Private equity acquisitions: physician considerations at different stages of career.

PURPOSE OF REVIEW: To assess the impact of private equity acquisitions on physician career considerations, with particular attention to stage of career. RECENT FINDINGS: Recent studies have demonstrated a clear increase in private equity acquisitions in ophthalmology, particularly in retina-oriented practices. Survey-related publications of recent fellow graduates may provide insights regarding considerations of early career ophthalmologists, whereas commentaries from senior ophthalmologists offer insights to considerations of late career physicians. To date, no published evidence exists regarding the differential financial and/or professional effects of private equity acquisitions on ophthalmologists with regards to career stage. Such effects may differ on the specific structure, nature, and terms of the private equity acquisition. SUMMARY: Private equity acquisitions in ophthalmology may have several short-term, mid-term, and long-term effects on physicians over a variety of financial and career considerations. As such, there may be a differential effect of private equity acquisitions on early, mid, and late career physicians. Future outcome-related data will be necessary to fully understand the impact of private equity acquisitions on physicians both professionally and with regards to clinical care.

FACTORS AFFECTING RETINAL REDETACHMENT AFTER SILICONE OIL REMOVAL FOR RHEGMATOGENOUS RETINAL DETACHMENTS.

PURPOSE: To report factors affecting the retinal redetachment rate after silicone oil removal (SOR) following rhegmatogenous retinal detachment (RRD) repair. METHODS: Retrospective cohort study from December 1, 2014, to March 1, 2020, of 205 consecutive patients treated for RRD with silicone oil (SO) tamponade and subsequent SOR with at least 6-month follow-up. Primary outcome measure was the rate of retinal redetachment after SOR. RESULTS: The retinal redetachment rate after SOR was 18.5%. Preoperative macula and lens status, proliferative vitreoretinopathy, previous retinectomy, retinal detachment size, concomitant phacoemulsification, previous scleral buckling, and endolaser during SOR did not affect the redetachment rate after SOR. Previous SO exchange was associated with increased redetachment (OR 2.53, 95% CI [1.11-5.80], P = 0.0278). Twelve months of SO tamponade had lower redetachment rates compared with 3 months (OR 0.25, 95% CI [0.04-0.09], P = 0.048). Shorter SO tamponade (3 vs. 12 months) had better final visual outcomes after SOR (0.80 ± 0.61 vs. 1.41 ± 0.66, P < 0.0001). CONCLUSION: No preoperative or intraoperative factors in this analysis influenced the risk of redetachment after SOR except duration of SO tamponade and previous SO exchange. Although longer SO tamponade duration may be associated with lower rates of redetachment, visual outcomes may be worse.

Agreement of optical coherence tomography thickness measurements between Heidelberg Eye Explorer and ImageJ software.

OBJECTIVE: To investigate the agreement and correlation of manual central foveal thickness (CFT) measurements using the Heidelberg Eye Explorer and ImageJ software. METHODS: Optical coherence tomography (OCT) images were identified. CFT was measured using the Heidelberg Eye Explorer caliper tool. Two independent graders measured the CFT of the same images using ImageJ software. A Pearson correlation coefficient, intraclass correlation coefficient, Bland-Altman plots, and coefficient of repeatability were used to assess the agreement and correlation between the Heidelberg Eye Explorer and ImageJ measurements. RESULTS: One-hundred and twenty-two OCT images from 91 patients were analyzed. Mean CFT as measured using the Heidelberg caliper tool was 264.8 ± 113 µm. Using ImageJ software, graders 1 and 2 obtained mean CFT values of 267 ± 114.3 µm and 270 ± 114.8 µm, respectively. Pearson correlation revealed a strong correlation between the Heidelberg and Image J measurements (r = 0.999, p < 0.0001). Bland-Altman plots noted a less than 4 µm mean difference between Heidelberg and ImageJ CFT values (2.67 ± 3.46 and 3.72 ± 2.78 µm for graders 1 and 2, respectively). CONCLUSION: There was strong agreement between the Heidelberg Eye Explorer and ImageJ software for manual CFT measurements. ImageJ may be a reliable tool for thickness measurements when proprietary OCT software is unavailable.

Pars Plana Vitrectomy for Idiopathic Epiretinal Membrane: OCT Biomarkers of Visual Outcomes in 322 Eyes.

OBJECTIVE: To investigate OCT-based biomarkers of visual acuity (VA) in eyes with idiopathic epiretinal membranes (ERMs) undergoing surgical intervention. PURPOSE: To assess the surgical outcomes of pars plana vitrectomy (PPV) and membrane peel (MP) surgery in eyes with idiopathic ERM and to identify potential imaging-based biomarkers of vision outcomes. METHODS: Retrospective, consecutive case series of eyes with idiopathic ERM that underwent PPV and MP surgery between January 1, 2017, and January 1, 2019. A previously described ERM grading scale was utilized for OCT analysis. The primary outcome was VA at postoperative month 6 and at final follow-up. The secondary outcome was the association of OCT structural features, including ectopic inner foveal layers (EIFLs), inner microcystoid changes, and ellipsoid zone (EZ) disruption, with VA outcomes. RESULTS: A total of 322 eyes with idiopathic ERM were included. The mean (± standard deviation) follow-up was 506.6 ± 324.6 days after MP surgery. VA improved from logarithm of the minimal angle of resolution value of 0.49 ± 0.27 (Snellen 20/61) before MP surgery to 0.41 ± 0.30 (Snellen 20/51, P < 0.001) at 6 months after MP surgery and to 0.31 ± 0.29 (Snellen 20/41, P < 0.001) at the final follow-up. A total of 21 (6.5%) eyes were graded as stage 1, 38 (11.8%) as stage 2, 188 (58.4%) as stage 3, and 75 (23.3%) as stage 4, with higher ERM stages associated with worse pre-MP VA (P < 0.001). The presence of inner microcystoid changes was associated with worse pre-MP VA (P = 0.04). Stage 4 ERM characteristics (P = 0.03), the presence of EZ disruption (P = 0.01) at month 3, and the presence of inner microcystoid changes at month 3 (P = 0.02) were associated with worse VA at 6 months. The presence of EIFL was not associated with the 6-month or final VA on multivariate analysis. When analyzed within defined age groups, patients older than 80 years had worse final VA (P = 0.02) and were more likely to have inner microcystoid changes on OCT (P = 0.01). CONCLUSIONS: VA improvement was noted after surgery in eyes with idiopathic ERM across all stages. Preoperative stage 4 characteristics were associated with worse VA at 6 months. Postoperative inner microcystoid changes and EZ disruption at month 3 were additional OCT biomarkers associated with worse 6-month and final VA outcomes.

Resource management with kernel-based approaches for grid-connected solar photovoltaic systems.

The increasing penetration of photovoltaic (PV) power generation into the distribution grids has resulted in frequent reverse active power flows, rapid fluctuations in voltage magnitudes, and power loss. To overcome these challenges, this paper identifies the resource management of grid-connected PV systems with active and reactive power injection capabilities using smart inverters. This approach is aimed to minimize the voltage deviations and power losses in the grid-connected systems to accommodate the high penetration of PV systems. A kernel-based approach is proposed to learn policies and evaluate the reactive power injections with smart inverters for improving grid profile, minimizing power losses, and maintaining safe operating voltage limits. The proposed approach performs inverter coordination through nonlinear control policies using anticipated scenarios for load and generation. To assess the performance of the proposed approach, numerical simulations are performed with a single-phase grid-connected PV system connected to an IEEE bus system. The results show the effectiveness of the proposed approach in minimizing power losses and achieving a good voltage regulation.

Determining the effect of low-dose isotretinoin on proliferative vitreoretinopathy: the DELIVER trial.

PURPOSE: To examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair. METHODS: Prospective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery. RESULTS: The single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%). CONCLUSION: The management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.

Psychometric properties of the severity of the dependence scale for Khat (SDS-Khat) in polysubstance users.

BACKGROUND: Current evidence suggests that the addiction on one substance may underpin or affect addiction on another in polysubstance users. However, there is no tool that has been shown to have psychometric validation for assessment of the severity of khat addiction in polysubstance users. METHODS: Polysubstance users with khat chewing habit (n = 178, age = 25.8 ± 3.6, BMI = 23.3 ± 2.8 kg/m2) were recruited from randomly selected houses for a cross-sectional study in Mizan, Ethiopia. The survey including severity of dependence scale for khat (SDS-khat), a brief metacognition questionnaire, and a semi-structured socio-demographics tool were administered by trained interviewers. RESULTS: There was no ceiling effect or floor effect in the SDS-Khat scores. Internal consistency was moderate (Cronbach's alpha = 0.58). Internal homogeneity was adequate (Item-total correlations of the SDS-Khat; r ≥ 0.55). Significant negative correlations between the SDS-Khat and the metacognition (r = -.19 to -.34, p < 0.05 or p < 0.01) indicated convergent validity. The findings of exploratory factor analysis were non-unanimous with a suggestion of two models, i.e., a 2-factor and a 1-factor model, while the confirmatory factor analysis favored 1-Factor model. CONCLUSION: The SDS-Khat has adequate psychometric validity for the assessment of psychological severity of khat addiction in the polysubstance users.

High-Dose (2.5 mg) Intravitreal Bevacizumab as Rescue Therapy for Persistent Postradiation Cystoid Macular Edema.

BACKGROUND/AIMS: To investigate the efficacy of intravitreal high-dose (2.5 mg/0.1 mL) bevacizumab as rescue therapy for postradiation cystoid macular edema (CME) resistant to standard-dose (1.25 mg/0.05 mL) bevacizumab. METHODS: Retrospective, interventional case series. RESULTS: Fifteen eyes of 15 patients were included. Eyes were treated with a mean of 10 standard-dose (1.25 mg) bevacizumab injections but failed to show CME resolution. Following 3 monthly treatments of high-dose (2.5 mg) bevacizumab, mean central macular thickness (CMT) reduced significantly from 406 ± 100 to 360 ± 83 µm (p = 0.01) and mean logMAR visual acuity improved from 0.55 ± 0.17 (Snellen 20/71) to 0.48 ± 0.21 (Snellen 20/60, p = 0.07). At the final follow-up of 9 months, CMT was 395 ± 124 µm (p = 0.67) and visual acuity was 0.51 ± 0.23 (Snellen 20/65, p = 0.22). Five eyes (30%) had a >10% reduction in CMT at the final follow-up. In these eyes, the observed CMT reduction was statistically significant (p = 0.04) and logMAR visual acuity was significantly better (p ≤ 0.01) compared to the remainder of the cohort. CONCLUSIONS: Overall, the use of high-dose (2.5 mg) bevacizumab did not result in a sustained, significant improvement in CMT and visual acuity outcomes following incomplete response to standard-dose (1.25 mg) bevacizumab. However, a minority of eyes exhibited favorable response with significant CMT reduction.

Correlation of Clinical Outcomes with Quantitative Polymerase Chain Reaction DNA Copy Number in Patients with Acute Retinal Necrosis.

PURPOSE: To correlate visual acuity outcomes and clinical features with quantitative PCR DNA copy number in patients with acute retinal necrosis (ARN). METHODS: Retrospective, consecutive case series. RESULTS: In total, 14 eyes of 13 patients were diagnosed with ARN, based on the American Uveitis Society criteria, and were followed for a mean of 324.5 days (median 250.5 days, SD ± 214 days). Anterior chamber fluid analyzed by quantitative PCR identified viral DNA in 11 of 14 eyes (78.5%). Varicella zoster virus (VZV) was identified in seven eyes (50%) and herpes simplex virus (HSV) in four eyes (28.5%). Mean DNA copy number was 7.9 × 106/mL (median 2.10 × 106/mL, range: 0-5.60 × 107/mL). Eyes with quantitative PCR DNA copy number of ≥5.0 × 106/mL (n = 6 eyes) had worse baseline visual acuity (logMAR 1.48 ± 0.71 vs 0.94 ± 0.76, p = 0.196) and final visual acuity (logMAR 2.10 ± 0.60 vs 0.82 ± 0.81, p = 0.007) compared with patients with a DNA copy number <5.0 × 106/mL (n = 8 eyes). Patients with a DNA copy number of ≥5.0 × 106/mL were more likely to have at least 5 clock hours of retinitis on funduscopic exam (p = 0.03) and developed retinal detachment more frequently (p = 0.08). CONCLUSIONS: Quantitative DNA copy number of ≥5.0 × 106/mL is associated with more extensive retinitis, worse visual acuity, and development of retinal detachment in patients with acute retinal necrosis.

Intravitreal Aflibercept as Rescue Therapy for Post-Radiation Cystoid Macular Edema Resistant to Intravitreal Bevacizumab: Outcomes at 1 Year.

BACKGROUND/AIMS: To investigate the efficacy of intravitreal aflibercept as rescue therapy for post-radiation cystoid macular edema (CME) resistant to prior treatment with intravitreal bevacizumab (IVB). METHODS: Retrospective, interventional, case-controlled series. Eyes with persistent post-radiation CME were treated with intravitreal aflibercept (2 mg/0.05 mL). Central macular thickness (CMT) and visual acuity were compared to a matched control group treated with only IVB at 1 year. RESULTS: Ten eyes of 10 patients were included, with 5 eyes in the intervention and 5 in the control group. The eyes in the intervention group had previously been treated with IVB (mean 11.6 injections, range 6-22) but failed to show resolution of CME. Following rescue treatment with a mean of 9 injections of aflibercept, the mean CMT was reduced from 463 ± 138 to 267 ± 80 µm (p = 0.02) and the mean Snellen visual acuity was improved from 20/67 to 20/42 (p = 0.03). At 1 year, the eyes in the intervention group had lower CMT (267 ± 80 vs. 361 ± 71 µm, p = 0.09) and significantly better Snellen visual acuity (20/48 vs. 20/76, p = 0.02) compared to the control group. CONCLUSIONS: Aflibercept may be an effective rescue therapy for persistent post-radiation CME in eyes with incomplete response to IVB, with reduction in CMT and improvement in visual acuity.

COTTON-WOOL SPOTS AFTER USE OF MACITENTAN FOR PULMONARY ARTERIAL HYPERTENSION.

PURPOSE: To report a case of transient, bilateral cotton spots after initiation of macitentan, an endothelin receptor antagonist used for the treatment of pulmonary arterial hypertension. METHODS: Case report. RESULTS: A 76-year-old woman with WHO Class IIIb pulmonary arterial hypertension was referred for evaluation of bilateral cotton-wool spots 1 week after starting macitentan therapy. The patient was asymptomatic and visual acuity was 20/25 in each eye. Fluorescein angiography and optical coherence tomography were completed. Given lack of symptoms and alternative treatment options, the patient was observed closely. The cotton-wool spots resolved 8 weeks after presentation and visual acuity remained stable at 20/25. Throughout the observation period, average mean arterial pressure was within normal limits at 84.8. CONCLUSION: In patients using endothelin receptor antagonists, medication side effect should be considered in the differential diagnosis of cotton-wool spots.

Ocriplasmin for Treatment of Vitreomacular Traction: An Update.

Pharmacologic vitreolysis with ocriplasmin, a 27 kilodalton serine protease, is an effective nonsurgical treatment option for vitreomacular traction (VMT). Data from phase III clinical studies, including the Microplasmin for Intravitreal Injection-Traction Release without Surgical Treatment (MIVI-TRUST) and Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) studies, have demonstrated the treatment efficacy of ocriplasmin for VMT and full-thickness macular hole (FTMH). Subgroup analysis of these clinical trials as well as post-marketing clinical series have aided in patient selection by identifying features associated with successful pharmacologic release of VMT with ocriplasmin, including adhesion diameter ≤1500 µm, absence of epiretinal membrane, phakic status, and age younger than 65. As a first-in-class therapeutic, ocriplasmin and its side effects have been carefully monitored by the vitreoretinal community. The following categories of related or possibly related adverse events have been identified: acute reduction in visual acuity, ERG changes, dyschromatopsia, retinal tear or detachment, lens subluxation or phacodonesis, abnormal pupillary reflex, retinal vascular changes, and OCT ellipsoid zone alterations. Adverse events have almost all been transient with restoration of visual acuity; however, in select patients, alterations may persist.