COVID-19 and Eye Banking: Ongoing Impacts of the Pandemic.

PURPOSE: The purpose of this study was to assess the impact of ongoing waves of the COVID-19 pandemic and resulting guidelines on the corneal donor pool with resumption of clinical operations. METHODS: A retrospective analysis of donors deemed eligible for corneal transplantation at an eye bank from July 1, 2020, through December 31, 2021. Donors ineligible due to meeting Eye Bank Association of America (EBAA) COVID-19 guidelines or a positive postmortem COVID-19 testing were examined. The correlation between COVID-19 rule outs and state COVID positivity was calculated. The number of scheduled surgeries, suitable corneas, imports, and international exports was compared with a pre-COVID period. Postmortem testing was reduced for the final 5 months of the study, and numbers were compared before and after the policy change. RESULTS: 2.85% of referrals to the eye bank were ruled out because of EBAA guidelines. 3.2% of postmortem tests were positive or indeterminate resulting in an ineligible tissue donor (0.42% of referrals). Over the 18-month period, there was a 4.30% shortage of suitable corneas compared with transplantation procedures. There was a significant correlation between postmortem testing and state COVID-19 positivity (r = 0.37, P <0.01), but not with EBAA guidelines (r = 0.19, P = 0.07). When postmortem testing was reduced, significantly more corneas were exported internationally. CONCLUSIONS: Although corneal transplant procedures were back to normal levels, there was a shortage of suitable corneal tissue. The discontinuation of postmortem testing was associated with a significant increase in international exports of corneal donor tissue.

Prediction of Visual Acuity in Patients With Microbial Keratitis.

PURPOSE: The purpose of this study was to predict visual acuity (VA) 90 days after presentation for patients with microbial keratitis (MK) from data at the initial clinical ophthalmic encounter. METHODS: Patients with MK were identified in the electronic health record between August 2012 and February 2021. Random forest (RF) models were used to predict 90-day VA < 20/40 [visual impairment (VI)]. Predictors evaluated included age, sex, initial VA, and information documented in notes at presentation. Model diagnostics are reported with 95% confidence intervals (CIs) for area under the curve (AUC), misclassification rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: One thousand seven hundred ninety-one patients were identified. The presenting logMAR VA was on average 0.86 (Snellen equivalent and standard deviation = 20/144 ± 12.6 lines) in the affected or worse eye, and 43.6% with VI. VI at 90-day follow-up was present in the affected eye or worse eye for 26.9% of patients. The RF model for predicting 90-day VI had an AUC of 95% (CI: 93%-97%) and a misclassification rate of 9% (7%-12%). The percent sensitivity, specificity, PPV, and NPV were 86% (80%-91%), 92% (89%-95%), 81% (74%-86%), and 95% (92%-97%), respectively. Older age, worse presenting VA, and more mentions of "penetrating keratoplasty" and "bandage contact lens" were associated with increased probability of 90-day VI, whereas more mentions of "quiet" were associated with decreased probability of 90-day VI. CONCLUSIONS: RF modeling yielded good sensitivity and specificity to predict VI at 90 days which could guide clinicians about the risk of poor vision outcomes for patients with MK.

Perspectives of U.S. Ophthalmology Residents and Medical Students on Ophthalmology Exposure during Medical School.

Introduction In recent decades, ophthalmology exposure in medical school has been increasingly reduced. In turn, medical students have expressed concern over their ophthalmic skills. Research investigating the status of ophthalmology education in U.S. undergraduate medical curricula is limited to institutional data devoid of the student or resident perspective. This study seeks to gain a better understanding of current ophthalmology education for U.S. medical students from the trainee point of view. Methods A cross-sectional survey was distributed to current U.S. medical students interested in ophthalmology and U.S. ophthalmology residents. Demographic data, ophthalmology curriculum information, respondent learning preferences, and personal reflections were recorded. Thematic analysis and chi-square tests were utilized. Results In total, 387/4,482 (8.6%) surveys were completed by respondents from 75 U.S. medical institutions. Most respondents were exposed to formal ophthalmology curriculum (63%), research (89%), mentorship (84%), and clinical experiences (87%) during medical school, and medical school curriculum was ranked the third most helpful resource for students to learn about ophthalmology. Yet, 29% of residents ( n = 55) did not feel confident in their diagnostic ophthalmology skills based on their medical school exposure. Student and resident recommendations for improving ophthalmology education delivery commonly referenced nontraditional ophthalmology resources such as online videos ( n = 83) to supplement traditional learning materials such as lectures ( n = 56). Discussion These findings suggest that primary ophthalmology exposure in medical school has shifted toward extracurricular activities such as research and clinical observation. Considering the increasing time demands placed on the medical education system, utilizing nontraditional educational materials to supplement current undergraduate medical education in ophthalmology may provide educators with a resource to improve learner confidence and resident preparedness.

Artificial intelligence and corneal diseases.

PURPOSE OF REVIEW: Artificial intelligence has advanced rapidly in recent years and has provided powerful tools to aid with the diagnosis, management, and treatment of ophthalmic diseases. This article aims to review the most current clinical artificial intelligence applications in anterior segment diseases, with an emphasis on microbial keratitis, keratoconus, dry eye syndrome, and Fuchs endothelial dystrophy. RECENT FINDINGS: Most current artificial intelligence approaches have focused on developing deep learning algorithms based on various imaging modalities. Algorithms have been developed to detect and differentiate microbial keratitis classes and quantify microbial keratitis features. Artificial intelligence may aid with early detection and staging of keratoconus. Many advances have been made to detect, segment, and quantify features of dry eye syndrome and Fuchs. There is significant variability in the reporting of methodology, patient population, and outcome metrics. SUMMARY: Artificial intelligence shows great promise in detecting, diagnosing, grading, and measuring diseases. There is a need for standardization of reporting to improve the transparency, validity, and comparability of algorithms.

Measuring impact of a quality improvement initiative on glaucoma clinic flow using an automated real-time locating system.

BACKGROUND: Lean methodology helps maximize value by reducing waste, first by defining what value and waste are in a system. In ophthalmology clinics, value is determined by the number of patients flowing through the clinic for a given time. We aimed to increase value using a lean-methodology guided policy change, then assessed its impact on clinic flow using an automated radiofrequency identification (RFID) based real-time locating system (RTLS). METHODS: A total of 6813 clinical visits occurred at a single academic institution's outpatient glaucoma clinic between January 5, 2018 to July 3, 2018. Over that period, 1589 patients comprising 1972 (29%) of visits were enrolled, with 1031 clinical visits occurring before and 941 visits after a policy change. The original policy was to refract all patients that improved with pinhole testing. The policy change was not to refract patients with a visual acuity ≥20/30 unless a specific request was made by the patient. Pre-post analysis of an automated time-motion study was conducted for the data collected 3 months before and 3 months after the policy change occurred on March 30, 2018. Changes to process and wait times were summarized using descriptive statistics and fitted to linear mixed regression models adjusting for appointment type, clinic volume, and daily clinic trends. RESULTS: One thousand nine hundred twenty-three visits with 1588 patients were included in the analysis. Mean [SD] age was 65.9 [14.7] years and 892 [56.2%] were women. After the policy change, technician process time decreased by 2.9 min (p < 0.0001) while daily clinical patient volume increased from 51.9 ± 16.8 patients to 58.4 ± 17.4 patients (p < 0.038). No significant difference was found in total wait time (p = 0.18) or total visit time (p = 0.83). CONCLUSIONS: Real-time locating systems are effective at capturing clinical flow data and assessing clinical practice change initiatives. The refraction policy change was associated with reduced technician process time and overall the clinic was able to care for 7 more patients per day without significantly increasing patient wait time.

Opioid Prescribing Patterns for Ulcerative Keratitis.

PURPOSE: The purpose of this study was to characterize rates of opioid prescription for different ulcerative keratitis types. METHODS: This cohort study included patients diagnosed with ulcerative keratitis according to the University of Michigan electronic health record data between September 1, 2014 and December 22, 2020. Ulcerative keratitis was categorized by etiologic type (bacterial, fungal, viral, acanthamoeba, inflammatory, polymicrobial, or unspecified) using rule-based data classification that accounted for billing diagnosis code, antimicrobial or antiinflammatory medications prescribed, laboratory results, and manual chart review. Opioid prescriptions were converted to morphine milligram equivalent and summed over 90 days from diagnosis. Opioid prescription rate and amount were compared between ulcerative keratitis types. RESULTS: Of 3322 patients with ulcerative keratitis, 173 (5.2%) were prescribed at least 1 opioid for pain management within 90 days of diagnosis. More patients with acanthamoeba (32.4%), fungal (21.1%), and polymicrobial (25.0%) keratitis were treated with opioids compared with bacterial (6.7%), unspecified (2.9%), or viral (1.8%) keratitis (all Bonferroni adjusted P < 0.05). For the 173 patients who were prescribed opioids, a total of 353 prescriptions were given within 90 days of diagnosis, with half given within the first week after diagnosis. The quantity of opioid prescribed within 90 days from diagnosis was not significantly different between ulcerative keratitis types (P = 0.6559). Morphine milligram equivalent units prescribed ranged from 97.5 for acanthamoeba keratitis to 112.5 for fungal keratitis. CONCLUSIONS: The type of ulcerative keratitis may influence the opioid prescription rate. Providers can better serve patients needing opioids for pain management through improved characterization of pain and development of more tailored pain management regimens.

Medical Trainees Comfort and Confidence in Providing Care to Arab and Muslim Patients at a Large Academic Medical Center.

PHENOMENON: There are currently 3.5 million Americans of Arab descent and 3.45 million Muslims living in the United States. These rapidly growing populations face significant health disparities, which is likely in part due to the lack of culturally competent physicians trained to treat these populations. While the Institute of Medicine calls for cross-cultural training for all providers, it is not clear if this need is being met. The purpose of this study is to examine medical trainees' current level of cultural training and whether this corresponds to confidence in caring for Arab and Muslim patients. APPROACH: The authors created an anonymous survey that was distributed via email to medical students and residents at Michigan Medicine between January and March 2020. Questions included trainees' comfort and confidence level in caring for Arab and Muslim patients, as well education received on this topic. FINDINGS: Results showed that 41% of respondents were confident in their ability to take a history from an Arab patient immigrated to the U.S. Additionally, 55% of non-Muslim participants reported that they felt comfortable in caring for fasting patients, while only 24% felt confident in their ability to answer patient questions about fasting. Approximately half of respondents felt confident in their ability to examine an Arabic-speaking woman (47%) or woman wearing a hijab (49%). The majority of respondents had not received any training or education in the care of Arab patients (64%) or fasting patients (81%). INSIGHT: Medical trainees at one large academic medical center in the state with the second largest Arab-American population, and one of the largest populations of Muslim-Americans lack comfort and confidence in providing culturally competent care for Arab and Muslim patients. Education of trainees about Arab and Muslim health should be implemented into the curriculum to optimize care delivered to this patient population.

Assessing Eye Health and Eye Care Needs Among North American Native Individuals.

IMPORTANCE: There are few population-level studies on ophthalmic conditions and services among North American Native individuals. OBJECTIVE: To evaluate whether disparities in ophthalmic conditions and services exist between North American Native individuals and non-Hispanic White individuals in the US. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used 100% Medicare fee-for-service (MFFS) enrollment data from the Vision and Eye Health Surveillance System (VEHSS) to examine ophthalmic conditions and service use in North American Native individuals and non-Hispanic White individuals in the US. In this study North American Native individuals included those who identified as American Indian, Native Alaskan, Native Hawaiian, and Pacific Islander. Data were analyzed from August 2020 to April 2021. INTERVENTIONS: Claims and sociodemographic characteristics were extracted and means computed for categories of ophthalmic conditions and select ophthalmic services. Ophthalmic conditions and services were defined in the VEHSS using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Logistic regression was used to model differences between age-adjusted mean ophthalmic condition and service claim rates among North American Native individuals and non-Hispanic White individuals for each age cohort. Matching ophthalmic condition claim rates and ophthalmic service claim rates was performed to examine disparities by racial group. MAIN OUTCOMES AND MEASURES: Mean age-adjusted claim rates for ophthalmic conditions and services among North American Native individuals vs non-Hispanic White individuals per 100 persons. RESULTS: Claims were identified for 177 100 Native American Native individuals and 24 438 000 non-Hispanic White individuals. In 16 of 17 ophthalmic condition categories and 6 of 9 service categories, North American Native individuals had significantly different claim rates from non-Hispanic White individuals. There were higher ophthalmic condition claim rates but lower service claim rates for North American Native individuals (vs non-Hispanic White individuals) for refractive errors (ophthalmic condition, 17.2 vs 11.1; service, 48.3 vs 49.6, respectively; P < .001); blindness and low vision (ophthalmic condition, 1.48 vs 0.75: service, 19.2 vs 20.1, respectively; P < .001); injury, burns, and surgical complications (ophthalmic condition, 1.8 vs 1.7; service, 19.2 vs 20.1, respectively; P < .001); and orbital and external disease (ophthalmic condition, 15.7 vs 13.3; service, 48.3 vs 49.6, respectively; P < .001). For diabetic eye diseases, North American Native individuals had higher ophthalmic condition claim rates (5.22 vs 2.20) but no difference in service claim rates (14.4 vs 14.8; P = .26) compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, North American Native individuals had higher prevalence of ophthalmic conditions but no corresponding increase in services (treatment for most ophthalmic conditions) compared with non-Hispanic White individuals. These results suggest worse eye health and higher unmet eyecare needs for North American Native individuals with MFFS coverage compared with non-Hispanic White individuals with MFFS coverage.

Surgical research journals - Under review: An assessment of diversity among editorial boards and outcomes of peer review.

BACKGROUND: The COVID-19 pandemic exposed racism as a public health crisis embedded in structural processes. Editors of surgical research journals pledged their commitment to improve structure and process through increasing diversity in the peer review and editorial process; however, little benchmarking data are available. METHODS: A survey of editorial board members from high impact surgical research journals captured self-identified demographics. Analysis of manuscript submissions from 2016 to 2020 compared acceptance for diversity, equity, and inclusion (DEI)-focused manuscripts to overall rates. RESULTS: 25.6% of respondents were female, 2.9% Black, and 3.3% Hispanic. There was variation in the diversity among journals and in the proportion of DEI submissions they attract, but no clear correlation between DEI acceptance rates and board diversity. CONCLUSIONS: Diversity among board members reflects underrepresentation of minorities seen among surgeons nationally. Recruitment and retention of younger individuals, representing more diverse backgrounds, may be a strategy for change. DEI publication rates may benefit from calls for increasing DEI scholarship more so than changes to the peer review process.

The Reporting of Race and Ethnicity in Surgery Literature.

Importance: The reporting of race provides transparency to the representativeness of data and helps inform health care disparities. The International Committee of Medical Journal Editors (ICMJE) developed recommendations to promote quality reporting of race; however, the frequency of reporting continues to be low among most medical journals. Objective: To assess the frequency as well as quality of race reporting among publications from high-ranking broad-focused surgical research journals. Design, Setting, and Participants: A literature review and bibliometric analysis was performed examining all human-based primary research articles published in 2019 from 7 surgical journals: JAMA Surgery, Journal of the American College of Surgeons, Annals of Surgery, Surgery, American Journal of Surgery, Journal of Surgical Research, and Journal of Surgical Education. The 5 journals that stated they follow the ICMJE recommendations were analyzed against the 2 journals that did not explicitly claim adherence. Main Outcomes and Measures: Measured study outcomes included race reporting frequency and use of the ICMJE recommendations for quality reporting of race. Results: A total of 2485 publications were included in the study. The mean (SD) frequency of reporting of race and ethnicity in publications of ICMJE vs non-ICMJE journals was 32.8% (8.4) and 32.0% (20.9), respectively (P = .72). Adherence to ICMJE recommendations for reporting race was more frequent in ICMJE journals than non-ICMJE journals (mean [SD] of 73.1% [17.8] vs 37.0% [10.2]; P < .001). Conclusions and Relevance: The frequency of race and ethnicity reporting among surgical journals is low. A journal's statement of adherence to ICMJE recommendations did not affect the frequency of race and ethnicity reporting; however, there was an increase in the use of ICMJE quality metrics. These findings suggest the need for increased and more standardized reporting of racial and ethnic demographic data among surgical journals.

Applying to be Doctors of Tomorrow: A Qualitative Study Exploring Motivations Towards Applying to a Medical Pipeline Program.

PURPOSE: To identify the motivations of adolescent students applying into medical pipeline programs that are focused on populations underrepresented in medicine. METHODS: The Doctors of Tomorrow (DoT) program is a medical pipeline program between the University of Michigan Medical School and Cass Technical High School in Detroit, Michigan, USA. As a component of the application process, ninth-grade students complete multiple free response essays that allow students to articulate their reasons for applying and their goals for participation in the program. Between 2013 and 2019, 323 ninth-grade students applied to DoT and 216 were accepted. The authors qualitatively analyzed all applications using theoretical coding methods to identify common themes discussed by students regarding their motivations for applying. The authors used Dedoose 8.3.17 (Los Angeles, CA) for qualitative analysis. RESULTS: Four main themes emerged after coding and thematic analysis: (1) Career Aspiration, (2) Exposure to the Medical Field, (3) Breadth of Mentorship, and (4) Longitudinal Professional Development. 'Health Disparities in Minority Communities,' a code used when students commented on issues of race, social determinants of health, and health disparities as motivators, was not identified as frequently as the other codes, despite it being a main topic within the pipeline program. CONCLUSIONS: Applicants to medical school pipeline programs articulate similar intrinsic motivations that can be used to inform what drives students to apply. Pipeline programs should consider these intrinsic motivations, while also creating structured activities from which students can learn and gain tangible benefits when designing curricula. While ninth-grade students acknowledge health disparities in minority communities, their current level of personal experience may not lead them to identify these disparities as significant motivators, and pipeline leaders should be aware of this when designing lesson plans concerning these topics.

Updated safety precautions and guidance on eye banking procedures during the coronavirus disease 2019 pandemic.

PURPOSE OF REVIEW: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious coronavirus causing the COVID-19 pandemic. Although airborne spread through infectious respiratory droplets is the primary source of transmission, recent literature has suggested the ocular surface may be able to harbor viral particles. Here, we aim to discuss how SARS-CoV-2 affects the ocular surface and updated guidance on how SARS-CoV-2 transmission should be considered in the setting of eye banking and corneal transplantation procedures. RECENT FINDINGS: SARS-CoV-2 RNA can be found on the ocular surface, which may suggest the eye as a site of viral replication. However, there is poor correlation between PCR positivity on the ocular surface and ocular symptoms. To date, although viral particles can be found on the ocular surface, use of standard antiseptic procedures during corneal tissue procurement appears to sufficiently reduce viral load. In addition, preprocedure testing may further decrease the chances of transplanting an infected cornea without significantly impacting the overall accessibility to corneal tissue by decreasing the donor pool. SUMMARY: Corneal transplantation remains a well tolerated and highly successful procedure with no evidence of viral transmission with transplantation. Although the ocular surface has the required receptors to allow for viral replication, there is no clear evidence that the eye is a site for primary viral infection.

The Lens: Can a Weekly Newsletter Improve Medical Student Knowledge of the Ophthalmology Literature?

OBJECTIVE: Medical trainees often report barriers to their active engagement with academic medical literature. We assessed whether subscription to The Lens, a weekly newsletter summarizing recent ophthalmology literature, improved readers' knowledge of the literature. DESIGN: The implementation, uptake, and feasibility of The Lens are described. To assess newsletter efficacy, a 14 question multiple-choice quiz was designed with seven questions based on research articles featured in The Lens and seven based on articles published in high impact ophthalmology journals that were not featured in The Lens. The quiz was statistically validated in a sub-sample of non-subscribers to confirm similar difficulty between Lens and non-Lens quiz items. Among subscribers, within-participant scores on each subsection were compared using paired t-tests. Linear regression was used to determine if participation-adjusted subscription length was associated with quiz scores, after covariate adjustment. SETTING AND PARTICIPANTS: Medical student subscribers of The Lens. RESULTS: Over 12 months, The Lens attained 352 subscribers and summarized 410 research articles in 40 newsletters, at a monetary cost of <$5 per issue. The survey sample comprises 59 medical students who subscribed to The Lens. Subjectively, 83.1% of subscribers reported that The Lens helped them learn about the ophthalmology literature. Among non-subscribers, scores on the Lens and non-Lens quiz subsections were similar (median paired difference = 0%), indicating that subsections were similar in difficulty. Lens subscribers correctly answered 51.1% of Lens items, compared to 42.9% of non-Lens items (mean paired difference, 8.2%; p=0.022), indicating that readers retained information presented in The Lens. In an adjusted linear regression model, each additional participation-adjusted month of subscription to The Lens was associated with a 2.7% improvement in Lens item quiz score (p=0.022). CONCLUSION: Weekly newsletters can help trainees across medical specialties overcome barriers to engagement with the academic literature and improve their knowledge of recently published studies.

Impact of the COVID-19 Pandemic on Keratoplasty and Corneal Eye Banking.

PURPOSE: The purpose of this study was to assess the impact of COVID-19 guidelines for corneal donor tissue screening and the utility of routine postmortem COVID-19 testing of donors intended for surgical use at a single eye bank. METHODS: A retrospective analysis of referrals to and eligible donors from an eye bank between March 1, 2020, and June 30, 2020, was performed, with the same time period in 2019 as a control. Referrals who were not procured because of Eye Bank Association of America COVID-19 guidelines and eye bank-specific restrictions were noted. The results of 1 month of routine postmortem testing performed by the eye bank were examined. Analysis of variance tests were performed to assess the change between donors from 2019 to 2020. RESULTS: There was a significant reduction in both the number of total referrals to the eye bank (P = 0.044) and donors eligible for surgical transplantation (P = 0.031). Eye Bank Association of America COVID-19 guidelines reduced the number of referrals over this period by 4% to 14%. Of the 266 surgically eligible donors who received postmortem COVID-19 testing in June by the eye bank, 13 resulted positive (4.9%). CONCLUSIONS: Despite a reduction in referrals and eligible corneal transplant donors at a single eye bank, there was a surplus of surgically suitable corneal tissue during the first wave of the COVID-19 pandemic. Eye banks should consider routine postmortem COVID-19 testing to identify asymptomatic infected donors although the risk of transmission of COVID-19 from infected donors is unknown.

Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience.

PURPOSE: To assess the initial utilization, safety, and patient experience with tele-ophthalmology during the COVID-19 pandemic. DESIGN: Cross-sectional study. METHODS: We conducted a telephone survey and interview of a random sample of patients who received different modalities of care (in-person, telephone, videocall, or visits deferred) during Michigan's shelter-in-place order beginning March 23, 2020. The survey assessed patient safety, patient satisfaction with care, perceptions of telehealth-based eye care, and worry about eyesight. Data were analyzed via frequency measures (eg, means and standard deviations), χ2 tests, ANOVA, and paired t tests. Interviews were analyzed using grounded theory. RESULTS: A total of 3,274 patients were called and 1,720 (53%) agreed to participate. In-person participants were significantly older than telephone (P = .002) and videocall visit (P = .001) participants. Significantly more white participants had in-person visits than minority participants (P = .002). In-person visit participants worried about their eyesight more (2.7, standard deviation [SD] = 1.2) than those who had telephone (2.5, SD = 1.3), videocall (2.4, SD = 1.1), or deferred visits (2.4, SD = 1.2) (P = .004). Of all telephone or videocall visits, 1.5% (n = 26) resulted in an in-person visit within 1 day, 2.9% (n = 48) within 2-7 days, and 2.4% (n = 40) within 8-14 days after the virtual visit demonstrating appropriate triage to telemedicine-based care. Patients frequently cited a desire for augmenting the telephone or videocall visits with objective test data. CONCLUSIONS: When appropriately triaged, tele-ophthalmology appears to be a safe way to reduce the volume of in-person visits to promote social distancing in the clinic. A hybrid model of eye care combining ancillary testing with a video or phone visit represents a promising model of care.

Patient Reported Outcomes in Microbial Keratitis.

PURPOSE: The aim of this investigation was to study the patient-reported outcomes of patients with microbial keratitis (MK) using the 9-item National Eye Institute-Visual Function Questionnaire (NEI VFQ-9). METHODS: Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, patients with MK and control patients who completed the NEI VFQ-9 within 7 days of their appointment were identified. The questionnaire is scored as a mean of the 9 items on a scale from 0 to 100, with higher scores indicating better functioning. Composite and individual item scores were compared between groups using the analysis of variance. RESULTS: In total, 916 questionnaires were completed from patients with acute MK (n = 84), nonacute MK (n = 30), MK with a corneal transplant (n = 21), from controls seen in a satellite comprehensive ophthalmology clinic (n = 528), and controls seen at a subspecialty ophthalmology clinic (n = 253). The mean NEI VFQ-9 composite scores per group were 66.6 (SD = 26.8), 78.1 (SD = 17.1), 58.6 (SD =21.6), 88.0 (SD = 10.2), and 83.5 (SD = 13.0), respectively (P < 0.0001). Both patients with acute MK and patients with MK requiring transplant reported significantly worse function than nonacute MK, comprehensive, and specialty patients. Patients with nonacute MK reported significantly worse function than comprehensive control patients (all Tukey-adjusted P < 0.05). DISCUSSION: Patients who had or eventually require corneal transplant for management of their MK report worse visual function than patients with nonacute MK. This may be important in helping physicians counsel their patients.

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach.

PRCIS: Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified. PURPOSE: The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics. METHODS: A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA). RESULTS: Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident). CONCLUSIONS: CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.

Procedures, Visits, and Procedure Costs in the Management of Microbial Keratitis.

PURPOSE: To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). METHODS: Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. RESULTS: A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was $1788.7 (SD = $3324.62). CONCLUSIONS: Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.

Change in Ophthalmic Clinicians' Attitudes Toward Telemedicine During the Coronavirus 2019 Pandemic.

Background: Ophthalmic clinicians report low confidence in telemedicine-based eye care delivery, but it may have changed given its rapid expansion during the coronavirus 2019 (COVID-19) pandemic. Introduction: The purpose of this study was to determine clinician confidence in telemedicine-based eye care services during COVID-19. Materials and Methods: An electronic survey was sent to clinicians at University of Michigan Kellogg Eye Center (April 17, 2020-May 6, 2020) when nonemergent in-person visits and procedures were restricted. The primary outcome was clinician confidence in using telemedicine-based eye care during COVID-19. Secondary outcomes included telemedicine utilization and its association with clinician confidence using Fisher's exact test. Results: Of the 88 respondents (90.7% response rate; n = 97 total), 83.0% (n = 73) were ophthalmologists and 17.0% (n = 15) were optometrists. Telemedicine utilization increased from 30.7% (n = 27) before the pandemic to 86.2% (n = 75) after the pandemic. Clinicians' confidence in their ability to use telemedicine varied with 28.6% (24/84) feeling confident/extremely confident, 38.1% (32/84) somewhat confident, and 33.3% (28/84) not-at-all confident. Most felt that telemedicine was underutilized (62.1%; 54/87) and planned continued use over the next year (59.8%; 52/87). Confident respondents were more likely to have performed three or more telemedicine visits (p = 0.003), to believe telemedicine was underutilized (p < 0.001), and to anticipate continued use of telemedicine (p = 0.009). Discussion: The majority of clinicians were at least somewhat confident about using telemedicine during the pandemic. Clinician confidence was associated with telemedicine visit volume and intention to continue using telemedicine. Conclusions: Policies that foster clinician confidence will be important to sustain telemedicine-based eye care delivery.

Eye banking in the coronavirus disease 2019 era.

PURPOSE OF REVIEW: Coronavirus disease 2019, caused by novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious; however, the different routes of transmission are not well understood. Transmission through tissue transplantation is possible and must be considered. This review will evaluate the current literature regarding routes of transmission, the likelihood of transmission through ocular tissue transplantation, and the guidelines in place to mitigate this risk. RECENT FINDINGS: Although respiratory droplets have been the primary route of SARS-CoV-2 transmission, there is evidence that transmission through blood donation and organ or tissue transplantation is possible. This includes corneal transplantation, as SARS-CoV-2 has been detected in conjunctival swabs of infected patients, and the ocular surface may play an important role in viral entry. Several tissue transplantation organizations have guidelines in place regarding the screening of donors and tissue procurement procedures, including clinical and/or PCR screening of donors. The Eye Bank Association of America (EBAA) is currently not recommending asymptomatic PCR screening. However, their antiseptic protocols may play an important role in viral inactivation. SUMMARY: Based on the current literature and guidelines, the risk of SARS-CoV-2 transmission through corneal transplantation is likely low. However, tissue screening guidelines need to be re-evaluated regularly as knowledge regarding the SARS-CoV-2 virus evolves.