Intravenous cyclophosphamide therapy for patients with severe ocular inflammatory diseases who failed other immunomodulatory therapies.

BACKGROUND: Ocular inflammatory diseases, including scleritis and uveitis, have been widely treated with immunomodulatory therapies (IMTs) as a steroid-sparing approach. Such strategy includes conventional therapies (antimetabolites, alkylating agents, and calcineurin inhibitors) as well as biologic agents like adalimumab, infliximab, rituximab, and tocilizumab. Cyclophosphamide (CP) is an alkylating agent and mainly inhibits the functioning of both T and B cells. Though known to have potential adverse events, including bone marrow suppression, hemorrhagic cystitis, and sterility, CP has been shown to be efficacious, especially in recalcitrant cases and when used intravenous (IV) for a limited period. MAIN FINDINGS: We conducted a retrospective case-series to assess the safety and efficacy of CP therapy for patients with severe ocular inflammatory diseases who failed other IMTs. Medical records of 1295 patients who presented to the Uveitis Clinic at the Byers Eye Institute at Stanford between 2017 and 2022 were reviewed. Seven patients (10 eyes) who received CP therapy for ocular inflammatory diseases with at least one year of follow-up were included. The mean age of the patients (4 males, 3 females) was 61.6 ± 14.9 (43.0-89.0) years. Clinical diagnoses included necrotizing scleritis (5 eyes), peripheral ulcerative keratitis (2 eyes), orbital pseudotumor (1 eye), HLA-B27 associated panuveitis and retinal vasculitis (2 eyes). Ocular disease was idiopathic in 3 patients, and was associated with rheumatoid arthritis, IgG-4 sclerosing disease, dermatomyositis, and ankylosing spondylitis in 1 patient each. All the patients had history of previous IMT use including methotrexate (5), mycophenolate mofetil (3), azathioprine (1), tacrolimus (1), adalimumab (2), infliximab (4), and rituximab (1). The mean follow-up time was 34.4 ± 11.0 (13-45) months, and mean duration of CP therapy was 11.9 ± 8.8 (5-28) months. Remission was achieved in 5 patients (71.4%). Four patients (57.1%) experienced transient leukopenia (white blood cell count < 4000/mL). SHORT CONCLUSION: CP therapy can be considered a potentially effective and relatively safe therapeutic option for patients with severe ocular inflammatory diseases who failed other IMTs including biologics (TNFa and CD20 inhibitors).

Association of Ocular Manifestations of Marfan Syndrome With Cardiovascular Complications.

PURPOSE: To evaluate associations between ocular manifestations of Marfan syndrome and cardiovascular complications. DESIGN: Retrospective cohort study. METHODS: The TriNetX Analytics platform, a federated health research network of aggregated deidentified electronic health record data of more than 119 million patients, was used to identify patients diagnosed with Marfan syndrome. Univariate logistic regression models were used to evaluate the association of ocular manifestations of Marfan syndrome (such as retinal tears/detachment, lens dislocation, and myopia), with cardiovascular comorbidities. Additional sensitivity analyses were performed using propensity matching. Odds ratios and 95% CIs were calculated for incidence of cardiovascular comorbidities (including aortic dissection, valvular disease, and arrhythmias) following diagnosis of Marfan syndrome. RESULTS: A total of 19,105 patients were identified who were diagnosed with Marfan disease without ocular manifestations, and an additional 3887 Marfan patients with ocular comorbidities. Patients who were diagnosed with ocular disease included 883 with ectopic lens, 417 with retinal tear or detachment, 683 with aphakia, 534 with pseudophakia, and 2465 with myopia. Patients with any ocular manifestations of Marfan were significantly more likely to be diagnosed with all cardiovascular comorbidities modeled including aortic aneurysm and dissection (OR 2.035; P < .0001), mitral valve prolapse (OR 2.725; P < .0001), tricuspid valve disorders (OR 2.142; P < .0001), cardiac arrhythmias (OR 1.836; P < .0001), and all cardiovascular outcomes combined (OR 2.194; P < .0001). CONCLUSIONS: In a large and diverse cohort of patients with Marfan syndrome, ocular manifestations of the disorder appear strongly associated with cardiovascular comorbidities.

Reporting Requirements, Confidentiality, and Legal Immunity for Physicians Who Report Medically Impaired Drivers.

Importance: Physicians play an important role in assessing patients' ability to drive. There is a dearth of peer-reviewed information on policies regarding physician reporting of medically impaired drivers. Objective: To investigate state reporting requirements and the availability of confidentiality and legal immunity for physicians who report medically impaired drivers. Design, Setting, and Participants: This cross-sectional study was conducted from November 1 to 30, 2022, in 3 rounds. First, all 50 US states' Department of Motor Vehicle (DMV) websites were systematically reviewed. Second, DMV staff from each state were surveyed via telephone. Third, each state's legal codes for driver licensing were reviewed. Main Outcomes and Measures: Outcome measures included the percentage of states with mandatory and voluntary reporting policies, reporting instructions on DMV websites, anonymous reporting options, and legal immunity for reporting physicians, in addition to characteristics of states' mandatory reporting policies (ie, types of medical conditions that require reporting) and policies surrounding the confidentiality of reports. The data were analyzed using descriptive statistics. Results: One-third of state DMV websites (17 [34%]) lacked instructions regarding physician reporting. Six states had mandatory reporting requirements; 4 of these states only required reporting of conditions characterized by lapses of consciousness. Only 3 states (6%) accepted anonymous reports, and 7 states (14%) deemed physician reports of medically impaired drivers confidential without exception. Nearly one-third of states (15 [30%]) deemed reports by physicians confidential, with the exception that reported drivers could find out who reported them if they asked for a copy of the reporting form. Most states (37 [74%]) had statutes that protected physicians from liability related to reporting medically impaired drivers. Conclusions and Relevance: This cross-sectional study of state reporting requirements regarding medically impaired drivers found many differences in state policies regarding mandatory reporting and the conditions that require reporting. There was also limited availability of online reporting instructions, anonymous reporting options, and legal protections for reporting physicians.

Risk of Retinal Artery Occlusion in Patients with Migraine.

PURPOSE: We sought to determine if migraine is associated with increased risk of retinal artery occlusion (RAO). DESIGN: Retrospective cohort study. METHODS: We reviewed a large insurance claims database for patients with migraine and matched control subjects without migraine between 2007 and 2016. Cox proportional hazard regression models were used to investigate the association between migraine and risk of all RAO, central RAO (CRAO), branch RAO (BRAO), and "other" RAO, which includes transient and partial RAO. Primary outcome measures included the incidence of all RAO, including CRAO, BRAO, and other RAO, after first migraine diagnosis. RESULT: There were 418,965 patients with migraine who met the study criteria and were included in the analysis with the appropriate matched control subjects. Among the 418,965 patients with migraine, 1060 (0.25%) were subsequently diagnosed with RAO, whereas only 335 (0.08%) of the patients without migraine were diagnosed with RAO. The hazard ratio (HR) for incident all RAO in patients with migraine compared with those without migraine was 3.48 (95% confidence interval [CI] 3.07-3.94; P < .0001). This association was consistent across all types of RAO, including CRAO (HR 1.62 [95% CI 1.15-2.28]; P = .004), BRAO (HR 2.09 [95% CI 1.60-2.72]; P < .001), and other types of RAO (HR 4.61 [95% CI 3.94-5.38]; P < .001). Patients with migraine with aura had a higher risk for incident RAO compared with those with migraine without aura (HR 1.58 [95% CI 1.40-1.79]; P < .001). This association was consistent for BRAO (HR 1.43 [95% CI 1.04-1.97]; P < .03) and other types of RAO (HR 1.67 [95% CI 1.45-1.91]; P < .001) but was not statistically significant for CRAO (HR 1.18 [95% CI 0.75-1.87]; P = .475). Significant risk factors for this association included increased age, male sex, acute coronary syndrome, valvular disease, carotid disease, hyperlipidemia, hypertension, retinal vasculitis or inflammation, and systemic lupus erythematosus. CONCLUSIONS: Migraine is associated with increased risk of all types of RAO and migraine with aura is associated with increased risk of RAO compared with migraine without aura.

A Prospective Comparison of Wavefront-Guided LASIK versus Wavefront-Guided PRK After Previous Keratorefractive Surgery.

PURPOSE: To compare the results of retreatment with wavefront-guided LASIK versus wavefront-guided PRK for residual refractive error following previous myopic keratorefractive surgery. METHODS: In this prospective study, 32 eyes of 28 patients after prior myopic keratorefractive surgery underwent retreatment with flap-lift wavefront-guided LASIK (n = 12) or wavefront-guided PRK (n = 20) for residual refractive error. Safety, efficacy, predictability, and wavefront outcomes were evaluated. RESULTS: At last follow-up, both LASIK and PRK retreatment resulted in similar improvement in visual acuity with respective mean ± standard deviation (SD) uncorrected distance visual acuity of -0.07 ± 0.11 logMAR and -0.06 ± 0.13 logMAR (p = 0.87). In the study, 16.7% of LASIK and 33.3% of PRK eyes gained one or more lines of best-corrected distance visual acuity (CDVA), while 16.7% and 9.5% of eyes lost one or more lines of CDVA with LASIK and PRK, respectively. One hundred % of LASIK eyes and 89.5% of PRK eyes were within ± 0.50 diopters of emmetropia. Wavefront analysis demonstrated similar reductions in total RMS error higher-order aberrations (p = 0.84) with no difference in coma, trefoil, or spherical aberration between eyes undergoing LASIK or PRK retreatment. CONCLUSION: Wavefront-guided LASIK and wavefront-guided PRK following previous keratorefractive surgery demonstrate similar safety, efficacy, and predictability with comparable wavefront outcomes.

Refractive Outcomes for Cataract Surgery With Toric Intraocular Lenses at a Veterans Affairs Medical Center.

Background: Refractive outcomes for cataract surgery with toric intraocular lenses (IOLs) are not well described in a teaching hospital setting. This study investigated the refractive outcomes of cataract surgery with toric IOLs at an academic-affiliated Veterans Affairs Medical Center (VAMC) and compared the accuracy of 2 biometric formulae for toric IOL power calculation. Methods: A retrospective chart review of patients who received cataract surgery with toric IOLs from November 2013 to May 2018 was conducted. The Holladay 2 and Barrett toric IOL formulae were used to predict the postoperative refraction for each cataract surgery. The main outcome measures were best-corrected visual acuity (BCVA) and the difference in cylinder between the preoperative and postoperative manifest refractions. The accuracy of each biometric formula was also assessed using 2-tailed t tests of the mean absolute error, and subgroup analyses were conducted for short, medium, and long eyes. Results: Of 325 charts reviewed, 283 patients met the inclusion criteria; 87% (248/283) of these surgeries were performed by resident surgeons. The median postoperative BCVA was 20/20, and 92% of patients had a postoperative BCVA of 20/25 or better. There was no statistically significant difference in mean absolute error between the 2 formulae for the entire axial length range (P = .21), as well as the short (P = .94), medium (P = .49), and long axial length (P = .08) groups. Conclusions: To our knowledge, this is the largest study that compared the performance of the Barrett toric and Holladay 2 formulae and the first that made the comparison in a teaching hospital setting. This study suggests that the 2 formulae have similar refractive outcomes across all axial lengths.

The prevalence of preoperative medical testing and consultation in cataract surgery patients at a teaching hospital.

PURPOSE: To investigate the prevalence of preoperative cataract surgery testing and consultation at a single United States teaching hospital. SETTING: Academic-affiliated Veterans Affairs Medical Center. DESIGN: Retrospective chart review. METHODS: This study included patients who received cataract surgery from 2014 to 2018. For patients with bilateral cataracts, the second surgery was excluded to ensure independent selection. Charlson Comorbidity Index (CCI) scores and heart disease status were recorded. The outcomes of interest were preoperative testing, such as complete blood count, chemistry panel, and echocardiography, and consultation (office visits to non-ophthalmologists) during the period between the date the decision was made to proceed with surgery and the cataract surgery date. RESULTS: For this study 1320 charts were reviewed; 1257 (95.2%) patients met the study criteria. The mean CCI score was 1.7; 42.0% (528/1257) had heart disease. The prevalence of preoperative testing was 0.08% (1/1257). The prevalence of preoperative consultation was 4.2% (53/1257); 86.8% (46/53) of patients received cardiology consultation; 17.0% (9/53) pulmonology; and 15.1% (8/53) primary care. Of the patients who received cardiac consultation, 63.0% (29/46) had heart disease; the remaining had an electrocardiogram abnormality. CONCLUSIONS: There was a low prevalence of preoperative testing and consultation for cataract surgery at this teaching hospital. Further studies using medical record data are needed to assess the current rates and the role of preoperative testing and consultation for cataract surgery patients.

Association of Visual Impairment With Risk of Incident Dementia in a Women's Health Initiative Population.

Importance: Dementia affects a large and growing population of older adults. Although past studies suggest an association between vision and cognitive impairment, there are limited data regarding longitudinal associations of vision with dementia. Objective: To evaluate associations between visual impairment and risk of cognitive impairment. Design, Setting, and Participants: A secondary analysis of a prospective longitudinal cohort study compared the likelihood of incident dementia or mild cognitive impairment (MCI) among women with and without baseline visual impairment using multivariable Cox proportional hazards regression models adjusting for characteristics of participants enrolled in Women's Health Initiative (WHI) ancillary studies. The participants comprised community-dwelling older women (age, 66-84 years) concurrently enrolled in WHI Sight Examination (enrollment 2000-2002) and WHI Memory Study (enrollment 1996-1998, ongoing). The study was conducted from 2000 to the present. Exposures: Objectively measured visual impairment at 3 thresholds (visual acuity worse than 20/40, 20/80, or 20/100) and self-reported visual impairment (determined using composite survey responses). Main Outcomes and Measures: Hazard ratios (HRs) and 95% CIs for incident cognitive impairment after baseline eye examination were determined. Cognitive impairment (probable dementia or MCI) was based on cognitive testing, clinical assessment, and centralized review and adjudication. Models for (1) probable dementia, (2) MCI, and (3) probable dementia or MCI were evaluated. Results: A total of 1061 women (mean [SD] age, 73.8 [3.7] years) were identified; 206 of these women (19.4%) had self-reported visual impairment and 183 women (17.2%) had objective visual impairment. Forty-two women (4.0%) were ultimately classified with probable dementia and 28 women (2.6%) with MCI that did not progress to dementia. Mean post-eye examination follow-up was 3.8 (1.8) years (range, 0-7 years). Women with vs without baseline objective visual impairment were more likely to develop dementia. Greatest risk for dementia was among women with visual acuity of 20/100 or worse at baseline (HR, 5.66; 95% CI, 1.75-18.37), followed by 20/80 or worse (HR, 5.20; 95% CI, 1.94-13.95), and 20/40 or worse (HR, 2.14; 95% CI, 1.08-4.21). Findings were similar for risk of MCI, with the greatest risk among women with baseline visual acuity of 20/100 or worse (HR, 6.43; 95% CI, 1.66-24.85). Conclusions and Relevance: In secondary analysis of a prospective longitudinal cohort study of older women with formal vision and cognitive function testing, objective visual impairment appears to be associated with an increased risk of incident dementia. However, incident cases of dementia and the proportion of those with visual impairment were low. Research is needed to evaluate the effect of specific ophthalmic interventions on dementia.

Assessing the Quality of Published Surveys in Ophthalmology.

PURPOSE: Surveys are an important research modality in ophthalmology, but their quality has not been rigorously assessed. This study evaluated the quality of published ophthalmic surveys. METHODS: Three survey methodologists, three senior ophthalmologists, and two research assistants developed a survey evaluation instrument focused on survey development and testing; sampling frame; response bias; results reporting; and ethics. Two investigators used the instrument to assess the quality of all ophthalmic surveys that were published between January 1, 2018 and December 31, 2018; indexed in MEDLINE/PubMed, Embase, and/or Web of Science; contained the search terms "ophthalmology" and "survey" or "questionnaire" in the title and/or abstract; and were available in English. RESULTS: The search identified 626 articles; 60 met the eligibility criteria and were assessed with the survey evaluation instrument. Most surveys (93%; 56/60) defined the study population; 48% (29/60) described how question items were chosen; 30% (18/60) provided the survey for review or described the questions in sufficient detail; 30% (18/60) were pre-tested or piloted; 25% (15/60) reported validity/clinical sensibility testing; 15% (9/60) described techniques used to assess non-response bias; and 63% (38/60) documented review by an institutional review board (IRB). CONCLUSION: The quality of published ophthalmic surveys can be improved by focusing on survey development, pilot testing, non-response bias and institutional review board review. The survey evaluation instrument can help guide researchers in conducting quality ophthalmic surveys and assist journal editors in evaluating surveys submitted for publication.

Accuracy of biometric formulae for intraocular lens power calculation in a teaching hospital.

AIM: To evaluate the accuracy of three commonly used biometric formulae across different axial lengths (ALs) at one United States Veterans Affairs teaching hospital. METHODS: A retrospective chart review was conducted from November 2013 to May 2018. One eye of each patient who underwent cataract surgery with a monofocal intraocular lens (IOL) was included. The range of postoperative follow-up period was from 3wk to 4mo. The Holladay 2, Barrett Universal II, and Hill-Radial Basis Function (Hill-RBF) formulae were used to predict the postoperative refraction for all cataract surgeries. For each formula, we calculated the prediction errors [including mean absolute prediction error (MAE)] and the percentage of eyes within ±0.25 diopter (D) and ±0.5 D of predicted refraction. We performed subgroup analyses for short (AL<22.0 mm), medium (AL 22.0-25.0 mm), and long eyes (AL>25.0 mm). RESULTS: A total of 1131 patients were screened, and 909 met the inclusion criteria. Resident ophthalmologists were the primary surgeons in 710 (78.1%) cases. We found no statistically significant difference in predictive accuracy among the three formulae over the entire AL range or in the short, medium, and long eye subgroups. Across the entire AL range, the Hill-RBF formula resulted in the lowest MAE (0.384 D) and the highest percentage of eyes with postoperative refraction within ±0.25 D (42.7%) and ±0.5 D (75.5%) of predicted. All three formulae had the highest MAEs (>0.5 D) and lowest percentage within ±0.5 D of predicted refraction (<55%) in short eyes. CONCLUSION: In cataract surgery patients at our teaching hospital, three commonly used biometric formulae demonstrate similar refractive accuracy across all ALs. Short eyes pose the greatest challenge to predicting postoperative refractive error.

Characteristics of Ophthalmology Trials Registered in ClinicalTrials.gov, 2007-2018.

PURPOSE: To perform a comprehensive analysis of characteristics of ophthalmology trials registered in ClinicalTrials.gov. DESIGN: Cross-sectional study. METHODS: All 4,203 ophthalmologic clinical trials registered on ClinicalTrials.gov between October 1, 2007, and April 30, 2018, were identified by using medical subject headings (MeSH). Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratios and 95% confidence intervals were determined for characteristics associated with early discontinuation. RESULTS: The majority of trials were multiarmed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). A total of 33% used a data-monitoring committee (DMC), and 50.6% incorporated blinding. Other groups (51.6%) were funded by industry, whereas 2.6% were funded by the US National Institutes of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH = 15.5%, Other = 3%, Industry = 1.5%; P < 0.001) or pediatric disease (NIH = 20.9%, Other = 5.9%, Industry = 1.4%; P < 0.001). Industry-sponsored trials (69.6% of phase 3 trials) were significantly more likely to be randomized (Industry = 68.7%, NIH = 58.9%, Other = 60.8%; P < 0.001) and blinded (Industry = 57.2%, NIH = 42.7%, Other = 43.5%; P < 0.001). A total of 359 trials (8.5%) were discontinued early, and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.55-0.95; P = 0.021) and/or had a DMC (HR, 0.71; 95% CI, 0.55-0.92; P = 0.010). CONCLUSIONS: Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, whereas Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically sound trials with deliberate funding allocation.

Multimodal Imaging and Functional Testing in a North Carolina Macular Disease Family: Toxoplasmosis, Fovea Plana, and Torpedo Maculopathy Are Phenocopies.

PURPOSE: To describe multimodal imaging and corresponding functional studies in a newly found family with North Carolina macular dystrophy (NCMD). To our knowledge, this is an original report using OCT angiography to evaluate persons with NCMD. DESIGN: A descriptive, retrospective study of a family with NCMD. PARTICIPANTS: A total of 3 participants, representing 3 generations of a single family, each demonstrating a different grade of NCMD, underwent clinical and genetic testing. METHODS: Diagnostic multimodal imaging and functional testing of the retina included color fundus photography, fundus autofluorescence, intravenous fluorescein angiography, spectral-domain OCT and OCT angiography, multifocal electroretinography, full-field electroretinography, and microperimetry. DNA sequencing was performed using Sanger sequencing techniques. MAIN OUTCOME MEASURES: Spectral-domain OCT images, fundus photographs, fundus autofluorescence images, fluorescein angiograms, OCT angiograms, multifocal electroretinography images, full-field electroretinography images, and microperimetry maps. Sanger sequencing was performed for molecular diagnosis. RESULTS: Multimodal imaging helped to demonstrate the nature of the retinal and choroidal lesions in each participant and the extent of visual function. Genetic testing demonstrated the variant 2 point mutation (chromosome 6: 99593111) in the deoxyribonuclease 1 hypersensitivity binding site on chromosome 6q16 causing overexpression of the retinal transcription factor PRDM13. CONCLUSIONS: NCMD has great phenotypic variability, which can be appreciated only by examining multiple family members. To our knowledge, this is an original report that shows a correlation of functional studies with multimodal imaging. These findings are consistent with NCMD being a developmental abnormality of the macula. All layers of the retina and choroid demonstrate maldevelopment and varying degrees of malfunction. Although PRDM13 is expressed in the amacrine cells, we have yet to identify an abnormality specific to this cellular layer. The retinal vasculature appears to be surprisingly well preserved or intact by OCT angiogram compared with that shown in intravenous fluorescein angiograms. OCT angiograms suggest that foveal hypoplasia is a phenocopy of grade 1 NCMD, torpedo maculopathy is a phenocopy of grade 2 NCMD, and in this single family, congenital toxoplasmosis is a phenocopy of grade 3 NCMD.

The route of the visual receptor rhodopsin along the cilium.

The photoreceptor outer segment is the most elaborate primary cilium, containing large amounts of rhodopsin (RHO) in disk membranes that grow from a connecting cilium. The movement of RHO along the connecting cilium precedes formation of the disk membranes. However, the route that RHO takes has not been clearly determined; some reports suggest that it follows an intracellular, vesicular route along the axoneme, possibly as an adaptation for the high load of delivery or the morphogenesis of the disk endomembranes. We addressed this question by studying RHO in cilia of IMCD3 cells and mouse rod photoreceptors. In IMCD3 cilia, fluorescence recovery after photobleaching (FRAP) experiments with fluorescently tagged RHO supported the idea of RHO motility in the ciliary plasma membrane and was inconsistent with the hypothesis of RHO motility within the lumen of the cilium. In rod photoreceptors, FRAP of RHO-EGFP was altered by externally applied lectin, supporting the idea of plasmalemmal RHO dynamics. Quantitative immunoelectron microscopy corroborated our live-cell conclusions, as RHO was found to be distributed along the plasma membrane of the connecting cilium, with negligible labeling within the axoneme. Taken together, the present findings demonstrate RHO trafficking entirely via the ciliary plasma membrane.This article has an associated First Person interview with the first author of the paper.

Fungal Endophthalmitis after Intravitreal Injections of Triamcinolone Contaminated by a Compounding Pharmacy: Five-Year Follow-up of 23 Patients.

PURPOSE: To report the 5-year outcome of an outbreak of Bipolaris hawaiiensis fungal endophthalmitis caused by contamination of intravitreal triamcinolone from Franck's Compounding Pharmacy in Ocala, Florida. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-three patients (n = 25 eyes). METHODS: Data was collected from the practice of a single retina specialist in Los Angeles (K.W.S) and a retina practice in New York City. Intravitreal injections of triamcinolone obtained from a single lot were subsequently found to be contaminated with Bipolaris hawaiiensis. MAIN OUTCOME MEASURES: Visual acuity; presence of vitreous cells, anterior chamber cells, or both; and detection of fungi or fungal elements in samples obtained by vitreous needle aspiration or vitreous biopsy. RESULTS: Fungal endophthalmitis developed in 92% (23/25) of eyes. Despite aggressive local and systemic long-term therapy, severe visual loss resulted in the majority of treated eyes and the enucleated eyes showed evidence of hyphae. CONCLUSIONS: These reported cases of Bipolaris hawaiiensis endophthalmitis provide important messages for clinicians and regulatory agencies. First, patients treated with high-dose, long-term, orally administered voriconazole appeared to achieve better outcomes in treatment of Bipolaris endophthalmitis. Second, treated eyes may still show signs of deterioration, indicating the potential survival of causative organisms or fibrosis encapsulating the ciliary body, leading to hypotony. Third, several parallels can be drawn between this outbreak and the fungal meningitis outbreak after Exserohilum rostratum contamination of methylprednisolone by the New England Compounding Center.

Postoperative Adverse Events, Interventions, and the Utility of Routine Follow-Up After 23-, 25-, and 27-Gauge Pars Plana Vitrectomy.

PURPOSE: To evaluate the utility of standard postoperative visit (POV) intervals in pars plana vitrectomy (PPV) as a function of adverse events (AEs) identified. DESIGN: Retrospective case review. METHODS: The medical records of all patients undergoing 23-, 25-, and 27-gauge PPV from January 1, 2016 to December 31, 2016 were reviewed. Each POV was assessed as a standard (s-POV), physicianadjusted (a-POV), or patient-initiated visit (p-POV). Preoperative features, diagnoses, and surgical procedures were evaluated to determine protective and risk factors for AEs. RESULTS: A total of 256 patients (310 PPVs) were included in this study. The most common cumulative postoperative AEs were elevated intraocular pressure (>30 mm Hg) (12.3%), cystoid macular edema (6.1%), and retinal detachment (5.8%). Patients with the diagnosis of macular hole or epiretinal membrane had the lowest relative risk of AEs [0.30; 95% confidence interval (CI), 0.12-0.75 and 0.36; 95% CI, 0.21-0.63, respectively]. There was no difference in time to AE among different vitrectomy gauge sizes (P = 0.733). Patients in a-POV and p-POV groups had a statistically significant higher incidence of AEs in the POV day 5-10 window (P = 0.004). CONCLUSIONS: The utility of standard POVs in detecting AEs is dependent on the indication for PPV. Specifically patients undergoing isolated macular surgery (epiretinal membrane peel or macular hole repair) had the lowest relative risk of postoperative AEs and may warrant a less-intensive follow-up regimen.

Engaging College-Level Baccalaureate-MD Students in Clinical Research.

College students in baccalaureate-MD (BA/MD) programs are well situated to get involved with clinical research as a component of their scholarly enrichment. The authors review the educational and professional development benefits of BA/MD college research in the United States (US), the lack of evidence-based strategies to guide program innovation, lessons from non-US medical school research enrichment efforts, and teaching models that can help boost BA/MD research engagement at the college level. Collaboration on part of program directors, faculty and students can help strengthen the quality and accessibility of research opportunities with a focus on longitudinal skills building and professional mentorship.

Resident Wellness in US Ophthalmic Graduate Medical Education: The Resident Perspective.

Importance: Wellness programs have become important strategies to combat burnout and depression among residents. However, the resident perspective on wellness in ophthalmic graduate medical education has not been solicited on a national level. Objectives: To report on residents' views of wellness initiatives in ophthalmic graduate medical education and identify potential strategies for promoting resident wellness. Design, Setting, and Participants: In this national survey of ophthalmology residents in the United States, conducted from September 21 to November 3, 2017, all 1048 ophthalmology residents listed on the websites of ophthalmology residency programs accredited by the Accreditation Council for Graduate Medical Education were emailed an anonymous online survey consisting of 12 multiple-choice questions with options for free-text answers. Residents also received a mailed letter with a survey link and a $1 incentive, as well as 2 reminder emails. Survey responses were analyzed using descriptive statistics, and the free-text answers were categorized. Main Outcomes and Measures: Main outcomes include residents' reports regarding their personal experiences with wellness during residency, support systems provided by their programs, and opportunities for improving wellness in ophthalmic graduate medical education. Results: Of 1048 residents, 241 (23.0%) responded to the survey. Most respondents (121 of 177 [68.4%]) reported that their programs faced an issue involving depression, burnout, or suicide among residents within the past year; 26.3% of respondents (61 of 232) reported being involved in a case when resident fatigue, burnout, or depression adversely affected a medical outcome or judgment. Fewer than half of the respondents (110 of 241 [45.6%]) reported that their residency programs placed moderate or major emphasis on promoting a culture of resident wellness, and only 26.7% (63 of 236) reported that their department had a formal resident wellness program. The most commonly cited barrier to resident wellness (59 of 236 [25.0%]) was a lack of time to attend wellness programs. Conclusions and Relevance: These results suggest that there is a substantial burden of burnout and depression among US ophthalmology residents and that there are opportunities to boost wellness in ophthalmic graduate medical education by making wellness curricula more accessible to residents and ensuring that residents have time to attend wellness programs.

Assessing and Promoting the Wellness of United States Ophthalmology Residents: A Survey of Program Directors.

OBJECTIVE: To report on the status of residency-based wellness initiatives in ophthalmic graduate medical education and identify strategies for promoting ophthalmology resident wellness by surveying US ophthalmology program directors (PDs). DESIGN: The PDs were each sent an e-mail containing a link to an anonymous online 15-question survey. The PDs also received a letter with the survey link and a $1 incentive. After 2 weeks, nonresponders received 2 weekly reminder e-mails and phone calls. Descriptive statistics were used to analyze the multiple choice responses and categorize the free response answers. SETTING: National survey. PARTICIPANTS: All 111 US ophthalmology PDs were invited to participate. RESULTS: Of 111 PDs, 56 (50%) responded; 14 (26%) of 53 respondents reported that their programs faced an issue involving resident depression, burnout, or suicide within the last year; 25 (45%) of 56 reported that their department had a resident wellness program. Respondents without wellness programs reported a shortage of time (19/30; 63%) and lack of training and resources (19/30; 63%) as barriers to instituting these programs. Respondents reported that the Accreditation Council for Graduate Medical Education could better promote resident wellness by providing training resources for burnout and depression screening (35/53; 66%), resilience skills building (38/53; 72%), and wellness program development (36/53; 68%). CONCLUSIONS: This survey suggests that there is a substantial burden of burnout and depression among residents in ophthalmic graduate medical education and that this burden can be addressed by promoting the training of educators to recognize the signs of burnout and depression, and providing resources to develop and expand formal wellness programs.