Varshini Varadaraj

Autorefraction-Based Prescription and Mailed Delivery of Eyeglasses

In the United States, approximately 8.2 million people older than 40 years of age have visual impairment resulting from uncorrected refractive error (RE). Subjective refraction (SR) performed by a licensed eye care professional remains the gold standard for correcting RE. However, trained experts often are expensive and underused by poorer populations. Difficulties with transportation, affordability, and coverage gaps are considerable barriers to accessing eye care services among disadvantaged individuals with visual impairment. Given that modern autorefractors provide an efficient and reliable objective measure of RE, autorefraction-based prescription of eyeglasses could reduce barriers to eye care access. The Screening to Prevent Glaucoma scheme is an ongoing community-based program aimed at streamlining screening approaches for glaucoma and other eye diseases in underserved populations in Baltimore. As part of the screening algorithm, participants undergo vision testing and autorefraction. Herein, we report the outcome of providing spectacles based on autorefraction results. Screening Eye Examination. Eye examinations performed by trained screeners included assessment of presenting visual acuity (VA), fundus photography, visual field assessment, and measurement of intraocular pressure. Presenting VA was tested using an iPod application (iPoD touch; Apple Inc., Cupertino, CA; developed by Manu Lakkur, based in San Francisco, CA), and if found to be worse than 20/40 in at least 1 eye, participants underwent autorefraction in both eyes using a Topcon KR800S autorefractor (Topcon Medical Systems, Inc., Oakland, CA). Objective refraction measurements were obtained for each eye, followed by machine-corrected VA measurements where the smallest line with 3 of 5 characters read correctly was considered the best-corrected VA. Autorefraction-Based Eyeglass Prescription. After an initial feasibility study, which demonstrated that autorefractiongenerated refractions were highly accurate compared with SRs, stringent eligibility criteria (Table S1, available at www.aaojournal.org) were developed and used from December 2015 through September 2016 to provide prescription glasses to individuals whose only vision problem identified on screening was RE. Participants demonstrating improvement with autorefraction to at least 20/30 could choose between receiving free corrective eyeglasses via mail or attending a free eye examination at Wilmer Eye Institute, Baltimore, Maryland (including free eyeglasses). Of 58 participants who were eligible for this study, 55 participants (94.8%) opted to receive autorefraction-based mail-in eyeglasses and 3 participants (0.05%) opted for an in-person eye examination at Wilmer Eye Institute. Mean age was 61.7 years (standard deviation [SD], 8.1 years), approximately half were women (52.7%), and most were black (92.7%). Based on autorefraction, mean right eye spherical equivalent, J0, and J45 were 0.23 diopters (D; SD, 1.86 D), 0.17 D (SD, 0.51 D), and 0.04 D (SD, 0.33 D), respectively. After correction of RE, subjective VA in the right eye obtained from autorefraction improved to 20/20 or better in 36 participants (65.5%), 20/25 in 12 participants (21.8%), and 20/30 in 7 participants (12.7%). Participants were provided plastic and metal frames to choose from. Given a choice, 36 participants (65.5%) chose to receive single-vision lenses and 19 participants (32.5%) preferred bifocals. Progressives were not offered. For participants requesting bifocals, segment heights were measured and they were prescribed near reading power measurements using a standard age nomogram. Interpupillary distance was measured using a digital pupillometer (Gizmo Supply Co., Fountain Valley, CA). Glasses were prepared at Wilmer Eye Institute and mailed to participants along with a survey designed to capture satisfaction with the autorefraction-based mail-in eyeglasses (Table S2, available at www.aaojournal.org). Participants were asked to test the new glasses for 2 weeks before answering and returning the satisfaction survey via mail. Thirty-nine of 55 participants (71%) returned satisfaction surveys. Nonrespondents (n 1⁄4 16) did not differ significantly from respondents in terms of age, race, or gender (P > 0.05 for all, t test). Thirty-three of 39 participants (85%) were extremely satisfied and 36 of 39 participants (92%) were extremely or moderately satisfied with the mailed eyeglasses (Table 3). The only participant who stated that she did not feel like autorefractionbased glasses improved her vision reported being unhappy with the lined bifocals that she had chosen and believed that she might have instead chosen single-vision glasses if she had had a chance to try them on at a clinic first. Participants who were dissatisfied or neutral did not differ from those who were satisfied in terms of presenting visual acuity, VA after autorefraction, or spherical equivalent (P > 0.05 for all, t test). This positive response to autorefraction-based spectacles and participants’ preference for this method of delivery suggest that this model could help to reduce the burden of uncorrected RE. There exists a pattern of underuse of eye care among low-income and minority populations. In a previous community-based eye screening study conducted in Baltimore, only 41% of participants scheduled for a definitive eye examination attended the visit, despite being offered free examinations and transportation. Although we recognize that SR is the gold standard for RE correction, our model of community screenings coupled with autorefraction-based mailed spectacles has the potential to reach those not seeking care. Our study did use strict eligibility criteria. In particular, all participants had to have spherical power between 6.00 andþ2.00 D and astigmatism of less than þ2.75 D, so our results cannot be generalized to those with higher RE. Likewise, our approach applies

International Medical Graduates—A Critical Component of the Global Health Workforce

Every year, thousands of applicants prepare their applications for residency in the United States, including candidates from medical schools outside the country. According to the Educational Commission on Foreign Medical Graduates, 12 355 international medical graduates (IMGs) participated in the 2017 US match (7284 [59%] of whom were not US citizens); of the latter group, 3814 (52.4%) were offered first-year positions, accounting for 13.2% of all awarded positions in the match.1 IMGs have faced a challenging year, with some affected by various iterations of a travel ban and further concerns related to H1-B visa restrictions. This is unfortunate, particularly when considering that IMGs provide care in many of the nation’s poorest and most rural communities. For decades, immigration of IMGs into the United States has been caught between increasing US demands for physicians and concerns that migration could exacerbate staff shortages in the home countries of these physicians. The latter concern has led to policies such as the Global Code of Practice on the Recruitment of Health Personnel (unanimously passed by

Comparison of self-refraction using a simple device, USee, with manifest refraction in adults

Background The USee device is a new self-refraction tool that allows users to determine their own refractive error. We evaluated the ease of use of USee in adults, and compared the refractive error correction achieved with USee to clinical manifest refraction. Methods Sixty adults with uncorrected visual acuity <20/30 and spherical equivalent between –6.00 and +6.00 diopters completed manifest refraction and self-refraction. Results Subjects had a mean (±SD) age of 53.1 (±18.6) years, and 27 (45.0%) were male. Mean (±SD) spherical equivalent measured by manifest refraction and self-refraction were –0.90 D (±2.53) and –1.22 diopters (±2.42), respectively (p = 0.001). The proportion of subjects correctable to ≥20/30 in the better eye was higher for manifest refraction (96.7%) than self-refraction (83.3%, p = 0.005). Failure to achieve visual acuity ≥20/30 with self-refraction in right eyes was associated with increasing age (per year, OR: 1.05; 95% CI: 1.00–1.10) and higher cylindrical power (per diopter, OR: 7.26; 95% CI: 1.88–28.1). Subjectively, 95% of participants thought USee was easy to use, 85% thought self-refraction correction was better than being uncorrected, 57% thought vision with self-refraction correction was similar to their current corrective lenses, and 53% rated their vision as “very good” or “excellent” with self-refraction. Conclusion Self-refraction provides acceptable refractive error correction in the majority of adults. Programs targeting resource-poor settings could potentially use USee to provide easy on-site refractive error correction.

Dual sensory impairment: The association between glaucomatous vision loss and hearing impairment and function.

Background Hearing impairment, vision impairment, and dual impairment (both hearing and vision impairment), have been independently associated with functional and cognitive decline. In prior studies of dual impairment, vision impairment is generally not defined or defined by visual acuity alone. Glaucoma is a leading cause of blindness and does not affect visual acuity until late in the disease; instead, visual field loss is used to measure vision impairment from glaucoma. Objective To examine the effect of glaucomatous visual field loss and hearing impairment on function. Design Cross-sectional. Setting Hospital-based clinic in Baltimore, Maryland. Subjects 220 adults, ≥55 years presenting to the glaucoma clinic. Methods Vision impairment was defined as mean deviation on visual field testing worse than -5 decibels in the better eye, and hearing impairment was defined as pure tone average worse than 25 decibels on threshold audiometry testing in the better ear. Standardized questionnaires were used to assess functional status. Results Five participants were excluded for incomplete testing, leaving 32 with vision impairment only, 63 with hearing impairment only, 42 with dual impairment, and 78 controls with no hearing impairment or vision impairment. Participants with dual impairment were more likely to be older and non-White. Dual impairment was associated with significantly more severe driving limitation and more difficulty with communication compared to those without sensory impairment when adjusted for age, race, gender and number of comorbidities. Conclusion Older individuals with glaucoma and hearing loss seem to have generally poorer functioning than those with single sensory loss. Health professionals should consider visual field loss as a type of vision impairment when managing patients with dual impairment.

Comparison of Access to Eye Care Appointments Between Patients With Medicaid and Those With Private Health Care Insurance

Importance Although low-income populations have more eye problems, whether they face greater difficulty obtaining eye care appointments is unknown. Objective To compare rates of obtaining eye care appointments and appointment wait times for those with Medicaid vs those with private insurance. Design, Setting, and Participants In this prospective, cohort study conducted from January 1, 2017, to July 1, 2017, researchers made telephone calls to a randomly selected sample of vision care professionals in Michigan and Maryland stratified by neighborhood (urban vs rural) and professional type (ophthalmologist vs optometrist) to request the first available appointment. Appointments were sought for an adult needing a diabetic eye examination and a child requesting a routine eye examination for a failed vision screening. Researchers called each practice twice, once requesting an appointment for a patient with Medicaid and the other time for a patient with Blue Cross Blue Shield (BCBS) insurance, and asked whether the insurance was accepted and, if so, when the earliest available appointment could be scheduled. Main Outcomes and Measures Rate of successfully made appointments and mean wait time for the first available appointment. Results A total of 603 telephone calls were made to 330 eye care professionals (414 calls [68.7%] to male and 189 calls [31.3%] to female eye care professionals). The sample consisted of ophthalmologists (303 [50.2%]) and optometrists (300 [49.8%]) located in Maryland (322 [53.4%]) and Michigan (281 [46.6%]). The rates of successfully obtaining appointments among callers were 61.5% (95% CI, 56.0%-67.0%) for adults with Medicaid and 79.3% (95% CI, 74.7%-83.9%) for adults with BCBS (P < .001) and 45.4% (95% CI, 39.8%-51.0%) for children with Medicaid and 62.5% (95% CI, 57.1%-68.0%) for children with BCBS (P < .001). Mean wait time did not vary significantly between the BCBS and Medicaid groups for both adults and children. Adults with Medicaid had significantly decreased odds of receiving an appointment compared with those with BCBS (odds ratio [OR], 0.41; 95% CI, 0.28-0.59; P < .001) but had increased odds of obtaining an appointment if they were located in Michigan vs Maryland (OR, 2.40; 95% CI, 1.49-3.87; P < .001) or with an optometrist vs an ophthalmologist (OR, 1.91; 95% CI, 1.31-2.79; P < .001). Children with Medicaid had significantly decreased odds of receiving an appointment compared with those with BCBS (OR, 0.41; 95% CI, 0.28-0.60; P < .001) but had increased odds of obtaining an appointment if they were located in Michigan vs Maryland (OR, 1.68; 95% CI, 1.04-2.73; P = .03) or with an optometrist vs an ophthalmologist (OR, 8.00; 95% CI, 5.37-11.90; P < .001). Conclusions and Relevance Callers were less successful in trying to obtain eye care appointments with Medicaid than with BCBS, suggesting a disparity in access to eye care based on insurance status, although confounding factors may have contributed to this finding. Improving access to eye care professionals for those with Medicaid may improve health outcomes and decrease health care spending in the long term.

Uncontrolled Hypertension Is Common in Glaucoma Clinics

BACKGROUND To determine the magnitude of uncontrolled hypertension and smoking among patients visiting an eye clinic, and ascertain if referral to care providers is effective. METHODS Information on smoking status and blood pressure (BP) was collected among patients ≥18 years visiting an eye clinic. Those with high BP (systolic: ≥140 mm Hg and/or diastolic: ≥90 mm Hg) received a pamphlet on harms of hypertension on vision and were referred to a primary care physician. Smokers received a pamphlet on negative effects of smoking on vision and were offered referral to a tobacco quitline. Patients were followed up for referral outcome within 10 weeks from screening. RESULTS Screening: A total of participants screened included 140 (29.5%) with high BP and 31 (6.6%) current smokers. In the high BP group, 92 (66%) subjects were previously diagnosed with hypertension. Follow-up: Of the 140 participants with elevated BP, 84 (60%) responded to follow-up. Among these 84 participants, 57 (67.9%) had consulted primary care, of whom 5 (8.8%) reported being newly diagnosed with hypertension, and 11 (19.3%) reported a change in their antihypertensive prescription. Among the 31 smokers, 24 (77.4%) were willing for quitline referral. Sixteen (66.7%) of these patients responded to follow-up, 8 (50%) of whom reported participation in a smoking-cessation program with 1 patient (6.3%) successfully quitting smoking. CONCLUSIONS Nearly one-third of patients attending an eye clinic had elevated BP, and a smaller, but substantial, number of patients were current smokers. Eye clinics may serve as point for identification and referral of these patients with unmet needs.

Impact of the Ability to Divide Attention on Reading Performance in Glaucoma

Purpose To determine if the ability to divide attention affects the relationship between glaucoma-related vision loss and reading speed. Methods Better eye mean deviation (MD), contrast sensitivity (CS), and better-eye distance visual acuity (VA) were measured in 28 participants with glaucoma and 21 controls. Reading speeds were assessed using MNRead, IRest, and sustained silent reading tests (words per minute, wpm). The ability to divide attention was measured using the Brief Test of Attention (BTA; scored 0–10). Multivariable linear regression models were used to determine the relationship between visual factors and reading speeds. Effect modification by BTA score (low BTA: <7; high BTA: ≥7) was examined. Results Worse CS (per 0.1 log unit) was associated with slower maximum reading speed on MNRead test for participants with low BTA scores (β = −9 wpm; 95% confidence interval [CI]: −16, −2), but not for those with high BTA scores (β = −2 wpm; 95% CI: −6, +2). Similarly, for the IRest test, worse CS was associated with slower reading speeds (β = −12 wpm; 95% CI: −20, −4) among those with low, but not high BTA scores (β = −4 wpm; 95% CI: −10, +2). For the sustained silent reading test, glaucoma status (versus controls), worse visual field (VF) MD (per 5 dB), and worse CS were associated with 39%, 21%, and 19% slower reading speeds, respectively, for those with low BTA scores (P < 0.05), but these associations were not significant among those with high BTA scores (P > 0.1 for all). Conclusions Decreased ability to divide attention, indicated by lower BTA scores, is associated with slower reading speeds in glaucoma with reduced CS and VF defects.