Virtual Visits in Ophthalmology: Timely Advice for Implementation During the COVID-19 Public Health Crisis.

Virtual visits (VVs) are necessitated due to the public health crisis and social distancing mandates due to COVID-19. However, these have been rare in ophthalmology. Over 3.5 years of conducting >350 ophthalmological VVs, our group has gained numerous insights into best practices. This communication shares these experiences with the medical community to support patient care during this difficult time and beyond. We highlight that mastering the technological platform of choice, optimizing lighting, camera positioning, and "eye contact," being thoughtful and creative with the virtual eye examination, and ensuring good documenting and billing will make a successful and efficient VV. Moreover, we think these ideas will stimulate further VV creativity and expertise to be developed in ophthalmology and across medicine. This approach, holds promise for increasing its adoption after the crisis has passed.

A Dosing Study of Bevacizumab for Retinopathy of Prematurity: Late Recurrences and Additional Treatments.

PURPOSE: Intravitreal bevacizumab is increasingly used to treat severe retinopathy of prematurity (ROP), but it enters the bloodstream, and there is concern that it may alter development of other organs. Previously we reported short-term outcomes of 61 infants enrolled in a dose de-escalation study, and we report the late recurrences and additional treatments. DESIGN: Masked, multicenter, dose de-escalation study. PARTICIPANTS: A total of 61 premature infants with type 1 ROP. METHODS: If type 1 ROP was bilateral at enrollment, then the study eye was randomly selected. In the study eye, bevacizumab intravitreal injections were given at de-escalating doses of 0.25 mg, 0.125 mg, 0.063 mg, or 0.031 mg; if needed, fellow eyes received 1 dose level higher: 0.625 mg, 0.25 mg, 0.125 mg, or 0.063 mg, respectively. After 4 weeks, additional treatment was at the discretion of the investigator. MAIN OUTCOME MEASURES: Early and late ROP recurrences, additional treatments, and structural outcomes after 6 months. RESULTS: Of 61 study eyes, 25 (41%; 95% confidence interval [CI], 29%-54%) received additional treatment: 3 (5%; 95% CI, 1%-14%) for early failure (within 4 weeks), 11 (18%; 95% CI, 9%-30%) for late recurrence of ROP (after 4 weeks), and 11 (18%; 95% CI, 9%-30%) for persistent avascular retina. Re-treatment for early failure or late recurrence occurred in 2 of 11 eyes (18%; 95% CI, 2%-52%) treated with 0.25 mg, 4 of 16 eyes (25%; 95% CI, 7%-52%) treated with 0.125 mg, 8 of 24 eyes (33%; 95% CI, 16%-55%) treated with 0.063 mg, and 0 (0%; 95% CI, 0%-31%) of 10 eyes treated with 0.031 mg. By 6 months corrected age, 56 of 61 study eyes had regression of ROP with normal posterior poles, 1 study eye had developed a Stage 5 retinal detachment, and 4 infants had died of preexisting medical conditions. CONCLUSIONS: Retinal structural outcomes are very good after low-dose bevacizumab treatment for ROP, although many eyes received additional treatment.

Periodic Trends in Internet Searches for Ocular Symptoms in the US.

PURPOSE: To identify periodic trends in internet searches for ocular symptoms and to determine the seasonal peaks and troughs. METHODS: This cross-sectional study examined publicly available Google Trends data from the United States (01/01/2015 to 12/31/2019). A list of common ocular symptoms was compiled from the American Academy of Ophthalmology Eye Health website and Wills Eye Manual. Ocular symptoms were stratified into categories involving vision change, eye pain, or eye redness. The search volume over time for each term was modeled using periodic regression functions and the goodness-of-fit was reported. Fisher's exact tests were used to compare the characteristics of periodic vs. non-periodic query terms. RESULTS: Seasonal trends were demonstrated by 45% (48/106) of the ocular symptoms included in this investigation. Search terms with best fit to the periodic model included stye (r2 = 0.89), pink eye (r2 = 0.82), dry eye (r2 = 0.76), blurry vision (r2 = 0.72), and swollen eye (r2 = 0.71). Periodic search terms were more likely to involve eye redness (21% vs. 11%, p = .014) and less likely to involve vision change (11% vs. 36%; p < .001). Periodic queries involving eye redness most often peaked in the spring and those involving eye pain peaked in the summer. CONCLUSION: Ocular symptom queries directly reflect seasonal trends for allergic eye disease and ocular trauma. Search query analyses can serve as accurate epidemiological tools with research and real-world clinical applications.

The impact of the COVID-19 pandemic on the surgical volume of pediatric ophthalmology and strabismus fellows.

This study used data from the annual fellowship survey over 7 academic years (2014-15 to 2020-21) to describe the trends in surgical experience for pediatric ophthalmology and strabismus fellows and to quantify the impact of the COVID-19 pandemic on trainee surgical volume. The overall number of procedures performed by fellows in the primary surgeon role declined during the first academic year impacted by the pandemic but recovered in the second year. There was an increase in the number of intraocular cases performed per year during the 7-year study interval.

Electroretinographic Responses in Retinopathy of Prematurity Treated Using Intravitreal Bevacizumab or Laser.

PURPOSE: Intravitreal injection of bevacizumab (IVB) offers advantages over laser photoablation for treatment of type 1 retinopathy of prematurity (ROP). However, retinal function has not, to date, been quantitatively compared following these interventions. Therefore, electroretinography (ERG) was used compare retinal function among eyes treated using IVB or laser, and control eyes. In addition, among the IVB-treated eyes, ERG was used to compare function in individuals in whom subsequent laser was and was not required. DESIGN: Prospective clinical cohort study. METHODS: ERG was used to record dark- and light-adapted stimulus/response functions in 21 children treated using IVB (12 of whom required subsequent laser in at least 1 eye for persistent avascular retina [PAR]). Sensitivity and amplitude parameters were derived from the a-wave, b-wave, and oscillatory potentials (OPs), representing activity in photoreceptor, postreceptor, and inner retinal cells, respectively. These parameters were then referenced to those of 76 healthy, term-born controls and compared to those of 10 children treated using laser only. RESULTS: In children with treated ROP, every ERG parameter was significantly below the mean in controls. However, these significant ERG deficits did not differ between IVB- and laser-treated eyes. Among children treated using IVB, no ERG parameter was significantly associated with dose or need for subsequent laser. CONCLUSION: Retinal function was significantly impaired in treated ROP eyes. Function in IVB-treated eyes did not differ from that in laser-treated eyes. Functional differences also did not distinguish those IVB-treated eyes that would subsequently need laser for PAR.

Topical cenegermin 0.002% for pediatric neurotrophic keratopathy.

PURPOSE: To evaluate the efficacy and safety of cenegermin 0.002% ophthalmic drops in the management of pediatric neurotrophic keratopathy (NK). METHODS: Retrospective chart review of children under the age of 18 years diagnosed with NK at Boston Children's Hospital/Massachusetts Eye and Ear Infirmary and treated with topical cenegermin 0.002% ophthalmic solution between June 2018 and June 2021 was performed. Data collection included etiology of NK, age at time of initiation of topical cenegermin, laterality, ethnicity, gender, history of previous ocular therapy, pre- and post-therapy best corrected visual acuity, pre- and post-therapy cornea examination, any adverse events from topical cenegermin, associated ocular conditions, and history of ocular surgeries. RESULTS: The current study includes four eyes of four pediatric patients with a mean age of 4.5 ± 2.0 years at the time of initiation of topical cenegermin therapy. The mean time from NK diagnosis until start of topical cenegermin drops was 5.2 ± 4.3 months and mean follow-up time was 15 ± 9.6 months. In all four patients, marked improvement in epitheliopathy was demonstrated after completion of therapy. Best corrected visual acuity was measurable in 3 eyes of 3 patients, and it improved from a mean of 0.07 ± 0.01 to a mean of 0.29 ± 0.26 (P = 0.3). No adverse events related to cenegermin therapy were noted. CONCLUSION: Topical cenegermin was effective in improving corneal healing for pediatric NK.

Comparison of fellowship match opportunities and results across pediatric surgical subspecialities.

There is a nationwide shortage of pediatric ophthalmologists, with trends in fellowship applicants foreshadowing a continued reduction in the number of active pediatric ophthalmologists in the years ahead. In this study, we investigated whether similar fellowship applicant shortages exist in other pediatric surgical subspecialties. We compared the match statistics of six pediatric surgical fellowships from 2015 to 2020. During the 6-year interval, a median of 12.2 pediatric ophthalmology fellowship positions (IQR, 12.1-12.4) were offered per 100 graduating residents, 8.7% of ophthalmology residents (IQR, 8.3%-9.3%) pursued pediatric subspecialty training, and 72% of available pediatric fellowship positions (IQR, 69%-74%) were filled. Pediatric general surgery had the highest percentage of available fellowship positions filled, 99% (IQR, 98%-100%), which was significantly higher than for pediatric ophthalmology (P = 0.024). None of the other subspecialties had a significant difference in available positions filled compared to pediatric ophthalmology (P > 0.05).

Etiology and outcomes of childhood glaucoma at a tertiary referral center.

PURPOSE: To describe the etiology, clinical features, and outcomes for a large contemporary cohort of children presenting with glaucoma at a tertiary referral center. METHODS: The medical records of patients presenting to Boston Children's Hospital from January 2014 to July 2019 with a diagnosis of childhood glaucoma were retrospectively reviewed. Data regarding etiology, treatment, and visual and anatomic outcomes were collected; visual acuity outcomes were analyzed by laterality and diagnosis categories, using the Childhood Glaucoma Research Network (CGRN) classifications. RESULTS: A total of 373 eyes of 246 patients (51% males) diagnosed with glaucoma before 18 years of age were identified. Mean follow-up was 7.04 ± 5.61 years; 137 cases were bilateral. The mean age at diagnosis was 4.55 ± 5.20 years. The most common diagnoses were glaucoma following cataract surgery (GFCS, 36.5%) and primary congenital glaucoma (PCG, 29.0%). Overall, 164 eyes (44.0%) underwent at least one glaucoma surgery. Intraocular pressure (IOP) was ≤21 mm Hg with or without glaucoma medications in 300 eyes (80.4%) at the last follow-up visit. Poor final best-corrected visual acuity (≤20/200) was found in 110 eyes; patients with poor final visual acuity tended to have poor visual acuity at presentation. The most common reason for poor vision was amblyopia. Uncontrolled IOP was an uncommon cause for vision loss. CONCLUSIONS: Childhood glaucoma can be challenging to manage, but poor vision usually results from amblyopia or presence of other ocular abnormalities or syndromes rather than glaucomatous optic neuropathy.

A decline in the strabismus surgical experience of ophthalmology residents in the United States from 2010 to 2019.

Subspecialty exposure during residency can influence the future pursuit of fellowship training. In this study, we compared the trends in strabismus surgical experience reported by graduating ophthalmology residents in the United States with other categories of ophthalmic surgery. Over the 10-year period (2010-2019), there was a decline in the total number of strabismus procedures performed during residency by ophthalmology residents graduating in a given year (1.4 fewer cases per year; 95% CI, 1.1-1.6 [P < 0.001]). Although several surgical categories experienced a decrease in cases performed in the assistant role, strabismus surgery was the only category with a decrease in cases performed in the surgeon role (0.4 fewer cases per year; 95% CI, 0.3-0.5 [P < 0.001]).

Longitudinal Change of Refractive Error in Retinopathy of Prematurity Treated With Intravitreal Bevacizumab or Laser Photocoagulation.

PURPOSE: To compare progression of myopia and refractive error in former premature infants with retinopathy of prematurity (ROP) treated using intravitreal bevacizumab (IVB) or laser. DESIGN: Retrospective clinical cohort study. METHODS: We identified premature infants with ROP treated using IVB from 2011 to 2020 and compared their longitudinal cycloplegic refraction data to that of infants with ROP treated using laser during the same timeframe. A subset of infants treated using IVB also underwent additional treatment using laser. We included cycloplegic refractions from 789 cumulative visits over a median 3.2 years. We used a linear mixed-effects model with a log decay function to evaluate how refraction changed with age after treatment. RESULTS: In aggregate, the model estimated a significant (P < .001) trend in refraction-from slight hyperopia to relatively more myopic states. However, progression in laser-treated eyes was significantly (P < .001) more rapid, regardless of treatment with IVB. The number of laser spots resulted in increased myopic progression by approximately 0.16 diopters per 100 laser spots. Both ROP stage and zone had a significant effect on myopic progression, with more severe disease resulting in faster myopic progression. Random effects, including individual subject variation with nested variance for left and right eye, accounted for 86.4% of the remaining variance not explained by age and treatment. CONCLUSIONS: Laser treatment for severe ROP increases the trend to severe myopia. In our sample, IVB did not affect myopic progression but did substantially reduce the amount of consequent laser required to treat ROP. The effect of laser persists after accounting for differences in ROP stage and zone.

Charting the Globe: How Technologies Have Affected Our Understanding of Retinal Findings in Abusive Head Trauma/Shaken Baby Syndrome.

Purpose: Ocular findings such as retinal hemorrhages are common in abusive head trauma (AHT). Binocular indirect ophthalmoscopy has been the standard for assessing the eyes of children who are victims of AHT. However, technological advances have changed our understanding of retinal findings in AHT.Methods: Literature review on AHT - retinal findings, imaging technologies, models of representation, and telemedicine applications.Results: Many studies suggest vitreoretinal traction from repetitive acceleration-deceleration shearing forces during shaking plays an important role in the development of retinal findings in AHT. This is further supported by different imaging modalities [optical coherence tomography (OCT); magnetic resonance imaging (MRI); fluorescein angiography (FA)] and models of representation (animal and mechanical models; finite element analysis).Conclusion: Emerging technologies have augmented our diagnostic abilities, enhanced our understanding regarding the pathophysiology of retinal findings, and strengthened the link between vitreoretinal traction and ocular pathology in AHT. Telemedicine is also starting to play an important role in AHT.

Rates of unverifiable and incomplete publications in pediatric ophthalmology fellowship applications.

The publication patterns of pediatric ophthalmology fellowship applicants and in particular the rates of unverifiable and incomplete publications have not been previously reported. A 5-year retrospective cross-sectional study of fellowship candidates found 2.1% of publications listed as published were unverifiable, and only 49% of manuscripts listed as pending publication were published within 5 years. There was lower likelihood to list an incomplete publication for applicants with additional degrees or prior fellowship training and higher likelihood with more manuscripts listed as in preparation. Sex, international medical graduate status, USMLE step scores, and number of publications did not corelate with unverifiable publications.

Ocular involvement in recurrent infectious mucocutaneous eruption (RIME): a variation on a theme.

We present 2 cases of pediatric patients with reactive infectious mucocutaneous eruption with ophthalmic involvement. In both cases, the disease processes behaved similarly to that seen in patients with Mycoplasma pneumoniae-induced rash and mucositis. Visual outcomes were good.

Amniotic membrane transplantation in a 2-month-old infant with toxic epidermal necrolysis.

PURPOSE: To report a case of 2-month-old boy with Stevens-Johnson syndrome (SJS)/Toxic epidermal necrolysis (TEN) and ocular involvement that was successfully treated with cryopreserved amniotic membrane transplantation (AMT). OBSERVATION: A 2-month-old otherwise healthy boy was referred to Boston Children's Hospital with extensive rash and desquamation concerning for SJS/TEN. A skin biopsy was performed which showed full-thickness epidermal necrosis. AMT was performed at the bedside under general anesthesia. A combination of tobramycin and dexamethasone ointment was prescribed four times per day. On reassessment two weeks following AMT, the entire ocular surface had healed with no signs of conjunctival and/or corneal inflammation or ulceration. CONCLUSION AND IMPORTANCE: To the best of our knowledge, our case represents the youngest patient with SJS/TEN to be managed by AMT and one of very few cases where acetaminophen is suspected to be the offending agent. This case highlights the efficacy of AMT at such a young age and feasibility of performing the procedure at bedside in these patients It also highlights that SJS/TEN can develop at such young age.

Virtual reality prototype for binocular therapy in older children and adults with amblyopia.

PURPOSE: To evaluate the best-corrected visual acuity and stereoacuity gains in children >7 years of age and adults with unilateral amblyopia treated with a prototype virtual reality-based binocular amblyopia therapy. METHODS: In this randomized, double masked, cross-in clinical trial, patients at Boston Children's Hospital with unilateral anisometropic and/or strabismic amblyopia and history of prior amblyopia treatment failure were randomized to either a full-treatment group (8 weeks of binocular treatment using therapeutic software application in virtual reality headset) or a sham-crossover group (4 weeks of sham treatment followed by 4 weeks of binocular treatment). Amblyopic eye visual acuity and stereoacuity were evaluated at 4, 8, and 16 weeks' follow-up. RESULTS: The study cohort included 20 participants (10 females), with a median age of 9 years (range, 7-38 years). In the full-treatment group (11 patients), the mean amblyopic eye logMAR visual acuity at 16 weeks was 0.49 ± 0.26, compared with 0.47 ± 0.20 at baseline. In the sham-crossover group, it was 0.51 ± 0.18 at 16 weeks, compared with 0.53 ± 0.21 at baseline. Stereoacuity (log arcsec) was significantly improved, from 7.3 ± 2 at baseline to 6.6 ± 2.3 at 8 weeks (P < 0.001) and 6.7 ± 2.6 at 16 weeks (P < 0.001). No significant adverse events (diplopia, asthenopia, or worsening strabismus) were noted in either group. CONCLUSIONS: Although the virtual reality-based prototype for binocular amblyopia therapy did not significantly improve visual acuity in the amblyopic eyes of older children and adults, stereoacuity did significantly improve compared with baseline; improvements were clinically minute. However, larger studies are required to confirm the results.

Retinopathy of prematurity screening and risk mitigation during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted the delivery of healthcare. Although most nonurgent ophthalmology visits at Boston Children's Hospital were canceled, premature infants at risk for retinopathy of prematurity (ROP) still required timely, in-person care during the initial 3-month period of the infection surge in Massachusetts. The purpose of the current study was to report our protocols for mitigating risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between infants and eye care providers and to compare examination rates and results with the same 3-month period in 2019. METHODS: During the infection surge, we added new infection control measures and strengthened existing ones. Additional personal protective equipment was used, and the number of ophthalmologists rotating in the three high-capacity NICUs we service was limited. RESULTS: More infants required ROP examinations during the study period in 2020 than in the same period in 2019, but fewer examinations were performed. There were no cases of missed progression to severe ROP during this time and no known transmission of SARS-CoV-2 between ROP patients and ophthalmology staff. CONCLUSIONS: Overall, effective ROP care was safely provided during the COVID-19 pandemic, and contact with this vulnerable population was minimized.

Mycoplasma Pneumoniae-Induced Rash and Mucositis: A Longitudinal Perspective and Proposed Management Criteria.

PURPOSE: To evaluate the natural history and ophthalmologic morbidity of Mycoplasma pneumoniae-induced rash and mucositis (MIRM) and propose a treatment algorithm. DESIGN: Retrospective, interventional case series. METHODS: Retrospective chart review of all MIRM patients examined by the department of ophthalmology at a tertiary children's hospital. Diagnosis was established clinically concomitant with either positive Mycoplasma pneumoniae IgM or PCR testing from January 1, 2010, until December 31, 2019. The main outcome measures were best-corrected visual acuity, long-term ocular sequelae, and duration and type of ophthalmic intervention. RESULTS: There were 15 patients (10 male and 5 female) aged 10.9 ± 4.2 years who had primary episodes of MIRM; of those, 4 had multiple episodes. All patients required topical steroid treatment, 3 required amniotic membrane transplantation, and 1 patient underwent placement of a sutureless biologic corneal badage device. There were no patients who suffered visual loss, but 1 was left with mild symblephara near the lateral canthus in each eye and 2 others had scarring of the eyelid margins and blepharitis. CONCLUSIONS: The ocular morbidity is significantly less in MIRM than in other closely related syndromes such as erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. However, these patients still require close observation and a low threshold for intervention to avoid permanent ophthalmic sequelae and possible blindness.

Prenatal diagnosis of intraconal lymphatic malformation on fetal magnetic resonance imaging.

Lymphatic malformations are benign hamartomatous tumors present at birth but usually diagnosed in early childhood. We report a case of prenatal diagnosis of an isolated unilateral retrobulbar lymphatic malformation with fetal magnetic resonance imaging (MRI). This was first detected at 27 weeks' gestational age. Postnatal ocular examinations at 4 days and 5 weeks of age showed no signs of optic nerve compromise. Postnatal MRI at 18 days of age showed slight increase in size of the lesion, and no intracranial vascular malformations were detected.