Importance
Glaucoma affects an estimated 2.7 million people in the US. It is the second-leading cause of irreversible blindness in the US and the leading cause of blindness in Black and Hispanic/Latino persons.


Objective
To update its 2013 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for glaucoma in adults.


Population
Adults 40 years or older who present in primary care and do not have signs or symptoms of open-angle glaucoma.


Evidence Assessment
The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for glaucoma in adults. The benefits and harms of screening for glaucoma in adults are uncertain. More research is needed.


Recommendation
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults. (I statement).

https://jamanetwork.com/journals/jama/articlepdf/2792609/jama_mangione_2022_us_220011_1652813391.43919.pdf

Screening for Primary Open-Angle Glaucoma: US Preventive Services Task Force Recommendation Statement.

Although glaucoma is one of the leading causes of irreversible blindness in the United States and the prevalence is expected to increase from 3 million to 6.3 million people by 2050,1 the US Preventive Services Task Force (USPSTF) concluded in both their 2013 and 2022 recommendations that there is insufficient evidence to assess the balance of benefits and harms of screening for primary open angle glaucoma in adults.2–4 One challenge that the USPSTF points out is that because there is a relatively low prevalence of primary open angle glaucoma in the general population, even accurate screening tests will generate too many false positive referrals, burdening both the patient and the health system. This challenge needs to be weighed against the reality that 50% of people with glaucoma remain undiagnosed.5 The report also states there is a lack of evidence on ways to help identify persons at increased risk who could benefit from screening. However, numerous community-based studies over the past 10 years—occurring in geographically diverse settings—have been published providing evidence that targeted screening in high-risk populations is highly sensitive in identifying those with both early and later stages of glaucoma.6–10 The National Academy of Science, Engineering and Medicine has recommended a call to action to make eye health a population health imperative to address eye care disparities.11 African Americans are 6–8 times more likely to experience blindness from glaucoma and 15 times more likely to be visually impaired from glaucoma, as compared with White Americans.12,13 Communities with a high proportion of people living in poverty, older adults and those who identify as Black and/or Hispanic, have higher rates of glaucoma and suspected glaucoma—a 20% case detection rate—as opposed to the 6%–8% case detection rate in the general population.7 The USPSTF seems to have concluded that in the general population, there is insufficient evidence for glaucoma screening, but fails to consider the need to target glaucoma screening to high-risk individuals (Black Americans, Hispanics, those who have a family history of glaucoma or perhaps those with a high genetic risk score).14 In 2019, the Centers for Disease Control and Prevention (CDC) Vision Health Initiative funded three 5-year research grants to design innovative glaucoma screening strategies among high-risk populations to generate evidence on how to best provide targeted glaucoma screening.15 The Screening and Interventions for Glaucoma and Eye Health through Telemedicine (SIGHT) Studies are taking place in Michigan, New York City, and Alabama (SIGHTSTUDIES.org).16 The Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Study (MI-SIGHT) has partnered with a free clinic and a Federally Qualified Health Center to set up a telemedicine-based eye health screening program in these primary care clinics that each serve small urban cities with high rates of poverty and high proportions of people who identify as Black.17 The MI-SIGHT study enrolled 2091 participants from July 2020 to June 2022; 66% earned <$30,000 per year, 56% identified as Black and 11% identified as Hispanic. To date, 24% screened positive for glaucoma or suspected glaucoma and 39% need follow-up ophthalmic care for identified eye diseases. A total of 58% reported their last eye exam was more than 2 years ago or that they never had one. To support people who screened positive for glaucoma and eye disease in obtaining the necessary follow-up eye care, the program also provides education and health care navigation, an important step in ensuring that those who screen positive for eye disease obtain treatment to mitigate vision loss. The MI-SIGHT study is testing whether personalized education and coaching will improve follow-up adherence for those referred to ophthalmology compared with usual care. In New York City (NYC-SIGHT), Columbia University Ophthalmology researchers designed the Manhattan Vision Screening and Follow-up Study to conduct community-based eye health screening and eye exams by an optometrist where people live.18 By partnering with the NYC Housing Authority and the NYC Department for the Aging, recruitment targets high-risk residents living in affordable (public) housing buildings or those attending Department for the Aging senior centers who have high rates of poverty and high proportions of people who identify as Black and Hispanic. The NYC-SIGHT study enrolled 708 participants from March 2021 to June 2022; 100% were at the NYC poverty measure, 52% identified as Black, and 42% identified as Hispanic. To date, 28% screened positive for glaucoma or suspected glaucoma and 66% need follow-up ophthalmic care for identified eye diseases. A total of 53% reported their last eye exam was more than 2 years ago or that they never had one. The Columbia study is providing patient navigators and free eyeglasses to residents randomized to the intervention group to determine whether this support will improve follow-up adherence for those referred to ophthalmology compared with usual care. The Alabama Screening and Intervention for Glaucoma and Eye Health through Telemedicine (AL-SIGHT) Study has implemented a telemedicine-based detection and management strategy for glaucoma-associated diseases and other eye diseases in patients seen at Federally Qualified Health Centers located in rural Alabama.14 This region is characterized by one of the highest concentrations of people who identify as Black in the United States. This region also has high rates of poverty, unemployment, and uninsurance, alongside inadequate educational systems, transportation, and community resources. There are only a few optometrists who largely practice in retail settings to provide eye care in this region and there are no ophthalmologists specializing in glaucoma who serve this region. The AL-SIGHT studies, using portable measurements of visual function and optic nerve and retinal structure, aim to increase the detection rates of glaucoma and eye diseases. The AL-SIGHT study enrolled 600 participants from November 2020 to September 2022; 46% identified as Black and 2% identified as Hispanic. To date, 25% screened positive for glaucoma or suspected glaucoma and 47% needed follow-up ophthalmic care for identified eye diseases. A total of 34% reported that their last eye exam was more than 2 years ago or that they never had one. The AL-SIGHT study is also testing whether evidence-based glaucoma education, combined with financial incentives, improves adherence to recommended follow-up glaucoma care. Among these 3 SIGHT studies, 25% of participants screened positive for glaucoma. Certainly, ascertainment bias may play a role—where those who know they have risk factors for disease are more likely to participate in a screening program. However, this bias works in favor of targeted screening because the overall population contains a larger number of people at greater risk of eye disease. Yet it is hard to fully quantify this effect, as many people who have risk factors for glaucoma may still have very limited knowledge about the importance of glaucoma screening.19 In 2022, Dr. Khawaja and colleagues in the United Kingdom analyzed the positive predictive value and false discovery rate for glaucoma screening to understand how the prevalence of disease impacts these values using 73% sensitivity and 96% specificity rates for screening with complete eye exams with measurement of intraocular pressure, central corneal thickness, and visual field. They found that even at these high levels of sensitivity and specificity, because the prevalence of glaucoma among adults over age 50 in the United Kingdom is 0.9%, the positive predictive value of the test is only 14% while the false discovery rate is very high at 86%.20 In a similar manner, for the general population over the age of 18 in the United States, there is a 1.4% prevalence of glaucoma, and so the positive predictive value would be only 21%, whereas the false discovery rate would remain high at 79%. This high false discovery rate leads to undue burden on the health care system and the patient. However, at the level of disease prevalence identified in the SIGHT studies cohorts—25%—the positive predictive value for bringing a patient in for further ophthalmic examination would be 86% and the false discovery rate would fall to 14%, which would put many fewer people at risk of overtreatment and help many more people gain access to appropriate management and treatment. Even if the rate of screening positive in a targeted program was 15%, the positive predictive value would be 76% and the false discovery rate would remain low at 24%. Given the successes of these 3 studies in (1) engaging individuals at high risk for eye disease and underutilization of eye care and (2) detecting high rates of glaucoma and glaucoma suspect in these populations, we believe that targeting glaucoma screening in high-risk populations is warranted. Furthermore, research in patient-reported outcome measures to assess vision-related quality of life has identified that even people with mild and moderate glaucoma have decreased quality of life, underscoring the importance in identifying and treating disease early, even before vision is lost.21 To truly reduce the population level burden of visual impairment and lost vision-related quality of life from glaucoma, it would be helpful if the USPSTF could reimagine a paradigm in which screening and support for treatment for high-risk people could be widely implemented in our country and, make recommendations to support such an imperative effort. Given the evidence of how treatment for glaucoma mitigates blindness that disproportionately affects minorities and underserved individuals, we hope that the USPSTF will provide more nuanced recommendations for glaucoma screening than in this current report such as recommending screening for high-risk individuals. It is time to rethink the USPSTF Glaucoma Screening Recommendations in Adults due to the mounting evidence to support targeting high-risk groups. Paula Anne Newman-Casey, MD, MS Department of Ophthalmology & Visual Sciences, W. K. Kellogg Eye Center University of Michigan, Ann Arbor, MI Lisa A. Hark, PhD, MBA Department of Ophthalmology, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY Lindsay A. Rhodes, MD, MSPH Department of Ophthalmology, Visual Sciences University of Alabama at Birmingham, Birmingham, AL 

It Is Time to Rethink Adult Glaucoma Screening Recommendations

Artificial intelligence for visually impaired

The utilization of corneal biomechanical features in evaluating glaucoma and its progression has received particular attention. The severity of corneal biomechanical changes can play an essential role in response to medical or surgical treatment. The present study evaluated the biomechanical features of the cornea in glaucoma patients in different subtypes and compared them with the normal condition.In this cross-sectional study, glaucoma patients and healthy individuals were referred to the tertiary hospital in 2021. Both eyes underwent a complete ophthalmologic examination, intraocular pressure measurement, and corneal biomechanical parameters using Corvis and ORA devices. Finally, data from both groups were compared.Based on the ORA evaluation, Lower CRF and CH were seen in glaucoma patients. In the Corvis evaluation, minor differences were observed in glaucoma as increased pachy, radius, and pachy slope, and decreased HC deformation amplitude, HC deflection amplitude, HC deflection area, deflection amplitude max, dArc length max, max inverse radius, and integrated radius. Lower ACD and higher CCT differentiated PACG from others. Lower CCT and higher C/D and WTW indicated NTG. Based on ORA, the highest CRF and CH were related to PACG and the lowest related to PEXG. In contrast, based on Corvis, higher pachy and radius and lower max inverse radius and integrated radius were specified for PACG. PEXG also had the highest values of the last two parameters.Evaluation of corneal biomechanical parameters and other indicators can be beneficial in assessing the status and severity of glaucoma and distinguishing between disease subtypes. 

https://doi.org/10.1016/j.amsu.2022.104677

Comparing corneal biomechanics and intraocular pressure between healthy individuals and glaucoma subtypes: A cross-sectional study

Importance
A 50% reduction of glaucoma-related blindness has previously been demonstrated in a population that was screened for open-angle glaucoma. Ongoing screening trials of high-risk populations and forthcoming low-cost screening methods suggest that such screening may become more common in the future. One would then need to estimate a key component of the natural history of chronic disease, the mean preclinical detectable phase (PCDP). Knowledge of the PCDP is essential for the planning and early evaluation of screening programs and has been estimated for several types of cancer that are screened for.


Objective
To estimate the mean PCDP for open-angle glaucoma.


Design, Setting, and Participants
A large population-based screening for open-angle glaucoma was conducted from October 1992 to January 1997 in Malmö, Sweden, including 32 918 participants aged 57 to 77 years. A retrospective medical record review was conducted to assess the prevalence of newly detected cases at the screening, incidence of new cases after the screening, and the expected clinical incidence, ie, the number of new glaucoma cases expected to be detected without a screening. The latter was derived from incident cases in the screened age cohorts before the screening started and from older cohorts not invited to the screening. A total of 2029 patients were included in the current study. Data were analyzed from March 2020 to October 2021.


Main Outcomes and Measures
The length of the mean PCDP was calculated by 2 different methods: first, by dividing the prevalence of screen-detected glaucoma with the clinical incidence, assuming that the screening sensitivity was 100% and second, by using a Markov chain Monte Carlo (MCMC) model simulation that simultaneously derived both the length of the mean PCDP and the sensitivity of the screening.


Results
Of 2029 included patients, 1352 (66.6%) were female. Of 1420 screened patients, the mean age at screening was 67.4 years (95% CI, 67.2-67.7). The mean length of the PCDP of the whole study population was 10.7 years (95% CI, 8.7-13.0) by the prevalence/incidence method and 10.1 years (95% credible interval, 8.9-11.2) by the MCMC method.


Conclusions and Relevance
The mean PCDP was similar for both methods of analysis, approximately 10 years. A mean PCDP of 10 years found in the current study allows for screening with reasonably long intervals, eg, 5 years.

Estimating the Length of the Preclinical Detectable Phase for Open-Angle Glaucoma.

Two 2013 systematic reviews to inform the US Preventive Services Task Force (USPSTF) found insufficient evidence to assess benefits and harms of screening for primary open-angle glaucoma (OAG) in adults.To update the 2013 reviews on screening for glaucoma, to inform the USPSTF.Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to February 2021); surveillance through January 21, 2022.Randomized clinical trials (RCTs) of screening, referral, and treatment; and studies of screening test diagnostic accuracy.One investigator abstracted data and a second checked accuracy. Two investigators independently assessed study quality.Eighty-three studies (N = 75 887) were included (30 trials and 53 diagnostic accuracy studies). One RCT (n = 616) found screening of frail elderly persons associated with no difference in vision outcomes vs no screening but with significantly greater falls risk (relative risk [RR], 1.31 [95% CI, 1.13-1.50]). No study evaluated referral to an eye health professional. For glaucoma diagnosis, spectral domain optical coherence tomography (providing high-resolution cross-sectional imaging; 15 studies, n = 4242) was associated with sensitivity of 0.79 (95% CI, 0.75-0.83) and specificity of 0.92 (95% CI, 0.87-0.96) and the Humphrey Visual Field Analyzer (for perimetry, or measurement of visual fields; 6 studies, n = 11 244) with sensitivity of 0.87 (95% CI, 0.69-0.95) and specificity 0.82 (95% CI, 0.66-0.92); tonometry (for measurement of intraocular pressure; 13 studies, n = 32 892) had low sensitivity (0.48 [95% CI, 0.31-0.66]). Medical therapy for ocular hypertension and untreated glaucoma was significantly associated with decreased intraocular pressure and decreased likelihood of glaucoma progression (7 trials, n = 3771; RR, 0.68 [95% CI, 0.49-0.96]; absolute risk difference -4.2%) vs placebo, but 1 trial (n = 461) found no differences in visual acuity, quality of life, or function. Selective laser trabeculoplasty and medical therapy had similar outcomes (4 trials, n = 957).This review found limited direct evidence on glaucoma screening, showing no association with benefits. Screening tests can identify persons with glaucoma and treatment was associated with a lower risk of glaucoma progression, but evidence of improvement in visual outcomes, quality of life, and function remains lacking. 

/pdf/screening-for-glaucoma-in-adults-3i8mt4hf.pdf

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Screening for Glaucoma in Adults