To prospectively monitor intraocular pressure (IOP) and gonioscopy changes within the first month after a single 4-mg intravitreal injection of triamcinolone acetonide (IVK) (Kenalog, Briston-Meyers Squibb, New York).Prospective comparative interventional case series.A consecutive series of 28 eyes of 14 patients with no prior intravitreal injections or history of glaucoma were prospectively enrolled. After baseline evaluation in both eyes, including IOP, gonioscopy, and optic nerve evaluation, a single 4-mg IVK was given in a standard sterile fashion in the eye to be treated. Eyes received IVK for macular edema associated with retinal vein occlusions and in conjunction with photodynamic therapy for choroidal neovascularization secondary to age-related macular degeneration, ocular histoplasmosis, and high myopia. The fellow eye served as the control. After the injection, IOP and gonioscopy were repeated at 1, 2, and 4-week intervals in both eyes.Of the 14 patients, the 5 women and 9 men had a mean age of 67.6 years. Mean baseline IOP of the treated and fellow control eyes were similar at 15.9 versus 16.6 mm Hg, respectively. The control eyes maintained a small IOP range (15.6 to 16.6 mm Hg) during the 1-month follow-up period. In the treated eyes, the mean maximum IOP was 54% above baseline during follow-up, compared with 11% for control eyes. Six of 14 (43%) treated eyes had IOP elevation to 24 mm Hg or higher with mean change of 8.6 mm Hg and a mean maximum IOP of 32.1 mm Hg. There was no correlation between IOP rise and age, sex, diagnosis, or optic nerve appearance. However, during the course of the study, 4 of 6 (67%) of the treated eyes that required topical drops for the IOP elevation had documented abnormal inferior angle changes characterized by pigmented particulate matter in the inferior angle not present at the baseline exam. The most frequent time point for an IOP elevation that required treatment was at 2-week postinjection. No eyes required surgical management of IOP during the course of this 4-week study.We observed a significant IOP rise in eyes after a single intravitreal injection of 4 mg of triamcinolone within 1 month of injection. In this study, the most frequent time point that required IOP treatment was at 2-week postinjection, suggesting that early and frequent monitoring of IOP should be considered. Two-thirds of eyes that required medical control of IOP developed gonioscopy changes, characterized by particulate matter in the inferior angle, not present at baseline. Eyes that developed gonioscopic changes were 5 times more likely to be treated for IOP elevation than those without gonioscopic findings.
To determine what criteria are being used by glaucoma specialists to refer patients to low vision services (LVS) and to identify potential barriers to LVS referral.A survey was emailed to members of the American Glaucoma Society (AGS). The number and percentage of responses to each survey question were examined.Reported criteria for referral included difficulty performing activities related to vision (78%), degree of visual field loss (63%), and difficulty with orientation and mobility (27%). Reported barriers to LVS referral included patients not expressing difficulty with activities related to vision (34%), not having enough time to counsel patients during clinic visits (32%), and perceiving that patients would not be able to afford LVS even if they were referred (31%).Among glaucoma specialists, patient-reported difficulties with vision-related activities were the most common criteria used for LVS referral. Reported barriers to LVS referral, including perceived patient economic restraints and insufficient time to counsel patients during clinic visits, need to be addressed through appropriate interventions.
Nonmedical out-of-pocket cost to both patients and their companions of office visits for routine glaucoma care has not been extensively studied in the United States. We evaluate potential key predictors of patient expenditures that are critical to assessing the cost-effectiveness of glaucoma health care delivery.In total, 300 patients responded to the survey in 3 clinics in 2 clinical practice settings. Main outcome measures included both average visit and yearly expenditures.Of the 300 patients, the majority were female (n=187, 62.3%) and African American (n=171, 57.0%). The median age was 66 years. The median [range; mean (SD)] expenditure per patient visit was $22.10 ($11.1, $42.9; $44.1 (72.8)). Patients with companions paid $38.77 more in average visit expenditure (β: 0.87, P<0.001). The average visit expenditure for retired patients was $17.37 less when compared with nonretired patients (β: -0.4, P=0.004). Patients living in a rural or suburban area paid $43.91 and $14.13 more per visit, respectively (β: 0.73, P=0.0004; β: 0.31, P=0.03), compared with patients living in an urban area. Patients with noncommercial insurance paid $24.01 less in average visit expenditure (β: -0.66, P=0.0008). The median yearly patient expenditure was $96.70 [$44.6, $222.7; $210.4 (333.9)]. Patients with companions paid $192.37 more in yearly expenditure (β: 0.9, P<0.001) than those without companions, whereas retired patients paid $80.83 less in yearly expenditure (β: -0.39, P=0.03) than nonretirees. Patients with noncommercial insurance paid $109.34 less in yearly expenditure (β: -0.63, P=0.01).Although a small part of the total cost of glaucoma care, nonmedical out-of-pocket costs constitute a substantial noncovered medical expense to most patients in the United States. Patients who are employed, come with companions, live in nonurban areas, or are on Medicare have greater expenditures.
The purpose of this study was to identify and measure plexus-specific absolute retinal capillary blood flow velocity and acceleration in vivo in both nonhuman primates (NHPs) and humans using erythrocyte mediated angiography (EMA) and optical coherence tomography angiography (OCTA).
To identify characteristics of ophthalmologists and practices who refer glaucoma patients to low vision services (LVS).An online survey was distributed to members of the American Glaucoma Society. The survey queried demographics of responders and their clinical practices, criteria and barriers to referral to LVS. Survey responders were categorized as high referrers if they reported referring >5 patients to LVS and low referrers if they referred ≤5. χ and Fischer exact tests were used to compare characteristics between high and low referrers. Logistic regression analyses were used to calculate odds ratios and 95% confidence intervals and determine factors associated with referrer status.High referrers to LVS tended to have >10 patients per month who had already seen a low vision provider (53% vs. 10%, P<0.001), reported following the American Academy of Ophthalmology's Preferred Practice Pattern (PPP) recommendations for LVS referrals (38% vs. 18%, P=0.011), and expressed satisfaction with their current referral practices (86% vs. 70%, P=0.049). In the fully adjusted model those who followed PPP were 2.5 times more likely to report being a high referrer as compared with a low referrer (95% confidence interval, 1.1-5.3). However, only 22% of ophthalmologists reported following these guidelines in their practice. The number of years in practice, practice location or type, volume of patients seen each week, and distance to a low vision clinic were not associated with referral.Familiarity with PPP guidelines may positively influence LVS referral practices.
Purpose: To report a series of cases with smokestack leakage on fundus fluorescein angiography outside the clinical setting of central serous chorioretinopathy. Methods: A multicenter, observational retrospective case series evaluating fundus fluorescein angiography on Topcon and Optos systems. Results: Seven patients with neovascularization due to ischemic retinopathy demonstrated a unique smokestack pattern of angiographic leakage. The patients' ages ranged between 44 and 71 years and were seen at 3 academic teaching hospitals in the Washington–Baltimore metropolitan area. Five patients had been diagnosed with proliferative diabetic retinopathy, one with sickle cell ischemic retinopathy, and one with branch retinal artery occlusion; none of the patients had a known history or clinical signs of current or past central serous chorioretinopathy. Conclusion: This is the first published case series to the author's knowledge of ischemic retinopathy displaying a smokestack leakage pattern on fundus fluorescein angiography that is classically described with idiopathic central serous chorioretinopathy.
