Relationship between Neighborhood-Level Social Risk Factor Measures and Presenting Glaucoma Severity Utilizing Multilevel Modeling.

Purpose: The neighborhood and built environment social determinant of health domain has several social risk factors (SRFs) that are modifiable through policy efforts. We investigated the impact of neighborhood-level SRFs on presenting glaucoma severity at a tertiary eye care center. Design: A cross-sectional study from August 2012 to May 2022 in the University of Michigan electronic health record (EHR). Participants: Patients with a diagnosis of any open-angle glaucoma with ≥1 eye care visit at the University of Michigan Kellogg Eye Center and ≥1 reliable visual field (VF). Methods: Participants who met inclusion criteria were identified by International Classification of Diseases ninth and tenth revision codes (365.x/H40.x). Data extracted from the EHR included patient demographics, address, presenting mean deviation (MD), and VF reliability. Addresses were mapped to SRF measures at the census tract, block group, and county levels. Multilevel linear regression models were used to estimate the fixed effects of each SRF on MD, after adjusting for patient-level demographic factors and a random effect for neighborhood. Interactions between each SRF measure with patient-level race and Medicaid status were tested for an additive effect on MD. Main Outcome Measures: The main outcome measure was the effect of SRF on presenting MD. Results: In total, 4428 patients were included in the analysis who were, on average, 70.3 years old (standard deviation = 11.9), 52.6% self-identified as female, 75.8% self-identified as White race, and 8.9% had Medicaid. The median value of presenting MD was -4.94 decibels (dB) (interquartile range = -11.45 to -2.07 dB). Neighborhood differences accounted for 4.4% of the variability in presenting MD. Neighborhood-level measures, including worse area deprivation (estimate, ß = -0.31 per 1-unit increase; P < 0.001), increased segregation (ß = -0.92 per 0.1-unit increase in Theil's H index; P < 0.001), and increased neighborhood Medicaid (ß = -0.68; P < 0.001) were associated with worse presenting MD. Significant interaction effects with race and Medicaid status were found in several neighborhood-level SRF measures. Conclusions: Although patients' neighborhood SRF measures accounted for a minority of the variability in presenting MD, most neighborhood-level SRFs are modifiable and were associated with clinically meaningful differences in presenting MD. Policies that aim to reduce neighborhood inequities by addressing allocation of resources could have lasting impacts on vision outcomes. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Should I Stay, or Should I Go? Emotional Exhaustion's Association with Intent to Leave in a National Sample of Female Physician Trainees.

Background: Physician burnout disproportionately affects women and contributes to attrition from the workforce, a costly problem that likely begins in training. Female physicians leave the workforce significantly earlier than male counterparts. The association between burnout and attrition intent in women physician trainees is unknown. Methods: This is a cross-sectional analysis of baseline data from a national sample of female physician trainees in a randomized controlled trial testing a well-being program in 2022. Participants completed surveys on burnout and intent to leave. Associations were analyzed using chi-square testing and univariable linear regression. Results: A total of 1,017 trainees responded. The average standard deviation (SD) age was 30.8 (4.0) years, 959 (94.3%) self-identified as a woman, and 540 (53.1%) as White. One-fifth (207, 20.7%) were in postgraduate year (PGY)-1, 198 (19.8%) PGY-2, and 595 (59.5%) ≥ PGY-3. Most scored positively for burnout; 77.5% experienced high emotional exhaustion (EE). One-fifth (20.6%) reported some intent to leave their program before graduation, and 32.7% reported intent to leave their specialty within 2 years. There was a strong association between EE scores and intent to leave: trainees reporting a high likelihood to leave before graduation had a 22.27 higher EE point average than those reporting no likelihood (95% confidence interval [CI]: 7.80, 36.74, p = 0.003). Conclusions: Attrition intent was associated with burnout. Addressing burnout during training will not only benefit trainees but could impact the retention of women physicians.

Antidepressant Medication Use for Treatment of Chronic Ocular Pain.

ABSTRACT: Chronic ocular pain (COP) is a leading cause of eye care visits in the US and has a substantial impact on quality of life and visual functioning. Although many conditions underlie COP, such as dry eye disease or post-herpetic neuralgia, some people experience pain without significant ocular signs on examination or known risk factors (eg, traumatic injury). Antidepressant medications that act primarily on the central nervous system, such as tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors, are often used to treat patients with COP, but a recent Cochrane review and network meta-analysis investigating 25 different antidepressants concluded that only two serotonin and norepinephrine reuptake inhibitors, have sufficient data to support their use in chronic pain. For all other medications, the evidence was of low certainty. We contend that while these medications are not a cure-all for chronic pain or COP, it is premature to conclude that these medications have no role in their treatment. We provide a rationale for continued use of antidepressant medications as part of a multimodal targeted treatment for patients with COP.

A Screening Strategy to Mitigate Vision Impairment by Engaging Adults Who Underuse Eye Care Services.

Importance: Underuse of eye care services leads to underdiagnosed and undertreated eye disease. Objective: To assess the reasons for underuse of eye care and whether a novel, free eye disease screening program is engaging adults who are both at high risk of eye disease and were underusing eye care services. Design, Setting, and Participants: In a population-based cross-sectional study, adult participants from the first year of the Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) Program were included. The participants were recruited from primary care clinics serving 2 low-income communities. Recruitment occurred between June 28, 2020 and June 27, 2021 at the free clinic, and between January 27, 2021 and January 26, 2022 at a federally qualified health clinic. Data were analyzed from December 7, 2022, to May 29, 2024. Participants received comprehensive eye disease screening and completed surveys assessing health and prior eye care use. Risk factors for eye disease included age 65 years and older, diabetes, personal or family history of eye disease, and self-identifying as Black or African American individuals who were aged 50 years or older. Underuse of eye care was defined as no eye examination in 2 or more years. Main Outcomes and Measures: Percentage of participants who were at high risk of eye disease and underused eye care services before accessing this program. Results: A total of 1171 MI-SIGHT participants were a mean (SD) age of 55 (14.5) years; 437 (38%) identified as male; 591 (54%) self-identified as Black or African American, 101 (10%) as Hispanic or Latino, and 371 (34%) as White; 492 (43%) had high school education or less, and 696 (70%) reported an annual household income of less than $30 000. Characteristics of participants reporting not having had an eye examination in 2 years or more included 23% (n = 151) of participants 65 years and over, 33% (n = 214) of participants who self-reported diabetes, 25% (n = 130) of participants reporting a family history of glaucoma, 3% (n = 14) of those with self-reported glaucoma; and 33% (n = 202) of Black or African-American participants aged 50 years and older. In participants who reported not having had an eye examination in 2 or more years, 21% (n = 137) screened positive for glaucoma, 20% (n = 129) for cataract, 6% (n = 38) for diabetic retinopathy, and 1% (n = 9) for age-related macular degeneration. Reported reasons for why participants had not had an eye examination included no insurance (175 of 627 [28%]), no reason to go (no problem) (135 of 627 [22%]), and cost of eye examination (101 of 627 [16%]). Conclusions and Relevance: The findings of this study suggest that placing eye disease detection programs in primary care clinics in underserved areas may improve eye disease detection and treatment, possibly mitigating needless vision loss in the US.

Neighborhood Poverty and Clinic Attendance in the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program.

PRECIS: Higher neighborhood-level poverty is associated with greater odds of missing a free eye disease screening appointment, underscoring the importance of community-based interventions to address upstream social determinants of health. PURPOSE: To investigate the association between neighborhood-level characteristics and attendance for a free eye disease screening. PATIENTS AND METHODS: The MI-SIGHT program is conducted in two community clinics in Southeastern Michigan. Participant-level demographics were extracted from electronic health records. Neighborhood level-characteristics including Area Deprivation Index (ADI), median household income (HHI), percent of households with >30% rent burden, percent of households without vehicles, percent of households in subsidized housing, and energy burden were obtained from the Wisconsin Neighborhood Atlas and the United States census. Logistic regression was used to model the probability of clinic visit attendance, which was the main outcome measure. RESULTS: 1431 participants were scheduled for screening appointments between July 2020 to November 2021, with a no-show rate of 23%. Individuals lived an average of 7.7 miles from each clinic (SD=8.1) and in neighborhoods with a mean ADI of 6.8 (SD=3.2, 1-10 scale where 10 is the most deprived). After adjusting for age, sex, race, and ethnicity, participants from neighborhoods with higher deprivation were more likely to have missed clinic visits. For example, there was an 8% higher odds of missed clinic visits for every 1-point increase in ADI (odds ratio, OR=1.08, P=0.020) and an 18% higher odds of a missed visit with every 10% increase in households without a vehicle (OR=1.18, P=0.013). CONCLUSION: Higher neighborhood-level poverty was associated with greater odds of missing a free eye disease screening appointment after adjusting for individual characteristics. Increased neighborhood-level resources are likely needed to bolster engagement in preventive eye care.

Health Care Use for Eye Pain.

Importance: National estimates regarding the frequency of presentations and patterns of care for eye pain are unknown. This information could guide research and clinical efforts to optimize outcomes. Objective: To estimate eye pain visits in the US in the outpatient and emergency department (ED) settings. Design, Setting, and Participants: This retrospective cross-sectional study of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (2008-2019) analyzed a population-based sample of visits to outpatient clinics and EDs. The sample consisted of patients presenting with eye pain. Data were analyzed from September 2023 to April 2024. Main Outcomes and Measures: Weighted sample data estimated outpatient and ED eye pain presentations including patient and clinician characteristics, diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]), and disposition. Results: From 2008 through 2019, 4.6 million (95% CI, 3.9 million to 5.3 million) outpatient and 1.0 million (95% CI, 0.8 million to 1.1 million) ED eye pain visits occurred annually. Patients were predominantly women (63.2% [95% CI, 59.4%-67.0%]) and older than 60 years (46.6% [95% CI, 42.4%-51.0%]) in the outpatient setting. Patients presenting to the ED were more often men (51.8% [95% CI, 48.7%-55.0%]) and aged younger than 45 years (aged <15 years: 16.4% [95% CI, 13.9%-18.8%]; 15-24 years: 19.2% [95% CI, 16.6%-21.7%]; and 25-44 years: 35.6% [95% CI, 32.7%-38.5%]). In nearly half of outpatient eye pain visits, the major problem was classified as nonacute (2.0 million [95% CI, 1.6 million to 2.3 million]). Eye pain was the primary reason for the visit (RFV) in 42.0% (95% CI, 37.8%-46.2%) of outpatient visits and 66.9% (95% CI, 62.9%-70.9%) of ED eye pain visits. It was the only RFV in 18.3% (95% CI, 15.0%-21.7%) of outpatient and 32.7% (95% CI, 29.0%-36.4%) of ED eye pain encounters. Ophthalmologists evaluated the largest number of outpatient visits (45.3% [95% CI, 38.8%-51.7%). The primary diagnosis was non-vision threatening for most outpatient (78.5% [95% CI, 56.8%-100%]) and ED (69.9% [95% CI, 62.1%-77.7%]) visits when eye pain was the primary RFV. Additional follow-up was scheduled in 89.4% (95% CI, 86.2%-92.6%) of visits. Conclusions and Relevance: More than 5 million eye pain visits occur annually; the largest percentage are outpatient with ophthalmologists. Most diagnoses were non-vision threatening in both the outpatient and ED setting and resulted in additional care. Expanding therapeutic approaches to treat the causes of eye pain may reduce the burden on the health care system and optimize outcomes.

Eye Care in Federally Qualified Health Centers.

PURPOSE: To assess changes in vision care availability at Federally Qualified Health Centers (FQHCs) between 2017 and 2021 and whether neighborhood-level demographic social risk factors (SRFs) associated with eye care services provided by FQHCs. DESIGN: Secondary data analysis of the Health Resources and Services Administration (HRSA) data and 2017-2021 American Community Survey (ACS). PARTICIPANTS: Federally Qualified Health Centers. METHODS: Patient and neighborhood characteristics for SRFs were summarized. Differences in FQHCs providing and not providing vision care were compared via Wilcoxon-Mann-Whitney tests for continuous measures and chi-square tests for categorical measures. Logistic regression models were used to test the associations between neighborhood measures and FQHCs providing vision care, adjusted for patient characteristics. MAIN OUTCOME MEASURES: Odds ratios (ORs) with 95% confidence intervals (CIs) for neighborhood-level predictors of FQHCs providing vision care services. RESULTS: Overall, 28.5% of FQHCs (n = 375/1318) provided vision care in 2017 versus 32% (n = 435/1362) in 2021 with some increases and decreases in both the number of FQHCs and those with and without vision services. Only 2.6% of people who accessed FQHC services received eye care in 2021. Among the 435 FQHCs that provided vision care in 2021, 27.1% (n = 118) had added vision services between 2017 and 2021, 71.5% (n = 311) had been offering vision services since at least 2017, and 1.4% (n = 6) were newly established. FQHCs providing vision care in 2021 were more likely to be in neighborhoods with a higher percentage of Hispanic/Latino individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0094), Medicaid-insured individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0120), and no car households (OR, 1.07, 95% CI, 1.01-1.13, P = 0.0142). However, FQHCs with vision care, compared to FQHCs without vision care, served a lower percentage of Hispanic/Latino individuals (27.2% vs. 33.9%, P = 0.0007), Medicaid-insured patients (42.8% vs. 46.8%, P < 0.0001), and patients living at or below 100% of the federal poverty line (61.3% vs. 66.3%, P < 0.0001). CONCLUSIONS: Vision care services are available at a few FQHCs, localized to a few states. Expanding eye care access at FQHCs would meet patients where they seek care to mitigate vision loss to underserved communities. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Place-Based Measures of Inequity and Vision Difficulty and Blindness.

Importance: Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty. Objective: To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty). Design, Setting, and Participants: This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023. Main Outcomes and Measures: The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression. Results: In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001). Conclusions and Relevance: In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

Locality is the strongest predictor of expert performance in image-based differentiation of bacterial and fungal corneal ulcers from India.

PURPOSE: This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography. METHODS: This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability ("calibration") and resolution ("boldness") and were compared between local (Indian) and external (non-Indian) experts. RESULTS: Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups ( P = 0.40). CONCLUSION: Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar.

Association of Contrast Sensitivity With Eye Disease and Vision-Related Quality of Life.

PURPOSE: To investigate contrast sensitivity (CS) as a screening tool to detect eye disease and assess its association with both eye disease and vision-related quality of life. DESIGN: Cross-sectional study. METHODS: Setting and population: Adults receiving care from a free clinic and a Federally Qualified Health Center in Michigan. MAIN OUTCOME MEASURES: Screening positive for eye disease and Visual Function Questionnaire (VFQ) score. OBSERVATION: Participants received a vision exam reviewed via telemedicine for disease, completed a demographic survey, and the 9-item VFQ. The ability of CS to predict eye disease was explored and area under the curve (AUC) is reported. Logistic and linear regression were used to investigate the continuous effect of CS on the probability of screening positive for eye disease and VFQ score, respectively, adjusting for age and visual acuity. RESULTS: 1159 included participants were, on average, 54.9 ± 14.5 years old, 62% identified as female, 34% as White, 54% as Black, 10% as Hispanic/Latino, and reported mean VFQ score of 79.7 ± 15.3. CS ranged from 0.00 to 1.95 log units (mean = 1.54 ± 0.24), 21% of eyes had glaucoma, 19% cataract, 6% DR, and 2% AMD. AUCs were 0.53 to 0.73. A 0.3 log unit decrease in better eye CS was associated with increased odds of glaucoma (odds ratio [OR] = 1.35, confidence interval [CI] = 1.09-1.67), cataract (OR = 1.35, CI = 1.05-1.72), DR (OR = 2.05, CI = 1.51-2.77), and AMD (OR = 2.08, CI = 1.10-3.91). A 0.3 log unit increase in better eye CS was associated with a 5.9 unit increase in VFQ. CONCLUSION: While CS alone is not sufficient to identify people with eye disease, it is an important measure of visual function that can add value to comprehensive eye screening.

Factors Associated With Laboratory Test Negativity Following a Transition in Specimen Collection in Microbial Keratitis Cases.

PURPOSE: Negative laboratory results make targeting microbial keratitis treatment difficult. We investigated factors associated with laboratory negativity in patients with microbial keratitis in the context of a transition to a new specimen collection method. METHODS: Microbial keratitis patients with associated laboratory tests were identified in the electronic health record of a tertiary care facility from August 2012 to April 2022. Patient demographics and laboratory results were obtained. Random sampling of 50% of charts was performed to assess the impact of the ocular history and pretreatment measures. The relationship between probability of negative laboratory results with demographics, ocular history, pretreatment measures, and utilization of a new specimen collection method (i.e. ESwab) was evaluated by multivariable logistic regression. RESULTS: Of 3395 microbial keratitis patients identified, 31% (n = 1051) had laboratory tests. Laboratory testing increased over time (slope = 2.5% per year, p < 0.001; 19.6% in 2013 to 42.2% in 2021). Laboratory negative rate increased over time (slope = 2.2% per year, p = 0.022; 48.5% in 2013 to 62.3% in 2021). Almost one-third of patients (31.2%, n = 164) were pretreated with steroids. Over two-thirds of patients were pretreated with antibiotics (69.5%, n = 367). 56.5% (n = 297) of patients were outside referrals. In multivariable regression, patients with corticosteroid pretreatment had lower odds of negative laboratory results (odds ratio [OR] = 0.49, p = 0.001). There were higher odds of negative laboratory results for every additional antibiotic prescribed to a patient prior to presentation (OR = 1.30, p = 0.006) and for specimens collected using ESwabs (OR = 1.69, p = 0.005). Age, prior eye trauma, outside referrals, and contact lens wear were not significantly associated with negative laboratory results. CONCLUSION: More microbial keratitis associated laboratory tests are being taken over time. Over 60% of tests were negative by 2022. Factors associated with negative laboratory test results included pretreatment with antibiotics and specimens collected with the new collection method.

Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes.

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan.

PURPOSE: To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Comparison of Culture Results and Visual Acuity in Contact Lens Related Microbial Keratitis.

PURPOSE: Evaluate the effect of corneal and contact lens-related (CLR) culture results on visual acuity (VA) in patients with microbial keratitis (MK). METHODS: MK patients with corneal and CLR cultures were identified in the University of Michigan electronic health record from August 2012 to April 2022. Test results were classified as laboratory-positive or laboratory-negative. Linear regression was used to examine trends of VA and associations between changes in VA (differences of VA at 90-day and baseline VA) and corneal and CLR culture results, after adjustment for baseline VA. One-sample t-tests were used to test if the slope estimates were different from zero. RESULTS: MK patients (n = 50) were on average 49 years old (standard deviation = 20.9), 56% female, and 90% White. Positive corneal and CLR cultures were reported in 60% and 64% of patients, respectively, and 38% reported both. The agreement rate between corneal and CLR culture results was 30% (n = 15/50). LogMAR VA improved over time in patients with positive corneal and CLR cultures (Estimate=-0.19 per 10-day increase, p = 0.002), and in those with negative corneal and positive CLR cultures (Estimate= -0.17 per 10-day increase, p = 0.004). Compared to patients with negative corneal and CLR cultures, there was a trend toward improvement in VA for patients with positive corneal and CLR cultures (Estimate=-0.68, p = 0.068), and those with negative corneal and positive CLR cultures (Estimate= -0.74, p = 0.059), after adjusting for baseline VA. CONCLUSIONS: Positive CLR cultures are associated with significant improvement in VA over time. These additional cultures can provide guidance on appropriate antimicrobial selection, especially when corneal cultures are negative.

Corneal Specialists' Confidence in Identifying Causal Organisms of Microbial Keratitis.

PURPOSE: Microbial keratitis (MK) is a potentially blinding corneal disease caused by an array of microbial etiologies. However, the lack of early organism identification is a barrier to optimal care. We investigated clinician confidence in their diagnosis of organism type on initial presentation and the relationship between confidence and presenting features. METHODS: This research presents secondary data analysis of 72 patients from the Automated Quantitative Ulcer Analysis (AQUA) study. Cornea specialists reported their confidence in organism identification. Presenting sample characteristics were recorded including patient demographics, health history, infection morphology, symptoms, and circumstances of infection. The association between confidence and presenting characteristics was investigated with 2-sample t-tests, Wilcoxon tests, and Chi-square or Fisher's exact tests. RESULTS: Clinicians reported being "confident or very confident" in their diagnosis of the causal organism in MK infections for 39 patients (54%) and "not confident" for 33 patients (46%). Confidence was not significantly associated with patient demographics, morphologic features, or symptoms related to MK. MK cases where clinicians reported they were confident, versus not confident in their diagnosis, showed significantly smaller percentages of previous corneal disease (0% versus 15%, p = 0.017), were not seen by an outside provider first (69% versus 94%, p = 0.015), or had no prior labs drawn (8% versus 33%, p = 0.046), and a significantly larger percentage of cases wore contact lenses (54% versus 28%, p = 0.029). CONCLUSION: In almost half of MK cases, cornea specialists reported lack of confidence in identifying the infection type. Confidence was related to ocular history and circumstances of infection but not by observable signs and symptoms or patient demographics. Tools are needed to assist clinicians with early diagnosis of MK infection type to expedite care and healing.

Automatic Classification of Slit-Lamp Photographs by Imaging Illumination.

PURPOSE: The aim of this study was to facilitate deep learning systems in image annotations for diagnosing keratitis type by developing an automated algorithm to classify slit-lamp photographs (SLPs) based on illumination technique. METHODS: SLPs were collected from patients with corneal ulcer at Kellogg Eye Center, Bascom Palmer Eye Institute, and Aravind Eye Care Systems. Illumination techniques were slit beam, diffuse white light, diffuse blue light with fluorescein, and sclerotic scatter (ScS). Images were manually labeled for illumination and randomly split into training, validation, and testing data sets (70%:15%:15%). Classification algorithms including MobileNetV2, ResNet50, LeNet, AlexNet, multilayer perceptron, and k-nearest neighborhood were trained to distinguish 4 type of illumination techniques. The algorithm performances on the test data set were evaluated with 95% confidence intervals (CIs) for accuracy, F1 score, and area under the receiver operator characteristics curve (AUC-ROC), overall and by class (one-vs-rest). RESULTS: A total of 12,132 images from 409 patients were analyzed, including 41.8% (n = 5069) slit-beam photographs, 21.2% (2571) diffuse white light, 19.5% (2364) diffuse blue light, and 17.5% (2128) ScS. MobileNetV2 achieved the highest overall F1 score of 97.95% (CI, 97.94%-97.97%), AUC-ROC of 99.83% (99.72%-99.9%), and accuracy of 98.98% (98.97%-98.98%). The F1 scores for slit beam, diffuse white light, diffuse blue light, and ScS were 97.82% (97.80%-97.84%), 96.62% (96.58%-96.66%), 99.88% (99.87%-99.89%), and 97.59% (97.55%-97.62%), respectively. Slit beam and ScS were the 2 most frequently misclassified illumination. CONCLUSIONS: MobileNetV2 accurately labeled illumination of SLPs using a large data set of corneal images. Effective, automatic classification of SLPs is key to integrating deep learning systems for clinical decision support into practice workflows.

Relationship between Unstable Housing, Food Insecurity, and Vision Status in the MI-SIGHT Community Eye Disease Screening Program.

PURPOSE: Assess rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical shop. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA] ≤ 20/50, best corrected visual acuity [BCVA] ≥ 20/40), URE without VI (PVA ≥ 20/40, had ≥ 2 lines of improvement to BCVA), and no or adequately corrected RE (PVA ≥ 20/40, < 2 line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared between groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, the average age was 55.1 years (standard deviation = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 (10.3%); 96 had VI from URE (8.2%), 168 (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI from URE reported having a college degree and a larger percentage reported income < $10 000 compared to participants with no or adequately corrected RE (3.2% versus 14.2%, P = 0.02; 45.5% versus 21.6%, respectively, P < 0.0001. Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (VFQ9 composite score 67.3 ± 19.6 versus 77.0 ± 14.4 versus 82.2 ± 13.3, respectively; P < 0.0001). 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical shop with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.