IRIS® Registry

IRIS® Registry at a Glance

Iris Registry
IRIS Registry
Data Type Health registry compiled from participating ophthalmology practices’ electronic medical records systems
Sample Convenience sample consisting of patients visiting IRIS-participating ophthalmology practices, representing approximately 95% of US ophthalmology practices
VEHSS Topics Included Service Utilization
Eye Health Conditions
Visual Function
Years Analyzed 2016, 2017, 2018
Approximate Size over 50 million patients

Compiled by the American Academy of Ophthalmology (AAO), IRIS® Registry (Intelligent Research In Sight) is the nation’s first comprehensive eye disease clinical registry. The IRIS® Registry enables ophthalmologists to use clinical data to improve care delivery and patient outcomes and help practices meet requirements of the federal Physician Quality Reporting System (PQRS). The IRIS® Registry uses methods compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to collect data from patient records directly from practices’ individual electronic medical record (EMR) systems. These EMR systems periodically report health record data based on the IRIS® Registry data fields on a nightly or weekly basis. The system tracks diagnosed disorders based on ICD-9/ICD-10 codes and also includes procedures and visual acuity measures and other clinical data documented in the medical record.

sample data map

IRIS® Registry

IRIS® Registry coverage began in 2013, but sample size has increased over time. As of 2019, IRIS® Registry contained more than 50 million patients and 230 million encounters. In 2018, the IRIS® Registry collected data from a convenience sample of more than 90% of ophthalmologists nationally.

The main advantages of IRIS® Registry are its wide coverage and availability of diagnostic test results such as acuity values. However, IRIS® Registry is a convenience sample of ophthalmology practices, and cannot by itself produce national prevalence estimates. IRIS® Registry is also a new data system and has not been externally evaluated for data completeness, reliability, or validity. The IRIS® Registry team provided summary-level frequencies and prevalence values to the VEHSS system and has not granted access to person-level data. This limits the ability of the VEHSS team to assess the quality of IRIS® Registry data.

Analysis Overview

For the VEHSS project, AAO analyzed IRIS® Registry data to estimate the prevalence rate of specific diagnoses, the rate of clinical procedures, and the prevalence rate of visual acuity values when reported, as observed over a single year of observations in the 2016-2018 IRIS® Registry data. AAO analyzed the 2016-2018 IRIS® Registry and supplied de-identified summary reports of frequencies and rates, summarized by state and by age group, race/ethnicity, sex, and insurer.

NORC further analyzed the summary data files, mapping outcomes to VEHSS-defined categories, calculating confidence intervals, and cleaning data. Results were further suppressed if the numerator was <3 and the denominator was less than 30, or the numerator was ≥3 and the denominator was ≤30.

A detailed description of the analytical steps is described in the report “VEHSS Claims & Registry Data Analysis Plan pdf icon[PDF – 579 KB]external icon.” Full analysis documentation is included in the “VEHSS IRIS® Registry Data Report pdf icon[PDF – 1.5 MB]external icon.”

Data Indicators and Case Definitions

IRIS® estimates include data indicators representing three topics of the overall VEHSS project:

  • Visual Function–best-corrected acuity measures.
  • Eye Health Conditions–medical conditions defined by ICD-10 code and classified into 17 main categories and 78 subgroups, as described in the report “VEHSS ICD9 and ICD10 Diagnosis Categories Report.”
  • Service Utilization–medical procedures and encounters as defined by CPT code and service date were reported by AAO, but are not yet included in our initial analyses.

Visual Function

Vision exam measures currently include best-corrected visual acuity. In our initial analyses, acuity is defined categorically and patients are divided into eight subgroups using acuity values contained in the IRIS® data (Table 1).

Table 1. Visual Function Topic Variables

Best-corrected Visual acuity

Visual Function Topic Variables
Category
Normal vision
Any vision loss (≤20/32 in better eye)
US blind (≤20/200 in better eye)
WHO blind (≤20/400 in better eye)
Monocular vision loss (≤20/70 in one eye with normal vision in the other)
Missing acuity (patient has no valid acuity measure)

Acuity measures are based on each patient’s last visual acuity observation in 2016, using their best-corrected acuity in the better-seeing eye. The prevalence rate of patients who exhibit moderate impairment in one eye with normal vision in the other are reported as having monocular vision loss.
Approximately 16% of IRIS® Registry’s current patients have no acuity values. It is unclear whether these missing values result from lack of measurement by the practice, data quality issues, or both. We anticipate that completeness of the patient acuity measures will increase over time. Additionally, IRIS® Registry does not currently have a high proportion of presenting visual acuity, uncorrected acuity, or other visual measures. AAO suggests that the recording and reporting to IRIS® Registry of such vision values was still subject to uncertainty, but that coverage was expected to improve over time. We will continue to investigate the option of including such measures in future analyses.

Eye Health Conditions

Eye Health Conditions are reported based on using the VEHSS-defined medical diagnosis categorization structure. As reported in the “VEHSS Diagnosis Code Categories and Crosswalk,” we identified all eye and vision related ICD10 diagnosis codes, and organized them into a 2-level categorization structure, including 17 Categories and 78 Subgroups, as listed in Table 2.

Eye Condition Included subgroups Subgroup description
Table 2. Medical Diagnosis Indicators Analyzed in VEHSS
Retinal Detachment and Defects​ Retinal Detachment and Defects Retinal detachment and retinal breaks without detachment.
Diabetic eye diseases Early/mild diabetic retinopathy Early/Mild Diabetic Retinopathy includes diagnosis codes for background diabetic retinopathy, nonproliferative diabetic retinopathy, or mild nonproliferative diabetic retinopathy.
Moderate /severe non-proliferative diabetic retinopathy Moderate /Severe Non-proliferative Diabetic Retinopathy includes diagnosis codes indicating moderate or severe nonproliferative diabetic retinopathy, without macular edema.
Proliferative diabetic retinopathy Proliferative Diabetic Retinopathy includes diagnosis codes indicating proliferative diabetic retinopathy, without macular edema.
Diabetic macular edema (DME) Diabetic Macular Edema (DME, CSDME) includes diagnosis codes indicating diabetic retinopathy of any type with the presence of macular edema (DME), including clinically significant diabetic macular edema (CSDME).
Other/unspecified diabetes related eye conditions Other/unspecified diabetes related eye conditions includes diagnosis codes indicating diabetic retinopathy of unspecified type, other ophthalmic complications of diabetes including diabetic cataract, or diabetes mellitus with ophthalmic complication resolved after treatment.
Age related macular degeneration (AMD) AMD, unspecified Unspecified macular degeneration includes diagnosis codes indicating degeneration of macula and/or posterior pole, but does not specify stage.
Early AMD Early AMD includes diagnosis codes indicating the presence of drusen (degenerative) of the macula.
Dry-form AMD Dry-form AMD indicates the presence of diagnosis codes for nonexudative age-related macular degeneration.
Geographic atrophy AMD Geographic atrophy AMD indicates the presence of ICD10 codes indicating advanced atrophic stage of dry-form AMD.
Wet-form AMD Wet-form AMD indicates the presence of diagnosis codes for exudative age-related macular degeneration.
Choroidal neovascularization AMD Choroidal neovascularization AMD indicates the presence of ICD10 codes specifying active choroidal neovascularization; advanced wet-form AMD.
Other Retinal Disorders Retina vascular disease, Occlusive (arterial, venous) Retina vascular disease, Occlusive (arterial, venous) includes diagnosis codes indicating unspecified or transient retinal vascular occlusion.
Other/unspecified retinal disorders Other/unspecified retinal disorders include diagnosis codes indicating age-related choroidal atrophy, diffuse secondary atrophy of choroid, retinoschisis, retinal cysts, cyst of ora serrata, retinopathy of prematurity, non-diabetic proliferative retinopathy, unspecified separation of retinal layers, central serous chorioretinopathy, detachment of retinal pigment epithelium, macular cyst, hole, or pseudohole, toxic maculopathy, puckering of macula, various forms of retinal degeneration, retinal hemorrhage, and other or unspecified retinal disorders.
Central retinal vein occlusion Central retinal vein occlusion indicates diagnosis codes for central retinal vein occlusion, with or without macular edema or retinal neovascularization.
Branch retinal vein occlusion Branch retinal vein occlusion indicates diagnosis codes for tributary (branch) retinal vein occlusion, with or without macular edema or retinal neovascularization, or venous engorgement.
Central retinal arterial occlusion Central retinal arterial occlusion indicates diagnosis codes for central retinal arterial occlusion, with or without macular edema or retinal neovascularization.
Branch retinal artery occlusion Branch retinal artery occlusion indicates diagnosis codes for tributary (branch) retinal arterial occlusion.
Retina vascular disease, Non-Occlusive Retina vascular disease, Non-Occlusive includes diagnosis codes indicating hypertensive or exudative retinopathy, changes in retinal vascular appearance, retinal micro-aneurysms, retinal telangiectasis, neovascularization, or vasculitis, intraretinal microvascular abnormalities, or unspecified background retinopathy.
Macular edema (Cystoid or non-diabetic) Macular edema (Cystoid or non-diabetic) indicates diagnosis codes for cystoid macular degeneration.
Hereditary chorioretinal dystrophy Hereditary chorioretinal dystrophy includes diagnosis codes indicating various types of chiorioretinal dystrophy, including circumpapillary, central choroidal atrophy, and choroideremia.
Myopic degeneration Myopic degeneration includes diagnosis codes indicating progressive high (degenerative) myopia.
Glaucoma Open-angle glaucoma Open-angle glaucoma includes diagnosis codes indicating unspecified open-angle glaucoma, pigmentary glaucoma, or capsular glaucoma with pseudoexfoliation of lens.
Primary open-angle glaucoma Primary open-angle glaucoma includes diagnosis codes for primary open-angle glaucoma of any stage.
Low-tension glaucoma Low-tension glaucoma includes diagnosis codes for low-tension glaucoma of any stage.
Glaucoma suspect Glaucoma suspect indicates diagnosis codes for pre-glaucoma, open-angle with borderline findings, ocular hypertension, steroid responder, or primary angle closure without damage.
Primary angle-closure glaucoma Primary angle-closure glaucoma includes diagnosis codes indicating primary, acute, chronic, intermittent or unspecified angle-closure glaucoma.
Narrow-angle glaucoma Narrow-angle glaucoma includes diagnosis codes indicating narrow angle glaucoma, anatomical or secondary to eye trauma.
Congenital glaucoma Congenital glaucoma includes diagnosis codes for congenital glaucoma or buphthalmos (enlargement of the eye in children).
Neovascular glaucoma Neovascular glaucoma includes diagnosis codes indicating glaucoma associated with vascular disorders, phacolytic or other specified glaucoma.
Other/unspecified glaucoma Other/unspecified glaucoma includes diagnosis codes indicating unspecified glaucoma, glaucoma secondary to drugs, other eye disorders or inflammation, hypersecretion glaucoma, increased episcleral venous pressure, or aqueous misdirection.
Cataracts Age-related cataract Age-related cataract indicates the presence of diagnosis codes for age-related incipient, polar, cortical, nuclear, morgagnian, other or unspecified cataract
Other or unspecified cataract Other or unspecified cataract includes diagnosis codes for various cataracts not specified as age-related or congenital, including traumatic cataract, drug-induced cataract, cataract with neovascularization, cataract secondary to ocular disorders, or unspecified cataracts.
Congenital Cataract Congenital Cataract includes diagnosis codes indicating congenital cataract, congenital aphakia, coloboma of lens, spherophakia, congenital lens malformations, or infantile or juvenile cataracts of any type.
Posterior capsular opacity Posterior capsular opacity includes diagnosis codes indicating posterior capsular opacity, Soemmering’s ring, or other secondary cataract.
Pseudophakia Pseudophakia includes diagnosis codes indicating the presence of intraocular lens, aphakia
Aphakia and other disorders of lens Aphakia and other disorders of lens includes diagnosis codes indicating aphakia, subluxation of lens, anterior dislocation of lens, posterior dislocation of lens, or other disorders of lens
Refraction and accommodation Myopia Myopia includes diagnosis codes indicating myopia in one or both eyes.
Hypermetropia Hypermetropia includes diagnosis codes indicating hypermetropia in one or both eyes.
Astigmatism Astigmatism includes diagnosis codes indicating regular, irregular, or unspecified astigmatism in one or both eyes.
Presbyopia Presbyopia includes diagnosis codes indicating presbyopia in one or both eyes.
Other disorder of refraction and accommodation Other disorder of refraction and accommodation includes diagnosis codes indicating anisometropia and aniseikonia, disorders of accommodation, internal ophthalmoplegia, paresis of accommodation, or spasm of accommodation.
Diagnosed Blindness and low vision Unqualified visual loss, both eyes Unqualified vision loss, both eyes includes a diagnosis code indicating unqualified visual loss in both eyes.
Unqualified vision loss in one eye, or unspecified visual loss Unqualified vision loss in one eye or unspecified vision loss includes diagnosis codes indicating unqualified vision loss in one eye, unspecified visual loss, or problems with sight.
Low vision or blindness, one eye Low vision or blindness in one eye includes diagnosis codes indicating low vision or blindness in one eye, normal vision in the other eye.
Blindness one eye, low vision other eye Blindness in one eye, low vision in other eye includes diagnosis codes indicating blindness in one eye, low vision in other eye.
Low vision, both eyes Low vision, both eyes includes diagnosis codes indicating low vision in both eyes.
Blindness, both eyes, including legal blindness Blindness, both eyes, including legal blindness includes diagnosis codes indicating blindness in both eyes, legal blindness, or cortical blindness.
Strabismus and amblyopia Strabismus Strabismus includes diagnosis codes indicating monocular or binocular strabismus, including esotropia, exotropia, heterophoria and other types, nerve palsy of the eye, ophthalmoplegia, Brown’s sheath syndrome, disorders of convergence or binocular movement, or other unspecified disorders of binocular vision.
Amblyopia Amblyopia includes diagnosis codes indicating amblyopia, including deprivation, strabismic, refractive, or unspecified amblyopia type, or ablyopia suspect.
Injury, burns and surgical complications of the eye Injury Injury includes diagnosis codes indicating injury to the eye or ocular adnexa, due to trauma, foreign bodies, penetrating wounds, bites, abrasions or other causes, or injury secondary to other ocular disorders.
Burn Burn includes diagnosis codes indicating any type of burn or corrosion of the eye or ocular adnexa.
Surgical complication Surgical complication includes diagnosis codes indicating or typically associated with surgical complications, including postprocedural inflammation or infection, mechanical complications, cataract fragments, and other conditions usually associated with procedures.
Disorders of optic nerve and visual pathways Optic nerve disorders Optic nerve disorders includes diagnosis codes indicating optic neuritis and other disorders of the optic nerve.
Disorders of the visual pathway and visual cortex Disorders of the visual pathway and visual cortex includes diagnosis codes indicating disorders of visual pathways and visual cortex.
Other visual disturbances Visual field defect Visual field defect includes diagnosis codes indicating defects of the visual field, including scotoma, sector or arcuate defects, localized visual field defects, homonymous bilateral field defects or contraction of the visual field.
Color blindness Color blindness included diagnosis codes indicating color vision deficiencies.
Night blindness Night blindness includes diagnosis codes indicating night blindness, abnormal dark adaptation and glare sensitivity.
Other/unspecified visual disturbances Other/unspecified visual disturbances includes other disturbances or defects of sight including subjective visual disturbances, diplopia, other and unspecified disorders of binocular vision, and vision sensitivity deficiencies.
All Infectious and inflammatory diseases Infectious diseases Infectious diseases includes diagnosis codes indicating an infection of the eye or ocular adnexa.
Keratitis Keratitis includes diagnosis codes indicating keratitis, including corneal ulcer, other and unspecified superficial keratitis without conjunctivitis, keratoconjunctivitis, corneal neovascularization, or other or unspecified forms of keratitis.
Conjunctivitis Conjunctivitis includes diagnosis codes indicating most forms of conjunctivitis, including mucopurulent, acute, chronic, blepharoconjunctivitis, or other disorders of conjunctiva, including pterygium, conjunctival degenerations and deposits, or conjunctival scars, hemorrhage, vascular disorders, or cysts.
Eyelid disorders Eyelid disorders includes diagnosis codes indicating hordeolum and chalazion or other inflammation of the eyelid, including Blepharitis, noninfectious dermatosis or other inflammation of the eyelid.
Other inflammatory conditions Other inflammatory conditions includes diagnosis codes indicating inflammation of the eye or ocular adnexa not otherwise classified.
Lacrimal system and orbit inflammation Lacrimal system and orbit inflammation includes diagnosis codes indicating disorders of the lacrimal system and inflammatory disorders of the orbit.
Endophthalmitis Endophthalmitis includes diagnosis codes indicating enophthalmitis and disorders of the globe including degenerative myopia and uveitis.
Orbital and external disease Congenital anomalies Congenital anomalies includes diagnosis codes indicating congenital malformations of the eye and ocular adnexa.
Other/unspecified orbital or external disease Other/unspecified orbital or external disease includes diagnosis codes indicating non-inflammatory disorders of the orbit.
Lacrimal diseases Lacrimal diseases includes diagnosis codes indicating disorders of the lacrimal system, including dacryoadenitis, epiphora, stenosis and insufficiency of lacrimal passages, or other changes or disorders of the lacrimal system.
Eyelid disorders Eyelid disorders includes diagnosis codes indicating non-inflammatory disorders of the eyelid, including entropion, ectropion, lagophthalmos, ptosis, blepharochalasis, xanthelasma disorders of the eyelid, or other non-specified, non-inflammatory eyelid disorders.
Dry eye syndrome Dry eye syndrome includes diagnosis codes indicating dry eye syndrome.
Disorders of the globe Disorders of the globe includes diagnosis codes indicating disorders of the globe, excluding endoophthalmitis, degenerative myopia, and hypotony of the eye.
Cancer and neoplasms of the eye diseases Malignant neoplasm of the eye Malignant neoplasm of the eye includes diagnosis codes indicating malignant neoplasm of the eye, or carcinoma in situ of the eye.
Benign neoplasm of the eye Benign neoplasm of the eye includes diagnosis codes indicating benign neoplasm of the eye.
Cornea disorders Keratoconus Keratoconus includes diagnosis codes indicating keratoconus or conical cornea conditions.
Endothelial dystrophy (inc Fuchs) Endothelial dystrophy includes diagnosis codes indicating Endothelial or Fuchs dystrophy.
Other Corneal disorders Other Corneal disorders includes diagnosis codes indicating corneal scars, opacities and other disorders of the cornea.
All Other eye disorders Other eye disorders Other eye disorders includes diagnosis codes related to vision, the eye and ocular adnexa that are not otherwise classified.

Denominators used to Calculate Prevalence Rates

The sample (denominator) of patients consists of the total number of current patients with an encounter with an IRIS-member provider during the year of observation.

Potential Limitations

This analysis is subject to a number of potential limitations. AAO reported summary outcome statistics using VEHSS-defined data indicators and case definitions for visual function, eye examinations, and medical diagnoses. Some of the possible limitations include the following:

  • VEHSS does not have access to patient-level data nor details on the process of mapping EMR data to IRIS® Registry. The quality of underlying EMR data, and the process of mapping EMR records to IRIS® Registry could not be validated by the VEHSS team.
  • IRIS® Registry data represents a convenience sample of current ophthalmology patients, and should not be considered representative of the general population. IRIS® Registry rates contained in this report are calculated on the basis of per 100 current ophthalmology patients, and are not representative of the overall population.
  • IRIS® Registry does not include all ophthalmology practices, and may be more likely to include practices who primarily serve Medicare patients because automated PQRS reporting is a motivating factor for providers to register with IRIS® Registry. The IRIS® Registry is a convenience sample and its representativeness of the population of all ophthalmology patients is still being studied.
  • IRIS® Registry only includes patients of ophthalmology practices. However, about 20% to 30% of providers in IRIS® Registry are optometrists who work for mixed-provider practices participating in IRIS® Registry.
  • IRIS® Registry includes services provided regardless of payer, but cannot identify the payer of specific procedures.
  • Eye-examination rates are not reported due to the lack of a suitable denominator.