Michael V. Boland

Choroidal Thickness Measured by Spectral Domain Optical Coherence Tomography: Factors Affecting Thickness in Glaucoma Patients

PURPOSE To measure choroidal thickness and to determine parameters associated with it. DESIGN Cross-sectional study. PARTICIPANTS Seventy-four glaucoma patients and glaucoma suspects. METHODS Spectral domain optical coherence tomography (SD-OCT) scans were obtained to estimate average choroidal thickness in a group of glaucoma suspects and glaucoma patients. The average thickness was calculated from enhanced depth SD-OCT images and manually analyzed with Image J software. Open-angle glaucoma, open-angle glaucoma suspect, primary angle-closure glaucoma, primary angle closure, and primary angle-closure suspect were defined by published criteria. Glaucoma suspects had normal visual fields bilaterally. Glaucoma was defined by specific criteria for optic disc damage and visual field loss in ≥1 eye. The most affected eye was analyzed for comparisons across individuals, and right/left and upper half/lower half comparisons were made to compare thickness against degree of visual field damage. MAIN OUTCOME MEASURES Average macular and peripapillary choroidal thickness measured using SD-OCT. RESULTS The choroidal-scleral interface was visualized in 86% and 96% of the macular and peripapillary scans, respectively. In multivariable linear regression analysis, the macular choroid was significantly thinner in association with 4 features: Longer eyes (22 μm per mm longer [95% confidence interval (CI), -33, -11]), older individuals (31 μm thinner per decade older [95% CI, -44, -17]), lower diastolic ocular perfusion pressure (26 μm thinner per 10 mmHg lower [95% CI, 8, 44]), and thicker central corneas (6 μm per 10 μm thicker cornea [95% CI, -10, 0]). The choroid was not significantly thinner in glaucoma patients than in suspects (14 μm [95% CI, -54, 26]; P = 0.5). Peripapillary choroidal thickness was not significantly different between glaucoma and suspect patients. Thickness was not associated with damage severity as estimated by visual field mean deviation or nerve fiber layer thickness, including comparisons of right with left eye or upper with lower values. CONCLUSIONS Age, axial length, CCT, and diastolic ocular perfusion pressure are significantly associated with choroidal thickness in glaucoma suspects and glaucoma patients. Degree of glaucoma damage was not consistently associated with choroidal thickness. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Comparative effectiveness of treatments for open-angle glaucoma: A systematic review for the U.S. preventive services task force

BACKGROUND Glaucoma is an acquired degeneration of the optic nerve and a leading cause of blindness worldwide. Medical and surgical treatments that decrease intraocular pressure may prevent visual impairment and blindness. PURPOSE To compare the effectiveness of medical, laser, and surgical treatments in adults with open-angle glaucoma with regard to decreasing intraocular pressure and preventing optic nerve damage, vision loss, and visual impairment. DATA SOURCES MEDLINE, CENTRAL, and an existing database for systematic reviews (through 2 March 2011); MEDLINE, EMBASE, LILACS, and CENTRAL for primary studies (through 30 July 2012). STUDY SELECTION English-language systematic reviews; randomized, controlled trials; and quasi-randomized, controlled trials for most outcomes and observational studies for quality of life and harms. DATA EXTRACTION Two investigators abstracted or checked information about study design, participants, and outcomes and assessed risk of bias and strength of evidence. DATA SYNTHESIS High-level evidence suggests that medical, laser, and surgical treatments decrease intraocular pressure and that medical treatment and trabeculectomy reduce the risk for optic nerve damage and visual field loss compared with no treatment. The direct effect of treatments on visual impairment and the comparative efficacy of different treatments are not clear. Harms of medical treatment are primarily local (ocular redness, irritation); surgical treatment carries a small risk for more serious complications. LIMITATION Heterogeneous outcome definitions and measurements among the included studies; exclusion of many treatment studies that did not stratify results by glaucoma type. CONCLUSION Medical and surgical treatments for open-angle glaucoma lower intraocular pressure and reduce the risk for optic nerve damage over the short to medium term. Which treatments best prevent visual disability and improve patient-reported outcomes is unclear.

Adoption and Perceptions of Electronic Health Record Systems by Ophthalmologists: An American Academy of Ophthalmology Survey

OBJECTIVE To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate and user satisfaction. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 592 members of the American Academy of Ophthalmology (AAO) participated. METHODS A total of 3796 AAO members were randomly selected on the basis of geography and solicited to participate in a study of EHR adoption. Among those solicited, 392 members completed a web-based version of the survey and 200 members completed a telephone-based version. The survey included sections assessing the current level of EHR adoption, the value of various EHR features, the practice demographics, and, for participants with an EHR, the details of their system. Responses were collected and analyzed using univariate statistical tests. MAIN OUTCOME MEASURES Current adoption rate of EHRs, user satisfaction with EHRs, and importance of various EHR features to both users and nonusers. RESULTS Overall, 12% of the practices surveyed had already implemented an EHR, 7% were in the process of doing so, and another 10% had plans to do so within 12 months. Both EHR users and nonusers rated the same EHR features as having the most value to their practices, and the 2 groups rated options for simplifying the EHR selection process similarly. Among those with an EHR in their practice, 69% were satisfied or extremely satisfied with their system, 64% reported increased or stable overall productivity, 51% reported decreased or stable overall costs, and 76% would recommend an EHR to a fellow ophthalmologist. CONCLUSIONS The adoption rate of EHRs by ophthalmology practices is low but comparable to that seen in other specialties. The satisfaction of those ophthalmologists already using an EHR is high. Because EHRs are part of the rapidly changing health information technology marketplace, the AAO Medical Information Technology Committee is planning to update these results on a regular basis.

Optic disc morphology in open-angle glaucoma compared with anterior ischemic optic neuropathies.

Purpose. To compare optic disc topography performed by confocal laser ophthalmoscopy in eyes with nonarteritic anterior ischemic optic neuropathy (NAION), arteritic anterior ischemic optic neuropathy (AAION), and open-angle glaucoma (OAG), adjusting for the amount of retinal ganglion cell (RGC) loss, as measured by nerve fiber layer (NFL) thickness and average visual field loss. Methods. At four referral centers, patients who met specific diagnostic criteria for OAG (103 persons, 152 eyes), NAION (53 persons, 57 eyes), or AAION (18 persons, 20 eyes) underwent Heidelberg Retinal Tomography (HRT; Heidelberg Engineering, Heidelberg, Germany), Stratus Optical Coherence Tomography (OCT; Carl Zeiss Meditec, Inc., Dublin, CA), and Humphrey visual field testing (HFA; Carl Zeiss Meditec, Inc.). HRT parameters were compared in univariate and multivariate models, accounting for degree of RGC loss by either OCT NFL thickness or visual field mean deviation (MD). Acute AION occurred at least 6 weeks before testing. Results. After adjustment for degree of injury according to either MD or mean NFL thickness, all HRT parameters were significantly different between OAG and both NAION and AAION. With similar damage, OAG eyes had larger, deeper cups; smaller rims; more cup volume; and less rim volume (all P < or = 0.001). There were differences in disc topography between NAION and AAION, but they were not consistent for both measures of damage. Disc area and MD were also significantly associated with many HRT parameters. NFL thickness was greater at the same MD for both AAION and NAION compared with OAG. Conclusions. NAION and AAION cause loss of RGCs, but have significantly different disc topography compared with OAG at a given level of RGC loss.

Special Requirements for Electronic Health Record Systems in Ophthalmology

UNLABELLED The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management. This has important implications for the design of electronic health record (EHR) systems that can be used intuitively and efficiently by ophthalmologists and that can promote improved quality of care. Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists. The purpose of this article is to summarize the special requirements of EHRs that are important for ophthalmology. The hope is that this will help ophthalmologists to identify important features when searching for EHR systems, to stimulate vendors to recognize and incorporate these functions into systems, and to assist federal agencies to develop future guidelines regarding meaningful use of EHRs. More broadly, the American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk, and ultimately will improve the ability of physicians to deliver the highest-quality medical care. FINANCIAL DISCLOSURE(S) Proprietary or commercial interest disclosure may be found after the references.

The relationship between better-eye and integrated visual field mean deviation and visual disability.

OBJECTIVE To determine the extent of difference between better-eye visual field (VF) mean deviation (MD) and integrated VF (IVF) MD among Salisbury Eye Evaluation (SEE) subjects and a larger group of glaucoma clinic subjects and to assess how those measures relate to objective and subjective measures of ability/performance in SEE subjects. DESIGN Retrospective analysis of population- and clinic-based samples of adults. PARTICIPANTS A total of 490 SEE and 7053 glaucoma clinic subjects with VF loss (MD ≤-3 decibels [dB] in at least 1 eye). METHODS Visual field testing was performed in each eye, and IVF MD was calculated. Differences between better-eye and IVF MD were calculated for SEE and clinic-based subjects. In SEE subjects with VF loss, models were constructed to compare the relative impact of better-eye and IVF MD on driving habits, mobility, self-reported vision-related function, and reading speed. MAIN OUTCOME MEASURES Difference between better-eye and IVF MD and relationship of better-eye and IVF MD with performance measures. RESULTS The median difference between better-eye and IVF MD was 0.41 dB (interquartile range [IQR], -0.21 to 1.04 dB) and 0.72 dB (IQR, 0.04-1.45 dB) for SEE subjects and clinic-based patients with glaucoma, respectively, with differences of ≥ 2 dB between the 2 MDs observed in 9% and 18% of the groups, respectively. Among SEE subjects with VF loss, both MDs demonstrated similar associations with multiple ability and performance metrics as judged by the presence/absence of a statistically significant association between the MD and the metric, the magnitude of observed associations (odds ratios, rate ratios, or regression coefficients associated with 5-dB decrements in MD), and the extent of variability in the metric explained by the model (R(2)). Similar associations of similar magnitude also were noted for the subgroup of subjects with glaucoma and subjects in whom better-eye and IVF MD differed by ≥ 2 dB. CONCLUSIONS The IVF MD rarely differs from better-eye MD, and similar associations between VF loss and visual disability are obtained using either MD. Unlike better-eye MD, IVF measurements require extra software/calculation. As such, information from studies using better-eye MD can be more easily integrated into clinical decision-making, making better-eye MD a robust and meaningful method for reporting VF loss severity.

Automated Telecommunication-Based Reminders and Adherence With Once-Daily Glaucoma Medication Dosing: The Automated Dosing Reminder Study

IMPORTANCE Topical glaucoma medications lower intraocular pressure and alter the course of the disease. Because adherence with glaucoma medications is a known problem, interventions are needed to help those patients who do not take their medications as prescribed. OBJECTIVE To assess the ability of an automated telecommunication-based intervention to improve adherence with glaucoma medications. DESIGN, SETTING, AND PARTICIPANTS We performed a prospective cohort study of medication adherence, followed by a randomized intervention for those found to be nonadherent, of individuals recruited from a university-based glaucoma subspecialty clinic. A total of 491 participants were enrolled in the initial assessment of adherence. Of those, 70 were nonadherent with their medications after 3 months of electronic monitoring and randomized to intervention and control groups. INTERVENTIONS A personal health record was used to store the list of patient medications and reminder preferences. On the basis of those data, participants randomized to the intervention received daily messages, either text or voice, reminding them to take their medication. Participants randomized to the control group received usual care. MAIN OUTCOMES AND MEASURES Difference in adherence before and after initiation of the intervention. RESULTS Using an intent-to-treat analysis, we found that the median adherence rate in the 38 participants randomized to the intervention increased from 53% to 64% (P < .05). There was no statistical change in 32 participants in the control group. To assess the real efficacy of the intervention, the same comparison was performed for the participants who successfully completed the study after randomization. Analyzed this way, the adherence rate in the 20 participants in the intervention group increased from 54% to 73% (P < .05), whereas there was again no statistical change in the 19 participants in the control group. Eighty-four percent of the participants who received reminders agreed they were helpful and would continue using them outside the study. CONCLUSIONS AND RELEVANCE Automated telecommunication-based reminders linked to data in a personal health record improved adherence with once-daily glaucoma medications. This is an effective method to improve adherence that could realistically be implemented in ophthalmology practices with a minimum amount of effort on the part of the practice or the patient.

Adoption of Electronic Health Records and Preparations for Demonstrating Meaningful Use: An American Academy of Ophthalmology Survey

OBJECTIVE To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate, user satisfaction, functionality, benefits, barriers, and knowledge of meaningful use criteria. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 492 members of the American Academy of Ophthalmology (AAO). METHODS A random sample of 1500 AAO members were selected on the basis of their practice location and solicited to participate in a study of EHR use, practice management, and image management system use. Participants completed the survey via the Internet, phone, or fax. The survey included questions about the adoption of EHRs, available functionality, benefits, barriers, satisfaction, and understanding of meaningful use criteria and health information technology concepts. MAIN OUTCOME MEASURES Current adoption rate of EHRs, user satisfaction, benefits and barriers, and availability of EHR functionality. RESULTS Overall, 32% of the practices surveyed had already implemented an EHR, 15% had implemented an EHR for some of their physicians or were in the process of implementation, and another 31% had plans to do so within 2 years. Among those with an EHR in their practice, 49% were satisfied or extremely satisfied with their system, 42% reported increased or stable overall productivity, 19% reported decreased or stable overall costs, and 55% would recommend an EHR to a fellow ophthalmologist. For those with an electronic image management system, only 15% had all devices integrated, 33% had images directly uploaded into their system, and 12% had electronic association of patient demographics with the image. CONCLUSIONS The adoption of EHRs by ophthalmology practices more than doubled from 2007 to 2011. The satisfaction of ophthalmologists with their EHR and their perception of beneficial effects on productivity and costs were all lower in 2011 than in 2007. Knowledge about meaningful use is high, but the percentage of physicians actually receiving incentive payments is relatively low. Given the importance of imaging in ophthalmology, the shortcomings in current image management systems need to be addressed. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Accuracy of Pupil Assessment for the Detection of Glaucoma: A Systematic Review and Meta-analysis

OBJECTIVE To assess the accuracy of using pupillary light reflex (PLR) in detecting glaucoma. CLINICAL RELEVANCE Glaucoma is a specific disease of the optic nerve and is often more severe in 1 eye. When large enough, this asymmetry in disease severity can cause a relative afferent pupillary defect (RAPD). Better detection of RAPDs may be one way to identify persons with glaucoma. METHODS We searched Medline and Embase through June 2012 and searched bibliographies for relevant studies for additional references. Two authors independently reviewed all articles and selected studies that assessed PLRs in patients with glaucoma. We analyzed data using mixed-effect bivariate summary receiver operating characteristic meta-analysis models. RESULTS A total of 30 studies were included in this review. An RAPD was observed in 9% to 82% of patients with glaucoma. Eleven studies with a total of 7271 participants were included in the analysis, and the pooled estimate corresponded to a sensitivity of 0.63 (95% confidence interval [CI], 0.43-0.80) and a specificity of 0.93 (95% CI, 0.85-0.97). After excluding 2 studies that used the swinging flashlight test, the sensitivity increased to 0.74 (95% CI, 0.59-0.85) with a specificity of 0.85 (95% CI, 0.77-0.90). Study designs and different pupil measurement techniques explained part of the heterogeneity between studies. CONCLUSIONS Patients with glaucoma frequently have an abnormal PLR and comparing the responses between the 2 eyes can in part distinguish between those with glaucoma and those without the disease. Newer instruments and analytic approaches to assess pupil function may improve the performance of pupil screening.

Symmetry of the pupillary light reflex and its relationship to retinal nerve fiber layer thickness and visual field defect

PURPOSE To assess the relationship between the pupillary light reflex (PLR) and visual field (VF) mean deviation (MD) and retinal nerve fiber layer (RNFL) thickness. METHODS A total of 148 patients with glaucoma (mean age 67 ± 11, 49% female) and 71 controls (mean age 60 ± 10, 69% female) were included in this study. Using a pupillometer, we recorded and analyzed pupillary responses at varied stimulus patterns (full field, superonasal and inferonasal quadrant arcs). We compared the responses between the two eyes, compared responses to stimuli in the superonasal and inferonasal fields within each eye, and calculated the absolute PLR value of each individual eye. We assessed the relationship among PLR, MD, and RNFL thickness using the Pearson correlation coefficient. For analyses performed at the level of individual eyes, we used multilevel modeling to account for between-eye correlations within individuals. RESULTS For every 0.3 log unit difference in between-eye asymmetry of PLR, there was an average 2.6-dB difference in visual field MD (correlation coefficient R = 0.83, P < 0.001) and a 3.2-μm difference in RNFL thickness between the two eyes (R = 0.67, P < 0.001). Greater VF damage and thinner RNFL for each individual eye were associated with smaller response amplitude, slower velocity, and longer time to peak constriction and dilation after adjusting for age and sex (all P < 0.001). However, within-eye asymmetry of PLR between superonasal and inferonasal stimulation was not associated with corresponding within-eye differences in VF or RNFL. CONCLUSIONS As measured by this particular device, the PLR is strongly correlated with VF functional testing and measurements of RNFL thickness.