Effect of race and ethnicity on surgical outcomes for rhegmatogenous retinal detachments

OBJECTIVE

To evaluate the effect of socioeconomic and demographic factors on outcomes in rhegmatogenous retinal detachments (RRDs).

DESIGN

Retrospective cohort study.

METHODS

A total of 71 white and 124 black and/or Hispanic patients who had surgical repair of RRDs between October 2013 and September 2021 at a single-centre safety net hospital. Main outcomes were single surgery success rates (SSSR) and postoperative visual acuity at 6-month and final follow-up.

RESULTS

Black and (or) Hispanic patients were significantly younger (black and [or] Hispanic, 50.7 years vs white, 57.6 years; p = 0.003), had lower mean household incomes (black and [or] Hispanic, $80,932 vs white, $92,911; p = 0.007), were more likely to have more than 1 retinal break (black and [or] Hispanic, 65% vs white, 49%; p = 0.04), and had higher rates of proliferative vitreoretinopathy (PVR) at presentation (black and [or] Hispanic, 35% vs white, 18%; p = 0.02). SSSR was similar (black and [or] Hispanic, 73.4% vs white, 73.2%; p = 0.98), but black and (or) Hispanic patients had worse visual acuity postoperatively (black and [or] Hispanic, 20/63 vs white, 20/40 at final follow-up; p = 0.03). While race was linked to visual outcome in univariate testing; multivariate analysis revealed only macula status (p = 0.007 at 6 months; p = 0.01 at final follow-up), presence of PVR (p < 0.001 at both time points), and SSSR (p = 0.003 at final follow-up) as predictors of worse visual outcomes.

CONCLUSIONS

Preoperative factors such as higher rates of PVR may contribute to worse vision outcomes in black and (or) Hispanic patients undergoing surgical repair for RRD.

Long-Term Satisfaction of Oral Sedation versus Standard-of-Care Intravenous Sedation for Ocular Surgery

Purpose

Long-term patient satisfaction may influence patients' perspectives of the quality of care and their relationship with their providers. This is a follow up to a comparative effectiveness study investigating oral to intravenous sedation (OIV study). The OIV study found that oral sedation was noninferior in patient satisfaction to standard intravenous (IV) sedation for anterior segment and vitreoretinal surgeries. This study aims to determine if patient satisfaction with oral sedation remained noninferior long term.

Patients and Methods

Patients were re-interviewed using the same satisfaction survey given during the OIV study. Statistical analysis involved t-tests for noninferiority of the long-term mean satisfaction score of oral and IV sedation. We also compared the original mean satisfaction score and the follow-up mean satisfaction score for each type of sedation and for both groups combined.

Results

Participants were interviewed at a median of 1225.5 days (range 754-1675 days) from their surgery. The original mean satisfaction score was 5.26 ± 0.79 for the oral treatment group (n = 52) and 5.27 ± 0.64 for the intravenous treatment group (n = 46), demonstrating noninferiority with a difference in mean satisfaction score of 0.015 (p < 0.0001). The follow-up mean satisfaction score was 5.23 ± 0.90 for oral sedation and 5.60 ± 0.61 for IV sedation, with a difference in the mean satisfaction score of 0.371 (p = 0.2071). Satisfaction scores did not differ between the original mean satisfaction score and the follow-up mean satisfaction score for the oral treatment group alone (p = 0.8367), but scores in the intravenous treatment group increased longitudinally (p = 0.0004).

Conclusion

In this study, long-term patient satisfaction with oral sedation was not noninferior to satisfaction with IV sedation, unlike our findings with short-term patient satisfaction in our original study. Patient satisfaction also remained unchanged over time for the oral treatment group, but patients in the intravenous treatment group reported higher long-term satisfaction with their anesthesia experience compared to the immediate post-operative period.

Patient Satisfaction with the Hybrid Telemedicine Model for Ophthalmology

Background: The purpose of this research was to compare patient satisfaction between hybrid ophthalmology telemedicine and standard-of-care in-person visits. A retrospective, cross-sectional, case-control analysis of patient satisfaction based on survey data was used. Methods: Responses to the National Research Council Health Patient Survey were retrieved for randomly sampled hybrid ophthalmology telemedicine and in-person visits between March 11, 2020 and December 31, 2021 at a hospital-based eye clinic in Boston, Massachusetts. The primary outcome was based on the question "How likely would you be to recommend this provider to your family and friends?" (0-10 scale) with a score of 9 or 10 coded as satisfied. Two-sample t-tests, Pearson's chi-square tests, and bivariate logistic regressions were used to compare patient satisfaction scores between the hybrid and in-person cohorts. Demographic data, including age, sex, language, and self-reported race and ethnicity, were used as potential predictors of patient satisfaction in a multivariable logistic regression model. Results: There were 49 surveys from hybrid visits and 3,390 surveys from in-person visits. Hybrid visit patients reported high satisfaction scores without significant differences compared to in-person visit patients (hybrid 79% satisfied, in-person 82% satisfied, p = 0.728). Age was significantly associated with satisfaction in the hybrid cohort with the 65+ age group reporting lower satisfaction (below 65 years 100% satisfied, 65+ years 60% satisfied, p = 0.003). No association with age was observed in the in-person cohort. Conclusions: The hybrid ophthalmology telemedicine model can provide effective care without sacrificing patient satisfaction. Older patients may benefit from targeted interventions in future telemedicine models.

Diverse Research Teams and Underrepresented Groups in Clinical Studies

Importance

Several ophthalmic diseases disproportionately affect racial and ethnic minority patients, yet most clinical trials struggle to enroll cohorts that are demographically representative of disease burden; some barriers to recruitment include time and transportation, language and cultural differences, and fear and mistrust of research due to historical abuses. Incorporating diversity within the research team has been proposed as a method to increase trust and improve engagement among potential study participants.

Objective

To examine how demographic factors of potential research participants and personnel may be associated with patient consent rates to participate in prospective ophthalmic clinical studies.

Design, Setting, and Participants

This retrospective cohort study included patients from an urban, academic hospital who were approached for consent to participate in prospective ophthalmic clinical studies conducted between January 2015 and December 2021.

Main Outcomes and Measures

Multivariable logistic regression assessing associations between patient and research personnel demographics and rates of affirmative consent to participate was used.

Results

In total, 1380 patients (mean [SD] age, 58.6 [14.9] years; 50.3% male) who were approached for consent to participate in 10 prospective ophthalmic clinical studies were included. Of prospective patients, 566 (43.5%) were Black; 327 (25.1%), Hispanic or Latino; 373 (28.6%), White; 36 (2.8%), other race and ethnicity; and 78 (5.8%) declined to answer. Black patients (odds ratio [OR], 0.32; 95% CI, 0.24-0.44; P < .001) and Hispanic or Latino patients (OR, 0.31; 95% CI, 0.20-0.47; P < .001) were less likely to consent compared with White patients. Patients with lower socioeconomic status were less likely to consent than patients with higher socioeconomic status (OR, 0.43; 95% CI, 0.33-0.53; P < .001). Concordance between patient and research staff race and ethnicity was associated with increased odds of affirmative consent (OR, 2.72; 95% CI, 1.99-3.73; P < .001).

Conclusions and Relevance

In this cohort study, patients from underrepresented racial and ethnic groups and those with lower socioeconomic status were less likely to participate in ophthalmic clinical studies. Concordance of race and ethnicity between patients and research staff was associated with improved participant enrollment. These findings underscore the importance of increasing diversity in clinical research teams to improve racial and ethnic representation in clinical studies.

Socioeconomic Disparities in Patients Receiving Intravitreal Injections for Age-Related Macular Degeneration Amid the COVID-19 Pandemic

Purpose: To determine the effects of socioeconomic factors on visit adherence and the resultant visual outcomes for patients receiving intravitreal injections for neovascular age-related macular degeneration during the COVID-19 pandemic. Methods: In this retrospective case-control study, medical records were reviewed to collect appointment attendance, age, sex, self-reported race/ethnicity, primary language, marital status, insurance, distance from clinic, and Area Deprivation Index (ADI), a measure of socioeconomic disadvantage. Multivariate regression models were created to determine differences in socioeconomic factors between individuals who attended (show group) and those who did not attend (no-show group) appointments. Results: The study enrolled 126 patients in the show group and 115 in the no-show group. On univariate analysis, nonadherence was significantly higher in non-White patients than in White patients (P = .04), urban sites than in suburban sites (P = 1.7 × 10-4), and non-English-speaking patients than in English-speaking patients (P = 4.0 × 10-3). The associations remained significant in multivariate analysis for non-English-speaking patients (P = .03) and urban-site patients (P = .01) after adjusting for age, sex, self-reported race/ethnicity, primary language, marital status, insurance, distance from clinic, site of visit, and ADI. At 6 months and 1 year, a 1-, 2-, and 3-line vision loss was significantly higher in the no-show group than in the show group on univariate and multivariate analysis after adjusting for age, sex, race, lens status, and presence of glaucoma and diabetic retinopathy. Conclusions: Non-English-speaking patients and urban-based patients were less likely to present for intravitreal injection appointments during the initial peak of the COVID-19 pandemic. This disparity translated to worse vision outcomes at 6 months and 1 year.

Unrelenting Vision Loss: The Virulence of Klebsiella pneumoniae

A 37-year-old Hispanic male with a recent history of COVID-19 infection and type 2 diabetes mellitus was admitted to the hospital with shortness of breath, chest pain, and hyperglycemia. Eye exam and imaging findings indicated endogenous endophthalmitis confirmed by blood cultures that speciated to Klebsiella pneuomoniae. The patient's eye condition progressed, ultimately resulting in no light perception less than a month after the initial evaluation. Due to the rapidly progressive nature of Klebsiella endogenous endophthalmitis, we recommend that primary teams consult ophthalmology for close monitoring of patients with a high index of suspicion.

Incidence and Risk Factors for Delayed Retinal Tears after an Acute, Symptomatic Posterior Vitreous Detachment

PURPOSE

To determine the long-term incidence of and risk factors for delayed retinal tears after acute, symptomatic posterior vitreous detachment (PVD) without concurrent retinal tears.

DESIGN

Retrospective, observational case series.

SUBJECTS

Patients diagnosed with an acute, symptomatic PVD without concurrent retinal tears at a tertiary eye center between 2013 and 2018.

METHODS

This is a retrospective, consecutive, and observational case series. Acute and symptomatic PVD was defined as experiencing flashes or floaters for 1 month or less at the time of diagnosis. Patients with a retinal tear or detachment at or before the time of diagnosis were not included. The occurrence and timing of subsequent retinal tears after initial PVD diagnosis were recorded. The age, sex, race, refractive error, lens status, lattice degeneration status, and type of physician (retina specialist vs. nonretina specialist) who saw the patient were also recorded.

MAIN OUTCOME MEASURES

Time to the development of a delayed retinal tear.

RESULTS

A total of 389 eyes from 389 patients had acute and symptomatic PVDs without concurrent retinal tears or detachments at diagnosis. Kaplan-Meier analysis showed that 7.39% of eyes developed delayed retinal tears by 6.24 years after initial PVD diagnosis. Of these tears, 50% occurred within 4.63 months of PVD diagnosis, and 63.46% occurred within 1 year of PVD diagnosis. Cox-Mantel log-rank analysis showed that those who were younger (age < 60 years), myopic, or had lattice degeneration were more likely to develop tears. A multivariate Cox proportional-hazards models controlling for other significant risk factors supported lattice degeneration as a likely risk factor for delayed retinal tear.

CONCLUSIONS

This study demonstrates that 7.39% of patients with acute, symptomatic PVD without concurrent retinal tears develop delayed retinal tears by 6.24 years after PVD diagnosis, with many developing tears well after a typical 6-week follow-up time for PVD. Lattice degeneration is a significant risk factor for delayed tears. These findings can guide clinicians in establishing optimal follow-up protocols for patients with acute, symptomatic PVD.

FINANCIAL DISCLOSURE(S)

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

Upregulation of Neuroinflammatory Protein Biomarkers in Acute Rhegmatogenous Retinal Detachments

The purpose of this study is to characterize the inflammatory cytokine profile in rhegmatogenous retinal detachments (RRDs) compared to surgical controls. Vitreous humor was collected from patients undergoing vitrectomy for RRD and noninflammatory vitreoretinal diseases. A quantitative immunoassay was used to measure the levels of 36 cytokine markers. Linear regression analysis with the duration of detachment as the predictor and log-transformed cytokine levels as the outcome was conducted for normally distributed cytokines as determined by the Shapiro-Wilk test. The analysis was adjusted for age, sex, and race. The Kruskal-Wallis test was used for cytokines not normally distributed. Twenty-seven RRD cases and thirteen control cases were studied. Between all RRDs and controls, fibroblast growth factor 2 (FGF2) (p = 0.0029), inducible protein-10(IP-10) (p = 0.0021), monocyte chemoattractant protein-1 (MCP-1) (p = 0.0040), interleukin (IL)-16 (p = 0.018), IL-8 (p = 0.0148), IL-6 (p = 0.0071), eotaxin (p = 0.0323), macrophage inflammatory protein (MIP)-1 alpha (p = 0.0149), MIP-1 beta (p = 0.0032), and the thymus and activation regulated cytokine (TARC) (p = 0.0121) were elevated in RRD cases. Between acute RRDs (n = 16) and controls, FGF2 (p = 0.0001), IP10 (p = 0.0027), MCP-1 (p = 0.0015), MIP-1β (p = 0.0004), IL-8 (p = 0.0146), and IL-6 (p = 0.0031) were elevated. Determining alterations in inflammatory cytokine profiles may aid in understanding their impact on RRD development, clinical course, and complications before and after surgical repair.

Focal Laser Photocoagulation for Central Serous Chorioretinopathy in Under-Represented Populations: A Retrospective Case Series

This case series examines visual and anatomic outcomes of focal laser photocoagulation in the treatment of central serous chorioretinopathy (CSCR) with subretinal fluid (SRF) in under-represented populations. We reviewed records of 25 eyes with CSCR and SRF that underwent focal laser photocoagulation. Visual acuity (VA) and central macular thickness (CMT) were recorded prior to laser, after laser treatment, and at final follow-up and were all compared using Wilcox signed-rank tests after using Shapiro-Wilk tests to determine normality. The racial and ethnic breakdown of our cohort (n = 25) includes 64% Hispanic (n = 16), 20% black (n = 5), 12% Asian (n = 3), 4% other (n = 1). Patients were followed for a median of 15.5 months (range: 5.75-87 months) after treatment. The VA prior to laser compared to best-available VA significantly improved (p = 0.0003). Pre-laser CMT to post-laser CMT (p < 0.0001) and pre-laser CMT to final CMT (p < 0.0001) significantly improved. Excluding the one eye that developed a choroidal neovascular membrane, the pre-laser VA to final VA improved significantly (p = 0.0047) as well as the pre-laser CMT to final CMT (p < 0.0001). Of the 25 eyes, 4 had persistent SRF following laser, and of the 21 eyes with complete resolution of SRF, 2 developed recurrent SRF. Focal laser photocoagulation can significantly improve VA and CMT in CSCR with active SRF in patients who have been under-represented in prior clinical studies.

Ocular syphilis resurgence in an urban underserved community in the United States

AIM

To evaluate the clinical characteristics, demographics, and visual outcomes of patients with ocular syphilis at an urban hospital to increase awareness and assist in earlier diagnosis and treatment of the resurgent disease.

METHODS

A retrospective chart review was performed on patients with ICD-9 and ICD-10 diagnosis codes correlating with syphilis or syphilis-related ocular diseases between 2010 and 2019. Variables evaluated included age, gender, race, vision, ocular findings, human immunodeficiency virus (HIV) status and men who have sex with men status, recreational drug and alcohol use.

RESULTS

Ocular syphilis was diagnosed in 40 patients (53 eyes) of a total of 229 patients who tested positive for syphilis via serum and/or cerebrospinal fluid treponemal testing from 2010-2019. Among patients with ocular syphilis, most patients were males, aged 45 or above and Black, and had no diagnosed HIV infection. Approximately 50% patients had 20/40 vision or better. Nearly 50% had non-granulomatous anterior uveitis as their initial presentation, and 49% of patients had involvement of the posterior segment. Neovascular glaucoma (5.7%), papillitis (7.5%), vasculitis (5.7%), and retinal detachment (5.7%) were rarer presentations of the disease and were associated with a poorer visual prognosis.

CONCLUSION

Given the increased prevalence and protean manifestations of syphilis, early diagnosis and treatment are paramount. More studies on ocular syphilis are warranted to understand this resurging disease.

Outcomes of a Hybrid Ophthalmology Telemedicine Model for Outpatient Eye Care During COVID-19

IMPORTANCE

The hybrid ophthalmology telemedicine model asynchronously pairs an imaging appointment by a technician with a subsequent virtual appointment by a clinician. Although it has been mentioned in several studies as an alternative to standard in-person care during the COVID-19 pandemic, outcomes of this alternative clinical care model remain to be evaluated.

OBJECTIVE

To investigate the outcomes associated with the hybrid ophthalmology telemedicine model during the COVID-19 pandemic for nonurgent and nonprocedural ophthalmological care.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, cross-sectional study of all hybrid visits scheduled during the year 2020 in a single academic, hospital-based eye clinic in Boston, Massachusetts. All hybrid ophthalmology telemedicine visits completed in the year 2020 by opthalmologists and optometrists were included. Data were analyzed from January to December 2020.

EXPOSURES

Hybrid telemedicine clinical encounters.

MAIN OUTCOMES AND MEASURES

Four outcome metrics were calculated: (1) need for subsequent procedure visit, (2) medication change, (3) nonurgent, and (4) urgent consultation with another eye clinician. Adverse outcomes were defined as irreversible vision loss and the need for additional in-person evaluation to reach a management decision.

RESULTS

From April 9 to December 30, 2020, 889 patients (506 female patients [56.9%]; mean [SD] age, 62.1 [14.5] years; age range, 13-98 years) completed 940 hybrid visits. The most common visit indications were glaucoma (424 visits [45.1%]) and retinal diseases (499 visits [53.1%]). A total of 25 visits (2.7%) led to a procedure, 22 visits (2.3%) led to a change in medication, and 44 visits (4.7%) were referred for nonurgent consultation with another subspecialty with no instances of urgent referrals. Sixteen patients (1.7%) were referred to the on-call clinician for a same-day emergency in-person visit or recommended for a subsequent standard in-person visit to reach a management decision. There were no cases of irreversible vision loss following a hybrid visit.

CONCLUSIONS AND RELEVANCE

These findings suggest that with the appropriate patient selection and clinical setting, the hybrid ophthalmology telemedicine model may be a good alternative to standard in-person visits, particularly for patients with glaucoma and retinal diseases.

Patient Satisfaction With Oral vs Intravenous Sedation for Vitrectomy Surgery: A Randomized, Noninferiority Clinical Trial

Purpose:

This work aims to determine whether patient satisfaction with oral sedation is noninferior to intravenous (IV) sedation in vitrectomy surgery.

Methods:

This prospective, randomized, double-masked, noninferiority clinical trial measured patient satisfaction in 84 participants receiving oral or IV sedation during vitrectomy surgery under monitored anesthesia care. Patients were excluded if they were unable to receive benzodiazepines.

Results:

The primary outcome was patient satisfaction. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications. Among the 84 patients (46 [54.8%] men; mean [SD] age, 57.0 [12.7 years]), mean patient satisfaction scores were 5.22 ± 0.81 (range, 3.08-6; scale 1-6) with oral and 5.25 ± 0.63 (range, 3.83-6; scale 1-6) with IV sedation. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the groups of 0.03 (1-tailed 95% CI, infinity to 0.29), our results demonstrated the noninferiority of oral sedation ( P = .002). There were no significant differences in surgeon or anesthesia satisfaction or major intraoperative complications. Five patients receiving oral (11.9%) and 3 receiving IV (7.1%) sedation required supplemental IV sedation (difference, 4.8%; P = .46).

Conclusions:

Patient satisfaction for oral sedation was noninferior to IV sedation for vitrectomy surgery.

Simultaneous visible light optical coherence tomography and near infrared OCT angiography in retinal pathologies: A case study

A dual-channel optical coherence tomography system with wavelengths in the visible and near-infrared light ranges can provide both structural and functional information for retinal microvasculature simultaneously. We applied this integrated system in an ongoing clinical study of patients with various retinal pathologies. Here, we present case study results of patients with diabetic retinopathy, central retinal vein occlusion, and sickle cell retinopathy compared to a healthy subject. For the first time, this comparison validates the system's ability to detect structural anomalies in both en face and B-scan images with simultaneous retinal optical coherence tomography angiography and measurement of sO₂ in parafoveal vessels that are around 20-30 µm in diameter. This integrated system represents a powerful instrument with potentially far-reaching clinical implications for the early detection and diagnosis of retinal vascular diseases.

Diagnosis and Management of Degenerative Retinoschisis and Related Complications

Degenerative retinoschisis is a common condition characterized by elevation of the inner layers of the peripheral retina. While uncomplicated retinoschisis (i.e. with no associated retinal layer breaks) is almost invariably a benign process, retinal detachment associated with isolated outer layer breaks (termed schisis-detachment) is fairly common. Historically, schisis-detachment has been treated with a variety of interventions ranging from retinopexy to intraocular surgery. Based on published descriptions of the natural history of the disease, these interventions are likely unnecessary in many cases and may place the patient's vision at unnecessary risk. Progressive symptomatic schisis-related retinal detachment, on the other hand, is a vision threatening condition that requires intervention. While clinical examination remains the mainstay of diagnosis, recent advances in multimodal imaging can provide supplemental information in subtle cases and may prove valuable for long-term disease monitoring. When evaluating patients with peripheral retinal elevation, it is important for ophthalmologists to make an accurate diagnosis and understand the risk-benefit ratio associated with intervention. Thus, we summarize the current literature on the natural history, clinical and imaging diagnosis, and surgical management of degenerative retinoschisis and its related complications.

Global Health Curricula in Ophthalmology Residency Programs in the United States

Objective The aim of the study is to investigate the design, content, and administration of global health curricula within ophthalmology residency programs in the United States (U.S.) and share the curriculum utilized in the Department of Ophthalmology at Boston University School of Medicine (BUSM).

Design A survey designed through the Association of University Professors in Ophthalmology platform was emailed to residency program directors at 106 accredited ophthalmology residency programs.

Setting BUSM Department of Ophthalmology, Boston, MA. Tertiary clinical care.

Participants Twenty-eight ophthalmology residency program directors responded, which represent 26% of the total number of residency programs in the United States. Twenty-seven programs fully completed the survey, and one program partially completed the survey.

Results Of the respondents, three programs do not include global health curricula. The most common curricular elements included are: lectures (n = 15, 60%); wet laboratories (n = 10, 40%); and journal clubs (n = 9, 36%). In terms of annual frequency, global health activities occur: twice a year (n = 12, 46%); less than once a year (n = 10, 39%); or every few months (n = 4, 15%). Fewer than half of programs (n = 10, 42%) incorporate local outreach at least once a year into their program. Twelve programs (48%) do not incorporate ethics-related topics, while the 13 remaining programs (52%) incorporate them at least once annually. The most common curricular topic is surgical techniques, with manual small incision cataract surgery (MSICS) being the most frequently emphasized (n = 17, 68%).

Conclusion A robust global health curricula combined with a hands-on international component can contribute to a well-rounded training experience. Many ophthalmology residency programs value the importance of incorporating global health into their residents' training. The most common elements of global health curricula in U.S. ophthalmology residency programs included are teaching of surgical techniques for resource-limited settings and international electives. Further investigation into the impact of different components of a global health curriculum on both resident experience and international partnerships is warranted.

Chorioretinal paracoccidioidomycosis treated with intravitreal voriconazole and therapeutic vitrectomy

Purpose

To report a case of aggressive chorioretinal paracoccidioidomycosis requiring treatment with systemic antifungal agents, frequent intravitreal voriconazole injections, and surgical excision.

Observations

A Brazilian man in his mid-30s with a history of chronic, biopsy-proven cutaneous paracoccidioidomycosis, chronic sinusitis, and perichondritis secondary to paracoccidioidomycosis presented with profound vision loss. He was found to have significant vitreous inflammation and a large chorioretinal lesion in the posterior pole concerning for ocular involvement. He was treated initially with combined topical and systemic steroids as well as systemic antifungals and antibiotics, then with serial intravitreal voriconazole injections resulting in a significant reduction of intraocular inflammation and subretinal fluid. The residual tractional retinal detachment from the chorioretinal lesion was addressed surgically by pars plana vitrectomy.

Conclusion and importance

Intravitreal voriconazole can be an effective adjuvant treatment for the vitreous inflammation and subretinal fluid associated with chorioretinal paracoccidioidomycosis. Surgical intervention may be indicated in cases complicated by tractional retinal detachment.

Risk factors for fellow eye treatment in protocol T

PURPOSE

To identify risk factors for fellow eye treatment of diabetic retinopathy with Vascular Endothelial Growth Factor (VEGF) injections during the Diabetic Retinopathy Clinical Research Network (DRCR.Net) Protocol T trial METHODS: In this post-hoc analysis of randomized clinical trial data, Cox regression analysis was performed at 52 and 104 weeks to determine risk factors for treatment in 360 fellow eyes. Survival analysis was performed to determine mean time to treatment based upon medication used.

RESULTS

Of 360 fellow eyes, 142 (39.4%) required treatment between weeks 4 and 104. Risk factors predicting a lower likelihood of year 1 treatment included older subject age (Hazard Ratio [HR]=0.98, 95% CI 0.96-0.99; p = 0.02) and higher baseline study eye ETDRS score (HR=0.98, 95% CI 0.97-0.99, p = 0.04). Center-involving DME at baseline in the fellow eye was predictive of a higher treatment need at both 52 (HR=1.89, 95% CI 1.42-2.51, p < 0.0001) and 104 weeks (HR=2.68, 95% CI 1.75-4.11, p < 0.0001). Subjects treated in the study eye with aflibercept (HR=0.574, 95% CI 0.371-0.887, p = 0.013) and ranibizumab (HR=0.58, 95%CI 0.36-0.94, p = 0.03) were less likely to require first year fellow eye injection than subjects treated with bevacizumab although this difference was no longer significant at week 104 (aflibercept HR=0.77, 95% CI 0.52-1.16, p = 0.21; ranibizumab HR=0.66, 95% CI 0.43-1.00, p = 0.05). Mean time to treatment was significantly shorter in the bevacizumab group (bevacizumab 25.83 weeks, aflibercept 38.75 weeks, ranibizumab 34.70 weeks (p=0.012)).

CONCLUSION

Bilateral treatment with intravitreal anti-VEGF injections was common during the DRCR.net Protocol T. Medication choice may impact the risk of fellow eye treatment.

The Impact of Race on Short-term Treatment Response to Bevacizumab in Diabetic Macular Edema

PURPOSE

To determine the impact of race and ethnicity on efficacy of intravitreal bevacizumab for diabetic macular edema in anti-vascular endothelial growth factor (VEGF) treatment-naive patients.

DESIGN

Retrospective cohort study.

METHODS

Setting: Urban-based academic institution with affiliated private offices.

STUDY POPULATION

Intravitreal anti-VEGF naïve patients seen between 2010 and 2019 of White (W) race, Black (B) race, or Hispanic (H) ethnicity aged 18 years and older with diabetic macular edema who received intravitreal injections of bevacizumab. Exclusion criteria were prior intravitreal anti-VEGF treatment, invasive ophthalmologic interventions, and laser treatments within 3 months prior to first injection through the duration of the study. Exposures: Intravitreal bevacizumab.

MAIN OUTCOMES MEASURES

Percentage of patients with visual acuity (VA) improvement and mean percentage reduction in central macular thickness (CMT).

RESULTS

Percentage with VA improvement was 27% vs 39% vs 50% after 1 injection (n = 314), and 34% vs 55% vs 59% after 3 injections (n = 150) for B, H, and W cohorts, respectively. Black patients experienced lower odds of VA improvement compared with White and Hispanic patients after 1 injection (odds of 0.480, CI 0.284-0.814, P = .006) and 3 injections (odds of 0.342, CI 0.149-0.782, P = .008) while controlling for age, sex, baseline glycated hemoglobin (HbA_1c), baseline CMT, baseline VA, laser history, injection time course, and follow-up delay.

CONCLUSIONS

Black patients had a significantly lower likelihood of visual acuity improvement following intravitreal bevacizumab treatment compared with White and Hispanic patients. Further research is warranted to understand the effect of race and ethnicity on anti-VEGF efficacy to ensure optimal treatment for each individual.

Neurofilament light chain in the vitreous humor of the eye

BACKGROUND

Neurofilament light chain (NfL) is a promising biomarker of neurodegeneration in the cerebrospinal fluid and blood. This study investigated the presence of NfL in the vitreous humor and its associations with amyloid beta, tau, inflammatory cytokines and vascular proteins, apolipoprotein E (APOE) genotypes, Mini-Mental State Examination (MMSE) scores, systemic disease, and ophthalmic diseases.

METHODS

This is a single-site, prospective, cross-sectional cohort study. Undiluted vitreous fluid (0.5-1.0 mL) was aspirated during vitrectomy, and whole blood was drawn for APOE genotyping. NfL, amyloid beta (Aβ), total Tau (t-Tau), phosphorylated Tau (p-Tau181), inflammatory cytokines, chemokines, and vascular proteins in the vitreous were quantitatively measured by immunoassay. The main outcome measures were the detection of NfL levels in the vitreous humor and its associations with the aforementioned proteins. Linear regression was used to test the associations of NfL with other proteins, APOE genotypes, MMSE scores, and ophthalmic and systemic diseases after adjustment for age, sex, education level, and other eye diseases.

RESULTS

NfL was detected in all 77 vitreous samples. NfL was not found to be associated with ophthalmic conditions, APOE genotypes, MMSE scores, or systemic disease (p > 0.05). NfL levels were positively associated with increased vitreous levels of Aβ40 (p = 7.7 × 10-5), Aβ42 (p = 2.8 × 10-4), and t-tau (p = 5.5 × 10-7), but not with p-tau181 (p = 0.53). NfL also had significant associations with inflammatory cytokines such as interleukin-15 (IL-15, p = 5.3 × 10-4), IL-16 (p = 2.2 × 10-4), monocyte chemoattractant protein-1 (MCP1, p = 4.1 × 10-4), and vascular proteins such as vascular endothelial growth factor receptor-1 (VEGFR1, p = 2.9 × 10-6), Vegf-C (p = 8.6 × 10-6), vascular cell adhesion molecule-1 (VCAM-1, p = 5.0 × 10-4), Tie-2 (p = 6.3 × 10-4), and intracellular adhesion molecular-1 (ICAM-1, p = 1.6 × 10-4).

CONCLUSION

NfL is detectable in the vitreous humor of the eye and significantly associated with amyloid beta, t-tau, and select inflammatory and vascular proteins in the vitreous. Additionally, NfL was not associated with patients' clinical eye condition. Our results serve as a foundation for further investigation of NfL in the ocular fluids to inform us about the potential utility of its presence in the eye.

Combined phaco-vitrectomy provides lower costs and greater area under the curve vision gains than sequential vitrectomy and phacoemulsification

PURPOSE

A majority of phakic patients undergoing pars plana vitrectomy for epiretinal membrane or macular hole require subsequent cataract surgery within 1-2 years. Combined phaco-vitrectomy eliminates the need for a second surgery and may enable patients to attain their best vision sooner. This study aims to compare the visual outcomes, complication rates, and costs of combined phaco-vitrectomy versus sequential vitrectomy followed by cataract surgery.

METHODS

Records were searched by CPT® codes to identify patients with both cataract and vitrectomy surgery at our institution over a 5-year period (2013-2018). Chart review included medical history, demographics, exam findings, operating room records, visual acuity (VA), and clinical outcomes. Statistical analyses were performed with SPSS v19 (IBM). Area under the curve for visual acuity was calculated as the trapezoidal mean of the change in Early Treatment of Diabetic Retinopathy Study letters.

RESULTS

After exclusion, 81 eyes of 78 patients underwent both cataract and vitrectomy surgeries at our institution. Thirty-four eyes underwent separate, sequential vitrectomy then phacoemulsification surgery, and 47 eyes had combined phaco-vitrectomy surgery. Total operating room times (120.81 ± 3.41 vs 161.03 ± 5.45 min; p < 0.0001) and associated costs were significantly lower in the combined surgery compared with those in the sequential surgery group. Baseline and final visual acuity were similar between the two groups. Baseline VA was 35.53 letters (~ 20/200) and 32.81 letters (~ 20/220) and increased to final VA of 63.74 (~ 20/53) and 60.91 letters (~ 20/61), in the sequential and combined groups respectively. Area under the curve for vision was greater in the combined surgery group, with subjects gaining an average of + 9.11 ± 3.32 letters from sequential surgery, and + 19.53 ± 3.53 letters in the combined surgery group (p = 0.04). Additionally, patients in the combined group attained their best visual acuity 449 days (15 months) sooner than those receiving sequential surgery.

CONCLUSIONS

Combined phaco-vitrectomy surgery resulted in greater area under the curve visual acuity benefit and attainment of best visual acuity 15 months sooner compared with conventional sequential surgeries. There were no significant differences in complication rates or clinical outcomes between the groups, but operative times and costs were lower for combined surgery, supporting a favorable cost-benefit ratio. Graphical abstract.

Guiding Residency Program Educational Goals Using Institutional Keyword Reports from the Ophthalmic Knowledge Assessment Program Examination

Introduction Residency programs receive an institutional keyword report following the annual Ophthalmic Knowledge Assessment Program (OKAP) examination containing the raw number of incorrectly answered questions. Programs would benefit from a method to compare relative performance between subspecialty sections. We propose a technique of normalizing the keyword report to determine relative subspecialty strengths and weaknesses in trainee performance.

Methods We retrospectively reviewed our institutional keyword reports from 2017 to 2019. We normalized the percentage of correctly answered questions for each postgraduate year (PGY) level by dividing the percent of correctly answered questions for each subspecialty by the percent correct across all subsections for that PGY level. We repeated this calculation for each PGY level in each subsection for each calendar year of analysis.

Results There was a statistically significant difference in mean performance between the subspecialty sections (p = 0.038). We found above average performance in the Uveitis and Ocular Inflammation section (95% confidence interval [CI]: 1.02–1.18) and high variability of performance in the Clinical Optics section (95% CI: 0.76–1.34).

Discussion The OKAP institutional keyword reports are extremely valuable for residency program self-evaluation. Performance normalized for PGY level and test year can reveal insightful trends into the relative strengths and weaknesses of trainee knowledge and guide data-driven curriculum improvement.

Completing the Basic and Clinical Science Course as a First-Year Ophthalmology Resident

Background The Basic and Clinical Science Course (BCSC) is the primary educational curriculum for ophthalmology resident physicians in the United States. The Ophthalmic Knowledge Assessment Program (OKAP) examination is an annual evaluation completed by residents that is based primarily on the BCSC curriculum. First-year ophthalmology residents are encouraged to complete the 13 volume BCSC series in preparation for the OKAP examination while balancing a steep clinical learning curve and substantial call schedule. By calculating the daily time commitment necessary to read each volume in the series, we hope to help residents create a realistic study plan to compete the entire BSCS series before the OKAP examination.

Methods We determine the word counts of each volume using an electronic copy of the 2018–2019 BCSC series. We include all text sections and legends, and we exclude all figures and tables. We calculate the time per day of dedicated reading required to complete a goal number of BCSC books between the start of ophthalmology residency (postgraduate year 2 [PGY2]) and the OKAP examination by developing a formula that is a function of self-assessed reading speed.

Results A first-year ophthalmology (PGY2) resident with an average reading speed of 250 words per minute must read for 25.0 minutes per day to complete the entire BCSC series before the OKAP examination. If studying is initiated at the beginning of intern (PGY1) year, the resident must read for 10.2 minutes per day. We introduce a formula and provide a table to guide residents on the amount of time needed to dedicate to reading the BCSC each day as a function of self-assessed reading speed.

Discussion Completion of all volumes of the BCSC requires a daily commitment with little room for missed sessions. The commitment is substantially more realistic if initiated during the PGY1 year; thus, residency programs should encourage an early start to OKAP preparation. We hope with a better understanding of the daily time commitment involved in completing the BCSC series, ophthalmology residents will be able to develop more successful study plans.

Endogenous Endophthalmitis in the American and Korean Population: An 8-year Retrospective Study

PURPOSE

To study the clinical features of endogenous endophthalmitis (EE) in sample patient populations from the USA and South Korea over an 8-year period.

METHODS

We reviewed data from 128 eyes of 60 American and 48 Korean patients diagnosed with EE and compared their clinical characteristics.

RESULTS

Fungemia and liver abscess were the most common extraocular infection sources among American (26.7%) and Korean patients (33.3%), respectively. Klebsiella pneumoniae and Candida species were the most common pathogens of EE in the Korean and the American patients, respectively. Endophthalmitis caused by fungi had a better visual prognosis than that caused by bacteria (p = 0.001). Vitrectomy was beneficial for eyes with EE due to virulent bacteria presenting with worse than counting finger vision.

CONCLUSIONS

The predisposing conditions and responsible organisms for EE vary in different regions of the world. The visual prognosis was strongly influenced by the underlying pathogen.

Emergency occlusive techniques

Emergency occlusive therapy may be indicated in the management of acute arterial injury or expanding arteriovenous fistula. Intra-arterial occlusion may be performed at the time of diagnostic angiography. Selective placement of catheters permits percise diagnosis and management. We wish to report eight cases to demonstrate the efficacy of different occlusive agents. No adverse reactions were noted in this series of patients. We feel that emergency occlusive therapy is rapid and safe. It may facilitate and occasionally obviate surgical management.