Creating consistency in the diagnosis of convergence insufficiency: screening methods.

PURPOSE: To determine the sensitivity of various clinical tests in the diagnosis of convergence insufficiency. METHODS: A total of 254 patients were recruited with complaints consistent with convergence problems but no prior history of strabismus surgery, eye exercises, prism use, recent concussion, or other ocular or neurological diseases. Each patient completed the convergence insufficiency symptom survey (CISS), and the following data were collected: ocular alignment at distance and near, convergence and divergence fusional amplitudes at distance and near, near-point of convergence (NPC) using an accommodative target and red lens, and assessment of quality of convergence movement (QoCM) and quality of fusional movements (QoFM). The sensitivity of each clinical test was calculated. RESULTS: Measurement of NPC using red lens and subjective assessment of the QoCM and QoFM were the most sensitive diagnostic tools for near symptoms consistent with convergence insufficiency: 93.3%, 98.4%, and 94.5% respectively. CISS score, convergence fusional amplitude at near, and exophoria at near had lower sensitivities: 62.9%, 46.0%, and 72.0%, respectively. Although the majority of our patients had a heterophoria or heterotropia at distance (96.8%) and/or near (98.8%), most presented with only small phorias. Furthermore, of those who had a deviation at near, only 22% had the near exophoria exceeding the distance exophoria by 10Δ. CONCLUSIONS: In our study cohort, NPC with red lens and subjective assessment of QoCM and QoFM proved to be the most sensitive screening tools for near symptoms consistent with convergence insufficiency.

Thyroid Eye Disease and its Vision-Threatening Manifestations in the Academy IRIS Registry: 2014-2018.

PURPOSE: To evaluate prevalence of thyroid eye disease (TED) and associated factors in the American Academy of Ophthalmology IRISⓇ Registry (Intelligent Research in Sight). DESIGN: Cross-sectional analysis of the IRIS Registry. METHODS: IRIS Registry patients (18-90 years old) were classified as TED (ICD-9: 242.00, ICD-10: E05.00 on ≥2 visits) or non-TED cases, and prevalence was estimated. Odds ratios (OR) and 95% Confidence Intervals (CIs) were estimated using logistic regression. RESULTS: 41,211 TED patients were identified. TED prevalence was 0.09%, showed a unimodal age distribution (highest prevalence in ages 50-59 years (y) (0.12%)), higher rates in females than males (0.12% vs. 0.04%) and in non-Hispanics than Hispanics (0.10% vs. 0.05%). Prevalence differed by race (from 0.08% in Asians to 0.12% in Black/African-Americans), with varying peak ages of prevalence. Factors associated with TED in multivariate analysis included age: ((18-<30y (reference), 30-39y: OR (95%CI) 2.2 (2.0, 2.4), 40-49y: 2.9 (2.7,3.1), 50-59y: 3.3 (3.1, 3. 5), 60-69y: 2.7 (2.54, 2.85), 70+: 1.5 (1.46, 1.64)); female sex vs male (reference), 3.5 (3.4,3.6), race: White (reference), Blacks: 1.1 (1.1,1.2), Asian: 0.9 (0.8,0.9), Hispanic ethnicity vs not Hispanic (reference), 0.68 (0.6,0.7), smoking status: (never (ref), former: 1.64 (1.6,1.7), current 2.16: (2.1,2.2)) and Type 1 diabetes (yes vs no (reference): 1.87 (1.8, 1.9). CONCLUSIONS: This epidemiologic profile of TED includes new observations such as a unimodal age distribution and racial variation in prevalence. Associations with female sex, smoking, and Type 1 diabetes are consistent with prior reports. These findings raise novel questions about TED in different populations.

Open-Globe Injury Repairs in the American Academy of Ophthalmology IRIS® Registry 2014 - 2018: Incidence, Risk Factors, and Visual Outcomes.

PURPOSE: To estimate incidence and evaluate demographic risk factors and visual acuity (VA) outcomes of open-globe injuries requiring surgical repair in the IRIS® Registry (Intelligent Research in Sight). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with open-globe injury repairs (OGRs) were identified by Current Procedural Terminology codes (65275, 65280, 65285, 65286, 65235, 65260, and 65265) from 2014 through 2018 in the IRIS Registry. METHODS: Logistic regression models adjusting for age, sex, race, ethnicity, United States region, concurrent and subsequent surgeries, and baseline VA. MAIN OUTCOME MEASURES: Outcomes included annual and 5-year incidence rates per 100 000 people and factors associated with OGR, VA better than 20/40, and VA of 20/200 or worse at final follow-up (3-12 months after OGR). RESULTS: Thirteen thousand seven hundred sixty-six OGRs were identified; 5-year cumulative incidence was 28.0 per 100 000 patients. Open-globe repair was associated with age 21 to 40 years compared with younger than 21 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.5-1.7]), male sex (OR, 2.8; 95% CI, 2.7-2.9), Black versus White race (OR, 1.3; 95% CI, 1.2-1.4), Hispanic versus non-Hispanic ethnicity (OR, 1.7; 95% CI, 1.6-1.8), and South (OR, 1.4; 95% CI, 1.3-1.5) and West (OR, 1.3; 95% CI, 1.2-1.4) versus Midwest regions and associated inversely with Asian versus White race (OR, 0.6; 95% CI, 0.6-0.7). Visual acuity outcomes, analyzed in a subset of 2966 patients with VA data available, showed vision impairment (VA < 20/40) at final follow-up was associated with VA of 20/200 or worse at presentation (20/200 better than 20/40; OR, 11.1; 95% CI, 8.0-15.7), older age (e.g., > 80 years vs. < 21 years; OR, 5.8; 95% CI, 3.2-10.7), and Black versus White race (OR, 1.8; 95% CI, 1.3-2.6). Risk factors were similar for VA of 20/200 or worse after OGR. Among the 1063 patients undergoing OGR with VA of 20/200 or worse at presentation, VA did not improve to better than 20/200 at follow-up in 35% of patients (1063/2996). CONCLUSIONS: Our findings bring to light racial disparities in risk of OGR and poor visual outcomes that warrant further exploration. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Novel Virtual Vision Screening Program: Give Kids Sight Day 2020.

PURPOSE: To determine whether a low-technology novel virtual vision screening protocol can reliably screen pediatric visual acuity. METHODS: Give Kids Sight Day (GKSD), an annual out-reach program, aims to provide free vision screening and ophthalmic care to underserved children in Philadelphia, Pennsylvania. Children were screened virtually through the low-technology protocol. Based on screening results, 152 children were provided in-person eye examinations. Data from in-person examinations were compared to data from virtual screenings for 151 children who were seen in-person. RESULTS: Of 475 children screened virtually, 152 children were seen in-person for examination, and 151 children were included in the analysis. Results from 151 children (mean age: 10.7 years, age range: 5 to 18 years, 43% female, 28% speaking a non-English language) were reviewed. There was a moderate correlation (R = .64, P < .0001; n = 100 children) between screening and in-person visual acuity without refractive correction and a strong correlation (R = 0.82, P < .0001; n = 18 children) between screening and in-person visual acuity with refractive correction. Of the 140 children who were seen in-person, 133 children were provided glasses prescriptions. Seventeen children required a referral to a pediatric ophthalmologist for evaluation of ophthalmic conditions, most commonly strabismus (5.3%) and amblyopia (4%). CONCLUSIONS: The GKSD virtual visual acuity testing demonstrated good correlation with in-person visual acuity testing, supporting the virtual screening approach as a useful tool for future applications in widespread community vision outreach programs. Further studies are needed to refine virtual ophthalmic screening to optimize its applications in bridging the gaps in ophthalmic care. [J Pediatr Ophthalmol Strabismus. 2023;60(6):390-395.].

Clinical outcomes in children and adolescents referred for increased cup:disk ratio at a tertiary referral center.

PURPOSE: To report clinical outcomes and risk factors for glaucoma in children and adolescents referred for increased cup:disk ratios (CDRs) to a tertiary referral center. METHODS: This retrospective, single-center study examined all pediatric patients evaluated for increased CDR at Wills Eye Hospital. Patients who had previous known ocular disease were excluded. Demographic data, including sex, age, and race/ethnicity were recorded, as were baseline and follow-up ophthalmic examination findings, including intraocular pressure (IOP), CDR, diurnal curve, gonioscopy findings, and refractive error. Risks of glaucoma diagnosis based on these data were analyzed. RESULTS: A total of 167 patients were included, of whom 6 were found to have glaucoma. Despite more than 2 years' follow-up on 61 patients, all glaucoma patients were identified within the first 3 months of evaluation. Baseline IOP was statistically significantly higher in glaucomatous patients than nonglaucomatous patients (28 ± 7 vs 15 ± 4, resp. [P = 0.0002]), as was maximum IOP on diurnal curve (24 ± 3 vs 17 ± 3 [P = 0.0005]). CONCLUSIONS: In our study cohort, diagnosis of glaucoma was apparent in the first year of evaluation. Baseline IOP and maximal IOP on diurnal curve were found to be statistically significantly associated with glaucoma diagnosis in pediatric patients referred for increased CDR.

Understanding the Use of the Newcastle, PEDIG, and LACTOSE Control Scores Among Pediatric Ophthalmologists for Intermittent Exotropia.

PURPOSE: To determine the clinical use patterns of control scores for intermittent exotropia. The Newcastle Control Score, Pediatric Eye Disease Investigator Group (PEDIG) score, and Look And Cover, then Ten seconds of Observation Scale for Exotropia (LACTOSE) Control Score were developed to quantify control of exodeviations. METHODS: A short survey was posted on the American Association for Pediatric Ophthalmology and Strabismus forum in August and September 2021. Respondents were asked about their assessment of control in intermittent exotropia, including knowledge and use of the various control scales. RESULTS: One hundred fourteen pediatric ophthalmologists responded; 54.4% (n = 62) reported not using any specific control score for intermittent exotropia, although 61.4% (n = 70) were familiar with the PEDIG score, 37.7% (n = 43) with the Newcastle Control Score, and 7.9% (n = 9) with the LACTOSE Control Score. The PEDIG score was the most widely used (26.3%, n = 30), but 36.7% (n = 11) of respondents reported that the scale is too time-intensive, limiting its use. To improve the use of the control scores, participants recommended promoting wider understanding of the scales (45.6%, n = 52). CONCLUSIONS: Most responding pediatric ophthalmologists do not use a specific control score in managing intermittent exotropia. The PEDIG score is the most frequently used but is reported as time-intensive. Although the LACTOSE Control Score was designed to provide a quicker alternative, it is not widely known. Promoting wider awareness and understanding of intermittent exotropia control scores may be helpful to allow for more objective quantification of control in intermittent exotropia. [J Pediatr Ophthalmol Strabismus. 2023;60(2):131-138.].

Is There Gender Bias in Perceptions of Strabismus Among Adults?

PURPOSE: To investigate the effect of gender, type, and size of horizontal deviation on the perceived severity or need for intervention for strabismus among adults in the general population. METHODS: Eight photographs of individuals aged 25 to 35 years were digitally manipulated to create 30 prism diopters (PD) of exotropia, 30 PD of esotropia, 50 PD of exotropia, and 50 PD of esotropia in both men and women. A survey asked respondents to rank these photographs by their severity or need for intervention from 1 (greatest need) to 8 (least need) to assess for unconscious bias for gender, strabismus type, or deviation size. RESULTS: A total of 203 adult respondents completed the survey. Participants ranked men with both large esotropia and large exotropia (median rank = 1.5, interquartile range [IQR] = 1.5 to 1.5) as needing correction more urgently than similar women (median rank = 3.5, IQR = 3.5 to 4) (P < .0001). The median rank was 4 (IQR = 3.75 to 4.25) for all men combined and 5 (IQR = 4.75 to 5.25) for all women (P < .0001). Photographs with exotropia (median rank = 4, IQR = 3.75 to 4.5) were perceived as more severe than photographs with esotropia (median rank = 5, IQR = 4.5 to 5.25) (P < .0001). Respondents' gender, age, or history of strabismus did not significantly impact their rankings. CONCLUSIONS: Male photographs were perceived as having a greater need for strabismus intervention than female photographs despite similar type and size of deviations. Exotropia was perceived as more severe than esotropia for smaller deviations only. More studies on the perceptions of strabismus are needed to understand whether unconscious bias affects patient care. [J Pediatr Ophthalmol Strabismus. 2023;60(6):396-401.].

Factors Affecting the Perception of Strabismus Among Pediatric Ophthalmologists.

PURPOSE: To define potential factors that influence the perceived urgency of strabismus surgery with a specific focus on the contributions of gender, degree of strabismus, and direction of strabismus. METHODS: An electronic survey was sent to members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Respondents provided demographic information and ranked eight photographs of adults digitally altered to create varying degrees of strabismus according to perceived urgency for surgery. RESULTS: Pediatric ophthalmologists ranked deviations of increasing size with increasing treatment urgency. Men were perceived with higher urgency for treatment compared to women in the smaller angles of strabismus. No consistent preference for type of deviation was found. CONCLUSIONS: The gender of the patient and the amount of misalignment may influence the urgency of surgical management among strabismus surgeons. [J Pediatr Ophthalmol Strabismus. 2023;60(4):257-262.].

Female Editorial Authorship Trends in High-Impact Ophthalmology Journals.

IMPORTANCE: Individuals with perceived experience and expertise are invited by editorial boards to provide commentary through editorials. Female representation among editorialists is not yet defined. OBJECTIVE: To determine female representation as editorial authors in 3 high-impact general ophthalmology journals. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study investigates the proportion of female authorship in editorials published between 2005 to 2009 and 2015 to 2019 in 3 journals: Ophthalmology, JAMA Ophthalmology, and American Journal of Ophthalmology. Data were collected from April to June 2020. MAIN OUTCOMES AND MEASURES: Proportions of female first and senior (last or solo) authors between 2005 to 2009 compared with 2015 to 2019. Secondary outcome measures include representation by sex across degree types and subspecialties. Comparisons were made for all editorialists and ophthalmologist editorialists. RESULTS: Of 814 editorial articles, there were 1179 (first and senior) authors identified. Women held 301 (25.5%) of these authorships, including 116 of 365 first authorships (32.9%) and 185 of 814 senior authorships (23.9%). Overall, female first and senior authorships grew by 68.0% between 2005 to 2009 and 2015 to 2019 (85 of 469 [18.1%] vs 216 of 710 [30.4%]; difference, 12.3%; 95% CI, 7.4-317.2; P < .001). Between 2005 to 2009 and 2015 to 2019, first and senior authorships by women increased (first: 33 of 133 [24.8%] vs 83 of 232 [35.8%]; difference, 11.0%; 95% CI, 1.4-320.6; P = .03; senior: 52 of 336 [15.5%] vs 133 of 478 [27.8%]; difference, 12.3%; 95% CI, 6.8-317.9; P < .001). JAMA Ophthalmology most substantially contributed to the increase in female first and senior authorships (13.8% and 16%), although the test for homogeneity among the 3 journals was not significant. The proportion of female ophthalmologist first authors was greater than the proportion of American Board of Ophthalmology-certified female ophthalmologists (81 of 281 [28.9%] vs 123 of 672 [18.3%]; difference, 10.6%; 95% CI, 5.3-315.9; P < .001). CONCLUSIONS AND RELEVANCE: The proportion of female senior authors increased by 68.0% between 2005 to 2009 and 2015 to 2019, but female authors represented only 25.5% of editorialists. Compared with male ophthalmologists, female ophthalmologists were more commonly first than senior authors. Additionally, female authors were more likely to be nonophthalmologists or to hold nonmedical, non-PhD degrees. While the swelling rank of female editorialists has paralleled the rising proportion of female ophthalmologists over time, parity by sex has yet to be attained. Greater awareness of disparities and strategies to mitigate them may help equalize representation.

Falsely high rebound tonometry.

BACKGROUND: Rebound tonometry (RBT) can be used to measure intraocular pressure (IOP) in children unable to tolerate measurement with applanation tonometry (AT) while awake. RBT readings are often 2-3 mm Hg higher than AT. We have experienced children with a repeatedly higher difference between RBT and AT measurements (≥6 mm Hg). The purpose of this study was to identify demographic and ocular characteristics that contribute to this artifactuous discrepancy. METHODS: The medical records of pediatric patients with IOP measured by RBT followed by AT within 6 months without intervening surgery or change in medical management were retrospectively reviewed to identify potential predictors of greater difference between RBT and AT readings. RESULTS: A total of 123 eyes of 65 patients were included. In patients with normal IOP (≤24 mm Hg), 18.5% had a ≥6 mm Hg difference between RBT and AT, with RBT being higher. Risk factors for this included presence of persistent fetal vasculature (PFV), increased corneal diameter, and higher initial RBT value (>20). In patients with elevated IOP (>24 mm Hg), 77% had ≥6 mm Hg difference, with larger corneal diameter being the sole predictor. Eyes were less likely to have significant RBT-AT difference if there was corneal opacity or iris abnormalities in eyes with elevated IOP (>24 mm Hg). CONCLUSIONS: In some children, RBT readings are ≥ 6 mm Hg higher than AT readings. Caution should be taken when interpreting RBT values in patients with PFV, increased corneal diameter, and higher initial RBT values.

Resolution of Pseudophakic Cystoid Macular Edema: 2 mg Intravitreal Triamcinolone Acetonide versus 40 mg Posterior Sub-Tenon Triamcinolone Acetonide.

PURPOSE: To compare 2 mg intravitreal triamcinolone (IVT) versus 40 mg posterior sub-Tenon triamcinolone acetonide (STT) for the treatment of eyes with pseudophakic cystoid macular edema. METHODS: A retrospective, single-center review of eyes receiving 2 mg IVT between 3/1/2012-3/1/2017 and 40 mg STT between 1/1/2015-3/1/2017. Visual acuity (VA) and central macular thickness (CMT) were recorded at baseline, 1-, 3-, and 6-month follow-up visits. RESULTS: Forty-five eyes were included in the IVT group and 50 eyes in the STT group. Change in VA from baseline to 1, 3, and 6 months was not significantly different between IVT and STT (6 months: 2.3 lines vs. 2.4 lines, p = .10). The IVT group achieved significantly better CMT improvement from baseline compared to STT at 1 month (255 µm vs. 187 µm; p = .03), but this difference was not present at month 3 (214 µm vs. 212 µm; p = .79) or month 6 (176 µm vs. 207 µm; p = .29). During the 6-month follow-up period, approximately 7% of eyes in the IVT group and 12% of eyes in the STT group developed ocular hypertension (p = .43), and all cases were successfully managed with topical anti-ocular hypertensive therapy or observation. CONCLUSIONS: 2 mg IVT and 40 mg STT both achieved significant improvement in vision and CMT with no significant difference between interventions at 3- and 6-month follow-up.

Marijuana and Glaucoma: A Social Media Content Analysis.

PURPOSE: This study analyzes the content quality and characteristics of the most popular and highly ranked search results on the internet related to glaucoma and medical cannabis (MC). DESIGN: Internet-based, cross-sectional study. PARTICIPANTS: Not applicable. METHODS: Google and 2 social media platforms (Facebook, YouTube) were used to identify online information most accessible to patients. Search criteria included "glaucoma" AND "marijuana" or "cannabinoid" or "CBD." The top 20 Google search and YouTube results for each search term and the posts from the top 9 patient-based glaucoma Facebook groups were aggregated and analyzed using the search criteria. MAIN OUTCOME MEASURES: The quality of the content was graded by 2 independent graders using a previously validated Sandvik score and previously reported risk score. The differing values were resolved by a final grader. Additional analysis included whether the source was professional (by physician or medical organization) or shared an opinion on MC (pro, mixed, or against) use in glaucoma. RESULTS: This search resulted in an aggregate of 51 websites on Google, 126 posts from Facebook groups, and 37 videos on YouTube. The mean (± standard deviation) Sandvik score and risk score were 11.0 (±2.23), 10.2 (±1.12), 10.6 (±1.89) and 0.27 (±0.49), 0.46 (±0.62), 0.97 (±0.90) for Google, Facebook, and YouTube, respectively. Analysis of variance showed statistically significant differences in Sandvik (P = 0.01) and risk (P < 0.0001) scores across the 3 platforms. A significant portion of online material was pro-MC use in the setting of glaucoma (24% of Google, 59% of YouTube, and 21% of Facebook results). Professional content had a significantly higher content quality score and a lower risk score, and was less likely to recommend MC use in glaucoma. CONCLUSIONS: Despite American Academy of Ophthalmology, Canadian Ophthalmological Society, and American Glaucoma Society statements against MC use in patients with glaucoma, a significant portion of online material recommends its use. With the wide variation in quality and content of online information, it is important for physicians to be aware of the different platforms and opinions that are readily available to patients.

Predictors of Success in Selective Laser Trabeculoplasty.

PURPOSE: Selective laser trabeculoplasty (SLT) is a common procedure to lower intraocular pressure (IOP) in patients with glaucoma. However, reports are conflicting regarding what factors contribute to SLT success. The purpose of this study was to determine predictors of SLT success. DESIGN: Retrospective case series. PARTICIPANTS: All patients treated with SLT between January 1, 2012, and June 30, 2018. METHODS: Baseline, demographic, procedural, and ophthalmic examination data were recorded at the time of first SLT treatment. Intraocular pressure and medication data were recorded at all follow-up visits. MAIN OUTCOME MEASURES: Selective laser trabeculoplasty success was defined as IOP decrease of 20% or more from baseline at the 3-month, 6-month, and 12-month follow-up visits. Eyes were considered to have failed and were censored when additional SLT or glaucoma surgery was performed. Patients were excluded if they had less than 3 months of follow-up. RESULTS: A total of 997 eyes from 677 patients were included in the study. Mean age was 70.2±11.5 years. Selective laser trabeculoplasty success was achieved in 227 eyes (22.8%), whereas 770 eyes (77.2%) did not meet success criteria. Intraocular pressure before SLT was 21.9±5.2 mmHg while taking 2.0±1.2 medications in eyes with successful SLT, compared with 19.0±5.0 mmHg (P < 0.0001) while taking 2.1±1.3 medications (P = 0.52) in eyes with SLT failure. At the 1-year follow-up, mean IOP in eyes with SLT success was 14.7±3.2 mmHg with 2.0±1.2 medications, compared with 16.3±4.7 mmHg (P = 0.008) with a mean of 1.9±1.3 medications (P = 0.37) in eyes with SLT failure. Eyes with SLT success more often showed greater angle pigment (P = 0.03). Age, glaucoma severity, total SLT power, type of glaucoma, severity of glaucoma, visual field mean defect, and retinal nerve fiber layer thickness were not found to correlate with success. No difference was found between the rate of success based on treatments before SLT, whether surgical or medical. CONCLUSIONS: In this large cohort of eyes undergoing SLT, greater IOP and angle pigment before SLT correlated positively with SLT success. Age, total SLT power, severity of glaucoma, and prior treatments were not associated with SLT success or failure.

Outcomes of Ahmed Glaucoma Valve Implantation With Viscoelastic Fill at Both Beginning and End of Surgery.

PRéCIS:: Intracameral injection of viscoelastic at the beginning of Ahmed FP7 implantation did not reduce early postoperative complication rates. PURPOSE: To evaluate early postoperative complication rates after a modified technique in which the anterior chamber (AC) is filled with viscoelastic at the beginning of Ahmed FP7 implantation before conjunctival peritomy. SUBJECTS AND METHODS: A retrospective chart review was performed of eyes that underwent Ahmed FP7 implantation with or without viscoelastic fill to ~20 mm Hg by finger tension by a single surgeon (M.R.M). Viscoelastic prevented the AC from becoming shallow at any time during surgery, and additional viscoelastic was injected into the AC at the end of surgery to achieve a final intraocular pressure (IOP) of 20 mm Hg. RESULTS: A total of 159 eyes of 159 patients were included. Mean age was 76.4±10.4 years. Mean preoperative IOP was 30.3±9.7 mm Hg on 2.7±1.2 glaucoma medications. On postoperative day 1, there was an IOP spike ≥30 mm Hg in 0% of patients. Within the first postoperative month, hypotony (<5 mm Hg) occurred in 19 (21.8%) eyes that received viscoelastic fill compared with 5 (13.2%) eyes that did not receive viscoelastic fill (P=0.26). During the early postoperative period (≤3 mo), there was no difference in AC depth, microhyphema, choroidal effusion, or leakage between the 2 groups (P≥0.30 for all). There was a higher rate of layered hyphemas in the viscoelastic-fill group at postoperative week 1 (P=0.01). At 3-month follow-up, mean IOP was 14.9±5.5 mm Hg on 1.6±0.8 medications in the viscoelastic-fill group and 16.0±5.2 mm Hg on 1.0±1.2 medications in the nonviscoelastic-fill group (IOP P=0.35). Compared with baseline, change in IOP at 3 months was similar between both groups (P=0.15). Rates of additional medications and procedures did not differ between the 2 groups at any postoperative visit. CONCLUSIONS: Early intracameral injection of viscoelastic during Ahmed glaucoma valve implantation did not reduce early postoperative complication rates.

Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States.

BACKGROUND/OBJECTIVES: Patients with ophthalmic emergencies often present to emergency rooms. Emergency medicine (EM) physicians should feel comfortable encountering these conditions. We assessed EM physicians' comfort working up, diagnosing, and managing ophthalmic emergencies. SUBJECTS/METHODS: 329 EM physicians participated in this cross-sectional multicentre survey. Questions inquired about the amount, type, and self-perceived adequacy of ophthalmic training. Likert scales were used to assess confidence and comfort working up, diagnosing, and managing ophthalmic emergencies. RESULTS: Participants recall receiving a median of 5 and 10 h of ophthalmic training in medical school and residency, respectively. Few feel this prepared them for residency (16.5%) or practice (52.0%). Only 50.6% feel confident with their ophthalmic exam. Most (75.0%) feel confident in their ability to identify an ophthalmic emergency, but 58.8% feel well prepared to work them up. Responders feel more comfortable diagnosing acute retrobulbar hematoma (72.5%), retinal detachment (69.8%), and acute angle closure glaucoma (78.0%) than central retinal artery occlusion (28.9%) or giant cell arteritis (53.2%). Only 60.2% feel comfortable determining if canthotomy and cantholysis is necessary in the setting of acute retrobulbar hematoma, and 40.3% feel comfortable performing the procedure. There was a trend towards attending physicians and providers in urban and academic settings feeling more comfortable diagnosing and managing ophthalmic emergencies compared to trainees, non-urban, and non-academic physicians. CONCLUSIONS: Many participants do not feel comfortable using ophthalmic equipment, performing an eye exam, making vision or potentially life-saving diagnoses, or performing vision-saving procedures, suggesting the need to increase ophthalmic training in EM curricula.

Fornix-Based Trabeculectomy Conjunctival Closure: Winged Sutures versus Modified Wise Closure.

PURPOSE: To compare the midterm safety and efficacy profile of winged sutures versus modified Wise closure for fornix-based trabeculectomy. DESIGN: Retrospective comparative study. PARTICIPANTS: Consecutive cases that underwent fornix-based trabeculectomy by a single surgeon between January 5, 2015, and May 8, 2017. METHODS: Potential cases were identified using the Current Procedural Terminology code, and their charts were reviewed thoroughly. Only 1 eye per patient was included. Demographic and clinical data were collected. MAIN OUTCOME MEASURES: Primary outcomes were bleb leak and subsequent surgical revision rates. Secondary outcomes included intraocular pressure (IOP), number of glaucoma medications (NGM), visual acuity (VA), and other complications. RESULTS: A total of 313 patients were identified, 157 with winged sutures and 156 with modified Wise closure. Baseline demographic and clinical characteristics were similar between the 2 groups. Twenty-six cases (16.6%) of winged sutures and 10 cases (6.4%) of modified Wise group developed bleb leak (P = 0.007), but only a total of 10 eyes needed bleb revision (P = 0.336). Other complications were similar in rates between the groups (P > 0.05). At 6 months, the modified Wise group had significantly greater IOP reduction (-3.10±1.29 [standard error], P = 0.016). Number of glaucoma medications reduction and VA evolution were similar between the 2 groups (P > 0.05). CONCLUSIONS: Fornix-based trabeculectomy with either closure technique was effective in lowering IOP and NGM with comparable safety profile at 6 months. Furthermore, modified Wise closure provided larger IOP reduction and lower bleb leak rate, suggesting a potential superiority to winged sutures. Our study was limited by mitomycin C (MMC) delivery method change near the time of conjunctival closure change, although MMC delivery methods did not show significance in any outcome model.

Randomized phase II/III confirmatory treatment selection design with a change of survival end points: Statistical design of Radiation Therapy Oncology Group 1216.

BACKGROUND: To confirm the treatment effects of concurrent cetuximab plus docetaxel observed in Radiation Therapy Oncology Group (RTOG) 0234 and single out the effect of cetuximab, we designed RTOG 1216, a randomized phase II/III study, which uses an intermediate end point to select the best regimen for definitive testing of survival benefit. METHODS: In phase II, the best regimen should demonstrate statistically significant efficacy against the control with predefined advantage over the competing arm regarding disease-free survival (DFS). We evaluate operating characteristics of the randomized II/III group sequential design through simulations and numerical integrations under the null and various alternative hypotheses. RESULTS: Results show the randomized II/III design yields substantial savings on sample size and time with well-controlled type I and type II error rates. CONCLUSION: Overall, the proposed randomized II/III design has desirable properties that offer cost effectiveness, operational efficiency, and, most importantly, scientific innovation that can be considered for similar clinical research settings.

Acanthamoeba Keratitis: Are Recent Cases More Severe?

PURPOSE: To identify a recent change in disease severity and visual outcomes of patients with Acanthamoeba keratitis (AK) at Wills Eye Hospital (WEH). METHODS: A retrospective chart review was performed of all cases diagnosed with AK at WEH between January 1, 2009, and December 31, 2015. Failure of treatment was defined as having a final best-corrected visual acuity worse than 20/100 and/or requiring keratoplasty. The patients were grouped into 2 outcome categories: successfully treated and those who failed treatment; and prognostic factors associated with failure status were evaluated. Additionally, patients who presented from 2009 to 2012 (labeled "first interval") were compared with those who presented more recently from 2013 to 2015 (labeled "second interval") to determine whether the treatment outcomes and patients' characteristics from the 2 intervals were different. RESULTS: Fifty-nine patients were diagnosed. The rate of treatment failure in the second interval was significantly higher than in the first interval (68% vs. 28%, P = 0.004). Compared with the patients in the first interval, those who presented in the second interval were significantly older, were treated with more corticosteroids before diagnosis, had more days from the symptom onset to initiation of AK treatment, and presented to WEH with poorer vision. CONCLUSIONS: In recent years, the general profile of patients with AK has changed at WEH. Currently, we are treating older patients with more severe keratitis who are presenting later and with worse vision compared with our previous patients. At the same time, treatment outcomes have been poorer.

Prognostic Value of p16 Status on the Development of a Complete Response in Involved Oropharynx Cancer Neck Nodes After Cisplatin-Based Chemoradiation: A Secondary Analysis of NRG Oncology RTOG 0129.

PURPOSE: To determine the relationship between p16 status and the regional response of patients with node-positive oropharynx cancer treated on NRG Oncology RTOG 0129. METHODS AND MATERIALS: Patients with N1-N3 oropharynx cancer and known p16 status who underwent treatment on RTOG 0129 were analyzed. Pathologic complete response (pCR) rates in patients treated with a postchemoradiation neck dissection (with p16-positive or p16-negative cancer) were compared by Fisher exact test. Patients managed expectantly were compared with those treated with a neck dissection. RESULTS: Ninety-nine (34%) of 292 patients with node-positive oropharynx cancer and known p16 status underwent a posttreatment neck dissection (p16-positive: n=69; p16-negative: n=30). The remaining 193 patients with malignant lymphadenopathy at diagnosis were observed. Neck dissection was performed a median of 70 (range, 17-169) days after completion of chemoradiation. Neither the pretreatment nodal stage (P=.71) nor the postradiation, pre-neck dissection clinical/radiographic neck assessment (P=.42) differed by p16 status. A pCR was more common among p16-positive patients (78%) than p16-negative patients (53%, P=.02) and was associated with a reduced incidence of local-regional failure (hazard ratio 0.33, P=.003). On multivariate analysis of local-regional failure, a test for interaction between pCR and p16 status was not significant (P=.37). One-hundred ninety-three (66%) of 292 of initially node-positive patients were managed without a posttreatment neck dissection. Development of a clinical (cCR) was not significantly influenced by p16-status (P=.42). Observed patients with a clinical nodal CR had disease control outcomes similar to those in patients with a pCR neck dissection. CONCLUSIONS: Patients with p16-positive tumors had significantly higher pCR and locoregional control rates than those with p16-negative tumors.