and current VH practices, as well as plans for future use was distributed among eye care providers nationwide. Results: Of the 117 eye care providers who completed the survey, 96.6% were not using VH before the COVID-19 pandemic. In contrast, 77.4% reported using VH during the pandemic. The majority of visits were for red eye (64.4%, n = 56) and ocular surface complaints (58.6%, n = 51). Examination components tested virtually varied, but most respondents felt these were at least "somewhat reliable." Almost half of respondents (45%) felt it was "very easy" or "somewhat easy" to implement VH and the majority (53.8%, n = 43) were able to get it up and running in under a week. The majority felt the transition to VH was positive (57.5%), however, only 50.4% (n = 53) of those providers planned to use VH regularly once able to see patients safely in clinic again. Conclusions: While the majority of U.S. eye care providers who responded were not using VH before the COVID-19 pandemic, just months into the U.S. outbreak, 77.4% were using VH in their daily practice. In general, providers used these platforms for urgent examinations, adnexal disease, and postoperative care most often. The majority felt the transition was a positive one, however, only half planned to continue regular use of VH once the pandemic ended.

Sustained-release drug delivery systems for the treatment of glaucoma.

Glaucoma, a leading cause of irreversible blindness, affects more than 64 million people worldwide and is expected to grow in number due to the aging global population and enhanced methods of detection. Although topical therapies are often effective when used as prescribed, the drawbacks of current medical management methods include poor patient adherence, local and systemic side effects, and in some cases, limited therapeutic efficacy. Novel ocular drug delivery platforms promise to deliver differentiated drug formulations with targeted delivery leveraging patient-independent administration. Several platforms are in various stages of development with promising pre-clinical and clinical data. The Bimatoprost Sustained Release (SR) intracameral implant was approved in the United States in March of 2020, making it the first long-term injectable therapy available for the treatment of glaucoma. This review aims to provide an update on novel sustained release drug delivery systems that are available today as well as those that might be commercialized in coming years.