Using choroidal thickness to detect myopic macular degeneration.

AIM: To explore the usage of choroidal thickness measured by swept-source optical coherence tomography (SS-OCT) to detect myopic macular degeneration (MMD) in high myopic participants. METHODS: Participants with bilateral high myopia (≤-6 diopters) were recruited from a subset of the Guangzhou Zhongshan Ophthalmic Center-Brien Holden Vision Institute High Myopia Cohort Study. SS-OCT was performed to determine the choroidal thickness, and myopic maculopathy was graded by the International Meta-Analysis for Pathologic Myopia (META-PM) Classification. Presence of MMD was defined as META-PM category 2 or above. RESULTS: A total of 568 right eyes were included for analysis. Eyes with MMD (n=106, 18.7%) were found to have older age, longer axial lengths (AL), higher myopic spherical equivalents (SE), and reduced choroidal thickness in each Early Treatment Diabetic Retinopathy Study (ETDRS) grid sector (P<0.001). The area under the receiver operating characteristic (ROC) curves (AUC) for subfoveal choroidal thickness (0.907) was greater than that of the model, including age, AL, and SE at 0.6249, 0.8208, and 0.8205, respectively. The choroidal thickness of the inner and outer nasal sectors was the most accurate indicator of MMD (AUC of 0.928 and 0.923, respectively). An outer nasal sector choroidal thickness of less than 74 µm demonstrated the highest odds of predicting MMD (OR=33.8). CONCLUSION: Choroidal thickness detects the presence of MMD with high agreement, particularly of the inner and outer nasal sectors of the posterior pole, which appears to be a biometric parameter more precise than age, AL, or SE.

Four-Year Progression of Myopic Maculopathy in Children and Adolescents With High Myopia.

Importance: Individuals with high myopia younger than 18 years are at relatively high risk of progressively worsening myopic maculopathy. Additional studies are needed to investigate the progression of myopic maculopathy in this age group, as well as the risk factors associated with progression. Objective: To investigate the 4-year progression of myopic maculopathy in children and adolescents with high myopia, and to explore potential risk factors. Design, Setting, and Participants: This hospital-based observational study with 4-year follow-up included a total of 548 high myopic eyes (spherical power -6.00 or less diopters) of 274 participants aged 7 to 17 years. Participants underwent comprehensive ophthalmic examination at baseline and 4-year follow-up. Myopic maculopathy was accessed by the International Photographic Classification and Grading System. The data analysis was performed from August 1 to 15, 2023. Main Outcomes and Measures: The progression of myopic maculopathy progression over 4 years and associated risk factors. Results: The 4-year progression of myopic maculopathy was found in 67 of 548 eyes (12.2%) of 274 participants (138 girls [50.4%] at baseline and 4-year follow-up) with 88 lesion changes, including new signs of the tessellated fundus in 16 eyes (18.2%), diffuse atrophy in 12 eyes (13.6%), patchy atrophy in 2 eyes (2.3%), lacquer cracks in 9 eyes (10.2%), and enlargement of diffuse atrophy in 49 eyes (55.7%). By multivariable analysis, worse best-corrected visual acuity (odds ratio [OR], 6.68; 95% CI, 1.15-38.99; P = .04), longer axial length (AL) (OR, 1.73; 95% CI, 1.34-2.24; P < .001), faster AL elongation (OR, 302.83; 95% CI, 28.61-3205.64; P < .001), and more severe myopic maculopathy (diffuse atrophy; OR, 4.52; 95% CI, 1.98-10.30; P < .001 and patchy atrophy; OR, 3.82; 95% CI, 1.66-8.80; P = .002) were associated with myopic maculopathy progression. Conclusions and Relevance: In this observational study, the progression of myopic maculopathy was observed in approximately 12% of pediatric high myopes for 4 years. The major type of progression was the enlargement of diffuse atrophy. Risk factors for myopic maculopathy progression were worse best-corrected visual acuity, longer AL, faster AL elongation, and more severe myopic maculopathy. These findings support consideration of follow-up in these individuals and trying to identify those at higher risk for progression.

Predictors of student mask mandate policies in United States school districts during the COVID-19 pandemic.

Introduction: Although factors such as urbanicity, population demographics, and political affiliation have been linked with COVID-19 masking behavior and policy in community settings, little work has investigated factors associated with school mask policies. We sought to characterize United States state and school district student COVID-19 masking policies during the 2021-22 school year and determine predictors of these mandates at four time points, including before and after federal guidance relaxed school mask recommendations in February 2022. Methods: Student mask policies for US states and the District of Columbia, as well as a sample of 56 districts were categorized as prohibited, recommended, or required in September 2021, November 2021, January 2022, and March 2022 based on the Johns Hopkins eSchool+ Initiative School Reopening Tracker. Changes in policies over time were characterized. Generalized estimating equations and logistic regression were used to evaluate whether political affiliation of governor, urbanicity, economic disadvantage, and race/ethnic composition of district students, and county-level COVID-19 incidence predicted the presence of a district mask mandate at any time point and at all four time points. Results: State and district policies changed over time. Districts that implemented student mandates at any point were more likely to be in states with Democratic governors (AOR: 5.52; 95% CI: 2.23, 13.64) or in non-rural areas (AOR: 8.20; 95% CI: 2.63, 25.51). Districts that retained mask mandates at all four time points were more likely to have Democratic governors (AOR: 5.39; 95% CI: 2.69, 10.82) and serve a smaller proportion of economically disadvantaged students (AOR: 0.97; 95% CI: 0.95, 0.99). Districts serving a larger proportion of students from minoritized racial/ethnic groups were more likely to have mask mandates at any or all timepoints. Notably, county-level COVID-19 prevalence was not related to the presence of a mask mandate at any or all time points. By March 2022, no factors were significantly associated with district mask policy. Discussion: Political, geographic, and demographic characteristics predicted the likelihood of student mask mandates in the 2021-22 school year. Public health promotion messages and policy must account for variation in these factors, potentially through centralized and consistent messaging and unbiased, trustworthy communication.

Comparing Ahmed-FP7 to Baerveldt-250 and Baerveldt-350 surgical outcomes: 1-year results from a retrospective cohort study leveraging the electronic health record.

OBJECTIVE: To compare outcomes following Ahmed-FP7 (AGI-FP7), Baerveldt-250mm2 (BGI-250), or Baerveldt-350mm2 (BGI-350) implantation. METHODS AND ANALYSIS: Retrospective cohort study comprising 800 eyes from 800 individuals who underwent surgery 1 January 2016-31 December 2020 at a tertiary-care institution. Data were extracted from standardised fields in the electronic health record. Primary outcome was failure (defined as intraocular pressure (IOP) ≤5 mm Hg or >18 mm Hg or reduction <20% at two consecutive visits from month 3 onwards; or visual acuity (VA) loss ≥3 lines; or return to the operating room (OR)). Secondary outcomes were IOP, VA, number of follow-up visits and return to the OR. RESULTS: A total of 523 AGI-FP7, 133 BGI-250 and 144 BGI-350 cases were analysed. The AGI-FP7 group was more likely to be younger and diagnosed with secondary glaucoma, with a higher mean baseline IOP (28.5±12.2 vs 22.0±7.7 mm Hg in BGI-250 and 23.4±9.0 in BGI-350, p<0.001). Cumulative failure rate at month 12 was 30% (AGI-FP7) vs 39% (BGI-250) vs 33% (BGI-350, p=0.159). Mean IOP at month 12 was lower in the BGI-350 group compared with AGI-FP7 (12.4±4.4 vs 14.8±5.6 mm Hg, p=0.003) but not BGI-250 (vs 13.1±4.6, p=0.710). Target IOP was achieved in 71% of AGI-FP7, 66% BGI-250, and 76% BGI-350. VA loss and rates of return to the OR did not differ between groups. Both BGI-250 and BGI-350 had more follow-up visits than AGI-FP7 (p<0.001). CONCLUSION: These three glaucoma drainage devices performed similarly within 1 year, with no difference in failure rates despite differing baseline patient characteristics.

Using deep leaning models to detect ophthalmic diseases: A comparative study.

Purpose: The aim of this study was to prospectively quantify the level of agreement among the deep learning system, non-physician graders, and general ophthalmologists with different levels of clinical experience in detecting referable diabetic retinopathy, age-related macular degeneration, and glaucomatous optic neuropathy. Methods: Deep learning systems for diabetic retinopathy, age-related macular degeneration, and glaucomatous optic neuropathy classification, with accuracy proven through internal and external validation, were established using 210,473 fundus photographs. Five trained non-physician graders and 47 general ophthalmologists from China were chosen randomly and included in the analysis. A test set of 300 fundus photographs were randomly identified from an independent dataset of 42,388 gradable images. The grading outcomes of five retinal and five glaucoma specialists were used as the reference standard that was considered achieved when ≥50% of gradings were consistent among the included specialists. The area under receiver operator characteristic curve of different groups in relation to the reference standard was used to compare agreement for referable diabetic retinopathy, age-related macular degeneration, and glaucomatous optic neuropathy. Results: The test set included 45 images (15.0%) with referable diabetic retinopathy, 46 (15.3%) with age-related macular degeneration, 46 (15.3%) with glaucomatous optic neuropathy, and 163 (55.4%) without these diseases. The area under receiver operator characteristic curve for non-physician graders, ophthalmologists with 3-5 years of clinical practice, ophthalmologists with 5-10 years of clinical practice, ophthalmologists with >10 years of clinical practice, and the deep learning system for referable diabetic retinopathy were 0.984, 0.964, 0.965, 0.954, and 0.990 (p = 0.415), respectively. The results for referable age-related macular degeneration were 0.912, 0.933, 0.946, 0.958, and 0.945, respectively, (p = 0.145), and 0.675, 0.862, 0.894, 0.976, and 0.994 for referable glaucomatous optic neuropathy, respectively (p < 0.001). Conclusion: The findings of this study suggest that the accuracy of this deep learning system is comparable to that of trained non-physician graders and general ophthalmologists for referable diabetic retinopathy and age-related macular degeneration, but the deep learning system performance is better than that of trained non-physician graders for the detection of referable glaucomatous optic neuropathy.

Low Vision Rehabilitation Service Utilization Before and After Implementation of a Clinical Decision Support System in Ophthalmology.

Importance: Electronic clinical decision support systems apply clinical guidelines in real time and offer a new approach to improve referral and utilization of low vision rehabilitation (LVR) care. Objective: To characterize patients and factors associated with LVR service utilization with and without the use of an electronic health record (EHR) clinical decision support system (CDSS) alert. Design, Setting, and Participants: Quality improvement study using EHR data to compare patients who did and did not utilize LVR service after referral between November 6, 2017, and October 5, 2019, (primary) and to assess overall service utilization rate from September 1, 2016, to April 2, 2021, regardless of referral status (secondary). Participants in the primary analysis were patients at a large ophthalmology department in an academic medical center in the US who received an LVR referral recommendation from their ophthalmologist according to the CDSS alert. The secondary analysis included patients with best documented visual acuity (BDVA) worse than 20/40 before, during, and after the CDSS implementation. Data were analyzed from August 2021 to April 2022. Exposures: Number and locations of referral recommendations for LVR service according to the CDSS alert in the primary analysis; active CDSS implementation in the secondary analysis. Main Outcomes and Measures: LVR service utilization rate was defined as the number of patients who accessed service among those who were referred (primary) and among those with BDVA worse than 20/40 (secondary). EHR data on patient demographics (age, sex, race, ethnicity) and ophthalmology encounter characteristics (numbers of referral recommendations, encounter location, and BDVA) were extracted. Results: Of the 429 patients (median [IQR] age, 71 [53 to 83] years; 233 female [54%]) who received a CDSS-based referral recommendation, 184 (42.9%) utilized LVR service. Compared with nonusers of LVR, users were more likely to have received at least 2 referral recommendations (12.5% vs 6.1%; χ21 = 5.29; P = .02) and at an ophthalmology location with onsite LVR service (87.5% vs 78.0%; χ21 = 6.50; P = .01). Onsite LVR service (odds ratio, 2.06; 95% CI, 1.18-3.61) persisted as the only statistically significant factor after adjusting for patient demographics and other referral characteristics. Among patients whose BDVA was worse than 20/40 before, during, and after the CDSS implementation regardless of referral status, the LVR service utilization rate was 6.1%, 13.8%, and 7.5%, respectively. Conclusions and Relevance: In this quality improvement study, ophthalmologist referral recommendations and onsite LVR services at the location where patients receive other ophthalmic care were significantly associated with service utilization. Ophthalmology CDSSs are promising tools to apply clinical guidelines in real time to improve connection to care.

Associations of Midlife and Late-Life Blood Pressure Status With Late-Life Retinal OCT Measures.

Purpose: To explore the relationship of long-term blood pressure (BP) patterns with late-life optical coherence tomography (OCT) structural measures reflecting optic nerve health. Methods: Participants in this community-based cohort study of black and white individuals were part of the Atherosclerosis Risk in Communities study and the nested Eye Determinants of Cognition (EyeDOC) study. Participants had BP measured six times from 1987 to 2017 and were categorized into five BP patterns: sustained normotension; midlife normotension, late-life hypertension (systolic BP [SBP] >140 mmHg or diastolic BP [DBP] >90 mmHg or antihypertensive medication use); sustained hypertension; midlife normotension, late-life hypotension (SBP <90 mmHg or DBP <60 mmHg); and midlife hypertension, late-life hypotension. Multivariable linear regression modeling was used to evaluate associations between BP patterns and late-life OCT ganglion cell complex (GCC) and peripapillary retinal nerve fiber layer (RNFL) thickness. Results: In total, 931 eyes of 931 participants (mean age at EyeDOC visit = 80 years; 63% female; 45% black) were included. Mean GCC and RNFL thicknesses in the sustained normotension pattern were 90.8 ± 10.3 µm and 89.9 ± 11.2 µm versus 89.4 ± 11.9 µm and 90.1 ± 12.2 µm in the sustained hypertension pattern (P > 0.05). Compared to the sustained normotension pattern, no significant differences in GCC or RNFL thickness were found for any anomalous BP pattern. Conclusions: Assessment of long-term BP status showed no significant associations with late-life OCT structural measures. Translational Relevance: OCT imaging results in our population-based sample suggest that neither hypertension, even when present in midlife, nor late-life hypotension are significant risk factors for late-life optic nerve damage.

Visual Acuity: Assessment of Data Quality and Usability in an Electronic Health Record System.

Objective: To examine the data quality and usability of visual acuity (VA) data extracted from an electronic health record (EHR) system during ophthalmology encounters and provide recommendations for consideration of relevant VA end points in retrospective analyses. Design: Retrospective, EHR data analysis. Participants: All patients with eyecare office encounters at any 1 of the 9 locations of a large academic medical center between August 1, 2013, and December 31, 2015. Methods: Data from 13 of the 21 VA fields (accounting for 93% VA data) in EHR encounters were extracted, categorized, recoded, and assessed for conformance and plausibility using an internal data dictionary, a 38-item listing of VA line measurements and observations including 28 line measurements (e.g., 20/30, 20/400) and 10 observations (e.g., no light perception). Entries were classified into usable and unusable data. Usable data were further categorized based on conformance to the internal data dictionary: (1) exact match; (2) conditional conformance, letter count (e.g., 20/30+2 - 3); (3) convertible conformance (e.g., 5/200 to 20/800); (4) plausible but cannot be conformed (e.g., 5/400). Data were deemed unusable when they were not plausible. Main Outcome Measures: Proportions of usable and unusable VA entries at the overall and subspecialty levels. Results: All VA data from 513 036 encounters representing 166 212 patients were included. Of the 1 573 643 VA entries, 1 438 661 (91.4%) contained usable data. There were 1 196 720 (76.0%) exact match (category 1), 185 692 (11.8%) conditional conformance (category 2), 40 270 (2.6%) convertible conformance (category 3), and 15 979 (1.0%) plausible but not conformed entries (category 4). Visual acuity entries during visits with providers from retina (17.5%), glaucoma (14.0%), neuro-ophthalmology (8.9%), and low vision (8.8%) had the highest rates of unusable data. Documented VA entries with providers from comprehensive eyecare (86.7%), oculoplastics (81.5%), and pediatrics/strabismus (78.6%) yielded the highest proportions of exact match with the data dictionary. Conclusions: Electronic health record VA data quality and usability vary across documented VA measures, observations, and eyecare subspecialty. We proposed a checklist of considerations and recommendations for planning, extracting, analyzing, and reporting retrospective study outcomes using EHR VA data. These are important first steps to standardize analyses enabling comparative research.

Neighbourhood Disadvantage and Vision Screening Failure Rates: Analysis of a School-Based Vision Program in Baltimore, Maryland.

PURPOSE: To investigate the relationship between neighbourhood disadvantage and vision screening failure rates. METHODS: This analysis uses aggregate data from pre-kindergarten to eighth grade schools participating in a school-based vision programme in Baltimore, Maryland, from 2016 to 2019. Data on number of students screened and number of students who failed vision screening per grade level were recorded for each school. The Area Deprivation Index (ADI) was obtained for each school using the school's ZIP+4 code. The association between vision screening failure rates by grade and school ADI was analysed using negative binomial regression models, adjusted for grade level and accounting for clustering by school. RESULTS: Nine hundred seventy-two grades across 117 schools were included in this analysis. Median national ADI percentile across the sample was 71 [interquartile range (IQR): 48-85] (100 = most deprived). The median grade-level screening failure rate across the entire sample was 33% [IQR: 26-41%]. School ADI was not associated with vision screening failure rate (incidence rate ratio (IRR) = 1.01 per 10 percentage point increase in ADI, 95% CI: 0.99, 1.03, p = 0.217). CONCLUSIONS: In this study, there was no association between vision screening failure rates and school ADI. With one in three students failing screening in a high poverty public school district, these findings suggest a high need for vision services across schools in all neighbourhoods. Future work should investigate the impact of students' home ADI and socioeconomic status on vision screening outcomes.

Circular RNA hsa_circ_0007990 as a blood biomarker for unruptured intracranial aneurysm with aneurysm wall enhancement.

Background: Circular RNAs (circRNAs) may involve the formation and rupture of intracranial aneurysms (IA). Inflammation plays a vital role in the development and progression of IA, which can be reflected by aneurysm wall enhancement (AWE) on high-resolution vessel wall magnetic resonance imaging (HR-VWI). This study aims to evaluate the role of circRNAs as the blood inflammatory biomarker for unruptured IA (UIA) patients with AWE on HR-VWI. Methods: We analyzed the circRNA expression profiles in the peripheral blood samples among subjects from saccular UIA with AWE, UIA without AWE, and healthy controls by the circRNA microarray. The differential expression of hsa_circ_0007990 was assessed. We constructed the hsa_circ_0007990-microRNA-mRNA network and the regulatory axis of hub genes associated with the AWE in UIA. Results: Eighteen patients harboring saccular UIAs with HR VWI and five healthy controls were included. We found 412 differentially expressed circRNAs between UIA patients and healthy controls by circRNA microarray. Two hundred thirty-one circRNAs were significantly differentially expressed in UIA patients with AWE compared with those without AWE. Twelve upregulated circRNAs were associated with AWE of UIA, including hsa_circ_0007990, hsa_circ_0114507, hsa_circ_0020460, hsa_circ_0053944, hsa_circ_0000758, hsa_circ_0000034, hsa_circ_0009127, hsa_circ_0052793, hsa_circ_0000301 and hsa_circ_0000729. The expression of hsa_circ_0007990 was increased gradually in the healthy control, UIA without AWE, and UIA with AWE confirmed by RT-PCR (P<0.001). We predicted 4 RNA binding proteins (Ago2, DGCR8, EIF4A3, PTB) and period circadian regulator 1 as an encoding protein with hsa_circ_0007990. The hsa_circ_0007990-microRNA-mRNA network containing five microRNAs (miR-4717-5p, miR-1275, miR-150-3p, miR-18a-5p, miR-18b-5p), and 97 mRNAs was constructed. The five hub genes (hypoxia-inducible factor 1 subunit alpha, estrogen receptor 1, forkhead box O1, insulin-like growth factor 1, CREB binding protein) were involved in the inflammatory response. Conclusion: Differentially expressed blood circRNAs associated with AWE on HR-VWI may be the novel inflammatory biomarkers for assessing UIA patients. The mechanism of hsa_circRNA_0007990 for UIA progression needs to investigate further.

Associations among Visual, Auditory, and Olfactory Functions in Community-Based Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study.

Purpose: Objective examination of relationships among visual, hearing, and olfactory function may yield mechanistic insights and inform our understanding of the burden of multiple-sensory impairments. Methods: This cross-sectional study capitalized on continuous measures of visual acuity (VA), contrast sensitivity, pure tone audiometry, Quick Speech-in-Noise (QuickSIN), and Sniffin' Sticks from a subset of ARIC participants at two community sites (EyeDOC Study, 2017-2019). Scales of all measures were aligned such that higher values indicated greater impairment. Intersensory bivariate associations were assessed graphically, and correlations assessed using Kendall's tau. Intersensory associations, independent of age, education, smoking, diabetes, and hypertension, were examined using linear regression. Analyses were stratified by community/race (Washington County/White vs Jackson/Black) and sex (men vs women) to explore community-sex heterogeneity. Results: We included 834 participants (mean age, 79 years); 39% were from Jackson and 63% females. We found weak intersensory correlations (tau generally ≤0.15). In the demographics-adjusted regression models, results were heterogeneous across communities and sex. Worse near VA, contrast sensitivity, and olfaction were associated with worse QuickSIN and worse near VA was associated with worse olfaction in some but not all community/race-sex groups (e.g., Jackson/Black women, 0.1 logMAR worse near VA was associated with 0.27 units increase in QuickSIN [95% confidence interval, 0.10-0.45]). Associations were modestly attenuated by adjustment for the shared risk factors of smoking, diabetes, and hypertension. Conclusions: Visual dysfunction showed little or no association with hearing or olfaction impairments, suggesting a modest role for shared risk factors. Translational Relevance: Visually impaired individuals have only a modestly higher risk of other sensory impairment.

Effect of Combined Surgery in Patients with Complex Nanophthalmos.

(1) Background: To evaluate the efficacy and safety of combined surgery (limited pars plana vitrectomy, anterior-chamber stabilized phacoemulsification, IOL implantation and posterior capsulotomy, LPPV + ACSP + IOL + PC) in complex nanophthalmos. (2) Methods: Patients with complex nanophthalmos were recruited to undergo LPPV + ACSP + IOL + PC from January 2017 to February 2021. Preoperative and post-operative intraocular pressure (IOP), best corrected visual acuity (BCVA), anterior chamber depth (ACD), and number of glaucoma medications were compared using the paired t-test or Wilcoxon signed rank sum tests. Surgical success rate was evaluated. Surgery-associated complications were documented. (3) Results: Forty-five eyes of 37 patients with complex nanophthalmos were enrolled. The mean follow-up period was 21.7 ± 10.6 months after surgery. Mean IOP decreased from 32.7 ± 8.7 mmHg before surgery to 16.9 ± 4.5 mmHg (p < 0.001) at the final follow-up visit, mean logMAR BCVA improved from 1.28 ± 0.64 to 0.96 ± 0.44 (p < 0.001), mean ACD significantly increased from 1.14 ± 0.51 mm to 3.07 ± 0.66 mm (p < 0.001), and the median number of glaucoma medications dropped from 3 (1, 4) to 2 (0, 4) (p < 0.001). The success rate was 88.9% (40 eyes) at the final follow-up visit. Two eyes had localized choroidal detachments which resolved with medical treatment. (4) Conclusions: LPPV + ACSP + IOL + PC is a safe and effective surgical procedure, which can decrease IOP, improve BCVA, deepen the anterior chamber, and reduce the number of glaucoma medications in patients with complex nanophthalmos. It can be considered as one of the first treatment in nanophthalmic eyes with complex conditions.

Using Electronic Clinical Decision Support to Examine Vision Rehabilitation Referrals and Practice Guidelines in Ophthalmology.

Purpose: To examine ophthalmologist use of an electronic health record (EHR)-based clinical decision support system (CDSS) to facilitate low vision rehabilitation (LVR) care referral. Methods: The CDSS alert was designed to appear when best documented visual acuity was <20/40 or hemianopia or quadrantanopia diagnosis was identified during an ophthalmology encounter from November 6, 2017, to April 5, 2019. Fifteen ophthalmologists representing eight subspecialties from an academic medical center were required to respond to the referral recommendation (order, don't order). LVR referral rates and ophthalmologist user experience were assessed. Encounter characteristics associated with LVR referrals were explored using multilevel logistic regression analysis. Results: The alert appeared for 3625 (8.9%) of 40,931 eligible encounters. The referral rate was 14.8% (535/3625). Of the 3413 encounters that met the visual acuity criterion only, patients who were worse than 20/60 were more likely to be referred, and 32.4% of referred patients were between 20/40 and 20/60. Primary reasons for deferring referrals included active medical or surgical treatment, refractive-related issues, and previous connection to LVR services. Eleven of the 13 ophthalmologists agreed that the alert was useful in identifying candidates for LVR services. Conclusions: A CDSS for patient identification and referral offers an acceptable mechanism to apply practice guidelines and prompt ophthalmologists to facilitate LVR care. Further study is warranted to optimize ophthalmologist user experience while refining alert criteria beyond visual acuity. Translational Relevance: The CDSS provides the framework for multi-center research to assess the development of pragmatic algorithms and standards for facilitating LVR care.

Doxycycline vs Placebo at 12 Weeks in Patients With Mild Thyroid-Associated Ophthalmopathy: A Randomized Clinical Trial.

Importance: Mild thyroid-associated ophthalmopathy (TAO) negatively impacts quality of life, yet no clinical guidelines for its treatment are available. Existing evidence supports the use of doxycycline in treating mild TAO. Objective: To evaluate the short-term (12 weeks) efficacy of doxycycline in treating mild TAO. Design, Setting, and Participants: In this placebo-controlled multicenter randomized double-masked trial, 148 patients were assessed for eligibility. After exclusions (patients who were pregnant or lactating, had an allergy to tetracyclines, or had uncontrolled systematic diseases), 100 patients with mild TAO (orbital soft tissue affected mildly) at 5 centers in China were enrolled from July 2013 to December 2019 and monitored for 12 weeks. Interventions: Participants were randomly assigned 1:1 to receive doxycycline (50 mg) or placebo once daily for 12 weeks. Main Outcomes and Measures: The primary outcome was the rate of improvement at 12 weeks compared with baseline assessed by a composite indicator of eyelid aperture (reduction ≥2 mm), proptosis (reduction ≥2 mm), ocular motility (increase ≥8°), and Graves ophthalmopathy-specific quality-of-life (GO-QOL) scale score (increase ≥6 points). Adverse events were recorded. Results: A total of 50 participants were assigned to doxycycline and 50 to placebo. The mean (SD) age was 36.7 (9.1) years; 75 participants (75.0%) were female and 100 (100.0%) were Asian. Medication compliance was checked during participant interviews and by counting excess tablets. At week 12, the improvement rate was 38.0% (19 of 50) in the doxycycline group and 16.0% (8 of 50) in the placebo group (difference, 22.0%; 95% CI, 5.0-39.0; P = .01) in the intention-to-treat population. The per-protocol sensitivity analysis showed similar results (39.6% [19 of 48] vs 16.0% [8 of 50]; difference, 23.6%; 95% CI, 6.4-40.8; P = .009). No adverse events other than 1 case of mild gastric acid regurgitation was recorded in either group. Conclusions and Relevance: The results of this study indicate that oral doxycycline, 50 mg daily, resulted in greater improvement of TAO-related symptoms at 12 weeks compared with placebo in patients with mild TAO. These findings support the consideration of doxycycline for mild TAO but should be tempered by recognizing the relatively short follow-up and the size of the cohort. Trial Registration: ClinicalTrials.gov Identifier: NCT02203682.

Association of Optical Coherence Tomography and Optical Coherence Tomography Angiography Retinal Features With Visual Function in Older Adults.

Importance: Although there is abundant evidence relating neuronal and vascular optical coherence tomography (OCT) and OCT angiography (OCTA) measures to retinal disease, data on the normative distribution of retinal features and their associations with visual function in a healthy, older, community-based population are sparse. Objectives: To characterize the normative OCT and OCTA measures in older adults and describe their associations with visual function. Design, Setting, and Participants: This was a cross-sectional, observational study conducted from May 17, 2017, to May 31, 2019. The study included a community-based sample. Participants in the Atherosclerosis Risk in Communities study from Jackson, Mississippi (all self-reported Black participants), and Washington County, Maryland (all self-reported White participants), were recruited in the Eye Determinants of Cognition study (EyeDOC). Data analyses were conducted from June 14, 2020, to May 31, 2021. Main Outcomes and Measures: Retinal measurements, including retinal nerve fiber layer (RNFL) thickness, macular ganglion cell complex (GCC) thickness, macular vessel density (VD) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), and foveal avascular zone (FAZ) area, were captured with spectral-domain OCT and OCTA. Visual function, including presenting distance vision, corrected distance vision, near visual acuity (VA), and contrast sensitivity (CS), was assessed. Results: A total of 759 participants (mean [SD] age, 80 [4.2] years; 480 female participants [63%]; 352 Black participants [46%]) were included in the study. Mean (SD) GCC thickness (89.2 [9.3] µm vs 92.3 [8.5] µm) and mean (SD) FAZ (0.36 [0.16] mm2 vs 0.26 [0.12] mm2) differed between Jackson and Washington County participants, respectively. Mean (SD) RNFL thickness and mean (SD) VD in SCP and DCP were greater for participants 80 years or younger than for participants older than 80 years (RNFL: ≤80 years, 93.2 [10.5] µm; >80 years, 91.1 [11.6] µm; VD SCP, ≤80 years, 44.3% [3.5%]; >80 years, 43.5% [3.8%]; VD DCP, ≤80 years, 44.7% [4.9%]; >80 years, 43.7% [4.8%]). Linear regression showed each 10-µm increment in RNFL thickness and GCC thickness was positively associated with 0.016 higher logCS among all participants (RNFL: 95% CI, 0.005-0.027; P = .004; GCC: 95% CI, 0.003-0.029; P = .02), with stronger associations among Jackson participants. The associations of VA and structural measures were found only in Jackson participants, with coefficients per 10-µm increment of 0.012 logMAR VA (RNFL: 95% CI, 0.000-0.023; P = .049) and 0.020 logMAR VA (GCC: 95% CI, 0.004-0.034; P = .04). Conclusions and Relevance: In this cross-sectional study, better CS was associated with greater RNFL thickness and GCC thickness, but no visual measures were associated with angiographic features overall. These findings suggest that clinical application of normative references for OCT- and OCTA-based measures should consider demographic and community features.

Identifying Accessibility Requests for Patients With Disabilities Through an Electronic Health Record-Based Questionnaire.

Importance: People with disabilities experience disparities in health care access and outcomes, and inaccessible health care facilities are major barriers to health care access. Methods to collect accessibility request information are needed to improve health care outcomes for patients with disabilities. Objective: To evaluate an electronic health record (EHR)-based questionnaire designed to identify accessibility requests for patients with disabilities at an eye clinic. Design, Setting, and Participants: This cross-sectional pilot study implemented an EHR questionnaire and prospectively collected data on accessibility requests at a university-based eye clinic. The study included 55 722 patients making appointments at the Johns Hopkins Wilmer Eye Institute from April 1, 2019, to March 31, 2020. Main Outcomes and Measures: The Wilmer Eye Institute staff were trained to assess accessibility requests of patients making appointments in-person or via telephone using a standardized script and entering patient responses into the EHR. Data were later extracted for analysis and used to determine the proportion of patients making eye appointments who reported a disability accessibility request (physical, sensory, or intellectual) during their clinic visit. Results: Accessibility request data were collected from 250 932 patient encounters. Patients had a mean (SD) age of 61.9 (20.6) years; most were women (146 846 [58.5%]) and were White individuals (162 720 [64.9%]). Of these, 23 510 (9.4%) encounters were associated with an accessibility request. The most reported accessibility request was mobility related (18 857 [7.5%]) (needing a cane, crutches, motorized scooter, walker, wheelchair, stretcher, assistance standing, or transport services), followed by sensory-related (2988 [1.2%]) (visual, hearing, or speech impairment), intellectual (353 [0.1%]), and other (1312 [0.5%]) (assistance with filling forms or service animal) requests. Patients with an accessibility request compared with those without, were older (72.6 vs 60.8 years), less likely to be White individuals (59.7% vs 65.4%), and more likely to be women (62.6% vs 58.1%), receiving Medicare (69.6% vs 41.5%), and have vision impairment (41.3% vs 13.6%) (P < .001 for all). Conclusions and Relevance: In this cross-sectional study, a substantial proportion of patients making eye appointments reported having accessibility requests as captured using a new EHR-based questionnaire. Such standardization of data collection for disability-related accessibility requests in EHR is scalable, could be expanded to other clinical settings, and has the potential to improve accessibility of health care interactions for patients with disabilities.

Noncycloplegic Compared with Cycloplegic Refraction in a Chicago School-Aged Population.

PURPOSE: To evaluate differences between autorefraction measurements with and without cycloplegia among school-aged individuals and to explore factors associated with significant differences. DESIGN: Cross-sectional, retrospective study. PARTICIPANTS: Individuals between 3 and 22 years of age evaluated at the Illinois College of Optometry from September 2016 through June 2019 who underwent same-day noncycloplegic and cycloplegic autorefraction of the right eye. METHODS: Demographic information including age, sex, and race or ethnicity were collected during the eye examination. Autorefraction was performed before and after cycloplegia. Myopia, defined as at least -0.50 diopter (D) spherical equivalent (SE), hyperopia, defined as at least +0.50 D SE, and astigmatism of at least 1.00 D cylinder were determined using noncycloplegic and cycloplegic autorefractions. Factors associated with at least 1.00 D more myopic SE or at least 0.75 D cylindrical difference by noncycloplegic autorefraction were assessed using logistic regression models. MAIN OUTCOME MEASURES: Differences between noncycloplegic and cycloplegic autorefraction measurements. RESULTS: The mean age was 10.8 ± 4.0 years for the 11 119 individuals; 52.4% of participants were female. Noncycloplegic SE measured 0.65 ± 1.04 D more myopic than cycloplegic SE. After adjusting for demographic factors and refractive error, individuals with at least 1.00 D of more myopic SE refraction by noncycloplegic autorefraction (25.9%) were more likely to be younger than 5 years (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.18-1.79) and 5 to younger than 10 years (OR, 1.32; 95% CI, 1.18-1.48) than those 10 to younger than 15 years. This difference of at least 1.00 D of more myopic SE was more likely to be observed in Hispanic people (OR, 1.23; 95% CI, 1.10-1.36) and those with hyperopia (OR range, 4.20-13.31). Individuals with 0.75 D or more of cylindrical difference (5.1%) between refractions were more likely to be younger than 5 years, to be male, and to have mild-moderate-high myopia or moderate-high hyperopia. CONCLUSIONS: Three quarters of school-aged individuals had < 1 D of myopic SE difference using noncycloplegic compared with cycloplegic autorefraction. Understanding measurement differences obtained for refractive error and associated factors may provide useful information for future studies or programs involving refraction in school-aged children.

Associations of Visual Function With Cognitive Performance in Community-Based Older Adults: The Eye Determinants of Cognition Study.

BACKGROUND: Given the detrimental impacts of visual and cognitive impairment separately, in older adults, understanding their coexistence could inform strategies against age-related cognitive changes. METHODS: Participants from Washington County (White) and Jackson (Black) sites of the Atherosclerosis Risk in Communities Study were recruited who differed on racial, regional, urbanicity, and community-based factors. Presenting distance visual acuity (DVA; representing vision loss due to disease or lack of eye-care), corrected DVA (representing optimal correction for refractive loss of vision), and contrast sensitivity were measured. Factor scores for global cognition, memory, executive function, and language domains were calculated for 3 visits. We quantified the associations of vision measures with change in cognitive scores, stratified by community/race, using generalized estimating equations. RESULTS: In 982 participants, mean (standard deviation [SD]) baseline age was 74 (4) years, with 37% males and 45% Jackson/Black participants. As hypothesized, after accounting for potential confounders, in the better-eye, worse presenting DVA was associated with greater 10-year decline rate in global cognition, memory, and executive function in Washington County/White participants (eg, global cognition: -0.08 SD [95% confidence interval: -0.12, -0.04]). Worse corrected DVA was associated with greater 10-year decline rate in executive function in Washington County/White participants (-0.10 SD [-0.15, -0.04]). Better contrast sensitivity was associated with lower 10-year decline rate in global cognition and executive function in Washington County/White participants (eg, global cognition: 0.10 SD [0.06,0.14]). None of these associations were confirmed in Jackson/Black participants. CONCLUSIONS: Our study supports a functional link between some vision measures and cognition in older adults, but in only 1 of the 2 communities studied.