Electronic Health Records in Ophthalmology: Source and Method of Documentation.

PURPOSE: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. DESIGN: EHR documentation review and analysis. METHODS: Setting: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. RESULTS: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. CONCLUSIONS: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

Two single-piece acrylic intraocular lens choices and their effect on patient-reported driving habits.

PURPOSE: To determine whether intraocular lens (IOL) type affects patient driving habits 6 months to 5 years after cataract surgery, and to determine whether there were differences in self-reported driving habits between patients who received 1 of 2 IOLs. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective case series. METHODS: Patients completed a telephone-administered Driving Habits Questionnaire (DHQ) 6 months to 5 years after having bilateral cataract surgery with a single-piece hydrophobic acrylic IOL, SN60WF (Group 1) or ZCB00 IOL (Group 2), in both eyes. RESULTS: The study comprised 260 patients (130 in each IOL group). Of these, 117 in Group 1 and 114 in Group 2 were still active drivers. The DHQ response differences for each IOL group did not reach statistical significance, except for self-rated quality of driving and difficulties with driving at night. For these significant differences, contradictory results were found. CONCLUSIONS: Patients with either of the monofocal IOLs had similar self-reported driving habits after bilateral cataract surgery. The choice of IOL did not affect patients' postoperative driving habits.

Thermal evaluation of two phacoemulsification systems.

OBJECTIVE: To compare thermal profiles of new transversal ultrasound power modulation to torsional ultrasound in an artificial chamber and cadaver eye. DESIGN: Laboratory investigation. METHODS: John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, was the study setting. Temperature increase after 30 seconds was measured at the needle midshaft in an artificial chamber and at maximal friction point in a cadaver eye. Ellips FX (transverse) was tested at 100% power, as was Signature with micropulse settings (6 milliseconds on and off). OZil (torsional only) was tested at 100% power in the artificial chamber and cadaver eye. Runs were completed with aspiration blocked. Temperature was continuously measured on the phacoemulsification sleeve using a microthermistor probe connected to the BAT-10 multipurpose thermometer, with an accuracy of ±0.1°C. RESULTS: Transversal FX had a greater temperature increase than micropulse (p < 0.001) and torsional (p < 0.001). Micropulse had a greater temperature increase than torsional (p < 0.001). The cadaver eye had a greater temperature increase than the artificial chamber for torsional (p < 0.001). CONCLUSIONS: Higher heat accumulation and potential for incisional burn occurred with the cadaver model than with the artificial chamber, suggesting the need for caution when using 100% torsional ultrasound with aspiration blocked. Transversal FX generated more heat than was reported originally. Further study is needed to determine the incidence of incisional burn with varied power settings for this new model. Micropulse generated more heat than previous reports, but the increased efficiency is likely to negate potentially increased incisional burn risk.

Lutein, zeaxanthin, and meso-zeaxanthin: The basic and clinical science underlying carotenoid-based nutritional interventions against ocular disease.

The human macula uniquely concentrates three carotenoids: lutein, zeaxanthin, and meso-zeaxanthin. Lutein and zeaxanthin must be obtained from dietary sources such as green leafy vegetables and orange and yellow fruits and vegetables, while meso-zeaxanthin is rarely found in diet and is believed to be formed at the macula by metabolic transformations of ingested carotenoids. Epidemiological studies and large-scale clinical trials such as AREDS2 have brought attention to the potential ocular health and functional benefits of these three xanthophyll carotenoids consumed through the diet or supplements, but the basic science and clinical research underlying recommendations for nutritional interventions against age-related macular degeneration and other eye diseases are underappreciated by clinicians and vision researchers alike. In this review article, we first examine the chemistry, biochemistry, biophysics, and physiology of these yellow pigments that are specifically concentrated in the macula lutea through the means of high-affinity binding proteins and specialized transport and metabolic proteins where they play important roles as short-wavelength (blue) light-absorbers and localized, efficient antioxidants in a region at high risk for light-induced oxidative stress. Next, we turn to clinical evidence supporting functional benefits of these carotenoids in normal eyes and for their potential protective actions against ocular disease from infancy to old age.

Effect of intraocular lens glistening size on visual quality.

PURPOSE: To determine whether intraocular glistenings have an impact on light scatter and visual function. SETTING: John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective cohort study. METHODS: Pseudophakic patients with visual acuity no worse than 0.02 logMAR and no ocular pathology were enrolled. All had received a single-piece high-refractive-index acrylic intraocular lens (IOL). All IOLs were photographed, and glistenings were analyzed for size and density. Outcome measures included logMAR corrected distance visual acuity (CDVA), mesopic 10% contrast logMAR CDVA with and without glare, and straylight determination with a straylight meter (C Quant log). RESULTS: All 79 patients had glistenings within 2 diameter groups: 6 to 25 µm and over 25 µm. Linear regression for the nonstratified group was significant for IOL glistening size versus contrast visual acuity with glare. Linear regression for the 6 to 25 µm group was significant for a measure of severity index (%area) versus the straylight meter measurements, %area/size versus straylight meter measurements, IOL age versus CDVA, IOL age versus contrast visual acuity, and IOL age versus contrast visual acuity with glare. Linear regression for the over 25 µm group was significant for IOL age versus glistening size and %area/size versus contrast visual acuity, and density versus CDVA and contrast visual acuity with glare. CONCLUSIONS: Glistening %area, at a key size, correlated with random light scatter. The age of the IOL likely affects glistening size and visual parameters. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effect of increased vacuum and aspiration rates on phacoemulsification efficiency.

PURPOSE: To evaluate the effect of vacuum and aspiration rates on phacoemulsification efficiency. SETTING: John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA. DESIGN: Experimental study. METHODS: Formalin-soaked porcine lenses were divided into 2.0 mm cubes, and 0.9 mm 30-degree beveled 20-degree bent tips were used with micropulse ultrasound (US) (6 milliseconds on and 6 milliseconds off) and a peristaltic flow system. Vacuum levels were tested at 200, 300, 400, and 500 mm Hg, and aspiration rates were tested at 20, 35, and 50 mL/min. Efficiency (time to lens removal) and chatter (number of lens fragment repulsions from the tip) were determined. RESULTS: Increasing vacuum increased efficiency only when going from 200 mm Hg to higher vacuum levels. Increasing aspiration increased efficiency at all points measured (25 mL/min versus 35 mL/min, P < .0001; 35 mL/min versus 50 mL/min, P = .012; 25 mL/min versus 50 mL/min, P < .0001). Chatter was highest at 200 mm Hg and decreased when vacuum was increased from 200 mm Hg to 300 mm Hg and up. Chatter decreased with increasing flow. CONCLUSIONS: Vacuum improved efficiency only up to 300 mm Hg and was more dependent on increasing flow. Similarly, chatter correlated with 200 mm Hg vacuum only and was more correlated with flow. Limitations of this study include use of only 1 US power modulation and hard nuclear material. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Optogenetics for retinal disorders.

Optogenetics is the use of genetic methods combined with optical technology to achieve gain or loss of function within neuronal circuits. The field of optogenetics has been rapidly expanding in efforts to restore visual function to blinding diseases such as retinitis pigmentosa (RP). Most work in the field includes a group of light-sensitive retinaldehyde-binding proteins known as opsins. Opsins couple photon absorption to molecular signaling chains that control cellular ion currents. Targeting of opsin genes to surviving retinal cells is fundamental to the success of optogenetic therapy. Viral delivery, primarily adeno-associated virus, using intravitreal injection for inner retinal cells and subretinal injection for outer retinal cells, has proven successful in many models. Challenges in bioengineering remain for optogenetics including relative insensitivity of opsins to physiologic light levels of stimulation and difficulty with viral delivery in primate models. However, targeting optogenetic therapy may present an even greater challenge. Neural and glial remodeling seen in advanced stages of RP result in reorganization of remaining neural retina, and optogenetic therapy may not yield functional results. Remodeling also poses a challenge to the selection of cellular targets, with bipolar, amacrine and ganglion cells all playing distinct physiologic roles, and affected by remodeling differently. Although optogenetics has drawn closer to clinical utility, advances in opsin engineering, therapeutic targeting and ultimately in molecular inhibition of remodeling will play critical roles in the continued clinical advancement of optogenetic therapy.

The effects of chronic AMPK activation on hepatic triglyceride accumulation and glycerol 3-phosphate acyltransferase activity with high fat feeding.

BACKGROUND: High fat feeding increases hepatic fat accumulation and is associated with hepatic insulin resistance. AMP Activated Protein Kinase (AMPK) is thought to inhibit lipid synthesis by the acute inhibition of glycerol-3-phosphate acyltransferase (GPAT) activity and transcriptional regulation via sterol regulatory element binding protein-1c (SREBP-1c). METHODS: The purpose of this study was to determine if chronic activation of AMPK prevented an increase in GPAT1 activity in rats fed a high fat diet. Rats were fed a control (C), or a high fat (HF) diet (60% fat) for 6 weeks and injected with saline or a daily aminoimidazole carboxamide ribnucleotide (AICAR) dose of 0.5 mg/g body weight. RESULTS: Chronic AMPK activation by AICAR injections resulted in a significant reduction in hepatic triglyceride accumulation in both the C and HF fed animals (C, 5.5±0.7; C+AICAR, 2.7 ±0.3; HF, 21.8±3.3; and HF+AICAR, 8.0±1.8 mg/g liver). HF feeding caused an increase in total GPAT and GPAT1 activity, which was not affected by chronic AMPK activation (GPAT1 activity vs. C, C+AICAR, 92±19%; HF, 186±43%; HF+AICAR, 234±62%). Markers of oxidative capacity, including citrate synthase activity and cytochrome c abundance, were not affected by chronic AICAR treatment. Interestingly, HF feeding caused a significant increase in long chain acyl-CoA dehydrogenase or LCAD (up 66% from C), a marker of fatty acid oxidation capacity. CONCLUSIONS: These results suggest that chronic AMPK activation limits hepatic triglyceride accumulation independent of a reduction in total GPAT1 activity.

Interrelationships between maternal carotenoid status and newborn infant macular pigment optical density and carotenoid status.

PURPOSE: Deposition of the macular pigment carotenoids lutein and zeaxanthin in the human retina occurs early in life. In this study, we examined the interrelationships of maternal carotenoid status and newborn infant macular pigment levels and systemic carotenoid status. As a secondary measure, we also evaluated the effects of intrauterine growth restriction (IUGR) on carotenoid status in term newborn infants. METHODS: We measured mother and infant skin carotenoids using resonance Raman spectroscopy (RRS), serum carotenoids by HPLC, and mother breast milk carotenoids by HPLC. We measured infant macular pigment levels using noninvasive blue light reflectometry. RESULTS: We enrolled 30 healthy term infants, their mothers, and 10 IUGR infants and their mothers. A subset of 16 infants was imaged for macular pigment optical density (MPOD). Infant serum zeaxanthin levels correlated with MPOD (r = 0.68, P = 0.007). Mother serum zeaxanthin levels correlated with infant MPOD (r = 0.59, P = 0.032). Infant and mother serum lutein did not correlate with MPOD. Mother-infant correlations were found for total serum carotenoids (r = 0.42, P = 0.020) and skin carotenoids (r = 0.48, P = 0.001). No difference was seen between IUGR infants and controls in total serum or skin carotenoids. Mothers of IUGR infants had lower total serum carotenoids (P = 0.019) and breast milk carotenoids than controls (P = 0.006). CONCLUSIONS: Our findings suggest that maternal zeaxanthin status may play a more important role than lutein status in macular pigment deposition in utero. Controlled trials are needed to determine whether maternal zeaxanthin prenatal supplementation can raise infant macular pigment levels and/or improve ocular function.