Association of fractal dimension and other retinal vascular network parameters with cognitive performance and neuroimaging biomarkers: The Multi-Ethnic Study of Atherosclerosis (MESA).

INTRODUCTION: Retinal vascular network changes may reflect the integrity of the cerebral microcirculation, and may be associated with cognitive impairment. METHODS: Associations of retinal vascular measures with cognitive function and MRI biomarkers were examined amongst Multi-Ethnic Study of Atherosclerosis (MESA) participants in North Carolina who had gradable retinal photographs at Exams 2 (2002 to 2004, n = 313) and 5 (2010 to 2012, n = 306), and detailed cognitive testing and MRI at Exam 6 (2016 to 2018). RESULTS: After adjustment for covariates and multiple comparisons, greater arteriolar fractal dimension (FD) at Exam 2 was associated with less isotropic free water of gray matter regions (ß = -0.0005, SE = 0.0024, p = 0.01) at Exam 6, while greater arteriolar FD at Exam 5 was associated with greater gray matter cortical volume (in mm3 , ß = 5458, SE = 20.17, p = 0.04) at Exam 6. CONCLUSION: Greater arteriolar FD, reflecting greater complexity of the branching pattern of the retinal arteries, is associated with MRI biomarkers indicative of less neuroinflammation and neurodegeneration.

Clinical characteristics and mortality rates for suprachoroidal hemorrhage: seven-year experience at a tertiary eye center.

PURPOSE: To investigate comorbidities and medications associated with acute (ASCH) and delayed (DSCH) suprachoroidal hemorrhage (SCH), and to explore visual outcomes and mortality following SCH. METHODS: Retrospective review of SCH cases diagnosed at a tertiary center between 2013 and 2019. Demographics, history, surgery type, visual acuity, intraocular pressure (IOP), and mortality data were reviewed. RESULTS: Fifty eyes of 50 patients experienced SCH related to surgery: 15 (30%) ASCH and 35 (70%) DSCH. Glaucoma surgery was the most common preceding surgery, and SCH was more likely to be delayed in glaucoma surgery relative to other surgeries (p = 0.001). The proportions of patients on anticoagulant, antiplatelet, or NSAID medications were 30% (n = 15), 52% (n = 26), and 12% (n = 6), respectively. The mean preoperative IOP was 25.0 ± 10.2 mmHg. The mean final best corrected visual acuity did not significantly differ between DSCH and ASCH (logMAR 1.92 vs. 2.36; p = 0.39). After controlling for pre-drainage visual acuity, final visual acuity was not statistically significantly different between eyes that were drained versus those that were not drained (p = 0.06). Of all 50 patients, the mortality rate was 12% with a mean time to mortality after SCH of 754 ± 564 days for those who died. CONCLUSION: DSCH was more common than ASCH, with glaucoma surgery being the most common procedure to result in SCH. Visual outcomes and mortality rate were comparable between ASCH and DSCH. Further research is needed regarding the role of surgical drainage on improving visual outcomes in eyes with SCH.

Impact of Intraocular Pressure Control on Rates of Retinal Nerve Fiber Layer Loss in a Large Clinical Population.

PURPOSE: To investigate the impact of intraocular pressure (IOP) control on rates of change of spectral-domain OCT (SD-OCT) retinal nerve fiber layer (RNFL) thickness in a large clinical population. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 85 835 IOP measurements and 60 223 SD-OCT tests from 14 790 eyes of 7844 patients. METHODS: Data were extracted from the Duke Glaucoma Registry, a large database of electronic medical records of patients with glaucoma and suspected disease followed over time at the Duke Eye Center and satellite clinics. All records from patients with a minimum of 6 months of follow-up and at least 2 good-quality SD-OCT scans and 2 clinical visits with Goldmann applanation tonometry were included. Eyes were categorized according to the frequency of visits with IOP below cutoffs of 21 mmHg, 18 mmHg, and 15 mmHg over time. Rates of change for global RNFL thickness were obtained using linear mixed models and classified as slow if change was slower than -1.0 µm/year; moderate if between -1.0 and -2.0 µm/year; and fast if faster than -2.0 µm/year. Multivariable models were adjusted for age, gender, race, diagnosis, central corneal thickness, follow-up time, and baseline disease severity. MAIN OUTCOME MEASURES: Rates of change in SD-OCT RNFL thickness according to levels of IOP control. RESULTS: Eyes had a mean follow-up of 3.5±1.9 years. Average rate of change in RNFL thickness was -0.68±0.59 µm/year. Each 1 mmHg higher mean IOP was associated with 0.05 µm/year faster RNFL loss (P < 0.001) after adjustment for potentially confounding variables. For eyes that had fast progression, 41% of them had IOP <21 mmHg in all visits during follow-up, whereas 20% of them had all visits with IOP <18 mmHg, but only 9% of them had all visits with IOP <15 mmHg. CONCLUSIONS: Intraocular pressure was significantly associated with rates of progressive RNFL loss in a large clinical population. Eyes with stricter IOP control over follow-up visits had a smaller chance of exhibiting fast deterioration. Our findings may assist clinicians in establishing target pressures in clinical practice.

From Machine to Machine: An OCT-Trained Deep Learning Algorithm for Objective Quantification of Glaucomatous Damage in Fundus Photographs.

PURPOSE: Previous approaches using deep learning (DL) algorithms to classify glaucomatous damage on fundus photographs have been limited by the requirement for human labeling of a reference training set. We propose a new approach using quantitative spectral-domain (SD) OCT data to train a DL algorithm to quantify glaucomatous structural damage on optic disc photographs. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 32 820 pairs of optic disc photographs and SD OCT retinal nerve fiber layer (RNFL) scans from 2312 eyes of 1198 participants. METHODS: The sample was divided randomly into validation plus training (80%) and test (20%) sets, with randomization performed at the patient level. A DL convolutional neural network was trained to assess optic disc photographs and predict SD OCT average RNFL thickness. MAIN OUTCOME MEASURES: The DL algorithm performance was evaluated in the test sample by evaluating correlation and agreement between the predictions and actual SD OCT measurements. We also assessed the ability to discriminate eyes with glaucomatous visual field loss from healthy eyes with area under the receiver operating characteristic (ROC) curves. RESULTS: The mean prediction of average RNFL thickness from all 6292 optic disc photographs in the test set was 83.3±14.5 µm, whereas the mean average RNFL thickness from all corresponding SD OCT scans was 82.5±16.8 µm (P = 0.164). There was a very strong correlation between predicted and observed RNFL thickness values (Pearson r = 0.832; R2 = 69.3%; P < 0.001), with mean absolute error of the predictions of 7.39 µm. The area under the ROC curves for discriminating glaucomatous from healthy eyes with the DL predictions and actual SD OCT average RNFL thickness measurements were 0.944 (95% confidence interval [CI], 0.912-0.966) and 0.940 (95% CI, 0.902-0.966), respectively (P = 0.724). CONCLUSIONS: We introduced a novel DL approach to assess fundus photographs and provide quantitative information about the amount of neural damage that can be used to diagnose and stage glaucoma. In addition, training neural networks to predict SD OCT data objectively represents a new approach that overcomes limitations of human labeling and could be useful in other areas of ophthalmology.

Review of Ophthalmology Medical Professional Liability Claims in the United States from 2006 through 2015.

PURPOSE: To describe characteristics of closed medical professional liability (MPL) claims against ophthalmologists in the United States. DESIGN: Retrospective analysis of MPL claims from 2006-2015. Data were obtained from the Physician Insurers Association of America (PIAA) Data Sharing Project (DSP). Comparison was made between ophthalmology and all healthcare specialties for physician demographics, prevalence and costs associated with closed claims, and resolution of claims. The most prevalent chief medical factor, presenting medical condition, operative procedure, outcomes, and resolution of ophthalmology claims were compared between the 2006-2010 and 2011-2015 periods. PARTICIPANTS: From 2006-2015, 90 743 MPL claims were closed: 2.6% (2325/90 743) of closed claims and 2.2% (564/24 670) of all paid claims were against ophthalmologists. METHODS: Retrospective analysis of MPL claims captured by the PIAA DSP over a 10-year period. MAIN OUTCOME MEASURES: Subspecialty pertaining to the claim, number of claims closed and paid, indemnity paid, allocated loss adjustment expenses, chief medical factor, presenting medical condition, operative procedure, outcome, and resolution. RESULTS: Only 24% of closed claims against ophthalmologists resulted in payment. Two-thirds were dropped, withdrawn, or dismissed. Ninety percent of claims that received a verdict were favorable toward the ophthalmologist. Cataract and cornea surgeries were the most prevalent and most costly operative procedures, accounting for 50% of all claims and $47 641 376 and $32 570 148 in total paid indemnity, respectively. Average indemnity was higher for corneal procedures ($304 476) than vitreoretinal procedures ($270 141) or oculoplastic procedures on the eyelid ($222 471) or orbit and eyeball ($183 467). The prevalence and cost of claims related to endophthalmitis declined from 2006-2010 (n = 38/1160 [3.3%]; average indemnity, $516 875) period to the 2011-2015 (n = 26/1165 [2.2%]; average indemnity, $247 083) period. Average indemnity paid ($280 227 vs. $335 578) and amount spent on legal defense ($41 450 vs. $46 391) was slightly lower among ophthalmologists compared with all healthcare specialties, respectively. CONCLUSIONS: Ophthalmology has a relatively low number of malpractice claims reported compared with other healthcare specialties and shows less spending on average indemnity and defense. Further studies are needed to investigate the reasons for the higher prevalence of claims related to cataract and corneal surgeries and the higher average indemnity paid for corneal procedures relative to vitreoretinal or oculoplastic procedures.

CT-Guided Wire Localization for Involved Axillary Lymph Nodes After Neo-adjuvant Chemotherapy in Patients With Initially Node-Positive Breast Cancer.

Resection of biopsy-proven involved axillary lymph nodes (iALNs) is important to reduce the false-negative rates of sentinel lymph node (SLN) biopsy after neo-adjuvant chemotherapy (NAC) in patients with initially node-positive breast cancer. Preoperative wire localization for iALNs marked with clips placed during biopsy is a technique that may help the removal of iALNs after NAC. However, ultrasound (US)-guided localization is often difficult because the clips cannot always be reliably visible on US. Computed tomography (CT)-guided wire localization can be used; however, to date there have been no reports on CT-guided wire localization for iALNs. The aim of this study was to describe a series of patients who received CT-guided wire localization for iALN removal after NAC and to evaluate the feasibility of this technique. We retrospectively analyzed five women with initially node-positive breast cancer (age, 41-52 years) who were scheduled for SLN biopsy after NAC and received preoperative CT-guided wire localization for iALNs. CT visualized all the clips that were not identified on post-NAC US. The wire tip was deployed beyond or at the target, with the shortest distance between the wire and the index clip ranging from 0 to 2.5 mm. The total procedure time was 21-38 minutes with good patient tolerance and no complications. In four of five cases, CT wire localization aided in identification and resection of iALNs that were not identified with lymphatic mapping. Residual nodal disease was confirmed in two cases: both had residual disease in wire-localized lymph nodes in addition to SLNs. Although further studies with more cases are required, our results suggest that CT-guided wire localization for iALNs is a feasible technique that facilitates identification and removal of the iALNs as part of SLN biopsy after NAC in situations where US localization is unsuccessful.

Predictors of appendicitis on computed tomography among cases with borderline appendix size.

Confident diagnosis of appendicitis when the appendix is borderline (6 to 7 mm) in size can be challenging. This retrospective study assessed computed tomography (CT) findings that are most predictive of appendicitis when the appendix is borderline in diameter. Three radiologists conducted separate, blind retrospective reviews of 105 contrast-enhanced CTs with borderline appendices. Presence or absence of appendicitis was confirmed by chart review of clinical or surgical outcomes. Logistic regression was used to determine the odds ratio (OR) and the receiver operating characteristic for CT features predictive of appendicitis. Absence of intraluminal air (OR = 5.11, p < 0.001), wall hyperemia (OR = 3.92, p = 0.002), wall thickening (OR = 29.7, p < 0.001), and fat stranding (OR = 3.85, p = 0.003) were significant findings in univariate logistic regression. Using a multivariate model, we found that the absence of intraluminal air (OR = 6.04, p = 0.002) and wall thickening (OR = 24.6, p < 0.001) remained statistically significant and were unaffected by adjustment for gender and pediatric age. The area under the curve was significantly greater for the multivariate model than the initial, clinical CT impressions (p = 0.024). The combination of wall thickening and absence of intraluminal air was 92.6 % (95 % CI 75.7-99.1) sensitive and 82.4 % (95 % CI 65.5-93.2) specific for appendicitis. Wall thickening and the absence of intraluminal air are prominent predictors of appendicitis and, if present together, these features may aid in identifying appendicitis on CT when the appendix is borderline in size.

Delays in time to surgery for minorities with temporal lobe epilepsy.

OBJECTIVES: To determine whether adult minority patients with medically refractory temporal lobe epilepsy (TLE) experience significantly longer times to anterior temporal lobectomy (ATL) following presurgical evaluation. METHODS: A retrospective cohort study of 223 adult patients with epilepsy (PWE) and unilateral mesial temporal sclerosis who completed presurgical evaluation in the epilepsy monitoring unit at University of California, San Francisco, between January 1, 1993 and December 31, 2010, with follow-up through December 31, 2012. Log-rank test was performed for Kaplan-Meier survival curves of time to ATL stratified by race/ethnicity and by limited English proficiency (LEP). Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards and Weibull modeling. RESULTS: African Americans (AAs) and Asian/Pacific Islanders (Asian/PIs) experienced significantly longer times to surgery than whites in Kaplan-Meier plots (log-rank test p = 0.02 and p = 0.005, respectively). AAs and Asian/PIs also had longer times to surgery after adjusting for frailty, LEP, sex, age, mesial temporal sclerosis (MTS) laterality, and nonconcordant ictal electroencephalography (EEG) (adjusted HR = 0.22, p = 0.006; adjusted HR = 0.25, p = 0.003, respectively). Patients with LEP experienced significantly longer times to surgery than patients proficient in English (log-rank test p = 0.0085; adjusted HR = 0.48, p = 0.041). In Cox modeling, nonconcordant ictal EEG studies (adjusted HR = 0.47, p = 0.01), left-sided MTS (adjusted HR = 0.69, p = 0.023), and female sex (adjusted HR = 0.72, p = 0.048) were risk factors for longer times to surgery. SIGNIFICANCE: AA and Asian/PI patients as well as those with LEP have significantly longer times to ATL following presurgical evaluation. Future studies should be aimed at identifying the source of these disparities and developing targeted interventions to address them. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

A Comparison of Black and Non-Black Patients in the Presentation and Treatment of Keratoconus.

Purpose: Patients with advanced keratoconus (KCN) are less likely to benefit from corneal cross-linking and may require a partial or full thickness keratoplasty. This study aimed to determine whether racial disparities exist in the clinical presentation and initial treatment recommendations for patients evaluated for KCN. Methods: A single-center retrospective review was conducted on all patients who presented to the cornea department for initial evaluation of KCN between 2018 and 2020. Patients who had undergone prior corneal procedures or surgeries were excluded. Baseline sociodemographic and clinical information was collected and stratified according to black versus non-black race. Generalized estimating equations were used to examine the association between black race and presenting corrected distance visual acuity (CDVA), presence of corneal scarring, keratometry values, Belin ABCD score, and treatment recommendations. Multivariate models were adjusted for patient demographics. Results: A total of 128 patients (251 eyes) were included in this study. In fully adjusted models, black individuals presented with significantly worse CDVA (p < 0.0001) and worse tomographic KCN staging according to the Belin ABCD criteria (p = 0.002) compared to non-blacks. Blacks were also more than four times as likely to present with a thinnest pachymetry <400 µm (p < 0.0001) and more than three times as likely to have corneal scarring (p = 0.001). Blacks were more than seven times more likely to have keratoplasty recommended as treatment than conservative management such as corneal cross-linking or contact lenses (p = 0.004). Conclusion: Compared with their non-black counterparts, blacks presented with significantly more advanced KCN, which placed them at risk of requiring more invasive treatment plans. Future studies should investigate reasons for such late presentations and aim to mitigate disparities in the presentation and management of KCN.

Why are patients noncompliant with follow-up recommendations after MRI-guided core needle biopsy of suspicious breast lesions?

OBJECTIVE: The objective of this study was to investigate patient and breast MRI characteristics associated with noncompliance with recommended follow-up after MRI-guided core needle biopsy of suspicious breast lesions. MATERIALS AND METHODS: A retrospective review was performed of 576 breast lesions biopsied under MRI guidance between 2007 and 2010. Patient follow-up was obtained from the medical record and from contact with referring physicians. RESULTS: Of 415 women who underwent 576 MRI-guided core needle biopsies for suspicious breast lesions, 123 (29.6%) patients representing 154 of 576 (26.7%) lesions were noncompliant with recommended excision or 6-month MRI follow-up. Referring physicians provided information for 63% (97/154) of lesions in noncompliant patients, of which 49.5% (48/97) were followed by mammography instead of excision or MRI. Noncompliance with MRI follow-up was significantly associated with referral for biopsy by outside hospital physicians (odds ratio [OR], 2.40; p = 0.0001) and with referral for screening MRI (1.46; p = 0.093) and biopsy of a focus or foci lesion (1.63; p = 0.088). Among 178 lesions in patients compliant with follow-up MRI after MRI-guided core needle biopsy, 7.9% (14/178) had abnormal follow-up MRI results, half of which (3.9%, 7/178) were found on repeat biopsy to be high-risk or malignant. CONCLUSION: Institutions performing MRI-guided core biopsies should be aware that patients referred from outside institutions are more likely to be noncompliant with recommended follow-up. Strategies to improve follow-up should include educating patients on the difference between mammography and MRI follow-up.

Distinguishing language and race disparities in epilepsy surgery.

This study aimed to identify whether race/ethnicity and limited English proficiency impact the likelihood of pursuing surgical treatment for medically refractory epilepsy. We conducted a retrospective cohort study of 213 patients with medically refractory epilepsy and mesial temporal sclerosis who were being considered for temporal lobectomy between January 1, 1993 and December 31, 2010 with follow-up through December 31, 2012. Demographic and clinical factors potentially associated with surgical utilization, including self-reported race/ethnicity and preferred language, were gathered from the medical record. Patients of Asian/Pacific Islander or African American race were significantly less likely to pursue surgical treatment of epilepsy compared with non-Hispanic whites in a multivariate logistic regression model (adjusted for nonconcordant ictal EEG, age, and limited English proficiency) (OR 0.20, p=0.003; OR 0.15, p=0.001, respectively). Limited English proficiency was also significantly associated with lower odds of surgery (OR 0.38, p=0.034). Both race and limited English proficiency contribute to disparities in the surgical management of medically refractory epilepsy, especially among Asian/Pacific Islanders and African Americans. Culturally sensitive patient-physician communication and patient education materials might aid in surgical decision-making among minority groups.

Relationship of Self-reported and Performance-based Visual Function With Performance-based Measures of Physical Function: The Health ABC Study.

BACKGROUND: To assess the relationship between self-reported and performance-based visual impairment (VI) and lower extremity physical function. METHODS: Cross-sectional analysis of 2 219 Health ABC participants who completed vision testing and the Short Physical Performance Battery (SPPB). Linear regression models used either self-reported (weighted visual function question [VFQ] score) or performance-based (visual acuity [VA], log contrast sensitivity [LCS], Frisby stereoacuity [SA]) to predict SPPB or its components-gait speed, chair stands, or standing balance-with and without covariate adjustment. RESULTS: Mean age was 73.5 years (range 69-80); 52.4% were female and 37.4% African American. All VI measures were strongly associated with SPPB in unadjusted and adjusted models (p < .001). A self-reported VFQ score 1 standard deviation lower than the mean (mean 87.8 out of 100) demonstrated a -0.241 (95% confidence interval [CI]: -0.325, -0.156) adjusted difference in SPPB. After controlling for covariates, VA of <20/40 (41%) demonstrated a -0.496 (-0.660, -0.331) lower SPPB score while SA score>85 arcsec (30%) had a -0.449 (-0.627, -0.271) adjusted SPPB score versus those with better visual function. LCS < 1.55 (28.6%) was associated with a -0.759 (-0.938, -0.579) lower and LCS ≤ 1.30 (8%) with a -1.216 (-1.515, -0.918) lower adjusted SPPB score relative to better LCS. In a final multivariable model containing multiple vision measures, LCS remained independently associated with SPPB and all components, while SA remained associated with balance (all p < .05). CONCLUSIONS: Both self-reported and performance-based VI are strongly associated with poor lower extremity physical function. These findings may identify a subgroup of older adults with co-existing visual and physical dysfunction who may benefit from targeted screening and intervention to prevent disability.

Corrigendum: Examining the intersection of cognitive and physical function measures: Results from the brain networks and mobility (B-NET) study.

[This corrects the article DOI: 10.3389/fnagi.2023.1090641.].

The relationship between visual function and physical performance in the Study of Muscle, Mobility and Aging (SOMMA).

PURPOSE: The relationship of types of visual function to different aspects of physical function, especially strength and coordination, has been understudied, but delineation of these relationships could suggest potentially modifiable targets prior to the onset of disability. METHODS: Cross-sectional analysis of visual function (self-reported eyesight and eye disease, visual acuity, contrast sensitivity) and physical function tests in 877 older adults (mean age 76.36±5.01 years, 59.2% women, and 13.3% Black race). Separate linear regression models were constructed for short physical performance battery (SPPB), expanded SPPB (eSPPB), their components (gait speed, chair stand, balance, narrow walk), stair climb, four-square step, leg extension peak power and strength, and grip strength. RESULTS: In adjusted models, worse acuity, worse contrast sensitivity, and self-reported poor vision were significantly associated with worse performance on the eSPPB and four-square step test. Worse contrast sensitivity, but not acuity, was significantly associated with shorter balance times, slower chair stand pace, longer stair climb time, and worse SPPB score. Associations of worse acuity and contrast sensitivity with weaker leg extension power, leg strength, and grip strength were attenuated by covariate adjustment. Self-reported macular degeneration, but not cataract or glaucoma, was associated with worse performance on SPPB, eSPPB, balance, stair climb, and four-square step tests in adjusted models. Worse contrast sensitivity and macular degeneration remained associated with worse SPPB and balance after controlling for visual acuity and self-reported eyesight. CONCLUSIONS: Poor contrast sensitivity was more strongly associated with worse physical performance than acuity, especially for complex tasks that dynamically challenge coordination and balance. Future studies should examine if older adults with contrast sensitivity impairment would benefit from targeted intervention to decrease their risk of disability.

Examining the intersection of cognitive and physical function measures: Results from the brain networks and mobility (B-NET) study.

Background and objectives: Although evidence exists that measures of mobility and cognition are correlated, it is not known to what extent they overlap, especially across various domains. This study aimed to investigate the intersection of 18 different objective cognitive and physical function measures from a sample of unimpaired adults aged 70 years and older. Research design and methods: Canonical correlation analysis was utilized to explore the joint cross-sectional relationship between 13 cognitive and 6 physical function measures in the baseline visit of the Brain Networks and Mobility Function (B-NET) Study (n = 192). Results: Mean age of participants was 76.4 years. Two synthetic functions were identified. Function 1 explained 26.3% of the shared variability between the cognition and physical function variables, whereas Function 2 explained 19.5%. Function 1 termed "cognitive and physical speed" related the expanded Short Physical Performance Battery (eSPPB), 400-m walk speed, and Dual Task gait speed measures of physical function to semantic fluency animals scores, Digit Symbol Coding (DSC), and Trail Making Test B. Function 2 termed "complex motor tasks and cognitive tasks" related the Force Plate Postural Sway Foam Task and Dual Task to the following cognitive variables: MoCA Adjusted Score, Verbal Fluency L words, Craft story immediate and delayed recall, and Trail Making Test B. Discussion and implications: We identified groups of cognitive and physical functional abilities that were linked in cross-sectional analyses, which may suggest shared underlying neural network pathway(s) related to speed (Function 1) or complexity (Function 2). Translational significance: Whether such neural processes decline before measurable functional losses or may be important targets for future interventions that aim to prevent disability also remains to be determined.

Association Between Contrast Sensitivity and Physical Function in Cognitively Healthy Older Adults: The Brain Networks and Mobility Function Study.

BACKGROUND: To evaluate whether contrast sensitivity is associated with lower extremity physical function in cognitively intact older adults. METHODS: Cross-sectional analysis of the relationship of binocular and worse eye log contrast sensitivity (LCS) to expanded Short Physical Performance Battery (eSPPB) and its components (gait speed, narrow walking speed, chair stand pace, and balance) in 192 cognitively healthy older adults. The association of LCS with postural sway and gait was also tested with tasks that further challenged functional reserve. RESULTS: Mean age was 76.4 years with 56% identifying as female and over 98.5% having good corrected visual acuity. Lower LCS was significantly associated with worse performance on the eSPPB, 4-M gait speed, narrow walking speed, and balance time in unadjusted and adjusted models. The relationship between worse eye LCS and larger postural sway was 3 times greater on a foam surface (beta 1.07, 95% CI [0.35, 1.80]) than a firm surface (beta 0.35, 95% CI [0.05, 0.65]), and both were robust to adjustment for confounders; similar findings were observed with binocular LCS. Lower binocular LCS had a greater decremental effect on gait velocity during the fast pace (beta -0.58, 95% CI [-0.90, -0.27]) than the usual pace (Beta -0.39 [-0.63, -0.15]) gait task. CONCLUSIONS: These findings suggest that cognitively unimpaired older adults without significant visual acuity impairment can have subtle preclinical deficits in contrast sensitivity and physical function that could place them at risk of mobility and balance issues. Future studies should determine whether this subset of older adults may benefit from targeted intervention to prevent disability.

Retinal Vascular Changes in Alzheimer's Dementia and Mild Cognitive Impairment: A Pilot Study Using Ultra-Widefield Imaging.

Purpose: Retinal microvascular abnormalities measured on retinal images are a potential source of prognostic biomarkers of vascular changes in the neurodegenerating brain. We assessed the presence of these abnormalities in Alzheimer's dementia and mild cognitive impairment (MCI) using ultra-widefield (UWF) retinal imaging. Methods: UWF images from 103 participants (28 with Alzheimer's dementia, 30 with MCI, and 45 with normal cognition) underwent analysis to quantify measures of retinal vascular branching complexity, width, and tortuosity. Results: Participants with Alzheimer's dementia displayed increased vessel branching in the midperipheral retina and increased arteriolar thinning. Participants with MCI displayed increased rates of arteriolar and venular thinning and a trend for decreased vessel branching. Conclusions: Statistically significant differences in the retinal vasculature in peripheral regions of the retina were observed among the distinct cognitive stages. However, larger studies are required to establish the clinical importance of our findings. UWF imaging may be a promising modality to assess a larger view of the retinal vasculature to uncover retinal changes in Alzheimer's disease. Translational Relevance: This pilot work reports an investigation into which retinal vasculature measurements may be useful surrogate measures of cognitive decline, as well as technical developments (e.g., measurement standardization), that are first required to establish their recommended use and translational potential.

Factors Associated with Ophthalmology Referral and Adherence in a Teleretinal Screening Program: Insights from a Federally Qualified Health Center.

Background: Early detection of ophthalmic conditions such as diabetic retinopathy (DR) and glaucoma is crucial to preventing vision loss. Previous studies have evaluated teleretinal screening programs for DR in well-insured populations. The purpose of this retrospective study was to evaluate a teleretinal screening program in a population of uninsured and underinsured patients seen in a Federally Qualified Health Center (FQHC). Methods: We conducted a retrospective chart review of patients (age ≥18) who underwent teleretinal imaging (TRI) at a FQHC between January 2015 and September 2019. TRI gradings and patient demographic and clinical information were abstracted. Factors associated with referral for a dilated eye exam by an ophthalmologist, adherence to recommended follow-up dilated eye exam, and ophthalmology visit attendance were examined. Results: 3130 TRIs were graded in 2216 eyes (1107 patients). 65.2% (N = 722) self-identified as Hispanic and 56.3% (N = 623) required interpreter services. Follow-up dilated fundus examination (DFE) was recommended for 388 TRIs, 49% (N = 190) of which were completed within 1 year. Adherence to the recommended ophthalmology exam was not associated with any baseline clinical or demographic characteristics (p > 0.05). Older age, male sex, hypertension, proteinuria, and higher A1c were significantly associated with greater odds of ophthalmology referral based on TRI (all p < 0.05), after adjusting for covariates. Less severe diabetic retinopathy, no insurance coverage, and Hispanic ethnicity were associated with lower odds of attending an ophthalmology visit, regardless of follow-up recommendations based on TRI (all p < 0.05). Conclusion: In an FQHC serving predominantly uninsured and underinsured patients, only 49% of recommended DFE were completed within one year. Less severe diabetic retinopathy, lack of insurance coverage, and Hispanic ethnicity were associated with a lower likelihood of having a DFE regardless of recommendation. These results suggest that greater system-level efforts are needed to increase adherence to follow-up eye exams after TRI to ensure sight-saving care for underserved populations.

Identifying Peripapillary Radial Capillary Plexus Alterations in Parkinson's Disease Using OCT Angiography.

PURPOSE: To compare radial peripapillary capillary (RPC) plexus vascular parameters and retinal nerve fiber layer (RNFL) thickness between those with Parkinson's disease (PD) and controls. DESIGN: Prospective, cross-sectional study. PARTICIPANTS: A total of 151 eyes of 81 PD participants and 514 eyes of 266 controls. METHODS: Participants underwent OCT angiography (OCTA) imaging using the Zeiss Cirrus HD-5000 AngioPlex (Carl Zeiss AG). Capillary perfusion density (CPD) and capillary flux index (CFI) were assessed using a 4.5 × 4.5-mm peripapillary scan, and RNFL thickness was assessed using a 200 × 200-µm optic nerve cube OCT scan. Hoehn and Yahr clinical staging for PD was determined by an experienced movement disorders specialist. Generalized estimating equations adjusted for age and sex were used for analysis. MAIN OUTCOME MEASURES: Differences in RNFL thickness, CPD, and CFI as assessed using multivariable generalized estimating equations between individuals with PD and controls. RESULTS: After adjustment for age and sex, average CPD (0.446% ± 0.018% vs. 0.439% ± 0.017%, P < 0.001) and CFI (0.434 ± 0.031 vs. 0.426 ± 0.036, P = 0.008) were significantly higher in PD eyes. Average RNFL thickness was similar between groups (PD 89.71 ± 10.45 µm vs. control 88.20 ± 10.33 µm, P = 0.19). Significant correlations between Hoehn and Yahr stage and OCTA parameters were not observed. The OCTA parameters were not significantly different between eyes of the same patient. CONCLUSIONS: Increased peripapillary microvascular density and flux were detected in a large cohort of individuals with PD compared with controls after adjusting for age and sex; however, RNFL thickness was similar between groups. Peripapillary OCTA parameters may not correlate with the severity of PD. OCTA may serve as a noninvasive method to identify novel biomarkers for the early diagnosis of PD; as such, this methodology deserves further investigation.