An Atypical Optic Nerve Head Mass.

A 47-year-old man presented with a sudden decrease in vision in the right eye and a history of binocular diplopia, bilateral cranial nerve 6 palsies, and an undifferentiated pontine mass. Examination revealed a large optic nerve head mass with optic disc hyperemia, scattered dot hemorrhages, a placoid lesion in the posterior pole, and a mass protruding out of the optic nerve head. What would you do next?

Performance Assessment of an Artificial Intelligence Chatbot in Clinical Vitreoretinal Scenarios.

PURPOSE: To determine how often ChatGPT is able to provide accurate and comprehensive information regarding clinical vitreoretinal scenarios. To assess the types of sources ChatGPT primarily utilizes and to determine if they are hallucinated. METHODS: A retrospective cross-sectional study. We designed 40 open-ended clinical scenarios across 4 main topics in vitreoretinal disease. Responses were graded on correctness and comprehensiveness by two blinded retina specialists. The primary outcome was the number of clinical scenarios that ChatGPT answered correctly and comprehensively. Secondary outcomes included: theoretical harm to patients, the distribution of the type of references utilized by the chatbot, and the frequency of hallucinated references. RESULTS: In June 2023, ChatGPT answered 83% (33/40) of clinical scenarios correctly but provided a comprehensive answer in only 52.5% (21/40) of cases. Subgroup analysis demonstrated an average correct score of 86.7% in nAMD, 100% in DR, 76.7% in retinal vascular disease and 70% in the surgical domain. There were 6 incorrect responses with 1 (16.7%) case of no harm, 3 (50%) cases of possible harm and 2 (33.3%) cases of definitive harm. CONCLUSION: ChatGPT correctly answered more than 80% of complex open-ended vitreoretinal clinical scenarios, with a reduced capability to provide a comprehensive response.

LONG-TERM USE OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: Although pivotal trials have demonstrated efficacy of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment. METHODS: Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti-vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated. RESULTS: A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline ( P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage. CONCLUSION: This neovascular age-related macular degeneration cohort received on average eight anti-vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.

Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study.

PURPOSE: To report on macular hole repair in macular telangiectasia type 2 (MacTel2). DESIGN: Global, multicenter, retrospective case series. PARTICIPANTS: Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH). METHODS: Standardized data collection sheet distributed to all surgeons. MAIN OUTCOME MEASURES: Anatomic closure and visual outcomes of MTMH. RESULTS: Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 µm (range, 34-573 µm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 µm (range, 97-697 µm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 µm (range, 132-687 µm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%. CONCLUSIONS: Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ophthalmologist Turnover in the United States: Analysis of Workforce Changes from 2014 through 2021.

PURPOSE: Physician turnover is costly to health care systems and affects patient experience due to discontinuity of care. This study aimed to assess the frequency of turnover by ophthalmologists and identify physician and practice characteristics associated with turnover. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Actively practicing United States ophthalmologists included in the Centers for Medicare and Medicaid Services Physician Compare and Physician and Other Supplier Public Use File between 2014 and 2021. METHODS: We collected data for each ophthalmologist that was associated with practice/institution and then calculated the rate of turnover both annually in each year window and cumulatively as the total proportion from 2014 to 2021. Multivariable logistic regression analysis was used to identify physician and practice characteristics associated with turnover. We also evaluated turnover characteristics surrounding the Coronavirus disease 2019 (COVID-19) pandemic. MAIN OUTCOME MEASURES: Ophthalmologist turnover, defined as a change of an ophthalmologist's National Provider Identifier practice affiliation from one year to the next. RESULTS: Of 13 264 ophthalmologists affiliated with 3306 unique practices, 34.1% separated from at least 1 practice between 2014 and 2021. Annual turnover ranged from 3.7% (2017) to 19.4% (2018), with an average rate of 9.4%. Factors associated with increased turnover included solo practice (adjusted odds ratio [aOR], 9.59), university affiliation (aOR, 1.55), practice location in the Northeast (aOR, 1.39), and practice size of 2 to 4 members (aOR, 1.21; P < 0.05 for all). Factors associated with decreased turnover included male gender (aOR, 0.87) and more than 5 years of practice: 6 to 10 years (aOR, 0.63), 11 to 19 years (aOR, 0.54), 20 to 29 years (aOR, 0.36), and ≥ 30 years (aOR, 0.18; P < 0.05 for all). In the initial year (2020) of the COVID-19 pandemic, annual turnover increased from 7.8% to 11.0%, then decreased to 8.7% in the postvaccine period (2021). CONCLUSIONS: One-third of United States ophthalmologists separated from at least 1 practice from 2014 through 2021. Turnover patterns differed by various physician and practice characteristics, which may be used to develop future strategies for workforce stability. Because administrative data cannot solely determine reasons for turnover, further investigation is warranted given the potential clinical and financial implications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Presence of Choroidal Caverns in Patients with Posterior and Panuveitis.

Choroidal caverns (CCs) have been described in association with age-related macular degeneration and pachychoroid disease. However, it is unknown if caverns are found in patients with chronic non-infectious uveitis (NIU). Herein, we evaluated patients with NIU who had optical coherence tomography and indocyanine green angiography for CCs. Clinical and demographic characteristics were extracted from the chart review. Univariate and multivariate mixed-effects logistical models were used to assess the association between clinical and demographic factors and the presence of CCs. One hundred thirty-five patients (251 eyes) met the inclusion criteria: 1 eye had anterior uveitis, 5 had intermediate uveitis, 194 had posterior uveitis, and 51 had panuveitis. The prevalence of CCs was 10%. CCs were only observed in patients with posterior and panuveitis, with a prevalence of 10.8% and 7.8%, respectively. Multifocal choroiditis (MFC) was the type of uveitis where CCs were most frequently observed, with 40% of eyes with MFC having CCs. In addition, male sex (p = 0.024) was associated with CCs. There was no significant difference in the degree of intraocular inflammation or mean subfoveal choroidal thickness between CC+ and CC- eyes. This is the first study to describe CCs in uveitis. Overall, these findings suggest that caverns may be a sequela of structural and/or vascular perturbations in the choroid from uveitis.

Comparison of the Safety and Efficacy of a 3-Dimensional Heads-up Display vs a Standard Operating Microscope in Retinal Detachment Repair.

Purpose: To evaluate the safety, efficacy, and efficiency of the Ngenuity 3-dimensional (3D) heads-up display (HUD) visualization system for primary rhegmatogenous retinal detachment (RRD) repair at a large academic medical center in the United States. Methods: This retrospective review comprised consecutive patients aged 18 years or older who had primary RRD repair (pars plana vitrectomy [PPV] alone or combined PPV and scleral buckle) performed by the same fellowship-trained vitreoretinal surgeon using the 3D visualization system and a traditional standard operating microscope (SOM) at Massachusetts Eye and Ear from June 2017 to December 2021. The minimum follow-up was 90 days. Results: The 3D HUD group comprised 50 eyes of 47 patients and the SOM group, 138 eyes of 136 patients. There were no between-group differences in single surgery anatomic success rates at 3 months (98% HUD vs 99% SOM; P = 1.00) or at the last follow-up (94% HUD vs 98% SOM; P = .40). The rate of postoperative proliferative vitreoretinopathy was similar between the 2 groups (3 months: 3% HUD vs 5% SOM, P = .94; last follow-up, 2% HUD vs 3% SOM, P = .93). There was no difference in the mean duration of surgery (57.4 ± 28.9 minutes HUD vs 59.4 ± 29.9 minutes SOM; P = .68). Conclusions: Anatomic and functional outcomes, in addition to surgical efficiency, of noncomplex primary RRD repair with a 3D HUD system were similar to those of surgery performed with an SOM.

The Effect of Sample Medication Use on Subsequent Anti-VEGF Agent Selection for Neovascular Age-Related Macular Degeneration.

PURPOSE: Medication samples of anti-VEGF agents can represent a good option for retina specialists to provide timely treatment for newly converted neovascular age-related macular degeneration (nvAMD) while prior-authorizations (PA) are pending. Our study examines the effect of medication sample use (ranibizumab or aflibercept) on future anti-vascular endothelial growth factor (VEGF) agent selection in nvAMD. DESIGN: Retrospective cohort study. PARTICIPANTS: nvAMD patients who underwent an initial anti-VEGF injection with a sample medication were compared to nvAMD control patients who never received a medication sample. METHODS: Charts from 2017 through 2020 were reviewed for data regarding demographics, anti-VEGF agent selection, and visual acuity outcomes for both groups. The utilization of different anti-VEGF agents in each group was compared at various time points using chi-square tests for independence of proportions. MAIN OUTCOME MEASURES: Anti-VEGF agent selection for the first four injections and at one year were examined. RESULTS: Adherence to the initial agent was high between first and subsequent injections (2nd, 3rd, 4th injection, and 1 year) in sample (96.2%, 95.9%, 91.9%, 93.4%, respectively), and control groups (98.1%, 94.2%, 94.9%, 87.8%, respectively). Bevacizumab usage was significantly lower among eyes receiving samples relative to controls at the second (1.9% vs. 38.7%, p < .001), third (3.1% vs. 41.3%, p < .001), fourth injections (4.7% vs. 40.4%, p < .001), and at 1 year (0% vs. 33.8%, p < .001). Aflibercept usage was significantly higher in sample eyes relative to controls at the second (78.3% vs. 43.4%, p < .001), third (76.3% vs. 41.5%, p < .001), and fourth injections (76.7% vs. 43.4%, p < .001), and at 1 year (77.0% vs. 52.7%, p < .001). CONCLUSIONS: Sample medications in nvAMD may be initiated for many reasons, including awaiting PA approval. Our study found that eyes receiving a sample anti-VEGF agent (ranibizumab or aflibercept) for their initial injection were less likely to receive bevacizumab at future visits relative to eyes that did not receive an anti-VEGF sample, even after one year of treatment. Given the persistent use of more expensive medications at subsequent injections for patients who were initiated on samples, insurance payors may consider waiving PA requirements for bevacizumab to avoid a paradoxical increase in health-care costs.

Systemic lymphoma masquerading as Vogt-Koyanagi-Harada syndrome: Report of a case with multimodal imaging and histopathology.

Purpose: To report a case of systemic diffuse large B cell lymphoma presenting with ocular manifestations and neurologic findings resembling Vogt-Koyanagi-Harada syndrome. Observations: A 51-year-old Caucasian man presented with headache, ear pain, and blurry vision in both eyes. He was found to have bilateral exudative retinal detachments. After a short period of initial improvement with high dose systemic corticosteroid, his condition significantly worsened. An extensive work-up, including a kidney biopsy, led to a diagnosis of systemic diffuse large B cell lymphoma. He had excellent recovery following treatment with appropriate chemotherapy. Conclusions and Importance: Systemic malignancy may present with ocular manifestations and may masquerade as another diagnosis. An unexpected clinical course may suggest an alternative diagnosis. A broad systemic work-up including an evaluation for malignancy should be considered for patients presenting with unexplained exam or systemic findings.

Toxic Keratoconjunctivitis from Coral Reef.

A 25-year-old woman presented with right eye pain, lid edema, conjunctival injection and chemosis, and mild corneal epitheliopathy after exposure to fluid content from an aquarium coral reef. Topical moxifloxacin and prednisolone were started 4 times daily, with full clinical resolution after 2 weeks. Toxin-mediated keratoconjunctivitis may occur after exposure to zoanthid coral reef, particularly in aquarium enthusiasts. Topical corticosteroids in tandem with topical antibiotics appear to be effective in mild disease. However, in severe cases that exhibit corneal infiltrates and stromal thinning, close observation is warranted in case of possible keratolysis.

Implementation and Impact of a Store-and-Forward Teledermatology Platform in an Urban Academic Safety-Net Health Care System.

Background:Minority and low-income patients disproportionately experience dermatologic access challenges. Store-and-forward (SAF) teledermatology has emerged as a model of care delivery that may improve access. We sought to evaluate patterns of utilization and overall impact after SAF teledermatology implementation in a safety-net health care system. Methods:We performed a retrospective review of 3,285 teledermatology consultations from 2014 to 2017 in an urban academic safety-net health care system. Results:A total of 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%) for skin lesions. The teledermatologist recommended in-person evaluation in 1,199 encounters (36.5%). Median wait time for a subsequent appointment was 36 days (range 0-244 days). Of subsequent in-clinic visits, 237 patients (26.4%) underwent skin biopsy. No-show rate after referral was 11.8%. In comparison, median wait time for dermatology appointment through standard referral was 64 days, with a no-show rate of 18.6%. Biopsy rate of patients referred via teledermatology was 26.4%, in comparison to a rate of 10.9% of patients referred directly from primary care provider. Discussion:Implementation of SAF teledermatology in a safety-net health system resulted in avoidance of 63.5% potential dermatology visits. Consultation typically resulted in a change in suspected diagnosis or management plan. Rates of concordance between teledermatology consults and in-person evaluations were high. Median wait time was reduced by almost half, no-show rate was reduced ∼37%, and biopsy rate was more than double for teledermatology patients compared with standard referral. Conclusion:These findings suggest that SAF teledermatology may improve access to high-quality dermatologic care and increase clinic efficiencies for patients in safety-net health care systems.

Outcomes of primary rhegmatogenous retinal detachment repair with extensive scleral-depressed vitreous removal and dynamic examination.

There are multiple surgical approaches to the repair of rhegmatogenous retinal detachment (RRD). Here, we evaluated the outcomes of small-gauge pars plana vitrectomy (PPV), alone or in combination with scleral buckle (SB-PPV), for RRD repair using a standardized technique by 3 vitreoretinal surgeons: "extensive" removal of the vitreous with scleral depression and dynamic examination of the peripheral retina. One hundred eighty seven eyes of 180 consecutive patients treated for primary RRD by three vitreoretinal surgeons at a tertiary academic medical center from September 2015 to March 2018 were analyzed. Most RRDs occurred in males (134 [71.3%] eyes), affected the left eye (102 [54.3%]), and were phakic (119 [63.3%]). PPV alone was performed in 159 eyes (84.6%), with a combined SB-PPV used in the remaining 29 eyes (15.4%); focal endolaser was used in all (100%) cases. The single surgery anatomic success rate was 186 eyes (99.5%) at 3 months, and 187 (100%) at last follow up. Overall best-corrected visual acuity (BCVA) had significantly improved at 3 months ([Snellen 20/47] P<0.00005) and last follow up ([Snellen 20/31] P<0.00005), as compared to day of presentation ([Snellen 20/234]). Our findings suggest that "extensive" removal of the vitreous and dynamic peripheral examination with scleral depression may lead to high single surgery success in primary uncomplicated RRD repair.