Evaluation and Optimization of Diabetic Retinopathy Screenings for Uninsured Latinx Patients in a Resource-Limited Student-Run Free Clinic.

Background: Diabetic retinopathy (DR) is a sight-threatening condition that causes progressive retina damage. Student-run free clinics represent a valuable opportunity to provide DR screenings to high-risk populations. We characterized the patient population, evaluated the performance, and conducted a needs assessment of DR screenings at the University of California, San Diego Student-Run Ophthalmology Free Clinic, which provides care to predominantly uninsured, Latino patients. Methods: Retrospective chart review was conducted of all patients seen at the free clinic since 2019 with a diagnosis of type II diabetes. Date and outcome of all DR-related screenings or visits from 2015 onward, demographics information, and DR risk factors such as A1c and insulin dependence were recorded. Predictors of diabetic retinopathy and frequency of DR screenings for each patient were analyzed using multiple logistic regression, t-test for equality of means, and Pearson's correlation. Results: Of 179 uninsured diabetic patients receiving care at the free clinic, 71% were female and average age was 59. 83% had hypertension, 93% had hyperlipidemia, and 79% had metabolic syndrome. Prevalence of non-proliferative DR was 34% and that of proliferative DR was 15% in diabetic patients. The free clinic capacity in recent years plateaued at just under 50% of patients seen for DR screening or visit per year, though average wait time was over 2 years between visits. Patients with higher no-show rates had less frequent DR screenings. Chronic kidney disease and poor glycemic control were the strongest predictors of DR. Conclusion: The student-run free ophthalmology clinic has been effective in providing screening and follow-up care for DR patients. Creation of a protocol to identify which patients are at highest risk of DR and should be seen more urgently, addressing no-shows, and implementation of a tele-retina program are potential avenues for improving clinic efficiency in a resource-limited setting for vulnerable populations.

Axial length and pharmacologic pupillary dilation in highly myopic patients.

PURPOSE: To determine how high myopia impacts pharmacological pupillary dilation, and to evaluate the relationship between the extent of pharmacologic pupillary dilation and axial length. METHODS: Patients were grouped into high myopes, defined as one or both eyes having a refractive error greater than - 6 diopters, and controls (between - 2 and + 2 diopters). Dilation was achieved with 1 drop each of tropicamide 1% and phenylephrine 2.5%. Pupil size was measured at full and dim light prior to dilation, then 15 and 30 min after dilation. Biometry was measured for each patient. Statistical analyses were performed using the Mann-Whitney-Wilcoxon tests, two-sample Welch's t-tests, and linear mixed effect models and generalized estimating equations models accounting for inter-eye correlation. RESULTS: Forty patients (20 high myopes and 20 controls, 80 eyes total) participated in the study. High myopes had larger pupils at baseline and achieved significantly greater pupillary size (7.08 mm, 95% CI: 6.97 to 7.19 mm) than controls (6.23 mm, 95% CI: 5.94 to 6.52 mm) after 30 min of dilation (P < .0005). Fully dilated pupil size at 30 min was significantly correlated with both refractive error (r = - 0.57, P < .0005) and axial length (r = 0.47, P < .0005). Generalized estimating equations and linear mixed effect models identified other predictive variables of pupil size after dilation including age and white-to-white diameter. CONCLUSIONS: Highly myopic patients dilate to a larger pupillary size compared to other patients. Predicting dilation based on extent of myopia could facilitate intraocular surgery planning and reduce clinic wait times for myopic patients.

Gender Disparities in Depression, Stress, and Social Support Among Glaucoma Patients.

Purpose: To understand differences in measures of depression, stress, and social support by gender among those diagnosed with glaucoma. Methods: We obtained a cohort of glaucoma patients (any type) ages 18 years and over who answered the COVID-19 Participant Experience (COPE) survey of the NIH All of Us Research Program. We analyzed several measures of depression, stress, and social support by gender. Logistic regression was used to evaluate the association among reported stress associated with social distancing, depression (using Patient Health Questionnaire-9 [PHQ-9] scores), and measures of social support by self-reported gender, with men as the reference group. Multivariable models were adjusted for age, race and ethnicity, health insurance status, education, and income. Results: Of 3633 glaucoma patients, 56.8% were women. Many patients had a PHQ-9 score > 4 (33.3%), indicating mild, moderate, or severe depression. In multivariable models, women were significantly more likely to report a PHQ-9 score > 4 (odds ratio [OR] = 1.40; 95% confidence interval [CI], 1.20-1.62; P < 0.001) and some or a lot of stress (OR = 1.34; 95% CI, 1.14-1.57; P < 0.001) compared with men. Further, women were significantly less likely to report having help all or most of the time if they needed someone to prepare meals (OR = 0.78; 95% CI, 0.67-0.92; P = 0.002) or perform daily chores (OR = 0.79; 95% CI, 0.67-0.91; P = 0.003) than men. Conclusions: Women with glaucoma were more likely to experience depression and stress and were less likely to have social support on some measures than men. Translational Relevance: The disproportionate burden of psychosocial factors among women may complicate glaucoma management.

Refractive Changes After Implantation of Reversed Intraocular Lens in Cataract Surgery: A Mathematical Model.

PURPOSE: To develop a mathematical model that can predict the amount of refractive change caused by implantation of an intraocular lens (IOL) in a reversed position during cataract surgery. METHODS: A theoretical mathematical formula based on the Gullstrand eye model was constructed to estimate the refractive change of the eye after implantation of a reversed IOL. The refractive change caused by implantation of the IOL in a reversed position was calculated based on the exchange of the anterior curvature with the posterior curvature of the IOL, and the lengthening of the distance between the IOL and the retina. In case of a three-piece IOL with angulation, the amount of refractive change was calculated based on its angle and the total refractive power of the eye, which is dependent on the focal length of the eye. RESULTS: Calculated refractive change for one-piece IOLs was less than 0.10 diopter (D). For three-piece IOLs, the calculated refractive change makes the eye on average 0.77 D more myopic and can increase with the total refractive power of the patient's eye. The mathematical model was applied to seven previously published cases of reverse IOL implantation. CONCLUSIONS: This calculation demonstrates that with an upside-down IOL, there is a small refractive change in the one-piece IOL, including a toric IOL without angulation, but there can be a large refractive change in the three-piece IOL with angulation, especially using a higher power IOL or with a shorter axial length. [J Refract Surg. 2023;39(5):326-331.].

Mental health and social support among glaucoma patients enrolled in the NIH All of Us COVID-19 Participant Experience (COPE) survey.

BACKGROUND: The COVID-19 pandemic created many challenges for our society. In this study, we explore how measures of mental health, coping strategies, and social support during the pandemic varied by glaucoma status. METHODS: A cohort of patients aged 40 and over enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, who answered the COVID-19 Participant Experience (COPE) survey was obtained. We analyzed several measures of mental health, coping strategies, and social support used during the early stages of the COVID-19 pandemic. Surveys were recurring and answered from May 2020 to February 2021. Demographics and the most recently answered survey responses were obtained and stratified by glaucoma status. Pearson's Chi-squared tests and multivariable logistic regressions adjusting for age, gender, race, ethnicity, and income were used to generate p-values, odds ratios (ORs) and 95% confidence intervals (CIs) between outcome measures and glaucoma status. RESULTS: Of 42,484 patients who responded to All of Us COPE survey items, 2912 (6.9%) had a diagnosis of glaucoma. On Pearson's Chi-squared tests glaucoma patients were less likely to report drinking alcohol (P = 0.003), eating more food than usual (P = 0.004), and using marijuana (P = 0.006) to cope with social distancing than those without a diagnosis of glaucoma. Further, glaucoma patients had lower rates of probable mild, moderate, or severe depression as calculated by Patient Health Questionnaire-9 (PHQ-9) scores (P < 0.001) and had lower rates of reporting some or a lot of stress from social distancing (P < 0.001). However, glaucoma patients were less likely to report having someone to help prepare meals (P = 0.005) or help with daily chores (P = 0.003) if they became sick with COVID-19. In multivariable logistic regression analyses adjusting for confounding factors, no differences were found for measures of mental health or social support. CONCLUSIONS: Glaucoma patients did not fare worse on many measures of mental health and coping strategies during the early stages of the COVID-19 pandemic compared those without glaucoma. However, a substantial proportion of glaucoma patients still endorsed stress, social isolation, and probable depression, representing challenges for disease management.

Ultraviolet light exposure and its penetrance through the eye in a porcine model.

AIM: To determine the amount of ultraviolet (UV) light irradiance that various layers of the eye receive as sunlight passes through the eye, and to investigate the protective benefits of UV light-blocking contact lenses. METHODS: Twenty-four porcine eyes were prepared in one of three ways: isolated cornea, cornea and lens together, or whole eye preparation. UV light irradiance was measured with a UV-A/B light meter before and after the eye preparations were placed over the meter to measure UV light penetration in each eye structure. In the whole eye preparation, a hole was placed in the fovea to measure light as it passed through the vitreous. Subsequently, UV-protective contact lenses were placed over the structures, and UV light penetrance was measured. Measurements of UV light exposure were taken outdoors at various locations and times. RESULTS: Cornea absorbed 63.56% of UV light that reached the eye. Cornea and lens absorbed 99.34% of UV light. Whole eye absorbed 99.77% of UV light. When UV-protective contact lenses were placed, absorption was 98.90%, 99.55%, and 99.87%, respectively. UV light exposure was dependent on directionality and time of day, and was greatest in areas of high albedo that reflect significant amounts of light, such as a beach. CONCLUSION: Cornea absorbs the majority of UV light that reaches the eye in this model. UV-protective contact lenses reduce UV exposure to the eye. Locations with high albedo expose the eye to higher levels of UV light.

Role of FGF10/FGFR2b Signaling in Homeostasis and Regeneration of Adult Lacrimal Gland and Corneal Epithelium Proliferation.

Purpose: Fibroblast growth factor 10 (FGF10) is involved in eye, meibomian, and lacrimal gland (LG) development, but its function in adult eye structures remains unknown. This study aimed to characterize the role of FGF10 in homeostasis and regeneration of adult LG and corneal epithelium proliferation. Methods: Quantitative reverse transcription PCR was used for analysis of FGF10 expression in both early postnatal and adult mouse LG, and RNA sequencing was used to analyze gene expression during LG inflammation. FGF10 was injected into the LG of two mouse models of Sjögren's syndrome and healthy controls. Flow cytometry, BrdU cell proliferation assay, immunostaining, and hematoxylin and eosin staining were used to evaluate the effects of FGF10 injection on inflammation and cell proliferation in vivo. Mouse and human epithelial cell cultures were treated with FGF10 in vitro, and cell viability was assessed using WST-8 and adenosine triphosphate (ATP) quantification assays. Results: The level of Fgf10 mRNA expression was lower in adult LG compared to early postnatal LG and was downregulated in chronic inflammation. FGF10 injection into diseased LGs significantly increased cell proliferation and decreased the number of B cells. Mouse and human corneal epithelial cell cultures treated with FGF10 showed significantly higher cell viability and greater cell proliferation. Conclusions: FGF10 appears to promote regeneration in damaged adult LGs. These findings have therapeutic potential for developing new treatments for dry eye disease targeting the ability of the cornea and LG to regenerate.

The Effect of Anti-Inflammatory Topical Ophthalmic Treatments on In Vitro Corneal Epithelial Cells.

Purpose: To compare the effect of three commonly prescribed anti-inflammatory eye drops on corneal epithelial cells in vitro. Methods: Three different lines of human corneal epithelial cells were tested: primary cells cultured from donor tissue, commercially available primary cells, and immortalized cells. Cells were seeded on 96-well plates and treated with the following eye drops: cyclosporine 0.05%, lifitegrast 5%, and tacrolimus 0.03% or 0.1%. Exposure times tested were 30 seconds, 1 minute, 2 minutes, 1 hour, 2 hours, 4 hours, and 24 hours. Brightfield images and viability assays were analyzed 48 to 72 hours after the initiation of treatments. At least five replicates were tested per drug and time exposure. Results: Commercially obtained primary cells showed reduced viability following 1 hour with tacrolimus 0.1% (8%; P = 0.043%) and 4 hours with tacrolimus 0.03% (17%; P = 0.042%). Lifitegrast exposure reduced primary cell viability after 4 hours (10%; P = 0.042). Cell viability in primary cells was not deleteriously affected following exposure to cyclosporine for up to 4 hours. A similar trend was observed in both primary cells cultured from donor tissue and immortalized human corneal epithelial cells, demonstrating greater decreases in cell viability in tacrolimus compared to lifitegrast and cyclosporine. Light microscopy imaging for analysis of cell morphology and confluence supported the results. Conclusions: Tacrolimus showed the highest impact on corneal epithelium survival in vitro, and cyclosporine proved the most protective. Translational Relevance: Comparing anti-inflammatory eye drops on corneal epithelial cells in vitro may inform eye drop selection and development for clinical purposes.

Advancements in intraocular lens power calculation formulas.

PURPOSE OF REVIEW: We review recent studies comparing intraocular lens (IOL) formulas with an emphasis on selection of the highest performing formulas based on patient axial length, age, and history of previous corneal refractive surgery. RECENT FINDINGS: The Barrett Universal II formula based on a theoretical model has consistently demonstrated high accuracy. The Olsen four-factor formula using ray tracing optics and the Hill-RBF calculator using artificial intelligence have also demonstrated good prediction results after being updated. Notably, the Kane formula, incorporating artificial intelligence, has overall shown the best performance for all axial lengths. Although newly developed and updated IOL formulas have improved refractive prediction in patients with short or long axial length eyes or prior history of corneal refractive surgery, these challenging cases still require special consideration. The Barrett True-K formula has shown accurate results regardless of preoperative data in eyes with previous myopic refractive surgery. SUMMARY: Advancements in optical biometry and IOL calculation formulas continue to improve refractive outcomes. The clinician can optimize refractive outcomes in the majority of patients with the use of formulas that have shown consistent results and accuracy in several large studies.

Efficient use of ultrasound in cataract surgery.

PURPOSE OF REVIEW: Modern phacoemulsification machines apply ultrasound through a variety of settings and parameters to remove a cataract. Using these new technologies efficiently is critical for both reducing surgical times and improving postoperative outcomes. The present article reviews recent findings in phacodynamics to explore the optimum use of ultrasound in cataract surgery. RECENT FINDINGS: In studies seeking to determine the optimum parameters in both fluidics and power, increased power and aspiration does not necessarily equate to more efficiency. New developments, such as torsional ultrasound, micropulse, and burst mode have shown increased efficiency in randomized control trials and in-vitro compared with conventional ultrasound. Regarding vacuums, the venturi pump has demonstrated greater efficiency compared with the peristaltic pump. We also explore other parameters, such as chamber pressure and tip selection. Meta-analyses on femtosecond-laser assisted cataract surgery (FLACS) have shown similar long-term visual outcomes compared to conventional cataract surgery. SUMMARY: Though conventional cataract surgery remains highly effective, surgeons have increasing options for customizing their ultrasound settings and phacoemulsification techniques.

Recent developments in anterior capsulotomy for cataract surgery.

PURPOSE OF REVIEW: Successful anterior capsulotomy is an important step in cataract surgery. This article reviews the various anterior capsulotomy techniques available to surgeons to optimize the step, including those that have become available since the introduction of femtosecond-laser-assisted cataract surgery (FLACS). Studies comparing the relative advantages of each technique will be emphasized. RECENT FINDINGS: Manual continuous curvilinear capsulorhexis (CCC) and FLACS remain the two most widely studied techniques for achieving anterior capsulotomy. Each technique has been shown to be effective for a wide range of patients and cataract surgery complications. Meta-analyses have shown that FLACS provides similar results to manual CCC for long-term cataract surgery outcomes. Several alternative methods for anterior capsulotomy have been described, which aim to provide some of the advantages of laser capsulotomy at a lower cost; among these, precision pulse capsulotomy (PPC) and selective laser capsulotomy (SLC) have been investigated the most in the literature so far. SUMMARY: Cataract surgeons have an increasing number of techniques for anterior capsulotomy available. Manual CCC and FLACS remain the most widely used, and most well studied. The latest techniques, PPC and SLC, have shown promise in the few studies performed since they were introduced.

Impact of COVID-19 on the Delivery of Eye Care to Uninsured Diabetic Patients at a Student-Run Free Clinic: A Comprehensive Evaluation of Eye Clinic Performance.

Background: Diabetic retinopathy is the leading cause of blindness among working-age adults in the United States and requires timely screening and management. This study evaluates the impact of the coronavirus disease 2019 (COVID-19) pandemic on diabetic retinopathy screening (DRS) for uninsured, predominantly Latino patients at the University of California San Diego Student-Run Free Clinic Project (SRFCP). Methods: A retrospective chart review was conducted of all living diabetic patients at SRFCP who were seen in 2019 (n=196), 2020 (n=183), and 2021 (n=178). Ophthalmology clinic referrals, scheduled patient visits, and visit outcomes were analyzed longitudinally to determine the impact of the pandemic on screening patterns. Results: The study population was 92.1% Latino, 69.5% female, with a mean age of 58.7 years. The distribution of patients seen (p<0.001), referred (p=0.012), and scheduled (p<0.001) in 2020 and 2021 significantly differed from 2019. In 2019, 50.5% of 196 patients eligible for DRS were referred, 49.5% were scheduled, and 45.4% were seen. In 2020, 41.5% of 183 eligible patients were referred, but only 20.2% were scheduled and 11.4% were seen. In 2021, there was a rebound: 63.5% of 178 patients were referred, 56.2% scheduled and 46.1% seen. No shows and cancellations represented 12.4% and 6.2% of the 97 encounters scheduled in 2019, but were markedly higher (10.8% and 40.5% respectively) for the 37 encounters scheduled in 2020. Conclusions: The COVID-19 pandemic significantly impacted the delivery of eye care at SRFCP. The need for annual DRS exceeded the capacity of the ophthalmology clinic in all years studied, but the difference was especially pronounced with more stringent COVID-19 restrictions in 2020. SRFCP patients could benefit from telemedicine DRS programs to improve screening capacity.