Eye Pain During Hemodialysis in Severe Proliferative Diabetic Retinopathy With Neovascular Glaucoma.

Purpose: To report a case of severe eye pain developing during dialysis. Methods: A case report was performed. Results: A 41-year-old man with uncontrolled type 2 diabetes and end-stage nephropathy developed severe pain in the left eye during hemodialysis. A decline in vision in both eyes was reported over the preceding year, with blindness in the left eye for 6 months. The best-corrected visual acuity was 20/150 OD and light perception OS. The intraocular pressure was 14 mm Hg and 59 mm Hg, respectively. An examination found disc neovascularization with a "volcanic eruption" of vitreous hemorrhage from the optic nerve in the right eye and significant corneal edema and iris neovascularization with no posterior view in the left eye. The patient required urgent cyclophotocoagulation for neovascular glaucoma (NVG) in the left eye, bilateral antivascular endothelial growth factor injections, and panretinal photocoagulation in the right eye for proliferative diabetic retinopathy. Conclusions: Worsening eye pain during hemodialysis in a patient with NVG indicates severely limited outflow capacity and requires immediate intervention.

Probing versus primary nasal endoscopy for the treatment of congenital dacryocystoceles.

PURPOSE: To compare outcomes and complications of three surgical techniques for the treatment of congenital dacryocystoceles: nasolacrimal probing and irrigation (P+I), P+I plus nasal endoscopy (NE) with intranasal cyst marsupialization, and primary NE with intranasal cyst marsupialization. METHODS: The medical records of children ≤2 years of age at a single academic center with a diagnosis of dacryocystocele from 2012 to 2022 were retrospectively identified and reviewed. The primary outcome was resolution of the dacryocystocele (ie, elimination of the medial canthal mass and resolution of tearing or discharge) after a single procedure ("primary success"). Surgical techniques were compared using exact logistic regression. RESULTS: Of 54 patients, 21 (39%) underwent P+I, 23 (43%) underwent P+I plus nasal endoscopy, and 10 (18%) underwent primary NE. Primary success was 76% for P+I and 100% for the other two cohorts. Most patients (89%) who underwent P+I received general anesthesia compared with none who underwent primary nasal endoscopy. Most complications were related to the use of general anesthesia, with a complication rate of 10% for P+I, 48% for P+I plus NE, and 0% for primary NE. Most P+I procedures required hospital admission compared to half of primary NE procedures. CONCLUSIONS: In our study cohort, primary NE provided good outcomes and was associated with a lower complication rate than P+I with or without NE.

Training visual pattern recognition in ophthalmology using a perceptual and adaptive learning module.

OBJECTIVE: To evaluate the efficacy of a perceptual and adaptive learning module (PALM) for teaching the identification of 5 optic nerve findings. METHODS: Second- through fourth-year medical students were randomized to the PALM or a video didactic lecture. The PALM presented the learner with short classification tasks consisting of optic nerve images. Learner accuracy and response time guided the sequencing of successive tasks until mastery was achieved. The lecture was a narrated video designed to simulate a portion of a traditional medical school lecture. Accuracy and fluency on a pretest, post-test, and 1-month delayed test were compared within and between groups. RESULTS: Eighty-three students participated. Accuracy and fluency improved significantly (p < 0.001) from pretest to post-test for both the PALM (accuracy, Cohen's d = 2.94; fluency, d = 3.39) and the lecture (accuracy, d = 2.32; fluency, d = 1.06). For the delayed test, PALM performance remained significantly greater (p < 0.001) than the pretest in both accuracy (d = 0.89) and fluency (d = 1.16), whereas lecture performance remained greater in accuracy only (d = 0.44; p = 0.02). CONCLUSIONS: The PALM facilitated visual pattern recognition for optic nerve diseases among novice learners using a single brief self-guided session. The PALM may be applied alongside traditional didactic lectures to expedite visual pattern recognition in ophthalmology.

Pediatric Cataract: Disparately Blinding Globally and in the United States.

Childhood cataract is a complex condition requiring longitudinal care, including early diagnosis, timely referral to a specialist, early surgical intervention, and dedicated postoperative care. Adherence to refractive correction and amblyopia therapy are critical for visual rehabilitation, even months to years after the cataract is removed. We review the impact of the social determinants of health on each step in the visual rehabilitation pathway for children with congenital and infantile cataracts. Children from socioeconomically marginalized backgrounds are more likely to experience delays in access to care and utilization of surgical services. They are also less likely to adhere to amblyopia therapy, with corresponding decrements in visual outcomes. Additional sociocultural factors, including parental stress, self-efficacy, and health literacy, pose barriers for these children. Standardizing clinical roles, improving health communication, managing parental stress, and implementing systemic policy changes may alleviate socioeconomic disparities in outcomes for children with cataracts.

Ultra-Widefield Imaging as a Teleophthalmology Screening Tool for Ocular Pathology.

Background: Prior studies have validated ultra-widefield imaging as a remote screening tool for diabetic retinopathy. The aim of this study was to determine its use in screening for any fundus pathology in a routine patient population. Methods: In this prospective randomized study, patients underwent both slit lamp indirect ophthalmoscopy and ultra-widefield imaging. Ultra-widefield images were independently reviewed by two optometrists, and discrepancies were adjudicated by a retina specialist. Clinical findings from slit-lamp examiners and image-reviewers were coded into themes and clinically meaningful findings were extracted. Cohen's kappa was used to estimate agreement for these findings between the two image-reviewers and between the image-reviewers and slit-lamp examiners. Results: Nine-hundred eyes of 450 patients were examined and imaged, of which 616 eyes were analyzed. At least one abnormal fundus finding was present on ophthalmoscopy in 71 eyes (11%) and on adjudicated image interpretation in 166 eyes (27%). Agreement between the two image-reviewers was moderate to substantial for most clinically meaningful findings, including optic disc hemorrhage (κ = 0.8), macular exudates (κ = 0.7), and macular pigmentary changes (κ = 0.7). Agreement between examiners and image-reviewers was moderate to substantial for optic disc hemorrhage (κ = 1), indistinct optic disc margins (κ = 0.5), drusen (κ = 0.4), pigmentary changes (κ = 0.4), and hemorrhage (κ = 0.8). A total of 187 findings were detected by imaging but not examination, compared with 42 that were detected on examination but not imaging. Conclusion: In a routine patient population, ultra-widefield imaging agreed with standard-of-care slit-lamp examinations and detected more fundus findings.

Health Disparity Curricula for Ophthalmology Residents: Current Landscape, Barriers, and Needs.

Background Social determinants of health play a critical role in visual health outcomes. Yet, there exists no structured curriculum for ophthalmology residents to identify and address health disparities relevant to eye care or no a standard assessment of health disparities education within ophthalmology residency programs. This study aims to characterize current health disparity curricula in ophthalmology residency programs in the United States, determine resident confidence in addressing health disparities in the clinical setting, and identify perceived barriers and needs of program directors (PDs) and residents in this area. Design This was a cross-sectional survey study. Methods A closed-ended questionnaire with comments was distributed to the Accreditation Council for Graduate Medical Education-accredited ophthalmology residency PDs and residents in April 2021 and May 2022. The questionnaire solicited characteristics of any existing health disparity curricula, PD and resident perceptions of these curricula, and residents' experience with and confidence in addressing health disparities in the delivery of patient care. Results In total, 29 PDs and 96 residents responded. Sixty-six percent of PDs stated their program had a formal curriculum compared to fifty-three percent of residents. Forty-one percent of PDs and forty-one percent of residents stated their program places residents in underserved care settings for more than 50% of their training. Most residents (72%) were confident in recognizing health disparities. Sixty-six percent were confident in managing care in the face of disparities and fifty-nine percent felt they know how to utilize available resources. Residents were most concerned with the lack of access to resources to help patients. Forty-five percent of PDs felt the amount of time dedicated to health disparities education was adequate. Forty-nine percent of residents reported they felt the amount of training they received on health disparities to be adequate. The top barrier to curriculum development identified by PDs was the availability of trained faculty to teach. Time in the curriculum was a major barrier identified by residents. Conclusions Roughly half of ophthalmology residency programs who responded had a health disparity curriculum; however, both PDs and residents felt inadequate time is dedicated to such education. National guidance on structured health disparity curricula for ophthalmology residents may be warranted as a next step.

Next-generation sequencing of a large uveal melanoma with whole genome doubling and a PBRM1 mutation.

Purpose: To report a large uveal melanoma with extra-scleral extension which underwent spontaneous infarction and its unique molecular signature profile. Observations: An 81-year-old female presented with a blind, painful eye. Intraocular pressure was 48 mm Hg. There was a large subconjunctival melanotic mass overlying a choroidal melanoma with anterior extension involving the ciliary body and the iridocorneal angle and iris. Ultrasonography confirmed a dome-shaped anterior cilio-choroidal mass with extra-scleral extension. The patient underwent enucleation and pathologic evaluation confirmed cilio-choroidal melanoma. The posterior half of the tumor involving the ciliary body and the extra-scleral component were spontaneously infarcted and were composed of large melanophages. Next-generation sequencing demonstrated a splice site mutation in PBRM1 and whole-genome doubling in addition to a GNAQ hotspot mutation, chromosome 3 loss and 8q gain. Conclusions and importance: This case of a large, auto-infarcted uveal melanoma demonstrates a PBRM1 mutation and whole-genome doubling.

External Subretinal Fluid Drainage in Scleral Buckling: Before Versus after Cryotherapy and Buckle Placement, A Pilot Study.

In this retrospective comparative case series at a teaching hospital, we reviewed adult patients with rhegmatogenous retinal detachment who underwent scleral buckling surgery with external drainage of subretinal fluid performed before versus after placement of the scleral buckle. Eight eyes in each group were roughly matched for age, sex, baseline visual acuity (VA), and detachment characteristics. The complication rate was 0% for the "before" group and 37% for the "after" group (p = 0.100). In the "after" group, two eyes (25%) developed iatrogenic retinal holes and one eye (12%) developed self-limited subretinal hemorrhage during external needle drainage. The duration of surgery was significantly shorter for the "before" group (mean 89 ± 16 min) compared to the "after" group (118 ± 20 min) (p = 0.008). The primary anatomic success rate was 100% for the "before" group and 75% for the "after" group (p = 0.233). Final VA was not significantly different between the groups or from baseline. In conclusion, while limited by our small sample size, this pilot study suggests that drainage of subretinal fluid before scleral buckle placement may be safer and more efficient compared to draining after buckle placement. Initial drainage may facilitate retinochoroid apposition to allow targeted cryopexy and precise buckle placement.

Efficacy of the Fluocinolone Acetonide (Yutiq) Intravitreal Implant as Monotherapy for Uveitis.

PURPOSE: To evaluate the efficacy of the fluocinolone acetonide intravitreal implant (Yutiq) as monotherapy for uveitis. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients at a single academic health-care institution. METHODS: Medical record review of patients with non-infectious uveitis actively suppressed on an alternative anti-inflammatory regimen who received a fluocinolone acetonide implant. The primary outcome was continued control of inflammation based on clinical examination, optical coherence tomography, and fluorescein angiography. RESULTS: Thirteen patients (19 eyes) received an implant. Median follow-up was 6 months. Uveitis control was achieved in 14 eyes (74%), though three (21%) required a topical steroid after insertion. The remaining five eyes (26%) required additional intraocular treatments. CONCLUSION: The fluocinolone acetonide implant may not suffice as monotherapy for all patients with uveitis, but it may be effective as an adjunctive treatment. We propose a clinical workflow for the selection and treatment of patients who may benefit from it.

Socioeconomic Correlates of Keratoconus Severity and Progression.

PURPOSE: The purpose of this study was to investigate the social determinants of health for keratoconus. METHODS: In this retrospective cohort study of patients with keratoconus, the electronic health record was reviewed for keratometry, treatments received, clinical comorbidities, and social characteristics. Outcomes included severe keratoconus at presentation (steep keratometry ≥52 diopters), disease progression (≥0.75 diopters increase from the first to the most recent clinical visit), and corneal transplantation. Logistic regression was used to evaluate factors associated with severity at presentation and corneal transplantation. Cox proportional hazards modeling was used to evaluate progression. RESULTS: A total of 1038 patients with keratoconus were identified, 725 (70%) of whom had baseline imaging. Compared with commercially insured patients, Medicaid recipients were more likely to have severe keratoconus, independent of social and clinical confounders [odds ratio (OR) 1.94, 95% confidence interval (CI), 1.12-3.35, P = 0.017]. Male sex was independently associated with progression (hazard ratio = 1.38, 95% CI, 1.03-1.84, P = 0.030). Medicare and Medicaid recipients were more likely to require transplantation compared with commercially insured patients (OR 2.71, 95% CI, 1.65-4.46, P < 0.001 and OR 1.74, 95% CI, 1.08-2.80, P = 0.022, respectively). Other social determinants of health, including non-White race/ethnicity, limited English proficiency, and unemployment, were associated with the outcomes only in univariate analysis. Obstructive sleep apnea, atopy, body mass index, and tobacco use were not associated with any outcome. CONCLUSIONS: Socioeconomic factors were more consistent predictors of keratoconus severity and corneal transplantation compared with clinical factors that have received relatively greater attention in the keratoconus literature.

Parental Keratoconus Literacy: A Socioeconomic Perspective.

Purpose: To assess the impact of parental socioeconomic status and keratoconus literacy on pediatric eye rubbing and keratoconus severity. Methods: In this mixed-methods study, pediatric keratoconus patients (age ≤ 18 years) were retrospectively identified. Sociodemographic and clinical characteristics were extracted from the electronic medical record (EMR). Telephone surveys were subsequently conducted to assess parental keratoconus literacy, receipt of counseling on keratoconus prevention, eye rubbing, and household socioeconomic factors not available in the EMR. Parents reporting poor keratoconus literacy were probed via semi-structured interview to explore barriers to their understanding. Results: Forty-eight patients met inclusion criteria, 22 (46%) of whom were reached by telephone. Most patients were insured by Medicaid (73%) and current eye rubbers (82%). Few parents reported good or excellent keratoconus literacy now (32%) or at the time of diagnosis (18%). Parents with a high-school education, limited English proficiency, lower income level, and Medicaid insurance tended to have lower keratoconus literacy, though this was not statistically significant. Parental keratoconus literacy was not correlated with disease severity. High-school education, limited English proficiency, lower income level, and Medicaid insurance were correlated with steeper keratometry readings, which was statistically significant for high-school education. In-depth interviews revealed parents felt unconfident with eye health in general and perceived a personal responsibility for learning more. Conclusion: This is the first study exploring keratoconus literacy from a socioeconomic perspective, demonstrating lower literacy among socioeconomically marginalized parents and a tendency toward more severe disease in their children.

Trends in Corneal Topography and Tomography Imaging for Keratoconus Management.

Purpose: To describe trends in the use of corneal topography and tomography for the management of keratoconus patients at a single academic institution and to identify how these trends may be associated with different procedural interventions. Patients and Methods: In this retrospective cohort study, keratoconus patients treated from 2012 to 2019 were identified. The electronic health record was reviewed for the presence of corneal topography or tomography imaging completed within seven days of the first visit and the highest level of intervention at the first and most recent visit. Patients were grouped as pediatric (<18 years) or adult (≥18 years). Chi-square tests and linear regressions were used to evaluate trends and to determine which factors were predictive for receiving corneal collagen cross-linking (CXL) versus other surgical interventions (intrastromal corneal ring segments, lamellar keratoplasty, or penetrating keratoplasty) by the most recent visit. Results: A total of 873 keratoconus patients met inclusion criteria. The use of corneal topography at the first visit remained relatively consistent from 2012 to 2019, while corneal tomography usage at the first visit increased from 3.9% in 2015, when corneal tomography was introduced, to 52.8% in 2019. Each year was associated with an 11.2% ± 1.9% increase in the use of corneal tomography at the first visit in pediatric patients and 6.7% ± 0.5% in adult patients. Use of corneal tomography at the first visit was a significant predictor for receiving CXL procedures (P < 0.001) and a negative predictor for requiring other surgical interventions (P = 0.032) when controlling for the year of the first visit. Conclusion: Obtaining corneal tomography at the first visit has become the standard of care in keratoconus, especially for pediatric patients. Moreover, the increase in corneal tomography imaging has coincided with an increase in CXL procedures and decrease in other surgical interventions.

Patching for Amblyopia: A Novel Occlusion Dose Monitor for Glasses Wearers to Track Adherence.

PURPOSE: To evaluate the acceptability of a novel occlusion dose monitor (ODM) for glasses wearers with amblyopia. The novel ODM consists of a patch worn over the glasses, a logger affixed to the glasses frame, and a system that processes the logged data for interpretation by an algorithm. METHODS: In this pilot study, pediatric amblyopes (ages 2-8) were recruited for a cosmesis test of a sham logger for a 1-week period. Patients were then recruited to test a functional ODM for a 2-week period and their parents were asked to document patch wear in a diary. Feedback was solicited using a modified Pediatric Eye Disease Investigator Group (PEDIG) Amblyopia Treatment Index (ATI). RESULTS: Five children tested the sham logger and eight children tested the functional ODM. Early feedback recommended esthetic modifications including the use of colored shrink wrap to affix the logger to the glasses' frame. The modified patch did not reduce patients' willingness to wear the patch as compared to a standard patch. ODM-recorded wear correlated with diary-recorded wear. The specific timestamps for wear were identical for patients with good ODM-diary concordance. CONCLUSIONS: The novel ODM is acceptable for parents and children and correlates with diary records of patch wear.

In the Mind of the Ophthalmology Residency Applicant: Deciding Where to Apply, Interview, and Rank.

Objective This article characterizes the resources used by ophthalmology residency applicants when deciding where to apply, interview, and rank. Design Cross-sectional, online survey. Participants All applicants to the University of California-San Francisco ophthalmology residency program during the 2019 to 2020 and 2020 to 2021 application cycles. Methods A secure, anonymous, 19-item post-match questionnaire was distributed to participants inquiring about demographic information, match outcomes, and resources used to learn and make decisions about residency programs. Results were analyzed using qualitative and quantitative methods. Main Outcome Measures Qualitative ranking of resources used to decide where to apply, interview, and rank. Results One hundred thirty-six of 870 solicited applicants responded to the questionnaire, for a response rate of 15.6%. Digital platforms were ranked as more important resources than people (i.e., faculty, career advisors, residents, and program directors) when applicants were deciding where to apply and interview. Digital platforms became far less important when applicants were formulating their rank lists, at which time the program's academic reputation, perceived happiness of residents and faculty, interview experience, and geographic location were more important. When learning about residency programs, 100% of respondents engaged with program Web sites, and the majority engaged with program emails ( n =88 [85.4%]), Doximity ( n =82 [79.6%]), Reddit ( n =64 [62.1%]), Instagram ( n =59 [57.3%]), the FREIDA residency program database ( n =55 [53.4%]), and YouTube ( n =53 [51.5%]). All 13 digital platforms included in the survey were utilized by at least 25% of respondents, largely passively (i.e., reading rather than producing content). Respondents indicated that the most important topics to include on program Web sites were the number of residents accepted per year, current resident profiles, and resident alumni job/fellowship placement. Conclusion Applicants engage heavily with digital media in deciding where to apply and interview but rely heavily on their personal experiences with the program in deciding where to rank. Ophthalmology programs may facilitate recruitment of applicants by optimizing their digital media platforms.

COCCIDIOIDAL ENDOPHTHALMITIS: EXCELLENT RECOVERY OF VISION WITH AGGRESSIVE USE OF INTRAVITREAL ANTIFUNGALS AND VITRECTOMY.

PURPOSE: To report a case of Coccidioides immitis endophthalmitis with severe vision loss and a return to excellent vision after aggressive intervention. METHODS: Case report. RESULTS: A 41-year-old man with a history of solid organ transplantation who complained of floaters and decreased vision in the setting of disseminated Coccidioides infection was found to have presumed coccidioidal endophthalmitis with visual acuities of 20/20 in the right eye and 20/200 in the left eye. The patient was managed with intravenous amphotericin B, oral voriconazole, and intravitreal injections of amphotericin B and voriconazole in the left eye every three days. Five weeks after presentation, his visual acuity remained 20/20 in the right eye and improved to 20/40 in the left eye. The patient was transitioned to twice weekly intravitreal injections and oral voriconazole on hospital discharge. One week later, vision in the left eye decreased to 20/500 with worsening vitritis, prompting vitrectomy. Vision in the left eye subsequently improved to 20/30. Five weeks later, the patient developed a macula-on inferior rhegmatogenous retinal detachment in the left eye and underwent a second vitrectomy, with scleral buckle, laser, and gas injection. Vision in the left eye returned to 20/25. In total, the patient received 22 amphotericin B and 17 voriconazole intravitreal injections in the left eye with two vitrectomies. Vision in the right eye remained 20/20 throughout his treatment course. At four months after presentation, the patient remained on oral voriconazole with no evidence of active intraocular infection on examination. CONCLUSION: Aggressive medical and surgical management can be successful in ocular conservation and restoration of vision in coccidioidal endophthalmitis. Very mild disease may be conservatively monitored and managed with systemic antifungal therapy alone. In severe disease, early diagnosis and prompt and aggressive use of systemic and intravitreal antifungals may spare panophthalmitis and preserve vision.

Corneal Toxicity of Intravitreal Methotrexate Used for the Treatment of Proliferative Vitreoretinopathy in Silicone Oil-Filled Eyes: A Case Series.

PURPOSE: The purpose of this study was to evaluate the corneal toxicity of intravitreal methotrexate used for the prevention of proliferative vitreoretinopathy (PVR). METHODS: In this retrospective case series, eyes with recurrent retinal detachment secondary to PVR were treated with intravitreal injections of 400 µg methotrexate at an average frequency of every 7 days after vitrectomy with silicone oil tamponade. Corneas were examined for corneal epitheliopathy by slit-lamp biomicroscopy before each injection. RESULTS: Thirteen eyes of 12 patients were reviewed. All had a history of recurrent retinal detachment secondary to PVR treated with vitrectomy and silicone oil. The median age was 35 years (range: 9-83). Four patients (33%) were female. The median follow-up duration was 8 weeks (range: 5-10). The median BCVA (logMAR notation) was 2.00 preoperatively, 2.00 at 1 month postoperatively, and 2.00 at the most recent follow-up (P = 0.969). Ten eyes (77%) were pseudophakic. Nine eyes (69%) had a preexisting ocular comorbidity. The median number of injections was 8 (range: 5-10). The median interval time between each injection was 7.0 days (range: 5.8-10.5), and the median follow-up period beyond last injection was 16 weeks (range: 8-28). Two eyes (15.4%) developed mild corneal epitheliopathy during the course of the treatment. CONCLUSIONS: Most eyes in this small series tolerated methotrexate injections without corneal toxicity. In eyes that developed epitheliopathy, the findings were mild and not treatment-limiting.

Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients.

Background: In contrast to physician implicit bias toward patients, bias and microaggressions from patients toward physicians have received comparatively less attention. Materials and Methods: We captured physician experiences of gendered microaggressions from patients by conducting a mixed-methods survey-based study of physicians at a single academic health care institution in May 2019. A quantitative portion assessed the frequency of gendered microaggressions (microaggression experiences [ME] score) and the association with measures of perceived impacts (job satisfaction, burnout, perceived career impacts, behavioral modifications). A one-tailed Wilcoxon rank sum test compared distributional frequencies of microaggressions by gender, and by gender and race. Chi-square tests measured the associations between gendered microaggressions and perceived impacts. Welch two-sample t-tests assessed differences in ME scores by rank and specialty. Linear regression assessed the association of ME scores and job satisfaction/burnout. A qualitative portion solicited anecdotal experiences, analyzed by inductive thematic analysis. Results: There were 297 completed surveys (response rate 27%). Female physicians experienced a significantly higher frequency of gendered microaggressions (p < 0.001) compared with male physicians. Microaggressions were significantly associated with job satisfaction (chi-square 6.83, p = 0.009), burnout (chi-square 8.76, p = 0.003), perceived career impacts (chi-square 18.67, p < 0.001), and behavioral modifications (chi-square 19.96, p < 0.001). Trainees experienced more microaggressions (p = 0.009) and burnout (p = 0.009) than faculty. Higher ME scores predicted statistically significant increases in burnout (p < 0.0001) and reduced job satisfaction (p = 0.02). Twelve microaggressions themes emerged from the qualitative responses, including role questioning and assumption of inexperience. The frequency of microaggressions did not vary significantly by race; however, qualitative responses described race as a factor. Conclusions: Physicians experience gendered microaggressions from patients, which may influence job satisfaction, burnout, career perceptions, and behavior. Future research may explore the multidirectionality of microaggressions and tools for responding at the individual and institutional level.