Prevalence and Risk Factors of Blindness Among Primary Angle Closure Glaucoma Patients in the United States: An IRIS Registry Analysis

PURPOSE

To assess the prevalence and risk factors of blindness among patients newly diagnosed with primary angle closure glaucoma (PACG) in the United States.

DESIGN

Retrospective cross-sectional study.

METHODS

Eligible patients from the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) Registry had newly diagnosed PACG, defined as: 1) observable during a 24-month lookback period from index date of PACG diagnosis; 2) no history of eye drops, laser, or cataract surgery unless preceded by a diagnosis of anatomical narrow angle (ANA); and 3) no history of glaucoma surgery. Logistic regression models were developed to identify risk factors for any (one or both eyes) or bilateral (both eyes) blindness (visual acuity ≤20/200) at first diagnosis of PACG.

RESULTS

Among 43,901 eligible patients, overall prevalence of any and bilateral blindness were 11.5% and 1.8%, respectively. Black and Hispanic patients were at higher risk of any (odds ratios [ORs] 1.42 and 1.21, respectively; P < .001) and bilateral (ORs 2.04 and 1.53, respectively; P < .001) blindness compared with non-Hispanic White patients adjusted for ocular comorbidities. Age <50 or >80 years, male sex, Medicaid or Medicare insurance product, and Southern or Western practice region also conferred a higher risk of blindness (OR > 1.28; P ≤ .01).

CONCLUSIONS

Blindness affects 1 of 9 patients with newly diagnosed PACG in the IRIS Registry. Black and Hispanic patients and Medicaid and Medicare recipients are at significantly higher risk. These findings highlight the severe ocular morbidity among patients with PACG and the need for improved disease awareness and detection methods.

Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States

PURPOSE

To assess patterns in gonioscopy during initial glaucoma evaluations in the United States.

DESIGN

Retrospective, case-control study.

METHODS

Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics DataMart. Initial evaluation was defined as follows: (1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; (2) continuously observable during a 36-month lookback period; (3) no history of glaucoma medications, laser, or surgical procedures; and (4) optical coherence tomography (OCT) or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes.

RESULTS

Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (P < .001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared with Asians. Age ≥60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (P < .001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (P < .01).

CONCLUSIONS

More than 70% patients undergoing initial glaucoma evaluation in the United States do not have a record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.

Educational intervention to adopt selective laser trabeculoplasty as first-line glaucoma treatment: Randomized controlled trial: Educational intervention on selective laser trabeculoplasty

PURPOSE

To determine the efficacy of an educational intervention on patient adoption and attitudes toward selective laser trabeculoplasty (SLT) as first-line treatment for glaucoma.

METHODS

This study is a randomized controlled trial. Subjects include 33 patients within 1-year diagnosis of either primary open-angle glaucoma, ocular hypertension, or pseudoexfoliation syndrome. After informed consent, subjects were randomly assigned to a Usual Care or Educational Intervention group. All subjects completed a pre-intervention questionnaire. The Educational Intervention group was shown a slideshow presentation and a 3-min video and given a post-intervention questionnaire. Follow-up examinations were reviewed for 6 months to determine subject completion of SLT, the primary outcome. Secondary outcomes include assessment of attitude toward SLT before and after intervention.

RESULTS

Age, gender, and baseline characteristics between the groups did not differ. The Usual Care group had a higher proportion of African Americans (77% vs 31%, p = 0.04). At 6 months following the intervention, 63% of subjects underwent SLT compared to 35% of Usual Care subjects (p = 0.12). Older age was associated with decreased SLT uptake (OR 0.90, 95% CI 0.82-0.99, p = 0.03). Prior to the intervention, there were no differences in attitudes of both groups regarding SLT therapy. Nineteen percent of Educational Intervention subjects changed positively toward SLT (p = 0.08) and 50% scheduled an SLT appointment after intervention (p = 0.005).

CONCLUSIONS

A slideshow and video-based educational intervention may positively enhance patient adoption of SLT.Clinical trial registration name, number, URL: Educational Intervention to Adopt SLT as First-Line Glaucoma Treatment, NCT03365778, https://clinicaltrials.gov/ct2/show/NCT03365778.

Evolution of Cyclophotocoagulation

Cyclodestructive techniques have been a treatment option for refractory glaucoma since its first use in the 1930s. Over the past nine decades, cyclodestruction has advanced from the initial cyclodiathermy to micropulse transscleral cyclophotocoagulation (MP-TSCPC) which is the current treatment available. Complications associated with cyclodestruction including pain, hyphema, vision loss, hypotony and phthisis have led ophthalmologists to shy away from these techniques when other glaucoma treatment options are available. Recent studies have shown encouraging clinical results with fewer complications following cyclophotocoagulation, contributing greatly to the current increase in the use of cyclophotocoagulation as primary treatment for glaucoma. We performed our literature search on Google Scholar Database, Pubmed, Web of Sciences and Cochrane Library databases published prior to September 2017 using keywords relevant to cyclodestruction, cyclophotocoagulation and treatment of refractory glaucoma.

Risk factors for infection with multidrug-resistant bacteria in non-ventilated patients with hospital-acquired pneumonia

OBJECTIVE:

To identify risk factors for the development of hospital-acquired pneumonia (HAP) caused by multidrug-resistant (MDR) bacteria in non-ventilated patients.

METHODS:

This was a retrospective observational cohort study conducted over a three-year period at a tertiary-care teaching hospital. We included only non-ventilated patients diagnosed with HAP and presenting with positive bacterial cultures. Categorical variables were compared with chi-square test. Logistic regression analysis was used to determine risk factors for HAP caused by MDR bacteria.

RESULTS:

Of the 140 patients diagnosed with HAP, 59 (42.1%) were infected with MDR strains. Among the patients infected with methicillin-resistant Staphylococcus aureus and those infected with methicillin-susceptible S. aureus, mortality was 45.9% and 50.0%, respectively (p = 0.763). Among the patients infected with MDR and those infected with non-MDR gram-negative bacilli, mortality was 45.8% and 38.3%, respectively (p = 0.527). Univariate analysis identified the following risk factors for infection with MDR bacteria: COPD; congestive heart failure; chronic renal failure; dialysis; urinary catheterization; extrapulmonary infection; and use of antimicrobial therapy within the last 10 days before the diagnosis of HAP. Multivariate analysis showed that the use of antibiotics within the last 10 days before the diagnosis of HAP was the only independent predictor of infection with MDR bacteria (OR = 3.45; 95% CI: 1.56-7.61; p = 0.002).

CONCLUSIONS:

In this single-center study, the use of broad-spectrum antibiotics within the last 10 days before the diagnosis of HAP was the only independent predictor of infection with MDR bacteria in non-ventilated patients with HAP.

Biomarkers in community-acquired pneumonia: a state-of-the-art review

Community-acquired pneumonia (CAP) exhibits mortality rates, between 20% and 50% in severe cases. Biomarkers are useful tools for searching for antibiotic therapy modifications and for CAP diagnosis, prognosis and follow-up treatment. This non-systematic state-of-the-art review presents the biological and clinical features of biomarkers in CAP patients, including procalcitonin, C-reactive protein, copeptin, pro-ANP (atrial natriuretic peptide), adrenomedullin, cortisol and D-dimers.