Access to Pediatric Eye Care by Practitioner Type, Geographic Distribution, and US Population Demographics.

Importance: Investigating disparities in service coverage of pediatric optometrists and pediatric ophthalmologists in relation to patient demographics will illuminate vulnerable populations and inform future interventions. Objective: To characterize the geographic distribution of pediatric eye care practitioners and analyze its association with population demographics. Design, Setting, and Participants: In this cross-sectional study, 4 public databases were used to identify the addresses of pediatric optometrists and pediatric ophthalmologists in the US in April 2023. Addresses were geocoded, and population demographic data were collected. Pediatric optometrists and pediatric ophthalmologists listed in the public databases, as well as respondents to the 2020 US census, were included in this study. Data were analyzed from April to July 2023. Exposures: Public databases and US census data of eye practitioners and their practice locations. Main Outcomes and Measures: Geographic distribution of pediatric optometrists and pediatric ophthalmologists as listed in public databases and correlations between service coverage and US population demographics. Results: A total of 586 pediatric optometrists (302 female [51.5%]) and 1060 pediatric ophthalmologists (590 male [55.7%]) were identified. Among US counties, 203 (6.5%) had at least 1 pediatric optometrist, and 308 (9.7%) had at least 1 pediatric ophthalmologist, showing substantial geographic overlap (odds ratio, 12.7; 95% CI, 9.4-17.4; P < .001). In the 2834 counties without pediatric ophthalmologists, 2731 (96.4%) lacked pediatric optometrists. There were more pediatric ophthalmologists per million people (3.3) compared with pediatric optometrists per million people (2.5) across all states (difference, 0.8; 95% CI, 0-1.9; P = .047). Among counties with practitioners, the median (IQR) number of pediatric optometrists per million people was 7.8 (0.4-245.0), surpassing the median (IQR) number of pediatric ophthalmologists per million people, 5.5 (1.0-117.0). Counties with pediatric ophthalmologists had higher mean (SD) household incomes than counties with pediatric optometrists ($76 126.87 [$21 879.23] vs $68 681.77 [$18 336.40]; difference, -$7445.10; 95% CI, $2519.51-$12 370.69; P = .003) and higher mean (SD) population with bachelor's degrees than counties with pediatric optometrists (79 016 [82 503] vs 23 076 [44 025]; difference, -55 940; 95% CI, -73 035 to -38 845; P < .001), whereas counties with neither specialist type had the lowest mean (SD) household income ($57 714.03 [$2731.00] vs $78 388.67 [$18 499.21]; difference, -$20 675.00; 95% CI, -$21 550.90 to -$19 799.10; P < .001) and mean (SD) population with bachelor's degrees (5113 [12 875] vs 167 015 [216 486]; difference, -161 902; 95% CI, -170 388.9 to -153 415.1; P < .001) compared with counties with practitioners. Conclusions and Relevance: Geographic disparities in pediatric eye care access, compounded by socioeconomic differences, underscore the urgency of augmenting practitioner support in underserved areas.

Burn Induced Cicatricial Eyelid Retraction: A Challenging Case and Review of Management Principles.

Thermal and chemical burns can result in cicatricial eyelid retraction, characterized by an abnormal resting position of the eyelid margin and increased palpebral fissure height. Eyelid retraction often leads to exposure keratopathy, which can cause complications ranging from mild dry eye to globe-threatening ulceration and perforation. Prompt intervention includes aggressive lubrication, moisture chambers, eyelid tarsorrhaphy and retraction repair surgery. Discussed here is a burn patient with severe cicatricial retraction and ectropion leading to severe exposure keratopathy and infectious corneal ulceration with perforation. The patient required aggressive medical intervention, as well as two surgeries to restore the normal eyelid anatomy to protect the globe.

Access to Pediatric Ophthalmological Care by Geographic Distribution and US Population Demographic Characteristics in 2022.

Importance: The geographic distribution of pediatric ophthalmological care has not been reported on since 2007; understanding this distribution could shed light on potential avenues to increase access, which is a necessary first step in addressing the pediatric ophthalmological needs of underserved areas. Objective: To analyze the number and location (ie, geographic distribution) of pediatric ophthalmologists in relation to US population demographic characteristics. Design, Setting, and Participants: In this cross-sectional study, public databases from the American Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus were used to identify pediatric ophthalmologists in the US as of March 2022. Main Outcomes and Measures: Geographic distribution of pediatric ophthalmologists listed in public databases and any association between pediatric ophthalmologist distribution and US population demographic characteristics. Addresses were geocoded using ArcGIS Pro (Esri). Results: A total of 1056 pediatric ophthalmologists (611 men [57.9%]) were identified. States with the most pediatric ophthalmologists were California (n = 116 [11.0%]), New York (n = 97 [9.2%]), Florida (n = 69 [6.5%]), and Texas (n = 62 [5.9%]), the 4 most populous states. A total of 2828 of 3142 counties (90.0%) and 4 of 50 states (8.0%) had 0 pediatric ophthalmologists. In 314 counties (10.0%) with 1 or more pediatric ophthalmologists, the mean (range) pediatric ophthalmologists per million persons was 7.7 (0.4-185.5). The range of practitioner to million persons has increased since 2007. Counties with 1 or more pediatric ophthalmologists had a higher median (SD) household income compared with counties with 0 pediatric ophthalmologists ($70 230.59 [$18 945.05] vs $53 263.62 [$12 786.07]; difference, -$16 966.97; 95% CI, -$18 544.57 to -$14 389.37; P < .001). Additionally, the proportion of families in each county without internet service (8.0% vs 4.7%; difference, 3.4%; 95% CI, 3.0%-3.7%; P < .001), the proportion of persons younger than 19 years without health insurance (5.7% vs 4.1%; difference, 1.6%; 95% CI, 1.1%-2.2%; P < .001), and the proportion of households without vehicle access (2.1% vs 1.8%; difference, 0.3%; 95% CI, 0.6%-5.2%; P = .001) were greater in counties with 0 compared with counties with 1 or more pediatric ophthalmologists. Conclusion and Relevance: This cross-sectional study found that disparities in access to pediatric ophthalmological care have increased over the past 15 years and are associated with lower socioeconomic status. As patients may rely on online sources to identify the nearest pediatric ophthalmologist, accurate publicly available databases are important.

Photoreceptive Ganglion Cells Drive Circuits for Local Inhibition in the Mouse Retina.

Intrinsically photosensitive retinal ganglion cells (ipRGCs) exhibit melanopsin-dependent light responses that persist in the absence of rod and cone photoreceptor-mediated input. In addition to signaling anterogradely to the brain, ipRGCs signal retrogradely to intraretinal circuitry via gap junction-mediated electrical synapses with amacrine cells (ACs). However, the targets and functions of these intraretinal signals remain largely unknown. Here, in mice of both sexes, we identify circuitry that enables M5 ipRGCs to locally inhibit retinal neurons via electrical synapses with a nonspiking GABAergic AC. During pharmacological blockade of rod- and cone-mediated input, whole-cell recordings of corticotropin-releasing hormone-expressing (CRH+) ACs reveal persistent visual responses that require both melanopsin expression and gap junctions. In the developing retina, ipRGC-mediated input to CRH+ ACs is weak or absent before eye opening, indicating a primary role for this input in the mature retina (i.e., in parallel with rod- and cone-mediated input). Among several ipRGC types, only M5 ipRGCs exhibit consistent anatomical and physiological coupling to CRH+ ACs. Optogenetic stimulation of local CRH+ ACs directly drives IPSCs in M4 and M5, but not M1-M3, ipRGCs. CRH+ ACs also inhibit M2 ipRGC-coupled spiking ACs, demonstrating direct interaction between discrete networks of ipRGC-coupled interneurons. Together, these results demonstrate a functional role for electrical synapses in translating ipRGC activity into feedforward and feedback inhibition of local retinal circuits.SIGNIFICANCE STATEMENT Melanopsin directly generates light responses in intrinsically photosensitive retinal ganglion cells (ipRGCs). Through gap junction-mediated electrical synapses with retinal interneurons, these uniquely photoreceptive RGCs may also influence the activity and output of neuronal circuits within the retina. Here, we identified and studied an electrical synaptic circuit that, in principle, could couple ipRGC activity to the chemical output of an identified retinal interneuron. Specifically, we found that M5 ipRGCs form electrical synapses with corticotropin-releasing hormone-expressing amacrine cells, which locally release GABA to inhibit specific RGC types. Thus, ipRGCs are poised to influence the output of diverse retinal circuits via electrical synapses with interneurons.