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Olfactory sensory neurons (OSNs) form embryonically and mature perinatally, innervating glomeruli and extending dendrites with multiple cilia. This process and its timing are crucial for odor detection and perception and continues throughout life. In the olfactory epithelium (OE), differentiated OSNs proceed from an immature (iOSN) to a mature (mOSN) state through well-defined sequential morphological and molecular transitions, but the precise mechanisms controlling OSN maturation remain largely unknown. We have identified that a GTPase, ARL13B, has a transient and maturation state-dependent expression in OSNs marking the emergence of a primary cilium. Utilizing an iOSN-specific Arl13b-null murine model, we examined the role of ARL13B in the maturation of OSNs. The loss of Arl13b in iOSNs caused a profound dysregulation of the cellular homeostasis and development of the OE. Importantly, Arl13b null OSNs demonstrated a delay in the timing of their maturation. Finally, the loss of Arl13b resulted in severe deformation in the structure and innervation of glomeruli. Our findings demonstrate a previously unknown role of ARL13B in the maturation of OSNs and development of the OE.

Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap.Population-based analysis of procedure rates comparing pandemic (March 1, 2020 to December 31, 2021) to a pre-pandemic baseline (January 1, 2017 to February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the pre-pandemic baseline. Analyses were stratified by procedure type (out-patient, in-patient), body region, and funding category (activity-based funding programs vs. global budget).281,328 fewer scheduled procedures were performed during the COVID-19 period compared to the pre-pandemic baseline (Rate Ratio 0.78; 95%CI 0.77-0.80). In-patient procedures saw a larger reduction (24.8%) in volume compared to out-patient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the pre-pandemic baseline (50%). Body systems funded predominantly through global hospital budgets (e.g. gynecology, otologic surgery) saw the least months at or above baseline volumes whereas those with multiple activity-based funding options (e.g. musculoskeletal, abdominal) saw the most months at or above baseline volumes.Those needing procedures funded though global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.

The aim of this work is to evaluate the extent to which the eye's curvature deformation, due to changes in the intraocular pressure (IOP), can be directly tracked by an overlying contact lens.In this experimental study, using 12 cadaveric eyes, the IOP was increased from 10 to 36 mmHg, while video imaging was used to capture the three experimental variations. The deformation of the bare eye was used as a control, while the deformation of an overlying silicone grided contact lens and an overlying microfluidic IOP-sensing contact lens were examined and compared.The relation between the slope of the radius of corneal curvature versus the IOP for both the bare eye and the marker contact lens yielded a linear relationship with a RThe deformation from the curvature of the eye is significant enough from 10 to 36 mmHg that a silicone contact lens can capture and mimic those changes. The results show promise for optimization in contact lens-based IOP monitoring.

Purpose To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication. Design Population-based study. Participants All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019. Methods Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken. Main Outcome Measures Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence. Results In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66–70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48–0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39–1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30–0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31–0.49), and retina surgery (OR, 0.46; 95% CI, 0.41–0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91–0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84–0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90–0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05–1.05 per year). Conclusions Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Rationale, aims and objectives Physician consultations are a limited resource. Anesthesiologists provide anaesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. Method A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002 to 2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anaesthesia consultation. Results A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anaesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year), despite a less than 40% increase in practicing Canadian Anesthesiologists over this same timeframe. Each year, an average of 19.3% of the consults (range: 17.7-20.5%) were for patients that did not progress to having surgery. Of those that did have surgery following the anaesthesia consult, 37.2% were ASA Classification I or II. The most common surgical procedures (percent of total) following anaesthesia consult were: Knee arthroplasty (9.5%), hip arthroplasty (5.8%), cataract extraction (4.1%), repair of muscle of chest/abdomen (3.3%), hysterectomy (2.8%), and cholecystectomy (2.7%). Conclusions This study reveals data on utilization and trends over time of preoperative anaesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery.

Hearing loss is one of the most common sensory impairments and hearing aids are the most common unmet assistive device need among individuals with a disability. The benefits of hearing interventions are well-documented as they are known to deter the sequalae of hearing loss including social isolation, poor mental health, falls and cognitive decline. Identifying trends in hearing aid users can provide valuable information for improving access to hearing loss interventions.Data were retrieved from ICES databases that were used to generate a cohort of 372,448 individuals in Ontario, Canada, who first claimed hearing aids between April 2007 and March 2018 through the Assistive Devices Program.The data indicated that the frequency distribution of hearing aids has steadily inclined since 2007. The mean age of hearing aid users was 70.25 ± 14.70 years and higher neighbourhood income quintile was associated with greater hearing aid use (This study examines patient demographics and clinical comorbidities in a cohort of hearing aid users in Ontario. The results identify associations between demographics and comorbidities that provide information relevant for improving access to hearing interventions and clinical decision-making in primary care.Implications for RehabilitationScreening for hearing loss (using an audiogram) in elderly individuals that manage multiple comorbidities, and any patient with significant risk factors for hearing loss (e.g., noise exposure history, prior ototoxic medications, prior head injury, history of ear surgery, family history of hearing loss) will identify deficits and direct appropriate hearing interventions.Improving access to care in low-income communities should include community-based education around expectation management and communication strategies to reinforce proper use and care of hearing devices.Geographic proximity to hearing testing facilities and hearing aid dispensaries is a significant barrier to hearing rehabilitation strategies.

To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation.Prospective multicentred interventional observational study.Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario.We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF).Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye.For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score-3 can be used as a guideline for lowest priority.

PURPOSE To evaluate evolution in the distribution of new glaucoma patients between ophthalmologists and optometrists, and to examine factors predicting provider type, in the context of expansion in the scope of optometry practice. PATIENTS AND METHODS A population-based study was undertaken using validated datasets in Ontario, Canada from 2007 to 2018, encompassing time before and after optometry practice scope expansion in 2011. All patients aged 66 and older receiving a glaucoma suspect diagnosis or first-line therapy for glaucoma from ophthalmologists or optometrists were enrolled. Predictors of provider type were evaluated using logistic regression. RESULTS From 2007 to 2018, 401,560 patients received initial glaucoma care, including 303,440 by ophthalmologists and 98,120 by optometrists. Population rates of glaucoma suspect diagnosis increased for both providers over the study period. The rate of therapy initiation increased annually among optometrists after 2011, while the rate remained stable over that period among ophthalmologists. By 2018, 88% of patients initiating therapy and 59% of patients first diagnosed as a glaucoma suspect received that care from ophthalmologists. In the final study year, therapy initiations per provider were lower among optometrists (median: 2/provider; interquartile range: 1 to 3) than among ophthalmologists (median: 26.5/provider, interquartile range: 10 to 53). Patients were more likely to receive care from an ophthalmologist than an optometrist if they were older, had higher ocular or systemic comorbidity, or lived in urban settings. CONCLUSIONS Optometrists have a large and growing role in diagnosing glaucoma suspects; however, despite scope expansion, optometrists play a much smaller role in initiating glaucoma therapy.

An important potential unintended consequence of the growth of surgical subspecialization is the narrowing of surgical practice among comprehensive ophthalmologists. We investigated trends in the narrowing of surgical practice and the exclusive provision of cataract surgery.Population-based, retrospective study.All ophthalmologists and all ophthalmologic surgical patients in Ontario from 1994 to 2016.We linked several health care databases to evaluate the proportion of ophthalmologists who exclusively provided cataract surgery (and no other ophthalmologic surgery) and the proportion who provided other types of ophthalmologic surgical care. To further investigate surgical focus, we evaluated the proportion of surgical cases within each surgical area for each ophthalmologist.Between 1994 and 2016, the proportion of ophthalmologists who exclusively provided cataract surgery rose from 10.0% to 34.9% (p0.0001). In contrast, the proportions of ophthalmologists providing other types of subspecialized surgical care were stable over the study period. Cataract surgeons showed high degrees of focus with a median percentage of surgical cases approaching 100% in all years. Among exclusive cataract surgeons, the median annual cataract case volume increased from 138 (interquartile range: 87-214) to 529 (interquartile range: 346-643) between 1994 and 2009 (p0.0001) and then plateaued.Between 1994 and 2016, exclusive cataract surgical focus among ophthalmologists in Ontario rose dramatically from 1 in 10 to 1 in 3 surgeons. This evolution was similar among recent graduates and established ophthalmologists. Our data may have important implications for policies regarding surgeon human resources as well as residency and fellowship training programs.

To evaluate the long-term evolution of first-line glaucoma therapy (FLGT) initiated by ophthalmologists and optometrists.Retrospective population-based study using validated provincial health care databases.194,759 Ontario residents, 66 years of age or older, who received FLGT between 2007 and 2018.A total of 194,759 individuals from 12 annual cohorts were enrolled, and rates of first-line medical treatment (prostaglandin analogue [PGA], beta-blocker, alpha-2-agonist, and carbonic anhydrase inhibitor) and laser trabeculoplasty (LT) were calculated. Provider (ophthalmologist or optometrist) rates also were assessed.Across the entire study period, of the 194,759 enrolled individuals who received FLGT, 60.2% initially received medical treatment and 39.8% underwent LT. Approximately 94.6% were treated by ophthalmologists. PGA therapy was the most common therapy prior to 2010, whereupon LT became the most common FLGT. By 2015, LT exceeded the total of all medications as FLGT. The annual rate of initial medication prescriptions by optometrists rose to 101.4 per 100,000 population between 2011 and 2018. In 2018, PGA and non-PGA prescription rates by ophthalmologists were 2.6 and 5.0 times higher, respectively, than prescription rates by optometrists.LT therapy has become the most common FLGT for Ontario residents 66 years of age or older. PGAs remain the most frequently prescribed glaucoma medication. While ophthalmologists continue to provide the majority of FLGT, optometrists now provide a small but growing fraction of FLGT following the introduction of glaucoma medication prescribing privileges.

Background Jurisdictions worldwide ramped down ophthalmic surgeries to mitigate the effects of COVID-19, creating a global surgical backlog. We sought to predict the long-term impact of COVID-19 on the timely delivery of non-emergent ophthalmology sub-specialty surgical care in Ontario. Methods This is a microsimulation modelling study. We used provincial population-based administrative data from the Wait Time Information System database in Ontario for January 2019 to May 2021 and facility-level data for March 2018 to May 2021 to estimate the backlog size and wait times associated with the COVID-19 pandemic. For the postpandemic recovery phase, we estimated the resources required to clear the backlog of patients accumulated on the wait-list during the pandemic. Outcomes were accrued over a time horizon of 3 years. Results A total of 56 923 patients were on the wait-list in the province of Ontario awaiting non-emergency ophthalmic surgery as of Mar. 15, 2020. The number of non-emergency surgeries performed in the province decreased by 97% in May 2020 and by 80% in May 2021 compared with the same months in 2019. By 2 years and 3 years since the start of the pandemic, the overall estimated number of patients awaiting surgery grew by 129% and 150%, respectively. The estimated mean wait time for patients for all subspecialty surgeries increased to 282 (standard deviation [SD] 91) days in March 2023 compared with 94 (SD 97) days in 2019. The provincial monthly additional resources required to clear the backlog by March 2023 was estimated to be a 34% escalation from the prepandemic volumes (4626 additional surgeries). Interpretation The estimates from this microsimulation modelling study suggest that the magnitude of the ophthalmic surgical backlog from the COVID-19 pandemic has important implications for the recovery phase. This model can be adapted to other jurisdictions to assist with recovery planning for vision-saving surgeries.

To examine postoperative opioid-prescribing patterns following otologic surgery.Retrospective population-based descriptive study.All hospitals in the Canadian province of Ontario.Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses.The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019.This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.

Purpose Tamsulosin is associated with intraoperative floppy iris syndrome (IFIS), an important risk factor for complications during cataract surgery. Significant efforts have been made to increase awareness of the risks associated with tamsulosin, and educational initiatives have fostered the uptake of technical adjustments to decrease adverse event rates among tamsulosin-exposed patients. However, the effectiveness of these efforts at the population level has not been studied. Design Population-based study to evaluate cataract surgical adverse event rates over time among patients exposed to tamsulosin and those not exposed to this drug. Participants All male patients 66 years of age and older undergoing cataract surgery in Ontario, Canada, between January 1, 2003, and December 31, 2013, were included in the study. Methods Linked healthcare databases were used to study the evolution in the risk of cataract surgical adverse events over time among tamsulosin-exposed and non–tamsulosin-exposed patients adjusting for patient-, surgeon-, and institution-level covariates. The study timeframe incorporated periods before and after the first reports of tamsulosin-associated IFIS. Main Outcome Measures Four important cataract surgical adverse events were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Results Among patients exposed to tamsulosin, the risk of surgical adverse events decreased over time (odds ratio, 0.95 per year; 95% confidence interval, 0.91–0.99 per year). This trend was observed across patient age strata. Among patients not recently exposed to tamsulosin, the risk of surgical adverse events also decreased over time (odds ratio, 0.96 per year; 95% confidence interval, 0.95–0.98 per year). Conclusions The risk of cataract surgical complications among both tamsulosin-exposed and non–tamsulosin-exposed patients declined between 2003 and 2013. Tamsulosin remains an important risk factor for cataract surgical adverse events, and ongoing efforts will be needed to develop and disseminate surgical approaches that mitigate the risks posed by tamsulosin.

To determine the feasibility and acceptability of connecting optometrists to ophthalmologists on an eConsult service.Descriptive analysis of utilization data and an anonymous survey.All eConsult cases sent by optometrists between March 2019 and February 2020 (utilization data); optometrists and ophthalmologists participating in the eConsult Vision Pilot Project (survey).Utilization data for the study period were collected automatically and underwent descriptive analysis. Participating optometrists and ophthalmologists received an email invitation to a survey assessing the project.Thirteen optometrists from 5 clinics in the southeast region and 7 ophthalmologists were recruited to participate in the pilot project. Optometrists sent 109 eConsults in a 13-month period, representing 33% of all cases submitted to ophthalmology through the eConsult service provincially (March 2019-March 2020). Sixty-eight percent of respondents to an anonymous online survey valued the recruitment and engagement of eye care professionals from the same health region. The influence of the eConsult service was reported to have a "somewhat positive" (27%) to "very positive" (50%) influence on the relationship between the two professional groups.The eConsult Vision Pilot Project fills a gap in service and provides an opportunity for patients to get access to specialty advice. We demonstrated that allowing optometrists to solicit specialist advice from ophthalmologists was acceptable and feasible.

OBJECTIVE To investigate preoperative patient demographics and comorbidities in relation with postsurgical complications following vestibular schwannoma surgery. STUDY DESIGN Retrospective population-based cohort study. SETTING All hospitals in the Canadian province of Ontario. PATIENTS This study includes 1,456 patients who underwent vestibular schwannoma surgery from April 1, 2002 to March 31, 2018 in Ontario, Canada. INTERVENTION/OUTCOME MEASURES For all surgical patients, the demographic data, preoperative comorbidities, and postoperative complications were evaluated. Postoperative complications were examined immediately following surgery in the hospital as well as 1 year following the hospital discharge. RESULTS The most common comorbidities in this cohort were hypertension (30.22%), diabetes (9.48%), asthma (13.53%), and chronic obstructive pulmonary disease (6.73%). Diabetes was the most impactful comorbidity and was associated with higher risk of myocardial infarction (RR = 4.58, p

Glaucoma is the leading cause of irreversible blindness around the world. With its slow asymptomatic progression, there is an emphasis on early detection and frequent monitoring. A novel microfluidic contact lens has been established as a potential way to track the fluctuations of the intraocular pressure (IOP) which is a key indicator for diagnosing and monitoring glaucoma progression. The purpose of this article is to determine the effect of physiological variations of the eye on the performance of the microfluidic contact lens. Ultrasound biomicroscopy (UBM) was used to measure the central corneal thickness (CCT) and radius of corneal curvature (RCC) for a series of 16 fresh enucleated porcine eyes. The effect of these corneal anatomic features on device performance was then assessed by systematically adjusting intraocular pressure from 10 to 34 mmHg and monitoring the device indicator response. The performance of the microfluidic contact lens was determined by finding the amount the indicator fluid shifted in position as a result of 1 mmHg IOP increase. The relationship between IOP and indicator fluid was found to be linear for all eyes. The slope of the indicator fluid movement as a result of the IOP was evaluated against the CCT and RCC of each porcine eye. This yielded low correlation coefficients, 0.057 for CCT and 0.024 for RCC, meaning that these physiological differences showed no systematic impact on the measurements made with the contact lens.

¬ Rationale, aims and objectives: Physician consultations are a limited resource. Anesthesiologists provide anesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. Method: A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002-2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anesthesia consultation. Results: A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year). Each year, an average of 19.32% of the consults (range: 17.69-20.49%) were for patients that did not progress to having surgery. Of those that did have surgery following the anesthesia consult, 37.23% were ASA Classification I or II. The most common surgical procedures (percent of total) following anesthesia consult were: Knee implantation of internal device (9.46%), hip implantation of internal device (5.84%), cataract excision (4.09%), repair of muscle of chest/abdomen (3.31%), uterus excision (2.76%), and gallbladder excision (2.67%). Conclusions: This study reveals data on utilization and trends over time of preoperative anesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery that may not require consultation.

To evaluate evolution in the distribution of new glaucoma patients between ophthalmologists and optometrists, and to examine factors predicting provider type, in the context of expansion in the scope of optometry practice.A population-based study was undertaken using validated datasets in Ontario, Canada from 2007 to 2018, encompassing time before and after optometry practice scope expansion in 2011. All patients aged 66 and older receiving a glaucoma suspect diagnosis or first-line therapy for glaucoma from ophthalmologists or optometrists were enrolled. Predictors of provider type were evaluated using logistic regression.From 2007 to 2018, 401,560 patients received initial glaucoma care, including 303,440 by ophthalmologists and 98,120 by optometrists. Population rates of glaucoma suspect diagnosis increased for both providers over the study period. The rate of therapy initiation increased annually among optometrists after 2011, while the rate remained stable over that period among ophthalmologists. By 2018, 88% of patients initiating therapy and 59% of patients first diagnosed as a glaucoma suspect received that care from ophthalmologists. In the final study year, therapy initiations per provider were lower among optometrists (median: 2/provider; interquartile range: 1 to 3) than among ophthalmologists (median: 26.5/provider, interquartile range: 10 to 53). Patients were more likely to receive care from an ophthalmologist than an optometrist if they were older, had higher ocular or systemic comorbidity, or lived in urban settings.Optometrists have a large and growing role in diagnosing glaucoma suspects; however, despite scope expansion, optometrists play a much smaller role in initiating glaucoma therapy.

To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication.Population-based study.All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019.Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken.Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence.In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66-70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48-0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39-1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30-0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31-0.49), and retina surgery (OR, 0.46; 95% CI, 0.41-0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91-0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84-0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90-0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05-1.05 per year).Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Background In Canada, First Nations populations experience a higher incidence of diabetes and diabetes-related complications than other people. Given the paucity of information on use of preventive eye examinations and the need for interventional care for severe retinopathy among First Nations people, we carried out a population-based study to compare rates of eye examinations and interventional therapies to treat vision-threatening stages of diabetic retinopathy among First Nations people and other people with diabetes in Ontario. Methods In collaboration with the Chiefs of Ontario, we carried out a population-based study to identify cohorts of First Nations people and other people with diabetes in Ontario from 1995/96 to 2014/15. We used linked health administrative databases to evaluate rates of eye examination (2005/06-2014/15) and severe diabetic retinopathy treatment and compared them between the 2 populations, and between First Nations people living in and outside of First Nations communities. Results We identified 23 013 First Nations people and 1 364 222 other people diagnosed with diabetes from 1995/96 to 2014/15, of whom 49.8% (95% confidence interval [CI] 48.9%-50.7%) and 53.8% (95% CI 53.7%-54.0%), respectively, received an eye examination in 2014/15. Eye examination rates were similar for First Nations people regardless of whether they lived in or outside a First Nations community. First Nations people developed severe diabetic retinopathy at a faster rate than other people (hazard ratio 1.19, 95% CI 1.02-1.38). The gap between First Nations people and other people in the proportion requiring therapy for severe diabetic retinopathy was especially prominent among younger people. There were no significant differences in rates of diabetic retinopathy treatment in First Nations people stratified by place of residence. Interpretation Eye examination rates remain suboptimal among people with diabetes in Ontario and were lower among First Nations people. This is particularly concerning in light of our other findings showing an increased risk of requiring treatment for advanced diabetic retinopathy and the accelerated rate of diabetic retinopathy progression among First Nations people with diabetes.

Purpose Reports have questioned the technical proficiency of newly graduating surgeons. However, objective data supporting these concerns are limited. Surgical outcomes among recent graduates are an important indicator of residency programs' ability to graduate surgeons who are ready to meet the needs of their patients. This study aimed to investigate the association between a surgeon's number of years of independent practice and the risk of surgical adverse events. Design Population-based cohort study. Participants All patients 66 years of age or older undergoing isolated cataract operations in Ontario, Canada, between January 1, 1997, and December 31, 2013. Methods Cataract surgical outcomes for all operations performed by surgeons commencing practice in the study period were evaluated using linked health care databases. Main Outcome Measures Four serious complications were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Analyses controlled for patient-, surgeon-, and institution-level covariates. Results The study evaluated 1 431 320 cataract operations. Surgeons in their first year of independent practice were more than 9 times more likely to have high complication rates (≥2%) than surgeons in their tenth year (odds ratio [OR], 9.3; 95% confidence interval [CI], 2.7–31.9). Each additional year of independent practice was associated with a 10% decrease in the risk of patients experiencing an adverse surgical event (OR, 0.90 per year of surgeon independent practice; 95% CI, 0.87–0.94). Conclusions In this population-based study, surgical complications were significantly more likely early in surgeons' careers. Interventions may be needed in postgraduate surgical training and early independent career monitoring and mentoring processes to ensure patient safety while continually renewing the surgical workforce.

Cataract surgery is the most common operation performed in most developed countries, including Canada. Nuanced, evidence-driven policies are needed to ensure appropriate access to this sight-saving operation while maintaining the highest standards in quality of care. The Vision Health Services Research Program at Queen's University, in partnership with members of the Ontario Provincial Vision Task Force, has developed evidence to inform policies aimed at optimizing both access and quality across the eye care spectrum.

BACKGROUND: Across Canada, graduates from several medical and surgical specialties have recently had difficulty securing practice opportunities, especially in specialties dependent on limited resources such as ophthalmology. We aimed to investigate whether resource constraints in the health care system have a greater impact on the volume of cataract surgery performed by recent graduates than on established physicians. METHODS: We used population-based administrative data from Ontario for the period Jan. 1, 1994, to June 30, 2013, to compare health services provided by recent graduates and established ophthalmologists. The primary outcome was volume of cataract surgery, a resource-intensive service for which volume is controlled by the province. RESULTS: When cataract surgery volume in Ontario entered a period of government-mandated zero growth in 2007, the mean number of cataract operations performed by recent graduates dropped significantly (−46.37 operations/quarter, 95% confidence interval [CI] −62.73 to −30.00 operations/quarter), whereas the mean rate for established ophthalmologists remained stable (+5.89 operations/quarter, 95% CI 95% CI −1.47 to +13.24 operations/quarter). Decreases in service provision among recent graduates did not occur for services without volume control. The proportion of recent graduates providing exclusively cataract surgery increased over the study period, and recent graduates in this group were 5.24 times (95% CI 2.15 to 12.76 times) more likely to fall within the lowest quartile for cataract surgical volume during the period of zero growth in provincial cataract volume (2007–2013) than in the preceding period (1996–2006). INTERPRETATION: Recent ophthalmology graduates performed many fewer cataract surgery procedures after volume controls were implemented in Ontario. Integrated initiatives involving multiple stakeholders are needed to address the issues facing recently graduated physicians in Canada.

Objective To report on patterns of optometry prescribing and adherence to prescribing regulations at a tertiary care ophthalmology centre. Design Prospective cohort study. Participants All new referrals from optometrists and other health care professionals to the emergency eye care service (n = 1965) between July 2011 and June 2012, as well as optometry referrals to 2 subspecialty services (glaucoma [n = 71] and cornea [n = 212]). Methods In our primary analysis, the frequency of prescribing and classes of medications prescribed were reported and compared amongst various referral sources to the emergency eye care service. As a secondary analysis, we reported frequency of prescribing in optometry referrals to 2 subspecialty clinics. Adherence to prescribing guidelines was reported for all optometry referrals. Results Of 296 referrals from optometrists to the emergency eye care service, 20 (6.8%) had received a prescription medication; this was significantly less compared to emergency and family physicians ( p Conclusions After the introduction of prescribing privileges, optometrists prescribe a variety of medications in their practices. Current prescribing guidelines are not always followed in practice, suggesting that continued study and collaboration is necessary to create an optimal model of interdisciplinary care that provides access to the highest quality of care.

Vitamin D has emerged as a potentially important molecule in ophthalmology. To date, all ophthalmic data pertaining to vitamin D has been restricted primarily to tear and serum analysis in human patients. Considering the isolated nature of the eye, we sought to determine the presence of intraocular vitamin D in ocular disease. Methods 25-Hydroxyvitamin D3 (25(OH)D3) concentrations were measured in the eye and blood of 120 participants undergoing ophthalmic procedures. Ocular localization of the 1,25-dihydroxyvitamin D3-generating (CYP27B1) and deactivating (CYP24A1) hydroxylases was performed by immunohistochemistry. Gene expression of CYP27B1, CYP24A1 and VEGF-A was measured in eyes from patients with and without disease. Results 25(OH)D3 was quantified in 112 ocular samples. In 40 cataract patient samples, the average 25(OH)D3 concentration was 0.057 ng/mL, compared to 72 retinal disease patient samples, average of 0.502 ng/mL (p Conclusions Our data confirms that vitamin D is present in the humours of the human eye and that local synthesis/degradation is possible via the ocular CYP27B1 and CYP24A1. This argues for a functional role for local vitamin D production and signaling in the eye and suggests that vitamin D may be an important intraocular mediator in disease pathogenesis.

BackgroundGlaucoma is the second leading cause of blindness in the world and the first leading cause of irreversible vision loss. Currently, the primary methodology of testing for the intraocular pressure (IOP) is during clinical office hours, which only provide a limited amount of information on the trends and fluctuations of the IOP. Therefore, a continuous monitoring system is required to properly determine the peaks of pressure and to negate any false results obtained by sparse, clinic hour testing. The objective of this study is to determine the ability of a newly designed contact lens with an embedded microchannel, to accurately measure the fluctuations in the IOP.MethodsExperimentation was completed on fresh enucleated porcine eyes. The contact lens was placed on the porcine eye and utilising a camera the fluid movement, within the microchannel in the contact lens, was recorded. A micro-pressure catheter, threaded into the centre of the vitreous chamber, recorded the true IOP and was compared with the displacement of the indicator fluid within the microchannel.ResultsThe contact lenses showed a consistent linear responsiveness to changes in IOP and robust to the effects of anatomical differences among eyes. The indicator fluid had an average fluid movement of 28 um/mm Hg between all the trials. Additionally, the devices showed the ability to measure both increases and decreases in IOP during cyclical fluctuations.ConclusionThe described inexpensive and non-invasive sensor is able to reliably monitor the IOP changes based on porcine eye model.

Importance Evidence suggests that the quality of some aspects of care provided by physicians may decrease during their late career stage. However, to our knowledge, data regarding the association of advancing surgeon career phase with cataract surgical outcomes have been lacking. Objective To investigate whether an increase in cataract surgical adverse events occurs during later surgeon career stages. Design, Setting, and Participants This population-based study of 499 650 cataract operations performed in Ontario, Canada, between January 1, 2009, and December 31, 2013, investigated the association between late surgeon career stage and the risk of surgical adverse events. Linked health care databases were used to study cataract surgical complications while controlling for patient-, surgeon-, and institution-level covariates. All ophthalmologists who performed cataract surgery in Ontario within the study period were included in the analysis. Exposures Isolated cataract surgery performed by surgeons at early, mid, and late career stages. Main Outcomes and Measures Four serious adverse events were evaluated: dropped lens fragments, posterior capsule rupture, suspected endophthalmitis, and retinal detachment. Results Of 416 502 participants, 244 670 (58.7%) were women, 90 429 (21.7%) were age 66 to 70 years, 111 530 (26.8%) were age 71 to 75 years, 90 809 (21.8%) were age 76 to 80 years, and 123 734 (29.7%) were 81 years or older. Late-career surgeons performed 143 108 of 499 650 cataract operations (28.6%) during the study period. Late surgeon career stage was not associated with an increased overall risk of surgical adverse events (odds ratio [OR] vs midcareer, 1.06; 95% CI, 0.85-1.32). In a sensitivity analysis with surgeon volume removed from the model, late career stage was still not associated with overall adverse surgical events (OR, 1.10; 95% CI, 0.88-1.38). Among individual complications, late surgeon career stage was associated with an increased risk of dropped lens fragment (OR, 2.30; 95% CI, 1.50-3.54) and suspected endophthalmitis (OR, 1.41; 95% CI, 1.01-1.98). These corresponded with small absolute risk differences of 0.11% (95% CI, 0.085%-0.130%) and 0.045% (95% CI, 0.028%-0.063%) for dropped lens fragment and suspected endophthalmitis, respectively. Conclusions and Relevance These findings suggest that later-career surgeons are performing a substantial proportion of cataract operations with overall low surgical adverse event rates. Future studies might extend evaluations to the frequency of secondary surgical interventions as additional measures of surgical care quality.

During the latest Campanian–Maastrichtian the northwestern Australian margin was situated between the cool-water Austral Province to the south and the warm-water Tethyan Province to the north. The transitional nature of calcareous microfossil assemblages on the margin makes application of Tethyan biostratigraphic zonation schemes awkward, as many marker-species are missing or have different ranges. This study presents an integrated uppermost Campanian–Maastrichtian calcareous microfossil zonation based on two Ocean Drilling Program (ODP) holes on the Exmouth Plateau and eight petroleum exploration wells from the Vulcan Sub-basin. The zonation is refined and revised from the previously unpublished KCN (nannofossils), KPF (planktonic foraminifera), KBF (benthonic foraminifera) and KCCM (composite nannofossil and planktonic foraminifera) zonations, which are commonly used for petroleum exploration wells drilled on the northwestern margin. Revision of the zonations has highlighted a major Upper Campanian to lower Upper Maastrichtian disconformity on the Exmouth Plateau, which went largely unnoticed in previous examinations of the ODP material, but had been recorded previously elsewhere on the northwestern margin. The duration of the disconformity in the Vulcan Sub-basin is unclear, since intervals of the succession may be condensed in this area.

Tamsulosin is associated with intraoperative floppy iris syndrome (IFIS), an important risk factor for complications during cataract surgery. Significant efforts have been made to increase awareness of the risks associated with tamsulosin, and educational initiatives have fostered the uptake of technical adjustments to decrease adverse event rates among tamsulosin-exposed patients. However, the effectiveness of these efforts at the population level has not been studied.Population-based study to evaluate cataract surgical adverse event rates over time among patients exposed to tamsulosin and those not exposed to this drug.All male patients 66 years of age and older undergoing cataract surgery in Ontario, Canada, between January 1, 2003, and December 31, 2013, were included in the study.Linked healthcare databases were used to study the evolution in the risk of cataract surgical adverse events over time among tamsulosin-exposed and non-tamsulosin-exposed patients adjusting for patient-, surgeon-, and institution-level covariates. The study timeframe incorporated periods before and after the first reports of tamsulosin-associated IFIS.Four important cataract surgical adverse events were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis.Among patients exposed to tamsulosin, the risk of surgical adverse events decreased over time (odds ratio, 0.95 per year; 95% confidence interval, 0.91-0.99 per year). This trend was observed across patient age strata. Among patients not recently exposed to tamsulosin, the risk of surgical adverse events also decreased over time (odds ratio, 0.96 per year; 95% confidence interval, 0.95-0.98 per year).The risk of cataract surgical complications among both tamsulosin-exposed and non-tamsulosin-exposed patients declined between 2003 and 2013. Tamsulosin remains an important risk factor for cataract surgical adverse events, and ongoing efforts will be needed to develop and disseminate surgical approaches that mitigate the risks posed by tamsulosin.

PURPOSE To highlight the potential risk of glaucoma drainage device erosion following ptosis surgery. METHODS Case report. RESULTS A 71-year-old man underwent uncomplicated superotemporal Ahmed glaucoma valve implantation in the left eye in 2008. Approximately 8 years later, the patient underwent bilateral ptosis repair, which successfully raised the upper eyelid position. Three months postoperatively, the patient's glaucoma drainage implant tube eroded through the corneal graft tissue and overlying conjunctiva to become exposed. A graft revision surgery was successfully performed with no further complications. CONCLUSIONS Caution and conservative lid elevation may be warranted when performing ptosis repair in patients with a glaucoma drainage implant, and patients with a glaucoma implant undergoing ptosis surgery should be followed closely for signs of tube erosion.

Purpose To investigate the effect of anti-inflammatory therapy on selective laser trabeculoplasty (SLT) outcomes. Design Randomized, double-masked, placebo-controlled trial. Participants Patients with primary open-angle or pseudo-exfoliation glaucoma. Methods Patients undergoing SLT were randomized to receive placebo (artificial tears), prednisolone acetate 1%, or ketorolac tromethamine 0.5% eye drops 4 times per day for 5 days commencing immediately after SLT. Main Outcome Measures Change in intraocular pressure (IOP) from baseline to the 1-month post-SLT visit. Results Mean change in IOP at the 1-month primary outcome time point, as well as all other time points, was not significantly different among groups ( P = 0.99). Likewise, a repeated-measures, mixed-effects model did not find significant differences in IOP outcome at the 1-month time point ( P = 0.95). The IOP was reduced in all groups at the 1-month post-SLT time point and all other time points, and no significant differences were found between groups using separate unadjusted cross-sectional analyses of variance ( P > 0.15 for analyses at all time points). Treatment failure rates were not different among groups ( P = 0.75), and at 1 year after SLT, the percentage of patients maintaining a 20% IOP reduction ranged from 18% to 22% in the 3 study groups. Conclusions Anti-inflammatory therapy after SLT does not seem to substantially influence the IOP-lowering effect of SLT. In this study of patients with low baseline IOP, SLT showed limited efficacy in achieving a sustained reduction in IOP.

Intravenous administration of vascular endothelial growth factor (VEGF)-inhibiting drugs is associated with adverse gastrointestinal (GI) events. Clinical trials of VEGF inhibitors used for the treatment of retinal diseases have suggested higher risks of adverse GI events among patients treated with bevacizumab. However, population-based studies have been lacking.Our objective was to assess risks for GI adverse events associated with intravitreal injections of VEGF-inhibiting drugs.We conducted a population-based, nested case-control study of 114,427 older adults in Ontario, Canada, with retinal disease identified between 1 November 2005 and 30 April 2011. Of these, 3,582 cases were admitted to hospital or assessed in an emergency department for GI adverse events. Controls were matched to cases on the basis of age, sex, and outcome history.Patients experiencing adverse events were equally as likely as matched controls to have been exposed to bevacizumab or ranibizumab. Adjusted odds ratios for bevacizumab were 1.05 (95 % confidence interval [CI] 0.69-1.61) for upper GI ulceration, 1.29 (95 % CI 0.86-1.96) for diverticular disease, 1.49 (95 % CI 0.84-2.63) for pancreatitis, 0.82 (95 % CI 0.53-1.29) for cholelithiasis, and 1.45 (95 % CI 0.67-3.12) for cholecystitis. For ranibizumab they were 1.25 (95 % CI 0.88-1.77) for upper GI ulceration, 1.12 (95 % CI 0.83-1.52) for diverticular disease, 0.85 (95 % CI 0.51-1.40) for pancreatitis, 0.77 (95 % CI 0.53-1.11) for cholelithiasis, and 0.83 (95 % CI 0.44-1.56) for cholecystitis. Results were similar when the analysis was restricted to patients only exposed to a single type of VEGF inhibitor.In this population-based study, intravitreal injections of bevacizumab and ranibizumab were not associated with increased risks of adverse GI events.

PURPOSE OF REVIEW The development of vascular endothelial growth factor (VEGF) inhibitors has revolutionized the treatment of retinal diseases. However, VEGF functions in many physiological and pathological processes. Consequently, inhibition of this signalling molecule carries the potential to cause serious adverse events. RECENT FINDINGS Numerous clinical trials, meta-analyses and population-based studies have provided data regarding the safety of intravitreal VEGF inhibitor injections. Although individual trials and some meta-analyses have not found significant risks, other meta-analyses have suggested possible risks, especially in patients with multiple baseline risk factors. Population-based studies have not found increased risks of vascular adverse events. SUMMARY Overall, results across studies with differing methodologies provide some reassurance that the widespread use of intravitreal injections of VEGF inhibitors has not resulted in significant increases in the risks of adverse events. However, ongoing vigilance and further study remain priorities, with a particular need for greater evaluation of high-risk subgroups. Rapidly evolving treatment options for ocular diseases including new drugs and new delivery technologies will require ongoing evaluations of safety.

PURPOSE β-adrenergic receptor antagonists (β-blockers) used in the treatment of glaucoma are an often-overlooked source of systemic adverse events. Ophthalmic timolol has been associated with severe systemic adverse events including numerous cases resulting in death. In recent years the number of fixed-dose combination therapies for glaucoma has grown rapidly, and among available combination therapies only the nonselective β-blocker timolol is used as the β-blocker component. METHODS A population-based study was conducted in Ontario, Canada between January 1, 2001 and December 31, 2012 to assess the shift to combination therapies in the management of glaucoma, and to investigate the impact of this shift on the relative use of selective and nonselective β-blockers in patients with this disease. RESULTS Between 2001 and 2012 timolol (nonselective β-blocker) use grew at an average annual rate of 2.2% (P

Reports have questioned the technical proficiency of newly graduating surgeons. However, objective data supporting these concerns are limited. Surgical outcomes among recent graduates are an important indicator of residency programs' ability to graduate surgeons who are ready to meet the needs of their patients. This study aimed to investigate the association between a surgeon's number of years of independent practice and the risk of surgical adverse events.Population-based cohort study.All patients 66 years of age or older undergoing isolated cataract operations in Ontario, Canada, between January 1, 1997, and December 31, 2013.Cataract surgical outcomes for all operations performed by surgeons commencing practice in the study period were evaluated using linked health care databases.Four serious complications were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Analyses controlled for patient-, surgeon-, and institution-level covariates.The study evaluated 1 431 320 cataract operations. Surgeons in their first year of independent practice were more than 9 times more likely to have high complication rates (≥2%) than surgeons in their tenth year (odds ratio [OR], 9.3; 95% confidence interval [CI], 2.7-31.9). Each additional year of independent practice was associated with a 10% decrease in the risk of patients experiencing an adverse surgical event (OR, 0.90 per year of surgeon independent practice; 95% CI, 0.87-0.94).In this population-based study, surgical complications were significantly more likely early in surgeons' careers. Interventions may be needed in postgraduate surgical training and early independent career monitoring and mentoring processes to ensure patient safety while continually renewing the surgical workforce.

Purpose To evaluate trends in glaucoma surgery subspecialization. Design Population-based analysis of incisional glaucoma surgery and laser trabeculoplasty practice patterns among all ophthalmologists in Ontario, Canada, from 1995 through 2010. Participants All ophthalmologists in Ontario, Canada, providing universal health care for the provincial population of approximately 12 million. Methods The province of Ontario provides government-funded universal health care insurance to all citizens through the Ontario Health Insurance Plan (OHIP). Anonymized physician services data were obtained from the OHIP database, which has excellent accuracy for procedure performance. Main Outcome Measures Proportion of ophthalmologists providing incisional glaucoma surgery and laser trabeculoplasty and the distribution of these surgical and laser procedures among ophthalmologists. Results Between 1995 and 2010, the median number of ophthalmologists in Ontario was 427 (35.1 per 1 million population), ranging from 417 to 453 (32.9–40.3 per 1 million population). The percentage of ophthalmologists providing incisional glaucoma surgery dropped from 35% in 1995 to 19% in 2010, a 47% decline. Over the same period, the mean number of incisional glaucoma surgeries performed per surgeon doubled, and the percentage of incisional glaucoma operations provided by high-volume surgeons rose from 23% to 59%. The percentage of ophthalmologists performing laser trabeculoplasty was relatively stable (48% in 1995 to 50% in 2010). Conclusions Over the past 16 years, the proportion of ophthalmologists providing incisional glaucoma surgery has declined significantly. At the same time, the proportion of incisional glaucoma surgery provided by high-volume glaucoma surgeons has more than doubled. These trends will have important implications for stakeholders from policy makers and hospitals to academic departments and residency education programs. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.