Demographic and Systemic Risk Factors for Persistent Corneal Edema Following Cataract Surgery in Patients With and Without Diabetes.

PURPOSE: To identify risk factors associated with the development of corneal edema (CE) and the need for corneal transplantation following cataract surgery. DESIGN: Retrospective cohort study. METHODS SETTING: Nation-wide sample of Medicare beneficiaries from 2011-2015. STUDY POPULATION: Medicare beneficiaries aged over 65 years who received cataract surgery between 2011-2014 with at least 1 year of continuous follow-up. Data was retrieved from the Denominator and Physician Supplier Part B file from the Center for Medicare and Medicaid Services. MAIN OUTCOME(S) AND MEASURE(S): The main outcome was the association between demographic characteristics (e.g., age, sex, race/ethnicity) and systemic factors including diabetes status, hypertension, and tobacco use on the incidence of CE and the subsequent need for corneal transplantation following cataract surgery. RESULTS: Among 187,746 beneficiaries, 67,734 had diabetes and 120,012 did not. Beneficiaries with diabetes were more likely to develop CE compared to those without (Odds ratio [OR] 1.19, 95% Confidence Interval [CI] [1.02-1.40]). Compared to those aged 65-74, beneficiaries aged 75-84 and over 85 were more likely to develop CE (OR 1.29 [1.09-1.52]) and OR 1.96 [1.55-2.46], respectively). Asian (OR 2.42 [1.66-3.40]), Hispanic (OR 2.60 [1.73-3.74]), and North American Native (OR 3.59 [1.78-6.39]) race was associated with increased likelihood of developing CE. North American Native beneficiaries had higher risk of requiring corneal transplantation compared to White beneficiaries (OR 9.30 [2.26-25.31]). Female sex decreased likelihood of requiring corneal transplantation post-operatively (OR 0.56 [0.36-0.87]). Amongst those with diabetes, the presence of proliferative diabetic retinopathy increased the likelihood of developing CE (OR 1.94 [1.05-3.39]). CONCLUSION: Older age, diabetes, and non-White race elevate the risk of CE following cataract surgery, with race incurring the highest risk. Further research is needed to understand the factors underlying the significantly increased risk of CE in racial and ethnic minorities within the United States.

Demographic and Psychiatric Associations With Dry Eye in a Medicare Population.

PURPOSE: The purpose of this study was to investigate the impact of demographic characteristics and psychiatric comorbidity on the prevalence of dry eye disease in the American geriatric population. METHODS: Data were collected from a 2011 nationwide sample of Medicare beneficiaries aged 65 years and older (N = 1,321,000). Age, sex, race/ethnicity, residential area, climate region, and income, along with psychiatric comorbidities including depression and anxiety, were collected. Multivariable logistic regression models were used to assess the relationship between demographic and psychiatric factors and the prevalence of dry eye disease. RESULTS: Among 21,059 patients with clinically significant dry eye, women had higher odds of having dry eye compared with men [odds ratio (OR) 2.03, 95% confidence interval (1.97-2.10)]. Asian and Native American patients had increased odds of having dry eye compared with White patients [OR 1.85 (1.69-2.02) and OR 1.51 (1.19-1.93)], while Black patients were less likely to have dry eye [OR 0.83 (0.79-0.87)]. Patients aged 75 to 84 years and 85+ were more likely to have dry eye compared with those aged 65 to 74 years [OR 1.49 (0.45-1.53) and OR 1.54 (1.48-1.60)]. Having both depression and anxiety were associated with higher odds of having dry eye [OR 2.38 (2.22-2.55)] compared with having depression alone [OR 1.95 (1.86-2.04)] or anxiety alone [OR 2.22 (2.10-2.35)]. CONCLUSIONS: Significant racial and regional disparities in dry eye prevalence were found. Psychiatric association with dry eye varied with age, sex, race, and residence region. Further research is needed to comprehend the underlying mechanisms, implications, and to address disparities in the diagnosis and management of dry eye.

Association Between Serum Vitamin D Levels and Myopia in the National Health and Nutrition Examination Survey (2001-2006).

PURPOSE: To assess the relationship between serum vitamin D levels and myopia in people aged 12-50 years using the National Health and Nutrition Examination Survey (NHANES) database. METHODS: Demographics, vision, and serum vitamin D levels from NHANES (2001-2006) were analyzed. Multivariate analyses were performed to examine the relationship between serum vitamin D levels and myopia while controlling for sex, age, ethnicity, education level, serum vitamin A, and poverty status. The main outcome was presence or absence of myopia, defined as a spherical equivalent of -1 diopters or more. RESULTS: Of the 11669 participants, 5,310 (45.5%) had myopia. The average serum vitamin D concentration was 61.6 ± 0.9 nmol/L for the myopic group and 63.1 ± 0.8 nmol/L for the non-myopic group (p = .01). After adjusting for all covariates, having higher serum vitamin D was associated with lower odds of having myopia (odds ratio 0.82 [0.74-0.92], p = .0007). In linear regression modeling that excluded hyperopes (spherical equivalent > +1 diopters), there was a positive relationship between spherical equivalent and serum vitamin D levels. Specifically, as serum vitamin D doubled, spherical equivalent increased by 0.17 (p = .02) indicating a positive dose-response relationship between vitamin D and myopia. CONCLUSIONS: Participants with myopia, on average, had lower serum concentrations of vitamin D compared to those without myopia. While further studies are needed to determine the mechanism, this study suggests that higher vitamin D levels are associated with lower incidence of myopia.

Depression in Individuals With Diabetic Retinopathy in the US National Health and Nutrition Examination Survey, 2005-2008.

PURPOSE: To examine the relationship between diabetic retinopathy (DR) and depression in the United States. DESIGN: Retrospective, cross-sectional study. METHODS: National Health and Nutrition Examination Survey (NHANES) participants between 2005 and 2008 (ages 40-85 years) were included. Prevalence of major depression among DR stages as determined by retinal imaging was estimated. Multivariable models assessed associations between depression and DR. RESULTS: Depression was more common in those with moderate to severe DR (16%) than in those with no DR (7%), mild nonproliferative diabetic retinopathy (NPDR, 6%), or proliferative DR (5%). In a model with DR stages that adjusted for demographic factors, there was an association between moderate to severe DR and depression (odds ratio [OR], 2.46, 95% CI, 1.03-5.85). CONCLUSIONS: Depression was more prevalent in those with moderate to severe NPDR than in those with no DR, mild NPDR, or proliferative DR. This relationship is statistically significant after adjustment for demographic factors.

Anthropometric Measures and Their Relationship to Steep Cornea in the United States Population.

PURPOSE: The aim of this study was to determine the relationship between anthropometric measures and steep cornea. METHODS: Participants from the 1999 to 2008 US National Health and Nutrition Examination Survey visual examination were included (20,165 subjects). Cases had a mean dioptric power, averaged across the meridians, ≥ 48.0 diopters (n = 171). Separate multivariable models assessed body mass index, height, and weight in relation to steep cornea. Analyses included both overall and sex-stratified populations. RESULTS: A relationship between BMI and steep cornea in the overall population was not detected ( P for trend = 0.78). There was a strong inverse relationship between height (adjusted for weight) and steep cornea in the overall population ( P for trend <0.0001) and in women ( P for trend <0.0001). For every 1-inch increase in height, there was a 16% reduced odds of steep cornea in the overall population (OR, 0.84; 95% CI: 0.77-0.92). A relationship between weight and steep cornea was not detected in the overall population (P for trend = 0.79). CONCLUSIONS: Greater height was associated with a lower risk of steep cornea.

National trends in surgical subspecialisation in ophthalmology in the USA.

BACKGROUND/AIMS: To assess surgical patterns in ophthalmology by subspecialty in the USA. METHODS: Ophthalmic surgeons were categorised as comprehensive/subspecialist based on billed procedures in the 2017-2018 Medicare Provider Utilization and Payment Data. Poisson regression models assessed factors associated with physicians performing surgeries in the core domain (eg, cataract extractions) and subspecialty domain. Models were adjusted for provider gender, time since graduation, geographical region, practice setting and hospital affiliation. RESULTS: There were 10 346 ophthalmic surgeons, 74.7% comprehensive and 25.3% subspecialists. Cataract extractions were performed by 6.0%, 9.9%, 21.0%, 88.1% and 95.3% of specialists in surgical retina, neuro-ophthalmology/paediatrics, oculoplastics, glaucoma and cornea, respectively. Retina specialists were more likely to perform cataract surgery if they were 20-30 or>30 years in practice (relative risk: 2.20 (95% CI: 1.17 to 4.12) and 3.74 (95% CI: 1.80 to 7.76), respectively) or in a non-metropolitan setting (3.78 (95% CI: 1.71 to 8.38)). Among oculoplastics specialists, male surgeons (2.71 (95% CI: 1.36 to 5.42)), those in practice 10-20 years or 20-30 years (1.93 (95% CI: 1.15 to 3.26) and 1.91 (95% CI: 1.11 to 3.27), respectively) and in non-metropolitan settings (3.07 (95% CI: 1.88 to 5.02)) were more likely to perform cataract surgery. Only 26 of the 2620 subspecialists performed surgeries in two or more subspecialty domains. CONCLUSIONS: There is a trend towards surgical subspecialisation in ophthalmology in the USA whereby some surgeons focus their surgical practice on subspecialty procedures and rarely perform surgeries in the core domain.

Characterizing astigmatism in the United States.

PURPOSE: To study astigmatism and astigmatism rule by (1) determining changes in prevalence in the United States between 1971 to 1975 and 1999 to 2008 and (2) identifying associations with demographic factors. SETTING: National survey. DESIGN: Retrospective cross-sectional study. METHODS: Participants of the 1971 to 1975 and 1999 to 2008 National Health and Nutrition Examination Survey (NHANES) aged 20 to 74 years representing the U.S population were included. The 1971 to 1975 NHANES measured astigmatism in participants using an algorithm based on presenting visual acuity, lensometry, and objective refraction. Similar methods were implemented using the 1999 to 2008 NHANES data for comparison. Prevalence of clinically significant astigmatism (≥1.0 diopters [D]) was identified, and logistic regression models were used to assess demographic associations with rule of astigmatism. RESULTS: A total of 3371 and 13 10 participants were included from the 1970s and 2000s NHANES. Main outcomes were prevalence estimates of astigmatism and odds ratios estimating associations with demographic characteristics. There was an increase in astigmatism from the 1970s to 2000s (14% [95% CI: 13.2-14.5] vs 24% [22.8-24.6], which was more pronounced in men (12% [10.8-12.7] vs 23% [21.9-24.2]) than in women (16% [14.9-16.8] vs 24% [23.0-25.7]). In adjusted analysis of the 2000s cohort, myopic patients had 8.34 (CI: 7.30-9.54) times greater odds of astigmatism than nonmyopic patients. In the 2000s, there was increased odds of against-the-rule (ATR) astigmatism in men (odds ratio [OR], 1.4; 95% CI: 1.1-1.8) compared with women, in nonmyopic patients (OR, 2.3; 95% CI: 1.7-3.1) compared with myopic patients, and in patients aged 60 to 74 years (OR, 3.7; 95% CI: 2.7-5.1) compared with those aged 20 to 39 years. CONCLUSIONS: There is greater prevalence of astigmatism and ATR astigmatism in 1999 to 2008 compared with 30 years before in the U.S. Factors associated with ATR astigmatism were being male, White, and nonmyopic.

Geographic variations in gender differences in cataract surgery volume among a national cohort of ophthalmologists.

PURPOSE: To assess factors associated with gender disparities in cataract surgery volume and evaluate how these differences have changed over time. SETTING: Cataract surgeons in the 2012 to 2018 Medicare database. DESIGN: Retrospective study. METHODS: The association of provider gender with the number of cataract surgeries per office visit billed was assessed with negative binomial regression models, controlling for calendar year, years in practice, hospital affiliation, geographic region, rurality, density of ophthalmologists, and the national percentile of Area Deprivation Index (ADI) score for the practice location. RESULTS: There were 8480 cataract surgeons, most of whom were male (78%). Male surgeons worked in more deprived areas with a higher ADI (median: 40 vs 33, P < .001). Female surgeons performed fewer cataracts per year (140 [95% CI, 126-154] vs 276 [95% CI, 263-288], P < .001) and billed fewer office visits (1038 [95% CI, 1008-1068] vs 1505 [95% CI, 1484-1526], P < .001). In multivariate analysis, the number of cataract surgeries per office visit was greater for males compared with females in all years in the South (average incidence rate ratio 1.80), Midwest (1.50), and West (1.53), but not in the Northeast (1.16). The relative rate of cataract surgeries between male and female surgeons in each region did not change significantly over time from 2012 to 2018 ( P > .05 in each region). CONCLUSIONS: Gender disparities in cataract volume among male and female surgeons have remained unchanged over time from 2012 to 2018. The higher cataract volume among male surgeons may be explained in part by provider practice location. Further studies are needed to better understand and address gender disparities.

Survival of penetrating keratoplasty: a claims-based longitudinal analysis.

OBJECTIVES: To report real-world long-term survival of primary penetrating keratoplasty (PK) in the United States and analyze risk factors associated with failure. DESIGN: Retrospective longitudinal cohort study using a large commercial insurance database. PARTICIPANTS: Ten million patients enrolled in the database from 2011 to 2017 were identified using Current Procedural Terminology codes for PK. METHODS: Kaplan-Meier survival analysis was performed to determine failure rate and risk factors impacting graft outcomes. RESULTS: Five hundred and ninety-six primary PKs were identified. The 3-year survival was 78% (confidence interval [CI]: 73%-82%), 5-year survival was 76% (CI: 70%-80%), and 7-year survival was 73% (CI: 66%-79%). CONCLUSION: This study demonstrated a significantly lower 5-year success rate for primary PK performed for all causes than previously published case series in the United States.

Gender-Specific Trends in Ophthalmologist Medicare Collections.

PURPOSE: To assess the factors influencing the Medicare collections disparity between male and female ophthalmologists. DESIGN: Retrospective cohort study. METHODS: The Medicare Provider Utilization and Payment Data from 2012-2015 were combined with the 2015 Physician Compare National Downloadable file and US Census data. Three complementary regression models were generated for number of patients seen, number of services performed per patient, and the amount collected per service. Predictor variables included gender, calendar year, geography, years since medical school graduation, and subspecialty. RESULTS: After adjusting for age, geography, and subspecialty, women ophthalmologists collected 42% less as compared to male ophthalmologists, with the median male ophthalmologist out-earning the 75th-percentile female ophthalmologist across almost all age groups, practice categories, and geographic regions. Although women are entering more lucrative subspecialties (cataract and retina) at a higher rate than before, the percentage of women pursuing these subspecialties remains lower than that of men. CONCLUSIONS: Compared with men, women ophthalmologists see fewer patients and have lower Medicare collections. The observed gender gap in collections was highly persistent across years in practice, subspecialty, and geographic region. Future studies are warranted to examine whether the observed gender collections gap results from structural inequities, social circumstances, or personal choices.