Incidence of Sympathetic Ophthalmia after Intraocular Surgery: A Systematic Review and Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can present after trauma or intraocular surgery (IOS). The incidence of SO after IOS varies among studies. The purpose of this review was to determine the incidence proportion of SO after IOS. CLINICAL RELEVANCE: The incidence proportion of SO after IOS can provide physicians and patients with information on the risk of SO during the consent process before surgery. METHODS: In this systematic review and meta-analysis, MEDLINE, EMBASE, and Cochrane databases were searched from inception to January 1, 2023 for population-based studies of SO after IOS. Two reviewers independently screened the results. Random-effects meta-analyses calculated incidence proportion. Subgroup analysis assessed SO incidence based on IOS type and technological advancements. Study quality and bias were assessed using the Newcastle-Ottawa scale and the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS: The final meta-analyses included 19 studies, with 118 cases of SO occurring after 505 178 inciting events. The estimated overall incidence proportion of SO after IOS was 0.061% (95% confidence interval [CI], 0.033%-0.111%; I2 = 83%), and the estimated incidence rate was 9.24 cases per 100 000 person-years (95% CI, 4.03-21.19; I2 = 88%). The average study duration across these studies was 10.8 years. Within the reviewed literature, SO after glaucoma and vitreoretinal IOS was studied most, with 9 and 6 studies, respectively. Observed differences in incidence between glaucoma (0.098%; 95% CI, 0.042%-0.232%; I2 = 40%) and vitreoretinal (0.043%; 95% CI, 0.022%-0.085%; I2 = 88%) IOS were not statistically significant (P = 0.14). Also, no significant difference was found in the incidence proportion before and after 1975, when modern intraocular surgical techniques emerged (0.060% vs. 0.058%; P = 0.98). The outcome measures showed low-certainty Grades of Recommendation, Assessment, Development, and Evaluation evidence. DISCUSSION: Sympathetic ophthalmia after IOS is rare and might not have changed over the past 5 decades. The estimated incidence proportion of SO may be useful during the consent process before surgery. Also, no significant difference may exist in the incidence of SO between glaucoma and vitreoretinal IOS, based on low-certainty evidence. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Impact of the use of anti-glaucoma medications on the risk of herpetic keratitis recurrence.

PURPOSE: Numerous case reports have associated anti-glaucoma medications with recurrence of herpes simplex virus (HSV) and herpes zoster virus (HZV) keratitis. The aim of our study was to determine whether different anti-glaucoma agents are associated with recurrence of herpetic keratitis. METHODS: This was a retrospective cohort study using health databases from a Canadian province from January 2001 to December 2012. A new cohort of users on topical prostaglandins (PGs), beta blockers (BBs), alpha-2 agonists (AAs) and carbonic anhydrase inhibitors (CAIs) was created. The date of the third anti-glaucoma drug dispensation within 90 days was deemed the index date of the case. Herpetic keratitis events, as defined by an ICD-9/10 code for HSV or HZV keratitis, or the dispensation of an anti-viral medication by either an ophthalmologist or an optometrist, were examined prior to and following the index date. Risk ratios (RRs) were computed to compare the risk of HSV/HZV keratitis among the PG, BB, AA, and CAI groups individually and collectively while adjusting for age and sex. RESULTS: Among 19,986 users of glaucoma medications identified, there were 684 cases of HSV/HZV keratitis. There was no increased risk of HSV/HZV keratitis recurrence for any of the four glaucoma medications classes individually or collectively when adjusted for age and sex. There was also no increased risk for redeveloping either HSV keratitis only or HZV keratitis only amongst all anti-glaucoma users. CONCLUSION: There is no association between the use of topical ocular hypotensive therapies and HSV/HZV keratitis recurrence. Further studies are needed to confirm these findings.

Gender and editorship in oculoplastics societal publications.

PURPOSE: The editorship of medical journals is a leadership role that can affect recognition and career advancement. We determine the gender representation of the editorial boards of oculoplastic surgery journals in comparison to the proportion of women in oculoplastics societies. METHODS: The gender composition of the American, European and Asia-Pacific societies of oculoplastic and reconstructive surgery and the editorial boards of their respective society journals were determined with online searches in March 2021. Statistical tests for the equality of proportions were performed. RESULTS: Excluding 44 individuals with missing gender data, the three combined oculoplastics societies comprised 1,230 distinct members, with 29% women. The editorial review boards of the three official society publications comprised 59 medical editors, 22% of which were women. There was no statistically significant difference in the proportion of women editors versus women OPRS members (p = .201) but the study is underpowered to detect a 7% difference. A sensitivity analysis with the missing data did not alter the conclusions. The mean h-index/m-quotient of the women editors was 20.50/0.87 and for the men 21.05/0.84, with no statistically significant difference (p = .903/0.851). CONCLUSION: Women are underrepresented on the editorial boards of oculoplastic journals. Possible methods to improve gender balance include multicriteria objective decision-making criteria for editor nominations, mentoring peer reviewers that are women, and appointing a journal editor for equity, diversity and inclusion.

Medications for attention deficit hyperactivity disorder associated with increased risk of developing glaucoma.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) therapies including atomoxetine, methylphenidate, and amphetamines are some of the most prescribed medications in North America. Due to their sympathomimetic action, these drugs are contraindicated in patients with a history of angle closure glaucoma (ACG). This study aims to determine the risk of ACG and open angle glaucoma (OAG) among users of these treatments. METHODS: This is a retrospective cohort study with a case control analysis using the PharMetrics Plus Database (IQVIA, USA). We created a cohort of new users of atomoxetine, methylphenidate, and amphetamines and they were followed to the first diagnosis of (1) ACG or OAG; or (2) end of follow up. For each case, four age-matched controls were selected. A conditional logistic regression model was used to adjust for confounders and to calculate adjusted incidence-rate-ratios (aIRRs). RESULTS: A total of 240,257 new users of the ADHD medications were identified. The mean age was 45.0 ± 19.4 years and 55% of the cohort was female. Regular users of atomoxetine and amphetamines had a higher aIRR for developing ACG compared with non-users (aIRR = 2.55 95% CI [1.20-5.43] and 2.27 95% CI [1.42-3.63], respectively); while users of methylphenidate had a higher aIRR for developing OAG (aIRR = 1.23 95% CI [1.05-1.59]). CONCLUSIONS: Use of amphetamines and atomoxetine had a higher risk for ACG, while use of methylphenidate was associated with a higher risk for OAG. Given the prevalence of ADHD medication use (medically and recreationally), our current data on their associated risk of glaucoma have profound public health implications.

Outcomes of Scleral Buckling After Failed Pneumatic Retinopexy.

Purpose: To assess the visual and anatomic outcomes of eyes that had secondary scleral buckle (SB) surgery after unsuccessful pneumatic retinopexy (PR) for rhegmatogenous retinal detachment (RRD). Methods: A retrospective study, performed over a 12-year period, comprised patients who had secondary SB procedures after failed primary PR. Clinical parameters (eg, best-corrected visual acuity [BCVA], lens status, macula status, details of RRD and subretinal fluid) were assessed at presentation, before additional procedures, and at follow-up (6 months, 1 year, and last visit). Statistical comparisons were made using Brown-Forsythe and Welch analysis-of-variance tests, with significance levels set at P < .05. Results: Fifty-four eyes with adequate follow-up were included. Forty-four (81.5%) of 54 eyes had successful retinal reattachment with secondary SB alone. The remaining eyes had subsequent pars plana vitrectomy (PPV). Patients presenting with macula-on RRD who had successful secondary SB had no statistically significant change in BCVA from baseline (mean final, 0.23 ± 0.25 logMAR [Snellen 20/34]; P = .999). There was a statistically significant improvement in BCVA in patients presenting with macula-off RRD who had successful secondary SB (mean final, 0.32 ± 0.36 logMAR [20/42]; P < .001 and mean change, -1.06 ± 0.85 logMAR). Ten patients presenting with macula-off RRD who had failed secondary SB had a significant improvement in the final BCVA (mean final, 0.22 ± 0.28 logMAR [20/33]; P = .044), despite the need for an additional PPV to achieve reattachment. Conclusions: Secondary SB remains a good option for RRD repair after unsuccessful PR and may avoid the need for PPV.

A unique case of glaucoma associated with heterotopic bone formation in the anterior chamber angle.

Purpose: To describe a unique case of unilateral open angle glaucoma secondary to heterotopic bone formation in the anterior chamber angle. Observations: A 57 year-old male with an unremarkable history presented with right eye pain. Anterior segment examination demonstrated a solid, white deposit overlying the trabecular meshwork and peripheral iris associated with an intraocular pressure of 44 mmHg. The left eye examination was unremarkable. Biopsy of the material surprisingly showed heterotopic bone. Removal of the material and medical treatment were unable to adequately control the intraocular pressure and a trabeculectomy was successfully performed. Conclusions and Importance: This case demonstrates a unique cause of secondary open angle glaucoma: heterotopic bone formation in the anterior chamber angle.

Pathophysiology of Corneal Endothelial Cell Loss in Dry Eye Disease and Other Inflammatory Ocular Disorders.

PURPOSE: Dry eye disease (DED) and other inflammatory ocular disorders have been reported to be associated with decreased corneal endothelial cell density (CECD), however the mechanism of underlying endothelial cell loss remains unknown. METHODS: We conducted a comprehensive literature search of English-written publications on dry eye disease, corneal endothelial cell loss, Sjögren's syndrome, and Graft Vs Host Disease (GVHD), to review the effects of DED and other inflammatory ocular surface conditions on CECD. RESULTS: A total of 78 studies were included in our study. Loss of corneal neurotrophic support, cytotoxic stress, and a heightened immune response, all of which may occur secondarily to a common causative agent such as inflammation, are major contributors to reduced CECD. CONCLUSION: More studies are needed to determine how the interrelated pathways of altered corneal nerve function and upregulated expression of inflammatory activity influence corneal endothelial cell loss.

Exploring Ophthalmologists' Adoption of Telemedicine during the COVID-19 Pandemic: A Mixed Methods Study.

INTRODUCTION: The COVID-19 pandemic promoted hitherto unseen uptake of telemedicine by ophthalmologists. We performed a mixed methods study to explore patters of utilization during the pandemic and perceived future utility. METHODS: Ophthalmologists practicing in Canada between March and July 2020 were invited to complete an online questionnaire assessing demographics, clinical practice characteristics and telemedicine utilization prior to and during the pandemic. Descriptive and bivariate statistics were used to analyze the data. Agglomerative hierarchical cluster analysis was used to identify groups who varied on the types of visits offered using telemedicine. Ten one-on-one interviews were conducted and analyzed using thematic content analysis to explain trends observed in the survey data. RESULTS: Seventy-three ophthalmologists completed the survey. Six percent reported using telemedicine prior to the pandemic compared to 80% during the pandemic. A significant majority (81%) primarily used the telephone for telemedicine visits. Overall, visit volumes during the pandemic declined to 40% of pre-pandemic levels, with a smaller decline for ophthalmologists who used telemedicine than those who did not. Those who used telemedicine for all visit types were more likely to use telemedicine software and to anticipate a modest-to-large role for telemedicine in their future practice. DISCUSSION: For many ophthalmologists, integrating telemedicine into clinical practice may have partially offset the disruption to normal clinical activities during the pandemic. While the majority saw telemedicine as a temporary solution, a sizeable minority appear to have made considerable use of the technology and see an ongoing role for it once regular clinical activities resume.

Effects of hormonal contraceptives on dry eye disease: a population-based study.

BACKGROUND: Hormonal contraceptives (HCs) are a known risk factor for dry eye disease (DED), yet the relationship between HCs use and DED in women of child-bearing age remains debatable. The aim of this study was to determine the association between HCs and DED in females of reproductive age. METHODS: This was a retrospective cohort study using data from IQVIA's electronic medical record (IQVIA, USA). 4,871,504 women (age 15-45) between 2008 and 2018 were followed to the first diagnosis of DED as defined by an ICD-9/10 code. DED cases also required at least two prescriptions of cyclosporine or lifitegrast topical drops within 60 days of the first code. The date of the first code was designated as the index date. Regular HCs users needed to have at least two prescriptions in both the first year and second year prior to the index date. For each case, five controls were selected and matched to cases by age and follow-up time. A conditional logistic regression model was used to adjust for confounders of DED and to calculate odds ratios (ORs). RESULTS: HCs users were at a higher risk for DED than non-users. Regular users of HCs were more likely to develop DED (ORs = 2.73, 95% CI [2.21-3.73]) than irregular users. Those who used a greater number of HCs were at a higher risk for DED. CONCLUSIONS: This study indicates an increased risk of DED with HCs use in women of child-bearing age.

Navigating Personal and Professional Development Through Social Media in Ophthalmology.

Background: Although social media use among physicians skyrocketed during the COVID-19 pandemic, its role for networking, mentorship, and support among ophthalmologists remains unknown. The objective of this study was to elucidate how ophthalmologists use social media for navigating challenges related to personal and professional development. Methods: This was a cross-sectional survey study conducted during the height of the COVID-19 pandemic. A 40-item questionnaire investigating the usage of social media was developed and distributed to active social media users in ophthalmology including trainees and practitioners from November 2020 to December 2020 via social media channels. Quantitative responses were analyzed using descriptive and basic statistics, while a thematic analysis was conducted to examine the qualitative responses. Results: One hundred and forty-nine respondents (67% women) completed the survey, with 56% of participants between the ages of 25-35 years old. Women were more likely to report experiencing workplace discrimination (p < 0.005) and work-life imbalance (p < 0.05) compared to men, and social media was found to be useful in addressing those challenges in addition to parenting and mentorship (p < 0.005 and p < 0.001, respectively). Compared to their older counterparts, younger ophthalmologists (<45 years old) cited more challenges with practice management (p < 0.005) and turned to social media for corresponding guidance (p < 0.05). Compared to late career ophthalmologists, trainees were more likely to report difficulties with career development (p < 0.05), practice management (p < 0.0001), and financial planning (p < 0.05), and found social media beneficial for learning financial literacy (p < 0.05). A qualitative analysis of the free-response texts found both positive and negative viewpoints of social media use in ophthalmology. Conclusion: Social media is an invaluable tool for enhancing professional and personal growth for ophthalmologists, particularly for women, trainees, and younger surgeons through education and community-building. Future directions include exploring how social media can be used to improve mentorship, outreach, and training in ophthalmology.

Research productivity and impact of Canadian academic ophthalmologists: trends in H-index, gender, subspecialty, and faculty appointment.

OBJECTIVE: H-index has historically functioned as a metric of academic success for acquisition of research grants, awards, and faculty appointments. Our objective was to characterize the landscape of Canadian academic ophthalmology on the basis of research productivity and impact-as measured by H-index-with gender, subspecialty, and faculty appointment. DESIGN: Cross-sectional study based on data abstracted from publicly available databases. PARTICIPANTS: Academic ophthalmologists from all schools in Canada with an ophthalmology residency program. METHODS: Academic ophthalmologists and their faculty appointments were identified from university websites. gender was determined from available provincial College of Physicians and Surgeons or ophthalmology society databases. H-indices were collected from Scopus and Web of Science. Descriptive, univariate, and multivariate statistics were used to analyze the relationship of H-index with gender, faculty appointment, and subspecialty. RESULTS: We included data from 696 academic ophthalmologists. The mean H-indices for lecturers and assistant, associate, and full professors were 4.0 (±5.6), 5.6 (±5.0), 8.8 (±6.3), and 15 (±12), respectively. H-index had a significant positive correlation with faculty appointment (0.521, 95% confidence interval 0.469-0.579, p = 1.77e-41). The mean H-index was 6.7 (±8.2) for women and 8.1(±8.4) for men (p = 0.0635). Women comprised 27% of faculty positions, and men were more likely to have a higher faculty appointment than women (p = 0.0073). The top subspecialties for underrepresentation of women were surgical retina, medical retina, and oculoplastics. CONCLUSIONS: Faculty appointments are associated with research productivity, as measured by H-index. There are significant gender disparities in faculty appointments and subspecialty representation. Future directions include exploring other contributory factors to success in academic ophthalmology.

The Incidence of Sympathetic Ophthalmia After Trauma: A Meta-analysis.

PURPOSE: Sympathetic ophthalmia (SO) is a rare, bilateral panuveitis that occurs following open globe injury (OGI), with a variable incidence reported in the literature. Our objective was to determine the incidence proportion and incidence rate of SO following OGI to help guide shared physician-patient decision making. DESIGN: Systematic review and meta-analysis. METHODS: A systematic literature search was performed using the MEDLINE, EMBASE, and Cochrane databases from inception to November 2020 for population-based studies on OGI and SO in adults and children. Two reviewers independently screened search results. Random-effects meta-analyses were performed to calculate the incidence proportion and incidence rate. The Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool was used to assess the risk of bias. The study was registered on PROSPERO CRD42020198920. RESULTS: A total of 24 studies were utilized in the meta-analyses. After OGI, the estimated overall incidence proportion of SO was 0.19% (95% CI 0.14%-0.24%) and the incidence rate of SO was 33 per 100,000 person-years, (95% CI 19.61-56.64) with I2 of 13% and 72%, respectively. CONCLUSIONS: SO after OGI is rare. The estimated incidence proportion and incidence rate are useful when counselling patients regarding management options after OGI. Further studies are needed to examine the influence of age, the extent and location of trauma, timing of repair, and prophylactic eye removal on the incidence of SO.

A review of robotic surgical training: establishing a curriculum and credentialing process in ophthalmology.

Ophthalmic surgery requires a highly dexterous and precise surgical approach to work within the small confines of the eye, and the use of robotics offers numerous potential advantages to current surgical techniques. However, there is a lag in the development of a comprehensive training and credentialing system for robotic eye surgery, and certification of robotic skills proficiency relies heavily on industry leadership. We conducted a literature review on the curricular elements of established robotics training programs as well as privileging guidelines from various institutions to outline key components in training and credentialing robotic surgeons for ophthalmic surgeries. Based on our literature review and informal discussions between the authors and other robotic ophthalmic experts, we recommend that the overall training framework for robotic ophthalmic trainees proceeds in a stepwise, competency-based manner from didactic learning, to simulation exercises, to finally operative experiences. Nontechnical skills such as device troubleshooting and interprofessional teamwork should also be formally taught and evaluated. In addition, we have developed an assessment tool based on validated global rating scales for surgical skills that may be used to monitor the progress of trainees. Finally, we propose a graduating model for granting privileges to robotic surgeons. Further work will need to be undertaken to assess the feasibility, efficacy and integrity of the training curriculum and credentialing practices for robotic ophthalmic surgery.

Risk of Gynecomastia with Users of Proton Pump Inhibitors.

INTRODUCTION: Proton pump inhibitors (PPIs) are commonly prescribed for many gastrointestinal diseases. A number of case reports have linked PPIs to gynecomastia in men, but large epidemiologic studies are lacking. OBJECTIVE: To quantify the risk of gynecomastia with PPIs in male patients. METHODS: Using the PharMetrics Plus™ health claims database from the United States, a retrospective cohort study of new PPI users and new amoxicillin users from 2006 to 2016 was conducted. Diagnosis of gynecomastia was identified by the International Classification for Diseases, 9th edition (ICD-9) and 10th edition (ICD-10) codes. Cases were defined as patients with two codes for gynecomastia within 90 days, with the first code as the event code. Hazard ratios (HRs) were computed by adjusting for alcoholic cirrhosis, hyperthyroidism, testicular cancer, Klinefelter syndrome, and obesity, as well as the use of ketoconazole, risperidone, spironolactone, and androgen deprivation therapy. A sensitivity analysis defining exposure with two PPI prescriptions was also undertaken. RESULTS: There were 389 cases of gynecomastia diagnosed among 220,791 new PPI users, and 996 gynecomastia cases were diagnosed among 837,740 new amoxicillin users. The crude HR for PPI use compared to amoxicillin use was 1.70 (95% confidence interval [CI]: 1.461-1.976). The adjusted HR for the sensitivity analysis was 1.299 (95% CI: 1.146-1.473). The adjusted HR was 1.4795 (95% CI: 1.2431-1.7609) for patients over 50 years old and 1.324 (95% CI: 1.1133-1.5745) for patients 50 years old or younger. CONCLUSION: This large retrospective cohort study suggests that patients who used PPIs are at higher risk of developing gynecomastia. Clinicians may want to convey this information to male patients who require long-term PPI therapy.

Risk of Parkinson's disease in patients with neovascular age-related macular degeneration.

PURPOSE: To examine the risk of developing Parkinson's Disease (PD) in patients who are newly diagnosed with neovascular age-related macular degeneration (nAMD). METHODS: This was a cohort study using the British Columbia (BC) Retinal Disease Database. Data from 2009 to 2013 was accessed. Rates of PD in patients prior to the diagnosis of nAMD were computed and compared to the rates of patients newly diagnosed with PD after the diagnosis of nAMD. RESULTS: The rate of PD prior to the diagnosis of nAMD was 1.42 per 100,000 person-years. The rate of PD after the diagnosis of nAMD was 2.88/100,000 person-years. The rate ratio was 2.03 (95% CI; 1.31-3.16). CONCLUSIONS: The findings suggest that patients who are diagnosed with nAMD are at a significantly higher risk of developing PD later in life. More studies are needed to identify the pathological mechanism between the two diseases.