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Health care teams are most effective at addressing complex problems and improving health outcomes for underserved populations when team members bring diverse life experiences and perspectives to the effort. With rates of visual impairment expected to increase in the United States by 2050, especially among minority populations, diversification of the ophthalmology workforce will be critical in reducing disparities in access to and quality of vision health care. Currently, ophthalmology is less diverse with respect to race, ethnicity, and gender than graduating medical classes and other medical specialties, as well as the general US population. In addition, data on diversity in sexual orientation and gender identity, socioeconomic status, and disability are lacking in ophthalmology. The Minority Ophthalmology Mentoring and Rabb-Venable Excellence in Ophthalmology Programs are examples of initiatives to increase racial and ethnic diversity in the workforce and can serve as models for increasing other aspects of inclusiveness. Other strategies for improving vision health care for all Americans include continuing to support existing diversity programs and creating new ones; addressing unconscious and implicit bias in medical school, residency, and faculty selections; conducting holistic reviews of medical school and residency applications; diversifying selection committees and leadership; and encouraging faculty development of underrepresented groups.

To evaluate differences in Medicare reimbursements between male and female ophthalmologists between 2013 and 2019.Retrospective cohort study.Ophthalmologists receiving Medicare reimbursements between 2013 and 2019.The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to determine total reimbursements and number of services submitted by ophthalmologists between 2013 and 2019. Reimbursements were standardized to account for geographic differences in Medicare reimbursement per service. Data from the American Community Survey (ACS) were used to determine socioeconomic characteristics (unemployment, poverty, income, and education) by zip code for the location of each physician's practice. A multivariate linear regression model was used to evaluate differences in annual reimbursements by sex, accounting for calendar year, years of experience, total number of services, ACS zip code data, and proportion of procedural services.Annual Medicare reimbursement and use of billing codes (e.g., outpatient office visits and eye examinations, diagnostic testing, laser treatment, and surgery).Among 20 281 ophthalmologists who received Medicare reimbursements between 2013 and 2019, 15 451 (76%) were men. The most common billing codes submitted were for outpatient visits and eye examinations (13.8 million charges/year), diagnostic imaging of the retina (5.6 million charges/year), intravitreal injections (2.9 million charges/year), and removal of cataract with insertion of lens (2.4 million charges/year). Compared with men, female ophthalmologists received less in median annual reimbursements (median, $94 734.21 [interquartile range (IQR), $30 944.52-$195 701.70] for women vs. $194 176.90 [IQR, $76 380.76-$355 790.80] for men; P0.001) and billed for fewer annual median services (median, 1228 [IQR, 454-2433] vs. 2259 [IQR, 996-4075, respectively]; P0.001). After adjustment for covariates, female ophthalmologists billed for 1015 fewer services (95% confidence interval [CI], 1001-1029; P0.001) and received $20 209.12 less in reimbursements than men (95% CI, -$21 717.57 to -$18 700.66; P0.001).Female ophthalmologists billed for fewer services and received less in reimbursement from Medicare than men over time and across all categories of billing codes. Disparities persisted after controlling for physician and practice characteristics.

The human retina is a complex multi-layered tissue which offers a unique window into systemic health and disease. Optical coherence tomography (OCT) is widely used in eye care and allows the non-invasive, rapid capture of retinal measurements in exquisite detail. We conducted genome- and phenome-wide analyses of retinal layer thicknesses using macular OCT images from 44,823 UK Biobank participants. We performed phenome-wide association analyses, associating retinal thicknesses with 1,866 incident ICD-based conditions (median 10-year follow-up) and 88 quantitative traits and blood biomarkers. We performed genome-wide association analyses, identifying inherited genetic markers which influence the retina, and replicated our associations among 6,313 individuals from the LIFE-Adult Study. And lastly, we performed comparative association of phenome- and genome-wide associations to identify putative causal links between systemic conditions, retinal layer thicknesses, and ocular disease.Independent associations with incident mortality were detected for photoreceptor thinning and ganglion cell complex thinning. Significant phenotypic associations were detected between retinal layer thinning and ocular, neuropsychiatric, cardiometabolic and pulmonary conditions. Genome-wide association of retinal layer thicknesses yielded 259 loci. Consistency between epidemiologic and genetic associations suggested putative causal links between thinning of the retinal nerve fiber layer with glaucoma, photoreceptor segment with AMD, as well as poor cardiometabolic and pulmonary function with PS thinning, among other findings.In conclusion, retinal layer thinning predicts risk of future ocular and systemic disease. Furthermore, systemic cardio-metabolic-pulmonary conditions promote retinal thinning. Retinal imaging biomarkers, integrated into electronic health records, may inform risk prediction and potential therapeutic strategies.One Sentence SummaryPhenome- and genome-wide associations of retinal OCT images across nearly 50,000 individuals identifies ocular and systemic phenotypes linked to retinal layer thinning, inherited genetic variants linked to retinal layer thickness, and putative causal links between systemic conditions, retinal layer thickness, and ocular disease.

Supplemental Digital Content is available in the text., Background: The microvasculature, the smallest blood vessels in the body, has key roles in maintenance of organ health and tumorigenesis. The retinal fundus is a window for human in vivo noninvasive assessment of the microvasculature. Large-scale complementary machine learning-based assessment of the retinal vasculature with phenome-wide and genome-wide analyses may yield new insights into human health and disease. Methods: We used 97 895 retinal fundus images from 54 813 UK Biobank participants. Using convolutional neural networks to segment the retinal microvasculature, we calculated vascular density and fractal dimension as a measure of vascular branching complexity. We associated these indices with 1866 incident International Classification of Diseases–based conditions (median 10-year follow-up) and 88 quantitative traits, adjusting for age, sex, smoking status, and ethnicity. Results: Low retinal vascular fractal dimension and density were significantly associated with higher risks for incident mortality, hypertension, congestive heart failure, renal failure, type 2 diabetes, sleep apnea, anemia, and multiple ocular conditions, as well as corresponding quantitative traits. Genome-wide association of vascular fractal dimension and density identified 7 and 13 novel loci, respectively, that were enriched for pathways linked to angiogenesis (eg, vascular endothelial growth factor, platelet-derived growth factor receptor, angiopoietin, and WNT signaling pathways) and inflammation (eg, interleukin, cytokine signaling). Conclusions: Our results indicate that the retinal vasculature may serve as a biomarker for future cardiometabolic and ocular disease and provide insights into genes and biological pathways influencing microvascular indices. Moreover, such a framework highlights how deep learning of images can quantify an interpretable phenotype for integration with electronic health record, biomarker, and genetic data to inform risk prediction and risk modification.

We report the sensitivity and specificity of van Herick (VH) grading in detecting gonioscopically-defined primary angle closure suspects (PACS) among subjects screened for participation in a population-based trial in southern China. A cut-off of VH≤25% was found to have sensitivity and specificity rates of 98.2% and 25.9%, respectively. Rates were adjusted for missing gonioscopy data, resulting in a sensitivity and specificity of 92.5% and 61.5%, respectively.

To evaluate associations between visual impairment, anxiety, and depression during the COVID-19 pandemic in the United States.Retrospective cross-sectional design.This study included a cohort of U.S. adults enrolled in the National Institutes of Health All of Us Research Program. Individuals who were blind/visually impaired (BVI) were identified via Systematized Nomenclature of Medicine (SNOMED) codes and compared with a control cohort. Prevalences of baseline, new, and worsened depression and anxiety, as defined by SNOMED codes and medication use, were compared between the 2 groups. Anxiety and depression during the COVID-19 pandemic were evaluated using the Generalized Anxiety Disorder 7 and the Patient Health Questionnaire 9 surveys, respectively.A total of 324,915 participants (7526 BVI individuals and 317,389 control individuals) were included. BVI individuals had higher prevalences of baseline anxiety and depression (50.4% vs 28.7%; p0.001), new anxiety and depression (0.98% vs 0.66%; p0.001), and worsened anxiety and depression throughout the COVID-19 pandemic (0.19% vs 0.07%; p0.001) compared with control individuals. Being BVI was significantly associated with baseline and worsened anxiety and depression after controlling for age, sex, race, ethnicity, and comorbidity (adjusted odds ratio [aOR] = 1.61; 95% CI, 1.46-1.78 and aOR = 2.07; 95% CI, 1.03-4.13). Similarly, being BVI was associated with a 2.07 point increase on the Generalized Anxiety Disorder 7 survey (adjusted β = 2.07; 95% CI, 1.32-3.27) and a 2.96 point increase on the Patient Health Questionnaire 9 survey (adjusted β = 2.96; 95% CI, 1.64-5.36).These findings indicate that BVI individuals were disproportionately affected by anxiety and depression at baseline and throughout the pandemic, highlighting an important need to promote access to mental health services among this population.

Purpose Understanding trends and patterns in the use of minimally invasive glaucoma surgery (MIGS) and patient profiles undergoing each procedure is important given their relative expense and unknown long-term safety and effectiveness. Design Retrospective analysis. Participants Minimally invasive glaucoma surgeries and standard glaucoma surgeries recorded in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry. Methods We used the data from IRIS® Registry between 2013 and 2018 (inclusive) to measure the annual number of MIGS and standard surgical techniques (trabeculectomy or glaucoma drainage device [GDD] placement) performed in the United States, stratified by demographic characteristics. Secondary analyses of concurrent surgeries and of subsequent surgeries for MIGS and standard surgical technique also were conducted. Main Outcome Measures Trends and sociodemographic characteristics of MIGS use in the United States. Results Two hundred three thousand three hundred thirty-two eyes and 232 537 unique procedures had associated, documented International Statistical Classification of Diseases and Related Health Problems (ICD), Ninth or Tenth Revision, codes for glaucoma and were included in final analyses. Among eyes with documented glaucoma diagnoses, a substantial increase in annual MIGS procedures occurred over the study period (from 7586 in 2013 to 39 677) and a smaller decrease in standard glaucoma procedures (from 16 215 to 13 701). The proportion of iStent procedures almost tripled during the study period (from 14% to 40%), and by 2017 accounted for almost half (43.7%) of all glaucoma surgeries in the United States. Twenty-one thousand twenty-five of all eyes (10.3%) underwent multiple procedures: 7638 (36.3%) on the same day and 13 387 (63.7%) on subsequent days. Endocyclophotocoagulation and iStent placement were the most common concurrent procedures (55.4% of all concurrent procedures). Trabeculectomy and GDD placement were most commonly followed by another standard glaucoma surgery, but when followed by sequential MIGS, endocyclophotocoagulation and goniotomy were the most common procedures performed (33.0% and 21.9%, respectively). Conclusions A significant increase in MIGS use occurred over the recent 6-year period, despite limited evidence of their long-term safety or effectiveness, highlighting the need for trials comparing safety and outcomes of novel MIGS versus traditional surgical treatments for glaucoma.

To estimate the heritability of ocular biometric and anterior chamber morphologic parameters and to determine predictors of angle closure concordance in South Indian probands with angle closure and their siblings DESIGN: Prospective observational cohort study METHODS: Subjects received a standardized ophthalmic examination, A-scan ultrasonography, pachymetry, and anterior segment optical coherence tomography (ASOCT) imaging. Heritability was calculated using residual correlation coefficients adjusted for age, sex, and home setting. Concordant sibling pairs were defined as both proband and sibling with angle closure. Predictors of angle closure concordance among siblings were calculated using multivariable logistic regression models.A total of 345 sibling pairs participated. All anterior chamber parameters were highly heritable (P.001 for all). Similarly, all iris parameters, axial length, lens thickness (LT), central corneal thickness, anterior lens curvature, lens vault (LV), spherical equivalent, and intraocular pressure were moderately to highly heritable (P.004 for all). LV and LT were more heritable among concordant siblings (P.05 for both). In contrast, ASOCT angle parameters had statistically insignificant heritability estimates. In multivariable analyses, siblings older than their probands were more likely to be concordant for angle closure (OR 1.05, 95% CI 1.01, 1.09; P = .02) and siblings with deeper anterior chamber depths (ACDs) compared to their proband were less likely to be concordant for angle closure (OR 0.74, 95% CI 0.64, 0.86; P.001).Iris, anterior chamber, and lens parameters may be heritable whereas angle parameters were not. LT and LV may play important roles in the pathogenesis of angle closure. Siblings who are older or have a shallower ACD may need more careful disease monitoring.

To test whether the increase in insurance coverage in Massachusetts due to the Affordable Care Act (ACA) is associated with a decrease in glaucoma severity in patients presenting for the first time at a tertiary health system.Clinical and billing data of first-time glaucoma patients from a tertiary health system in Massachusetts from 2006 to 2021 was used. Pre-ACA is defined as before 2014 and post-ACA is defined as after 2014. Visual field mean deviation was used to define glaucoma severity: greater than -6 dB, less than -6 dB and greater than -12 dB, and less than -12 dB was classified as "mild," "moderate," and "severe" respectively. Ordinal logistic regression models adjusted for age, race, gender, and insurance type were used to determine the odds of presenting with more severe glaucoma.2,394 pre-ACA and 3,651 post-ACA first-time glaucoma patients were identified. There was no significant difference in the likelihood of more severe glaucoma at first presentation post-ACA compared to pre-ACA (OR=0.96; 95% CI 0.86-1.08; p=0.49) among the entire population. In stratified analyses, patients who utilized Medicaid for insurance had 52% decreased odds for presenting with more severe glaucoma at first presentation post-ACA compared to pre-ACA (OR=0.48; 95% CI 0.33-0.69; p0.001). This remained significant after adjustment for age, race, and gender (adjusted OR=0.44; 95% CI 0.29-0.65; p0.001).At a Massachusetts-based tertiary healthcare center, individuals on Medicaid were more likely to have more severe glaucoma at first presentation before the implementation of the ACA, compared to after.

To study the association between diabetic retinopathy (DR) and physical functional difficulty using contemporary psychometric validation techniques, and to explore the predictors of physical difficulty among those with diabetes, non-proliferative DR (NPDR), or proliferative DR (PDR). Cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) database from 2005–2008. Participants were classified as either (i) no diabetes no DR, (ii) diabetes without DR, (iii) mild/moderate NPDR, or (iv) severe NPDR/PDR. The presence of DR was detected by retinal imaging and severity was graded using the Early Treatment Diabetic Retinopathy Study Protocol. The physical difficulty was assessed using a 13-question self-reported questionnaire, validated using factor analysis and item response theory (graded response model) psychometric techniques. Secondary analyses of diabetes and DR populations most at risk of reporting greater physical functional difficulty were undertaken. A total of 5321 participants over the age of 40 were included in our study. Of the 13 original physical difficulty questions, one latent trait was identified and 9 questions demonstrated good discrimination and were subsequently retained. In univariable analyses, participants with diabetes and any form of DR all reported significantly higher physical functional difficulty vs those with neither diabetes nor DR (p

PurposeTo evaluate the potential of retinal optical coherence tomography (OCT) measurements and polygenic risk scores (PRS) to identify people at risk of cognitive impairment.MethodsUsing OCT images from 50 342 UK Biobank participants, we examined associations between retinal layer thickness and genetic risk for neurodegenerative disease and combined these metrics with PRS to predict baseline cognitive function and future cognitive deterioration. Multivariate Cox proportional hazard models were used to predict cognitive performance. P values for retinal thickness analyses are false-discovery-rate-adjusted.ResultsHigher Alzheimer’s disease PRS was associated with a thicker inner nuclear layer (INL), chorio-scleral interface (CSI) and inner plexiform layer (IPL) (all pConclusions and relevanceRetinal OCT measurements are significantly associated with genetic risk of neurodegenerative disease and may serve as biomarkers predictive of future cognitive impairment.

Investigate associations of race/ethnicity and preferred language with baseline glaucoma severity, VF test frequency and disease progression.Retrospective cohort study.Patients receiving VF testing at a tertiary eyecare center between 1998 and 2020 with self-identified race, ethnicity and preferred language were included. Outcome measures were VF MD and age at first visit, VF test frequency, VF MD progression.Among 29,891 patients with VF measurements between 1998 and 2020, 55.1% were female, 71.0% self-identified as White/Caucasian, 14.0% as Black/African American, 7.4% as Asian and 6.4% as Hispanic, and 11.2% preferred a language other than English. Mean VF MD at presentation was worse among Black (-9.3±9.7 dB), Asian (-6.2±7.6 dB) and Hispanic (-8.3±9.3 dB) patients (vs. Whites [-5.5±7.3 dB, p0.001] or non-Hispanics [-6.2±7.8 dB, p0.001]). After controlling for age, gender and English proficiency, disparities in glaucoma severity at presentation were reduced, especially among Asian and Hispanic patients. Despite greater severity at presentation, Black patients had lower VF test frequency/person-years (1.07±0.53) compared to Whites (1.12±0.52, p=0.006) and worse VF MD progression (-0.43 dB/year, 95% CI -0.67 to -0.28, p0.001). In contrast, Hispanics had a higher VF frequency vs. non-Hispanics (1.18±0.64 vs. 1.11±0.52, p0.001), and no difference in VF progression (p=0.77).Black, Asian and Hispanic patients had greater baseline severity vs. Whites. Unlike other groups, Black patients had a lower VF frequency vs. Whites and greater VF progression. Disparities in baseline severity were partially explained by English proficiency, especially for Asian and Hispanic patients.

To determine the effectiveness of trabeculectomy and glaucoma drainage device (GDD) surgery performed with concurrent phacoemulsification compared with stand-alone procedures.Multicenter retrospective cohort study.Patients in the Intelligent Research in Sight Registry who underwent trabeculectomy or GDD from 2013 through 2019.The Kaplan-Meier survival analysis was used to determine reoperation rates. Reoperation was defined as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine reoperation risk factors.Reoperation rate, intraocular pressure (IOP), visual acuity, reoperation procedure type, postoperative complications, and predictors of surgical failure.A total of 117 697 eyes undergoing glaucoma surgery alone and 35 657 eyes undergoing surgery with phacoemulsification were included. The cumulative reoperation rates at postoperative years 1 and 3 were 4.9% and 11.5%, respectively, for trabeculectomy alone and 3.0% and 7.3%, respectively, for trabeculectomy combined with phacoemulsification (P0.001). The reoperation rates at postoperative 1 and 3 years were 3.8% and 7.8%, respectively, for GDD alone and 2.1% and 5.4%, respectively, for GDD with phacoemulsification (P0.001). Stand-alone procedures achieved greater IOP reduction by percentage change from baseline (trabeculectomy alone, 35.3% vs. trabeculectomy with phacoemulsification, 23.1%, P0.001; and GDD alone, 36.0% vs. GDD with phacoemulsification, 29.3%; P0.001). Visual acuity improved by 0.12 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI], 0.11-0.12) and 0.10 logMAR (95% CI, 0.08-0.11) after trabeculectomy and GDD with phacoemulsification and declined by 0.15 logMAR (95% CI, 0.14-0.15) and 0.12 logMAR (95% CI, 0.11-0.12) after stand-alone trabeculectomy and GDD. The overall documented complication rate was 2.9% for GDD and 1.4% for trabeculectomy. Age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical failure risk. The most common reoperation procedure was GDD.Reoperation rates within the first 3 years after trabeculectomy and GDD with and without phacoemulsification were low. Trabeculectomy and GDD with phacoemulsification had lower reoperation rates than those with stand-alone procedures. However, stand-alone procedures resulted in greater IOP reduction compared with combined procedures. Postoperative complications were uncommon overall. Patient age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical success.

Purpose To compare early postoperative intraocular pressure (IOP) in patients who underwent cataract surgery alone with those who underwent cataract surgery combined with implantation of a Hydrus Microstent (HMS) (Ivantis, Irvine, CA). Design Subanalysis of data from the randomized controlled HORIZON trial, a multicenter trial including 26 US and 12 international sites. Participants Participants with mild/moderate primary open-angle glaucoma (POAG) and visually significant cataract with mean modified diurnal IOP between 22 and 34 mmHg after washout of IOP-lowering medications. Methods A total of 556 subjects were randomized in a 2:1 ratio to undergo cataract surgery with placement of the HMS versus cataract surgery alone (no microstent [NMS]). All eyes were washed out of IOP-lowering medications before surgery and remained unmedicated until surgery. No IOP-lowering prophylaxis was used postoperatively. Comprehensive eye examination including measurement of intraocular pressure was conducted on postoperative day (POD) 1, week 1, and month 1. Main Outcome Measures Postoperative IOP >40 mmHg was analyzed as the primary outcome. Incidence of IOP increase >10 mmHg above baseline, unmedicated IOP, and mean IOP were analyzed as secondary outcomes. Results A total of 369 eyes were randomized to the HMS group, and 187 eyes were randomized to cataract surgery alone. The HMS and NMS groups did not differ with respect to baseline demographic or ocular characteristics. On POD1, the incidence of IOP spike >40 mmHg was significantly higher at 14.4% in the NMS group compared with 1.4% in the HMS group (P 40 mmHg, whereas the presence of HMS was associated with a lower likelihood of postoperative IOP spike. Conclusions The addition of an HMS at the time of cataract surgery lowered the risk of markedly elevated IOP in the early postoperative period in patients with glaucoma.

Purpose: To compare corrected intraocular pressure (IOP) by tonopachy with that of Goldmann applanation tonometry (GAT) in normal and glaucomatous patients. Methods: In this cross-sectional study, IOP and central corneal thickness (CCT) were measured in 426 eyes (213 normal eyes and 213 glaucomatous eyes) of 426 patients by tonopachy followed by GAT and ultrasound pachymetry. IOP was corrected for CCT by in-built formula in tonopachy and Ehlers correction factor for Goldmann tonometer. Limits of agreements were assessed using Bland–Altman plots. Intraclass correlation coefficient was calculated to estimate the absolute agreement between single and average measurements of IOP and CCT of tonopachy with that of Goldmann tonometer and ultrasound pachymetry respectively. Results: Mean corrected IOP measured with tonopachy and GAT in glaucomatous eyes was 17.63 ± 5.04 mmHg and 19.42 ± 5.83 mmHg, and in controls it was 13.4 ± 2.5 mmHg and 16.2 ± 3.1 mmHg, respectively. Limits of agreement ranged from –4.63 to +9.25 mmHg for total population (mean = 2.31), ˗6.01 to +9.59 mmHg (mean = 1.79) for glaucoma group and ˗2.99 to +8.65 mmHg (mean = 2.83) for controls. Intraclass correlation coefficient for IOP measurement between tonopachy and Goldmann tonometer was 0.84 for total population, 0.85 for glaucoma group, and 0.63 for controls, respectively. Conclusion: Corrected IOP obtained by tonopachy showed moderate agreement with GAT and it is more in glaucoma patients than controls. Thus, tonopachy can be used as a screening tool, but cannot replace GAT.

The feasibility of implementing a computerized adaptive test (CAT) system in routine clinical care in ophthalmology has not been assessed. We evaluated the implementation of a glaucoma-specific CAT (GlauCAT) in outpatients at Massachusetts Eye and Ear Institute.In this implementation study (July 2020-April 2021), 216 adults (mean ± SD age 64.8 ± 15.3 years; 56.0% women) completed six adaptive GlauCAT quality of life (QOL) tests on an internet-enabled tablet at the clinic. A real-time printable report summarizing domain scores was shared with physicians prior to consultation. The implementation was evaluated using Proctor's outcomes: acceptability (patient satisfaction); appropriateness (independent complete rate [%]); feasibility (acceptance rate [%]; completion time); and fidelity (percentage of patients discussing GlauCAT results with their physician). Physician barriers/facilitators were explored using open-ended questions.Patients' mean ± SD satisfaction score was 3.5 ± 0.5 of 4, with95% of patients willing to recommend it to others. Of the 216 (89.2%) patients accepting to participate, 173 (80%) completed GlauCAT independently. Patients took 8 minutes and 5 seconds (median) to complete all 6 GlauCAT tests. Almost two-thirds (n = 136/216) of the patients reported discussing their GlauCAT results with their doctor. Physicians described the GlauCAT summary report as helpful and user-friendly, although lack of time and uncertainty about how to action information were reported.Pilot implementation of six GlauCAT QOL tests in glaucoma outpatient clinics was feasible and acceptable. Integration of GlauCAT with electronic medical records (EMRs) and evaluation of long-term implementation outcomes are needed.GlauCAT's multiple outcomes and low test-taking burden makes it attractive for measuring glaucoma-specific QOL in routine clinical care.

ObjectivesMeasure quality of life (QoL) outcomes using a novel computerised adaptive test in a clinical setting, and determine the social and demographic factors associated with specific QoL domains in patients with glaucoma.DesignCross-sectional study between July 2020 and April 2021.ParticipantsEnglish-speaking adults presenting to glaucoma clinic. Patients with cognitive impairment on a six-item cognitive impairment screen or with intraocular surgery within 90 days prior to presentation were excluded.ResultsOf 206 patients surveyed, mean age was 64.8 years (SD 15.2), 122 (56.7%) were female and 159 (74.7%) were white. On multivariable regression, visual acuity was associated with greater activity limitation (β=−2.8 points, 95% CI −3.8 to –1.8, pConclusionsIn a busy glaucoma clinic where QoL was measured with online adaptive tests for glaucoma, we found that several demographic and clinical variables are associated with lower domain scores, suggesting that patients with predisposing demographic and clinical factors are at a higher risk of worse QoL.

Introduction: The retinal fundus is a window for non-invasive assessment of the microvasculature. However, the range of phenotypes and inherited genetic variants associated with the retinal microvasculature remain unknown. Hypothesis: Deep learning of retinal fundus images enables large-scale quantification of vascular indices and an unbiased assessment of phenotypes and genetic variants linked to the microvasculature. Methods: We utilized 97,895 retinal fundus images from 54,813 UK Biobank participants (ages 40-70y, 55% female). Using convolutional neural networks to segment vessels, we calculated vascular branching complexity using fractal dimension (FD), and vascular density, and associated these indices with 1,100 incident ICD-based conditions (median 10y follow-up) and 88 quantitative traits, adjusting for age, sex, smoking status, and ethnicity. Genome-wide association study (GWAS) among 38,932 unrelated individuals was performed. Results: Low retinal vascular FD and density were significantly associated with increased risk of incident hypertension, congestive heart failure, renal failure, type 2 diabetes, sleep apnea, anemia, and multiple ocular conditions. Low retinal vascular FD and density were also linked to quantitative traits including elevated blood pressure, anemia indices, abnormal pulmonary function tests, measures of metabolic disease (high HbA1c, % body fat, BMI), and ocular traits (decreased visual acuity and increased intraocular pressure). GWAS of vascular FD and density identified loci enriched among pathways linked to angiogenesis (VEGF, PDGFR, angiopoietin, and WNT signaling pathways), and inflammation (interleukin, cytokine signaling). Conclusions: Through phenotypic and genotypic analyses, our study showed that the retinal vasculature may serve as a biomarker for future cardiometabolic and ocular disease, and provided insights on genes and biological pathways influencing microvascular indices.

PURPOSE: To estimate the incidence of corneal endothelial transplantation and identify risk factors among patients with non-infectious ocular inflammation. DESIGN: Retrospective cohort study. METHODS: Adult patients attending United States tertiary uveitis care facilities diagnosed with non-infectious ocular inflammation were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Time-to-event analysis was used to estimate the incidence of corneal endothelial transplantation (CET), including penetrating keratoplasty, Descemet stripping endothelial keratoplasty, or Descemet Membrane Endothelial Keratoplasty procedures. The incidence of CET was calculated; potential risk factors for CET were also evaluated using Cox regression, accounting for correlation between eyes of the same patient. RESULTS: Overall, 14,264 eyes met eligibility criteria for this analysis with a median follow-up 1.8 eye-years. The Kaplan-Meier estimated incidence of CET within 10 years was 1.10% (95% CI, 0.68%–1.53%). Risk factors for CET included age >60 years vs.

The strength of the relationship between diabetes, diabetic retinopathy (DR), and glaucoma remains controversial. We review evidence supporting and refuting this association and explore mechanistic pathological and treatment relationships linking these diseases. While studies have shown diabetes/DR may increase the risk for glaucoma, this remains inconsistently demonstrated. Diabetes/DR may contribute toward glaucomatous optic neuropathy indirectly (either by increasing intraocular pressure or vasculopathy) or through direct damage to the optic nerve. However, certain elements of diabetes may slow glaucoma progression, and diabetic treatment may concurrently be beneficial in glaucoma management. Diabetes plays a significant role in poor outcomes after glaucoma surgery. While the relationship between diabetes/DR and glaucoma remains controversial, multiple mechanistic links connecting pathophysiology and management of diabetes, DR, and glaucoma have been made. However, a deeper understanding of the causes of disease association is needed.

Purpose Evaluate differences in eye care utilization among patients with glaucoma by race and socioeconomic status (SES). Design Retrospective cohort study. Participants Representative 5% sample of Medicare beneficiaries aged > 65 years with continuous part A/B enrollment between January 1, 2014, and July 1, 2014, at least 1 diagnosis code for glaucoma within that period, and a glaucoma diagnosis in the Chronic Conditions Warehouse before January 1, 2014. Methods The following race/ethnicity categories were defined in our cohort: non-Hispanic White, Black/African American, Hispanic, and Asian/Pacific Islander. Low SES was defined as having 2 or more enrollment-based low-income indicators (dual eligibility for Medicare/Medicaid, Part D limited income subsidies, and eligibility for Part A and B State buy-in). Negative binomial regression analyses were carried out to compare relative rate ratios (RRs) of eye care utilization among racial groups stratified by low and non-low SES. Main Outcome Measures Measured from July 1, 2014, to December 31, 2016: eye examinations and eye care–related office visits; eye care–related inpatient and emergency department (ED) encounters; eye care–related nursing home and home-visit encounters; visual field and retinal nerve fiber OCT tests; glaucoma lasers and surgeries. Results Among 78 526 participants with glaucoma, mean age was 79.1 years (standard deviation, 7.9 years), 60.9% were female, 78.4% were non-Hispanic White, and 13.8% met enrollment-based criteria for low-SES. Compared with White beneficiaries, Blacks had lower counts of outpatient visits (RR, 0.92; 95% confidence interval [CI], 0.90–0.93), visual field (VF) tests (RR, 0.92; 95% CI, 0.90–0.94), but more inpatient/ED encounters (RR, 2.42; 95% CI, 1.55–3.78) and surgeries (RR, 1.14; 95% CI, 1.03–1.27). Hispanics had fewer outpatient visits (RR, 0.97; 95% CI, 0.95–0.98) and retinal nerve fiber layer (RNFL) OCT tests (RR, 0.89; 95% CI, 0.86–0.93), but more inpatient/ED encounters (RR, 2.32; 95% CI, 1.18–4.57) and selective laser trabeculoplasty (SLT) (RR, 1.25; 95% CI, 1.11–1.42) versus non-Hispanic Whites. In the non-low SES group, Black versus White disparities persisted in outpatient visits (RR, 0.93; 95% CI, 0.92–0.95), VF (RR, 0.96; 95% CI, 0.94–0.98), RNFL OCT (RR, 0.81; 95% CI, 0.78–0.83), and inpatient/ED encounters (RR, 2.57; 95% CI, 1.55–4.26). Conclusions Disparities were found in eye care utilization among Black and Hispanic patients with glaucoma. These differences persisted among Blacks after stratification by SES, suggesting that systemic racism may be an independent driver in this population.

IntroductionAge-related macular degeneration (AMD) is a blinding condition for which there is currently no early-stage clinical biomarker. AMD is characterized by thinning of the outer retina and drusen formation leading to thickening of the Bruch’s membrane and RPE complex, but the timing between these two events, as well as the role of genetic variants in these processes, are unclear. Here, we jointly analyzed genomic, electronic health record, and optical coherence tomography (OCT) data across 44,823 individuals from the UK Biobank to characterize the epidemiological and genetic associations between retinal layer thicknesses and AMD.MethodsThe Topcon Advanced Boundary Segmentation algorithm was used for automated retinal layer segmentation. We associated 9 retinal layer thicknesses with prevalent AMD (present at enrollment) in a logistic regression model, and with incident AMD (diagnosed after enrollment) in a Cox proportional hazards model. Next, we tested the association of AMD-associated genetic alleles, individually and as a polygenic risk score (PRS), with retinal layer thicknesses. All analyses were adjusted for age, age2, sex, smoking status, and principal components of ancestry.ResultsPhotoreceptor segment (PS) thinning was observed throughout the lifespan of individuals analyzed and accelerated at age 45, while retinal pigment epithelium and Bruch’s membrane complex (RPE+BM) thickening started after age 57. Each standard deviation (SD) of PS thinning and RPE+BM thickening were associated with prevalent AMD (PS: OR 1.37, 95% CI 1.25-1.49, P=2.5×10−12; RPE+BM: OR=1.34, 95% CI 1.27-1.41, P=8.4×10−28) and incident AMD (PS: HR 1.35, 95% CI 1.23-1.47, P=3.7×10−11; RPE+BM: HR 1.14, 95% CI 1.06-1.22, P=0.00024). An AMD polygenic risk score (PRS) was associated with PS thinning (Beta -0.21 SD per 2-fold genetically increased risk of AMD, 95% CI -0.23 to -0.19, P=2.8×10−74), and its association with RPE+BM was U-shaped (thinning with AMD PRSndpercentile and thickening with AMD PRS>92ndpercentile suggestive of drusen formation). The loci with strongest support were AMD risk-raising variantsCFH:rs570618-T,CFH:10922109-C, andARMS2/HTRA1:rs3750846-C on PS thinning, andSYN3/TIMP3:rs5754227-T on RPE+BM thickening.ConclusionsEpidemiologically, PS thinning precedes RPE+BM thickening by decades, and is the retinal layer most strongly predictive of future AMD risk. Genetically, AMD risk variants are associated with decreased PS thickness. Overall, these findings support PS thinning as an early-stage clinical biomarker for future AMD development.

Purpose: To examine patterns of standard (trabeculectomy or glaucoma drainage devices, GDDs) vs novel (minimally invasive glaucoma surgery, MIGS) surgical techniques in the US.Methods: We used the American Academy of Ophthalmology (AAO) IRIS® Registry (Intelligent Research in Sight) queried between 2013 and 2018 (inclusive) to calculate the cumulative proportion of stand-alone, concurrent (same day) or sequential (subsequent day) glaucoma surgical techniques performed in each glaucoma diagnosis type. Secondary analyses of adjusted proportions of concurrent and sequential surgeries stratified by glaucoma diagnosis were also performed.Results: Of 203,146 eyes receiving glaucoma surgeries, open angle glaucoma (OAG) was most likely to undergo all types of intervention. The iStent was the most commonly performed MIGS, primarily for those with normal tension glaucoma (NTG) or OAG (p < .001). Conversely, GDD was the most commonly performed procedure in secondary glaucoma or other (specified) glaucoma (p < .001). ECP and iStent were the most common concurrent procedures performed; most often for OAG and NTG (p < .001). After an initial standard surgery, most eyes underwent recurrent standard interventions (90.3%). ECP was the most common MIGS performed after an initial standard surgery; particularly in primary angle-closure (PACG) and secondary glaucoma eyes (p < .001).Conclusion: Glaucoma type may influence the choice of glaucoma procedures and the decision to perform concurrent as well sequential surgical procedures. Given the poorly understood long term safety and effectiveness of MIGS, and with substantially increasing use of MIGS procedures in recent years, future studies comparing their safety and effectiveness vs standard interventions, for a variety of glaucoma types, is needed.

Background Over 2 billion people suffer from vision impairment or blindness globally, and access to validated visual measurement tools in imperative in accurately describing and managing the burden of eye disease. The present study applies contemporary psychometric validation techniques to the widely used 33-item Indian Visual Function Questionnaire (IND-VFQ-33). Methods We first estimated the polychoric correlation between each pair of items. Next, an unrotated and oblique Promax rotated factor analysis, item response theory (IRT, using a graded response model (GRM)), and differential item functioning (DIF) testing were applied to the IND-VFQ-33. We subsequently propose a validated IND-VFQ-33 questionnaire after psychometric testing, data reduction, and adjustment. Results Exploratory unrotated factor analysis identified two factors; one with a particularly high eigenvalue (18.1) and a second with a lower eigenvalue still above our threshold (1.1). A subsequent oblique Promax factor rotation was undertaken for a 2-factor solution, revealing two moderately correlated factors (+ 0.68) with clinically discrete item loadings onto either Factor 1 (21 items; collectively labelled “daily activities”) or Factor 2 (5 items; collectively labelled “bright lights”). IRT confirmed high item discrimination for all remaining items with good separation between difficulty thresholds. We found significant DIF on depression for six items in Factor 1 (all uniform DIF, except item 21 (non-uniform DIF) with no substantive difference in beta thresholds for any item and no substantive difference in expected individual or sum score, by depression at baseline. For Factor 2, only one item demonstrated significant uniform DIF on gender, similarly without major differences in beta thresholds or expected total score between gender at baseline. Consequently, no further item recalibration or reduction was undertaken after IRT and DIF analysis. Conclusion Applying IRT and DIF validation techniques to the IND-VFQ-33 identified 2 discrete factors with 26 uniquely-loading items, clinically representative of difficulty performing daily activities and experiencing difficulty due to bright lights/glare respectively. The proposed modified scale may be useful in evaluating symptomatic disease progression or response to treatment in an Indian population.

Understanding trends and patterns in the use of minimally invasive glaucoma surgery (MIGS) and patient profiles undergoing each procedure is important given their relative expense and unknown long-term safety and effectiveness.Retrospective analysis.Minimally invasive glaucoma surgeries and standard glaucoma surgeries recorded in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.We used the data from IRIS Registry between 2013 and 2018 (inclusive) to measure the annual number of MIGS and standard surgical techniques (trabeculectomy or glaucoma drainage device [GDD] placement) performed in the United States, stratified by demographic characteristics. Secondary analyses of concurrent surgeries and of subsequent surgeries for MIGS and standard surgical technique also were conducted.Trends and sociodemographic characteristics of MIGS use in the United States.Two hundred three thousand three hundred thirty-two eyes and 232 537 unique procedures had associated, documented International Statistical Classification of Diseases and Related Health Problems (ICD), Ninth or Tenth Revision, codes for glaucoma and were included in final analyses. Among eyes with documented glaucoma diagnoses, a substantial increase in annual MIGS procedures occurred over the study period (from 7586 in 2013 to 39 677) and a smaller decrease in standard glaucoma procedures (from 16 215 to 13 701). The proportion of iStent procedures almost tripled during the study period (from 14% to 40%), and by 2017 accounted for almost half (43.7%) of all glaucoma surgeries in the United States. Twenty-one thousand twenty-five of all eyes (10.3%) underwent multiple procedures: 7638 (36.3%) on the same day and 13 387 (63.7%) on subsequent days. Endocyclophotocoagulation and iStent placement were the most common concurrent procedures (55.4% of all concurrent procedures). Trabeculectomy and GDD placement were most commonly followed by another standard glaucoma surgery, but when followed by sequential MIGS, endocyclophotocoagulation and goniotomy were the most common procedures performed (33.0% and 21.9%, respectively).A significant increase in MIGS use occurred over the recent 6-year period, despite limited evidence of their long-term safety or effectiveness, highlighting the need for trials comparing safety and outcomes of novel MIGS versus traditional surgical treatments for glaucoma.

To study the association between diabetic retinopathy (DR) and physical functional difficulty using contemporary psychometric validation techniques, and to explore the predictors of physical difficulty among those with diabetes, non-proliferative DR (NPDR), or proliferative DR (PDR).Cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) database from 2005-2008. Participants were classified as either (i) no diabetes no DR, (ii) diabetes without DR, (iii) mild/moderate NPDR, or (iv) severe NPDR/PDR. The presence of DR was detected by retinal imaging and severity was graded using the Early Treatment Diabetic Retinopathy Study Protocol. The physical difficulty was assessed using a 13-question self-reported questionnaire, validated using factor analysis and item response theory (graded response model) psychometric techniques. Secondary analyses of diabetes and DR populations most at risk of reporting greater physical functional difficulty were undertaken.A total of 5321 participants over the age of 40 were included in our study. Of the 13 original physical difficulty questions, one latent trait was identified and 9 questions demonstrated good discrimination and were subsequently retained. In univariable analyses, participants with diabetes and any form of DR all reported significantly higher physical functional difficulty vs those with neither diabetes nor DR (p 0.01 for all). In multivariable analyses, while those with diabetes or any form of DR remained more likely to report higher physical difficulty vs those with neither diabetes nor DR, only those with severe NPDR/PDR reported substantially higher scores (2.1 sum points higher, p = 0.002). Among participants with diabetes or any form of DR, those with 3 or more medical comorbidities and those with depression reported substantially higher sum physical difficulty scores (p 0.05 for all).Those with diabetes or DR experience greater functional physical difficulty than those without, particularly profound among those with severe forms of DR. For those with DR, the presence of concurrent depression or medical comorbidities conferred a significantly higher risk of physical difficulty. Providers and healthcare systems should be aware of particularly vulnerable DR populations at increased risk of experiencing daily functioning deficits.

To identify common causes of emergency department-treated eye injury among older adults in the United States and to characterize fall-related ocular trauma in this population.Retrospective cohort study.Data from the National Electronic Injury Surveillance System, a nationally representative database of US emergency department-treated injuries, was used to assemble a cohort of adults ≥65 years of age with eye injuries between January 1, 2000 and December 31, 2019. Demographic information, diagnosis, disposition, injury location, and the consumer product associated with injury were collected. Narrative descriptions of all injuries were reviewed to identify eye injuries caused by falls.Four thousand nine hundred fifty-three eye injuries among older adults were reported from 2000-2019, a stratified probability sample representing approximately 238,162 injuries, with an average annual frequency of 12,000 injuries. Falls accounted for 11.5% of these injuries. Fall-related eye injuries commonly presented from home (66.5%) and were more likely to occur in the winter than eye injuries from other causes (28.1% vs 18.4%, P.01). Risk factors for fall-related eye injury included older age (odds ratio [OR] 1.11 [95% confidence interval {CI} 1.10-1.13 per year), female sex (OR 2.3 [95% CI 1.6-3.1] vs male), black race (OR 2.4 [95% CI 1.3-4.5] vs white), and presentation from a nursing home (OR 12.7 [95% CI 4.9-32.8] vs other locations). Older adults with fall-related injuries were more likely to be hospitalized (OR 22.8 [95% CI 15.3-33.9]) and to have a ruptured globe (OR 14.1 [95% CI 6.5-30.6]) than those with fall-unrelated injury.Falls are an important mechanism of ocular trauma in older adults and are associated with worse outcomes compared with eye injuries from other causes.