External Disruption of Ocular Development in Utero.

The intricate steps of human ocular embryology are impacted by cellular and genetic signaling pathways and a myriad of external elements that can affect pregnancy, such as environmental, metabolic, hormonal factors, medications, and intrauterine infections. This review focuses on presenting some of these factors to recognize the multifactorial nature of ocular development and highlight their clinical significance. This review is based on English-language articles sourced from PubMed, Web of Science, and Google Scholar; keywords searched included "ocular development in pregnancy," "ocular embryology," "maternal nutrition," "ophthalmic change," and "visual system development." While some animal models show the disruption of ocular embryology from these external factors, there are limited post-birth assessments in human studies. Much remains unknown about the precise mechanisms of how these external factors can disrupt normal ocular development in utero, and more significant research is needed to understand the pathophysiology of these disruptive effects further. Findings in this review emphasize the importance of additional research in understanding the dynamic association between factors impacting gestation and neonatal ocular development, particularly in the setting of limited resources.

Ophthalmology Departments Remain Among the Least Diverse Clinical Departments at United States Medical Schools.

PURPOSE: The current demographics of the ophthalmology workforce do not reflect the diverse United States population, which has implications for addressing health disparities. The demographics of ophthalmology department faculty may influence the recruitment of underrepresented students into the field. This study sought to determine how the racial and ethnic demographics of ophthalmology department faculty compare with those of other clinical departments at United States medical schools. DESIGN: Secondary data analysis of medical school faculty demographic data from the 2019 American Association of Medical Colleges (AAMC) Faculty Roster. PARTICIPANTS: Clinical faculty and department chairs at United States medical schools. METHODS: We analyzed the racial and ethnic demographics of clinical department faculty and department chairpersons using data from the 2019 AAMC Faculty Roster. We calculated the proportion of underrepresented minority (URM) faculty in ophthalmology and in 17 other clinical departments. We analyzed these data for statistically significant differences between ophthalmology and other clinical departments. In addition, we compared the percentage of URM ophthalmology faculty with the proportion of URM persons among graduating United States medical students and in the United States population using data from the Medical School Graduation Questionnaire and the United States census, respectively. MAIN OUTCOME MEASURES: The proportion of URM persons, defined as Black, Hispanic or Latino, Native American, or Native Hawaiian or Pacific Islander among clinical faculty and department chairs. RESULTS: Ophthalmology faculty are less racially and ethnically diverse than graduating medical students and the general United States population. When compared with 17 other clinical departments, ophthalmology has the third-lowest proportion of URM faculty, with only radiology and orthopedic surgery having a smaller proportion of URM faculty. These differences were statistically significant in most departments (12 of 18). No statistically significant difference was found in the proportion of URM department chairs in ophthalmology compared with most other clinical departments, although the absolute number of URM chairs in ophthalmology is low at only 8 chairpersons. CONCLUSIONS: More work must be done to increase the recruitment of URM physicians into ophthalmology faculty positions to obtain parity with other clinical departments and with the diverse patient populations that physicians serve.

Ophthalmic Medication Expenditures and Out-of-Pocket Spending: An Analysis of United States Prescriptions from 2007 through 2016.

PURPOSE: To estimate temporal trends in total and out-of-pocket (OOP) expenditures for ophthalmic prescription medications among adults in the United States. DESIGN: Retrospective, longitudinal cohort study. PARTICIPANTS: Participants in the 2007 through 2016 Medical Expenditure Panel Survey (MEPS) 18 years of age or older. The MEPS is a nationally representative survey of the noninstitutionalized, civilian United States population. METHODS: We estimated trends in national and per capita annual ophthalmic prescription expenditures by pooling data into 2-year cycles and using weighted linear regressions. We also identified characteristics associated with greater total or OOP expenditures with multivariate weighted linear regression. Costs were adjusted to 2016 United States dollars using the gross domestic product price index. MAIN OUTCOME MEASURES: Trends in total and OOP annual expenditures for ophthalmic medications from 2007 through 2016 as well as factors associated with greater expenditures. RESULTS: From 2007 through 2016, 9989 MEPS participants (4.2%) reported ophthalmic medication prescription use. Annual ophthalmic medication use increased from 10.0 to 12.2 million individuals from 2007 and 2008 through 2015 and 2016. In this same period, national expenditures for ophthalmic medications increased from $3.39 billion to $6.08 billion and OOP expenditures decreased from $1.34 to $1.18 billion. Per capita expenditure increased from $338.72 to $499.42 (P < 0.001), and per capita OOP expenditure decreased from $133.48 to $96.67 (P < 0.001) from 2007 and 2008 through 2015 and 2016, respectively. From 2015 through 2016, dry eye (29.5%) and glaucoma (42.7%) medications accounted for 72.2% of all ophthalmic medication expenditures. Patients who were older than 65 years (P < 0.001), uninsured (P < 0.001), and visually impaired (P < 0.001) were significantly more likely to have greater OOP spending on ophthalmic medications. CONCLUSIONS: Total ophthalmic medication expenditure in the United States increased significantly over the last decade, whereas OOP expenses decreased. Increases in coverage, copayment assistance, and use of expensive brand drugs may be contributing to these trends. Policy makers and physicians should be aware that rising overall drug expenditures ultimately may increase indirect costs to the patient and offset a decline in OOP prescription drug spending.

Corneal hysteresis and anterior segment optical coherence tomography anatomical parameters in primary angle closure suspects.

IMPORTANCE: Corneal hysteresis (CH) is a dynamic marker of structural and functional changes in the cornea associated with intraocular pressure (IOP) and central corneal thickness, but its utility in assessing primary angle closure suspects (PACS) has not been fully elucidated. BACKGROUND: This study assesses if anterior segment measurements correlate with CH in PACS patients. DESIGN: IRB-approved retrospective review of imaging and records at a university practice. PARTICIPANTS: Sixty-three eyes from 37 patients diagnosed as PACS, without other ocular pathology. METHODS: Every eye underwent measurements including: ocular response analyzer (ORA), anterior segment optical coherence tomography (OCT) and a clinical evaluation. ORA measurements were correlated with other anatomic parameters using a mixed effects multivariable linear regression framework. MAIN OUTCOME MEASURES: ORA measurements included: CH, corneal resistance factor, Goldmann IOP (IOPg ) and corneal compensated IOP (IOPcc ). Anterior segment OCT measurements included: central corneal thickness (CCTOCT ), nasal and temporal peripheral corneal thicknesses (PCT1 and PCT2), anterior chamber depth (ACD), nasal angle to temporal angle distance (ATA) and temporal and nasal angle measurements. Clinical measurements included: central corneal thickness via pachymetry, IOP measured by Goldmann applanation, axial length by A-scan ultrasound and spherical equivalent. RESULTS: CH was negatively correlated with IOPcc, and ACD CH was positively correlated with CCTOCT , CCTp , CRF, PCT1 and PCT2. Females were found to have lower CH. In multivariable regression controlling for gender, CCT, PCT, IOP and ACD, no correlation was seen between CH and anatomic measurements. CONCLUSIONS AND RELEVANCE: CH values in PACS do not correlate with anterior segment anatomy.

Incremental Revisions across the Life Span of Ophthalmic Devices after Initial Food and Drug Administration Premarket Approval, 1979-2015.

PURPOSE: To characterize the frequency, nature, and regulatory mechanisms by which ophthalmic devices are iteratively modified after initial Food and Drug Administration (FDA) Premarket Approval (PMA). DESIGN: Retrospective cross-sectional analysis using publicly available FDA data. PARTICIPANTS: Ophthalmic devices initially approved via the FDA's PMA pathway between January 1, 1979 and December 31, 2015. METHODS: We used the FDA's PMA Database to identify and characterize initial approvals and subsequent postmarket modifications to Class III ophthalmic devices. The FDA Recalls Database was used to identify associated safety events. MAIN OUTCOME MEASURES: Median iterated life span (timespan across which modifications occurred after initial PMA) and median number of supplements approved per device, by device type, and overall, stratified by regulatory pathway and modification type. RESULTS: Between 1979 and 2015, the FDA approved 168 original ophthalmic devices via the PMA pathway and 2813 subsequent modifications. More than one third (n = 64; 38%) of original approvals were intraocular lenses. Overall, devices underwent a median of 11 postmarket modifications (interquartile range [IQR], 3-24.8) across a median 10.0-year iterated life span (IQR, 4.1-16.7). The majority of devices (n = 144; 86%) underwent more than 1 postapproval modification, including more than 1 design modification (n = 84; 50%). The median number of changes altering device design or labeling was 3.5 (IQR, 1-9). Although manufacturing alterations (n = 834 of 2813; 30%) were the most frequent type of revision, changes involving device design (n = 667; 24%) and labeling (n = 417; 15%) were common. Recalled devices underwent more frequent postapproval modifications per year (median, 1.4; IQR, 0.7-2.3; mean, 1.5; 95% confidence interval, 1.1-1.9) in the period preceding recall than did nonrecalled devices (median, 0.5; IQR, 0.2-1.1; mean, 0.8; 95% confidence interval, 0.7-1.0) across their market approval period (P < 0.001). CONCLUSIONS: Most ophthalmic devices approved via the FDA's PMA pathway have undergone extensive revisions, including serial design and labeling changes, since their initial approvals, often without supporting clinical data. Ophthalmologists should take into consideration that cumulative revisions may render the clinical evidence that supported an original FDA approval less relevant to newer device models.

Irreversible Blindness Following Periocular Autologous Platelet-Rich Plasma Skin Rejuvenation Treatment.

A 49-year-old woman developed acute visual loss in the right eye following bilateral cosmetic platelet-rich plasma injections to rhytids in the glabellar region. External exam showed skin necrosis in the region over the right rhytids and restricted right ocular motility. Dilated fundus exam was significant for ophthalmic artery occlusion. Imaging revealed right eye extraocular muscle ischemia and optic nerve infarction, along with right frontal, parietal, and occipital lobe infarction. Work-up for thromboembolic and vascular etiologies were negative. To our knowledge, this is the first case reported of extensive ischemia following autologous platelet-rich plasma therapy.

Efficacy of the Amsler Grid Test in Evaluating Glaucomatous Central Visual Field Defects.

PURPOSE: To investigate the efficacy of the Amsler grid test in detecting central visual field (VF) defects in glaucoma. DESIGN: Prospective, cross-sectional study. PARTICIPANTS: Patients with glaucoma with reliable Humphrey 10-2 Swedish Interactive Threshold Algorithm standard VF on the date of enrollment or within the previous 3 months. METHODS: Amsler grid tests were performed for each eye and were considered "abnormal" if there was any perceived scotoma with missing or blurry grid lines within the central 10 degrees ("Amsler grid scotoma"). An abnormal 10-2 VF was defined as ≥3 adjacent points at P < 0.01 with at least 1 point at P < 0.005 in the same hemifield on the pattern deviation plot. Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area were calculated with the 10-2 VF as the clinical reference standard. Among eyes with an abnormal 10-2 VF, regression analyses were performed between the Amsler grid scotoma area and the 10-2 VF parameters (mean deviation [MD], scotoma extent [number of test points with P < 0.01 in total deviation map] and scotoma mean depth [mean sensitivity of test points with P < 0.01 in total deviation map]). MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of the Amsler grid scotoma area. RESULTS: A total of 106 eyes (53 patients) were included (mean ± standard deviation age, 24-2 MD and 10-2 MD = 66±12 years, -9.61±8.64 decibels [dB] and -9.75±9.00 dB, respectively). Sensitivity, specificity, and positive and negative predictive values of the Amsler grid test were 68%, 92%, 97%, and 46%, respectively. Sensitivity was 40% in eyes with 10-2 MD better than -6 dB, 58% in eyes with 10-2 MD between -12 and -6 dB, and 92% in eyes with 10-2 MD worse than -12 dB. The area under the receiver operating characteristic curve of the Amsler grid scotoma area was 0.810 (95% confidence interval, 0.723-0.880, P < 0.001). The Amsler grid scotoma area had the strongest relationship with 10-2 MD (quadratic R(2)=0.681), followed by 10-2 scotoma extent (quadratic R(2)=0.611) and 10-2 scotoma mean depth (quadratic R(2)=0.299) (all P < 0.001). CONCLUSIONS: The Amsler grid can be used to screen for moderate to severe central vision loss from glaucoma.

Effect of supine body position on central corneal thickness.

BACKGROUND: To evaluate the effect of supine body position on central corneal thickness (CCT) in open-angle glaucoma patients and in healthy subjects. DESIGN: A cross-sectional study at a university eye clinic. PARTICIPANTS: Twenty-three subjects were recruited in each group, for a total of 46 patients. METHODS: CCT was measured using an ultrasound pachymeter in each subject. Three consecutive measurements in each eye were first taken in the sitting position, and repeated after 10 min and 30 min in a supine position. Results were analyzed using mixed model repeated measures, which adjusted for age, gender and laterality of eyes. MAIN OUTCOME MEASURES: CCT RESULTS: In healthy subjects, CCT decreased with supine positioning at 10 min (mean = -5.2 µm, P = 0.0043) and at 30 min (mean = -6.5 µm, P < 0.0001). In the glaucoma group, CCT decreased with supine positioning at 10 min (mean = -6.7 µm, P = 0.0043) and at 30 min (mean = -10.2 µm, P < 0.0001). There was no statistically significant difference between the CCT at 10 min supine and at 30 min supine in the healthy subjects (P = 0.37) and glaucoma patients (P = 0.14). CCT was shown to decrease linearly over time (P < 0.0001), and the slopes were not statistically different between groups (P = 0.40). CONCLUSIONS: CCT is a dynamic measurement that can be influenced by body position. It decreases linearly in the first 30 min of supine positioning at a similar rate in both open angle glaucoma patients and in healthy subjects.

Development and Evaluation of Aeyeconsult: A Novel Ophthalmology Chatbot Leveraging Verified Textbook Knowledge and GPT-4.

OBJECTIVE: There has been much excitement on the use of large language models (LLMs) such as ChatGPT in ophthalmology. However, LLMs are limited in that they are trained on unverified information and do not cite their sources. This paper highlights a new methodology to create a generative AI chatbot to answer eye care related questions which uses only verified ophthalmology textbooks as data and cites its sources. SETTING: Yale School of Medicine Department of Ophthalmology and Visual Science. DESIGN/METHODS: Aeyeconsult, an ophthalmology chatbot, was developed using GPT-4 (the LLM used to power the publicly available chatbot ChatGPT-4), LangChain, and Pinecone. Ophthalmology textbooks were processed into embeddings and stored in Pinecone. User queries were similarly converted, compared to stored embeddings, and GPT-4 generated responses. The interface was adapted from public code. Both Aeyeconsult and ChatGPT-4 were tested on the same 260 questions from OphthoQuestions.com, with the first response from Aeyeconsult and ChatGPT-4 recorded as the answer. RESULTS: Aeyeconsult outperformed ChatGPT-4 on the OKAP dataset, with 83.4% correct answers compared to 69.2% (p = 0.0118). Aeyeconsult also had fewer instances of no answer and multiple answers. Both systems performed best in General Medicine, with Aeyeconsult achieving 96.2% accuracy. Aeyeconsult's weakest performance was in Clinical Optics at 68.1%, but it still outperformed ChatGPT-4 in this category (45.5%). CONCLUSION: LLMs may be useful in answering ophthalmology questions but their trustworthiness and accuracy is limited due to training on unverified internet data and lack of source citation. We used a new methodology, using verified ophthalmology textbooks as source material and providing citations, to mitigate these issues, resulting in a chatbot more accurate than ChatGPT-4 in answering OKAPs style questions.

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.

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.

Kahook Dual Blade versus Trabectome (KVT): Comparing Outcomes in Combination with Cataract Surgery.

Purpose: To compare the safety and efficacy of Kahook Dual Blade (KDB) versus Trabectome with cataract surgery in reducing intraocular pressure (IOP) and medications used by patients with glaucoma. Methods: Retrospective chart review comparing eyes after KDB or Trabectome with cataract surgery at 2 academic centers. Surgical success was defined as IOP <21 mmHg with ≥20% IOP reduction at post-operative month 12 (POM12). Changes in IOP, number of glaucoma medications, and adverse events were assessed. Results: Ninety eyes in the KDB group and 125 eyes in the Trabectome group were included. Mean changes in IOP at POM12 were -1.9 ± 4.9 mmHg (11.2%, P = 0.002) in the KDB group and -3.5 ± 5.5 mmHg (19.1%, P < 0.001) in the Trabectome group, without a significant difference between the groups (P = 0.20). Mean change in glaucoma medications at POM12 was -0.8 ± 1.5 in the KDB group (58%, P < 0.001) and -0.3 ± 1.3 (38%, P = 0.003) in the Trabectome group, with KDB having a greater decrease in medications (P = 0.02). The percentage of eyes achieving success was 30% for the KDB group and 54% for the Trabectome group (P = 0.01). Hyphema was the most common complication, with an incidence of 3% for the KDB group and 14% for the Trabectome group (P = 0.01). Conclusion: KDB or Trabectome with cataract surgery is safe and effective at lowering IOP and medication burden, with KDB resulting in a greater reduction in medications and Trabectome more frequently achieving success with an increased incidence of hyphema. Considering the study's limitations, the outcomes were similar.

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.

Enhanced depth imaging optical coherence tomography of deep optic nerve complex structures in glaucoma.

OBJECTIVE: To assess the usefulness of enhanced depth imaging (EDI) optical coherence tomography (OCT) for evaluating deep structures of the optic nerve complex (ONC; optic nerve head and peripapillary structures) in glaucoma. DESIGN: Prospective, observational study. PARTICIPANTS: Seventy-three established glaucoma patients (139 eyes) with a range of glaucomatous damage. METHODS: Serial horizontal and vertical EDI OCT images of the ONC were obtained from both eyes of each participant. Deep ONC structures, including the lamina cribrosa (LC), short posterior ciliary artery (SPCA), central retinal artery (CRA), central retinal vein (CRV), peripapillary choroid and sclera, and subarachnoid space around the optic nerve, were investigated for their visibility and morphologic features. MAIN OUTCOME MEASURES: Deep ONC structures identified in EDI OCT images. RESULTS: Visual field mean deviation of 139 included eyes was -11.8 ± 8.6 dB (range, -28.70 to -2.01 dB). The anterior laminar surface was identified in all eyes in the central laminar area and in 91 (65%) eyes in the periphery beneath the neuroretinal and scleral rims or vascular structures. The LC pores with various shapes and sizes were visualized in 106 (76%) eyes, mainly in the central and temporal areas of the LC. Localized LC lesions seen on optic disc photographs were identified as focal LC defects (partial loss of LC tissue) in the EDI OCT images. The locations of the CRA and CRV were identified in all eyes. In the LC, the CRA maintained a straight shape with a consistent caliber, but the CRV (and tributaries) assumed a more irregular shape. The SPCAs, their branches through the emissary canals in the sclera, or both were visualized in 120 (86%) eyes. The subarachnoid space around the optic nerve was identified with varying degrees of clarity in 25 eyes (18%): 17 had high myopia and extensive parapapillary atrophy. Intrachoroidal cavitation or choroidal schisis, which had been unrecognized clinically, was identified in 2 eyes (1%) with high myopia. CONCLUSIONS: Enhanced depth imaging OCT was able to visualize a wide variety of deep ONC structures in glaucoma patients and may be helpful in detecting, conceptualizing, and understanding basic and complicated in vivo anatomic and pathologic features of the ONC in glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Rates of visual field progression in distinct optic disc phenotypes.

BACKGROUND: To determine if optic disc phenotype is correlated with the rate of glaucomatous visual field progression. DESIGN: Retrospective cohort. PARTICIPANTS OR SAMPLES: Treated glaucoma patients. METHODS: The optic disc stereophotographs of glaucoma patients were reviewed by two investigators masked to all clinical and perimetric data. Each disc was classified as focal ischaemic, myopic, senile sclerotic and generalized enlargement. Visual field progression (defined as at least two adjacent test points in the same hemifield progressing by more than 1.0 dB/year at P < 0.01) was evaluated using automated pointwise linear regression. MAIN OUTCOME MEASURES: Association between optic disc phenotypes and other clinical variables and rates of visual field progression. RESULTS: 264 optic disc stereophotographs (127 generalized enlargement, 41 focal ischaemic, 54 myopic and 42 senile sclerotic) were evaluated. In the univariate analyses, it was found that patients with senile sclerotic discs were older (p = 0.002) and those with generalized enlargement had better baseline visual field mean deviation (p < 0.001) and higher intraocular pressure (p = 0.006) compared with the other groups. More disc haemorrhages were detected in the focal ischaemic and senile sclerotic groups (p = 0.010). After adjusting for other risk factors (intraocular pressure, age, central corneal thickness, disc haemorrhage), there were no differences among groups regarding the risk (p = 0.58) and velocity (p = 0.21) of visual field progression. CONCLUSIONS: Visual field progression was similar among the four optic disc phenotypes in treated glaucoma after adjusting for other known risk factors. The division of disc appearance into clinical phenotypes does not appear to provide independent information regarding the risk of progression in clinical practice.

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.

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.

Anterior Subcapsular Cataract Formation With Long-term Topical Netarsudil Treatment for Glaucoma.

PURPOSE: The purpose of this study was to describe anterior subcapsular cataract development in patients on long-term topical netarsudil use. PATIENTS AND METHODS: This clinical observational study summarizes a similar cataract pattern demonstrated in a series of patients from a single physician practice and a university-based outpatient clinic during their routine clinical follow-up visits from October 2020 to August 2021. All patients have been using topical netarsudil once daily for at least 15 months. No anterior capsular changes have been observed in any patient at the time when netarsudil was initiated. RESULTS: Five eyes from 4 patients between the ages of 41 and 61 and 1 eye from a patient aged 84 were found to develop anterior subcapsular opacities 15 to 37 months after beginning netarsudil. These cataracts were overall small, 1 to 3 mm, round, oval or ring-shaped, central or paracentral with mild density. No other risk factors for cataract development apart from age were found in these patients. CONCLUSION: Patients on long-term netarsudil should be monitored for potential development of anterior subcapsular cataracts.

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.