Reaching Target Communities in a Community Preschool Vision Screening Program.

PURPOSE: To develop a method to identify preschools with the greatest need for vision screening, correlations between socioeconomic status, preschool capacity, and rates of pediatric vision screenings performed by a community vision screening program were investigated. Geoinformatics mapping software was used to visually display the areas of greatest need. METHODS: Vision screening data from a community vision screening program, child care facility data from California Department of Social Services, and income data from the U.S. Census Bureau through ArcGIS software (Esri) were collected. When possible, data were consolidated at the ZIP code level. Kolmogorov-Smirnov analysis was used to determine correlations between data elements. Licensed child care facilities were scored on a scale (from 1 to 5) based on the socioeconomic status of the ZIP code and the facility capacity. The scoring system prioritized larger facilities in lower income communities to most efficiently use vision screening program resources. RESULTS: There was a positive correlation between the capacity of the child care facility and the median household income (P = .005). Second, we found a positive correlation between child care capacity and the median household income (P = .005). Licensed child care facilities were mapped and colored using GIS software according to their cumulative score. CONCLUSIONS: Challenges to vision screening in under-served communities include the lack of child care facilities and smaller facility size. The use of a scoring system and mapping software can direct vision screening programs to reach a greater number of children with the most efficient use of resources. [J Pediatr Ophthalmol Strabismus. 2022;59(6):375-379.].

Access to Pediatric Eye Care Following Vision Screening.

PURPOSE: To quantify the accessibility of eye care providers from photoscreening centers within the vision screening region in relation to population density and median household income. METHODS: Driving times between vision screening locations and eye care centers were mapped and analyzed using OpenStreetMap software (Open Street Map Foundation). U.S. Census Bureau data of population density and median household income were linked with screening centers using ArcGIS Online (Esri) to determine correlations with driving times. RESULTS: A total of 290 driving times for 145 photo-screening centers, 147 optometrists, and 7 pediatric ophthalmologists were calculated and mapped. Median driving times from a photoscreening center to the nearest optometrist and ophthalmologist were 4.74 and 25.10 minutes, respectively, with 90% of the screening centers residing within 12.46 and 67.19 minutes of the nearest optometrist and ophthalmologist, respectively. Driving times to optometrists are far less than times to pediatric ophthalmologists due to the greater number of optometrists. Decreasing driving times with increasing population and median household income indicate the concentration of optometrists and pediatric ophthalmologists within urbanized areas. CONCLUSIONS: Most photoscreening centers reside within 5 and 70 minutes of the nearest optometrist and pediatric ophthalmologist, respectively. Driving times indicate the region's greater accessibility to optometrists than to pediatric ophthalmologists. Eye care centers tend to be localized within urbanized areas with higher population densities and higher median household incomes. [J Pediatr Ophthalmol Strabismus. 2022;59(6):369-374.].

Results of a community vision-screening program using the Spot photoscreener.

PURPOSE: To describe the results of vision screenings performed with the Spot photoscreener in the community setting. METHODS: Low-income, predominantly Hispanic children in day care and preschool settings were screened by lay operators using the Spot photoscreener. Inclusion criteria were age 6-72 months and availability of a complete photoscreening record. Referral criteria were based on Vision Screening Committee of American Association for Pediatric Ophthalmology and Strabismus guidelines. Data were stratified by age group and analyzed for percentage of children referred for hyperopia, myopia, astigmatism, anisometropia, anisocoria, and ocular misalignment. Vision screening records were compared with comprehensive eye examination records from an optometrist or ophthalmologist to determine positive predictive value. RESULTS: Vision screening examinations were performed on 8,317 subjects from September 2011 through May 2012. The mean age of the 7,814 subjects (3953 males) meeting inclusion criteria was 44.4 months. The Spot referred 2,393 (30.6%). Of the screened population, the suspected reason for referral was astigmatism in 1,863 (23.8%), ocular misalignment in 879 (11.3%), anisometropia in 90 (1.2%), myopia in 82 (1.1%), hyperopia in 63 (0.8%), and anisocoria in 16 (0.2%). Comprehensive examination reports, including a cycloplegic refraction, were available for 300 referred children (12.5%). The reason for referral was confirmed in 55.7%, with an overall positive predictive value of 65.7%. CONCLUSIONS: The Spot photoscreener yielded a high overall referral rate. Although a high prevalence of astigmatism may be expected in this population, a high referral rate for suspected ocular misalignment led to a very high proportion of false positive referrals, suggesting that the software for this algorithm is in need of refinement.

Ocular complications after open and hand-assisted laparoscopic donor nephrectomy.

OBJECTIVES: To compare the incidence of ocular complications (OC) and corneal abrasion (CA) after hand-assisted laparoscopic donor nephrectomy (HALDN) and open donor nephrectomy (ODN). METHODS: A retrospective review was conducted of 241 consecutive patients (141 HALDN and 100 ODN) over a 9-year period. OC were strictly defined as ocular complaints requiring any treatment or ophthalmologic consultation. Chi-square tests were used to compare the incidence of OC and CA by type of surgery. RESULTS: OC were observed in 9 HALDN patients (6.4%) and no ODN patients (0%; P = .01). All OC in HALDN patients involved the dependent eye (P <.001). CA occurred in 2 HALDN patients (1.4%) compared with no ODN patients (0%; P = .23). HALDN patients had significantly higher net fluid intake than the ODN patients (P <.01). CONCLUSIONS: The increased OC and CA seen in HALDN patients may result from the increased fluid intake, flank positioning, and potential increased venous compression resulting from the effects of the pneumoperitoneum. The fact that the dependent eye was involved in all patients suggests conjunctival edema as a potential common pathway. The high frequency of OC suggests the importance of techniques to minimize OC after HALDN.

Cost-utility analysis of screening and laser treatment of retinopathy of prematurity.

PURPOSE: Retinopathy of prematurity (ROP) is a major cause of lifelong blindness beginning in infancy. Utility analysis is used to describe the effect of illness and medical intervention on an individual's quality of life during the course of a lifetime. In this study, cost-utility analysis is used to evaluate the cost-effectiveness of both screening and laser photoablation for ROP. METHODS: Data from 2 neonatal intensive care units were recorded for infants screened and treated for ROP between March 4, 2004, and January 5, 2006. The cost model was developed using procedures classified by Current Procedural Terminology and the costs paid for by the Centers for Medicare and Medicaid Services for 2006. Visual acuities were obtained from 10-year post-laser data and from the 10-year post-CRYO-ROP untreated cohort. RESULTS: During the study period, 515 infants received screening and treatment for ROP. They required a mean 3.4 exams per infant; 11.2% received laser photoablation. Mean visual acuities were 0.5 (Snellen 20/40) for laser-treated eyes and 0.20 (Snellen 20/100) for those who did not receive treatment. The cost-effectiveness of screening and laser photoablation of ROP in 2006 is $650/quality-adjusted life years. When discounted 3% per year for the time value of money, the cost is $1,565/ quality-adjusted life years. CONCLUSIONS: The screening and laser photoablation of ROP continue to be extremely cost-effective medical interventions.

Human recombinant erythropoietin and the incidence of retinopathy of prematurity: a multiple regression model.

BACKGROUND: Recombinant human erythropoietin (rhEPO) is used for the treatment of anemia of prematurity. However, it has also been found to have properties similar to vascular endothelial growth factor (VEGF), the major angiogenic factor implicated in the pathogenesis of retinopathy of prematurity (ROP). We sought to determine whether rhEPO is an independent risk factor for the development of ROP. METHODS: Data were analyzed from 264 infants admitted to the Loma Linda University Children's Hospital neonatal intensive care unit in 1994 and 2002. The data included demographic characteristics, incidence of major morbidities, rhEPO treatment, number of red blood cell transfusions received, and incidence and severity of ROP. A multiple logistic regression model was used to determine the relation of the studied risk factors to the incidence (any stage) and severity (threshold ROP requiring cryotherapy or laser photocoagulation) of ROP. RESULTS: The risk of developing ROP increased among infants who received >20 doses of rhEPO was higher compared with those who received < or =20 doses (OR, 3.53; 95% CI, 1.59, 7.85). These infants were also more likely to require laser photocoagulation (OR, 4.31; 95% CI, 1.99, 9.33). The age at which rhEPO was started was also a significant risk factor, with those starting rhEPO after 20 days of age having almost fourfold the risk of ROP compared with those starting it on or before 20 days of age (OR, 3.57; 95% CI, 1.59, 8.03). CONCLUSIONS: rhEPO was found to be a significant independent risk factor for the development of ROP.

Simplified technique for laparoscopic extravesical ureteral reimplantation in the porcine model.

BACKGROUND AND PURPOSE: Laparoscopic intravesical and standard Lich-Gregoir repair have been reported but are technically challenging. Herein, we present our experience with a simplified laparoscopic reimplantation of the ureter to correct vesicoureteral reflux (VUR). MATERIALS AND METHODS: Bilateral VUR was created cystoscopically in six minipigs, as confirmed by a static cystogram 6 weeks later. The laparoscopic extravesical correction of VUR was performed utilizing a full-thickness cystotomy. The ureter was transposed inside the bladder, and a full-thickness bladder closure was performed. No attempt was made to cover the ureter with urothelium. No stents or catheters were utilized postoperatively. Three months after reimplantation, the animals were evaluated with serology, a static cystogram, an intravenous urogram (IVU), and gross pathologic and histopathologic examination. RESULTS: The postoperative cystograms confirmed no reflux in all the reimplanted ureters and residual grade 1 to 3 reflux in the non-reimplanted ureters. All pigs voided normally and were completely continent. Cystoscopic evaluation revealed complete epithelialization over the reimplanted ureter. One surgical complication occurred: the ureter was incorporated into the bladder closure and became obstructed. The IVU in all other pigs demonstrated patent ureters with prompt function. CONCLUSIONS: Laparoscopic reimplantation of the ureter utilizing this modified Lich-Gregoir approach corrected reflux in all animals. The full-thickness bladder incision and intravesical transposition of the ureter greatly simplifies the laparoscopic procedure. This laboratory experience encourages further clinical evaluation in the pediatric population with VUR.

Simplified laparoscopic radical cystectomy with orthotopic ileal neobladder creation in a porcine model.

BACKGROUND AND PURPOSE: Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model. MATERIALS AND METHODS: Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed. RESULTS: Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals. CONCLUSIONS: Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.

Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty.

PURPOSE: To compare Acucise endopyelotomy (Applied Medical, Irvine, California), laparoscopic pyeloplasty, and open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: A retrospective review of all adult patients undergoing surgical correction of UPJ obstruction between December 1999 and August 2001 at Vanderbilt University Medical Center was performed. Patients undergoing UPJ correction with Acucise endopyelotomy (N = 9), laparoscopic pyeloplasty (N = 16), and open pyeloplasty (N = 7) were compared in regard to demographic information, operative data, recovery parameters, cost data, and outcome (as determined by diuretic renography, the Whitaker test, or both). RESULTS: Success rates of 56%, 94%, and 86% were obtained for Acucise endopyelotomy, laparoscopic pyeloplasty, and open pyeloplasty, respectively. There were no differences between the Acucise endopyelotomy and laparoscopic pyeloplasty groups in age, American Society of Anesthesiology (ASA) score, length of follow-up, estimated blood loss (EBL), hospital stay, total hospital cost, or analgesic requirement. The Acucise patients demonstrated shorter operating times (1.7 v 3.3 hours; P < 0.001) and time to oral intake (7.9 v 16 hours; P = 0.008) than the laparoscopic pyeloplasty group. When the laparoscopic pyeloplasty patients were compared with the open pyeloplasty patients, there was no difference in operative time, EBL, time to oral intake, or total hospital costs. The laparoscopically treated patients demonstrated significantly lower analgesic requirements (27.2 v 124.2 mg of morphine sulfate equivalent; P = 0.02) and shorter hospital stays (1.4 v 3.0 days; P = 0.03) than the open surgery patients. The Acucise patients demonstrated shorter operative time (1.7 v 3.4 hours; P < 0.001), shorter hospital stay (1.3 v 3.0 days; P = 0.02), and lower analgesic requirement (22.4 v 124.2 mg of morphine sulfate equivalent; P = 0.02) than the open surgery patients. CONCLUSIONS: Laparoscopic pyeloplasty achieves a success rate equal to that of open pyeloplasty while providing a recovery similar to that obtained with Acucise endopyelotomy and is gaining popularity as the treatment of choice for UPJ obstruction.

Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk.

BACKGROUND AND PURPOSE: The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications. PATIENTS AND METHODS: All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons. RESULTS: The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12). CONCLUSIONS: Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.