Impact of Bariatric Surgery on Treatment Burden and Progression of Diabetic Retinopathy

Purpose: To assess the severity, progression, and treatment burden of diabetic retinopathy (DR) in patients after bariatric surgery compared with controls. Methods: A retrospective cohort study was performed of patients with type 2 diabetes and DR seen at the Duke Eye Center between 2014 and 2023. Clinical data included hemoglobin A1c (HbA1c), diagnostic stage of DR, diabetic macular edema (DME) or vitreous hemorrhage (VH), visual acuity (VA), and treatment burden at baseline and follow-up. Generalized estimating equation analysis was used to account for the correlation between 2 eyes of the same patient. Results: Sixteen patients who had bariatric surgery were matched by age, sex, and duration of diabetes with 60 control patients managed medically during the same time period. The HbA1c level, severity of DR, presence of DME or VH, VA, and treatment burden were not significantly different (all P > .05) at the baseline examination. On average, patients were followed for 6 years. The HbA1c level at the follow-up was significantly lower in the bariatric surgery group (6.4% vs 8.5%; P < .001). At the follow-up, the treatment burden was reduced in the bariatric surgery group compared with the control group (P = .04). There was a clear trend toward reduced progression of DR and treatment burden in the bariatric surgery group over the follow-up. Conclusions: Bariatric surgery may improve glycemic control, stabilize DR progression, and reduce the treatment burden, which may have a significant impact on quality of life for patients with DR.

Spiral scanning improves subject fixation in widefield retinal imaging

Point scanning retinal imaging modalities, including confocal scanning light ophthalmoscopy (cSLO) and optical coherence tomography, suffer from fixational motion artifacts. Fixation targets, though effective at reducing eye motion, are infeasible in some applications (e.g., handheld devices) due to their bulk and complexity. Here, we report on a cSLO device that scans the retina in a spiral pattern under pseudo-visible illumination, thus collecting image data while simultaneously projecting, into the subject's vision, the image of a bullseye, which acts as a virtual fixation target. An imaging study of 14 young adult volunteers was conducted to compare the fixational performance of this technique to that of raster scanning, with and without a discrete inline fixation target. Image registration was used to quantify subject eye motion; a strip-wise registration method was used for raster scans, and a novel, to the best of our knowledge, ring-based method was used for spiral scans. Results indicate a statistically significant reduction in eye motion by the use of spiral scanning as compared to raster scanning without a fixation target.

Ocular Mucous Membrane Pemphigoid: The Effect of Risk Factors at Presentation on Treatment Outcomes

PURPOSE

Analyze the influence of risk factors at presentation in the long-term immunosuppressive therapy (IMT) outcomes of ocular mucous membrane pemphigoid (OMMP).

DESIGN

Retrospective multicenter study.

PARTICIPANTS

Patients with OMMP seen at the Duke Eye Center, Tecnologico de Monterrey, and Hospital Clinic of Barcelona from 1990 to 2022.

METHODS

Data at presentation on demographics, direct immunofluorescence, ocular findings, sites of extraocular manifestations (EOMs), and previous treatments in patients with a clinical or laboratory diagnosis of OMMP, were analyzed with multivariable analysis and Kaplan-Meier plots to identify factors associated with adverse outcomes.

MAIN OUTCOME MEASURES

(1) Inflammatory control (no conjunctival inflammation in both eyes at 3 months on IMT); (2) relapse (new-onset inflammation after absolute control in either eye); (3) progression (≥ 1 cicatrizing stage progression in either eye); and (4) vision loss (≥ 2 Snellen lines).

RESULTS

A total of 117 patients (234 eyes), 61% (71/117) of whom were women, with a mean age of 66.6 (SD: 12.4) years (range: 37-97 years) and median follow-up of 34 months (interquartile range: 16-66 months; range: 3-265 months), were enrolled. Inflammatory control was achieved in 57% of patients (67/117), with high-risk EOM (HR-EOM), including esophageal, nasopharyngeal, and/or genital involvement (adjusted odds ratio [aOR]: 12.51; 95% confidence interval [CI]: 2.61-59.99; P = 0.002) and corneal scarring (aOR: 3.06; 95% CI, 1.15-8.14; P = 0.025), as significant risk factors for persistent inflammation. Disease relapse, progression, and vision loss occurred in 20% of patients (23/117), 12% of patients (14/117), and 27% of patients (32/117), respectively. Baseline corneal scarring was a risk factor for relapse (adjusted hazard ratio: 4.14; 95% CI: 1.61-10.62; P = 0.003), progression (aOR: 11.46; 95% CI: 1.78-73.75; P = 0.010), and vision loss (aOR: 3.51; 95% CI: 1.35-9.10; P = 0.010). HR-EOM was associated with stage progression (aOR, 34.57; 95% CI, 6.57-181.89; P<0.001) and vision loss (aOR, 8.42; 95% CI, 2.50-28.42; P = 0.001). No significant differences were found between IMT regimes and relapse (P = 0.169).

CONCLUSIONS

Ocular mucous membrane pemphigoid presenting with HR-EOMs and corneal scarring has an increased risk of stage progression and vision loss. Corneal scarring and severe inflammation at baseline were associated with an increased risk of relapse. A disease progression staging system incorporating both the HR-EOMs and corneal involvement is required to predict the visual outcome of OMMP better.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Gradeability and Reproducibility of Geographic Atrophy Measurement in GATHER-1, a Phase II/III Randomized Interventional Trial

Objective

To validate GATHER-1 inclusion criteria and the study's primary anatomic end point by assessing the reproducibility of geographic atrophy (GA) measurements and factors that affect reproducibility.

Design

Post hoc analysis of phase II/III clinical trial.

Subjects

All 286 participants included in the GATHER-1 study.

Methods

For each subject, blue-light fundus autofluorescence (FAF), color fundus photographs, fluorescein angiograms, and OCT scans were obtained on the study eye and fellow eye. Geographic atrophy area and other lesion characteristics were independently graded by 2 experienced primary readers. If the 2 readers differed on gradeability, GA area (> 10%) or other lesion characteristics, the image was graded by an arbitrator whose measurement or characterization was the final grade.

Main Outcome Measures

The main outcome measures were gradeability and reproducibility of FAF imaging data. Imaging data included lesion area, confluence of GA with peripapillary atrophy (PPA), whether GA involved the foveal centerpoint, and type of hyperautofluorescence pattern.

Results

A total of 2004 images (1002 visits, 286 participants) were analyzed. Gradeability (90.5%) and interreader gradeability concordance (90.2%) were high across all visits. Study eye images were more gradable compared with fellow-eye images. A greater proportion of smaller lesions required arbitration, but interreader reproducibility was consistently high for all images. There was no difference in gradeability, gradeability concordance, or lesion-area concordance for images with PPA-confluent GA compared with those with nonconfluent PPA. Foveal centerpoint-involving lesions had lower gradeability and lesion-area concordance. Images with diffuse patterns of hyperautofluorescence had better gradeability and gradeability concordance than those with nondiffuse patterns but had no difference in lesion-area or lesion-area concordance.

Conclusions

There is high gradeability and excellent reproducibility measures across all images. These data support the validity of conclusions from GATHER-1 and the chosen inclusion criteria and end point.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Peripapillary Optical Coherence Tomography Angiography in Alzheimer's Disease, Mild Cognitive Impairment, and Normal Cognition

OBJECTIVE

This study aimed to identify peripapillary microvascular changes in Alzheimer's disease (AD) and mild cognitive impairment (MCI).

PATIENTS AND METHODS

In this prospective study, 66 eyes of 36 subjects with AD, 119 eyes of 63 with MCI, and 513 eyes of 265 controls with normal cognition were enrolled. Peripapillary capillary perfusion density (CPD), capillary flux index (CFI), and retinal nerve fiber layer (RNFL) thickness were determined.

RESULTS

Average CPD differed significantly between all three groups (P = 0.001), being significantly greater in AD vs controls (0.446 ± 0.015 vs 0.439 ± 0.017, P = 0.001) and MCI vs controls (0.443 ± 0.020 vs 0.439 ± 0.017, P = 0.007) but not AD vs MCI (P = 0.69). CFI and average RNFL thickness did not significantly differ among groups (all P > 0.05).

CONCLUSION

Peripapillary CPD is increased in eyes with AD or MCI compared to controls despite similar RNFL thickness. [Ophthalmic Surg Lasers Imaging Retina 2024;55:78-84.].

Characterizing differences in retinal and choroidal microvasculature and structure in individuals with Huntington's Disease compared to healthy controls: A cross-sectional prospective study

OBJECTIVE

To characterize retinal and choroidal microvascular and structural changes in patients who are gene positive for mutant huntingtin protein (mHtt) with symptoms of Huntington's Disease (HD).

METHODS

This study is a cross-sectional comparison of patients who are gene positive for mHtt and exhibit symptoms of HD, either motor manifest or prodromal (HD group), and cognitively normal individuals without a family history of HD (control group). HD patients were diagnosed by Duke movement disorder neurologists based on the Unified Huntington's Disease Rating Scale (UHDRS). Fovea and optic nerve centered OCT and OCTA images were captured using Zeiss Cirrus HD-5000 with AngioPlex. Outcome metrics included central subfield thickness (CST), peripapillary retinal nerve fiber layer (pRNFL) thickness, ganglion cell-inner plexiform layer (GCIPL) thickness, and choroidal vascularity index (CVI) on OCT, and foveal avascular zone (FAZ) area, vessel density (VD), perfusion density (PD), capillary perfusion density (CPD), and capillary flux index (CFI) on OCTA. Generalized estimating equation (GEE) models were used to account for inter-eye correlation.

RESULTS

Forty-four eyes of 23 patients in the HD group and 77 eyes of 39 patients in the control group were analyzed. Average GCIPL thickness and FAZ area were decreased in the HD group compared to controls (p = 0.001, p < 0.001). No other imaging metrics were significantly different between groups.

CONCLUSIONS

Patients in the HD group had decreased GCIPL thickness and smaller FAZ area, highlighting the potential use of retinal biomarkers in detecting neurodegenerative changes in HD.

Differences in Retinal and Choroidal Microvasculature and Structure in Dementia With Lewy Bodies Compared With Normal Cognition

Purpose: To evaluate the retinal and choroidal microvasculature and structure in individuals with dementia with Lewy bodies (DLB) compared with controls with normal cognition using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods: An institutional review board-approved cross-sectional comparison of patients with DLB and cognitively normal controls was performed. The Cirrus HD-OCT 5000 with AngioPlex (Carl Zeiss Meditec) was used to obtain OCT and OCTA images. Results: Thirty-four eyes of 18 patients with DLB and 85 eyes of 48 cognitively normal patients were analyzed. The average capillary perfusion density (CPD) was higher in the DLB group than in the control group (P = .005). The average capillary flux index (CFI) and ganglion cell inner-plexiform layer (GC-IPL) thickness were lower in the DLB group than in the control group (P = .016 and P = .040, respectively). Conclusions: Patients with DLB had an increased peripapillary CPD, decreased peripapillary CFI, and attenuated GC-IPL thickness compared with those with normal cognition.

Acute, Treatment-Naïve Branch Retinal Vein Occlusion in Younger Individuals: Risk Factors and Clinical Outcomes

Purpose: To compare the risk factors and clinical outcomes in patients younger than 50 years with acute, treatment-naïve branch retinal vein occlusion (BRVO) with outcomes in patients 50 years or older. Methods: Patients diagnosed with acute, treatment-naïve BRVO at Duke Eye Center over a 9.5-year period who had BRVO with onset 3 months or less before presentation, BRVO with macular involvement, and 12 months or more of follow-up were included. Demographic data, presenting clinical features, risk factors, treatment patterns, and clinical outcomes were extracted during a retrospective review of medical records. Results: Of 302 patients identified, 23 were younger than 50 years (younger group) and 279 were 50 years or older (older group). Compared with older patients, younger patients had similar rates of hypertension (P = .275), diabetes mellitus (P = 1.000), smokers (P = .787), and open-angle glaucoma (P = .628). The younger group had a lower rate of hyperlipidemia than the older group (35% vs 59%) (P = .028). The 2 groups had similar presenting logMAR visual acuities (VAs) in the BRVO eye (P = .131). At the final follow-up, younger patients had significantly better logMAR VA in the BRVO-affected eye than older patients (mean 0.51 ± 0.65 vs 1.01 ± 1.20) (P = .016). The 2 groups had similar treatment burdens at 1 year (P = .516) and at the final follow-up (P = .782). Conclusions: Younger patients with acute, treatment-naïve BRVO have similar risk factors and treatment patterns as older patients, except for a lower rate of hyperlipidemia. Younger patients with BRVO may have similar presenting VA as older BRVO patients but better final VA, suggesting that age may be a potential prognostic factor.

Glaucoma Fellows-in-Training Recent Surgery Trends

PURPOSE

The volume of microinvasive glaucoma surgery (MIGS) has increased dramatically in recent years, from 31 059 in 2013 to 69 420 in 2018. We investigated the impact of this trend on trainees by determining the proportion of glaucoma surgeries performed by fellows-in-training comprised by MIGS, trabeculectomies, and aqueous shunts.

DESIGN

Retrospective analysis.

PARTICIPANTS

Fellows-in-training at Glaucoma Fellowship Programs certified by the Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO-FCC) METHODS: We analyzed aggregate summaries of surgeries performed by fellows as reported to the AUPO-FCC from the academic years (AYs) beginning in 2014 through AY 2020. Each report lists the average number of procedures performed per surgery type per fellow. We combined these averages to create a sum "average number surgeries performed" across glaucoma surgeries and computed the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of surgeries performed per year.

MAIN OUTCOME MEASURES

Average number of procedures performed for each surgery type as well as the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of procedures performed per year.

RESULTS

Average number of MIGS performed is significantly greater in later years compared with earlier years (P < 0.001). The average number of trabeculectomies performed between AYs 2014 and AY 2020 ranged from 21.8 to 31.9 and decreased, on average, by - 0.80 year-to-year. The average number of aqueous shunts performed between AY 2014 and AY 2020 ranged from 44.7 to 49.5, with an average increase of + 0.8 year-to-year. The total average number of procedures performed (across all 3 surgical subtypes) increased on average by + 4.8 procedures each year.

CONCLUSIONS

Since 2014, fellows are performing increasing numbers of MIGS procedures, whereas the total number of trabeculectomies and aqueous shunt surgeries performed each year remain similar, resulting in a net increase in total number of procedures performed per fellow each year. This suggests the increase in MIGS is not associated with a substantial decline in trabeculectomies or aqueous shunts performed by glaucoma fellows.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Longitudinal Assessment of the Choroidal Vascularity Index in Eyes with Branch Retinal Vein Occlusion-Associated Cystoid Macular Edema

INTRODUCTION

Cystoid macular edema (CME) is the most common cause of central vision loss in eyes with branch retinal vein occlusion (BRVO eyes). In recent literature, choroidal vascularity index (CVI) has been proposed to be an enhanced depth imaging optical coherence tomography (EDI-OCT) metric that may help characterize choroidal vascular changes in the setting of retinal ischemia, and potentially prognose visual outcomes and treatment patterns for patients with BRVO-related CME. This study sought to further characterize choroidal vascular changes in BRVO by comparing the CVI, subfoveal choroidal thickness (SFCT), and central subfield thickness (CST) in BRVO eyes with CME compared to unaffected fellow eyes.

METHODS

This was a retrospective cohort study. Subjects included treatment-naïve BRVO eyes with CME diagnosed within 3 months of onset of symptoms and unaffected fellow eyes. EDI-OCT images were collected at baseline and at the 12-month follow-up visit. CVI, SFCT, and CST were measured. Demographics, treatment patterns, and best-corrected visual acuity (VA) were abstracted. Median CVI, SFCT, CST, and VA were compared between the two cohorts. Longitudinal relationships between these variables were analyzed.

RESULTS

A total of 52 treatment-naïve eyes with BRVO and CME and 48 unaffected fellow eyes were identified. Baseline CVI was lower in eyes with BRVO than in fellow eyes (64.7% vs. 66.4%, P = 0.003). At 12 months, there was no difference in CVI between BRVO eyes and fellow eyes (65.7% vs 65.8%, P = 0.536). In BRVO eyes, there was a strong correlation between reduced CST and improved VA over the 12-month study period (r = 0.671, P < 0.001).

CONCLUSION

There are differences in CVI in treatment-naïve BRVO eyes with CME at presentation compared to fellow eyes, but these differences resolve over time. Anatomic changes in macular thickness in BRVO eyes with CME may be correlated with VA outcomes.

Intrasession Repeatability of OCT Angiography Parameters in Neurodegenerative Disease

Purpose

To assess the intrasession repeatability of macular OCT angiography (OCTA) parameters in Alzheimer's disease (AD), mild cognitive impairment (MCI), Parkinson's disease (PD), and normal cognition (NC).

Design

Cross sectional study.

Subjects

Patients with a clinical diagnosis of AD, PD, MCI, or NC were imaged. Images with poor quality and of those with diabetes mellitus, glaucoma, or vitreoretinal disease were excluded from analysis.

Methods Intervention or Testing

All participants were imaged using the Zeiss Cirrus HD-5000 with AngioPlex (Carl Zeiss Meditec, Software Version 11.0.0.29946) and repeat OCTA images were obtained for both eyes. Perfusion density (PFD), vessel density (VD), and Foveal avascular zone (FAZ) area were measured from 3 × 3 mm and 6 × 6 mm OCTA images centered on the fovea using an ETDRS grid overlay.

Main Outcome Measures

Intraclass correlation coefficients were used to quantify repeatability of PFD, VD, and FAZ area measurements obtained from imaging.

Results

3 × 3 mm scans of 22 AD, 40 MCI, 21 PD, and 26 NC participants and 6 × 6 mm scans of 29 AD, 44 MCI, 29 PD, and 30 NC participants were analyzed. Repeatability values ranged from 0.64 (0.49-0.82) for 6 × 6 mm PFD in AD participants to 0.87 (0.67-0.92) for 3 × 3 mm PFD in AD participants. No significant differences were observed in repeatability between NC participants and those with neurodegenerative disease.

Conclusions

Overall, similar OCTA repeatability was observed between NC participants and those with neurodegeneration. Regardless of diagnostic group, macular OCTA metrics demonstrated moderate to good repeatability.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

The effect of sex on retinopathy of prematurity severity among premature mixed-sex multiple gestation infants

This retrospective study of 68 premature infants examined whether there was a difference between male and female mixed-sex multiple gestation infants with regard to stage of retinopathy of prematurity (ROP) developed or need for ROP treatment. We found that among mixed-sex twin infants there was no statistically significant difference between sexes in most severe ROP stage developed or need for ROP treatment, but males were treated at an earlier postmenstrual age (PMA) than females, despite females having a lower mean birthweight and slower mean growth velocity compared to males.

Systematic analysis of levels of evidence supporting American Academy of Ophthalmology Preferred Practice Pattern guidelines, 2012-2021

BACKGROUND

Despite the increased emphasis on evidence-based medicine, the current state of evidence behind ophthalmology clinical practice guidelines is unknown. The purpose of this systematic analysis was to understand the levels of evidence (LOE) supporting American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) guidelines, assess changes over time, and compare LOE across ophthalmology subspecialties.

METHODS

All current PPP guidelines and their immediate predecessors were comprehensively reviewed to identify all recommendations with LOE provided (I [randomized controlled trials], II [case-control or cohort studies], and III [nonanalytic studies]).

RESULTS

Twenty-three out of 24 current PPPs had a prior edition. Among the PPPs with a prior edition, the number of recommendations with LOE decreased from 1254 in prior PPPs to 94 in current PPPs. The number of recommendations with LOE I decreased from 114 to 83, LOE II decreased from 147 to 2, and LOE III decreased from 993 to 9. However, the proportion of LOE I recommendations increased from 9 to 88%, driven by a disproportionate decrease in reporting of evidence lower than LOE I. Subgroup analysis by subspecialty showed similar trends (LOE I recommendations in prior PPPs vs current PPPs: retina: 57 [12%] vs 19 [100%]; cornea: 33 [5%] vs 24 [100%]; glaucoma: 9 [23%] vs 17 [100%]; cataract: 13 [17%] vs 18 [100%]).

CONCLUSIONS

Trends in LOE reporting in PPP guidelines indicate an increasing emphasis on evidence from randomized controlled trials from 2012 to 2021. The decline in the number of recommendations with LOE reported suggests an area for improvement in future guidelines as the presence of LOE is crucial to facilitate interpretation of clinical practice guidelines.

Continuous Hypoxia Reduces Retinal Ganglion Cell Degeneration in a Mouse Model of Mitochondrial Optic Neuropathy

Purpose

To test whether continuous hypoxia is neuroprotective to retinal ganglion cells (RGCs) in a mouse model of mitochondrial optic neuropathy.

Methods

RGC degeneration was assessed in genetically modified mice in which the floxed gene for the complex I subunit NDUFS4 is deleted from RGCs using Vlgut2-driven Cre recombinase. Beginning at postnatal day 25 (P25), Vglut2-Cre;ndufs4loxP/loxP mice and control littermates were housed under hypoxia (11% oxygen) or kept under normoxia (21% oxygen). Survival of RGC somas and axons was assessed at P60 and P90 via histological analysis of retinal flatmounts and optic nerve cross-sections, respectively. Retinal tissue was also assessed for gliosis and neuroinflammation using western blot and immunofluorescence.

Results

Consistent with our previous characterization of this model, at least one-third of RGCs had degenerated by P60 in Vglut2-Cre;ndufs4loxP/loxP mice remaining under normoxia. However, continuous hypoxia resulted in complete rescue of RGC somas and axons at this time point, with normal axonal myelination observed on electron microscopy. Though only partial, hypoxia-mediated rescue of complex I-deficient RGC somas and axons remained significant at P90. Hypoxia prevented reactive gliosis at P60, but the retinal accumulation of Iba1+ mononuclear phagocytic cells was not substantially reduced.

Conclusions

Continuous hypoxia achieved dramatic rescue of early RGC degeneration in mice with severe mitochondrial dysfunction. Although complete rescue was not durable to P90, our observations suggest that investigating the mechanisms underlying hypoxia-mediated neuroprotection of RGCs may identify useful therapeutic strategies for optic neuropathies resulting from less profound mitochondrial impairment, such as Leber hereditary optic neuropathy.

Pregnant individuals' information needs and intention to vaccinate their children with routine and COVID-19 vaccines: Findings from a cross-sectional survey

OBJECTIVE

The current study assessed pregnant individuals' intention to accept routine and COVID-19 vaccines for their baby after birth, and to identify key demographic (e.g., age) and nondemographic characteristics (e.g., prior birth) associated with vaccination intention.

METHODS

The authors conducted a cross-sectional survey with pregnant individuals attending prenatal practices affiliated with a large academic medical center and two rural county health departments in the southeastern United States. The survey included 11 questions and was self-administered by pregnant individuals in clinic settings. The final analysis included responses from 443 pregnant individuals.

RESULTS

Only 67% of pregnant individuals planned to vaccinate their baby with all recommended routine vaccines; an additional 22% reported having questions about recommendations. Only 35% of pregnant individuals said they would vaccinate their baby as soon as possible with a COVID-19 vaccine. Younger pregnant individuals and those identifying as Black or African American had lower routine and COVID-19 vaccination intention. Routine vaccination, but not COVID-19 vaccination intention, was associated with familiarity with routine vaccination schedule, trimester of pregnancy, Hispanic ethnicity, history of prior birth, and having access to a computer.

CONCLUSION

Study findings support differential tailoring of future interventions targeting pregnant individuals to promote routine and COVID-19 vaccines for children.

Quantitative comparison of blood vessel changes after treatment of retinopathy of prematurity with laser versus bevacizumab

Current therapies for treatment-indicated (type 1) retinopathy of prematurity mainly consist of laser photocoagulation and intravitreal anti-vascular endothelial growth factor (eg, bevacizumab) injection. The first visible signs of acute-phase regression are typically vascular, including decreased plus disease. Using a semiautomated computer program, we quantitatively compared posterior pole vascular changes following treatment with laser versus bevacizumab and found that in the first month following treatment, vascular dilation and tortuosity significantly decreased following either treatment modality, but tortuosity decreased earlier and faster after bevacizumab.

Longitudinal analysis of the retina and choroid in cognitively normal individuals at higher genetic risk for Alzheimer disease

PURPOSE

To assess baseline differences and longitudinal rate of change in retinal and choroidal imaging parameters between APOE ε4 carriers and non-carriers with normal cognition.

DESIGN

Prospective study.

SUBJECTS

413 eyes of 218 individuals with normal cognition aged ≥55 years with known APOE status (98 ε4 carriers, 120 non-carriers). Exclusion criteria included diabetes mellitus, uncontrolled hypertension, glaucoma, and vitreoretinal or neurodegenerative disease.

METHODS

Optical coherence tomography (OCT) and OCT angiography (OCTA) was performed at baseline and at 2 years [Zeiss Cirrus HD-OCT 5000 with AngioPlex (Zeiss Meditec, Dublin, CA)]. Groups were compared using sex- and age-adjusted generalized estimating equations.

MAIN OUTCOME MEASURES

OCT: retinal nerve fiber layer thickness, macular ganglion cell-inner plexiform layer thickness, central subfield thickness (CST), choroidal vascularity index. OCTA: foveal avascular zone area, perfusion density (PD), vessel density, peripapillary capillary perfusion density and capillary flux index (CFI). Rate of change per year was calculated.

RESULTS

At baseline, ε4 carriers demonstrated decreased CST (p=0.018), PD in the 6mm Early Treatment Diabetic Retinopathy Study (ETDRS) circle (p=0.049), and temporal CFI (p=0.047). Seventy-one ε4 carriers and 78 non-carriers returned at 2 years; at follow-up, the 6mm ETDRS circle (p=0.05) and outer ring (p=0.049) showed decreased PD in ε4 carriers, with no differences in rates of change between groups (all p>0.05).

CONCLUSIONS

There were measured differences in CST, PD, and peripapillary CFI between APOE ε4 carriers and non-carriers with normal cognition. Larger and longer-term studies may further elucidate the potential prognostic value of these findings.

Preliminary Results of Uveal Melanoma Treated With Iodine-125 Plaques: Analysis of Disease Control and Visual Outcomes With 63 Gy to the Target Volume

Purpose

Our purpose was to review the preliminary outcomes of patients with uveal melanoma treated with iodine-125 plaques using a novel treatment planning approach.

Methods and Materials

This was a single institution, retrospective review of patients treated with iodine-125 brachytherapy for uveal melanoma from November 2016 to February 2019. We used 3-dimensional treatment planning with the Eye Physics Plaque Simulator to ensure that a minimum of 63 Gy covered a 2-mm circumferential tumor margin and the apex height of the tumor over 94 hours. Primary endpoints were local failure, systemic metastasis, final visual acuity (VA), and radiation retinopathy. Associations between primary endpoints and tumor characteristics/radiation dose were performed using univariate analysis.

Results

Sixty-nine patients were included in the analysis. Mean largest basal diameter was 11.67 mm (range, 6-18; median, 12), and the average tumor thickness to the inner sclera was 3.18 mm (range, 0.5-9.3; median, 2.8). Molecular testing that was successfully performed in 59 patients revealed that 27% (16 of 59) had class 2 gene expression profile designation. Average follow-up posttreatment was 28.3 months (range, 4-46; median, 29), with 6% (4 of 69) developing local failure and 6% (4 of 69) developing metastasis over this duration. Average final VA (0.57 logMAR [Snellen 20/74]; range, 0-2.9; median, 0.3) was decreased from baseline (0.34 logMAR [Snellen 20/44]; range, 0-2.3; median, 0.1), and 48% (33 of 69) developed radiation retinopathy. Fifty percent of patients had a final VA 20/40 or better and 22% had a final VA 20/200 or worse.

Conclusions

In patients with uveal melanoma, preliminary results with brachytherapy using Eye Physics plaques with a treatment plan that delivers 63 Gy to a 2-mm circumferential tumor margin and the tumor apex suggest effective disease control and favorable VA outcomes.

Elevated Levels of Growth/Differentiation Factor-15 in the Aqueous Humor and Serum of Glaucoma Patients

Dysregulated levels of growth/differentiation factor-15 (GDF15), a divergent member of the transforming growth factor-beta super family, have been found to be associated with the pathology of various diseases. In this study, we evaluated the levels of GDF15 in aqueous humor (AH) and serum samples derived from primary open-angle glaucoma (POAG) and age- and gender-matched non-glaucoma (cataract) patients to assess the plausible association between GDF15 and POAG. GDF15 levels were determined using an enzyme-linked immunosorbent assay, and data analysis was performed using the Wilcoxon rank sum test, or the Kruskal–Wallis test and linear regression. GDF15 levels in the AH (n = 105) of POAG patients were significantly elevated (by 7.4-fold) compared to cataract patients (n = 117). Serum samples obtained from a subgroup of POAG patients (n = 41) also showed a significant increase in GDF15 levels (by 50%) compared to cataract patients. GDF15 levels were elevated in male, female, African American, and Caucasian POAG patients. This study reveals a significant and marked elevation of GDF15 levels in the AH of POAG patients compared to non-glaucoma cataract control patients. Although serum GDF15 levels were also elevated in POAG patients, the magnitude of difference was much smaller relative to that found in the AH.

Repeatability of Peripapillary OCT Angiography in Neurodegenerative Disease

Purpose

To assess the repeatability of peripapillary OCT angiography (OCTA) in those with Alzheimer disease (AD), mild cognitive impairment (MCI), Parkinson disease (PD), or normal cognition.

Design

Cross-sectional.

Participants

Patients with a clinical diagnosis of AD, MCI, PD, or normal cognition were imaged. Those with glaucoma, diabetes mellitus, vitreoretinal pathology, and poor-quality images were excluded.

Methods

Each eligible eye of each participant underwent 2 OCTA 4.5 × 4.5-mm peripapillary scans in a single session using a Zeiss Cirrus HD-OCT 5000 with AngioPlex (Carl Zeiss Meditec). The Zeiss software (v11.0.0.29946) quantified measures of perfusion in the radial peripapillary capillary (RPC) plexus in 4 sectors (superior, nasal, inferior, temporal). The average of these sectors was calculated and reported.

Main Outcome Measures

Radial peripapillary capillary plexus perfusion was quantified using 2 parameters: capillary perfusion density (CPD) and capillary flux index (CFI). Intraclass correlation coefficients (ICCs) were used to quantify repeatability. For subjects who had both eyes included, the average values of each scan pair were used to assess interocular symmetry of CPD and CFI.

Results

Of 374 eyes, 46 were from participants who had AD, 85 were from participants who had MCI, 87 were from participants who had PD, and 156 were from participants who had normal cognition. Capillary perfusion density ICC in AD = 0.88 (95% confidence interval [CI], 0.79–0.93), MCI = 0.95 (0.92–0.96), PD = 0.91 (0.87–0.94), and controls = 0.90 (0.87–0.93). Capillary flux index ICC in AD = 0.82 (0.70–0.90), MCI = 0.87 (0.80–0.91), PD = 0.91 (0.87–0.94) and controls = 0.85 (0.79–0.89). There were no significant differences in interocular variation in average CPD and CFI in AD, MCI, or PD (all P > 0.05). Isolated interocular sectoral CPD differences were noted in AD (nasal, P = 0.049; temporal, P = 0.024), PD (nasal, P = 0.036), and controls (nasal, P = 0.016). Interocular differences in CFI in the superior sector in MCI (P = 0.028) and in average CFI for controls (P = 0.035) were observed.

Conclusions

Peripapillary OCTA repeatability in AD, MCI, and PD is good-excellent and similar to those with normal cognition. Insignificant interocular asymmetry in peripapillary OCTA suggests neurodegeneration may proceed uniformly; future studies may reveal the appropriateness of single-eye imaging.

Photographic assessment of eyelid position using a simple measurement tool paired with cell phone photography in a pediatric population

PURPOSE

This proof-of-concept study evaluates the ability to assess eyelid measurements and the reproducibility of eyelid measurements using a simple measurement tool paired with digital cell phone photography in children.

METHODS

Seventy consecutive patients and their siblings, 2-19 years of age, were prospectively enrolled. Participants underwent clinical examination and cell phone photography with a simple measurement tool. An ophthalmologist and nonophthalmologist assessed photographs for interpalpebral fissure distance (IPFD), margin reflex distance-1 (MRD1), and levator function (LF). Clinical examinations and photographs were repeated on the same day in a random sample (n = 20). The agreement of grading photographs compared to clinical examination was assessed using Bland-Altman plots. Intra-grader repeatability of the clinical examination, repeatability of photographic technique, and interobserver reproducibility of photographic assessment was evaluated with intraclass correlation coefficients (ICC).

RESULTS

Of photographs acquired, both graders considered quality good/fair in 100% to assess IPFD and MRD1, and 70% to assess LF. The mean difference (limits of agreement) in mm between clinical examination and photographic assessment was 1.1 (-1.5 to 3.8) for IPFD, 0.7 (-1.8 to 3.1) for MRD1, and 1.1 (-3.5 to 5.7) for LF. Intraobserver repeatability on clinical examination was excellent for IPFD (ICC = 0.81), MRD1 (ICC = 0.88), and LF (ICC = 0.94). Repeatability of photographic technique was fair for IPFD (ICC = 0.44) and good for MRD1 (ICC = 0.74) and LF (ICC = 0.77). Interobserver photographic assessment repeatability was excellent for IPFD (ICC = 0.94), MRD1 (ICC = 0.96), and LF (ICC = 0.92).

CONCLUSIONS

Photographic assessment of eyelid measurements in children is possible, highly reproducible between graders, and enables documentation for future comparison.

A Pilot Study of Medical Misinformation Perceptions and Training Among Practitioners in North Carolina (USA)

Medical misinformation (MM) is a problem for both medical practitioners and patients in the 21^st century. Medical practitioners have anecdotally reported encounters with patient-held misinformation, but to date we lack evidence that quantifies this phenomenon. We surveyed licensed practitioners in the state of North Carolina to better understand how often patients mention MM in the clinical setting, and if medical practitioners are trained to engage with patients in these specific conversations. We administered an anonymous, online survey to physicians and physician assistants licensed to practice in the state of North Carolina. Questions focused on demographics, clinical encounters with MM, and training to discuss MM with patients. We received over 2800 responses and analyzed 2183 after removing ineligible responses. Our results showed that most respondents encountered MM from patients (94.2% (2047/2183)), with no significant differences between clinical specialty, time spent in practice, or community type. When asked about specific training, 18% (380/2081) reported formal experiences and 39% (807/289) reported informal experiences. MM has been salient due to the COVID-19 pandemic; however, it was present before and will remain after the pandemic. Given that MM is widespread but practitioners lack training on engaging patients in these conversations, a sustained effort to specifically train current and future practitioners on how to engage patients about MM would be an important step toward mitigating the spread of MM.

Assessing the Retinal Microvasculature in Individuals With Early and Late-Onset Alzheimer's Disease

BACKGROUND AND OBJECTIVE

To evaluate retinal microvascular changes in early and late-onset Alzheimer's disease (AD).

PATIENTS AND METHODS

Eighty-six eyes of 50 late-onset AD participants, 27 eyes of 15 early onset AD participants, and 111 eyes of 57 cognitively normal controls were included. Optical coherence tomography angiography (OCTA) vessel density (VD) and perfusion density (PD) in Early Treatment Diabetic Retinopathy Study 3-mm and 6-mm circles and rings were assessed.

RESULTS

There was decreased PD in early onset AD 3-mm circle (P = .026) and ring (P = .026) versus controls as well as in late-onset AD 3-mm circle (P = .023) and ring (P = .023) versus controls. There was decreased VD in late-onset AD 3-mm circle (P = .012) and ring (P = .006). No parameters differed between early and late-onset AD (P > .05).

CONCLUSIONS

AD eyes exhibited decreased retinal microvascular density compared to controls. Retinal parameters may not differ between early onset AD and late-onset AD after adjusting for age. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:336-344.].

Prophylactic laser versus continued surveillance after initial bevacizumab treatment for retinopathy of prematurity

Guidelines on managing infants after initial anti-vascular endothelial growth factor (VEGF) treatment (eg, bevacizumab) for retinopathy of prematurity (ROP) are limited. We found that following initial bevacizumab treatment for ROP, prophylactically lasering infant eyes before hospital discharge reduced the number and duration of outpatient ROP screening examinations compared with following infants, per current United States (US) ROP screening guidelines.

Co-Prevalence of Alzheimer's Disease and Age-Related Macular Degeneration Established by Histopathologic Diagnosis

BACKGROUND

Previous epidemiologic studies have suggested an association between AMD and AD, and several therapeutic agents are being developed based on this principle. However, prior studies have provided conflicting results due in part to their reliance on clinical diagnoses that are not based on gold-standard histopathology.

OBJECTIVE

To use histopathologic standards for diagnosis in order to determine the co-prevalence of AD among patients with and without AMD.

METHODS

This is a cross-sectional study of 157 autopsy ocular specimens from patients with and without AMD that were greater than 75 years of age at death. Sarks staging was used to document the severity of AMD, and Braak and Braak staging was used to assess the severity of AD in corresponding brain specimens. The prevalence of AD within different severities of AMD was determined using univariable and multivariable logistic regression.

RESULTS

58% of autopsy eyes had AMD. The prevalence of AD was lower in AMD subjects (63%) compared to non-AMD subjects (73%), even when grouped by severity (all p > 0.15). The likelihood of AD was significantly less in AMD subjects, even after adjusting for age and sex in multivariable analysis (OR 0.47, p = 0.049).

CONCLUSION

Histopathologic diagnoses fail to support an increase in prevalence of AD among subjects with AMD, even when disease severity is considered.

Quantitatively comparing weekly changes in retinal vascular characteristics of eyes eventually treated versus not treated for retinopathy of prematurity

PURPOSE

To quantitatively compare retinal vascular characteristics over time in eyes eventually treated versus not treated for retinopathy of prematurity (ROP), using ROPtool analysis of narrow-field retinal images.

METHODS

This longitudinal study used prospectively collected narrow-field retinal images of infants screened for ROP, prior to treatment, if needed. Images were analyzed using a methodology that combines quadrant-level measures from several images of the same eye. For the longitudinal analysis, one examination per postmenstrual age (PMA) was included per eye. We compared the following ROPtool indices and their change per week between eyes eventually treated versus not treated for ROP: tortuosity index (TI), dilation index (DI), sum of adjusted indices (SAI), and tortuosity-weighted plus (TWP). Analysis was performed on three levels: eye (mean value/eye), quadrant (highest quadrant value/eye), and blood vessel (highest blood vessel value/eye).

RESULTS

Of 832 examinations (99 infants), 745 images (89.5%) had 3-4 quadrants analyzable by ROPtool. On the eye level, ROPtool indices differed between eyes eventually treated versus not treated at PMA of 33-35 and 37 weeks for TI, SAI, and TWP, and at PMA of 33-34 and 37 weeks for DI (P ≤ 0.0014), and change per week differed between eyes eventually treated versus not treated only for SAI at PMA of 32 weeks (P < 0.001).

CONCLUSIONS

Quantitative analysis of retinal vascular characteristics using ROPtool can help predict eventual need for treatment for ROP as early as 32 weeks PMA. ROPtool index values were more useful than change in these indices to predict eyes that would eventually need treatment for ROP.

Teleophthalmology: Evaluation of Phone-based Visual Acuity in a Pediatric Population

Purpose

With the recent rise of teleophthalmology due to coronavirus disease, health care needs accurate and reliable methods of checking visual acuity remotely. The visual acuity as measured by the GoCheck Kids application was compared with that of the Amblyopia Treatment Study (ATS) and the authors' clinic protocol.

Design

This was a prospective, comparison of visual acuity assessment methods.

Methods

Established patients (3-18 years of age) in the practice of a single pediatric ophthalmologist were eligible. Visual acuity was measured 1) by GoCheck Kids mobile application, by the patient's family member; 2) by HOTV-ATS, by study personnel; and 3) by regular clinic protocol, by an ophthalmic technician. To assess agreement between measurement of acuity, intraclass correlations with 95% confidence intervals (CI) were computed.

Results

A total of 53 children participated. The mean differences between GoCheck Kids and HOTV-ATS acuities (0.094) were significantly different (P < .001). The intraclass correlation coefficient (ICC) was 0.55 (95% CI: 0.40-0.68). The mean differences between GoCheck Kids and chart acuities (0.010) were not significantly different (P = .319; ICC: 0.59; 95% CI: 0.45-0.71). The mean differences between HOTV-ATS and chart acuities (0.084) were significantly different (P < .001; ICC: 0.66; 95% CI: 0.53-0.76). The percentages of eyes with visual acuity measured by GoCheck Kids within 1 line of the HOTV-ATS and chart acuity were 65.3% and 86.7%, respectively.

Conclusions

GoCheck Kids as checked by a family member provided a modest correlation of visual acuity compared to the chart screen and a fair correlation of visual acuity compared to HOTV-Amblyopia Treatment Study protocol, although most were within 1 line.

Local Anatomic Precursors to New-Onset Geographic Atrophy in Age-Related Macular Degeneration as Defined on OCT

PURPOSE

In macula-wide analyses, spectral-domain (SD) optical coherence tomography (OCT) features including drusen volume, hyperreflective foci, and OCT-reflective drusen substructures independently predict geographic atrophy (GA) onset secondary to age-related macular degeneration (AMD). We sought to identify SD OCT features in the location of new GA before its onset.

DESIGN

Retrospective study.

PARTICIPANTS

Age-Related Eye Disease Study 2 Ancillary SD OCT Study participants.

METHODS

We analyzed longitudinally captured SD OCT images and color photographs from 488 eyes of 488 participants with intermediate AMD at baseline. Sixty-two eyes with sufficient image quality demonstrated new-onset GA on color photographs during study years 2 through 7. The area of new-onset GA and one size-matched control region in the same eye were segmented separately, and corresponding spatial volumes on registered SD OCT images at the GA incident year and at 2, 3, and 4 years previously were defined. Differences in SD OCT features between paired precursor regions were evaluated through matched-pairs analyses.

MAIN OUTCOME MEASURES

Localized SD OCT features 2 years before GA onset.

RESULTS

Compared with paired control regions, GA precursor regions at 2, 3, and 4 years before (n = 54, 33, and 25, respectively) showed greater drusen volume (P = 0.01, P = 0.003, and P = 0.003, respectively). At 2 and 3 years before GA onset, they were associated with the presence of hypertransmission (P < 0.001 and P = 0.03, respectively), hyperreflective foci (P < 0.001 and P = 0.045, respectively), OCT-reflective drusen substructures (P = 0.004 and P = 0.03, respectively), and loss or disruption of the photoreceptor zone, ellipsoid zone, and retinal pigment epithelium (RPE, P < 0.001 and P = 0.005-0.045, respectively). At 4 years before GA onset, precursor regions were associated with photoreceptor zone thinning (P = 0.007) and interdigitation zone loss (P = 0.045).

CONCLUSIONS

Evolution to GA is heralded by early local photoreceptor changes and drusen accumulation, detectable 4 years before GA onset. These precede other anatomic heralds such as RPE changes and drusen substructure emergence detectable 1 to 2 years before GA. This study thus identified earlier end points for GA as potential therapeutic targets in clinical trials.

Matrix metalloproteinase 9 positivity predicts long term decreased tear production

PURPOSE

To investigate long-term correlations between Matrix Metalloproteinase-9 (MMP-9) testing and dry eye (DE) parameters. Additionally, to evaluate variability in MMP-9 results over time and with anti-inflammatory treatment.

METHODS

Retrospective cohort study of DE patients with equal MMP-9 testing results (positive or negative) in both eyes and a minimum of 6 months of follow up. Our main outcome measure was to examine whether initial MMP-9 status affected change in DE parameters over time. Secondarily, we evaluated the frequency of MMP-9 status change over time and examined whether MMP-9 status change was impacted by treatment.

RESULTS

67 patients (76% female) fit the inclusion criteria. Mean age was 63 years with a mean follow up of 10.6 months. The majority (37/67, 55%) had concomitant systemic immune disease. MMP-9 testing was positive in both eyes in 39 individuals (58%) and negative in both eyes in 27 (42%) individuals. Of all DE parameters, initial MMP status predicted change in tear production. Individuals in the MMP-9 positive group had a greater decrease in production from baseline to final visit compared to the negative group (-2.6 vs 2.1, P = 0.013). In those initially MMP-9 positive, the frequency of becoming MMP-9 negative was higher in eyes treated with anti-inflammatory therapy compared to artificial tears (22.9% vs 3.3%, P = 0.106). However, only Lifitegrast 5% showed statistical significance compared to artificial tears (31.3% vs 3.3%, P = 0.044).

CONCLUSIONS

Eyes with detectable MMP-9 had significantly decreased tear production over time compared to those without detectable MMP-9. Anti-inflammatory treatment more frequently normalized MMP-9 compared to PFATs.

Morphological characteristics of early- versus late-onset macular edema in preterm infants

Macular images of infants with early-onset edema (occurring at or before 33 weeks' postmenstrual age [PMA]) and infants with late-onset edema (at or after 36 weeks' PMA) were compared. At first appearance, early-onset edema has a more severe morphology, with foveal bulging and elongated cystoid spaces than late-onset edema, which presents as small cystoid spaces outside the foveal center. Morphological variations may be an indicator of the underlying cause of edema in preterm infants. The presence of mostly parafoveal small cystoid spaces in the late-onset edema group may be suggestive of an association with neurological injury.

Assessment of Visual and Retinal Function Following In Vivo Genipin-Induced Scleral Crosslinking

Purpose

Genipin has been proposed as a possible neuroprotective therapy in myopia and glaucoma. Here, we aim to determine the effects of prolonged genipin-induced scleral stiffening on visual function.

Methods

Eyes from Brown Norway rats were treated in vivo with either a single 15 mM genipin retrobulbar injection or sham retrobulbar injection and were compared to naïve eyes. Intraocular pressure, optomotor response, and electroretinograms were repeatedly measured over 4 weeks following retrobulbar injections to determine visual and retinal function. At 4 weeks, we quantified retinal ganglion cell axon counts. Finally, molecular changes in gene and protein expression were analyzed via real-time polymerase chain reaction (RT-PCR) and proteomics.

Results

Retrobulbar injection of genipin did not affect intraocular pressure (IOP) or retinal function, nor have a sustained impact on visual function. Although genipin-treated eyes had a small decrease in retinal ganglion cell axon counts compared to contralateral sham-treated eyes (−8,558 ± 18,646; mean ± SD), this was not statistically significant (P = 0.206, n = 9). Last, we did not observe any changes in gene or protein expression due to genipin treatment.

Conclusions

Posterior scleral stiffening with a single retrobulbar injection of 15 mM genipin causes no sustained deficits in visual or retinal function or at the molecular level in the retina and sclera. Retinal ganglion cell axon morphology appeared normal.

Translational Significance

These results support future in vivo studies to determine the efficacy of genipin-induced posterior scleral stiffening to help treat ocular diseases, like myopia and glaucoma.

Effect of ICD-9 to ICD-10 Transition on Accuracy of Codes for Stage of Diabetic Retinopathy and Related Complications: Results from the CODER Study

PURPOSE

When the International Classification of Diseases 9th Revision (ICD-9) transitioned to the International Classification of Diseases 10th Revision (ICD-10), there was a marked increase in the complexity of International Classification of Diseases (ICD) codes with potential for improved specificity in clinical database research. The purpose of this study was to characterize the accuracy of coding for stage of diabetic retinopathy (DR) and DR-related complications (including vitreous hemorrhage, retinal detachment, and neovascular glaucoma) during this transition.

DESIGN

Retrospective chart review of 3 time periods corresponding to the use of ICD-9: 2014-2015; "early" use of ICD-10, 2015-2016; and "late" use of ICD-10, 2018-2019.

PARTICIPANTS

Patients aged 18 years or older with a diagnosis of DR at a multispecialty academic institution.

METHODS

Positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, and kappa (κ) statistics were generated for each diagnosis. Generalized estimating equation (GEE) models were used to assess the significance of the variables.

MAIN OUTCOME MEASURE

The main outcome was the proportion of agreement between the ICD code and the documented chart standard for stage of DR and DR-related complications.

RESULTS

A total of 600 patients were included in the study (average age, 61 years; range, 25-93 years). Overall, there was substantial agreement between the ICD codes for stage of DR and the documented standard (κ = 0.66). The proportion of ICD codes in agreement with the documented standard diagnosis increased with time: 66.5%, 78.5%, and 83.3% for ICD-9, "early" ICD-10, and "late" ICD-10, respectively. The odds of agreement were 2.67 (95% confidence interval [CI], 1.49-4.76, P < 0.001) and 3.96 (95% CI, 2.34-6.69, P < 0.0001) times greater for "early" and "late" ICD-10 codes compared with ICD-9 codes, respectively. For specific codes, the overall PPV, NPV, sensitivity, and specificity for nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) were excellent (>90%). The odds of agreement were 19.70 (95% CI, 11.54-33.64, P < 0.0001) times greater for PDR than NPDR. Compared with the stage of DR, DR-related diagnoses were overall less accurately coded (κ = 0.61, 0.48, and 0.52 for vitreous hemorrhage, retinal detachment, and neovascular glaucoma, respectively).

CONCLUSIONS

Coding in ICD-10 is more accurate than in ICD-9, particularly for PDR compared with NPDR. The increased accuracy emphasizes the potential for ICD-10 coding to be used effectively in database research.

Treatment Patterns and Clinical Outcomes for Central Retinal Vein Occlusion in the Antivascular Endothelial Growth Factor Era

Purpose:

This article describes treatment patterns and visual outcomes for central retinal vein occlusion (CRVO) in the antivascular endothelial growth factor (anti-VEGF) era.

Methods:

A retrospective cohort study of eyes diagnosed with CRVO between 2009 and 2016 was conducted. Treatment history and visual acuity (VA) measurements were abstracted from medical records and analyzed.

Results:

A total of 476 eyes of 476 patients (median age 67 years, median follow-up 25.4 months) were included. Optical coherence tomography was obtained in 93.9% and fluorescein angiography in 80% of cases on presentation. Mean VA at presentation and final visit was 20/60 and 20/94, respectively, for eyes with nonischemic CRVO, whereas that of ischemic cases remained worse than 20/800 at final follow-up. Intravitreal bevacizumab was the most common first treatment (42.2%). Intravitreal steroid was the first treatment in 3.6% and ultimately administered in 11.3% of eyes. In the first year, an average of 5.2 ± 3.6 and 2.2 ± 3.4 anti-VEGF injections were given in treatment-naive and nontreatment-naive eyes, respectively.

Conclusions:

In our real-world cohort, anti-VEGF injection burden and frequency are lower than in published clinical trials. Visual outcomes in both ischemic and nonischemic eyes with CRVO are poorer than expected and worse than those recorded in controlled trial settings.

Visual Acuity Assessment and Vision Screening Using a Novel Smartphone Application

OBJECTIVES

To evaluate a smartphone-based application's (Peek Acuity) ability to assess visual acuity and screen for ocular conditions in children, we compared visual acuity assessment between Peek Acuity and the pediatric ophthalmology examination and evaluated Peek Acuity's ability to identify children with referable ocular conditions.

STUDY DESIGN

We prospectively recruited 111 children age 3-17 years, presenting to a pediatric ophthalmology clinic, who could follow instructions. Monocular visual acuity assessments by Peek Acuity and standard clinical methods were performed in randomized order. We compared visual acuity assessments between methods using intraclass correlation coefficient (ICC) and evaluated Peek Acuity's ability to identify children with referable ocular conditions.

RESULTS

ICC comparing visual acuity assessed between methods was 0.88 (95% CI 0.83-0.92) for first and 0.85 (95% CI 0.78-0.89) for second eyes examined. ICC among 3 to 5-year-olds (preschool-age children) was 0.88 (95% CI 0.77-0.94) for first and 0.45 (95% CI 0.13-0.68) for second eyes examined. Peek Acuity had a sensitivity of 83%-86% for decreased vision and 69%-83% for referable ocular disease. Sensitivity was highest among 3 to 5-year-olds with decreased vision, 93%-100%.

CONCLUSIONS

Overall, Peek Acuity visual acuity assessment correlated well with visual acuity assessed by standard clinical methods, though preschool-age children appeared more susceptible to examination fatigue. Peek Acuity performed adequately as a screening tool and had the greatest sensitivity among those with decreased vision and preschool-age children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03212222.

Longitudinal Study of Visual Function in Dry Age-Related Macular Degeneration at 12 Months

PURPOSE

To report the 1-year progression of visual impairment on psychophysical tests of visual function in patients with early and intermediate age-related macular degeneration (AMD).

DESIGN

Prospective, observational study.

PARTICIPANTS

Patients with early and intermediate AMD were enrolled from the existing population at the Duke Eye Center, and healthy age-matched control participants were recruited from family members or friends of the AMD patients and from the Duke Optometry and Comprehensive Eye Clinics.

METHODS

Patients and control participants recruited during the baseline study were assessed at both 6 and 12 months after the initial study visit. Measurements of visual function included best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), low-luminance deficit (LLD), microperimetry percent-reduced threshold (PRT), microperimetry average threshold (AT), and cone contrast tests (CCTs).

MAIN OUTCOME MEASURES

Changes in BCVA, LLVA, LLD, microperimetry PRT, microperimetry AT, and CCT results from baseline to 6 months and to 12 months were assessed.

RESULTS

Eighty-five patients completed the 12-month examination (19 control participants, 27 early AMD patients, and 39 intermediate AMD patients). Longitudinal analysis detected significant changes from baseline within each group in microperimetry PRT and AT and in the intermediate AMD group only for BCVA and CCT results (P < 0.05).

CONCLUSIONS

Microperimetry and CCT are able to detect functional changes resulting from progression of dry AMD within a period as short as 12 months. These functional markers may be useful end points in future clinical trials that assess the effect of potential treatments for AMD.

Gray Optic Disc Crescent: Evaluation of Anatomic Correlate by Spectral-Domain OCT

PURPOSE

To test the hypothesis that the anatomic correlate of the gray optic disc crescent is pigmentation of externally oblique border tissue of Elschnig.

DESIGN

Retrospective study.

PARTICIPANTS

African-American adult men with or without clinically apparent gray optic disc crescents.

METHODS

McNemar's test for paired data and kappa statistic with 95% confidence intervals were used to examine the relationships between eyes with or without gray optic disc crescents and corresponding spectral-domain (SD) OCT images with enhanced depth imaging (EDI).

MAIN OUTCOME MEASURES

Correlation between clinical gray optic disc crescents and hyperreflectivity of externally oblique border tissue of Elschnig by SD OCT with EDI.

RESULTS

Twenty-five eyes had clinically apparent gray optic disc crescents, of which SD OCT with EDI revealed hyperreflectivity (interpreted as increased pigmentation) of externally oblique (obtuse angle) border tissue of Elschnig in 22 eyes, that is, extending into Bruch's membrane opening and presumably visible by funduscopy. Thirty-two eyes from matched participants had no apparent gray optic disc crescent, of which SD OCT with EDI revealed hyperreflectivity of the border tissue of Elschnig in 23 eyes, but with a nonoblique (right angle) or internal (acute angle) angle, which would presumably obstruct funduscopic visualization.

CONCLUSIONS

Observations by SD OCT with EDI suggest that the anatomic correlate of the gray optic disc crescent is pigmentation of externally oblique border tissue of Elschnig.

Non-contact retinal imaging compared to indirect ophthalmoscopy for retinopathy of prematurity screening: infant safety profile

OBJECTIVE

Most retinopathy of prematurity screening involves an ophthalmologist performing indirect ophthalmoscopy, which can be stressful to infants. The purpose of this study is to evaluate the safety profile (using cardiopulmonary events as an indicator) of imaging infants with a non-contact retinal camera compared to examining them using indirect ophthalmoscopy.

STUDY DESIGN

Prospective cohort study of 99 infants at a community hospital who were examined using indirect ophthalmoscopy and imaged using a non-contact retinal camera for retinopathy of prematurity. We evaluated the difference in the occurrence of safety events (i.e., clinically significant bradycardia, tachycardia, oxygen desaturation, or apnea) following the clinical examination versus retinal imaging.

RESULT

Safety events occurred after 0.8% (n = 1) of imaging sessions and 5.8% (n = 18) of clinical examinations (mean difference = -0.055 (p = 0.015), favoring imaging).

CONCLUSION

Retinal imaging with a non-contact camera was well tolerated and less stressful to infants compared to indirect ophthalmoscopy by an ophthalmologist.

The role of cystoid macular edema as a marker in the progression of non-paraneoplastic autoimmune retinopathy

PURPOSE

To determine the relationship between cystoid macular edema (CME) and disease severity and progression in non-paraneoplastic autoimmune retinopathy (npAIR).

METHODS

A retrospective study was conducted on patients seen between 2008 and 2016 with npAIR as defined by electroretinogram (ERG) dysfunction, visual field changes, presence of antiretinal antibodies, a negative malignancy workup, and no other apparent cause for visual dysfunction. Optical coherence tomography (OCT) scans were reviewed for each patient. A minimum follow-up of 1 year was necessary for study inclusion. The presence or absence of CME and the length of the preserved EZ on the centermost line scan of the SD-OCT images was recorded at each visit. The main outcome measure assessed was the rate of EZ loss (EZ final - EZ initial / days follow-up) over time, a marker for disease progression.

RESULTS

Thirty-two eyes (16 patients) were included with an average follow-up of 42 months. Twenty-one eyes (66%) had CME on initial presentation and final follow-up (group 1), eight eyes (25%) did not have CME on presentation or final follow-up (group 2), and three eyes (9%) did not have CME on presentation but developed CME during follow-up (group 3). Group 1 eyes had a lower maximal a-wave amplitude (59.0 vs. 220.9 mV, p = 0.012) and lower maximal b-wave amplitude (88.1 vs 256.9 mV, p = 0.017) on baseline ERG compared to Group 2 eyes. The rate of EZ loss over time was significantly greater for group 1 with CME compared to group 2 without CME both at 12 months (- 1.26 μm/day vs. - 0.26 μm/day, p = 0.022) and at final follow-up (- 1.03 μm/day vs. - 0.08 μm/day, p = 0.012).

CONCLUSIONS

CME was associated with decreased ERG amplitudes and greater velocity of EZ loss, suggesting that CME is a useful biomarker of more severe and more progressive disease in npAIR.

Evaluating a Portable, Noncontact Fundus Camera for Retinopathy of Prematurity Screening by Nonophthalmologist Health Care Workers

PURPOSE

To evaluate (1) the feasibility of non-ophthalmologist healthcare workers (HCWs) to obtain images of sufficient quality for retinopathy of prematurity (ROP) screening using a FDA-approved portable, non-contact, narrow-field fundus camera (i.e., Pictor™), and (2) the accuracy of grading these images to identify infants who developed treatment-warranted (type 1) ROP.

DESIGN

Prospective cohort study.

SUBJECTS

Infants undergoing routine ROP screening examinations (i.e. birth weight ≤1500 grams and/or gestational age ≤30 weeks or selected infants with a birth weight of 1500-2000g or gestational age >30 weeks and an unstable clinical course).

METHODS

We prospectively recruited infants undergoing ROP screening examinations at a community hospital. On the same day an ophthalmologist examined them, a trained HCW imaged their retinas using the non-contact camera. Two masked ROP experts graded these images remotely. We calculated both the percentage of gradable images (i.e. having at least 3 quadrants with sufficient image quality), as well as the accuracy of identifying infants who developed type 1 ROP.

MAIN OUTCOME MEASURES

Percentage of gradable images and the sensitivity and specificity of each grader for identifying infants with type 1 ROP by grading for the presence of pre-plus or plus disease.

RESULTS

Ninety-nine infants were included. Overall, 92.4% and 94.2% of all infant imaging sessions were considered gradable by graders 1 and 2, respectively. Amongst gradable images, the sensitivity of both graders for identifying type 1 ROP by grading for the presence of pre-plus or plus disease was 100% (95% confidence interval (CI): 95-100%) and the specificity 91% (95% CI: 83-95%) for grader 1 and 93% (95% CI: 86-96%) for grader 2.

CONCLUSIONS

It was highly feasible for trained HCWs to obtain digital retinal images of sufficient quality for ROP screening using a non-contact fundus camera. By grading for the presence of pre-plus or plus disease, graders identified infants who developed type 1 ROP with high sensitivity and specificity. The use of portable, non-contact retinal cameras by trained HCWs could increase our workforce in ROP screening and identify infants needing an indirect ophthalmoscopy examination by an ophthalmologist.

Association of Low Luminance Questionnaire With Objective Functional Measures in Early and Intermediate Age-Related Macular Degeneration

Purpose

To determine whether Low Luminance Questionnaire (LLQ) scores are associated with objective measures of visual function in early and intermediate age-related macular degeneration (AMD).

Methods

Cross-sectional study of subjects with early AMD Age-Related Eye Disease Study (AREDS) stage 2, N = 33), intermediate AMD (AREDS stage 3, N = 47), and age-matched healthy controls (N = 21). Subjects were interviewed with the LLQ. Psychophysical tests performed included best-corrected visual acuity (BCVA), mesopic microperimetry, dark adaptometry (DA), low luminance visual acuity (LLVA), and cone contrast test (CCT). Low luminance deficit (LLD) was the difference in the number of letters read under photopic versus low luminance settings. The relationship between LLQ and visual function test scores was assessed with linear regression.

Results

Subjects with intermediate AMD had significantly lower LLQ composite scores (mean = 75.8 ± 16.7; median = 76, range [29, 97]) compared with early AMD (mean = 85.3 ± 13.3; median = 88, range [50, 100], P = 0.007) or controls (mean = 91.4 ± 6.5; median = 94, range [79, 99], P < 0.001) in the overall cohort. LLQ composite scores were associated with computerized BCVA (β = 0.516), computerized LLVA at two background luminance (1.3 cd/m², β = 0.660; 0.5 cd/m², β = 0.489) along with their respective computerized LLDs (β = −0.531 and −0.467), rod intercept (β = −0.312), and CCT green (β = 0.183) (all P < 0.05). Only the computerized LLVAs and computerized LLDs remained statistically significant after adjusting for AMD versus control status (P < 0.05). Among AMD subjects, LLQ composite scores were significantly associated with the computerized LLVAs (β = 0.622 and 0.441) and LLDs (β = −0.795 and −0.477) at both the 1.3 and 0.5 cd/m² luminance levels, respectively, and these associations remained significant after adjusting for AMD severity (P < 0.05).

Conclusions

Among subjects with early and intermediate AMD, LLQ scores were significantly associated with computerized LLVA and LLD. LLQ is a useful patient-centered functional measure of visual impairment in early and intermediate AMD.

Volumetric Measurement of Subretinal Blebs Using Microscope-Integrated Optical Coherence Tomography

PURPOSE

We advance studies of subretinal treatments by developing a microscope-integrated optical coherence tomography (MIOCT) image-based method for measuring the volume of therapeutics delivered into the subretinal space.

METHODS

A MIOCT image-based volume measurement method was developed and assessed for accuracy and reproducibility by imaging an object of known size in model eyes. This method then was applied to subretinal blebs created by injection of diluted triamcinolone. Bleb volumes obtained from MIOCT were compared to the intended injection volume and the surgeon's estimation of leakage.

RESULTS

Validation of the image-based volume measurement method showed accuracy to ±1.0 μL (6.0% of measured volume) with no statistically significant variation under different imaging settings. When this method was applied to subretinal blebs, four of 11 blebs without surgeon-observed leakage yielded a mean volume of 32 ± 12.5 μL, in contrast to the intended 50 μL volume injected from the delivery device. This constituted a mean difference of -18 μL (mean percent error, 36 ± 25%). For all 11 blebs, the surgeon's estimations of leakage were significantly different from and showed no correlation with the volume loss based on image-based volume measurements (P < 0.001, paired t-test; intraclass correlation = 0).

CONCLUSIONS

We validated an accurate and reproducible method for measuring subretinal volumes using MIOCT. Use of this method revealed that the intended volume might not be delivered into the subretinal space. MIOCT can allow for accurate assessment of subretinal dose delivered, which may have therapeutic implications in evaluating the efficacy and toxicity of subretinal therapies.

TRANSLATIONAL RELEVANCE

Use of MIOCT can provide feedback on the accuracy of subretinal injection volumes delivered.

Identifying risk factors for blindness from primary open-angle glaucoma by race: a case-control study

Purpose

To examine the factors associated with blindness from primary open-angle glaucoma (POAG) among black and white patients at our institution.

Patients and methods

For this retrospective, case-control study, patients legally blind from POAG ("cases") were matched on age, race, and gender with non-blind POAG patients ("controls"). Thirty-seven black case-control pairs and 19 white case-control pairs were included in this study. Clinical variables were compared at initial presentation and over the course of follow-up.

Results

Black case-control pairs and white case-control pairs had similar characteristics at presentation, including cup-to-disc ratio and number of glaucoma medications. However, over the course of follow-up, black cases underwent significantly more glaucoma surgeries than matched controls (2.4 versus 1.2, p=0.001), whereas white cases and controls had no significant difference in glaucoma operations (0.9 versus 0.6, p=0.139). Our analysis found that glaucoma surgery is associated with blindness in black patients (odds ratio [OR] 1.6, 95% CI 1.1-2.2) but not in white patients (OR 1.5, 95% CI 0.7-3.2).

Conclusion

Black and white case-control pairs with POAG shared similar risk factors for blindness at presentation. However, over the follow-up period, black cases required significantly more glaucoma surgeries compared to black controls, whereas there was no significant difference in surgery between white cases and controls. There was no difference in medication changes in either case-control set.

Evaluation of inner retinal layers as biomarkers in mild cognitive impairment to moderate Alzheimer's disease

Inner retina in Alzheimer's Disease (AD) may experience neuroinflammation resulting in atrophy. The objective of our study was to determine whether retinal GCIPL (ganglion cell-inner plexiform layer) or nerve fiber layer (NFL) thickness may serve as noninvasive biomarkers to diagnose AD. This cross-sectional case-control study enrolled 15 mild cognitive impairment (MCI) patients, 15 mild-moderate AD patients, and 18 cognitively normal adults. NFL and GCIPL thicknesses on optical coherence tomography (OCT) were measured using Duke Optical Coherence Tomography Retinal Analysis Program (DOCTRAP) and Spectralis software. We demonstrated that regional thicknesses of NFL or GCIPL on macular or nerve OCTs did not differ between groups. However, a multi-variate regression analysis identified macular areas with a significant thickening or thinning in NFL and GCIPL in MCI and AD patients. Our primary findings controvert previous reports of thinner NFL in moderate-to-severe AD. The areas of thickening of GCIPL and NFL in the macula adjacent to areas of thinning, as revealed by a more complex statistical model, suggest that NFL and GCIPL may undergo dynamic changes during AD progression.

Impact of Microscope-Integrated OCT on Ophthalmology Resident Performance of Anterior Segment Surgical Maneuvers in Model Eyes

Purpose

The integration of swept-source optical coherence tomography (SS-OCT) into the operating microscope enables real-time, tissue-level three-dimensional (3D) imaging to aid in ophthalmic microsurgery. In this prospective randomized controlled study, we evaluated the impact of SS microscope-integrated OCT (MI-OCT) on ophthalmology residents' performance of ophthalmic microsurgical maneuvers.

Methods

Fourteen ophthalmology residents from a single institution were stratified by year of training and randomized to perform four anterior segment surgical maneuvers on porcine eyes with (MI-OCT+) or without (MI-OCT−) direct intraoperative OCT guidance. Subsequently, both groups repeated the same maneuvers without MI-OCT feedback to test whether initial MI-OCT experience affected subsequent surgical performance. Finally, the MI-OCT− group was crossed over and allowed to repeat the same maneuvers with direct MI-OCT guidance. Each resident completed a survey at the completion of the study.

Results

With direct MI-OCT feedback, residents demonstrated enhanced performance in depth-based anterior segment maneuvers (corneal suture passes at 50% and 90% depth and corneal laceration repair) compared with the residents operating without MI-OCT. Microscope-integrated OCT+ residents continued to outperform the controls when both groups subsequently operated without MI-OCT. For clear corneal wound geometry, there was no statistically significant effect of MI-OCT as applied in this study. Overall, the resident surgeons rated their subjective experience of using MI-OCT very favorably.

Conclusions

Microscope-integrated OCT feedback enhances performance of ophthalmology residents in select anterior segment surgical maneuvers. Microscope-integrated OCT represents a valuable tool in the surgical education of ophthalmology residents.

Analysis of Cerebrospinal Fluid Pressure Estimation Using Formulae Derived From Clinical Data

Purpose

To evaluate a frequently used regression model and a new, modified regression model to estimate cerebrospinal fluid pressure (CSFP).

Methods

Datasets from the Beijing iCOP study from Tongren Hospital, Beijing, China, and the Mayo Clinic, Rochester, Minnesota, were tested in this retrospective, case-control study. An often-used regression model derived from the Beijing iCOP dataset, but without radiographic data, was used to predict CSFP by using demographic and physiologic data. A regression model was created using the Mayo Clinic dataset and tested against a validation group. The Mayo Clinic-derived formula was also tested against the Beijing Eye Study population. Intraclass correlation was used to assess predicted versus actual CSFP.

Results

The Beijing-derived regression equation was reported to have an intraclass correlation coefficient (ICC) of 0.71, indicating strong correlation between predicted and actual CSFP in the study population. The Beijing iCOP regression model poorly predicted CSFP in the Mayo Clinic population with an ICC of 0.14. The Mayo Clinic-derived regression model similarly did not predict CSFP in its Mayo Clinic validation group (ICC 0.28 ± 0.04) nor in the Beijing Eye Study population (ICC 0.06).

Conclusions

Formulae used to predict CSFP derived from clinical data fared poorly against a large retrospective dataset. This may be related to differences in lumbar puncture technique, in the populations tested, or the timing of collection of physiologic variables in the Mayo Clinic dataset. Caution should be used when interpreting results based on formulaic derivation of CSFP.

Effect of thermal pulsation treatment on tear film parameters in dry eye disease patients

PURPOSE

The goal of this study was to evaluate the effect of thermal pulsation treatment on tear film parameters, specifically osmolarity and matrix metalloproteinase-9 (MMP-9), in patients with meibomian gland dysfunction (MGD) and dry eye disease (DED).

METHODS

A single-center review of 189 eyes that underwent thermal pulsation treatment was performed. Data were collected on pre and posttreatment osmolarity, MMP-9, tear break-up time (TBUT), and ocular surface disease index (OSDI) score. Statistical analyses were performed to detect any significant differences after treatment.

RESULTS

Thermal pulsation treatment led to significant improvements in TBUT (mean increase from 4.5 to 8.5 seconds [P<0.001]), OSDI score (mean decrease from 50.5 to 41.6 [P=0.024]), and MMP-9 (50% positive rate pretreatment compared to 26% positive rate post treatment [P<0.0001]). In the subset of patients who had a baseline osmolarity >307 mOsm/L (ie, diagnostic for DED), there was a significant improvement in the mean tear osmolarity from 317.1 to 306.6 mOsms/L after treatment (P=0.002).

CONCLUSION

Treating MGD is an important component of caring for the DED patient. Thermal pulsation treatment can improve MMP-9 levels on the ocular surface of patients with MGD and DED, as well as improve osmolarity in those with abnormal initial values. The present study suggests that meibomian glands play an important role in tear film dynamics and, as such, effective therapy such as thermal pulsation treatment aimed at improving meibomian gland health, can aid the restoration of normal tear film parameters and decrease patient symptoms of DED and MGD.

Comparison of Visual Outcomes in Coats' Disease: A 20-Year Experience

PURPOSE

To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice.

DESIGN

Single-center retrospective cohort study.

PARTICIPANTS

Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015.

METHODS

Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015).

MAIN OUTCOME MEASURES

Visual acuity (VA).

RESULTS

Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P = 0.03), but remained stable for decade 2 eyes (P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P < 0.001).

CONCLUSIONS

The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

Systematic review of topical antimicrobial therapy for acute otitis externa

OBJECTIVE: To determine the efficacy of topical antimicrobials for acute otitis externa.

STUDY DESIGN: Systematic review and random effects metaanalysis of randomized, controlled trials with parallel groups permitting one or more of the following comparisons: antimicrobial vs placebo, antiseptic vs antimicrobial, quinolone antibiotic vs nonquinolone antibiotic, steroid-antimicrobial vs antimicrobial, or antimicrobial-steroid vs steroid.

RESULTS: Twenty trials met inclusion criteria and 18 had data suitable for pooling. Topical antimicrobials increased absolute clinical cure rates over placebo by 46% (95% confidence interval [CI], 29% to 63%) and bacteriologic cure rates by 61% (95% CI, 46% to 76%). No significant differences were noted in clinical cure rates for other comparisons, except that steroid alone increased cure rates by 20% compared with steroid plus antibiotic (95% CI, 3% to 38%). Quinolone drops increased bacteriologic cure rates by 8% compared with nonquinolone antibiotics (95% CI, 1% to 16%), but had statistically equivalent rates of clinical cure and adverse events

CONCLUSION: Topical antimicrobial is highly effective for acute otitis externa with clinical cure rates of 65% to 80% within 10 days of therapy. Minor differences were noted in comparative efficacy, but broad confidence limits containing small effect sizes make these of questionable clinical significance.

SIGNIFICANCE: Summary estimates from the 13 meta-analyses can be used to facilitate evidence-based management recommendations and clinical practice guideline development. © 2006 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. All rights reserved.

Optical Coherence Tomography Reflective Drusen Substructures Predict Progression to Geographic Atrophy in Age-related Macular Degeneration

PURPOSE

Structural and compositional heterogeneity within drusen comprising lipids, carbohydrates, and proteins have been previously described. We sought to detect and define phenotypic patterns of drusen heterogeneity in the form of optical coherence tomography-reflective drusen substructures (ODS) and examine their associations with age-related macular degeneration (AMD)-related features and AMD progression.

DESIGN

Retrospective analysis in a prospective study.

PARTICIPANTS

Patients with intermediate AMD (n = 349) enrolled in the multicenter Age-Related Eye Disease Study 2 (AREDS2) ancillary spectral-domain optical coherence tomography (SD OCT) study.

METHODS

Baseline SD OCT scans of 1 eye per patient were analyzed for the presence of ODS. Cross-sectional and longitudinal associations of ODS presence with AMD-related features visible on SD OCT and color photographs, including drusen volume, geographic atrophy (GA), and preatrophic features, were evaluated for the entire macular region. Similar associations were also made locally within a 0.5-mm-diameter region around individual ODS and corresponding control region without ODS in the same eye.

MAIN OUTCOME MEASURES

Preatrophy SD OCT changes and GA, central GA, and choroidal neovascularization (CNV) from color photographs.

RESULTS

Four phenotypic subtypes of ODS were defined: low reflective cores, high reflective cores, conical debris, and split drusen. Among the 349 participants, there were 307 eligible eyes and 74 (24%) had at least 1 ODS. The ODS at baseline were associated with (1) greater macular drusen volume at baseline (P < 0.001), (2) development of preatrophic changes at year 2 (P = 0.001-0.01), and (3) development of macular GA (P = 0.005) and preatrophic changes at year 3 (P = 0.002-0.008), but not development of CNV. The ODS at baseline in a local region were associated with (1) presence of preatrophy changes at baseline (P = 0.02-0.03) and (2) development of preatrophy changes at years 2 and 3 within the region (P = 0.008-0.05).

CONCLUSIONS

Optical coherence tomography-reflective drusen substructures are optical coherence tomography-based biomarkers of progression to GA, but not to CNV, in eyes with intermediate AMD. Optical coherence tomography-reflective drusen substructures may be a clinical entity helpful in monitoring AMD progression and informing mechanisms in GA pathogenesis.

An upright eyedrop bottle: accuracy, usage of excess drops, and contamination compared to a conventional bottle

Purpose

This study tested the feasibility of using an upright eyedrop bottle (UEB), a device designed to assist patients with eyedrop placement without reclining their head.

Patients and methods

Experienced eyedrop users were enrolled who answered “yes” to the question, “Do you ever have trouble getting your eyedrops in?” After being shown a multimedia presentation and answering a questionnaire regarding eyedrop usage, participants were observed instilling eyedrops. Participants were instructed to instill a single eyedrop in each eye with both a standard bottle and the UEB. They repeated this process three times. With each trial, the amount of time taken to instill drops was recorded, as well as whether a drop landed in the eye (accuracy), if excess drops were used, and if the bottle tip was contaminated.

Results

Forty participants were enrolled, with an average age of 72.4±8.9 years; the majority were females (24 females). Thirty-four participants had been using eyedrops for at least 1 year. The time required to instill eyedrops was significantly less with the UEB in the second and third trials. There was no difference in accuracy between the conventional bottle and the UEB in the left or right eye in any trials. Significantly more participants used excess number of drops while using the conventional bottle in both the left and right eyes in all three trials. The bottle tip was never contaminated with the UEB. Depending on the trial and the eye, the conventional bottle was contaminated by between 42% and 53% of participants.

Conclusion

The UEB has the potential to assist patients with eyedrop placement. Although there was no difference in accuracy between the UEB and the conventional bottle, the UEB was associated with less use of excess drops and less contamination of the bottle tip, compared to the conventional bottle.