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Editors Selection IGR 15-1

Clinical Forms of Glaucoma: Preventing Acute Angle Closure

Comment by Harrison Bannett & Christopher Teng on:

100577 Potentially Missed Opportunities in Prevention of Acute Angle-Closure Crisis, Wu AM; Stein JD; Shah M, JAMA ophthalmology, 2022; 140: 598-603

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This study includes 1179 Medicare beneficiaries with a diagnosis of AACC, they discovered that only 796 (67.5%) had consulted with an ophthalmologist or optometrist at least once within the two-year interval prior to developing AACC. Of those 796 individuals, only 264 (33.2%) underwent gonioscopy in the two years prior to developing AACC, 113 (42.8%) of which received a diagnosis of anatomic narrow angles. The authors also discovered that of the original cohort, 414 patients (35.1%) received at least one medication associated with increased risk of AACC before developing the disease. In the two-year look-back period, 464 (39.4%) individuals were diagnosed with open-angle glaucoma (OAG) or suspected OAG.

The authors raise several good points about the state of ophthalmic care and the recognition of AACC risk factors. Firstly, one-third of patients received no eye care in the two years prior to their AACC. Secondly, most patients (66.8%) who received eye care, did not undergo gonioscopy at any visit prior to the AACC. Gonioscopy is a critical skill for every ophthalmologist and appears to be underutilized. Furthermore, proper gonioscopic technique is necessary to assess for narrow angles. Anterior segment imaging techniques (optical coherence tomography and ultrasound biomicroscopy) show promise as an adjunct method for angle assessment. The authors call attention to newer studies demonstrating a relatively low rate or progression from suspected primary angle closure in Chinese patients, but note this may not be generalizable to the US population. The authors also suggest using electronic health record flags to prompt gonioscopic evaluation.

This study is limited by its retrospective nature and reliance on billing data, which may be missing data collected, but not billed at a visit. They also include only insured patients, so the data may not be generalized to uninsured persons.

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