Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the ability to screen for glaucoma using a Food Drug Administration (FDA) Class II diagnostic digital fundus photography system used for diabetic retinopathy screening (DRS). METHODS:All research participants underwent a comprehensive eye examination as well as non-mydriatic 45°single photograph retinal imaging centered on the macula. Optic nerve images within the 45° non-mydriatic and non-stereo DRS image were evaluated by two methods: 1) grading by three glaucoma specialists, and 2) a computer-aided automated segmentation system to determine the vertical cup-to-disc ratio (VCDR). Using VCDR from clinical assessment as gold standard, VCDR results from two methods were compared to that from clinical assessment. Inter-grader agreement was assessed by computing intraclass correlation coefficient (ICC). In addition, sensitivity and specificity were calculated. RESULTS:Among 245 fundus photos, 166 images met quality specifications for analysis. Fifty images were not processed by the automated system due to the poor quality of the optic disc, and 29 images did not include the optic nerve head due to the patient movement during the photo acquisition. The ICC value for the VCDR between the gold standard clinical exam and the automated system was 0.41, indicating fair agreement. The ICC value between the three ophthalmologists and the gold standard was 0.51, 0.56, and 0.69, respectively, indicating fair to moderate agreement. DISCUSSION/CONCLUSIONS:Assessing the VCDR on non-mydriatic and non-stereo DRS fundus photographs by either the computer-aided automated segmentation system or by glaucoma specialists showed similar fair to moderate agreement. In summary, optic nerve assessment for glaucoma from these 45° non-mydriatic and non-stereo DRS images is not yet suitable for tele-glaucoma screening.

PRECIS:Gonioscopy-assisted transluminal trabeculotomy (GATT) is a novel technique that lowers intraocular pressure (IOP) by fracturing the trabecular meshwork. In this retrospective chart review, GATT was found to be effective at lowering the intraocular pressure for steroid-induced glaucoma (SIG). PURPOSE:GATT is a novel microinvasive glaucoma surgery that builds on traditional trabeculotomy techniques to decrease the proximal resistance of conventional outflow, and it is proposed to be an effective surgical treatment for SIG. The purpose of this study is to evaluate the efficacy of GATT for lowering the IOP in SIG. METHODS AND PATIENTS:A retrospective chart review was performed of all GATT procedures performed on patients with a predominant diagnosis of steroid-induced glaucoma between March 1, 2016 and March 30,2018 at the University of Michigan. Primary outcome measures include IOP, the number of IOP-lowering medications prescribed, and the topical steroid dosing over the duration of follow-up. RESULTS:A total of 13 patients with steroid-induced glaucoma underwent the GATT procedure. There was a significant reduction in the mean IOP at all postoperative visits. The average IOP decreased by 16.4 (55%) to 19.5 mm Hg (63%) between 3 and 24 months postoperatively. By 24 months, all patients had a reduction in IOP of >20%. The number of glaucoma medications also decreased significantly from an average of 3.1 medications preoperatively to an average of 0.8 medications at last follow-up. The majority of patients (>67%) required continued use of steroids at all postoperative visits. The most common postoperative complication was a transient hyphema (38%). No patients required a repeat glaucoma surgery or anterior chamber washout. CONCLUSIONS:This small case series suggests that GATT is an effective and safe surgical technique to decrease IOP and decrease medication burden in patients with predominantly steroid-induced glaucoma. To our knowledge, this is the first study looking specifically at the efficacy of GATT for predominantly SIG.

Importance:For research involving big data, researchers must accurately identify patients with ocular diseases or phenotypes of interest. Reliance on administrative billing codes alone for this purpose is limiting. Objective:To develop a method to accurately identify the presence or absence of ocular conditions of interest using electronic health record (EHR) data. Design, Setting, and Participants:This study is a retrospective analysis of the EHR data of patients (n = 122 339) in the Sight Outcomes Research Collaborative Ophthalmology Data Repository who received eye care at participating academic medical centers between August 1, 2012, and August 31, 2017. An algorithm that searches structured and unstructured (free-text) EHR data for conditions of interest was developed and then tested to determine how well it could detect the presence or absence of exfoliation syndrome (XFS). The algorithm was trained to search for evidence of XFS among a sample of patients with and without XFS (n = 200) by reviewing International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-9 or ICD-10) billing codes, the patient's problem list, and text within the ocular examination section and unstructured (free-text) data in the EHR. The likelihood that each patient had XFS was estimated using logistic least absolute shrinkage and selection operator (LASSO) regression. The EHR data of all patients were run through the algorithm to generate an XFS probability score for each patient. The algorithm was validated with review of EHRs by glaucoma specialists. Main Outcomes and Measures:Positive predictive value (PPV) and negative predictive value (NPV) of the algorithm were computed as the proportion of patients correctly classified with XFS or without XFS. Results:This study included 122 339 patients, with a mean (SD) age of 52.4 (25.1) years. Of these patients, 69 002 (56.4%) were female and 99 579 (81.4%) were white. The algorithm assigned a less than 10% probability of XFS for 121 085 patients (99.0%) as well as an XFS probability score of more than 75% for 543 patients (0.4%), more than 90% for 353 patients (0.3%), and more than 99% for 83 patients (0.07%). Validated by glaucoma specialists, the algorithm had a PPV of 95.0% (95% CI, 89.5%-97.7%) and an NPV of 100% (95% CI, 91.2%-100%). When there was ICD-9 or ICD-10 billing code documentation of XFS, in 86% or 96% of the records, respectively, evidence of XFS was also recorded elsewhere in the EHR. Conversely, when there was clinical examination or free-text evidence of XFS, it was documented with ICD-9 codes only approximately 40% of the time and even less often with ICD-10 codes. Conclusions and Relevance:The algorithm developed, tested, and validated in this study appears to be better at identifying the presence or absence of XFS in EHR data than the conventional approach of assessing only billing codes; such an algorithm may enhance the ability of investigators to use EHR data to study patients with ocular diseases.

PURPOSE:The main purpose of this study was to use Lean analysis to identify how often and when wait times occur during a glaucoma visit to identify opportunities for additional patient engagement. METHODS:This prospective observational time-motion study measured process and wait times for 77 patient visits from 12 ophthalmologists at an academic glaucoma clinic over a 3-month period. Value stream maps visually diagramed the process of a clinical visit from the patient's perspective. Descriptive statistics were calculated for process times, wait times, and the frequency of 10+ minute wait times during each part of the visit. Key stakeholders participated in a root cause analysis to identify reasons for long wait times. The main outcome measure was average times (hours: minutes: seconds) for process times and wait times. RESULTS:Twenty-nine new visit (NV) patients and 48 return visit (RV) patients were included. Total time in clinic was 187.1±44.5 (mean±SD) minutes for NV patients and 102.0±44.7 minutes for RV patients. Wait time for NV patients was 63.7±33.4 minutes (33.1% of total appointment time) and for RV patients was 52.6±31.6 minutes (49.4% of the total appointment time). All NV patients and 87.5% of RV patients had at least one 10+ minute wait time during their clinic visit and the majority (75.9% NV, 60.4% RV) had >1. CONCLUSIONS:Currently, sufficient wait time exists during the visit for key portions of glaucoma education such as teaching eye drop instillation.

The glaucoma surgical landscape has changed dramatically over the last decade with the introduction and integration of micro-invasive glaucoma surgery (MIGS) techniques. These modalities target physiologic outflow pathways or optimize previously utilized glaucoma surgical methods in order to deliver safety, efficacy, and individualized care to the patient. MIGS techniques can be classified based on anatomical location as well as method of intraocular pressure (IOP) reduction. This review will focus on MIGS optimizing the conventional outflow pathway via intervention at Schlemm's canal, MIGS optimizing the uveoscleral outflow pathway via suprachoroidal shunting, and MIGS optimizing the transscleral or subconjunctival outflow pathway which has long been utilized by glaucoma surgeons performing traditional filtration procedures. The wide array of currently available MIGS modalities can be staggering to the glaucoma care provider, but an understanding of the landscape and the large classes of interventional strategies can allow for clinical decision making based on the specifics of the patient's needs and the pathophysiology of their disease.