Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project.

Introduction: Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes. Methods: An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM. Results: Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM. Discussion: Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

INCREASED DISTANCE FROM THE CLINIC LEADS TO HIGHER LOSS TO FOLLOW-UP AFTER PARS PLANA VITRECTOMY IN DIABETIC PATIENTS.

PURPOSE: The importance of consistent outpatient follow-up for management of diabetic eye disease has been well-established. The objective of this study was to identify patient factors associated with being lost to follow-up in postsurgical patients after undergoing pars plana vitrectomy for diabetic eye disease. METHODS: The charts of diabetic patients undergoing pars plana vitrectomy for nonclearing vitreous hemorrhage at an academic medical center by a single surgeon between 2012 and 2019 were reviewed. The rates of loss to follow-up during the postoperative period were compared based on patient distance from the clinic and insurance status. RESULTS: A total of 144 patients met inclusion criteria. A total of 45 patients (31.25%) were lost to follow-up during the 3-month postoperative period. The rate of loss to follow-up increased with every postoperative visit and was significantly higher for patients living greater than 30 miles from the clinic versus patients living within 30 miles from the clinic. There was no statistically significant difference in loss to follow-up based on insurance status. CONCLUSION: Increased distance from the clinic presents a challenge to providing safe and effective postsurgical care to diabetic patients. This presents opportunities for comanagement or other creative strategies to improve postsurgical follow-up rates for at-risk patients.

Survey of current retinopathy of prematurity practices in China.

AIM: To understand retinopathy of prematurity (ROP) screening and treatment preferences among Chinese ophthalmologists. METHODS: A Chinese language survey was administered anonymously using WebQ (Catalyst, Seattle, WA, USA) among Chinese ROP screeners from December 2016 to January 2017. RESULTS: Among 70 ophthalmologists contacted, 65 responded (93%; 78% female, mean age 40y, 57% pediatric ophthalmologists and 25% retina specialists). Most used screening criteria of birth weight ≤2 kg (62%) with variation in cut-off gestational age (≤37wk, 34%; ≤34wk, 22%; ≤32wk, 31%). RetCam (Natus Medical Incorporated, Pleasanton, CA, USA) wide-field fundus photography assisted most screeners (72%) and was exclusively used by many (29%). Among 55 ophthalmologists treating ROP, anti-vascular endothelial growth factor (VEGF) was preferred over laser for both zone I (76% vs 24%) and zone II ROP (58% vs 42%). Retina specialists (P=0.004) and ophthalmologists with >3mo of training (P=0.03) were more likely to use anti-VEGF over laser for zone I ROP. Lack of laser training (8/20, 40%), access (6/20, 30%) and anesthesia (4/20, 20%) were common barriers to laser treatment. CONCLUSION: Chinese ROP screeners favor anti-VEGF injection and RetCam imaging for ROP management. A better understanding of ROP screening and treatment informs future research and education efforts in China.

SHORT-TERM COMPUTER-ASSISTED QUANTIFICATION OF PLUS DISEASE AFTER TREATMENT OF TYPE 1 RETINOPATHY OF PREMATURITY WITH INTRAVITREAL BEVACIZUMAB OR RETINAL LASER PHOTOCOAGULATION.

PURPOSE: To compare objectively measured changes in plus disease after bevacizumab and laser for Type 1 retinopathy of prematurity. METHODS: ROPtool (a computer program) analyzed fundus images at baseline, 1 week, and subsequent examinations. RESULTS: Six infants (9 eyes) were treated with bevacizumab and 7 (12 eyes) with laser. One week after treatment, bevacizumab compared with laser resulted in a greater median percent change from pretreatment in tortuosity (-53.8 vs. -0.2%, P < 0.001) and overall plus disease (-20.1 vs. -3.1%, P < 0.001). Change in dilation did not differ (-3.5 vs. -5.5%, P = 0.48). After week 1, all median ROPtool parameters continued to decrease for both groups. At last follow-up (median 3, range: 2-10 weeks), both bevacizumab and laser significantly decreased tortuosity (-54.3 and -23.8%), dilation (-8.7 and -7.5%), and overall plus disease (-27.3 and -10.3%). CONCLUSION: Improvement in plus disease, in particular tortuosity, likely occurs more quickly after bevacizumab compared with laser, particularly at 1 week after treatment. These results guide clinical expectations for plus disease resolution after both treatment modalities.

Retinal Defects Three Months After Intravitreal Dexamethasone Implant.

Intravitreal dexamethasone implants are commonly used to treat macular edema and noninfectious uveitis, and side effects including glaucoma and cataract formation are frequently managed. Rarely, the implant can cause an impact injury. However, this case shows peripheral retinal defects in a vitrectomized eye with abutting dexamethasone intravitreal implant without a flap, operculum, or other evidence of traction, developing 3 months after insertion, excluding the chance of injury from impact. The presence of an intravitreal dexamethasone implant appeared to cause destruction of juxtaposed retinal tissue. This report describes evaluation and management of this previously unreported complication. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e211-e214.].

First Clinical Application of Low-Cost OCT.

PURPOSE: We present the design of a new low-cost optical coherence tomography (OCT) system and compare its retinal imaging capabilities to a standard commercial system through a clinical study. METHODS: A spectral-domain OCT system was designed using various cost-reduction techniques to be low-cost, highly portable, and completely stand-alone. Clinical imaging was performed on 120 eyes of 60 patients (60 eyes of normal volunteers and 60 eyes with retinal disease) using both the low-cost OCT and a Heidelberg Engineering Spectralis OCT. Contrast-to-noise ratio (CNR) was measured from resulting images to determine system performance. RESULTS: The low-cost OCT system was successfully applied to clinical imaging of the retina. The system offers an axial resolution of 8.0 µm, a lateral resolution of 19.6 µm, and an imaging depth of 2.7 mm for a 6.6-mm field of view in the X and Y directions. Total cost is $5037, a significant size reduction compared to current commercial higher performance systems. Mean CNR value of low-cost OCT images is only 5.6% lower compared to the Heidelberg Spectralis. CONCLUSIONS: The images captured with the low-cost OCT were of adequate resolution and allowed for clinical diagnostics. It offers comparable performance as a retinal screening tool at a fraction of the cost of current commercial systems. TRANSLATIONAL RELEVANCE: Low-cost OCT has the potential to increase access to retinal imaging.

Evaluation of retinopathy of prematurity incidence with telemedicine confirmation in Gansu, China: a pilot study.

PURPOSE: To determine the incidence of retinopathy of prematurity (ROP) in Gansu, China by combining bedside examinations with remote RetCam (Clarity Medical Systems, Pleasanton, CA, USA) diagnosis. METHODS: ROP screening via indirect ophthalmoscopy followed by RetCam imaging was performed from 2014 to 2015. Three ROP-experienced ophthalmologists interpreted images remotely. Incidence of ROP was determined by combining bedside and telemedicine diagnoses. RESULTS: Of 139 examined infants and 137 complete records, 20 (14.6%) patients developed ROP, with 11 (8.0%) stage 1, six (4.4%) stage 2, and three (2.2%) stage 3 based on combined diagnoses. Perinatal asphyxia was significantly associated with ROP incidence (p = 0.01). ROP incidence by combined diagnosis (20/137 or 14.6%) versus clinician diagnosis alone (21/137 or 15.3%, p = 0.50) was similar. Telemedicine changed diagnoses in 4/21 (19.0%) ROP cases. CONCLUSIONS: Telemedicine may be helpful in confirming ROP incidence and may serve as a training and support model for less experienced and professionally isolated ROP examiners.

Intraocular and extraocular hemorrhage associated with ligature release of non-valved glaucoma drainage implant.

PURPOSE: To report a rare complication of non-valved glaucoma drainage device surgery. OBSERVATIONS: An 85-year-old pseudophakic white male presented with painless vision loss and bloody tears. He was 5 weeks removed from uncomplicated non-valved glaucoma drainage device (Baerveldt 101-350, [AMO, Santa Clara, CA]). There was serosanguinous discharge without apparent source and a 25% layering hyphema in the anterior chamber. The tube was unobstructed in the anterior chamber and not abutting the iris. There was no presence of neovascularization or other abnormal vessels in the angle. After clearing of the hyphema, the patient had persistent vitreous hemorrhage necessitating pars plana vitrectomy. No source of hemorrhage was identified. CONCLUSIONS AND IMPORTANCE: This is the first report of a rare occurrence of intraocular and extraocular hemorrhage associated following spontaneous release of ligature of a non-valved glaucoma drainage implant. The presumed mechanism was sudden shallowing of the anterior chamber resulting in the tube irritating uveal vasculature. We do not have an explanation for the extraocular blood.

The Relationship of Vogt-Koyanagi-Harada Syndrome to Ocular Hypertension and Glaucoma.

PURPOSE: Vogt-Koyanagi-Harada (VKH) syndrome is a systemic inflammatory autoimmune disease with associated ophthalmic pathology. Glaucoma has been reported in patients with VKH. The purpose of this report is to examine the frequency and types of glaucoma associated with VKH. METHODS: This was a retrospective case series. Electronic medical records of patients with VKH were reviewed from two medical centers: Duke University and the University of North Carolina. RESULTS: Of 45 eyes with VKH, 28 (62%) developed ocular hypertension (OHT) or glaucoma. In the patients with VKH and OHT/glaucoma, 18/28 (64%) had posterior synechiae and/or peripheral anterior synechiae. CONCLUSIONS: We have shown a high prevalence of OHT and glaucoma in eyes with VKH. Furthermore, in addition to secondary open angle from corticosteroid treatment and uveitis, secondary angle closure resulting from posterior synechiae, frequently associated with iris bombé configuration, is an important cause of glaucoma in VKH eyes.

AMBULATORY BLOOD PRESSURE PATTERNS IN PATIENTS WITH RETINAL VEIN OCCLUSION.

PURPOSE: Failure of blood pressure (BP) to dip during sleep (nondipper pattern) is associated with cardiovascular disease and stroke. The prevalence and degree of nondipping and masked hypertension in patients with retinal vein occlusion (RVO), which is associated with stroke, has not been previously examined. METHODS: We measured clinic and 24-hour ambulatory BPs in 22 patients with RVO and 20 control participants without known eye disease matched by age and sex. Mean BP dipping, defined as the ratio of difference in mean awake and sleep systolic BPs to mean awake systolic BP, and masked and nocturnal hypertension were compared between groups. RESULTS: Mean 24-hour ambulatory BP was 144/79 mmHg among those with RVO and 136/77 mmHg among controls. Patients with RVO had an almost 2-fold higher prevalence of nondipping pattern (80.8% [95% confidence interval, 52.8-94.1] vs. 50.4% [95% confidence interval, 26.1-74.5]; P = 0.008). Average sleep systolic BP dip in patients with RVO was 6.1% versus 11.9% in controls (P = 0.004). More patients with RVO had masked hypertension by ambulatory BPs than controls (71% vs. 50%), but this difference was not statistically significant. CONCLUSION: Our data suggest an association between RVO and nondipper BP pattern. Ambulatory BP monitoring may be useful in the evaluation of patients with RVO by identifying those who may benefit from more aggressive BP control.

The Characteristics and Short-term Refractive Error Outcomes of Cystoid Macular Edema in Premature Neonates as Detected by Spectral-Domain Optical Coherence Tomography.

BACKGROUND AND OBJECTIVE: To explore characteristics associated with cystoid macular edema (CME) in neonates screened for retinopathy of prematurity (ROP). PATIENTS AND METHODS: In this institutional review board-approved, prospective, observational study, premature neonates underwent imaging with handheld spectral-domain optical coherence tomography. RESULTS: Of 73 included infants (median gestational age [GA]: 28 weeks, range 23-33 weeks; birth weight: 966 g, range 506 g-1695 g), 28 (38%) had CME and 17/28 (61%) had ROP. CME was associated with ROP (P=.03) and younger GA (P=.04), but not associated with sex, race, birth weight, postmenstrual age at imaging, ROP severity, or myopia at median 6 months corrected age. CME resolved in three cases after bevacizumab treatment for type 1 ROP and in five cases without treatment. CME appeared in two cases several weeks following injections. CONCLUSION: CME was associated with ROP and younger GA, but not with myopia. Intravitreal bevacizumab for type 1 ROP has inconclusive effects on CME.

Topical nepafenac after intravitreal injection: a prospective double-masked randomized controlled trial.

PURPOSE: To evaluate if a single drop of nepafenac can reduce the ocular discomfort after intravitreal injections compared with placebo. METHODS: One hundred and twenty patients undergoing intravitreal injections of bevacizumab or ranibizumab received a drop of nepafenac or placebo (Systane Ultra) after the injection in a prospective, double-masked, randomized controlled design. Patients rated their pain levels from 0 to 3 (no pain, mild pain, moderate pain, severe pain) at 1 hour, 6 hours, and 24 hours after the procedure. RESULTS: Statistically significant reduction of postinjection pain with nepafenac was noted 6 hours after the injection when compared with placebo (0.8 ± 0.6 [standard deviation] vs. 1.3 ± 0.8, P < 0.001) with similar trends at 1 hour (1.1 ± 0.7 vs. 1.3 ± 0.7, P = 0.12) and 24 hours (0.3 ± 0.5 vs. 0.5 ± 0.6, P = 0.15). CONCLUSION: A single drop of nepafenac is effective in reducing discomfort after intravitreal injections.

Peripheral retinal nonperfusion in fellow eyes in coats disease.

PURPOSE: To measure peripheral nonperfusion and describe bilateral vascular abnormalities in patients with Coats disease, emphasizing subtle findings in the contralateral eyes of patients diagnosed with unilateral disease. METHODS: Clinical records, including retina drawings and fluorescein angiography images obtained under anesthesia, were retrospectively reviewed from consecutive pediatric patients with Coats disease. The main outcome measure was disk diameters of peripheral nonperfusion and proportion of Coats disease patients with bilateral findings. RESULTS: Twenty-two of 32 patients with Coats disease had bilateral abnormal peripheral vasculature. In Group 1 (classic Coats disease: presumed unilateral, ocular only disease), 15 of 24 patients had peripheral nonperfusion >2 disk diameters in their contralateral eyes, 5 with telangiectasis and/or microaneurysms. Seven of 8 patients in Group 2 (Coats-like disease: systemic and/or clinically bilateral disease) had bilateral vascular anomalies. CONCLUSION: Bilateral vascular abnormalities are more common in Coats disease than previously reported. This observation supports a systemic and/or genetic association with Coats disease. Patients with Coats disease should have careful evaluation of the periphery of the less affected eye, preferably with fluorescein angiography, to identify vascular changes not visible clinically. Both eyes warrant surveillance over the lifetime of the patient for potential progression to exudative disease that would warrant treatment.

Pars plana vitrectomy for rhegmatogenous retinal detachment associated with benign retinal tumors.

Two patients with known histories of benign retinal tumors presented with rhegmatogenous retinal detachments (RRD) in the same eye. One had a retinocytoma and presenting vision of 20/50, while the other had congenital hypertrophy of the retinal pigment epithelium and vision of 20/30. Both had subretinal fluid accumulation in a configuration consistent with a retinal break near the tumor; however, no breaks were detected on examination or intraoperatively. Pars plana vitrectomy (PPV), drainage retinotomy, fluid-air exchange, barrier laser around the tumor, and gas tamponade successfully reattached the retina in both cases. After 12 and 6 months of follow-up, respectively, final vision was 20/25 and the retina remained attached. RRD may be associated with benign retinal tumors presumably with microscopic breaks at the margins. In these cases, PPV, drainage retinotomy, fluid-air exchange, endolaser around the tumor, and gas tamponade can be effective for treatment.

Enhanced depth imaging spectral domain optical coherence tomography in syphilitic chorioretinitis.

PURPOSE: To describe the enhanced depth imaging optical coherence tomography features in syphilitic chorioretinitis. METHODS: This is a case report. RESULTS: A 69-year-old man was diagnosed with syphilitic chorioretinitis after presenting with a 3-week history of blurred vision in his right eye. Fundus examination revealed vitritis and retinal whitening along the inferotemporal arcade. Enhanced depth imaging optical coherence tomography showed choroidal thickening and increased reflectivity of the overlying retina. Intravenous penicillin G was started and clinical improvement followed with corresponding reduction in choroidal thickness and decreased reflectivity of the overlying retina. CONCLUSION: Enhanced depth imaging optical coherence tomography can be used in conjunction with clinical examination to localize tissue involvement in syphilitic chorioretinitis and monitor treatment response.

Determination of retinal and vitreous temperature in vitrectomy.

PURPOSE/BACKGROUND: To maximize recovery after neurologic injury, physicians use therapeutic hypothermia of 90°F to 93°F (32.2-33.9°C). Temperatures below this are avoided because of increased side effects. The extent to which the retina is cooled during routine vitreous surgery is unknown. This study seeks to describe the temperature changes of the vitreous and retinal surface during vitreous surgery. METHODS: In this prospective study of 6 patients undergoing vitrectomy, a 23-gauge thermoprobe was used to measure intraocular temperatures before, during, and after vitrectomy. RESULTS: Before vitrectomy, the mean midvitreous temperature was 93.1°F (33.9°C) and retinal temperature was 94.7°F to 95.4°F (34.8-35.2°C). During vitrectomy, the mean midvitreous cavity temperature was 76.9°F (24.9°C) and retinal temperature was 83.2°F to 85.1°F (28.4-29.5°C). After completion of vitrectomy and with a closed infusion line, the mean midvitreous cavity temperature was 87.0°F (30.6°C) and retinal temperature was 90.1°F to 90.9°F (32.3-32.7°C). These changes in temperature before, during, and after vitrectomy were found to be statistically significant. CONCLUSION: During routine vitreous surgery, the vitreous cavity and retina are cooled to much lower temperatures than those used in therapeutic hypothermia. Rapid rewarming occurs within the eye once the infusion line is closed.