Regional Variation of Infectious Agents Causing Endogenous Endophthalmitis in the United States: A National Database Analysis.

OBJECTIVE: To describe regional variation in microbes causing infectious endogenous endophthalmitis (EE) in the United States. DESIGN: This is a retrospective, national database analysis utilizing the 2002-2014 National Inpatient Sample database. SUBJECTS: Using the International Classification of Disease 9 codes, we identified cases with EE. Cases were stratified regionally into Northeast, South, West, or Midwest. METHODS: Unadjusted chi-square analysis followed by adjusted multivariate logistic regression was performed to evaluate variation in demographic factors, comorbidities using the Elixhauser Comorbidity Index (ECI), microbial variation, mortality, and use of vitrectomy or enucleation by region. MAIN OUTCOME MEASURES: Proportion of microbes, mortality, and vitrectomy by region in addition to factors with significant odds ratios for mortality and for in-hospital vitrectomy. RESULTS: A total of 10 912 patients with infectious EE were identified, with 2063 cases in the Northeast (18.9%), 2145 cases in the Midwest (19.7%), 4134 cases in the South (37.9%), and 2570 cases in the West (23.6%). Chi-square analysis indicated significant regional variation in patient demographics, microbes causing the infection, ECI, mortality, and surgical intervention. The 4 most common microbes for all regions were methicillin-sensitive Staphylococcus aureus (MSSA), Streptococcus, Candida, and methicillin-resistant Staphylococcus aureus. Methicillin-sensitive S. aureus was the most common cause of EE in all regions, although the proportion of MSSA infection did not significantly vary by region (P = 0.03). Further, there was significant regional variation in the proportion of other microbes causing the infection (P < 0.001). Higher rates of vitrectomies were seen in the South and Midwest regions than that in the Northeast and West (P = 0.04). CONCLUSIONS: Regional variation exists in the infectious microbes causing EE. Further studies are needed to elucidate the etiology of these variations. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Klebsiella Endogenous Endophthalmitis During the COVID-19 Pandemic.

Purpose: To describe the characteristics of Klebsiella pneumoniae endogenous endophthalmitis (KEE) encountered during the COVID-19 pandemic. Methods: This retrospective consecutive case series evaluated eyes that presented with KEE between March 2020 and July 2022. Results: Seven eyes of 5 patients developed KEE. Between January 2020 and July 2022, KEE was observed in 42% of consecutive EE cases compared with 7.8% during the preceding 13 years. COVID-19 was positive in 4 of 5 patients before they developed KEE. Only 1 patient presented with a VA better than hand motions (20/400). All eyes were treated with urgent vitrectomy and intravitreal and systemic antibiotics. No improvement in vision occurred in any patient; VA remained light perception to no light perception in 60% of eyes. Conclusions: The visual prognosis in KEE is extremely poor. The presence of a preceding COVID-19 infection in 80% of patients may signal a new risk factor for KEE. Patients with a hypervirulent Klebsiella syndrome should be routinely screened for EE.

EyeArt artificial intelligence analysis of diabetic retinopathy in retinal screening events.

PURPOSE: Early detection and treatment of diabetic retinopathy (DR) are critical for decreasing the risk of vision loss and preventing blindness. Community vision screenings may play an important role, especially in communities at higher risk for diabetes. To address the need for increased DR detection and referrals, we evaluated the use of artificial intelligence (AI) for screening DR. METHODS: Patient images of 124 eyes were obtained using a 45° Canon Non-Mydriatic CR-2 Plus AF retinal camera in the Department of Endocrinology Clinic (Newark, NJ) and in a community screening event (Newark, NJ). Images were initially classified by an onsite grader and uploaded for analysis by EyeArt, a cloud-based AI software developed by Eyenuk (California, USA). The images were also graded by an off-site retina specialist. Using Fleiss kappa analysis, a correlation was investigated between the three grading systems, the AI, onsite grader, and a US board-certified retina specialist, for a diagnosis of DR and referral pattern. RESULTS: The EyeArt results, onsite grader, and the retina specialist had a 79% overall agreement on the diagnosis of DR: 86 eyes with full agreement, 37 eyes with agreement between two graders, 1 eye with full disagreement. The kappa value for concordance on a diagnosis was 0.69 (95% CI 0.61-0.77), indicating substantial agreement. Referral patterns by EyeArt, the onsite grader, and the ophthalmologist had an 85% overall agreement: 96 eyes with full agreement, 28 eyes with disagreement. The kappa value for concordance on "whether to refer" was 0.70 (95% CI 0.60-0.80), indicating substantial agreement. Using the board-certified retina specialist as the gold standard, EyeArt had an 81% accuracy (101/124 eyes) for diagnosis and 83% accuracy (103/124 eyes) in referrals. For referrals, the sensitivity of EyeArt was 74%, specificity was 87%, positive predictive value was 72%, and negative predictive value was 88%. CONCLUSIONS: This retrospective cross-sectional analysis offers insights into use of AI in diabetic screenings and the significant role it will play in automated detection of DR. The EyeArt readings were beneficial with some limitations in a community screening environment. These limitations included a decreased accuracy in the presence of cataracts and the functional cost of EyeArt uploads in a community setting.

Epidemiological Trends of Ocular Injuries in Infants.

Approximately 21,000 consumer product-related ocular injuries occurred in infants in the United States from 2009 to 2019; toys being the most common (12.9%) consumer product in the 1- to 4-month age cohort, detergents in the 5- to 8-month (21.6%) cohort, and chemicals for the 9- to 12-month (34.0%) age cohort. These results identify an important preventable consumer product-related public health problem in infants. [J Pediatr Ophthalmol Strabismus. 2023;60(4):e41-e44.].

Work-related ocular trauma in the United States: a National Trauma Databank study.

PURPOSE: This study aims to investigate trends and risk factors associated with work-related ocular injuries occurring in adults aged 19-64 using the National Trauma Databank (NTDB). METHODS: In this retrospective, cross-sectional study, the NTDB was used to collect all patients with an ICD-9 code of work-related ocular trauma from 2007 to 2014. Demographic data and risk factors collected included age, gender, race, setting, machinery, and mechanism. Descriptive statistics, univariate, and logistic regression multivariate analyses were conducted. RESULTS: Between 2007 and 2014, 234,983 cases of work-related trauma were identified, of which 11,097 (5.7%) cases involved ocular trauma. The mean age of patients was 40.7 years (SD = 12.2), and the majority of patients (93.7%) were male. Most injuries occurred in an industrial facility, and the most common injuries were orbital floor fractures (OFFs), ocular contusions, open wounds to the adnexa, and open globe injuries (OGIs). OFFs most commonly involved a concurrent fracture of another facial or skull bone. Male gender (RR = 1.22; CI 1.09-1.38), accidental falls (RR = 1.50; CI 1.41-1.60), trauma from falling objects (RR = 1.34; CI 1.21-1.48), involvement in an unarmed fight (RR = 1.63; CI 1.39-1.91), assault by a blunt object (RR = 1.59; CI 1.31-1.91), and injury caused by animals (RR = 1.63; CI 1.30-2.02) were risk factors for OFFs. Patients with OFFs were less likely to have a concurrent OGI (RR = 0.27; CI 0.23-0.32). On the other hand, injuries occurring in industrial facilities (RR = 1.29; CI 1.11-1.51) and injuries with a loose foreign body striking the eye or adnexa (RR = 1.54; CI 1.28-1.84) were risk factors for OGI. The most common causes of work-related ocular trauma were accidental falls, motor vehicle accidents, and accidentally being struck in the eye. The mean length of hospital stay was 6.56 days (SD = 10.82); 36.7% of patients required ICU admission, and the overall in-hospital mortality rate was 2.8%. CONCLUSION: The majority of work-related ocular trauma occurred in men, most commonly in industrial locations. Accidental falls were the most common identified cause of trauma. OFF was the most common ocular injury; 80% of OFF cases involved additional facial and skull fractures. Patients with OFFs were less likely to have a concurrent OGI compared with patients without OFFs.

Trends in Endogenous Endophthalmitis in Rural and Urban Settings in the United States.

PURPOSE: The objective of this study is to explore and compare trends in urban and rural cases of endogenous endophthalmitis (EE) in the United States. METHODS: This study utilizes data from the 2002-2014 National Inpatient Sample (NIS) Database. Disease diagnoses and procedures were identified using codes from the International Classification of Diseases, Ninth Revision (ICD-9). Cases of EE were defined as cases of endophthalmitis in the setting of bacteremia or candidemia without a recent history of ocular trauma. The NIS Database defines urban and rural hospitals based on the hospital county's population statistics. Statistical analysis was performed using IBM SPSS 23. RESULTS: We identified 8255 cases of EE. Of these cases, 523 (6.3%) occurred in rural areas; 7733 (93.7%) occurred in urban areas. Of the cases of EE, 7692 (93.2%) were bacterial EE, 412 (5.0%) were candida EE, and 151 (1.8%) were mixed EE. Candida EE was observed in 1.7% of rural cases and 5.2% of urban cases (p < .001). Pars plana vitrectomies were performed more often in urban hospitals than in rural hospitals (11.5% vs. 2.9%; p < .001). CONCLUSION: Endogenous endophthalmitis remains a rare but devastating ocular infection. In this study, we have demonstrated that there are important differences in cases of EE that present to urban and rural hospitals. Future investigations into these differences in patient demographics, source/systemic infections, and hospital courses may allow clinicians and hospitals to develop a more targeted approach to treating EE based on the type of community from which the patient presents.

Epidemiology of United States tennis-related ocular injuries from 2000 to 2019.

PURPOSE: To characterize trends in ocular tennis injuries over the last 20 years. METHODS: The National Electronic Injury Surveillance System was utilized to characterize tennis-related eye injuries in a nationally representative sample of emergency department visits. Data were divided into 5 age groups, and various demographic information was obtained. RESULTS: Approximately 16,000 tennis-related ocular injuries were identified with males being affected nearly 2:1 compared to females. The youngest age group (0-20) had the greatest proportion of injuries, with most injuries in boys 11-15 years old. Injuries occurred most often during the spring season. Most patients were treated and released from the ED. Of those patients who were hospitalized, one-third had an open globe injury. CONCLUSIONS: The overall number of injuries trended downward during the timespan of the study. Although most patients did not experience serious visual consequences, the greatest proportion of ocular tennis injuries occurred in the pediatric age group in whom the risk of amblyopia is high. Primary care providers and tennis regulatory bodies should consider recommending eye safety sports goggles in children to mitigate the potential for significant visual morbidity.

Educational quality and content of YouTube videos on diabetic macular edema.

PURPOSE: Diabetic macular edema (DME) is a vision-threatening complication of diabetes mellitus due to increased vascular permeability. Patients are increasingly using YouTube videos to educate themselves about DME. This study analyzes the content and quality of YouTube videos about DME. METHODS: Videos were searched in December 2021 for "diabetic macular edema." The first 100 videos sorted by both relevance and view count were reviewed (n = 200). Quantitative metrics and content were collected. Two reviewers assessed videos using the JAMA (0-4), modified DISCERN (1-5), and Global Quality Scale (GQS, 1-5). Videos were sorted into author groups: 1 (academic institutions/organizations), 2 (private practices/organizations), and 3 (independent users; ophthalmologist users noted). Statistical analyses were deemed significant at a = 0.05. RESULTS: One hundred four videos were included after applying exclusion criteria. Overall mean + standard deviations were 2.25 ± 0.83 (JAMA), 3.47 ± 0.55 (DISCERN), and 3.95 ± 0.95 (GQS). 51.9% of videos stated a definition, 32.7% mentioned screening, and 50% mentioned any DME risk factor. Healthcare professional-targeted videos had higher JAMA and DISCERN scores than patient-targeted videos (p < 0.05). Videos using ophthalmologists had higher JAMA and DISCERN scores than those lacking their presence (p < 0.05). JAMA scores significantly varied between author groups; within group 3, ophthalmologist-authored videos had higher DISCERN scores (p < 0.05). CONCLUSION: Videos without ophthalmologists or targeted toward patients had poor quality and content coverage. The rising prevalence of diabetes, coupled with increased internet use for acquiring medical information, creates a strong need for high-quality information about DME.

Risk factors for ischemic cerebral stroke in patients with acute amaurosis fugax.

OBJECTIVE: The National Stroke Association and the American Heart Association consider retinal ischemia, as in the case of amaurosis fugax (AF), to be a stroke event. The purpose of this study was to evaluate the risk factors for ischemic cerebral stroke in patients hospitalized for acute AF. METHODS: The National Inpatient Sample Database from 2002 to 2014 was used to identify patients 21 years of age and older with a primary admission diagnosis of AF with the ICD-9 code 362.34. Comorbidity measures and in-hospital events were extracted using relevant ICD-9 codes. Statistical analyses were performed using IBM SPSS 25 and R package. RESULTS: A weighted total of 12,142 patients was identified. The most common comorbidities in this cohort with AF included hypertension, dyslipidemia, tobacco use, coronary artery disease (CAD), and diabetes mellitus. Multivariable regression analysis showed comorbidities of hypercoagulable state, systemic vasculitis, CAD, and atherosclerosis to be independent risk factors for ischemic stroke in patients with AF. In contrast, dyslipidemia was associated with a decreased risk. Asian/Pacific Islander race conferred a 5-fold increased risk compared with Whites. CONCLUSION: Ischemic stroke and myocardial infarction were diagnosed in 0.3%-0.9% of hospitalized acute AF cases. Presence of hypercoagulable state, systemic vasculitis, CAD, and atherosclerosis each individually increased the risk of ischemic stroke by more than 3-fold; patients with these risk factors and acute AF should be closely monitored for developing acute systemic thrombotic events.

Epidemiology of ocular injuries associated with landscaping tools.

The purpose of this retrospective, cross-sectional study was to determine and analyze the trends in ocular injuries related to landscaping activities and equipment from 2010 to 2019. A total of 168,845 ocular injuries were associated with landscaping activities with the majority of cases occurring in men (80.4%) between the ages of 41-60 during the summer months of June, July, and August. The majority of ocular injuries did not require admission (97.8%) but of those that were admitted 42% had an open globe injury (n = 399). The results of this investigation provide useful information for emergency room physicians and ophthalmologists in understanding the prevalence of these landscaping-associated ocular injuries and further draw suspicion for the incidence of open globe injuries in this population.

The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis.

PURPOSE: Characterize the impact of frailty on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients. DESIGN: Population-level, retrospective cohort study. PARTICIPANTS: Adult inpatients within the National Inpatient Sample (years 2002-2014) diagnosed with bacterial septicemia. METHODS: Septicemic patients were classified as frail or nonfrail using the previously validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, and diagnosis of EE was abstracted from International Classification of Diseases 9 codes. We used multivariable logistic regression to generate odds ratios (ORs) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood culture-proven organism class, inpatient length of stay, and total charges billed to insurance. MAIN OUTCOME MEASURES: Incidence of EE among septicemic patients; rates of EE development among frail and nonfrail patients; blood culture-proven microbe type, length of stay, and total charges billed to insurance. RESULTS: 9294 of 18 470 658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition [68%]). Odds of developing EE were 16.7% higher for frail patients (OR, 1.167; 95% confidence interval, 1.108-1.229) when controlling for age, sex, race, concomitant human immunodeficiency virus/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, sex, race, and Elixhauser comorbidity score (OR, 1.279; 95% confidence interval, 1.056-1.549). Higher rates of methicillin-resistant Staphylococcus aureus bacteremia (14.3% vs. 10.9%, P = 0.000016), gram-negative bacteremia (7.6% vs. 4.9%, P = 0.000003), and concomitant candidemia (10.4% vs. 7.0%, P = 0.0000004) were associated with frailty. Hospital stays were significantly longer (median, 14 days; interquartile range, 19 days; P < 0.00001) and total charges billed to insurance were significantly greater (median, $96 398; interquartile range, $154,682; P < 0.00001) among frail EE patients. CONCLUSIONS: Frailty syndrome is independently associated with development of EE in the setting of bacterial septicemia; frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and it predisposes to higher rates of in-hospital death and health care resource usage.

Epidemiology of Ocular Injuries Related to Toy Guns in Pediatric Patients From 2000 to 2019.

The popularity of toy guns among children is a growing public health concern due to reports of ocular injury. Most ocular injuries caused by toy guns occur in children younger than 10 years and at home. Dissemination of this information to parents and pediatricians is important to formulate safety measures. [J Pediatr Ophthalmol Strabismus. 2022;59(3):e29-e31.].

Enucleation in pediatric open globe injuries: demographics and risk factors.

PURPOSE: The purpose of this study is to report the demographics and risk factors for undergoing primary enucleation in the setting of acute open globe injury (OGI) in the pediatric population in the USA. METHODS: This retrospective, cross-sectional study of pediatric patients with OGIs in the USA between 2002 and 2014 was conducted utilizing data from the National Inpatient Sample Database. Descriptive statistics, chi-square testing, and univariate and multivariable analyses were performed. RESULTS: In the USA, 8944 cases of pediatric OGI were identified between 2002 and 2014 in the NIS Database, of which 344 underwent primary enucleation. Blacks and Asian/Pacific Islanders made up higher proportions of enucleated cases compared to non-enucleated cases. Older age, male sex, being Black or Asian/Pacific Islander, OGI with an intraocular foreign body, rupture type OGI, and concurrent endophthalmitis were identified as risk factors for undergoing enucleation. There was no significant difference in insurance status among enucleated versus non-enucleated cases. Mean length of hospital stay (in days) was almost 3 times higher in enucleated OGIs. By hospital's geographic location, the Midwest hospitals had a greater proportion of enucleated versus non-enucleated cases compared to other regions. CONCLUSION: Significant demographic differences were identified in OGI patients that underwent primary enucleation versus repair with regard to age, sex, race, the geographic location of hospital admission, mean length of hospital stay, type of ocular injury, and other ocular complications. Most pediatric traumatic enucleations between 2002 and 2014 were reported in teenagers (16-20 age group), in males, and in Blacks.

Epidemiology of welding-associated ocular injuries.

PURPOSE: Currently, there exists a lack of recent epidemiological data concerning ocular injuries due to welding related activities. Our study analyzes trends in ocular injuries related to usage of welding equipment in the U.S. from 2010 to 2019. METHODS: Using the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) Database, we queried data from January 1st 2010 to December 31st 2019 using the corresponding product code for welding equipment (896). Results were stratified by year, and standard descriptive statistical methods were applied to components including gender, age, diagnoses, and ED disposition. Circumstances leading up to the injuries were reviewed as well. RESULTS: Between 2010 and 2019 a total of 109,127 welding-associated ocular injuries occurred in the United States (95% CI, 86937-131,316). Estimates show a decreasing trend in cases from 13,415 (95% CI, 9979-16,851) in 2010 to 6944 (95% CI, 4868-9020) in 2019. A majority of cases occurred in men (98.2%) and in the 10-49 year age range (83.8%). 3.3% of cases involved spectators and 44% were bilateral. The top three ocular injury diagnoses were flash burns (62.1%), foreign body implantation (19.6%), and contusions/abrasions (11.1%). The number of radiation injuries trended down from 9286 in 2010 to 4023. With respect to a documented location, 38.9% occurred at home and 4.5% occurred in a school setting. Most patients (99.9%) were discharged from the ED; 0.1% were admitted to the hospital. CONCLUSIONS: The data suggests that number of ocular injuries related to welding has decreased significantly over the past 10 years. The most common injuries were radiation burns, foreign body disruption, and contusions/abrasions of the eye. Patients were predominantly men and between the ages of 10 and 49. Of note, almost half of all ocular injuries due to welding were bilateral, and 3% of ocular injuries were seen in spectators.

Epidemiologic trends in pediatric ocular injury in the USA from 2010 to 2019.

PURPOSE: Epidemiologic studies related to the demographics and trends of ocular injury in the pediatric cohort in the last decade are limited. This study describes epidemiologic trends in consumer product-related pediatric ocular injuries from 2010 to 2019. METHODS: This is a retrospective observational study utilizing data from the National Electronic Injury Surveillance System (NEISS). Inclusion criteria include pediatric patients ages 1-20 presenting to NEISS emergency departments with an ocular injury from January 1, 2010, to December 31, 2019. Outcome measures include prevalence of ocular injury related to consumer products stratified by age group, sex, and injury setting. RESULTS: There were an estimated 636,582 consumer product (CP)-related incidents of ocular injury in children ages 1-20 years with an average age of 9.7 years (SD = 5.92) between 2010 and 2019; 416,378 (65.4%) patients were males with a male-to-female ratio of 1.9:1. The annual incidence of CP-related ocular injury in males decreased from 2010 to 2019 while that in females remained unchanged. The greatest number of injuries occurred in the 1-5-year age group (31%) followed 6-10 group (25%), 16-20 (22%), and 11-15 (21%). Ocular contusion was the most common diagnosis. The most common setting of injury was home (63%). The majority (96%) of patients were treated and released from the ED suggesting a minor injury. Of the 1% of patients admitted to the hospital with ocular injuries, one-fourth were due to an open globe injury. Most ocular injuries occurred in the summer months, and presentation to the ED was more frequent on the weekend than a weekday. Over one-fourth (28%) of injuries were sports-related followed by detergents/chemicals (16%), toys (11%), home workshop equipment (8%), kitchenware (5.0%), and home furniture in (4.4%). CONCLUSIONS: The frequency and rate of pediatric ocular injuries in the USA decreased during the last decade. Sports and non-powder guns caused the greatest number of eye injuries in the older pediatric cohorts (11-15- and 16-20-year age groups), while detergents/chemicals accounted for nearly 1/3 of all injuries in younger children (1-5 years). Prophylactic measures targeted to specific age groups will be important in reducing eye injuries further.