Variations in Electronic Health Record-Based Definitions of Diabetic Retinopathy Cohorts: A Literature Review and Quantitative Analysis.

Purpose: Use of the electronic health record (EHR) has motivated the need for data standardization. A gap in knowledge exists regarding variations in existing terminologies for defining diabetic retinopathy (DR) cohorts. This study aimed to review the literature and analyze variations regarding codified definitions of DR. Design: Literature review and quantitative analysis. Subjects: Published manuscripts. Methods: Four graders reviewed PubMed and Google Scholar for peer-reviewed studies. Studies were included if they used codified definitions of DR (e.g., billing codes). Data elements such as author names, publication year, purpose, data set type, and DR definitions were manually extracted. Each study was reviewed by ≥ 2 authors to validate inclusion eligibility. Quantitative analyses of the codified definitions were then performed to characterize the variation between DR cohort definitions. Main Outcome Measures: Number of studies included and numeric counts of billing codes used to define codified cohorts. Results: In total, 43 studies met the inclusion criteria. Half of the included studies used datasets based on structured EHR data (i.e., data registries, institutional EHR review), and half used claims data. All but 1 of the studies used billing codes such as the International Classification of Diseases 9th or 10th edition (ICD-9 or ICD-10), either alone or in addition to another terminology for defining disease. Of the 27 included studies that used ICD-9 and the 20 studies that used ICD-10 codes, the most common codes used pertained to the full spectrum of DR severity. Diabetic retinopathy complications (e.g., vitreous hemorrhage) were also used to define some DR cohorts. Conclusions: Substantial variations exist among codified definitions for DR cohorts within retrospective studies. Variable definitions may limit generalizability and reproducibility of retrospective studies. More work is needed to standardize disease cohorts. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A case of herpes simplex virus and cytomegalovirus retinitis coinfection.

PURPOSE: To describe a case of a 64-year-old male presenting with cytomegalovirus (CMV) and herpes simplex virus (HSV) retinitis coinfection in the setting of Burkitt's lymphoma. METHODS: Case report including multimodal imaging and anterior chamber polymerase chain reaction results. RESULTS: This case highlights the importance of the clinical exam and maintaining high diagnostic suspicion for viral retinitis in immunocompromised patients. CONCLUSIONS: Aqueous fluid PCR can be a useful adjunctive test to distinguish and confirm a diagnosis of viral retinitis. Given the limited sample volume of aqueous biopsy, it is important to prioritize the order of PCR testing based on clinical suspicion of the causative agent.

Implementation of a pilot teleretinal screening protocol for hydroxychloroquine retinopathy in a Los Angeles County safety net clinic.

INTRODUCTION: This study aimed to determine whether teleretinal screening for hydroxychloroquine retinopathy (HCQR) improves clinical efficiency and adherence to recommended screening guidelines compared to face-to-face screening among patients in a large safety net medical system. METHODS: In this retrospective cohort study of a consecutive sample of 590 adult patients with active HCQ prescriptions seen in the outpatient ophthalmology clinic at Los Angeles County + University of Southern California Medical Center from 1 September 2018 to 25 November 2019, 203 patients underwent technician-only tele-HCQR screening (THRS), and 387 patients underwent screening with traditional face-to-face visits (F2FV) with an eye-care provider. Data on clinic efficiency measures (appointment wait time and encounter duration) and adherence to recommended screening guidelines were collected and compared between the two cohorts. RESULTS: Compared to F2FV, the THRS cohort experienced significantly shorter median (interquartile range) time to appointment (2.5 (1.5-4.6) vs. 5.1 (2.9-8.4) months; p < 0.0001), shorter median encounter duration (1 (0.8-1.4) vs. 3.7 (2.5-5.2) hours; p < 0.0001) and higher proportion of complete baseline screening (102/104 (98.1%) vs. 68/141 (48.2%); p < 0.001) and complete chronic screening (98/99 (99%) vs. 144/246 (58.5%); p < 0.001). DISCUSSION: A pilot THRS protocol was successfully implemented at a major safety net eye clinic in Los Angeles County, resulting in a 50.9% reduction in wait times for screening, 72.9% reduction in encounter duration and 49.9% and 40.5% increases in proportions of complete baseline and chronic screening, respectively. Tele-HCQ retinal screening protocols may improve timeliness to care and screening adherence for HCQR in the safety net setting.

PURTSCHER-LIKE RETINOPATHY ASSOCIATED WITH ATYPICAL HEMOLYTIC UREMIC SYNDROME: CASE REPORT AND REVIEW OF OUTCOMES.

PURPOSE: The purpose of this study was to report the case of a patient presenting with newly diagnosed atypical hemolytic uremic syndrome (aHUS) and Purtscher-like retinopathy. METHODS: This is an observational case report and review of literature. A 38-year-old woman presented with 3 months of rashes, fevers, arthralgias, and abdominal pain. Initial workup was suggestive of hypereosinophilic syndrome or adult-onset Still's disease. The patient developed acute renal failure and progressively blurry vision bilaterally over the course of 5 days. Funduscopic examination was notable for numerous Purtscher flecken and cotton-wool spots, with rare intraretinal hemorrhages at the posterior pole. The constellation of renal failure, hemolytic anemia, and thrombocytopenia prompted a workup for thrombotic microangiopathy that was remarkable for a mutation in the gene coding for complement protein C9. RESULTS: The patient was diagnosed with aHUS and treated with intravenous pulse dose steroids for 3 days and an extended course of eculizumab. The patient's renal failure resolved, and her visual acuity improved, although she had residual visual field constriction and developed bilateral optic atrophy. Outcomes of other cases of Purtscher-like retinopathy related to aHUS are reviewed. CONCLUSION: Purtscher-like retinopathy is a rare but severe ophthalmic complication of aHUS. Eculizumab is an effective treatment for the systemic illness caused by aHUS, and anatomical resolution of Purtscher-like retinopathy may follow, although visual prognosis remains guarded. Recovery of visual acuity may lag behind resolution of macular edema in these patients.

Factors Affecting Ophthalmology Trainees to Pursue Vitreoretinal Surgery Fellowship.

Objective The aim of this study was to understand the factors that ophthalmology trainees consider in pursuing vitreoretinal surgery (VRS) fellowship training. Methods This is a prospective observational survey study. Survey invitations were disseminated to postgraduate year 4 (PGY)-4 ophthalmology residents at Accreditation Council for Graduate Medical Education-accredited residency programs and surgical retina fellows at Association of University Professors of Ophthalmology Fellowship Compliance Committee-compliant fellowship programs in the United States. Survey questions on factors related to VRS were administered employing a 5-point Likert scale. Responses from ophthalmology residents pursuing surgical retina were combined with surgical retina fellows' responses and compared with responses from PGY-4 residents not pursuing vitreoretinal surgery. Results Eighty-one resident surveys were completed. Forty-three fellow surveys were completed. Fifty-seven out of eighty-one (70.4%) residents were not pursuing surgical retina, and a total of 67 trainees (24 residents, 43 fellows) were pursuing surgical retina. The following factors were associated with pursuing VRS training: male gender ( p = 0.031); having performed retina research during residency ( p ≤ 0.001); enjoying surgical retina procedures ( p ≤ 0.001), enjoying surgical retina patient outcomes ( p ≤ 0.001), and working with vitreoretinal surgeons ( p ≤ 0.001); finding surgical retina prestigious ( p ≤ 0.001); perceiving their residency having a strong record of matching surgical retina ( p = 0.039); liking the potential financial income from surgical retina ( p ≤ 0.001); and having vitreoretinal mentors during residency ( p = 0.014). A majority of trainees (31/57, 54.4%) not pursuing surgical retina disagreed or strongly disagreed with enjoying the patient outcomes in surgical retina. A third of female residents not pursuing surgical retina felt having a female surgical retina mentor would have made them more likely to pursue the field. Conclusion Longer retina rotations, encouraging resident participation in retina research, and increasing mentorship opportunities of female trainees from female retina specialists may increase resident interest in pursuing surgical retina fellowship.

Incidence of Proliferative Diabetic Retinopathy and Other Neovascular Sequelae at 5 Years Following Diagnosis of Type 2 Diabetes.

OBJECTIVE: To determine the incidence and risk factors for developing proliferative diabetic retinopathy (PDR), tractional retinal detachment (TRD), and neovascular glaucoma (NVG) at 5 years after the initial diagnosis of type 2 diabetes. RESEARCH DESIGN AND METHODS: Insured patients aged ≥18 years with newly diagnosed type 2 diabetes and 5 years of continuous enrollment were identified from a nationwide commercial claims database containing data from 2007 to 2015. The incidences of PDR, TRD, and NVG were computed at 5 years following the index diagnosis of type 2 diabetes. Associations between these outcomes and demographic, socioeconomic, and medical factors were tested with multivariable logistic regression. RESULTS: At 5 years following the initial diagnosis of type 2 diabetes, 1.74% (1,249 of 71,817) of patients had developed PDR, 0.25% of patients had developed TRD, and 0.14% of patients had developed NVG. Insulin use (odds ratio [OR] 3.59, 95% CI 3.16-4.08), maximum HbA1c >9% or >75 mmol/mol (OR 2.10, 95% CI 1.54-2.69), renal disease (OR 2.68, 95% CI 2.09-3.42), peripheral circulatory disorders (OR 1.88, 95% CI 1.25-2.83), neurological disease (OR 1.62, 95% CI 1.24-2.11), and older age (age 65-74 years) at diagnosis (OR 1.62, 95% CI 1.28-2.03) were identified as risk factors for development of PDR at 5 years. Young age (age 18-23 years) at diagnosis (OR 0.46, 95% CI 0.29-0.74), Medicare insurance (OR 0.60, 95% CI 0.70-0.76), morbid obesity (OR 0.72, 95% CI 0.59-0.87), and smoking (OR 0.84, 95% CI 0.70-1.00) were identified as protective factors. CONCLUSIONS: A subset of patients with type 2 diabetes develop PDR and other neovascular sequelae within the first 5 years following the diagnosis with type 2 diabetes. These patients may benefit from increased efforts for screening and early intervention.

Rates of Eye Care and Diabetic Eye Disease among Insured Patients with Newly Diagnosed Type 2 Diabetes.

PURPOSE: To determine rates of eye examinations and diabetic eye disease in the first 5 years after diagnosis of type 2 diabetes (DM2) among continuously insured adults. DESIGN: Retrospective, longitudinal cohort study. PARTICIPANTS: Insured patients aged 40 years or older with newly diagnosed DM2 (n = 42 684), and control patients without diabetes matched on age, sex, and race were identified from a nationwide commercial claims database containing data from 2007 to 2015. METHODS: All patients were tracked for 6 years: 1 year before and 5 years after the index diabetes diagnosis. Receipt of eye care for individual patients was identified using International Classification of Diseases 9th edition (ICD-9) procedure codes or Current Procedural Terminology (CPT) codes indicating an eye examination, as well as encounters indicating the patient was seen by an ophthalmologist. A diagnosis of diabetic eye disease was determined by using ICD-9 codes. MAIN OUTCOME MEASURES: Outcome measures included annual receipt of eye care and development of diabetic eye disease, namely, diabetic retinopathy (DR). Associations between these outcomes and demographic factors were tested with multivariable logistic regression. RESULTS: Diabetic patients received more eye examinations than controls in each year, but no more than 40.4% of diabetic patients received an examination in any given year. Patients with Medicare Advantage received fewer eye examinations at 5 years (odds ratio [OR], 0.79; P < 0.01) than those with private insurance but were less likely to develop DR (OR, 0.71; P < 0.01). Hispanic patients had higher rates of DR (OR, 1.60; P < 0.01) and received fewer eye examinations (OR, 0.75; P < 0.01) at 5 years compared with White patients. Men received fewer eye examinations (OR, 0.84; P < 0.01) and were more likely to develop DR at 5 years (OR, 1.17; P < 0.01) than women. Patients with higher education were more likely to receive an eye examination and less likely to develop DR. CONCLUSIONS: The majority of diabetic patients do not receive adequate eye care within the 5 years after initial diabetes diagnosis despite having insurance. Efforts should be made to improve adherence to screening guidelines, especially for vulnerable populations.

Interleukins and cytokine biomarkers in uveitis.

Interleukins and cytokines are involved in the pathogenesis of uveitis of heterogeneous origin. Understanding the basics of the ocular immune privilege is a fulcrum to discern their specific role in diverse uveitis to potentially translate as therapeutic targets. This review attempts to cover these elements in uveitis of infectious, noninfectious and masquerade origin. Insights of the molecular targets in novel therapy along with the vision of future research are intriguing.

Incidence, prevalence, and risk factors of infectious uveitis and scleritis in the United States: A claims-based analysis.

BACKGROUND: Ocular inflammation causes significant visual morbidity in the United States, yet little is known about the epidemiology of infectious uveitis and scleritis. This study aims to evaluate the epidemiology of infectious uveitis/scleritis employing a large national medical claims database. METHODS: This was a retrospective, case-control study, employing Optum's de-identified Clinformatics® Data Mart Database, containing data from 21.5 million privately insured individuals with enrollment for at least 15 months within 2007-2015. Inclusion in the uveitis/scleritis sample required an index uveitis/scleritis diagnosis based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Exclusion criteria included index date within 3 months after intraocular surgery. Rates for uveitis/scleritis were determined by anatomic site. Multivariable logistic regression analyses were performed to determine odds ratios for the incidence and prevalence of uveitis/scleritis by anatomic category. FINDINGS: Infectious etiologies accounted for less than 20% of uveitis/scleritis, with mean rates of 18.9 (incidence) and 60.6 (prevalence) per 100,000 persons. The mean prevalences of infectious anterior, intermediate, posterior, panuveitis, and scleritis were 27.7, 0.17, 23.4, 4.4, and 4.6, per 100,000, respectively. Overall risk of prevalent infectious uveitis/scleritis increased with age (OR>3.3 for each decade over age 18, p<0.01), female sex (OR = 1.2, p<0.01), non-Hispanic white race (OR<1 for all other races, p<0.01), as well as the East South Central census division (OR = 1.2, p<0.01), comprising Alabama, Kentucky, Missouri, and Tennessee. Medical comorbidities, including HIV infection (OR = 6.4, p<0.01) and rheumatologic disease (OR = 1.9, p<0.01), were common in the infectious uveitis/scleritis cohort. CONCLUSIONS: The incidence and prevalence of infectious uveitis/scleritis in the United States were higher than previously reported estimates but remained lower than in developing countries. Rates varied by age, sex, race, and medical comorbidities, and may reflect differential susceptibility to various infectious agents with disparate geographic distributions within the United States.

Multimodal imaging reveals pathological edges of disease activity in tuberculosis-associated multifocal serpiginoid chorioiditis.

Tuberculosis associated serpiginous-like choroidopathy can lead to significant vision loss. The anatomical cause for this visual decline can be elucidated using multimodal retinal imaging. Imaging modalities used in this case, most notably, optical coherence tomography angiography (OCTA), demonstrated specific atrophy of the choriocapillaris.

Assessment of Eye Disease and Visual Impairment in the Nursing Home Population Using Mobile Health Technology.

BACKGROUND AND OBJECTIVE: To characterize the burden of eye disease and the utility of teleophthalmology in nursing home patients, a population with ophthalmic needs not commensurate with care received. PATIENTS AND METHODS: Informed consent was obtained from 78 California Bay Area skilled nursing facility patients. Near visual acuity (VA) and anterior/posterior segment photographs were taken with a smartphone-based VA app and ophthalmic camera system. The Nursing Home Vision-Targeted Health-Related Quality of Life questionnaire was also administered. Risk factors for visual impairment were assessed. Institutional review board approval was obtained from Stanford University. RESULTS: Cataracts (51%), diabetic retinopathy (DR) (12%), optic neuropathy (12%), and age-related macular degeneration (AMD) (10%) were common findings; 11.7% had other referral-warranted findings. AMD and DR correlated with a higher risk of poor VA, with adjusted odds ratios of 22 (P = .01) and 43 (P = .004). CONCLUSIONS: This study demonstrated a high prevalence of poor VA and ophthalmic disease in the nursing home population impacting quality of life. Smartphone-based teleophthalmology platforms have the potential to increase access to eye care for nursing home patients. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:262-270.].

Quantifying Subclinical and Longitudinal Microvascular Changes Following Episcleral Plaque Brachytherapy Using Spectral Domain-Optical Coherence Tomography Angiography.

PURPOSE: To assess longitudinal microvascular changes in eyes treated with I-125 episcleral plaque brachytherapy (EPB). METHODS: High resolution OCT angiograms of the central 3×3mm macula were obtained from I-125 episcleral plaque brachytherapy treated and untreated fellow eyes of 61 patients. Capillary density (vessel skeleton density, VSD) and caliber (vessel diameter index, VDI) were quantified using previously validated semi-automated algorithms. Nonperfusion was also quantified as flow impairment regions (FIR). Exams from treated and fellow eyes obtained pre-treatment and at 6-month, 1-year, and 2-year intervals were compared using generalized estimating equation linear models. Dosimetry maps were used to evaluate spatial correlation between radiation dose and microvascular metrics. RESULTS: At 6 months, treated eyes had significantly lower VSD (0.145 ± 0.003 vs 0.155 ± 0.002; p = 0.009) and higher FIR (2.01 ± 0.199 vs 1.46 ± 0.104; p = 0.010) compared to fellow eyes. There was a significant decrease in VSD and a corresponding increase in FIR even for treated eyes without clinically identifiable retinopathy at 6 months. VDI was significantly higher in treated eyes than in fellow eyes at 2 years (2.92 ± 0.025 vs 2.84 ± 0.018; p < 0.001). When our cohort was categorized into low dose radiation (<15Gy) and high dose radiation (>45Gy) to the fovea, there were significant differences in VSD and FIR between groups. CONCLUSIONS: OCTA can be used to quantify and monitor EPB induced retinopathy, and can detect vascular abnormalities even in the absence of clinically observable retinopathy. OCTA may therefore be useful in investigating treatment interventions that aim to delay EPB-induced radiation retinopathy.

Astigmatic outcomes in myopic wavefront-guided laser in situ keratomileusis versus wavefront-guided photorefractive keratectomy using vector analysis.

PURPOSE: To compare astigmatic outcomes between eyes having wavefront-guided laser in situ keratomileusis (LASIK) and eyes having wavefront-guided photorefractive keratectomy (PRK). SETTING: Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA. DESIGN: Prospective randomized case series. METHODS: Patients had refractive surgery, with one eye treated with LASIK and the other treated with PRK. Eyes were randomized according to ocular dominance. Astigmatism vectors were evaluated using the Alpins vector analysis of astigmatism. RESULTS: Thirty-four patients (68 eyes) had vector analysis; the LASIK and PRK groups had similar target-induced astigmatism vectors (P = 0.75), surgically induced astigmatism vectors (P = 0.86), difference vectors (P = 1.0), indices of success (P = 0.4), correction indices (P = 0.28), and flattening indices (P = 0.5). CONCLUSION: Based on Alpins vector analysis of astigmatism, there were no statistically significant differences between eyes that had LASIK and eyes that had PRK.

Vector Analysis of 1-Year Astigmatic Outcomes From a Randomized Fellow Eye Comparison of Photorefractive Keratectomy Using 2 Excimer Laser Platforms.

OBJECTIVE: To compare the astigmatic outcomes of photorefractive keratectomy (PRK) with a wavefront-guided (WFG) and a wavefront-optimized (WFO) excimer laser performed on two different platforms. METHODS: Setting: institutional. DESIGN: Prospective, randomized, fellow eye comparison clinical trial. PARTICIPANTS: A total of 142 eyes of 71 patients with myopia of 12 diopters (D) or less and astigmatism of 3D or less were enrolled at the Byers Eye Institute at Stanford between April 2009 and March 2011. INTERVENTION: One eye of each patient underwent WFG-PRK with the VISX CustomVue Star S4 IR (Abbott Medical Optics, Abbott Park, IL) and the contralateral eye underwent WFO-PRK with the Wavelight Allegretto Eye-Q 400-Hz laser platform (Alcon, Inc., Hüenberg, Switzerland). Alpins vector analysis of astigmatism was performed using manifest refraction measured preoperatively and 12 months postoperatively and vertexed to the corneal plane. Eyes were stratified for subgroup analysis based on preoperative manifest astigmatism. RESULTS: WFG-PRK and WFO-PRK were similar regarding surgically induced astigmatism, difference vector, magnitude of error, correction index, flattening index, and index of success. The angle of error was 60% less in the WFG group compared with the WFO group (4.9±1.1° vs. 11.8±2.4°, P=0.01). CONCLUSIONS: WFG-PRK with the VISX CustomVue Star S4 IR and WFO-PRK with the Alcon WaveLight Allegretto Eye-Q 400-Hz excimer laser platform produce similar astigmatic results in myopic patients; however, the WFG mode may produce slightly more predictable astigmatic corrections.

POLYPOIDAL CHOROIDAL VASCULOPATHY: A CLINICOPATHOLOGIC STUDY.

PURPOSE: To present a unique case of polypoidal choroidal vasculopathy presenting as a blind, painful eye with a suspected intraocular mass, and to correlate clinical findings with histopathologic studies. METHODS: Clinical case report and literature review. RESULTS: A 58-year-old Vietnamese man presented with a blind, painful eye with concern for an intraocular mass. B-scan ultrasonography showed massive intraocular hemorrhage and could not rule out a tumor. The patient underwent enucleation and the histopathologic findings were consistent with polypoidal choroidal vasculopathy. CONCLUSION: Polypoidal choroidal vasculopathy can present with dense vitreous hemorrhage and may masquerade as an intraocular mass. It can progress rapidly and lead to profound, irreversible vision loss. A diagnosis of polypoidal choroidal vasculopathy should be considered in patients of African or East Asian origin presenting with vitreous hemorrhage.