Faculty Bibliography

Wearing contact lenses has been identified as a risk factor for the development of eye conditions such as giant papillary conjunctivitis and keratitis. We hypothesized that wearing contact lenses is associated with changes in the ocular microbiota. We compared the bacterial communities of the conjunctiva and skin under the eye from 58 subjects and analyzed samples from 20 subjects (9 lens wearers and 11 non-lens wearers) taken at 3 time points using a 16S rRNA gene-based sequencing technique (V4 region; Illumina MiSeq). We found that using anesthetic eye drops before sampling decreases the detected ocular microbiota diversity. Compared to those from non-lens wearers, dry conjunctival swabs from lens wearers had more variable and skin-like bacterial community structures (UniFrac;P value = <0.001), with higher abundances ofMethylobacterium,Lactobacillus,Acinetobacter, andPseudomonasand lower abundances ofHaemophilus,Streptococcus,Staphylococcus, andCorynebacterium(linear discriminant analysis [LDA] score = >3.0). The results indicate that wearing contact lenses alters the microbial structure of the ocular conjunctiva, making it more similar to that of the skin microbiota. Further research is needed to determine whether the microbiome structure provides less protection from ocular infections. IMPORTANCE: As in other body sites (i.e., the gut, skin, and mouth), the eye has a normal community of bacteria which are expected to confer resistance that provides protection from invaders. However, the eye microbiome has been largely neglected and is relevant to eye health and understanding eye diseases and to discovery of its functions. This report of a baseline study shows differences in the eye microbiome of contact lens wearers in relation to those of non-lens wearers and has the potential to help future studies explore novel insights into a possible role of the microbiome in the increased risk for eye infections in contact lens wearers.

OBJECTIVE:: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. METHODS:: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. RESULTS:: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. CONCLUSIONS:: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

Purpose Diabetic retinopathy is among the leading causes of preventable vision loss in workingaged individuals, and early diagnosis may prevent progression to advanced disease. Our objective was to study the potential use of a retinal acuity meter (RAM) with a brightness acuity meter (BAM) [AMA Optics, Fair Oaks, California, United States of America] as a screening tool to identify patients with early diabetic macular edema. Methods Diabetic patients were recruited in the ophthalmology clinic at Bellevue Hospital Center, New York. We performed the following exams: hemoglobin A1c (HbA1c), central foveal thickness (CFT) by spectral domain optical coherence tomography (SD-OCT) with the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, DE) and visual acuity with the RAM. Macular edema was de ned as CFT greater than 300 mum. After a 15-second macular photostress (MP) using the BAM, recovery time to RAM baseline visual acuity was measured without knowledge of the OCT data. Results A total of 47 eyes from 26 patients were analyzed. 17 eyes had macular edema and among these 35.5% were female, with a mean age of 60.8 years, mean HbA1c of 8.6%, mean recovery time of 24 sec and mean CFT of 327 mum. 30 eyes were without macular edema and among these 36.7% were female, with a mean age of 52.9 years and a mean HbA1c of 8.4%, mean recovery time of 19 sec and mean CFT of 264 mum. Retinal acuity ranged from 20/20 to 20/400 and MP recovery time ranged from 5 to 42 seconds. There was a signi cant correlation between recovery time greater than 21 secs and CFT by OCT greater than 300 mum (Chi square test = 5.8 , p = 0.02, Figure). The relationships between CFT or MP recovery and HbA1c did not show signi cant correlation. Conclusions Diabetic patients with central foveal thickness by OCT greater than 300 mum demonstrated signi cantly delayed MP recovery time as measured by the retinal and brightness acuity meters. Given the ease of use, these instruments could serve non-ophthalmologists, e.g., internists, as screening tools of macular function in patients with diabetes. Early referrals to ophthalmologists based on these screening results may result in prevention of irreversible vision loss

Purpose: To evaluate the cornea ulcer microbiology of patients at an urban city hospital. Methods: Corneal ulcer patients examined and cultured were identified retrospectively. The media and stains submitted were assessed, and the microbiology was analyzed. Gram stains were analyzed and correlated with positive cultures. The use of topical antibiotic and/or topical steroid at time of culture was analyzed to correlate with positive results. Results: 114 corneal ulcers were treated over 10 years (1/2004 to 12/2013). 71/114 (62.3%) ulcers were cultured. 68/71 (95.8%) of the cultures submitted were corneal scrapings plated on blood, chocolate, thioglycolate, sabaround's, and slides for gram stains. 3 included KOH stains for fungus. 3/71 submissions were corneal swab with gram stain.17/68 (25%) culture submissions from scrapings were incomplete, missing one of the media plates. 9/71(12.7%) submissions did not include a gram stain. 0/3 corneal swabs yielded a positive result. 24/68 (35.3%) of corneal scraping cultures yielded a positive result, including 1 mixed bacterial and 1 fungal. The most common was pseudomonas aeruginosa 8/68 (11.8%), followed by serratia 4/68, coag negative staph 3/68, and stenotrophomonas maltophilia 2/68. There was one positive result each for Bacillus, strep pneumoniae, MRSA, and beta strep group G. One culture grew both bacillus and coag negative staph. One culture grew Aspergillus. At time of culture, 21 patients were on a topical antibiotic (including the patient whose culture grew Aspergillus), 3 were on a topical steroid, and 2 were on both. Compared to positive cultures in patients not on any medications (14/41 or 24%), positive cultures were found in 6/23 (26%) of patients on topical antibiotic with or without steroids (P=0.849), and 2/3 (66%) of patients on steroid alone (P=0.267). 12/62 (19%) gram stains were positive. 5/5 gram stains that showed an organism had corresponding growth in culture. 8/12 (66.7%) of positive gram stains eventually yielded growth of a microorganism compared to 14/50 (28%) of negative gram stains (P=0.012). 0/3 of KOH stains submitted yielded fungal elements. Conclusions: The majority of ulcers cultured yielded bacteria, with pseudomonas the most common. The use of topical antibiotic or steroid did not statistically affect culture yield. A positive gram stain does correlate with a positive culture yield. However, there is a high frequency of incomplete cultures

PURPOSE:: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. METHODS:: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. RESULTS:: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). CONCLUSIONS:: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.

PURPOSE: To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. DESIGN: Prospective interventional cohort study. METHODS: setting: Academic City Hospital, Bellevue Hospital. participants: A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. interventions: The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. main outcome measures: Barriers to administration of the vaccine were evaluated. RESULTS: A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P