Parental Stress in a Pediatric Ophthalmology Population.

To determine the rate of parental stress within a pediatric ophthalmology population, parents in an urban or suburban community pediatric ophthalmology clinic were administered the Parental Stress Index Short Form survey. Demographic information and parental depression or anxiety data were collected and analyzed using an independent sample t-test and chi-squared analysis. Stress measures were recorded as percentiles. One hundred and twenty-one surveys revealed the following mean percentiles: Total Stress, 45.9 ± 22.4; Parental Distress (PD), 49.7 ± 19.8; and Parent Child Dysfunctional Interaction (P-CDI), 45.1 ± 23.6. The PD percentiles of the non-married parents, those with positive parental depression or anxiety scores, and those with a high school diploma or less were 55.9 ± 18.5 versus 45.2 ± 19.6, p < 0.01; 55.2 ± 18.6 versus 46.7 ± 19.9, p < 0.05; and 56.8 ± 18.2 versus 47.0 ± 19.8, p < 0.01, respectively. The parents with a high school diploma or less in a suburban environment demonstrated higher PD/P-CDI scores versus those of an urban population. Those with median household incomes (MHI) below USD 60,000 in both the total and suburban populations showed higher PD scores. There is no significant difference in parental stress between the pediatric ophthalmology patients and the general population. The parents who are unmarried, depressed, have a high school degree or less, or an MHI below USD 60,000 experience significantly higher stress levels.

Predictors of intraocular pressure reduction after femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: a prospective trial.

PURPOSE: To evaluate the association between postoperative intraocular pressure (IOP) reduction and phacoemulsification parameters in patients who underwent both conventional phacoemulsification surgery (CPS) and femtosecond laser-assisted cataract surgery (FLACS). METHODS: This was a prospective multicenter comparative study that enrolled 90 participants who underwent cataract surgery at the University of Maryland Medical System and the Wilmer Eye Institute. Patients underwent FLACS in one eye and CPS in the fellow eye. IOP was measured prior to surgery and monitored through six months postoperatively. Demographic, clinical, biometric, and intraoperative variables including cumulative dissipated energy (CDE), aspiration time, and phacoemulsification time were analyzed for any significant association with postoperative IOP. Postoperative IOP reduction was the primary outcome variable. A secondary goal of the study was to determine differences in postoperative IOP reduction between CPS and FLACS cohorts. RESULTS: In total, 157 non-glaucomatous eyes were included. Using multivariable analysis, we found preoperative IOP to be consistently associated with postoperative IOP reduction in the entire cohort. At the 6-month follow-up visit, there was a 12.4% reduction in IOP (-2.2 ± 3.4 mm Hg) seen, with no statistically significant difference between FLACS and CPS (12.3% ± 19.4% vs 12.5% ± 19.3%, respectively, p = 0.32). FLACS reduced the CDE required for phacoemulsification (6.6 ± 4.4%-seconds vs 8.6 ± 6.9%-seconds, respectively, p < 0.05). CDE was a predictor of IOP response at 6 months, but subgroup analysis revealed that this trend was driven by seven eyes requiring high CDE, and for the majority of eyes, CDE did not influence the size of the decrease. The seven eyes experiencing highest CDE were less likely to show IOP reduction at 6 months. CONCLUSION: Both FLACS and CPS resulted in similar and significant IOP reductions through 6 months after surgery. Preoperative IOP was significantly associated with IOP reduction, and CDE generally did not influence the size of the decrease.

The role of trabeculectomy in the era of minimally invasive glaucoma surgery.

PURPOSE OF REVIEW: This review discusses recent findings in surgical management of glaucoma, focusing on trabeculectomy and minimally invasive glaucoma surgery (MIGS). We discuss how the role these procedures play in conjunction with phacoemulsification. RECENT FINDINGS: New findings of the Primary Trab Vs Tube study and findings regarding the Hydrus, Xen 45, Kahook dual blade, Ab-interno Canaloplasty and head-to-head MIGS studies are summarized. SUMMARY: Patients with glaucoma greatly benefit from combining cataract surgery with a MIGS procedure that can be tailored to disease severity and medication use. Certain MIGS combined with phacoemulsification in severe and refractory glaucoma can potentially delay incisional glaucoma, although trabeculectomy- mitomycin C (MMC) still remains the best option in certain patient populations. We provide an update in the MIGS treatment paradigm based on newer, stronger evidence.

Postoperative complications of Ab-Interno XEN implantation in primary angle closure glaucoma.

The XEN Gel Stent offers a unique Ab-interno approach for managing glaucoma and has shown a favorable risk profile relative to traditional trabeculectomy. XEN implantation has almost exclusively been reported in patients with open angle glaucoma and data in patients with angle closure glaucoma is limited. We report a postoperative complication of the XEN Gel Stent in a patient with primary angle closure glaucoma. An 86-year-old man with primary angle closure glaucoma underwent combined phacoemulsification and XEN implantation. After approximately two months, intraocular pressure was elevated and the stent was occluded by iris pigmentary deposits, traversing from the proximal to the distal conjunctival ends of the stent. Using an Ab-interno approach, the implant was successfully explanted, and the patient's intraocular pressure was notably lowered.

Measurement of Retinal Microvascular Blood Velocity Using Erythrocyte Mediated Velocimetry.

Changes in retinal blood flow may be involved in the pathogenesis of glaucoma and other ocular diseases. Erythrocyte mediated velocimetry (EMV) is a novel technique where indocyanine green (ICG) dye is sequestered in erythrocyte ghosts and autologously re-injected to allow direct visualization of erythrocytes for in vivo measurement of speed. The purpose of this study is to determine the mean erythrocyte speed in the retinal microvasculature, as well as the intravisit and intervisit variability of EMV. Data from 23 EMV sessions from control, glaucoma suspect, and glaucoma patients were included in this study. In arteries with an average diameter of 43.11 µm ± 6.62 µm, the mean speed was 7.17 mm/s ± 2.35 mm/s. In veins with an average diameter of 45.87 µm ± 12.04 µm, the mean speed was 6.05 mm/s ± 1.96 mm/s. Intravisit variability, as measured by the mean coefficient of variation, was 3.57% (range 0.44-9.68%). Intervisit variability was 4.85% (range 0.15-8.43%). EMV may represent reliable method for determination of retinal blood speed, potentially allowing insights into the effects of pharmacologic agents or pathogenesis of ocular diseases.

Ocular dialysis disequilibrium-Management of intraocular pressure during hemodialysis of open angle glaucoma: A case report and review of the literature.

It has been shown that patients with end-stage renal disease (ESRD) have an increased risk for changes in intraocular pressure during hemodialysis, or ocular dialysis disequilibrium which can cause pain or discomfort during treatment and lead to decreased vision over time. This is a case of an elderly male with ESRD who was having headaches, nausea, and eye pain during hemodialysis due to increased intraocular pressures. Using a higher sodium prescription resolved his symptoms and normalized his intraocular pressures. This case illustrates that modification in dialysate tonicity can decrease changes in intraocular pressures while patients are on hemodialysis, a vision saving consideration for patients.

Anterior segment ultrasound biomicroscopy image analysis using ImageJ software: Intra-observer repeatability and inter-observer agreement.

PURPOSE: In this novel study, we demonstrate a standardized imaging and measurement protocol of anterior segment (AS) structures with reliability analysis using ultrasound biomicroscopy (UBM) and ImageJ software. METHODS: Ten pediatric and young adult patients undergoing examination under anesthesia for AS pathology were imaged using UBM. Four trained observers analyzed 20 images using ImageJ. Forty-five structural parameters were measured. Those that relied on the trabecular-iris angle (TIA) as a reference landmark were labeled TIA-dependent (TD) and all others were labeled non-TIA dependent (NTD). Intra-observer repeatability (IOR) and inter-observer agreement (IOA) of measurements were determined using coefficient of variation (CV) and intra-class correlation (ICC) followed by assessment of Bland-Altman plots (BAP) for each pair of observers, respectively. RESULTS: For NTD parameters, non-ciliary body (CB) related measurements showed CV range 0.60-16.22% and ICC range 0.84-0.89, whereas CB-related parameters showed CV range 2.86-23.40% and ICC range 0.29-0.92. For TD parameters, parameters < 2 degrees removed from reference showed CV range 0.02-5.40% and ICC range 0.89-1.00, whereas parameters > 1 degree removed showed CV range 0.63-27.44% and ICC range 0.22-1.00. No systematic proportional bias was detected by BAPs. CONCLUSIONS: Preplaced landmarks yielded good IOR and IOA in quantitative assessment of AS structures that were NTD and non-CB-related or less removed from the reference. CB-related NTD measurements varied greatly in IOR and IOA, indicating protocol modifications or CB qualitative assessments needed to improve accuracy. Variability in TD measurements increased the further removed from the reference, which supports implementation of a reliable reference landmark to minimize variation.

A Pilot Study on the Effects of Physician Gaze on Patient Satisfaction in the Setting of Electronic Health Records.

PURPOSE: To determine the amount of time ophthalmologists using Electronic Health Records (EHRs) spend looking at the patient and its correlation on patient satisfaction. METHODS: This prospective cohort study examined 67 patients seeking care at two different ophthalmology clinics. Videos of entire office visits were recorded and each video was graded for amount of time spent by physicians gazing at the patient, computer, paper medical records, or other areas. Videos were also graded for the amount of time examining the patient, and the physician speaking during each visit. A patient satisfaction survey was administered at the end of each office encounter. Time of physician gaze to the patient was correlated to satisfaction outcome measures. RESULTS: Ophthalmologists spent 28.0% ± 21.2% of the visit looking at the computer. Overall, patient satisfaction levels were very high (4.8 ± 0.5, 5-point Likert scale). Ophthalmologists spent the same amount of time looking at patients who were extremely satisfied (28.8% ± 16.7%) as those who were not extremely satisfied (28.8% ± 15.9%). CONCLUSIONS: Ophthalmologists on EHRs spend over a third of each patient visit looking at the computer. However, patient satisfaction levels are very high. The amount of time that the ophthalmologist gazes at the patient or the computer does not appear to have an effect on patient satisfaction in this particular study. Further research still needs to be performed regarding the effects of EHRs on the patient experience. Physicians should continue to be sensitive to their patients' needs and approach the use of EHRs in patient encounters on an individual basis.

Noninvasive Assessment of Retinal Blood Flow Using a Novel Handheld Laser Speckle Contrast Imager.

PURPOSE: We assessed the image quality and reproducibility of blood flow measurements from a novel handheld laser speckle imager in handheld and stabilized use cases. METHODS: Eleven dilated human subjects were imaged with the XyCAM Handheld Retinal Imager investigational device (XyCAM HRI) in the handheld and stabilized use case in nine consecutive imaging sessions. Subjects then underwent standard color fundus photography using a Topcon TRC 50DX. The vessel-to-background contrast of the XyCAM HRI red-free photo was compared to the fundus photograph, while the coefficient of variation of blood flow measurements in specific arteries and veins also was determined. RESULTS: Vessel-to-background contrast was statistically greater in the handheld use case when compared to the standard color fundus photographs (P = 0.01). Estimates of mean blood flow velocity (BFV) were highly correlated between the stabilized and handheld use case (r 2 = 0.96). Peak velocity estimates in arteries were significantly higher than those in veins (P < 0.05). CONCLUSIONS: The XyCAM HRI prototype can acquire fundus photographs with the same or better level of clarity as color fundus photographs, and reproducibly acquire functional blood flow information in the handheld use case. TRANSLATIONAL RELEVANCE: To our knowledge, this is the first human study of a handheld laser speckle retinal imaging device. Determination of retinal blood flow has applications to ophthalmic and systemic disease and a portable handheld retinal imager that determines blood flow may be widely adopted at the point of care.

A Systematic Evaluation of State Laws Governing Optometric Glaucoma Management in the United States Upto 2015.

PURPOSE: To describe state laws that govern the optometric practice of glaucoma management in the United States and to correlate those laws with state demographics upto 2015. MATERIALS AND METHODS: We performed a cross-sectional ecological study of the 50 United States and the District of Columbia. Regulations governing optometric scope of practice as written by each state Board of Optometry were reviewed. Specific optometric privileges assessed included: ability to manage glaucoma independently, use of diagnostic pharmaceutical agents, use of therapeutic pharmaceutical agents (including topical and oral steroids and other oral pharmaceutical agents), IV injections, intraocular injections, therapeutic lasers, presence of defined referral, and comanagement guidelines, and hours of yearly continuing education needed for glaucoma management. Optometric privilege was compared with demographic and employment information for each state. RESULTS: Optometrists in all states, except for Massachusetts, and the District of Columbia are allowed to manage glaucoma; 16 states have defined comanagement guidelines. Therapeutic lasers are allowed in 3 states: Kentucky, Louisiana, and Oklahoma. States with defined comanagement guidelines had a mean of 6.9±1.9 ophthalmologists per 100,000 people, significantly more than the 5.3±1.1 in states without defined comanagement of glaucoma (P<0.01). Binary logistic regression showed that, accounting for population and area, the higher the number of optometrists in a state, the less likely there is to be defined comanagement [ß (SE)=-0.008 (0.003), P=0.02] and the greater the number of ophthalmologists in a given state, the more likely a state has defined comanagement [ß (SE)=-0.13 (0.006)]. CONCLUSIONS: There is a diversity of regulations that govern optometric management of glaucoma in each of the 50 states and the District of Columbia. The number of optometrists and ophthalmologists in a state may influence state regulations governing optometric practice and referral guidelines.

Pupillary block due to reverse implantation of a sulcus intraocular lens.

An 88-year-old woman with a history of complicated cataract extraction by phacoemulsification with sulcus intraocular lens (IOL) placement developed pseudophakic pupillary block after reverse implantation of the IOL. In the postoperative period, she had persistently elevated intraocular pressures (IOP) and was diagnosed with chronic angle-closure glaucoma that was treated medically. She presented 5 years later with acute pupillary block. The diagnosis of reverse IOL implantation was confirmed by ultrasound biomicroscopy. An IOL repositioning, anterior synechialysis, and Baerveldt tube shunt placement led to resolution of the pupillary block and a well-controlled IOP.