INDUCTION OF MACULAR DETACHMENT FOR THE TREATMENT OF PERSISTENT OR RECURRENT IDIOPATHIC MACULAR HOLES.

PURPOSE: To analyze the efficacy of induced macular detachment for the treatment of persistent or recurrent idiopathic macular holes after treatment with one or more standard pars plana vitrectomies (PPVs) with internal limiting membrane peeling. METHODS: This study is a retrospective consecutive case series of 10 patients who underwent a PPV with subretinal balanced salt solution injection from 2011 to 2014 to treat persistent or recurrent idiopathic macular holes. All patients had previously undergone PPV with internal limiting membrane peeling. Visual acuity, ocular examination findings, and optical coherence tomographic images were reviewed preoperatively and postoperatively to assess the anatomical and visual outcomes of this procedure. RESULTS: Nine of the 10 patients who underwent the procedure had closure of their macular holes postoperatively (90%) and remained closed 6 months postoperatively. Most patients reported a subjective visual improvement. A mean objective visual improvement of 16 letters (Early Treatment Diabetic Retinopathy Study, 0.324 logMAR) was seen between preoperative and 6-month postoperative assessments of all patients (pre = 1.490, post = 1.166; P = 0.022). Subgroup analysis of patients with successful closure revealed 20 letters of improvement (0.398 logMAR) in visual acuity (pre = 1.491, post = 1.093; P = 0.004). There were no intraoperative or postoperative complications. CONCLUSION: In eyes with persistent or recurrent idiopathic macular holes after standard PPV with internal limiting membrane peeling, repeat PPV with subretinal balanced salt solution injection to create a macular detachment may be a viable surgical treatment option. Our results show improved anatomical and visual outcomes postoperatively that compare favorably to other case series describing various surgical treatments for these challenging cases.

Imaging Characteristics and Clinical Utility of Half-Dose versus Full-Dose Ultrawidefield Fundus Fluorescein Angiography.

PURPOSE: In early 2022, a fluorescein shortage occurred in the United States. To meet the standard of care for patients who required ultrawidefield fundus fluorescein angiography (UWFFA), a regimen of half-dose (250 mg) sodium fluorescein (10%) was adopted instead of the full dose (500 mg) at the Cole Eye Institute (CEI). In this paper, we compare the image quality, clinical utility, and the side-effect profile of half-dose versus full-dose fluorescein in UWFFA for a cohort of stable patients. DESIGN: Retrospective chart review. PARTICIPANTS: Patients with retinal vascular disease were included if they received half-dose and full-dose UWFFA (Optos California) within 6 months at the CEI. Eyes were excluded if they received intraocular injections, laser procedures, new immunosuppression, and worsened or improved inflammation on clinical examination. METHODS: Quantitative assessment of vascular leakage was performed using a machine learning-enhanced automated segmentation platform. Leakage from late-phase UWFFA images was compared between half-dose and full-dose images. Qualitative assessment of image quality and relative vascular leakage was performed by 2 masked independent reviewers. Side effects after fluorescein administration were recorded for each patient. MAIN OUTCOME MEASURES: Masked leakage grading and automated leakage scores. RESULTS: There were 52 eyes of 35 patients, 42 (81%) uveitic, 5 (9%) diabetic, and 4 (8%) normal controls. Patients had no change to their visual acuity (logarithm of the minimum angle of resolution mean, 0.3 ± 0.6), anterior chamber and vitreous cell between UFFWA's. UWFFA images were deemed of equal quality and leakage by both masked reviewers (78%-87% agreement; κ, 0.642). Automated leakage analysis showed mildly increased leakage in half-dose images overall (3.8% vs. 2.8%; P = 0.01) and in the macula (1.5% vs. 0.6%; P = 0.01). Side effects included nausea (half [n = 3, 9%] vs. full [n = 2, 6%]; P = 0.69) and urticaria (n = 0, 0% vs. n = 1, 2%; P = 0.99) and were not different between doses. CONCLUSIONS: In this cohort, half-dose UWFFA produced images that were of similar quality, clinical utility and with a similar side effect profile compared with full dose. Half-dose UWFFA can be used to accurately assess the retinal vasculature and could be used primarily as a method to save cost and prevent waste. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Short-Term Outcomes of Faricimab in Patients with Neovascular Age-Related Macular Degeneration on Prior Anti-VEGF Therapy.

PURPOSE: A subset of patients with neovascular age-related macular degeneration (nAMD) experience treatment burden and suboptimal response with anti-VEGF therapy. The aim of this study was to investigate the effect of switching to a novel, bispecific agent, faricimab, in patients with nAMD currently treated with anti-VEGF. DESIGN: Retrospective, noncomparative cohort study. SUBJECTS: Patients with nAMD previously treated with anti-VEGF and switched to intravitreal faricimab injection (IFI) at the Cleveland Clinic's Cole Eye Institute. METHODS: Switching and administration schedule of IFI was at the discretion of the clinician. Visual acuity (VA) and macular OCT parameters, including central subfield thickness (CST), maximum pigment epithelial detachment (PED) height, and presence of subretinal (SRF) or intraretinal fluid (IRF), were assessed at baseline (day of first IFI) and after each IFI. MAIN OUTCOME MEASURES: Central subfield thickness and presence of IRF or SRF after ≥ 3 IFIs. RESULTS: One hundred twenty-six eyes of 106 patients were included in the analysis with a mean follow-up time of 24.3 ± 5.2 weeks. Before switching to IFI, patients received a mean of either aflibercept (20.0 ± 8.4, mean ± standard deviation), bevacizumab (7 ± 8.9), ranibizumab (1.9 ± 8.5), or brolucizumab (0.3 ± 1.6) injections. The most common agent used before switching to IFI was aflibercept (n = 110, 87%), and the mean treatment interval with any anti-VEGF was 5.6 ± 1.6 weeks before switching. Central subfield thickness was reduced from baseline after the first IFI (266.8 ± 64.7 vs. 249.8 ± 58.6 µm, P = 0.02) and persisted over the 3 IFIs (P = 0.01). Pigment epithelial detachment height was reduced after the third IFI (249.6 ± 179.0 vs. 206.9 ± 130.0 µm, P = 0.01). The mean VA (62.9 vs. 62.7 approximate ETDRS letters, P = 0.42) and interval between injections (6.3 vs. 5.7 weeks, P = 0.16) was similar after the third IFI compared with baseline. Eleven (8.7%) eyes were switched back to their previous anti-VEGF, including 2 (1.6%) eyes from 1 patient with intraocular inflammation requiring cessation of IFI. There were no other adverse events from switching. CONCLUSIONS: Switching to faricimab resulted in a reduction in mean CST (-11.6 µm, P = 0.01) and PED height (-44.2 µm, P = 0.01) after 3 injections, with stable VA and at a similar treatment interval to prior anti-VEGF therapy. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Assessing the medical reasoning skills of GPT-4 in complex ophthalmology cases.

BACKGROUND/AIMS: This study assesses the proficiency of Generative Pre-trained Transformer (GPT)-4 in answering questions about complex clinical ophthalmology cases. METHODS: We tested GPT-4 on 422 Journal of the American Medical Association Ophthalmology Clinical Challenges, and prompted the model to determine the diagnosis (open-ended question) and identify the next-step (multiple-choice question). We generated responses using two zero-shot prompting strategies, including zero-shot plan-and-solve+ (PS+), to improve the reasoning of the model. We compared the best-performing model to human graders in a benchmarking effort. RESULTS: Using PS+ prompting, GPT-4 achieved mean accuracies of 48.0% (95% CI (43.1% to 52.9%)) and 63.0% (95% CI (58.2% to 67.6%)) in diagnosis and next step, respectively. Next-step accuracy did not significantly differ by subspecialty (p=0.44). However, diagnostic accuracy in pathology and tumours was significantly higher than in uveitis (p=0.027). When the diagnosis was accurate, 75.2% (95% CI (68.6% to 80.9%)) of the next steps were correct. Conversely, when the diagnosis was incorrect, 50.2% (95% CI (43.8% to 56.6%)) of the next steps were accurate. The next step was three times more likely to be accurate when the initial diagnosis was correct (p<0.001). No significant differences were observed in diagnostic accuracy and decision-making between board-certified ophthalmologists and GPT-4. Among trainees, senior residents outperformed GPT-4 in diagnostic accuracy (p≤0.001 and 0.049) and in accuracy of next step (p=0.002 and 0.020). CONCLUSION: Improved prompting enhances GPT-4's performance in complex clinical situations, although it does not surpass ophthalmology trainees in our context. Specialised large language models hold promise for future assistance in medical decision-making and diagnosis.

Efficacy of ab-interno gelatin microstent implantation in primary and refractory glaucoma.

OBJECTIVE: To evaluate the outcomes of ab interno gelatin microstent implantation alone and in combination with phacoemulsification for the reduction of intraocular pressure (IOP). DESIGN: Retrospective cohort study. PARTICIPANTS: 141 eyes of 141 patients with any glaucoma subtype, including refractory glaucoma, operated in the Centre Hospitalier de l'Université de Montréal (CHUM) from 2015-2018. Patients were included if they were over 40 years of age and had a preoperative IOP of >18 mm Hg on maximum tolerated medical therapy. METHODS: All patients received ab-interno microstent implantation (XEN-45, Allergan, Madison, NJ) with mitomycin C +/- combined phacoemulsification. The primary outcome was complete surgical success (IOP 6-18 mm Hg and <20% reduction from baseline without IOP medications or reoperations or cyclophotocoagulation); secondary outcomes included qualified success allowing for medications, percentage reduction in mean IOP and medications, and reduction in number of complications, interventions, and reoperations. RESULTS: Mean follow-up was 30.5 ± 10.2 months (±SD). Mean IOP was 23.3 ± 7.0 mm Hg on 3.4 ± 0.8 medications at baseline and 13.3 ± 4.7 mm Hg on 1.9 ± 1.5 medications at 24 months of follow-up (p < 0.001). From 24-month survival analysis estimates, complete success was achieved in 34.1% of microstent eyes versus 20.7% with combined phacoemulsification (p = 0.02); 79.1% versus 75.1% achieved qualified success, respectively (p = 0.86). Cases with combined phacoemulsification had a higher rate of failure (hazard ratio [HR] = 1.6, 95% CI 1.1-2.3, p = 0.02). Needling with mitomycin-C or 5-fluorouracil postoperatively occurred in 54 eyes (38.3%). Complications included transient hypotony (10.6%), transient hyphema (6.4%), macular edema (4.3%), and microstent exposure (2.8%). There were 33 eyes (23.4%) with reoperations and 14 (9.9%) requiring subsequent cyclophotocoagulation lasers. CONCLUSIONS: Microstent implantation required topical therapy in most cases 24 months following surgery in primary and refractory glaucoma and, when combined with phacoemulsification, had a higher risk of failure.

Consumption of a high-fat diet rapidly exacerbates the development of fatty liver disease that occurs with chronically elevated glucocorticoids.

Chronically elevated glucocorticoids (GCs) and a high-fat diet (HFD) independently induce insulin resistance, abdominal obesity, and nonalcoholic fatty liver disease (NAFLD). GCs have been linked to increased food intake, particularly energy-dense "comfort" foods. Thus we examined the synergistic actions of GCs and HFD on hepatic disease development in a new rodent model of chronically elevated GCs. Six-week-old male Sprague-Dawley rats received exogenous GCs, via subcutaneous implantation of four 100-mg corticosterone (Cort) pellets, to elevate basal GC levels for 16 days (n = 8-10 per group). Another subset of animals received wax pellets (placebo) to serve as controls. Animals from each group were randomly assigned to receive a 60% HFD or a standard high-carbohydrate (13% fat and 60% carbohydrate) diet. Cort + HFD resulted in central obesity, despite a relative weight loss, a 4-fold increase in hepatic lipid content, hepatic fibrosis, and a 2.8-fold increase in plasma alanine aminotransferase levels compared with placebo + chow controls. Hepatic injury developed independent of inflammation, as plasma haptoglobin levels were reduced with Cort treatment. Insulin resistance and hepatic steatosis occurred with Cort alone; these outcomes were further exacerbated by the HFD in the presence of elevated Cort. In addition to fatty liver, the Cort + HFD group also developed severe insulin resistance, hyperinsulinemia, hyperglycemia, and hypertriglyceridemia, which were not evident with HFD or Cort alone. Thus a HFD dramatically exacerbates the development of NAFLD and characteristics of the metabolic syndrome in conditions of chronically elevated Cort.

Long-term outcomes following primary versus secondary Boston keratoprosthesis type 1 implantation.

BACKGROUND/AIMS: To compare long-term outcomes of primary versus secondary (postgraft failure) Boston keratoprosthesis type 1 (KPro) implantation. METHODS: Medical records of patients at the Centre hospitalier de l'Université de Montréal having undergone KPro implantation between 2008 and 2017 were reviewed and included if they had a preoperative Snellen best-corrected visual acuity (BCVA) of 20/100 or worse and a minimum of 5 years of follow-up. Eighty-two eyes were separated into two cohorts (40 primary, 42 secondary KPro) and BCVA, complications and device retention were evaluated between groups. RESULTS: BCVA improved from baseline in both groups at each year; this was significant at all five postoperative years in the primary group and the first 3 years in the secondary group (p<0.05). Mean BCVA was similar between groups at 5 years (logarithm of minimal angle resolution 1.3±0.8 in the primary group vs 1.5±0.8 p<0.05). Idiopathic vitritis, choroidal detachment and new glaucoma occurred more after primary KPro (n=7, 17.5% vs n=1, 2.4%; n=11, 27.5% vs n=3, 7.14% and n=14, 35% vs n=6, 14%, respectively; p<0.05). Primary KPro had lower retention (n=28, 70% vs n=38, 91%, p<0.05) at final follow-up. There was more aniridia in the primary group (n=19, 48% vs n=6, 14%, p<0.01). Within each group, 50% of removals occurred in aniridic eyes. CONCLUSION: Primary KPro yielded favourable long-term visual outcomes but had more complications and lower retention rates than secondary KPro, likely explained by preoperative indications. Primary device implantation represents a favourable option for patients for whom grafts are likely to fail.

Size Matters: Ab Interno Canaloplasty Revision with Suture Trabeculotomy.

Aim: To report the efficacy of the revision of failed ab interno canaloplasty with micro-invasive suture trabeculotomy (MIST) over a follow-up period of 24 months. Materials and methods: A retrospective analysis was performed on 23 eyes with open-angle glaucoma (OAG), on whom an ab interno canaloplasty revision with MIST was performed for glaucoma progression. The primary outcome was the proportion of eyes with a significant intraocular pressure (IOP) reduction at 12 months post trabeculotomy, defined as an IOP ≤ 18 mm Hg or ≥20% reduction in IOP without any secondary intervention (SI), and with the same or fewer number of glaucoma medications (NGM). All parameters, including best corrected visual acuity (BCVA), IOP, NGM, and SI, were evaluated at 1, 6, 12, 18, and 24 months. Results: At 12 months, eight out of 23 eyes (36.4%) achieved complete success, maintained in six eyes (27.3%) at 24 months. A significantly lower mean IOP was recorded at all visits [14.3 ± 4.0 mm Hg at 24 months vs 23.1 ± 6.8 mm Hg at baseline (BL)] with a percent IOP change of up to 27.3% at 24 months postoperatively. NGM and BCVA did not significantly decrease from BL. A total of 11 eyes (47.8%) needed an SI throughout the follow-up period. Conclusion: Ab interno trabeculotomy in patients with failed canaloplasty was not shown to be effective in providing a satisfactory control of IOP in OAG patients, possibly due to the small suture gauge used in the initial canaloplasty. Clinical significance: Further research is needed to optimize the surgical outcome. How to cite this article: Seif R, Jalbout NDE, Sadaka A, et al. Size Matters: Ab Interno Canaloplasty Revision with Suture Trabeculotomy. J Curr Glaucoma Pract 2022;16(3):152-157.

Risk factors for epiretinal membrane formation and peeling following pars plana vitrectomy for primary rhegmatogenous retinal detachment, an OCT guided analysis.

BACKGROUND: To evaluate the rate and risk factors of epiretinal membrane (ERM) formation and need for ERM peeling after pars plana vitrectomy (PPV) for uncomplicated primary rhegmatogenous retinal detachment (RRD). METHODS: Retrospective, single-center, cohort study of 119 consecutive patients (119 eyes) that underwent RRD repair using PPV. The primary outcomes were ERM formation, classified using an optical coherence tomography grading system, and the rate of ERM peeling. Visual acuity, postoperative complications, and risk factors for ERM formation and peeling were also identified. RESULTS: Postoperative ERM formation occurred in 69 eyes (58.0%); 56 (47.1%) were stage 1, 9 (7.6%) stage 2, 3 (2.5%) stage 3, and 1 (0.8%) stage 4. Only 6 (5.0%) eyes required secondary PPV for a visually significant ERM, with a mean time to reoperation of 488 ± 351 days. Risk factors for ERM formation included intraoperative cryotherapy, more than 1000 laser shots, 360° laser photocoagulation, and choroidal detachment (p < 0.01). Eyes with more than 3 tears had a trend towards increased ERM surgery (p = 0.10). CONCLUSIONS: Visually significant ERM formation following PPV for primary RRD was uncommon in this cohort (5%). Half of the ERMs were detected after the first post-operative year, indicating that this complication may be underreported in studies with only 1-year follow-up.

Endophthalmitis in Eyes With the Boston Type I Keratoprosthesis: Incidence, Recurrence, Risk Factors, and Outcomes.

PURPOSE: To determine the incidence and recurrence of Boston type I keratoprosthesis (KPro)-associated endophthalmitis, and its microbiological profile, risk factors, and outcomes. METHODS: This is a retrospective study of 158 consecutive KPro procedures with a median follow-up of 78.4 months. Medical charts were reviewed for ocular history, contact lens and topical antibiotic use, visual acuity, and complications. For eyes with endophthalmitis, time to infection, culture results, and recurrences were collected. Cox regression analyses identified risk factors for endophthalmitis and compared the risk for visual failure, KPro retention, and globe loss between eyes with and without endophthalmitis. RESULTS: The incidence and recurrence rates of endophthalmitis were of 1.7% and 6.0% per procedure-year, respectively. First episodes occurred at a median of 18.6 months. Eight of 18 episodes (44%) were culture positive, isolating mainly Gram-positive bacteria (7 [88%]). Previous ocular burn (hazard ratio: 7.34, 95% confidence interval: 1.91-28.15), infectious keratitis (5.09, 1.70-15.22), corneal melt (4.55, 1.50-13.83), and postoperative contact lens wear (4.19, 1.17-15.04) were risk factors. Eyes with endophthalmitis did not have a higher risk for visual failure (1.74, 0.78-3.91) but were more likely to not retain the KPro (2.81, 1.15-6.88) and undergo evisceration (2.81, 1.15-6.88). All eyes lost ≥ 2 lines of vision during the endophthalmitis episode. CONCLUSIONS: Endophthalmitis is rare but vision and globe threatening in eyes with KPro. Given the increased associated risk, corneal melts and infectious keratitis must be promptly treated, postoperative contact lenses should be considered on a case-by-case basis, and patients with ocular burns might require more aggressive antimicrobial prophylaxis.

Correlation of ocular rigidity with intraocular pressure spike after intravitreal injection of bevacizumab in exudative retinal disease.

BACKGROUND/AIMS: To evaluate the non-invasive measurement of ocular rigidity (OR), an important biomechanical property of the eye, as a predictor of intraocular pressure (IOP) elevation after anti-vascular endothelial growth factor (anti-VEGF) intravitreal injection (IVI). METHODS: Subjects requiring IVI of anti-VEGF for a pre-existing retinal condition were enrolled in this prospective cross-sectional study. OR was assessed in 18 eyes of 18 participants by measurement of pulsatile choroidal volume change using video-rate optical coherence tomography, and pulsatile IOP change using dynamic contour tonometry. IOP was measured using Tono-Pen XL before and immediately following the injection and was correlated with OR. RESULTS: The average increase in IOP following IVI was 19±9 mm Hg, with a range of 7-33 mm Hg. The Spearman correlation coefficient between OR and IOP elevation following IVI was 0.796 (p<0.001), showing higher IOP elevation in more rigid eyes. A regression line was also calculated to predict the IOP spike based on the OR coefficient, such that IOP spike=664.17 mm Hg·µL×OR + 4.59 mm Hg. CONCLUSION: This study shows a strong positive correlation between OR and acute IOP elevation following IVI. These findings indicate that the non-invasive measurement of OR could be an effective tool in identifying patients at risk of IOP spikes following IVI.

Long-term visual outcomes of the Boston type I keratoprosthesis in Canada.

BACKGROUND/AIMS: To evaluate long-term visual outcomes of Boston type I keratoprosthesis (KPro) surgery and identify risk factors for visual failure. METHODS: Single surgeon retrospective cohort study including 85 eyes of 74 patients who underwent KPro implantation to treat severe ocular surface disease, including limbal stem cell deficiency, postinfectious keratitis, aniridia and chemical burns. Procedures were performed at the Centre hospitalier de l'Université de Montréal from October 2008 to May 2012. All patients with at least 5 years of follow-up were included in the analysis, including eyes with repeated KPro. Main outcome measures were visual acuity (VA), visual failure, defined as a sustained worse than preoperative VA, postoperative complications, and device retention. RESULTS: Mean follow-up was 7.2±1.3 years (±SD). Mean VA was 2.1±0.7 (logarithm of minimal angle resolution) preoperatively and 1.9±1.2 at last follow-up. There were 2.4% of patients with VA better than 20/200 preoperatively and 36.5% at last follow-up. Maintenance of improved postoperative VA was seen in 61.8% of eyes at 7 years. Preoperative factors associated with visual failure were known history of glaucoma (HR=2.7 (1.2 to 5.9), p=0.02) and Stevens-Johnson syndrome (HR=7.3 (2.5 to 21.4) p<0.01). Cumulative 8-year complication rates were 38.8% retroprosthetic membrane formation, 25.9% hypotony, 23.5% new onset glaucoma, 17.6% retinal detachment, 8.2% device extrusion and 5.9% endophthalmitis. The majority (91.8%) of eyes retained the device 8 years after implantation. CONCLUSION: Almost two-thirds of patients had improved VA 7 years after KPro implantation. Preoperative risk factors for visual failure were known glaucoma and Stevens-Johnson syndrome.

Usefulness of Prestorage Corneal Swab Culture in the Prevention of Contaminated Corneal Tissue in Corneal Transplantation.

PURPOSE: To assess the efficacy of the prestorage corneal swab (PCS) culture to screen for corneal graft contamination after storage in Optisol-GS. METHODS: A retrospective analysis of all PCS cultures was performed at the Eye Bank of Québec in Hôpital Maisonneuve-Rosemont from September 2013 to June 2016. Whole corneal culture was performed on rejected grafts because of a positive PCS, and a contamination rate was calculated. In addition, contamination rates of corneoscleral rims were compared between corneas tested with PCS and those of imported corneas which did not have PCS. RESULTS: Among the 1966 PCS cultures performed, 814 (41.4%) were positive for growth. Pathogenic bacteria were present in 144 (7.3%) corneas, including Staphylococcus aureus (n = 96, 11.8% of all positive cultures), Enterobacteriaceae (n = 14, 1.7%), and Pseudomonas aeruginosa (n = 6, 0.7%). After preservation in Optisol-GS, only 7 (6.9%) corneas remained contaminated (95% confidence interval 5.1-9.3). The sensitivity of the PCS culture was 87.5% (95% confidence interval 47.4-99.7). There was no significant difference in corneoscleral rim contamination between corneas tested with PCS (1/388; 0.2%) compared with imported, nonswabbed corneas (3/214; 1.4%) (P = 0.131). Therefore, the cost to recover the loss of tissue rejected because of false-positive PCS by purchasing corneal tissue was calculated to be $142,884 (CAD) per year. CONCLUSIONS: Despite the high sensitivity of PCS cultures, there was no significant reduction of infection after corneal transplantation using this technique. In consequence, 93% of the corneas possibly suitable for transplantation were rejected. This suggests that the PCS culture alone is a poor test for detecting clinically relevant corneal contamination.

Population trends in adult strabismus surgery.

OBJECTIVE: To review the trends in adult strabismus procedures in Ontario from 2000-2013. DESIGN: Population-based, retrospective data analysis. PARTICIPANTS: All patients 18 years or older who underwent a strabismus related procedure in Ontario and all ophthalmologists who performed these procedures from 2000-2013. METHODS: Ontario Health Insurance Plan billing claims for strabismus procedures were collected and subdivided by number of muscles repaired, the use of adjustable sutures, repeat procedures, and pharmacological injection of the extraocular muscles adjusted by the total adult population. The number of ophthalmologists performing adult strabismus surgery was also analyzed, subdivided by high-volume and low-volume surgeons. RESULTS: From 2000-2013, per 100 000 adult population, the number of total strabismus surgeries in Ontario increased 26.0%; single-muscle surgery increased 24.2%, 2-muscle surgery increased 43.1%, and 3 or more muscle surgery increased 3.8%. During the study period, strabismus procedures using adjustable sutures increased 30.3%, and repeat procedures increased 19.1%. The number of surgeons performing adult strabismus surgery decreased 30.0% from 2000-2013. In 2013, 92.6% of surgeries were performed by 35.7% of surgeons who performed adult strabismus surgery. CONCLUSION: From 2000-2013, more strabismus surgery was performed in adults by fewer surgeons, including procedures using adjustable sutures and repeat procedures. These increases may be due to increases in health care funding and a heightened awareness of the functional and psychosocial benefits of strabismus surgery.

Effect of Eye Masks on Neonatal Stress Following Dilated Retinal Examination: The MASK-ROP Randomized Clinical Trial.

IMPORTANCE: Although screening examinations for retinopathy of prematurity (ROP) prevent blindness, they are physiologically stressful for infants. Photosensitivity during mydriasis may contribute to postexamination stress, and reducing light stimulation may make infants more comfortable. OBJECTIVE: To determine the effect of a phototherapy mask worn during mydriasis on infant stress in the 12-hour period following ROP screening. DESIGN, SETTING, AND PARTICIPANTS: The Effect of Eyemasks on Neonatal Stress Following Dilated Retinal Examination (MASK-ROP) randomized clinical trial with patient recruitment from April 2016 to June 2017 at neonatal intensive care units at St Michael's Hospital and Sunnybrook Health Sciences Center in Toronto, Ontario, Canada. A consecutive series of infants with birth weight of less than 1500 g and/or gestational age of less than 32 weeks undergoing their first ROP screening were analyzed beginning in July 2017. Analysis was intention to treat. INTERVENTIONS: Patients were randomized to wear a phototherapy mask for a minimum of 4 hours after dilating drop instillation in addition to standard comfort measures. MAIN OUTCOMES AND MEASURES: Number of desaturation, bradycardic, or apneic events during the 12-hour postexamination period. RESULTS: Of 51 infants who were examined, 28 (54.9%) were randomized to the treatment group (ie, used a mask) and 23 (45.1%) to the control group. Overall, 10 (35.7%) and 13 infants (56.5%) received ventilator support at the time of examination in the treatment and control groups, respectively. The mean (SD) gestational age was 27.9 (2.4) weeks, 32 (63%) were boys, and the mean (SD) birth weight was 1058.6 (312.0) g. The number of all stressful events were lower in the treatment group compared with controls in the 12-hour postexamination period, adjusted for events prior to examination and ventilation status (mean [95% CI] events, 1.0 [0.6-1.8] vs 1.7 [1.0-1.7]; rate ratio [RR], 0.57; 95% CI, 0.3-1.2; P = .12). Risk factors associated with increased stress included younger gestational age (RR, 1.32; 95% CI, 1.2-1.5 per week), lower birth weight (RR, 1.39; 95% CI, 1.2-1.5 per 100 g), ventilator support around the time of examination (RR, 2.67; 95% CI, 1.3-5.6), intraventricular hemorrhage (RR, 3.78; 95% CI, 1.9-7.3), and hyponatremia (RR, 3.42; 95% CI, 1.8-6.6). No adverse events occurred while using eye masks. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that light sensitivity may play a role in stress observed in the late postexamination period. However, unequal distribution of infants receiving ventilator support placed certain neonates at higher risk of stress, and the clinical significance of this intervention's benefit could not be concluded with confidence. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03824782.

Surgeon perspectives on learning ab-interno gelatin microstent implantation.

OBJECTIVE: To evaluate and compare the surgeon's learning experience with an ab-interno gelatin microstent (XEN-45, Allergan) to other glaucoma surgeries. DESIGN: Cross-sectional survey study. METHODS: All surgeons in Canada who used the gelatin microstent were identified and given an anonymous online survey (FluidSurveys, Survey Monkey) designed to evaluate key factors associated with the device, including prior surgical experience, patient selection criteria, analysis of each surgical step, and postoperative care. The survey was validated using input from 3 experienced glaucoma surgeons. RESULTS: Surgeons were in early to mid-career (11.8 ± 7.2 operating years) and experienced with filtration surgery (94.1% very comfortable). Surgeons would more commonly operate on patients who had moderate to advanced disease (88.2% and 76.5% of surgeons felt appropriate to operate, respectively); had a diagnosis of primary open angle glaucoma or pseudoexfoliative glaucoma (70.6%); were on 2, 3, or 4 glaucoma medications (70.6%, 75.5%, 70.6%, respectively); and had previously undergone microinvasive glaucoma surgery (83.3%). Creation of the scleral tunnel into the subconjunctival space was rated the most difficult step of the surgery. Most surgeons (52.9%) required 6-10 cases to be comfortable with the procedure and felt it was easier to gain proficiency with ab-interno microstent implantation than traditional filtration surgery (94.1% agree or strongly agree). CONCLUSION: The group of glaucoma surgeons surveyed felt it was easier to gain proficiency with gelatin microstent implantation than with traditional filtration surgery.

Population-based analysis of intraocular lens exchange and repositioning.

PURPOSE: To determine the incidence and trends in intraocular lens (IOL) repositioning, exchange, and explantation. SETTING: Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada. DESIGN: Population-based retrospective data analysis. METHODS: Service claims from 2000 to 2013 were analyzed for the total yearly number of IOL repositionings, exchanges, and explantations in Ontario, Canada, including the number of surgeons performing them by subspecialty. The 5-year incidence proportion of secondary IOL surgery for patients who had cataract surgery in 2000 and 2009 was calculated and then stratified by sex, age, and year of second surgery. RESULTS: Of the 1252 secondary procedures performed in 2013 (75.6% increase from 2000), 43.2% were repositionings without suturing, 31.6% were exchanges without suturing, 10.5% were sutured repositionings, 7.0% were sutured exchanges, and 7.7% were explantations. The incidence proportion of risk for secondary IOL surgery was 0.93% from 2000 to 2004, which decreased to 0.78% from 2009 to 2013 (16.4% decrease; odds ratio, 0.83; 95% confidence interval [CI], 0.72-0.94; P < .001). Patients who had these procedures were 1.56 times more likely to be men (95% CI, 1.39-1.76; P < .001) and 1.52 times more likely to be younger than 65 years (95% CI, 1.33-1.73; P < .001). From 2000 to 2013, sutured repositionings and explantations increased by 568% and 531%, respectively, whereas exchanges without suturing decreased by 22.6%. In 2013, 11.6% of surgeons performed 52.0% of all secondary IOL surgeries. CONCLUSIONS: Although the absolute number of secondary IOL procedures increased from 2000 to 2013, the 5-year risk for surgery decreased. A large proportion of the surgeries was performed by a small number of surgeons, which suggests subspecialization.