Faculty Bibliography

OBJECTIVE:To estimate temporal trends in total and out-of-pocket (OOP) expenditures for ophthalmic prescription medications among adults in the United States. DESIGN/METHODS:A retrospective longitudinal cohort study. PARTICIPANTS/METHODS:Participants in the 2007-2016 Medical Expenditure Panel Survey (MEPS), age 18 years or older. The MEPS is a nationally representative survey of the noninstitutionalized, civilian US population. METHODS:We estimated trends in national and per capita annual ophthalmic prescription expenditures by pooling data into 2-year cycles and using weighted linear regressions. We also identified characteristics associated with greater total or OOP expenditure with multivariable weighted linear regression. Costs were adjusted to 2016 US dollars using the Gross Domestic Product Price Index. MAIN OUTCOME MEASURES/METHODS:Trends in total and OOP annual expenditures for ophthalmic medications from 2007-2016 as well as factors associated with greater expenditure. RESULTS:From 2007-2016, 9,989 (4.2%) MEPS participants reported ophthalmic medication prescription use. Annual ophthalmic medication utilization increased from 10.0 to 12.2 million individuals from 2007-2008 to 2015-2016. In this same time period, national expenditures for ophthalmic medications increased from $3.39 billion to $6.08 billion and OOP expenditures decreased from $1.34 to $1.18 billion. While the average number of ophthalmic prescriptions filled did not change over the study period (4.2, p=0.10), the average expenditure per prescription increased significantly from $72.30 to $116.42 (p<0.001). Per capita expenditure increased from $338.72 to $499.42 (p<0.001) and per capita OOP expenditure decreased from $133.48 to $96.67 (p<0.001) from 2007-2008 to 2015-2016 respectively. In 2015-2016, dry eye (29.5%) and glaucoma (42.7%) medications accounted for 72.2% of all ophthalmic medication expenditures. Patients who were older than 65 (p<0.001), uninsured (p<0.001), and visually impaired (p<0.001) were significantly more likely to have greater OOP spending on ophthalmic medications. CONCLUSION/CONCLUSIONS:Total ophthalmic medication expenditure in the United States increased significantly over the last decade while OOP expenses decreased. Increases in coverage, copayment assistance and utilization of expensive brand drugs may be contributing to these trends. Policy makers and physicians should be aware that rising overall drug expenditures may ultimately increase indirect costs to the patient and offset a decline in OOP prescription drug spending.

Aim/UNASSIGNED:The aim of this study is to report cyclodialysis cleft creation during Kahook dual blade (KDB) goniotomy. Background/UNASSIGNED:No known reports of cyclodialysis clefts have been published to the authors' knowledge after KDB goniotomy. Case description/UNASSIGNED:A 55-year-old myopic male with primary open angle glaucoma in both eyes (OU) underwent routine cataract extraction and intraocular lens implant with KDB goniotomy in the right eye (OD). Preoperative intraocular pressures (IOP) OD were in the low 20 mm Hg range on timolol and bimatoprost. Postoperative IOP was 4 mm Hg, with a moderate depth anterior chamber. Gonioscopy was slit in all quadrants, with no structures visible, and no improvement on indentation. Mild macular choroidal folds were present OD. Ultrasound biomicroscopy (UBM) revealed an area of supraciliary fluid. Anterior chamber reformation with viscoelastic was performed and repeat gonioscopy revealed a cyclodialysis cleft from 2:00 to 3:00. Treatment with multiple sessions of argon laser photocoagulation successfully closed the cleft. Conclusion/UNASSIGNED:KDB goniotomy may be complicated by cyclodialysis cleft formation and hypotony maculopathy. Visualization of a cleft on gonioscopy may require anterior chamber reformation. Clinical significance/UNASSIGNED:With an increasing use of KDB for goniotomy, previously unreported complications may arise including cyclodialysis cleft and resultant hypotony maculopathy. Because cleft following KDB goniotomy is rare, suspicion may be low and diagnosis could be delayed in the setting of postoperative hypotony with closed angles. How to cite this article/UNASSIGNED:Cyclodialysis Cleft Associated with Kahook Dual Blade Goniotomy. J Curr Glaucoma Pract 2019;13(2):74-76.

IMPORTANCE/OBJECTIVE:Corneal hysteresis (CH) is a dynamic marker of structural and functional changes in the cornea associated with intraocular pressure (IOP) and central corneal thickness, but its utility in assessing primary angle closure suspects (PACS) has not been fully elucidated. BACKGROUND:This study assesses if anterior segment measurements correlate with CH in PACS patients. DESIGN/METHODS:IRB-approved retrospective review of imaging and records at a university practice. PARTICIPANTS/METHODS:Sixty-three eyes from 37 patients diagnosed as PACS, without other ocular pathology. METHODS:Every eye underwent measurements including: ocular response analyzer (ORA), anterior segment optical coherence tomography (OCT) and a clinical evaluation. ORA measurements were correlated with other anatomic parameters using a mixed effects multivariable linear regression framework. MAIN OUTCOME MEASURES/METHODS:), nasal and temporal peripheral corneal thicknesses (PCT1 and PCT2), anterior chamber depth (ACD), nasal angle to temporal angle distance (ATA) and temporal and nasal angle measurements. Clinical measurements included: central corneal thickness via pachymetry, IOP measured by Goldmann applanation, axial length by A-scan ultrasound and spherical equivalent. RESULTS:, CRF, PCT1 and PCT2. Females were found to have lower CH. In multivariable regression controlling for gender, CCT, PCT, IOP and ACD, no correlation was seen between CH and anatomic measurements. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:CH values in PACS do not correlate with anterior segment anatomy.

BACKGROUND: To evaluate the effect of supine body position on central corneal thickness (CCT) in open-angle glaucoma patients and in healthy subjects. DESIGN: A cross-sectional study at a university eye clinic. PARTICIPANTS: Twenty-three subjects were recruited in each group, for a total of 46 patients. METHODS: CCT was measured using an ultrasound pachymeter in each subject. Three consecutive measurements in each eye were first taken in the sitting position, and repeated after 10 min and 30 min in a supine position. Results were analyzed using mixed model repeated measures, which adjusted for age, gender and laterality of eyes. MAIN OUTCOME MEASURES: CCT RESULTS: In healthy subjects, CCT decreased with supine positioning at 10 min (mean = -5.2 microm, P = 0.0043) and at 30 min (mean = -6.5 microm, P < 0.0001). In the glaucoma group, CCT decreased with supine positioning at 10 min (mean = -6.7 microm, P = 0.0043) and at 30 min (mean = -10.2 microm, P < 0.0001). There was no statistically significant difference between the CCT at 10 min supine and at 30 min supine in the healthy subjects (P = 0.37) and glaucoma patients (P = 0.14). CCT was shown to decrease linearly over time (P < 0.0001), and the slopes were not statistically different between groups (P = 0.40). CONCLUSIONS: CCT is a dynamic measurement that can be influenced by body position. It decreases linearly in the first 30 min of supine positioning at a similar rate in both open angle glaucoma patients and in healthy subjects.

PURPOSE: The aim of this study was to describe the clinical and histopathological features of a 36-year-old male with hundreds of recurrent, unilateral, free-floating, pigmented cysts in the anterior chamber causing ocular hypertension. PROCEDURES: The patient was referred to ocular oncology for blurry vision of the right eye and was found to have myriad pigmented, free-floating cysts in the anterior chamber and heavy pigmentation of the angle on gonioscopy. Anterior chamber washout was performed, and the fluid recovered was sent for pathological analysis. RESULTS: The pathology report demonstrated rare nonpigmented epithelial cells, more consistent with iris stromal cysts or secondary implantation epithelial cysts. CONCLUSIONS: This paper highlights the first documented case of innumerable spontaneously occurring, unilateral, free-floating, pigmented cysts in the anterior chamber. While clinical diagnosis suggested iris pigment epithelial cysts, pathology suggested iris stromal cysts or secondary implantation epithelial cysts.

PURPOSE: To investigate the efficacy of the Amsler grid test in detecting central visual field (VF) defects in glaucoma. DESIGN: Prospective, cross-sectional study. PARTICIPANTS: Patients with glaucoma with reliable Humphrey 10-2 Swedish Interactive Threshold Algorithm standard VF on the date of enrollment or within the previous 3 months. METHODS: Amsler grid tests were performed for each eye and were considered "abnormal" if there was any perceived scotoma with missing or blurry grid lines within the central 10 degrees ("Amsler grid scotoma"). An abnormal 10-2 VF was defined as >/=3 adjacent points at P < 0.01 with at least 1 point at P < 0.005 in the same hemifield on the pattern deviation plot. Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area were calculated with the 10-2 VF as the clinical reference standard. Among eyes with an abnormal 10-2 VF, regression analyses were performed between the Amsler grid scotoma area and the 10-2 VF parameters (mean deviation [MD], scotoma extent [number of test points with P < 0.01 in total deviation map] and scotoma mean depth [mean sensitivity of test points with P < 0.01 in total deviation map]). MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area. RESULTS: A total of 106 eyes (53 patients) were included (mean +/- standard deviation age, 24-2 MD and 10-2 MD = 66+/-12 years, -9.61+/-8.64 decibels [dB] and -9.75+/-9.00 dB, respectively). Sensitivity, specificity, and positive and negative predictive values of the Amsler grid test were 68%, 92%, 97%, and 46%, respectively. Sensitivity was 40% in eyes with 10-2 MD better than -6 dB, 58% in eyes with 10-2 MD between -12 and -6 dB, and 92% in eyes with 10-2 MD worse than -12 dB. The area under the receiver operating characteristic curve of the Amsler grid scotoma area was 0.810 (95% confidence interval, 0.723-0.880, P < 0.001). The Amsler grid scotoma area had the strongest relationship with 10-2 MD (quadratic R2=0.681), followed by 10-2 scotoma extent (quadratic R2=0.611) and 10-2 scotoma mean depth (quadratic R2=0.299) (all P < 0.001). CONCLUSIONS: The Amsler grid can be used to screen for moderate to severe central vision loss from glaucoma.