Genetic Risk Evaluation in Wet Age-Related Macular Degeneration Treatment Response.

OBJECTIVE: To evaluate the pharmacogenetic relationship between CFH haplotypes and single nucleotide polymorphisms (SNPs) with response to ranibizumab treatment for neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS: This was a prospective cohort study involving 70 treatment-naive nAMD patients. Patients were genotyped for CFH haplotypes and SNPs in the C3, ARMS2, and mtDNA genes. Visual acuity and central macular thickness were assessed at baseline and during 6 monthly follow-up visits. Multivariate logistic regression was used to determine the association between genotypes and a gain of ≥15 letters at the 6-month endpoint after adjusting for potential confounders. RESULTS: CFH haplotypes were associated with a gain of ≥15 letters at the 6-month endpoint (p = 0.046). Patients expressing protective haplotypes were more likely to achieve a gain of ≥15 letters relative to the greatly increased risk haplotypes [OR 6.58 (95% CI: 1.37, 31.59)]. CONCLUSION: CFH is implicated in nAMD patient treatment response to ranibizumab.

Functional Domains of Substance Use and their Implications to Trauma: A Systematic Review of Neuroimaging Studies.

Substance use disorder (SUD) is a significant health problem, and trauma exposure is a known risk factor for the escalation of substance use. However, the shared neural mechanisms through which trauma is associated with substance use are still unknown. Therefore, we systematically review neuroimaging studies focusing on three domains that may contribute to the overlapping mechanisms of SUD and trauma-reward salience, negative emotionality, and inhibition. Using PRISMA guidelines, we identified 45 studies utilizing tasks measuring these domains in alcohol, tobacco, and cannabis use groups. Greater reward, lesser regulation of inhibitory processes, and mixed findings of negative emotionality processes in individuals who use substances versus controls were found. Specifically, greater orbitofrontal cortex, ventral tegmental area, striatum, amygdala, and hippocampal activation was found in response to reward-related tasks, and reduced activation was found in the inferior frontal gyrus and hippocampus in response to inhibition-related tasks. Importantly, no studies in trauma-exposed individuals met our review criteria. Future studies examining the role of trauma-related factors are needed, and more studies should explore inhibition- and negative-emotionality domains in individuals who use substances to uncover clinically significant alterations in these domains that place an individual at greater risk for developing a SUD.

Incidental finding of a retained intracorneal wooden foreign body.

We present a case of an intracorneal wooden foreign body that remained undetected for 15 years following an ocular injury sustained during gardening. The patient presented with stable visual acuity despite the long-standing presence of a wooden splinter embedded in the cornea. Interestingly, Pentacam corneal tomography did not show any abnormalities despite the foreign body piercing through the corneal stroma and endothelium. This case may serve as an opportunity to re-examine the approach to managing chronic and stable intracorneal wooden foreign bodies and explore the implications of continued observation rather than surgical management.

Pleiotropy of a Stickler syndrome genotype.

PURPOSE: To report a case of pleiotropy in the COL2A1 gene typically associated with Stickler Syndrome Type 1. OBSERVATIONS: A patient with a confirmed mutation of the COL2A1 gene presented with an isolated retinitis pigmentosa phenotype. CONCLUSIONS: The mutated COL2A1 gene in Stickler Syndrome Type 1 represents a site of pleiotropy, highlighting a change in phenotype across the same genotype potentially due to tissue alternative splicing.

Analysis of ophthalmology subspecialty opioid prescribing patterns during the opioid public health crisis.

OBJECTIVE: To describe opioid prescribing practices of ophthalmology subspecialties and determine whether opioid prescribing has decreased during the public health crisis. DESIGN: Retrospective cohort study. PARTICIPANTS: Ophthalmologists prescribing at least 11 medications billed to the Medicare Part D prescription drug plan. METHODS: Publicly available Medicare data sets based on claims from the years 2016, 2017, and 2018 were used. Fellowship status was assumed based on subspecialty society membership or use of specified Current Procedural Terminology codes. The main outcome was the percentage of physicians in each subspecialty prescribing opioids. RESULTS: The database included 19,762, 19,790, and 19,840 ophthalmologists in the years 2016, 2017, and 2018, respectively. Only the subspecialties of comprehensive ophthalmology (43.5% vs 39.6% vs 35.7%; p < 0.001; φc = 0.066), retina (66.5% vs 60.7% vs 54.5%; p < 0.001; φc = 0.101), cornea (82.8% vs 83.9% vs 77.2%; p = 0.03; φc = 0.076), and glaucoma (53.4% vs 46.4% vs 42.0%; p < 0.001; φc = 0.094) underwent a small but significant reduction in the proportion of physicians prescribing opioids. The subspecialties of oculoplastics (86%-88.8%), cornea (77.2%-82.8%), retina (54.5%-66.5%), and pediatrics (51.5%-57.9%) had the highest percentage of physicians prescribing opioids. The subspecialties of glaucoma, uveitis, and comprehensive ophthalmology had the lowest percentage of opioid prescribers. Among physicians with more than 10 opioid claims, median opioid claims did not change drastically. Opioids contributed only a small proportion of medication claims for all subspecialties. CONCLUSION: All subspecialties experienced either a small reduction or no significant change in the percentage of opioid prescribers during the period analyzed. We hope to encourage collaboration between ophthalmology subspecialties in striving to reduce opioid prescribing. Further studies are needed to better fine-tune opioid prescribing practices.

Patient Clinical Outcomes in Standalone Versus a Combined Ophthalmology-rheumatology Uveitis Clinic.

BACKGROUND: To evaluate uveitis care outcomes in standalone versus a combined ophthalmology-rheumatology clinic. METHODS: Participants were patients aged 18 years and older with a minimum 12-month history of chronic uveitis prior to being referred to the combined uveitis clinic at Kresge Eye Institute and who were treated in the combined clinic for at least 6 months. Best corrected visual acuity (BCVA), objective markers of inflammation, and achieving targeted dose of immunomodulatory therapy (IMT) were compared in the cohort of uveitis patients 6 months prior to and after the initial evaluation in the combined clinic. RESULTS: Sixty-six percent of study participants were female with a mean age of 51.5 years. BCVA improved from 0.58 logMAR (Snellen: ~20/74) at the initial combined clinic visit to 0.50 logMAR (Snellen: ~20/63) 6 months after the first combined visit (p = 0.0137). The establishment of the combined uveitis clinic led to higher frequency of patients at target dose of IMT: an increase from 49.0% at 6 months prior to the combined visit to 70.1.4% and 79.8% at the initial combined visit and 6 months after the combined visit, respectively. CONCLUSION: A combined model of management for chronic uveitis patients wherein rheumatological services are coupled with ophthalmic care leads to improvement in patient clinical outcomes and achieving target therapy.

Recurrent Unprovoked Deep Vein Thromboses in the Setting of Sarcoidosis.

Sarcoidosis is described as a state of immune-mediated chronic systemic inflammatory disease that is typically characterized by non-caseating granulomas. It involves multiple organs like the lungs, lymph nodes, eyes, skin, and liver. Besides the solid organ involvement, it is also known to be associated with various pro-thrombotic states leading to pulmonary embolism and deep vein thrombosis. Mechanical factors causing the venous stasis were considered the major contributing factors. However, based on recent studies, chronic inflammation from macrophages and activated leukocytes are also hypothesized to further activate thrombin and fibrin formation. Regardless of the etiology, the management focuses on life-long anticoagulation to prevent further episodes of thrombosis. Herein we present a case of a 38-year-old male with a history of sarcoidosis who was admitted after having recurrent deep vein thromboses. Further investigations revealed a negative hypercoagulable workup or other auto-immune processes and the absence of any granulomas causing mechanical compression on large vessel venous vasculature. He was adequately managed with anticoagulation therapy and followed up outpatient with no further similar episodes. This case adds to the growing understanding that the mechanisms by which sarcoidosis induces thromboembolism is primarily pro-inflammatory rather than mechanical in nature.

Baseline Diabetes Knowledge Assessment Amongst Adults With Type 1 and Type 2 Diabetes Receiving Eye Care at a Tertiary Ophthalmic Centre in Canada.

OBJECTIVES: The aim of this work was to assess the current state of baseline knowledge of diabetes and diabetic retinopathy (DR) in new patients referred to a tertiary retina service from their primary eye care provider. METHODS: This single-centre, prospective, observational study included patients presenting to the retina clinic at the Hamilton Regional Eye Institute, a major tertiary referral centre, for their initial consultation for diabetes- or DR-associated complications. Upon recruitment into the study, patients were asked to complete a 35-item questionnaire regarding diabetes and associated complications. All data were coded and analyzed using statistical software. RESULTS: A total of 98 patients participated in the study, which included 50 men and 48 women. Seventy-eight patients (79.6%) were Caucasian. We found that 56.1% (n=55) of the patients did not know the meaning of "HbA1C" (glycated hemoglobin) and only 26.5% of patients sampled were aware of their DR status. Bivariate analysis revealed that patients who had postsecondary education (p<0.001) or those who had education on complications of diabetes (p<0.05) were more likely to know their DR status. More importantly, it was found that 56.1% of patients expressed interest in a future diabetes seminar. CONCLUSIONS: It is evident that a significant proportion of patients do not have adequate knowledge of diabetes or DR, and this is related to their level of education and lack of being taught about diabetes complications. Our findings may guide prevention initiatives by primary eye care providers and promote increased awareness about diabetes and DR for prevention of disease complications, including blindness.

Quantifying Areas of Vascular Leakage in Sickle Cell Retinopathy Using Standard and Widefield Fluorescein Angiography.

BACKGROUND AND OBJECTIVE: To evaluate neovascular surface area change in sickle cell retinopathy following scatter photocoagulation treatment in wide- and standard-field fluorescein angiography (FA) scans using ImageJ software. PATIENTS AND METHODS: Images of 11 patients with wide- or standard-field FA scans pre- and post-treatment for sickle cell retinopathy were evaluated retrospectively by two graders using ImageJ. Graders traced lesions in the late arteriovenous phase and calculated the lesion area and intensity relative to the optic disc. Changes in area and intensity pre- to post-treatment were assessed using dependent t-tests. RESULTS: Pre- to post-treatment, lesion area decreased by 3.34 ± 2.43 to 3.66 ± 3.72 disc areas (P < .001), whereas intensity decreased by 11.36 ± 25.87 to 22.97 ± 69.25 units (P = .104). Neovascular area declined status post-aphotocoagulation by 3.83 ± 3.65 disc areas (P = .003) for widefield images and by 2.81 ± 3.55 discs areas (P = .034) for standard fluorescein images. No statistical difference in area reduction was appreciated between imaging modalities (P = .652) CONCLUSION: Neovascular area decreased significantly following scatter photocoagulation in both standard-field and widefield FA scans without an appreciable difference between imaging modalities. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:153-158.].

Quantifying vitreous inflammation in uveitis: an optical coherence tomography prospective study.

OBJECTIVE: To quantify vitreous inflammation in a uveitis cohort using optical coherence tomography and correlate findings to gold-standard Nussenblatt scores. DESIGN: Prospective cohort study. PARTICIPANTS: 36 eyes from 19 patients primarily with pan uveitis. METHODS: Study participants were scanned with optical coherence tomography and evaluated by 2 independent graders using open-source ImageJ software. Graders characterized the mean intensity of the vitreous in a 67 500-pixel box immediately above the internal limiting membrane and over the fovea and divided it by the mean intensity of the retinal pigment epithelial layer (RPE). The vitreous to retinal pigment epithelial layer ratio (VIT/RPE) ratios were correlated to Nussenblatt vitreous haze scores recorded by an independent uveitis specialist blinded to the graders' reads. Grader 1 measured intensity a second time after a 48-hour washout period, and the intraclass correlation coefficients (2,1) were calculated for intra- and intergrader reliability. RESULTS: 21 (58.3%) eyes had a Nussenblatt score of 0, 9 (25.0%) had a score of 0.5, and the remaining 6 (16.7%) had a score ranging from 1 to 4. The r values for VIT/RPE intensity ratio regressed against Nussenblatt scores were 0.670, 0.672, and 0.660 for grader 1 read 1, grader 1 read 2, and grader 2 read 1, respectively (p < 0.001 for all linear correlations). The intragrader reliability was 0.999 (p < 0.001) and intergrader reliability was 1.000 (p < 0.001). CONCLUSION: The VIT/RPE intensity ratio is a clinically relevant measure that reliably captures inflammation in uveitis and correlates well with gold-standard Nussenblatt scores.

Does patient education improve compliance to routine diabetic retinopathy screening?

Introduction: Diabetic retinopathy (DR) screening relies on adherence to follow-up eye care. This article assesses if a model of patient education and tele-retina screening among high-risk patients with DR can achieve increased rates of compliance within a one-year follow-up. Methods: Between May 2014 and May 2016, DR screening was conducted in a cohort of 101 patients with diabetes in Southern Ontario. Optical coherence tomography and fundus photography images were used to visualize the retina remotely. Enrolled patients participated in an educational seminar at the screening site with the expressed purpose of enhancing patient understanding of DR. A chi-squared test was used to assess patient compliance to follow-up examinations within 6­12 months, while pre-to post-screening HbA1c levels were compared using a dependent t-test. Results: Of 101 patients who completed the study, 33 patients (32.6%) have never previously been screened for DR. Baseline compliance to annual screening increased from 36 patients (35.6%) to 51 patients (50.5%) after the tele-retina programme (p = 0.03). Eighty-nine patients (88%) were referred to an optometrist for ongoing care compared with 12 patients (11.9%) to an ophthalmologist for management of DR. Overall, 100 patients (99.0%) were satisfied with the tele-retina screening. There was no significant change in pre- to-post screening HbA1c levels (p = 0.91). Discussion: Patient education-focused tele-retina screening for DR significantly increased compliance to follow-up in a high-risk, non-compliant patient population. Management of diabetes as captured by HbA1c levels remain unchanged in the cohort indicating a need for ongoing inter-professional collaboration in education and vision screening.

Evaluating patient preparedness for cataract surgery and satisfaction with preoperative care.

OBJECTIVE: To evaluate preoperative preparedness and patient satisfaction after implementation of the Cataract Screening Preprocedural Questionnaire (CSPQ) at Hamilton Regional Eye Institute. DESIGN: Single-centred, prospective, cross-sectional study. PARTICIPANTS/METHODS: One-hundred fifty-one adult patients undergoing elective cataract surgery completed the CSPQ questionnaire. Based on the responses, patients were triaged to the preoperative anaesthesia clinic or booked directly for surgery. Outcome measures included anxiety level, delays or cancellations in surgery, preoperative blood pressure, glucose levels, and satisfaction with the quality of preoperative instructions provided. Results were compared between patients who attended and those who bypassed the preoperative anaesthesia clinic. RESULTS: Of the study population, 87 patients were female (57.6%) and the mean age was 72.0 ± 10.5 years. Only 11 patients (7.43%) were referred for preoperative consultation. Patients reported receiving preoperative instructions via handouts (94%) and verbally in combination with handouts (59.33%). Patients felt that adequate information was provided regarding preoperative medications (96.69%), eye drops (99.34%), fasting guidelines (98.68%), arrival time (99.34%), and instructions for accompaniment/drivers postoperatively (100%). All patients were compliant with the fasting guidelines. Patient satisfaction with the information received regarding cataract surgery and anaesthesia were 4.39 ± 0.88 and 3.80 ± 0.95, respectively. There was no difference in the anxiety level between patients who attended and those who bypassed the preoperative clinic (4.09 ± 2.92 and 5.18 ± 2.57, p = 0.14). There were no cancellations, delays, or immediate postoperative systemic complications. CONCLUSIONS: The CSPQ model can be effectively used to streamline the preoperative preparation of patients for cataract surgery while maintaining a high degree of patient satisfaction with the perioperative experience.

How symbiosis and ecological context influence the variable expression of transgenerational wing induction upon fungal infection of aphids.

Aphids, like most animals, mount a diverse set of defenses against pathogens. For aphids, two of the best studied defenses are symbiont-conferred protection and transgenerational wing induction. Aphids can harbor bacterial symbionts that provide protection against pathogens, parasitoids and predators, as well as against other environmental stressors. In response to signals of danger, aphids also protect not themselves but their offspring by producing more winged than unwinged offspring as a way to ensure that their progeny may be able to escape deteriorating conditions. Such transgenerational wing induction has been studied most commonly as a response to overcrowding of host plants and presence of predators, but recent evidence suggests that pea aphids (Acyrthosiphon pisum) may also begin to produce a greater proportion of winged offspring when infected with fungal pathogens. Here, we explore this phenomenon further by asking how protective symbionts, pathogen dosage and environmental conditions influence this response. Overall, while we find some evidence that protective symbionts can modulate transgenerational wing induction in response to fungal pathogens, we observe that transgenerational wing induction in response to fungal infection is highly variable. That variability cannot be explained entirely by symbiont association, by pathogen load or by environmental stress, leaving the possibility that a complex interplay of genotypic and environmental factors may together influence this trait.

Ophthalmology referrals from optometry: a comparative study (the R.O.C.S study).

OBJECTIVE: To characterize emergency optometrist referrals triaged at a tertiary ophthalmology care centre by physical examination findings and provisional diagnosis accuracy. DESIGN: Prospective case review. PARTICIPANTS: Consecutive patients referred to a tertiary eye care clinic for an after-hours ocular consult. METHODS: Variables extracted from the patient charts included date of referral, age, sex, eye(s) under examination, referral visual acuity (VA), referral intraocular pressure (IOP), the referring optometrist's provisional diagnosis, VA at the time of the ophthalmologist consultation, IOP at the time of the ophthalmologist consultation, number of days between referral and ophthalmic consultation, and the ophthalmologist's diagnosis. Optometrist VA measures were correlated against ophthalmologist measures for left eye, right eye, diseased eye, and nondiseased eye. The independent t test was used to compare IOP measures between clinicians, and the absolute frequency of agreement between localization of eye pathology was reported. RESULTS: After categorizing disease by anatomic location, absolute agreement between optometrist provisional diagnosis and ophthalmologist diagnosis was 60.0%. Strong correlations were found between optometrist and ophthalmologist VA measurements. IOP measurements were reported less frequently by optometrists. In cases in which referral IOP was documented, no significant difference was observed between clinician measures. CONCLUSIONS: VA and IOP measurements by optometrists are reliable, although IOP measurements were included less frequently in optometrist referrals. Optometrist referrals correctly localized eye pathology in 60.0% of cases. Two cases of retinal tear and 2 cases of retinal detachment, for which a precise reason for referral is ideal, were referred for other reasons.

Patient satisfaction with wait times at an emergency ophthalmology on-call service.

OBJECTIVE: To assess patient satisfaction with emergency ophthalmology care and determine the effect provision of anticipated appointment wait time has on scores. DESIGN: Single-centre, randomized control trial. PARTICIPANTS: Fifty patients triaged at the Hamilton Regional Eye Institute (HREI) from November 2015 to July 2016. METHODS: Fifty patients triaged for next-day appointments at the HREI were randomly assigned to receive standard-of-care preappointment information or standard-of-care information in addition to an estimated appointment wait time. Patient satisfaction with care was assessed postvisit using the modified Judgements of Hospital Quality Questionnaire (JHQQ). In determining how informing patients of typical wait times influenced satisfaction, the Mann-Whitney U test was performed. As secondary study outcomes, we sought to determine patient satisfaction with the intervention material using the Fisher exact test and the effect that wait time, age, sex, education, mobility, and number of health care providers seen had on satisfaction scores using logistic regression analysis. RESULTS: The median JHQQ response was "very good" (4/5) and between "very good" and "excellent" (4.5/5) in the intervention and control arms, respectively. There was no difference in patient satisfaction between the cohorts (Mann-Whitney U = 297.00, p = 0.964). Logistic regression analysis demonstrated that wait times influenced patient satisfaction (OR = 0.919, 95% CI 0.864-0.978, p = 0.008). Of the intervention arm patients, 92.0% (N = 23) found the preappointment information useful, whereas only 12.5% (N = 3) of the control cohort patients noted the same (p < 0.001). CONCLUSION: Provision of anticipated wait time information to patients in an emergency on-call ophthalmology clinic did not influence satisfaction with care as captured by the JHQQ.

Ophthalmic referrals from emergency wards-a study of cases referred for urgent eye care (The R.E.S.C.U.E Study).

OBJECTIVE: To characterize emergency department (ED) referrals in order to identify the most common pathologies, compare accuracy of diagnosis, and measure correlation of visual acuity (VA) and intraocular pressure (IOP) measurements between the ED and ophthalmology setting. DESIGN, SETTING, AND PARTICIPANTS: Retrospective chart review of consecutive patients referred for an ocular emergency after hours to a tertiary care emergency eye clinic in Hamilton, Ontario, between February 17, 2015, and May 3, 2015 (n = 288). METHODS: Variables extracted from the patients' charts included date of referral, age, sex, eye(s) under examination, VA at the time of referral, IOP at the time of the referral, site of referral, the referring physician's provisional diagnosis, VA at the time of the ophthalmologist consultation, IOP at the time of the ophthalmologist consultation, number of days between referral and ophthalmic consultation, and the ophthalmologist's diagnosis. RESULTS: Agreement between ED provisional diagnosis and ophthalmology was good at 79.4% when classified according to anatomic location of pathology. A strong correlation was found between VA measurements in the ED and ophthalmology setting (p < 0.001). IOP measurement was infrequently checked in ED and a significant difference existed between ER physician and ophthalmologist measurements (p = 0.010) where ophthalmology reported lower IOP. CONCLUSIONS: The 5 highest volume diagnoses in descending order were posterior vitreous detachment/vitreous syneresis, corneal abrasion, keratitis, anterior uveitis, and retinal tear/detachment. Visual acuity measurements in ED are reliable. IOP is infrequently checked in the ED and more unreliable when measured over 20 mm Hg.