In November, the American Academy of Ophthalmology launched its Intelligent Research in Sight Registry with an official announcement at its annual meeting in New Orleans.
The Academy describes the registry as a central collection and reporting software tool that amasses and processes patient data from a practice’s electronic health records system. The registry’s goal is to enable ophthalmologists to statistically analyze their own care, compare it to the care provided by their colleagues and highlight areas for improvement. The registry will also be able to automatically submit the requisite outcomes data to meet requirements for the Physician Quality Reporting System and meaningful use of an EHR system. In the future, the AAO hopes the registry data will enable clinical trials of drugs and interventions, as well.
William L. Rich III, MD, medical director of health policy for the AAO, says the IRIS Registry software is “EHR agnostic,” since it can be made to work with any EHR system after a period of installation and testing. After installation, the registry program unobtrusively pulls the requisite data off the EHR system throughout the practice day. “We learned that this cannot interfere with workflow,” Dr. Rich says. “And, we learned that if this interferes with workflow, it won’t happen. This cannot interfere with workflow—it won’t.” The registry software is designed and maintained by FIGMD (Hanover Park, Ill.), which also created the PINNACLE Registry for the American College of Cardiology a decade ago.
David May, MD, PhD, a cardiologist from Lewisville, Texas, who oversees his practice’s participation in PINNACLE, says ophthalmologists will come to appreciate their registry’s benefits. “You can look at the data by office location, provider and even disease process,” he says. “You will become very proud of the quality work that you do, because as soon as you begin to get reports back from the registry itself, you begin to make improvements in your processes. And there is a dramatic improvement that takes place, the entire care team will be excited about it.” The registry provides a monthly report showing how the practice is measuring up. The report data can also be accessed at any time and manipulated in various ways on the screen, such as comparing a practice’s providers’ outcomes with each other, to look for ways they can improve.
Since the registry is national, a surgeon can make a query of the entire database to look for trends, get a better understanding of a disease or detect the emerging side effects of drugs. Dr. Rich uses the discovery of intraoperative floppy iris syndrome as an example. “Over a period of years, David Chang discovered he was having more complications, and had a fellow look at the records of the patients he had a complication with, and they found that these patients were 95 percent male,” Dr. Rich says. “They then looked at their medication history and made the connection. With the IRIS Registry, you’d just have to push a button and ask: ‘How many broken capsules are there, and is there any race, sex or use of meds in which this complication is greater?’ You could figure this out in a week rather than in years.”
In terms of usage, though a practice that’s still using paper charts can enter data through a web portal, Michael F. Chiang, MD, professor of ophthalmology and medical informatics and clinical epidemiology at Oregon Health & Science University, says that can become onerous. “If you don’t have an EHR, it takes more time to enter those data fields in,” he says. “So, for practical purposes, it’s better with an EHR.”
Dr. Chiang also says the data will be as secure as possible. “The data are identified data,” he says. “They need to be because the registry is certified for PQRS data submission. The data are stored securely in the cloud, to the highest industry standards, and are fully HIPAA compliant. The registry data are stored separately from the protected health information, and everything that gets transmitted back and forth is fully encrypted.”
The IRIS Registry is due to go live in April 2014. To see which EHR vendors are currently certified to work with the registry, visit http://www.aao.org/iris-registry/. At this time, 120 ophthalmology practices and around 1,000 physicians are participating, representing approximately 370,000 patient encounters. Dr. Rich estimates the database will have data from more than 18 million patients by 2016. Though the annual fee for participation is still being determined, Dr. Rich says that during the initial roll-out phase the first 2,000 practices that enroll can use the registry free for two years.
“This registry is really different,” Dr. Rich says. “We’ve learned from the leaders in registry development—ACC and the Society for Thoracic Surgery—and we’ve built on their template. We can follow the patients longitudinally and overlay the interventions such as new treatments in macular degeneration, cataract and glaucoma devices. So this is really a game-changer.”
Long-term Pill Use Raises Risk of Glaucoma
Women who have taken oral contraceptives for three or more years are twice as likely to suffer from glaucoma, say researchers at University of California, San Francisco, Duke University School of Medicine and Third Affiliated Hospital of Nanchang University in China. The researchers caution gynecologists and ophthalmologists to be aware of the fact that oral contraceptives might play a role in glaucomatous diseases, and inform patients to have their eyes screened for glaucoma if they also have other risk factors.
The study is the first to establish an increased risk of glaucoma in women who have used oral contraceptives for three or more years. The researchers utilized 2005-2008 data from the National Health and Nutrition Examination Survey, administered by the Centers for Disease Control, which included 3,406 female participants aged 40 years or older from across the United States who completed the survey’s vision and reproductive health questionnaire and underwent eye exams. It found that females who had used oral contraceptives, no matter which kind, for longer than three years are 2.05 times more likely to also report that they have the diagnosis of glaucoma.
Although the results of the study do not speak directly to the causative effect of oral contraceptives on the development of glaucoma, it indicates that long-term use of oral contraceptives might be a potential risk factor for glaucoma, and may be considered as part of the risk profile for a patient together with other existing risk factors. These include factors such as African-American ethnicity, family history of glaucoma, history of increased eye pressure or existing visual field defects. Previous studies have shown that estrogen may play a significant role in the pathogenesis of glaucoma.
“This study should be an impetus for future research to prove the cause and effect of oral contraceptives and glaucoma,” said Shan Lin, MD, lead researcher and professor of clinical ophthalmology at the University of California, San Francisco. “At this point, women who have taken oral contraceptives for three or more years should be screened for glaucoma and followed closely by an ophthalmologist, especially if they have any other existing risk factors.”
NAION: Steroid Plus Standard Care Improves Vision
In a prospective, randomized trial of 60 patients with nonarteritic anterior ischemic optic neuropathy (NAION), investigators have shown that the addition of the corticosteroid fluocortolone (FC) to standard therapy significantly improves both short- and long-term visual acuity, especially when given soon after the onset of symptoms. Their results were published in Restorative Neurology and Neuroscience.
NAION can affect both eyes in up to 19 percent of cases within five years and occurs in about 2.3 per 100,000 adults over the age of 50. Incidence increases steadily with age. Patients have few well-tested or effective treatment options beyond the standard administration of pentoxifylline (PFX), which is thought to improve visual acuity by improving the microcirculation in oxygen-deprived optic nerve tissue. No current treatment reverses or limits the course of the disease. The goal of this study was to see whether adding a steroid to PTX could improve vision, perhaps by reducing edema or inflammation.
Researchers from the Institute of Experimental Ophthalmology, University of Münster, Germany, studied 55 patients diagnosed with NAION who had developed sudden loss of visual acuity less than three days before the initial consultation. These patients were treated with PFX as well as adjunctive therapy with FC during the first two to three months (which was gradually tapered). The control group received only PFX.
Investigators found that PFX alone had no significant beneficial effects on either visual acuity (as measured as best-corrected visual acuity) or visual field after three days and six months of treatment. Adding FC significantly boosted outcomes: Those receiving FC were more likely to experience improvement and less likely to have worsened visual acuity. Progress was even more pronounced after six months of therapy. More than two-thirds of NAION patients treated with the combination therapy had better long-term vision compared to only 14 percent of those only treated with PFX.
“NAION is caused by ischemia of the optic nerve head. This restriction of blood supply, depending upon its degree, results in primary irreversible loss of retinal ganglion cells and secondary delayed RGC loss related to subsequent optic-disc edema,” says Verena Prokosch, PhD, Institute of Experimental Ophthalmology.
“Corticosteroids do not appear to reduce primary cell death, explaining the lack of benefit of FC therapy in patients with a BCVA score worse than 0.05. This may not be the case for patients with moderate BCVA loss who suffer secondary RGC loss due to optic-nerve swelling, revealing a possible therapeutic window for FC,” explains co-author Solon Thanos, MD, Institute of Experimental Ophthalmology. Prof. Thanos suggests that the pronounced long-term effect of FC on visual acuity found in the study could be attributed to early and prolonged treatment at a dose higher than previously tested.
Big-City Dwellers Court Dry Eye
Residents of major cities with high levels of air pollution have an increased risk of dry-eye syndrome, according to a study presented at the AAO meeting that examined the health records of 606,708 U.S. veterans. The researchers suggest that environmental manipulations should be considered as part of the overall control and management of patients with dry eye.
Those living in areas with high levels of air pollution had the highest magnitude of increased risk for dry eye, at an incidence rate ratio of 1.4. Most metropolitan areas, including New York City, Chicago, Los Angeles and Miami showed relatively high prevalence of dry eye (17 to 21 percent) and high levels of air pollution.
Additionally, the risk of dry eye was 13 percent higher in ZIP codes in high altitude areas. Higher humidity and wind speed were inversely associated with the risk of DES when controlled for air pollution and other weather conditions. The research findings suggest that primary-care physicians and eye-care professionals should be aware of the association between environmental conditions and dry eye, and elicit an environmental history when assessing patients with dry eye.