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Purpose: The volume of microinvasive glaucoma surgery (MIGS) has increased dramatically in recent years, from 31 059 in 2013 to 69 420 in 2018. We investigated the impact of this trend on trainees by determining the proportion of glaucoma surgeries performed by fellows-in-training comprised by MIGS, trabeculectomies, and aqueous shunts., Design: Retrospective analysis., Participants: Fellows-in-training at Glaucoma Fellowship Programs certified by the Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO-FCC) METHODS: We analyzed aggregate summaries of surgeries performed by fellows as reported to the AUPO-FCC from the academic years (AYs) beginning in 2014 through AY 2020. Each report lists the average number of procedures performed per surgery type per fellow. We combined these averages to create a sum "average number surgeries performed" across glaucoma surgeries and computed the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of surgeries performed per year., Main Outcome Measures: Average number of procedures performed for each surgery type as well as the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of procedures performed per year., Results: Average number of MIGS performed is significantly greater in later years compared with earlier years (P < 0.001). The average number of trabeculectomies performed between AYs 2014 and AY 2020 ranged from 21.8 to 31.9 and decreased, on average, by - 0.80 year-to-year. The average number of aqueous shunts performed between AY 2014 and AY 2020 ranged from 44.7 to 49.5, with an average increase of + 0.8 year-to-year. The total average number of procedures performed (across all 3 surgical subtypes) increased on average by + 4.8 procedures each year., Conclusions: Since 2014, fellows are performing increasing numbers of MIGS procedures, whereas the total number of trabeculectomies and aqueous shunt surgeries performed each year remain similar, resulting in a net increase in total number of procedures performed per fellow each year. This suggests the increase in MIGS is not associated with a substantial decline in trabeculectomies or aqueous shunts performed by glaucoma fellows., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Despite the increased emphasis on evidence-based medicine, the current state of evidence behind ophthalmology clinical practice guidelines is unknown. The purpose of this systematic analysis was to understand the levels of evidence (LOE) supporting American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) guidelines, assess changes over time, and compare LOE across ophthalmology subspecialties., Methods: All current PPP guidelines and their immediate predecessors were comprehensively reviewed to identify all recommendations with LOE provided (I [randomized controlled trials], II [case-control or cohort studies], and III [nonanalytic studies])., Results: Twenty-three out of 24 current PPPs had a prior edition. Among the PPPs with a prior edition, the number of recommendations with LOE decreased from 1254 in prior PPPs to 94 in current PPPs. The number of recommendations with LOE I decreased from 114 to 83, LOE II decreased from 147 to 2, and LOE III decreased from 993 to 9. However, the proportion of LOE I recommendations increased from 9 to 88%, driven by a disproportionate decrease in reporting of evidence lower than LOE I. Subgroup analysis by subspecialty showed similar trends (LOE I recommendations in prior PPPs vs current PPPs: retina: 57 [12%] vs 19 [100%]; cornea: 33 [5%] vs 24 [100%]; glaucoma: 9 [23%] vs 17 [100%]; cataract: 13 [17%] vs 18 [100%])., Conclusions: Trends in LOE reporting in PPP guidelines indicate an increasing emphasis on evidence from randomized controlled trials from 2012 to 2021. The decline in the number of recommendations with LOE reported suggests an area for improvement in future guidelines as the presence of LOE is crucial to facilitate interpretation of clinical practice guidelines., (© 2023. The Author(s).)

Purpose: A centralized eye donation registry for research could help to bridge the gap between patients interested in donating their eyes to science and scientists who conduct research on human eye tissue. Previous research has demonstrated patient and family support for such a registry. In this study, we assessed the views that eye care professionals have toward an eye donation registry for research., Materials and Methods: Surveys were distributed to all 46 clinical faculty members of the Duke University Eye Center. In addition to collecting demographic information, the surveys assessed clinicians' experience with discussing eye donation with patients, described the proposed eye donation registry for research and asked how the registry would affect the clinicians' practice., Results: A total of 21 eye care professionals returned the survey. Thirty-three percent reported discussing eye donation with patients, and 43% reported that a patient has asked about donating their eyes for research on their disease. Eighty-six percent of eye care professionals reported that a centralized registry would improve the way they work with patients who express a desire to donate their eyes for research., Conclusions: The majority of eye care professionals at our academic institution indicated that an eye donation registry for research would improve how they work with patients who are interested in donating their eyes for research on their disease. Future research should examine how best to communicate this registry to ophthalmic patients.

Objective: To examine the associations of provider-patient communication, glaucoma medication adherence self-efficacy, and outcome expectations with glaucoma medication adherence., Design: Prospective, observational cohort study., Participants: Two hundred seventy-nine patients with glaucoma who were newly prescribed or taking glaucoma medications were recruited at 6 ophthalmology clinics., Methods: Patients' visits were video recorded and communication variables were coded using a detailed coding tool developed by the authors. Adherence was measured using Medication Event Monitoring Systems for 60 days after their visits., Main Outcome Measures: The following adherence variables were measured for the 60-day period after their visits: whether the patient took 80% or more of the prescribed doses, percentage of the correct number of prescribed doses taken each day, and percentage of the prescribed doses taken on time., Results: Higher glaucoma medication adherence self-efficacy was associated positively with better adherence with all 3 measures. Black race was associated negatively with percentage of the correct number of doses taken each day (β = -0.16; P < 0.05) and whether the patient took 80% or more of the prescribed doses (odds ratio, 0.37; 95% confidence interval, 0.16-0.86). Physician education about how to administer drops was associated positively with percentage of the correct number of doses taken each day (β = 0.18; P < 0.01) and percentage of the prescribed doses taken on time (β = 0.15; P < 0.05)., Conclusions: These findings indicate that provider education about how to administer glaucoma drops and patient glaucoma medication adherence self-efficacy are associated positively with adherence., Competing Interests: Drs. Sleath, Blalock, Carpenter, Muir, Sayner, Giangiacomo, and Slota indicate no conflict of interest., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this preliminary study was to describe the extent to which providers used collaborative goal setting and individualized assessment with patients who were newly prescribed glaucoma medications., Methods: English-speaking glaucoma suspect patients from six ophthalmology clinics who were newly prescribed glaucoma medications had their medical visits videotaped and were interviewed after the visits. The videotapes were transcribed and coded to examine provider use of collaborative goal setting and individualized assessment., Results: Fifty-one patients seeing 12 ophthalmologists participated. Providers gave patients glaucoma treatment options during 37% of the visits; only five providers gave patients treatment options Providers asked for patient treatment preferences in less than 20% of the visits; only two providers asked for patient treatment preferences. Providers were significantly more likely to ask African American patients for their preferences or ideas concerning treatment than non-African American patients (Pearson χ² = 4.1, p = 0.04). Providers were also significantly more likely to ask African American patients about their confidence in using glaucoma medication regularly than non-African American patients (Pearson χ² = 8.2, p = 0.004). Providers asked about patient views about glaucoma in less than 20% of the visits; five providers asked patients their views on glaucoma and its treatment. Providers were significantly more likely to ask African American patients about their views on glaucoma than non-African American patients (Pearson χ² = 5.62, p = 0.02)., Conclusions: Eye care providers often did not use collaborative goal setting or conduct individualized assessments of patient views on glaucoma when prescribing treatment for the first time.

In 1997, Ebrahimzadeh, Davalos, and Lee wrote in this journal that only 32% of the ophthalmic patient educational materials reviewed were written at or below the recommended eighth-grade reading level. Since that time, the National Assessment of Adult Literacy found that more than one-third of adult Americans possess only basic or below basic health literacy skills, defined as the ability to understand written information in a healthcare setting. Subsequently, investigators have shown that poor health literacy skills are associated with poor prescription medication adherence, increased hospital admissions, and increased mortality. We review the readability of currently available ophthalmic educational materials, with particular attention to the health literacy status of the patient population for which the materials are intended. Examples of prose at various readability levels are provided. Optimizing patient education and improving clinical outcomes requires understanding the attributes that the patient brings to the patient-physician relationship, including health literacy., (Published by Elsevier Inc.)

Ailin Song,1 Nicholas A Johnson,1 Delaram Mirzania,1,2 Alexandria M Ayala,1 Kelly W Muir,3,4 Atalie C Thompson3,5 1Duke University School of Medicine, Durham, NC, USA; 2Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Health, Ann Arbor, MI, USA; 3Department of Ophthalmology, Duke University, Durham, NC, USA; 4Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA; 5Wake Forest Baptist Health, Winston Salem, NC, USACorrespondence: Atalie C Thompson, Wake Forest Baptist Health, Janeway Tower, 6 th Floor, 1 Medical Center Blvd, Winston Salem, NC, 27103, USA, Tel +1 650-868-8050, Email ataliethompson@gmail.comBackground: Early detection of ophthalmic conditions such as diabetic retinopathy (DR) and glaucoma is crucial to preventing vision loss. Previous studies have evaluated teleretinal screening programs for DR in well-insured populations. The purpose of this retrospective study was to evaluate a teleretinal screening program in a population of uninsured and underinsured patients seen in a Federally Qualified Health Center (FQHC).Methods: We conducted a retrospective chart review of patients (age ≥ 18) who underwent teleretinal imaging (TRI) at a FQHC between January 2015 and September 2019. TRI gradings and patient demographic and clinical information were abstracted. Factors associated with referral for a dilated eye exam by an ophthalmologist, adherence to recommended follow-up dilated eye exam, and ophthalmology visit attendance were examined.Results: 3130 TRIs were graded in 2216 eyes (1107 patients). 65.2% (N = 722) self-identified as Hispanic and 56.3% (N = 623) required interpreter services. Follow-up dilated fundus examination (DFE) was recommended for 388 TRIs, 49% (N = 190) of which were completed within 1 year. Adherence to the recommended ophthalmology exam was not associated with any baseline clinical or demographic characteristics (p > 0.05). Older age, male sex, hypertension, proteinuria, and higher A1c were significantly associated with greater odds of ophthalmology referral based on TRI (all p < 0.05), after adjusting for covariates. Less severe diabetic retinopathy, no insurance coverage, and Hispanic ethnicity were associated with lower odds of attending an ophthalmology visit, regardless of follow-up recommendations based on TRI (all p < 0.05).Conclusion: In an FQHC serving predominantly uninsured and underinsured patients, only 49% of recommended DFE were completed within one year. Less severe diabetic retinopathy, lack of insurance coverage, and Hispanic ethnicity were associated with a lower likelihood of having a DFE regardless of recommendation. These results suggest that greater system-level efforts are needed to increase adherence to follow-up eye exams after TRI to ensure sight-saving care for underserved populations.Keywords: teleretinal screening, teleophthalmology, uninsured, underinsured, adherence, ophthalmology referral

Andrew M Williams,1 Kelly W Muir2,3 1Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 2Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA; 3Durham VA Medical Center, Health Services Research and Development, Durham, NC, USA Abstract: There is a severe shortage of donor corneas available worldwide for transplantation, with the number of patients in need of transplant greatly exceeding the number of cornea tissues available. Understanding awareness and attitudes about corneal donation worldwide is a critical step toward addressing this shortage. In this review, awareness of corneal donation and reported willingness to donate are summarized from 55 published studies across 13 countries. In general, many more respondents indicated positive attitudes toward eye donation and willingness to donate their eyes than the number of respondents who have pledged their eyes for donation, suggesting an unrealized potential of additional donors. Specifically, of 38,851 respondents across all included studies, 52% endorsed a willingness to donate their eyes after death, yet only 5% reported being a pledged donor. The most commonly cited reason for not being a registered eye donor was lack of awareness about eye donation. The disconnection between the large number of people who expressed willingness to donate and the scarcity of individuals who have pledged their eyes for donation could be addressed through educational media campaigns, collaborations with medical personnel, partnerships with grief counselors and religious leaders, use of social media, and educational sessions with medical students and staff. Keywords: eye donation, corneal transplantation, attitudes, eye bank, organ donation

Andrew M Williams,1 Wei Huang,2 Kelly W Muir,3,4 Sandra S Stinnett,3 Jordan S Stone,5 Jullia A Rosdahl3 1Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 2Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC, USA; 3Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA; 4Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC, USA; 5School of Medicine, University of California San Diego, La Jolla, CA, USA Purpose: To examine the factors associated with blindness from primary open-angle glaucoma (POAG) among black and white patients at our institution.Patients and methods: For this retrospective, case–control study, patients legally blind from POAG (“cases”) were matched on age, race, and gender with non-blind POAG patients (“controls”). Thirty-seven black case–control pairs and 19 white case–control pairs were included in this study. Clinical variables were compared at initial presentation and over the course of follow-up.Results: Black case–control pairs and white case–control pairs had similar characteristics at presentation, including cup-to-disc ratio and number of glaucoma medications. However, over the course of follow-up, black cases underwent significantly more glaucoma surgeries than matched controls (2.4 versus 1.2, p=0.001), whereas white cases and controls had no significant difference in glaucoma operations (0.9 versus 0.6, p=0.139). Our analysis found that glaucoma surgery is associated with blindness in black patients (odds ratio [OR] 1.6, 95% CI 1.1–2.2) but not in white patients (OR 1.5, 95% CI 0.7–3.2).Conclusion: Black and white case–control pairs with POAG shared similar risk factors for blindness at presentation. However, over the follow-up period, black cases required significantly more glaucoma surgeries compared to black controls, whereas there was no significant difference in surgery between white cases and controls. There was no difference in medication changes in either case–control set. Keywords: health disparities, glaucoma surgery, glaucoma treatment, glaucoma medications

Isaiah J Davies,1 Ninita H Brown,2 Joanne C Wen,3 Sandra S Stinnett,1 Kelsey Kubelick,4,5 Roma P Patel,6 Kristin L Benokraitis,7 Latoya Greene,1 Curry Cheek,1 Kelly W Muir1,8 1Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA; 2Metrolina Eye Associates, Charlotte, NC, USA; 3Department of Ophthalmology, University of Washington, Seattle, WA, USA; 4Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 5Wallace H Coulter Department of Biomedical Engineering, Emory University School of Medicine, Atlanta, Georgia, USA; 6University of California Davis Health System Eye Center, Sacramento, CA, USA; 7EG-GILERO, Durham, NC, USA; 8Health Services Research & Development, Durham VA Medical Center, Durham, NC, USA Purpose: This study tested the feasibility of using an upright eyedrop bottle (UEB), a device designed to assist patients with eyedrop placement without reclining their head. Patients and methods: Experienced eyedrop users were enrolled who answered “yes” to the question, “Do you ever have trouble getting your eyedrops in?” After being shown a multimedia presentation and answering a questionnaire regarding eyedrop usage, participants were observed instilling eyedrops. Participants were instructed to instill a single eyedrop in each eye with both a standard bottle and the UEB. They repeated this process three times. With each trial, the amount of time taken to instill drops was recorded, as well as whether a drop landed in the eye (accuracy), if excess drops were used, and if the bottle tip was contaminated. Results: Forty participants were enrolled, with an average age of 72.4±8.9 years; the majority were females (24 females). Thirty-four participants had been using eyedrops for at least 1 year. The time required to instill eyedrops was significantly less with the UEB in the second and third trials. There was no difference in accuracy between the conventional bottle and the UEB in the left or right eye in any trials. Significantly more participants used excess number of drops while using the conventional bottle in both the left and right eyes in all three trials. The bottle tip was never contaminated with the UEB. Depending on the trial and the eye, the conventional bottle was contaminated by between 42% and 53% of participants. Conclusion: The UEB has the potential to assist patients with eyedrop placement. Although there was no difference in accuracy between the UEB and the conventional bottle, the UEB was associated with less use of excess drops and less contamination of the bottle tip, compared to the conventional bottle. Keywords: glaucoma, compliance, medical devices

Daniel B Moore,1 Rebecca F Neustein,2 Sarah K Jones,1 Alan L Robin,3 Kelly W Muir1,4 1Duke Eye Center, Duke University Medical Center, Durham, NC, 2Emory School of Medicine, Atlanta, GA, 3Department of Ophthalmology, Johns Hopkins School of Medicine and International Health, Bloomberg School of Public Health, Baltimore, MD, 4Health Services Research & Development, Durham VA Medical Center, Durham, NC, USA Abstract: As they grow older, most children with glaucoma must eventually face the transition to self-administering medications. We previously reported factors associated with better or worse medication adherence in children with glaucoma, using an objective, electronic monitor. Utilizing the same data set, the purpose of the current study was to determine whose report (the caregiver’s or the child’s) corresponded better with electronically monitored adherence. Of the 46 participants (22 girls), the mean age of children primarily responsible, and caregiver primarily responsible for medication administration was 15±2 and 10±2 years, respectively. For the children whose caregiver regularly administered the eyedrops, the caregiver’s assessment of drop adherence was associated with measured adherence (P=0.012), but the child’s was not (P=0.476). For the children who self-administered eyedrops, neither the child’s (P=0.218) nor the caregiver’s (P=0.395) assessment was associated with measured percent adherence. This study highlights potential errors when relying on self-reporting of compliance in patients and caregivers with pediatric glaucoma, particularly when the child is responsible for administering their own eyedrops. Frank discussions about the importance of medication adherence and how to improve compliance may help both the child and caregiver better communicate with the treating provider. Keywords: glaucoma, children, adherence

Anita Vin,1 Suzanne Schneider,2 Kelly W Muir,1,3 Jullia A Rosdahl11Department of Ophthalmology, Duke University, Durham, NC, 2Department of Health Philosophy and Promotion, Maryland University of Integrative Health, Laurel, MD, 3Durham VA Medical Center, Durham, NC, USAIntroduction: Adherence to glaucoma medications is essential for successful treatment of the disease but is complex and difficult for many of our patients. Health coaching has been used successfully in the treatment of other chronic diseases. This pilot study explores the use of health coaching for glaucoma care.Methods: A mixed methods study design was used to assess the health coaching intervention for glaucoma patients. The health coaching intervention consisted of four to six health coaching sessions with a certified health coach via telephone. Quantitative measures included demographic and health information, adherence to glaucoma medications (using the visual analog adherence scale and medication event monitoring system), and an exit survey rating the experience. Qualitative measures included a precoaching health questionnaire, notes made by the coach during the intervention, and an exit interview with the subjects at the end of the study.Results: Four glaucoma patients participated in the study; all derived benefits from the health coaching. Study subjects demonstrated increased glaucoma drop adherence in response to the coaching intervention, in both visual analog scale and medication event monitoring system. Study subjects’ qualitative feedback reflected a perceived improvement in both eye and general health self-care. The subjects stated that they would recommend health coaching to friends or family members.Conclusion: Health coaching was helpful to the glaucoma patients in this study; it has the potential to improve glaucoma care and overall health.Keywords: motivation, behavior change, adherence, medication, health

Jullia A Rosdahl,1 Kelly W Muir1,2 1Department of Ophthalmology, Duke University, Durham, NC, USA; 2Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC, USA Objective: The goal of the study was to determine which glaucoma quiz provides the best information about patient glaucoma knowledge to clinicians in clinical practice settings. Methods: Four glaucoma quizzes were identified from the literature and national eye education programs and were qualitatively analyzed to categorize questions by topic. Quizzes were assessed by 64 glaucoma specialists using an online survey, with descriptive statistics. Comments about the quizzes were analyzed qualitatively using themes and representative quotations. Results: Quizzes covered content that was important for glaucoma diagnosis and management. The National Eye Health Education Program (NEHEP) and Prevent Blindness America quizzes covered primarily diagnosis, screening, and risk factors, and the quizzes from the literature primarily covered causes of glaucoma, vision loss, eye drops, and systemic disease. Overall, the NEHEP quiz was ranked best for clinical practice, ranked first by 38%. Ranked second overall, the Gray quiz was ranked first by 34% and last by 34%. Conclusion: The NEHEP quiz was rated most useful for assessing baseline general glaucoma knowledge for a busy clinical practice. The Gray quiz appears to be more useful as part of a comprehensive education program, perhaps in combination with an ophthalmic educator. Keywords: patient education, quiz, clinical practice