Faculty Bibliography

BACKGROUND:Despite females comprising 50.8% of the U.S. population, the percentage of females in the physician workforce is only 36.3%. Studies have examined sex trends within select specialties, however there is insufficient literature studying trends across all specialties. In this study, the authors examined trends in the proportion of female residents from 2011 to 2019 across all specialties, including both surgical and non-surgical.  METHODS: Data on the proportion of female residents from 2011 to 2019 in all specialties was extracted from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books and analyzed with the chi-square test for trend. RESULTS:From 2011 to 2019, there was a statistically significant increase in the percentage of female residents in surgical specialties (p < 0.001) and no significant change in the percentage of female residents in non-surgical specialties. In the same time period, the specialty with the highest percentage of females was Obstetrics & Gynecology (81.3%), and the specialty with the lowest percentage of females was Orthopedic Surgery (13.8%). CONCLUSIONS:Although there has been a positive overall trend in the percentage of females entering medical and surgical specialties, the percentage of females in medicine overall still lies below that of the entire population. Increased efforts are needed to increase female representation in medicine, especially in the U.S. in specialties where they are traditionally underrepresented.

PURPOSE/OBJECTIVE:To report the incidence of immediate (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) and identify factors associated with undergoing ISBCS. DESIGN/METHODS:Retrospective cohort study. SUBJECTS/METHODS:Medicare beneficiaries aged ≥65 who underwent ISBCS and DSBCS from 2011 to 2019. METHODS:Population-based analysis of the 100% Medicare fee-for-service carrier claims data. Logistic regression models were performed to evaluate factors associated with ISBCS. MAIN OUTCOME MEASURES/METHODS:1) Incidence of ISBCS and DSBCS, 2) demographic, ocular and medical characteristics associated with receipt of ISBCS, and 3) rates of endophthalmitis and cystoid macular edema (CME) after ISBCS or DSBCS. RESULTS:A total of 4,014 (0.2%) ISBCS and 1,944,979 (99.8%) DSBCS patients were identified. Black (OR:2.31, 95%CI: 2.06-2.59), Asian (OR:1.82, 95%CI: 1.51-2.12), or Native American (OR:2.42, 95%CI: 1.81-3.23) patients were more likely to receive ISBCS compared to White patients. Patients residing in rural areas had higher likelihood of ISBCS (OR:1.26, 95%CI: 1.17-1.35) compared to metropolitan areas. Patients operated at a hospital compared to ambulatory setting (OR:2.71, 95%CI: 2.53-2.89) were more likely to receive ISBCS. Patients with bilateral complex vs. non-complex cataract (OR:3.23, 95%CI: 2.95-3.53) were more likely to receive ISBCS. Patients with a Charlson comorbidity index (CCI) of 1-2 (OR:1.45, 95%CI: 1.29-1.62), 3-4 (OR:1.70, 95%CI: 1.47-1.97), 5-6 (OR:1.97, 95%CI: 1.62-2.39), and CCI≥7 (OR:1.97, 95%CI: 1.55-2.50) were all more likely to receive ISBCS compared to those with CCI=0. In contrast, patients with glaucoma (OR:0.82, 95%CI: 0.76-0.89), macular degeneration (OR:0.75, 95%CI: 0.68-0.82), and macular hole/epiretinal membrane (OR:0.55, 95%CI: 0.48-0.65) were less likely to undergo ISBCS compared to those without. Cumulatively, there was no significant difference in endophthalmitis rate within 42 days between ISBCS (1.74 per 1,000 ISBCS) and DSBCS (1.01 per 1,000 DSBCS; p=0.15). Similarly, there was no significant cumulative difference between ISBCS (1.79 per 100 ISBCS) and DSBCS (1.96 per 100 DSBCS) CME rates (p=0.48). CONCLUSION/CONCLUSIONS:Overall utilization of ISBCS among Medicare beneficiaries remains low over the past decade, though rates of endophthalmitis and CME were comparable to DSBCS. Race, geography, systemic and ocular comorbidities were associated with receiving ISBCS. ISBCS represents a potential opportunity to improve access to cataract surgery.

PURPOSE/OBJECTIVE:Since the exact development of posterior subcapsular cataracts (PSCs) is poorly understood, we review various risk factors and propose a two-stage etiology for PSCs. METHODS:The biological mechanisms associated with age-related cataracts (primarily nuclear cataracts, cortical cataracts and PSCs) were reviewed in relation to selected risk factors that induce PSCs (including atopy, diabetes, hypoparathyroidism, myopia, retinitis, solar radiation, steroid use, uveitis, vitrectomy and ionizing radiation). We particularly focused on ionizing radiation, as this is known to be a risk factor specific to PSCs. Based on an analysis of the reviewed material, we propose a detailed explanation of the etiology of PSCs. CONCLUSIONS:Lens epithelial cells (LECs) and lens fiber cells are normally hypoxic and therefore very sensitive to changes in oxidative stress, as quantified by the radiation oxygen effect. We hypothesize that the development of PSC opacities is a two-stage process. Stage I, early in life, is driven by risk factors that promote oxidative stress and ion-pump disruption, harming lens fibers and causing aberrant LECs to proliferate and ectopically migrate as Wedl cells (perhaps by processes associated with an epithelial to mesenchymal transition) to the posterior pole region. After a latent period, in Stage II, the development of PSCs advances mainly due to chronic inflammation and other premature aging-related mechanisms that promote mature vacuolar or plaque PSC. This two-stage hypothesis of PSC etiology accounts for risk factors, such as aging, diabetes and ionizing radiation, which directly affects LECs and the lens. In addition, these risk factors can damage other ocular regions, such as the retina and vitreous, that also indirectly contribute to the development of PSCs. It is possible that the incidence of PSCs may be reduced by reversing the effects of Stage I through various means, including ocular antioxidants.

PURPOSE/OBJECTIVE:To evaluate visual and refractive outcomes and rotational stability of toric intraocular lens (IOL) implantation in eyes with previous ocular surgeries. METHODS:This controlled, longitudinal cohort study included a total of 133 eyes (59 study cases with a history of corneal, vitreoretinal, and/or glaucoma surgery and 74 randomly selected controls without a history of ocular surgery) that had cataract and corneal astigmatism treated with toric IOL implantation. Postoperative outcomes were recorded at postoperative 1 month and 3 to 12 months. RESULTS:Refractive prediction errors were within ±1.00 diopter (D) of target in 93.5% and 88.4% of the study cases at postoperative 1 month and 3 to 12 months, respectively. They were within ±0.50 D of target in 56.5% and 60.5% of the cases during the same follow-up intervals, respectively. Study cases showed statistically significantly inferior uncorrected distance visual acuity (UDVA) compared to controls at 1 month postoperatively (0.27 ± 0.24 and 0.17 ± 0.21 logMAR, respectively, P = .027) but not during the later follow-up (0.19 ± 0.19 and 0.16 ± 0.19 logMAR, respectively, P = .431). Corrected distance visual acuity (CDVA) was slightly lower in the study cases than in controls at 1 month postoperatively (0.13 ± 0.16 and 0.07 ± 0.14, respectively, P = .005) and subsequent follow-up months (0.10 ± 0.13 and 0.03 ± 0.10, respectively, P < .001). Of the examined study cases, 93.9% and 88.4% had IOL axes within 5° of intended axis at postoperative 1 month and 3 to 12 months, respectively. CONCLUSIONS:Toric IOLs provided significant and sustained improvement in visual acuity and refraction in eyes with a history of prior ophthalmic surgery. Refractive outcomes achieved postoperatively were comparable to those in eyes without a prior history of ophthalmic surgery, although the rate of visual recovery may be different. [J Refract Surg. 2019;35(12):781-788.].

OBJECTIVE:To assess the regional variability of corneal endothelial cell density (ECD) between guttae and non-guttae areas in subjects with Fuchs endothelial corneal dystrophy (FECD) using non-contact specular microscopy and confocal microscopy. DESIGN:Retrospective chart review from 2009 to 2014 at the Massachusetts Eye and Ear Infirmary. PARTICIPANTS:One hundred fifteen eyes of 73 subjects with FECD. METHODS:Subjects with FECD underwent same-day specular and confocal microscopy in the same eye. Clinical stage of disease was documented on the day of image acquisition. Regional variability of ECD associated with guttae and non-guttae areas was assessed. Manual endothelial cell counts were performed. RESULTS:; p < 0.0001) as determined by confocal microscopy. CONCLUSION:These findings support confocal microscopy as an alternative to specular microscopy for evaluating the corneal endothelium of patients with FECD, especially those with advanced disease. Confocal microscopy also revealed regional differences in ECD in guttae and non-guttae areas in patients with FECD.

PURPOSE/OBJECTIVE:Corneal transplantation is the standard of care for pediatric corneal opacities, but little consensus exists on optimal surgical management. Our goal was to evaluate cross-sectional data of donor and recipient characteristics collected from eye banks providing tissue for pediatric corneal transplant cases to assess surgical trends in pediatric keratoplasty over the past 13 years. METHODS:We performed a retrospective review of recipient data, collected from 4 major eye banks, for pediatric patients (<18 years) who underwent corneal transplantation between January 2005 and December 2017. We analyzed trends in surgical indications, types of keratoplasty, and donor/recipient characteristics. RESULTS:Our database included 2620 total pediatric cases. Penetrating keratoplasty (PKP) remains the most common surgery performed (79.8%), but more partial-thickness transplant cases [eg, endothelial keratoplasty (EK)] have been performed since 2008. The most commonly reported transplant indication was ectasias/thinnings (34.1%) overall and congenital opacities (17.0%) in children less than 5 years. Average donor age was significantly lower for the youngest recipient age group of less than 5 years (P < 0.001); endothelial cell count was also higher, and death-to-surgery time was lower for PKP and EK cases versus other keratoplasties. CONCLUSIONS:Indications for transplant vary across age groups but are consistent with previous reports. Popularity of partial-thickness transplants has increased since 2008. Surgeons prefer younger donor tissue for younger patients and have higher thresholds for endothelial cell count for PKP and EK cases. Centralized tracking of pediatric keratoplasty cases is necessary for further investigation of long-term outcomes.

Purpose/UNASSIGNED:To evaluate the effects of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) medications in combination with cataract surgery in treating amblyopia in adult patients. Patients and methods/UNASSIGNED:A retrospective chart review study was conducted on patients who had undergone cataract surgery at the Johns Hopkins Hospital Wilmer Eye Institute. Six inclusion criteria were used to assess patient eligibility: 1) >18 years of age, 2) diagnosis of amblyopia, 3) diagnosis of cataract and treatment with surgery, 4) electronic medical record contains pre-surgery and post-surgery visual acuity (VA) measurements, 5) electronic medical record contains information on whether the patient was ever prescribed a SSRI/SNRI and the treatment duration, and 6) interocular VA difference of two lines or more on Snellen chart prior to cataract surgery. From each record, preoperative VA, postoperative VA, date of surgery, date at which postoperative VA was measured, and age at surgery were collected. Results/UNASSIGNED:<0.005). Conclusion/UNASSIGNED:This study suggests that patients with amblyopia undergoing cataract surgery may potentially have a greater visual improvement when treated with SSRI/SNRIs.

PURPOSE/OBJECTIVE:To facilitate development of standardized guidelines for management of pediatric patients undergoing keratoplasty, particularly the youngest cohort, through a comprehensive survey assessing recent trends in practice patterns of corneal specialists and pediatric ophthalmologists. METHODS:A cross-sectional, observational study of current practices pertaining to pediatric keratoplasty was performed by designing a 20-question survey focused on preoperative indications, surgical techniques, and postoperative management. This survey was sent electronically to corneal specialists and pediatric ophthalmologists. Results were compared with the findings of previous studies regarding pediatric keratoplasty. RESULTS:Of the 80 ophthalmologists who responded, 51.3% currently perform pediatric keratoplasty; only 20% have performed >50 cases. The majority (73.8%) completed solely corneal fellowships; all perform penetrating keratoplasty, 35.2% also perform endothelial keratoplasty, and 37% also perform lamellar keratoplasty. Peters anomaly was the most common indication for transplantation (34.3%). The majority believe that 1 to 3 months is the optimal age range to perform keratoplasty for both monocular and binocular congenital corneal opacities, although 13% stated that they would never perform keratoplasty in a patient with a monocular opacity. All surgeons report modifying their intraoperative techniques for pediatric patients, but specific practices and postoperative management protocols vary. There is a consensus regarding the importance of amblyopia therapy in these patients. CONCLUSIONS:Our results were consistent with the published literature regarding the indication and types of surgery performed. Variability among surgical techniques and postoperative management protocols highlights the necessity of creating standardized guidelines to optimize management of pediatric patients undergoing keratoplasty. Collaborative efforts between corneal and pediatric specialists are crucial for defining visual rehabilitation protocols to enhance visual outcomes.

PURPOSE:This review summarizes the conclusions and recommendations of the new National Council on Radiation Protection and Measurements (NCRP) Commentary No. 26 guidance on radiation dose limits for the lens of the eye. The NCRP addressed radiation protection principles in respect to the lens of the eye, discussed the current understanding of eye biology and lens effects, reviewed and evaluated epidemiology, and assessed exposed populations with the potential for significant radiation exposures to the lens while suggesting monitoring and protection practices. CONCLUSIONS:Radiation-induced damage to the lens of the eye can include the loss of clarity resulting in opacification or clouding several years after exposure. The impact is highly dependent on the type of radiation, how the exposure of the lens was delivered, the genetic susceptibilities of the individual exposed, and the location of the opacity relative to the visual axis of the individual. The preponderance of epidemiological evidence suggests that lens damage could occur at lower doses than previously considered and the NCRP has determined that it is prudent to reduce the recommended annual lens of the eye occupational dose limit from an equivalent dose of 150 mSv to an absorbed dose of 50 mGy. Significant additional research is still needed in the following areas: comprehensive evaluation of the overall effects of ionizing radiation on the eye, dosimetry methodology and dose-sparing optimization techniques, additional high quality epidemiology studies, and a basic understanding of the mechanisms of cataract development.