Evaluation of the Consistency of Glaucomatous Visual Field Defects Using a Clustered SITA-Faster Protocol.

PURPOSE: Frontloading SITA-Faster (SFR) visual fields (2 tests per eye on the same visit) has been shown to provide repeatable perimetric data at minimal time cost. This study reports the outcomes of using frontloaded SFR in the evaluation of pointwise visual field (VF) defects in a cohort of patients with glaucoma when transitioned from SITA-Standard (SS). DESIGN: Prospective, cross-sectional study. PARTICIPANTS: A total of 144 eyes of 91 patients with confirmed or suspected glaucoma who had an SS test on a previous visit. METHODS: Two SFR tests (T1, T2) per eye on the same visit. MAIN OUTCOME MEASURES: Global sensitivity, reliability indices, and pointwise deviation map probability scores from the pattern deviation grid of each patient were compared across the 3 sequential tests to evaluate the consistency of VF defects. RESULTS: The mean age was 68.6 years, and 79.2% of patients had a diagnosis of glaucoma. There was no significant difference in mean deviation (MD) across the 3 tests (-5.83 decibels [dB], -5.28 dB, and -5.71 dB in SS, SFR1, and SFR2, respectively, repeated-measures analysis of variance [ANOVA], P = 0.48). The frontloaded SFR tests provided repeatable VFs that confirmed existing pointwise data on the SS in 4661 (62.3%) locations, reversed an SS defect in 614 (8.2%) locations, and demonstrated a new repeatable defect in 406 (5.4%) locations of the pattern deviation grid. A new defect of at least 3 contiguous points was identified in 20.1% of eyes. The non-repeatable points on the 2 SFR tests displayed no significant difference in the distribution of defect/nondefect points based on test order or peripheral versus central locations. There was no significant difference in the rate of obtaining at least 1 reliable test result between SS and the frontloaded SFR T1 and T2 (P = 0.77). Test duration significantly decreased from SS to SFR1/2 (379 vs. 160 vs. 158 seconds, P < 0.0001). CONCLUSIONS: Frontloading SFR tests can provide repeatable data for the evaluation of the consistency of pattern deviation defects in glaucoma, with no observable decline in performance from test fatigue. This is achieved at equivalent duration and reliability as a single SS test. Frontloading SFR may be helpful in increasing testing frequency/quantity to meet recommended guidelines for progression analysis. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Glaucoma Suspects: The Impact of Risk Factor-Driven Review Periods on Clinical Load, Diagnoses, and Healthcare Costs.

PURPOSE: To model the healthcare impact (clinical attendance time and financial cost) and clinical outcomes (glaucoma diagnoses) of different risk factor-driven review frequencies for glaucoma suspect patients up until the point of discharge or diagnosis. METHODS: Medical records of 494 glaucoma suspects were examined to extract the clinical diagnosis. Two criteria for review periods were defined, based on contrasting stringency from established clinical guidelines: American Academy of Ophthalmology (AAO), more stringent/less frequent; and the Australian National Health and Medical Research Council (NHMRC), less stringent/more frequent. We used these data to model patient outcomes and healthcare costs using a Markov model. RESULTS: The less stringent/more frequent criterion resulted in more high-risk glaucoma suspects requiring more frequent review compared with the more stringent/less frequent criterion. Across the 15 Markov cycles (7.5 years), the less stringent/more frequent review criterion resulted in 6.6% more diagnoses and fewer overall clinical visits (14.7%) and reduced cost per diagnosis by 12% to 32% (P < 0.0001). The number of glaucoma diagnoses made using each criterion converged at 2.5 to 3 years. CONCLUSIONS: The stringency of risk assessments for glaucoma suspects impacts review periods and therefore clinical load, healthcare costs, and diagnosis rates. Using current testing methods, more frequent review periods appear advantageous for diagnostic efficiency, with both lower clinic load and lower cost up until the point of discharge or glaucoma diagnosis. TRANSLATIONAL RELEVANCE: A less stringent criterion for assessing the risk of developing glaucoma potentially offers a more cost-effective method for reviewing glaucoma suspects, especially within the first 2.5 years.

Deployment of the Water Drinking Test and iCare HOME Phasing for Intraocular Pressure Profiling in Glaucoma Evaluation.

SIGNIFICANCE: Intraocular pressure (IOP) profiling is an important component of the glaucoma examination. Two techniques for profiling are the water drinking test (WDT) and iCare HOME phasing, but the correlations between techniques and their ease of deployment have not been studied. These questions are important in determining suitability for clinical deployment. PURPOSE: This study aimed to compare the IOP results of the WDT and iCare HOME phasing in patients with suspected or newly diagnosed glaucoma. METHODS: Ninety-eight consecutive patients attending a glaucoma clinic underwent IOP profiling using both techniques. For the WDT, patients ingested 10 mL/kg body weight of water after a baseline applanation IOP measurement and then underwent serial IOP measurements approximately every 15 minutes, ceasing after 30 minutes of consecutive measurements within 3 mmHg of baseline. Patients successfully certified for self-administration of the iCare HOME were loaned the instrument for 1 week and instructed to take four measurements per day. RESULTS: Twenty-seven patients (28%) successfully obtained four measurements per day using iCare HOME, and 96 patients (98%) were able to complete the WDT. Intraocular pressure profiles showed no difference between the time for peak IOP and across nearly all IOP parameters obtained from profiling except for the standard deviation of IOP measurements obtained using the iCare HOME (P = .005). There were moderate correlations between peak IOPs obtained using each technique (r = 0.67, P = .001, right eye; r = 0.66, P = .002, left eye) but no correlation between the daily range (iCare HOME) or peak-trough difference (WDT; r = 0.21, P = .28, right eye; r = 0.27, P = .02, left eye). Bland-Altman analysis returned similar results for peak and range. CONCLUSIONS: Intraocular pressure profiling using both techniques can reveal the peak IOP, and these measurements are strongly correlated. Most patients were unable to complete the iCare HOME according to the manufacturer's recommendations. Clinicians should select the most appropriate technique for each patient.

Headaches related to latanoprost in open-angle glaucoma.

Clinical relevance: The existing notion that topical latanoprost can lead to symptoms of headaches by reporting three cases of headache symptoms that developed following instillation of latanoprost prescribed as first-line therapy for newly diagnosed primary open-angle glaucoma (POAG) is explored in this case series.Background: Prostaglandin analogues (PGAs) are often used as first-line treatment in the treatment of POAG. An uncommon and infrequently reported side effect of PGAs is headaches.Methods: A retrospective review of patient records was conducted on patients seen at the Centre for Eye Health between April 2016 and August 2017. Clinical findings, including outcomes following interventions such a punctal occlusion, as well as the proposed pharmacological mechanism underlying this phenomenon are presented and discussed.Results: Case 1 is a 62-year-old Caucasian male diagnosed with POAG and prescribed latanoprost in both eyes. At the follow-up visit, he reported waking up in with a dull throbbing headache following instillation of the eye drops the night before. Case 2 is a 58-year-old Asian male with POAG prescribed latanoprost to both eyes. Within a week, he developed symptoms of recurrent progressively worsening headaches post-instillation which persisted into the morning. Case 3 is a 75-year-old Caucasian male with POAG prescribed latanoprost for both eyes. He developed latanoprost sensitivity as well as headache symptoms associated with the eye drops which resolved followed its cessation. All patients reported initial symptoms of headaches associated with latanoprost use however the headaches were not persistent with intermittent punctal occlusion (cases 1 and 2) or intra-class drug rechallenge (case 3).Conclusion: Although there may be a yet-undiscovered link between a headache response and latanoprost, these cases call to question the pharmacological relationship between latanoprost and headache symptoms. A systemic approach to critically examine the pathophysiological link between pharmacological therapy and potential adverse effects is proposed.

Management of open-angle glaucoma by primary eye-care practitioners: toward a personalised medicine approach.

Glaucoma is the leading cause of irreversible blindness worldwide. As a chronic disease, glaucoma presents a significant burden to the individual, health-care provider and the health-care system. Currently, strategies for treating glaucoma are focused on lowering intraocular pressure, which is aimed at slowing or arresting disease progression over time. This is the only current accepted therapeutic strategy for glaucoma, and can be achieved using topical drugs, laser trabeculoplasty, filtration surgery or cyclodestructive techniques. The lowering of intraocular pressure has been well-supported by numerous large-scale seminal clinical trials in primary open-angle glaucoma, in both its early and advanced stages. Although such guidance remains current, in the last 10-years, there has been a significant evolution in preferred first-line therapies in the treatment of open-angle glaucoma with a resultant shift in practice patterns, particularly early in the course of the disease. These changes reflect both from the perspective of the doctor - in titrating the most effective and least risky treatment modality - and the perspective of the patient, in consenting to a treatment that preserves vision and results in minimal negative impact on quality of life. In this review, the most recent evidence regarding treatment modalities for early primary open-angle glaucoma is presented and an updated framework for management guidance is proposed.

Glaucoma Community Care: Does Ongoing Shared Care Work?

PURPOSE: We assessed a novel, public, vertical integrated care model for glaucoma management in the community. METHODS: This study was a retrospective, longitudinal study of 266 patients diagnosed or suspected of glaucoma. Patients were stratified to either ongoing ophthalmology-led (n = 81) or optometry-led shared care (n = 185). Demographics and clinical characteristics, including the re-referral rate and timeliness of follow up were analysed. RESULTS: Just under half (565/1224, 46%) of all follow up consultations over the total study period of 45 months were seen in optometry-led care, with a re-referral rate to ophthalmology of 21%. Treated patients showed a median intraocular pressure reduction of 20% and a median time delay of just two days between the actual and recommended review period. CONCLUSIONS: Shared care provides an effective option for managing the ongoing care burden in chronic stable glaucoma cases at low risk of vision loss.

Impact of referral refinement on management of glaucoma suspects in Australia.

BACKGROUND: In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia. METHODS: Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated. RESULTS: Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ2 test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001). CONCLUSION: Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists.

SIGNIFICANCE: In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE: The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS: The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS: Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS: Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.

Seeing the difference-Painless progressive vision loss in a vasculopath.

A 78-year-old Caucasian man with significant vascular disease reported sudden onset of worsened vision during a routine wound-care appointment for nonhealing necrotic leg ulcers. He described painless blurring of vision with grey scotomas in his right eye, his only well-seeing eye, after trauma to the left eye as a child. He presented with retinal ischemia, a cotton wool spot, and optic nerve swelling. Temporal artery biopsy showed myxoid degeneration and extensive calcium deposition, which also was present on imaging throughout his carotid and vertebral arterial system-the clinical picture of calciphylaxis.

Consistency of Structure-Function Correlation Between Spatially Scaled Visual Field Stimuli and In Vivo OCT Ganglion Cell Counts.

Purpose: To investigate the effect of stimulus size and disease status on the structure-function relationship within the central retina, we correlated the differential light sensitivity (DLS) with Goldmann stimulus size I to V (GI-V) and optical coherence tomography (OCT) derived in vivo ganglion cell count per stimulus area (GCc) within the macular area in normal subjects and patients with early glaucoma. Methods: Humphrey Field Analyzer 10-2 visual field data with GI through V and Spectralis OCT macular ganglion cell layer (GCL) thickness measurements were collected from normal and early glaucoma cohorts including 25 subjects each. GCc was calculated from GCL thickness data and correlated with DLSs for different stimulus sizes. Results: Correlation coefficients attained with smaller stimulus size were higher compared to larger stimulus sizes in both normal (GI-GII: R2 = 0.41-0.43, GIII-GV: R2 = 0.16-0.41) and diseased cohorts (GI-GII: R2 = 0.33-0.41, GIII-GV: R2 = 0.19-0.36). Quadratic regression curves for combined GI to V data demonstrated high correlation (R2= 0.82-0.90) and differed less than 1 dB of visual sensitivity within the GCc range between cohorts. The established structure-function relationship was compatible with a histologically derived model correlation spanning the range predicted by stimulus sizes GI to GIII. Conclusions: Stimulus sizes within critical spatial summation area (GI-II) improved structure-function correlations in the central visual field. The structure-function relationship was identical in both normal and diseased cohort when GI to GV data were combined. Congruency of GI and GII structure-function correlation with those previously derived with GIII from more peripheral locations further suggests that the structure-function relationship is governed by the number of ganglion cell per stimulus area.

Microwash or macrowash technique to maintain a clear cornea during cataract surgery.

We describe a technique of irrigating and thereby rapidly and effectively clearing the cornea of relatively large amounts of surface contaminants that reduce surgical visibility and may contribute to endophthalmitis. This technique is referred to as "macrowash." If the technique is required, it is usually at the commencement of cataract surgery, immediately after placement of the surgical drape. The technique not only saves time, but also reduces the volume of irrigating solution required by the "microwash" technique, which is traditionally carried out by the scrub nurse/surgical assistant using a Rycroft cannula attached to a 15 mL container of irrigating solution.

Laser corneal biofilm disruption for infectious crystalline keratopathy.

Crystalline keratopathy can be successfully treated by the Nd:YAG laser. We present two cases of crystalline keratopathy managed this way. A 36-year-old female contact lens wearer presented with crystalline keratopathy following recent treatment with topical steroids and antibiotics for a corneal abscess. In this case crystalline keratopathy developed despite the intensive topical antibiotic treatment. A 55-year-old man with a history of acne rosacea, chronic myelomonocytic leukaemia, asthma and Crohn's disease presented with crystalline keratopathy following an episode of infectious keratitis. Treatment with the Nd:YAG laser to the area of involvement was instituted in both cases. Noticeable resolution occurred within days, with subsequent full recovery. No side-effects from the use of the Nd:YAG laser were noted. There have been only two cases previously reported using this treatment modality.

Corneal indentation in the early management of acute angle closure.

PURPOSE: To describe in detail corneal indentation (CI) in the management of a series of patients treated for acute angle closure (AAC). DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: Seven consecutive patients (8 eyes) referred to the authors with the diagnosis of AAC. Patients presented to the Prince of Wales Hospital, Randwick, or to the private practices of the authors. INTERVENTION: Seven patients (8 eyes) underwent CI as part of their early management for AAC. MAIN OUTCOME MEASURES: Reduction in intraocular pressure (IOP), symptoms of AAC and pain relief. RESULTS: Of the 7 patients, complete data were available for 6. The IOP was significantly reduced (P<0.05) and 3 of 4 patients with severe acute pain reported early resolution of pain after CI. The average reduction in IOP was 20.9 mmHg (range +1 to -45). All patients subsequently underwent definitive management with laser peripheral iridotomies or lensectomy using phacoemulsification. Three patients treated acutely with CI without any medical agents had a mean IOP reduction of 21 mmHg (range, 20-23) after indentation. CONCLUSIONS: Corneal indentation is a rapid, portable, and effective method of reducing elevated IOP in the setting of AAC. It can be performed with instrumentation that is readily at hand and allows for rapid pain relief. This reduction in IOP improves corneal clarity and permits further definitive management of the patient with AAC. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.