Challenges of ophthalmic care in the developing world.

Global blindness exacts an enormous financial and social cost on developing countries. Reducing the prevalence of blindness globally requires a set of strategies that are different from those typically used in developed countries. This was the subject of the 2013 Knapp symposium at the American Ophthalmological Society Annual Meeting, and this article summarizes the presentations of epidemiologists, health care planners, and ophthalmologists. It explores a range of successful strategies from the multinational Vision 2020 Initiative to disease-specific schemes in cataract, trachoma control, infectious corneal ulceration, cytomegalovirus retinitis, and retinopathy of prematurity. In each example, the importance of an attitudinal change set toward public health becomes clear. There is reason for optimism in the struggle against global blindness in large measure because of innovative programs such as those described here.

Glaucoma screening: current perspectives and future directions.

INTRODUCTION: Glaucoma is an optic neuropathy with characteristic progressive optic nerve degeneration. Early detection and treatment may prevent blindness; however, the value of glaucoma screening has been debated. METHODS: Articles pertaining to glaucoma screening were reviewed. RESULTS: In reviewing the glaucoma literature, there is a lack of a sensitive and specific screening test and concerns over cost-effectiveness. Methods of screening include population-based screening and opportunistic case finding, which both have advantages and disadvantages. CONCLUSIONS: Additional research is needed to better understand glaucoma progression as well as to identify improved screening tests. Consideration must be given not only to the feasibility of performing a glaucoma screening, but also to the follow-up and long-term care for glaucoma patients.

Glaucoma public service announcements: factors associated with follow-up of participants with risk factors for glaucoma.

PURPOSE: To determine the prevalence of follow-up and factors associated with completing an eye examination after a glaucoma public service announcement. DESIGN: Cross-sectional observational study. PARTICIPANTS: Individuals who participated in the Glaucoma EyeCare Program by calling a toll-free telephone number and receiving referral by meeting inclusion criteria. METHODS: The Glaucoma EyeCare Program uses public service announcements to encourage those at increased risk for glaucoma to obtain an eye examination. The program requires interested persons to dial a toll-free telephone number to collect demographic, medical, and socioeconomic information, and refers those at higher risk of glaucoma to an ophthalmologist for a free eye examination. The ophthalmologist completes an outcome form, which indicates whether the participant obtained an eye examination and the results of this eye examination. We determined the factors associated with obtaining an eye examination. MAIN OUTCOME MEASURES: Sociodemographic characteristics associated with obtaining an eye examination after referral through the Glaucoma EyeCare Program. RESULTS: Ophthalmologists returned outcome forms for 1514 of 6343 participants (24%). Of those with outcome forms, 671 (44.3%) had an eye examination, 756 (49.9%) did not make an appointment, and 87 (5.7%) made an appointment but did not complete the examination. A multivariate logistic regression model showed younger age, female gender, lack of health insurance, medical history of diabetes, and shorter distance to be associated with obtaining an eye examination. CONCLUSIONS: Public service announcements encourage participants to have an eye examination. Multiple factors alter the success of obtaining an eye examination. Future studies are needed regarding the best method of decreasing the risk of undiagnosed glaucoma.

A perspective on commercial relationships between ophthalmology and industry.

Relationships between physicians and industry including pharmaceutical companies and device manufacturers are being closely scrutinized by the public and the media. These companies can contribute beneficially to patient outcomes by supporting research that improves eye care. However, ethical issues may arise that affect practicing ophthalmologists, researchers, academic faculty, and ophthalmologic organizations. These topics were discussed at a symposium sponsored by the American Ophthalmological Society in May 2008. After this meeting, the council of the society developed this perspective to clarify some of the issues at the interface of industry and ophthalmology. The perspective is intended to provide some guidance to physicians, researchers, and professional societies and to enhance further dialogue.

Glaucoma in the United States and europe: predicting costs and surgical rates based upon stage of disease.

PURPOSE: Primary open-angle glaucoma is a significant health-economic burden in both the United States and Europe that is likely to increase. This study compared treatment patterns and cost among patients with primary open-angle glaucoma in these locations. METHODS: Retrospective medical chart reviews were conducted in the United States (1990 to 2002) and Europe (1995 to 2003). A total sample of 151 US charts and 194 European charts was studied, and patients were assigned a baseline intraocular pressure (IOP) and baseline stage, using a 6-stage visual functional glaucoma staging algorithm. Resource utilization and direct costs were assessed by stage of disease using publicly available United States and European costs. Cox Proportional Hazards modeling were used to examine covariates predicting glaucoma surgery. Total cost was predicted, adjusting for covariates using Generalized Linear Models, with baseline stage as the independent variable. RESULTS: Glaucoma surgery requirement was highly associated with baseline disease stage and IOP increase before surgery in the United States and somewhat associated with these factors in Europe. Within both locations, baseline IOP was highly associated with glaucoma surgery requirement. Controlling for covariates, patients at higher baseline stages incurred greater costs in the United States (P=0.0017) and Europe (P=0.0715). Surgery and medication were also highly predictive of increased cost (P<0.0001). Cost of care differed greatly between the European countries, with costs lowest in Italy. CONCLUSIONS: Increases in annual cost were related to higher baseline IOP, higher baseline stage, medication, and surgery. Thus, significant potential savings and reductions in annual healthcare burden are possible if patients are diagnosed and treated at earlier stages of glaucoma.

Categorizing the stage of glaucoma from pre-diagnosis to end-stage disease.

PURPOSE: To provide a reliable, comprehensive staging system to assess glaucoma stage in the absence of an universally accepted glaucoma staging system (GSS) on the basis of visual field results. DESIGN: Literature review and GSS adaptation. METHODS: After a review of published GSSs was conducted, the Bascom Palmer (Hodapp-Anderson-Parrish) GSS was selected as an appropriate platform for a retrospective GSS on the basis of visual fields. The system was modified by a panel of glaucoma specialists, and additional modifications were made after pilot testing to cover the full range of disease progression, from preglaucoma diagnosis to complete blindness; the ordered stages reflect the typical progression of glaucoma. RESULTS: The GSS is comprised of six ordered stages and is on the basis of the Humphrey visual field. The completed GSS was validated by reviewing patient charts from 12 US glaucoma centers. CONCLUSIONS: The GSS allows accurate staging of 100% of glaucoma on the basis of visual fields and other data, enabling evaluation of disease progression and resource utilization at various glaucoma stages. Additionally, treatment costs may be assigned to determine cost-effectiveness of treatment. Research utilizing the GSS has found that cost of care increases with increasing disease severity. The GSS may be used as the basis for creating treatment guidelines, which have the potential to delay glaucoma progression and lower treatment costs.

A multicenter, retrospective pilot study of resource use and costs associated with severity of disease in glaucoma.

OBJECTIVE: To examine resource consumption and the direct costs of treating glaucoma at different disease severity levels. DESIGN: Observational, retrospective cohort study based on medical record review. PARTICIPANTS: One hundred fifty-one records of patients with primary open-angle or normal-tension glaucoma, glaucoma suspect, or ocular hypertension (age > or =18 years) were randomly selected from 12 sites in the United States and stratified according to severity based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients had to have been followed up for a minimum of 5 years. Patients with concomitant ocular disease likely to affect glaucoma treatment-related resource consumption were excluded. METHODS: Glaucoma severity was assessed and assigned using a 6-stage glaucoma staging system, modified from the Bascom Palmer (Hodapp-Anderson-Parrish) system. Clinical and resource use data were collected from the medical record review. Resource consumption for low-vision care and vision rehabilitation was estimated for patients with end-stage disease based on specialist surveys. For each stage of disease, publicly available economic data were then applied to assign resource valuation and estimate patient-level direct costs from the payer perspective. MAIN OUTCOME MEASURES: Average annual resource use and estimated total annual direct cost of treatment were calculated at the patient level and stratified by stage of disease. Direct costs by specific resource types, including ophthalmology visits, glaucoma surgeries, medications, visual field examinations, and other glaucoma services, were also assessed. RESULTS: Direct ophthalmology-related resource use, including ophthalmology visits, glaucoma surgeries, and medication use, increased as disease severity worsened. Average direct cost of treatment ranged from $623 per patient per year for glaucoma suspects or patients with early-stage disease to $2511 per patient per year for patients with end-stage disease. Medication costs composed the largest proportion of total direct cost for all stages of disease (range, 24%-61%). CONCLUSIONS: The study results suggest that resource use and direct cost of glaucoma management increase with worsening disease severity. Based on these findings, a glaucoma treatment that delays the progression of disease could have the potential to significantly reduce the health economic burden of this chronic disease over many years.

Converting to SITA-standard from full-threshold visual field testing in the follow-up phase of a clinical trial.

PURPOSE: To evaluate the impact of converting from Humphrey 24-2 full-threshold (FT) visual field (VF) testing to SITA-Standard (SS) VF testing during the follow-up phase of a clinical trial. METHODS: VF data were obtained from 243 patients in the Collaborative Initial Glaucoma Treatment Study (CIGTS) who had follow-up visits in 2004. FT and SS VF tests were performed in random order on the same day. RESULTS: The average duration of the SS test (6.3 minutes) was shorter (P < 0.0001, paired t-test) than the FT test (11.8 minutes). The mean deviation did not differ between SS and FT testing. A small difference was found in the pattern SD (PSD) (P = 0.02). The mean CIGTS score from the FT test (4.5) was significantly lower (P < 0.0001) than the mean CIGTS score from the SS test (6.0). Although the two tests yielded identical Glaucoma Hemifield Test (GHT) results in 179 patients (76%), 16 patients had a normal GHT result on FT testing and an SS test result that was outside normal limits. Six patients had the reverse finding. The most significant factor associated with an increased (positive) difference between the CIGTS VF score generated from SS and FT testing was conducting the FT test first (P < 0.0001). CONCLUSIONS: Although SS and FT testing yielded very similar mean deviation results, the CIGTS VF score and GHT differed between SS and FT tests. Changing the approach used to measuring a study's primary VF outcome should be accompanied by a critical evaluation of the change's impact.

Intraocular pressure in a Somali population living in the United States.

PURPOSE: Intraocular pressure is a risk factor for the development of glaucomatous optic neuropathy. With few exceptions, higher mean intraocular pressure and greater prevalences of glaucoma have been reported for individuals of African origin. This study was performed to compare the mean intraocular pressure of a group of ethnic East Africans living in the United States with that of Caucasians living in the same community. PATIENTS AND METHODS: Retrospective comparison of Somali patients 30 years of age or greater with age- and gender-matched Caucasian control subjects. All patients were seen in the same clinic in Seattle, Washington, between July 1996 and March 1998. Patients were excluded for conditions or medications affecting intraocular pressure and for a diagnosis of glaucoma. Mean intraocular pressure of the two populations was compared using an independent sample two-tailed t test. RESULTS: Following exclusions and defined age limits, 57 Somali patients and 57 Caucasian control subjects were included in the final analysis. Mean age of Somalis was 48.5 +/- 12.2 years versus 48.1 +/- 11.3 years for control subjects (P = 0.84). The mean intraocular pressure of Somalis was 13.76 +/- 3.63 mm Hg versus 13.94 +/- 2.78 mm Hg for control subjects (P = 0.77). CONCLUSION: Some populations of African origin may not have higher mean intraocular pressures compared with non-African populations. Consideration of ethnic and racial origins more specific than "African" should be given when evaluating intraocular pressure in individual patients.

The collaborative initial glaucoma treatment study: baseline visual field and test-retest variability.

PURPOSE: To compare the baseline Collaborative Initial Glaucoma Treatment Study (CIGTS) visual field (VF) score and mean deviation (MD), investigate test-retest variability, and identify variables associated with VF loss and VF measurement variability. METHODS: Baseline data from a randomized clinical trial of 607 patients with newly diagnosed open-angle glaucoma were collected at 14 clinical centers. The CIGTS VF score and MD were obtained from 24-2 VF tests (Zeiss-Humphrey Systems, Dublin, CA) at two visits approximately 2 weeks apart. RESULTS: Although most baseline CIGTS VF scores showed limited field loss, 15% (91/607) of patients showed a substantial deficit (VF score >10 on a 0-20 scale). A small but significant learning effect was seen over the two baseline measures for CIGTS VF score and MD. CIGTS VF score and MD correlate highly (r = -0.93); both have high test-retest correlation (0.83 and 0.91, respectively). Variables associated with greater baseline VF loss for both CIGTS VF score and MD include (probabilities for VF only): male sex (P = 0.018), black race (P

Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study.

The purpose of this study was to gain insights into why patients are not compliant with their glaucoma medications. Patients were recruited from lists provided by two ophthalmologists. Each patient had seen a minimum of two ophthalmologists for their glaucoma, and was taking at least two topical medications for glaucoma. Qualitative methodology was utilized, including two focus groups and eleven in-depth interviews in patients' homes. The results showed that forgetfulness was the number one reported reason for non-compliance. Patients did not claim to be non-compliant specifically because of side effects, but they did complain about them. Communication between physicians and patients is a key factor in compliance for glaucoma patients. Specifically, patients would like their physicians to teach them how to instill their eye drops, tell them about new/alternate medications and procedures as they become available, and offer new ways to make their regimen easier. Patients often do not tell their physician if they experience a side effect unless it is intolerable to them, yet they do realize the seriousness of glaucoma, and the consequences of not following their doctor's orders. Finally, while cost was not a reported deterrence to compliance, some patients would prefer less expensive alternatives.

Topographic mapping of glaucomatous visual field defects to scanning laser polarimetry of the peripapillary nerve fiber layer.

BACKGROUND AND OBJECTIVE: To map retinal sensitivity values within glaucomatous visual field defects (VFD) to corresponding values of scanning laser polarimetry (SLP) of the peripapillary retinal nerve fiber layer using the Wirtschafter disc sector classification. METHODS: Eyes with glaucomatous VFD (N = 28) underwent SLP and Humphrey automated perimetry. The Wirtschafter disc sector classification was used to obtain SLP values corresponding to VFD. The average and modulated SLP values were calculated and correlated with VFD. RESULTS: No significant correlation was found between retinal sensitivity and the Wirtschafter disc sector SLP values, using average values (P =.904) or modulated values (P =.409). CONCLUSION: Despite use of modulation parameters customized to correspond with the Wirtschafter disc sector classification, topographic mapping of retinal sensitivity levels within glaucomatous VFD to corresponding SLP values was not possible in this group of glaucomatous eyes.

Clinician change detection viewing longitudinal stereophotographs compared to confocal scanning laser tomography in the LSU Experimental Glaucoma (LEG) Study.

PURPOSE: To compare optic nerve head (ONH) surface change detection by confocal scanning laser tomography (CSLT) within the LSU Experimental Glaucoma (LEG) study to expert clinicians viewing the LEG stereophotographs. DESIGN: Experimental study. PARTICIPANTS: Four fellowship-trained glaucoma specialists. METHODS: In the LEG study, six 15 CSLT images (TopSS, Laser Diagnostics Technologies, San Diego, CA) and four 2x optic disc stereophotographs were obtained from both eyes of 12 monkeys on 3 separate days and then every 2 weeks after laser to one eye (study eye) to elevate intraocular pressure. ONH surface change detection within the CSLT images is described in our companion report. In this report, the preliminary study compared change detection by the CSLT multivariate strategy with that of a single clinician viewing stereophotograph pairs on three separate occasions as the "gold standard." The main study compared change detection by three additional clinicians viewing a subset of LEG stereophotograph pairs on three separate occasions with that of the CSLT multivariate strategy as the "gold standard." Clinician change detection was assessed for partial (two of three occasions) or complete (three of three occasions) agreement. Three comparison groups within the main study are emphasized: 44 group A comparisons assessed false-positive change detection (specificity); 38 group B comparisons assessed change detection within 38 instances (11 onset and 27 progression events) of CSLT-detected study eye change; and 30 group C comparisons assessed change detection within 30 instances in which the CSLT failed to detect change in study eyes. MAIN OUTCOME MEASURES: Clinician change detection within each comparison with either partial or complete agreement. RESULTS: Within the main study, intrareading (-.29 to 0.67) and interreading (0.24--0.56) session agreement for each clinician was slight to moderate by kappa test. Good specificity (less than 10% false-positive change detection) was achieved within the 44 group A comparisons by two of the three clinicians, but only when the more stringent criterion (change detection on three of three occasions) was applied. Of the 38 group B comparisons (in which the CSLT detected change), the two clinicians who achieved good specificity in group A failed to detect change in 25 and 16 instances, respectively, using the more stringent (three of three) criterion. Similarly, of the 30 group C comparisons (in which the CSLT failed to detect change), these two clinicians detected change in three and seven instances, respectively, but in only one comparison did they both detect change. CONCLUSIONS: This study provides the first direct evidence that an existing CSLT may reasonably meet or exceed the ONH surface change detection performance of fellowship-trained glaucoma specialists in at least those eyes with good CSLT reproducibility.