Factors associated with loss to follow-up in patients with advanced age-related macular degeneration: A telehealth recall initiative

INTRODUCTION

Patients with advanced age-related macular degeneration (AMD) frequently experience loss to follow-up (LTFU), heightening the risk of vision loss from treatment delays. This study aimed to identify factors contributing to LTFU in patients with advanced AMD and assess the effectiveness of telephone-based outreach in reconnecting them with eye care.

METHODS

A custom reporting tool identified patients with advanced AMD who had not returned for eye care between 31 October 2021 and 1 November 2022. Potentially LTFU patients were enrolled in a telephone outreach programme conducted by a telehealth extender to encourage their return for care. Linear regression analysis identified factors associated with being LTFU and likelihood of accepting care post-outreach.

RESULTS

Out of 1269 patients with advanced AMD, 105 (8.3%) did not return for recommended eye care. Patients LTFU were generally older (89.2 ± 8.9 years vs. 87.2 ± 8.5 years, p = 0.02) and lived farther from the clinic (25 ± 43 miles vs. 17 ± 30 miles, p = 0.009). They also had a higher rate of advanced dry AMD (26.7% vs. 18.5%, p = 0.04) and experienced worse vision in both their better-seeing (0.683 logMAR vs. 0.566 logMAR, p = 0.03) and worse-seeing (1.388 logMAR vs. 1.235 logMAR, p = 0.04) eyes. Outreach by a telehealth extender reached 62 patients (59%), 43 through family members or healthcare proxies. Half of the cases where a proxy was contacted revealed that the patient in question had died. Among those contacted directly, one third expressed willingness to resume eye care (20 patients), with 11 scheduling appointments (55%). Despite only two patients returning for in-person eye care through the intervention, the LTFU rate halved to 4.4% by accounting for those patients who no longer needed eye care at the practice.

CONCLUSIONS

There is a substantial risk that older patients with advanced AMD will become LTFU. Targeted telephone outreach can provide a pathway for vulnerable patients to return to care.

Retinal injury from a laser skin resurfacing device during medical tourism: a public health concern

BACKGROUND

Laser skin resurfacing is a popular cosmetic procedure for noninvasive skin rejuvenation. Since health insurance plans often do not cover these types of procedures, patients often pay out of pocket. Consequently, there is an incentive to go abroad, where prices are more affordable. However, practitioners in destination countries may lack rigorous training on laser safety, regulatory oversight, or licensing, especially on devices used for "cosmetic" procedures. In certain cases, this can lead to tragic outcomes, especially when underqualified practitioners operate medical-grade laser devices.

CASE PRESENTATION

A 29-year-old woman suffered a retinal burn from a handheld Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser pulse device used to perform skin resurfacing treatment at a medical spa in Vietnam. The patient was not adequately informed about the potential risk to her vision and was not provided with any eye protection. A momentary, unintended laser exposure to the patient's right eye led to irreversible vision loss due to a macular burn. This incident caused immediate pain, followed by the sudden appearance of floaters, along with a retinal and vitreous hemorrhage. Despite treatment with off-label bevacizumab for the development of a choroidal neovascular membrane, vision remained at the level of counting fingers because of the presence of the macular scar.

CONCLUSION

When utilizing laser-based devices, it is crucial to employ safety measures, such as the wearing of safety goggles or the use of eye shields to protect ocular tissues from potential damage. The growing availability of cosmetic laser devices presents a substantial public health risk, because numerous operators lack adequate training in essential safety standards, or they neglect to follow them. Furthermore, patients seeking services abroad are subject to the regulatory practices of the destination country, which may not always enforce the requisite safety standards. Further research is needed to determine regional and global incidence of laser-related injuries to help direct educational and regulatory efforts.

Targeted Telephone-Based Outreach Reconnects Glaucoma Patients With Subspecialty Care

PRCIS

A personalized telephone-based intervention is a cost-effective method to return overdue patients with open angle glaucoma (OAG) to subspecialty care. Patients who accepted care overwhelmingly preferred in-person appointments with their provider instead of hybrid visits with telehealth.

PURPOSE

To evaluate the effectiveness of a telephone-based outreach strategy to reconnect OAG patients with subspeciality care.

PATIENTS AND METHODS

Established patients with OAG who were seen before March 1, 2021, but had not returned for care in the following year were contacted via a telephone-based intervention. Patients lost to follow-up (LTF) were offered the option of an in-person visit or a hybrid telehealth visit, which combined in-office testing of vision, intraocular pressure, and optic nerve imaging with a virtual consultation with their glaucoma specialist on a separate date.

RESULTS

Of 2727 patients with OAG, 351 (13%) had not returned for recommended care. Outbound calls reached 176 of those patients (50%). Nearly half of all patients contacted readily accepted care, with 71 scheduling in-person appointments (93%) and 5 selecting hybrid visits (6.6%). Medication refills were requested by 17 of those 76 patients, representing nearly a third of the 56 patients who were treated with topical glaucoma medications. Assessment of the program 90 days later found that 40 patients had returned for care, 100 patients had transferred or declined further care, and 40 patients were identified as deceased, lowering the LTF rate to 6.4%, with 15 patients still scheduled for future visits. On the basis of an average call duration of 2.8±2.0 minutes, the added cost of returning a patient with OAG to care by the program was $28.11.

CONCLUSIONS

Providing targeted outreach by telephone is an effective and cost-efficient strategy to reconnect OAG patients LTF with subspecialty care.

Patient adherence to therapy after switch to aflibercept from bevacizumab or ranibizumab for treatment-refractory neovascular age-related macular degeneration

PURPOSE

Clinical trials have demonstrated that switching patients from intravitreal bevacizumab (IVB) or ranibizumab (IVR) to aflibercept (IVA) for treatment-refractory neovascular age-related macular degeneration (nAMD) can decrease the injection frequency. This study evaluated whether there was a difference in the rate of injections or nonadherent events after switching therapies.

METHODS

The study comprised a retrospective, cross-sectional analysis of patients treated for nAMD from 2010 to 2018 who received ≥3 intravitreal injections of IVB/IVR prior to switching to IVA because of treatment-refractory nAMD. The treatment index, outcomes, and adherence to treatment were compared between both treatment regimens.

RESULTS

Sixty-two patients (67 eyes) met inclusion criteria. There was no change in the treatment index (0.65 versus 0.66, P = 0.650) or the number of nonadherent events (33 versus 36, P = 0.760) after the switch from IVB/IVR to IVA. Central macular thickness (CMT) increased 7.7%±13.8% in eyes that had a nonadherent event (283±69 µm to 304±75 µm after resuming care, P = 0.039). There was no short-term impact on visual acuity (VA) for this subset of eyes (0.387±0.202 LogMAR versus 0.365±0.156 LogMAR, P = 0.636). Patients who had nonadherent events ended the study with similar VA compared with patients who had no treatment lapses (0.370±0.616 LogMAR versus 0.337±0.638 LogMAR, P = 0.843).

CONCLUSION

Switching from IVB/ IVR to IVA for treatment-refractory nAMD in a real-world setting does not reduce the treatment index or increase adherence to treatment. Although there were short-term anatomical effects resulting from missed treatments, VA remained stable.

Telehealth improves follow-up and monitoring of age-related macular degeneration during the COVID-19 pandemic

PURPOSE

To prevent vision loss, it is important to monitor patients with age-related macular degeneration (AMD) for the development of choroidal neovascularization. The coronavirus disease 2019 (COVID-19) pandemic caused many patients to miss or delay visits. To offset those gaps in care, providers utilized telehealth (TH) to evaluate patients for symptoms of disease progression and provide health education on the importance of continuous monitoring.

METHODS

This study evaluates the impact of TH encounters on the rate of return for recommended in-person examinations for 1103 patients with non-neovascular (dry) AMD seen in an outpatient ophthalmology clinic in 2019 and due for return evaluation after the outbreak of COVID-19 in 2020. Logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with TH utilization and in-person return.

RESULTS

422 patients (38%) utilized TH during the study period. Patients who completed a TH encounter were more likely to return for an in-person examination as compared with those who did not receive TH (OR: 1.8, CI 95%: 1.4-2.3, P < 0.001). Completing a TH visit was associated with the detection of new wet AMD (OR: 3.3, 95% CI 1.04-10.6, P = 0.043), as well as with an earlier return for those patients who were found to have disease progression (62 ± 54 days vs. 100 ± 57 days, P = 0.049).

CONCLUSION

Completing a TH visit increased the rate at which patients with dry AMD returned for recommended in-person eye examinations. In many cases, this permitted the earlier detection of wet AMD, which is linked with achieving better outcomes.

Correction: Onwuka et al. Consequences of Real-World Surveillance of Fellow Eyes in Neovascular Age-Related Macular Degeneration. Life 2023, 13, 385

Text Correction [...].

The effects of female sex hormones on the human cornea across a woman's life cycle

The cornea is a hormone-responsive tissue that responds to changing levels of female sex hormones. This review focuses on the structural and functional changes in the human cornea associated with the hormonal milestones of menarche, pregnancy, and menopause, as well as consequences stemming from the use of exogenous sex hormones for fertility control and replacement. Articles were identified by searching PubMed without language or region restrictions. The primary outcomes evaluated were changes in central corneal thickness (CCT), intraocular pressure (IOP), and quality of the ocular tear film. The potential impact of hormone-associated changes on the diagnosis and surgical management of common eye diseases, as well as the potential use of sex hormones as therapeutic agents is also considered. Understanding the physiological effects of female sex hormones on the cornea is important because that knowledge can shape the management decisions physicians and women face about ocular health across their life stages.

Factors Associated with Utilization of Teleretinal Imaging in a Hospital-Based Primary Care Setting

Regular eye examinations to screen for the initial signs of diabetic retinopathy (DR) are crucial for preventing vision loss. Teleretinal imaging (TRI) offered in a primary care setting provides a means to improve adherence to DR screening, particularly for patients who face challenges in visiting eye care providers regularly. The present study evaluates the utilization of TRI to screen for DR in an outpatient, hospital-based primary care clinic. Patients with diabetes mellitus (DM) but without DR were eligible for point-of-care screening facilitated by their primary care provider, utilizing a non-mydriatic, handheld fundus camera. Patient demographics and clinical characteristics were extracted from the electronic medical record. Patients who underwent TRI were more likely to be male, non-White, and have up-to-date monitoring and treatment measures, including hemoglobin A1c (HbA1c), microalbumin, and low-density lipoprotein (LDL) levels, in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. Our findings demonstrate that TRI can reduce screening costs compared to a strategy where all patients are referred for in-person eye examinations. A net present value (NPV) analysis indicates that a screening site reaches the break-even point of operation within one year if an average of two patients are screened per workday.

Diabetic microaneurysms detected by fluorescein angiography spatially correlate with regions of macular ischemia delineated by optical coherence tomography angiography

Purpose

To characterize the relationship between diabetic macular ischemia (DMI) delineated by optical coherence tomography angiography (OCTA) and microaneurysms (MAs) identified by fundus fluorescein angiography (FFA).

Methods

Patients with diabetic retinopathy (DR) who underwent OCTA and FFA were retrospectively identified. FFA images were cropped and aligned with their respective OCTA images using i2k Align Retina software (Dual-Align, Clifton Park, NY, USA). Foveal avascular zone (FAZ) and ischemic areas were manually delineated on OCTA images, and MAs were marked on the corresponding FFA images before overlaying paired scans for analysis (ImageJ; National Institutes of Health, Bethesda, MD, USA).

Results

Twenty-eight eyes of 20 patients were included. The average number of MAs identified in cropped FFA images was 127 ± 42. More DMI was noted in the superficial capillary plexus (SCP; 36 ± 13%) compared to the deep capillary plexus (DCP; 28 ± 14%, P < 0.001). Similarly, more MAs were associated with ischemic areas in SCP compared to DCP (92.0 ± 35.0 vs. 76.8 ± 36.5, P < 0.001). Most MAs bordered ischemic areas; fewer than 10% localized inside these regions. As DMI area increased, so did associated MAs (SCP: r = 0.695, P < 0.001; DCP: r = 0.726, P < 0.001). Density of MAs surrounding FAZ (7.7 ± 6.0 MAs/mm2) was similar to other DMI areas (SCP: 7.0 ± 4.0 MAs/mm2, P = 0.478; DCP: 9.2 ± 10.9 MAs/mm2, P = 0.394).

Conclusion

MAs identified in FFA strongly associate with, and border areas of, DMI delineated by OCTA. Although more MAs are localized to SCP ischemia, the concentration of MAs associated with DCP ischemia is greater. By contrast, few MAs are present inside low-flow regions, likely because capillary loss is associated with their regression.

Effectiveness and Financial Viability of Telehealth Physician Extenders for Re-Engagement of Patients with Diabetic Retinopathy

Purpose: To assess the effectiveness and financial implications of employing a telehealth physician extender program to re-engage patients with diabetic retinopathy (DR) who are lost to follow-up (LTF). Methods: Established patients with DR unevaluated in the prior 12 months were identified as LTF, and randomized to receive a recall intervention or standard operating procedure (SOP). For the intervention, a telehealth physician extender performed outbound calls, offering each patient a symptom screening questionnaire following a physician-directed escalation pathway and assistance in scheduling a return appointment. All patients retained the ability to schedule an appointment by means of SOP. Appointment schedule and adherence rates were assessed 30 days after a 6-week intervention period. Call times were digitally measured to estimate intervention labor cost. Results: Four hundred twenty-five of 2,514 established patients with DR were LTF (17%). One hundred fifty-seven patients were assigned to the intervention group; the remaining 268 formed the SOP group. Sixty-six outbound calls reached patients (42%). At the time of program assessment, the intervention group demonstrated a higher rate of appointment scheduling (31% vs. 14%, p < 0.001) and adherence (14% vs. 7%, p = 0.020). The measured call duration was 2.3 ± 1.9 min, yielding an estimated cost of US$4.70 per appointment scheduled. Conclusion: Re-engagement by a telehealth physician extender improves the rate at which patients with DR return for eye care, and can be done at a reasonable cost. This method of improving adherence with follow-up should be readily translatable to other health care settings.

Second eyes to develop neovascular age-related macular degeneration have fewer symptoms and better one-year visual outcomes

BACKGROUND

This study compares the visual and anatomical outcomes for the eyes of patients who developed sequential neovascular age-related macular degeneration (nAMD), both at the time of diagnosis and at one year after treatment.

METHODS

The study comprised a retrospective case series of 52 patients whose eyes were diagnosed sequentially with nAMD. All eyes were treated with three monthly loading doses of anti-vascular endothelial growth factor agents, followed by further intravitreal injections, as required. Baseline characteristics and outcomes at one year after diagnosis and initial treatment were compared between first and second eyes and included visual acuity (VA), central macular thickness (CMT), and pigment epithelial detachment (PED) height on optical coherence tomography (OCT) imaging.

RESULTS

VA at diagnosis was better for second eyes compared with first eyes to develop nAMD (logMAR 0.68 ± 0.51 versus logMAR 0.41 ± 0.34, P = 0.002) and remained so at one year (logMAR 0.61 ± 0.60 versus logMAR 0.42 ± 0.37, P = 0.041). Similarly, PED height at diagnosis was higher in first eyes (225 ± 176 μm versus 155 ± 144 μm, P = 0.003) and also at one year (188 ± 137 μm versus 140 ± 112 μm, P = 0.019). Whereas most patients reported symptoms at first eye diagnosis (71.2%), half as many second eyes were symptomatic (28.8%, P < 0.001). Significantly more symptomatic first eyes experienced visual distortions (32.4% versus 13.3%) or scotomas (29.4% versus 6.7%), compared with a less specific visual complaint of blurry vision (38.2% versus 80.0%, P = 0.006).

CONCLUSIONS

Compared with first eyes to develop nAMD, second eyes tended to have better vision, smaller PED heights, and fewer symptoms likely because monitoring permitted earlier diagnosis.

Predictors, Disparities, and Facility-Level Variation: SGLT2 Inhibitor Prescription Among US Veterans With CKD

RATIONALE & OBJECTIVE

Sodium/glucose cotransporter 2 (SGLT2) inhibitors are recommended for type 2 diabetes mellitus (T2DM) in patients with chronic kidney disease (CKD) or atherosclerotic cardiovascular disease (ASCVD). We evaluated factors associated with SGLT2 inhibitor prescription, disparities by race and sex, and facility-level variation in prescription patterns.

STUDY DESIGN

Retrospective cohort.

SETTING & PARTICIPANTS

A national sample of US veterans with comorbid T2DM, CKD, and ASCVD with a primary care visit between January 1 and December 31, 2020.

EXPOSURE

Race, sex, and individual Veterans Affairs (VA) location.

OUTCOME

SGLT2 inhibitor prescription.

ANALYTICAL APPROACH

Multivariable logistic regression assessed associations of race and sex with SGLT2 inhibitor prescription. Facility-level variation in SGLT2i prescription was quantified by median rate ratios (MRR), which express the likelihood that 2 randomly selected facilities differ in their use of SGLT2 inhibitor among similar patients.

RESULTS

Of 174,443 patients with CKD, T2DM, and ASCVD, 20,024 (11.5%) were prescribed an SGLT2 inhibitor. Lower odds of SGLT2 inhibitor prescription were seen in Black or African American patients compared with White patients (OR, 0.87 [95% CI, 0.83-0.91]) and among women compared with men (OR, 0.59 [95% CI 0.52-0.67]). The adjusted MRR for SGLT2 inhibitor prescription was 1.58 (95% CI 1.48-1.67) in the total cohort, indicating an unexplained 58% variation in treatment between VA facilities, independent of patient and facility characteristics. Facility-level variation was evaluated among Black or African American patients (MRR, 1.55 [95% CI 1.41-1.68]), White patients (MRR, 1.57 [95% CI 1.47-1.66]), women (MRR, 1.40 [95% CI 1.28-1.51]), and men (MRR, 1.57 [95% CI 1.48-1.67]).

LIMITATIONS

Albuminuria was not assessed.

CONCLUSIONS

Prescription for SGLT2 inhibitors was low among likely eligible patients, with evident disparities by sex and race and between individual VA facilities. Efforts are needed to study and address the reasons for these disparities to improve equitable adoption of these important medications.

Association of Diet Quality with Metabolic (Dysfunction) Associated Fatty Liver Disease in Veterans in Primary Care

BACKGROUND

Diet is associated with metabolic (dysfunction)-associated fatty liver disease (MAFLD), but the dietary composition associated with MAFLD risk has not been well-examined.

AIM

The purpose of this study was to assess the association of two healthy eating indices with the presence and severity of MAFLD in a sample of Veterans in a primary care setting.

METHODS

This was a single center cross-sectional study using a random stratified sample of Veterans enrolled in primary care. Participants underwent a Fibroscan and completed an interviewer-administered Diet History Questionnaire II from which we calculated the Healthy Eating Index-2015 and Alternate Mediterranean Diet Score. We used multivariable logistic regression models to assess associations of dietary quality with MAFLD.

RESULTS

We analyzed data from 187 participants, 53.5% of whom were female. On average, participants were 50.2 years of age (SD, 12.3 years) with an average BMI of 31.7 kg/m2. MAFLD was detected in 78 (42%) and at least moderate fibrosis in 12 (6%) participants. We found that the Alternate Mediterranean Diet Score was inversely associated with MAFLD (adjusted OR = 0.85, 95%CI 0.72-1.00), but controlling for BMI and total energy intake attenuated the association (adjusted OR = 0.92, 95%CI 0.74-1.15). We found no statistically significant associations between the Healthy Eating Index-2015 and MAFLD or advanced fibrosis.

DISCUSSION

We found that the Alternate Mediterranean Diet Score was significantly associated with lower MAFLD risk in Veterans; however, the association was mediated by BMI and total energy intake. A Mediterranean-style diet could potentially help reduce the risk of MAFLD, particularly if it helps control total energy intake and weight.

Birt-Hogg-Dubé syndrome associated with chorioretinopathy and nyctalopia: a case report and review of the literature

PURPOSE

To report a rare case of Birt-Hogg-Dubé Syndrome (BHD) with progressive chorioretinopathy.

METHODS

Case report.

RESULTS

A 55-year-old woman presented with longstanding nyctalopia attributed to a congenital retinal dystrophy, but no prior genetic testing. Her posterior pole examination demonstrated retinal pigment epithelium (RPE) mottling with extensive macular drusen and paracentral chorioretinal atrophy, consistent with a fleck retinopathy. Her past medical history was remarkable for nephrectomy for unilateral renal malignancy, parotid tumors and thyroid nodules. Dark adaptation time was prolonged, and electroretinography (ERG) revealed abnormal waveforms with depressed amplitudes. Genetic testing confirmed a deletion mutation in the folliculin (FLCN) gene and was negative for other relevant mutations, including EFEMP1 responsible for autosomal dominant macular and peripapillary drusen in Doyne honeycomb retinal dystrophy and TIMP3 responsible for Sorsby Fundus Dystrophy.

CONCLUSION

BHD is a rare autosomal-dominant disorder with multi-systemic clinical manifestations caused by a mutation in the FLCN gene. Affected individuals are prone to renal and pulmonary cysts, renal cancer, and fibrofolliculomas. Reports on ocular manifestations of BHD include eyelid fibrofolliculomas, flecked chorioretinopathy, choroidal melanoma, choroidal melanoma with sector melanocytosis, and retinal pigment epithelial micro-detachments. In this case of BHD, we note a fleck retinopathy with bilateral chorioretinal atrophy, displaying a phenotype of extensive chorioretinopathy associated with impaired dark adaptation and ERG abnormalities.

ABBREVIATIONS

BHD: Birt-Hogg-Dubé syndrome; FLCN: Folliculin. RPE: retinal pigment epithelium; OD: Oculus dexter (right eye); OS: Oculus sinister (left eye). OU: Oculus uterque (both eyes); ERG: electroretinogram; mfERG: multifocal electroretinography. ffERG: full-field electroretinography; FAF: fundus autofluorescence; OCT: optical coherence tomography; FA: fluorescein angiography; DA: dark-adapted; LA: light-adapted; mTOR: mammalian target of rapamycin; EFEMP1: epithelial growth factor-containing fibulin-like extracellular matrix protein 1; VPS13B: Vacuolar Protein Sorting 13 Homolog B; AGBL5: AATP/GTP-Binding Protein Like 5; ALMS1: Alstrom Syndrome 1; COL1BA1: Collagen Type I Beta, Alpha Chain 1; PDE6A: Rod Phosphodiesterase 6-alpha; USH2A: Usherin 2a; VCAN: Versican; RP: Retinitis pigmentosa; AR: Autosomal recessive.

Characteristics associated with persistent versus transient food insecurity among US veterans screened in the Veteran Health Administration

BACKGROUND

Awareness of negative health impacts associated with food insecurity among US veterans is growing. Yet, little research has examined characteristics associated with persistent versus transient food insecurity.

OBJECTIVE

To investigate characteristics associated with persistent versus transient food insecurity among US veterans.

DESIGN

The study used a retrospective, observational design to examine data from Veteran Health Administration (VHA) electronic medical records.

PARTICIPANTS/SETTING

The sample consisted of veterans (N=64,789) who screened positive for food insecurity in VHA primary care during fiscal years 2018-2020 and were rescreened within 3-15 months.

MAIN OUTCOME MEASURES

Food insecurity was operationalized using the VHA food insecurity screening question. Transient food insecurity was a positive screen followed by a consecutive negative screen within 3-15 months. Persistent food insecurity was a positive screen followed by a consecutive positive screen within 3-15 months.

STATICAL ANALYSES

A multivariable logistic regression model was used to assess characteristics (e.g., demographics, disability rating, homelessness, physical and mental health conditions) associated with persistent versus transient food insecurity.

RESULTS

Veterans with increased odds of persistent versus transient food insecurity included men (AOR=1.08, 95%CI[1.01, 1.15]) and those from Hispanic (AOR=1.27, 95%CI[1.18, 1.37]) or Native American (AOR=1.30, 95%CI[1.11, 1.53]) racial/ethnic groups. Psychosis (AOR=1.16, 95%CI[1.06, 1.26]), substance use disorder excluding tobacco/alcohol (AOR=1.11, 95%CI[1.03, 1.20]), and homelessness (AOR=1.32, 95%CI[1.26, 1.39]) were associated with increased odds of persistent versus transient food insecurity. Veterans who were married (AOR=0.87, 95%CI[0.83, 0.92]) or had service-connected disability rating of 70-99% (AOR=0.85, 95%CI[0.79, 0.90]) or 100% (AOR=0.77, 95%CI[0.71, 0.83]) had lower odds of persistent versus transient food insecurity.

CONCLUSIONS

Veterans at risk for persistent versus transient food insecurity may struggle with underlying issues like psychosis, substance use, and homelessness alongside racial/ethnic inequities and gender differences. More research is needed to understand characteristics and mechanisms that increase risk for persistent versus transient food insecurity among veterans.

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention-Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Multimodal image alignment aids in the evaluation and monitoring of sector retinitis pigmentosa

PURPOSE

To present a semi-automated method of image alignment to aid in monitoring the progression of inherited retinal degenerations (IRDs).

RESULTS

A 22-year-old woman presented with nyctalopia and a family history of retinitis pigmentosa (RP), but with no prior genetic testing. Fundus examination showed a sectoral retinal degeneration involving the inferior and nasal retina with rare, pigmented deposits. Goldmann kinetic perimetry demonstrated corresponding superotemporal visual field defects. The best-corrected visual acuity was 20/20 in both eyes. Multimodal imaging delineated geographically restricted peripheral retinal degeneration extending to the inferior edge of the macula. Central visual function remained intact with normal multifocal electroretinography findings. Optical coherence tomography (OCT) through the leading edge of the retinal degeneration confirmed loss of the photoreceptor layer and associated retinal pigment epithelium. In the region of retinal degeneration, loss of vascular flow density was noted on optical coherence tomography angiography (OCTA). Genetic testing identified a pathologic sequence variant in RHO (c.68C>A, p.Pro23His), confirming autosomal dominant sector retinitis pigmentosa (SRP). Image alignment allowed for precise measurement of the progression of SRP over a period of 18 months.

CONCLUSION

SRP is a rare subtype of RP characterized by focal, typically inferior and nasal, retinal degeneration of the peripheral retina. Although the onset and extent of peripheral retinal degeneration varies, compared with RP, SRP typically progresses more slowly to involve the macula. In this report, we highlight the utility of image registration and alignment to aid in monitoring disease progression in IRDs by means of multimodal imaging.

Consequences of Real-World Surveillance of Fellow Eyes in Neovascular Age-Related Macular Degeneration

This study investigated whether the interval of monitoring at-risk, fellow eyes of patients with unilateral neovascular age-related macular degeneration (nAMD) has any bearing on the severity of the disease at the time of diagnosis. The study comprised a retrospective, cross-sectional comparative case series of treatment-naïve eyes in patients who were diagnosed sequentially with nAMD. We compared the visual acuity (VA) and central macular thickness (CMT) of patients who were actively receiving intravitreal injections (IVIs) of anti-vascular endothelial growth factor (anti-VEGF) agents at the time of second eye diagnosis with the VA and CMT of patients who had ceased treatment in their first eye because of reaching end-stages of disease. Intervals of visits and frequency of monitoring the macula of fellow eyes by means of optical coherence tomography (OCT) were abstracted from the medical record. We found that the at-risk fellow eyes of patients who had stopped treatment for nAMD in their first eye prior to fellow eye conversion were monitored significantly less frequently than the fellow eyes of patients who continued to receive treatment at the time of second eye diagnosis. Despite less frequent monitoring, VA and CMT were similar at the time of fellow eye diagnosis for both groups.

Papilledema and retinopathy lead to diagnosis of IgA nephropathy: a case report

This case features a young healthy male who was diagnosed with immunoglobulin A (IgA) nephropathy after presenting with blurry vision that was caused by hypertensive retinopathy and papilledema. In this report, we examine the relationship between hypertension and increased intracranial pressure (ICP), along with the ocular signs of IgA nephropathy that may present in the setting of kidney disease.

648. Cefiderocol as Rescue Therapy for Pseudomonas aeruginosa and Other Difficult-To-Treat Gram-Negative Infections

Background

Cefiderocol is a novel siderophore cephalosporin and the only beta-lactam that has demonstrated in vitro activity against metallo-beta-lactamase producing organisms. The open-label phase 3 study CREDIBLE-CR unexpectedly found a higher mortality rate in the cefiderocol group compared to best available therapy. Post-approval, real-world clinical data of cefiderocol use are limited. We sought to describe nationwide, real-world outcomes, clinical characteristics, and microbiological characteristics of infections treated with cefiderocol.

Cefiderocol use since FDA approval (Nov 2019)

Methods

The Department of Veterans Affairs (VA) Corporate Data Warehouse was queried to identify any patient prescribed cefiderocol at any of the 171 VA medical centers from date of FDA approval in 11/2019 until 11/2021. Clinical, pharmacy, demographics, and microbiology data were computationally extracted, supplemented by manual review. All patient charts were manually reviewed to determine the indication for cefiderocol and clinical outcomes.

Results

Twenty-five patients have been prescribed cefiderocol; two received only one dose, and one patient had incomplete records. Prior to 2021 there were four prescription, and since 2021 there have been 21 prescriptions. Of the 22 evaluated patients, their median age was 70 years and 82% were receiving care in the ICU. Infecting organisms (n=25) were Pseudomonas aeruginosa 63%, A. baumannii 18.5%, and Enterobacterales 18.5%. Cefiderocol susceptibility was tested on 17 isolates, of which 15 (88.2%) were susceptible. The two non-susceptible organisms were A. baumannii and P. aeruginosa. The susceptibilities of the 25 strains overall were as follows: carbapenems (13.8%), ceftazidime/avibactam (4 of 12, or 33.3%), and ceftolozane/tazobactam (7 of 15, or 46.7%). The most common infectious syndromes were pulmonary and central line-related infections, occurring in 38.5% and 23.1%, respectively. The 28-day mortality rate was 31.8%, 28-day clinical failure rate was 45.5%, and the 28-day microbiological failure rate was 31.8%.

Conclusion

Patients prescribed cefiderocol in this series had severe infections with high rates of mortality and few alternative antibiotic options. Susceptibility to cefiderocol was higher than for other antibiotics tested.

Disclosures

Barbara Trautner, MD, PhD, Genetech: Advisor/Consultant.

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.

953. Implementation Outcomes in an Antibiotic Stewardship Program (Kicking CAUTI) in Four Veterans Hospitals Correlated with Clinical Outcomes

Background

One of the major barriers to scale up of antibiotic stewardship interventions is the difficulty of engaging already overtaxed personnel. As part of a multisite antibiotic stewardship project to decrease antibiotics treatment of asymptomatic bacteriuria, we explored how to measure local implementation efforts, and what dose of the intervention was necessary to improve clinical outcomes.

Methods

The intervention was implemented in 4 different sites from February 2019 through May 2020. We chose 3 measures of implementation: the number of intervention delivery sessions (adoption), total number of health care professionals reached (penetration), and minutes spent in delivery of the intervention (adoption). Local site champions kept activity logs. Antibiotic prescriptions were included if ordered within one calendar day prior or two days after a urine culture was ordered on the same patient. Correlation between implementation measures and clinical outcomes (number of urine cultures ordered, days of antibiotic treatment (DOT), and length of antibiotic treatment (LOT)) was calculated using the mixed linear models method.

Results

Overall, the minutes spent in delivery ranged from 2567 minutes at the most engaged site to 679 in the least engaged site (Figure 1). The number of healthcare professionals reached ranged from 798 to 433, and the number of sessions delivered ranged from 240 to 45. Minutes spent in delivery was inversely correlated with two of our three clinical metrics, DOT (R -0.3, P=0.04) and LOT (R -0.3, P=0.02); minutes spent and urine cultures were not significantly correlated (Table 1). We did not find a significant relationship between the number of intervention delivery sessions or total number of health care professionals reached and any of the clinical outcomes. Figure 1

Deformation of Aflibercept and Ranibizumab Syringes Causes Variation in Intravitreal Injection Volume and Risks Retinal Tear Formation

PURPOSE

The intravitreal injection volume is known to vary with plunger alignment and the speed of injection. We investigated the role that syringe stopper deformation plays in allowing excess volumes to be injected into the eye and the potential for the vitreous humor to become incarcerated when excess force is released within the eye.

DESIGN

Experimental study.

METHODS

Aflibercept prefilled syringes (PFSs), ranibizumab PFSs, and 1-ml tuberculin (TB) syringes were subjected to increasing injection force to assess the extent to which each design allowed for excess volumes to be expelled after the stopper reached the bottom of the syringe barrel (i.e., after the 50-μl dose was expelled).

MAIN OUTCOME MEASURES

Additional volume expelled with stopper deformation.

RESULTS

Syringe stoppers are capable of deformation into the dead space when additional force is applied. This allows for progressively greater medication doses to be administered. At an additional force of 3.92 N after the syringe stopper came in contact with the bottom of the syringe barrel, the aflibercept PFSs, ranibizumab PFSs, and 1-ml TB syringes dispensed an additional 17.2%, 11.4%, and 0.8% higher volume than the intended volume of 50 μl, respectively. Upon release of this force, a proportional volume was observed to be drawn back into the needle.

CONCLUSIONS

The intravitreal injection volume varies with the force applied to fully depressed syringes because of syringe stopper deformation. We advise that performing forceful intravitreal injections be avoided to prevent excessive dosing of medication. We also caution that pressure applied to the plunger during intravitreal injections not be released while the needle is in the vitreous cavity to guard against vitreous incarceration, which could lead to retinal tear formation or detachment.

Risk factors associated with sickle cell retinopathy: findings from the Cooperative Study of Sickle Cell Disease

Background

Sickle cell retinopathy (SCR) is one of the most important ocular manifestations of sickle cell disease (SCD). This study aims to assess the prevalence of SCR in SCD, identify risk factors for its development and progression to proliferative sickle cell retinopathy (PSCR), and evaluate the potential implications of these results on clinical practice.

Methods

This research is a secondary analysis of patients diagnosed with SCD from the epidemiological, multicenter Cooperative Study of Sickle Cell Disease (CSSCD). We included all patients who completed a full ophthalmic evaluation. We identified clinical and laboratory SCD characteristics associated with SCR using multivariate logistic regression models. Proliferative sickle cell retinopathy (PSCR) was diagnosed according to the Goldberg classification system.

Results

Of the 1904 study participants with SCD who met the inclusion criteria, 953 (50.1%) had retinopathy; of which 642 (67.3%) had bilateral disease. SCR was associated with older age (p < 0.001), history of smoking (p = 0.001), hematuria (p = 0.050), and a lower hemoglobin F (HbF) level (p < 0.001). PSCR risk increased with smoking (p = 0.005), older age (p < 0.001) higher hemoglobin level (p < 0.001) and higher white blood cell count (p = 0.011). Previous blood transfusion (p = 0.050), higher reticulocyte count (p = 0.019) and higher HbF level (p < 0.001) were protective factors against the development of PSCR. Ocular symptoms were associated with progression to PSCR in patients with SCR (p = 0.021).

Conclusion

In this cohort of individuals with SCD, half of the participants had signs of SCR. Smoking and blood hemoglobin level were the two modifiable risk factors associated with increased retinopathy progression. Screening to identify the different stages of retinopathy, actively promoting smoking cessation, and optimizing the hematological profile of patients with SCD should guide treatment protocols designed to prevent the vision-threatening complications of the disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00419-8.

Visual recovery after unilateral optic nerve sheath fenestration for pseudotumor cerebri syndrome

PURPOSE

To evaluate the effect of optic nerve sheath fenestration (ONSF) on the rate of visual function improvement in patients with pseudotumor cerebri syndrome (PTCS).

METHODS

Retrospective chart review of patients with PTCS who underwent ONSF between 1998 and 2017. Visual function was evaluated by evaluating visual field (VF), mean deviation (MD), retinal nerve fiber layer (RNFL) thickness, papilledema grade, and visual acuity (VA) prior to and after ONSF.

RESULTS

Seventeen female patients aged 17 to 36 years underwent unilateral ONSF. Follow-up averaged 40.1 months. VF MD improved steadily in both eyes up to 12 months. Average RNFL thickness improved in the operated eye from 347 ± 166 mm to 92 ± 27 mm (p < .001) and the non-operated eyes from 306 ± 165 mm to 109 ± 46 mm (p < .001). The grade of papilledema improved in the operated eye from 3.3 ± 1.3 to 0.3 ± 0.7 and the non-operated eye from 3.0 ± 1.6 to 0.18 ± 0.4. There was an exponential rate of improvement in papilledema and RNFL thickness, with the greatest improvement occurring within the first 30 days. Average visual acuity remained intact in both eyes before and after surgery.

CONCLUSIONS

ONSF in appropriately selected patients leads to rapid improvement in papilledema and a steady recovery in VF.

Intraocular pressure decreases in eyes with glaucoma-related diagnoses after conversion to aflibercept for treatment-resistant age-related macular degeneration

OBJECTIVE

To understand intraocular pressure (IOP) response after switching from intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) to intravitreal aflibercept (IVA) for treatment-resistant neovascular age-related macular degeneration (nAMD) in patients with and without coexisting glaucoma-related diagnoses.

METHODS

Retrospective, cross-sectional comparative case series of 62 eyes of 58 patients treated with intravitreal injection for nAMD from March 2010 to April 2018. Patients with glaucoma-related diagnoses, defined here as open-angle glaucoma or suspicion of open-angle glaucoma, ocular hypertension, and/or narrow-angle glaucoma, were compared to those without glaucoma. IOP data were collected at baseline, at the three visits where patients received loading doses of IVB/IVR, and at all of the visits following the switch to IVA through the end of follow-up.

RESULTS

19 eyes with pre-existing glaucoma-related diagnoses were compared to 43 eyes without such diagnoses. Baseline IOP was similar for glaucoma and non-glaucoma patients. The loading doses of IVB/IVR did not impact IOP; however, a small, sustained rise in IOP was noted among patients with glaucoma-related diagnoses by the final IVB/IVR injections before the switch to IVA (∆IOP 1.61 ± 0.52 mmHg, P < 0.002). After conversion to IVA, pre-injection IOP declined in eyes both with (-1.59 ± 0.54 mmHg, P < 0.001) and without (-0.99 ± 0.28 mmHg, P < 0.001) glaucoma-related diagnoses.

CONCLUSIONS

IOP in patients with glaucoma-related diagnoses appears to be more sensitive to intravitreal injections than it is in patients without glaucoma-related diagnoses. It rises with IVB/IVR and declines after the switch to IVA. Switching patients with nAMD to IVA may present an opportunity to lower IOP in patients with glaucoma.

Natriuretic peptides, extracellular volume, and subclinical cardiovascular changes in chronic kidney disease stages 1-3: a pilot study

Natriuretic peptide levels are elevated in persons with chronic kidney disease (CKD) stages 1-3, but it remains unclear whether this is associated with extracellular volume excess or early cardiovascular changes. We hypothesized that patients with CKD stages 1-3 would have evidence of cardiovascular changes, which would associate with brain natriuretic peptide (BNP), amino-terminal-pro-BNP (NT-pro-BNP), and patient-reported symptoms.Outpatients with CKD stages 1-3 and non-CKD controls were enrolled. Cardiovascular parameters included extracellular water (ECW) normalized to body weight measured using whole-body multifrequency bioimpedance spectroscopy, and total peripheral resistance index (TPRI) and cardiac index measured by impedance cardiography. Dyspnea, fatigue, depression, and quality of life were quantified using questionnaires.Among 21 participants (13 with CKD), median (IQR) BNP was 47.0 (28.0-302.5) vs 19.0 (12.3-92.3) pg/mL, p=0.07, and NT-pro-BNP was 245.0 (52.0-976.8) vs 26.0 (14.5-225.8) pg/mL, p=0.08, in the CKD and control groups, respectively. Those with CKD had higher pulse pressure (79 (66-87) vs 64 (49-67) mm Hg, p=0.046) and TPRI (3721 (3283-4278) vs 2933 (2745-3198) dyn×s/cm5/m2, p=0.01) and lower cardiac index (2.28 (2.08-2.78) vs 3.08 (2.43-3.37) L/min/m2, p=0.02). In the overall cohort, natriuretic peptides correlated with pulse pressure (BNP r=0.59; NT-pro-BNP r=0.58), cardiac index (BNP r=-0.76; NT-pro-BNP r=-0.62), and TPRI (BNP r=0.48), p<0.05 for each, but not with ECW/weight. TPRI and blood pressure correlated moderately with symptoms.Elevated natriuretic peptides may coincide with low cardiac index and elevated peripheral resistance in patients with CKD stages 1-3. The role of these biomarkers to detect subclinical cardiovascular changes needs to be further explored.

Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

Purpose

The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19.

Methods

This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed.

Results

The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ²=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ²=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ²=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ²=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model.

Conclusion

Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

Correlates of Glucagon-Like Peptide-1 Receptor Agonist Use Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes Mellitus (from the Department of Veterans Affairs)

This study used data from the Veterans Affairs administrative and clinical dataset to evaluate determinants of glucagon-like peptide-1 receptor agonist (GLP-1 RA) use among patients with concomitant atherosclerotic cardiovascular disease and diabetes mellitus and an antecedent primary care provider visit. The prevalence of GLP-1 RA use was 8.0%. In multivariable-adjusted models, White race, hypertension, obesity, higher hemoglobin A1c, ischemic heart disease, chronic kidney disease, a higher number of primary care provider visits, and previous cardiology or endocrinology visits were directly associated with GLP-1 RA use. Older age, having a physician primary care provider, and receiving care at a teaching facility were inversely associated with GLP-1 RA use. Our data can help inform targeted interventions to promote equitable access to GLP-1 RA and incentivize the adoption of these disease-modifying agents in high-risk patient populations.

Correlates of SGLT-2-inhibitiors use among patients with atherosclerotic cardiovascular disease and type 2 diabetes mellitus: Insights from the department of veterans affairs

This study using data from the Veterans Affairs (VA) administrative and clinical dataset examined determinants of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) use among patients with concomitant atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus. The aim of the present analysis was to identify barriers and facilitators associated with SGLT-2i in a real-world contemporary patient population in order to improve utilization of these guideline-directed agents.

An initiative to improve follow-up of patients with diabetic retinopathy

BACKGROUND

This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at identifying and reducing the number of patients with diabetic retinopathy (DR) lost to follow-up (LTF).

METHOD

Providers were enlisted to review the EMRs and re-engage patients with DR seen 1 year prior and who had not returned for care within the past 6 months. Binary logistic regression analysis was used to identify demographic, clinical and sociomedical factors associated with being LTF, as well as those predictive of re-engagement.

RESULTS

Out of 673 patients with DR, 78 (12%) were identified as LTF. Patients LTF were more likely to be younger (p = 0.001) and have poorly controlled haemoglobin A1c (HbA1c ≥ 8%, p = 0.04) and cholesterol (LDL ≥ 100 mg/dL, p < 0.001) levels. These patients were also more likely to have completed fewer ophthalmology appointments (p < 0.001), and less likely to have had retinal imaging within the last year (p < 0.001). Charts reviewed 1 month after the EMR-based initiative revealed that 22 patients (28%) had been successfully re-engaged by providers, while 56 patients (72%) remained LTF. History of prior treatment for DR was associated with re-engagement by providers (p = 0.04). One month following the provider-based intervention, the LTF rate dropped to 8.3%, and by 1 year only 3.6% of the patients remained LTF.

CONCLUSIONS

Electronic medical record-based tools can successfully identify DR patients as being LTF, offering an opportunity for providers to re-engage patients in a timely manner. Future studies are needed to determine the long-term impact of patient re-engagement on DR outcomes and efficiency of clinical practice.

Missed Opportunities to Promptly Diagnose and Treat Adrenal Tumors

INTRODUCTION

Adrenal mass management guidelines are insufficiently applied, and timeliness of treatment is unknown. We evaluated missed opportunities to promptly diagnose and treat adrenal tumors that ultimately required adrenalectomy.

METHODS

From the Veterans Affairs Corporate Data Warehouse, we identified patients who underwent adrenalectomy (2010-2016) in the South-Central Veterans Affairs HealthCare Network and reviewed their records. Diagnostic timeliness was assessed by the interval between initial (index) imaging with adrenal abnormality and the next diagnostic step. Workup was defined as early (interval ≤6 mo) or late (>6 mo). Adrenalectomy was considered prompt when the interval between index imaging and adrenalectomy was ≤12 mo and delayed when this was >12 mo. We quantified diagnostic and treatment delays and assessed factors associated with delayed adrenalectomy.

RESULTS

During the study period, 84 patients underwent adrenalectomy: male (86.9%), White (57.1%), with a mean age of 58.7 y (±8.8). Of those, 25 (29.8%) had late workup, and 36 (42.9%) had delayed surgery (median interval: 44 mo, range 14-282). Late hormonal workup occurred in 24 of 36 (66.7%) patients with delayed surgery, compared with one of 48 (2.1%, P < 0.001) with prompt surgery.

CONCLUSIONS

Missed opportunities in prompt diagnosis and treatment were common in patients with adrenal masses ultimately requiring adrenalectomy. Late hormonal workup is associated with delayed adrenalectomy. Interventions are needed to aid clinicians to recognize the presence, promptly evaluate, and make guideline-informed decisions on the management of an adrenal mass.

Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs

OBJECTIVE

There is mounting evidence regarding the cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their use.

RESEARCH DESIGN AND METHODS

We used the nationwide Veterans Affairs (VA) health care system data set from 1 January 2020 to 31 December 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1 RA and the facility-level variation in their use. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1 RA in patients with ASCVD and T2DM.

RESULTS

Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received an SGLT2i while 8.0% of patients received a GLP-1 RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10th-90th percentile) facility-level rates were 14.92% (9.31-22.50) for SGLT2i and 10.88% (4.44-17.07) for GLP-1 RA. There was significant facility-level variation among SGLT2i use-MRRunadjusted: 1.41 (95% CI 1.35-1.47) and MRRadjusted: 1.55 (95% CI 1.46 -1.63). Similar facility-level variation was observed for use of GLP-1 RA-MRRunadjusted: 1.34 (95% CI 1.29-1.38) and MRRadjusted: 1.78 (95% CI 1.65-1.90).

CONCLUSIONS

Overall utilization rates of SGLT2i and GLP-1 RA among eligible patients are low, with significantly higher residual facility-level variation in the use of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients.

Assessing optometric care delivered by telehealth during the COVID-19 public health emergency

Background:

The emergence of coronavirus disease 2019 (COVID-19) forced many eye care providers to implement telehealth services while in-person visits were reserved for essential and/or emergency eye care.

Objective:

This study documents how an optometry group successfully implemented telehealth to care for patients during the outbreak of the COVID-19 pandemic in the United States.

Design:

Retrospective, comparative case series.

Methods:

Records were reviewed for patients seen in an academic optometry clinic from 23 March through 7 April 2020, the period of the Massachusetts stay-at-home advisory issued in response to COVID-19. Patients who completed telehealth visits were compared with those who received in-person care. Services delivered by telehealth included a check of symptoms, medication refills, health education, and assurance of future follow up. The study took into account the reason for each visit, as well as the rate of scheduled and completed follow-up appointments. Patient satisfaction with in-person care was evaluated by Press Ganey patient experience surveys.

Results:

Out of 855 patients scheduled, 421 patients completed telehealth encounters (49%), and 46 patients completed in-clinic visits (5.4%). A further 272 patients canceled appointments (32%), 123 patients were unable to be contacted (14%), and 8 patients declined care offered by telehealth (0.94%). Most patients who were cared for by telehealth returned to see optometrists (88%). By contrast, most patients who required in-person visits during this period were subsequently seen by ophthalmologists (58%, p < 0.001). Patient satisfaction remained high for in-person visits that took place during the COVID-19-related emergency, with improvements noted in patient satisfaction regarding ‘information about delays’ (47 % versus 100%, p = 0.007) and ‘concern for questions or worries’ (76% versus 100%, p = 0.037) compared with the same period 1 year prior.

Conclusion:

Optometrists rapidly embraced telehealth to deliver eye care to their patients during the COVID-19 public health emergency. Most eye issues were able to be addressed through telehealth; urgent eye problems were triaged and referred to the optometry clinic, when appropriate.

Optical Coherence Tomography Angiography Biomarkers Predict Anatomical Response to Bevacizumab in Diabetic Macular Edema

PURPOSE

To identify biomarkers that may predict an early anatomical response to the treatment of diabetic macular edema (DME) with intravitreal bevacizumab (IVB) by means of optical coherence tomography angiography (OCTA).

METHODS

This study is a retrospective study of treatment-naïve patients with DME who underwent 6 × 6 mm OCTA imaging of the macula at baseline and after three monthly IVB injections. Thirty-six eyes of 23 patients were included. Eyes that demonstrated evidence of an early anatomical response, consisting of a >10% decrease in central macular thickness (CMT) (n = 18), were compared with those eyes that failed to show such an improvement (n = 18).

RESULTS

At baseline, early-response eyes had worse starting best-corrected visual acuity (BCVA, LogMAR 0.84 ± 0.41 versus LogMAR 0.51 ± 0.15, p = 0.004) and a larger CMT (490 ± 135 µm versus 356 ± 33 µm, p = 0.001), but smaller foveal avascular zones (FAZ) (0.309 ± 0.098mm versus 0.413 ± 0.095 mm, p = 0.003) compared with eyes that proved refractory to three monthly injections of IVB. The vascular density (VD) in both the foveal superficial and deep capillary plexuses was significantly greater in eyes that showed an early-treatment response compared with eyes that were non-responders (24.86 ± 6.90% versus 19.98 ± 7.13%, p = 0.045 and 32.30 ± 4.88% versus 26.95 ± 7.25%, p = 0.028, respectively). Early-treatment response to IVB was predicted by starting CMT (r ²= 0.266, p = 0.001), FAZ size (r ²= 0.234, p = 0.003), and VD in the superficial parafovea (r ²= 0.217, p = 0.004) and deep fovea (r ²= 0.157, p = 0.037).

CONCLUSION

Projection-resolved OCTA may be useful in predicting an early anatomical response of DME to treatment with IVB.

End-stage crystalline maculopathy with retinal atrophy in Sjögren-Larsson syndrome: a case report and review of the literature

Sjögren-Larsson syndrome (SLS) is a rare, autosomal recessive neurocutaneous disorder. It is caused by the inheritance of sequence variants in the ALDH3A2 gene, which codes for fatty aldehyde dehydrogenase (FALDH). Universal signs of the condition are congenital ichthyosis, spastic paresis of the lower and upper limbs, and reduced intellectual ability. In addition to this clinical triad, patients with SLS experience dry eyes and decreased visual acuity caused by a progressive retinal degeneration. Examination of the retina in patients with SLS often reveals glistening yellow crystal-like deposits surrounding the fovea. This crystalline retinopathy often develops in childhood and is considered pathognomonic for the disease. The metabolic disorder typically shortens lifespan to half that of the unaffected population. However, now that patients with SLS live longer, it becomes increasingly important to understand the natural course of the disease. Our case describes a 58-year-old woman with advanced SLS whose ophthalmic examination illustrates the end-stage of the retinal degeneration. Optical coherence tomography (OCT) and fluorescein angiography confirm the disease is restricted to the neural retina with dramatic thinning of the macula. This case is unique since it is among the most advanced both in terms of chronological age and severity of retinal disease. While the accumulation of fatty aldehydes, alcohols, and other precursor molecules is the probable cause of retinal toxicity, a more complete understanding of the course of retinal degeneration may aid in the development of future treatments. The aim of our presentation of this case is to increase awareness of the disease and to foster interest in therapeutic research which may benefit patients with this rare condition.

Optic neuropathy after COVID-19 vaccination: a report of two cases

PURPOSE

We report two cases of optic nerve pathology after the administration of the Pfizer-BioNTech and AstraZeneca-Oxford COVID-19 vaccines, respectively, and describe the implications for management of post-vaccination central nervous system (CNS) inflammation.

CASE REPORTS

A 69-year-old woman presented with bilateral optic nerve head oedema, 16 days after the second dose of the Pfizer-BioNTech vaccine. She was diagnosed with post-vaccination CNS inflammatory syndrome and was treated for five days with intravenous methylprednisolone at a dose of 1 gram per day. Her optic disc swelling improved, and her vision stabilised. A 32-year-old woman presented six days after her first dose of the AstraZeneca-Oxford vaccine with two days of sudden onset of progressive blurring of vision in her left eye. Posterior segment examination revealed left optic disc swelling, and an MRI of the brain, orbit, and cervical spine was significant for left optic nerve enhancement. The patient was diagnosed with a unilateral post-vaccination optic neuritis. She was treated with a three-day course of intravenous methylprednisolone followed by oral prednisone. Her optic disc swelling and visual field improved, and she recovered 6/6 vision.

CONCLUSIONS

Clinicians and patients should be aware of the potential for post-vaccination CNS inflammatory syndromes associated with COVID-19 vaccine administration. Neuroimaging and cerebrospinal fluid analysis may aid in the diagnosis of the cause of vision loss. Further studies are needed to evaluate the spectrum and frequency of optic nerve involvement associated with COVID-19 vaccination.

73. Identification of Novel Factors Associated with Inappropriate Treatment of Asymptomatic Bacteriuria Treatment in Acute and Long-term Care

Background

Inappropriate treatment of asymptomatic bacteriuria (ASB) is a major driver of antibiotic overuse. Demographic and laboratory factors associated with inappropriate antibiotic treatment include older age, pyuria, leukocytosis and dementia. To gain a deeper understanding of inappropriate ASB treatment, we performed an in-depth review of provider documentation capturing a broader range of misleading factors associated with ASB treatment.

Methods

We reviewed a random sample of 10 positive urine cultures per month per facility from acute or long-term care wards at eight Veteran’s Administration (VA) facilities from 2017-2019 (n=960). Trained chart reviewers classified cultures as UTI or ASB and as treated or untreated. Charts were searched specifically for mention of 8 categories of potentially misleading symptoms that often lead to overtreatment of ASB (e.g. “prior history of UTI”) (Figure legend). We also created a ‘suspected systemic inflammatory response syndrome (SIRS)’ category that included any mention of leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, or hypothermia. Generalized estimating equations logistic regression was used for analysis.

Results

Our study included 575 cultures from patients that were primarily white (71%) males (94%) from acute medicine units (75.7%) with a mean age of 76. Twenty-eight percent (n=159) of ASB cases received antibiotics. In addition to the usual known predictors, multiple new misleading symptoms were found to be associated with ASB treatment (Table). Novel, independent predictors of ASB treatment included behavioral issues, such as falls or fatigue (odds ratio (OR): 1.8; 95% CI: 1.05-3.07), urine characteristics, such as cloudy or odorous urine (OR: 1.41; 95% CI: 1.13-1.75), voiding issues (OR: 1.86; 95% CI: 1.43-2.41), and a single, free text mention of a SIRS criteria (OR: 1.63; 95% CI: 1.16-2.3).

Conclusion

Our in-depth chart review, with attention to misleading symptoms and any documentation of the provider thought process, highlights new factors associated with inappropriate ASB treatment. Patients with even a single SIRS criteria are at risk for unnecessary treatment of ASB; this finding can help design antibiotic stewardship interventions.

Disclosures

Barbara Trautner, MD, PhD, Genentech (Consultant, Scientific Research Study Investigator)

An Initiative to Improve Follow-up of Patients with Glaucoma

Purpose

This study describes the implementation of an electronic medical record (EMR)-based initiative aimed at reducing the number of patients with glaucoma-related diagnoses lost to follow-up (LTF) and reviews its short-term outcomes.

Design

Retrospective, comparative case series.

Participants

Patients with glaucoma-related diagnoses seen 1 year prior at the Lahey Medical Center and who had not returned within the 6-month period between January 1, 2020, and June 30, 2020, which spanned the outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic in the United States.

Methods

An EMR-based tool was designed to identify patients suspected of being LTF with glaucoma-related diagnoses. Providers were enlisted to review the EMR for each of these patients and re-engage them, as appropriate. One month later, the initiative was evaluated by means of a retrospective chart review. Binary logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with being LTF.

Main Outcome Measures

Patients who completed a telemedicine or in-person appointment, or had a future scheduled or ordered return appointment, were considered re-engaged.

Results

Of the 3551 patients seen during the study period, 384 patients were identified as LTF (11%), with 60 identifying COVID-19 as the reason for canceling their visit (16%). Patients who lived farther from the eye clinic (P < 0.001) or who had a history of canceling or missing an appointment (P < 0.001) were more likely to be LTF. Patients with open-angle glaucoma (P = 0.042) or who had completed a visual field (P < 0.001) or ophthalmic imaging (P < 0.001) within the past year were less likely to be LTF. One month after the re-engagement initiative, 124 LTF patients (32%) had been re-engaged (40% through telemedicine), 238 patients (62%) had future scheduling orders in place, and 22 patients (6%) had no active plan for future follow-up.

Conclusions

An EMR-based tool is an effective method for identifying patients at risk of being LTF and provides an opportunity for providers to recall and re-engage patients. Use of telemedicine to recontact LTF patients shows promise of improving the management of glaucoma, enhancing clinical productivity, and documenting treatment plans, thereby potentially reducing medicolegal liability.

Association of patient, provider and facility related characteristics with statin associated side effects and statin use: Insight from the veteran's affairs healthcare system

BACKGROUND

Statin associated side effects (SASE) are a leading cause of statin discontinuation.

OBJECTIVE

We evaluated patient, provider, and facility characteristics associated with SASEs and whether these characteristics impact statin utilization.

METHODS

Patients with atherosclerotic cardiovascular disease (ASCVD) receiving care across the Veterans Affairs healthcare system from October 1, 2014 to September 30, 2015 were included. Multivariable logistic regression analyses were performed to determine (a) factors associated with SASE and (b) factors associated with statin use in those with SASE.

RESULTS

Our cohort included 1,225,576 patients with ASCVD. Of these, 171,189 (13.7%) had at least 1 reported SASE since year 2000. The most significant odds for SASEs were observed with female sex (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.36, 1.45), White race (OR 1.43, 95% CI 1.41, 1.45), hypertension (OR 1.37, 95% CI 1.33, 1.41) and ischemic heart disease (IHD: OR 1.45, 95% CI 1.43, 1.47). Lower odds were noted with care at a teaching facility (OR 0.89, 95% CI 0.88, 0.90). Factors most associated with being on a statin among patients with SASE included having diabetes (OR 1.18, 95% CI 1.15, 1.20), IHD (OR 1.39, 95% CI 1.35, 1.43) and a higher number of cardiology visits (OR 1.08, 95% CI 1.07, 1.09), while female sex was associated with lower odds (OR 0.65, 95% CI 0.61, 0.69).

CONCLUSION

There are significant disparities in statin use by sex, ASCVD type, and comorbidities among secondary prevention patients with SASE, which represent areas for improvement in optimizing statin utilization.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System

Purpose

We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes.

Methods

A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations.

Results

Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973–0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47–2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13–2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89–7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73–35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations.

Conclusion

Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

Quality of referrals for glaucoma assessment: a cross-sectional survey of clinical data and outcomes

PURPOSE

This study assessed the completeness of clinical information provided by ophthalmological and optometric referrals to glaucoma specialists consulting for open-angle glaucoma (OAG).

METHODS

A retrospective, cross-sectional study of 72 internal referrals for evaluation of OAG in a multispecialty group practice was performed. The quality of the referral was assessed based on: (1) the completeness of the clinical triad of intraocular pressure measurement, visual field (VF), and cup-to-disk ratio for each eye; (2) the availability of the data necessary to calculate an ocular hypertension treatment study (OHTS) score; and (3) the presence of retinal nerve fiber layer (RNFL) imaging by mean of optical coherence tomography.

RESULTS

The clinical triad was available in 57% of referrals, whereas an OHTS score was calculable in 24% of referrals (p < 0.001); RNLF imaging was available in 51% of referrals (p = 0.859). The completeness of clinical information was similar for ophthalmological and optometric referrals. From the date of referral to the time of the consultation, there was a significant increase in the availability of the clinical triad (57-65%; p = 0.013) and the OHTS score (24-5%; p = 0.004) but not for RNFL imaging (51-56%; p = 0.618). The most common missing clinical information was VF testing, which was absent in 42% of referrals.

CONCLUSIONS

Key clinical data necessary for effective diagnosis and staging of OAG was lacking for many patients referred to glaucoma specialists.

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

Importance

There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.

Objective

To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

Design, Setting, and Participants

This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).

Exposures

Women vs men with premature and extremely premature ASCVD.

Main Outcomes and Measures

Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8).

Results

We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD.

Conclusions and Relevance

This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.

Health care costs associated with primary care physicians versus nurse practitioners and physician assistants

BACKGROUND

Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving.

PURPOSE

This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians).

METHODS

A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs.

RESULTS

The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively.

IMPLICATIONS FOR PRACTICE

This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area.

Modeling the impact of COVID-19 on Retina Clinic Performance

BACKGROUND

COVID-19, a highly contagious respiratory virus, presents unique challenges to ophthalmology practice as a high-volume, office-based specialty. In response to the COVID-19 pandemic, many operational changes were adopted in our ophthalmology clinic to enhance patient and provider safety while maintaining necessary clinical operations. The aim of this study was to evaluate how measures adopted during the pandemic period affected retina clinic performance and patient satisfaction, and to model future clinic flow to predict operational performance under conditions of increasing patient and provider volumes.

METHODS

Clinic event timestamps and demographics were extracted from the electronic medical records of in-person retina encounters from March 15 to May 15, 2020 and compared with the same period in 2019 to assess patient flow through the clinical encounter. Patient satisfaction was evaluated by Press Ganey patient experience surveys obtained from randomly selected outpatient encounters. A discrete-events simulation was designed to model the clinic with COVID-era restrictions to assess operational performance under conditions of increasing patient and provider volumes.

RESULTS

Retina clinic volume declined by 62 % during the COVID-19 health emergency. Average check-in-to-technician time declined 79 %, total visit length declined by 46 %, and time in the provider phase of care declined 53 %. Patient satisfaction regarding access nearly doubled during the COVID-period compared with the prior year (p < 0.0001), while satisfaction with overall care and safety remained high during both periods. A model incorporating COVID-related changes demonstrated that wait time before rooming reached levels similar to the pre-COVID era by 30 patients-per-provider in a 1-provider model and 25 patients-per-provider in a 2-provider model (p < 0.001). Capacity to maintain distancing between patients was exceeded only in the two 2-provider model above 25 patients-per-provider.

CONCLUSIONS

Clinic throughput was optimized in response to the COVID-19 health emergency. Modeling these clinic changes can help plan for eventual volume increases in the setting of limits imposed in the COVID-era.

Automated Image Alignment for Comparing Microvascular Changes Detected by Fluorescein Angiography and Optical Coherence Tomography Angiography in Diabetic Retinopathy

PURPOSE

To quantitatively compare microvascular features in the macula of patients with diabetic retinopathy (DR) using fluorescein angiography (FA) and optical coherence tomography angiography (OCTA).

METHODS

Patients with DR were recruited from the Cairo University Hospital. FA was performed using a Topcon TRC-50DX or Heidelberg Spectralis HRA+OCT. OCTA was performed using an Optovue RTVue-XR Avanti. FA images were cropped and aligned to the corresponding OCTA images using i2k Align Retina software. The foveal avascular zone (FAZ), area of ischemia, and microaneurysms (MAs) were manually quantified using ImageJ. The fractal dimension (FD) was calculated from each skeletonized image using the FracLac plugin of ImageJ after retinal vascular segmentation.

RESULTS

Twenty-four eyes of 17 patients were evaluated, but only 18 eyes were successfully aligned. There was no difference in FAZ area measured for FA and OCTA images. Compared with OCTA images, FD was significantly less for FA images (1.66 ± 0.048 versus 1.72 ± 0.023, p < .001). Significantly more MAs were identified on FA images (102 ± 27.5) compared with OCTA (47.5 ± 11.7, p < .0001). The number of MAs on FA correlated with decreasing best corrected visual acuity (r² = 0.315, p = .015) and increasing central macular thickness (r² = 0.492, p = .001). No such associations were found with MAs detected on OCTA. Nevertheless, the area of ischemia in the FA images (8.5 ± 4.1%) was significantly smaller compared with the area measured in both the superficial (30.7 ± 9.5%) and deep capillary plexus (21.6 ± 10.9%) of the OCTA (p < .001). Interestingly, number of MAs in the FA images correlated with increasing area of ischemia in the FA (r² = 0.568, p < .001) but only the superficial segment of the depth-resolved OCTA scans (r² = 0.539, p < .001).

CONCLUSIONS

OCTA is a non-invasive tool capable of resolving the retinal vasculature in greater detail when compared with FA but detects significantly fewer MAs. Automatic alignment facilitates quantitative comparison of the microvascular features in DR.