Current utility of first-line FT4 and TSH in screening for central hypothyroidism.

BACKGROUND: Thyroid testing strategies vary across laboratories. First-line combined thyroid stimulating hormone (TSH) and freeT4 (FT4) have historically been preferred by many laboratories as this detects individuals with undiagnosed central hypothyroidism who can be missed with a first-line TSH-only strategy. However, an up-to-date evaluation of the utility of this approach is lacking. OBJECTIVES: We investigated the clinical utility of first-line TSH and FT4 in the detection of central hypothyroidism in current day practice. DESIGN, PATIENTS, AND MEASUREMENTS: The All-Wales laboratory information system was queried to identify thyroid function tests in patients aged ≥16 years with decreased FT4 and inappropriate TSH (low-FT4). The 1-year incidence of low-FT4 was determined using mid-year population data. Clinical information of patients with low-FT4 was reviewed to determine causes of low-FT4 and the incidence of central hypothyroidism. RESULTS: The incidence of low-FT4 varied according to FT4 assay method (range: 98-301 cases/100,000 population/year). Fifteen new cases of central hypothyroidism were detected in two health boards, equivalent to 2 cases/100,000 population/year. Positive predictive value of low-FT4 for central hypothyroidism was 2%-4%. In a cross-section of primary care patients, low-FT4 was detected in 0.5% of all thyroid tests with assay-related differences in detection rates. CONCLUSIONS: Although low-FT4 is a common laboratory finding, the incidence of central hypothyroidism remains rare. With the currently increased rates of thyroid testing and increased use of medications that decrease FT4, low-FT4 has a much lower predictive value for central hypothyroidism than previously reported. Thyroid screening strategies will need to balance the yield from first line TSH and FT4 testing with the cost of investigating individuals with non-pathological laboratory abnormalities.

THE SPECTRUM OF INTERNAL LIMITING MEMBRANE DISEASE IN ALPORT SYNDROME: A Multimodal Imaging Study.

PURPOSE: To characterize the spectrum of internal limiting membrane (ILM) disease in Alport syndrome using multimodal imaging, including widefield (WF) and ultra-widefield (UWF) modalities, and to report their relative prevalence according to the genetic pattern of inheritance. METHODS: Cross-sectional clinical study of patients diagnosed with Alport syndrome. All patients underwent UWF color photography and autofluorescence, WF-optical coherence tomography angiography and spectral-domain optical coherence tomography. Demographics, past medical and ophthalmic history, and genetic mutation history were collected. RESULTS: Forty-two eyes of 21 patients (11 men; age 36.6 ± 12.9 years) were included. Macular spectral-domain optical coherence tomography revealed ILM granularity, more frequent in X-linked Alport syndrome and corresponding to dot maculopathy on color fundus. Mid-peripheral spectral-domain optical coherence tomography scans revealed multilamellated ILM in eight eyes (19%), presumably progressive, which corresponded to a cavitary pattern on en-face OCT. En-face OCT revealed multiple areas of retinal nerve fiber layer dehiscence in the macula, overlapping with vascular lacunae on optical coherence tomography angiography, and a coarse arrangement of retinal nerve fiber layer above and below the temporal raphe in 20 eyes (52%). CONCLUSION: Multimodal imaging allowed for the detection/characterization of retinal findings (ILM granularity, progressive ILM lamellation, retinal nerve fiber layer dehiscence, vascular lacunae, and coarse arrangement of retinal nerve fiber layer toward the disc) as multifaceted manifestations of ILM disease in Alport syndrome.

REVIEW OF OPHTHALMIC AND BREASTFEEDING MEDICINE EVIDENCE: Real and Theoretical Risks of Intravitreal Anti-Vascular Endothelial Growth Factor Administration in Lactating Women.

BACKGROUND/PURPOSE: There is limited research regarding the consequences of treating lactating mothers with intravitreal anti-vascular endothelial growth factor (VEGF) agents. Balancing the need for vision-saving treatment, the benefits of breastfeeding, and the concern for affecting the newborn can present a conflict for both mothers and ophthalmologists. This review summarizes the state of the literature regarding the use of intravitreal anti-VEGF agents during breastfeeding along with details about their pharmacology. RESULTS: Bevacizumab and aflibercept have Fc domains subjecting them to FcRn recycling and extending their half-life compared with ranibizumab which is an antibody fragment and lacks the Fc domain. Case reports and small studies have shown that ranibizumab has the lowest serum concentration after intravitreal injection and the least effect on plasma-free VEGF concentrations and breastmilk VEGF levels. CONCLUSION: Clinical and pharmacologic data suggest that ranibizumab has less systemic circulation and effect on maternal serum and breastmilk VEGF levels when compared to bevacizumab and aflibercept. However, there is significant need for further research on the degree and duration to which intravitreal agents circulate systemically, what fraction is transferred into breastmilk and is absorbed, and whether this results in any functional adverse effects to the infant. Other factors to consider in the medical decision-making of lactating mothers necessitating intravitreal anti-VEGF treatment include the gestational and post-natal age of the child and whether it is feasible to avoid breastfeeding for the half-life duration of the intravitreal agent rather than ceasing breastfeeding altogether.

SEMIAUTOMATED QUANTITATIVE APPROACH TO CHARACTERIZE TREATMENT RESPONSE IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Real-World Study.

PURPOSE: To perform a quantitative study of the vascular microstructure in actively treated choroidal neovascularization by optical coherence tomographic angiography. METHODS: Patients undergoing individualized anti-vascular endothelial growth factor therapy of minimum 12 months duration were included in this cross-sectional observational study and imaged using optical coherence tomographic angiography. En face optical coherence tomographic angiography images were analyzed for quantitative features, such as junction density, vessel length, and lacunarity using validated software (Angiotool). Patients were divided into 2 groups depending on their individualized treatment interval: "good responders, treated less frequently than 6 weeks" versus "poor responders, treated every 6 weeks or more frequently." Nonparametric testing was used to assess differences between these groups. RESULTS: Twenty-five eyes of 23 consecutive patients with a median 58-month history of choroidal neovascularization, treated by median of 34 anti-vascular endothelial growth factor injections, were included in the analysis. There was no significant difference between any of the microvascular choroidal neovascularization features between the 2 groups (P > 0.05). CONCLUSION: The semiautomated vessel segmentation software provides an objective and quantitative approach for choroidal neovascularization characterization. The consistently nonsignificant outcomes between the groups may provide evidence to support the "normalization hypothesis." This would suggest that regardless of treatment interval, individualized therapy in these eyes established vessel stability.

Relapsed Burkitt Lymphoma Presenting as an Isolated Infiltrative Optic Neuropathy.

We report a case of relapsed sporadic Burkitt lymphoma (BL) presenting as an isolated infiltrative optic neuropathy. This is a single-patient, retrospective case report of a patient seen by the ophthalmology service at our institution. To our knowledge, our case is the first to report isolated infiltrative optic neuropathy associated with sporadic BL as the sole manifestation of recurrence. The possibility of disease relapse should be considered for patients with a history of lymphoreticular malignancy who present with acute visual symptoms suggestive of optic neuropathy.

Spectral domain optical coherence tomography in the evaluation and management of infectious retinitis.

PURPOSE: To describe spectral domain optical coherence tomography (SD-OCT) findings of infectious retinitis, including affected layer of retinal involvement, changes at the vitreoretinal interface, and response to therapy. METHODS: Observational case series. A retrospective review of five patients with infectious retinitis: one with toxoplasmosis, three with herpetic retinitis secondary to cytomegalovirus, and one with herpetic retinitis secondary to varicella zoster virus. Each patient underwent a complete ophthalmologic examination, fundus photography, and SD-OCT imaging (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany) of the affected retina at the initial visit with serial fundus photography and SD-OCT imaging at follow-up visits. Approval was obtained from the Institutional Review Board of Northwestern University. RESULTS: Spectral domain ocular coherence tomography of retinitis associated with Toxoplasma, cytomegalovirus, or varicella zoster virus demonstrates full-thickness disruption of the retinal architecture and overall thickening. This was in contrast to clinically imitating lesions such as cotton-wool spots, which only showed focal swelling of the inner retina. There was a clear demarcation between the area of active retinitis and unaffected retina. Inactivity was apparent when the previously affected thickened area became atrophic. The SD-OCT also demonstrated changes at the vitreoretinal interface where there was frequently a detachment of the posterior hyaloid (four of five cases) associated with overlying vitreous debris and formation of tractional changes. In the case of varicella zoster virus retinitis, this traction subsequently led to a total retinal detachment. CONCLUSION: In the assessment of infectious retinitides, SD-OCT is a helpful adjunct to clinical examination and fundus photography. It provides high-resolution detail regarding the border of infectious activity, the vitreoretinal interface, and the differentiation of lesions that can clinically mimic active retinitis. Serial SD-OCT also provides further insight into response to therapy and postinfectious retinal changes by highlighting areas that are at greater risk for complications such as retinal detachment.

A Review of the Prevalence of Ophthalmologic Diseases in Native American Populations.

PURPOSE: Compared with the general population in North America, Native American/American Indian and Alaska Native (AI/AN) populations experience a disparate prevalence of eye diseases. Visual impairment is a barrier to communication, interferes with academic and social success, and decreases overall quality of life. The prevalence of ocular pathology could serve as an indicator of health and social disparities. Therefore, the objective of this research was to perform a thorough review comparing the prevalence of common ophthalmological pathologies between AI/AN and non-AI/AN individuals in North America. DESIGN: Retrospective, cross-sectional study. METHODS: A total of 57 articles were retrieved and reviewed, and 14 met the criteria outlined for inclusion. These articles were retrieved from PubMed, MEDLINE, and ISI Web of Knowledge. Only studies that were peer reviewed in the last 25 years and reported on the prevalence of eye diseases in AI/AN compared with a non-AI/AN population met criteria. RESULTS: Rates of retinopathy, cataracts, visual impairment, and blindness were clearly higher for AI/AN compared with non-AI/AN counterparts. Although rates of macular degeneration and glaucoma were similar between AI/AN and non-AI/AN populations, the treatment rates were lower and associated with poorer outcomes in AI/AN individuals. CONCLUSIONS: There are considerable inequities in the prevalence and treatment rates of ophthalmologic conditions in AI/AN individuals. A likely explanation is the barrier of lack of access to adequate health and eye care. Because of substantial underinsurance and geographic variability, attention needs to be brought to expanding eye care access to AI/AN communities. The results are subject to the availability of appropriate technology, health literacy, and language.

Accelerated progression of diabetic retinopathy following severe COVID-19 infection.

Purpose: The impact of SARS-CoV-2 infection on pre-existing retinal pathology is currently unknown. Observations: We present a unique case of rapidly progressing diabetic retinopathy (DR) following severe COVID-19 infection requiring supplemental oxygen and subsequent long-COVID. Conclusions and importance: Following infection with SARS-CoV-2, the associated acute and possible long-term hypoxia has the potential to affect the retina and accelerate the natural course of diabetic retinopathy.

Evaluation of Virtual Vitreoretinal Surgery Fellowship Interview and Match Experience.

Purpose: To evaluate applicants' and programs' experiences during the 2019 and 2020 fellowship application seasons. Methods: An anonymous survey of vitreoretinal surgery fellowship program directors (PDs) (n = 21) and applicants from the 2019 traditional (n = 24) and 2020 virtual (n = 17) match cycles (before and during COVID-19 pandemic, respectively) was conducted. The questions assessed demographics, interview experiences, and overall interview costs. Statistical significance was determined using unpaired and paired 2-sided t tests for applicants and PDs, respectively (P < .05). Results: In 2020, 17.6% of applicants and 15.8% of PDs strongly agreed that they were able to convey themselves well during the interview compared with 50% and 73.7%, respectively, in 2019 (P = .002 and P < .001, respectively). In 2020, 5.9% of applicants and 10.5% of PDs strongly agreed that they gained a good understanding of their counterpart compared with 41.7% and 47.4%, respectively, in 2019 (P < .001 and P = .01, respectively). Regarding cost, 83.3% of applicants and 21.1% of programs spent more than $2000 in 2019, whereas 17.6% of applicants and no program did so in 2020. Conclusions: Although virtual interviews allowed fellowship recruitment to continue during the pandemic, both applicants and PDs expressed uncertainty regarding their abilities to portray themselves and gauge those with whom they interviewed. The benefits of virtual interviews, including decreased cost, increased efficiency, and convenience, must be weighed against these factors.

Vitreoretinal Abnormalities during Macular Hole Repair in Alport Syndrome.

PURPOSE: To describe abnormal vitreoretinal findings during macular hole repair in Alport syndrome (AS). METHODS: Case report of preoperative, intraoperative, and postoperative findings related to macular hole surgery in a patient with AS. OBSERVATIONS: A 50-year-old woman with Alport syndrome was found to have bilateral full-thickness macular holes. Surgery was recommended for her left eye given recent onset of vision loss and smaller hole size (313 um). Intraoperatively, the vitreous was found to have fine fibrillar strands and to be abnormally adherent to the retinal surface. There was little to no internal limiting membrane (ILM) present. Vitrectomy was performed with posterior cortical hyaloid peeling and 15% C3F8 gas tamponade. Two months after surgery, the macular hole was successfully closed. CONCLUSIONS: Abnormal vitreous composition and adherence to the retinal surface may contribute to macular hole formation in AS patients. Standard surgical approaches including ILM peeling may not be feasible, though thorough removal of the posterior cortical hyaloid may be sufficient to achieve macular hole closure.

Clinical outcomes in neovascular age-related macular degeneration: a cohort study of patients with care delay due to the COVID-19 pandemic.

The COVID-19 pandemic has led to both intentional and unintentional care delay among age-related neovascular macular degeneration (nvAMD) patients. Prior studies have demonstrated that patients who discontinue nvAMD treatment for prolonged intervals are at high risk for vision loss, but less is known regarding shorter-term delay, such as during the height of the pandemic. Previous studies have looked at COVID-19 related delay in care and have shown a loss of visual acuity (VA) among these patients, but studies are limited by short follow-up or insufficient comparisons. This was an observational cohort study of nvAMD patients from March 1, 2019, through July 1, 2021, who experienced care delay. VA was modeled using a linear longitudinal mixed-effects model comparing historic data pre-lockdown to data post-lockdown. Covariates included baseline anatomic variables, demographic variables, and time intervals (treatment interval, delay interval). Secondary anatomic and treatment outcomes were modeled using a multilevel binary logistic regression model. 163 eyes among 116 patients were included. Initial longitudinal mixed-effects models found that although overall VA decreased at a yearly rate, when comparing pre-lockdown and post-lockdown time periods, VA slopes were not statistically different. Single-covariate longitudinal models showed that age, sex, and delay interval significantly affected VA slope. The multivariate longitudinal model found that a longer delay interval significantly decreased rate of VA loss. Multilevel binary logistic regression models showed a significant increase in odds of anti-VEGF treatment, presence of subretinal fluid, and macular hemorrhages in the post-lockdown period. Overall, when compared to historic data, rate of VA loss among our cohort did not vary significantly in pre-versus post-lockdown time periods, although treatment and anatomic variables did worsen post-lockdown suggesting that patients may be appropriately delayed but this comes at the risk of increased need for treatment.

The Association of Intravitreal Anti-VEGF Injections With Kidney Function in Diabetic Retinopathy.

Purpose: To examine whether patients with diabetic retinopathy receiving intravitreal anti-VEGF injections are at increased risk of kidney function decline. Design: Retrospective cohort study. Participants: Included 187 patients who received intravitreal anti-VEGF injections for proliferative diabetic retinopathy (PDR) and/or diabetic macular edema (DME), and 929 controls with non-PDR who did not receive injections, at a large tertiary care center in Chicago, Illinois. Methods: We queried our institutional enterprise data warehouse to identify patients with diabetic retinopathy, determined whether they received intravitreal anti-VEGF injections, and followed kidney function for all patients over time. Main Outcome Measures: We assessed time to sustained 40% decline in estimated glomerular filtration rate (eGFR) from baseline in patients receiving intravitreal anti-VEGF injections and compared it with controls using Kaplan-Meier and multivariable adjusted Cox proportional hazards regression models. Results: This study included 1116 patients (565 female [50.6%]; mean [standard deviation {SD}] age, 57.3 [13.6] years; mean [SD] eGFR, 65.3 [32.1] ml/min/1.73 m2). Of these, 187 patients received ≥ 1 intravitreal anti-VEGF injection (mean [SD], 11.4 [13.1] injections) for PDR and/or DME, and 929 controls with non-PDR received no injections. Intravitreal anti-VEGF injection use was not associated with an increased risk of kidney function decline (hazard ratio [HR], 1.44; 95% confidence interval [CI], 0.97-2.15). Subgroup analyses revealed that use of intravitreal anti-VEGF injections was associated with increased risk of kidney function decline in male patients (HR, 1.87; 95% CI, 1.11-3.14) but not female patients (HR, 0.97; 95% CI, 0.50-1.89). Intravitreal anti-VEGF injection use was also associated with an increased risk of kidney function decline in patients with baseline eGFR > 30 ml/min/1.73 m2 (HR, 1.86; 95% CI, 1.15-3.01), but not in individuals with baseline eGFR ≤ 30 ml/min/1.73 m2 (HR, 0.97; 95% CI, 0.45-2.10). Among patients who received injections, receiving ≥ 12 injections was not associated with risk of kidney function decline (HR, 1.13; 95% CI, 0.52-2.49). Conclusions: Intravitreal anti-VEGF injections for patients with diabetic retinopathy are overall well-tolerated with respect to kidney function, but the use of intravitreal anti-VEGF injections was associated with an increased risk of kidney function decline in certain subgroups of patients. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Macular Perfusion Deficits on OCT Angiography Correlate with Nonperfusion on Ultrawide-field Fluorescein Angiography in Diabetic Retinopathy.

OBJECTIVE: To evaluate the correlation between nonperfusion parameters on OCT angiography (OCTA) and ultrawide-field fluorescein angiography (UWF-FA) in subjects with diabetes mellitus (DM). DESIGN: Prospective, cross-sectional study. SUBJECTS: Subjects with DM and a wide range of diabetic retinopathy (DR) severity seen at a tertiary referral center. METHODS: We used averaged 3 × 3 mm OCTA scans to measure geometric perfusion deficit (GPD), vessel density, and vessel length density in the full retina, superficial capillary plexuses (SCPs), and deep capillary plexuses (DCPs). Nonperfusion was manually delineated on UWF-FA to quantify central, peripheral, and total retinal nonperfusion (mm2 and % area). MAIN OUTCOME MEASURES: Correlation between OCTA parameters and UWF-FA nonperfusion, and accuracy of these OCTA and UWF-FA parameters in detecting clinically referable eyes, using receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, and area under the ROC curve (AUC). RESULTS: The study included 67 eyes (12 eyes with no signs of DR, 8 mild, 22 moderate, 14 severe nonproliferative DR, and 11 treatment-naive proliferative DR). There was a fair-to-moderate correlation between either central or total retinal nonperfusion on UWF-FA (mm2) and GPD in the SCP (r = 0.482 and r = 0.464, respectively) and DCP (r = 0.470 and r = 0.456, respectively). Receiver operating characteristic analysis showed the DCP GPD significantly superior to other OCTA parameters at the DCP with the largest overall AUC on OCTA for distinguishing referable DR (0.905). Furthermore, the GPD parameter had the largest AUC in each respective capillary layer compared with other parameters. Overall, the total UWF-FA nonperfusion area showed a comparable AUC (0.907) and performed significantly better than peripheral nonperfusion (P = 0.041). Comparing the AUC values between GPD and UWF-FA nonperfusion parameters showed no significant difference in discerning referable DR. CONCLUSIONS: Nonperfusion as quantified on OCTA (3 × 3 mm) correlated with UWF-FA parameters and both were comparable in detecting referable DR. These macular OCTA metrics, particularly DCP GPD, have the potential for gauging the overall ischemic status of the retina, with an important clinical role in identifying eyes with clinically referable DR. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

MACULAR HOLE FORMATION ASSOCIATED WITH INTENSE PULSED LIGHT THERAPY.

PURPOSE: To describe the first case of macular hole formation following intense pulsed light therapy. METHODS: This is a retrospective case report. A 68-year-old woman presented with blurry vision that occurred 1 day following intense pulsed light therapy for hair removal. RESULTS: A full thickness macular hole, which had not been previously documented was noted on fundus exam. Ocular coherence tomography confirmed a full-thickness macular hole. DISCUSSION: Laser treatment for hair removal has been reported to cause ocular injuries including iris atrophy, pupillary distortion, cataracts, and uveitis. Intense pulsed light therapy, a specific type of laser therapy, has been reported to cause iris transillumination defects, anterior uveitis, and pupil abnormalities. Our case is the first to describe a macular hole secondary to intense pulsed light therapy. The etiology of the macular hole is postulated to be secondary to possible thermal injury with absorption of energy at the level of the retinal pigment epithelium. This emphasizes the role and importance of preventative measures, such as protective glasses in reducing the risk of ocular injuries.

Scleral rupture during retinal detachment repair with primary scleral buckle and cryoretinopexy in a patient with microspherophakia.

Purpose: The purpose of this report is to describe a case of a patient with microspherophakia (MSP) who had a scleral rupture during a retinal detachment (RD) repair with primary scleral buckle and cryoretinopexy. Observations: A 48-year-old woman with MSP presented with six days of expanding loss of vision and photopsias. Examination revealed a superior retinal detachment involving the macula associated with two superior retinal tears. The patient underwent successful placement of a segmental buckle. During cryoretinopexy treatment of the tears, a 4 mm full-thickness scleral rupture occurred. The sclera was immediately closed with interrupted 8-0 nylon sutures and reinforced with a processed pericardium allograft. Subsequent combined phacoemulsification with capsulectomy, zonulectomy, and pars plana vitrectomy with retinal reattachment was performed nine days post buckle placement. Conclusions and importance: This case illustrates that a patient with MSP, even observed in the absence of a genetic syndrome or familial condition, may be at increased risk of scleral rupture during RD repair. Though future investigations are necessary to confirm this association, surgeons should take a conservative approach by having a high clinical suspicion for compromised scleral integrity in patients with MSP and proceeding with caution in procedures that may pose a risk of scleral rupture. A pericardium allograft can be an effective adjunct for scleral rupture repair.

Characterization of Choriocapillaris and Choroidal Abnormalities in Alport Syndrome.

Purpose: To analyze the characteristics of the choriocapillaris and the choroid in patients with Alport syndrome (AS) and investigate their clinical and demographic associations. Methods: Multicenter, cross-sectional study. Forty-two eyes with AS were consecutively enrolled. A cohort of 33 healthy eyes was included as controls. Demographics and medical history were collected for each participant. Each eye underwent 3 × 3 swept-source optical coherence tomography angiography (PLEX Elite 9000 2.0; Carl Zeiss Meditec, Dublin, CA, USA) and spectral-domain OCT (Spectralis HRA2; Heidelberg Engineering, Heidelberg, Germany). Choriocapillaris flow deficit (FD) number, mean FD size, total FD area, FD density, subfoveal choroidal thickness (CT), total CT, and choroidal vascularity index (CVI) were compared between AS and control eyes. Factors associated with the FD density and the CVI in AS were explored with multivariable linear mixed models. Results: There was high intragroup variability in choriocapillaris and choroidal measurements in patients with AS. Choriocapillaris FD in patients with AS were more numerous compared to controls (P = 0.02). FD density in eyes with AS increased with older age (estimate = 0.31% for each year; 95% confidence interval [CI], 0.06-0.57; P = 0.02) and was higher in patients with a history of kidney transplant (estimate = 9.66% in case of positive history; 95% CI, 3.52-15.8; P = 0.006). The CVI was lower in eyes with dot maculopathy (estimate = -3.30% if present; 95% CI, -6.38 to -0.21; P = 0.04) and anterior lenticonus (estimate = -6.50% if present; 95% CI, -10.99 to -2.00; P = 0.006). Conclusions: Patients with AS with kidney involvement requiring transplant may present with more severe choriocapillaris impairment. Lower choroidal vascularity was found in the presence of other ocular structural abnormalities. Translational Relevance: An increased load of choriocapillaris flow deficits on optical coherence tomography angiography was found in patients with Alport syndrome who also had severe kidney disease requiring transplant.

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study.

BACKGROUND: With the increased sharing of electronic health information as required by the US 21st Century Cures Act, there is an increased risk of breaching patient, parent, or guardian confidentiality. The prevalence of sensitive terms in clinical notes is not known. OBJECTIVE: The aim of this study is to define sensitive terms that represent the documentation of content that may be private and determine the prevalence and characteristics of provider notes that contain sensitive terms. METHODS: Using keyword expansion, we defined a list of 781 sensitive terms. We searched all provider history and physical, progress, consult, and discharge summary notes for patients aged 0-21 years written between January 1, 2019, and December 31, 2019, for a direct string match of sensitive terms. We calculated the prevalence of notes with sensitive terms and characterized clinical encounters and patient characteristics. RESULTS: Sensitive terms were present in notes from every clinical context in all pediatric ages. Terms related to the mental health category were most used overall (254,975/1,338,297, 19.5%), but terms related to substance abuse and reproductive health were most common in patients aged 0-3 years. History and physical notes (19,854/34,771, 57.1%) and ambulatory progress notes (265,302/563,273, 47.1%) were most likely to include sensitive terms. The highest prevalence of notes with sensitive terms was found in pain management (950/1112, 85.4%) and child abuse (1092/1282, 85.2%) clinics. CONCLUSIONS: Notes containing sensitive terms are not limited to adolescent patients, specific note types, or certain specialties. Recognition of sensitive terms across all ages and clinical settings complicates efforts to protect patient and caregiver privacy in the era of information-blocking regulations.

Contrast Sensitivity Testing in Age-Related Macular Degeneration Using Motion Diamond Stimulus.

PURPOSE: This study was performed to characterize changes in contrast sensitivity (CS) that occur in patients with age-related macular degeneration (AMD) using a novel test, the motion diamond stimulus (MDS). METHODS: This was a cross-sectional study in which 20 subjects with unilateral exudative AMD (eAMD) and contralateral dry AMD received 3 assessments: the Pelli-Robson (PR) CS Chart, the MDS test, and a visual function questionnaire-25 (VFQ-25). CS results from the PR, and MDS tests were compared across 3 groups: eyes with eAMD vs dry AMD, eAMD vs control, dry AMD vs control. Healthy, undilated eyes from another study served as the control group. Significance was determined using ANOVA analysis for the MDS output parameters (α: overall contrast threshold, ß: adaptability of the visual system) and PR logCS. Patients were also administered the VFQ-25 to assess vision-related quality of life. RESULTS: The ANOVA of the MDS data demonstrated a significant difference in visual function according to the ß parameter of the 3 groups, but no significant difference in the α parameter. PR CS results for the 3 groups were significantly different, further supporting the MDS results. Post-hoc analysis showed a significant difference in ß and PR log CS between the eAMD and control eyes. CONCLUSION: The MDS test is valuable in discerning CS impairments in patients with AMD. It can provide further insight into the visual changes experienced by patients with AMD and has potential to quantify visual function changes that are not found on visual acuity testing alone.

SEROUS MACULAR DETACHMENT ASSOCIATED WITH WALDENSTROM MACROGLOBULINEMIA MANAGED WITH IBRUTINIB: A CASE REPORT AND NEW INSIGHTS INTO PATHOGENESIS.

PURPOSE: To report a case of serous macular detachment in a patient with Waldenstrom macroglobulinemia treated with ibrutinib. METHODS: The patient underwent a complete ophthalmic examination and imaging at presentation and at follow-up visits up to 13 months. RESULTS: At presentation, there were serous macular detachments bilaterally with no dye leakage on fluorescein angiography or vasculature abnormalities on optical coherence tomography angiography. After treatment with ibrutinib, there was near resolution of the patient's retinopathy with an improvement in vision at 13 months' follow-up. CONCLUSION: Serous macular detachments in Waldenstrom macroglobulinemia-associated retinopathy may be due to the disruption of the retinal pigment epithelium pump mechanism by hyperglobulinemia. The favorable course of this patient, treated with the novel tyrosine kinase inhibitor ibrutinib, suggests this may be the preferred treatment for Waldenstrom macroglobulinemia patients with associated retinopathy.