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ABSTRACT: To determine the change in intraocular pressure (IOP) after cataract extraction in the observation group of the Ocular Hypertension Treatment Study.
Comparative case series.
Forty-two participants (63 eyes) who underwent cataract surgery in at least 1 eye during the study and a control group of 743 participants (743 eyes) who did not undergo cataract surgery.
We defined the "split date" as the study visit date at which cataract surgery was reported in the cataract surgery group and a corresponding date in the control group. Preoperative IOP was defined as the mean IOP of up to 3 visits before the split date. Postoperative IOP was the mean IOP of up to 3 visits including the split date (0, 6, and 12 months' with "0 months" equaling the split date). In both groups, we censored data after initiation of ocular hypotensive medication or glaucoma surgery of any kind.
Difference in preoperative and postoperative IOP.
In the cataract group, postoperative IOP was significantly lower than the preoperative IOP (19.8 ± 3.2 mmHg vs. 23.9 ± 3.2 mmHg; P<0.001). The postoperative IOP remained lower than the preoperative IOP for at least 36 months. The average decrease in postoperative IOP from preoperative IOP was 16.5%, and 39.7% of eyes had postoperative IOP ≥ 20% below preoperative IOP. A greater reduction in postoperative IOP occurred in the eyes with the highest preoperative IOP. In the control group, the corresponding mean IOPs were 23.8 ± 3.6 before the split date and 23.4 ± 3.9 after the split date.
Cataract surgery decreases IOP in patients with ocular hypertension over a long period of time.
Ophthalmology 05/2012; 119(9):1826-31. · 5.45 Impact Factor
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Journal of glaucoma 09/2011; · 1.74 Impact Factor
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ABSTRACT: To determine the associations between medical, demographic, socioeconomic, and ocular factors and adherence to topical glaucoma ocular hypotensive therapy.
One hundred sixteen patients with ocular hypertension or open-angle glaucoma from 2 tertiary glaucoma services participated in this prospective study. Adherence to ocular hypotensive therapy was measured using an electronic dose monitor (Travatan Dosing Aid, Alcon Laboratories Inc., Fort Worth, TX) and collected data at 3 months after enrollment. We used 3 different definitions of adherence: 1) Definition 1: the proportion of days taking the prescribed number of drops within 3 hours of the prescribed dosing time; 2) Definition 2: the proportion of days taking any drops within 3 hours of the prescribed dosing time; and 3) Definition 3: the proportion of days taking any drops within 6 hours of the prescribed dosing time. Univariate and multivariate models were used to determine the association between the 3 adherence definitions, medical, demographic, socioeconomic, and ocular factors at 3-month follow-up. The main outcome measures for this study were risk factors for poor objective medication adherence.
Adherence, using Definition 1, Definition 2, and Definition 3, was 64%, 75%, and 80%, respectively. Age, total number of other eye diseases, and race were significantly associated with full treatment adherence (Definition 1), with race alone significantly predicting 11% of full treatment adherence. For Definition 2, age, income, level of education, and total number of eye diseases were significantly associated with partial adherence (3 h), again race alone significantly predicted 15% of partial adherence (any drops within 3 h). For Definition 3, race, income, level of education, and total number of other eye diseases significantly predicted partial adherence (any drops within 6 h), both race and income predicted 19% of partial treatment adherence. Significant differences for adherence rates between patients of European descent and those of African descent were found for all 3 definitions with those who were less adherent more likely to be of African descent.
Electronic dose monitors provide important information regarding adherence to topical ocular hypotensive medications in glaucoma patients. Electronic dose monitors show low adherence in a significant number of participants. Future studies are needed to determine the reasons for these differences in health behaviors related to glaucoma treatment, which should guide treatment of poor adherence with glaucoma therapy.
Journal of glaucoma 05/2011; 21(4):234-40. · 1.74 Impact Factor
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ABSTRACT: To determine the prevalence of follow-up and factors associated with completing an eye examination after a glaucoma public service announcement.
Cross-sectional observational study.
Individuals who participated in the Glaucoma EyeCare Program by calling a toll-free telephone number and receiving referral by meeting inclusion criteria.
The Glaucoma EyeCare Program uses public service announcements to encourage those at increased risk for glaucoma to obtain an eye examination. The program requires interested persons to dial a toll-free telephone number to collect demographic, medical, and socioeconomic information, and refers those at higher risk of glaucoma to an ophthalmologist for a free eye examination. The ophthalmologist completes an outcome form, which indicates whether the participant obtained an eye examination and the results of this eye examination. We determined the factors associated with obtaining an eye examination.
Sociodemographic characteristics associated with obtaining an eye examination after referral through the Glaucoma EyeCare Program.
Ophthalmologists returned outcome forms for 1514 of 6343 participants (24%). Of those with outcome forms, 671 (44.3%) had an eye examination, 756 (49.9%) did not make an appointment, and 87 (5.7%) made an appointment but did not complete the examination. A multivariate logistic regression model showed younger age, female gender, lack of health insurance, medical history of diabetes, and shorter distance to be associated with obtaining an eye examination.
Public service announcements encourage participants to have an eye examination. Multiple factors alter the success of obtaining an eye examination. Future studies are needed regarding the best method of decreasing the risk of undiagnosed glaucoma.
Ophthalmology 03/2011; 118(7):1327-33. · 5.45 Impact Factor
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ABSTRACT: To determine the change in vision-related quality-of-life scores after providing eyeglasses to American Indian/Alaska Natives with undercorrected refractive error.
Prospective, comparative (nonrandomized) interventional study.
We compared a group with undercorrected refractive error to a control group who did not need a change in eyeglasses. Undercorrected refractive error was defined as distance visual acuity 20/40 or worse in the better-seeing eye that could be improved by at least 2 lines in Snellen visual acuity. Intervention was the provision of new glasses to the undercorrected refractive error group members, based on results of manifest refraction. The main outcome measures were the differences in the 25-Item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) scores from baseline (Time 1) to the time after providing eyeglasses (Time 2).
The NEI VFQ-25 median Composite score at Time 1 was significantly lower in those with undercorrected refractive error when compared to the control group (75 vs 92, P = .001). The median Composite score for the undercorrected refractive error group improved to 96 (P < .001) at Time 2 when compared to Time 1, while the control group remained stable at 93 (P = .417). The undercorrected refractive error group showed significantly greater improvement than the control group in 8 of 12 subscale scores and in the overall Composite score (all P values ≤ .05). A multivariate linear regression analysis, which controlled for differences in age, percent self-identified American Indian/Alaskan Native, and best-corrected visual acuity between the undercorrected refractive error and control group, showed eyeglasses to be significantly associated with improvement in NEI VFQ-25 composite score.
Visual impairment from undercorrected refractive error is common in American Indian/Alaskan Natives. Providing eyeglasses results in a large, significant increase in vision-related quality of life.
American journal of ophthalmology 10/2010; 151(1):175-182.e2. · 3.83 Impact Factor
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ABSTRACT: To compare optic disc changes using automated analysis of Heidelberg retina tomograph (HRT) images with assessments, by glaucoma specialists, of change in stereoscopic photographs.
Baseline and follow-up stereophotographs and corresponding HRT I series of 91 eyes from 56 patients were selected. The selection criteria were sufficiently long, good-quality HRT series (7 visits in > or =70 months of follow-up) and follow-up photographs contemporaneous with the final HRT image. Topographic change analysis (TCA), statistic image mapping (SIM), and linear regression of rim area (RALR) across time were applied to HRT series. Glaucomatous change determined from stereophotographs by expert observers was used as the reference standard.
Expert observers identified 33 eyes (36%) as exhibiting glaucomatous change. Altering HRT progression criteria such that 36% of eyes progressed according to each method resulted in concordance between HRT methods and stereophotograph assessment of 54% for TCA, 65% for SIM, and 67% for RALR (Cohen kappa = 0.05, 0.23, and 0.30, respectively). Receiver operating characteristic curves of the HRT analyses revealed poor precision of HRT analyses to predict stereophotograph-assessed change: areas under the curve were 0.61 for TCA, 0.62 for SIM, and 0.66 for RALR.
Statistical methods for detecting structural changes in HRT images exhibit only moderate agreement with each other and have poor agreement with expert-assessed change in optic disc stereophotographs.
Archives of ophthalmology 05/2010; 128(5):560-8. · 3.86 Impact Factor
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Steven L Mansberger
American journal of ophthalmology 01/2010; 149(1):1-3. · 3.83 Impact Factor
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ABSTRACT: To determine the demographic factors associated with central corneal thickness (CCT) in Northwestern American Indians/Alaskan Natives (AI/ANs) and to compare these CCT measurements with those of White and African-American persons.
Cross-sectional comparative, observational study.
We performed ultrasonic pachymetry (DGH-500 Pachette; DGH Technologies, Exton, Pennsylvania, USA) on a random sample of AI/AN subjects from three randomly selected AI/AN tribes in the Northwest United States (n = 429). Pachymetry also was performed on a convenience sample of White (n = 46) and African-American (n = 33) persons. Our main outcome measure was the average of right and left eye CCT.
Average AI/AN CCT was 554.8 +/- 33.9 microm. AI/AN CCT was found to be thicker than that of African Americans (528.5 +/- 33.2 microm) but similar to that of White persons (551.9 +/- 28.3 microm). CCT was greater in AI/AN females than in AI/AN males (557.6 +/- 33.3 microm vs 550.1 +/- 34.5 microm; P = .03). We found no difference in CCT based on percent AI/AN heritage, age, and keratometry readings. We found no significant differences in mean CCT between AI/ANs with glaucoma (556.2 microm) and those who did not have glaucoma (556.6 microm).
CCT measurements for the Northwest AI/AN population are similar to those of White persons but thicker than those of African-American persons. Although glaucoma is common in AI/ANs, we did not find an association with thin CCT. We need future studies to explore the risk factors for glaucoma in AI/ANs.
American journal of ophthalmology 08/2008; 146(5):747-51. · 3.83 Impact Factor
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ABSTRACT: To compare the intraocular pressure (IOP) responses of self-identified African American and white participants in the Ocular Hypertension Treatment Study to therapeutic trials of topical, nonselective beta-adrenergic antagonists or prostaglandin analogues.
Multivariate models that adjusted for baseline IOP and corneal thickness were used to estimate IOP response by race. Participants included 536 who were prescribed topical beta-adrenergic antagonists and 191 who were prescribed prostaglandin analogues, 25% of whom were African American.
Intraocular pressure response in the ipsilateral eye after 4 to 6 weeks of a therapeutic trial.
Intraocular pressure response to nonselective beta-adrenergic antagonists did not differ between African American and white participants. Intraocular pressure response to prostaglandin analogues was slightly greater in African American participants, but this difference was not statistically significant. With both classes of medication, greater IOP reduction was associated with higher baseline IOP and thinner central corneal measurement.
We found no statistically significant differences in IOP response to topical, nonselective beta-adrenergic antagonists or prostaglandin analogues between self-identified African American and white individuals. Application to Clinical Practice Studies of IOP response to medication should statistically adjust for baseline IOP and central corneal thickness. Clinicians should consider factors other than ethnicity when choosing an ocular hypotensive medication for a patient.
clinicaltrials.gov Identifier: NCT00000125.
Archives of Ophthalmology 05/2007; 125(4):454-9. · 3.71 Impact Factor
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ABSTRACT: To compare the diagnostic performance of multifocal visual evoked potential (mfVEP) and standard automated perimetry (SAP), in eyes with high-risk ocular hypertension or early glaucoma.
Both eyes of 185 individuals with high-risk ocular hypertension or early glaucoma were evaluated. Subjects ranged in age from 37 to 87 (mean +/- SD: 61 +/- 11 years). Pattern-reversal mfVEPs were obtained by using VERIS (Electro-Diagnostic Imaging, San Mateo, CA) with a four-electrode array and were analyzed with custom software. SAP visual fields (SITA-standard; Carl Zeiss Meditec, Inc., Dublin, CA) were obtained within 22.3 +/- 27.0 days of the mfVEP. Stereo disc photographs and Heidelberg Retina Tomograph (HRT) images were obtained during one visit, which was within 24.8 +/- 50.4 days of the mfVEP and 33.1 +/- 62.9 days of the SAP visual field. Abnormalities on the mfVEP were defined by using a variety of cluster criteria: SAP with pattern standard deviation (PSD) P </= 0.05 or glaucoma hemifield test (GHT) outside normal limits, according to OHTS criteria (SAP-OHTS). In separate analyses cluster criteria were used to determine SAP abnormalities. Disc photographs were graded as either glaucomatous optic neuropathy (GON) or normal by two independent masked experts, and disagreements were adjudicated by a third masked expert. The overall Moorfields regression analysis (MRA) result from the HRT was used as a separate diagnostic classification. All eyes classified as "borderline" by the MRA were assigned to the normal category (i.e., "within normal limits"). Sensitivity for mfVEP or SAP was defined as the percentage of GON eyes that had an abnormality on the functional test. Specificity for mfVEP or SAP was defined as the percentage of eyes with normal optic disc structure that had normal functional test
results. Disc photographs from 50% of eyes were graded GON. Both eyes were graded GON in 71 (38%) of the 185 subjects. Exactly half as many eyes were abnormal by HRT MRA. The average SAP mean deviation (MD) was +0.3 +/- 2.1 dB; average PSD was 2.3 +/- 1.9 dB. By OHTS criteria, 83 (22%) of the 370 eyes had an abnormal SAP. Depending on the cluster criterion used, the proportion of eyes with an abnormal SAP ranged from 8% to 26% and with an abnormal mfVEP, from 14% to 45%. A criterion with an estimated specificity in normal subjects of 91% resulted in 102 (28%) eyes with an abnormal mfVEP. For criteria with estimated specificities of 95% and 99%, respectively, 88 (24%) eyes and 52 (14%) eyes had an abnormal mfVEP. Agreement between SAP and mfVEP ranged from 75% to 81%. The sensitivity of SAP-OHTS to detect GON (using the disc photograph as diagnostic standard) was 29%, whereas specificity was 84%. Sensitivity of the mfVEP to detect GON, for cluster criteria with disc structure specificity between 84% and 87%, ranged from 28% to 32%. When the HRT MRA was used as the diagnostic standard, sensitivities of both functional tests to detect GON increased to 42%.
The diagnostic performance of mfVEP was similar to that of SAP. However, the two modalities agreed in only approximately 80% of eyes, suggesting that they may detect slightly different functional deficits.
Investigative Ophthalmology & Visual Science 03/2007; 48(3):1173-80. · 3.60 Impact Factor
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ABSTRACT: To determine the effect of screening location on the frequency of abnormal test results with Frequency Doubling Technology (FDT) perimetry.
Retrospective cross-sectional study.
The Vision Screening Outreach Project conducted FDT testing in community sites surrounding Portland, Oregon. The sites were separated into a specific location type: health care clinics, work sites, senior centers, festivals/fairs, food banks/shelters, and other locations. These locations were compared for differences in the proportion of screening failures.
Screening failure (defined as a repeatable, abnormal FDT result in either eye).
There were 9052 participants from 211 locations in Oregon and Washington. On initial FDT testing, the right and left eye had abnormal results in 18% (1654/9052) and 21% (1918/9052) of participants. Of those with abnormal FDT results, approximately 30% of eyes reverted to normal on repeat testing. Overall, 13% of participants were screening failures. Screening failure was highly associated with age (P<0.001). After controlling for age, participants at senior centers (P<0.001) were most likely to be screening failures and participants at work sites (P=0.006) were least likely to be screening failures when compared with health clinics.
An investigator should repeat an initially abnormal FDT result when screening with FDT. Age and the location of testing influence the probability of a screening failure. Screening in senior centers is most likely to result in screening failure. However, only a randomized controlled trial can determine the true benefit of FDT screening in these locations.
Journal of Glaucoma 02/2007; 16(1):73-80. · 1.78 Impact Factor
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ABSTRACT: To investigate the ability of ophthalmologists to estimate an individual's risk of converting from ocular hypertension to glaucoma, and to compare these estimates to a risk calculator.
Cross-Sectional Survey.
Fifty-one ophthalmologists estimated the probability of developing glaucoma of 4 factitious patients with ocular hypertension, after a didactic review of the Ocular Hypertension Treatment Study (OHTS) results. We compared the physician estimates to the probability estimates of a risk calculator on the basis of the multivariate Cox proportional hazard model of the OHTS results.
The average estimates given by the ophthalmologists (mean probability+/-SD) of developing glaucoma in 5 years for patient no. 1, patient no. 2, patient no. 3, and patient no. 4 were 6.5%+/-8.4 (range 1 to 50), 30.6%+/-20.5 (range 1 to 100), 7.1%+/-5.1 (range 0 to 20), and 21.1%+/-17.3 (range 1 to 80), respectively. The risk calculator estimated the probability of glaucoma in these same patients to be 13.7%, 53.8%, 5.1%, and 41.9%, respectively.
The ophthalmologists showed a high range of estimates for the probability of developing glaucoma in the same ocular hypertensive patients. This may lead to either under or over treatment of patients. Clinicians need a more exact method to determine the probability of glaucoma from ocular hypertension.
Journal of Glaucoma 11/2006; 15(5):426-31. · 1.78 Impact Factor
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ABSTRACT: This article provides a basis for understanding modern visual field analysis techniques. It describes some of these tests, including their advantages and disadvantages, and the settings in which different tests might be used most successfully. It also includes an examination of the value of visual field assessment from a public health standpoint with particular attention paid to morbidity, cost/benefit ratios, and quality of life correlations.
Ophthalmology Clinics of North America 10/2005; 18(3):365-73, v-vi.
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ABSTRACT: Little information exists regarding the causes of visual impairment and the most common eye problems in American Indians/Alaska Natives.
We randomly sampled American Indians/Alaska Natives older than 40 years from 3 tribes within the Northwest region.
We found a higher prevalence of visual impairment and normal-tension glaucoma, as well as a lower prevalence of ocular hypertension, in American Indians/Alaska Natives compared with previous results in other racial/ethnic groups.
American Indians/Alaska Natives have a need for vision correction. Future interventions in American Indians/Alaska Natives should include providing spectacles for refractive error, detecting glaucoma, and preventing visual impairment from age-related maculopathy and cataracts.
American Journal of Public Health 06/2005; 95(5):881-6. · 3.93 Impact Factor
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Steven L Mansberger,
Chris A Johnson,
George A Cioffi,
Dongseok Choi,
S R Krishnadas,
M Srinivasan,
V Balamurugan,
Usha Kim,
Scott D Smith,
John H Wilkins,
David C Gritz
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ABSTRACT: To determine the feasibility and diagnostic precision of Frequency Doubling Technology (FDT) perimetry as a method to detect glaucoma in rural villages of a developing country.
Cross-sectional study.
Testing included FDT perimetry (C-20-5 screening protocol), tonometry, anterior segment biomicroscopy, and dilated ophthalmoscopy in 296 rural, non-English speaking residents of Southern India over 35 years old. Participants repeated the FDT if they had a location with reduced sensitivity or an unreliable result. We defined an abnormal FDT as one location of reduced sensitivity present on both the initial and repeat examination. We determined the diagnostic precision of FDT separately for a glaucomatous optic disc, a cup to disc ratio (C/D) > or = 0.7, and a C/D > or = 0.8.
Ninety-three percent of subjects were able to complete the test satisfactorily. With repeat FDT testing, 37% of eyes with abnormal FDT results subsequently converted to normal and 67% of eyes with unreliable results subsequently became reliable. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for a glaucomatous optic disc were 7%, 87%, 13%, 76%, and 69%, respectively; for a C/D > or = 0.7, they were 0%, 87%, 0%, 91%, and 81%, respectively; and for a C/D > or = 0.8, they were 0%, 87%, 0%, 99%, and 87%, respectively.
Clinicians can use FDT perimetry to rapidly screen for glaucoma in rural villages of a developing country. FDT testing had high specificity and negative predictive value, but low sensitivity and positive predictive value. The low sensitivity suggests that FDT has limited applicability as the sole test for glaucoma screening in this population. Repeat testing of FDT results that are unreliable or suspected of being abnormal is beneficial for this screening procedure.
Journal of Glaucoma 05/2005; 14(2):128-34. · 1.78 Impact Factor
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ABSTRACT: To evaluate ganglion cell loss in early glaucoma using a variety of psychophysical tests and to identify optimal perimetric technique(s) for detection of early glaucomatous visual function loss.
Five perimetric tests, short wavelength automated perimetry (SWAP), temporal modulation perimetry (TMP), frequency doubling technology perimetry (FDT), detection acuity perimetry (DAP), and resolution acuity perimetry (RAP) were compared in their ability to discriminate between normal individuals and patients with early glaucoma or glaucoma suspects. Comparisons were also made by their ability to produce repeatable defects. The tests examined different visual functions that are likely to be mediated by different retinal ganglion cell subpopulations, thereby permitting examination of hypotheses of ganglion cell death in early glaucoma.
All visual field tests demonstrated high performance in separating glaucoma patients from normal individuals. SWAP, TMP, FDT, and DAP provided the greatest discrimination between normal individuals and high- and low-risk glaucoma suspects. However, SWAP, TMP, and FDT obtained better consistency across the various analysis approaches (global indices and pointwise) than DAP and RAP. Of all the test types, FDT exhibited the highest proportion of repeatable abnormal test locations, with poor confirmation rates achieved by DAP and RAP.
The performance of SWAP, FDT, and TMP suggests that these test types may all be suitable for detection of early loss of visual function in glaucoma. Ganglion cell subpopulations with lower levels of redundancy and/or those with larger cell sizes offer the most parsimonious explanation for earliest ganglion cell losses occurring in glaucoma.
Journal of Glaucoma 03/2005; 14(1):11-9. · 1.78 Impact Factor
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Steven L Mansberger
Journal of Glaucoma 09/2004; 13(4):345-7. · 1.78 Impact Factor
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ABSTRACT: To determine if topographic differences exist between large cup-to-disk ratio (C/D) eyes with standard achromatic automated perimetry (SAP) abnormalities and those with only short-wavelength automated perimetry (SWAP) abnormalities.
Cross-sectional study.
The setting was a referral university-based clinical practice. We selected one eye of 72 patients with a vertical C/D of at least 0.8 by ophthalmoscopy. Patients performed SWAP, SAP, and confocal scanning laser ophthalmoscopy. We compared optic disk topography in eyes with and without visual field abnormalities and controlled for the influence of disk area.
Disk area was a confounder of many topographic measures. After controlling for disk area, eyes with abnormal SAP had differences in rim volume, cup shape, rim area, retinal nerve fiber layer thickness, and retinal nerve fiber layer cross-sectional area when compared with eyes with normal SAP (P <.05). Rim volume and rim area were different in the SWAP comparison (P <.05).
Investigators should control for disk area when evaluating topographic measures by confocal scanning laser ophthalmoscopy. In eyes with a large C/D, optic disk topography is more glaucomatous in eyes with SAP abnormalities than in those with only SWAP abnormalities. Eyes with large C/D and only SWAP abnormalities may have fewer glaucomatous optic disk changes than such eyes with SAP abnormalities. This indicates that SWAP is likely to correspond to abnormalities in optic disk topography at an earlier stage of glaucomatous optic neuropathy than SAP. Therefore, clinicians should consider SWAP testing in glaucoma suspects to detect glaucomatous visual field loss at an earlier stage of structural loss.
American Journal of Ophthalmology 11/2003; 136(5):888-94. · 4.22 Impact Factor
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Journal of Glaucoma 03/2002; 11(1):71-4. · 1.78 Impact Factor
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ABSTRACT: To determine if a community screening with Frequency Doubling Technology perimetry (FDT) results in a high proportion of follow-up with an eye care provider and the factors associated with follow-up.
Cross-sectional study.
Telephone survey
We conducted a telephone survey of participants with abnormal results 3-6 months after the community screening.
We were able to interview 121 participants (57% of 212 eligible subjects). Sixty-nine percent (83 of 121) of participants visited an eye care provider after the screening. Patients were more likely to attain an eye exam if they were female, older, or had an educational level of high school or more (p<0.05). Of those participants who did not visit an eye care provider, 41% (18/38) did not believe the results of the test, 21% (8/38) reported not having insurance or an eye care provider, 11% (4/38) did not have time for an eye exam, and 11% (4/38) reported not knowing they needed to see an eye care provider.
A community screening program with FDT encouraged more than two thirds of participants with abnormal results to seek an eye exam. The most common reason not to attain an eye exam was failing to recognize the importance of an abnormal test result.
Ophthalmic Epidemiology 14(3):134-40. · 1.45 Impact Factor
