Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center.

Aims and background: Practice guidelines assert that high-risk glaucoma suspects should be treated. Yet, there is ambiguity regarding what constitutes a high enough risk for treatment. The purpose of this study was to determine which factors contribute to the decision to treat glaucoma suspects and ocular hypertensive patients in an academic ophthalmology practice. Materials and methods: Retrospective cohort study of glaucoma suspects or ocular hypertensives at an academic ophthalmology practice from 2014 to 2020. Demographics, comorbidities, intraocular pressure (IOP), optical coherence tomography (OCT) findings, and visual field measurements were compared between treated and untreated patients. A multivariable logistic regression model assessed predictors of glaucoma suspected treatment. Results: Of the 388 patients included, 311 (80%) were untreated, and 77 (20%) were treated. There was no statistical difference in age, race/ethnicity, family history of glaucoma, central corneal thickness (CCT), or any visual field parameters between the two groups. Treated glaucoma suspects had higher IOP, thinner retinal nerve fiber layers (RNFL), more RNFL asymmetry, thinner ganglion cell-inner plexiform layers (GCIPL), and a higher prevalence of optic disc drusen, disc hemorrhage, ocular trauma, and proliferative diabetic retinopathy (PDR) (p < 0.05 for all). In the multivariable model, elevated IOP {odds ratio [OR] 1.16 [95% confidence interval (CI) 1.04-1.30], p = 0.008}, yellow temporal [5.76 (1.80-18.40), p = 0.003] and superior [3.18 (1.01-10.0), p = 0.05] RNFL quadrants, and a history of optic disc drusen [8.77 (1.96-39.34), p = 0.005] were significant predictors of glaucoma suspect treatment. Conclusion: Higher IOP, RNFL thinning, and optic disc drusen were the strongest factors in the decision to treat a glaucoma suspect or ocular hypertensive patient. RNFL asymmetry, GCIPL thinning, and ocular comorbidities may also factor into treatment decisions. Clinical significance: Understanding the clinical characteristics that prompt glaucoma suspect treatment helps further define glaucoma suspect disease status and inform when treatment should be initiated. How to cite this article: Ciociola EC, Anderson A, Jiang H, et al. Decision Factors for Glaucoma Suspects and Ocular Hypertensive Treatment at an Academic Center. J Curr Glaucoma Pract 2023;17(3):157-165.

Should All Patients With Pulmonary Hypertension Undergoing Non-Cardiac Surgery Be Managed by Cardiothoracic Fellowship-Trained Anesthesiologists?

OBJECTIVES: To identify differences in practice patterns and outcomes related to the induction of general anesthesia for patients with pulmonary hypertension (PH) performed by anesthesiologists who have completed a cardiothoracic fellowship (CTA group) vs those who have not (non-CTA group). DESIGN: Retrospective study with propensity score matching. SETTING: Operating room. PARTICIPANTS: All adult patients with PH undergoing general anesthesia requiring intubation at a single academic center over 5 years. INTERVENTIONS: Patient baseline characteristics, peri-induction management variables, post-induction mean arterial pressure (MAP), and other outcomes were compared between CTA and non-CTA groups. METHODS AND MAIN RESULTS: Following propensity scoring matching, 402 patients were included in the final model, 100 in the CTA group and 302 in the non-CTA group. Also following matching, only cases of mild to moderate PH without right ventricular dysfunction remained in the analysis. Matched groups were overall statistically similar with respect to baseline characteristics; however, there was a greater incidence of higher ASA class (P = .025) and cardiology and thoracic procedures (P < .001) being managed by the CTA group. No statistical differences were identified in practice patterns or outcomes related to the induction of anesthesia between groups, except for longer hospital length of stay in the CTA group (P = .008). CONCLUSIONS: These results provide early evidence to suggest the induction of general anesthesia of patients with non-severe PH disease can be comparably managed by either anesthesiologists with or without a cardiothoracic fellowship. However, these findings should be confirmed in a prospective study.

Predictors of Post-induction Hypotension for Patients With Pulmonary Hypertension.

Purpose The purpose is to identify predictors of post-induction hypotension (PIH) during general anesthesia in a population of patients with varying degrees of pulmonary hypertension (PH). Methods This is a single-center, retrospective, observational study of perioperative data obtained via electronic health records from patients with PH undergoing surgery over a five-year period. Baseline patient characteristics, peri-induction management variables, and pre-induction mean arterial pressure (MAP) were statistically analyzed using Kruskal-Wallis rank sum tests, Pearson's chi-squared tests, and logistic regression analysis to identify risk factors for PIH. We further assessed the relationship between PH and PIH using propensity score matching. Primary outcomes include a percent decrease in post-induction blood pressure as well as a post-induction nadir with a threshold of 55 mm Hg. Results Eight hundred fifty-seven patients in the cohort stratified by severity of PH reveal that advanced age (p < 0.001), higher BMI (P = 0.002), higher American Society of Anesthesiologists (ASA) score (P = 0.001), and renal and cardiac comorbidities (P < 0.001) are associated with PH severity. None of our tested parameters were significantly predictive for PIH in patients with PH. Right heart failure was found to be weakly and non-significantly predictive of PIH in patients with PH (P = 0.052, odds ratio [OR] = 1.116). Diabetes (P = 0.007, OR = 0.919) and maintenance of spontaneous ventilation (P = 0.012, OR = 0.925) were associated with decreased rates of PIH. Conclusion Hypotension after induction of general anesthesia in patients with PH is a serious problem, yet statistically significant risk factors were not identified. History of diabetes and preservation of spontaneous ventilation had a significant but weak effect of decreasing rates of PIH. This pilot study was limited by retrospective design and warrants further analysis with a prospective cohort.

The Relationship of Travel Distance to Postoperative Follow-up Care on Glaucoma Surgery Outcomes.

PRéCIS:: This study addresses the paucity of literature examining glaucoma patients' distance from clinic on postoperative follow-up outcomes. Greater distance from clinic was associated with higher likelihood of loss to follow-up and missed appointments. PURPOSE: To investigate the relationship of patient travel distance and interstate access to glaucoma surgery postoperative follow-up visit attendance. METHODS AND PARTICIPANTS: Retrospective longitudinal chart review of all noninstitutionalized adult glaucoma patients with initial trabeculectomies or drainage device implantations between April 4, 2014 and December 31, 2018. Patients were stratified into groups on the basis of straight-line distance from residence to University of North Carolina at Chapel Hill's Kittner Eye Center and distance from residence to interstate access. Corrective procedures, visual acuity, appointment cancellations, no-shows, and insurance data were recorded. Means were compared using 2-tailed Student t-test, Pearson χ, analysis of variance, and multivariate logistical regression determined odds ratios for loss to follow-up. RESULTS: In total, 199 patients met all inclusion criteria. Six-month postoperatively, patients >50 miles from clinic had greater odds of loss to follow-up compared with patients <25 miles (odds ratios, 3.47; 95% confidence interval, 1.24-4.12; P<0.05). Patients >50 miles from clinic had significantly more missed appointments than patients 25 to 50 miles away, and patients <25 miles away (P=0.008). Patients >20 miles from interstate access had greater loss to follow-up than those <10 miles (t(150)=2.05; P<0.05). Mean distance from clinic was 12.59 miles farther for patients lost to follow-up (t(197)=3.29; P<0.01). Patients with Medicaid coverage had more missed appointments than those with Medicare plans (t(144)=-2.193; P<0.05). CONCLUSIONS: Increased distance from clinic and interstate access are associated with increased missed appointments and loss to follow-up. Glaucoma specialists should consider these factors when choosing surgical interventions requiring frequent postoperative evaluations.