Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): optometric exam improves access and utilization of eye care services.

PURPOSE: To describe the benefits of optometric evaluation for detection of vision-affecting conditions in the context of community-based eye health screenings and identify factors associated with having a recent dilated eye exam. METHODS: Enrolled participants were age 40 and older, living independently in affordable housing developments in New York City. Eye health screening failure and criteria for seeing the on-site study optometrist were defined as visual acuity 20/40 or worse in either eye, intraocular pressure 23-29 mmHg, or an unreadable fundus image. The optometrist conducted a manifest refraction using loose lenses and used a portable slit lamp and ophthalmoscope to perform a non-dilated anterior and posterior segment ocular health evaluation. Demographics, social determinants of health, eye health screening results, and rates of suspected ophthalmic conditions were recorded. To determine factors associated with having a recent dilated eye exam, which was the main outcome for this statistical analysis, a stepwise multivariate logistic regression was performed. RESULTS: A total of 708 participants were screened, 308 attended the optometric exam; mean age 70.7 ± 11.7 [standard deviation (SD)] years. Among this subgroup, 70.1% identified as female, 54.9% self-identified as African American, 39% as Hispanic/Latino, and 26.6% Dominican ethnicity; 78.2% (241/308) had not undergone a dilated eye exam within the last year, 71.4% reported they did not have an eye care provider. Stepwise multivariate logistic regression analysis indicated that participants who self-reported having cataracts (odds ratio (OR) 2.15; 95% confidence interval (CI) 1.03-4.47; p = 0.041), self-reported having glaucoma/glaucoma suspect (OR 5.60; 95% CI 2.02-15.43; p = 0.001), or spoke Spanish as their primary language (OR 3.25; 95% CI 1.48-7.11; p = 0.003) had higher odds of having a recent dilated eye exam. CONCLUSIONS: This community-based screening initiative demonstrated the effectiveness of optometric exams in detecting vision-affecting conditions and identified factors associated with having a recent dilated eye exam. Optometrists play a vital role in increasing access to eye care for high-risk, underserved populations. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04271709).

Orbital marginal cell lymphoma and mantle cell lymphoma subclone in patient with monoclonal gammopathy of unknown significance.

Indolent lymphomas have the potential to transform into more aggressive phenotypes. This phenomenon is best exemplified by the transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma into diffuse large B-cell lymphoma. However, it is less common to find multiple small cell lymphomas in the orbit, particularly mantle cell lymphoma. We present a case of an extranodal marginal zone lymphoma arising in the orbit that acquired a subclonal t(11;14) (q13;32) CCND1-IGH translocation, giving rise to a subclone of mantle cell lymphoma. The management of this tumor was targeted towards the more aggressive mantle cell subclone. The tumor exhibited an incomplete response to rituximab alone. To the best of the authors' knowledge, this represents the first such case to be described irrespective of site of origin.

Cutaneous T-cell lymphoma of the eyelid masquerading as dermatitis.

Cutaneous T-cell lymphoma (CTCL) may pose a diagnostic challenge for physicians, as clinical presentation and histologic analysis may mimic benign dermatologic conditions. The authors present a case of recurrent CTCL in which the recurrence was limited to the eyelid and misdiagnosed as a contact dermatitis. To the best of the authors' knowledge, this is the first reported case of recurrent CTCL that has presented solely as dermatitis of the eyelid.

Comparing preoperative imaging modalities in patient selection for breast intraoperative radiotherapy.

BACKGROUND: This study evaluated the relative accuracy of mammography, ultrasound, and magnetic resonance imaging (MRI) in predicting the tumor size of early stage breast tumors in preoperative selection of patients for intraoperative radiotherapy (IORT). METHODS: We identified 156 patients with clinical T1/T2, N0 breast cancer who underwent IORT. Clinical, pathologic, and radiation data were collected. The preoperative tumor size obtained by imaging was compared with tumor pathological size. RESULTS: The median patient age was 66. The mean tumor size at excision was 1.05 cm (0.1-3.0 cm). Out of the 156 patients, 98 had a reported, nonzero tumor size by mammography, 131 by ultrasound, and 76 by MRI. The mean difference between imaging and the tumor size was +0.062 ± 0.54 cm for mammography, -0.11 ± 0.43 cm for ultrasound, and +0.33 ± 0.55 cm for MRI, with positive values indicating an overestimate of the tumor size. MRI produced more overestimates of tumor size of at least 0.5 cm than mammography or ultrasound in a paired analysis of patients who received both modalities. CONCLUSIONS: Accuracy of imaging modalities in determining tumor size can influence patients' eligibility for IORT. Mammography and ultrasound showed acceptable accuracy in predicting size. MRI overestimated tumor size and may inappropriately exclude patients from IORT. We would discourage ruling out candidates for IORT on the basis of large size by MRI alone.

Detecting Established Glaucoma Using OCT Alone: Utilizing an OCT Reading Center in a Real-World Clinical Setting.

Purpose: We evaluated the ability of an optical coherence tomography (OCT)-based reading center for glaucoma (ORG) to detect established glaucoma using OCT alone. Methods: This study included eyes from 70 consecutive patients with established glaucoma (i.e. moderate or severe glaucoma according to the International Classification of Diseases [ICD]-10 guidelines) and 20 consecutive healthy subjects, who had no evidence of glaucomatous optic neuropathy (GON) or visual field (VF) loss in either eye. Using a standardized ORG quality assessment, 33 eyes were excluded due to media opacity (12), poor image quality (13), or epiretinal membrane (8). Of the remaining 147 eyes, 86 had established glaucoma and 36 were from healthy controls (total n = 122). Based on the OCT report alone and applying a previously described evaluation method, the presence of GON in each eye was determined by two masked ORG graders. The main outcome measures were sensitivity and specificity for detection of eyes with established glaucoma. Results: Of the 86 eyes with established glaucoma (average mean deviation [MD] = -10.9 ± 7.7 dB, range = -0.5 to -31.5 dB), only one eye (MD = -0.46) was missed (sensitivity = 98.8%). However, the other eye of this patient was correctly classified as GON. Therefore, at a patient level, sensitivity was 100%. None of the 36 healthy eyes was classified as GON by the ORG (specificity = 100%). Conclusions: An OCT-based reading center is able to identify eyes with established glaucoma using OCT alone with high sensitivity and specificity. Translational Relevance: Our study validates the use of a systematic OCT-based approach for glaucoma detection in a real-world setting.

Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): Subanalysis of Referral to Ophthalmology.

PURPOSE: The Manhattan Vision Screening and Follow-up Study aims to provide access to eye care for underserved populations, detect native rates of ocular pathology, and refer participants with eye disease to ophthalmology. This subanalysis describes the reasons for referral to ophthalmology and identifies risk factors associated with being referred. METHODS: Enrolled participants were aged ≥40 years, living independently in public housing developments and able to provide consent for eye health screenings. Those with habitual visual acuity 20/40 or worse, intraocular pressure (IOP) 23-29 mmHg, or an unreadable fundus image failed and were scheduled with the on-site optometrist. The optometric exam determined whether further referral to ophthalmology for a clinic exam was warranted. Those with an abnormal image or IOP ≥30 mmHg were referred directly to ophthalmology. Main outcome was factors associated with referral to ophthalmology. RESULTS: A total of 708 individuals completed the eye health screening over 15 months. A total of 468 participants were referred to ophthalmology (250 had an abnormal image and 218 were referred by the optometrist). Those referred were predominantly older adults (mean age 70.0 ± 11.4 years), female (66.7%), African American (55.1%) and Hispanic (39.5%). Seventy percent of participants had not had a recent eye exam. Stepwise multivariate logistic regression analysis showed that participants with pre-existing glaucoma (OR 3.14, 95% CI 1.62 to 6.08, p = 0.001), an IOP ≥23 mmHg (OR 5.04, 95% 1.91 to 13.28, p = 0.001), or vision impairment (mild) (OR 2.51, 95% CI 1.68 to 3.77, p = 0.001) had significantly higher odds of being referred to ophthalmology. CONCLUSION: This targeted community-based study in Upper Manhattan provided access to eye care and detected a significant amount of ocular pathology requiring referral to ophthalmology in this high-risk population.

Clinical Evaluation of Patients with Retinitis Pigmentosa.

This chapter describes the clinical evaluation process of patients with retinitis pigmentosa (RP). The clinical evaluation consists of a complete history and ophthalmic examination. Here, we outline the aspects of the history and ophthalmic exam that are most important for the evaluation of RP patients. In addition, the expected findings of RP patients and the etiology of these findings are discussed.

Measure of Visual Function.

This chapter describes various methods of the assessment of visual function used for assessing disease progression and treatment response in patients with retinitis pigmentosa (RP). These methods include full-field stimulus testing (FST), near-infrared autofluorescence (NIR-AF), quantitative fundus autofluorescence (qAF), and quantitative near-infrared autofluorescence (qNIR-AF). This chapter will also outline the protocol for adaptive optics (AO) imaging of RP patients and cover how each of these methods is used for RP patients, with details including the expected findings, as evidenced by recent literature.

Remote Contrast Sensitivity Testing Seems to Correlate With the Degree of Glaucomatous Macular Damage.

PRCIS: Remote contrast sensitivity (CS) testing through a free downloadable home test correlates with glaucomatous macular damage measured by 10-2 visual field (VF) testing. PURPOSE: To assess the feasibility and validity of home CS monitoring as a measure of glaucomatous damage using a free downloadable smartphone application. METHODS: Twenty-six participants were asked to remotely use the Berkeley Contrast Squares (BCS) application, a free downloadable tool that records the user's CS for varying degrees of visual acuity. An instructional video detailing how to download and use the application was sent to the participants. Subjects were asked to send logarithmic CS results with a minimum 8-week test-retest window, and test-retest reliability was measured. Results were validated against office-based CS testing that was collected within the previous 6 months. Validity analysis was also carried out to determine whether CS as measured by BCS is a good predictor of 10-2 and 24-2 VF mean deviation (MD). RESULTS: There was a high BCS test-retest reliability with an intraclass correlation coefficient score of 0.91 and a significant correlation between repeat test results and baseline test scores (Pearson, 0.86, P < 0.0001). There was significant agreement between unilateral CS scores as measured by BCS and office-based CS testing ( b = 0.94, P < 0.0001, 95% CI: 0.61 to 1.27). Unilateral CS as measured by BCS was significantly associated with 10-2 VF MD ( r2 = 0.27, P = 0.006, 95% CI: 3.7 to 20.6), but not with 24-2 VF MD ( P = 0.151). CONCLUSION: This study suggests that a free, rapid home CS test correlates with glaucomatous macular damage as measured by 10-2 VF.

Association of Patterns of Glaucomatous Macular Damage With Contrast Sensitivity and Facial Recognition in Patients With Glaucoma.

Importance: Facial recognition is a critical activity of daily living that relies on macular function. Glaucomatous macular damage may result in impaired facial recognition that may negatively affect patient quality of life. Objective: To evaluate the association of patterns of glaucomatous macular damage with contrast sensitivity and facial recognition among patients with glaucoma. Design, Setting, and Participants: In this prospective cohort study at a single tertiary care center, 144 eyes of 72 consecutive patients with glaucoma with good visual acuity (20/40 or better in each eye) were studied. Data were collected from March to April 2019. Exposures: Eyes with macular damage were categorized as having focal, diffuse, or mixed (focal and diffuse) damage based on optic disc and macular spectral-domain optical coherence tomography and 10-2 visual field (VF) damage. Only eyes with focal or diffuse damage were included. Higher-acuity and lower-acuity eyes were determined by 10-2 VF mean deviation (MD). Facial disability was defined as facial recognition scores at the 2% level of normal participants. Main Outcomes and Measures: (1) Monocular contrast threshold as measured by the Freiburg Visual Acuity and Contrast Test and (2) binocular facial recognition as measured by the Cambridge Face Memory Test. Results: Of the 72 included patients, 49 (68%) were White and 41 (57%) were female, and the mean (SD) age was 67.0 (11.6) years. Eyes with diffuse damage had greater contrast impairment compared with eyes with focal damage (ß = -0.5; 95% CI, -0.6 to -0.4; P < .001) after adjusting for 10-2 VF MD, 24-2 VF MD, age, presence of an early cataract, and number of drops. Similarly, Cambridge Face Memory Test scores were significantly lower in patients with diffuse rather than focal macular damage, regardless of eye (better-seeing eye: ß = 10.0; 95% CI, 2.0 to 18.2; P = .001; worse-seeing eye: ß = 5.5; 95% CI, 0.8 to 10.0; P = .23). Relative risk of facial disability was greater for patients with diffuse but not focal macular damage in the better-seeing eye (relative risk, 86.2; 95% CI, 2.7 to 2783.3; P = .01). Conclusions and Relevance: In this cohort study, diffuse rather than focal glaucomatous macular damage was associated with diminished facial recognition and contrast sensitivity. Evaluation of macular optical coherence tomography and 10-2 VF and resultant detection of diffuse macular damage may help minimize glaucoma-related visual disability.

Macular Damage in Glaucoma is Associated With Deficits in Facial Recognition.

PURPOSE: This report examines the relationship between glaucomatous macular damage and facial recognition. In addition, it assesses the role of contrast sensitivity (CS) as an intermediary step in the causal pathway between macular damage and impairment of facial recognition. DESIGN: Prospective cross-sectional study. METHODS: This study was conducted in a single tertiary care center. The study population included 144 eyes of 72 participants with a diagnosis of open angle glaucoma in one or both eyes and a visual acuity of 20/40 or better in each eye. The presence or absence of macular damage was determined by comparing corresponding regions of the retinal nerve fiber layer and the retinal ganglion cell layer with spectral-domain optical coherence tomography with the 10-2 visual field (VF). Better and worse eye was determined by 10-2 VF mean deviations (MDs). Interventions were 1) macular function as measured by 10-2 VF and 2) CS as measured by the Freiburg Visual Acuity and Contrast Test (FrACT). The primary outcome measure was the Cambridge Face Memory Test (CFMT) score. RESULTS: Regardless of eye, there was a significant correlation between facial recognition and 10-2 VF MD (P < .0001 better, worse eye). The 10-2 VF MD remained a significant predictor of facial recognition after adjusting for potential confounders including glaucoma severity, CS, age, and visual acuity (P = .004 better eye, P = .019 worse eye). CONCLUSIONS: Even with good central visual acuity, patients with glaucomatous macular damage exhibit diminished facial recognition, which is partly mediated through diminished CS.

Diffuse Macular Damage in Mild to Moderate Glaucoma Is Associated With Decreased Visual Function Scores Under Low Luminance Conditions.

PURPOSE: Glaucoma patients commonly report increasing visual problems under low luminance or glare conditions, yet there is limited understanding of the structural basis of visual functional losses. This report examines the relationship between glaucomatous macular damage, assessed using structure-function correlation, and visual difficulty under low luminance conditions, as measured by Low Luminance Questionnaire (LLQ). DESIGN: Observational cohort study. METHODS: Setting: Tertiary care referral center. PARTICIPANTS: A total of 252 eyes of 126 participants with mild or moderate open-angle glaucoma (24-2 mean deviation [MD] better than -12 dB) selected from a consecutive sample. PREDICTOR: Focal and diffuse macular defects were identified based on corresponding abnormal regions on probability maps from spectral-domain optical coherence tomography (SDOCT) optic disc and macular cube scans, and 10-2 and 24-2 visual fields (VF). MAIN OUTCOME MEASURE: LLQ scores. RESULTS: Eighty-two of the 126 (65%) better eyes (defined by 24-2 VF MD) had evidence of macular damage, while the remaining 44 did not have macular damage. Of the 82 with damage, 33 (40%) had diffuse damage and 49 (60%) had focal damage. After adjusting for 24-2 MD and age in the multivariable regression, diffuse macular damage remained a significant predictor of the LLQ subscales "difficulty with extreme lighting" (P = .0024), ''difficulty with low lighting" (P = .037), and "diminished mobility"; (P = .042). In contrast, there was no significant difference in LLQ scores in any subscale between participants with focal macular damage and those without macular damage. CONCLUSION: Mild diffuse glaucomatous macular damage, as detected by abnormal topographic regions on measures of structure and function, is associated with decreased LLQ scores.

A Single-Institution Experience in the Preoperative Selection of DCIS Patients for IORT using the ASTRO Consensus Guidelines.

PURPOSE: Intraoperative radiation therapy (IORT) as a form of accelerated partial breast irradiation (APBI) is controversial given the limited evidence to support its efficacy. However, it remains an attractive option for low-risk patients with ductal carcinoma in situ (DCIS), who derive a small absolute benefit in local control with standard whole breast irradiation (WBI). We examine how the American Society for Therapeutic Radiation Oncology (ASTRO) APBI consensus guidelines (CG) may be applied to the preoperative selection of patients with DCIS for IORT and determine treatment outcomes by CG group. METHODS AND MATERIALS: We identified patients with biopsy-proven pure DCIS enrolled in an institutional prospective registry IORT database using the Zeiss Intrabeam® device between September 2013 and February 2017. Based on available preoperative clinicopathologic information, patients were deemed suitable, cautionary, or unsuitable for IORT according to the ASTRO CG. Change in CG group based on final pathologic diagnosis was determined, and additional therapy was recommended for unsuitable patients. Outcome in terms of ipsilateral breast tumor recurrence was determined. RESULTS: A total of 61 DCIS lesions in 60 patients were treated with IORT. Preoperatively, 21 patients (35%) were suitable and 36 (59%) were cautionary. Four (6%) were unsuitable because of lesion size but declined WBI. Final pathologic diagnosis changed the CG grouping of 10 patients (16%) because of either occult high-grade disease in 2 (3%) or close/positive margins in 8 (13%). Ultimately 12 patients total were considered unsuitable, of whom 8 (66%) accepted additional WBI after IORT. At a median follow-up of 2.2 years, ipsilateral breast tumor recurrence was identified among 2 suitable, 1 cautionary, and no unsuitable patients. CONCLUSION: Further investigation is necessary to refine selection of patients with DCIS who may be optimally treated with IORT alone. High acceptance of additional therapy among unsuitable patients resulted in excellent outcomes. The use of biomarkers in addition to traditional clinical and pathologic factors may help to better select patients for IORT.