A Google Trends Approach to Identify Distinct Diurnal and Day-of-Week Web-Based Search Patterns Related to Conjunctivitis and Other Common Eye Conditions: Infodemiology Study.

BACKGROUND: Studies suggest diurnal patterns of occurrence of some eye conditions. Leveraging new information sources such as web-based search data to learn more about such patterns could improve the understanding of patients' eye-related conditions and well-being, better inform timing of clinical and remote eye care, and improve precision when targeting web-based public health campaigns toward underserved populations. OBJECTIVE: To investigate our hypothesis that the public is likely to consistently search about different ophthalmologic conditions at different hours of the day or days of week, we conducted an observational study using search data for terms related to ophthalmologic conditions such as conjunctivitis. We assessed whether search volumes reflected diurnal or day-of-week patterns and if those patterns were distinct from each other. METHODS: We designed a study to analyze and compare hourly search data for eye-related and control search terms, using time series regression models with trend and periodicity terms to remove outliers and then estimate diurnal effects. We planned a Google Trends setting, extracting data from 10 US states for the entire year of 2018. The exposure was internet search, and the participants were populations who searched through Google's search engine using our chosen study terms. Our main outcome measures included cyclical hourly and day-of-week web-based search patterns. For statistical analyses, we considered P<.001 to be statistically significant. RESULTS: Distinct diurnal (P<.001 for all search terms) and day-of-week search patterns for eye-related terms were observed but with differing peak time periods and cyclic strengths. Some diurnal patterns represented those reported from prior clinical studies. Of the eye-related terms, "pink eye" showed the largest diurnal amplitude-to-mean ratios. Stronger signal was restricted to and peaked in mornings, and amplitude was higher on weekdays. By contrast, "dry eyes" had a higher amplitude diurnal pattern on weekends, with stronger signal occurring over a broader evening-to-morning period and peaking in early morning. CONCLUSIONS: The frequency of web-based searches for various eye conditions can show cyclic patterns according to time of the day or week. Further studies to understand the reasons for these variations may help supplement the current clinical understanding of ophthalmologic symptom presentation and improve the timeliness of patient messaging and care interventions.

Opportunities of Digital Infrastructures for Disease Management-Exemplified on COVID-19-Related Change in Diagnosis Counts for Diabetes-Related Eye Diseases.

Background: Retrospective research on real-world data provides the ability to gain evidence on specific topics especially when running across different sites in research networks. Those research networks have become increasingly relevant in recent years; not least due to the special situation caused by the COVID-19 pandemic. An important requirement for those networks is the data harmonization by ensuring the semantic interoperability. Aims: In this paper we demonstrate (1) how to facilitate digital infrastructures to run a retrospective study in a research network spread across university and non-university hospital sites; and (2) to answer a medical question on COVID-19 related change in diagnostic counts for diabetes-related eye diseases. Materials and methods: The study is retrospective and non-interventional and runs on medical case data documented in routine care at the participating sites. The technical infrastructure consists of the OMOP CDM and other OHDSI tools that is provided in a transferable format. An ETL process to transfer and harmonize the data to the OMOP CDM has been utilized. Cohort definitions for each year in observation have been created centrally and applied locally against medical case data of all participating sites and analyzed with descriptive statistics. Results: The analyses showed an expectable drop of the total number of diagnoses and the diagnoses for diabetes in general; whereas the number of diagnoses for diabetes-related eye diseases surprisingly decreased stronger compared to non-eye diseases. Differences in relative changes of diagnoses counts between sites show an urgent need to process multi-centric studies rather than single-site studies to reduce bias in the data. Conclusions: This study has demonstrated the ability to utilize an existing portable and standardized infrastructure and ETL process from a university hospital setting and transfer it to non-university sites. From a medical perspective further activity is needed to evaluate data quality of the utilized real-world data documented in routine care and to investigate its eligibility of this data for research.

COVID-19 pandemic decreased the ophthalmic outpatient numbers and altered the diagnosis distribution in a community hospital in Taiwan: An observational study.

The aim of this study was to determine the effect of Coronavirus disease 2019 (COVID-19) pandemic on ophthalmic outpatient numbers and ophthalmic diagnosis distribution in a community hospital (Taipei City Hospital Zhongxiao Branch) in Taiwan. The COVID-19 pandemic period in Taiwan was defined as May 1 to July 31, 2021. Demographic data, including age, gender, and top 10 diagnoses from ophthalmic outpatients during this period, were collected. A corresponding control group from the same time in 2020 was also collected. The distribution of different diagnoses was analyzed, and the data of 10 most prominent diagnoses with decreased percentage of case numbers during the COVID-19 pandemic period were obtained. The number of cases during the COVID-19 pandemic decreased by 46.9% compared to the control group. The top three most common diagnoses were dry eye syndrome, glaucoma, and macular diseases. The 10 most prominent diagnoses with decreased number of cases during the COVID-19 pandemic were cataract, refraction & accommodation, macular degeneration, conjunctivitis, retinal detachment, vitreous body disorders, ophthalmic complications of diabetes mellitus, glaucoma, dry eye, and retinal vein occlusion. Identifying and treating these patients as scheduled may yield the highest cost-benefit effect in preventing visual loss during the COVID-19 pandemic.

Case Report: Rhino-orbital Mucormycosis Related to COVID-19: A Case Series Exploring Risk Factors.

There has been a surge of rhino-orbital mucormycosis cases in India in the wake of the second wave of the COVID-19 pandemic. It has been widely suggested that dysglycemia resulting from diabetes which is a common comorbidity in COVID-19 patients, and indiscriminate steroid use has resulted in this surge. We report a series of 13 cases of rhino-orbital mucormycosis in COVID-19 patients admitted to our center between mid-April and early June 2021. The cases showed a male preponderance, two patients had loss of vision, and four of them showed intracranial extension of disease. Twelve patients had received steroids and 12 had preexisting or newly diagnosed diabetes, both steroid use and diabetes being the most common identified risk factors. Considering other possible risk factors, immunosuppressed state, antiviral or ayurvedic (Indian traditional) medications, and oxygen therapy were not associated with a definite risk of mucormycosis, because they were not present uniformly in the patients. We propose that COVID-19 itself, through molecular mechanisms, predisposes to mucormycosis, with other factors such as dysglycemia or steroid use increasing the risk.

Teaming-up nurses with ophthalmologists to expand the reach of eye care in a middle-income country: Validation of health data acquisition by nursing staff in a telemedicine strategy.

Telemedicine can be used to conduct ophthalmological assessment of patients, facilitating patient access to specialist care. Since the teleophthalmology models require data collection support from other health professionals, the purpose of our study was to assess agreement between the nursing technician and the ophthalmologist in acquisition of health parameters that can be used for remote analysis as part of a telemedicine strategy. A cross-sectional study was conducted with 140 patients referred to an ophthalmological telediagnosis center by primary healthcare doctors. The health parameters evaluated were visual acuity (VA), objective ophthalmic measures acquired by autorefraction, keratometry, and intraocular pressure (IOP). Bland-Altman plots were used to analyze agreement between the nursing technician and the ophthalmologist. The Bland-Altman analysis showed a mean bias equal to zero for the VA measurements [95%-LoA: -0.25-0.25], 0.01 [95%-LoA: -0.86-0.88] for spherical equivalent (M), -0.08 [95%-LoA: -1.1-0.95] for keratometry (K) and -0.23 [95%-LoA: -4.4-4.00] for IOP. The measures had a high linear correlation (R [95%CI]: 0.87 [0.82-0.91]; 0.97 [0.96-0.98]; 0.96 [0.95-0.97] and 0.88 [0.84-0.91] respectively). The results observed demonstrate that remote ophthalmological data collection by adequately trained health professionals is viable. This confirms the utility and safety of these solutions for scenarios in which access to ophthalmologists is limited.

Pediatric eye emergency department activity during the first wave of Covid-19 pandemic.

BACKGROUND: We investigated the volume and the characteristics of pediatric eye emergency department (PEED) consultations performed at our tertiary eye center during the early months of the COVID-19 pandemic and we compared them to those carried out in the same time interval of the previous three years. METHODS: Ophthalmic emergency examinations of patients aged ≤18 years old and done during the national COVID-19 lockdown (March 9th, 2020 - May 3rd, 2020) and in the corresponding date range of the previous three years (2017, 2018, and 2019) have been considered and reviewed. The following features were retrieved and analyzed: age, gender, duration and type of accused symptoms, traumatic etiology, and the discharge diagnosis. RESULTS: 136, 133, and 154 PEED visits have been performed respectively in 2017, 2018, and 2019, while 29 patients presented in 2020. Therefore, the volume of PEED activity decreased by 79.4% (p < 0.0001). Demographical and clinical characteristics were comparable to those of the pre-COVID period. Despite the absolute reduction in the number of traumas, urgent conditions increased significantly from 30.7 to 50.7% (p = 0.024). CONCLUSIONS: PEED activity decreased consistently after the onset of the pandemic and it was mainly attended by those children whose conditions required prompt assistance, reducing the number of patients diagnosed with milder pathologies. At the end of the emergency, better use of PEED could avoid overcrowding and minimize waste, allowing resource optimization for the management of urgent cases.

Identification of tear-based protein and non-protein biomarkers: Its application in diagnosis of human diseases using biosensors.

Discovery of robust, selective and specific biomarkers are important for early diagnosis and monitor progression of human diseases. Eye being a common target for several human diseases, vision impediment and complications are often associated with systemic and ocular diseases. Tears are bodily fluids that are closest to eye and are rich in protein content and other metabolites. As a biomarker repository, it advantages over other bodily fluids due to the ability to collect it non-invasively. In this review, we highlight some recent advancements in identification of tear-based protein biomarkers like lacryglobin and cystatin SA for cancer; interleukin-6 and immunoglobulin-A antibody for COVID-19; tau, amyloid-ß-42 and lysozyme-C for Alzheimer's disease; peroxiredoxin-6 and α-synuclein for Parkinson's disease; kallikrein, angiotensin converting enzyme and lipocalin-1 for glaucoma; lactotransferrin and lipophilin-A for diabetic retinopathy and zinc-alpha-2 glycoprotein-1, prolactin and calcium binding protein-A4 for eye thyroid disease. We also discussed identification of tear based non-protein biomarkers like lysophospholipids and acetylcarnitine for glaucoma, 8-hydroxy-2'-deoxyquanosine and malondialdehyde for thyroid eye disease. We elucidate technological advancement in developing tear-based biosensors for diagnosis and monitoring diseases such as diabetes, diabetic retinopathy and Alzheimer's disease. Altogether, the study of tears as potential biomarkers for early diagnosis of human diseases is promising.

Association of Ocular Adverse Events With Inactivated COVID-19 Vaccination in Patients in Abu Dhabi.

Importance: As vaccinations against COVID-19 continue, potential ocular adverse events should be reported in detail to increase awareness among the medical community, although typically, a causal relationship cannot be established definitively. Objective: To describe ocular adverse events that occur soon after receiving an inactivated COVID-19 vaccination (Sinopharm). Design, Setting, and Participants: This case series took place from September 2020 to January 2021 at Cleveland Clinic Abu Dhabi, a tertiary referral center. Patients who reported ocular adverse events and presented within 15 days from the first of 2 doses of an inactivated COVID-19 vaccine were analyzed. Main Outcomes and Measures: Each patient underwent Snellen best-corrected visual acuity that was then converted to logMAR, applanation tonometry, and biomicroscopic examination with indirect ophthalmoscopy. Color fundus photography was obtained with a conventional 9-field fundus photography camera or with a widefield fundus photography system. Optical coherence tomography and optical coherence tomographic angiography images were obtained. Sex, race, age, and clinical data were self-reported. Results: Nine eyes of 7 patients (3 male individuals) presenting with ocular complaints following COVID-19 vaccine were included in the study. The mean (SD) age was 41.4 (9.3) years (range, 30-55 years); the mean best-corrected visual acuity was 0.23 logMAR (range, 0-1 logMAR; approximate Snellen equivalent, 20/32). The mean time of ocular adverse event manifestations was 5.2 days (range, 1-10 days). One patient was diagnosed with episcleritis, 2 with anterior scleritis, 2 with acute macular neuroretinopathy, 1 with paracentral acute middle maculopathy, and 1 with subretinal fluid. Conclusions and Relevance: In this case series study of 7 patients, the timing of transient and ocular complications 5.2 days after vaccination with an inactivated COVID-19 vaccine supported an association with the ocular findings, but a causal relationship cannot be established from this study design.

Telemedicine Evaluations in Neuro-Ophthalmology During the COVID-19 Pandemic: Patient and Physician Surveys.

BACKGROUND: The novel coronavirus 2019 (COVID-19) pandemic has transformed health care. With the need to limit COVID-19 exposures, telemedicine has become an increasingly important format for clinical care. Compared with other fields, neuro-ophthalmology faces unique challenges, given its dependence on physical examination signs that are difficult to elicit outside the office setting. As such, it is imperative to understand both patient and provider experiences to continue to adapt the technology and tailor its application. The purpose of this study is to analyze both neuro-ophthalmology physician and patient satisfaction with virtual health visits during the time of the COVID-19 pandemic. METHODS: Across three institutions (NYU Langone Health, Indiana University Health, and Columbia University Medical Center), telemedicine surveys were administered to 159 patients. Neuro-ophthalmologists completed 157 surveys; each of these were linked to a single patient visit. Patient surveys consisted of 5 questions regarding visit preparation, satisfaction, challenges, and comfort. The physician survey included 4 questions that focused on ability to gather specific clinical information by history and examination. RESULTS: Among 159 patients, 104 (65.4%) reported that they were satisfied with the visit, and 149 (93.7%) indicated that they were comfortable asking questions. Sixty-eight (73.9%) patients found the instructions provided before the visit easy to understand. Potential areas for improvement noted by patients included more detailed preparation instructions and better technology (phone positioning, Internet connection, and software). More than 87% (137/157) of neuro-ophthalmologists surveyed reported having performed an examination that provided enough information for medical decision-making. Some areas of the neuro-ophthalmologic examination were reported to be easy to conduct (range of eye movements, visual acuity, Amsler grids, Ishihara color plates, and pupillary examination). Other components were more difficult (saccades, red desaturation, visual fields, convergence, oscillations, ocular alignment, and smooth pursuit); some were especially challenging (vestibulo-ocular reflex [VOR], VOR suppression, and optokinetic nystagmus). Clinicians noted that virtual health visits were limited by patient preparation, inability to perform certain parts of the examination (funduscopy and pupils), and technological issues. CONCLUSIONS: Among virtual neuro-ophthalmology visits evaluated, most offer patients with appointments that satisfy their needs. Most physicians in this cohort obtained adequate clinical information for decision-making. Even better technology and instructions may help improve aspects of virtual health visits.

Pathology of the Brain and the Eye in Severe Acute Respiratory Syndrome Coronavirus-2-Infected Patients: A Review.

BACKGROUND: Patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may present or eventually develop central nervous system and ophthalmic signs and symptoms. Varying reports have emerged regarding isolation of viral RNA from these tissue sites, as well as largely autopsy-based histopathologic descriptions of the brain and the eye in patients with COVID-19. EVIDENCE ACQUISITION: A primary literature search was performed in literature databases such as PubMed, Google Scholar, and Cochrane Library. Keywords were used alone and in combination including the following: SARS CoV-2, COVID-19, eye, brain, central nervous system, histopathology, autopsy, ocular pathology, aqueous, tears, vitreous, neuropathology, and encephalitis. RESULTS: The reported ophthalmic pathologic and neuropathologic findings in patients with SARS-CoV-2 are varied and inconclusive regarding the role of direct viral infection vs secondary pathology. The authors own experience with autopsy neuropathology in COVID-19 patients is also described. There is a particular paucity of data regarding the histopathology of the eye. However, it is likely that the ocular surface is a potential site for inoculation and the tears a source of spread of viral particles. CONCLUSIONS: Additional large postmortem studies are needed to clarify the role of SARS-CoV in the ophthalmic and neuropathologic manifestations of COVID-19.

Human tear fluid analysis for clinical applications: progress and prospects.

Introduction: Human blood and saliva are increasingly under investigation for the detection of biomarkers for early diagnosis of non-communicable (e.g.cancers) and communicable diseases like COVID-19. Exploring the potential application of human tears, an easily accessible body fluid, for the diagnosis of various diseases is the need of the hour.Areas covered: This review deals with a comprehensive account of applications of tear analysis using different techniques, their comparison and overall progress achieved till now. The techniques used for tear fluid analysis are HPLC/UPLC/SDS-PAGE, CE, etc., together with ELISA, Mass Spectrometry, etc. But, with advances in instrumentation and data processing methods, it has become easy to couple the various separation methods with highly sensitive optical techniques for the analysis of body fluids.Expert opinion: Tear analysis can provide valuable information about the health condition of the eyes since it contains several molecular constituents, and their relative concentrations may alter under abnormal conditions. Tear analysis has the advantage that it is totally non-invasive. This study recommends tear fluid as a reliable clinical sample to be probed by highly sensitive optical techniques to diagnose different health conditions, with special emphasis on eye diseases.

Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience.

PURPOSE: To assess the initial utilization, safety, and patient experience with tele-ophthalmology during the COVID-19 pandemic. DESIGN: Cross-sectional study. METHODS: We conducted a telephone survey and interview of a random sample of patients who received different modalities of care (in-person, telephone, videocall, or visits deferred) during Michigan's shelter-in-place order beginning March 23, 2020. The survey assessed patient safety, patient satisfaction with care, perceptions of telehealth-based eye care, and worry about eyesight. Data were analyzed via frequency measures (eg, means and standard deviations), χ2 tests, ANOVA, and paired t tests. Interviews were analyzed using grounded theory. RESULTS: A total of 3,274 patients were called and 1,720 (53%) agreed to participate. In-person participants were significantly older than telephone (P = .002) and videocall visit (P = .001) participants. Significantly more white participants had in-person visits than minority participants (P = .002). In-person visit participants worried about their eyesight more (2.7, standard deviation [SD] = 1.2) than those who had telephone (2.5, SD = 1.3), videocall (2.4, SD = 1.1), or deferred visits (2.4, SD = 1.2) (P = .004). Of all telephone or videocall visits, 1.5% (n = 26) resulted in an in-person visit within 1 day, 2.9% (n = 48) within 2-7 days, and 2.4% (n = 40) within 8-14 days after the virtual visit demonstrating appropriate triage to telemedicine-based care. Patients frequently cited a desire for augmenting the telephone or videocall visits with objective test data. CONCLUSIONS: When appropriately triaged, tele-ophthalmology appears to be a safe way to reduce the volume of in-person visits to promote social distancing in the clinic. A hybrid model of eye care combining ancillary testing with a video or phone visit represents a promising model of care.

A Virtual Clinical Reasoning Case for Medical Students Using an Ophthalmology Model: A Case of Red Eye.

Introduction: Triggered by the COVID-19 pandemic, medical education has moved online, tasking medical educators with developing virtual learning experiences. This is particularly challenging for less-represented disciplines, such as ophthalmology. We designed a red eye clinical reasoning case for preclinical medical students, which can be delivered virtually, using video conference software. Methods: We developed a 90-minute red eye/clinical reasoning workshop for which prereading was assigned to students. We then delivered a virtual development session to nonophthalmologist copreceptors and provided a session faculty guide. The entire first-year medical student class (No. = 140) participated in one of four identical workshops, which included virtual small- and large-group discussions. Students completed a knowledge pre- and posttest, and an optional session postsurvey. Results: Knowledge gains from pretest (No. = 94) to posttest (No. = 73) were statistically significant (p < .05), with average scores improving from 57% to 70%. Overall, students were satisfied, rating the following items 4 or 5 out of 5: session (86%, No. = 31), virtual format (83%, No. = 30), and if they recommended future use (69%, No. = 35). Discussion: This novel, virtual clinical reasoning case simulated small- and large-group learning, achieved knowledge gains, and was well received by students. Minor technical challenges were encountered but successfully remedied, without apparent disruption to learning. This virtual medical education model can be used to enhance ophthalmology education in preclinical medical students and can be adapted for virtual design of other curricular content.

Changes in patient visits and diagnoses in a large academic center during the COVID-19 pandemic.

BACKGROUND: To minimize the risk of viral transmission, ophthalmology practices limited face-to-face encounters to only patients with urgent and emergent ophthalmic conditions in the weeks after the start of the COVID-19 epidemic in the United States. The impact of this is unknown. METHODS: We did a retrospective analysis of the change in the frequency of ICD-10 code use and patient volumes in the 6 weeks before and after the changes in clinical practice associated with COVID-19. RESULTS: The total number of encounters decreased four-fold after the implementation of clinic changes associated with COVID-19. The low vision, pediatric ophthalmology, general ophthalmology, and cornea divisions had the largest total decrease of in-person visits. Conversely, the number of telemedicine visits increased sixty-fold. The number of diagnostic codes associated with ocular malignancies, most ocular inflammatory disorders, and retinal conditions requiring intravitreal injections increased. ICD-10 codes associated with ocular screening exams for systemic disorders decreased during the weeks post COVID-19. CONCLUSION: Ophthalmology practices need to be prepared to experience changes in practice patterns, implementation of telemedicine, and decreased patient volumes during a pandemic. Knowing the changes specific to each subspecialty clinic is vital to redistribute available resources correctly.

Patient Perceptions of SARS-CoV-2 Exposure Risk and Association With Continuity of Ophthalmic Care.

Importance: Patient perceptions regarding the risks of obtaining in-person ophthalmic care during the coronavirus disease 2019 (COVID-19) pandemic may affect adherence to recommended treatment plans and influence visual outcomes. A deeper understanding of patient perspectives will inform strategies to optimize adherence with vision-preserving therapies. Objective: To evaluate perceptions of COVID-19 exposure risk and their association with appointment attendance among patients at high risk of both reversible and irreversible vision loss from lapses in care. Design, Setting, and Participants: This survey study included a nonvalidated telephone survey designed in April and May of 2020 and a retrospective medical record review conducted in parallel with survey administration from May 22 to August 18, 2020. Participants were recruited from 2 tertiary eye care centers (Emory Eye Center in Atlanta, Georgia, and W.K. Kellogg Eye Center in Ann Arbor, Michigan). The study included a random sample of patients with diagnoses of exudative age-related macular degeneration (AMD) or diabetic retinopathy (DR) who received an intravitreal injection between January 6 and March 13, 2020, and were scheduled for a second injection between March 13 and May 6, 2020. Main Outcomes and Measures: Association between perceptions regarding COVID-19 risks and loss to follow-up. Results: Of 1004 eligible patients, 423 (42%) were successfully contacted, and 348 (82%) agreed to participate (participants' mean [SD] age, 75 [12] years; 195 women [56%]; 287 White [82%] patients). Respondents had a mean (SD) of 2.7 (1.1) comorbidities associated with severe COVID-19, and 77 (22%) knew someone with COVID-19. Of all respondents, 163 (47%) were very concerned or moderately concerned about vision loss from missed treatments during the pandemic. Although 208 (60%) believed the COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exposure at the eye clinic was extremely unlikely or unlikely, 49 (14%) believed it was extremely likely or likely. Seventy-eight participants (22%) were lost to follow-up. Concern regarding COVID-19 exposure during clinic visits (odds ratio [OR], 3.9; 95% CI, 1.8-8.4) and diagnosis of DR (vs AMD) (OR, 8.130; 95% CI, 3.367-20.408) were associated with an increase in likelihood of loss to follow-up. Conclusions and Relevance: Among patients at high risk for vision loss from lapses in care, many expressed concerns regarding the effect of the pandemic on their ability to receive timely care. Survey results suggest that fear of SARS-CoV-2 exposure was associated with a roughly 4-fold increase in the odds of patient loss to follow-up. These results support the potential importance of clearly conveying infection-control measures.