Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis.

Importance: Neighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health. Objective: To investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK. Design, Setting, and Participants: This was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record. Main Outcomes and Measures: Individual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics. Results: A total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40. Conclusion and Relevance: Findings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience.

PURPOSE: To assess the initial utilization, safety, and patient experience with tele-ophthalmology during the COVID-19 pandemic. DESIGN: Cross-sectional study. METHODS: We conducted a telephone survey and interview of a random sample of patients who received different modalities of care (in-person, telephone, videocall, or visits deferred) during Michigan's shelter-in-place order beginning March 23, 2020. The survey assessed patient safety, patient satisfaction with care, perceptions of telehealth-based eye care, and worry about eyesight. Data were analyzed via frequency measures (eg, means and standard deviations), χ2 tests, ANOVA, and paired t tests. Interviews were analyzed using grounded theory. RESULTS: A total of 3,274 patients were called and 1,720 (53%) agreed to participate. In-person participants were significantly older than telephone (P = .002) and videocall visit (P = .001) participants. Significantly more white participants had in-person visits than minority participants (P = .002). In-person visit participants worried about their eyesight more (2.7, standard deviation [SD] = 1.2) than those who had telephone (2.5, SD = 1.3), videocall (2.4, SD = 1.1), or deferred visits (2.4, SD = 1.2) (P = .004). Of all telephone or videocall visits, 1.5% (n = 26) resulted in an in-person visit within 1 day, 2.9% (n = 48) within 2-7 days, and 2.4% (n = 40) within 8-14 days after the virtual visit demonstrating appropriate triage to telemedicine-based care. Patients frequently cited a desire for augmenting the telephone or videocall visits with objective test data. CONCLUSIONS: When appropriately triaged, tele-ophthalmology appears to be a safe way to reduce the volume of in-person visits to promote social distancing in the clinic. A hybrid model of eye care combining ancillary testing with a video or phone visit represents a promising model of care.

Persistent Opioid Use after Ophthalmic Surgery in Opioid-Naive Patients and Associated Risk Factors.

PURPOSE: To determine the rate and risk factors for new persistent opioid use after ophthalmic surgery in the United States. DESIGN: Retrospective claims-based cohort analysis. PARTICIPANTS: Opioid-naive patients 13 years of age and older who underwent incisional ophthalmic surgery between January 1, 2012, and June 30, 2017, and were included in Optum's de-identified Clinformatics Data Mart database. METHODS: New persistent opioid use was defined as filling an opioid prescription in the 90-day and the 91- to 180-day periods after the surgical procedure. The outcome variable was an initial perioperative opioid prescription fill. Rates of new persistent opioid use were calculated, and multivariate logistic regression models were used to identify variables increasing the risk of new persistent use and refill of an opioid prescription after the initial perioperative prescription in first 30 days. MAIN OUTCOME MEASURES: New persistent opioid use and refill. RESULTS: A total of 327 379 opioid-naive patients (mean age, 67 years [standard deviation, 16 years]; 178 067 women [54.4%]) who underwent ophthalmic surgery were examined. Among these patients, 14 841 (4.5%) had an initial perioperative opioid fill. The rate of new persistent opioid use was 3.4% (498 of 14 841 patients) compared with 0.6% (1833 of 312 538 patients) in patients who did not have an initial perioperative opioid fill. After adjusting for patient characteristics, initial perioperative opioid fill was associated independently with increased odds of new persistent use (adjusted odds ratio [OR], 6.21; 95% confidence interval [CI], 5.57-6.91; P < 0.001). Among patients who had filled an initial perioperative prescription, a prescription size of 150 morphine milligram equivalents or more was associated with an increased odds of refill (adjusted OR, 1.87; 95% CI, 1.58-2.22; P < 0.001). CONCLUSIONS: Exposure to opioids in the perioperative period is associated with new persistent use in patients who were previously opioid-naive. This suggests that exposure to opioids is an independent risk factor for persistent use in patients undergoing incisional ophthalmic surgery. Surgeons should be aware of those risks to identify at-risk patients given the current national opioid crisis and to minimize prescribing opioids when possible.

Patient-Reported Outcomes After Corneal Transplantation.

PURPOSE: To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK) using the National Eye Institute Visual Function Questionnaire (NEI-VFQ 9). METHODS: Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, questionnaire responses were obtained from 103 PKP patients, 24 DALK patients, 42 DSAEK patients, and 50 DMEK patients undergoing postoperative examination. No exclusions were made based on preoperative diagnosis, age, complications, or comorbidities. Associations between clinical characteristics and vision-related quality of life were analyzed using nonparametric and linear regression methods. RESULTS: Patients were surveyed an average of 1.5 years postoperatively (range 24 d to 4.4 yrs). Participants who had undergone DALK, DMEK, DSAEK, and PKP had median composite VFQ scores of 77.8, 84.2, 76.1, and 70.6, respectively (P= 0.002). There were no significant differences in VFQ scores between patients treated with DMEK versus DSAEK (P = 0.440) or between patients treated with PKP versus DALK (P = 1.000). Higher postoperative acuities in the operative and fellow eyes were associated with higher VFQ scores (P < 0.001 and P < 0.001). When controlling for postoperative acuity by regression modeling, surgery type was not associated with patient-reported composite VFQ scores. CONCLUSIONS: In this study, patient-reported vision-related quality of life was similar among DMEK and DSAEK participants and also among DALK and PKP participants. When controlling for postoperative acuity, vision-related quality of life was similar among all study participants, irrespective of the keratoplasty technique.

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach.

PRCIS: Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified. PURPOSE: The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics. METHODS: A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA). RESULTS: Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident). CONCLUSIONS: CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.

Association of Limiting Opioid Prescriptions With Use of Opioids After Corneal Surgery.

Importance: Opioids, which carry a high risk for addiction and overdose, are commonly prescribed after corneal surgery. Data are lacking describing opioid prescribing practices and opioid needs by patients after ophthalmic surgery. Objectives: To quantify opioid use and to assess the association of decreasing the number of opioid tablets prescribed after corneal surgery with postsurgical use. Design, Setting, and Participants: This prospective cohort study investigated opioid use after corneal surgery using direct interviews of 2 adult patient cohorts separated by an updated opioid prescribing guideline. The first cohort survey assessed the quantity of opioid tablets used after surgery. The cornea division of a tertiary care academic medical center reviewed the use needs and decreased the number of tablets prescribed after routine cases. Simultaneously, a statewide opioid monitoring program began that provided patients with opioid information. A second unique cohort received a more detailed survey to assess use, opioid disposal, and pain control. Data for the first cohort were collected from December 1, 2017, through January 19, 2018; for the second cohort, from June 1 to September 15, 2018. Data were analyzed from October 24, 2018, through September 24, 2019. Exposure: Corneal surgery. Main Outcomes and Measures: Differences in use of opioid tablets used by both patient cohorts, assessed using the 2-sample t test. Results: Of 112 eligible, contacted patients, 82 consented to participate (42 men [51%]; mean [SD] age, 42.5 [17.8] years) and were included in the analysis; 38 of 42 participated in the first cohort and 44 of 70 participated in the second cohort. Of those receiving opioid prescriptions, the first cohort was prescribed significantly more tablets than the second cohort (mean [SD], 18.8 [4.2] vs 6.6 [3.1]; difference, 12.2 [95% CI, 10.4-14.0]; P < .001). The first cohort used significantly more tablets than the second cohort (mean [SD], 8.3 [7.0] vs 4.0 [3.2]; difference, 4.3 [95% CI, 1.4-7.2]; P = .005) and had significantly more leftover tablets (mean [SD], 10.3 [6.9] vs 2.9 [2.7]; difference, 7.5 [95% CI, 4.7-10.2]; P < .001). In the detailed survey for the second cohort, 19 of 27 patients reported pain control as adequate (70% [95% CI, 50%-86%]); 6 of 27, as more than needed (22% [95% CI, 9%-42%]). Twenty of 28 participants (71% [95% CI, 55%-88%]) had leftover tablets; 17 of these (85% [95% CI, 62%-97%]) did not dispose of leftovers, and 3 (15% [95% CI, 3%-38%]) threw away or flushed leftovers. Conclusions and Relevance: After an assessment of opioid needs, physicians prescribed fewer opioid pills. However, patients who underwent cornea surgery and received fewer tablets continued to have adequate pain control and used even fewer tablets compared with the initial cohort. Patients with unused opioid tablets did not dispose of them properly.

Characterization of Epiretinal Proliferation in Full-Thickness Macular Holes and Effects on Surgical Outcomes.

PURPOSE: Epiretinal proliferation is a distinct clinical entity from epiretinal membrane that classically is associated with lamellar macular holes, but its prevalence and association with full-thickness macular holes (FTMH) have not been well described. We characterized macular hole-associated epiretinal proliferation (MHEP) and its effects on long-term surgical outcomes. DESIGN: Multicenter, interventional, retrospective case-control study. PARTICIPANTS: Consecutive eyes that underwent surgery for FTMH with a minimum of 12 months follow-up. METHODS: All eyes underwent pars plana vitrectomy, removal of any epiretinal membranes, and gas tamponade, with or without internal limiting membrane (ILM) peeling. Spectral-domain OCT imaging was obtained before and after surgery. MAIN OUTCOME MEASURES: Improvement in visual acuity and single-surgery hole closure rates in eyes with, versus without, MHEP at 12 months. RESULTS: Seven hundred twenty-five charts were analyzed, and 113 patients met inclusion criteria. Of 113 eyes with FTMH, 30 (26.5%) showed MHEP. Patients with FTMH and MHEP were older (P < 0.002) and more often men (P = 0.001), and showed more advanced macular hole stages than those without MHEP (P = 0.010). A full posterior vitreous detachment was more common in eyes with MHEP (P < 0.004). Twelve months after surgery, FTMH with MHEP patients showed significantly less improvement in visual acuity (P = 0.019) with higher rates of ellipsoid and external limiting membrane defects (P < 0.05) and with a higher rate of failure to close with 1 surgery compared to FTMH without MHEP (26.7% vs. 4.8%; P = 0.002]). Peeling the ILM was associated with improved rates of hole closure in FTMH with MHEP (P < 0.001). Multivariate testing confirmed that the presence of MHEP was an independent risk factor for less visual improvement (P = 0.031) and for single-surgery nonclosure (P = 0.009) and that ILM peeling improved single-surgery closure rates (P = 0.026). CONCLUSIONS: We found that FTMH with MHEP showed poorer anatomic and visual outcomes after vitrectomy compared with FTMH without MHEP. Internal limiting membrane peeling was associated with improved closure rates and should be considered when MHEP is detected before surgery.

Predictors of Endophthalmitis after Intravitreal Injection: A Multivariable Analysis Based on Injection Protocol and Povidone Iodine Strength.

PURPOSE: To determine the incidence of endophthalmitis after anti-vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection. DESIGN: Retrospective, single-center cohort study. PARTICIPANTS: All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31, 2017. METHODS: Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol. MAIN OUTCOME MEASURES: Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs). RESULTS: A total of 154 198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39-37.46; P < 0.001) and 0.5% Tetravisc (Ocusoft, Richmond, TX; OR, 3.95; 95% CI, 1.15-13.50; P = 0.03) use were independent risk factors for endophthalmitis after injection. Lid speculum use, povidone iodine strength (5% vs. 10%), injection location (superior or inferior), conjunctival displacement, use of provider gloves, use of a strict no-talking policy, use of subconjunctival lidocaine, and topical antibiotic use were not statistically significant predictors of endophthalmitis after injection. There was no difference in endophthalmitis rate among the anti-VEGF agents (bevacizumab, ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept). CONCLUSIONS: The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection.

27-GAUGE SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENSES WITH HAPTIC FLANGING: Short-Term Clinical Outcomes and a Disinsertion Force Study.

PURPOSE: To determine whether haptic flanging during 27-gauge sutureless intrascleral fixation of intraocular lenses (IOLs) increases IOL stability and to report the short-term clinical outcomes of sutureless intrascleral surgery using 27-gauge trocar cannulas with haptic flanging. METHODS: Retrospective surgical case series using live and cadaveric human eyes. RESULTS: In the cadaveric experiment using five eyes, flanged haptics required more force to dislocate the IOL compared with unflanged haptics (14 ± 4 vs. 3 ± 1 g, P = 0.03). The clinical series included 52 eyes from 52 patients. The average age at the time of surgery was 73 ± 14 years, with a mean follow-up of 27 ± 19 weeks. The most common indication for surgery was IOL dislocation/subluxation (n = 43, 83%). Mean visual acuity improved from 20/140 preoperatively to 20/50 at postoperative Month 1 (P < 0.001). The most common postoperative issue was intraocular pressure elevation (n = 12, 23%). Two patients (4%) needed a reoperation for IOL dislocation. CONCLUSION: Haptic flanging during 27-gauge sutureless intrascleral surgery creates a more stable scleral-fixated IOL compared with the traditional unflanged technique based on a cadaveric human eye study. In addition, this variation of sutureless intrascleral surgery seems safe and effective for patients who require secondary IOLs.

Self-reported Eyeglass Use by US Medicare Beneficiaries Aged 65 Years or Older.

Importance: Medicare benefits do not include coverage for eyeglasses except after cataract surgery. Understanding the implications of a change to this policy would require knowing the number of Medicare beneficiaries who use eyeglasses, but no recent estimates are available. Objective: To estimate the number of older adults with Medicare who use eyeglasses. Design, Setting, Participants: This cross-sectional study used data from the 2015 US National Health and Aging Trends Study. Nationally representative data from 7497 respondents were reviewed and sample weights were applied so that the data represented 43.9 million Medicare beneficiaries aged 65 years or older. The estimates were based on the following 4 groupings of beneficiaries: (1) number who used eyeglasses for distance vision correction and had distance vision impairment, (2) number who did not use eyeglasses for distance vision correction and had distance vision impairment, (3) number who used eyeglasses for near vision correction and had near vision impairment, and (4) number who did not use eyeglasses for near vision correction and had near vision impairment. The prevalence of self-reported use of glasses was estimated using the results of this survey and the Medicare enrollment file. Data were analyzed from July 12, 2017, to November 30, 2017. Main Outcomes and Measures: Self-reported use of eyeglasses or contact lenses. Results: Of the estimated 43.9 million Medicare beneficiaries aged 65 years or older in 2015, approximately 40.5 million (92.4%; 95% CI, 91.6%-93.1%) reported using eyeglasses for either distance or near vision correction. Differences in sociodemographics were observed between those who reported using eyeglasses. Individuals who were older, were nonwhite, had lower educational levels, were less affluent, and had prior cataract surgery were significantly less likely to use eyeglasses. Approximately 27 million beneficiaries (61.7%; 95% CI, 60.3%-63.1%) used eyeglasses for distance vision correction, and approximately 37.2 million beneficiaries (84.8%; 95% CI, 83.8%-85.8%) used eyeglasses for near vision correction. Conclusions and Relevance: Potential sociodemographic disparities in eyeglass use by age, race/ethnicity, educational level, and income were identified. This finding suggests that innovative public policy solutions are needed to address these disparities among the large number of Medicare beneficiaries who use eyeglasses.

Association of Social Support Network Size With Receipt of Cataract Surgery in Older Adults.

Importance: Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults' social support networks and their likelihood of receiving cataract surgery. Objective: To determine if older adults with smaller social support networks are less likely to receive cataract surgery. Design, Setting, and Participants: Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study. Main Outcomes and Measures: Multivariable logistic regression was performed to evaluate if the number of persons in an individual's social support network influenced whether that individual received cataract surgery during a given year of the study. Results: Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% CI, 37.28-40.35) were aged 70 to 74 years, 5211 (weighted, 52.32%; 95% CI, 50.19-54.44) were women; 5899 (weighted, 78.53%; 95% CI, 76.29-80.61) were white, 2249 (weighted, 9.55%; 95% CI, 8.45-10.78) were black, 537 (weighted, 7.18%; 95% CI, 5.88-8.73) were Hispanic, and 303 (weighted, 4.74%; 95% CI, 3.56-62.9) reported other races. Medicare beneficiaries with smaller social support networks (0-2 individuals) were less likely to receive cataract surgery in a given year (adjusted odds ratio, 0.60; 95% CI, 0.37-0.96) than those with larger support networks (≥3 individuals). The adjusted predicted proportion of Medicare beneficiaries undergoing cataract surgery was 4.7% (95% CI, 2.7%-6.7%) and 7.5% (95% CI, 6.9%-8.1%) for those with small and large social support networks, respectively. Having fewer non-spouse/partner family members in the support network was associated with decreased odds of receiving cataract surgery (adjusted odds ratio, 0.60; 95% CI, 0.43-0.85), but having spouses/partners (adjusted odds ratio, 0.97; 95% CI, 0.77-1.22) and nonfamily members (adjusted odds ratio, 0.90; 95% CI, 0.72-1.11) did not have a significant association. Conclusions and Relevance: Medicare beneficiaries with fewer non-spouse/partner family members in their social support networks were less likely to receive cataract surgery. These findings suggest that attention should be given to patients with smaller support networks to ensure that they receive cataract surgery when it is indicated.

STRUCTURAL ANALYSIS AND COMPREHENSIVE SURGICAL OUTCOMES OF THE SUTURELESS INTRASCLERAL FIXATION OF SECONDARY INTRAOCULAR LENSES IN HUMAN EYES.

PURPOSE: To describe surgical outcomes and structural characteristics of intraocular lenses (IOLs) implanted with transconjunctival sutureless intrascleral (SIS) fixation in human eyes. DESIGN: Retrospective interventional surgical case series involving live and cadaveric human eyes. METHODS: In this study, we investigated the surgical outcomes and structural anatomy of secondary IOLs implanted with the SIS technique in human eyes. All cases involving SIS IOL fixation performed at a single academic center from January 1, 2012, through July 30, 2016, were reviewed to describe the surgical technique, common indications, clinical outcomes, and the rate of common operative complications. To investigate the structure of SIS-fixated IOLs in vivo, slit-lamp biomicroscopy, ultrasound biomicroscopy, and intraoperative endoscopy were analyzed to describe anatomical outcomes. The primary anatomical outcomes were the optic pupillary centration and location of haptic externalization. Results were correlated with cadaveric human eyes that underwent the SIS-IOL technique. Cadaveric eyes were imaged and analyzed using high-resolution photography for centration, stress measurements at the haptic-optic junction, and qualitative descriptors of IOL optic and haptic position. RESULTS: A total of 122 consecutive patients who underwent IOL placement using SIS technique were included in the study with mean follow-up of 1.52 years (range, 0.4-4.5 years). The majority (75%) of patients received a new 3-piece IOL for primary aphakia or after IOL exchange. The other patients (25%) had a dislocated 3-piece IOL that was rescued using the SIS technique. Preoperative mean Snellen visual acuity was 20/633 (logarithm of the minimum angle of resolution = 1.501). At the final visit, the mean best-corrected visual acuity was 20/83 (logarithm of the minimum angle of resolution = 0.6243) and final mean spherical equivalent was -0.57 diopters. The most common complications were vitreous hemorrhage (22% of eyes), which resolved spontaneously in most cases, and cystoid macular edema. The rates of IOL dislocation, IOL decentration, haptic erosion, IOL tilting, iris capture, and endophthalmitis were low. Intraoperative endoscopy and ultrasound biomicroscopy demonstrated a securely fixated IOL and well-centered optic without iris or ciliary body touch. Structural study of cadaveric eyes confirmed IOL optic and haptic anatomy observed during live human surgery. The ab interno haptic insertion was the anterior pars plana, away from the iris, ciliary processes and ora serrata. The degree of haptic externalization was correlated with the degree of strain on the haptic-optic junction. The angle of the haptic-optic junction in SIS-fixated IOLs (33.97°) was not significantly different compared with overlaid native nonfixated IOL (32.93°) but increased slightly with degree of haptic tip externalization (36.26 and 39.16 for 2 and 3 mm haptic externalizations, respectively). CONCLUSION: In this comprehensive study, we demonstrate the surgical outcomes achieved with SIS fixation of IOLs. Surgical and postoperative complications do occur, albeit at a low rate, and can effectively be managed with excellent anatomical and visual outcomes. The structural and anatomical data in this study may help guide SIS placement and optimize long-term surgical results.

Scleral-Fixated Intraocular Lenses: Past and Present.

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Human iris three-dimensional imaging at micron resolution by a micro-plenoptic camera.

A micro-plenoptic system was designed to capture the three-dimensional (3D) topography of the anterior iris surface by simple single-shot imaging. Within a depth-of-field of 2.4 mm, depth resolution of 10 µm can be achieved with accuracy (systematic errors) and precision (random errors) below 20%. We demonstrated the application of our micro-plenoptic imaging system on two healthy irides, an iris with naevi, and an iris with melanoma. The ridges and folds, with height differences of 10~80 µm, on the healthy irides can be effectively captured. The front surface on the iris naevi was flat, and the iris melanoma was 50 ± 10 µm higher than the surrounding iris. The micro-plenoptic imaging system has great potential to be utilized for iris disease diagnosis and continuing, simple monitoring.

Quantitative Analysis of Endothelial Cell Loss in Preloaded Descemet Membrane Endothelial Keratoplasty Grafts.

PURPOSE: Availability of preloaded Descemet membrane endothelial keratoplasty (pDMEK) tissue may increase acceptance of DMEK in surgical management of endothelial disease. The goal of this study was to determine the safety of pDMEK grafts for 24 hours before surgery by analyzing endothelial cell loss (ECL) using 2 image analysis software programs. METHODS: A total of 18 cadaveric corneas were prepared for DMEK using a standardized technique and loaded in a modified Jones tube injector. Nine of the corneas were injected into Calcein AM vital dye after 1 minute (controls), and the remaining 9 corneas were left preloaded for 24 hours before injection into vital dye for staining. The stained corneas were imaged using an inverted confocal microscope. ECL was then analyzed and quantified by 2 different graders using 2 image analysis software programs. RESULTS: The control DMEK tissue resulted in 22.0% ± 4.0% ECL compared with pDMEK tissue, which resulted in 19.2% ± 7.2% ECL (P = 0.31). Interobserver agreement was 0.93 for MetaMorph and 0.92 for Fiji. The average time required to process images with MetaMorph was 2 ± 1 minutes and with Fiji was 20 ± 10 minutes. Intraobserver agreement was 0.97 for MetaMorph and 0.93 for Fiji. CONCLUSIONS: Preloading DMEK tissue is safe and may provide an alternative technique for tissue distribution and surgery for DMEK. The use of MetaMorph software for quantifying ECL is a novel and accurate imaging method with increased efficiency and reproducibility compared with the previously validated Fiji.

Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability.

PURPOSE: Corneal and anterior segment diseases cause most of the urgent visits to eye care professionals. We evaluated the diagnostic accuracy of detecting corneal diseases using external photographs from 2 portable cameras for telemedicine purposes. METHODS: This is a prospective study of adults with a clinical diagnosis of corneal pathology including corneal abrasions, ulcers, scars, and pterygia. A cornea specialist provided the gold standard diagnosis by slit-lamp examination. Images of both eyes were obtained using iTouch 5S and Nidek VersaCam cameras in multiple gazes and interpreted by 3 cornea specialists for the presence of pathology. Accuracy to detect disease was compared with gold standard diagnosis, stratified by the camera and grader. Reliability was evaluated with weighted kappa statistics. Graders assessed image quality on a Likert scale from 1 (poor) to 9 (optimal). RESULTS: A total of 198 eyes (110 subjects) were photographed. By gold standard diagnosis, 59 eyes (30%) had corneal scars, 34 (17%) had ulcers, 13 (7%) had abrasions, 10 (5%) had pterygia, and 82 (41%) were normal. Sensitivity to detect AS pathology ranged from 54% to 71% for the iTouch and 66% to 75% for the Nidek, across graders; specificity ranged from 82% to 96% for the iTouch and 91% to 98% for the Nidek. The intergrader reliability was moderate to strong (kappa ranges: 0.54-0.71 for the iTouch; 0.75-0.76 for the Nidek). Quality ratings were variable between graders. CONCLUSIONS: External photographs taken by standard, nonenhanced portable cameras and interpreted remotely by ophthalmologist graders yielded sensitivity values that are not yet suitable for telemedicine applications. Additional work is needed to improve the ability to detect AS pathology remotely.

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy.

PURPOSE: To analyze predictors of image quality for a handheld nonmydriatic fundus camera used for screening of vision-threatening diabetic retinopathy. METHODS: An ophthalmic photographer at an Aravind Eye Hospital obtained nonmydriatic and mydriatic fundus images from 3 fields in 275 eyes of 155 participants over 13 months using a Smartscope camera (Optomed, Oulu, Finland) and a Topcon tabletop fundus camera (Topcon, Tokyo, Japan). Two fellowship-trained retina specialists graded the images. Repeated-measures logistic regression assessed predictors of the main outcome measure: gradability of the fundus images. RESULTS: Of 2,475 images, 76.2% of the Smartscope nonmydriatic images, 90.1% of the Smartscope mydriatic images, and 92.0% of the Topcon mydriatic images were gradable. Eyes with vitreous hemorrhage (OR = 0.24, p < 0.0001) or advanced cataract (OR = 0.08, p < 0.0001) had decreased odds of image gradability. Excluding eyes with cataract or vitreous hemorrhage, nonmydriatic macular image gradability improved from 68.4% in the first set of 55 eyes to 94.6% in the final set of 55 eyes. CONCLUSION: With sufficient training, paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera, particularly in patients with clear lenses and clear ocular media.