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To compare patient demographic data; level of severity; and clinical, diagnostic, and surgical practice patterns in patients with primary open-angle glaucoma (POAG) in an academic setting vs nonacademic setting using the American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight).A retrospective cohort study of IRIS Registry data that included patients with POAG who were seen between January 2016 and December 2019 and had at least 1 year of follow-up.Of 3 707 084 distinct eyes with POAG, 3% (109 920) were included in the academic subcohort and 97% (3 597 164) were included in the nonacademic subcohort. Among the findings of greatest note (P.0001 for all comparisons) were a higher proportion of eyes of Black patients, a higher proportion of eyes with level 3 severity, and a higher mean cup-to-disc ratio in eyes in the academic setting. The relative frequency of gonioscopy, pachymetry, and visual field testing in conjunction with new patient visits was also notably higher in the academic setting. For glaucoma surgical procedures, the greatest proportional differences in relative frequency were seen for tube shunt procedures (2.55-fold higher in the academic setting), iStent and Hydrus procedures (2.52-fold higher in the nonacademic setting), and endoscopic cyclophotocoagulation (5.80-fold higher in the nonacademic setting).Based on IRIS Registry data, notable differences appear to exist with regard to ethnoracial groups, glaucoma severity, and diagnostic and surgical practice patterns in academic vs nonacademic settings. By understanding these differences, potential opportunities exist in the development of educational programs related to clinical and surgical glaucoma care.

To assess risk factors for repeat keratoplasty after endothelial keratoplasty (EK).Retrospective cohort study.EK procedures performed between 2013 and 2018 in the IRIS Registry (Intelligent Research in Sight) were identified.Patients aged 18 years and older who underwent EK.(1) Risk factors for repeat keratoplasty and (2) complication rates after EK. A Kaplan-Meier survival analysis was used to determine the probability of repeat keratoplasty. A multivariable shared frailty survival model was used to assess risk factors.A total of 59 344 procedures were identified in the registry, of which 30 600 EK procedures met the inclusion criteria for the analysis. The probability of repeat keratoplasty was 17.4% (95% CI 16.7-18.0) at 5 years. Risk factors for repeat keratoplasty include postoperative rebubbling procedure (HR 2.24, 95% CI 2.05-2.45), prior failed graft (HR 2.07, 95% CI 1.84-2.32) or bullous keratopathy (HR 1.47, 95% CI 1.33-1.61) vs Fuchs dystrophy as surgical indication; subsequent routine cataract surgery (HR 1.61, 95% CI 1.45-1.79), as well as subsequent (HR 1.53, 95% CI 1.39-1.69) and prior/concurrent (HR 1.23, 95% CI 1.11-1.36) glaucoma surgery or history of glaucoma (HR 1.24, 95% CI 1.14-1.35). Medicaid (HR 1.47, 95% CI 1.13-1.92), military/government (HR 1.29, 95% CI 1.03-1.60), Medicare Fee-for-Service (HR 1.17, 95% CI 1.05-1.31) or Medicare Managed (HR 1.17, 95% CI 1.01-1.36) insurances vs private insurance, as well as Black vs White race (HR 1.25, 95% CI 1.11-1.40) and smoking (HR 1.16, 95% CI 1.05-1.27) were also associated with an increased risk of undergoing repeat keratoplasty.Black race, government-based insurance plans, and smoking were identified as independent factors associated with repeat keratoplasty in addition to history of glaucoma, glaucoma surgery, and prior graft failure or bullous keratopathy as surgical indication.

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.

Purpose Minimally invasive glaucoma surgery (MIGS) is increasingly performed at the time of cataract extraction. Understanding the demographic and clinical characteristics of patients undergoing MIGS procedures may provide insight into patient selection. This study evaluates racial-ethnic and other differences in the use of MIGS in persons with cataract and open-angle glaucoma (OAG). Design Retrospective cohort study using Intelligent Research in Sight (IRIS) Registry data. Participants Patients aged ≥ 40 years with a diagnosis of OAG and no history of MIGS or cataract surgery who were undergoing cataract extraction, with or without MIGS, during 2013 to 2017 in the United States. Methods Multivariable logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Main Outcome Measures Variables assessed include age, sex, race-ethnicity, disease severity, insurance type, census region, comorbidity, and cup-to-disc ratio (CDR). Results The odds of MIGS use was greater among patients who were aged ≥ 60 years (OR, 1.10 [95% CI, 1.05–1.16]); Black (OR, 1.11 [CI, 1.07–1.15]) compared with White; a Medicare recipient (OR, 1.12 [CI, 1.10–1.15]) versus privately insured; or in the Midwest (OR, 1.32 [CI, 1.28–1.36]) or Northeast (OR, 1.26 [CI, 1.22–1.30]) compared with the South. Having moderate rather than mild glaucoma (OR, 1.07 [CI, 1.04–1.11]) and a higher CDR (OR for 0.5 to 0.8 vs. 0.8 to 1.0 vs. Conclusions This analysis highlights the importance of capturing race-ethnicity data and other pertinent patient characteristics in electronic health records to provide insight into practice patterns. Such data can be used to assess the long-term performance of MIGS and other procedures in various patient populations.

Purpose To identify systematic reviews of interventions for glaucoma conditions and to assess their reliability, thereby generating a list of potentially reliable reviews for updating glaucoma practice guidelines. Design Cross-sectional study. Participants Systematic reviews of interventions for glaucoma conditions. Methods We used a database of systematic reviews and meta-analyses in vision research and eye care maintained by the Cochrane Eyes and Vision United States Satellite. We examined all Cochrane systematic reviews of interventions for glaucoma conditions published before August 7, 2019, and all non-Cochrane systematic reviews of interventions for glaucoma conditions published between January 1, 2014, and August 7, 2019. Main Outcome Measures We assessed eligible reviews for reliability, extracted characteristics, and summarized key findings from reviews classified as reliable. Results Of the 4451 systematic reviews in eyes and vision identified, 129 met our eligibility criteria and were assessed for reliability. Of these, we classified 49 (38%) as reliable. We found open-angle glaucoma (22/49) to be the condition with the most reviews and medical management (17/49) and intraocular pressure (IOP; 43/49) to be the most common interventions and outcomes studied. Most reviews found a high degree of uncertainty in the evidence, which hinders the possibility of making strong recommendations in guidelines. These reviews found high-certainty evidence about a few topics: reducing IOP helps to prevent glaucoma and its progression, prostaglandin analogs are the most effective medical treatment for lowering IOP, laser trabeculoplasty is as effective as medical treatment as a first-line therapy in controlling IOP, the use of IOP-lowering medications in the perioperative or postoperative periods to accompany laser (e.g., trabeculoplasty) reduces the risk of postoperative IOP spikes, conventional surgery (i.e., trabeculectomy) is more effective than medications in reducing IOP, and antimetabolites and β-radiation improve IOP control after trabeculectomy. The evidence is weak regarding the effectiveness of minimally invasive glaucoma surgeries. Conclusions Most systematic reviews evaluating interventions for glaucoma are of poor reliability. Even among those that may be considered reliable, important limitations exist in the value of information because of the uncertainty of the evidence as well as small and sometimes unimportant clinical differences between interventions.

Purpose This study compared 1-year results for the composite treatment outcome from the Tube Versus Trabeculectomy (TVT) randomized controlled trial (RCT) to those from an IRISⓇ (Intelligent Research In Sight) Registry cohort of analogous eyes. Design Retrospective clinical study with comparison to an RCT. Methods Subjects’ eyes in the IRIS Registry received either a glaucoma drainage implant (tube) or underwent trabeculectomy after a previous trabeculectomy and/or cataract extraction and had data for 1-year follow-up analyses. Outcome Eyes were classified as failing if they had hypotony (intraocular pressure (IOP) ≤5 mm Hg) or inadequate IOP control (IOP >21 mm Hg or not reduced at least 20% below baseline) on 2 consecutive follow-up visits after 3 months, a reoperation for glaucoma, or no light perception vision and as successful otherwise. Failure risk was compared by treatment, demographic, and clinical variables and was compared to analogous failure risks from the TVT RCT. Results The TVT IRIS Registry cohort included 419 eyes, 236 tube eyes (56.3%) and 183 trabeculectomy eyes (43.7%). In this cohort, there was no significant failure risk difference (12.3% for tube eyes and 16.4% for trabeculectomy eyes, P = 0.231). Comparing the studies, there was a significantly greater risk of failure in the TVT IRIS Registry tube eyes than in the TVT RCT tube eyes (3.8%; P Conclusions Our results were different from those in the TVT RCT. Possible reasons include non-Baerveldt tubes, greater severity among tube eyes, and practice patterns that reflect real-world data, which are different than those in RCTs.

In 2019, the American Academy of Ophthalmology (AAO) created the Task Force on Myopia in recognition of the substantial global increases in myopia prevalence and its associated complications. The Task Force, led by Richard L. Abbott, MD, and Donald Tan, MD, comprised recognized experts in myopia prevention and treatment, public health experts from around the world, and organization representatives from the American Academy of Family Physicians, American Academy of Optometry, and American Academy of Pediatrics. The Academy's Board of Trustees believes that myopia is a high-priority cause of visual impairment, warranting a timely evaluation and synthesis of the scientific literature and formulation of an action plan to address the issue from different perspectives. This includes education of physicians and other health care providers, patients and their families, schools, and local and national public health agencies; defining health policies to ameliorate patients' access to appropriate therapy and to promote effective public health interventions; and fostering promising avenues of research.

Purpose Detailed study of ophthalmic immune-related adverse events (AEs), including determination of incidence and recurrence rates, is of integral importance in cancer immunotherapy to inform management and treatment guidelines. Design Retrospective registry study. Participants Patients newly diagnosed with ophthalmic immune-related AEs between January 1, 2013, and December 31, 2017, in the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS®) Registry. Methods Data were collected from electronic health records of IRIS® Registry participating ophthalmology practices. Patients with select ophthalmic immune-related AEs were identified by International Classification of Diseases diagnosis codes. The primary exposure of interest was prior initiation of immune checkpoint inhibitors (ICIs). Main Outcome Measures Incidence of ophthalmic immune-related AEs within 1 year after initiation of ICI therapy was determined. Incidence rate ratios (IRRs) were derived by comparing incidence of ophthalmic immune-related AEs after ICIs versus rates of the same ocular complications in patients not taking ICIs in the entire registry population. Rates of ophthalmic immune-related AEs in patients with a past history of ocular inflammation or other specific ophthalmic condition before initiation of ICIs were examined further. Results A total of 3123 patients who received anti-CTLA-4 or anti-programmed cell death 1 (PD-1) therapy were identified, 112 of whom demonstrated an ophthalmic immune-related AE. Incidence rates for anterior uveitis, the most common ophthalmic immune-related AE, were 8209 per 100 000 for ipilimumab (anti-CTLA-4), 2542 per 100 000 for nivolumab (anti-PD-1), 2451 per 100 000 for pembrolizumab (anti-PD-1), 5556 per 100 000 for ipilimumab plus nivolumab, and 3740 per 100 000 among all ICIs. Rates of ophthalmic immune-related AEs among patients receiving ICI therapy were higher compared with baseline rates in the general registry population (anterior uveitis IRR, 13.9; other uveitis IRR, 43.0; papilledema IRR, 38.3). Patients with a history of uveitis or other ocular inflammatory condition demonstrated high recurrence rates of ophthalmic immune-related AEs after initiating ICIs (up to 51.1%). Conclusions For patients initiating ICI therapy, early coordination with ophthalmic subspecialist care is important because rates of ophthalmic immune-related AEs are elevated compared with ocular complication rates in the entire registry population and patients with a history of prior autoimmune ocular disease are at high risk of recurrence of ocular complications.

Purpose To investigate the rate of return to the operating room after vitrectomy surgery for vitreous opacities. Design Retrospective registry cohort. Participants Individuals receiving care in ophthalmology practices participating in the Intelligent Research in Sight (IRIS®) Registry. Methods Data from the IRIS Registry were analyzed for patients who underwent vitrectomy for vitreous opacities. Cases were identified by the combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), codes (379.21, 379.22, 379.24, and 379.25), and a Current Procedural Terminology (CPT) code for vitrectomy surgery. Main Outcome Measures The number and percentage of eyes that underwent additional eye surgery within 1 year after vitrectomy for vitreous opacities were identified, as was the nature of the additional procedures per CPT code. Results Fifty thousand eight hundred thirty-six eyes that underwent vitrectomy surgery linked to one of the ICD-9-CM or ICD-10-CM codes for vitreous opacities were identified. In 17 615 eyes, the surgery was linked to the vitreous opacities code exclusively, and not to epiretinal membrane or macular hole codes. Of these, 2187 eyes (12.4%) returned to the operating room for cataract surgery, and 643 eyes (3.7%) returned to the operating room for a noncataract procedure. Four hundred fifty-seven eyes (2.6%) returned to the operating room for retinal detachment repair. Conclusions In the IRIS Registry, eyes undergoing vitrectomy for vitreous opacities returned to the operating room for an ophthalmic surgery other than cataract extraction 3.7% of the time, and retinal detachment repair was performed 2.6% of the time.

Purpose To model Medicare Part B and patient savings associated with increased bevacizumab payment and utilization for intravitreal anti-vascular endothelial growth factor (VEGF) therapy. Design Cost analysis. Methods Medicare claims and IRIS® Registry data were used to calculate Medicare Part B expenditures and patient co-pays for anti-VEGF agents with increasing reimbursement and utilization of bevacizumab relative to ranibizumab and aflibercept. Main outcome measures Medicare Part B costs and patient co-pays for anti-VEGF agents in the Medicare fee-for-service (FFS) population. Results Increasing bevacizumab reimbursement to $125.78, equalizing the dollar margin with aflibercept, would result in Medicare Part B savings of $468 million and patient savings of $119 million with a 10% increase in bevacizumab market share. Conclusions Increased utilization of bevacizumab achievable with increased reimbursement to eliminate the financial disincentive to its use would result in substantial savings to the Medicare Part B program and to patients receiving anti-VEGF intravitreal injections.

Purpose To compare the average intraocular pressure (IOP) among smokers, past smokers, and never smokers using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry. Design Retrospective database study of the IRIS® Registry data. Participants Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017. Methods Patients were divided into current smoker, past smoker, and never smoker categories. The IOP was based on an average measurement, and separate analyses were performed in patients with and without a glaucoma diagnosis based on International Classification of Diseases (Ninth Edition and Tenth Edition) codes. Stratified, descriptive statistics by glaucoma status were determined, and the relationship between smoking and IOP was assessed with a multivariate linear regression model. Main Outcome Measures Mean IOP. Results A total of 12 535 013 patients were included. Compared with never smokers, current and past smokers showed a statistically significantly higher IOP by 0.92 mmHg (95% confidence interval [CI], 0.88–0.95 mmHg) and 0.77 mmHg (95% CI, 0.75–0.79 mmHg), respectively, after adjusting for age, gender, glaucoma, age-related macular degeneration, diabetic retinopathy, cataract, glaucoma surgery, cataract surgery, and first-order interactions. In addition, the difference in IOP between current and never smokers was the highest in the fourth decade, regardless of the glaucoma status (glaucoma group, 1.14 mmHg [95% CI, 1.00–1.29 mmHg]; without glaucoma group, 0.68 mmHg [95% CI, 0.65–0.71 mmHg]). Conclusions Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.

Purpose To determine recent incidence and visual outcomes for acute-onset endophthalmitis after cataract surgery performed in the United States. Design Retrospective cohort study. Participants United States cataract surgery patients, 2013-2017 (5 401 686 patients). Methods Cases of acute-onset postoperative endophthalmitis occurring within 30 days after cataract surgery were identified using diagnosis codes in the American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry database, drawn from electronic health records in ophthalmology practices across the nation. Annual and aggregate 5-year incidences were determined for all cataract surgeries and specifically for standalone procedures versus those combined with other ophthalmic surgeries. Patient characteristics were compared. Mean and median visual acuity was determined at 1 month preoperative as well as 1 week, 1 month, and 3 months postoperative among patients with and without endophthalmitis. Main Outcome Measures Incidence of acute-onset postoperative endophthalmitis after cataract surgery. Results A total of 8 542 838 eyes underwent cataract surgery, 3629 of which developed acute-onset endophthalmitis (0.04%; 95% confidence interval, 0.04%–0.04%). Endophthalmitis incidence was highest among patients aged 0 to 17 years (0.37% over 5 years), followed by patients aged 18 to 44 years (0.18% over 5 years; P Conclusions Acute-onset endophthalmitis occurred in 0.04% of 8 542 838 cataract surgeries performed in the United States between 2013 and 2017. Risk factors may include younger age, cataract surgery combined with other ophthalmic surgeries, and anterior vitrectomy. Visual acuity outcomes vary; however, patients can recover excellent vision after surgery. Big data from clinical registries like the IRIS Registry has great potential for evaluating rare conditions such as endophthalmitis, including developing benchmarks, longer-term time trend investigation, and comprehensive analysis of risk factors and prophylaxis.

This retrospective analysis of the IRIS ® Registry (Intelligent Research in Sight) sought to characterize real-world treatment patterns and visual outcomes among patients with diabetic macular edema in US clinical practice.

Purpose To investigate ophthalmologists’ rate of attestation to meaningful use (MU) of their electronic health record (EHR) systems in the Medicare EHR Incentive Program and their continuity and success in receiving payments in comparison with other specialties. Design Administrative database study. Participants Eligible professionals participating in the Medicare EHR Incentive Program. Methods Based on publicly available data sources, subsets of payment and attestation data were created for ophthalmologists and for other specialties. The number of eligible professionals attesting was determined using the attestation data for each year and stage of the program. The proportion of attestations by EHR vendor was calculated using all attestations for each vendor. Main Outcome Measures Numbers of ophthalmologists attesting by year and stage of the Medicare EHR Incentive Program, incentive payments, and number of attestations by EHR vendor. Results In the peak year of participation, 51.6% of ophthalmologists successfully attested to MU, compared with 37.1% of optometrists, 50.2% of dermatologists, 54.5% of otolaryngologists, and 64.4% of urologists. Across the 6 years of the program, ophthalmologists received an average of $17 942 in incentive payments compared with $11 105 for optometrists, $16 617 for dermatologists, $20 203 for otolaryngologists, and $23 821 for urologists. Epic and Nextgen were the most frequently used EHRs for attestation by ophthalmologists. Conclusions Ophthalmology as a specialty performed better than optometry and dermatology, but worse than otolaryngology and urology, in terms of the proportion of eligible professionals attesting to MU of EHRs. Ophthalmologists were more likely to remain in the program after their initial year of attestation compared with all eligible providers. The top 4 EHR vendors accounted for 50% of attestations by ophthalmologists.

Purpose To describe the rates of strabismus, strabismus surgery, and strabismus surgery reoperations among all age groups in the United States. Design Retrospective analysis of electronic health record data. Participants Patients from the IRIS (Intelligent Research in Sight) Registry. Methods Description of the types and rates of strabismus and strabismus surgery from 2013 to 2016 with subgroups by age, sex, race/ethnicity, and region of the United States. Main Outcome Measure The 1-year reoperation rate for strabismus surgery performed during 2013–2015 for all age groups. Results A total of 30 827 185 unique patients were identified; 846 477 (2.75%) had a diagnosis of strabismus: 3.02% of male patients and 2.55% of female patients (difference = 0.47%, 95% confidence interval [CI], 0.46–0.48, P Conclusions Strabismus is an uncommonly reported diagnosis in ophthalmologic practice. Overall, approximately 1 in 750 patients in the IRIS Registry received strabismus surgery (1 in 20 with a strabismus diagnosis) during a 4-year period. Reoperations during the first year after surgery were performed for 1 in 15 patients, increasing with age at surgery. “Big” data from clinical data registries represent real-world care that can be used to develop benchmarks for clinical outcomes and to identify areas for practice improvement and training program design.

Purpose Glaucoma is a well-documented complication of corneal transplants, contributing significantly to ultimate visual loss. Reported incidence of glaucoma following corneal transplants is highly variable, and definitions of posttransplant glaucoma are inconsistent. Here we use glaucoma surgery as a more rigid and specific endpoint to compare rates following different corneal transplant surgeries. Design Retrospective cohort study. Methods A 5% random sample of Medicare beneficiaries from 2010-2013 was obtained and patients were identified with Current Procedural Terminology (CPT) codes for penetrating keratoplasty (PK), endothelial keratoplasty (EK), anterior lamellar keratoplasty (ALK), and keratoprosthesis (KPro). Rates of glaucoma surgery within the same year following the abovementioned corneal transplants were analyzed. Subgroup analyses included patients who carried preexisting glaucoma diagnoses prior to corneal transplant surgery. Results There were 3098 patients who underwent corneal transplants during the study period, including 1919 EK, 1012 PK, 46 ALK, 32 KPro, and 89 both PK and EK. Rates of glaucoma surgery ranged from 6.1% to 9.4% in the corneal transplant groups, without statistically significant differences among groups. However, 10.0% of patients with preexisting glaucoma required glaucoma surgery following any transplant surgery, compared with 5.3% of patients without preexisting glaucoma. This included 12.4% of PK patients with preexisting glaucoma compared with 2.8% of PK patients without preexisting glaucoma (P Conclusions Despite literature suggesting that more angle-altering cornea surgeries confer higher risk, we found no statistically significant differences among various transplant groups. Patients with preexisting glaucoma, however, had higher risk of glaucoma surgery within the same year following corneal transplant surgery, which was especially pronounced in the PK group. These patients require special care when considering long-term effects of corneal transplants.

Purpose To investigate the rate of return to the operating room after vitrectomy surgery to treat macular hole or epiretinal membrane. Design A retrospective registry cohort. Participants Individuals receiving care in ophthalmology practices participating in the Academy IRIS (Intelligent Research in Sight) Registry. Methods Data from the IRIS Registry were analyzed for patients who underwent vitrectomy for macular holes or epiretinal membranes. Cases were identified by the combination of International Classification of Diseases, 9th revision code (362.54, 362.56) and a current procedural terminology (CPT) code for vitrectomy surgery between January 1, 2013 and June 30, 2017. Main Outcome Measures The eyes that underwent additional eye surgery within 1 year after initial vitrectomy for macular hole or epiretinal membrane were identified, as was the nature of the additional procedures per CPT code. Results A total of 41 475 eyes underwent vitrectomy for macular hole and 73 219 eyes underwent vitrectomy for epiretinal membrane during the study period. In the macular hole group, 7573 had a second surgery within 1 year, and 2827 (6.8%) had a second surgery that was not cataract related. In the epiretinal membrane group, 12 433 had a second surgery within 1 year, 4022 (5.5%) of which were not cataract related. In the macular hole group, 4.6% of eyes returned to the operating room for another macular hole repair surgery, and 2.0% returned for retinal detachment repair. In the epiretinal membrane group, 1.4% returned for a second vitrectomy with membrane stripping, and 2.5% returned for retinal detachment repair. Conclusions This registry-based study encompassed a large number of patients but was limited by the inaccessibility of some information and the potential for inaccurate medical records or coding, as it obtained data from multiple electronic health records entities. Excluding cataract surgery, approximately 6% of eyes that underwent vitrectomy to address macular hole or epiretinal membrane returned for a second ophthalmic procedure within a year. In the macular hole group, most secondary non-cataract surgeries were for another macular hole repair procedure. For both macular holes and epiretinal membranes, approximately 2% of eyes required retinal detachment repair surgery within 1 year.

Purpose To describe the characteristics of the patient population included in the 2016 IRIS ® Registry (Intelligent Research in Sight) database for analytic aims. Design Description of a clinical data registry. Participants The 2016 IRIS Registry database consists of 17 363 018 unique patients from 7200 United States–based ophthalmologists in the United States. Methods Electronic health record (EHR) data were extracted from the participating practices and placed into a clinical database. The approach can be used across dozens of EHR systems. Main Outcome Measures Demographic characteristics. Results The 2016 IRIS Registry database includes data about patient demographics, top-coded disease conditions, and visit rates. Conclusions The IRIS Registry is a unique, large, real-world data set that is available for analytics to provide perspectives and to learn about current ophthalmic care and treatment outcomes. The IRIS Registry can be used to answer questions about practice patterns, use, disease prevalence, clinical outcomes, and the comparative effectiveness of different treatments. Limitations of the data are the same limitations associated with EHR data in terms of documentation errors or missing data and the lack of images. Currently, open access to the database is not available, but there are opportunities for researchers to submit proposals for analyses, for example through a Research to Prevent Blindness and American Academy of Ophthalmology Award for IRIS Registry Research.

Purpose To identify sustained differences in intraocular pressure (IOP) after intravitreous injections of anti–vascular endothelial growth factor (VEGF) drugs. Design Database study. Participants Patients seeing an ophthalmic provider who contributes to the database. Methods We identified a total of 23 776 unique patients who received only a single type of anti-VEGF medication (bevacizumab, aflibercept, or ranibizumab) by injection in the right eye in the American Academy of Ophthalmology Intelligent Research in Sight Registry. Subgroups included patients with age-related macular degeneration only and patients who had not received an anti-VEGF injection for at least 1 year before the study. We examined those with at least 12, 18, and 25 injections for each of these 3 medications. For all groups, we used fellow, untreated eyes for comparison. Main Outcome Measures The mean change in IOP from baseline at a minimum of 1 year of follow-up and the proportion of eyes with a clinically significant IOP increase (defined as sustained rise of at least 6 mmHg to an IOP of more than 21 mmHg). Results All patients in all groups receiving all drugs showed a decrease in IOP from baseline, with a mean of 0.9 mmHg in treated eyes compared with an average decrease of 0.2 mmHg in fellow untreated eyes, a statistically significant difference. A generalized linear model accounting for confounders associated bevacizumab with slightly less lowering of IOP than aflibercept and ranibizumab in most subgroups. A clinically significant IOP increase was seen in 2.6% of eyes receiving injections compared with 1.5% in the associated untreated fellow eyes. Clinically significant IOP increases occurred at a rate of 1.9%, 2.8%, and 2.8% for aflibercept, ranibizumab, and bevacizumab, respectively, which was significantly higher than untreated fellow eyes for bevacizumab and ranibizumab, but not for aflibercept. Conclusions These analyses from real-world data indicate that anti-VEGF intravitreous injections are associated with a small but statistically significant decrease in IOP over time. A proportion of patients, on average 2.6%, experienced a sustained clinically significant IOP rise with these drugs overall compared with 1.5% in the fellow untreated eyes. However, such an increase was not seen with aflibercept.

Purpose: To evaluate whether cataract surgery is associated with decreased risks of central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) development using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry. Design: Retrospective database study of the IRIS Registry data. Participants: Patients in the IRIS Registry who underwent cataract surgery and 1:1 matched control participants from the IRIS Registry using a decision tree classifier as a propensity model. Methods: Control and treatment groups initially were selected using Current Procedural Terminology codes for uncomplicated cataract surgery and other straightforward criteria. To accomplish treatment–control matching, a decision tree classifier was trained to classify patients as treatment versus control based on a set of chosen predictors for treatment, where best-corrected visual acuity and age were the most important predictors. Treatment and control participants subsequently were matched using the classifier, the visit dates, and the identifications of the practice. Cox regression was performed on the matched groups to measure the hazard ratio (HR) of retinal vein occlusion development adjusted for age, sex, race, primary insurance type, and previous diagnosis of diabetic retinopathy (DR), glaucoma, and narrow angles. Main Outcome Measure: The HR of retinal vein occlusion developing in patients who underwent cataract surgery compared with matched control participants. Results: The HRs for CRVO and BRVO developing in patients who underwent cataract surgery compared with matched control participants who did not during the first year after either cataract surgery or baseline visit were 1.26 [95% confidence interval [CI], 1.16–1.38; P < 0.001] and 1.27 [95% CI, 1.19–1.36; P < 0.001], respectively, after controlling for age, sex, race, insurance, and history of DR, glaucoma, and narrow angles. Diabetic retinopathy was the strongest predictor associated with CRVO (2.79 [95% CI, 2.43–3.20; P < 0.001]) and BRVO (2.35 [95% CI, 2.09–2.64; P < 0.001]) development after cataract surgery. Conclusions: Cataract surgery is associated with a small increase in risk of retinal vein occlusions within the first year; however, the incidence is low and likely not clinically significant.

Purpose To characterize treatment patterns and outcomes in eyes with treatment-naive myopic choroidal neovascularization (mCNV) in the United States. Design Retrospective cohort study. Participants Individuals aged 18 years and older seen in clinics participating in the American Academy of Ophthalmology's IRIS (Intelligent Research in Sight) Registry. Methods We analyzed data from the IRIS Registry, from January 1, 2012 to December 31, 2014, to identify cases of treatment-naive mCNV, which was defined as the presence of myopic refractive error worse than −6.0 diopters with the presence of subretinal/choroidal neovascularization as indicated by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of "362.16: Retinal Neovascularization NOS." Main Outcome Measures Type of initial treatment for mCNV was categorized as the administration of 1 of the following within the first 365 days after the diagnosis date: (1) observation (i.e., no treatment); (2) intravitreal anti-VEGF injection; (3) verteporfin photodynamic therapy (vPDT); or (4) laser photocoagulation. We assessed the difference between logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) on the diagnosis date (baseline) and 1 year after the diagnosis date. Anti-VEGF injection frequency per treated eye over a 1-year period was also estimated. Results We identified 185 patients with treatment-naive mCNV in 1 or both eyes. Treatment within 1 year of diagnosis was recorded for 73.0% (135/185); the remainder was classified as "observation." Nearly all treatment (134/135; 99.3%) consisted of anti-VEGF injections; 0.7% (1/135) received vPDT. Those treated with anti-VEGF injections showed significant improvement in VA at 1 year (mean logMAR VA improvement of 0.17 units, 95% confidence interval [CI], 0.12–0.20, P P Conclusions In the United States, anti-VEGF injection was the most frequently utilized treatment for mCNV. Those treated were observed to gain vision. However, one quarter of patients received no treatment and lost vision. Further studies are needed to understand the sociodemographic and health-systems barriers surrounding the delivery of anti-VEGF injections to patients with mCNV.

To describe the effect of health status and geographic region of the United States on the prevalence of strabismus and strabismus surgery in the aged Medicare fee-for-service population.A 5% sample of Medicare claims was used to identify aged beneficiaries diagnosed with strabismus and those having strabismus surgery between 2002 and 2010. The Charlson Comorbidity Index (CCI), a measure of systemic health, was calculated. The regional analysis divided the United States into East, West, Midwest, and South. Analyses were adjusted for age, sex, race, CCI, and region.The 5% sample for 2010 included 1,237,469 unique beneficiaries. Strabismus was diagnosed in 8,470 (0.68%) and strabismus surgery was performed on 197 (0.016%). Pooled data from 2002 through 2010 found the prevalence of strabismus increasing significantly with increasing comorbidity (P0.0001): 0.52% (CCI, 0), 0.65% (CCI, 1-2), 0.77% (CCI, 3-4), and 0.82% (CCI, 5 or higher). Conversely, the prevalence of strabismus surgery declined slightly with increasing comorbidity (P = 0.088): 0.016% (CCI, 0), 0.017% (CCI, 1-2), 0.015% (CCI, 3-4), and 0.015% (CCI, 5 or higher). The diagnosis of strabismus was made least frequently in the South (P0.0001), whereas strabismus surgery was performed more often in the West (P = 0.006). All significant effects remained after adjustment.The prevalence of strabismus increases significantly with declining health status; however, health status had little effect on the rate of strabismus surgery. Regional rates of strabismus diagnosis and surgery differ widely.

Objective To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate, user satisfaction, functionality, benefits, barriers, and knowledge of meaningful use criteria. Design Population-based, cross-sectional study. Participants A total of 492 members of the American Academy of Ophthalmology (AAO). Methods A random sample of 1500 AAO members were selected on the basis of their practice location and solicited to participate in a study of EHR use, practice management, and image management system use. Participants completed the survey via the Internet, phone, or fax. The survey included questions about the adoption of EHRs, available functionality, benefits, barriers, satisfaction, and understanding of meaningful use criteria and health information technology concepts. Main Outcome Measures Current adoption rate of EHRs, user satisfaction, benefits and barriers, and availability of EHR functionality. Results Overall, 32% of the practices surveyed had already implemented an EHR, 15% had implemented an EHR for some of their physicians or were in the process of implementation, and another 31% had plans to do so within 2 years. Among those with an EHR in their practice, 49% were satisfied or extremely satisfied with their system, 42% reported increased or stable overall productivity, 19% reported decreased or stable overall costs, and 55% would recommend an EHR to a fellow ophthalmologist. For those with an electronic image management system, only 15% had all devices integrated, 33% had images directly uploaded into their system, and 12% had electronic association of patient demographics with the image. Conclusions The adoption of EHRs by ophthalmology practices more than doubled from 2007 to 2011. The satisfaction of ophthalmologists with their EHR and their perception of beneficial effects on productivity and costs were all lower in 2011 than in 2007. Knowledge about meaningful use is high, but the percentage of physicians actually receiving incentive payments is relatively low. Given the importance of imaging in ophthalmology, the shortcomings in current image management systems need to be addressed. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose To discuss the current trend toward greater use of electronic health records and how these records could enhance public health surveillance of eye health and vision-related conditions. Design Perspective, comparing systems. Methods We describe 3 currently available sources of electronic health data (Kaiser Permanente, the Veterans Health Administration, and the Centers for Medicare & Medicaid Services) and how these sources can contribute to a comprehensive vision and eye health surveillance system. Results Each of the 3 sources of electronic health data can contribute meaningfully to a comprehensive vision and eye health surveillance system, but none currently provide all the information required. The use of electronic health records for vision and eye health surveillance has both advantages and disadvantages. Conclusions Electronic health records may provide additional information needed to create a comprehensive vision and eye health surveillance system. Recommendations for incorporating electronic health records into such a system are presented.

Purpose To assess the current burden of ocular toxocariasis (OT) and to gain knowledge regarding the diagnostic and treatment practices used in the ophthalmologic community in the United States. Design Web-based, cross-sectional survey. Participants Subspecialty ophthalmologists who are currently practicing in the United States. Methods An electronic survey was sent to 3020 ophthalmologic subspecialists belonging to the American Uveitis Society (AUS), the American Society of Retina Specialists (ASRS), or the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) to capture demographic, clinical, diagnostic, and treatment data on patients with OT seen in their practices between September 2009 and September 2010. Main Outcome Measures The demographic, epidemiologic, and clinical characteristics of each reported patient with OT. Results A total of 159 patients with OT were reported by 559 respondents (19%). The median patient age was 11.5 years (range, 1–66 years). Seventy-two patients (45%) with OT lived in the Southern region of the United States. Thirty-one (69%) of 45 patients with OT owned a dog or cat. Vision loss was reported in 46 (85%) of 54 patients with OT; 32 (71%) of 45 patients had permanent vision loss, 13 patients (29%) had temporary vision loss, and duration of vision loss was unreported for 1 patient. Of the 32 patients with OT with permanent vision loss, 30 (94%) had a subretinal granulomatous mass/scar, peripheral granuloma with traction bands, or posterior pole granuloma noted on ophthalmologic examination. Subretinal granulomatous mass/scar, vitritis, and scotoma were the most common ophthalmologic signs found on examination of patients with OT. Conclusions Ocular toxocariasis continues to occur in the United States, where it affects mainly children and causes permanent vision loss in many patients. Healthcare professionals should counsel patients and their family members about prevention strategies in an effort to decrease infection rates and morbidity due to Toxocara . Further improvement of diagnostic and treatment tools is needed to assist ophthalmologists in treating patients with OT. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose To evaluate the impact of the Diabetes 2000 program, an initiative launched by the American Academy of Ophthalmology in 1990 to improve nationwide screening of diabetic retinopathy (DR) and to reduce the prevalence and severity of the condition. Design Retrospective, observational case study of Diabetes 2000 program. Methods This is a perspective piece with a review of literature and personal opinions. Results Patients with diabetes are likely to see an increase in the disease burdens associated with DR unless effective programs for early detection and control of DR are implemented. Conclusions Despite recent efforts to educate both patients and physicians alike about the importance of routine DR screening, the lessons learned from the Diabetes 2000 program illustrate the need for new strategies capable of improving accessibility to high-quality eye care, increasing involvement of primary care physicians in DR screening and encouraging at-risk individuals to seek testing.

Article-at-a-Glance Background The American Academy of Ophthalmology (AAO; San Francisco) launched a national eye care outcomes initiative in 1996, in response to strong interest by third-party payers and managed care in performance measurement and outcomes. The AAO's outcomes initiative NEON (National Eyecare Outcomes Network) began with the design and launch of a prospective observational registry of patients undergoing cataract surgery. Methods Participants submitted a common set of data regarding patients' demographics, preoperative ophthalmologic history, physical exam, test results, functional status and symptoms, intraoperative procedures and events, and postoperative outcomes for all patients undergoing first or second eye cataract surgery. Results Between January 1, 1996, and March 30, 2001, a total of 249 ophthalmologists submitted data on 17,876 patients undergoing first or second eye surgery. All preoperative, intraoperative, and postoperative clinical data forms were submitted for 9,937 patients (55.7%). After surgery, 93% of patients achieved a best corrected visual acuity of 20/40, 89% improved their visual functioning, and 92% experienced fewer cataract-related symptoms. Discussion At the end of March 2001, NEON was discontinued because of a lack of participation and demand by members or third parties for this information. The momentum for accountability and performance measures never quite materialized into advantages for contracting for physicians or requirements by payers. In the future, more scientific evidence regarding the validity and meaning of outcome measures and differences in measurements, investment in health information technology infrastructure, use of technology to collect information at the point of care, and incentives favoring data collection and analysis will be needed to pave the way for renewed interest in outcomes.