Faculty Bibliography

Importance/UNASSIGNED:Interest is growing in targeting physician attire to improve the patient experience. Few studies in ophthalmology have examined patient preferences for physician attire. Objective/UNASSIGNED:To understand patient preferences for physician attire in ophthalmology practices in the United States. Design/UNASSIGNED:Survey-based, cohort study. Setting/UNASSIGNED:Two private and two academic ophthalmology practices. Participants/UNASSIGNED:A convenience sample of patients receiving ophthalmic care between June 1, 2015 and October 31, 2016. Methods/UNASSIGNED:A questionnaire containing 22 questions and photographs of a male and female physician in seven forms of attire were presented to patients; 14 unique questionnaires were randomly distributed. Patient preference for physician attire was the primary outcome determined by summing ratings of how knowledgeable, trustworthy, caring, approachable, and comfortable the pictured physician made the respondent feel. One-way ANOVA assessed differences in mean composite scores. Comparisons between respondent demographics, practice type, and attire preferences were assessed by chi-square tests. Patient satisfaction was assessed by agreement with questions about importance of physician attire and whether this influences happiness with care. Results/UNASSIGNED:< 0.05). Preferences for attire varied by clinical setting: patients preferred surgeons (45.2%) and physicians in emergency rooms (41.7%) in scrubs rather than formal attire with white coat. Conclusions/UNASSIGNED:Physician attire is important to patients receiving ophthalmic care. Policies aimed at physician attire in ophthalmology practices should be considered.

PURPOSE/OBJECTIVE:To describe the study protocol and baseline characteristics of the African Descent and Glaucoma Evaluation Study (ADAGES) III. DESIGN/METHODS:Cross-sectional, case-control study. PARTICIPANTS/METHODS:Three thousand two hundred sixty-six glaucoma patients and control participants without glaucoma of African or European descent were recruited from 5 study centers in different regions of the United States. METHODS:Individuals of African descent (AD) and European descent (ED) with primary open-angle glaucoma (POAG) and control participants completed a detailed demographic and medical history interview. Standardized height, weight, and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA, and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California, San Diego, Data Coordinating Center for standardized processing and quality review. MAIN OUTCOME MEASURES/METHODS:Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and control participants were described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use, or past glaucoma surgery. Ocular conditions, including diabetic retinopathy, age-related macular degeneration, and past cataract surgery, were recorded. RESULTS:The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD control participants, and 227 ED control participants. The AD POAG patients and control participants were significantly younger (both, 67.4 years) than ED POAG patients and control participants (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared with ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all P < 0.001). Family history of glaucoma did not differ between AD and ED POAG patients. CONCLUSIONS:With its large sample size, extensive specimen collection, and deep phenotyping of AD and ED glaucoma patients and control participants from different regions in the United States, the ADAGES III genomics study will address gaps in our knowledge of the genetics of POAG in this high-risk population.

OBJECTIVE:Find genetic contributions to glaucoma in African Americans. DESIGN/METHODS:Cross-sectional, case-control study. PARTICIPANTS/METHODS:1875 POAG cases and 1709 controls, self-identified as African Descent (AD), from the African Descent and Glaucoma Evaluation Study (ADAGESIII) and Wake Forest School of Medicine. METHODS:MegaChip genotypes were imputed to Thousand Genomes data. Association of SNPs with POAG and advanced POAG was tested by linear mixed model correcting for relatedness and population stratification. Genetic risk scores were tested by Receiver Operator Characteristics (ROC-AUC). MAIN OUTCOME/RESULTS:POAG defined by visual field loss without other non-ocular conditions (N=1875). Advanced POAG was defined by age-based mean deviation of visual field (N=946). RESULTS:) was observed, not in LD with the previously reported ED SNP. Additional previously identified loci associated with POAG in AD were: 8q22, AFAP1, TMCO1. An AUC of 0.62 was observed with an unweighted genetic risk score composed of 11 SNPs in candidate genes. Two additional risk scores were studied by using a penalized matrix decomposition with cross-validation; risk scores of 50 and 400 SNPs were identified with ROC of AUC=0.74 and AUC=0.94, respectively. CONCLUSIONS:A novel association with advanced POAG in the ENO4 locus was putatively identified in subjects of African descent. In addition to this finding, this GWAS in AD POAG subjects contributes to POAG genetics by identification of novel signals in prior loci (9p21), as well as advancing the fine-mapping of regions due to shorter average linkage disequilibrium (FNDC3B). While not useful without confirmation and clinical trials, the use of genetic risk scores demonstrated that considerable AD-specific genetic information remains in these data.

Purpose: To assess whether microvascular dropout as measured by fractal self-similarity breakdown of optical coherence tomography angiography (OCTA) occurs in a sectoral fashion in eyes with primary open angle glaucoma (POAG) compared to control patients.
Method(s): A retrospective study using OCTA images obtained on 40 eyes with POAG, and 14 control eyes. OCTA images with peripapillary scans of 4.5mm x 4.5mm diameters were obtained using RTVue XR Avanti (Optovue Inc., Fremont, CA, USA), and standardized and binarized using ImageJ (National Institutes of Health, Bethesda, Maryland, USA). Fractal dimension by means of box-counting algorithm using box sizes with increasing exponential factor of two with grid algorithm on Fractalyse (TheMA, Besancon Cedex, France) was plotted against linear box dimension and first local peak (FLP) representing smallest box size resolution before breakdown of self-similarity was recorded. The ratio of superior to inferior (SI Ratio) of FLP was the main outcome measure.
Result(s): There is significant difference between control and POAG eyes (p = 0.01), with POAG having larger superior to inferior (SI Ratio) of FLP (1.40 +/-0.93) compared to control (1.00 +/-0.0). The increased SI FLP ratio of the POAG eyes reflects a preferential loss of self-similarity in the superior quadrant (i.e. higher FLP values) rather than increased self-similarity in the inferior quadrant (FLP inferior = 8.0 +/-0 and FLP superior = 11.2 +/-7.4 in POAG, FLP inferior = 8.0 +/-0 and FLP superior = 8.0 +/-0 in controls).
Conclusion(s): The measurement of box size of the first local maximum of fractal dimension as a function of increasing box size represents the smallest box size resolution prior to loss of uniformity of the vascular pattern's fractal dimension. While this loss of uniformity may be related to resolution in normal eyes, the preferential loss of microvascular complexity inferior to the optic disc in POAG eyes suggests asymmetric small vessel dropout in the POAG. This accords well with the asymmetric loss demonstrated in a prior OCTA study. Our study was not designed to determine whether microvascular loss occurred as a consequence or as a cause of axonal loss. We propose FLP SI Ratio as a useful measure of POAG-associated microvascular dropout

PURPOSE/OBJECTIVE:To evaluate the efficacy and safety of a tube fenestration stented with a 10-0 polyglactin suture for controlling early postoperative intraocular pressure (IOP) after Baerveldt glaucoma implant (BGI) surgery. METHODS:The medical records of 110 patients (119 eyes) who underwent BGI surgery with a tube fenestration stented with a 10-0 polyglactin suture anterior to an occlusive tube ligature were retrospectively reviewed. Main outcome measures included IOP and number of glaucoma medications at postoperative day 1, week 1, and weeks 2 to 3 as well as complications occurring before ligature release. RESULTS:Mean±SD preoperative IOP was 30.9±9.3 mm Hg using an average of 3.8±1.1 glaucoma medications. A statistically significant reduction in IOP and glaucoma medications was observed at all timepoints during the first 3 postoperative weeks compared with baseline (P<0.001). Mean IOP on postoperative day 1, week 1, and weeks 2 to 3 was 18.4±12.2 mm Hg on no medication, 15.9±9.4 mm Hg on 1.0±1.3 medications, and 16.7±8.2 mm Hg on 1.2±1.5 medications, respectively. In total, 44 eyes (37%) achieved IOP control without glaucoma medication during period of tube occlusion. CONCLUSIONS:The use of a single, monofilament 10-0 polyglactin suture to stent a fenestration proximal to the occlusive ligature of a BGI tube is effective in controlling IOP in the early postoperative period. Hypotony-related complications were infrequent and resolved in all cases with in-office interventions.

PURPOSE OF REVIEW/OBJECTIVE:Micro-invasive glaucoma surgery (MIGS) is gaining favor with both comprehensive ophthalmologists and glaucoma specialists due in part to its improved safety profile when compared to traditional incisional glaucoma surgery. Despite a micro-invasive approach and minimal induced tissue trauma, each MIGS procedure is associated with unique complications. The present article summarizes evidence from the 2016 to 2017 review period regarding the safety profiles of Schlemm's canal-based, suprachoroidal, and subconjunctival microstents. RECENT FINDINGS/RESULTS:Ab-interno microstents are subject to intraoperative malpositioning, which can result in luminal obstruction and decreased efficacy. Acutely elevated intraocular pressure (IOP) has been observed with the iStent (Glaukos Corp., Laguna Hills, CA, USA; 2-4.3%), Hydrus Microstent (Ivantis Inc., Irvine, CA, USA; 6%), Cypass Microstent (Alcon, Fort Worth, TX, USA; 3-10.8%), and Xen Gel Stent (Allergan Plc, Dublin, Ireland; 21.5%). Meanwhile, most cases of hypotony (IOP < 6 mmHg) occurred within the first postoperative month, resolved with conservative treatment and without further surgical intervention, and were not associated with vision-threatening sequelae. SUMMARY/CONCLUSIONS:Interest in MIGS continues to grow as these procedures allow surgeons to intervene earlier in the disease course for patients with milder stages of glaucoma. Complications associated with MIGS, albeit infrequent and mostly transient, do occur despite a less invasive approach than trabeculectomy and tube shunt surgery.

PURPOSE/OBJECTIVE:The purpose of this study is to assess surgical practice patterns among the American Glaucoma Society (AGS) membership. METHODS:An anonymous online survey evaluating the use of glaucoma surgeries in various clinical settings was redistributed to AGS members. Survey responses were compared with prior results from 1996, 2002, and 2008 to determine shifts in surgical practice patterns. Questions were added to assess the preferred approach to primary incisional glaucoma surgery and phacoemulsification combined with glaucoma surgery. RESULTS:A total of 252 of 1091 (23%) subscribers to the AGS-net participated in the survey. Percentage use (mean±SD) of trabeculectomy with mitomycin C (MMC), glaucoma drainage device (GDD), and minimally invasive glaucoma surgery (MIGS) as an initial surgery in patients with primary open angle glaucoma was 59%±30%, 23%±23%, and 14%±20%, respectively. Phacoemulsification cataract extraction alone was the preferred surgical approach in 44%±32% of patients with primary open angle glaucoma and visually significant cataract, and phacoemulsification cataract extraction was combined with trabeculectomy with MMC in 24%±23%, with MIGS in 22%±27%, and with GDD in 9%±14%. Although trabeculectomy was selected most frequently to surgically manage glaucoma in 8 of 8 clinical settings in 1996, GDD was preferred in 7 of 8 clinical settings in 2016. CONCLUSIONS:The use of GDD has increased and that of trabeculectomy has concurrently decreased over the past 2 decades. Trabeculectomy with MMC is the most popular primary incisional surgery when performed alone or in combination with phacoemulsification cataract extraction. Surgeons frequently manage coexistent cataract and glaucoma with cataract extraction alone, rather than as a combined cataract and glaucoma procedure.

Vitreous occlusion of a glaucoma drainage implant (GDI) can lead to failure of the device and severely elevated intraocular pressure. The pathophysiology of tube obstruction is related to central and anterior displacement of vitreous that is drawn into and condenses within the proximal lumen of the tube. This can occur from days to years following GDI surgery. Successful management of vitreous-tube obstruction generally requires manual removal of the condensed vitreous plug with end-grasping forceps. This technique achieves reversal of tube blockage and restoration of GDI function. Amputation of the incarcerated vitreous alone with vitrectomy or neodymium:yttrium-aluminum-garnet vitreolysis does not consistently restore GDI function and risks persistent intraluminal tube obstruction.