A Systematic Review of Ophthalmology Education in Medical Schools: The Global Decline

TOPIC

This systematic review examines geographical and temporal trends in medical school ophthalmology education in relation to course and student outcomes.

CLINICAL RELEVANCE

There is increasing evidence suggesting a decline in ophthalmology teaching in medical schools, raising concern for the adequacy of eye knowledge across the rest of the medical profession.

METHODS

Systematic review of Embase and SCOPUS, with inclusion of studies containing data on medical school ophthalmological course length, and/or one or more outcome measures on student ophthalmology knowledge, skills, self-evaluation of knowledge or skills, or student course appraisal. The systematic review was registered prospectively on PROSPERO, ID CRD42022323865. Results were aggregated with outcome sub-group analysis and description in relation to geographical and temporal trends. Descriptive statistics including nonparametric correlations were utilised to analyse data and trends.

RESULTS

Systematic review yielded 4 596 publication titles, of which 52 were included in the analysis, with data from 19 countries. Average course length ranged from 12.5-208.7 hours, with significant continental disparity between mean course length. Africa reported the longest average course length at 103.3 hours, and North America reported the shortest at 36.4 hours. On average course lengths have been declining over the last two decades, from an average overall course length of 92.9 hours in the 2000s, to 52.9 hours in the 2020s. Mean student self-evaluation of skills was 51.3%, and student self-evaluation of knowledge was 55.4%. Objective mean assessment mark of skills was 57.5%, and of knowledge was 71.7%, compared to an average pass mark of 66.7%. On average 26.4% of students felt confident in their ophthalmology knowledge, and 34.5% in their skills.

CONCLUSIONS

The majority of the evidence describes declining length of courses devoted to ophthalmology in the last 20 years, significant student dissatisfaction with courses and content, and suboptimal knowledge and confidence.

Quantification and Predictors of Visual Field Variability in Healthy, Glaucoma Suspect, and Glaucomatous Eyes Using SITA-Faster

PURPOSE

The newly released Swedish Interactive Thresholding Algorithm (SITA)-Faster (SFR) has significantly shorter testing durations compared with older SITA algorithms, but its variability is uncertain. This study quantified and established threshold limits of test-retest variability across the 24-2 test grid using SFR.

DESIGN

Cross-sectional study with prospective longitudinal arm.

PARTICIPANTS

1426 eyes of 787 patients with healthy, suspected glaucoma, or manifest glaucoma eyes from hospital- and university- eye clinics.

METHODS

Two SFR tests per eye at a baseline visit and at two follow-up visits.

MAIN OUTCOME MEASURES

Pointwise variability measured by test-retest difference in pointwise sensitivity between tests one and two, mean global variability (test-retest variance) measured by average of pointwise variability for each participant, global sensitivity, and reliability indices of each eye.

RESULTS

Of the 1426 eyes, 540 eyes (37.9%) had a diagnosis of glaucoma, 753 eyes (52.8%) were suspected of having glaucoma, and the remaining 133 eyes (9.3%) were healthy. Of 74 152 pointwise sensitivities obtained, the mean test-retest difference was 2.17 ± 2.9 dB, whereas the mean test-retest variance for each participant was 2.17 ± 1.2 dB. Pointwise and global variability increased with worsening threshold sensitivity and (MD), respectively, and was greater for peripheral compared with central test locations. In the longitudinal cohort, no significant difference in mean test-retest variance was found across the 3 visits (mean variability, 2.10 dB vs. 2.16 dB vs. 2.16 dB at visits F0 vs. F1 vs. F2; P = 0.53, repeated-measures analysis of variance). Baseline MD (-0.19 dB; 95% CI, -0.22 to 0.16 dB; P < 0.0001) and abnormally high sensitivity on glaucoma hemifield test (1.14 dB; 95% CI, 0.78-1.51 dB; P < 0.0001) were significantly associated with increased variability. Finally, test-retest MD showed minimal change around the recommended 15% false-positive cutoff threshold.

CONCLUSIONS

The variability of SFR increases with worsening threshold sensitivity, is stable over time, and is greater for peripheral compared with central test locations. Worse baseline MD and abnormally high sensitivity are significant predictors of increased variability. A cutoff of 15% in false-positive results may be inappropriate as a threshold for judging test reliability in SFR.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Acute angle closure glaucoma misdiagnosed as sinusitis

A 69-year-old woman developed severe right suprabulbar pain with blurred right-sided vision. There were no haloes around lights, photophobia, nausea or vomiting. Investigations in the emergency department excluded a posterior communicating/internal carotid artery aneurysm. However, she did not have an ophthalmological assessment and the initial diagnosis was of sinusitis-related headache. An urgent ear, nose and throat assessment found no abnormality, but a local ophthalmologist subsequently diagnosed and managed the patient's acute angle closure crisis. Periocular pain always deserves detailed assessment with an accurate history, visual acuity assessment and intraocular pressure measurement.

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.

Autonomous assessment of spontaneous retinal venous pulsations in fundus videos using a deep learning framework

The presence or absence of spontaneous retinal venous pulsations (SVP) provides clinically significant insight into the hemodynamic status of the optic nerve head. Reduced SVP amplitudes have been linked to increased intracranial pressure and glaucoma progression. Currently, monitoring for the presence or absence of SVPs is performed subjectively and is highly dependent on trained clinicians. In this study, we developed a novel end-to-end deep model, called U3D-Net, to objectively classify SVPs as present or absent based on retinal fundus videos. The U3D-Net architecture consists of two distinct modules: an optic disc localizer and a classifier. First, a fast attention recurrent residual U-Net model is applied as the optic disc localizer. Then, the localized optic discs are passed on to a deep convolutional network for SVP classification. We trained and tested various time-series classifiers including 3D Inception, 3D Dense-ResNet, 3D ResNet, Long-term Recurrent Convolutional Network, and ConvLSTM. The optic disc localizer achieved a dice score of 95% for locating the optic disc in 30 milliseconds. Amongst the different tested models, the 3D Inception model achieved an accuracy, sensitivity, and F1-Score of 84 ± 5%, 90 ± 8%, and 81 ± 6% respectively, outperforming the other tested models in classifying SVPs. To the best of our knowledge, this research is the first study that utilizes a deep neural network for an autonomous and objective classification of SVPs using retinal fundus videos.

High Polygenic Risk is Associated with Earlier Initiation and Escalation of Treatment in Early Primary Open Angle Glaucoma

PURPOSE

To assess whether a glaucoma polygenic risk score (PRS) was associated with treatment commencement or escalation in early primary open angle glaucoma.

DESIGN

Prospective longitudinal observational cohort study.

PARTICIPANTS

Participants from the PROGRESSA study (Progression Risk of Glaucoma: RElevant SNPs with Significant Association) were divided into a cohort of glaucoma suspects who were treatment naive at enrolment, and early manifest and suspect glaucoma cases on treatment at enrolment.

METHODS

A per-allele weighted glaucoma PRS was calculated for 1,107 participants. Multivariable mixed effects Cox proportional regression analysis assessed the association between PRS and time to commencement of intraocular pressure (IOP) lowering therapy in 416 glaucoma suspects who were treatment naive at study enrolment. Secondary analysis evaluated the association between PRS and escalation of IOP lowering therapy amongst 691 suspect and early manifest glaucoma cases who were on IOP lowering therapy at enrolment.

MAIN OUTCOME MEASURES

Commencement or escalation of IOP lowering therapy.

RESULTS

A higher glaucoma PRS was associated with a greater risk of commencing IOP-lowering therapy within 5 years (HR: 1.45/Standard Deviation (SD) 95% Confidence Interval (CI) [1.27, 1.62] P<0.001). This finding persisted after adjustment for relevant demographic and clinical parameters (adjusted HR: 1.23/SD 95%CI [1.07, 1.43] P=0.005). Participants in the upper population-based quintile had a 3.3 times greater risk of commencing therapy by 5 years than the lowest quintile (HR: 3.30 95%CI [1.63, 6,70] P<0.001), and a 5.4 greater risk of commencing IOP lowering therapy by 2 years than the lowest quintile (HR: 5.45 95%CI [2.08, 14.25] P<0.001). A higher glaucoma PRS was associated with a greater risk of treatment escalation amongst cases on treatment at enrolment (HR: 1.19/SD 95%CI [1.09, 1.31] P<0.001). In combined analysis of treatment naive suspects and treated cases, participants in the top population-based quintile were at 2.3 times greater risk of requiring initiation or escalation of IOP lowering therapy than the lowest quintile (HR: 2.33 95%CI [1.75, 3.01] P<0.001).

CONCLUSIONS

This study demonstrates novel associations between glaucoma polygenic risk and risk of commencement or escalation of IOP lowering therapy, building upon previous work highlighting the potential clinical utility of genetic risk stratification in glaucoma.

Physical Activity Is Associated With Macular Thickness: A Multi-Cohort Observational Study

Purpose

To assess the association between physical activity and spectral-domain optical coherence tomography (SD-OCT)-measured rates of macular thinning in an adult population with primary open-angle glaucoma.

Methods

The correlation between accelerometer-measured physical activity and rates of macular ganglion cell-inner plexiform layer (GCIPL) thinning was measured in 735 eyes from 388 participants of the Progression Risk of Glaucoma: RElevant SNPs with Significant Association (PROGRESSA) study. The association between accelerometer-measured physical activity and cross-sectional SD-OCT macular thickness was then assessed in 8862 eyes from 6152 participants available for analysis in the UK Biobank who had SD-OCT, ophthalmic, comorbidity, and demographic data.

Results

Greater physical activity was associated with slower rates of macular GCIPL thinning in the PROGRESSA study (beta = 0.07 µm/y/SD; 95% confidence interval [CI], 0.03-0.13; P = 0.003) after adjustment for ophthalmic, demographic and systemic predictors of macular thinning. This association persisted in subanalyses of participants characterized as glaucoma suspects (beta = 0.09 µm/y/SD; 95% CI, 0.03-0.15; P = 0.005). Participants in the upper tertile (greater than 10,524 steps/d) exhibited a 0.22-µm/y slower rate of macular GCIPL thinning than participants in the lower tertile (fewer than 6925 steps/d): -0.40 ± 0.46 µm/y versus -0.62 ± 0.55 µm/y (P = 0.003). Both time spent doing moderate/vigorous activity and mean daily active calories were positively correlated with rate of macular GCIPL thinning (moderate/vigorous activity: beta = 0.06 µm/y/SD; 95% CI, 0.01-0.105; P = 0.018; active calories: beta = 0.06 µm/y/SD; 95% CI, 0.006-0.114; P = 0.032). Analysis among 8862 eyes from the UK Biobank revealed a positive association between physical activity and cross-sectional total macular thickness (beta = 0.8 µm/SD; 95% CI, 0.47-1.14; P < 0.001).

Conclusions

These results highlight the potential neuroprotective benefits of exercise on the human retina.

Association Between Body Mass Index and Primary Open Angle Glaucoma in Three Cohorts

PURPOSE

To evaluate the relationship between body mass index (BMI) and glaucoma progression.

DESIGN

Multicohort observational study.

METHODS

This study combined a retrospective longitudinal analysis of suspect and early manifest primary open angle glaucoma cases from the Progression Risk of Glaucoma: RElevant SNPs with Significant Association (PROGRESSA) study with 2 replication cohorts from the UK Biobank and the Canadian Longitudinal Study of Ageing (CLSA). In the PROGRESSA study, multivariate analysis correlated BMI with longitudinal visual field progression in 471 participants. The BMI was then associated with glaucoma diagnosis and cross-sectional vertical cup-disc ratio (VCDR) measurements in the UK Biobank, and finally prospectively associated with longitudinal change in VCDR in the CLSA study.

RESULTS

In the PROGRESSA study, a lower BMI conferred a faster rate of visual field progression (mean duration of monitoring (5.28 ± 1.80 years (10.6 ± 3.59 visits) (β 0.04 dB/year/SD95% CI [0.005, 0.069]; P = .013). In the UK Biobank, a 1 standard deviation lower BMI was associated with a worse cross-sectional VCDR (β -0.048/SD 95% CI [-0.056, 0.96]; P < .001) and a 10% greater likelihood of glaucoma diagnosis, as per specialist grading of retinal fundus imaging (OR 0.90 95% CI [0.84, 0.98]; P = .011). Similarly, a lower BMI was associated with a greater risk of glaucoma diagnosis as per International Classification of Disease data (OR 0.94/SD; 95% CI [0.91, 0.98]; P = .002). Body mass index was also positively correlated with intraocular pressure (β 0.11/SD; 95% CI [0.06, 0.15]; P < .001). Finally, a lower BMI was then associated with greater VCDR change in the CLSA (β -0.007/SD; 95% CI [-0.01, -0.001]; P = .023).

CONCLUSIONS

Body mass index correlated with longitudinal and cross-sectional glaucomatous outcomes. This supports previous work illustrating a correlation between BMI and glaucoma.

Association of High Polygenic Risk With Visual Field Worsening Despite Treatment in Early Primary Open-Angle Glaucoma

Importance

Irreversible vision loss from primary open-angle glaucoma (POAG) can be prevented through timely diagnosis and treatment, although definitive diagnosis can be difficult in early-stage disease. As a consequence, large numbers of individuals with suspected glaucoma require regular monitoring, even though many of these may never develop disease and other high-risk individuals with suspected glaucoma may have delayed or inadequate treatment. POAG is one of the most heritable common diseases, and this provides an opportunity to use genetic instruments in risk-stratified screening, diagnosis, and treatment of early glaucoma.

Objective

To assess the association of glaucoma polygenic risk with glaucoma progression in early-stage disease.

Design, Setting, and Participants

This cohort study used clinical and genetic data obtained from a longitudinal cohort study, Progression Risk of Glaucoma: Relevant SNPs With Significant Association (PROGRESSA). Participants of European ancestry with characteristic optic nerve head changes suggestive of glaucoma were included. Data were collected between February 2012 and June 2020. Analysis took place between July 2020 and April 2022.

Main Outcomes and Measures

The association of a glaucoma polygenic risk score (PRS) (2673 uncorrelated variants) with rate of peripapillary retinal nerve fiber layer thinning on optical coherence tomography and progression of visual field loss on 24-2 Humphrey visual fields.

Results

A total of 1777 eyes from 896 individuals had sufficient data for structural progression analyses and 1563 eyes from 808 individuals for functional progression analyses. The mean (SD) age was 62.1 (9.9) years, 488 (44%) were male, and 1087 of 1103 individuals (98.5%) had European ancestry. An ancestrally matched normative population cohort (n = 17 642) was used for PRS reference. Individuals in the top 5% PRS risk group were at a higher risk of visual field progression compared with the remaining 95% after 5 years (hazard ratio, 1.5; 95% CI, 1.13-1.97; P = .005). Conversely, those in the bottom 20% PRS risk group were at a lower risk of visual field progression compared with an intermediate risk group over 3 years (hazard ratio, 0.52; 95% CI, 0.28-0.96; P = .04).

Conclusions and Relevance

In this study, high polygenic risk was associated with more rapid structural and functional progression in early POAG, despite more intensive treatment. A PRS may serve as a valuable adjunct to identify individuals who stand to benefit the most from more frequent surveillance and earlier or more intensive treatment.

Apparent Defective Abduction Without Diplopia

Sixth nerve palsies present with horizontal diplopia and typically have a neurological or neurovascular aetiology. They can be confirmed by clinically evaluating the velocity of the abducting saccade, which is slowed. Three cases are presented in which the patients had apparent defective abduction of one eye, resulting from not only neurological causes but also orbital causes. Clinicians should have a high index of suspicion in patients with defective abduction without diplopia and should include apparent defective abduction without diplopia (ADAD) in the list of potential differential diagnoses, considering not only neurological involvement but also orbital involvement.

The APOE E4 Allele Is Associated with Faster Rates of Neuroretinal Thinning in a Prospective Cohort Study of Suspect and Early Glaucoma

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Genetic Risk of Cardiovascular Disease Is Associated with Macular Ganglion Cell-Inner Plexiform Layer Thinning in an Early Glaucoma Cohort

PURPOSE

To evaluate the association between genetic risk for cardiovascular disease and retinal thinning in early glaucoma.

DESIGN

Prospective, observational genetic association study.

PARTICIPANTS

Multicohort study combining a cohort of patients with suspect and early manifest primary open-angle glaucoma (POAG), a cohort of patients with perimetric POAG, and an external normative control cohort.

METHODS

A cardiovascular disease genetic risk score was calculated for 828 participants from the Progression Risk of Glaucoma: Relevant SNPs [single nucleotide polymorphisms] with Significant Association (PROGRESSA) study. Participants were characterized as showing either predominantly macular ganglion cell-inner plexiform layer (GCIPL), predominantly peripapillary retinal nerve fiber layer (pRNFL) or equivalent macular GCIPL and pRNFL spectral-domain OCT thinning. The cardiovascular disease genetic risk scores for these groups were compared to an internal reference group of stable suspected glaucoma and of an external normative population. Replication was undertaken by comparing the phenotypes of participants from the Australia New Zealand Registry of Advanced Glaucoma (ANZRAG) with the normative control group.

MAIN OUTCOME MEASURES

Spectral-domain OCT and Humphrey Visual Field (HVF) change.

RESULTS

After accounting for age, sex, and intraocular pressure (IOP), participants with predominantly macular GCIPL thinning showed a higher cardiovascular disease genetic risk score than reference participants (odds ratio [OR], 1.76/standard deviation [SD]; 95% confidence interval [CI], 1.18-2.62; P = 0.005) and than normative participants (OR, 1.32/SD; 95% CI, 1.12-1.54; P = 0.002). This finding was replicated by comparing ANZRAG participants with predominantly macular GCIPL change with the normative population (OR, 1.39/SD; 95% CI, 1.05-1.83; P = 0.022). Review of HVF data identified that participants with paracentral visual field defects also demonstrated a higher cardiovascular disease genetic risk score than reference participants (OR, 1.85/SD; 95% CI, 1.16-2.97; P = 0.010). Participants with predominantly macular GCIPL thinning exhibited a higher vertical cup-to-disc ratio genetic risk score (OR, 1.48/SD; 95% CI, 1.24-1.76; P < 0.001), but an IOP genetic risk score (OR, 1.12/SD; 95% CI, 0.95-1.33; P = 0.179) comparable with that of the normative population.

CONCLUSIONS

This study highlighted the relationship between cardiovascular disease and retinal thinning in suspect and manifest glaucoma cases.

Practising refraction in ophthalmology: instructive or outdated? A prospective study and literature review

CLINICAL RELEVANCE

Many ophthalmologists preform clinical refactions, although little is known of the perceptions and practise of refraction by ophthalmologists and key barriers preventing this aspect of ophthalmic practice.

BACKGROUND

Although there are numerous studies on visual acuity in ophthalmology, there is no study to date on the practice of refraction by ophthalmologists. This study evaluates the practice patterns of ophthalmologists in current practice. It specifically addresses perceptions of ophthalmologists about (a) the importance of refraction in clinical practice, and (b) barriers to performing refraction. The methodology and frequency of performing refraction by ophthalmologists is also assessed.

METHODS

This cross-sectional study was conducted at the Annual Scientific Congress of the Royal Australian and New Zealand College of ophthalmologists in 2017, held in Perth, Australia. All attending ophthalmologists and ophthalmology trainees were invited to participate. Participants completed a 17-variable questionnaire on the perceptions of practitioners about refraction and their practice of it. Data were analysed using Microsoft Excel and IBM SPSS Version 24.

RESULTS

At this Congress, 213 attendees completed the survey, with most being consultant general ophthalmologists (85%). Twenty-six percent of participants either 'really loved' or 'liked' refracting patients. Those who reported feeling competent with refraction were more likely to perform it themselves (p = 0.001). Individuals most commonly reported taking 3-5 minutes to refract a patient (38%). Participants under the age of 65, and participants practising paediatric ophthalmology, were more likely to perform a refraction.

CONCLUSIONS

The literature indicates that this is the first study to describe the practice patterns of refraction by ophthalmologists. Although ophthalmologists found refraction important, the majority preferred patients to be refracted by others. Key barriers to ophthalmologists performing refraction included the time required to perform the refraction, a busy clinic, and the availability of alternative providers.

Subpalpebral Antibiotic Lavage as Safe, Emergent, and Cost-Effective Management of Acute Infectious Keratitis Related to Contact Lens Overwear: Case Report and Literature Review

PURPOSE

The aim of this study is to describe the technique of subpalpebral antibiotic lavage (SAL), which is a highly therapeutic, efficient, and cost-effective method for managing severe bacterial keratitis.

METHODS

This case report describes a 26-year-old woman with severe bacterial keratitis in the right eye due to contact lens overwear, with progressive corneal thinning, a hypopyon, impending perforation, and marked visual loss to perception of light despite treatment with intensive topical antibiotics. This was managed with SAL that involves the insertion of a cannula transcutaneously into the upper conjunctival fornix to provide continuous antibiotic irrigation of the ocular surface.

RESULTS

By 11 weeks after presentation, the cornea and anterior chamber appeared clinically quiescent, and visual acuity improved to 20/40 corrected in the right eye.

CONCLUSIONS

Bacterial keratitis is a potentially blinding condition for which contact lens wear is an important risk factor. Most cases are successfully managed with topical medications; however, in cases of treatment failure, a second-line approach such as SAL can be sight-saving. SAL uses readily available equipment for the delivery of high concentrations of antibiotics to the ocular surface, thus increasing therapeutic efficacy and reducing nursing staff workload. Despite its advantages, the literature reveals apparent underutilization of this technique.

Irritable bowel syndrome and risk of glaucoma: An analysis of two independent population-based cohort studies

OBJECTIVE

Irritable bowel syndrome (IBS) is a chronic disorder associated with an abnormal gastrointestinal microbiome. Microbiome-host interactions are known to influence organ function including in the central nervous system; thus, we sought to identify whether IBS may be a risk factor for the development of glaucoma.

DESIGN

Two prospective cohort studies.

SUBJECTS

The 1958 United Kingdom Birth Cohort (UKBC; 9091 individuals) and the Danish National Registry of Patients (DNRP; 62,541 individuals with IBS and 625,410 matched general population cohort members).

METHODS

In the UKBC, participants were surveyed throughout life (including at ages 42 and 50). The DNRP contains records of hospital-based contacts and prescription data from the national prescription database.

MAIN OUTCOME MEASURE

The main outcome measure was incidence of glaucoma. In the UKBC, incident glaucoma at age 50 (n = 48) was determined through comparison of survey responses at ages 42 and 50 years. In the DNRP, glaucoma was assessed by hospital diagnosis (n = 1510), glaucoma surgery (n = 582) and initiation of glaucoma medications (n = 1674).

RESULTS

In the UKBC, the odds ratio (OR) of developing glaucoma between ages 42 and 50 in persons with a chronic IBS diagnosis was increased [OR: 5.84, 95% confidence interval (CI): 2.26-15.13]. People with an IBS diagnosis in the DNRP had a hazard ratio (HR) of 1.35 for developing physician-diagnosed glaucoma (95% CI: 1.16-1.56), an HR of 1.35 for undergoing glaucoma surgery (95% CI: 1.06-1.70) and an HR of 1.19 for initiating glaucoma medication (95% CI: 1.03-1.38).

CONCLUSIONS

In two large European cohort studies, IBS is a risk factor for glaucoma.

Screening for Glaucomatous Visual Field Defects in Rural Australia with an iPad

Aim and objective

Developing improved methods for early detection of visual field defects is pivotal to reducing glaucoma-related vision loss. The Melbourne Rapid Fields screening module (MRF-S) is an iPad-based test, which allows suprathreshold screening with zone-based analysis to rapidly assess the risk of manifest glaucoma. The versatility of MRF-S has potential utility in rural areas and during infectious pandemics. This study evaluates the utility of MRF-S for detecting field defects in non-metropolitan settings.

Materials and methods

This was a prospective, multicenter, cross-sectional validation study. Two hundred and fifty-two eyes of 142 participants were recruited from rural sites through two outreach eye services in Australia. Participants were tested using MRF-S and compared with a reference standard; either Zeiss Humphrey Field Analyzer or Haag-Streit Octopus performed at the same visit. Standardized questionnaires were used to assess user acceptability. Major outcome measures were the area under the curve (AUC) for detecting mild and moderate field defects defined by the reference tests, along with corresponding performance characteristics (sensitivity, specificity).

Results

The mean test duration for MRF-S was 1.88 minutes compared with 5.92 minutes for reference tests. The AUCs for mild and moderate field defects were 0.81 [95% confidence interval (CI): 0.75–0.87] and 0.87 (95% CI: 0.83–0.92), respectively, indicating very good diagnostic accuracy. Using a risk criterion of 55%, MRF-S identified moderate field defects with a sensitivity and specificity of 88.4 and 81.0%, respectively.

Conclusion and clinical significance

The MRF-S iPad module can identify patients with mild and moderate field defects while delivering favorable user acceptability and short test duration. This has potential application within rural locations and amidst infectious pandemics.

How to cite this article

Chia MA, Trang E, Agar A, et al. Screening for Glaucomatous Visual Field Defects in Rural Australia with an iPad. J Curr Glaucoma Pract 2021;15(3):125–131.

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: a multimethod study

OBJECTIVES

The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme.

DESIGN

Multimethod: survey and retrospective review of referral forms.

SETTING

Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia.

PARTICIPANTS

Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed.

RESULTS

Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases.

CONCLUSIONS

This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes.

A combined convolutional and recurrent neural network for enhanced glaucoma detection

Glaucoma, a leading cause of blindness, is a multifaceted disease with several patho-physiological features manifesting in single fundus images (e.g., optic nerve cupping) as well as fundus videos (e.g., vascular pulsatility index). Current convolutional neural networks (CNNs) developed to detect glaucoma are all based on spatial features embedded in an image. We developed a combined CNN and recurrent neural network (RNN) that not only extracts the spatial features in a fundus image but also the temporal features embedded in a fundus video (i.e., sequential images). A total of 1810 fundus images and 295 fundus videos were used to train a CNN and a combined CNN and Long Short-Term Memory RNN. The combined CNN/RNN model reached an average F-measure of 96.2% in separating glaucoma from healthy eyes. In contrast, the base CNN model reached an average F-measure of only 79.2%. This proof-of-concept study demonstrates that extracting spatial and temporal features from fundus videos using a combined CNN and RNN, can markedly enhance the accuracy of glaucoma detection.

A Polygenic Risk Score Predicts Intraocular Pressure Readings Outside Office Hours and Early Morning Spikes as Measured by Home Tonometry

PURPOSE

Intraocular pressure (IOP) elevations may occur in early morning or outside office hours and can be missed during routine in-clinic IOP measurements. Such fluctuations or peaks likely contribute to glaucoma progression. We sought to investigate the relationship between an IOP polygenic risk score (PRS) and short-term IOP profile.

DESIGN

Cross-sectional study.

PARTICIPANTS

Four hundred seventy-three eyes from 239 participants with suspected or established primary open-angle glaucoma sampled from 4 outpatient clinics in Australia between August 2016 and December 2019.

METHODS

Participants underwent Icare HOME (Icare Oy, Vanda, Finland) tonometer measurements to record IOP 4 times daily for 5 days. Unreliable measurements were excluded. A minimum of 2 days with at least 3 reliable measurements were required. We used a validated IOP PRS derived from 146 IOP-associated variants in a linear regression model adjusted for central corneal thickness and age.

MAIN OUTCOME MEASURES

Highest recorded early morning IOP and mean IOP within and outside office hours. Early morning IOP spikes were defined by a higher early morning IOP than the maximum in-office hours IOP.

RESULTS

Reliable measurements were obtained from 334 eyes of 176 participants (mean age, 64 ± 9 years). Eyes in the highest IOP PRS quintile showed an early morning IOP increase of 4.3 mmHg (95% confidence interval [CI], 1.4-7.3; P = 0.005) and mean increase in IOP outside office hours of 2.7 mmHg (95% CI, 0.61-4.7; P = 0.013) than the lowest quintile, which were significant independently after accounting for a recent in-clinic IOP measured by Goldmann applanation tonometry. Eyes in the highest PRS quintile were 5.4-fold more likely to show early morning IOP spikes than the lowest quintile (odds ratio 95% CI, 1.3-23.6; P = 0.023).

CONCLUSIONS

A validated IOP PRS was associated with higher early morning IOP and mean IOP outside office hours. These findings support a role for genetic risk prediction of susceptibility to elevated IOP that may not be apparent during in-clinic hours, requiring more detailed clinical phenotyping using home tonometry, the results of which may guide additional interventions to improve IOP control.

Low-Grade Versus Medium-Grade Nuclear Sclerotic Cataract Density Produces Identical Surgical and Visual Outcomes: A Prospective Single-Surgeon Study

Purpose To determine whether the incidence of major complications and postoperative corrected distance visual acuity are comparable for surgery on low-grade versus medium-grade nuclear sclerotic cataracts. Design This was a prospective, consecutive, single-surgeon, no-exclusion study of 1025 cataract cases with one-month follow-up. Methods Patients were divided into two cohorts according to the nuclear sclerosis grade at presentation, as classified using the Lens Opacities Classification System (LOCS) III. Cohort A, representing low-grade nuclear sclerotic cataracts (grades 1-2), consisted of 739 eyes, while Cohort B, representing medium-grade nuclear sclerotic cataracts (grades 3-6), consisted of 286 eyes. Results There was no significant difference in major intraoperative or postoperative complications (p>0.999) between Cohorts A and B. The mean logMar preoperative corrected distance visual acuity (CDVA) in Cohort A was 0.245 as compared with 0.346 in Cohort B (p<0.001). There was no significant difference between cohorts for postoperative CDVA at one day (-0.168 versus -0.118; p=0.070), one week (-0.180 versus -0.147; p=0.405), or one month (-0.185 versus -0.161; p=0.569). Conclusions There was no significant difference in the incidence of operative complications or postoperative CDVA between the cohorts. These findings suggest that, in experienced hands, surgery for medium-grade nuclear sclerotic cataracts is equally effective and safe as compared with that for low-grade nuclear sclerotic cataracts.

Curettage for Copious Conjunctival Concretions

Management of multiple exposed eyelid concretions can be performed successfully in an anesthetized eyelid with gentle curettage of the concretions using a small chalazion curette. It has the advantage of managing the patient supine, providing better eyelid stability and visibility, and minimizing risk in the event of patient movement. This curettage technique was used to facilitate the successful resolution of a patient’s ocular surface irritative symptomatology due to multiple exposed concretions.

Corneal Stiffness Parameters Are Predictive of Structural and Functional Progression in Glaucoma Suspect Eyes

PURPOSE

To investigate corneal stiffness parameters (SPs) as predictors of future progression risk in glaucoma suspect eyes.

DESIGN

Prospective, longitudinal study.

PARTICIPANTS

Three hundred seventy-one eyes from 228 primary open-angle glaucoma suspects, based on optic disc appearance, with normal baseline Humphrey Visual Field (HVF; Carl Zeiss Meditec) results.

METHODS

Baseline corneal SPs were measured using Corvis ST (Oculus Optikgeräte GmbH). Participants were followed up every 6 months with clinical examination, HVF testing, and OCT. The baseline SP at first applanation (SP-A1) and highest concavity predicted the prospective outcome measures.

MAIN OUTCOME MEASURES

Structural progression was measured by the OCT rate of thinning of the retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL). Functional progression was assessed by permutation analysis of pointwise linear regression criteria on HVF testing.

RESULTS

Stiffness parameters correlated positively with central corneal thickness (CCT), which was adjusted for in all analyses. A higher SP-A1, suggestive of a stiffer cornea, was associated with a faster rate of RNFL thinning (P < 0.001), synergistic with thinner CCT (P = 0.004) over a mean follow-up of 4.2 years. Eyes with higher SP-A1 and thinner CCT (thin and stiff corneas) showed accelerated RNFL thinning by 0.72 μm/year relative to eyes with lower SP-A1 and thicker CCT (95% confidence interval [CI], 0.17-1.28; P = 0.011) and were at 2.9-fold higher likelihood of fast RNFL progression of more than 1 μm/year (95% CI, 1.4-6.1; P = 0.006). Consistent results also were observed with GCIPL thinning. Furthermore, a higher SP-A1 was associated with a greater risk of visual field progression (P = 0.002), synergistic with thinner CCT (P = 0.010). Eyes with higher SP-A1 and thinner CCT were at 3.7-fold greater risk of visual field progression relative to eyes with thicker CCT and lower SP-A1 (95% CI, 1.3-10.5; P = 0.014).

CONCLUSIONS

Glaucoma suspect eyes with higher corneal SPs and lower CCT, suggestive of thin and stiff corneas, are at greater risk of progression. Corneal SPs seem to act synergistically with CCT as risk factors for glaucoma progression.

Assessment of Obstructive Sleep Apnoea and Sleeping Laterality by Evaluating Upper Eyelid Distraction: A Prospective, Comparative Polysomnographic Study

Objective Our goal was to evaluate upper eyelid laxity by digital distraction, with the aim to determine sleeping laterality and the likelihood of obstructive sleep apnoea (OSA), and correlate these findings with polysomnography (PSG). Design We conducted a prospective, single-centre multidisciplinary study in a large sleep and respiratory department and an ophthalmology department within a tertiary referral university teaching hospital. Methods Patients with known OSA were evaluated using techniques based on the Lateralising Eyelid Sleep Compression (LESC) study. Upper eyelid laxity was assessed by two masked investigators, and the eyelid side with greater laxity was regarded as indicative of that patient's sleeping laterality: 'investigator-detected sleeping laterality' (ID SL). Each patient was then asked about the laterality of his or her accustomed sleeping position: 'patient-reported sleeping laterality' (PR SL). PSG was conducted according to the standard protocol of the Department of Sleep and Respiratory Medicine (DSRM). 'Polysomnography-detected sleeping laterality' (PSG SL) permitted the extraction of sleep positional data by two masked sleep scientists. Results The reliability of the LESC technique for diagnosing ID SL was demonstrated to be statistically significant (p<0.01). Upper eyelid laxity was significantly greater on the patients' sleeping side (t=6.340, df=45, p<0.01, two-tailed). There was a significant correlation between PR SL and ID SL (r_s =0.33). However, PSG SL did not correlate with sleeping laterality compared with both ID SL and PR SL. Conclusion This study confirms that there is a statistically significant correlation of sleeping laterality with increasing upper eyelid laxity in OSA. Counterintuitively, PSG SL correlated poorly with ID SL and PR SL. This may likely be explained by the technical limitations implicit in current PSG techniques.

Cardiovascular Disease Predicts Structural and Functional Progression in Early Glaucoma

PURPOSE

To investigate the association between cardiovascular disease and baseline structural defects and disease progression in glaucoma.

DESIGN

Prospective, longitudinal study of preperimetric and perimetric glaucoma.

PARTICIPANTS

Two thousand six hundred twenty-eight eyes from 1314 participants recruited to the Progression Risk of Glaucoma: Relevant SNPs with Significant Association (PROGRESSA) study were evaluated for baseline and longitudinal structural thinning using spectral-domain OCT and for visual field progression on Humphrey visual field (HVF) assessment.

METHODS

Patients were classified as either predominantly macula ganglion cell-inner plexiform layer (mGCIPL), predominantly peripapillary retinal nerve fiber layer (pRNFL), or both mGCIPL and pRNFL structural change at enrollment, and then evaluated for longitudinal OCT or HVF progression. Cardiovascular disease and medication characteristics of the participants were compared with a reference group of stable patients.

MAIN OUTCOME MEASURES

OCT and HVF baseline status and longitudinal progression.

RESULTS

After accounting for age and cardiovascular characteristics, patients with predominantly mGCIPL thinning at baseline showed a higher prevalence of hypertension (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.66-4.41; P < 0.001), antihypertensive use (OR, 2.03; 95% CI, 1.20-3.46; P = 0.008), and statin use (OR, 1.98; 95% CI, 1.07-3.66; P = 0.029) than reference patients. Patients with predominantly pRNFL thinning exhibited a comparable prevalence of cardiovascular disease or medication with reference patients. Review of longitudinal OCT and HVF data (mean follow-up, 5.34 ± 1.29 years) showed that hypertension was associated with an increased risk of both OCT (OR, 1.79; 95% CI, 1.17-2.75; P = 0.006) and HVF progression (OR, 1.92; 95% CI, 1.18-3.15; P = 0.013). A 1-standard deviation (approximately 21 mmHg) increase in systolic blood pressure at baseline was associated with a greater risk of OCT progression (OR, 1.27; 95% CI, 1.01-1.63; P = 0.041) and HVF progression (OR, 1.32; 95% CI, 1.01-1.73; P = 0.043). The association between systolic blood pressure and structural progression was comparable to that observed between intraocular pressure and structural progression (OR, 1.30; 95% CI, 1.01-1.67; P = 0.039).

CONCLUSIONS

Cardiovascular disease is an important risk factor for glaucoma progression.

Assessment of Saccadic Velocity at the Bedside

Saccades are a key component for the assessment and diagnosis of Neuro-ophthalmological disorders. Traditionally, clinicians have been taught to use large amplitude saccades (LAS) to assess saccadic velocity (SV), when small amplitude saccades (SAS) may be more effective. This study aimed to evaluate the advantages of SAS over LAS by presenting a video to 108 clinicians where both methods were used to assess a patient with a unilateral partial 6th nerve palsy. SAS was the preferred method in identifying the 6th nerve palsy by 43/55 (78.2%) of Neurologists, and 36/53 (67.9%) of Ophthalmologists. These findings indicate that SAS may be a more effective method than LAS for determining SV.

Objective Quantification of Spontaneous Retinal Venous Pulsations Using a Novel Tablet-Based Ophthalmoscope

Purpose

Dynamic assessment of retinal vascular characteristics can aid in identifying glaucoma-specific biomarkers. More specifically, a loss of spontaneous retinal venous pulsations (SVPs) has been reported in glaucoma, but a lack of readily available tools has limited the ability to explore the full potential of SVP analysis in glaucoma assessment. Advancements in smart technology have paved the way for the development of portable, noninvasive, and inexpensive imaging modalities. By combining off-the-shelf optical elements and smart devices, the current study aims to determine whether SVPs can be detected and quantified using a novel tablet-based ophthalmoscope in glaucoma and glaucoma suspects.

Methods

Thirty patients, including 21 with confirmed glaucoma (9 men; average age 75 ± 8 years) and 9 glaucoma suspects (5 men; average age 64 ± 9 years), were studied. All patients had intraocular pressure measurements, Humphrey visual field assessment, optical coherence tomography, and a 10-second videoscopy of the retinal circulation. The retinal vasculature recordings (46° field of view at 30 frames per second) were analyzed to extract SVP amplitudes.

Results

SVPs were detected and quantified in 100% of patients with glaucoma and those with suspected glaucoma using the novel device. The average SVP amplitudes in glaucoma and glaucoma suspects were 42.6% ± 10.7% and 34% ± 6.7%, respectively.

Conclusions

Our results suggest that a novel tablet-based ophthalmoscope can aid in documenting and objectively quantifying SVPs in all patients.

Translational Relevance

Outcomes of this study provide an innovative, portable, noninvasive, and inexpensive solution for objective assessment of SVPs, which may have clinical relevance in glaucoma screening.

An Intraocular Pressure Polygenic Risk Score Stratifies Multiple Primary Open-Angle Glaucoma Parameters Including Treatment Intensity

PURPOSE

To examine the combined effects of common genetic variants associated with intraocular pressure (IOP) on primary open-angle glaucoma (POAG) phenotype using a polygenic risk score (PRS) stratification.

DESIGN

Cross-sectional study.

PARTICIPANTS

For the primary analysis, we examined the glaucoma phenotype of 2154 POAG patients enrolled in the Australian and New Zealand Registry of Advanced Glaucoma, including patients recruited from the United Kingdom. For replication, we examined an independent cohort of 624 early POAG patients.

METHODS

Using IOP genome-wide association study summary statistics, we developed a PRS derived solely from IOP-associated variants and stratified POAG patients into 3 risk tiers. The lowest and highest quintiles of the score were set as the low- and high-risk groups, respectively, and the other quintiles were set as the intermediate risk group.

MAIN OUTCOME MEASURES

Clinical glaucoma phenotype including maximum recorded IOP, age at diagnosis, number of family members affected by glaucoma, cup-to-disc ratio, visual field mean deviation, and treatment intensity.

RESULTS

A dose-response relationship was found between the IOP PRS and the maximum recorded IOP, with the high genetic risk group having a higher maximum IOP by 1.7 mmHg (standard deviation [SD], 0.62 mmHg) than the low genetic risk group (P = 0.006). Compared with the low genetic risk group, the high genetic risk group had a younger age of diagnosis by 3.7 years (SD, 1.0 years; P < 0.001), more family members affected by 0.46 members (SD, 0.11 members; P < 0.001), and higher rates of incisional surgery (odds ratio, 1.5; 95% confidence interval, 1.1-2.0; P = 0.007). No statistically significant difference was found in mean deviation. We further replicated the maximum IOP, number of family members affected by glaucoma, and treatment intensity (number of medications) results in the early POAG cohort (P ≤ 0.01).

CONCLUSIONS

The IOP PRS was correlated positively with maximum IOP, disease severity, need for surgery, and number of affected family members. Genes acting via IOP-mediated pathways, when considered in aggregate, have clinically important and reproducible implications for glaucoma patients and their close family members.

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.

Clinical Evaluation of Swedish Interactive Thresholding Algorithm-Faster Compared With Swedish Interactive Thresholding Algorithm-Standard in Normal Subjects, Glaucoma Suspects, and Patients With Glaucoma

PURPOSE

To compare the visual fields results obtained using the Swedish interactive thresholding algorithm-Standard (SS) and the Swedish interactive thresholding algorithm-Faster (SFR) in normal subjects, glaucoma suspects, and patients with glaucoma and to quantify potential time-saving benefits of the SFR algorithm.

DESIGN

Prospective, cross-sectional study.

METHODS

One randomly selected eye from 364 patients (77 normal subjects, 178 glaucoma suspects, and 109 patients with glaucoma) seen in a single institution underwent testing using both SS and SFR on the Humphrey Field Analyzer. Cumulative test time using each algorithm was compared after accounting for different rates of test reliability. Pointwise and cluster analysis was performed to determine whether there were systematic differences between algorithms.

RESULTS

Using SFR had a greater rate of unreliable results (29.3%) compared with SS (7.7%, P < .0001). This was mainly because of high false positive rates and seeding point errors. However, modeled test times showed that using SFR could obtain a greater number of reliable results within a shorter period of time. SFR resulted in higher sensitivity values (on average 0.5 dB for patients with glaucoma) that was greater under conditions of field loss (<19 dB). Cluster analysis showed no systematic patterns of sensitivity differences between algorithms.

CONCLUSIONS

After accounting for different rates of test reliability, SFR can result in significant time savings compared with SS. Clinicians should be cognizant of false positive rates and seeding point errors as common sources of error for SFR. Results between algorithms are not directly interchangeable, especially if there is a visual field deficit <19 dB.

Factors Affecting Adherence to Topical Glaucoma Therapy: A Quantitative and Qualitative Pilot Study Analysis in Sydney, Australia

PURPOSE

To assess which factors in the lives and disease of patients with glaucoma affect their adherence to topical glaucoma therapy and the quantitative significance of this effect. To assess qualitatively the most influential barriers to adherence from the perspective of the patient.

DESIGN

Multicenter, prospective, cross-sectional pilot study.

PARTICIPANTS

A total of 145 patients, attending outpatient metropolitan glaucoma clinics in Sydney, Australia, who were prescribed topical glaucoma medications.

METHODS

A structured interview-based questionnaire was conducted with 145 individuals using glaucoma eye drops that had been prescribed at least 2 weeks previously. The questionnaire involved 2 novel questions on adherence, 29 questions on factors identified or postulated in the literature as affecting adherence for quantitative analysis, and 1 open-response question on patient-identified causes of nonadherence for qualitative analysis. This questionnaire represents the broadest coverage of factors hypothesized to affect adherence in a single study in the glaucoma medication adherence literature to date.

MAIN OUTCOME MEASURES

Adherence rate, risk factors for poor adherence, and patient-identified barriers to adherence.

RESULTS

In response to the question "How many days have you missed a drop in the last 2 weeks," 69.7% of patients reported total adherence. Four factors were significantly related to an increased likelihood of reporting having missed drops in the last 2 weeks. These were difficulty applying drops (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.02-5.44; P < 0.05), a past or current diagnosis of depression (OR, 3.61; 95% CI, 1.53-8.52; P < 0.01), patient self-rating of own memory ≤ 7 of 10 (OR, 3.15; 95% CI, 1.36-7.30; P < 0.01), and self-reported motivation score ≤ 6 of 10 (OR, 10.94; 95% CI, 3.00-39.81; P < 0.01). Patient understanding of glaucoma, ethnicity, and socioeconomic status were among the 25 factors found not to have a statistically significant correlation with adherence.

CONCLUSIONS

There is a significant proportion of patients taking their topical glaucoma medications less often than prescribed. Adherence to topical glaucoma therapies is negatively correlated to several factors: difficulty applying drops, a past or current diagnosis of depression, poor self-rating of own memory, and poor self-rating of own motivation. These may prove useful in designing interventions to improve adherence in these patients.

Prevalence and type of artefact with spectral domain optical coherence tomography macular ganglion cell imaging in glaucoma surveillance

Purpose

The ganglion cell analysis (GCA) of the CIRRUS^TM HD-OCT (Carl Zeiss, Meditec; Dublin, CA) provides measurement of the macular ganglion cell-inner plexiform layer (GCIPL) thickness. This study determined the frequency of scan artefacts and errors in GCIPL imaging in individuals undergoing HD-OCT surveillance for glaucoma.

Method

A total of 1439 eyes from 721 subjects enrolled in a prospective study assessing predictors of glaucoma progression underwent macular GCIPL imaging with the CIRRUS HD-OCT at recruitment. The prevalence of acquisition errors, segmentation errors, and co-morbid macular pathology was determined.

Results

A total of 87 (6.0%) of the 1439 scans had either acquisition errors, segmentation artefacts, or other macular pathology. The most common co-morbid macular pathology was epiretinal membrane in 2.2% of eyes.

Conclusion

The macular GCIPL scan was artefact free in 94% of eyes. However, epiretinal membrane and high myopia can cause scan artefact and should be considered when interpreting the results.