Changes to ophthalmic clinical care during the coronavirus disease 2019 pandemic.

PURPOSE OF REVIEW: Given the impact that society as a whole, and medicine specifically, has experienced as a result of the COVID-19 pandemic, an examination of clinical care changes enacted in the field of ophthalmology is of interest to the specialty. RECENT FINDINGS: In order to adapt to the reality of the COVID-19 pandemic, measures, such as broadening telehealth capabilities, adopting universal masking, careful sanitation procedures, applying virtual teaching in academic environments, and deferring elective surgeries were put in place. These were aimed at reducing person-to-person spread of SARS-CoV-2. Though best efforts were made at triaging ophthalmic emergencies during these times, unfortunate delays in care were observed in some circumstances. Finally, a prospective study interrogating the risk of spread at slit lamp distances for short periods of time was encouraging, suggesting low risk of transmissibility, though limited by a small case-positive sample size. SUMMARY: Significant changes have been made in the design and delivery of ophthalmic care during the COVID-19 pandemic. Some of these, such as telemedicine, may provide value in a postpandemic world.

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients.

BACKGROUND: Heart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients. METHODS: HF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively. RESULTS: Of the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03). CONCLUSION: An ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients.

Local Firework Restrictions and Ocular Trauma.

Importance: Fireworks can cause vision-threatening injuries, but the association of local legislation with the mitigation of these injuries is unclear. Objective: To evaluate the odds of firework-related ocular trauma among residents of areas where fireworks are permitted vs banned. Design, Setting, and Participants: This case-control study was conducted at a level 1 trauma center in Seattle, Washington, among 230 patients presenting with ocular trauma in the 2 weeks surrounding the Independence Day holiday, spanning June 28 to July 11, over an 8-year period (2016-2022). Exposures: Firework ban status of patient residence. Main Outcomes and Measures: Odds of firework-related injuries among residents of areas where fireworks are legal vs where they are banned, calculated as odds ratios (ORs) and 95% CIs. Results: Of 230 consultations for ocular trauma during the study period, 94 patients (mean [SD] age, 25 [14] years; 86 male patients [92%]) sustained firework-related injuries, and 136 (mean [SD] age, 43 [23] years; 104 male patients [77%]) sustained non-firework-related injuries. The odds of firework-related ocular trauma were higher among those living in an area where fireworks were legal compared with those living in an area where fireworks were banned (OR, 2.0 [95% CI, 1.2-3.5]; P = .01). In addition, the odds of firework injuries were higher for patients younger than 18 years (OR, 3.1 [95% CI, 1.7-5.8]; P < .001) and for male patients (OR, 3.3 [95% CI, 1.5-7.1]; P = .004). Firework injuries were more likely to be vision threatening (54 of 94 [57%]) compared with non-firework-related injuries (54 of 136 [40%]; OR, 2.1 [95% CI, 1.2-3.5]; P = .01). Conclusions and Relevance: This case-control study suggests that the odds of firework-related ocular trauma were slightly higher among residents of areas where fireworks were legal compared with residents of areas where fireworks were banned. Although these results suggest that local firework bans may be associated with a small reduction in the odds of firework-related ocular trauma, additional studies are warranted to assess what actions might lead to greater reductions.

Methodologic Considerations for Studying the Ocular Surface Microbiome.

The ocular surface microbiome, unlike that of the skin or gut, has not been well characterized. Culture experiments historically suggested a nearly sterile ocular surface, but initial application of molecular methods such as 16S ribosomal RNA and high-throughput sequencing demonstrated a surprisingly rich ocular surface microbiome. However, a major limitation in studying such a low-biomass niche is the potential for artifactual results when amplification-based techniques such as ribosomal polymerase chain reaction and shotgun sequencing are used. It will be essential to establish standards across the field for sample collection, positive and negative controls, and limitation of contamination in both the laboratory setting and computational analysis. New developments in ocular microbiome research, including the generation of reference reagents and fluoroscopic imaging techniques, provide improved means to validate sequencing results and to visualize complex interactions between host cells and bacteria. Through more thorough characterization of the ocular surface microbiome, the connections between a dysregulated surface and ophthalmic disease may be better understood. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Detection of Leptospirosis Genome from the Aqueous Humor of a Patient with Bilateral Uveitis.

BACKGROUND: Leptospira species are difficult to culture. Thus, when there is suspicion for an infectious etiology to uveitis, bacterial cultures may fail to identify Leptospira. We describe a case of leptospirosis-associated uveitis that evaded culture and molecular assays. DNA sequencing of the aqueous fluid showed the presence of Leptospira spp. METHODS: Retrospective case review of clinical and laboratory features of a patient with ocular leptospirosis is presented. RESULTS: DNA sequencing identified the genome of Leptospirosis spp. in the aqueous humor. CONCLUSION: Metagenomic sequencing, by virtue of its unbiased nature, can be a helpful adjunctive test when a strong clinical suspicion for intraocular infection persists despite negative routine culture and molecular assays.

Keratoprosthesis, silicone oil placement, and fluocinolone acetonide implant for treatment of uveitis-associated hypotony and keratopathy.

PURPOSE: To describe a case series of combined Boston Type 1 Keratoprosthesis with pars plana vitrectomy, silicone oil placement, and fluocinolone acetonide intravitreal 0.59 mg implant (RETISERT®), and report its safety and efficacy in preventing phthisis bulbi in patients with uveitis-associated hypotony and concurrent corneal edema. FINDINGS: A retrospective review of patients with chronic uveitis, corneal decompensation and concurrent hypotony who underwent the combined approach described here between 2015 and 2020 was conducted. Three patients were treated using the combined approach. Post-operative recovery was unremarkable in all cases and the patients' corneal condition remained stable on follow up. No patient developed phthisis, retroprosthetic membrane, or infectious endophthalmitis. Average intraocular pressure one year after intervention was 2.7 to 6.4 mmHg higher compared to a year prior. CONCLUSIONS: The approach described is potentially safe and effective in preventing phthisis and membrane formation in uveitis-associated hypotony and keratopathy.

Comparison of CD4 Counts with Mycophenolate Mofetil versus Methotrexate from the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial.

PURPOSE: Sub-analysis of the FAST Trial comparing change in CD4 (∆CD4) from baseline through 12 months in uveitis patients treated with mycophenolate mofetil (MMF) and methotrexate (MTX). METHODS: Patients were randomly allocated to 1.5 g twice daily MMF or 25 mg weekly MTX. Individuals with CD4 counts at baseline, 6 months (or treatment failure prior), and 12 months (or treatment failure between 6 and 12 months) were included. The association between treatment and ∆CD4 (cells/µL) was analyzed using multivariable linear regression. RESULTS: There was no significant difference in ∆CD4 between MMF and MTX at 6 months (-31.7 cells/µL for MMF compared to MTX; 95% CI: -358.2 to 294.8, P = .85) and 12 months (-78.3 cells/µL for MMF compared to MTX; 95% CI: -468.0 to 311.3; P = .69). CONCLUSION: There was no significant difference in ∆CD4 between MMF and MTX from baseline to 12 months, suggesting that MMF does not confer additional risk of CD4 lymphopenia in uveitic patients.ClinicalTrials.gov Identifier: NCT01829295.

Reducing missed injuries at a level II trauma center.

The phenomenon of missed injury in trauma patients has been recognized for some time. Tertiary examination has been proposed as one strategy to decrease the incidence of missed injuries. The tertiary examination is a comprehensive reevaluation that includes a repeated head-to-toe examination and review of all laboratory and radiologic studies, completed within 24 hours of admission. The purpose of this study was to assess the statistical significance of missed injuries discovered through tertiary examinations at a level II trauma center. Over a period of 6 months, a tertiary examination was completed before discharge of admitted patients who met activation criteria. Of the 90 patients, 13 had a missed injury (incidence of 14%), which was significant. The 16 missed injuries represented only 2.7% of the total 589 injuries, which was not significant. The most commonly missed injuries were fractures of the extremities. We propose that tertiary examinations be adopted as a standard of care for patients admitted to level II trauma centers.

Indications and outcomes of resident-performed cataract surgery requiring return to the operating room.

PURPOSE: To identify the clinical and operative factors predicting reoperation within 30 days of resident-performed cataract surgery and correlate them with 1-year visual outcomes. SETTING: Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA. DESIGN: Retrospective cohort study. METHODS: The study assessed patients who had resident-performed cataract surgery between 2005 and 2013 and required return to the operating room for a second surgery on the same eye within 30 days. Preoperative and intraoperative risk factors were assessed. Outcome measures included corrected distance visual acuity (CDVA) at 1 year. RESULTS: A review of 6644 resident-performed cataract surgeries showed that 54 eyes (0.85%) of 54 patients required a return to the operating room within 30 days. The reoperation rate was higher in the first half of the academic year (1.18%) than in the second half (0.55%) (P = .004). The mean CDVA 1 year postoperatively was 20/40, with a loss of lines of vision in 4 eyes. The mean operative time was 59.23 minutes ± 35.05 (SD). A longer intraoperative time was predictive of a worse visual outcome (P < .01). CONCLUSIONS: Despite the need for reoperation within 30 days, most patients achieved improved visual acuity. The reoperation rate was significantly lower in the second half of the academic year. Increased operation times correlated with worse visual acuity independent of other variables.

In-utero radiofrequency ablation in fetal piglets: Lessons learned.

INTRODUCTION: Radiofrequency ablation (RFA) is increasingly utilized in minimally invasive fetal intervention. However, the response of different fetal tissues to RFA is poorly characterized. We sought to determine the extent of RFA damage in a fetal environment. METHODS: 90Day gestation Yorkshire piglets (term 115days) were subjected to RFA of the chest and abdominal viscera under various temperatures and wattages. The extent of tissue damage was determined by NADPH diaphorase histochemistry. RESULTS: Tyne temperature was widely variable and displayed varying responses between lung and liver tissue. Tyne exposure to amniotic fluid resulted in an increase in amniotic fluid temperature. Collateral damage, even across the diaphragm, was readily seen, and ultrasonography did not always reflect this injury. CONCLUSIONS: Utilization of extracorporeal tynes heats fluid at a greater rate than solid tissue and reliance on temperature sensitive probes may result in overheating. The extent of injury may extend beyond damage observed by ultrasound examination and varies for different tissues. Additional studies on the use of devices that regulate tyne temperature are needed to define optimal conditions and better define the extent of adjacent tissue injury.