Lisa A. Hark

Importance: This study evaluates two rapid electrophysiological glaucoma diagnostic tests that may add a functional perspective to glaucoma diagnosis.Background: This study aimed to determine the ability of two office‐based electrophysiological diagnostic tests, steady‐state pattern electroretinogram and short‐duration transient visual evoked potentials, to discern between glaucomatous and healthy eyes.Design: This is a cross‐sectional study in a hospital setting.Participants: Forty‐one patients with glaucoma and 41 healthy volunteers participated in the study.Methods: Steady‐state pattern electroretinogram and short‐duration transient visual evoked potential testing was conducted in glaucomatous and healthy eyes. A 64‐bar‐size stimulus with both a low‐contrast and high‐contrast setting was used to compare steady‐state pattern electroretinogram parameters in both groups. A low‐contrast and high‐contrast checkerboard stimulus was used to measure short‐duration transient visual evoked potential parameters in both groups.Main Outcome Measures: Steady‐state pattern electroretinogram parameters compared were MagnitudeD, MagnitudeD/Magnitude ratio, and the signal‐to‐noise ratio. Short‐duration transient visual evoked potential parameters compared were amplitude and latency.Results: MagnitudeD was significantly lower in glaucoma patients when using a low‐contrast (P = 0.001) and high‐contrast (P < 0.001) 64‐bar‐size steady‐state pattern electroretinogram stimulus. MagnitudeD/Magnitude ratio and SNR were significantly lower in the glaucoma group when using a high‐contrast 64‐bar‐size stimulus (P < 0.001 and P = 0.010, respectively). Short‐duration transient visual evoked potential amplitude and latency were not significantly different between the two groups.Conclusions and relevance: Steady‐state pattern electroretinogram was effectively able to discern between glaucomatous and healthy eyes. Steady‐state pattern electroretinogram may thus have a role as a clinically useful electrophysiological diagnostic tool.

Background Over the past 50 years, there has been a decline in the number of physicians pursuing careers in clinical research. In ophthalmology, the need for clinician-investigators continues to grow with the increasing eye-care demands of the aging population. Expert panels have recommended exposing medical students early in their training to structured, didactic curricula with clinical research experience and mentoring opportunities. Methods To address this need, the Department of Research, Wills Eye Hospital, developed an 8-week Clinical Vision Research Training and Mentoring Program for undergraduate and medical students. The curriculum included an 11-hour lecture series on topics in research methods in ophthalmology and a 10-hour scientific writing workshop series. The program also involved hands-on participation in vision research projects and shadowing in one of Wills' subspecialty services. Students completed 40-question pre- and posttests on ophthalmology and research methodology. Scores were analyzed using a paired-sample t-test. The program also utilized a satisfaction survey. Results During 2014 and 2015, a total of 34 students out of 56 applicants were accepted to the Clinical Vision Research Training and Mentoring Program. Students scored significantly higher on the posttest (mean [M] = 79.78%, standard deviation [SD] = 6.25) than on the pretest (M = 71.43%, SD = 8.43); p< 0.001. Using a satisfaction survey, students strongly agreed that they were satisfied with the program and that the lecture series and manuscript writing workshops enhanced their learning. Conclusions The Wills Eye Clinical Vision Research Training and Mentoring Program provided an evidence-based foundation in research methods and manuscript development for students interested in careers in ophthalmology. Students emerged with clinical research skills and an increased understanding and appreciation of vision research. Results of the pre- and posttest analysis indicate that lecture material supplemented with hands-on experience can lead to better understanding of ophthalmology. This pilot program can serve as a research training and mentoring model for ophthalmology and other medical and surgical specialties.

Purpose: To utilize the Travoprost Dosing Aid (DA) in the assessment of patient medication adherence, while also determining whether or not altering the functionality of the DA in three randomized subject groups can reduce observer effect. Methods: Forty-five subjects were randomized into three groups: two with monitored DAs and one without monitoring. One group of subjects was given a DA that both monitored drop usage and had visual and audible alarms, while the other monitored group included subjects given a DA that had no alarms but continued to monitor drop usage. The third group was given a DA that had no alarm reminders or dose usage monitoring. Subjects were informed that some monitors would not be functional, in an attempt to reduce observer effect, or the effect of being monitored on subject behavior and adherence. A six-item questionnaire was also utilized to assess how the subjects felt about their adherence and DA use. Results: The overall adherence rates were found to be 78% in the fully functional group (95% confidence interval: 70–88) and 76% in the no alarms group (95% confidence interval: 65–89). No association was seen between questionnaire response and medication adherence. The patients in the DA group without alarms had a significantly higher odds ratio of medication adherence if they reported on the questionnaire that using the DA did affect how much they used their drops. Conclusion: Though the use of DA was expected to reveal different rates of adherence depending on the functionality of the DA between groups, patients with a nonfunctioning DA did not have a significant difference in medication adherence compared to those given a fully functional DA. This supports that an observer effect was not reduced despite these interventions, and that the subjects adhered to taking their medications as if they had a functioning DA and were being monitored.

Purpose: Patients with glaucoma who do not keep their follow-up eye care appointments are at risk for developing more severe ocular disease. The primary aim of the current study was to evaluate whether the use of a patient navigator altered adherence to follow-up eye care appointments in community-versus office-based settings. Patients and methods: Patients diagnosed with a glaucoma-related condition following a comprehensive eye examination at 43 community sites in Philadelphia, PA, USA, were enrolled in this prospective, randomized, controlled trial. Patients were randomized into three groups for a 1-year period: Group 1 (G1) received follow-up eye care in a community-based setting with assistance from a patient navigator; Group 2 (G2) received follow-up eye care in an office-based setting with assistance from a patient navigator; and Group 3 (G3) received follow-up eye care in an office-based setting without a patient navigator (usual care). Adherence rates were compared among these three groups using a chi-squared test at a significance level of 0.05. Results: A total of 155 patients with glaucoma-related diagnoses were enrolled. The mean age (±standard deviation) was 71.2 (±10.0) years. Patients were predominantly female (65.8%, n=102/155) and African-American (71.6%, n=111/155). The mean (±standard deviation) number of follow-up visits during the 1-year study period was 1.3 (±1.3) for G1, 1.6 (±1.3) for G2, and 1.3 (±1.1) for G3 (P=0.48). Appointment adherence, defined as attendance of ≥1 follow-up visit, was 69.8% (n=37/53) for G1, 82.5% (n=47/57) for G2, and 73.3% (n=33/45) for G3, (P=0.28). Sub-analysis of adherence rates for patients who attended ≥2 follow-up visits were 91.3% (n=21/23) for G1, 74.3% (n=26/35) for G2, and 66.7% (n=18/27) for G3, (P=0.11). Conclusion: Help from a patient navigator did not increase the likelihood of keeping ≥1 follow-up appointment in an office-based setting. Adherence rates for follow-up appointments reached close to 70% or above in a self-selected patient population.

Lack of patient adherence with eye appointments can decrease ocular outcomes. This prospective, randomized, single-blinded controlled study assessed the effectiveness of multiple interventions in improving follow-up adherence to recommended eye appointments. Patients due for follow-up appointments were randomly assigned to usual care, automated intervention, or personal intervention. Automated-intervention patients and personal-intervention patients received a call one month prior to the recommended follow-up date, and a mailed appointment reminder letter. The call was automated for automated-intervention patients and personalized for personal-intervention patients. The primary outcome was adherence to the follow-up appointment. The secondary outcome was rate of appointment scheduling. Patients in the personal-intervention group had greater adherence to follow-up recommendations (38%) than patients in the usual care group (28%) and the automated-intervention group (30%). Personal intervention significantly increased appointment scheduling (51%) over usual care (32%) and automated intervention (36%). These results support systems-level changes to improve patient follow-up adherence in urban primary eye care settings.

Purpose: The Wills Eye Glaucoma Research Center initiated a 2-year demonstration project to develop and implement a community-based intervention to improve detection and management of glaucoma in Philadelphia. Methods: The glaucoma detection examination consisted of: ocular, medical, and family history; visual acuity testing; corneal pachymetry; biomicroscopy of the anterior segment; intraocular pressure (IOP) measurement; gonioscopy; funduscopy; automated visual field testing; and fundus-color photography. Treatment included laser surgery and/or IOP-lowering medication. A cost analysis was conducted to understand resource requirements. Outcome measures included; prevalence of glaucoma-related pathology and other eye diseases among high-risk populations; the impact of educational workshops on level of knowledge about glaucoma (assessed by pre- and post-test evaluation); and patient satisfaction of the glaucoma detection examinations in the community (assessed by satisfaction survey). Treatment outcome measures were change in IOP at 4–6 weeks and 4–6 months following selective laser trabeculoplasty treatment, deepening of the anterior chamber angle following laser-peripheral iridotomy treatment, and rate of adherence to recommended follow-up examinations. Cost outcomes included total program costs, cost per case of glaucoma detected, and cost per case of ocular disease detected. Results: This project enrolled 1649 participants (African Americans aged 50+ years, adults 60+ years and individuals with a family history of glaucoma). A total of 1074 individuals attended a glaucoma educational workshop and 1508 scheduled glaucoma detection examination appointments in the community setting. Conclusions: The Philadelphia Glaucoma Detection and Treatment Project aimed to improve access and use of eye care and to provide a model for a targeted community-based glaucoma program.