Modeling the impact of COVID-19 on Retina Clinic Performance.

BACKGROUND: COVID-19, a highly contagious respiratory virus, presents unique challenges to ophthalmology practice as a high-volume, office-based specialty. In response to the COVID-19 pandemic, many operational changes were adopted in our ophthalmology clinic to enhance patient and provider safety while maintaining necessary clinical operations. The aim of this study was to evaluate how measures adopted during the pandemic period affected retina clinic performance and patient satisfaction, and to model future clinic flow to predict operational performance under conditions of increasing patient and provider volumes. METHODS: Clinic event timestamps and demographics were extracted from the electronic medical records of in-person retina encounters from March 15 to May 15, 2020 and compared with the same period in 2019 to assess patient flow through the clinical encounter. Patient satisfaction was evaluated by Press Ganey patient experience surveys obtained from randomly selected outpatient encounters. A discrete-events simulation was designed to model the clinic with COVID-era restrictions to assess operational performance under conditions of increasing patient and provider volumes. RESULTS: Retina clinic volume declined by 62 % during the COVID-19 health emergency. Average check-in-to-technician time declined 79 %, total visit length declined by 46 %, and time in the provider phase of care declined 53 %. Patient satisfaction regarding access nearly doubled during the COVID-period compared with the prior year (p < 0.0001), while satisfaction with overall care and safety remained high during both periods. A model incorporating COVID-related changes demonstrated that wait time before rooming reached levels similar to the pre-COVID era by 30 patients-per-provider in a 1-provider model and 25 patients-per-provider in a 2-provider model (p < 0.001). Capacity to maintain distancing between patients was exceeded only in the two 2-provider model above 25 patients-per-provider. CONCLUSIONS: Clinic throughput was optimized in response to the COVID-19 health emergency. Modeling these clinic changes can help plan for eventual volume increases in the setting of limits imposed in the COVID-era.

Changes in flare after intravitreal injection of three different anti-vascular endothelial growth factor medications.

PURPOSE: To compare the change in anterior chamber flare after intravitreal injection of the anti-vascular endothelial growth factor agents bevacizumab, aflibercept, and ranibizumab. METHODS: Sixty-one eyes of 53 patients underwent intravitreal injection with anti-vascular endothelial growth factor medications for exudative age-related macular degeneration, diabetic macular edema, or retinal vein occlusion. There were a total of 26 eyes injected with bevacizumab, 14 eyes injected with aflibercept, and 21 eyes injected with ranibizumab. Anterior segment flare was measured with a laser flare meter (Kowa) before intravitreal injection and 1 day after injection. The change in flare was analyzed. RESULTS: The mean change in flare after 1 day was +2.5 photons per millisecond in patients who received bevacizumab, 0.0 photons per millisecond for aflibercept, and -0.2 photons per millisecond for ranibizumab. There was a statistically significant difference between the 3 medications (P = 0.006). Pairwise analysis of the change in flare showed a statistically significant difference between bevacizumab and ranibizumab (P = 0.002). The change in flare in patients who received aflibercept was not different from that in those who received bevacizumab (P = 0.08) or ranibizumab (P = 0.99). CONCLUSION: There was a statistically significant increase in flare after bevacizumab injection compared with ranibizumab. This difference was small and is not believed to be clinically significant. There was no statistical difference in the change in flare between aflibercept and the other medications, although the number of eyes in the aflibercept group was small.

End-stage crystalline maculopathy with retinal atrophy in Sjögren-Larsson syndrome: a case report and review of the literature.

Sjögren-Larsson syndrome (SLS) is a rare, autosomal recessive neurocutaneous disorder. It is caused by the inheritance of sequence variants in the ALDH3A2 gene, which codes for fatty aldehyde dehydrogenase (FALDH). Universal signs of the condition are congenital ichthyosis, spastic paresis of the lower and upper limbs, and reduced intellectual ability. In addition to this clinical triad, patients with SLS experience dry eyes and decreased visual acuity caused by a progressive retinal degeneration. Examination of the retina in patients with SLS often reveals glistening yellow crystal-like deposits surrounding the fovea. This crystalline retinopathy often develops in childhood and is considered pathognomonic for the disease. The metabolic disorder typically shortens lifespan to half that of the unaffected population. However, now that patients with SLS live longer, it becomes increasingly important to understand the natural course of the disease. Our case describes a 58-year-old woman with advanced SLS whose ophthalmic examination illustrates the end-stage of the retinal degeneration. Optical coherence tomography (OCT) and fluorescein angiography confirm the disease is restricted to the neural retina with dramatic thinning of the macula. This case is unique since it is among the most advanced both in terms of chronological age and severity of retinal disease. While the accumulation of fatty aldehydes, alcohols, and other precursor molecules is the probable cause of retinal toxicity, a more complete understanding of the course of retinal degeneration may aid in the development of future treatments. The aim of our presentation of this case is to increase awareness of the disease and to foster interest in therapeutic research which may benefit patients with this rare condition.

Eye issues in Sjogren-Larsson Syndrome Sjögren-Larsson syndrome (SLS) is a rare, inherited condition that affects the skin and nervous system. It is caused by variations in a gene that controls the way fats are broken down in the body. The three key signs of the disease are (1) peeling, dry skin; (2) muscle stiffness and impaired movement of the arms and legs; and (3) reduced intellectual ability. Most signs of the condition appear shortly after birth. Genetic testing and counseling services can help patients and their families to understand what to expect with SLS. Caring for people with SLS requires teamwork by specialists like neurologists and physical therapists. Because eye problems are common, the early consultation of an eye doctor is also important. An eye examination can also confirm the diagnosis of SLS. SLS often causes the eyes to appear red, feel dry, or become irritated. This can make it hard to see in bright light. Decreased vision at night is also common. This is caused by the progressive loss of the central part of the retina which is needed to see fine details. Because SLS shortens lifespan, it is rare for anyone to reach the final stages of the disease. As patients with SLS are living longer, as illustrated by the individual in our case study, it becomes important to understand how the disease progresses. Unfortunately, treatments to restore vision are not yet available. Nevertheless, some protective measures can be taken. Eye examinations in early childhood are important for preventing damage to the eyes. Wearing glasses can improve vision, as well as protect eyes from accidental injury or falls. Eye drops can provide relief from dry eyes, and sunglasses can reduce glare and sensitivity to light. In the future, gene therapy may be used to treat SLS.

Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19. Methods: This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed. Results: The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ 2=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ 2=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ 2=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ 2=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model. Conclusion: Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

Randomized trial of anesthetic methods for intravitreal injections.

PURPOSE: To compare the effectiveness of four different anesthetic methods for intravitreal injection. METHODS: Twenty-four patients each received four intravitreal injections using each of four types of anesthesia (proparacaine, tetracaine, lidocaine pledget, and subconjunctival injection of lidocaine) in a prospective, masked, randomized block design. Pain was graded by the patient on a 0 to 10 scale for both the anesthesia and the injection. RESULTS: The average combined pain scores for both the anesthesia and the intravitreal injection were 4.4 for the lidocaine pledget, 3.5 for topical proparacaine, 3.8 for the subconjunctival lidocaine injection, and 4.1 for topical tetracaine. The differences were not significant (P = 0.65). There were also no statistical differences in the individual anesthesia or injection pain scores. Subconjunctival lidocaine injection had the most side effects. CONCLUSION: Topical anesthesia is an effective method for limiting pain associated with intravitreal injections.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System.

PURPOSE: We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes. METHODS: A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations. RESULTS: Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973-0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47-2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13-2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89-7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73-35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations. CONCLUSION: Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

Early Conversion to Aflibercept for Persistent Diabetic Macular Edema Results in Better Visual Outcomes and Lower Treatment Costs.

PURPOSE: To evaluate the functional and anatomic outcomes, as well as cost-effectiveness, of the timing of conversion to intravitreal aflibercept (IVA) in patients with treatment-resistant diabetic macular edema (DME). METHODS: Thirty consecutive eyes (25 patients) were identified that were treated with ≥3 intravitreal bevacizumab (IVB) and/or ranibizumab (IVR) injections prior to treatment with ≥3 IVA injections. Eyes that received ≤6 IVB and/or IVR injections (early-switch) were compared to those that received ≥7 injections (late-switch) prior to conversion to IVA. Treatment effectiveness was measured in quality-adjusted life years (QALYs). A micro-simulation model examined the impact of treatment duration on outcomes. RESULTS: Early- (n=18) and late- (n=12) switch eyes had similar vision prior to conversion to IVA. Despite improvements in retinal thickness, only the early-switch eyes maintained vision gains after conversion to IVA through the end of follow-up (p=0.027). Early switch saved $22,884/eye and produced an additional 0.027 QALYs. CONCLUSION: Early conversion to IVA optimizes vision outcomes and results in lower overall treatment expenditures.

Preferential Hyperacuity Perimetry to detect hydroxychloroquine retinal toxicity.

PURPOSE: To determine if Preferential Hyperacuity Perimetry (PHP) testing can detect the presence of retinal toxicity due to hydroxychloroquine (HCQ) or chloroquine administration. METHODS: Fifteen patients were divided into three groups. Five patients had confirmed HCQ or chloroquine toxicity, five patients had suspected HCQ toxicity, and five patients had history of long-term use of HCQ or chloroquine but no evidence of toxicity. All patients underwent PHP testing. RESULTS: All patients with either known or suspected toxicity based upon standardized visual field testing and/or fluorescein angiography demonstrated significant hyperacuity defects on PHP testing. None of the patients on long-term HCQ therapy, without clinical suspicion of toxicity, demonstrated a PHP hyperacuity defect. CONCLUSION: Results of this pilot study with patients with known or suspected HCQ or chloroquine toxicity suggest that PHP may be a useful adjunct for testing of patients suspicious for toxicity due to these medications. Further testing is warranted.

Profound choroidal hypoperfusion after combined photodynamic therapy and intravitreal triamcinolone acetonide.

BACKGROUND AND OBJECTIVE: To report a case series of patients with profound choroidal hypoperfusion on fluorescein angiography following combined photodynamic therapy (PDT) and intravitreal triamcinolone acetonide (IVT) for age-related macular degeneration. PATIENTS AND METHODS: A retrospective chart review was performed of all 108 patients (155 treatments) who had combined PDT/IVT between January 2002 and December 2004 at the institution. RESULTS: Fifteen patients were identified with "profound choroidal hypoperfusion." There were no common risk factors identified. Hypoperfusion occurred in some patients after their initial treatment, whereas in others it developed only after repeated treatments. Two patients had severe vision loss associated with profound choroidal hypoperfusion. CONCLUSIONS: Profound choroidal hypoperfusion can be seen after combined therapy with PDT/ IVT. Although adding triamcinolone acetonide to PDT may improve efficacy, it may also change the side effect profile and severe vision loss may occur. Changes in treatment parameters may improve combined therapy.

Effect of Fluid Status at Week 12 on Visual and Anatomic Outcomes at Week 52 in the VIEW 1 and 2 Trials.

BACKGROUND AND OBJECTIVE: To evaluate effect of retinal fluid status at week 12 on visual and anatomic outcomes at week 52 in patients with neovascular age-related macular degeneration from the VIEW studies. PATIENTS AND METHODS: Post-hoc analysis included 1,465 eyes treated with intravitreal aflibercept (Eylea; Regeneron, Tarrytown, NY) 2 mg every 4 weeks (2q4) or every 8 weeks following three initial monthly injections (2q8) or ranibizumab (Lucentis; Genentech, South San Francisco, CA) 0.5 mg every 4 weeks (Rq4), which had known retinal fluid status at weeks 12 and 52. RESULTS: At 12 weeks, 512 (35%) eyes had fluid and 953 (65%) were fluid-free. Two hundred three (41.5%), 148 (29.8%), and 161 (33.5%) eyes had fluid in Rq4, 2q4, and 2q8, respectively. Best-corrected visual acuity (BCVA) change at week 52 from baseline was independent of retinal fluid status at week 12 or treatment assignment. Eyes were more likely to remain fluid-free at week 52 if absent of fluid at week 12. CONCLUSION: At week 52, 2q4, 2q8, and Rq4 improved BCVA independent of fluid status at week 12.

Symptoms of musculoskeletal disorders in ophthalmologists.

OBJECTIVE: To describe the presence of musculoskeletal disorders (MSDs) of the neck, low back, and upper extremity among ophthalmologists. DESIGN: Survey. METHODS: Mail survey using a pretested instrument to 2,529 ophthalmologists in the Northeastern United States; 697 ophthalmologists (28%) returned a completed survey. RESULTS: Self-reported prevalence of neck, upper body, or lower back symptoms in the prior month was 51.8%. Low back pain was present in 39% of respondents, followed by upper extremity symptoms (32.9%) and neck pain (32.6%). Approximately 15% of ophthalmologists were slightly to moderately limited in their work as a result of these symptoms. CONCLUSION: MSD symptoms appear to be common among ophthalmologists. With a relatively low response rate, however, it is plausible that asymptomatic subjects represent a large percentage of the nonrespondents. Additional investigation is warranted to evaluate ergonomic risk factor exposure and establish injury prevention guidelines.

Early treatment of cystoid macular edema secondary to branch retinal vein occlusion with intravitreal triamcinolone acetonide.

BACKGROUND AND OBJECTIVE: To determine the efficacy of intravitreal triamcinolone acetonide (IVTA) in the early treatment of severe cystoid macular edema (CME) related to acute branch retinal vein occlusion. PATIENTS AND METHODS: Retrospective, non-comparative case series. Twelve eyes with severe CME (foveal thickness > 450 microm) secondary to acute branch retinal vein occlusion received IVTA. RESULTS: Average follow-up was 15.3 months. Mean visual acuity was 0.88 LogMar units (20/160) initially, 0.55 LogMar units (20/70) at 1 week, 0.46 LogMar units (20/60) at 1 month, and 0.49 LogMar units (20/60) at last follow-up. Visual acuity improved by 3 lines or greater in 42% of patients at 1 week, 50% at 1 month, and 42% at last follow-up. Average foveal thickness was 589 microm (range, 460 to 840 microm) at baseline, 237 microm at 1 week, 196 microm at 1 month, and 235 microm at last follow-up. All eyes showed reduction of foveal thickness as measured by optical coherence tomography. Eight eyes developed recurrent CME at an average of 5.5 months after initial IVTA injection. Ten eyes required additional intervention during the follow-up period. CONCLUSIONS: Early treatment of severe CME secondary to branch retinal vein occlusion with IVTA is effective in reducing foveal thickness as measured by optical coherence tomography and improving visual acuity. However, monotherapy with IVTA can be associated with a significant rate of recurrent CME.

Percutaneous carotid artery angioplasty and stenting for ocular ischemic syndrome.

PURPOSE: To describe percutaneous carotid angioplasty and stenting to treat ocular ischemic syndrome resulting from severe intracranial carotid artery stenosis. DESIGN: Retrospective case series of 3 patients with ocular ischemic syndrome and intracranial carotid artery stenosis. INTERVENTION: All patients underwent carotid artery evaluation, including ultrasound, transcranial Doppler, magnetic resonance imaging or magnetic resonance angiography,and angiography. Carotid angioplasty and stenting was performed in all patients. MAIN OUTCOME MEASURES: Carotid angiography, fluorescein angiography, and transcranial Doppler imaging were used to evaluate cerebral and ocular perfusion. RESULTS: Cerebral perfusion improved in all patients. Fluorescein angiography arteriovenous transit times improved in 2 patients. One patient had a correction in the reversal of flow through the ophthalmic artery. Visual acuity remained stable or improved in all patients. There were no complications associated with the procedure. CONCLUSIONS: Intracranial carotid artery stenosis is a rare cause of ocular ischemic syndrome. With the advent of carotid angioplasty and stenting, stenotic lesions previously not amenable to carotid endarterectomy are now treatable with stenting. A complete work-up of the carotid artery is necessary in all cases of ocular ischemic syndrome to ensure evaluation of the entire carotid artery system. Early diagnosis of intracranial carotid stenosis is important for preservation of visual function and reducing risk of cerebral vascular event.

Anatomic and visual outcomes of noninfectious endophthalmitis after intravitreal triamcinolone.

PURPOSE: To describe the anatomic and visual outcomes of patients in whom noninfectious endophthalmitis developed after injection of intravitreal triamcinolone acetonide. DESIGN: Retrospective case series. METHODS: Ophthalmologic evaluations of patients in whom noninfectious endophthalmitis developed after intravitreal triamcinolone took place on the day of injection, at the time of presentation of noninfectious endophthalmitis, at the time of clearance of inflammation, and on follow-up examination. Seventeen eyes of 17 patients were identified from 2 institutions. Noninfectious endophthalmitis was identified based on history of visual loss immediately or soon after injection, lack of ocular pain, hypopyon, anterior or vitreous inflammation, and triamcinolone crystals present in the anterior or posterior chambers. Main outcome measures were Snellen visual acuity (VA) and mean foveal thickness by optical coherence tomography. RESULTS: Mean VA and mean foveal thickness on the day of injection of intravitreal triamcinolone were 20/132 (logarithm of the minimum angle of resolution [logMAR], 0.82 +/- 0.45) and 432 +/- 118 microm, respectively. Mean VA at time of noninfectious endophthalmitis (mean, 1.9 days after injection) was 20/4444 (logMAR, 2.35 +/- 0.98). At last follow-up (mean, 57.6 days), VA and mean foveal thickness were 20/56 (logMAR, 0.44 +/- 0.30) and 301 +/- 71 microm, respectively. CONCLUSIONS: VA and mean foveal thickness in all patients with noninfectious endophthalmitis after intravitreal triamcinolone improved to better than preinjection levels in this series. At last follow-up, no patient had sustained visual loss from noninfectious endophthalmitis. Noninfectious endophthalmitis after intravitreal triamcinolone may not exclude good visual and anatomic prognoses.

Intravascular lymphoma masquerading as Vogt-Koyanagi-Harada syndrome.

PURPOSE: To describe the clinical course of a case of intravascular lymphoma. DESIGN: Case report. METHODS: Retrospective chart review. RESULTS: A 56-year-old man presented with blurry vision associated with fever and decreased hearing. Ocular exam including fluorescein angiography and OCT was consistent with Vogt-Koyanagi-Harada syndrome and the patient initially improved with corticosteroids. Clinical deterioration led to further systemic workup and revealed intravascular lymphoma. The patient was started on chemotherapy with resolution of visual complaints. CONCLUSIONS: Intravascular lymphoma can present as a masquerade of VKH syndrome. Diagnosis can be aided with measurement of LDH and skin biopsy.

Effect of adjunctive diclofenac with verteporfin therapy to treat choroidal neovascularization due to age-related macular degeneration: phase II study.

BACKGROUND: To determine short-term effects of topical diclofenac administered in conjunction with verteporfin therapy for predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD). METHODS: Randomized, multicenter (14), prospective, placebo-controlled, double-masked clinical trial. Patients (n=61) were randomly assigned to treatment with diclofenac sodium ophthalmic solution 0.1% or placebo and followed for 12 weeks. Patients instilled diclofenac or placebo two drops four times daily, 2-4 days before verteporfin treatment until 2 weeks after treatment, then two drops twice daily for 10 weeks. This exploratory study was not powered to detect differences between treatment groups. Statistical analyses were conducted solely to aid interpretation of results. RESULTS: In diclofenac-treated eyes, mean changes in visual acuity letter score from baseline in the diclofenac and placebo groups were +1.8 letters and -1.0 at week 1 (P=0.505 between groups). Mean visual acuity letter scores decreased in both groups at all subsequent visits, with a mean change at 12 weeks of -7.4 with diclofenac and -2.6 with placebo (P=0.213). Percentages of eyes with stable or improved vision (change or=5 letters) were similar in the diclofenac and placebo groups at all study visits. No significant between-group differences in changes from baseline in lesion area, greatest linear dimension (GLD), fluorescein leakage, or retinal thickness were detected. CONCLUSION: In patients with predominantly classic subfoveal CNV due to AMD, administration of topical diclofenac with verteporfin therapy was associated with similar vision outcomes to placebo plus verteporfin therapy.

Homocysteine: a risk factor for retinal venous occlusive disease.

PURPOSE: Recent studies have shown a relationship between elevated levels of homocysteine and vascular disease including cerebrovascular accidents and myocardial infarctions. We evaluated patients with a recent retinal vein occlusion to determine if there was an associated elevation of homocysteine. DESIGN: Age and gender matched case-controlled study. PARTICIPANTS: Twenty patients with retinal venous occlusive disease within the previous 6-month period and 40 control patients without retinal venous occlusive disease were enrolled in the study. METHODS: Twenty patients with a history of retinal vein occlusion underwent laboratory testing to determine serum homocysteine levels. In addition, a health survey was completed and several laboratory tests relating to vascular disease including cholesterol were checked. Two control groups were selected. The first group included patients with diabetes and no history of retinal vascular occlusive disease. The second control group included nondiabetic patients who also had no prior history of retinal vascular occlusive disease. MAIN OUTCOME MEASURES: The main parameter measured in this study is fasting homocysteine. RESULTS: Fifteen of 20 patients (75%) with retinal vein occlusion disease had an elevated fasting serum homocysteine level, whereas only 5 of 40 control patients (13%) had an abnormal homocysteine level (P < 0.0005). CONCLUSIONS: Patients with retinal venous occlusive disease have higher levels of homocysteine, which may serve as a modifiable risk factor.