Faculty Bibliography

PRECISE/UNASSIGNED:In this article, we describe the development of validated software that automates cost-effectiveness analyses of minimally invasive glaucoma surgeries based on modifications to robust mathematical models of glaucoma progression and management discussed in previous literature. PURPOSE/OBJECTIVE:To develop a validated application to streamline use of cost-effectiveness (CE) in clinical management and investigations of minimally invasive glaucoma surgeries (MIGS) in the United States. DESIGN/METHODS:Automated cost-utility analysis adapted from Markov models described in prior literature. PARTICIPANTS/METHODS:Patients of ages 65 years and greater with mild to moderate primary open-angle glaucoma irrespective of concurrent visually significant cataract. METHODS:Markov models simulating glaucoma progression through 37 states and death were constructed based on previous CE models of minimally invasive trabecular meshwork stents. These states represent combinations of various glaucoma severity (mild, moderate, advanced, and severe/blind) with differences in clinical management, including use of up to 4 medications, selective laser trabeculoplasty, or incisional surgery. These are not mutually exclusive and are based on decisions related to the rate of thinning of the retinal nerve fiber layer. Rather than using fixed sets of transition probabilities for specific surgical interventions, new transition probabilities are dynamically derived based on the expected reduction in intraocular pressure related to visual field mean deviation decline. In addition to the generic MIGS arm, two comparison arms (cataract-surgery or medications-only) are included. Medication reduction, whole costs, and utilities are modifiable inputs in the model. Optimal and worst-case results are determined by uncomplicated or complicated (secondary surgical intervention required/medication nonadherence) intervention outcomes. The model was entirely re-implemented in R and validated by comparing results to TreeAge data. MAIN OUTCOME MEASURES/METHODS:Total costs, quality adjusted life years (QALY), and incremental cost-effectiveness ratio (ICER). RESULTS:An optimal-case 35-year CE-analysis of the implantation of Hydrus and iStent inject devices provided values of costs and QALY that were similar to prior data (R vs. TreeAge): Hydrus (Cost: $50446.53 vs. $48026.13; QALY: 12.18 vs. 12.26), iStent inject (Cost: $52323.43 vs. $49599.86; QALY: 12.13 vs. 12.21), cataract (Cost: $54150.56 vs. $54409.25; QALY: 12.03 vs. 12.04). Trends of ICER over time were also very similar. CONCLUSIONS:Novel software is available to aid in CE analyses of MIGS with modifiable inputs and outcomes of interest. Such a tool makes CE more accessible for use in clinical management decisions and may guide future investigation.

PURPOSE/UNASSIGNED:To report a case of delayed diagnosis of a pituitary tumor impacting vision. The patient had undergone bilateral cataract surgery with multifocal lenses, and even an intraocular lens (IOL) exchange for persistent visual dissatisfaction, which was ultimately due to the tumor and not the visually significant cataracts or the intra-ocular lens. METHODS/UNASSIGNED:Single case report and narrative review. RESULTS/UNASSIGNED:An 81-year-old male patient presented with visually significant nuclear sclerotic cataracts that were consistent with his chief complaint of decreased visual acuity and colors not being vivid. About one month after uneventful sequential cataract phacoemulsification with multifocal IOL insertion, he complained of bilateral visual dissatisfaction, primarily with color and contrast issues. This was attributed to his non-adaption to the bilateral multifocal intra-ocular lenses. A unilateral IOL exchange of the multifocal lens to a monofocal lens occurred without complication. Still, the persistence of visual dissatisfaction after a unilateral IOL exchange prompted consultation with neuro-ophthalmology where he was diagnosed with a pituitary macroadenoma. CONCLUSION/UNASSIGNED:Prior to performing an IOL exchange in patients with persistent visual dissatisfaction after multifocal lens placement, other causes of visual dissatisfaction should be thoroughly investigated.

BACKGROUND AND OBJECTIVE/OBJECTIVE:The increasing use of retinal diagnostic imaging necessitates a standardized viewing technique. This study investigates visual search patterns among ophthalmologists at various experience levels using eye-tracking technology. PATIENTS AND METHODS/METHODS:Participants included postgraduate year 2, 3, and 4 residents, retina fellows, and attending ophthalmologists, who analyzed fundus images while their eye movements were tracked. RESULTS:Results indicated that attendings had shorter fixation durations (0.15 ± 0.04 seconds) and saccade lengths (0.06° ± 0.01°), indicating faster image information processing than novice physicians. Experts also analyzed a higher proportion of the image area (49.43% ± 7.34%) and possessed a global-focal search pattern, suggesting increased thoroughness. CONCLUSION/CONCLUSIONS:.

PURPOSE/OBJECTIVE:To develop consensus nomenclature amongst international retinal specialists for the distinctive optical coherence tomography (OCT) finding of a lesion originating from the retinal capillary bed, measuring ≥100 µm in size, and characterized by a hyperreflective wall with a hyporeflective lumen. METHODS:A comprehensive literature search was performed from inception to January 2024 on three databases to elicit publications reporting on relevant vascular abnormalities and corresponding nomenclature. A panel of retinal specialists with expertise in this topic reviewed the list of candidate terms and proposed other names for the lesion of interest. A refined list was then incorporated into a Delphi survey, which was distributed to the general membership of the International Retinal Imaging Society (IntRIS). Consensus was defined as at least 70% agreement amongst participants. RESULTS:An expert panel (n=11) reviewed candidate names for the lesion, with poor agreement noted amongst panel members regarding the relevant nomenclature. In the first Delphi survey, (n=70 IntRIS members), the need for a unified nomenclature was highlighted and two leading candidate names were established: large retinal capillary aneurysm (LRCA, n=38, 54.3%) and retinal capillary macroaneurysm (n=14, 20.0%). A second follow-up survey (n=54 IntRIS members) established LRCA (n=44, 81.5%) as the consensus term to identify the OCT vascular abnormality. CONCLUSION/CONCLUSIONS:This Delphi project reached consensus on a unifying term, large retinal capillary aneurysm, for a specific and signature OCT lesion. Identification of this characteristic OCT finding and adoption of this term may facilitate diagnosis, guide therapeutic decisions, and improve clinical and scientific communication.

Neuropathic corneal pain (NCP) is an underdiagnosed ocular disorder caused by aberrant nociception and hypersensitivity of corneal nerves, often resulting in chronic pain and discomfort even in the absence of noxious stimuli. Recently, microneuromas (aberrant growth and swelling of the corneal nerve endings) detected using in vivo confocal microscopy (IVCM) have emerged as a promising biomarker for NCP. However, this process is time-intensive and error-prone, limiting its clinical use and availability. In this work, we present a new NCP screening system based on a deep learning model trained to detect microneuromas using a multisite dataset with a combined total of 103,168 IVCM images. Our model showed excellent discriminative ability detecting microneuromas (AuROC: 0.97) and the ability to generalize to data from a new institution (AuROC: 0.90). Additionally, our pipeline provides an uncertainty quantification mechanism that allows it to communicate when its predictions are reliable, further increasing its clinical relevance.

BACKGROUND:The number of pediatric ophthalmology and strabismus (PO&S) fellowship positions filled each year remains consistently lower compared with other subspecialities. It is unclear where along the recruitment pathway trainees interested in pediatrics decide to select other subspecialities. This study assesses for differences in the competitiveness of ophthalmology residency applicants based on interest in PO&S, which may impact their ability to matriculate into residency. METHODS:and Mann-Whitney U tests were used to compare categorical and continuous variables, respectively. RESULTS:Of the 631 applications reviewed, 125 (19.8%) of applicants stated a subspeciality interest. Among those who stated an interest, 34 (27.2%) were interested in PO&S. When compared to all other applicants (with or without a stated subspecialty interest), applicants interested in PO&S were more likely to be female (P < 0.001). No significant difference was found in academic, research, or extracurricular variables based on subspeciality interest in PO&S. The same was true when applicants interested in PO&S were compared to those interested in competitive subspecialities (cornea, glaucoma, retina, or oculoplastics). CONCLUSIONS:Applicants interested in PO&S were observed to be as competitive as other applicants. Among students who expressed a fellowship interest, there was a high proportion interested in pediatrics. Recruitment efforts can be targeted toward encouraging medical students interested in pediatrics to apply into ophthalmology.

To describe chorioretinal changes in a single case of Boucher-Neuhauser Syndrome (BNHS) over 45 years of follow-up. Methods: Retrospective chart review was performed. Color fundus photography from 1977 to 2003 was obtained and digitized. Current fundus photography was obtained with widefield imaging. High-resolution spectral-domain optical coherence tomography (OCT) was performed. Genetic analysis was performed using an inherited retinal disorders panel. Results: Fundus examination demonstrated central chorioretinal atrophy with sclerotic choroidal vessels. Short posterior ciliary arteries became more prominent and tortuous over time. Mid-peripheral atrophy extends to the equator and demonstrates a scalloped pattern with islands of atrophy intervening with areas of normal retina. The far periphery remained minimally affected. High-resolution OCT demonstrated outer retinal atrophy and choriocapillaris loss. Genetic testing showed a homozygous variant for PNPLA6 and a heterozygous variant for TYRP1. Conclusion: Chorioretinal changes in BNHS vary in onset and severity. It is important to diagnose this condition in order to begin timely management of visual and systemic sequelae.