Outcomes following repair of early-onset versus delayed-onset rhegmatogenous retinal detachments after acute posterior vitreous detachment.

AIM: To report anatomical and functional outcomes after surgical repair of acute-onset vs delayed-onset rhegmatogenous retinal detachments (RDs) following acute posterior vitreous detachment (PVD). METHODS: A retrospective, comparative interventional cohort study where patients presenting to a single-centre retina practice between October 2015 and March 2020 with delayed RDs (diagnosed ≥42 days after initial presentation of acute PVD) were compared with a 2:1 age-matched and gender-matched acute RD cohort (PVD and RD at initial presentation). The primary outcome was the final attachment rate and single surgery anatomic success (SSAS) at 3 months after RD repair. RESULTS: A total of 210 eyes were analysed-70 in the delayed RD group and 140 in the acute RD group. SSAS was 58/70 (82.9%) for the delayed RD group and 112/140 (80%) for the acute RD group (p=0.71). At the time of RD diagnosis, mean (SD) logarithm of minimum angle of resolution visual acuity (VA) was 0.51 (0.70) (Snellen, 20/65) in the delayed RD group vs 1.04 (0.92) (Snellen, 20/219) in the acute RD group (p<0.001). Mean VA was better at 1 and 3 months post-repair in the delayed RD group (p=0.005 and 0.041, respectively) but similar by 6 months, 12 months and at the final visit post-repair (p=0.48, 0.27, and 0.23, respectively). CONCLUSIONS: Delayed-onset RDs occurring ≥6 weeks after initial presentation to a retina specialist with an acute PVD generally had better VA at the time of RD diagnosis and faster post-surgical visual recovery compared with acute-onset RDs diagnosed at the initial presentation. No significant difference in anatomic outcomes was seen between the two groups.

Limitations of direct-to-consumer genetic testing for age-related macular degeneration.

The availability of direct-to-consumer genetic testing (DTCGT) for age-related macular degeneration (AMD) provides the public with access to disease risk estimations that may be used to guide lifestyle adjustments. However, AMD development risk is more complex than can be captured by gene mutations alone. The methodologies employed by current DTCGTs to estimate AMD risk vary and are limited in several ways. Genotyping-based DTCGT is biased toward European ancestry and only considers a limited number of genes. Whole genome sequencing based DTCGTs uncovers several genetic variations with unknown relevance, making risk interpretation challenging. In this perspective, we describe the limitations of the DTCGT for AMD.

Economic Evaluation of Artificial Intelligence Systems Versus Manual Screening for Diabetic Retinopathy in the United States.

BACKGROUND: The objective of this economic modeling study was to compare the cost effectiveness of fully automated retinal image screening (FARIS) to the current practice of universal ophthalmologist referral for diabetic retinopathy in the United States (US) health care system. METHODS: A Markov decision-analytic model was used to compare the automated versus manual screening and management pathway for diabetic patients with unknown retinopathy status. Costs (in 2021 US dollars), quality-adjusted life year (QALY) gains, and incremental cost-effectiveness ratios were calculated. Sensitivity analysis was performed against a $50,000/QALY willingness-to-pay threshold. RESULTS: FARIS was the dominant screening strategy, demonstrating cost savings of 18.8% at 5 years with equivalent net QALY gains to manual screening. Cost-effectiveness status was dependent on FARIS detection specificity, with a threshold value of 54.8%. CONCLUSION: Artificial intelligence-based screening represents an economically advantageous screening modality for diabetic retinopathy in the US, offering equivalent long-term utility with significant potential cost savings. [Ophthalmic Surg Lasers Imaging Retina 2023;54:272-280.].

THE EFFECT OF ENDOPHTHALMITIS ON RECURRENCE OF MACULAR EDEMA IN EYES RECEIVING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR.

PURPOSE: Visual outcomes after postinjection endophthalmitis have been well-studied, but the effect of endophthalmitis on the underlying exudative disease process remains unclear. We investigate the need for continued anti-vascular endothelial growth factor injections after endophthalmitis. METHODS: Eyes that developed endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor between January 1, 2016, and May 31, 2018, at a single academic retina practice were identified. Retrospective chart review was performed to determine 1) the proportion of eyes without recurrence of macular edema or subretinal fluid after endophthalmitis and 2) the proportion achieving a 12-week or greater interval between anti-vascular endothelial growth factor injections or exudation after endophthalmitis compared with internal controls before endophthalmitis. RESULTS: Of 50 eyes with endophthalmitis, seven (14.0%) had no fluid recurrence at a mean of 98.1 week. Of 43 eyes with recurrence, 48.0% achieved a >12-week recurrence-free interval after endophthalmitis (vs. 8.3% before endophthalmitis; P < 0.0001). Eyes with compared to those without choroidal neovascularization were more likely to achieve this interval (60.5% vs. 8.3%, respectively; P = 0.002). CONCLUSION: Endophthalmitis after anti-vascular endothelial growth factor injection is associated with relative stability of the underlying exudation. Further research is necessary to elucidate the mechanism, which may be useful in developing strategies and targets for the treatment of exudative macular diseases.

Orbital Cellulitis Following Uncomplicated Glaucoma Drainage Device Surgery: Case Report and Review of Literature.

PURPOSE: Orbital cellulitis (OC) is a rare postoperative complication of glaucoma drainage device (GDD) implantation. To date, there have only been 10 reported cases of OC following GDD implantation. CASE REPORT: Here, we report a case of OC in a 57-year-old man who developed pain, proptosis, and limited extraocular motility two days after uneventful Ahmed FP7 implantation in the right eye. Contrast-enhanced computed tomography of the orbits demonstrated fat stranding and a small fluid collection, consistent with OC. He had minimal improvement with intravenous antibiotics and ultimately underwent GDD explantation. A systematic review of the literature showed that the development of OC following GDD implantation can occur in the early or late postoperative period. Immediate hospitalization with intravenous administration of broad-spectrum antibiotics is recommended. Explantation of the infected GDD is often required for source control. CONCLUSION: OC is a rare postoperative complication of GDD implantation. Prompt evaluation and treatment are required, often combined with GDD explantation.

Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States.

BACKGROUND/OBJECTIVES: Patients with ophthalmic emergencies often present to emergency rooms. Emergency medicine (EM) physicians should feel comfortable encountering these conditions. We assessed EM physicians' comfort working up, diagnosing, and managing ophthalmic emergencies. SUBJECTS/METHODS: 329 EM physicians participated in this cross-sectional multicentre survey. Questions inquired about the amount, type, and self-perceived adequacy of ophthalmic training. Likert scales were used to assess confidence and comfort working up, diagnosing, and managing ophthalmic emergencies. RESULTS: Participants recall receiving a median of 5 and 10 h of ophthalmic training in medical school and residency, respectively. Few feel this prepared them for residency (16.5%) or practice (52.0%). Only 50.6% feel confident with their ophthalmic exam. Most (75.0%) feel confident in their ability to identify an ophthalmic emergency, but 58.8% feel well prepared to work them up. Responders feel more comfortable diagnosing acute retrobulbar hematoma (72.5%), retinal detachment (69.8%), and acute angle closure glaucoma (78.0%) than central retinal artery occlusion (28.9%) or giant cell arteritis (53.2%). Only 60.2% feel comfortable determining if canthotomy and cantholysis is necessary in the setting of acute retrobulbar hematoma, and 40.3% feel comfortable performing the procedure. There was a trend towards attending physicians and providers in urban and academic settings feeling more comfortable diagnosing and managing ophthalmic emergencies compared to trainees, non-urban, and non-academic physicians. CONCLUSIONS: Many participants do not feel comfortable using ophthalmic equipment, performing an eye exam, making vision or potentially life-saving diagnoses, or performing vision-saving procedures, suggesting the need to increase ophthalmic training in EM curricula.

Rare Presentation of Bilateral Central Retinal Vein Occlusion and Leukemic Retinopathy in a Young Adult Diagnosed with T-cell Acute Lymphoblastic Leukemia.

Simultaneous bilateral central retinal vein occlusion (CRVO) is a rare presentation that warrants consideration of an underlying hyperviscosity state. Increased serum viscosity can lead to the hematologic emergency of leukostasis with resultant vascular obstruction and hypoxic tissue damage. The following case demonstrates the first case of bilateral CRVO in a young adult secondary to acute lymphoblastic leukemia (ALL). A 23-year-old female presented to the emergency department (ED) with two days of worsening bilateral blurry vision and bitemporal headache. Her ocular exam was significant for bilateral intraretinal hemorrhages consistent with CRVO with chest radiograph demonstrating widened mediastinum with perihilar lymphadenopathy and serologic testing revealing ALL with blast crisis. The patient was subsequently admitted to the oncology service for induction chemotherapy. Patients with new headache and bilateral vision changes should prompt a thorough neurological and ophthalmologic exam to assess for underlying systemic pathologies. Concurrent bilateral CRVO is a rare but specific finding for systemic hyperviscosity syndrome, blood dyscrasia, polycythemia, or other serious illness. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality.

Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment.

PURPOSE: To determine the incidence and timing of delayed retinal breaks and retinal detachments (RDs) after acute posterior vitreous detachment (PVD) and associated risk factors. DESIGN: Retrospective case-control study. PARTICIPANTS: Acute PVD eyes treated between October 2015 and August 2018 at a single academic retina practice. METHODS: Eyes with a PVD diagnosis and history of extended ophthalmoscopic examination on presentation were identified using diagnostic billing codes. The number of eyes with a history of laser retinopexy, cryotherapy for retinal tear, or RD repair was determined using procedural billing codes, and the duration between initial and treatment visits was measured. Records of eyes with a delayed retinal break or RD and of a reference group comprising the first 100 presenting eyes with no initial or delayed retinal break or RD were reviewed to determine and compare the presence of select risk factors on initial examination. MAIN OUTCOME MEASURES: Development of a delayed retinal break or RD. RESULTS: Of 7999 eyes with acute PVD, 1280 (16.0%) showed a retinal break and 499 (6.2%) showed an RD on presentation. Delayed retinal breaks and RDs were found in 209 (2.6%) and 80 (1.0%) eyes, respectively. Of delayed breaks, 116 (55.5%) were found in 6 weeks or less and 93 (44.5%) were found more than 6 weeks after presentation. Of delayed RDs, 26 (32.5%) were found in 6 weeks or less and 54 (67.5%) were found more than 6 weeks after presentation. Compared with the reference group, vitreous hemorrhage (hazard ratio, 2.53 [P < 0.001] and 2.80 [P = 0.001]) and male gender (hazard ratio, 1.36 [P = 0.03] and 1.87 [P = 0.02]) were risk factors for delayed retinal breaks and RDs, respectively. Pseudophakia (hazard ratio, 2.10; P = 0.004) was also a risk factor for delayed RD; older age (odds ratio, 0.96; P = 0.01) was slightly protective. Vitreous hemorrhage was a risk factor for earlier retinal breaks (≤6 weeks vs. >6 weeks; odds ratio, 3.58; P < 0.001). CONCLUSIONS: Clinically significant rates of newly detected retinal breaks and RDs may occur after acute PVD, suggesting that repeat examination may be prudent in these patients.

Current Practice Preferences and Safety Protocols for Intravitreal Injection of Anti-Vascular Endothelial Growth Factor Agents.

PURPOSE: To assess current practice preferences and safety measures used for intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) medications and to assess the variability of practice patterns between academic and nonacademic and between early- and later-career ophthalmologists. DESIGN: Cross-sectional survey. PARTICIPANTS: Practicing retina specialists who administer intravitreal anti-VEGF injections from the membership pool of the American Society of Retina Specialists. METHODS: Participants were contacted by e-mail to participate in an anonymous 31-question survey on a common online platform, SurveyMonkey. MAIN OUTCOME MEASURES: Preferred practices for various aspects of administering IVIs and adherence to the most recently published guidelines on IVI techniques. RESULTS: Preinjection antibiotic drops were used always or often by 10.9% (43/396) of participants. Antibiotics after injection were used always or often by 16.6% (66/398) of participants. Longer (>15 years) compared with shorter (0-15 years) duration of practice was associated with always or often instilling preinjection antibiotics (13.7% vs. 6.7%; P = 0.028), scrubbing eyelids or lashes with antiseptic (43.6% vs. 30.5%; P = 0.008), and being less likely to instill antiseptic immediately before injection (89.7% vs. 95.7%; P = 0.029). Practicing for more than 25 years was associated with always or often instilling antibiotics after injection (22.5% vs. 13.3%; P = 0.017). Academic compared with nonacademic providers were more likely to wear a cap (16.3% vs. 6.8%; P = 0.006), mask (43.0% vs. 29.9%; P = 0.022), and gloves (64.0% vs. 52.1%; P = 0.050) and to drape the patient (17.4% vs. 9.1%; P = 0.027). CONCLUSIONS: Techniques for IVIs vary widely. Use of periprocedure antibiotics has declined, consistent with new evidence demonstrating lack of efficacy in endophthalmitis prevention as well as their potential harm. However, later-career physicians were more likely to continue to use antibiotics and other techniques advised against in the most recent recommendations of expert consensus groups in the United States and Europe. Academic practitioners were more likely to use protective wear during the procedure.

Outcomes of Eyes Lost to Follow-up with Proliferative Diabetic Retinopathy That Received Panretinal Photocoagulation versus Intravitreal Anti-Vascular Endothelial Growth Factor.

PURPOSE: To compare anatomic and functional outcomes in eyes with proliferative diabetic retinopathy (PDR) that were lost to follow-up (LTFU) for more than 6 months after treatment with either intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) agents or panretinal photocoagulation (PRP). DESIGN: Retrospective cohort study. PARTICIPANTS: Fifty-nine patients who were LTFU immediately after treatment for more than 6 months between September 2013 and September 2016. METHODS: Patients with eyes receiving either intravitreal anti-VEGF treatment or PRP with the next follow-up visit occurring more than 6 months after treatment were identified. Visual acuity (VA) and anatomic outcomes at the visit before being LTFU, the return visit, the 6-month visit after return, the 12-month visit after return, and the final visit were gathered and compared between the 2 treatment groups. MAIN OUTCOMES MEASURES: Visual acuity and anatomic outcomes. RESULTS: Seventy-six eyes of 59 patients were included in the study, of which 30 received IVI with anti-VEGF and 46 received PRP. In the anti-VEGF group, mean VA worsened significantly when comparing the visit before being LTFU (0.43±0.38 logarithm of the minimum angle of resolution [logMAR]) with the return visit (0.97±0.80 logMAR; P = 0.001) as well as with the final visit (0.92±0.94 logMAR; P = 0.01). In the PRP group, mean VA worsened significantly when comparing the visit before being LTFU (0.42±0.34 logMAR) with the return visit (0.62±0.64 logMAR; P = 0.03). However, no significant difference was observed at the final visit (0.46±0.47 logMAR; P = 0.38). There was a significantly greater number of eyes with tractional retinal detachment in the IVI group compared with the PRP group at the final visit (10 vs. 1, respectively; P = 0.005). There was a significantly greater incidence of neovascularization of the iris in the IVI arm compared with the PRP arm at the final visit (4 vs. 0, respectively; P = 0.02). CONCLUSIONS: Eyes with PDR that received only intravitreal anti-VEGF demonstrated worse anatomic and functional outcomes after being LTFU compared with eyes that received PRP. Given the potential sequelae of being LTFU, the choice of treatment for PDR must be considered carefully.

Use of Molecular Profiling to Guide Treatment Decisions in Patients with Neuroendocrine Tumors: Preliminary Results.

This case series demonstrates the potential of molecular profiling to improve selection of antitumor therapies in the treatment of patients with neuroendocrine and carcinoid tumors. Carcinoid tumors resected at one institution over a 3-year period were sent for molecular profiling to guide choice of treatment. Potentially beneficial therapies were identified based on the measured expression of 20 proteins and oncogenes and a comprehensive review of the chemotherapy response literature. The clinical charts of 41 patients were reviewed retrospectively, and 12 were selected as representatives of the range of effects molecular profiling has on carcinoid treatment. Their presentation, molecular profile results, treatment, and disease progression is reviewed in the following case series. A total of nine patients were treated with drugs identified as potentially beneficial by molecular profile reports. These include capecitabine, 5-fluorouracil, temozolomide, oxaliplatin, and gemcitabine. Based on clinical symptoms, serum markers of disease, and radiographic evidence five of nine patients responded to treatment, two had mixed responses, and two did not respond to treatment. At this early juncture, our critique of molecular profiling for neuroendocrine tumors is favorable, as a significant number of our patients responded to drugs identified by molecular profiling as potentially beneficial.

Awareness and Knowledge of Emergent Ophthalmic Disease Among Patients in an Internal Medicine Clinic.

IMPORTANCE: Emergent ophthalmic disease can lead to permanent visual impairment or blindness if medical attention is delayed. Awareness and knowledge of emergent ophthalmic disease may be important for early medical presentation and maximization of visual prognosis in some cases. OBJECTIVE: To assess public awareness and knowledge of 4 emergent ophthalmic diseases. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted from June 1 to July 30, 2015, in the waiting rooms of the outpatient internal medicine resident clinic at Mount Sinai Hospital. A written survey was administered to evaluate awareness and knowledge of retinal detachment, acute angle-closure glaucoma, giant cell arteritis, and central retinal artery occlusion. Awareness of each disease was assessed by whether participants knew what the diseases were (yes or no). Knowledge was evaluated by responses to 3 questions for each disease, including 1 question about basic pathophysiologic features, 1 question about basic symptoms, and 1 question about basic treatment options. All English-speaking patients who were physically and cognitively able to fill out the survey without assistance were considered eligible and offered the opportunity to participate during times of survey distribution; 237 completed the survey. Demographic information, including age, sex, race, income, and educational level, was collected. Data were assessed from August 1 to 7, 2015. MAIN OUTCOMES AND MEASURES: Awareness of each ophthalmic disease was determined by the proportion of respondents who answered yes, and knowledge was determined by the proportion of aware respondents who answered the knowledge questions correctly. RESULTS: Two hundred thirty-seven patients (of 227 who gave complete demographic information, 76 men [33.5%], 151 women [66.5%], and mean [SD] age, 51.3 [16.8] years) completed the survey. Awareness of each of the diseases studied was low; 61 of 220 respondents (27.7%; 95% CI, 21.8%-33.6%) were aware of retinal detachment; 32 of 219 respondents (14.6%; 95% CI, 9.9%-19.3%), acute angle-closure glaucoma; 11 of 216 respondents (5.1%; 95% CI, 2.2%-8.0%), giant cell arteritis; and 10 of 218 respondents (4.6%; 95% CI, 1.8%-7.4%), central retinal artery occlusion. Respondents who were aware and knowledgeable ranged from 29 of 199 (14.6%) for the pathophysiologic features of retinal detachment, 1 of 208 (0.5%) for the symptoms and 2 of 203 (1.0%) for treatment of giant cell arteritis, and 1 of 193 (0.5%) for the pathophysiologic features of central retinal artery occlusion. CONCLUSIONS AND RELEVANCE: Levels of awareness and knowledge of emergent ophthalmic diseases are low. These results indicate a need to educate the public about these acutely vision-threatening entities to ensure early medical presentation, to achieve the best possible visual prognosis, and to preserve quality of life.

Elevated Serum Pancreastatin Is an Indicator of Hepatic Metastasis in Patients With Small Bowel Neuroendocrine Tumors.

OBJECTIVES: Serum pancreastatin is a sensitive and specific diagnostic biomarker in neuroendocrine tumors (NETs). Elevated pancreastatin levels are associated with worse progression-free survival and overall survival in small bowel and pancreatic NETs. In this study, we investigated the clinical significance of elevated serum pancreastatin in identifying metastatic disease to the liver. METHODS: Retrospective chart review of patients with NET managed at a single institution was performed. The site of primary tumor, laboratory data, and presence of metastatic disease were reviewed. The sensitivity, specificity, and positive and negative predictive values for pancreastatin as indicator of liver metastasis were ascertained. RESULTS: Data were abstracted from 77 patient records. Small bowel was the primary tumor site in 44 patients (57%), and 49 patients had metastasis to the liver (64%). Sensitivity and specificity of serum pancreastatin was 85.7% and 66.7%, respectively, which compared with 61.5% and 43.8% for chromogranin A, in identifying liver metastasis in patients with primary tumors of the small bowel. CONCLUSIONS: Elevated serum pancreastatin is a sensitive and specific assay for detecting the incidence of liver metastasis in patients with small-bowel NET. Routine measurement of pancreastatin in patients with NET, especially in patients with small bowel primaries, is supported.

Lack of a clinically significant impact of race on morbidity and mortality in abdominal surgery: an analysis of 186,466 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Poorer surgical outcomes in black compared with white patients have been reported, but it remains unclear if race independently predicts worse outcomes. We investigated if blacks have poorer outcomes than whites following abdominal surgery at quality-seeking hospitals. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Program database, patients who were black or white and underwent common abdominal surgery procedures were identified. A total of 19,326 (10%) blacks and 167,140 (90%) whites undergoing abdominal surgery were analyzed. Statistical analyses were performed using SPSS v20. RESULTS: Thirty-day mortality for blacks compared with whites was not statistically significant for any procedures reviewed (all P > .05). Thirty-day morbidity for blacks was slightly higher in appendectomy (P < .0001), small bowel resection (P < .0001), and partial colectomy (P < .0001). CONCLUSION: Black compared with white patients did not have increased mortality following abdominal surgery but had minor, clinically insignificant, increased morbidity in appendectomy, small bowel resection, and partial colectomy.

Laparoscopic resection of gastric and small bowel gastrointestinal stromal tumors: 10-year experience at a single center.

BACKGROUND: Complete curative resection remains the treatment of choice for nonmetastatic gastrointestinal stromal tumors (GISTs). The safety and feasibility of laparoscopy in the treatment of this disease has been shown, however, the long-term oncologic outcomes of this technique remain unclear. STUDY DESIGN: An ongoing prospectively maintained database including all laparoscopically resected gastric and small bowel GISTs (n = 116) at Mount Sinai Medical Center from July 1999 to December 2011 was retrospectively analyzed. Recurrence and survival outcomes were calculated using the Kaplan-Meier method and compared with log-rank test. RESULTS: Tumors were of gastric (77.6%) and small bowel (22.4%) origins. Overall mean tumor size was 4.0 cm (±2.7 cm) and R0 resection was achieved in 113 (97.4%) cases. Overall perioperative complication rate was 14.7%, with a reoperative rate of 4.3% at 90 days. When comparing gastric with small bowel GISTs, a more acute presentation requiring emergent resections was noted in patients with small bowel GISTs (p = 008). However tumor size, operative data, and perioperative outcomes were comparable in both groups (p = NS). At a median follow-up of 56.4 months (range 0.1 to 162.4 months), recurrence rate was 7.8% and comparable in both gastric and small bowel GISTs (p = NS). Risk factors for recurrence on univariate analysis were presence of ulceration/necrosis (p < 0.001) and tumor size >5 cm (p = 0.05). Overall 10-year survival rate was 90.8%. Gastric and small bowel overall survival rates were similar (90.7% vs 91.3%, respectively). Overall 10-year disease-free survival was 80.0% (84.3% gastric vs 71.6% small bowel; p = NS). CONCLUSIONS: Our series demonstrates the safety and feasibility of laparoscopy in patients undergoing resection of small bowel and gastric GISTs. Comparable long-term oncologic outcomes with a 10-year survival of 90.8% were achieved.