The Effect of Racial/Ethnic and Socioeconomic Differences on Visual Impairment Prior to Cataract Surgery.

PURPOSE: To compare the associations of race/ethnicity and socioeconomic status (SES) with visual impairment (VI) prior to surgical removal of cataracts across two large health systems in the U.S. Mid-Atlantic region. DESIGN: Multi-institutional cross-sectional data study. PARTICIPANTS: Patients aged 65 and older who underwent cataract surgery at Johns Hopkins Hospital (JHH) and Kaiser Permanente (KP) between January 1, 2017 and December 31, 2019. METHODS: Covariates included patient age, sex, smoking status, surgery laterality, Charlson Comorbidity Index (CCI), and ocular comorbidities. Multivariable generalized estimating equation models were used to examine the association of race/ethnicity and area deprivation index (ADI) with visual acuity. MAIN OUTCOME MEASURES: Visual acuity prior to cataract surgery was assessed using Log of Minimum Angle of Resolution (logMAR). Race/ethnicity and ADI were the main exposures of interest. RESULTS: At JHH, 11,509 patients (17,731 eyes) were included, while KP had 7,143 patients (10,542 eyes). After adjusting for covariates, Black (ß, 0.49), Asian (ß, 0.83), and Hispanic patients (ß, 0.95) were more likely to have worse visual acuity secondary to cataracts at JHH (P < 0.001 for all) compared to White patients. Similarly, at KP, Black (ß, 0.56), Asian (ß, 0.70), and Hispanic patients (ß, 0.89) were more likely to have worse visual acuity (P < 0.001 for all) compared to White patients. Compared to those living in the least disadvantaged neighborhoods (Quartile [Q]1 ADI) at JHH, higher ADI quartiles (more deprived) were more likely to have worse visual acuity (ß, 0.27; P = 0.001 for Q2, ß, 0.40; P = 0.001 for Q3, ß, 0.95; P < 0.001 for Q4). There was no significant association found between ADI and VI secondary to cataracts at KP. CONCLUSIONS: Among older adults, non-White race/ethnicity was independently associated with VI secondary to cataracts in two large health systems in the U.S. Mid-Atlantic region, after adjustment for ADI. Area deprivation was also associated with VI but only in the JHH system. Our study suggests that non-White patients and those with lower SES are at greater risk of VI secondary to cataracts possibly due to social, structural and institutional barriers.

Salary Negotiations: Gender Differences in Attitudes, Priorities, and Behaviors of Ophthalmologists.

PURPOSE: To investigate attitudes, priorities, and behaviors of ophthalmologists in salary negotiations. DESIGN: Cross-sectional study. METHODS: A Qualtrics survey was disseminated to U.S.-based practicing ophthalmologists between November 1, 2021 and March 31, 2022 and assessed attitudes, behaviors, and priorities surrounding salary negotiation during the respondents' first negotiation as a practicing physician and currently. Optional case-based scenarios were also included. RESULTS: Of 424 respondents, 155 (36.5%) identified as male (M) and 269 (63.3%) identified as female (F). Men were more likely to negotiate salary for their first position as an independent ophthalmologist (M 78.3%, F 68.2%; P = .04). Respondents of both genders assessed their success similarly; 85.0% of men and 75.7% of women (P = .07) felt that their negotiation was very successful or somewhat successful. Women were more likely to select "flexibility in clinic/OR schedule for personal commitments" as a priority during salary negation for their first position (M 14.8%, F 23.1%; P = .04). Women ophthalmologists reported feeling more uncomfortable (M 36.1%, F 49.1%; P = .01), intimidated (M 20.0%, F 43.5%; P < .01), and were less likely to feel well-trained (M 24.5%, F 13.0%; P < .01). Most respondents never received formal training in negotiation. CONCLUSIONS: We found significant gender differences among ophthalmologists in attitudes, priorities and behaviors surrounding salary negotiation. There were low reported levels of formal negotiation training, which appears to disadvantage women more than men. These gender disparities suggest that incorporating education about negotiation skills and career development early in training may be impactful.

Predictors of intraocular pressure reduction after femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: a prospective trial.

PURPOSE: To evaluate the association between postoperative intraocular pressure (IOP) reduction and phacoemulsification parameters in patients who underwent both conventional phacoemulsification surgery (CPS) and femtosecond laser-assisted cataract surgery (FLACS). METHODS: This was a prospective multicenter comparative study that enrolled 90 participants who underwent cataract surgery at the University of Maryland Medical System and the Wilmer Eye Institute. Patients underwent FLACS in one eye and CPS in the fellow eye. IOP was measured prior to surgery and monitored through six months postoperatively. Demographic, clinical, biometric, and intraoperative variables including cumulative dissipated energy (CDE), aspiration time, and phacoemulsification time were analyzed for any significant association with postoperative IOP. Postoperative IOP reduction was the primary outcome variable. A secondary goal of the study was to determine differences in postoperative IOP reduction between CPS and FLACS cohorts. RESULTS: In total, 157 non-glaucomatous eyes were included. Using multivariable analysis, we found preoperative IOP to be consistently associated with postoperative IOP reduction in the entire cohort. At the 6-month follow-up visit, there was a 12.4% reduction in IOP (-2.2 ± 3.4 mm Hg) seen, with no statistically significant difference between FLACS and CPS (12.3% ± 19.4% vs 12.5% ± 19.3%, respectively, p = 0.32). FLACS reduced the CDE required for phacoemulsification (6.6 ± 4.4%-seconds vs 8.6 ± 6.9%-seconds, respectively, p < 0.05). CDE was a predictor of IOP response at 6 months, but subgroup analysis revealed that this trend was driven by seven eyes requiring high CDE, and for the majority of eyes, CDE did not influence the size of the decrease. The seven eyes experiencing highest CDE were less likely to show IOP reduction at 6 months. CONCLUSION: Both FLACS and CPS resulted in similar and significant IOP reductions through 6 months after surgery. Preoperative IOP was significantly associated with IOP reduction, and CDE generally did not influence the size of the decrease.

Assessing the Reliability of Intraocular Pressure Measurements Using Rebound Tonometry.

PRECIS: In a trio of prospective studies, the iCare rebound tonometer demonstrated significantly lower test-retest variability than Goldmann tonometry with good interoperator and interdevice reproducibility, supporting its value in monitoring intraocular pressure (IOP) changes over time. PURPOSE: The purpose of this study was to characterize intraoperator and interoperator and interdevice reliability of IOP measurements with rebound tonometry (RT, ic100). METHODS: Three prospective cross-sectional studies were conducted in distinct sample of adult patients with established glaucoma, suspected glaucoma, or no glaucoma at the West Virginia University Eye Institute. Participants in study 1 underwent 5 RT measurements in one randomly selected eye and 5 Goldmann tonometry measurements in the fellow eye by 1 operator; intraoperator variability was compared using the F test. In study 2, 3 operators each obtained 3 RT measurements in participants in randomized operator order. In study 3, a single operator collected 3 measurements each with 3 RTs in randomized device order. Between-operator and between-device reproducibility were characterized using intraclass correlation coefficients (ICCs). RESULTS: Overall, 28, 19, and 25 subjects participated in the 3 respective studies. Within-subject variance across subjects was 0.757 in RT measurements and 2.471 in Goldmann measurements (P=0.0035). Interoperator reproducibility of RT measurements was good in both eyes [ICC for right eyes 0.78, 95% confidence interval (CI): 0.60-0.85; ICC for left eyes 0.75, 95% CI: 0.50-0.83]. Interdevice reproducibility of RT measurements was good approaching excellent (ICC for right eyes 0.87, 95% CI: 0.83-0.90; ICC for left eyes 0.89, 95% CI: 0.86-0.91). CONCLUSIONS: The RT's lower measurement variability and good interoperator and interdevice reproducibility suggest that it can characterize IOP changes over time more robustly than Goldmann tonometry, aiding clinicians in assessing the effectiveness of glaucoma therapy and the consistency of IOP control.

Survey of musculoskeletal disorders among US ophthalmologists.

PURPOSE: To characterize the prevalence of work-related musculoskeletal disorders (MSD), symptoms, and risk factors among ophthalmologists. METHODS: An online survey was distributed to ophthalmologist members of the Maryland Society of Eye Physicians and Surgeons. The survey consisted of 34 questions on respondent demographics, practice characteristics, pain, and effects of MSD on their practice patterns. Participants were excluded if they were not ophthalmologists or if they had MSD symptoms prior to the start of their ophthalmology career. Demographics and practice patterns were compared for those with or without MSD symptoms using the Welch t test and the Fisher exact test. RESULTS: The survey was completed by 127 of 250 active members (response rate, 51%). Of the 127, 85 (66%) reported experiencing work-related pain, with an average pain level of 4/10. With regard to mean age, height, weight, years in practice, number of patients seen weekly, and hours worked weekly, there was no difference between respondents reporting pain and those without. Those reporting MSD symptoms spent significantly more time in surgery than those who did not (mean of 7.9 vs 5.3 hours/week [P < 0.01]). Fourteen percent of respondents reported plans to retire early due to their symptoms. CONCLUSIONS: A majority of respondents experienced work-related MSD symptoms, which was associated with time spent in surgery. Modifications to the workplace environment focusing on ergonomics, particularly in the operating room, may benefit ophthalmologists.

Overlapping Immunohistochemical Features of Adenocarcinoma of the Nonpigmented Ciliary Body Epithelium and Renal Cell Carcinoma.

PURPOSE: To find immunohistochemical markers that distinguish adenocarcinoma of the nonpigmented ciliary epithelium (NPCE) from metastatic carcinoma, especially metastatic renal cell carcinoma. DESIGN: Retrospective case series. METHODS: Three cases of adenocarcinoma of the NPCE were examined histologically with hematoxylin-eosin stain and immunohistochemical stains including vimentin, AE1/AE3, Cam 5.2, CK7, PAX2, PAX8, AMACR, and CAIX. We also reviewed previously reported cases of this tumor. RESULTS: We found that the immunohistochemical profile of adenocarcinoma of the NPCE can overlap with renal cell carcinoma. Both tumors can express vimentin, cytokeratin AE1/AE3, Cam 5.2, PAX2, PAX8, and AMACR. One of the adenocarcinomas of the NPCE in our series also expressed CD10 and the renal cell carcinoma marker (RCC Ma). Carbonic anhydrase IX (CAIX) was not detected in any of the 3 tumors. CONCLUSIONS: Adenocarcinomas arising in phthisic eyes can be diagnostically challenging. We have found it particularly difficult to distinguish adenocarcinoma of the NPCE from metastatic carcinoma, especially metastatic clear cell renal cell carcinoma and papillary renal cell carcinoma. Because of the immunophenotypic overlap, most patients will require systemic workup including imaging of the kidneys to be certain of the diagnosis.

Syphilitic retinitis presentations: punctate inner retinitis and posterior placoid chorioretinitis.

PURPOSE: To describe two distinct presentations of syphilitic fundus features in a series of patients with ocular syphilis. METHODS: This is a retrospective, interventional case series of 22 eyes from 16 serology confirmed cases. Clinical examination, fluorescein angiography, and optical coherence tomography were performed at presentation and following high-dose intravenous penicillin G. RESULTS: In our cohort, the mean age was 47.6 years (range 24-59 years) and 14 patients were male (87.5%), 11 patients were positive for human immunodeficiency virus (68.8%), and 6 had bilateral involvement (37.5%). Mean best-corrected visual acuity improved from 0.99 ± 0.79 logarithm of the minimal angle of resolution (LogMAR) at the time of presentation to 0.29 ± 0.36 LogMAR on final visit (P < 0.01). Posterior segment examinations in eyes with retinitis showed two distinct types (1) discrete, placoid lesions in the macula consistent with acute syphilitic posterior placoid chorioretinitis or (2) punctate inner retinitis with corresponding fluorescein pooling in a segmental pattern. These findings rapidly resolved after antibiotic therapy. CONCLUSION: In the era of resurgence, ocular syphilis may present with two phenotypes of discrete retinal lesions. Recognition of the characteristic ocular features may help make the diagnosis and monitor treatment response.

Effect of intraoperative factors on IOP reduction after phacoemulsification.

The purpose of the study was to determine the independent predictors of long-term intraocular pressure (IOP) reduction after cataract surgery with phacoemulsification. This is a retrospective review of uncomplicated cataract surgeries from 2006 to 2008 at the Baltimore VA Medical Center with longitudinal follow-up. Demographic, clinical, biometric, and intraoperative variables including phacoemulsification parameters were recorded. Univariate and multivariate linear regression were used to analyze the relationship between these variables and postoperative IOP, which was the outcome variable. Analysis was performed in 115 eyes of 115 patients who underwent uncomplicated phacoemulsification during the study period. There was an average postoperative IOP reduction through 12, 24, and 36 months of -1.7 ± 3.1, -1.5 ± 3.8, and -1.3 ± 2.6 mmHg, respectively. Higher preoperative IOP (P < 0.001), a more anterior relative lens position (P < 0.05), and longer phaco time (P < 0.05) were significantly associated with greater postoperative decrease in IOP using univariate analysis. Using multivariate analysis, preoperative IOP (P < 0.001), and phaco time (P = 0.038) were associated with greater postoperative IOP reduction through 24 months. Phaco time is independently associated with IOP reduction after adjusting for age and preoperative IOP. Higher preoperative IOP is associated with a greater IOP-lowering effect after phacoemulsification.

THE EFFECT OF INTERNAL LIMITING MEMBRANE PEELING ON IDIOPATHIC EPIRETINAL MEMBRANE SURGERY, WITH A REVIEW OF THE LITERATURE.

PURPOSE: To examine the effect of internal limiting membrane (ILM) removal on epiretinal membrane (ERM) surgery by comparing best-corrected visual acuity (BCVA), optical coherence tomography central macular thickness (CMT) changes, ERM recurrence, and need for repeat surgery. METHODS: Retrospective study of 251 consecutive patients (251 eyes) who underwent pars plana vitrectomy for idiopathic ERM by a single surgeon with over 1 year of follow-up data. Data were collected preoperatively and postoperatively at 3 months, 1 year, 2 years, and at the last visit. The ILM was not specifically removed in the earlier group of patients and was removed after staining of the ILM in the later group. RESULTS: One hundred and forty eyes (55.8%) did not have an ILM peel (non-ILM group), and 111 eyes (44.2%) did have an ILM peel (ILM group). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Total follow-up time for the ILM group was 32.1 months and 45.4 months for the non-ILM group (P = 0.002). Both groups had improvement in BCVA. The ILM group improved by 12 Early Treatment Diabetic Retinopathy Study letters and the non-ILM group improved by 10.5 Early Treatment Diabetic Retinopathy Study letters. There was no significant difference in the final BCVA (P = 0.18) or total change of BCVA (P = 0.48). Cataract status preoperatively did not affect the total change of BCVA, but being phakic at the most recent visit was associated with a slight loss of visual acuity. Both groups had improvement in optical coherence tomography appearance, for the CMT in the ILM group decreased by 83 µm and the CMT in the non-ILM group decreased by 110 µm. There was no significant difference in the final CMT (P = 0.07); however, the non-ILM group tended to have a lower final CMT. Some degree of ERM recurrence was detected by slit-lamp biomicroscopy in 2 eyes (1.8%) of the ILM group and in 32 eyes (22.9%) of the non-ILM group (P ≤ 0.0001). None of the eyes with ILM removal required repeat vitrectomy, whereas 17 eyes (12.1%) of the non-ILM group did require vitrectomy, showing that ILM removal had a significant effect on the need for repeat vitrectomy (P < 0.0001) between non-ILM versus ILM peel groups. CONCLUSION: The rate of recurrent ERM and need for repeat ERM surgery is lower in eyes where the ILM is removed with the ERM, whereas BCVA and CMT were similar with or without ILM removal. Complete ILM removal around the macula should be considered for the treatment of eyes with idiopathic ERMs to reduce the incidence of ERM recurrences.