Publications by authors named "David C Musch"

189 Publications

Patching and Atropine for Severe Amblyopia: Are Both Better Than Patching Alone?

JAMA Ophthalmol 2021 Jul 15. Epub 2021 Jul 15.

Children's Eye Care of Michigan, West Bloomfield.

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http://dx.doi.org/10.1001/jamaophthalmol.2021.2425DOI Listing
July 2021

Mid-Life Vision Impairment and Cognitive Function in Later Life: the Study of Women's Health Across the Nation, Michigan Cohort.

J Gerontol A Biol Sci Med Sci 2021 Jun 21. Epub 2021 Jun 21.

Department of Epidemiology, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI.

Background: In older adults, vision impairment (VI) is associated with worse cognitive function. However, the relationship between mid-life vision and future cognitive function remains unknown.

Methods: The Study of Women's Health Across the Nation (SWAN), Michigan site, is a longitudinal cohort of mid-life women age 42-52 years at baseline. Presenting Titmus visual acuity (VA) in the better-seeing eye was assessed at baseline and categorized as no or mild VI (VA ≥20/60), or moderate or worse VI (VA <20/60). Cognitive function was measured 8 times over 15 years using the East Boston Memory Test immediate (EBMTi) and delayed (EBMTd) recall and the Digit Span Backwards (DSB) test. Linear mixed models with a random intercept and slope for age were constructed to detect associations between VI at baseline and future repeated measures of cognitive function, adjusting for age, race, education, financial strain, alcohol use, and tobacco use.

Results: 394 women age 42-52 at baseline with maximum follow-up of 20 years were included in this analysis. After covariate adjustment, moderate or worse VI was associated with lower EMBTi (β= -0.56, p=0.012), EBMTd (β= -0.60, p=0.009) and DSB (β= -0.84, p=0.04). While we detected significant associations between VI and levels of cognitive function scores, rates of cognitive decline as individuals aged did not vary by VI status.

Conclusion: Moderate or worse VI, assessed during mid-life, was associated with lower scores on measures of cognitive function over a 15 year period during which women transitioned from mid-life to older adulthood.
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http://dx.doi.org/10.1093/gerona/glab180DOI Listing
June 2021

Demographic, Clinical, and Psychosocial Predictors of Change in Medication Adherence in the Support, Educate, Empower Program.

Ophthalmol Glaucoma 2021 Jun 30. Epub 2021 Jun 30.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan. Electronic address:

Purpose: To investigate whether demographic, clinical, or psychosocial factors act as moderators of change in medication adherence in the Support, Educate, Empower (SEE) program.

Design: Prospective, single-arm pilot study with a pre-post design.

Participants: Patients with glaucoma aged ≥ 40 years and taking ≥ 1 glaucoma medication were recruited from the University of Michigan Kellogg Eye Center. Those who had electronically measured adherence ≤ 80% in the 3-month eligibility monitoring period were enrolled in the SEE program.

Methods: Medication adherence was monitored electronically during the 7-month intervention and calculated as the percentage of doses taken correctly. Change in adherence at different points in the SEE program and cumulative change in adherence were modeled with linear regression, and baseline demographic, clinical, and psychosocial factors were investigated for significant associations.

Main Outcome Measures: Demographic, clinical, and psychosocial variables associated with change in medication adherence in the SEE program.

Results: Thirty-nine participants completed the SEE program. These participants were on average 63.9 years old (standard deviation [SD], 10.7 years), 56% (n = 22) were male, 44% (n = 17) were White, and 49% (n = 19) were Black. Medication adherence improved from an average of 59.9% (SD, 18.5%) at baseline to 83.6% (SD, 17.5%) after the final SEE session, for an increase of 23.7% (SD, 17.5%). Although participants with lower income (< $25 000 and $25 000-50 000 vs. >$50 000) had lower baseline adherence (48.4% and 64.1% vs. 70.4%), these individuals had greater increases in adherence during the first month of medication reminders (19.6% and 21.6% vs. 10.2%; P = 0.05 and P = 0.007, respectively). Participants taking fewer glaucoma medications also had significantly greater increases in adherence with medication reminders (P < 0.001). Those with higher levels of glaucoma-related distress (GD) had lower baseline adherence and greater increases in adherence with glaucoma coaching (P = 0.06).

Conclusions: Patient-level factors associated with relatively greater improvements in medication adherence through the SEE Program included lower income, fewer glaucoma medications, and increased GD. These findings demonstrate that the SEE program can improve glaucoma self-management even among participants with social and psychological barriers to medication adherence.
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http://dx.doi.org/10.1016/j.ogla.2021.06.001DOI Listing
June 2021

Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis.

Clin Ophthalmol 2021 18;15:2077-2087. Epub 2021 May 18.

Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA.

Background/aims: To determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI).

Methods: A retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis.

Results: In this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9-10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1-11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5-19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1-0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis.

Conclusion: Prompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.
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http://dx.doi.org/10.2147/OPTH.S307718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141272PMC
May 2021

Impact of the COVID-19 Pandemic on Keratoplasty and Corneal Eye Banking.

Cornea 2021 08;40(8):1018-1023

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI.

Purpose: The purpose of this study was to assess the impact of COVID-19 guidelines for corneal donor tissue screening and the utility of routine postmortem COVID-19 testing of donors intended for surgical use at a single eye bank.

Methods: A retrospective analysis of referrals to and eligible donors from an eye bank between March 1, 2020, and June 30, 2020, was performed, with the same time period in 2019 as a control. Referrals who were not procured because of Eye Bank Association of America COVID-19 guidelines and eye bank-specific restrictions were noted. The results of 1 month of routine postmortem testing performed by the eye bank were examined. Analysis of variance tests were performed to assess the change between donors from 2019 to 2020.

Results: There was a significant reduction in both the number of total referrals to the eye bank (P = 0.044) and donors eligible for surgical transplantation (P = 0.031). Eye Bank Association of America COVID-19 guidelines reduced the number of referrals over this period by 4% to 14%. Of the 266 surgically eligible donors who received postmortem COVID-19 testing in June by the eye bank, 13 resulted positive (4.9%).

Conclusions: Despite a reduction in referrals and eligible corneal transplant donors at a single eye bank, there was a surplus of surgically suitable corneal tissue during the first wave of the COVID-19 pandemic. Eye banks should consider routine postmortem COVID-19 testing to identify asymptomatic infected donors although the risk of transmission of COVID-19 from infected donors is unknown.
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http://dx.doi.org/10.1097/ICO.0000000000002748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244805PMC
August 2021

Ocular Manifestations of Hospitalized COVID-19 Patients in a Tertiary Care Academic Medical Center in the United States: A Cross-Sectional Study.

Clin Ophthalmol 2021 13;15:1551-1556. Epub 2021 Apr 13.

Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, MI, USA.

Purpose: Studies have identified a wide range of ocular signs and symptoms in coronavirus disease 2019 (COVID-19) patients; however, these studies were often conducted outside of the United States. We aim to investigate the ocular manifestations of hospitalized COVID-19 patients at a tertiary care medical center in the United States.

Patients And Methods: A retrospective, cross-sectional study was conducted on individuals aged 18 and over who were hospitalized for COVID-19 between March 10, 2020 and April 13, 2020. The electronic health record was reviewed for all patients, and a follow-up phone survey was conducted on patients who were discharged home. Data on patient history, physical exam, laboratory results, and hospital disposition were collected and analyzed.

Results: A total of 400 patients were included. The mean patient age was 61.7 years (SD 15.5) and 233 (58.3%) were males. Ocular signs and symptoms were noted in 38 (9.5%) patients. The most common ocular abnormality was conjunctival injection, followed by vision changes and ocular irritation. Among the 38 patients, 30 (79.0%) developed ocular involvement prior to day 30 of onset of their COVID symptoms. Univariate analysis showed that age, gender, ocular history, fever, mechanical ventilation, and increasing inflammatory markers were not significantly associated with the presence or development of ocular symptoms.

Conclusion: In this study, 9.5% of hospitalized COVID-19 patients exhibited ocular signs and symptoms. Factors associated with severe systemic COVID-19 disease were not associated with developing ocular abnormalities. The rate of ocular manifestations of COVID-19 should not be ignored, and thus physicians should routinely evaluate for ocular involvement in hospitalized COVID-19 patients.
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http://dx.doi.org/10.2147/OPTH.S301040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053508PMC
April 2021

Calculation of test-retest variability in phase I/IIa clinical trials for Inherited Retinal Degenerations.

Ophthalmic Genet 2021 Jun 17;42(3):283-290. Epub 2021 Mar 17.

Department of Ophthalmology and Visual Sciences, Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.

: Several novel treatments of inherited retinal degenerations have undergone phase I/IIa clinical trials with limited sample size, yet investigators must still determine if toxicity or an efficacy signal occurred or if the change was due to test-retest variability (TRV) of the measurement tool.: Synthetic datasets were used to compare three types of TRV estimators under different sample sizes, mean drift, skewness, and number of baseline measurements.: Mixed effects models underestimated the standard deviation of measurement error (SDEM); the unbiased change score estimator method (UBS) was more accurate. The fixed effect model had less bias and smaller standard deviation than UBS if >2 baseline measurements. The change score estimator had no bias; other estimators introduced bias for lower variability. With sample size <10, all estimators had high variance. With sample size ≥10, the differences between methods were often minimal. The pooled estimator model did not capture drift, whereas a fixed effect regression or mixed effects models accounted for drift while maintaining an accurate measure of variance. With small sample sizes, the bootstrap estimates of SDEM were severe underestimates, while the jackknife estimates were mildly low but much better. The jackknife was more accurate for the unbiased change score method than for the pooled estimator.: The ideal phase I/IIa study has ≥20 subjects and uses UBS or its fixed effect model generalization if >2 baseline measurements. With non-ideal study parameters, investigators should at least quantify the error estimate present in their data analysis.
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http://dx.doi.org/10.1080/13816810.2021.1897848DOI Listing
June 2021

Contemporary Management of Complex and Non-Complex Rhegmatogenous Retinal Detachment Due to Giant Retinal Tears.

Clin Ophthalmol 2021 8;15:1013-1022. Epub 2021 Mar 8.

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA.

Purpose: To investigate the clinical features and surgical outcomes of rhegmatogenous retinal detachment (RRD) associated with giant retinal tears (GRTs) at a tertiary referral center.

Patients And Methods: A retrospective, non-consecutive interventional case series of GRT-associated RRDs that underwent primary surgical repair at the University of Michigan W.K. Kellogg Eye Center between January 1, 2011 and July 1, 2020. Clinical characteristics and preoperative, perioperative, and postoperative data were collected.

Results: Forty-eight eyes of 47 patients with GRT-associated RRDs met inclusion criteria, including those that were children (under 12 years, N=4, 8.3%), associated with a history of trauma (N=20, 41.7%) or with grade C proliferative vitreoretinopathy (PVR-C) (N=7, 14.6%) at baseline. Median age was 46 years (interquartile range (IQR): 29 years, range: 4 to 72 years), median follow-up was 28 months (IQR: 43 months, range: 3-124 months), and 83.3% (N=40) of subjects were male. Primary surgical repair for GRT-associated RRDs included pars plana vitrectomy (PPV) (N=40, 83.3%), scleral buckle (SB) (N=1, 2.1%), or combined PPV/SB (N=7, 14.6%). Surgical approach commonly involved the use of perfluorocarbon liquid (N=43, 90%) and gas tamponade (N=39, 81%). Single surgery anatomic success (SSAS) was 75% (95% CI: 60%, 85%) at 3 months and 65% (95 CI: 47%, 78%) at 2 years. Final anatomic success was achieved in all 48 eyes (100%). Median visual acuity improved from 20/250 preoperatively to 20/60 at final follow-up, with 44% (N=20) of eyes achieving postoperative visual acuity of 20/40 or better.

Conclusion: In this series from a tertiary referral center, both complex and non-complex GRT-associated RRDs were most commonly managed with PPV alone, perfluorocarbon liquid, and gas tamponade with favorable final anatomic and visual outcomes comparable to other modern GRT series.
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http://dx.doi.org/10.2147/OPTH.S299762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953883PMC
March 2021

Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT): Baseline Methodology for Implementing and Assessing a Community-based Program.

J Glaucoma 2021 05;30(5):380-387

Department of Ophthalmology and Visual Sciences.

Precis: The Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program leverages community-engaged research, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to improve glaucoma screening in underserved communities.

Purpose: To describe the methodology of the implementation and evaluation of the MI-SIGHT Program.

Methods: The MI-SIGHT Program uses community engagement, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to glaucoma identification and care among underserved populations. The MI-SIGHT Program will be evaluated in 2 community clinics: Hamilton Community Health Network, a federally qualified health center in Flint, Michigan, and the Hope Clinic, a free clinic in Ypsilanti, Michigan. A Community Advisory Board including the research team and health care providers, administrators, and patients from both clinics will guide program implementation. An ophthalmic technician at the community clinics will conduct screening tests for glaucoma and eye disease. The data will be transmitted through electronic health record to be reviewed by an ophthalmologist who will make recommendations for follow-up care. The ophthalmic technician will conduct a return visit to fit low-or no-cost glasses, help arrange follow-up with an ophthalmologist, and provide education. Those diagnosed with glaucoma or suspected glaucoma will be randomized to standard education or personalized glaucoma education and coaching. Costs will be assessed.

Results: The authors hypothesize that the MI-SIGHT Program will detect a higher prevalence rate of glaucoma than that found in the general population, improve upon presenting visual acuity, enhance vision-related quality of life, and demonstrate that personalized glaucoma education and coaching improve adherence to follow-up care.

Conclusion: The MI-SIGHT Program may serve as a model for glaucoma screening and care in high-risk communities.
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http://dx.doi.org/10.1097/IJG.0000000000001812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085066PMC
May 2021

Progression of Myopia in School-Aged Children After COVID-19 Home Confinement.

JAMA Ophthalmol 2021 03;139(3):293-300

Department of Strabismus and Pediatric Ophthalmology, Tianjin Medical University Eye Hospital, Tianjin, China.

Importance: Time spent in outdoor activities has decreased owing to home confinement for the coronavirus disease 2019 (COVID-19) pandemic. Concerns have been raised about whether home confinement may have worsened the burden of myopia owing to substantially decreased time spent outdoors and increased screen time at home.

Objective: To investigate the refractive changes and prevalence of myopia in school-aged children during the COVID-19 home confinement.

Design, Setting, And Participants: A prospective cross-sectional study using school-based photoscreenings in 123 535 children aged 6 to 13 years from 10 elementary schools in Feicheng, China, was conducted. The study was performed during 6 consecutive years (2015-2020). Data were analyzed in July 2020.

Exposures: Noncycloplegic photorefraction was examined using a photoscreener device.

Main Outcomes And Measures: The spherical equivalent refraction was recorded for each child and the prevalence of myopia for each age group during each year was calculated. The mean spherical equivalent refraction and prevalence of myopia were compared between 2020 (after home confinement) and the previous 5 years for each age group.

Results: Of the 123 535 children included in the study, 64 335 (52.1%) were boys. A total of 194 904 test results (389 808 eyes) were included in the analysis. A substantial myopic shift (approximately -0.3 diopters [D]) was found in the 2020 school-based photoscreenings compared with previous years (2015-2019) for younger children aged 6 (-0.32 D), 7 (-0.28 D), and 8 (-0.29 D) years. The prevalence of myopia in the 2020 photoscreenings was higher than the highest prevalence of myopia within 2015-2019 for children aged 6 (21.5% vs 5.7%), 7 (26.2% vs 16.2%), and 8 (37.2% vs 27.7%) years. The differences in spherical equivalent refraction and the prevalence of myopia between 2020 and previous years were minimal in children aged 9 to 13 years.

Conclusions And Relevance: Home confinement during the COVID-19 pandemic appeared to be associated with a significant myopic shift for children aged 6 to 8 years according to 2020 school-based photoscreenings. However, numerous limitations warrant caution in the interpretation of these associations, including use of noncycloplegic refractions and lack of orthokeratology history or ocular biometry data. Younger children's refractive status may be more sensitive to environmental changes than older ages, given the younger children are in a critical period for the development of myopia.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.6239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809617PMC
March 2021

Clinical trial design for neuroprotection in autosomal dominant retinitis pigmentosa; outcome measure considerations.

Ophthalmic Genet 2021 04 6;42(2):170-177. Epub 2021 Jan 6.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.

: To identify structural and functional outcome measures among patients with Rho-positive autosomal dominant Retinitis Pigmentosa (adRP) to aid neuroprotection trial design.: This was a retrospective cohort study of 52 patients with Rho-positive adRP. We measured Goldmann Visual Fields (GVF) constriction in four sectors (nasal, temporal, inferior, superior), and sectoral Ellipsoid Zone (EZ) width degeneration using Spectral Domain Optical Coherence Tomography (OCT) scans. Disease progression trajectories were projected using mixed effects modeling.: Superior GVF was most constricted at presentation and had the shallowest trajectory (less steep negative slope); Inferior GVF was less constricted (corrected < .001) and had a steeper negative slope (corrected = .019) than superior GVF. Temporal EZ was most stable on OCT with a relatively shallow negative trajectory (corrected = .011).: Patients' superior visual fields presented with more constriction and subsequently had a shallow negative slope suggesting the corresponding inferior retina may be "burned out" at presentation. Targeted therapies for adRP will likely show a greater efficacy signal if delivered to the superior and nasal retina, which may demonstrate more change on OCT and GVF over the course of a neuroprotection trial.: Mixed effects analysis of sectoral visual field constriction and EZ degeneration in Rho-positive adRP can prove useful in monitoring therapeutic efficacy and identifying targets for local therapies.
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http://dx.doi.org/10.1080/13816810.2020.1867752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987885PMC
April 2021

The Michigan Vision-Related Anxiety Questionnaire: A Psychosocial Outcomes Measure for Inherited Retinal Degenerations.

Am J Ophthalmol 2021 05 9;225:137-146. Epub 2020 Dec 9.

Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA. Electronic address:

Objective: We sought to construct and validate a patient-reported outcome measure for screening and monitoring vision-related anxiety in patients with inherited retinal degenerations.

Design: Item-response theory and graded response modeling to quantitatively validate questionnaire items generated from qualitative interviews and patient feedback.

Methods: Patients at the Kellogg Eye Center (University of Michigan, Ann Arbor, Michigan, USA) with a clinical diagnosis of an inherited retinal degeneration (n = 128) participated in an interviewer-administered questionnaire. The questionnaire consisted of 166 items, 26 of which pertained to concepts of "worry" and "anxiety." The subset of vision-related anxiety questions was analyzed by a graded response model using the Cai Metropolis-Hastings Robbins-Monro algorithm in the R software mirt package. Item reduction was performed based on item fit, item information, and item discriminability. To assess test-retest variability, 25 participants completed the questionnaire a second time 4 to 16 days later.

Results: The final questionnaire consisted of 14 items divided into 2 unidimensional domains: rod function anxiety and cone function anxiety. The questionnaire exhibited convergent validity with the Patient Health Questionnaire for symptoms of depression and anxiety. This vision-related anxiety questionnaire has high marginal reliability (0.81 for rod-function anxiety, 0.83 for cone-function anxiety) and exhibits minimal test-retest variability (ρ = 0.81 [0.64-0.91] for rod-function anxiety and ρ = 0.83 [0.68-0.92] for cone-function anxiety).

Conclusions: The Michigan Vision-Related Anxiety Questionnaire is a psychometrically validated 14-item patient-reported outcome measure to be used as a psychosocial screening and monitoring tool for patients with inherited retinal degenerations. It can be used in therapeutic clinical trials for measuring the benefit of an investigational therapy on a patient's vision-related anxiety.
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http://dx.doi.org/10.1016/j.ajo.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184579PMC
May 2021

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach.

J Glaucoma 2021 May;30(5):402-409

Department of Ophthalmology and Visual Sciences.

Prcis: Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified.

Purpose: The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics.

Methods: A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA).

Results: Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident).

Conclusions: CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.
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http://dx.doi.org/10.1097/IJG.0000000000001756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084870PMC
May 2021

The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India.

Ophthalmology 2021 Jul 27;128(7):1060-1069. Epub 2020 Nov 27.

Aravind Eye Hospital, Pondicherry, India.

Purpose: To assess whether routine fundus photography (RFP) to screen for posterior segment disease at community eye clinics (vision centers [VCs]) in India increases referral to centralized ophthalmolic care.

Design: Stepped-wedge, cluster-randomized trial.

Participants: Patients aged 40 to 75 years and those aged 20 to 40 years with a known history of hypertension or diabetes mellitus presenting to 4 technician-run VCs associated with the Aravind Eye Care System in India.

Methods: VCs (clusters) were randomized to standard care or RFP across five 2-week study periods (steps). Patients in each cluster received standard care initially. At the start of each subsequent step, a randomly chosen cluster crossed over to providing RFP to eligible patients. All clusters took part in RFP during the last step. Standard care involved technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist. RFP involved eye exams, dilation and 40-degree fundus photography, and teleconsultation with an ophthalmologist.

Main Outcome Measures: Standard care and RFP clusters were compared by the proportion of patients referred for in-person evaluation by an ophthalmologist because of fundus photography findings and urgency of referral (urgently in ≤ 2 weeks vs. nonurgently in > 2 weeks). Generalized linear mixed models adjusting for cluster and step were used to estimate the odds of referral due to fundus photography findings compared with standard care.

Results: A total of 1447 patients were enrolled across the VCs, including 737 in the standard care group and 710 in the RFP group. Compared with standard care, the RFP group had a higher proportion of referrals due to fundus photography findings (11.3% vs. 4.4%), nonurgent referrals due to fundus photography (9.3% vs. 3.3%), and urgent referrals due to fundus photography (1.8% vs. 1.1%). The RFP intervention was associated with a 2-fold increased odds of being referred because of photography findings compared with standard care (odds ratio, 2.07; 95% confidence interval, 0.98-4.40; P = 0.058).

Conclusions: Adding RFP to community eye clinics was associated with an increased odds of referral compared with standard care. This increase in referral was mostly due to nonurgent posterior segment disease.
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http://dx.doi.org/10.1016/j.ophtha.2020.11.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8155108PMC
July 2021

The Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Pilot Study on Glaucoma Medication Adherence.

Ophthalmol Glaucoma 2020 Jul - Aug;3(4):228-237. Epub 2020 Apr 30.

Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.

Purpose: To assess the efficacy of the Support, Educate, Empower (SEE) glaucoma coaching program on medication adherence among glaucoma patients with low adherence.

Design: Uncontrolled intervention study with a pre-post design.

Participants: Glaucoma patients ≥ age 40, taking ≥1 medication, who self-reported poor adherence were recruited from the University of Michigan Kellogg Eye Center. Adherence was monitored electronically for a 3-month baseline period; participants with median adherence of ≤80% were enrolled in the SEE program.

Methods: Participants' adherence was monitored electronically (AdhereTech, New York, NY) during the 7-month program. Adherence was calculated as the percentage of doses taken on time of those prescribed. The SEE program included (1) automated medication reminders, (2) 3 in-person counseling sessions with a glaucoma coach who had training in motivational interviewing (MI), and (3) 5 phone calls with the same coach for between-session support. The coach used a web-based tool to generate an education plan tailored to the patient's glaucoma diagnosis, test results, and ophthalmologist's recommendations (www.glaucomaeyeguide.org). The tool guided an MI-based conversation between coach and patient to identify barriers to adherence and possible solutions. Descriptive statistics were used to summarize baseline patient characteristics, and differences between those who did and did not complete the SEE program were tested with 2-sample t tests, chi-square tests, and Fisher exact tests. Adherence was compared before and after the SEE program with paired t tests.

Main Outcome Measure: Change in electronically monitored medication adherence.

Results: A total of 48 participants were enrolled. The participants were 54% male, 46% white, and on average 64 years of age (standard deviation [SD], 10.8 years), with an average worse-eye mean deviation (MD) of -7.9 dB (SD, 8.8 dB). Those completing the SEE program (n = 39) did not differ significantly from those who dropped out (n = 9) on gender, race, age, MD, or baseline adherence. Medication adherence improved from 59.9% at baseline to 81.3% (P < 0.0001) after completing the SEE program. Ninety-five percent of participants showed an improvement in adherence (mean relative improvement, 21.4%; SD, 16.5%; range, -3.2% to 74.4%; median, 20.1%). Fifty-nine percent of participants showed adherence of >80% on completing the SEE program.

Conclusions: The SEE program participants showed clinically meaningful, statistically significant improvement in glaucoma medication adherence.
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http://dx.doi.org/10.1016/j.ogla.2020.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528849PMC
April 2020

Recipient Factors Associated With Graft Detachment of a Subsequent Eye in Sequential Descemet Membrane Endothelial Keratoplasty.

Cornea 2020 Oct;39(10):1243-1246

Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI.

Purpose: To evaluate the recipient factors associated with graft detachment in the subsequent eye of patients who underwent sequential Descemet membrane endothelial keratoplasty (DMEK).

Methods: A retrospective, consecutive case series with 158 eyes of 79 patients who underwent DMEK surgeries in both eyes between October 2013 and April 2019 for treatment of Fuchs endothelial dystrophy. The main outcome measure was the presence of graft detachment (any amount of detachment) at postoperative 1 week in the subsequent eye. Preoperative, intraoperative, and postoperative factors were evaluated for association with graft detachment.

Results: Of 79 patients (158 eyes) with a mean follow-up of 11.7 ± 8.4 months, 18 patients (36 eyes) developed graft detachment in both eyes 1 week postoperatively. The risk of detachment in the subsequent eye was increased when the first eye had any amount of detachment [odds ratio = 2.8; 95% confidence interval (CI) = 1.1-7.3; P = 0.037]. When the first eye had a clinically significant detachment (>30% detached), the risk of detachment occurring in the subsequent eye was greater (odds ratio = 15.7; 95% CI = 1.8-134.5; P = 0.012). This risk of graft detachment in the subsequent eye increased 33% for every 5% increase in the detachment percentage in the first eye (odds ratio = 1.3; 95% CI = 1.1-1.6; P = 0.008).

Conclusions: The presence of graft detachment after DMEK increases the risk of graft detachment in subsequent DMEK in the contralateral eye. Modification in perioperative care and surgical technique in the contralateral eye, such as a larger gas bubble, use of SF6 20%, and combining cataract surgery, may be needed when graft detachment occurs after DMEK in the first eye.
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http://dx.doi.org/10.1097/ICO.0000000000002432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258963PMC
October 2020

The Michigan Retinal Degeneration Questionnaire: A Patient-Reported Outcome Instrument for Inherited Retinal Degenerations.

Am J Ophthalmol 2021 02 26;222:60-68. Epub 2020 Aug 26.

Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA. Electronic address:

Purpose: To create a psychometrically validated patient-reported outcome measure for inherited retinal degenerations.

Design: Qualitative and quantitative patient-reported outcome (PROs) questionnaire development using item response theory validation.

Methods: One hundred twenty-eight patients with a diagnosis of an inherited retinal degeneration at the Kellogg Eye Center (University of Michigan) were recruited and administered a 166-item questionnaire comprising 7 expert-defined domains. The questionnaire was re-administered 4-16 days later to a subset of 25 participants to assess test-retest variability. Graded response models were fit by Cai's Metropolis-Hastings Robbins-Monro algorithm using the R (version 3.6.3) package mirt. Model data were fit to assess questionnaire dimensionality, to estimate item information, and to score participants. Poorly functioning items were removed, and the model was refit to create the final questionnaire.

Results: The psychometrically validated PROs measure was reduced to a 59-item questionnaire measuring 7 unidimesnional domains: central vision, color vision, contrast sensitivity, scotopic function, photopic peripheral vision, mesopic peripheral vision, and photosensitivity. A total of 39 items were removed because of poor factor loading, low item information, poor person-ability differentiation, or high item-level interdependence. This novel questionnaire produces a reliable domain score for person ability that does not show significant test-retest variability across repeated administration.

Conclusions: The final PRO questionnaire, known as the Michigan Retinal Degeneration Questionnaire, is psychometrically validated and available for use in the evaluation of patients with inherited retinal degenerations.
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http://dx.doi.org/10.1016/j.ajo.2020.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907279PMC
February 2021

Advancing Clinical Trials for Inherited Retinal Diseases: Recommendations from the Second Monaciano Symposium.

Transl Vis Sci Technol 2020 06 3;9(7). Epub 2020 Jun 3.

Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France.

Major advances in the study of inherited retinal diseases (IRDs) have placed efforts to develop treatments for these blinding conditions at the forefront of the emerging field of precision medicine. As a result, the growth of clinical trials for IRDs has increased rapidly over the past decade and is expected to further accelerate as more therapeutic possibilities emerge and qualified participants are identified. Although guided by established principles, these specialized trials, requiring analysis of novel outcome measures and endpoints in small patient populations, present multiple challenges relative to study design and ethical considerations. This position paper reviews recent accomplishments and existing challenges in clinical trials for IRDs and presents a set of recommendations aimed at rapidly advancing future progress. The goal is to stimulate discussions among researchers, funding agencies, industry, and policy makers that will further the design, conduct, and analysis of clinical trials needed to accelerate the approval of effective treatments for IRDs, while promoting advocacy and ensuring patient safety.
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http://dx.doi.org/10.1167/tvst.9.7.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414644PMC
June 2020

Willingness to pay for cataract surgery in baiyin district, northwestern China.

Ophthalmic Epidemiol 2021 Jun 21;28(3):205-212. Epub 2020 Aug 21.

Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China.

Purpose: To investigate willingness to pay for cataract surgery, and its associations, in Northwestern China.

Methods: Four hundred thirty-eight persons aged 50 years and above, diagnosed with cataract indicated for surgery, identified in an outreach screening program were included. Subjects were offered a willingness-to-pay interview for the maximal amount that the subjects would be willing to pay for a cataract surgery. Age, gender, literacy, education level, occupation, and annual household income were recorded.

Results: Among 328 (74.9%) subjects who completed the interview, 197 (60.1%) participants were willing to pay something for the cataract surgery (mean, 902.9 ± 856.7 renminbi[RMB], [US$ 145 ± 137]; median, 500RMB, US$ 78). Individuals with presenting visual acuity (PVA) in the worse eye ≤6/60 (OR: 2.1, 95% CI: 1.3-3.2) and a high annual household incomes (OR: 2.0, 95% CI: 0.9-4.6) were likely to be willing to pay for the surgery, as revealed in the regression models. Willingness to pay any amount for cataract surgery was more likely among literate persons (OR: 1.5, 95% CI: 1.0-2.4) and persons with non-agricultural occupation (OR: 1.8, 95% CI: 1.0-3.2).

Conclusions: The amount that subjects were willing to pay is significantly less than the current cost of cataract surgery (5000 RMB, US$320) in the area. Providing low-cost cataract surgery to patients in a financially sustainable manner is important to increase uptake of cataract surgery among rural residents in Northwest China.
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http://dx.doi.org/10.1080/09286586.2020.1812089DOI Listing
June 2021

Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Program Pilot Study on Eye Drop Instillation Technique and Self-Efficacy.

Ophthalmol Glaucoma 2021 Jan-Feb;4(1):42-50. Epub 2020 Aug 8.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan. Electronic address:

Purpose: To assess the Support, Educate, Empower (SEE) personalized glaucoma coaching program impact on (1) eye drop instillation technique and (2) eye drop instillation self-efficacy.

Design: Prospective pre-post pilot study.

Participants: Patients with a diagnosis of glaucoma or ocular hypertension taking ≥1 glaucoma medication, ≥40 years old, spoke English, self-administered their eye drops, and ≤80% adherent to their glaucoma medication by electronic monitoring.

Methods: Eye drop administration was video recorded before the first SEE in-person coaching session, which included teaching eye drop instillation techniques using a motivational interviewing-based approach. At the third and final in-person counseling session 6 months later, eye drop administration was video recorded. Participants' self-efficacy was assessed using the validated Eye Drop Technique Self-Efficacy Scale (EDTSES) survey at baseline and 1 month after completion of the program. Before and after intervention videos were assessed by an observer masked to time point. Before versus after intervention comparisons were made using McNemar's and paired t tests.

Main Outcome Measures: The main outcome was change in participants' eye drop instillation technique as measured by (1) accuracy of an eye drop landing on the eye, (2) ability to instill an eye drop on the first attempt, and (3) contaminating the bottle by contact with ocular surface, eyelashes, and skin. The secondary outcome measure was before versus after change in the EDTSES score (6 items, each assessed on a 3-point Likert scale, with higher scores indicating better self-efficacy).

Results: Thirty-nine participants completed the SEE intervention, 38 with before and after EDTSES scores and 31 with video recordings. Six of 31 participants instilling drops outside the eye before intervention improved their technique after intervention, whereas 2 participants worsened (P = 0.157). From before to after intervention, participants demonstrated significant improvement in not touching the ocular surface (P = 0.046), the eyelashes (P = 0.020), or the skin (P = 0.025) with the bottle tip. A significant increase was found in eye drop instillation self-efficacy from an average score of 2.6 (standard deviation [SD], 0.3) to 2.8 (SD, 0.2) on the EDTSES score (P = 0.007).

Conclusions: The SEE program significantly decreased eye drop bottle contamination, increased eye drop instillation self-efficacy, and demonstrated an insignificant increase in ability to instill drops successfully and accurately.
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http://dx.doi.org/10.1016/j.ogla.2020.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854833PMC
August 2020

Content generation for patient-reported outcome measures for retinal degeneration therapeutic trials.

Ophthalmic Genet 2020 08 22;41(4):315-324. Epub 2020 Jun 22.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School , Ann Arbor, Michigan, USA.

Purpose: Generate content for a patient-reported outcome (PRO) measure for use in future clinical trials for inherited retinal degenerations.

Methods: Patients at the University of Michigan Kellogg Eye Center with a clinical diagnosis of inherited retinal degeneration with varying phenotypes were recruited for interviews. First, in-depth interviews were performed to solicit a wide range of patient experiences pertaining to visual function. Coders qualitatively analyzed the transcripts from these interviews using Atlas.ti software (Version 8.1.3 (522)) to draft questionnaire items. Next, the questionnaire was tested and refined based on participant feedback in cognitive interviews and administrator feedback in the pilot survey administration (pilot interviews).

Results: A total of 55 participants with a clinical diagnosis of inherited retinal degeneration were interviewed throughout the three study phases: in-depth interviews (n = 26), cognitive interviews (n = 16), and pilot interviews (n = 13). Coded items were analyzed for frequency of occurrence and related themes, then organized into common domains. Within each domain, PRO items were drafted to address the functional limitations or adaptations experienced by patients.

Conclusions: Items for a PRO measure have been drafted and evaluated for interpretability in the target inherited retinal degeneration patient population. Content validity for the items was established through a process of in-depth interviews, cognitive interviews, and pilot interviews.
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http://dx.doi.org/10.1080/13816810.2020.1776337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7503769PMC
August 2020

Randomized Safety and Feasibility Trial of Ultra-Rapid Cooling Anesthesia for Intravitreal Injections.

Ophthalmol Retina 2020 10 15;4(10):979-986. Epub 2020 Apr 15.

Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan.

Purpose: To test the safety and preliminary efficacy of rapid, nonpharmacologic anesthesia via cooling for intravitreal injections.

Design: Single-center, randomized phase 1 dose-ranging safety study (ClinicalTrials.gov identifier, NCT02872012).

Participants: Adults 18 years of age or older with a diagnosis of exudative macular degeneration or diabetic macular edema requiring bilateral anti-vascular endothelial growth factor therapy were included.

Methods: A handheld device was developed to provide anesthesia via cooling to a focal area on the surface of the eye before intravitreal treatment (IVT). In 22 patients undergoing bilateral IVT, 1 eye was randomized to receive standard of care (SOC) lidocaine-based anesthesia and the other eye received cooling-anesthesia at 1 of 5 different temperatures and cooling times. Subjective pain was assessed via the visual analog scale (VAS; range, 1-10) at 2 time points: (1) immediately after IVT and (2) 4 hours after IVT. Treated eyes were assessed for ocular safety 24 hours after IVT.

Main Outcome Measures: We determined the occurrence of adverse events in eyes treated with cooling anesthesia. Mean VAS pain scores immediately after IVT and 4 hours after IVT in eyes receiving cooling anesthesia were compared with eyes receiving SOC.

Results: A total of 44 eyes were treated, 22 with cooling anesthesia and 22 with SOC. No dose-related toxicity was found with cooling anesthesia. Mild, transient adverse events were recorded in 32% of patients treated with cooling anesthesia versus 44% of patients receiving SOC. The mean±standard error of the mean (SEM) VAS pain scores immediately after intravitreal injection were 2.3 ± 0.4 for patients receiving SOC and 2.2 ± 0.6 in patients receiving -10° C cooling anesthesia (P = 0.8). Mean±SEM pain scores 4 hours after injection were 1.6 ± 0.4 for SOC and 1.2 ± 0.5 in the combined -10° C arms (P = 0.56). Total mean±SEM procedure time was 124 ± 5 seconds for patients treated with cooling anesthesia versus 395 ± 40 seconds for SOC (P < 0.0001).

Conclusions: Ultra-rapid cooling of the eye for anesthesia was well tolerated, with -10° C treatment resulting in comparable levels of anesthesia to SOC with a reduction in procedure time.
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http://dx.doi.org/10.1016/j.oret.2020.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541410PMC
October 2020

A community-based effort to increase the rate of follow-up eye examinations of school-age children who fail vision screening: a randomized clinical trial.

J AAPOS 2020 04 7;24(2):98.e1-98.e4. Epub 2020 Mar 7.

Children's Hospital of Michigan, Detroit, Michigan.

Purpose: To determine whether enhanced follow-up after failed vision screening, involving more communication with parents/guardians than occurs in a standard protocol, would result in a higher rate of post-screening examination by an eye care provider.

Methods: In a study conducted from January through December 2017, 162 children in first- and third-grade who failed a vision screening in their Wayne County, Michigan, schools were randomly assigned to receive an enhanced or the standard follow-up protocol.

Results: The average age of the children was 7.9 ± 1.1years; 84 (52%) were males. In the enhanced follow-up group, 52 of 80 (65%) had a documented eye examination within 16 weeks of their screening; the rate in those receiving standard follow-up was 48% (39/82). The intergroup difference in follow-up was 17.4% (95% CI, 2.4%-32.5%). The enhanced follow-up group's odds of obtaining a documented eye examination was twice that of the standard follow-up group (OR = 2.05; 95% CI, 1.09-3.85; P = 0.026).

Conclusions: In this study cohort, methods to enhance communication proved effective in increasing the likelihood that children who failed vision screenings would receive an examination by an eye care provider.
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http://dx.doi.org/10.1016/j.jaapos.2019.12.012DOI Listing
April 2020

Patient-reported outcome measures in inherited retinal degeneration gene therapy trials.

Ophthalmic Genet 2020 02 26;41(1):1-6. Epub 2020 Feb 26.

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Patient-reported outcome (PRO) measures have the potential to uniquely capture patient experience and serve as an outcome measure in inherited retinal degeneration (IRD) gene therapy trials. An IRD-specific patient-reported outcome measure may yield valuable information that has not been obtained from inherited retinal dystrophy gene therapy trials published to-date. Existing PRO measures have inherent limitations for use in IRD gene therapy trials. Developing an applicable patient-reported outcome measure for such trials needs to incorporate patient input from the target population, demonstrate sound psychometric properties, and be made in accordance with U.S. Food and Drug Administration (FDA) guidelines. This review will discuss the currently available PRO instruments, their limitations for IRD therapeutic trials, and suggestions for future PRO development in IRD populations. The PRO instruments highlighted were identified in PubMed search of English-language journals and previously published review articles.
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http://dx.doi.org/10.1080/13816810.2020.1731836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110960PMC
February 2020

The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study.

Ophthalmology 2020 04 10;127(4):477-483. Epub 2020 Jan 10.

Department of Ophthalmology and Visual Sciences, Medical School, University of Michigan, Ann Arbor, Michigan; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan.

Purpose: To evaluate the relationship between medication adherence and visual field progression in participants randomized to the medication arm of the Collaborative Initial Glaucoma Treatment Study (CIGTS).

Design: The CIGTS was a randomized, multicenter clinical trial comparing initial treatment with topical medications to trabeculectomy for 607 participants with newly diagnosed glaucoma.

Participants: Three hundred seven participants randomized to the medication arm of the CIGTS.

Methods: Participants were followed up at 6-month intervals for up to 10 years. Self-reported medication adherence and visual fields were measured. Medication adherence was assessed by telephone from responses to the question, "Did you happen to miss any dose of your medication yesterday?" The impact of medication adherence on mean deviation (MD) over time was assessed with a linear mixed regression model adjusting for the effects of baseline MD and age, cataract extraction, interactions, and time (through year 8, excluding time after crossover to surgery). Medication adherence was modeled as a cumulative sum of the number of prior visits where a missed dose of medication was reported.

Main Outcome Measure: Mean deviation over time.

Results: Three hundred seven subjects (306 with adherence data) were randomized to treatment with topical medications and followed up for an average of 7.3 years (standard deviation, 2.3 years). One hundred forty-two subjects (46%) reported never missing a dose of medication over all available follow-up, 112 patients (37%) reported missing medication at up to one third of visits, 31 patients (10%) reported missing medication at one third to two thirds of visits, and 21 patients (7%) reported missing medication at more than two thirds of visits. Worse medication adherence was associated with loss of MD over time (P = 0.005). For subjects who reported never missing a dose of medication, the average predicted MD loss over 8 years was 0.62 dB, consistent with age-related loss (95% confidence interval [CI], 0.17-1.06; P = 0.007); subjects who reported missing medication doses at one third of visits had a loss of 1.42 dB (95% CI, 0.86-1.98; P < 0.0001); and subjects who reported missing medication doses at two thirds of visits showed a loss of 2.23 dB (95% CI, 1.19-3.26; P < 0.0001).

Conclusions: This longitudinal assessment demonstrated a statistically and clinically significant association between medication nonadherence and glaucomatous vision loss.
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http://dx.doi.org/10.1016/j.ophtha.2019.10.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093219PMC
April 2020

Diagnostic Accuracy of Rapid Assessment of Avoidable Blindness: A Population-based Assessment.

Am J Ophthalmol 2020 05 14;213:235-243. Epub 2019 Dec 14.

Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou, China; Project Vision Charitable Foundation, Hong Kong, China. Electronic address:

Objectives: To evaluate the diagnostic accuracy of rapid assessment of avoidable blindness (RAAB).

Design: Population-based diagnostic accuracy study.

Methods: A total of 2145 (95.3%, 2145/2250) subjects aged 50 years and older who participated in the RAAB survey were included. All the recruited participants underwent ophthalmic examination according to the RAAB protocol and then were reexamined with instruments in a mobile eye clinic set up in a village center on the same day. Examination in the mobile clinic included standardized visual acuity (VA) tests using logMAR charts, refraction, slit-lamp biomicroscopy, and dilated fundal examination with a binocular indirect ophthalmoscope. Blindness and economic blindness were defined as VA in the better-seeing eye <3/60 and <6/60, respectively. Visual impairment (VI) was defined as VA <6/18 in the better eye. The primary cause of blindness and VI was defined according to the cause of VI in the participant's better eye.

Main Outcome Measures: The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the curve (AUC) of receiver operating characteristics of RAAB for detection of blindness and the principal causes of VI.

Results: A total of 1816 subjects (84.7%), including 686 men (37.8%) and 1130 women (62.2%), underwent ophthalmic examination in the mobile eye clinic. The mean (±standard deviation) age was 64.4 ± 9.6 years. The sensitivities, specificities, AUC, PLR, and NLR of RAAB were 90.3%, 99.3%, 0.948, 124.0, and 0.10, respectively, for detection of blindness (presenting visual acuity, PVA <3/60); 89.5%, 98.7%, 0.940, 69.2, and 0.11, respectively, for detection of economic blindness (PVA <6/60); and 90.3%, 97.7%, 0.940, 38.7, and 0.10, respectively, for detection of VI (PVA <6/18). The sensitivities, specificities, AUC, PLR, and NLR were 90.5%, 98.1%, 0.943, 48.1, and 0.10; and 60.4%, 98.7%, 0.796, 46.4, and 0.40 for detection of VI (PVA <6/18) owing to cataract and refractive error, respectively.

Conclusion: The diagnostic performances of RAAB were high for detecting the prevalence of blindness, VI, and VI owing to cataract.
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http://dx.doi.org/10.1016/j.ajo.2019.12.009DOI Listing
May 2020

Comparison of Fundus-Guided Microperimetry and Multifocal Electroretinography for Evaluating Hydroxychloroquine Maculopathy.

Transl Vis Sci Technol 2019 Sep 27;8(5):19. Epub 2019 Sep 27.

Department of Ophthalmology and Visual Sciences, Medical School, University of Michigan, Ann Arbor, MI, USA.

Purpose: To compare retinal function by using fundus-guided microperimetry (MP) and multifocal electroretinography (mfERG) for detecting hydroxychloroquine (HCQ) maculopathy.

Methods: Forty-six eyes of 25 patients referred to our clinical practice for HCQ maculopathy assessment and 3 groups of normal control subjects were evaluated by mfERG and MP. Macular structure was assessed using spectral-domain optical coherence tomography (SD-OCT). Ring ratios from the three innermost mERG rings were compared with average sensitivity of each MP ring at approximately equivalent distances from the fovea. HCQ toxicity was defined as an mfERG ring ratio or mean MP ring sensitivity >2 standard deviations below the normal mean. The sensitivity and specificity of MP to detect HCQ toxicity relative to mfERG were evaluated.

Results: MP rings MR2 and MR3 were positively correlated with corresponding mfERG ring ratios (r = 0.52, = 0.002 and r = 0.56, < 0.001 respectively). Ring 2 and ring 3 measures of MP and mfERG were significantly worse in HCQ eyes than controls ( < 0.001). The sensitivity of MP to detect toxicity for MR1 through MR3 ranged from 33% to 88%, whereas specificity ranged from 72% to 85%. Through rings 1 to 3, the frequency of abnormal function ranged from 20% to 48% for MP, 11% to 35% for mfERG, and 41% to 45% for SD-OCT.

Conclusions: The frequency of detection of HCQ toxicity with MP was greater than with mfERG. MP showed an overall good sensitivity and moderate specificity in detecting HCQ-induced functional deficits.

Translational Relevance: Results from this study may allow clinicians to improve screening accuracy for HCQ toxicity by using the alternative modality of MP.
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http://dx.doi.org/10.1167/tvst.8.5.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6779178PMC
September 2019

Evaluation of Systematic Reviews of Interventions for Retina and Vitreous Conditions.

JAMA Ophthalmol 2019 12;137(12):1399-1405

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Importance: Patient care and clinical practice guidelines should be informed by evidence from reliable systematic reviews. The reliability of systematic reviews related to forthcoming guidelines for retina and vitreous conditions is unknown.

Objectives: To summarize the reliability of systematic reviews on interventions for 7 retina and vitreous conditions, describe characteristics of reliable and unreliable systematic reviews, and examine the primary area in which they appeared to be lacking.

Design, Setting, And Participants: A cross-sectional study of systematic reviews was conducted. Systematic reviews of interventions for retina- and vitreous-related conditions in a database maintained by the Cochrane Eyes and Vision United States Satellite were identified. Databases that the reviewers searched, whether any date or language restrictions were applied, and bibliographic information, such as year and journal of publication, were documented. The initial search was conducted in March 2007, and the final update was performed in July 2018. The conditions of interest were age-related macular degeneration; diabetic retinopathy; idiopathic epiretinal membrane and vitreomacular traction; idiopathic macular hole; posterior vitreous detachment, retinal breaks, and lattice degeneration; retinal and ophthalmic artery occlusions; and retinal vein occlusions. The reliability of each review was evaluated using prespecified criteria. Data were extracted by 2 research assistants working independently, with disagreements resolved through discussion or by 1 research assistant with verification by a senior team member.

Main Outcomes And Measures: Proportion of reviews that meet all of the following criteria: (1) defined eligibility criteria for study selection, (2) described conducting a comprehensive literature search, (3) reported assessing risk of bias in included studies, (4) described using appropriate methods for any meta-analysis performed, and (5) provided conclusions consistent with review findings.

Results: A total of 327 systematic reviews that addressed retina and vitreous conditions were identified; of these, 131 reviews (40.1%) were classified as reliable and 196 reviews (59.9%) were classified as not reliable. At least 1 reliable review was found for each of the 7 retina and vitreous conditions. The most common reason that a review was classified as not reliable was lack of evidence that a comprehensive literature search for relevant studies had been conducted (149 of 196 reviews [76.0%]).

Conclusion And Relevance: The findings of this study suggest that most systematic reviews that addressed interventions for retina and vitreous conditions were not reliable. Systematic review teams and guideline developers should work with information professionals who can help navigate sophisticated and varied syntaxes required to search different resources.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.4016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802257PMC
December 2019

Self-reported Eye Care Use Among US Adults Aged 50 to 80 Years.

JAMA Ophthalmol 2019 Sep;137(9):1061-1066

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Contemporary data on use of eye care by US adults are critical, as the prevalence of age-related eye disease and vision impairment are projected to increase in the coming decades.

Objectives: To provide nationally representative estimates on self-reported use of eye care by adults aged 50 to 80 years, and to describe the reasons that adults do and do not seek eye care.

Design, Setting, And Participants: The National Poll on Healthy Aging, a cross-sectional, nationally representative online survey was conducted from March 9 to 24, 2018, among 2013 individuals aged 50 to 80 years.

Main Outcomes And Measures: The proportion of US adults who received an eye examination within the past 2 years as well as the sociodemographic and economic factors associated with receipt of eye care.

Results: Among 2013 adults aged 50 to 80 years (survey-weighted proportion of women, 52.5%; white non-Hispanic, 71.1%; mean [SD] age, 62.1 [9.0] years), the proportion reporting that they underwent an eye examination in the past year was 58.5% (95% CI, 56.1%-60.8%) and in the past 2 years was 82.4% (95% CI, 80.4%-84.2%). Among those with diabetes, 72.2% (95% CI, 67.2%-76.8%) reported undergoing an eye examination in the past year and 91.3% (95% CI, 87.7%-93.9%) in the past 2 years. The odds of having undergone an eye examination within the past 2 years were higher among women (adjusted odds ratio [AOR], 2.00; 95% CI, 1.50-2.67), respondents with household incomes of $30 000 or more (AOR, 1.57; 95% CI, 1.08-2.29), and those with a diagnosed age-related eye disease (AOR, 3.67; 95% CI, 2.37-5.69) or diabetes (AOR, 2.30; 95% CI, 1.50-3.54). The odds were lower for respondents who were unmarried (AOR, 0.71; 95% CI, 0.53-0.96), from the Midwest (AOR, 0.55; 95% CI, 0.34-0.87) or West (AOR, 0.60; 95% CI, 0.38-0.94), or reported fair or poor vision (AOR, 0.43; 95% CI, 0.28-0.65). Reasons reported for not undergoing a recent eye examination included having no perceived problems with their eyes or vision (41.5%), cost (24.9%), or lack of insurance coverage (23.4%).

Conclusions And Relevance: In this study, the rate of eye examinations was generally high among US adults aged 50 to 80 years, yet there were several significant demographic and socioeconomic differences in the use of eye care. These findings may be relevant to health policy efforts to address disparities in eye care and to promote care for those most at risk for vision problems.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.1927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587143PMC
September 2019

Vision Impairment and Receipt of Eye Care Among Older Adults in Low- and Middle-Income Countries.

JAMA Ophthalmol 2019 02;137(2):146-158

Department of Ophthalmology and Visual Sciences, Center for Eye Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Vision impairment (VI), including blindness, affects hundreds of millions globally, and 90% of those with VI live in low- and middle-income countries. Cross-national comparisons are important to elucidate the unique and shared factors associated with VI and receipt of eye care in different countries and to target those most in need.

Objective: To identify the characteristics associated with VI and receipt of eye care in a sample of low- and middle-income countries.

Design, Setting, And Participants: In this study of cross-sectional survey data from wave 1 of the World Health Organization Study on Global Aging and Adult Health, data on sociodemographic characteristics and health were collected from nationally representative samples in China, Ghana, India, Mexico, Russia, and South Africa from 2007 to 2010. Probability sampling with multistage, stratified, random-cluster samples was used to identify households and participants. The survey was completed by 34 159 adults 50 years and older. Data were analyzed from December 2017 to February 2018.

Main Outcomes And Measures: We analyzed associations of individual-level and household-level covariates with 3 primary outcomes: distance VI (visual acuity worse than 6/18 in the better-seeing eye), near VI (visual acuity worse than 6/18 in the better-seeing eye), and receipt of an eye examination within the previous 2 years.

Results: The study sample in China consisted of 13 350 participants (50.2% female; mean [SD] age, 62.6 [9.0] years); in Ghana, 4725 participants (50.4% female; mean [SD] age, 64.2 [10.8] years); in India, 7150 participants (48.9% female; mean [SD] age, 61.5 [9.0] years); in Mexico, 2103 participants (52.3% female; mean [SD] age, 69.2 [9.2] years); in Russia, 3763 participants (61.1% female; mean [SD] age, 63.9 [10.4] years); and in South Africa, 3838 participants (55.9% female; mean [SD] age 61.6 [9.5]) (all demographic characteristics weighted to reflect respective populations). The weighted proportion of the study sample with distance VI ranged from 9.9% (95% CI, 9.3-10.5) in China to 25.4% (95% CI, 22.0-29.2) in Russia; near VI, from 28.5% (95% CI, 26.9-30.1) in Ghana to 43.1% (95% CI, 41.1-45.1) in India; and receipt of a recent eye examination, from 15.0% (95% CI, 13.8-16.2) in Ghana to 53.1% (95% CI, 49.3-56.8) in Russia. Educational attainment, medical comorbidities, and memory were significantly associated with all outcomes across most low- and middle-income countries. Female sex, low household wealth, food insecurity, no health insurance, rurality, disability, being unmarried, and low social participation were significantly associated with adverse vision-related outcomes, though less consistently.

Conclusions And Relevance: There are both common and unique characteristics associated with VI and receipt of eye care across low- and middle-income countries. Our findings suggest that recognizing these factors is important to identify those most at risk and allocate resources optimally. Additional local epidemiological studies are needed.
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http://dx.doi.org/10.1001/jamaophthalmol.2018.5449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440432PMC
February 2019
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