Identification and Prediction of Clinical Phenotypes in Hospitalized Patients With COVID-19: Machine Learning From Medical Records.

BACKGROUND: There is significant heterogeneity in disease progression among hospitalized patients with COVID-19. The pathogenesis of SARS-CoV-2 infection is attributed to a complex interplay between virus and host immune response that in some patients unpredictably and rapidly leads to "hyperinflammation" associated with increased risk of mortality. The early identification of patients at risk of progression to hyperinflammation may help inform timely therapeutic decisions and lead to improved outcomes. OBJECTIVE: The primary objective of this study was to use machine learning to reproducibly identify specific risk-stratifying clinical phenotypes across hospitalized patients with COVID-19 and compare treatment response characteristics and outcomes. A secondary objective was to derive a predictive phenotype classification model using routinely available early encounter data that may be useful in informing optimal COVID-19 bedside clinical management. METHODS: This was a retrospective analysis of electronic health record data of adult patients (N=4379) who were admitted to a Johns Hopkins Health System hospital for COVID-19 treatment from 2020 to 2021. Phenotypes were identified by clustering 38 routine clinical observations recorded during inpatient care. To examine the reproducibility and validity of the derived phenotypes, patient data were randomly divided into 2 cohorts, and clustering analysis was performed independently for each cohort. A predictive phenotype classifier using the gradient-boosting machine method was derived using routine clinical observations recorded during the first 6 hours following admission. RESULTS: A total of 2 phenotypes (designated as phenotype 1 and phenotype 2) were identified in patients admitted for COVID-19 in both the training and validation cohorts with similar distributions of features, correlations with biomarkers, treatments, comorbidities, and outcomes. In both the training and validation cohorts, phenotype-2 patients were older; had elevated markers of inflammation; and were at an increased risk of requiring intensive care unit-level care, developing sepsis, and mortality compared with phenotype-1 patients. The gradient-boosting machine phenotype prediction model yielded an area under the curve of 0.89 and a positive predictive value of 0.83. CONCLUSIONS: Using machine learning clustering, we identified and internally validated 2 clinical COVID-19 phenotypes with distinct treatment or response characteristics consistent with similar 2-phenotype models derived from other hospitalized populations with COVID-19, supporting the reliability and generalizability of these findings. COVID-19 phenotypes can be accurately identified using machine learning models based on readily available early encounter clinical data. A phenotype prediction model based on early encounter data may be clinically useful for timely bedside risk stratification and treatment personalization.

Outcomes and Complications in Patients With Hypermobile Ehlers-Danlos Syndrome Who Have Undergone Laser In Situ Keratomileusis Surgery.

PURPOSE: The purpose of this study was to determine the safety and outcomes of myopic laser in situ keratomileusis (LASIK) in patients who were secondarily diagnosed with hypermobile Ehlers-Danlos syndrome (EDS). METHODS: We conducted a case series study on patients with hypermobile EDS who underwent myopic LASIK surgery. Visual acuity, manifest refraction, a full dilated eye examination, biometry measurements, and Scheimpflug imaging were performed in the Wilmer outpatient clinic. RESULTS: There were 24 eyes of 12 patients included in this study. All participants were White women with a mean age of 46.58 years (SD 8.91 years). Participants were seen at an average of 13.83 years (SD 4.3 years, range 6-21 years) after undergoing LASIK. None of the patients in the series had a diagnosis of hypermobile EDS before LASIK surgery. Overall, 92% of patients were happy they got LASIK. The uncorrected distance visual acuity was 20/20 or better in 68% of eyes, and the best-corrected visual acuity was 20/20 or better in 92% of eyes. Manifest refraction was within 1 diopter of plano in 79% of patients. Dry eye symptoms were present in 83% of patients, and 46% of eyes had either punctate epithelial erosions or decreased tear break-up time. One of the 12 patients developed corneal ectasia in both eyes. CONCLUSIONS: Patients with hypermobile EDS are generally satisfied with myopic LASIK correction, with good visual acuity outcomes and low rates of myopic regression. However, the risk of corneal ectasia may prevent laser vision correction from being a viable treatment option in these patients. Further studies are needed to make a definitive recommendation.

Ehlers-Danlos syndromes and their manifestations in the visual system.

Ehlers-Danlos syndrome (EDS) is a rare, genetically variable, heterogenous group of (currently recognized) thirteen connective tissue disorders characterized by skin hyperextensibility, tissue fragility, and generalized joint hypermobility. In addition to these commonly recognized phenotypes, recent studies have notably highlighted variable ophthalmic features in EDS. In this review, we comprehensively gather and discuss the ocular manifestations of EDS and its thirteen subtypes in the clinical setting.

Post-traumatic headaches and vision: A review.

BACKGROUND: Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. OBJECTIVES: To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. METHODS: We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. RESULTS: Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. CONCLUSION: Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.

The impact of COVID-19 on ophthalmology resident surgical experience: a retrospective cross-sectional analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to in-office and surgical procedures in the field of ophthalmology. The magnitude of the impact of the pandemic on surgical training among ophthalmology residents is not known. This study aims to quantify changes in average case logs among United States (U.S.) ophthalmology residency graduates prior to and during the COVID-19 pandemic. METHODS: Retrospective, cross-sectional analysis of aggregate, national data on case logs of U.S. ophthalmology residency graduates from 2012 to 2020. The yearly percent change in the average number of procedures performed in the Accreditation Council for Graduate Medical Education (ACGME) ophthalmology resident case logs were analyzed using linear regression on log-transformed dependent variables. The average percent change from 2019 to 2020 was compared to the average yearly percent change from 2012 to 2019 for procedures performed as the primary surgeon, and primary surgeon and surgical assistant (S + A), as well as procedures for which there are ACGME minimum graduating numbers. RESULTS: Across all procedures and roles, average case logs in 2020 were lower than the averages in 2019. While average total cases logged as primary surgeon increased yearly by 3.2% (95% CI: 2.7, 3.8%, p < 0.001) from 2012 to 2019, total primary surgeon case logs decreased by 11.2% from 2019 to 2020. Cataract (-22.0%) and keratorefractive (-21.1%) surgery experienced the greatest percent decrease in average primary surgeon cases logged from 2019 to 2020. Average total cases logged as S + A experienced an average yearly increase by 1.2% (95% CI: 0.9,1.6%, p < 0.001) prior to 2020, but decreased by 9.6% from 2019 to 2020. For ACGME minimum requirements, similar changes were observed. Specifically, the average case logs in YAG, SLT, filtering (glaucoma), and intravitreal injections had been increasing significantly prior to 2020 (p < 0.05 for all) but decreased in 2020. CONCLUSIONS: These findings demonstrate the vulnerability of ophthalmology residency programs to a significant interruption in surgical volume. There is a critical need for development of competency-based, rather than volume-based, requirements to evaluate readiness for independent practice.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement.

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.

Objective Resident Characteristics Associated with Performance on the Ophthalmic Knowledge Assessment Program Examination.

Background To determine objective resident characteristics that correlate with Ophthalmic Knowledge Assessment Program (OKAP) performance, as well as to correlate OKAP performance with Accreditation Council for Graduate Medical Education (ACGME) milestone assessments, written qualifying examination (WQE) scores, and oral board pass rates. Methods Review of administrative records at an ACGME-accredited ophthalmology residency training program at an urban, tertiary academic medical center. Results The study included data from a total of 50 resident physicians who completed training from 2012 to 2018. Mean (standard deviation) OKAP percentile performance was 60.90 (27.51), 60.46 (28.12), and 60.55 (27.43) for Years 1, 2, and 3 examinations, respectively. There were no statistically significant differences based on sex, marital status, having children, MD/PhD degree, other additional degree, number of publications, number of first author publications, or grades on medical school medicine and surgery rotations. OKAP percentile scores were significantly associated with United States Medical Licensing Examination (USMLE) Step 1 scores (linear regression coefficient 0.88 [0.54-1.18], p = 0.008). Finally, continuous OKAP scores were significantly correlated with WQE ( r s = 0.292, p = 0.049) and oral board ( r s = 0.49, p = 0.001) scores. Conclusion Higher OKAP performance is correlated with passage of both WQE and oral board examinations during the first attempt. USMLE Step 1 score is the preresidency academic factor with the strongest association with success on the OKAP examination. Programs can utilize this information to identify those who may benefit from additional OKAP, WQE, and oral board preparation assistance.

Teleophthalmology in the Era of COVID-19: Characteristics of Early Adopters at a Large Academic Institution.

Introduction: COVID-19 led to rapid policy changes to expand telemedicine adoption. We examined rates of early telemedicine adoption among surgical departments at a large academic institution and compared provider characteristics associated with teleophthalmology. Methods: With data from departmental and electronic medical records across surgical departments at Johns Hopkins Medicine, we performed a retrospective analysis using the Fisher test and binomial logistic regression. Results: Telemedicine adoption in ophthalmology was disproportionately lower than other surgical departments. Providers who were female [odds ratio, OR, 2.42 (95% confidence interval, CI, 1.03-5.67)], clinical assistants, clinical associates, or instructors [OR 12.5 (95% CI 2.63-59.47)], associate professors [OR 4.38 (95% CI 1.42-13.52)], practiced for ≥36 years [OR 0.20 (95% CI 0.06-0.66)], cornea [OR 0.13 (95% CI 0.04-0.47)], glaucoma [OR 0.18 (95% CI 0.04-0.93)] or retina [OR 0.04 (95% CI 0.01-0.17)] specialists, or had a MD/MBBCh/MBBS [OR 0.30 (95% CI 0.10-0.94)] or second degree [OR 0.28 (95% CI 0.08-0.99)] were significantly more or less likely to adopt. When adjusted, cornea [adjusted OR 0.10 (95% CI 0.02-0.57)] or retina [adjusted OR 0.01 (95% CI 0.002-0.12)] specialists or providers who practiced for 12-18 years [adjusted OR 0.22 (95% CI 0.05-0.91)] or ≥36 years [adjusted OR 0.13 (95% CI 0.03-0.68)] were significantly more or less likely to adopt. Discussion: Subspecialty among other provider characteristics influences the likelihood of teleophthalmology adoption. As the pandemic continues, strategies to reduce adoption barriers are needed to ensure the provision of health care services.

Parental Leave Policy for Ophthalmology Residents: Results of a Nationwide Cross-Sectional Study of Program Directors.

BACKGROUND: Many residents become parents during residency and the adequacy of parental leave is integrally related to resident wellness. OBJECTIVE: To understand current parental leave policies in ophthalmology residency programs and program director perceptions of the impact of parental leave on trainees. DESIGN: Cross-sectional study. SETTING: Multicenter among all U.S. ophthalmology residency programs. PARTICIPANTS: Ophthalmology residency program directors during the 2017 to 2018 academic year. RESULTS: Sixty-eight percent (82/120) program directors participated in this study. The majority of programs had written maternity leave policies (89%) and partner leave policies (72%). The typical duration of maternity leave taken ranged from 4 to 6 weeks while typical partner leave duration taken ranged from 1 day to 2 weeks. Residents who take leave may need to extend training at 72% of programs. Program directors perceived that parental leave negatively impacts resident scholarly activities and surgical skills and volume. Male program directors, relative to female program directors, perceived that becoming a childbearing parent negatively impacts resident dedication to patient care. Program directors raised concerns including local support and policy, extension of residency, impact on residents, impact on programs, consistency and fairness, and desire for national policy change. CONCLUSIONS: Parental leave practices vary significantly among ophthalmology training programs with residents typically taking less leave than permitted. Program directors are challenged to accommodate parental leave while balancing resident training and wellness for all trainees in their program.

The Relationship Between Severe Visual Acuity Loss, Traumatic Brain Injuries, and Ocular Injuries in American Service Members From 2001 to 2015.

INTRODUCTION: Although traumatic brain injury (TBI) is known to cause many visual problems, the correlation between the extent of severe visual acuity loss (SVAL) and severity of TBI has not been widely explored. In this retrospective analysis, combined information from Department of Defense (DoD)/Veterans Affairs ocular injury and TBI repositories were used to evaluate the relationship between chronic SVAL, TBI, ocular injuries, and associated ocular sequelae for U.S. service members serving between 2001 and 2015. MATERIALS AND METHODS: The Defense and Veterans Eye Injury and Vision Registry (DVEIVR) is an initiative led by the DoD and Veterans Affairs that consists of clinical and related data for service members serving in theater since 2001. The Defense and Veterans Brain Injury Center (DVBIC) is the DoD's office for tracking TBI data in the military and maintains data on active-duty service members with a TBI diagnosis since 2000. Longitudinal data from these 2 resources for encounters between February 2001 and October 2015 were analyzed to understand the relation between SVAL, and TBI while adjusting for ocular covariates such as open globe injury (OGI), disorders of the anterior segment and disorders of the posterior segment in a logistic regression model. TBI cases in DVEIVR were identified using DVBIC data and classified according to International Statistical Classification of Diseases criteria established by DVBIC. Head trauma and other open head wounds (OOHW) were also included. SVAL cases in DVEIVR were identified using both International Statistical Classification of Diseases criteria for blindness and low vision as well as visual acuity test data recorded in DVEIVR. RESULTS: Data for a total of 25,193 unique patients with 88,996 encounters were recorded in DVEIVR from February, 2001 to November, 2015. Of these, 7,217 TBI and 1,367 low vision cases were identified, with 638 patients experiencing both. In a full logistic model, neither UTBI nor differentiated TBI (DTBI, ie, mild, moderate, severe, penetrating, or unclassified) were significant risk factors for SVAL although ocular injuries (disorders of the anterior segment, disorders of the posterior segment, and OGI) and OOHW were significant. CONCLUSION: Any direct injury to the eye or head risks SVAL but the location and severity will modify that risk. After adjusting for OGIs, OOHW and their sequelae, TBI was found to not be a significant risk factor for SVAL in patients recorded in DVEIVR. Further research is needed to explore whether TBI is associated with more moderate levels of vision acuity loss.

Contact Lens Wear, Corneal Complications, and U.S. Service Member Readiness.

INTRODUCTION: Ulcerative keratitis (UK), or corneal ulcer, is a sight-threatening and readiness-lowering medical condition that begins with a corneal infiltrative event (CIE). Contact lens (CL) wear poses a particular risk for a CIE and therefore is restricted for most active duty service members (SMs). In this study, we explored a large Department of Defense/Veterans Affairs (DoD/VA) database to estimate the prevalence of UK and CIE and their association with CL wear. MATERIALS AND METHODS: The DoD/VA Defense and Veterans Eye Injury Vision Registry, an initiative of the DoD/VA Vision Center of Excellence, was explored using natural language processing software to search for words and diagnostic codes that might identify cornea injuries and CL wear. The effect of UK and CIE on readiness was explored by evaluating the duration between the first and final visits noted in the database. RESULTS: A total of 213 UK cases were identified among the 27,402 SMs for whom data were recorded in Defense and Veterans Eye Injury Vision Registry. The odds ratios of UK and CIE being associated with CL wear were 13.34 and 2.20, respectively. A less specific code (superficial corneal injury) was found to be the most commonly used diagnosis in the database, and the odds ratio of CL wearers having that diagnosis was 2.25. CL-wearing patients with corneal disease also required more clinic encounters than those who did not wear CLs. CONCLUSIONS: This study supports the current restriction on CL wear among nonpilot active duty SMs and quantifies the significantly enhanced risk of developing corneal ulcers posed by that habit.

The Biomechanics of Indirect Traumatic Optic Neuropathy Using a Computational Head Model With a Biofidelic Orbit.

Indirect traumatic optic neuropathy (ITON) is an injury to the optic nerve due to head trauma and usually results in partial or complete loss of vision. In order to advance a mechanistic understanding of the injury to the optic nerve, we developed a head model with a biofidelic orbit. Head impacts were simulated under controlled conditions of impactor velocity. The locations of impact were varied to include frontal, lateral, and posterior parts of the head. Impact studies were conducted using two types of impactors that differed in their rigidity relative to the skull. The simulated results from both the impactors suggest that forehead impacts are those to which the optic nerve is most vulnerable. The mode and location of optic nerve injury is significantly different between the impacting conditions. Simulated results using a relatively rigid impactor (metal cylinder) suggest optic nerve injury initiates at the location of the intracranial end of the optic canal and spreads to the regions of the optic nerve in the vicinity of the optic canal. In this case, the deformation of the skull at the optic canal, resulting in deformation of the optic nerve, was the primary mode of injury. On the other hand, simulated results using a relatively compliant impactor (soccer ball) suggest that primary mode of injury comes from the brain tugging upon the optic nerve (from where it is affixed to the intracranial end of the optic canal) during coup countercoup motion of the brain. This study represents the first published effort to employ a biofidelic simulation of the full length of the optic nerve in which the orbit is integrated within the whole head.

Survey of Ehlers-Danlos Patients' ophthalmic surgery experiences.

BACKGROUND: Ehlers-Danlos Syndrome (EDS) is a rare disease affecting approximately 1 in 5,000 people. Although ophthalmic conditions associated with EDS have been described, little data exist concerning ophthalmic surgical outcomes experienced by EDS patients. METHODS: Patients with EDS were surveyed via the EDS Society and asked about their ophthalmic surgical experiences including procedure, complications, and the timing with respect to receiving the EDS diagnosis. Complications were confirmed as such by subspecialists. RESULTS: Of 579 respondents, 467 reported confirmed EDS, and 112 of those had an ophthalmic procedure, including refractive surgery, cataract/lens surgery, retinal surgery, strabismus surgery, oculoplastic surgery, corneal surgery, and laser surgery for glaucoma. The rate of confirmed complications was: 23%-refractive, 33%-lens/cataract, 33%-retina, 59%-strabismus, 23%- oculoplastics, 0%-cornea, and 25%-glaucoma laser. In addition, 76% of patients underwent surgery prior to the EDS diagnosis. CONCLUSIONS: Patients with EDS may have elevated risk of postoperative ophthalmic surgical complications. It would seem reasonable to systemically and prospectively explore how patients with EDS respond to ophthalmic surgery. Furthermore, it would seem circumspect to ask surgical candidates patients about whether they carry a diagnosis of EDS or have signs and symptoms of EDS prior to surgery.

Underlying Ehlers-Danlos syndrome discovered during neuro-ophthalmic evaluation of concussion patients: a case series.

BACKGROUND: The Ehlers-Danlos syndromes are a heterogenous group of diseases that cause connective tissue defects. At present, there are no published reports focusing upon the neuro-ophthalmic symptoms that might occur in EDS patients after mild traumatic brain injury. The demographics and clinical course of seven patients with subclinical EDS and mild traumatic brain injury are presented. CASE PRESENTATION: This series describes patients with Ehlers Danlos Syndrome whose diagnosis was discovered in a neuro-ophthalmic clinic for brain injury. Patient demographics and neuro-ophthalmological symptoms are presented. CONCLUSIONS: Patients with subclinical EDS and brain injury may experience a slower, less complete recovery course. Heightened awareness of undiagnosed or underlying Ehlers Danlos Syndrome is important for patients and providers.

Resident and program characteristics that impact performance on the Ophthalmic Knowledge Assessment Program (OKAP).

BACKGROUND: To determine which resident and program characteristics correlate with ophthalmic knowledge, as assessed by resident Ophthalmic Knowledge Assessment Program (OKAP) performance. METHODS: An online survey was sent in June 2017 to all US ophthalmology residents who took the OKAP in April 2017. RESULTS: The survey response rate was 13.8% (192/1387 residents). The mean respondent age was 30.4 years, and 57.3% were male. The mean [SD] self-reported 2017 OKAP percentile was 61.9 [26.7]. OKAP performance was found to have a significant positive correlation with greater number of hours spent/week studying for the OKAPs (p = 0.007), with use of online question banks (p < 0.001), with review sessions and/or lectures arranged by residency programs (p < 0.001), and with OKAP-specific didactics (p = 0.002). On multivariable analysis, factors most predictive of residents scoring ≥75th percentile were, higher step 1 scores (OR = 2.48, [95% CI: 1.68-3.64, p < 0.001]), presence of incentives (OR = 2.75, [95% CI: 1.16-6.56, p = 0.022]), greater number of hours/week spent studying (OR = 1.09, [95% CI:1.01-1.17, p = 0.026]) and fewer hours spent in research 3 months prior to examination (OR = 1.08, [95% CI: 1.01-1.15, p = 0.020]. Lastly, residents less likely to depend on group study sessions as a learning method tended to score higher (OR = 3.40, [95% CI: 1.16-9.94, p = 0.026]). CONCLUSIONS: Programs wishing to improve resident OKAP scores might consider offering incentives, providing effective access to learning content e.g. online question banks, and adjusting the curriculum to highlight OKAP material. Step 1 scores may help educators identify residents who might be at risk of not performing as well on the OKAP.

Supervision and autonomy of ophthalmology residents in the outpatient clinic in the United States II: a survey of senior residents.

BACKGROUND: A balance between autonomy and supervision can be difficult to obtain in medical education. In this study, we sought to determine whether the presence and level of supervision of ophthalmology resident outpatient clinic correlates with metrics of resident success, professionalism and stress. METHODS: A survey was emailed to all US ophthalmology program directors requesting it be forwarded to PGY4 residents. Questions included whether their program provided a resident-hosted outpatient clinic, and if so, whether residents were mandated to discuss every patient with faculty. Residents were assigned to three categories based on this question (0: no clinic, 1: mandated faculty input, 2: discretionary faculty input). Success metrics included numbers of manuscripts submitted, OKAP scores and success in obtaining fellowships. Professionalism metrics included rating comfort obtaining informed consent, breaking bad news, managing time in clinic, and confidence in providing care in various settings. Residents affirming participation in a continuity clinic also provided perceptions of the level of supervision and how the clinic affected stress. RESULTS: Category 1 residents perceived somewhat too much supervision, while category 2 residents felt that they had somewhat insufficient supervision. The majority of residents in either category did not feel that the continuity clinic affected their overall stress, although those who reported a change in stress usually indicated that the presence of the clinic increased stress. There were no other statistically significant differences between the responses from any category. CONCLUSIONS: The presence of a resident-hosted continuity clinic neither adds nor detracts from the success or sense of professionalism of ophthalmology residents. However, when such a clinic is present, the degree of supervision appears to correlate inversely with resident perception of autonomy. These results suggest that the decision of a training program to offer a clinic hosted by residents offering comprehensive continuity care can be informed primarily by faculty and trainee philosophy and personal preferences without comprising education quality, clinical efficiency, residents' perception of stress or their success in fellowship matching.

Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department.

Importance: Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit. Objective: To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care. Design, Setting, and Participants: This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017. Main Outcomes and Measures: The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated. Results: The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges. Conclusions and Relevance: Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.

Cost of Military Eye Injury and Vision Impairment Related to Traumatic Brain Injury: 2001-2017.

INTRODUCTION: Annual incidence of eye injury among members of the US armed services is high and can cause vision impairment and blindness. Traumatic brain injury is also associated with visual function. An estimate of the cost of treatment, benefits for those who are disabled, productivity loss for those with reduced vision function, and the cost of replacing and retraining others to take the responsibility of those who are discharged from the military will provide a benchmark to which to compare the cost of new methods to prevent, diagnose, mitigate, treat, and rehabilitate vision loss after injury. MATERIALS AND METHODS: The modeling exercise used a combination of data from military websites, results previously published in the literature, and from other government websites. Data were combined to estimate the number of superficial injuries, the number of injuries with a high risk of blindness, the cost of medical care, the cost of disability benefits, and the cost of potential lost productivity. RESULTS: Over the time period in question, the average annual incidence of eye injury was 15,681 with 304 hospitalized and 298 at high risk of blindness. There were 4,394 annual TBI cases without injury to the eye but with visual impairment. The total cost of treatment, benefits, and potential lost productivity is $2.4 billion annually; $1.9 billion is associated with TBI. $11.7 million is associated with replacing and retraining members of the military. CONCLUSIONS: The cost of eye injury and vision dysfunction in the military is substantial. The cost of potential productivity loss associated with TBI makes up the largest proportion of total costs. Developing new standards to enhance eye safety and limit TBI could be cost-effective. Cost analyses such as this study should prove helpful in determining the economic return on investments to prevent, mitigate, treat, and rehabilitate visual system injury.