Researchers assessed the efficacy of the Support, Educate, Empower (SEE) glaucoma coaching program for medication adherence among poorly adherent glaucoma patients over 12 months following cessation of the intervention, as part of an uncontrolled intervention study with a pre/post design. 

The SEE cohort was recruited from the University of Michigan and included glaucoma patients 40 years old and older who were taking at least one medication and self-reporting poor adherence. Electronic medication monitoring of those who completed the program continued for up to one year post-coaching intervention.

Adherence, monitored electronically during the seven- and 12-month follow-up periods, was defined as the percentage of doses taken on time. Participants were censored for surgery, change in glaucoma medications or adherence monitor disuse. The SEE program included automated medication reminders, three motivational counseling sessions with a glaucoma coach and five phone calls with the coach for between-session support, followed by no contact between the study team and participants during the 12-month post-program follow-up. Baseline participant characteristics were summarized with descriptive statistics. Paired T tests and Wilcoxon signed rank tests were used to investigate significant changes in monthly adherence during follow-up.

The main outcome measure was a change in electronically monitored medication adherence over the 12 months following the conclusion of the SEE program.

Here are some of the findings: 

  • Of 48 participants, 39 (81 percent) completed the SEE program and continued electronic medication monitoring for up to one year after program cessation.
  • Participants were on average age 64 (SD: 10); 56 percent were male, with 49 percent black and 44 percent white.
  • The average length of follow-up was 284 days (SD: 110; range: 41 to 365 days).
  • Censoring occurred in 18 participants (56 percent).
  • Average adherence during the follow-up period was 67 percent (SD: 22 percent), which was significantly lower than adherence during the SEE program (mean: 81 percent, SD: 18 percent; p<0.0001), but significantly higher than baseline pre-program adherence (mean: 60 percent, SD: 18 percent; p=0.0393). 
  •  The largest monthly losses occurred at months one (mean: 7 percent; p=0.0001) and four (mean: 6 percent; p=0.0077).

Researchers concluded that glaucoma medication adherence decreased significantly in the year after cessation of the SEE coaching program but remained significantly higher than baseline. They suggested that intermittent reinforcement sessions may be necessary to maintain excellent long-term medication adherence.


Ophthalmol Glaucoma 2022; Aug 8. [Epub ahead of print]

Killeen OJ, Niziol LM, Cho J, et al


DR Telemedicine Outcomes with AI-based Image Analysis

Researchers examined real-world telemedicine outcomes of diabetic retinopathy screening with artificial intelligence-based image analysis, reflex dilation and secondary image overread in a primary care setting.

The screening test validity and reliability analysis included single institution review of 1,052 consecutive adult patients who received diabetic retinopathy photoscreening in the primary care setting over an 18-month period. Nonmydriatic fundus photographs were acquired and analyzed by the IDx-DR AI-based system. When nonmydriatic images were ungradable, reflex dilation (1% tropicamide) and mydriatic photography were performed for repeat AI-based analysis. Manual overread was performed on all images. Researchers recorded patient demographics, clinical characteristics and screening outcomes.

Here are some of the findings:

  • 91.7 percent (965/1,052) of patients had AI-gradable fundus photographs.
  • 55.1 percent (580/1052) of patients had gradable nonmydriatic imaging and 93.2 percent (440/472) with ungradable nonmydriatic photographs had reflex dilation.
  • 14.3 percent (138/965) of patients were AI-graded as “positive” (>mild NPDR) and 85.7 percent were graded as “negative” (827/965), with 100-percent sensitivity (CI, 90.8 to 100 percent), 89.2-percent specificity (CI, 87 to 91.1 percent), 27.5 percent positive predictive value (CI, 24 to 31.4 percent) and 100 percent negative predictive value (CI, 99.6 to 100 percent) vs. manual overread assessment of >mild NPDR requiring further evaluation with a comprehensive dilated exam.
  • Image gradeability was inversely related to patient age: images were 93.5 percent gradable (61.9 percent nonmydriatic) for patients ages <70 years vs. 85.3 percent gradable (31 percent nonmydriatic) for patients ages 70-plus (p<0.001).

Researchers determined the addition of AI-based image analysis into real-world primary care diabetic retinopathy screening yielded no false-negative results and offered excellent image gradeability within a protocol that combined nonmydriatic fundus photography and pharmacologic dilation as needed. They also found image gradeability was lower with increasing patient age. 


Am J Ophthalmol 2022; Aug 12. [Epub ahead of print].

Mehra AA, Softing A, Kabaalioglu Guner M, et al.


Refractive Surgery in Children

As amblyopia is often caused by uncorrected refractive error, laser vision correction has been suggested in some studies as a viable alternative to expensive and difficult traditional therapies. Based on a literature review, the American Academy of Ophthalmology stated in a recently published technology assessment that laser vision correction appears to address amblyopic refractive error and decrease anisometropia in children.

The researchers conducted a literature review of LASIK, PRK, LASEK and SMILE using the PubMed database and identified 137 articles. A total of 12 studies met inclusion criteria (all level III evidence; two case-control studies and 10 case series). Subjects, aged ≤18, had anisometropic myopia, anisometropic hyperopia or were mixed.

The group reported that all studies demonstrated an improvement in BCVA but that the magnitude of improvement varied. Successful outcomes ranged from 27 percent to 89 percent (residual refractive error within 1 D of target). Mean follow-up ranged from four months to seven years. The researchers noted the wide range but wrote that all studies still showed an improvement in the magnitude of anisometropia. They added that regression in refractive error was more common and occurred to a greater degree in myopic eyes, eyes with longer follow-up and younger patients. Common complications included corneal haze and striae.

While direct comparisons weren’t feasible due to differences in methodology, refractive error parameters and outcome measures, the group concluded that their findings suggest laser refractive surgery “may address amblyogenic refractive error in children and that it appears to decrease anisometropia.” They noted, however, that the evidence for amblyopia improvement is unclear and there isn’t any long-term safety data. Using laser refractive surgery in children has its own challenges, such as the potential need for general anesthesia, and doesn’t necessarily obviate the need for glasses, contact lenses or continued amblyopia therapy. 


Ophthalmology. 2022;1-9.

Cavuoto KM, Chang MY, Heidary G, et al.


VF Defects in Preperimetric Glaucoma Eyes 

Researchers evaluated whether baseline vessel density parameters derived from optical coherence tomography angiography were associated with development of glaucomatous visual field defects in preperimetric glaucoma (PPG) patients.

They retrospectively analyzed one eye from each of 200 consecutive PPG patients with normal standard automated perimetry and optical coherence tomography angiography at baseline. OCTA was used to measure the circumpapillary vessel density and parafoveal and perifoveal vessel density. Researchers measured retinal nerve fiber layer and macular ganglion cell inner plexiform layer thicknesses as reference standards. They stratified two patient groups based on development of repeatable glaucomatous visual field loss and constructed a Cox proportional hazards model to determine the ability of OCTA parameters to predict visual field defects. Researchers calculated correlation between these baseline OCTA parameters and the rate of global visual field sensitivity loss (dB/year) using linear regression analysis.

Here are some of the findings:

  • During a 3.1-year average follow-up period, 18 eyes (9 percent) developed glaucomatous VF defects.
  • At baseline, the lower inferior temporal circumpapillary vessel density (HR: 0.934; CI, 0.883 to 0.988; p=0.017) and thinner inferior RNFL (HR: 0.895; CI, 0.839 to 0.956; p=0.001) were predictive of glaucomatous VF loss. 
  •  A lower inferior temporal circumpapillary vessel density and thinner RNFL at baseline were associated with faster rates of global VF sensitivity loss (β=0.015; p=0.001).

Researchers found, in PPG eyes, a lower baseline inferior temporal circumpapillary vessel density was significantly associated with glaucomatous VF defect development and faster rate of global VF loss.

Br J Ophthalmol 2022; Aug 5. [Epub ahead of print].

Lee JY, Shin JW, Lee A, et al.