National Utilization of Glaucoma Laser and Surgical Management in Medicare Beneficiaries: Disparities and Accessibility.

PRCIS: In this population-based, cross-sectional study of Medicare beneficiaries, there were lower odds of national glaucoma surgery among ages older than 85, female sex, Hispanic ethnicity, and diabetic comorbidity. Glaucoma surgery rates were independent of ophthalmologist distribution. PURPOSE: With an increasing prevalence of glaucoma in the United States, it is crucial to elucidate surgical procedure accessibility to deliver quality care. The objective of this study was to estimate national access to surgical glaucoma care by (1) comparing diagnostic and surgical management Medicare insurance claims followed by (2) correlating Medicare treatment claims with regional ophthalmologist availability. PATIENTS AND METHODS: This cross-sectional study included Medicare claims from the 2017 Vision and Eye Health Surveillance System and workforce data from the 2017 Area Health Resource Files, both public domain databases. A total of 25,443,400 beneficiaries fully enrolled in Medicare Part B Fee-for-Service with glaucoma diagnosis claims were included. Rates of US MD ophthalmologists were determined by Area Health Resource Files distribution densities. Surgical glaucoma management rates included Medicare service utilization claims for drain, laser, and incisional glaucoma surgery. RESULTS: While Black, non-Hispanic Americans had the highest prevalence of glaucoma, Hispanic beneficiaries had the highest odds of surgery. Older age (85+ vs. 65-84 y; Odds Ratio [OR]=0.864; 95% Confidence Interval [CI], 0.854-0.874), female sex (OR=0.923; 95% CI, 0.914-0.932), and having diabetes (OR=0.944; 95% CI, 0.936-0.953) was associated with lower odds of having a surgical glaucoma intervention. Glaucoma surgery rates were not associated with ophthalmologist density by state. CONCLUSIONS: Glaucoma surgery utilization differences by age, sex, race/ethnicity, and systemic comorbidities warrant further investigation. Glaucoma surgery rates are independent of ophthalmologist distribution by state.

Iridoschisis: visual outcome in treated versus untreated eye.

A 67-year-old man was referred for iris color change. He was noted to have narrow angles with atrophic iris appearance and visually significant cataracts. The iris findings were consistent with iridoschisis. The patient was recommended to have cataract surgery. Unfortunately, he was lost to follow-up. One year later, he presented with chronic angle closure glaucoma on the right eye with very high pressure and very poor remaining vision. Left-eye vision was also compromised with cataract. Despite the presence of small pupil, abnormal iris stroma, and dense cataract, the patient underwent successful cataract surgery and achieved 20/20 vision post-operatively. Iridoschisis can cause substantial ocular morbidity if not treated timely.

Complication of an Ahmed glaucoma valve implant: tube exposure with methicillin-resistant Staphylococcus aureus infection.

Neovascular glaucoma is commonly treated surgically with implantation of glaucoma drainage devices. We report the case of a 57-year-old man who underwent an uneventful Ahmed glaucoma valve (AGV) placement for radiation-induced neovascular glaucoma but later developed early postoperative infection with tube exposure. The infection was identified 3 weeks postoperatively and antibiotic treatment was immediately initiated. However, the conjunctival melt progressed, and the AGV had to be removed. Culture of the device revealed methicillin-resistant Staphylococcus aureus (MRSA). There is a potential increased risk of postoperative infection and tube exposure following glaucoma valve implantation in patients with previous radiation therapy. To our knowledge, this is the second case in the literature of MRSA causing early postoperative infection following drainage device placement that required explantation.

Psychomotor vigilance and visual field test performance.

INTRODUCTION: Visual field test is an invaluable tool to evaluate the detection and progression of glaucoma. On the other hand, as a subjective test, reliable results depend on patients' optimum performance including vigilance during the test. The purpose of this study was to understand patient's attitude and preferences about the visual field test taking, and in addition to assess the relationship between the reliability indices of visual field testing (VFT) and the Walter Reed Psychomotor Vigilance Test (PVT). MATERIAL AND METHODS: In this cross-sectional, non-interventional study, VFT reliability indices were recorded for all 140 patients. In the 46 patients who completed the PVT, average reaction time and minimum reaction times were recorded. All 140 patients completed a survey about their VFT experience. RESULTS: Based on the survey results, most subjects found VFT to be difficult. Subjects who rated their VFT performance excellent/good had similar VFT reliability rates compared to the ones with fair/poor self-assessments. The average reaction time (RT) was 0.6 seconds (0.3-1.9 seconds). Higher average RT was associated with increased age and less formal education (p < 0.001 and 0.03, respectively). There was a marginally significant correlation between average RT and the VFT "reliability" status (p = 0.045). CONCLUSIONS: While VFT is the least favorable part of the work-up for glaucoma patients, their self-assessment about VFT performance did not correlate with current VF reliability indicators. Although reliability of the VFT was not strongly affected by slower reaction times when tested by the PVT, the effect of psychomotor reaction time on other aspects of test outcomes is unknown and warrants further investigation.

The effect of mydriatic solutions on cognitive function.

INTRODUCTION: Anticholinergic and sympathomimetic ophthalmic solutions are used for mydriasis. These solutions have well-documented systemic side effects despite their topical administration. However, no studies have been conducted regarding the effect of mydriatic drops on cognitive function. The purpose of this study is to determine the effect, if any, of mydriatic drops on cognitive function, including memory, concentration, and orientation. METHODS: Participants were randomized into two groups using the technique of permuted block randomization, and randomization was stratified by gender, age, and education. Participants in Group 1 completed the Montreal Cognitive Assessment (MoCA) test with undilated pupils, while participants in Group 2 completed the MoCA test with dilated pupils. Administration time of the MoCA test was approximately 10 minutes, and each participant could receive a maximum of 30 points, with a score of 26 or greater being considered normal cognitive function. Dilation was achieved in both eyes with a combination of tropicamide 0.5% and phenylephrine 2.5%. RESULTS: There was no statistical difference between the MoCA scores of Group 1 and Group 2 (p = 0.65). In addition, MoCA scores were not statistically different between the glaucoma and non-glaucoma subpopulations within each group. MoCA test scores were shown to correlate with education (p = 0.004), age (p = 0.0003), and race (p = 0.03). Patients with confirmed or suspected glaucoma whom eyes dilated required 10.8 minutes to complete the MoCA test, while patients with no confirmed or suspected glaucoma whom eyes dilated required 8.5 minutes to complete the test (p = 0.02). DISCUSSION: Age, race, and education were found to be the most important factors affecting cognitive function in this study. There was no significant difference in the MoCA test scores of participants with confirmed or suspected glaucoma and participants without glaucoma. There was also no significant difference in the MoCA scores of dilated participants and non-dilated participants as a whole. However, dilation significantly increased the amount of time required to complete the MoCA test among the glaucoma and suspected-glaucoma population. The results of this study suggest that physicians should spend more time with dilated glaucoma patients while explaining medical conditions and treatment instructions in order to ensure that patients have adequate time to comprehend instructions for glaucoma management.

Optic disc and visual test findings in patients with migraine.

This study was conducted to determine whether the optic disc appearance and the visual field parameters of patients with migraine vary from those of age-matched controls. Twenty-two patients with migraine and 20 control participants were enrolled in the study. The automated visual field tests by Humphrey Field Analyzer® and optic disc images by Topcon® fundus camera were obtained from each participant. Horizontal and vertical cup-to-disc ratios were calculated by a manual, planimetric technique performed by two independent observers. The visual field indices including mean deviation (MD) and pattern standard deviations (PSD) were documented. No difference was found in the average cup-to-disc ratio between patients with migraine and control participants. However, MD and PSD of the groups were different. The average MD in the migraine group was -0.86+1.21, and in the control group was 0.10+1.03 (p=0.009). The average PSD in the migraine group was 2.11+0.68 and in the control group was 1.68+0.44 (p=0.024). In conclusion, this study demonstrated that patients with migraine had decreased sensitivity in their visual fields compared to the control participants.

Prevalence of visual impairment and eye diseases in Arkansas.

Visual impairment and eye diseases are major public health concerns of the 21st century, particularly as our population ages. The prevalence of these conditions has not been described in Arkansas. We analyzed the vision module of the Arkansas behavioral risk factor surveillance system to estimate the burden due to these disabling conditions. The prevalence of glaucoma, age-related macular degeneration, and cataract among Arkansans > 40 years was found to be 5.5% (95% CI, 4.7 - 6.3), 5.3% (95% CI, 4.5 - 6.0), and 13.7% (95% CI, 12.6 - 14.8), respectively. Vision related quality of life was also studied. Public health strategies to reduce the burden due to visual impairment and eye diseases are the need of the hour.

Intraocular pressure change after temporal clear corneal phacoemulsification in normal eyes.

PURPOSE: To evaluate short- and long-term intraocular pressure (IOP) changes after temporal clear corneal phacoemulsification in normal eyes. METHODS: The charts of 266 consecutive non-glaucoma patients who underwent uneventful cataract surgery were reviewed. We recorded preoperative and postoperative (1 day, 1 week, 1 month, 3 months, 6 months, 1 year and 2 years) IOP measurements as well as anatomical properties obtained using Zeiss Humphrey IOL Master (Zeiss Meditech, Dublin, California, USA). RESULTS: Mean IOP reduction after cataract surgery was 8.2%, 4.6%, 6.7% and 7.8% at 3 months, 6 months, 1 year and 2 years, respectively. Lens thickness was the only anatomical characteristic that correlated significantly with IOP decrease after surgery. CONCLUSION: Temporal clear corneal phacoemulsification results in a decrease in postoperative IOP that persists for 2 years following surgery.

Glare testing in patients with cataract after dilation.

PURPOSE: To learn whether dilating the pupil will have an impact on glare testing for cataract evaluation. DESIGN: Evaluation of diagnostic test. PARTICIPANTS: Fifty-four adult patients at the Jones Eye Institute at the University of Arkansas for Medical Sciences. METHODS: One eye of each patient was randomized for study. The pupil size, visual acuity (VA) using the Early Treatment Diabetic Retinopathy Study (ETDRS) acuity chart, and glare testing with the Brightness Acuity Tester (BAT) at the medium setting were performed. The patients' eyes were then dilated with all measurements repeated. Each patient was then graded for cataracts using the Lens Opacification Classification System III by an independent observer. MAIN OUTCOME MEASURES: VA and BAT results. RESULTS: Compared with undilated BAT results, 29 of 54 patients (53.7%) lost 1 or more lines of vision during BAT testing after dilation. Undilated BAT results were predicted to within 1 line of accuracy in 44 of 54 patients (81.5%) by adjusting the dilated BAT result by the change in VA from dilation. With this method, results were predicted to within 2 lines of accuracy in 52 of 54 patients (96.3%). CONCLUSIONS: BAT results are affected by dilation half of the time and can be adjusted by the change in VA from dilation to predict undilated BAT results.