Trends in Ophthalmology Practice Consolidation: 2015-2022.

PURPOSE: To quantify trends in ophthalmology practice consolidation in the United States. DESIGN: A retrospective cross-sectional study. PARTICIPANTS: Providers in the Centers for Medicare and Medicaid Services (CMS) National Downloadable File with a primary specialty designation of ophthalmology. METHODS: We used the CMS database to determine national practice consolidation trends in ophthalmology on individual physician and group practice levels and analyzed by region, sex, and years spent in practice. We used the Cochran-Armitage test to determine the statistical significance of practice size differences between 2015 and 2022. MAIN OUTCOME MEASURES: Temporal practice size trends for physicians and practices in ophthalmology and regional, sex-specific, and age-related trends. RESULTS: Between 2015 and 2022, the number of ophthalmologists decreased from 17 656 to 17 615 (-0.2%), whereas the number of practices decreased from 7149 to 5890 (-18%). The percentage of ophthalmologists in practices of 1 to 2 members decreased from 35% to 28%, whereas those in groups of 50 or more increased from 7% to 11%. The percentage of practices with 1 to 2 members decreased from 75% to 71%, and those with 50 or more increased from 0.2% to 0.4%. Consolidation trends were significant on individual ophthalmologist (P < 0.001) and group practice (P < 0.001) levels. All regions, sexes, and subgroups of years spent in practice demonstrated consolidation (P < 0.001). The Northeast showed the greatest increase in groups of 50 or more physicians (+7%) between 2015 and 2022. Proportionally fewer female than male ophthalmologists were associated with practice sizes of 1 to 2 members in 2015 (29% and 36%, respectively) and 2022 (23% and 30%, respectively). Proportionally fewer ophthalmologists with 0 to 10 years of experience in practice were associated with practice sizes of 1 to 2 members than those with more than 30 years in practice in 2015 (18% and 48%, respectively) and 2022 (14% and 40%, respectively). CONCLUSIONS: Ophthalmology has undergone practice consolidation from 2015 to 2022. A decrease in the proportion of physicians affiliated with smaller practice sizes seems to have occurred. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Interprofessional Electronic Consultations for the Diagnosis and Management of Neuro-Ophthalmic Conditions.

BACKGROUND: Interprofessional electronic consultation (eConsult) is a telemedicine modality in which consulting providers review outside records and provide recommendations without in-person consultation. The purpose of this study was to describe the utilization of eConsults in the management of neuro-ophthalmic conditions. METHODS: Retrospective cohort study of all patients who received an eConsult for a neuro-ophthalmic condition at a single quaternary referral center from 2018 to 2020. Main outcome measures included proportion of eConsults in which sufficient data were provided to the neuro-ophthalmologist to generate a definitive management decision, proportion of patients for whom an in-person neuro-ophthalmology evaluation was recommended, and the eConsult's impact on patient care. RESULTS: Eighty eConsults were conducted on 78 patients during the 3-year study period. Forty-eight (60.0%) subjects were female, mean age was 54 years, and 65 (81.3%) were White. The median time from eConsult request to completion was 4 days (range: 0-34 days). The most frequent eConsult questions were vision/visual field disturbances in 28 (35.0%) cases, optic neuropathies in 22 (27.5%), and optic disc edema in 17 (21.3%). At the time of eConsult, sufficient prior information was provided in 35 (43.8%) cases for the neuro-ophthalmologist to provide a definitive management decision. In 45 (56.3%) eConsults, further diagnostic testing was recommended. In-person neuro-ophthalmology consultation was recommended in 24 (30.0%) cases. Sixty-one (76.3%) eConsults provided diagnostic and/or treatment direction, and 12 (15.0%) provided reassurance. CONCLUSION: eConsults increase access to timely neuro-ophthalmic care and provide diagnostic and treatment direction to non-neuro-ophthalmology providers when sufficient information is provided at the time of eConsult.

Characterization and Utility of Remote Interpretation of Visual Field Diagnostic Testing in an Academic Center.

BACKGROUND: The use of remote interpretation of data has risen in neuro-ophthalmology to increase efficiency and maintain social distancing due to the coronavirus disease-19 pandemic. The purpose of this study is to characterize the use and efficiency of remote interpretation of visual fields (VFs) in an academic center and to determine how often the VF interpretation was consistent with the patient's clinical history and imaging at the time of the consult. METHODS: This is a retrospective study at a single academic center that enrolled all patients receiving a remote interpretation of VF from January 1, 2012, through December 31, 2012. Data were collected regarding the referring department, indication for the VF, interpretation of the VF and comparison with any prior VFs, any associated interventions with the VF, and available follow-up VFs. The main outcome measures included 1) characterizing the use of remote VF interpretations and 2) how many remote VF interpretation results were consistent with the referring diagnosis based on the patient's clinical history and imaging. RESULTS: One hundred eighty patients received remote interpretation of VFs. The most frequent referring departments were endocrinology (79; 44%), neurology (51; 28%), and neurosurgery (43; 24%). The VF indications included parasellar lesion (107; 59%), seizure disorder (26; 14%), meningioma (19; 11%), vascular lesion (11; 6%), and others (17; 9%). There were 78 patients (43%) that had an intervention before the VF, whereas 49 (27%) were preoperative VFs. Eighty-seven (48%) of the VFs were interpreted as abnormal. Of all the 180 remote interpretation of VFs, 156 (87%) had VF interpretations that were consistent with the clinical question posed by the referring provider based on clinical history and imaging. Among the other 24 remote VF interpretations (13% of total remote VF interpretations), there was no clear interpretation because of either additional unexpected VF defects (n = 5, 21%), VF defect mismatch (n = 6, 25%), or unreliable VFs (n = 13, 54%). The median wait time for patients receiving remote VF interpretations was 1 day. CONCLUSIONS: Remote interpretation of VFs was most often requested by endocrinology, neurology, and neurosurgery and could be performed very quickly. The most common indications were parasellar lesions, and just less than half of patients receiving remote VF interpretations had a prior intervention. A majority of remote VF interpretations were able to answer the clinical question, given the patient's clinical history and imaging. Remote interpretation of VFs may thus offer referring departments a more efficient method of obtaining VF interpretations than in-office neuro-ophthalmology examinations.

Uveal melanoma: laboratory advances and new frontiers in patient care.

PURPOSE OF REVIEW: To review recent advancements in the genetic understanding, diagnosis, prognosis, and treatment of uveal melanoma (UM). RECENT FINDINGS: UM is a molecularly distinct melanocytic malignancy driven by mutations in GNAQ or GNA11, with mitogen-activated protein kinase pathway upregulation. Earlier diagnosis and treatment are important factors for improving life prognosis. These goals can be aided by more objective multimodal imaging risk factors for the prediction of malignant nevus transformation and novel treatment strategies such as customized radiation fields and nanoparticle therapy to reduce vision-threatening treatment side effects. The risk for metastatic disease can be reliably predicted through gene expression profiling or the Cancer Genome Atlas project classification, and combined use of clinical tumor features with molecular data allows for highly individualized patient prognosis. Patients with high-risk UM should be considered for clinical trials of adjuvant therapy to prevent metastatic disease. For patients with clinically evident metastasis, combination immunotherapy regimens, T cell-based therapies, and focal adhesion kinase inhibitors offer hope for improved clinical response rates. SUMMARY: Improved understanding of UM molecular pathogenesis and clinical trials of targeted therapy for prevention and treatment of metastatic disease may improve patient survival for this challenging disease.

Trends in Myopia and High Myopia from 1966 to 2019 in Olmsted County, Minnesota.

PURPOSE: To investigate the prevalence of myopia and high myopia in Olmsted County, Minnesota, from 1966 to 2019. DESIGN: Retrospective, cross-sectional, trend study. METHODS: Manifest refractions or lens prescription were converted to spherical equivalent (SE) to estimate the prevalence of adult myopia and high myopia. Age, sex, race, and visual acuity were recorded. Subjects with an SE of -0.5 diopters (D) or less were considered to have myopia; those with an SE of -6.0 D or less were considered to have high myopia. Exclusion criteria included visually significant cataract, pseudophakia, prior refractive surgery, or age less than 18 years. RESULTS: Among 81,706 sampled subjects, the myopia prevalence increased from 33.9% (95% CI, 31.1-36.8) in the 1960s to 57.1% (95% CI, 56.6-57.6) in the 2010s (P < .001). The high myopia prevalence increased from 2.8% (95% CI, 1.95-3.98) in the 1960s to 8.3% (95% CI, 8.08-8.62) in the 2010s (P < .001). Both male (32.0%-55.1%, P < .001) and female (40.6%-58.5%, P < .001) subjects experienced increasing myopia prevalence from the 1960s to the 2010s; both male (2.6%-7.4%, P < .001) and female (3.4%-9.1%, P < .001) subjects also had higher high myopia prevalence rates from the 1960s through the 2010s. Increasing myopia and high myopia prevalence was detected by decade in nearly all age groups (excluding 18- to 24-year-old high myopia subjects). White and Asian subjects had the highest myopia prevalence, whereas Black subjects had the lowest. From the 2000s to the 2010s, White (53.3%-57.0%, P < .001) and Black (41.0%-47.0%, P = .001) subjects had significant increases in myopia prevalence. The mean SE decreased from the 1960s (-0.42 D; 95% CI, -0.59 to +2.49) to the 2010s (-1.85 D; 95% CI, -1.88 to +2.96) (P < .001). CONCLUSIONS: From 1966 to 2019 in Olmsted County, Minnesota, there was a 68% and 199% increase in myopia and high myopia prevalence, respectively.

Appropriateness of Ophthalmology Recommendations From an Online Chat-Based Artificial Intelligence Model.

Objective: To determine the appropriateness of ophthalmology recommendations from an online chat-based artificial intelligence model to ophthalmology questions. Patients and Methods: Cross-sectional qualitative study from April 1, 2023, to April 30, 2023. A total of 192 questions were generated spanning all ophthalmic subspecialties. Each question was posed to a large language model (LLM) 3 times. The responses were graded by appropriate subspecialists as appropriate, inappropriate, or unreliable in 2 grading contexts. The first grading context was if the information was presented on a patient information site. The second was an LLM-generated draft response to patient queries sent by the electronic medical record (EMR). Appropriate was defined as accurate and specific enough to serve as a surrogate for physician-approved information. Main outcome measure was percentage of appropriate responses per subspecialty. Results: For patient information site-related questions, the LLM provided an overall average of 79% appropriate responses. Variable rates of average appropriateness were observed across ophthalmic subspecialties for patient information site information ranging from 56% to 100%: cataract or refractive (92%), cornea (56%), glaucoma (72%), neuro-ophthalmology (67%), oculoplastic or orbital surgery (80%), ocular oncology (100%), pediatrics (89%), vitreoretinal diseases (86%), and uveitis (65%). For draft responses to patient questions via EMR, the LLM provided an overall average of 74% appropriate responses and varied by subspecialty: cataract or refractive (85%), cornea (54%), glaucoma (77%), neuro-ophthalmology (63%), oculoplastic or orbital surgery (62%), ocular oncology (90%), pediatrics (94%), vitreoretinal diseases (88%), and uveitis (55%). Stratifying grades across health information categories (disease and condition, risk and prevention, surgery-related, and treatment and management) showed notable but insignificant variations, with disease and condition often rated highest (72% and 69%) for appropriateness and surgery-related (55% and 51%) lowest, in both contexts. Conclusion: This LLM reported mostly appropriate responses across multiple ophthalmology subspecialties in the context of both patient information sites and EMR-related responses to patient questions. Current LLM offerings require optimization and improvement before widespread clinical use.

Epidemiology of Uveitis in Olmsted County, Minnesota: A Population-Based Follow-Up Study.

PURPOSE: To update the incidence of uveitis in a Midwestern U.S. county population. METHODS: Retrospective population-based cohort study. All Olmsted County, Minnesota residents diagnosed with uveitis from January 1, 2006 to December 31, 2015 were identified via the Rochester Epidemiology Project. Diagnoses were confirmed by a uveitis specialist. RESULTS: There were 371 incident uveitis cases, yielding an overall age- and sex-adjusted incidence rate of 26.9 per 100,000 per year (95% CI: 24.1-29.7). Females accounted for 202 (54.4%) cases, 306 (82.5%) were White, and 299 (80.6%) were anterior uveitis. Highest incidence was observed in patients ≥65 years old. No difference in incidence existed between sexes (p = .17). Incidence rates increased with age for uveitis overall (all anatomic subtypes) (p < .001), anterior uveitis (p < .001), and posterior uveitis (p < .001). Idiopathic uveitis accounted for 168 (45.3%) cases, more frequently diagnosed in females (50.0%) than males (39.6%) (p = .05). CONCLUSION: Uveitis incidence increased 1.6-fold over a 50-year span in this predominately White U.S. Midwestern county population.

Predictive Value of the International Classification of Diseases, 9th Revision Codes for Identifying Ocular Oncology Diagnoses.

Introduction: The aim of this study was to determine the predictive value of International Classification of Diseases, 9th Revision (ICD-9) billing codes for identifying ocular oncology diagnoses. Methods: Population-based retrospective cohort study of all Olmsted County, Minnesota residents with any ocular neoplasm-related ICD-9 code from January 1, 2006 to October 1, 2015. All medical records were reviewed for confirmation of ocular neoplasm. Diagnoses with ≥5 cases confirmed via a medical record review were compared to corresponding ICD-9 codes. Main outcome measures included positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of ICD-9 codes. Results: Among 3,932 subjects with ≥1 ocular neoplasm-related ICD-9 code, 21 diagnoses met study criteria. The most frequent intraocular, extraocular/orbital, and ocular surface diagnoses were choroidal nevus (n = 824), epidermal inclusion cyst (n = 263), and conjunctival nevus (n = 74), respectively. PPVs ranged from 1.2% to 73.8%, NPVs from 96.9% to 100%, sensitivity from 0% to 100%, and specificity from 85.7% to 100%. Among malignant neoplasms, PPV ranged from 0% to 73.8%: ocular surface squamous neoplasia (PPV: 0%), choroidal melanoma (PPV: 25.0%), eyelid squamous cell carcinoma (PPV: 46.7%), and eyelid basal cell carcinoma (PPV: 73.8%). Among benign neoplasms, PPV ranged from 1.2% (dermoid cyst) to 61.6% (choroidal nevus). Conclusion: There was a wide variation in a predictive value of ocular neoplasm-related ICD-9 billing codes, which suggests that ocular oncology-related claims data alone may overestimate the true number of ocular oncology diagnoses.

Incidence and clinical characteristics of pediatric ocular tumors in a Midwestern US population.

PURPOSE: To investigate the incidence and clinical characteristics of pediatric ocular tumors in a US Midwestern county population. METHODS: Retrospective population-based cohort study of all Olmsted County, Minnesota, pediatric patients (<18 years old) diagnosed with any ocular neoplasm from January 1, 2006, to December 31, 2015. Subjects were identified via the Rochester Epidemiology Project, a record-linkage system that captures virtually all medical care provided in this county. Medical records were reviewed to confirm diagnoses. Age- and sex-adjusted incidence rates were calculated and adjusted to the 2010 Olmsted County, Minnesota, pediatric population. RESULTS: There were 87 incident pediatric ocular tumor diagnoses, yielding an overall age- and sex-adjusted incidence rate of 24.0 per 100,000 per year (95% CI, 19.0-29.1). Females accounted for 46 cases (53%) cases, and 62 (85%) were White. Incidence rate for ocular tumors overall did not differ by patient age (P = 0.08) or sex (P = 0.47). All tumors were benign lesions. The most frequent adnexal/orbital, ocular surface, and intraocular tumors were epidermal inclusion cyst in 18 (21%) cases, conjunctival nevus in 10 (12%), and choroidal nevus in 18 (21%), respectively. The mean follow-up duration was 25.5 months (range, 7 days to 138.6 months), and benign tumor growth occurred in one conjunctival nevus. There were no cases of malignant transformation. CONCLUSIONS: Pediatric ocular tumors were rare with an estimated incidence of approximately 1 in 4,200 pediatric patients in Olmsted County, Minnesota. All lesions were benign, with benign growth in only 1% of cases, and no tumors underwent malignant transformation.

Population-based incidence of intraocular tumours in Olmsted County, Minnesota.

BACKGROUND/AIMS: To determine population-based incidence of intraocular tumours in Olmsted County, Minnesota. METHODS: Record review of the Rochester Epidemiology Project medical record linkage system from 1 January 2006 to 31 December 2015 for patient demographics, tumour type by clinical diagnosis and presence or absence of confirmation by histopathology. The incidence rate of any intraocular tumour and of each tumour type was calculated per million person-years. Poisson regression analysis was used to analyse changes in incidence over time. RESULTS: There were 948 patients diagnosed with intraocular tumours resulting in an age-adjusted and sex-adjusted incidence rate of 727.5 per million (95% CI: 680.8 to 774.2, p<0.05). Most tumours were benign (953, 98%). Of the benign lesions, melanocytic lesions were the majority (942, 97%), with adjusted incidence rates of 646.9 (95% CI: 602.8 to 691.1) for choroidal nevus and 55.8 (95% CI: 43.2 to 64.8) for iris nevus. Malignant lesions were rare (16, 2%) with 13 cases of choroidal melanoma and 1 case each of iris melanoma, retinal leukaemic infiltration and metastasis. The adjusted incidence rate for choroidal melanoma was 7.1 (95% CI: 2.5 to 11.8). CONCLUSION: In a population-based setting, most intraocular tumours are benign and melanocytic. Although malignant lesions are less common, it is important to remain vigilant with appropriate monitoring given the potential for vision loss and life-threatening malignancy.

Choroidal Nevus Features Associated with Subspecialty Referral.

OBJECTIVE: To identify choroidal nevus features associated with referral to a retina or ocular oncology subspecialist. DESIGN: Population-based retrospective cohort study. SUBJECTS: Patients diagnosed with choroidal nevus. METHODS: Population-based retrospective cohort study of residents of Olmsted County, Minnesota, with an incident diagnosis of choroidal nevus from January 1, 2006, to December 31, 2015 using the Rochester Epidemiology Project, a medical record linkage system. Tumor features and patient demographics associated with referral to a retina or ocular oncology subspecialist were assessed. Wilcoxon rank sum test, chi-square test, and Fisher exact test were used for statistical analysis. MAIN OUTCOME MEASURES: Tumor features and patient demographics associated with referral to subspecialty care. RESULTS: There were 826 incident diagnoses of choroidal nevus, of which 88 cases (11%) were referred, with highest level of referral being retina in 29 cases (33%) and ocular oncology in 59 cases (67%). None of the analyzed demographic features were associated with choroidal nevus referral to subspecialty care. Tumor features associated with referral (vs. not referred) included greater mean basal diameter (4.6 mm vs. 2.4 mm, P < 0.001), greater mean tumor thickness (0.7 mm vs. 0.1 mm, P < 0.001), greater distance to optic disc (6.9 mm vs. 3.4 mm, P = 0.02), halo around nevus (5.7% vs. 0.4%, P < 0.001), and drusen on OCT (51% vs. 25%, P = 0.002). Presence of orange pigment (8% vs. 0%, P = 0.14), subretinal fluid (9% vs. 2.5%, P = 0.09), and low internal reflectivity on A-scan (7.7% vs. 0%, P = 1.00) were not found more frequently in the subspecialty referral group. CONCLUSIONS: Greater basal diameter and mean tumor thickness of choroidal nevus were associated with referral to retina or ocular oncology. However, several features associated with increased risk of malignant transformation were not associated with subspecialty referral. These findings highlight the importance of educating eye care providers about high-risk tumor features associated with choroidal nevus transformation to melanoma. In the primary eye care setting where not all multimodal imaging may be available, we encourage color photography and OCT with referral for any features of basal diameter > 5 mm, presence of subretinal fluid, or thickness too large for capture by enhanced-depth imaging OCT. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Incidence and distribution of ocular disorders in the first year of life.

PURPOSE: To describe the incidence and distribution of eye diseases affecting children in the first year of life in Olmsted County, Minnesota. METHODS: We conducted a population-based, retrospective medical record review of infants (≤1 year of age) residing in Olmsted County diagnosed with an ocular disorder from January 1, 2005, through December 31, 2014. RESULTS: A total of 4,223 infants were diagnosed with an ocular disorder, yielding an incidence of 20,242/100,000 births per year, or 1 in 4.9 live births (95% CI, 19,632-20,853). The median age at diagnosis was 3 months, and 2,179 (51.5%) were female. The most common diagnoses included conjunctivitis, in 2,175 (51.5%), nasolacrimal duct obstruction, in 1,432 (33.6%), and pseudostrabismus, in 173 (4.1%). Visual acuity was decreased in one or both eyes in 23 (0.5%) infants because of strabismus in 10 (43.5%) and cerebral visual impairment in 3 (13.0%). A majority of the infants (3,674 [86.9%]) were diagnosed and managed by a primary care provider, and 549 (13.0%) were evaluated and/or managed by an eye care provider. CONCLUSIONS: Although ocular disorders occurred in 1 in 5 infants in this cohort, most conditions were evaluated and managed by primary care providers. Understanding the incidence and distribution of ocular diseases among infants is useful for planning clinical resources.

Cancer Risk in Patients With Fuchs Endothelial Corneal Dystrophy.

PURPOSE: The purpose of this study is to quantify cancer risk in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: Using the 2014 to 2016 Medicare Limited 5% Data Sets-Carrier Line File, US Medicare fee-for-service beneficiaries (aged 65 years or older) with FECD and cancer were identified through International Classification of Diseases , ninth and 10th Revision diagnostic codes from January 1, 2014, to December 31, 2016. The main outcome measures were odds ratios (ORs) of cancer at various anatomic locations in patients with versus without FECD. RESULTS: Of the 1,462,740 Medicare beneficiaries, 15,534 patients (1.1%) had an International Classification of Disease code for FECD. Compared with US Medicare beneficiaries without FECD, patients with FECD were at increased risk for the following malignancies: breast [OR: 1.32; 95% confidence interval (CI): 1.22-1.43; P < 0.001], cutaneous basal cell (OR: 1.42; 95% CI: 1.35-1.49; P < 0.001), cutaneous melanoma (OR: 1.20; 95% CI: 1.03-1.40; P = 0.02), cutaneous squamous cell (OR: 1.45; 95% CI: 1.38-1.53; P < 0.001), ovarian (OR: 1.84; 95% CI: 1.48-2.30; P < 0.001), and thyroid (OR: 1.32; 95% CI: 1.04-1.68; P = 0.02). By contrast, FECD cases were at lower odds of having lung (OR: 0.81; 95% CI: 0.71-0.93; P = 0.003) and prostate cancer diagnoses (OR: 0.88; 95% CI: 0.81-0.96; P = 0.002). CONCLUSIONS: Patients with FECD aged 65 years or older may be at increased risk for cancer at several anatomic locations. Follow-up studies are needed to further explore the association of FECD and malignancy, elucidate potential disease mechanisms, and identify genetic and/or environmental risk factors.

Epidemiology and Clinical Characteristics of Presumed Ocular Histoplasmosis in Olmsted County, Minnesota.

PURPOSE: To describe the incidence, prevalence, and clinical characteristics of presumed ocular histoplasmosis syndrome (POHS) in a Histoplasma endemic region. METHODS: The International Classification of Diseases, 9th and 10th Revision codes were used to search the Rochester Epidemiology Project, a record-linkage system for medical care provided in Olmsted County, MN. Medical records were reviewed to confirm POHS diagnoses in county residents from January 1, 2006, to December 31, 2015. Age- and sex-adjusted incidence rates were calculated and adjusted to the 2010 U.S. White population. RESULTS: There were 18 incident cases (30 eyes) and 87 prevalent cases (131 eyes). The incidence rate was 1.35 per 100,000 per year. The mid-study prevalence rate was 0.064%. Choroidal neovascularization (CNV) occurred in 17.4% of the affected eyes. At the last follow-up, 16.8% of the affected eyes had POHS-related decreased visual acuity (<20/40). CONCLUSION: This study assesses the epidemiology and clinical features of POHS in a Midwestern U.S. county. ABBREVIATIONS/ACRONYMS: POHS = Presumed ocular histoplasmosis syndrome; ICD = International Classification of Diseases; CI = Confidence interval; VA = Visual acuity; Anti-VEGF = Anti-vascular endothelial growth factor; REP = Rochester Epidemiology Project, CNV = Choroidal neovascularization.

Incidence and Clinical Characteristics of Infantile Conjunctivitis in a Western Population.

OBJECTIVE: To describe the incidence and clinical characteristics of conjunctivitis in the first year of life. DESIGN: Population-based cohort study. PARTICIPANTS: All infant (≤12 months of age) residents of Olmsted County, Minnesota, diagnosed with conjunctivitis from January 1, 2005, through December 31, 2014. METHODS: The medical records of all potential cases identified by the Rochester Epidemiology Project database were reviewed. MAIN OUTCOME MEASURES: Incidence rate and clinical features of infantile conjunctivitis. RESULTS: A total of 2175 infants were diagnosed during the 10-year period, yielding an incidence of 10,422 per 100,000 children or approximately 1 in 10 infants by 1 year of age. The mean age at diagnosis was 4.9 months (range, 1 day-12 months), and 1001 (46.0%) were female. Both eyes were involved in 1180 (54.3%), the right eye alone in 506 (23.3%), and 489 (22.5%) in the left. Five hundred seventy-six (26.5%) of the 2175 were diagnosed at ≤30 days of life, from which topical cultures were obtained in 111 (19.7%). Only 36 (32.4%) of the cultures showed bacterial agents, with Chlamydia present in 3. Treatment for infantile conjunctivitis, where recorded, included topical antibiotics in 523 (90.8%) and simple observation in 47 (8.2%). CONCLUSIONS: Conjunctivitis in the first year of life occurred in approximately 10% of infants in this population-based cohort. More than half involved both eyes, one-quarter were identified in the first 30 days of life, and sight-threatening infectious agents were rare.

Accuracy of the International Classification of Diseases, 9th Revision for Identifying Infantile Eye Disease.

PURPOSE: To determine the predictive value of International Classification of Diseases, 9th Revision (ICD-9) codes for identifying infantile eye diagnoses. METHODS: Population-based retrospective cohort study of all residents of Olmsted County, Minnesota diagnosed at ≤1 year of age with an ocular disorder. The medical records of all infants diagnosed with any ocular disorder from January 1, 2005, through December 31, 2014, were identified. To assess ICD-9 code accuracy, the medical records of all diagnoses with ≥20 cases were individually reviewed and compared to their corresponding ICD-9 codes. Main outcome measures included positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of ICD-9 codes. RESULTS: In a cohort of 5,109 infants with ≥1 eye-related ICD-9 code, 10 ocular diagnoses met study criteria. The most frequent diagnoses were conjunctivitis (N = 1,695) and congenital nasolacrimal duct obstruction (N = 1,250), while the least common was physiologic anisocoria (N = 23). The PPVs ranged from 8.3% to 88.0%, NPVs from 96.3% to 100%, sensitivity from 3.0% to 98.7%, and specificity from 72.6% to 99.9%. ICD-9 codes were most accurate at identifying physiologic anisocoria (PPV: 88.0%) and least accurate at identifying preseptal cellulitis (PPV: 8.3%). In eye specialists versus non-eye specialists, there was a significant difference in PPV of ICD-9 codes for conjunctivitis (26.8% vs. 63.9%, p < .001), pseudostrabismus (85.9% vs. 25.0%, p < .001), and physiologic anisocoria (95.5% vs. 33.3%, p = .002). CONCLUSION: The predictive value of ICD-9 codes for capturing infantile ocular diagnoses varied widely in this cohort. These findings emphasize the limitations of database research methodologies that solely utilize claims data to identify pediatric eye diseases.Abbreviations/Acronyms PPV: positive predictive value; NPV: negative predictive value; CNLDO: congenital nasolacrimal duct obstruction.

Carbon Fiducial Markers for Tumor Localization in Stereotactic Irradiation of Uveal Melanoma.

PURPOSE: The aim of this study was to demonstrate the role of carbon fiducial markers (fiducials) for guiding radiotherapy in the management of uveal melanoma (UM). METHODS: This is a retrospective interventional case series at a single-center ocular oncology practice. The medical records were reviewed retrospectively for all patients with UM treated with stereotactic radiosurgery using episcleral fiducials. We report our short-term experience with surgical placement of fiducials, UM localization, treatment outcomes, and optimization approaches. RESULTS: We evaluated 11 cases of UM (mean age: 65 years; 64% female). The placed fiducials were numbered from 2 to 4, each secured to the sclera with a surgical microscope or surgical loupes and either 5-0 or 8-0 nylon sutures at 50% scleral depth and 3 mm beyond the tumor margin. Over a median follow-up of 11 months (range: 4.2-43.2 months), no recurrences of intraocular UM were observed. One case of enucleation after stereotactic radiosurgery developed because of radiation-related surface irritation, ocular dryness, and secondary keratopathy. Two patients (18%) with 5-0 nylon sutures required fiducial removal because of suture exposure, successfully accomplished in an outpatient setting. CONCLUSIONS: Fiducials represent a viable alternative to tantalum rings for guiding stereotactic radiotherapy to manage UM and provide additional definition of the tumor border with linear orientation that helps optimize targeted radiation delivery. Fiducial placement with a 3-mm margin from the visible tumor border should not result in clinically important radiation dose attenuation at the tumor margins. Anteriorly placed fiducials may cause discomfort, yet they are easily removed in the outpatient setting.

Clinical outcomes of Modified Collaborative Ocular Melanoma Study IRIS plaques for treatment of iris, iridociliary, and ciliary body melanoma.

BACKGROUND/OBJECTIVES: To report clinical outcomes of modified Collaborative Ocular Melanoma Study IRIS (COMS IRIS) plaques for treatment of iris, iridociliary, and ciliary body melanoma. SUBJECTS/METHODS: Retrospective, single-centre cohort study of iris melanoma treated with COMS IRIS plaque radiotherapy from July 26, 2010 to October 15, 2018. Medical records were reviewed for demographics, tumour features, treatment parameters, and clinical outcomes. RESULTS: There were 22 cases, diagnosed at mean age of 59 years (median 65, range 21-85 years) with female sex in 14 (64%). Presenting tumour features included Snellen visual acuity (VA) ≥ 20/40 in 18 (82%) cases, mean largest tumour basal diameter 4.7 mm (median 3.9, range 2.3-13.8 mm) and thickness 1.7 mm (median 1.6 mm, range 0.8-3.9 mm), iris stromal seeding in 3 (14%) cases, angle seeding in 16 (73%), and ciliary body involvement in 13 (59%). After mean follow-up of 51 months (median 44, range 4-113 months), Snellen VA was ≥20/40 in 14 (64%) cases, with local tumour recurrence in 2 (9%), and enucleation in 2 (9%). The 3-year Kaplan-Meier estimated risk of local tumour recurrence was 7%. The most common radiation side effects were cataract in 17 (77%) patients and dry eye in 5 (23%). Systemic metastasis occurred in no cases, and 1 (5%) non-melanoma-related death due to natural causes was observed at last follow-up. CONCLUSIONS: COMS IRIS plaques are effective for treatment of iris, iridociliary, and ciliary body melanoma with modest VA outcomes and low frequency of local tumour recurrence, enucleation, radiation side effects, and systemic metastasis.

Relationship of Body Mass Index With Fuchs Endothelial Corneal Dystrophy Severity and TCF4 CTG18.1 Trinucleotide Repeat Expansion.

PURPOSE: To investigate the association of body mass index (BMI) with Fuchs endothelial corneal dystrophy (FECD) severity and TCF4 CTG18.1 expansion. METHODS: A total of 343 patients with FECD were enrolled from the Mayo Clinic. FECD severity was graded by slit-lamp biomicroscopy. BMI values were obtained from the electronic medical records. DNA extracted from leukocytes was analyzed for CTG18.1 expansion length, with ≥40 repeats considered expanded. Wilcoxon signed-rank tests were used to compare FECD grade and CTG18.1 expansion length in patients by BMI (<25, ≥25 to <30, and ≥30 kg/m2). FECD grade was regressed on age, sex, BMI, and CTG18.1 expansion and, separately, BMI on CTG18.1 expansion. Models were investigated for effect modification by age and sex with an interaction term of P < 0.05 considered statistically significant. RESULTS: When examining the association between BMI and FECD, there was a significant interaction between BMI and sex (P for interaction = 0.004). When controlling for age and CTG18.1 expansion, a positive association was observed between BMI and FECD grade in women, but not in men. In addition, BMI was not associated with CTG18.1 expansion when controlling for age and sex. CONCLUSIONS: BMI was positively associated with FECD severity among women but not men. There was no significant association between BMI and CTG18.1 expansion. These findings suggest that increased BMI is potentially a modifiable risk factor for FECD disease progression among women.

Disease Expression and Familial Transmission of Fuchs Endothelial Corneal Dystrophy With and Without CTG18.1 Expansion.

Purpose: To characterize inheritance, penetrance, and trinucleotide repeat expansion stability in Fuchs endothelial corneal dystrophy (FECD). Methods: One thousand unrelated and related subjects with and without FECD were prospectively recruited. CTG18.1 repeat length (CTG18.1L) was determined via short tandem repeat assay and Southern blotting of leukocyte DNA. Multivariable logistic regression and generalized estimating equation models were employed. Results: There were 546 unrelated FECD cases (67.6% female; 70 ± 10 years) and 235 controls (63.8% female; 73 ± 8 years; all ≥ 50 years). CTG18.1 expansion (CTG18.1exp+) was observed in 424 (77.7%) cases and 18 (7.7%) controls (P = 2.48 × 10-44). CTG18.1 expansion was associated with FECD severity (P = 5.62 × 10-7). The family arm of the study included 331 members from 112 FECD-affected families; 87 families were CTG18.1exp+. Autosomal dominant inheritance with variable expression of FECD was observed, regardless of expansion status. FECD penetrance of CTG18.1 expansion increased with age, ranging from 44.4% in the youngest (19-46 years) to 86.2% in the oldest (64-91 years) age quartiles. Among 62 parent-offspring transmissions of CTG18.1exp+, 48 (77.4%) had a change in CTG18.1L ≤ 10 repeats, and eight (12.9%) were ≥50 repeats, including five large expansions (∼1000-2000 repeats) that contracted. Among 44 offspring who did not inherit the CTG18.1exp+ allele, eight (18.2%) exhibited FECD. Conclusions: CTG18.1 expansion was highly associated with FECD but demonstrated incomplete penetrance. CTG18.1L instability occurred in a minority of parent-offspring transmissions, with large expansions exhibiting contraction. The observation of FECD without CTG18.1 expansion among family members in CTG18.1exp+ families highlights the complexity of the relationship between the FECD phenotype and CTG18.1 expansion.