Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study.

PURPOSE: To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS: In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS: Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS: Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Alternaria fungal dacryocystitis with cutaneous fistula: a case report.

Alternaria is a fungal genus that can cause opportunistic human infection in immunocompromised hosts. While the majority of clinical manifestations are cutaneous or subcutaneous infections, there are reports of oculomycosis, which is most commonly present as keratomycosis or endophthalmitis.Here, we present a rare case of Alternaria dacryocystitis with cutaneous fistula in a diabetic patient. The patient was referred with a non-healing medial canthal wound and an initial biopsy report showing "ruptured hair follicle;" re-examination of the biopsy specimen with fungal stains led to the diagnosis of alternariosis. The patient underwent surgical debridement and systemic antifungal treatment, with complete resolution of the infection. In order to initiate prompt treatment and prevent invasive disease, fungal infection should be considered in an immunocompromised patient with chronic dacryocystitis and cutaneous fistula or a nonhealing medial canthus wound.

Predictive Modeling of New-Onset Postoperative Diplopia Following Orbital Decompression for Thyroid Eye Disease.

PURPOSE: To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques. METHODS: We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX). RESULTS: A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective. CONCLUSIONS: This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

Telemedicine Use by Oculoplastic Surgeons During the COVID-19 Pandemic.

Background: Telemedicine use expanded dramatically during the COVID-19 pandemic, including to surgical fields that had limited prior adoption of telehealth such as oculoplastic surgery. To assess telemedicine usage patterns, barriers to implementation, and satisfaction with telemedicine, we conducted a survey among members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Methods: We performed a Web-based, anonymous survey of ASOPRS members from November to December 2020. Statistical analyses were performed by using Fisher's exact and Chi-squared tests. Results: We received 196 unique survey responses from 963 invited participants (20.5% response rate). Among the 192 ASOPRS members who participated, the majority (79%) reported currently using telemedicine. Very few of those currently using telemedicine (14%) had used telemedicine before March 15, 2020 and a significant proportion (36%) were unsure or did not plan to use telemedicine post-pandemic. Telemedicine use was more common among participants with fewer years in practice (p < 0.01) and those who were university- versus self-employed (p < 0.01). The most common barriers to telemedicine use were technological issues, reimbursement concerns, and a perceived lack of patient acceptance. Nearly half of the surgeons reported being satisfied with telemedicine (48%), and the majority reported perceived patient satisfaction with telemedicine (74%). Discussion: Telemedicine adoption increased significantly among oculoplastic surgeons during the COVID-19 pandemic. However, many current users reported that they were unsure or did not plan to use telemedicine post-pandemic. Conclusions: Further research is needed to design sustainable telemedicine programs to enhance patient access to oculoplastic specialty care in the long term.

Simultaneous Orbital and Intracranial Abscesses in 17 Cases.

PURPOSE: To describe the demographics, clinical presentation, treatment, and outcomes of a rare cohort with simultaneous orbital and intracranial abscesses. METHODS: A historical cohort study of 17 patients with simultaneous orbital and intracranial abscesses between 2010 and 2018 was performed. The demographics, location of abscesses, treatment, and outcomes of these patients were analyzed. RESULTS: The mean age was 26.9 years (range 5-83 years). Fourteen patients (82%) were male. In this cohort, the most common orbital abscess location was the superior orbit, involved in 14 patients (82%). The most common site of intracranial abscess was the frontal lobe, involved in 16 patients (94%). Concurrent sinus disease was present in 16 patients (94%). Surgical evacuation was the standard of treatment, with 94% of patients undergoing at least one surgical procedure. Streptococcus species were the most common, isolated from 6 sinus cultures (43%), 3 orbitotomy cultures (21%), and 4 craniectomy cultures (36%). Staphylococcus species were also common. Most patients (94%) had stable or improved mental status and visual function at the conclusion of their treatment. CONCLUSIONS: Simultaneous orbital and intracranial abscesses are rare. Local invasion from the orbit into the intracranial space may occur from direct spread, thus superior orbital abscesses pose the greatest risk for intracranial spread. Additional factors such as infection with Streptococcus and Staphylococcus species as well as male sex appear to be risk factors for intracranial spread. For those who develop intracranial abscesses, young age and absence of seizures or altered mental status at presentation may be associated with favorable outcomes.

Two cases of epidemic keratoconjunctivitis-associated dacryocystitis.

This report presents two cases of epidemic keratoconjunctivitis (EKC)-associated dacryocystitis. Both patients presented with preseptal edema. Orbital computed tomography (CT) scans were performed out of concern for orbital cellulitis and revealed soft tissue edema involving the preseptal aspect of the eyelids and also the lacrimal sac. Both patients were initially diagnosed with bacterial preseptal cellulitis with dacryocystitis and admitted for treatment with intravenous antibiotics. After no improvement on antibiotics, both patients were noted to have exam findings consistent with viral conjunctivitis, and one patient had a positive conjunctival swab for adenovirus. Both patients were subsequently treated with topical steroids, and symptoms improved. EKC has previously been identified as a cause of acquired nasolacrimal duct obstruction and canalicular stenosis, and acute inflammation of the lacrimal apparatus may explain this link. Dacryocystitis may also be contributory to the copious tearing seen in patients with epidemic keratoconjunctivitis.

Recurrent natural killer/T-cell lymphoma of the lacrimal sac and nasolacrimal duct in a 59-year-old Caucasian woman.

A 59-year-old Caucasian woman with past medical history significant for Natural Killer (NK)/T-cell lymphoma of the right nasal septum in remission for nine months presented after surveillance PET-CT imaging revealed increased metabolic activity in the right nasolacrimal duct. She also reported ipsilateral epiphora starting around this time. The lacrimal sac and nasolacrimal ductal mucosa were biopsied via an external approach. Pathologic evaluation revealed a proliferation of lymphoid cells with necrotic tissue. Immunohistochemical staining demonstrated predominantly CD3+, EBER+, and CD56+ cells indicating recurrent NK/T-cell lymphoma. This case describes an unusual presentation of recurrent NK/T-cell lymphoma involving the lacrimal excretory system in a Caucasian adult. Recurrent malignancy should be considered in the differential of any patient with a history of a lymphoproliferative disorder near the lacrimal drainage system who presents with new onset epiphora.

Physical therapy for facial nerve palsy: applications for the physician.

PURPOSE OF REVIEW: The aim of this study was to describe the current state of physical therapy for facial nerve palsy, the evidence basis for these interventions and how therapy can be integrated with other medical and surgical interventions for facial nerve palsy, as it applies to ophthalmologists, oculoplastic surgeons and other specialists. RECENT FINDINGS: Many studies indicate that physical therapy is effective for the rehabilitation of patients with facial nerve palsy and can be used synergistically with interventions administered by physicians, such as targeted botulinum toxin injections. The field is limited by a relative paucity of high-quality randomized controlled trials. Alternative therapies including Brief Electrical Stimulation continue to be studied; however, they lack a scientific rationale and, anecdotally, appear to cause more problems in cases of incomplete facial nerve recovery. SUMMARY: Physical therapy, specifically neuromuscular retraining, is a useful intervention for treating facial nerve palsy. Care for these patients is best delivered in a multidisciplinary setting in which physical therapy and medical or surgical interventions can be closely integrated. Further study aimed at standardizing physical therapy and optimizing the integration of this with other treatments for facial nerve palsy are needed.

Carbon footprint and cost-effectiveness of cataract surgery.

PURPOSE OF REVIEW: This article raises awareness about the cost-effectiveness and carbon footprint of various cataract surgery techniques, comparing their relative carbon emissions and expenses: manual small-incision cataract surgery (MSICS), phacoemulsification, and femtosecond laser-assisted cataract surgery. RECENT FINDINGS: As the most commonly performed surgical procedure worldwide, cataract surgery contributes significantly to global climate change. The carbon footprint of a single phacoemulsification cataract surgery is estimated to be comparable to that of a typical person's life for 1 week. Phacoemulsification has been estimated to be between 1.4 and 4.7 times more expensive than MSICS; however, given the lower degree of postoperative astigmatism and other potential complications, phacoemulsification may still be preferable to MSICS in relatively resource-rich settings requiring high levels of visual function. Limited data are currently available regarding the environmental and financial impact of femtosecond laser-assisted cataract surgery; however, in its current form, it appears to be the least cost-effective option. SUMMARY: Cataract surgery has a high value to patients. The relative environmental impact and cost of different types of cataract surgery should be considered as this treatment becomes even more broadly available globally and as new technologies are developed and implemented.

Comparing the Impact of Refractive and Nonrefractive Vision Loss on Functioning and Disability: The Salisbury Eye Evaluation.

PURPOSE: To compare the effects of uncorrected refractive error (URE) and nonrefractive visual impairment (VI) on performance and disability measures. DESIGN: Cross-sectional, population-based study. PARTICIPANTS: A total of 2469 individuals with binocular presenting visual acuity (PVA) of ≥ 20/80 who participated in the first round of the Salisbury Eye Evaluation study. METHODS: The URE was defined as binocular PVA of ≤ 20/30, improving to >20/30 with subjective refraction. The VI was defined as post-refraction binocular best-corrected visual acuity (BCVA) of ≤ 20/30. The visual acuity decrement due to VI was calculated as the difference between BCVA and 20/30, whereas visual acuity due to URE was taken as the difference between PVA and BCVA. Multivariable regression analyses were used to assess the disability impact of (1) vision status (VI, URE, or normal vision) using the group with normal vision as reference and (2) a 1-line decrement in acuity due to VI or URE. MAIN OUTCOME MEASURES: Objective measures of visual function were obtained from timed performance of mobility and near vision tasks, self-reported driving cessation, and self-reported visual difficulty measured by the Activities of Daily Vision (ADV) scale. The ADV responses were analyzed using Rasch analysis to determine visual ability. RESULTS: Compared with individuals with normal vision, subjects with VI (n = 191) had significantly poorer objective and subjective visual functioning in all metrics examined (P < 0.05), whereas subjects with URE (n = 132) demonstrated slower walking speeds, slower near task performance, more frequent driving cessation, and lower ADV scores (P < 0.05), but did not demonstrate slower stair climbing or descent speed. For all functional metrics evaluated, the impact of VI was greater than the impact of URE. The impact of a 1-line VA decrement due to VI was associated with greater deficits in mobility measures and driving cessation when compared with a 1-line VA decrement due to URE. CONCLUSIONS: Visual impairment is associated with greater disability than URE across a wide variety of functional measures, even in analyses adjusting for the severity of vision loss. Refractive and nonrefractive vision loss should be distinguished in studies evaluating visual disability and be understood to have differing consequences.

Evaluation of real-world mobility in age-related macular degeneration.

BACKGROUND: Previous research has suggested an association between poor vision and decreased mobility, including restricted levels of physical activity and travel away from home. We sought to determine the impact of age-related macular degeneration (AMD) on these measures of mobility. METHODS: Fifty-seven AMD patients with bilateral, or severe unilateral, visual impairment were compared to 59 controls with normal vision. All study subjects were between the ages of 60 and 80. Subjects wore accelerometers and cellular network-based tracking devices over 7 days of normal activity. Number of steps taken, time spent in moderate-to-vigorous physical activity (MVPA), number of excursions from home, and time spent away from home were the primary outcome measures. RESULTS: In multivariate negative binomial regression models adjusted for age, gender, race, comorbidities, and education, AMD participants took fewer steps than controls (18% fewer steps per day, p = 0.01) and spent significantly less time in MVPA (35% fewer minutes, p < 0.001). In multivariate logistic regression models adjusting for age, sex, race, cognition, comorbidities, and grip strength, AMD subjects showed an increased likelihood of not leaving their home on a given day (odds ratio = 1.36, p = 0.04), but did not show a significant difference in the magnitude of time spent away from home (9% fewer minutes, p = 0.11). CONCLUSION: AMD patients with poorer vision engage in significantly less physical activity and take fewer excursions away from the home. Further studies identifying the factors mediating the relationship between vision loss and mobility are needed to better understand how to improve mobility among AMD patients.

Driving habits in older patients with central vision loss.

OBJECTIVE: To determine if central visual loss is associated with driving cessation, driving restriction, or other-driver preference. DESIGN: Cross-sectional study. PARTICIPANTS: Sixty-four subjects with bilateral visual loss (<20/32 in better eye) or severe unilateral visual loss (<20/200) from age-related macular degeneration (AMD) and 58 normally sighted controls between 60 and 80 years of age. METHODS: Participants self-reported driving habits. Other-driver preference was defined as preferring that another drive when there is more than 1 driver in the car. Subjects reporting 2 or more driving limitations were considered to have restricted their driving. MAIN OUTCOME MEASURES: Self-reported driving cessation, other-driver preference, and driving restriction. RESULTS: Age-related macular degeneration subjects were older (74.7 vs. 69.7 years), had worse visual acuity (VA; mean better-eye VA, 0.43 vs. 0.08 logarithm of minimum angle of resolution [logMAR]) and contrast sensitivity (CS; 1.4 vs. 1.9 log units of CS [logCS]), and were more likely to be white when compared with controls (P<0.001 for all). Drivers with AMD-related vision loss were more likely to avoid driving over longer distances, beyond 1 hour, at night, and in unfamiliar conditions (P < 0.05 for all). In multivariate models, driving cessation was associated with worse better-eye VA (odds ratio [OR], 1.5 per 1-line decrement in VA; P<0.001) and worse binocular CS (OR, 1.36 per 0.1 logCS increment; P = 0.005); however, AMD group status was not associated with driving cessation (OR, 1.9; P = 0.35). Factors predicting driving restriction were AMD (OR, 9.0; P = 0.004), worse vision (OR, 2.5 per line of VA loss; P<0.001), lower CS (OR, 2.2 per 0.1-logCS increment; P<0.001), and female gender (OR, 27.9; P = 0.002). Other-driver preference was more common with worse vision (OR, 1.6 per 0.1-logMAR increment; P = 0.003), female gender (OR, 4.5; P = 0.02), and being married (OR, 3.8; P = 0.04). CONCLUSIONS: Most patients with AMD-related central vision loss continue to drive, but demonstrate significant driving restrictions, especially with more severe VA and CS loss. Future work should determine which driving adaptations the visually impaired best balance safety and independence.

Fear of falling in age-related macular degeneration.

BACKGROUND: Prior studies have shown age-related macular degeneration (AMD) to be associated with falls. The purpose of this study is to determine if (AMD) and AMD-related vision loss are associated with fear of falling, an important and distinct outcome. METHODS: Sixty-five persons with AMD with evidence of vision loss in one or both eyes and 60 glaucoma suspects with normal vision completed the University of Illinois at Chicago Fear of Falling questionnaire. Responses were Rasch analyzed. Scores were expressed in logit units, with lower scores demonstrating lesser ability and greater fear of falling. RESULTS: Compared to glaucoma suspect controls, AMD subjects had worse visual acuity (VA) (median better-eye VA = 20/48 vs. 20/24, p < 0.001) and worse contrast sensitivity (CS) (binocular CS = 1.9 vs. 1.5 log units, p < 0.001). AMD subjects were also older, more likely to be Caucasian, and less likely to be employed (p < 0.05 for all), but were similar with regards to other demographic and health measures. In multivariable models controlling for age, gender, body habitus, strength, and comorbid illnesses, AMD subjects reported greater fear of falling as compared to controls (ß = -0.77 logits, 95% CI = -1.5 to -0.002, p = 0.045). In separate multivariable models, fear of falling increased with worse VA (ß = -0.15 logits/1 line decrement, 95% CI = -0.28 to -0.03, p = 0.02) and CS (ß = -0.20 logits/0.1 log unit decrement, 95% CI = -0.31 to -0.09, p = 0.001). Greater fear of falling was also associated with higher BMI, weaker grip, and more comorbid illnesses (p < 0.05 for all). CONCLUSIONS: AMD and AMD-related vision loss are associated with greater fear of falling in the elderly. Development, validation, and implementation of methods to address falls and fear of falling for individuals with vision loss from AMD are important goals for future work.

Review of recent advances in managing periocular skin malignancies.

Management of cutaneous malignancies can be particularly challenging when they are located in the periocular region. The standard of care for localized disease is complete surgical excision, but this may not be possible without significant disruption to visual structures and facial appearance. Definitive radiation may be an option for some patients who cannot or do not wish to undergo surgery. Advances in systemic treatment options for locally advanced and metastatic skin cancers in the past 10 years have prompted investigation into neoadjuvant treatment of periocular cancers. The use of chemotherapy, immune checkpoint inhibitors, and targeted therapies have all been reported with varying degrees of success. For many patients, targeted therapies or immune checkpoint inhibitors should be considered depending on the cancer type, symptoms, and goals with the input of a multidisciplinary cancer care team. In this article, we systematically review the latest updates in surgical, radiotherapeutic, and medical management of periocular malignancies.

Driving patterns in older adults with glaucoma.

BACKGROUND: The ability to drive is important for ensuring quality of life for many older adults. Glaucoma is prevalent in this age group and may affect driving. The purpose of this study is to determine if glaucoma and glaucomatous visual field (VF) loss are associated with driving cessation, limitations, and deference to another driver in older adults. METHODS: Cross-sectional study. Eighty-one glaucoma subjects and 58 glaucoma suspect controls between age 60 and 80 reported if they had ceased driving, limited their driving in various ways, or preferred another to drive. RESULTS: Twenty-three percent of glaucoma subjects and 6.9% of suspects had ceased driving (p = 0.01). Glaucoma subjects also had more driving limitations than suspects (2.0 vs. 1.1, p = 0.007). In multivariable models, driving cessation was more likely for glaucoma subjects as compared to suspects (OR = 4.0; 95% CI = 1.1-14.7; p = 0.03). The odds of driving cessation doubled with each 5 decibel (dB) decrement in the better-eye VF mean deviation (MD) (OR = 2.0; 95% CI = 1.4-2.9; p < 0.001). Glaucoma subjects were also more likely than suspects to report a greater number of driving limitations (OR = 4.7; 95% CI = 1.3-16.8; p = 0.02). The likelihood of reporting more limitations increased with the VF loss severity (OR = 1.6 per 5 dB decrement in the better-eye VF MD; 95% CI = 1.1-2.4; p = 0.02). Neither glaucoma nor VF MD was associated with other driver preference (p > 0.1 for both). CONCLUSIONS: Glaucoma and glaucomatous VF loss are associated with greater likelihood of driving cessation and greater limitation of driving in the elderly. Further prospective study is merited to assess when and why people with glaucoma change their driving habits, and to determine if their observed self-regulation of driving is adequate to ensure safety.

Physical Activity in Functionally Monocular Persons in the United States, 2003-2006.

Purpose: Real-world physical activity patterns in monocular persons have not been previously characterized. This study uses a nationally representative sample to compare the physical activity levels of functionally monocular to binocularly sighted persons in the United States. Methods: This cross-sectional study uses data from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey (NHANES) to compare differences in physical activity between functionally monocular and binocular participants. The main outcome measures were accelerometer-measured mean steps per day and mean daily minutes of moderate or vigorous physical activity (MVPA). Statistical analysis was conducted using multivariable negative binomial regression models adjusted for age. Results: In total, 7967 NHANES participants had complete visual acuity and accelerometer data. The mean age at baseline was 44.5 years, and a majority were Caucasian (73%) and female (51%). In models adjusted for age only, functionally monocular participants (n = 172) took fewer steps (9277 with 95% confidence interval [CI], 8800-9753 vs. 10,057 with 95% CI, 9832-10,281) and engaged in similar minutes of MVPA (26.75 with 95% CI, 22.0-31.5 vs. 26.70 with 95% CI, 25.6-27.7) per day compared to binocularly sighted participants (n = 7758). In our final model, functionally monocular participants took 16% fewer steps per day (P < 0.01) and engaged in 26% fewer minutes per day of MVPA (P = 0.01). Poorer visual acuity, older age, female gender, obesity, congestive heart failure, and arthritis were also associated with a statistically significant decrease in physical activity in both models. Conclusions: Functionally monocular persons have lower physical activity levels compared to those with binocular eyesight in the United States, even after adjusting for better-eye visual acuity. Translational Relevance: Our translational study provides insight into the epidemiology of physical activity and its impact on population health. We quantify real-world physical activity in two at-risk populations, monocular and blind individuals.

Ocular Emergencies During the Coronavirus Disease 'Safer at Home Order' in Wisconsin.

INTRODUCTION: The coronavirus pandemic created large shifts in utilization of hospital resources, patient presentations, and delivery of medical care. OBJECTIVES: This retrospective study evaluated the ocular emergencies at a tertiary-care academic hospital in Wisconsin during the COVID-19-related "Safer at Home" order. METHODS: Ophthalmology consultations performed March 23 through May 26, 2020, were compared to the same time period in the 4 preceding years and the subsequent year. Billing codes were obtained to evaluate the diagnoses and procedures performed during this time frame. RESULTS: In 2020, 155 consultations were performed (42 emergency department, 113 inpatient), compared to a mean of 214 over the 5 other study years. The incidence rate ratio (IRR) of total consultations in 2020 was 0.72 (P ≤ 0.001) compared to previous years. Significantly fewer emergency department consultations were performed (IRR 0.62, P ≤ 0.001), while inpatient consultations were similar (IRR 0.88, P = 0.119). The most common diagnosis across all study years was fracture of the skull/orbit with injury to the eye/orbit. In 2020, 13% of consultations led to a procedure, compared to a total of 16% in the other years (IRR 0.59, P = 0.018). CONCLUSIONS: This study demonstrated a 28% reduction in ophthalmology consultations at a major university hospital in Wisconsin during the COVID-19-related "Safer at Home" order, though the number of consultations leading to surgery were stable. This suggests that while patients with less acute needs may have deferred care, those requiring urgent surgery still presented to the emergency department. These data may help hospitals appropriately allocate eye care resources during future public health emergencies.

Psychological distress and well-being among sensory impaired individuals during COVID-19 lockdown measures.

PURPOSE: Hearing and vision impairment are prevalent chronic conditions associated with poorer mental health. Limitations of in-person contacts during COVID-19-related lockdown measures may affect those with sensory impairments more severely exacerbating mental health problems. We aimed to determine whether hearing and/or visual impairment were associated with more psychological distress during a time of lockdown measures in Spring/Summer 2020 in Wisconsin. METHODS: We included 1341(64% women, aged 20-92 years) Survey of the Health of Wisconsin COVID-19 survey participants (May 2020-July,2020). We assessed self-reported current mental health and well-being and vision and hearing impairment. Logistic regression models with sensory impairments as determinants and mental health outcomes were adjusted for age, gender, race, education, heart disease, hypertension, hyperlipidemia, and diabetes. RESULTS: Vision impairment was associated with increased odds of generalized anxiety disorder (odds ratio = 2.10; 95% confidence interval = 1.32-3.29) and depressive symptoms (2.57;1.58-4.11), greater likelihood to report loneliness (1.65;1.00-2.64) and hopelessness (1.45;1.01-2.08). Hearing impaired individuals reported more loneliness (1.80;1.05-2.98) and hopelessness (1.42;0.99-2.03). Exploratory analyses revealed that sensory impaired individuals less often chose walking as a coping strategy during the pandemic. CONCLUSIONS: Individuals with sensory impairment may represent a particularly vulnerable population during the COVID-19 pandemic. Future research should determine underlying reasons and interventions to mitigate this populations' disadvantages.

Visual field loss and accelerometer-measured physical activity in the United States.

OBJECTIVE: To determine whether visual field (VF) loss is associated with lower levels of accelerometer-defined walking or physical activity in a nationally representative sample of American adults. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 2934 adults aged 40 years or older who participated in the examination component of the 2005-2006 National Health and Nutritional Examination Survey. METHODS: Frequency-doubling technology (FDT) testing was performed in both eyes and used to categorize subjects as having no VF loss, unilateral VF loss, or bilateral VF loss. Accelerometer data were collected over 7 days of normal activity. MAIN OUTCOME MEASURES: Steps per day and daily minutes of moderate or vigorous physical activity (MVPA). RESULTS: A total of 1468 participants (50.0%) had complete FDT and accelerometer data. Individuals without VF loss averaged 9751 steps/day and 20.8 minutes/day of MVPA, compared with 8023 steps/day and 14.5 minutes/day for subjects with unilateral VF loss (age-adjusted P = 0.11 and P = 0.51) and 6840 steps/day and 10.1 minutes/day for subjects with bilateral VF loss (age-adjusted P = 0.02 and 0.09, respectively). In multivariable models adjusted for age, sex, race/ethnicity, education, and several comorbid illnesses, individuals with bilateral VF loss took 17% fewer steps per day (P < 0.01) and engaged in 30% less MVPA (P = 0.02) than individuals without VF loss. No significant difference in steps per day or MVPA was observed between individuals with unilateral VF loss and no VF loss (P > 0.05). In addition to VF loss, older age, female sex, arthritis, diabetes, congestive heart failure (CHF), and stroke were significantly associated with fewer daily steps and minutes of MVPA (P < 0.05). CONCLUSIONS: Bilateral VF loss is associated with less walking and physical activity in American adults. Patients with bilateral VF loss should be encouraged to engage safely in more physical activity. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Fear of falling and visual field loss from glaucoma.

OBJECTIVE: To determine if visual field (VF) loss resulting from glaucoma is associated with greater fear of falling. DESIGN: Prospective, observational study. PARTICIPANTS: Fear of falling was compared between 83 glaucoma subjects with bilateral VF loss and 60 control subjects with good visual acuity and without significant VF loss recruited from patients followed up for suspicion of glaucoma. METHODS: Participants completed the University of Illinois at Chicago Fear of Falling Questionnaire. The extent of fear of falling was assessed using Rasch analysis. MAIN OUTCOME MEASURES: Subject ability to perform tasks without fear of falling was expressed in logits, with lower scores implying less ability and greater fear of falling. RESULTS: Glaucoma subjects had greater VF loss than control subjects (median better-eye mean deviation [MD] of -8.0 decibels [dB] vs. +0.2 dB; P<0.001), but did not differ with regard to age, race, gender, employment status, the presence of other adults in the home, body mass index (BMI), grip strength, cognitive ability, mood, or comorbid illness (P ≥ 0.1 for all). In multivariate models, glaucoma subjects reported greater fear of falling as compared with controls (ß = -1.20 logits; 95% confidence interval [CI], -1.87 to -0.53; P = 0.001), and fear of falling increased with greater VF loss severity (ß = -0.52 logits per 5-dB decrement in the better eye VF MD; 95% CI, -0.72 to -0.33; P<0.001). Other variables predicting greater fear of falling included female gender (ß = -0.55 logits; 95% CI, -1.03 to -0.06; P = 0.03), higher BMI (ß = -0.07 logits per 1-unit increase in BMI; 95% CI, -0.13 to -0.01; P = 0.02), living with another adult (ß = -1.16 logits; 95% CI, -0.34 to -1.99 logits; P = 0.006), and greater comorbid illness (ß = -0.53 logits/1 additional illness; 95% CI, -0.74 to -0.32; P<0.001). CONCLUSIONS: Bilateral VF loss resulting from glaucoma is associated with greater fear of falling, with an impact that exceeds numerous other risk factors. Given the physical and psychological repercussions associated with fear of falling, significant quality-of-life improvements may be achievable in patients with VF loss by screening for, and developing interventions to minimize, fear of falling.