Faculty Bibliography

Telemedicine services facilitate the evaluation, diagnosis, and management of the remote patient. Telemedicine has rapidly flourished in the United States and has improved access to care, outcomes, and patient satisfaction. However, the use of telemedicine in ophthalmology is currently in its infancy and has yet to gain wide acceptance. Current models of telemedicine in ophthalmology are largely performed via "store and forward" methods, but remote monitoring and interactive modalities exist. Although studies have examined the effects of telemedicine, few reports have characterized its current status. We perform a descriptive analysis of the current state of teleophthalmology in the United States. We describe the use of teleophthalmology in the hospital and outpatient settings. We also review the applications to retinopathy of prematurity, diabetic retinopathy, age-related macular degeneration, and glaucoma, as well as anticipated barriers and hurdles for the future adoption of teleophthalmology. With ongoing advances in teleophthalmology, these models may provide earlier detection and more reliable monitoring of vision-threatening diseases.

Timely ophthalmologic consultation is important to ensure patients receive high quality ophthalmologic care in the Emergency Department (ED). Tele-ophthalmology may prove useful in safely and efficiently managing ED eye-related complaints. Prior to implementing such a solution, current consultation patterns must be understood. We aimed to assess case-mix acuity and consultation workflow patterns in the ophthalmology consult service at a tertiary emergency department in New York City. The medical records of patients with eye-related complaints who presented to the ED between January 1, 2015 and December 31, 2015 were reviewed. Visits were retrospectively assigned acuities and the ophthalmologic subspecialty involved in the case was recorded. The number of ophthalmologic consultations ordered and consultant response times were analyzed. Patients who were transferred to the ED for eye-related complaints were included. The ED received 1090 eye-related complaints in this period. 60% were retrospectively assigned low acuity, 27% were assigned medium acuity, and 13% were assigned high acuity. Ophthalmology was consulted on 19% of low, 18% of medium, and 48% of high acuity cases. 44% of complaints involved the anterior segment and 30% involved oculoplastics. 2/3 of transfer patients initially assigned high acuity were downgraded to low acuity upon examination. On average, the consult note was created and signed within 109 and 153 min, respectively, after consult order. ED consults are heavily weighted towards pathology of low-to-medium acuity affecting the anterior segment and ocular adnexa. Currently available tele-ophthalmology technology can potentially address a large volume of eye-related visits.

OBJECTIVE:To characterize utilization of laser and incisional glaucoma surgery among Medicare beneficiaries from 2008-2016 and to compare utilization of these surgeries by glaucoma subspecialists versus nonspecialists. DESIGN/METHODS:Retrospective, observational analysis. PARTICIPANTS/METHODS:1468035 Medicare beneficiaries who underwent ≥1 laser or incisional glaucoma surgery during 2008 to 2016. METHODS:Claims data from a 20% sample of enrollees in fee-for-service Medicare throughout the US were analyzed to identify all laser and incisional glaucoma surgeries performed during 2008-2016. We assessed utilization of traditional incisional glaucoma surgeries (trabeculectomy and glaucoma drainage implants (GDIs)) as well as microinvasive glaucoma surgeries (MIGS). Enrollee and procedure counts were multiplied by 5 to estimate utilization throughout all of Medicare. Using linear regression, we also compared trends in utilization of glaucoma surgeries among ophthalmologists we could characterize as glaucoma subspecialists and nonspecialists. MAIN OUTCOME MEASURE/METHODS:Numbers of laser and incisional glaucoma surgeries performed overall, and stratified by glaucoma subspecialist status RESULTS: The number of Medicare beneficiaries who underwent any glaucoma therapeutic procedure increased 10.6% from 218375 in 2008 to 241565 in 2016. The total number of traditional incisional glaucoma surgeries decreased 11.7% from 37225 in 2008 to 32885 in 2016 (p=0.02). By comparison, the total number of MIGS increased 426% from 13705 in 2012 (the first year there were codes available for these surgeries) to 58345 in 2016 (p=0.001). Throughout the study period, glaucoma subspecialists performed the majority of trabeculectomies (76.7% in 2008 and 83.1% in 2016) and GDIs (77.7% in 2008 and 80.6% in 2016). By comparison, many MIGS were performed by nonspecialists. The proportion of endocyclophotocoagulations, iStent insertions, goniotomies, and canaloplasties performed by subspecialists in 2016 were 22.0%, 25.2%, 56.9%, and 62.8%, respectively. CONCLUSION/CONCLUSIONS:From 2008-2016 we observed a large shift in practice away from traditional incisional glaucoma surgeries to MIGS. While glaucoma subspecialists continue to perform the majority of traditional incisional glaucoma surgeries, many MIGS are performed by nonspecialists. These results highlight the importance of training residents how to properly perform MIGS and manage these patients during the perioperative period. Future studies should explore the impact of this shift in care on outcomes and costs.

Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

Purpose : OCT Angiography (OCTA) can be used to measure retinal vessel density (VD). These scans can be of various sizes and may be centered on the optic nerve head (ONH) or macula. In this study, we examined the glaucoma discrimination performance of VD using different scanning sizes and locations and compared it with the performance of conventional structural and functional biomarkers to identify the best glaucoma discrimination scanning protocol. Methods : 79 healthy and glaucomatous eyes (50 subjects) were included in the study. Subjects with diabetes, vascular disease, or who were using medications known to affect retinal thickness were excluded. 3x3 and 6x6mm ONH and macula OCTA images were obtained using Cirrus HD-OCT Angioplex (Zeiss, Dublin, CA). Global and sectoral VD was calculated using native software on the device. Area under the receiver operating characteristics (AUC) was used to determine the discrimination ability of VD, retinal nerve fiber layer (RNFL) thickness, rim area, cup-to-disc (C/D) ratio, ganglion cell inner plexiform layer (GCIPL) thickness, and visual field mean deviation (MD). Bootstrapping was used for comparison between the AUCs. Results : Subjects with glaucoma had statistically significantly different measurements than healthy individuals for all tested parameters except for the majority of macula VD (both 3x3 and 6x6 scanning sizes; Table). VD measurements that had the best glaucoma discrimination ability were acquired from the ONH from all sectors of the 3x3 scans and in the outer and full sectors in the 6x6 scans (Table). For these ONH parameters, no significant difference was detected from the best discriminating parameter (average RNFL and rim area). All macula VD measurements had significantly worse discrimination performance. Conclusions : Among VD scanning options, the ONH scans are the most suitable for glaucoma discrimination. However, the coarse sampling in the larger scan (6x6mm) reduces this capability inside and immediately adjacent to the ONH

PURPOSE/OBJECTIVE:To characterize differences in resource utilization and cost of managing enrollees with exfoliation glaucoma (XFG) compared to primary open-angle glaucoma (POAG). DESIGN/METHODS:Retrospective utilization and cost comparison using Medicare claims data. METHODS:We identified Medicare beneficiaries with XFG or POAG and ≥5 years of continuous enrollment from January 2008 to December 2014. We distinguished newly-diagnosed cases from those with pre-existing disease. We compared ophthalmic resource utilization and costs over 2 years of follow-up for persons with newly-diagnosed and pre-existing XFG versus those with POAG. MAIN OUTCOME MEASURES/METHODS:Number of clinic visits, diagnostic procedures, medication fills, laser and incisional surgery, and mean eyecare costs per beneficiary. RESULTS:Among 192 eligible enrollees (median age 77.6 years) with newly-diagnosed XFG and 7339 enrollees (median age 77.3 years) with newly-diagnosed POAG, those with XFG had more office visits (mean, 9.1 vs. 7.9; p=0.001), cataract surgery (34.9% vs. 19.0%; p<0.0001) and glaucoma surgery (28.7% vs. 19.7%, p=0.002). They also experienced 27% higher mean total eyecare costs ($3260 vs. $2562, p=0.0001) over 2 years of follow-up. Among 2745 enrollees (median age 80.5 years) with pre-existing XFG and 89036 persons (median age 79.5) with pre-existing POAG, persons with XFG had more office visits (mean 9.3 vs. 7.3; p<0.0001), perimetry (85.3% vs. 79.8%; p<0.0001), cataract surgery (23.4% vs. 12.3%; p<0.0001), laser trabeculoplasty (18.6% vs. 9.6%; p<0.0001), trabeculectomy (8.1 vs. 1.8%; p<0.0001) and experienced 37% higher total mean eyecare costs ($3764 vs. $2739; p<0.0001). CONCLUSIONS:Healthcare resource utilization and costs are substantially higher for managing patients with XFG compared to POAG.