Vocal-cord dysfunction presenting as asthma

We identified five patients with a functional disorder of the vocal cords that mimicked attacks of bronchial asthma. Paroxysms of wheezing and dyspnea were refractory to standard therapy for asthma. During episodes of wheezing, the maximal expiratory and inspiratory flow-volume relationship was consistent with a variable extrathoracic obstruction. Laryngoscopy confirmed that wheezing was due to adduction of the true and false vocal cords throughout the respiratory cycle. During asymptomatic periods the maximal flow-volume relationship and laryngoscopic examination were normal. Provocation tests for bronchial asthma were negative. A variety of personality styles and psychiatric diagnoses were represented; patients were not aware of the vocal-cord dysfunction, which uniformly and dramatically responded to speech therapy and psychotherapy. This syndrome may be a form of conversion reaction.

A program for transtracheal oxygen delivery. Assessment of safety and efficacy

Over a 2-year period, the safety and efficacy of a program specifically designed for transtracheal oxygen therapy were evaluated in 100 patients with chronic hypoxemia. The four clinically defined phases of the program included patient orientation, evaluation, and selection (phase I); a new needle-wire guide-dilator transtracheal procedure and stent week (phase II); transtracheal oxygen delivery with an immature tract (phase III); and transtracheal oxygen delivery with a mature tract (phase IV). Sequelae and complications were minor, and patient acceptance was high. As compared with the nasal cannula, the transtracheal catheter was associated with a significant reduction in oxygen flow requirement during both rest and exercise. Adequate oxygenation was maintained over time, and erythrocythemia was alleviated with transtracheal delivery. We conclude that transtracheal oxygenation by this method has a low, acceptable morbidity; it is more efficient than nasal cannula delivery and may be more effective in some patients.

Comparison of Ophthalmologist and Large Language Model Chatbot Responses to Online Patient Eye Care Questions

Importance

Large language models (LLMs) like ChatGPT appear capable of performing a variety of tasks, including answering patient eye care questions, but have not yet been evaluated in direct comparison with ophthalmologists. It remains unclear whether LLM-generated advice is accurate, appropriate, and safe for eye patients.

Objective

To evaluate the quality of ophthalmology advice generated by an LLM chatbot in comparison with ophthalmologist-written advice.

Design, Setting, and Participants

This cross-sectional study used deidentified data from an online medical forum, in which patient questions received responses written by American Academy of Ophthalmology (AAO)-affiliated ophthalmologists. A masked panel of 8 board-certified ophthalmologists were asked to distinguish between answers generated by the ChatGPT chatbot and human answers. Posts were dated between 2007 and 2016; data were accessed January 2023 and analysis was performed between March and May 2023.

Main Outcomes and Measures

Identification of chatbot and human answers on a 4-point scale (likely or definitely artificial intelligence [AI] vs likely or definitely human) and evaluation of responses for presence of incorrect information, alignment with perceived consensus in the medical community, likelihood to cause harm, and extent of harm.

Results

A total of 200 pairs of user questions and answers by AAO-affiliated ophthalmologists were evaluated. The mean (SD) accuracy for distinguishing between AI and human responses was 61.3% (9.7%). Of 800 evaluations of chatbot-written answers, 168 answers (21.0%) were marked as human-written, while 517 of 800 human-written answers (64.6%) were marked as AI-written. Compared with human answers, chatbot answers were more frequently rated as probably or definitely written by AI (prevalence ratio [PR], 1.72; 95% CI, 1.52-1.93). The likelihood of chatbot answers containing incorrect or inappropriate material was comparable with human answers (PR, 0.92; 95% CI, 0.77-1.10), and did not differ from human answers in terms of likelihood of harm (PR, 0.84; 95% CI, 0.67-1.07) nor extent of harm (PR, 0.99; 95% CI, 0.80-1.22).

Conclusions and Relevance

In this cross-sectional study of human-written and AI-generated responses to 200 eye care questions from an online advice forum, a chatbot appeared capable of responding to long user-written eye health posts and largely generated appropriate responses that did not differ significantly from ophthalmologist-written responses in terms of incorrect information, likelihood of harm, extent of harm, or deviation from ophthalmologist community standards. Additional research is needed to assess patient attitudes toward LLM-augmented ophthalmologists vs fully autonomous AI content generation, to evaluate clarity and acceptability of LLM-generated answers from the patient perspective, to test the performance of LLMs in a greater variety of clinical contexts, and to determine an optimal manner of utilizing LLMs that is ethical and minimizes harm.

Demand and continuous flow intermittent mandatory ventilation systems

A mechanical lung was used to evaluate the pressure and flow characteristics of four demand and two continuous flow intermittent mandatory ventilation (IMV) systems. The amount of negative pressure required to initiate inspiratory flow and peak expiratory resistance were measured. The inspiratory pressure required to initiate flow in the demand mode was also compared to pressures generated in the assist mode. In addition, the peak expiratory resistance was measured with four commercially available exhalation valves. Results showed that the ventilator manometer measuring internal machine pressures significantly underestimated the amount of negative pressure required to open the demand valve (p less than 0.01). There are major differences in the flow and pressure characteristics among demand and continuous flow IMV systems. Systems that impose high inspiratory elastic threshold loads and expiratory flow resistive loads may have a deleterious effect on the mechanics of breathing, and thereby limit weaning success and eventually impair the recovery of certain patients in respiratory failure. The basic methodology, especially the simple technique of inserting an aneroid manometer in line next to a patient's ET tube, for measuring proximal negative inspiratory force (NIF test) can be easily applied to any and all ventilators at any practitioner's individual institution.

Alpha-crystallin-mediated protection of lens cells against heat and oxidative stress-induced cell death

In addition to their key role as structural lens proteins, α-crystallins also appear to confer protection against many eye diseases, including cataract, retinitis pigmentosa, and macular degeneration. Exogenous recombinant α-crystallin proteins were examined for their ability to prevent cell death induced by heat or oxidative stress in a human lens epithelial cell line (HLE-B3). Wild type αA- or αB-crystallin (WT-αA and WT-αB) and αA- or αB-crystallins, modified by the addition of a cell penetration peptide (CPP) designed to enhance the uptake of proteins into cells (gC-αB, TAT-αB, gC-αA), were produced by recombinant methods. In vitro chaperone-like assays were used to assay the ability of α-crystallins to protect client proteins from chemical or heat induced aggregation. In vivo viability assays were performed in HLE-B3 to determine whether pre-treatment with α-crystallins reduced death after exposure to oxidative or heat stress. Most of the five recombinant α-crystallin proteins tested conferred some in vitro protection from protein aggregation, with the greatest effect seen with WT-αB and gC-αB. All α-crystallins displayed significant protection to oxidative stress induced cell death, while only the αB-crystallins reduced cell death induced by thermal stress. Our findings indicate that the addition of the gC tag enhanced the protective effect of αB-crystallin against oxidative but not thermally-induced cell death. In conclusion, modifications that increase the uptake of α-crystallin proteins into cells, without destroying their chaperone-like activity and anti-apoptotic functions, create the potential to use these proteins therapeutically.

Pulsed nasal and transtracheal oxygen delivery

Oxygen conserving devices, the TTO catheters, electronic pulsed DODS and reservoir cannulas, increase efficacy of oxygen delivery; TTO also improves cosmetic appearance, comfort and compliance. We speculated that pulsing of oxygen transtracheally can increase efficiency of TTO. We modified the DODS to include settable delays and a rapid pre-inspiratory trigger. The first part of the study was performed with nasal oxygen on seven subjects and the second part, with TTO on 17 subjects. Nasal oxygen results indicate improved delivery efficiency with more rapid response. The TTO results indicate no significant change for each delay setting, but there was improvement in delivery efficiency when DODS was combined with TTO vs continuous flow TTO. Thus, early inspiratory delivery increases efficiency of oxygen therapy. Small delays in response time are critical in nasal delivery but not important in TTO. Pulsed TTO is more efficient than continuous flow TTO and merits long-term studies.

Accuracy of Intraoperative Aberrometry, Barrett True-K With and Without Posterior Cornea Measurements, Shammas-PL, and Haigis-L Formulas After Myopic Refractive Surgery

PURPOSE

To assess the accuracy of intraoperative aberrometry, the Barrett True-K No History (Barrett TKNH), Barrett TKNH with posterior corneal measurements (Barrett TKNH with PC), Shammas-PL, and Haigis-L formulas in patients with cataract who had prior myopic refractive surgery.

METHODS

This was a retrospective consecutive case series of patients with prior myopic refractive surgery undergoing cataract extraction. Mean absolute error (MAE) and median absolute error (MedAE) of refraction prediction were compared for each formula. Interactions of each biometry measurement were modeled for each formula to evaluate those with the most significant impact on refraction prediction.

RESULTS

One hundred sixteen eyes of 79 patients were analyzed. MAE was 0.40 ± 0.33 diopters (D) for intraoperative aberrometry and 0.42 ± 0.31 D for the Barrett TKNH, 0.38 ± 0.30 D for the Barrett TKNH with PC, 0.47 ± 0.38 D for the Shammas-PL, and 0.56 ± 0.39 D for the Haigis-L formulas. Comparisons between formulas were significant for Barrett TKNH versus Barrett TKNH with PC formulas (P = .046), Barrett TKNH with PC versus Shammas-PL formulas (P = .023), and for all comparisons with the Haigis-L formula (P < .001), and not significant for all other comparisons (P > .05). Eyes were within ±0.50 D of prediction 73%, 72%, 69%, 62%, and 52% of the time for intraoperative aberrometry, the Barrett TKNH with PC, Barrett TKNH, Shammas-PL, and Haigis-L formulas, respectively. Corneal asphericity (Q value) was significantly associated with prediction error for all five methods. Changes in anterior chamber depth had a significant impact on Shammas-PL prediction errors.

CONCLUSIONS

Newer technology using information from the posterior cornea modestly improved outcomes when compared to established methods for intraocular lens selection in eyes that had previous laser refractive surgery for myopia. [J Refract Surg. 2021;37(1):60-68.].

Oxygen therapy using pulse and continuous flow with a transtracheal catheter and a nasal cannula

Pulse delivery (PD) of oxygen was compared with continuous flow (CF) utilizing transtracheal oxygen catheter (TTO) and nasal cannula (NC) in 20 stable patients with chronic hypoxemia. Oxygen saturation, respiratory rate, and accuracy of pulsed oxygen delivery were measured during sleep studies and these parameters, as well as arterial blood gases, were evaluated during rest and exercise. Additionally, bulk liquid oxygen use was measured under each condition, for a period of 1 month. Pulse delivery NC was evaluated in six subjects, CF NC in 14 subjects, and PD and CF TTO in 20 subjects over the 1-month period. Results showed that, as a group, patients were adequately oxygenated when utilizing the PD with both NC and TTO as assessed by arterial blood gases, oximetry, and hematocrit. However, four subjects could not be adequately oxygenated on PD NC during exercise even at the maximum liter per minute setting and could not be studied with this mode of therapy. The PD settings in the remaining subjects were equivalent to continuous flow settings for TTO and NC as assessed by PaO2 for rest and SaO2 for exercise and sleep. Compared with standard CF NC, the daily bulk oxygen use was decreased by 29.4 percent with CF TTO, by 48.2 percent with PD NC, and by 49.9 percent with PD TTO. We conclude that, compared with CF NC, PD of oxygen via TTO or NC by this method appears to be a safe, reliable, effective, and cost-effective method of oxygen delivery in the majority of subjects when used with proper screening.

Posterior Capsule Rupture during Cataract Surgery in Eyes Receiving Intravitreal anti-VEGF Injections

PURPOSE

To examine the risk of posterior capsule rupture (PCR) during phacoemulsification cataract surgery in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections prior to surgery.

METHODS

A retrospective study was conducted of cataract surgeries at the Sue Anschutz-Rodgers UCHealth Eye Center from January 1, 2014, through December 31, 2018. The primary outcome was the occurrence of PCR during surgery. Other variables of interest included age, race, sex, ocular comorbidities, diabetes, mature cataract, primary surgeon, injection frequency and type, and date of most recent injection. Predictors of PCR were assessed using logistic regression with generalized estimating equations to account for correlation between patient eyes. Additional sub-analysis was performed on eyes with PCR with and without anti-VEGF injection history to compare intraoperative characteristics, post-operative complications, and visual outcomes.

RESULTS

In total 10,327 cataract surgeries were included in the analysis, and 308 of these eyes received anti-VEGF injections prior to surgery. Of the 308 eyes that received anti-VEGF injections, eight (2.6%) had a PCR during surgery compared to 45 of 10,019 eyes (0.5%) that did not receive injections (unadjusted OR = 5.9, 95% CI: 2.8-12.7, p < .0001). Males and diabetics were more likely to have received injections and had higher rates of PCR, so these variables were adjusted for in the multivariate analysis of the association between injections and PCR (adjusted OR = 4.7, 95% CI: 2.1-10.4, p-value = 0.0001). Eyes with mature cataracts and those that underwent surgery with a resident as the primary surgeon were also at higher risk of PCR, but these variables were not associated with the anti-VEGF injection. Injection frequency, time between most recent injection and surgery, and type of anti-VEGF agent were not significantly associated with PCR.

CONCLUSIONS

History of intravitreal anti-VEGF injections was associated with higher odds of PCR during cataract surgery.

Comparison of refractive prediction for intraoperative aberrometry and Barrett True K no history formula in cataract surgery patients with prior radial keratotomy

PURPOSE

To compare prediction errors of the Barrett True K No History (Barrett TKNH) formula and intraoperative aberrometry (IA) in eyes with prior radial keratotomy (RK).

METHODS

A retrospective, non-randomized study of all patients with RK who underwent cataract surgery using IA at the UCHealth Sue Anschutz-Rodgers Eye Center from 2014 to 2019 was conducted. Refraction prediction error (RPE) for IA and Barrett TKNH was compared. General linear modelling accounting for the correlation between eyes was used to determine whether absolute RPE differed significantly between Barrett TKNH and IA. Outcome by number of RK cuts was also compared between the two methods.

RESULTS

Forty-seven eyes (31 patients) were included. The mean RPEs for Barrett TKNH and IA were 0.04 ± 0.92D and 0.01 ± 0.92D, respectively, neither was significantly different than zero (p = 0.77, p = 0.91). The median absolute RPEs were 0.50D and 0.48D, respectively (p = 0.70). The refractive outcome fell within ± 0.50D of prediction for 51.1% of eyes with Barrett TKNH and 55.3% with IA, and 80.8% were within ± 1.00D for both techniques. Mean absolute RPE increased with a higher number of RK cuts (grouped into < 8 cuts and ≥ 8 cuts) for both Barrett TKNH (0.35D and 0.74D, p = 0.008) and IA (0.30D and 0.80D, p = 0.0001).

CONCLUSIONS

There is no statistically significant difference between Barrett TKNH and IA in predicting postoperative refractive error in eyes with prior RK. Both are reasonable methods for choosing intraocular lens power. Eyes with more RK cuts have higher prediction errors.

The Protective Effect of Metformin Use on Early Nd:YAG Laser Capsulotomy

Purpose

To determine the effect of metformin on early Nd:YAG laser treatment for posterior capsule opacification (PCO) and to explore a molecular mechanism to explain a possible protective effect of metformin against PCO.

Methods

We conducted: 1) a retrospective cohort study of patient eyes undergoing phacoemulsification at our institution; and 2) laboratory investigation of the effect of metformin on the behavior of lens epithelial cells in the context of an animal model for PCO. Population-averaged Cox proportional hazards modeling was used to estimate risk for time to Nd:YAG. For laboratory studies, expression of markers for epithelial-to-mesenchymal transition (EMT) implicated in PCO pathogenesis was measured in tissue culture and following extracapsular lens extraction in a mouse model.

Results

The rate of Nd:YAG laser capsulotomy was 13.1% among the 9798 eyes. Both metformin use and diabetes were protective factors for Nd:YAG laser capsulotomy in univariate analysis. However, in multivariable analysis with nondiabetics as the reference group, only metformin use among diabetics was significantly protective of Nd:YAG (hazard ratio: 0.68, 95% CI: 0.54–0.85, P = 0.0008), while eyes of patients with diabetes without metformin use did not significantly differ (P = 0.5026). Treatment of lens epithelial cells with metformin reduced the level of the EMT markers ⍺-SMA and pERK induced by TGF-β2. Similarly, metformin treatment reduced ⍺-SMA expression in lens epithelial cells following extracapsular lens extraction in a mouse model.

Conclusions

The protective effect of metformin against early Nd:YAG may relate to its ability to downregulate EMT in residual lens epithelial cells that otherwise trend toward myofibroblast development and PCO.

Bronchoalveolar lavage fluid neutrophils increase after corticosteroid therapy in smokers with idiopathic pulmonary fibrosis

Patients with idiopathic pulmonary fibrosis (IPF) are often cigarette smokers and are often being treated with corticosteroids at the time of bronchoalveolar lavage. We addressed the question of whether or not the bronchoalveolar lavage fluid (BALF) neutrophil content of patients with IPF undergoes changes in smokers different from those in nonsmokers after institution of corticosteroids. Eighteen patients were studied (10 smokers and 8 nonsmokers). Fourteen patients (6 smokers and 8 nonsmokers) were treated orally with prednisone. The histologic assessment of alveolar inflammation and inflammatory small airways disease was no different in smokers than in nonsmokers. None of the smokers treated with prednisone had pathologic evidence of emphysema in addition to IPF. Five of 6 smokers showed an increase in BALF neutrophils after 3 months of prednisone (p less than 0.05), whereas the nonsmokers' BALF neutrophils decreased or remained unchanged. This increase in BALF neutrophils in smokers was not associated with concomitant or subsequent clinical deterioration but, in fact, with clinical improvement after 3 months of therapy. These data indicate that the combination of cigarette smoking and corticosteroid therapy influences the BALF neutrophil content in patients with IPF and suggest that interval changes in BALF neutrophil content may not reflect the status of the inflammatory process or structural derangements in the lungs of some patients with IPF.

Cataract Surgery Outcomes in Human Immunodeficiency Virus Positive Patients at a Tertiary Care Academic Medical Center in the United States

Purpose: To compare cataract surgery complications and visual outcomes in patients with and without human immunodeficiency virus (HIV).Methods: A retrospective cohort study was conducted on eyes undergoing phacoemulsification cataract surgery at an academic eye center from 1/1/2014 to 8/31/18. Outcomes included best corrected distance visual acuity (CDVA), intraoperative complications, cystoid macular edema (CME), and persistent anterior uveitis (PAU). Binary outcomes were analyzed using logistic regressions with generalized estimating equations. Visual outcomes were analyzed using a linear mixed model.Results: 9756 eyes from 5988 patients were included in the analysis. Of these, 66 eyes from 39 patients were HIV positive (HIV+). HIV+ patients were significantly younger at the time of surgery than HIV negative patients (p < .0001). Among HIV+ patients with available lab data, the mean CD4 count was 697.3 (SD = 335.7), and 48.7% of subjects had an undetectable viral load. Five eyes from three HIV+ patients had a history of cytomegalovirus retinitis (CMVR). Positive HIV status was not associated with increased risk of intraoperative complications. Post-operative CDVA was better in the HIV negative group compared to the HIV+ group but not significantly different (about 20/24 vs. 20/28, p = .0829). Eyes from HIV+ patients were at increased risk of developing PAU after surgery (adjusted OR = 6.04, 95% CI: 2.42-15.1, p = .0001), as well as CME (adjusted OR = 3.25, 95% CI: 1.02-10.4, p = .0470).Conclusions: Eyes from HIV+ patients were at greater risk of developing PAU and clinically significant CME; however, HIV+ patients had similar CDVA after cataract surgery compared to HIV negative patients.

Predictors of Pseudophakic Retinal Tears at a Tertiary Care Academic Medical Center

PURPOSE

To describe the incidence and identify risk factors for retinal tears (RT) among patients who underwent cataract phacoemulsification surgery, as well as to describe the timing and features of the RTs.

DESIGN

Retrospective case-control study SUBJECTS: Patients who underwent cataract phacoemulsification surgery between January 2014 and December 2019 at an academic eye center in Colorado.

METHODS

Information was extracted from medical chart review into a cataract outcomes database. Measures of association and p-values were determined from logistic regression models with generalized estimating equations to account for some patients having two eyes included in the database.

MAIN OUTCOME MEASURES

RT diagnosis within one year following cataract surgery. Incidence of RTs were analyzed by demographics, comorbid medical history, ocular characteristics, surgical characteristics, and intra-operative complications.

RESULTS

In total 13,007 cataract surgeries were included in the analysis, and 79 (0.6%) of those eyes developed RTs within one year following cataract surgery. Males and patients <65 years old had higher incidences of RTs (0.8% vs 0.5% for females, p=0.0175 and 1.0% vs 0.2% for age, <65 years vs >75, p=0.0001). The mean preoperative best-corrected visual acuity was better for the RT group (logMAR 0.252 vs 0.366, p=0.0073) and axial myopia (>26mm) was more common (31.2% vs 10.9%, p<0.0001). Patients with intra-operative complications had a higher incidence of RTs (4.2%, p<0.0001). Mean time from cataract surgery to RT was 128 (SD=110) days. Most RTs were symptomatic (57.0%), located in the superior hemisphere (83.5%), and 40.5% were diagnosed concurrently with a retinal detachment. The multivariable model resulted in intra-operative complications, axial length, and preoperative visual acuity having the strongest association with RT.

CONCLUSION

Patients with better preoperative visual acuity, eyes with longer axial length, and those with intra-operative complications were at an increased risk for RT following cataract surgery. Careful counseling is important and post-operative follow-up is advised for patients identified pre-operatively as being at an elevated risk for RT given the large rate of asymptomatic RTs and high rate of progression to retinal detachment.

Breathing He-O2 shifts the lung pressure-volume curve of the dog

To determine whether breathing a mixture of 80% He-20% O2 affects the lung pressure-volume (PV) curve, eight anesthetized paralyzed dogs were studied in a volume-displacement plethysmograph. Static PV curves on air were compared with PV curves obtained after equilibration with He-O2. The He-O2 PV curves were significantly shifted upward by an average of 5% total lung capacity. There was no change in compliance, indicating that the shift was due to lung expansion rather than a change in elasticity. Pretreatment of the dogs with cyclooxygenase inhibitors abolished the PV shift with He-O2. Four dogs had PV curves recorded on air and a mixture of O2, SF6, and Ne, a gas mixture with the same density as air but with 45% greater viscosity. The PV curve shift was even greater than observed with He-O2 and could again be virtually abolished with a cyclooxygenase inhibitor. These results suggest that breathing a high-viscosity gas mixture results in alveolar duct dilatation due to the release of a prostaglandin bronchodilator. This may need to be taken into account in the analysis of flow augmentation with He-O2.

Two cases of pen ink scleral tattoos and a brief review of the literature

Purpose

Scleral tattooing, also known as episcleral, subconjunctival, or simply eyeball tattooing, is a relatively new form of extreme body modification that first emerged in 2007. There are few reports of the management of these tattoos in the medical literature, and we aim to increase the body of knowledge surrounding this rare and potentially dangerous practice.

Observations

We present two new cases of improvised scleral tattooing, both performed in prison using pen ink and insulin needles, and both with minimal complications and managed with topical medications. A brief review of the literature is included which details the dangers of scleral tattooing.

Conclusions and importance

We discuss management of complications for this new, previously unreported method of scleral tattooing using pen ink. Ophthalmologists should be aware of the presentation, possible complications, and management of these cases.

The effects of transtracheal gas delivery on central inspiratory neuromuscular drive

Previous studies have shown transtracheal delivery of low-flow oxygen (TTO) decreases inspired minute ventilation (Veinsp) and have postulated that this would result in a decrease in the work of breathing (WOB). We hypothesized that a fall in central inspiratory neuromuscular drive (CIND) with TTO would reflect a fall in WOB. We measured resting ventilatory parameters (RVP) and CIND by the mouth occlusion pressure technique (MOP) at different gas flow rates through the catheter in 21 subjects (13 men, 8 women; mean age, 60 +/- 10.6 years) with severe COPD with a mature intratracheal oxygen catheter (ITOC). We also constructed a lung/chest wall analog (LCA) to determine if flow through the catheter would alter pressure changes during inspiration. Inspiratory tidal volume (Vtinsp) and minute ventilation (Veinsp) decreased proportionally to the gas flow rate through the catheter. However, with increasing flow through the catheter, P0.1 increased in the LCA, presumably due to the Bernoulli effect. The lack of a similar change in the subject group suggests that CIND does, in fact, fall, and that possibly there is a decrease in WOB. This effect may be of benefit to patients with severe COPD.

Time Utilization and Refractive Prediction Enhancement Associated with Intraoperative Aberrometry Use During Cataract Surgery

Purpose

To evaluate the time cost of intraoperative aberrometry (IA), to compare IA prediction error to the prediction error associated with conventional formulas using preoperative calculations (PC) and evaluate when IA provides clinically relevant benefit.

Methods

This is a retrospective study of eyes that underwent cataract phacoemulsification surgery with IA at an academic eye center. IA versus PC prediction error were compared amongst various preoperative and intraoperative characteristics. Additionally, a dichotomous variable indicating clinically relevant benefit of IA, where IA absolute prediction error was less than 0.5D and PC absolute prediction error greater than 0.5D, was associated with clinical factors.

Results

Five hundred eyes of 341 patients were included in the analysis. The quantitative difference between mean absolute prediction errors for IA versus PC was between 0.0D and 0.03D in most subgroups. For the 11.0% of eyes that had clinically relevant benefit to IA, the multivariable model identified the following strongest predictors: prior myopic corneal refractive surgery (Odds ratio (OR) 3.9, p<0.01 for myopic LASIK/PRK, OR 5.5, p=0.01 for radial keratotomy), toric or multifocal/EDOF lens implantation (OR 2.7, p=0.03 for toric monofocal lenses, OR 3.1, p=0.01 for EDOF/multifocal lenses), and short and long axial lengths (p<0.01). On average, IA implementation added 3.0 minutes to surgery (p<0.01).

Conclusion

For greatest likelihood of a clinically meaningful improvement in outcomes despite increased surgical time, surgeons and patients should consider using IA for eyes with extremes in axial length, eyes with prior myopic corneal refractive surgery, or when implanting lenses with toric or extended-depth-of-focus/multifocal properties.

Disparities in eye clinic patient encounters among patients requiring language interpreter services

BACKGROUND

Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States.

METHODS

A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video).

RESULTS

A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers.

CONCLUSIONS

Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Visual Functioning and Mortality of Age-Related Macular Degeneration Patients in a Colorado Cohort

OBJECTIVE

To investigate the relationship between visual functioning as measured by the National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) and mortality in patients with various stages of age-related macular degeneration (AMD).

DESIGN

Observational cohort study.

PARTICIPANTS

Patients with AMD enrolled in the University of Colorado AMD Registry between July 9, 2014 and December 31, 2021 were included.

METHODS

Age-related macular degeneration cases were classified into early AMD, intermediate AMD, geographic atrophy, neovascular AMD, or both advanced types of AMD (neovasuclar and geographic atrophy both present) using multimodal imaging and the Beckman and Classification of Atrophy Meetings criteria. Visual Function Questionnaire -25 composite and subscale scores at the time of study enrollment were calculated. Cox proportional hazards modeling was used to assess time to event for mortality utilizing univariate and multivariable models, which adjusted for all variables significantly associated with mortality. The measures of association were hazard ratios (HRs) and 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

All-cause mortality statistics were obtained through a collaborative agreement with the Colorado Department of Public Health and Environment. Death rates through October 19, 2022 were compared by demographics and potential confounders.

RESULTS

Analysis was completed on a cohort of 876 patients, of which 180 (20.6%) died during the follow-up period. Average follow-up time for this cohort was 52.5 (standard deviation: 26.6) months. In univariate analysis, composite VFQ-25 score and all subscale scores aside from ocular pain were significantly associated with time to mortality. Additionally, age, AMD category, marital status, history of smoking, and multiple chronic comorbid conditions were significantly associated with time to mortality. In multivariable analysis, for each 10-point increase in a patient's VFQ-25 scores for general health and driving, the risk of death decreased with HR of 0.85 (95% CI: 0.80, 0.91; P < 0.0001) and 0.92 (95% CI: 0.87, 0.97; P = 0.005), respectively. Composite and other subscale scores were not significantly associated with mortality after adjusting for confounding variables.

CONCLUSIONS

This cohort of AMD patients had a 20% rate of death in the 52.5-month average follow-up time. Better general health and ability to drive, as measured by the VFQ-25, were each separately associated with significantly lower risk of death among individuals with AMD.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Gender as an effect modifier in the relationship between hypertension and reticular pseudodrusen in patients with early or intermediate age-related macular degeneration

AIM

To determine whether the prevalence of treated hypertension is higher among males or females with early/intermediate (e/i) age-related macular degeneration (AMD) with and without bilateral reticular pseudodrusen (RPD).

METHODS

Retrospective review of the records of patients with e/iAMD who were recruited into the University of Colorado AMD registry between July 2014 and November 2019. Images were classified using the Beckman Initiative criteria and presence/absence of RPD. Patients were categorized into three groups: 1) e/iAMD with RPD; 2) e/iAMD without RPD; 3) control patients who did not have AMD. Multinomial logistic regression analysis was used for adjusted analysis with odds ratios (OR) and confidence intervals (CI).

RESULTS

There were 260 patients with e/iAMD of which 101 had bilateral RPD and 159 had no RPD, and 221 controls. Overall, 62% of patients were female and the three groups did not differ by gender. When stratified by gender, the female e/iAMD/RPD group had a higher prevalence of hypertension, 64.1% vs 45.2% for controls, OR=2.2 (95%CI: 1.2-4.0). The frequency of hypertension in the e/iAMD/no RPD group was 54.1% and did not significantly differ from the control group. Among males, prevalence rates of treated hypertension did not differ. There is a significant interaction of hypertension and gender for the e/iAMD/RPD group such that women with e/iAMD who had RPD were significantly more likely to have hypertension (P=0.042). This relationship was not significant in the e/iAMD/no RPD group (P=0.269).

CONCLUSION

Among females treated hypertension is significantly higher among e/iAMD/RPD patients, whereas for males there is no significant association.