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    JAMA Ophthalmology

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    Effect of Personalized Diabetes Risk Assessments on Glycemic Control

    August JAMA Ophthalmology

    Although optimizing glycemic control is critical to reducing diabetes mellitus–related complications, long-term success is challenging. Aiello et al., from the Diabetic Retinopathy Clinical Research Network, studied whether point-of-care (POC) measurement of hemoglobin A1c (HbA1c) and personalized diabetes risk assessments performed during retinal ophthalmologic visits improved glycemic control.

    This office-based randomized, multicenter clinical trial was conducted at 42 sites. Investigators were assigned randomly to provide either a study-prescribed augmented diabetes assessment and education or usual care. Adults with type 1 or 2 diabetes enrolled in 2 cohorts: those with more-frequent-than-annual follow-up (502 control participants; 488 intervention participants) and those with annual follow-up (368 control participants; 388 intervention participants). Interventions included POC measurements of HbA1c, blood pressure, and retinopathy severity; individualized estimate of the risk of retinopathy progression; structured comparison and review of past and current clinical findings; and structured education with immediate assessment and feedback regarding participant’s understanding. These interventions were performed at enrollment and at routine ophthalmic follow-up visits scheduled at least 12 weeks apart.

    The main outcome measure was mean change in HbA1c level from baseline to 1-year follow-up. Secondary outcomes included body mass index, blood pressure, and responses to diabetes self-management practices and attitudes surveys. In the more-frequent follow-up cohort, the mean (SD) change in HbA1c level at 1 year was −0.1% (1.5%) in the control group and −0.3% (1.4%) in the intervention group. In the annual follow-up cohort, the mean (SD) change in HbA1c level was 0.0% (1.1%) in the control group and −0.1% (1.6%) in the intervention group. Results were similar for all secondary outcomes. The study failed to show that the addition of personalized education and risk assessment during retinal ophthalmologic visits resulted in a reduction in HbA1c level compared with usual care over 1 year. These data suggest that other types of interventions should be studied to help optimize glycemic control.

    Glaucoma-Related Adverse Events After Unilateral Cataract Removal

    August JAMA Ophthalmology

    Glaucoma-related adverse events constitute major sight-threatening complications of cataract removal in infancy. Freedman et al., for the Infant Aphakia Treatment Study Group, identified and characterized cases of glaucoma and glaucoma-related adverse events by the age of 5 years among children in the Infant Aphakia Treatment Study (IATS).

    In this secondary analysis of a multicenter randomized clinical trial of 114 infants with unilateral congenital cataract who were between ages 1 and 6 months at surgery, mean follow-up was 4.8 years. Participants were randomized at cataract surgery to either primary IOL implantation or aphakia (i.e., contact lens correction). The IATS used standardized definitions of glaucoma and glaucoma-related adverse events (the study called the latter “glaucoma + glaucoma suspect”) for diagnosis and surveillance. The main outcomes included development of glaucoma and glaucoma + glaucoma suspect in operated eyes of children up to age 5 years, plus IOP, visual acuity, and axial length at age 5 years.

    The estimates of the risk for glaucoma and glaucoma + glaucoma suspect at 4.8 years after surgery were 17% and 31%, respectively. No significant difference was identified between the IOL and aphakia groups for either outcome. However, younger (vs. older) age at surgery increased the risk for glaucoma (26% vs. 9%, respectively) at 4.8 years after surgery (HR, 3.2; 95% CI, 1.2-8.3); and smaller (vs. larger) corneal diameter increased the risk for glaucoma + glaucoma suspect (HR, 2.5; 95% CI, 1.3-5.0).  

    By 5-year follow-up, 20 eyes had developed glaucoma; of these, 19 (95%) had open-angle glaucoma. Most eyes received medication (19 of 20; 95%), and 8 of 20 eyes (40%) underwent surgery. The results suggest that glaucoma-related adverse events are common and increase between ages 1 and 5 years in children who had unilateral cataract removal at 1 to 6 months of age. Longer follow-up may further characterize glaucoma risk factors, long-term outcomes, potential differences between primary IOL and aphakia, and optimal timing of unilateral congenital cataract removal.

    Development and Validation of a Smartphone Visual Acuity Test

    August JAMA Ophthalmology

    Most visually impaired people live in low- and middle-income countries. To aid in monitoring vision worldwide, Bastawrous et al. designed and sought to validate a smartphone-based visual acuity test that is not dependent on familiarity with symbols or letters commonly used in the English language.

    This validation study, conducted from Dec. 11, 2013, to March 4, 2014, compared results from smartphone-based Peek Acuity to Snellen acuity charts and the Early Treatment of Diabetic Retinopathy Study (ETDRS) log-MAR chart (reference standard). This study was nested within the 6-year follow-up of the Nakuru Eye Disease Cohort in central Kenya and included 300 consecutively recruited adults aged 55 years or older.

    The main outcome measures were monocular logMAR VA scores for each test: ETDRS, Snellen, and Peek Acuity. Comparisons were also made of test-retest variability and measurement time in participants’ homes and temporary clinic settings in rural Kenya. The local Kenyan community health care workers readily accepted the Peek Acuity smartphone test; it required minimal training and took no longer to perform than the Snellen test.

    The 95% CI limits for test-retest variability of smartphone acuity data were ±0.033 logMAR. The mean differences between the smartphone test and the ETDRS chart, and between the smartphone test and Snellen acuity data were 0.07 (95% CI, 0.05-0.09) and 0.08 (95% CI, 0.06-0.10) logMAR, respectively, indicating that smartphone-based test acuities agreed well with those of the ETDRS and Snellen charts. These results demonstrate that the Peek Acuity smartphone test is capable of accurate and repeatable acuity measurements consistent with published data on the test-retest variability of acuities measured using 5-letter-per-line retroilluminated logMAR charts. 

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    JAMA Ophthalmology summaries are based on authors’ abstracts as edited by senior editor(s).

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