Q Fever-Associated Chorioretinitis.

Coxiella burnetii is the causative agent in Q fever, a zoonotic disease. Ocular manifestations of this disease are extremely rare and have been infrequently reported. In this report, we describe a rare case of chorioretinitis in a patient incompletely treated for Q fever. We highlight the unique ocular manifestation with multimodal imaging, and the importance of a thorough history and prompt and correct treatment of the disease with systemic therapy. [Ophthalmic Surg Lasers Imaging Retina 2024;55:412-414.].

Rising Incidence of Syphilitic Uveitis-Related Hospitalizations in the US.

Importance: The number of syphilis cases continues to increase in the US every year since 2001 with a 74% increase observed since 2017. In addition, there remains a national shortage of injectable penicillin G. Despite the increase in reported cases, to the authors' knowledge, there has been no recent nationwide study investigating the trends in incidence of syphilitic uveitis. Objective: To evaluate the national and regional incidence of syphilitic uveitis-related hospitalizations in the US. Design, Setting, and Participants: This was a retrospective, cross-sectional study. The Nationwide Inpatient Sample was queried to identify all inpatient admissions with a diagnosis of syphilitic uveitis in the US between the years 2010 and 2019. Analyses were performed to determine baseline sociodemographic characteristics and identify national and regional trends in incidence. All patients hospitalized with a diagnosis of syphilis, uveitis, and/or syphilitic uveitis were eligible for inclusion. Statistical analysis of study data took place in June 2023. Exposure: Diagnosis of syphilis, uveitis, and/or syphilitic uveitis on inpatient admissions during the years 2010 to 2019 in the Nationwide Inpatient Sample. Main Outcome Measures: The primary outcome was to determine trends in the national and regional incidence of syphilitic uveitis-related hospitalizations in the US. Secondary outcome measures included sociodemographic characteristics of patients with syphilitic uveitis, incidence stratified by sex and race and ethnicity, and median charge per syphilitic uveitis hospital admission. Results: From the Nationwide Inpatient Sample, inpatient data from 444 674 patients (median [IQR] age, 53 [37-67] years; 54.8% male) were analyzed. There were an estimated 5581 syphilitic uveitis-related hospitalizations during the 10-year study period. The median (IQR) age of individuals with syphilitic uveitis was 45 (35-55) years, and 4395 patients (78.9%) were male. Syphilitic uveitis disproportionately affected African American individuals (1787 patients [32%], although they compose 13.6% of the population) and those belonging to the lowest median household income quartile (2163 [38.8%]). The national incidence was 0.15 per 100 000 population and showed an increasing trend over the years, with the lowest incidence in 2011 (0.08 per 100 000 population) and the highest incidence in 2019 (0.23 per 100 000 population; P = .04). Regional analysis showed an increase in incidence across all 4 US geographical regions. A total of 1293 patients (23.2%) had comorbid AIDS. Conclusion and Relevance: Although this cross-sectional study only captured inpatient diagnosis, an increasing incidence of syphilitic uveitis-related hospitalizations was observed in the US between 2010 and 2019. Given the concomitant national shortage of injectable penicillin G, results suggest that clinicians should maintain a high index of suspicion for syphilis when evaluating patients with intraocular inflammation.

Domestic Violence-Related Ocular Injuries Among Adult Patients: Data from the Nationwide Emergency Department Sample, 2008-2017.

PURPOSE: To investigate domestic violence (DV)-related ocular injuries among adult emergency department (ED) patients in the US. METHODS: This was a retrospective, cross-sectional study of patients with a diagnosis of DV and diagnosis of ocular injury in the Nationwide Emergency Department Sample (NEDS) from 2008-2017. We identified patient- and hospital-level variables associated with DV-related ocular injuries. We calculated annual incidence rates using US Census data. Adjusting for inflation using the Consumer Price Index, we calculated mean and total charges. RESULTS: From 2008-2017, there were 26,215 ED visits for ocular injuries related to DV with an average incidence of 1.09 per 100,000 adult population (female patients, 84.5%; mean age [SE], 34.3 [0.2]). DV-related ocular injuries were most prevalent among patients in the lowest income quartile (39.1%) and on Medicaid (37.4%). Most ED visits presented to metropolitan teaching (55.4%), non-trauma (46.7%), and south regional (30.5%) hospitals. The most common ocular injury was contusion of eye/adnexa (61.1%). The hospital admission rate was 5.2% with a mean hospital stay of 2.9 [0.2]. The inflation-adjusted mean cost for medical services was $38,540 [2,310.8] per encounter with an average increase of $2,116 per encounter, annually. The likelihood of hospital admission increased for patients aged ≥60 years old, on Medicare, and with open globes or facial/orbital fractures (all p < .05). CONCLUSION: Contusion of the eye/adnexa was the most common ocular injury among patients with DV-related ED visits. To better facilitate referrals to social services, ophthalmologists should utilize DV screenings, especially towards women and patients of less privileged socioeconomic status.

Epidemiologic trends of domestic violence-related ocular injuries among pediatric patients: data from the Nationwide Emergency Department Sample 2008-2017.

PURPOSE: To study the epidemiology of all domestic violence (DV)-related ocular injuries among pediatric emergency department (ED) patients in the United States. METHODS: This is a retrospective, cross-sectional study of isolated children (<18 years of age) with a diagnosis of DV and primary or secondary diagnosis of ocular injuries in the Nationwide Emergency Department Sample, 2008-2017. We calculated annual incidence of DV-related ocular injuries and prevalence by demographic variables, including age, sex, and income quartile. Median charges, median length of inpatient hospital stay, and factors associated with hospitalization were also measured. RESULTS: From 2008 to 2017, there were 4,125 ED encounters, with an average incidence of 0.56 per 100,000 population (males, 50.0%; mean age [SE], 9.2 [0.3]). Patients in the lowest income quartile (42.6%) and with Medicaid insurance (63.2%) were the most prevalent. The most common known perpetrator was a family member (29.4%). Most ED encounters took place at southern regional (28.6%), metropolitan teaching (67.1%) and designated trauma hospitals (57.8%). Contusion of the eye/adnexa and being struck by or against an object were the most common ocular diagnosis and known mechanism of injury, respectively. An estimated 12.4% of patients were admitted with a median hospital stay of 4 (IQR, 2-6). Median charges during the study period were $27,415.10 (IQR, $13,142.70-$54,454.90). CONCLUSIONS: DV-related ocular injuries were most prevalent among patients with a low socioeconomic status. Given the historical underreporting of DV, future studies are warranted to identify more specific social determinants of health that contribute to such presentations.

Factors Associated With Visual Impairment Among Adults With a History of Criminal Justice Involvement.

The purpose of this study was to investigate the prevalence of and factors associated with visual impairment among adults with a history of criminal justice involvement (CJI). This retrospective, cross-sectional study reviewed adult respondents from the 2015-2018 National Survey on Drug Use and Health. We analyzed sociodemographic and health characteristics to determine factors associated with visual impairment among adults with and without a history of CJI. In this national, population-based study, we found similar rates of visual impairment among adults with and without CJI (5.7% vs. 4.2%, p < .001). However, adults with CJI were more likely to report visual impairment at a younger age. Among adults with CJI, visual impairment was associated with female sex, older age, Black/African American race, less education, lower income, and chronic health conditions (including diabetes, heart disease, respiratory illness, mental health symptoms, and hearing impairment). CJI in the past year (probation [adjusted odds ratio, AOR, 0.70; 95% confidence interval, CI, 0.53-0.93]; one arrest [AOR, 1.47; 95% CI, 1.14-1.89]; two or more arrests [AOR, 1.73; 95% CI, 1.29-2.33]) was uniquely associated with visual impairment among adults with a CJI history (p < .05 for all relationships). Research, screening, and treatment for visual impairment should include those with justice involvement to improve health equity.

Emergency Department Presentations of Acute Primary Angle Closure in the United States from 2008 to 2017.

Purpose: Acute primary angle closure (APAC) is an ophthalmologic emergency. Nationwide data on the epidemiology and clinical characteristics of APAC are lacking despite the associated visual morbidity. Patients and Methods: A retrospective cross-sectional study using the Nationwide Emergency Department Sample (NEDS). The NEDS was queried by ICD-9/10 code for cases of APAC presenting to the United States emergency departments over a ten-year period from 2008 to 2017. All identified cases were included to produce nationally representative estimates. Linear regression and seasonality tests were used to identify trends. Reported outcomes include the incidence, demographics, seasonality, and economic impact of APAC regionally and nationwide. Results: A total of 23,203 APAC-related ED visits were identified. The mean (SD) and median ages were 58.8 (16.2) and 60 years, respectively. Females (59.4%, p < 0.01), those in the lowest income quartile (6983, 30.1%, p < 0.01), and those in the seventh decade of life (5599, 24.1%) presented more frequently with APAC. The incidence of ED presentations within each age group rose with age and increased significantly over the study period (p < 0.01). The Northeast region had the highest average incidence (0.93 per 100,000 population). Significant seasonal variation was seen regionally and nationally (p < 0.01), with the highest average incidence in December and lowest in April. Median inflation adjusted charge per ED visit was $2496.10, and the total inflation adjusted charges equaled $101.5 million. Conclusion: The incidence of APAC-related ED visits continues to rise in the United States. High-risk groups include women, individuals of low socioeconomic status, and those between ages 50 and 70. Significant seasonal and regional trends were observed in ED presentations of APAC.

Association of the Affordable Care Act with Eye-Related Emergency Department Utilization in the United States.

PURPOSE: To investigate the association of the Affordable Care Act (ACA) with nationwide eye-related emergency department (ED) use. DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: All patients who presented to the ED with an eye-related primary diagnosis were eligible for inclusion. METHODS: Nationally representative data from the US Nationwide Emergency Department Sample were used to analyze eye-related ED visits before (2010-2013) and after (2014-2017) the ACA was mandated. All ED visits were categorized as emergent or nonemergent or could not be determined. MAIN OUTCOME MEASURES: The primary outcome was to compare the nationwide and regional incidence of eye-related ED visits per 100 000 US population before (2010-2013) and after (2014-2017) the ACA was mandated. Secondary outcome measures included change in payor status, proportion of urgent versus nonurgent visits, proportion of visits at teaching versus nonteaching hospitals, associated charges, and discharge disposition. RESULTS: A total of 16 808 343 eye-related ED visits occurred in the United States during the study period from 2010 to 2017. Of these, 8 088 203 ED visits occurred before the ACA was mandated (2010-2013), and 8 720 766 ED visits occurred after the ACA was mandated (2014-2017). After the ACA was mandated in 2014, there was an initial decline in incidence of eye-related ED visits from 652.4 per 100 000 population in 2013 to 593.0 per 100 000 population in 2014, followed by a rapid increase in incidence to 658.5 per 100 000 population in 2015, with a further increase to 746.6 per 100 000 population in 2016. The percentage of uninsured patients decreased from 19.0% to 14.3%. The increase in ED use was greatest for individuals in the lowest income quartile (895.1 per 100 000 population in 2013 to 964.0 per 100 000 in 2017). Overall, 44.8% of ED visits were due to nonemergent eye conditions. CONCLUSIONS: Although the ACA increased insurance coverage for Americans, theoretically increasing access to outpatient ophthalmic care, this did not decrease ED reliance for management of ophthalmic conditions. Additional measures beyond expanding insurance coverage may be necessary to provide high-quality, efficient, and equitable outpatient ophthalmic care to all Americans.

Gender Differences in Ophthalmic Procedural Volume: A Study of Male vs. Female Glaucoma Specialists.

PURPOSE: To investigate whether differences in procedural volume exist between practicing male and female glaucoma specialists. DESIGN: A cross-sectional analysis. SUBJECTS: A total of 213 female and 666 male glaucoma specialists who performed ≥ 11 traditional, incisional glaucoma procedures for Medicare beneficiaries between 2014 and 2018. METHODS: The 2014 to 2018 Medicare Provider Utilization and Payment Data database was queried using Current Procedural Terminology and Evaluation and Management codes to identify clinic visits and cataract, glaucoma drainage implant (GDI), trabeculectomy, minimally invasive glaucoma surgery (MIGS), and office-based glaucoma laser procedures. The number of procedures performed per provider was averaged and compared between genders. The univariate ordinary least squares linear regression analysis was used to investigate the effects of gender on procedural volume. The multivariate ordinary least squares linear regression analysis was used to examine the effects of gender, the number of group practice members, and the number of years after medical school graduation on cataract, GDI, trabeculectomy, MIGS, and glaucoma laser procedural volumes. MAIN OUTCOME MEASURES: Mean difference in the number of procedures by gender and predictors of procedural volume. RESULTS: In the univariate analysis, men performed an estimated 7.8 more MIGSs (95% confidence interval [CI], 2.7-12.9; P = 0.003), 138.9 more cataract procedures (95% CI, 59.6-218.3; P = 0.0006), and 1.99 more GDI procedures (95% CI, 0.03-3.95; P = 0.046) than women. This relationship remained true for MIGS and cataract procedures in the multivariate analysis after controlling for clinical volume, the number of group practice members, and the number of years after medical school graduation (MIGS, ß = 6.1 [95% CI, 0.5-11.8; P = 0.03]; cataract, ß = 110.2 [95% CI, 16.9-203.5; P = 0.02]). Glaucoma drainage implant procedures were no longer associated with the gender of the surgeon in the multivariate analysis (ß = 2.1, 95% CI, -0.1 to 4.2; P = 0.06). The volumes of trabeculectomy and office-based glaucoma laser procedures did not differ between the genders in both the univariate (glaucoma laser, ß = 7.0 [95% CI, -4.4 to 18.5; P = 0.23]; trabeculectomy, ß = 2.7 [95% CI, -0.8 to 6.2; P = 0.13]) and multivariate analyses (glaucoma laser, ß = -7.3 [95% CI, -18.7 to 4.1; P = 0.21]; trabeculectomy, ß = 1.7 [95% CI, -5.6 to 2.1; P = 0.38]). CONCLUSIONS: Women performed fewer MIGS and cataract procedures than men, even after controlling for clinical volume, the number of years after medical school graduation, and the number of group practice members. After controlling for these factors, there was no difference in the incisional glaucoma or glaucoma laser procedural volume between genders. Further research is needed to understand factors contributing to these differences.

Effectiveness of the Dexamethasone Implant in Lieu of Oral Corticosteroids in Intermediate and Posterior Uveitis Requiring Immunosuppression.

PURPOSE: To evaluate dexamethasone intravitreal implant effectiveness in lieu of high-dose oral prednisone for short-term treatment of noninfectious intermediate and posterior uveitis in patients requiring immunosuppression. METHODS: This is a proof-of-concept, open-label, non-comparative clinical trial with 12-month follow-up. The primary outcome was uveitis control without additional prednisone at 6 and 12 months. Secondary outcomes were need for multiple implants or additional prednisone, and safety data. RESULTS: 20 patients (28 eyes) were enrolled- 16 eyes had control by 6 months; 20 by 12 months. No patients required high-dose prednisone. 6 patients enrolled on prednisone: 2 stopped; 4 tapered to 7.5 mg daily or less by 12 months. 16 eyes required multiple implants; five required cataract surgery; 12 required drops to control IOP; 2 underwent glaucoma surgery. CONCLUSIONS: The dexamethasone implant was effective in lieu of high-dose prednisone although the majority required multiple implants. All patients decreased or discontinued prednisone during follow-up.

Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma.

Aim: To report a large hyphema following femtosecond laser-assisted cataract surgery (FLACS) and trabectome resulting in endocapsular hematoma. Background: Hyphema has previously been described following trabectome, however, no cases have been reported following FLACS or FLACS combined with microinvasive glaucoma surgery (MIGS). We report a case of a large hyphema following FLACS combined with MIGS that resulted in an endocapsular hematoma. Case description: A 63-year-old myopic female with exfoliation glaucoma underwent FLACS with a trifocal intraocular lens implant and Trabectome in the right eye. Significant intraoperative bleeding ensued following the trabectome and was treated with viscoelastic tamponade, anterior chamber (AC) washout, and cautery. The patient developed a large hyphema with intraocular pressure (IOP) rise that was treated with multiple AC taps, paracentesis, and eye drops. The hyphema took approximately 1 month to completely clear, leaving an endocapsular hematoma. This was treated successfully with Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser posterior capsulotomy. Conclusion: Hyphema may occur with angle-based MIGS in combination with FLACS and may cause endocapsular hematoma. An increase in episcleral venous pressure during the docking and suction phase of the laser may predispose to bleeding. Endocapsular hematoma is an uncommon finding after cataract surgery and may be treated with Nd:YAG posterior capsulotomy. How to cite this article: Chang EL, Apostolopoulos N, Mir TA, et al. Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma. J Curr Glaucoma Pract 2022;16(3):195-198.

Cilioretinal Artery Occlusion as the Presenting Manifestation of Left Atrial Myxoma.

Purpose: This work reports a case of left atrial myxoma presenting with cilioretinal artery occlusion. Methods: A case report is discussed. Results: A 57-year-old man was referred for acute vision loss in the left eye after a workup including electrocardiogram, magnetic resonance imaging of the brain without contrast, computed tomography angiography of the head and neck, erythrocyte sedimentation rate, and C-reactive protein had negative results. Examination revealed cilioretinal artery occlusion with visible emboli. Because an echocardiogram was not performed, the patient was referred to the emergency department. Echocardiogram revealed a large left atrial mass prolapsing into the left ventricle. The mass was excised, and pathology showed myxoma. Conclusions: This is the first case to our knowledge of isolated cilioretinal artery occlusion as the initial presentation of an atrial myxoma. Thorough and complete workup was crucial to averting further morbidity and mortality.

Pharmacologic interventions for mydriasis in cataract surgery.

BACKGROUND: Cataract surgery is one of the most common surgical procedures performed worldwide. Achieving appropriate intraoperative mydriasis is one of the critical factors associated with the safety and performance of the surgery. Inadequate pupillary dilation or constriction of the pupil during cataract surgery can impair the surgeon's field of view and make it difficult to maneuver instruments. OBJECTIVES: To evaluate the relative effectiveness of achieving pupillary dilation during phacoemulsification for cataract extraction using three methods of pupillary dilation: topical mydriatics, intracameral mydriatics, or depot delivery systems. We also planned to document and compare the risk of intraoperative and postoperative complications following phacoemulsification for cataract extraction, as well as the cost-effectiveness of these methods for pupillary dilation. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 January 2021. SELECTION CRITERIA: We included only randomized controlled trial (RCTs) in which participants underwent phacoemulsification for cataract extraction. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodology. MAIN RESULTS: We included a total of 14 RCTs (1670 eyes of 1652 participants) in this review. Of the 14 trials, 7 compared topical versus intracameral mydriatics, 6 compared topical mydriatics versus depot delivery systems, and 1 compared all three methods. We were unable to calculate overall estimates of comparative effectiveness for most outcomes due to statistical heterogeneity among the estimates from individual studies or because outcome data were available from only a single study. Furthermore, the certainty of evidence for most outcomes was low or very low, due primarily to imprecision and risk of bias. Comparison 1: topical mydriatics versus intracameral mydriatics Four RCTs (739 participants, 757 eyes) of the 8 RCTs that had compared these two methods reported mean pupillary diameters at the time surgeons had performed capsulorhexis; all favored topical mydriatics, but heterogeneity was high (I2 = 95%). After omitting 1 RCT that used a paired-eyes design, evidence from three RCTs (721 participants and eyes) suggests that mean pupil diameter at the time of capsulorhexis may be greater with topical mydriatics than with intracameral mydriatics, but the evidence is of low certainty (mean difference 1.06 mm, 95% confidence interval (CI) 0.81 mm to 1.31 mm; I2 = 49%). Four RCTs (224 participants, 242 eyes) reported mean pupillary diameter at the beginning of cataract surgery; the effect estimates from all trials favored topical mydriatics, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported mean pupillary diameter at the end of cataract surgery. Data for this outcome from the largest RCT (549 participants and eyes) provided evidence of a small difference in favor of intracameral mydriasis. On the other hand, 2 small RCTs (78 participants, 96 eyes) favored topical mydriatics, and the remaining 2 RCTs (172 participants) found no meaningful difference between the two methods, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported total intraoperative surgical time. The largest RCT (549 participants and eyes) reported decreased total intraoperative time with intracameral mydriatics, whereas 1 RCT (18 participants, 36 eyes) favored topical mydriatics, and the remaining 3 RCTs (232 participants) found no difference between the two methods, with very low-certainty evidence. Comparison 2: topical mydriatics versus depot delivery systems Of the 7 RCTs that compared these two methods, none reported mean pupillary diameter at the time surgeons performed capsulorhexis. Six RCTs (434 participants) reported mean pupillary diameter at the beginning of cataract surgery. After omitting 1 RCT suspected to be responsible for high heterogeneity (I2 = 80%), meta-analysis of the other 5 RCTs (324 participants and eyes) found no evidence of a meaningful difference between the two methods, with very low-certainty evidence. Three RCTs (210 participants) reported mean pupillary diameter at the end of cataract surgery, with high heterogeneity among effect estimates for this outcome. Estimates of mean differences and confidence intervals from these three RCTs were consistent with no difference between the two methods. A fourth RCT reported only means for this outcome, with low-certainty evidence. Two small RCTs (118 participants) reported total intraoperative time. Surgical times were lower when depot delivery was used, but the confidence interval estimated from one trial was consistent with no difference, and only mean times were reported from the other trial, with very low-certainty evidence. Comparison 3: Intracameral mydriatics versus depot delivery systems Only one RCT (60 participants) compared intracameral mydriatics versus depot delivery system. Mean pupillary diameter at the time the surgeon performed capsulorhexis, phacoemulsification time, and cost outcomes were not reported. Mean pupil diameter at the beginning and end of cataract surgery favored the depot delivery system, with very low-certainty evidence. Adverse events Evidence from one RCT (555 participants and eyes) comparing topical mydriatics versus intracameral mydriatics suggests that ocular discomfort may be greater with topical mydriatics than with intracameral mydriatics at one week (risk ratio (RR) 10.57, 95% CI 1.37 to 81.34) and one month (RR 2.51, 95% CI 1.36 to 4.65) after cataract surgery, with moderate-certainty evidence at both time points. Another RCT (30 participants) reported iris-related complications in 11 participants in the intracameral mydriatics group versus no complications in the depot delivery system group, with very low-certainty evidence. Cardiovascular related adverse events were rarely mentioned. AUTHORS' CONCLUSIONS: Data from 14 completed RCTs were inadequate to establish the superiority of any of three methods to achieve mydriasis for cataract surgery, based on pupillary dilation at different times during the surgery or on time required for surgery. Only one trial had a sample size adequate to yield a robust effect estimate. Larger, well-designed trials are needed to provide robust estimates for the comparison of mydriasis approaches for beneficial and adverse effects.

Incidence of Drug Use-Related Endogenous Endophthalmitis Hospitalizations in the United States, 2003 to 2016.

Importance: Complications arising from the nationwide opioid epidemic led to an increase in health care use. Few studies have investigated whether this is reflected in hospital admissions for endogenous endophthalmitis. Objective: To report changing trends in epidemiology, risk factors, hospital course, and costs associated with drug use-related endogenous endophthalmitis hospitalizations in the United States from 2003 to 2016. Design, Setting, and Participants: Nationwide, retrospective cross-sectional study using the National Inpatient Sample. A total of 56 839 patients admitted with a diagnosis of endogenous endophthalmitis were included. Data were analyzed between 2003 and 2016. Exposures: Inpatient admission for endogenous endophthalmitis during the years 2003 to 2016. Main Outcomes and Measures: The Nationwide Inpatient Sample was queried to identify all inpatient admissions with a diagnosis of endogenous endophthalmitis in the United States between the years 2003 and 2016. Analyses were performed to identify national and regional trends in incidence and prevalence of associated infectious and noninfectious comorbidities in patients with or without a history of drug dependence or use. Median and cumulative inflation-adjusted costs for admissions were calculated. Results: Of all patients, 55.6% were White, 13.6% were Black, and 10.6% were Hispanic. There were an estimated 56 839 endogenous endophthalmitis-related hospitalizations; 13.7% of these patients (n = 7783) had a history of drug dependence or use. The drug-using population was significantly younger (49.6 vs 57.5 years; difference, 7.9; 95% CI, 6.93-8.88; P < .001) and more likely to be male (61.8% [n = 35 127] vs 49.0% [n = 21 712]; difference, 12.8%; 95% CI, 11.6%-14.0%; P < .001). The incidence of endogenous endophthalmitis associated with drug dependence or use increased from 0.08 per 100 000 in 2003 to 0.32 per 100 000 population in 2016 across all 4 US geographic regions. Conclusions and Relevance: A 4-fold increase in drug use-related endogenous endophthalmitis hospitalizations was observed in the United States from 2003 to 2016, resulting in substantial health care use burden. These findings support the hypothesis that clinicians should maintain a high index of suspicion for endophthalmitis when evaluating patients with intraocular inflammation in the setting of drug dependence or use.

Epidemiology and outcomes of hyphema: a single tertiary centre experience of 180 cases.

PURPOSE: To characterize the epidemiology and outcomes of hyphema. METHODS: Retrospective case series. Medical records from patients with traumatic and spontaneous hyphema seen at the Wilmer Eye Institute, Johns Hopkins, from 2011 through 2017 were evaluated. Aetiology, demographics, clinical characteristics, complications, management and outcomes were ascertained. Multivariable logistic regression was used to identify factors associated with elevated intraocular pressure (IOP), rebleeding and poor outcome (final visual acuity ≤ 20/40) in traumatic hyphema. A safe frequency of follow-up was retrospectively determined. RESULTS: Traumatic hyphema (n = 152) was more common in males (78%) and adults (55%), with sports/recreational activities being the most frequent cause (40%). Elevated IOP was the most common complication (39%). Rebleeding occurred in seven patients (5%) and was more likely with a higher IOP on presentation (OR:1.1; p = 0.004). Thirty-seven patients (24%) had a poor outcome, mostly due to traumatic sequelae such as cataract (32%) or posterior segment involvement (30%). A poor outcome was more likely with worse presenting visual acuity (OR: 9.1; p = 0.001), rebleeding (OR: 37.5; p = 0.035) and age > 60 years (OR: 16.0; p = 0.041). Spontaneous hyphema (n = 28) did not have a gender predominance and was more common in adults > 60 years (71%). The most common cause was iris neovascularization (61%). Complications and visual outcomes were worse compared with traumatic hyphema. CONCLUSIONS: Traumatic hyphema continues to be common in young males engaging in sports, necessitating increased awareness for preventive eyewear. Older age and rebleeding can lead to poor outcomes. Elevated IOP at presentation predisposes to rebleeding and warrants frequent follow-up. Otherwise, routine follow-up at days 1, 3, 5, 7 and 14 is sufficient for uncomplicated cases.

Clinical Characteristics and Outcomes of Hyphema in Patients with Sickle Cell Trait: 10-Year Experience at the Wilmer Eye Institute.

PURPOSE: To report the clinical characteristics, complications, and outcomes of hyphema in patients with sickle cell trait (SCT). DESIGN: Retrospective case series. METHODS: Medical records of SCT patients (confirmed by hemoglobin electrophoresis) presenting with hyphema at the Wilmer Eye Institute over 10 years (January 2008 through December 2017) were reviewed in detail. Data were collected regarding etiology, demographics, clinical course and management. Main outcome measures included intraocular pressure (IOP) and visual acuity (VA). RESULTS: A total of 14 black patients (males: 57%; median age: 20 years) were included in the study with a median follow-up of 4 months (range: 1 week to 6 years). Ten patients had traumatic hyphema with a mean presenting VA of approximately 1.10 logMAR (Snellen equivalent=20/250) and a mean presenting IOP of 40 mmHg. Nine of them required medical intervention to lower IOP, and six of them ultimately required surgical intervention, primarily in the form of anterior chamber paracentesis and/or washout. The mean time to achieve IOP control was 3 days, and the mean final VA was approximately 0.10 logMAR (Snellen Equivalent=20/25). Four patients had non-traumatic hyphema with a mean presenting VA of approximately 1.8 logMAR (Snellen equivalent=20/1260) and a mean presenting IOP of 31 mmHg. Three of them required medical intervention to lower IOP, and two of them ultimately required surgical intervention. Overall, seven patients underwent anterior chamber washout, six needed an anterior chamber paracentesis to lower the IOP, two required tube shunt placement procedures and one patient underwent a trabeculectomy. The mean time to achieve IOP control was 5 days, and the mean final VA was approximately 0.80 logMAR (Snellen equivalent=20/125). CONCLUSION: Patients with SCT are likely to develop elevated IOP in the setting of hyphema, with a majority requiring one or more surgical interventions to achieve IOP control.

Intravitreal steroids for macular edema in diabetes.

BACKGROUND: Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME. OBJECTIVES: To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020. SELECTION CRITERIA: We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses. MAIN RESULTS: We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I2 = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I2 = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression. AUTHORS' CONCLUSIONS: Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.

Trends in Infantile Endogenous Endophthalmitis Hospitalizations in the United States: An Analysis from 2007 through 2014 Using the National Inpatient Sample.

PURPOSE: To determine the annual change in incidence of neonatal and infantile endogenous endophthalmitis in the United States between 2007 and 2014 and identify associated risk factors for development of endophthalmitis and mortality. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Neonates (<28 days; n = 1650) hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants (age range, 28 days-1 year; n = 1850) hospitalized between 2007 and 2014 across United States community hospitals were analyzed. METHODS: The Nationwide Inpatient Sample database was queried to identify neonates hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants hospitalized between 2007 and 2014 across the United States. National and regional incidence of neonatal and infantile endogenous endophthalmitis and comorbidities as well as risk factors in the development of the disease and predictive factors for mortality from the years 2007 through 2014 were calculated. MAIN OUTCOMES AND MEASURES: National incidence, regional incidence, and risk factors for development of neonatal and infantile endogenous endophthalmitis. RESULTS: The rate of decline in incidence of neonatal endogenous endophthalmitis was 4% from 2003 through 2014. The rate of decline in the infantile population was 7% from 2007 through 2014. In 2007, an estimated 291 total cases of infantile endophthalmitis were identified, in comparison with 140 cases in 2014. Comorbidities prevalent in the endophthalmitis population included prematurity, respiratory disorders, perinatal infections, and retinopathy of prematurity (ROP). Significant positive predictors for the development of endogenous endophthalmitis based on multivariate logistic regression were perinatal infections, candidemia, bacteremia, very low birth weight, prematurity, respiratory disorders, and ROP. Descriptive analyses showed that the in-hospital mortality rate for patients identified with endophthalmitis was 1.55% in comparison with infants without endophthalmitis. CONCLUSIONS: The incidence of endogenous endophthalmitis declined in both the neonatal and infantile population from 2007 through 2014. Odds of endogenous endophthalmitis were higher for premature and low-birthweight infants and those identified with perinatal infections, candidemia, bacteremia, respiratory disorders, or ROP. These findings are consistent with the decline observed in pediatric infectious disease-related hospitalizations in general.

Characteristics of Open Globe Injuries in the United States From 2006 to 2014.

Importance: Open globe injuries can lead to substantial visual morbidity and lifelong sequelae. Interventions to reduce the burden of open globe injuries in the United States require a better understanding of these injuries through well-designed epidemiologic investigations. Objective: To examine the incidence, common injury mechanisms, and economic burden of open globe injuries in the United States. Design, Setting, and Participants: This retrospective, cross-sectional study of US nationwide emergency department (ED) data assessed all ED visits of patients with a primary diagnosis of open globe injury in the Nationwide Emergency Department Sample (NEDS) from January 1, 2006, to December 31, 2014. Data analysis was performed from August 29, 2018, to November 11, 2019. Main Outcomes and Measures: Annual incidence of open globe injuries by age, sex, mechanism of injury, and concomitant diagnosis, as well as median charges associated with open globe injuries and variables associated with hospitalization. Results: A total of 124 989 ED visits for open globe injuries were assessed, with an incidence of 4.49 per 100 000 population in the United States from 2006 to 2014 (mean [SD] age of study participants, 37.7 [22.5] years; 94 078 [75.3%] male). The incidence was highest in 2006 (5.88 per 100 000 population) and decreased by 0.3% per month between 2006 and 2014 (incidence rate ratio, 0.99; 95% CI, 0.99-0.99; P < .001). Open globe injuries occurred in 37 060 individuals (30.6%) of low socioeconomic status. The most common injury mechanism was being struck by or against an object or person (40 119 of all 124 989 injury mechanisms [32.1%]). Open globe injuries associated with falls increased 6.6% between 2006-2010 and 2011-2015 (95% CI, 1.04-1.08; P < .001) and were the most common injury mechanism in individuals older than 70 years. The total cost associated with open globe injuries was $793 million. The cost of ED visits increased from $865 during 2006-2010 to $1557 during 2011-2015. Inpatient costs similarly increased from $21 527 during 2006-2010 to $30 243 during 2011-2015. Conclusions and Relevance: The incidence of open globe injuries in the United States decreased from 2006 to 2014. Although the data are from 5 to 13 years ago, these findings appear to provide valuable information for targeting preventive measures toward individuals at highest risk; targeting young men with lower socioeconomic status and individuals 70 years or older at an increased risk of falls may help lower the incidence of open globe injuries.

Eyes With Acute, Treatment-Naïve CRVO and Foveal Intraretinal Hemorrhage: Characteristics and Outcomes.

BACKGROUND AND OBJECTIVE: To compare outcomes in eyes with central retinal vein occlusion (CRVO) presenting with (group 1) or without (group 2) fovea-involving intraretinal hemorrhage (IRH). PATIENTS AND METHODS: Retrospective review of patients diagnosed with acute, treatment-naïve CRVO between January 2009 and July 2016. RESULTS: One hundred fifteen (39.8%) of 289 CRVO eyes had fovea-involving IRH. At baseline, eyes in group 1 had significantly worse visual acuity (VA) (1.2 ± 0.10 logMAR vs. 0.9 ± 0.06 logMAR; P = .001) and greater central subfield thickness (CST) (610.4 µm ± 35.9 µm vs. 435.0 µm + 21.6 µm; P < .001) than eyes in group 2. Final visual outcomes were comparable between groups (1.24 ± 0.09 logMAR vs. 1.02 ± 0.08 logMAR; P = .08). Group 1 received a significantly greater number of intravitreal anti-vascular endothelial growth factor injections during the first year (7.80 ± 0.40 vs. 5.20 ± 0.40; P = .001). CONCLUSIONS: Although treatment-naïve eyes with acute CRVO and fovea-involving IRH had worse VA and greater CST at presentation, the final VA was comparable to eyes without such a hemorrhage. Eyes with foveal IRH had a greater treatment burden in the first 12 months. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:752-759.].

Impact and Implication of Fovea-Involving Intraretinal Hemorrhage after Acute Branch Retinal Vein Occlusion.

PURPOSE: To compare clinical outcomes in patients with branch retinal vein occlusion (BRVO) with (group A) or without (group B) fovea-involving intraretinal hemorrhage (IRH). DESIGN: Retrospective cohort study. PARTICIPANTS: All patients diagnosed with acute, treatment-naive BRVO seen by the Duke Eye Center Retina Service from January 1, 2009, through June 30, 2017 who had treatment-naive BRVO with disease onset <3 months before presentation, macular involvement, spectral-domain OCT and color fundus photographs at presentation, and >12 months offollow-up. METHODS: Retrospective study using a database of patients diagnosed with BRVO over an 8-year period. The presence of fovea-involving IRH was determined from baseline fundus photographs by human graders and confirmed with multimodal imaging. Presenting features, treatment patterns, and clinical outcomes were compared. MAIN OUTCOME MEASURES: Visual acuity (VA), cystoid macular edema (CME), central subfield thickness (CST), and number of anti-vascular endothelial growth factor (VEGF) injections. RESULTS: Of 172 patients with BRVO, 33 (19.2%) presented with fovea-involving IRH. At presentation, group A had worse VA (0.54±0.06 logMAR [Snellen equivalent, 20/69] vs. 0.34±0.03 logMAR [Snellen equivalent, 20/44]; P = 0.001), greater CST (523.8±32 µm vs. 345.9±11.8 µm; P < 0.001), were more likely to have CME (93.9% vs. 48.2%; P < 0.001), and received more anti-VEGF injections in the first year (4.50±3.43 vs. 1.89±3.26; P < 0.001) than group B. Final VA was worse in group A (0.57±0.12 logMAR [Snellen equivalent, 20/74] vs. 0.35±0.05 logMAR [Snellen equivalent, 20/45]; P = 0.05). More patients in group A had loss of >2 lines of VA (36.4% vs. 18.7%; P = 0.04) or >3 lines (27.3% vs. 10.8%; P = 0.05) at final follow-up. Group A was more likely to have CME (63.6% vs. 27.3%; P < 0.001) at final follow-up with greater treatment burden, yet experienced a greater decrease in CST (-197.8±45.3 µm vs. -51.7±14.7 µm; P = 0.005). CONCLUSIONS: Acute BRVO presenting with fovea-involving IRH is associated with worse presenting features, greater treatment burden, and worse clinical outcomes despite current therapeutic interventions.