Factors Associated with Follow-Up Adherence After Teleophthalmology for Diabetic Eye Screening Before and During the COVID-19 Pandemic.

Abstract Background: Follow-up adherence with in-person care is critical for achieving improved clinical outcomes in telemedicine screening programs. We sought to quantify the impact of the COVID-19 pandemic upon follow-up adherence and factors associated with follow-up adherence after teleophthalmology for diabetic eye screening. Methods: We retrospectively reviewed medical records of adults screened in a clinical teleophthalmology program at urban and rural primary care clinics between May 2015 and December 2020. We defined follow-up adherence as medical record documentation of an in-person eye exam within 1 year among patients referred for further care. Regression models were used to identify factors associated with follow-up adherence. Results: Among 948 patients, 925 (97.6%) had health insurance and 170 (17.9%) were referred for follow-up. Follow-up adherence declined from 62.7% (n = 52) prepandemic to 46.0% (n = 40) during the pandemic (p = 0.04). There was a significant decline in follow-up adherence among patients from rural (p < 0.001), but not urban (p = 0.72) primary care clinics. Higher median household income (odds ratio [OR] 1.68, 95% confidence interval [CI]: 1.19-2.36) and obtaining care from an urban clinic (OR 5.29, 95% CI: 2.09-13.43) were associated with greater likelihood of follow-up during the pandemic. Discussion: Follow-up adherence remains limited after teleophthalmology screening even in a highly insured patient population, with a further decline observed during the COVID-19 pandemic. Our results suggest that rural patients and those with lower socioeconomic status experienced greater barriers to follow-up eye care during the COVID-19 pandemic. Conclusions: Addressing barriers to in-person follow-up care is needed to effectively improve clinical outcomes after teleophthalmology screening.

Extramacular Drusen and Progression of Age-Related Macular Degeneration: Age Related Eye Disease Study 2 Report 30.

PURPOSE: To identify the prevalence of extramacular drusen and their role in the progression of age-related macular degeneration (AMD). DESIGN: Retrospective analysis of a prospective cohort study. PARTICIPANTS: The study was conducted in 4168 eyes (2998 participants) with intermediate AMD in one or both eyes enrolled in the Age-Related Eye Disease Study 2 (AREDS2), a 5-year multicenter study of nutritional supplements. METHODS: Baseline 3-field 30-degree color photographs were evaluated for drusen characteristics outside the macular grid, including size, area, and location. The characteristics of extramacular drusen were compared with those of drusen within the macula. MAIN OUTCOME MEASURES: Progression rates to late AMD. RESULTS: Although extramacular drusen were observed in 3624 (86.9%) eyes, they represented a small area (< 0.5 mm2) in 50.3% of eyes, with only 17.5% exhibiting an area of > 1 disc area. Eyes with extramacular drusen exhibited larger macular drusen size and area than eyes without extramacular drusen (P < 0.001). Extramacular drusen were not associated with progression to late AMD. The hazard ratio adjusted for baseline age, sex, smoking, AMD severity level, and reticular pseudodrusen for 4043 eyes at risk of developing late AMD over 5 years was 1.17 (95% confidence interval [CI], 0.88-1.54; P = 0.27) for geographic atrophy and 0.96 (95% CI, 0.76-1.2; P = 0.7) for neovascular AMD. CONCLUSIONS: Extramacular drusen are commonly observed in eyes with AMD and are more frequent with an increasing drusen burden within the macula. In eyes with intermediate AMD, extramacular drusen do not confer additional risk to previously identified risk factors in progression to late AMD.

The Effect of Preoperative Opioid Dosage on Postoperative Outcomes in Patients Undergoing Knee Surgery.

BACKGROUND: Opioid prescription before knee replacement surgery is associated with longer hospital stays, more postsurgical pain, and a higher rate of complications. Despite the growing evidence against opioids, they remain popular preoperative pain management prescriptions. OBJECTIVES: The purpose of this study was to examine the effects of dosage of preoperative opioid use on orthopedic knee surgery pain control and postoperative outcomes and complications. STUDY DESIGN: Observational, retrospective evaluation. SETTING: University of Wisconsin Madison hospitals. METHODS: The patients underwent orthopedic knee surgery between May 1, 2014 and April 30, 2015. We randomly selected 197 patients and divided them into 2 groups that had preoperative opioid dosages of either low dose <= 120 mEq morphine (MME) or high dose >120 MME. Of 197 patients, 100 were in the low dose morphine group, whereas 97 were high dose. The cutoff at 120 MME was calculated to be the median dosage across all patients. The primary outcomes were compared, differences in postoperative pain control, and range of motion (ROM). Secondary outcomes included anesthetic complications, length of hospital stay, postoperative opioid dose, and postoperative complications. RESULTS: There were no statistically significant differences between the groups with regard to postoperative pain control, ROM, and immediate postoperative complications. Both groups showed similar length of hospitalization (2.199 to 2.304 days; P = 0.374), rate of postoperative infection, and joint intervention. The high dose group was more likely to have postoperative hemarthrosis and emergency department (ED) visits. However, the low dose group was more likely to have hypertension concurrently. LIMITATIONS: Because the study length was restricted to one year, the lack of data on longer term prognosis may limit extrapolation of data. Subjectivity of pain is difficult to measure and compare objectively. This study was not randomized prospectively, which may bias certain results due to unobserved differences. CONCLUSIONS: Preoperative opioid dose did not affect postoperative pain control or ROM in patients who received knee surgeries. Higher preoperative opioid doses were associated with more hemarthrosis and ED visits. Further exploration into quality of life indices and surgical complications such as need for revision may be a fruitful avenue. KEY WORDS: Opioids, analgesic, knee pain, total knee replacement, knee surgery, pre-operative opioids, knee outcomes.