Premature Emulsification of Silicone Oil After Retinal Detachment Repair in the Setting of High-Intensity Exercise.

PURPOSE: To describe a rare case of silicone oil emulsification which occurred only three months postoperatively. We discuss the implications for postoperative counseling. METHODS: Retrospective chart review of a single patient. RESULTS: 39-year-old female who presented with a right eye macula-on retinal detachment which was repaired with scleral buckle, vitrectomy, and silicone oil tamponade. Her course was complicated by extensive silicone oil emulsification within 3 months postoperatively, most likely due to shear forces induced by her daily CrossFit exercise regimen. CONCLUSION: Typical postoperative precautions after a retinal detachment repair include no heavy lifting or strenuous activity for one week. These restrictions may need to be more stringent and long-term for patients with silicone oil to prevent early emulsification.

Patient Accessibility to Eye Care in the United States.

PURPOSE: The United States (US) federal government uses health provider shortage areas (HPSAs) to define patient accessibility to primary care physicians. It is unclear whether HPSAs can be applied to eye care providers (ECPs). Our study determined the applicability of federal HPSA designations to ECP availability in the US. DESIGN: Cross-sectional study. PARTICIPANTS: US general population and ophthalmologists/optometrists in the Medicare database. METHODS: The primary care HPSA score, visual impairment prevalence, and ECP location were determined for each census tract or county using data from the US Department of Health and Human Services, the Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid Services. MAIN OUTCOME MEASURES: Association of HPSA with vision loss and ECP density was examined. The 2-step floating catchment area approach was used to newly define eye care shortage areas (patient accessibility score [PAS], higher being worse accessibility) for every county in the US, by weighting the 2-step FCA scores by prevalence of vision loss and ECP density. Multivariable logistic regression was used to identify sociodemographic variables associated with areas of ECP shortage. RESULTS: Among 72 735 census tracts included, statistically significant but weak correlations of HPSA score with visual impairment (VI) (r = 0.38; P < 0.0001) and ECP density per county population (r = -0.18; P < 0.0001) were found. Only 54.0% of census tracts with < 25th percentile ECP density per county were HPSAs (P < 0.0001). Of census tracts > than 75th percentile for VI only 58.0% were HPSAs (P < 0.0001). Multivariable regression found a higher odds of ECP PAS ≥ 75th percentile (worse accessibility) in rural counties (adjusted odds ratio [aOR], 2.47; 95% confidence interval [CI], 1.93-3.67; P < 0.001) and counties with a greater prevalence of residents with less than a high school education (aOR, 1.21; 95% CI, 1.19-1.25; P < 0.001), residents ≥ 65 years of age (aOR, 1.10; 95% CI, 1.07-1.13; P < 0.001), and uninsured residents (aOR, 1.04; 95% CI, 1.01-1.06; P < 0.001). Counties with a greater proportion of men (aOR, 0.93; 95% CI, 0.89-0.967; P < 0.001) or White residents (aOR, 0.99; 95% CI, 0.98-0.99) had a lower odds of ECP PAS ≥ 75th percentile. CONCLUSIONS: Current HPSAs only weakly correlate with ECP supply. We propose a new approach to identify counties with high need but limited access to eye care. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Geographic and socioeconomic access disparities to Phase 3 clinical trials in ophthalmology in the United States.

BACKGROUND/OBJECTIVE: To identify geographic and socioeconomic variables associated with residential proximity to Phase 3 ophthalmology clinical trial sites. METHODS: The geographic location of clinical trial sites for Phase 3 clinical trials in ophthalmology was identified using ClinicalTrials.gov. Driving time from each United States (US) census tract centroid to nearest clinical trial site was calculated using real traffic patterns. Travel data were crosslinked to census-tract level public datasets from United States Census Bureau American Community Survey (ACS). Cross-sectional multivariable regression was used to identify associations between census-tract sociodemographic factors and driving time (>60 min) from each census tract centroid to the nearest clinical trial site. RESULTS: There were 2330 unique clinical trial sites and 71,897 census tracts. Shortest median time was to retina sites [33.7 min (18.7, 70.1 min)]. Longest median time was to neuro-ophthalmology sites [119.8 min (48.7, 240.4 min)]. Driving >60 min was associated with rural tracts [adjusted odds ratio (aOR) 7.60; 95% CI (5.66-10.20), p < 0.0001]; Midwest [aOR 1.84(1.15-2.96), p = 0.01], South [aOR 2.57 (1.38-4.79), p < 0.01], and West [aOR 2.52 (1.52-4.17), p < 0.001] v. Northeast; and tracts with higher visual impairment [aOR 1.07 (1.03-1.10), p < 0.001)]; higher poverty levels [4th v.1st Quartile of population below poverty, aOR 2.26 (1.72-2.98), p < 0.0001]; and lower education levels [high school v. Bachelor's degree or higher aOR 1.02 (1.00-1.03), p = 0.0072]. CONCLUSIONS: There are significant geographic and socioeconomic disparities in access to ophthalmology clinical trial sites for rural, non-Northeastern, poorer, and lower education level census tracts, and for census tracts with higher levels of self-reported visual impairment.

Association of chronic central serous chorioretinopathy with subclinical Cushing's syndrome.

Purpose: To report the clinical course of a patient with central serous chorioretinopathy (CSCR) secondary to subclinical hypercortisolism before and after adrenalectomy. Observations: A 50-year-old female patient with multifocal, chronic CSCR was found to have an adrenal incidentaloma and was diagnosed with subclinical hypercortisolism. Patient elected to undergo minimally-invasive adrenalectomy and presented at 3 months after surgery without subretinal fluid. Conclusions and Importance: Subclinical Cushing's Syndrome (SCS) may present an underrecognized risk factor for developing chronic CSCR. Further investigation is needed to determine the threshold of visual comorbidity that may influence surgical management.

The evolving field of Big Data: understanding geographic information systems analysis and its transformative potential in ophthalmic research.

PURPOSE OF REVIEW: The purpose of this review to is to highlight alternative uses of Big Data in the pursuit of ophthalmologic public health. In particular, we highlight geographic information systems (GIS) analysis as a type of Big Data, summarize various GIS methods, and enumerate sources of geographic data. RECENT FINDINGS: The recent implementation of the IRIS Registry Data, has expanded our real-world knowledge of ophthalmology in the United States. Such innovations in Big Data allow us to better define ophthalmic diseases, treatments, and outcomes for underserved individuals and subpopulations. One underutilized source of Big Data entails use of geographic information to evaluate geographic heterogeneity and access across the United States. SUMMARY: GIS and Big Data allow for refined epidemiologic estimates of eye disease for specific communities. In particular, how GIS can enable researchers to examine disparities in access to ophthalmic care is reviewed. GIS best practices and some data sources for GIS in ophthalmology are also summarized.

Epiretinal Membrane Surgery after Retinal Detachment Repair: Visual Acuity Outcomes and OCT Analysis.

PURPOSE: To assess visual acuity (VA) outcomes of epiretinal membrane (ERM) surgery following primary rhegmatogenous retinal detachment (RD) repair and to identify OCT features predictive of visual outcomes. DESIGN: Retrospective, consecutive case series. SUBJECTS: Eyes undergoing pars plana vitrectomy (PPV) with membrane peel (MP) surgery for ERM following primary RD repair (PPV with or without scleral buckle (SB) and gas tamponade). METHODS: Retrospective chart review from 2015 to 2018. A previously described ERM grading scale was utilized for OCT structural analysis. MAIN OUTCOME MEASURES: Visual acuity (VA) and change in VA from pre- MP to 6 months and final follow-up. Secondary outcomes included RD and OCT features predictive of VA, as well as RD factors associated with need for subsequent MP surgery. RESULTS: 53 eyes of 53 patients underwent MP following RD repair. VA improved significantly from logMAR 1.00 ± 0.51 (Snellen 20/200) pre-MP to 0.45 ± 0.41 (20/56) at 6 months and 0.42 ± 0.41 (20/53) at final follow-up, (p<0.001) for each respectively. Macula on eyes had better 6 month [0.29 ± 0.18 (20/39) vs. 0.51 ± 0.46 (20/65), p=0.02] and final VA [0.29 ± 0.14 (20/39) vs. 0.46 ± 0.47 (20/58), p=0.04] after MP surgery. VA improved significantly from pre-MP to 6 months and final follow-up regardless of macula status. MP occurring ≤180 days from RD repair and IS/OS loss were associated with worse pre-MP VA [1.13 ± 0.09 (20/270) vs. 0.82 ± 0.07(20/132), p=0.01 and 1.21 ± 0.07 (20/324) vs. 0.74 ± 0.09 (20/110) p=0.0003, respectively]. IS/OS loss [adjusted means 0.54 ± 0.07 (20/69) vs. 0.25 ± 0.08 (20/36) at final visit, p=0.006] and RD repair with PPV/SB [0.53 ± 0.08 (20/68) vs. 0.31 ±0.07 (20/41) at final visit, p=0.03] were significantly associated with worse VA at both 6 months and final follow-up. CONCLUSIONS: Eyes undergoing MP after RD repair have significant visual acuity gains independent of macula-status at time of RD repair. Pre-operative IS/OS disruption was the OCT feature best predictive of visual acuity.

Outcomes of Eyes Lost to Follow-up with Neovascular Age-Related Macular Degeneration Receiving Intravitreal Anti-Vascular Endothelial Growth Factor.

PURPOSE: To determine outcomes of eyes with neovascular age-related macular degeneration (nAMD) receiving intravitreal anti-vascular endothelial growth factor (VEGF) injections who return after a period of being lost to follow-up (LTFU). DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: Eyes that received intravitreal bevacizumab, ranibizumab, or aflibercept for nAMD and were LTFU for >6 months. METHODS: Comparison of visual outcomes and structural parameters at the visit before LTFU, return visit, and final visit. MAIN OUTCOME MEASURES: Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), presence of subretinal fluid and intraretinal fluid, and central foveal thickness (CFT) by OCT. RESULTS: A total of 93 eyes of 77 patients were included in the analysis. Mean duration from date of LTFU to return was 346 (±122) days. Overall, 53.7% of patients had worse median logMAR VA by the final visit. Median logMAR VA worsened from 0.60 (0.40-2.00) (Snellen 20/80 [20/50-20/2000]) at the visit before LTFU to 1.00 (0.48-2.00) (20/200 [20/60-20/2000]) at the return visit (P < 0.001). Median logMAR VA remained worse at 6- and 12-months after return from LTFU: 1.00 (0.48-2.00) (20/200 [20/60-20/2000]) (P = 0.001) and 0.70 (0.44-1.30) (20/100 [20/55-20/399]) (P = 0.004), respectively. Despite a mean of 383 (±270) days of follow-up after returning and 5.0 (±5.1) additional injections, the median logMAR VA remained worse at 1.00 (0.54-2.00) (20/200 [20/70-20/2000]) at the final visit compared with the visit before LTFU (P < 0.001). There was greater worsening in mean logMAR VA from the visit before LTFU to the final visit in eyes that received bevacizumab (0.32) and ranibizumab (0.28) compared with aflibercept (P = 0.003, P = 0.04, and P = 0.03, respectively). Mean CFT increased from 201 (±106) µm at the visit before LTFU to 240 (±147) µm at return (P = 0.004). By the final visit, the mean CFT had decreased to 183 (±101) µm, which was not significantly different from the visit before LTFU (P = 0.10). CONCLUSIONS: Eyes with nAMD receiving intravitreal anti-VEGF that were LTFU experience significant VA decline at the return visit that persists on final follow-up despite normalization of CFT.

Visual Impairment and Eye Disease Among Children of Migrant Farmworkers.

PURPOSE: To determine the prevalence of reduced visual acuity and ocular disease in the children of migrant farmworkers in Georgia. METHODS: A retrospective chart review of data acquired by a vision screening was performed on 156 Haitian and Hispanic children of migrant farmworkers attending a summer school in Georgia. Reduced visual acuity at presentation was analyzed and stratified by ethnicity, type of ocular disease, and immediate resolution with refractive correction. RESULTS: The authors found that 20% of migrant farmworker children have a high prevalence of reduced visual acuity in the worse eye. Of those with worse-eye reduced visual acuity, 83% had uncorrected refractive error. The prevalence of uncorrected refractive error from astigmatism and high astigmatism was significantly higher among Hispanics than Haitians. The prevalence of amblyopia suspects among migrant farmworker children was 3%. Of the amblyopia suspects, 80% were anisometropic. CONCLUSIONS: Children of migrant farmworkers in Georgia have a higher rate of reduced visual acuity, largely from uncorrected refractive error, when compared to other Hispanic and African American children in the United States with a prevalence more aligned to children in Asian and Latin American countries than school children in the United States. This illustrates the need for improved access to screening and care in this vulnerable population. [J Pediatr Ophthalmol Strabismus. 2019;56(1):28-34.].

Efficacy of the combination of carteolol hydrochloride + latanoprost in the treatment of glaucoma and ocular hypertension.

INTRODUCTION: The only evidence-based mechanism for prevention and treatment of glaucomatous optic neuropathy is decreasing the intraocular pressure (IOP). Prescribing multiple ocular hypotensive agents, such as the combination of carteolol and latanoprost, may synergistically improve IOP; however, doing so may increase the complexity of a medication regimen, in turn, impairing patient adherence. Fixed-combination glaucoma medications offer convenience and effectiveness. New to this class of glaucoma medication is fixed combination carteolol-latanoprost (FCCL). Area covered: This review intends to give the reader a better understanding of the efficacy of the combination of carteolol and latanoprost separately, and where FCCL fits into the vast medical arsenal of IOP drops. Furthermore, it outlines the particular pharmacologic mechanisms targeted, the pharmacokinetics, effectiveness, the advantages of fixed-combination administration, and tolerability. Expert opinion: The combination of carteolol and latanoprost, separately or in a fixed-combination, is more effective than either drug alone. Given the early stage in development of FCCL, it has yet to be determined how FCCL compares to other fixed-combination medications. However, pending further approval, fixed-combination carteolol-latanoprost may represent a reasonable alternative for a patient whose IOP is inadequately controlled on a prostaglandin analog alone and for whom a simplified combination is preferred.