Uveitis Onset and Flare-Up: Does the Time of Year Matter?

PURPOSE: This retrospective chart review tests the hypothesis that initial presentation and flare-up of non-infectious anterior, intermediate, and posterior uveitis varies by month, temperature season, and calendar season among the patient population in Connecticut. METHODS: The medical records of all adult patients presenting with a chief concern or diagnosis of "uveitis" at a university-based clinic between March 2013 and February 2019 and a community-based clinic between January 2016 and February 2019 in Connecticut were reviewed. Ongoing, chronic uveitis and infectious/traumatic uveitis were excluded. Patient age, sex, comorbid autoimmune conditions, time of onset, and anatomical location of uveitis was collected. χ2 testing evaluated variation in uveitis presentation based on month, calendar season, and temperature. RESULTS: 353 cases of endogenous uveitis were identified among 272 patients. There was no significant variation by month, calendar season, or temperature across the entire population. There was no significant variation by temperature when assessing anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis cases separately. Though flare-ups did not show any significant seasonal trends, there was significant variation by temperature for new uveitis episodes. Uveitis episodes in patients with autoimmune conditions were shown to have significant variation by temperature. Uveitis episodes in HLA-B27 positive patients were found to have significant variation by both temperature and month. CONCLUSION: While variation by month, calendar season, or temperature is not present for all uveitis patients, a subset of patients with comorbid autoimmune conditions, specifically HLA-B27 positive, experience temperature variations with increasing incidence of flare-ups in transitional months in Connecticut.

Antibiotic Prescribing Patterns Among U.S. Ophthalmologists and Optometrists from 2018 to 2021 in the Medicare Part D Database.

Purpose: To assess antibiotic prescribing patterns among ophthalmologists and optometrists from 2018 to 2021. Methods: This is an observational, retrospective cohort study of the Medicare Part D prescriber public use files from 2018 to 2020. Prescription trends were analyzed with analysis of variance and negative binomial regression tests based on specialty, region, and types of antibiotics. Results: From 2018 to 2021, the number of ophthalmologists in the Medicare Part D database decreased from 18,452 to 18,285, and the number of optometrists increased from 23,071 to 24,734. Throughout the study period, the total number and proportion of antibiotic prescriptions by ophthalmologists and optometrists stayed almost constant with a dip in 2020, likely reflecting the effects of the COVID-19 pandemic. Both ophthalmologists and optometrists demonstrated geographic regional differences in prescribing patterns. The South consistently had the highest average number of claims per provider. Of the antibiotics prescribed by ophthalmologists in 2021, 48.6% are from the fluoroquinolone class, 20.5% are from the aminoglycoside class, and 18.2% are from the macrolide class. Optometrists were found to be more likely to prescribe antibiotics in a formulation combined with a corticosteroid throughout the study period. Conclusions: Our results have shown that prescribing patterns among ophthalmologists and optometrists have demonstrated significant changes in prescriptions of microbial resistance-promoting antibiotics. These patterns persist despite nation-wide attempts to control antimicrobial resistance.

Primary Practice Emphasis Area and Diversity Among Board-Certified Ophthalmologists.

PURPOSE: To describe the ophthalmology primary practice emphasis area by underrepresented in medicine (URiM) status using the American Board of Ophthalmology (ABO) Diplomates database. DESIGN: Retrospective cohort study. METHODS: The study was based on a retrospective review of the ABO database from 1992 to 2020. The datapoints recorded included age at time of graduation and at time of certification, sex/gender, self-reported race/ethnicity, year of graduation and of certification, region of practice in the United States, and the self-reported primary practice emphasis area within ophthalmology. The URiM cohort included self-identified Black, Hispanic/Latinx, American Indian and Alaska Native, and Native Hawaiian and Other Pacific Islander individuals. Statistical analysis was conducted using Pearson χ2, Student t, and Fisher exact tests. RESULTS: A total of 575 (10.1%) ophthalmologists self-identified as URiM, vs 5132 (89.9%) as non-URiM. Diplomates who were URiM were more likely to be female and to be older at the time of ABO certification than those who were not URiM (P < .001). Over time, there was a steady decrease in the percentage of diplomates who were URiM (P < .001). There was a statistically significantly higher percentage of URiM ophthalmologists who reported glaucoma as their primary area of emphasis (P = .039) and non-URiM ophthalmologists who reported oncology, pathology, international, or genetics (P = .015), but no significant differences in the remaining subspecialties (P ≥ .123). CONCLUSIONS: There were modest differences in reported ophthalmology primary practice emphasis areas between URiM and non-URiM ABO diplomates. Despite efforts to increase diversity in ophthalmology, the percentage of graduating URiM ABO diplomates has decreased over the past 2 decades.

Trends in Immunosuppressive Agent Use for Non-Infectious Uveitis by US Ophthalmologists in Medicare Beneficiaries and Association with Physician-Industry Interactions.

PURPOSE: To report the trends of immunosuppressive drug use for non-infectious uveitis and explore their relationship with industry payments. METHODS: A retrospective review of ophthalmologists reimbursed by Medicare for the administration of adalimumab (ADA), repository corticotropin (RCI), methotrexate (MTX), and mycophenolate mofetil (MMF) between 2014 and 2018. RESULTS: A total of 316 ophthalmologists were reimbursed by Medicare for 1567 ADA, 465 RCI, 1752 MTX, and 12 333 MMF administrations. The number and dollar amount of industry payments were positively associated with ADA and RCI use (P < 0.001). From 2014 to 2018, there was a positive trend in the proportion of ADA (P = 0.007) and RCI (P = 0.007) used and negative trend in the proportion of MMF (P = 0.025) used. CONCLUSION: From 2014 to 2018, the use of ADA and RCI increased while MMF decreased and MTX remained stable. There was a positive association between ADA and RCI use and physician-industry interactions. A causal relationship is not determined.

Female Authorship and Ophthalmology Journal Editorial Board Membership Trends Over the Last Decade, 2012-2021.

PURPOSE: To study the relationship between female authorship and editorial board membership in 3 ophthalmology journals from 2012 to 2021. DESIGN: Cross-sectional and trend study. METHODS: The prevalence of female first, senior authorship, and editorial board members were examined in Ophthalmology, JAMA Ophthalmology, and American Journal of Ophthalmology. Gender-API assigned gender to authors based on name and country. Editorial board (EB) information was manually extracted and grouped for comparison among leadership positions. Gender data collected on authorship and EB membership were compared. The proportion of women in EB positions was identified: editor-in-chief, mid-level editors, and consulting editors. Relationship between female authorship and editorial board membership was analyzed. RESULTS: Women published fewer articles as first (1547/4267) and senior (1165/4267) authors than did men. The proportion of women in senior authorship significantly increased from 2012 to 2021 (23.4% to 30.5%, P = .0046). Across EB, a significant increase in female members (13.9% to 34.6%, P = .0006) was observed. There was a significant correlation (P < .0001) between female EB members and female authors (r = 0.74, 95% CI = 0.51-0.87) for all journals. The odds of female first authorships were 1.89 (95% CI = 1.65-2.17) times higher for articles with female senior authors than for male senior authors (P < .0001). CONCLUSION: Female senior authorship significantly increased over the last decade. Journals with a higher representation of female EB members also had a higher representation of female authorship. This study found a positive association between first and senior female authorship; however, the gender gap persists. Continued efforts to reach equity in publications and EB representation are necessary.

Gender Distribution and Trends of Ophthalmology Subspecialties, 1992-2020.

PURPOSE: To describe the gender trends in ophthalmology primary practice areas using the American Board of Ophthalmology (ABO) diplomates. DESIGN: A trend study plus a cross-sectional study of the ABO's database. METHODS: The de-identified records of all (N = 12,844) ABO-certified ophthalmologists between 1992 and 2020 were obtained. The year of certification, gender, and self-reported primary practice for each ophthalmologist was recorded. Subspecialty was defined as the self-reported primary practice emphasis. Practice trends of the entire population and the subpopulation of subspecialists were explored based on gender and were then visualized using tables and graphs and analyzed using the χ2 or Fisher exact test. RESULTS: A total of 12,844 board-certified ophthalmologists were included. Nearly half (47%) reported a subspecialty as their primary practice area (n = 6042), of whom the majority were male (65%, n = 3940). In the first decade, men outnumbered women reporting subspecialty practices by more than 2:1. Over time, the number of women subspecialists increased whereas the number of men remained stable, such that by 2020 women comprised almost half of new ABO diplomates reporting subspecialty practice. When all subspecialists were compared within gender, there was not a significant difference (P = .15) between the percentage of male (46%) and female (48%) ophthalmologist reporting a subspecialty practice. However, a significantly greater proportion of women than men reported primary practice in pediatrics (20.1% vs 7.9%, P < .001) and glaucoma (21.8% vs 16.0%, P < .0001). Alternatively, a significantly greater proportion of men reported primary practice in vitreoretinal surgery (47.2% vs 22.0%, P < .0001). There was no significant difference between the proportion of men and women reporting cornea (P = .15) or oculoplastics (P = .31). CONCLUSIONS: The number of women in ophthalmology subspecialty practice has increased steadily over the past 30 years. Men and women subspecialize at the same rate, but significant differences exist between the types of ophthalmology practiced by each gender.

Treatment of non-infectious retinal vasculitis.

Retinal vasculitis (RV) refers to an entity in which the retinal vasculature is inflamed, frequently with indications of inflammation elsewhere in the eye. Non-infectious RV can be idiopathic or associated with systemic disease, ocular conditions, and malignancy. It can also be classified based on the vessel affected: artery, vein, or both. Due to the lack of strong evidence-based treatment trials and algorithms for RV, physicians must often rely on their experience, which creates great variability in treating this entity. This article provides an overview of various treatment modalities used in the management of non-infectious RV, with a focus on immunomodulatory therapies. We outline a potential stepwise approach of starting with steroids to control the acute inflammation and subsequently changing to immunomodulatory therapy (IMT) for long-term treatment.

Necrotic Uveal Melanoma Mimics Orbital Cellulitis: A Review.

Background: Uveal melanoma is the most common primary intraocular malignancy in adults, often resulting in painless vision loss. We report a case of necrotic uveal melanoma presenting with orbital inflammation mimicking orbital cellulitis and present a comprehensive review of the literature and tabulation of reported cases. Summary: Our review found 44 published reports of spontaneously necrotic uveal melanoma involving 55 patients. Of these reports, 26 patients (47%) presented with orbital cellulitis. Presenting symptoms of necrotic uveal melanoma with orbital cellulitis included proptosis (82.8%), pain (80.7%), vision loss (61.5%), and restricted extraocular movements (46.2%). Key Messages: Uveal melanoma can rarely mimic orbital cellulitis. Autoinfarction and tumor necrosis causes secondary orbital inflammation. Intraocular malignancy must remain in the differential for patients with orbital inflammation and vision loss.

Uveitis associated with tattoo granulomas.

Ocular symptoms are a common reason for patients to present to the emergency department or to their primary care physician. Though often benign, these symptoms can also be an early manifestation of systemic disease. We report the case of a patient who presented to the emergency department with 1 week of rash followed by 2 days of fever, sore throat, chills, blurry vision and photophobia. His physical examination was notable for a desquamative rash over his tattoos, left-sided tonsillar exudate and pharyngeal oedema without lymphadenopathy. Biopsy of his tattoos revealed subepithelial non-caseating granulomas, confirming the diagnosis of tattoo granulomas with uveitis. The patient was started on corticosteroids and methotrexate and responded well to treatment. This case emphasises the importance of recognising ocular symptoms that are indicative of systemic disease and require further evaluation.

Management of noninfectious scleritis.

Scleritis is a manifestation of inflammatory eye disease that involves the sclera. It can be divided into multiple subtypes, including diffuse anterior, nodular anterior, necrotizing, and posterior scleritis. In many cases, scleritis is restricted to the eye; however, it can occur in the context of systemic illness, particularly autoimmune and infectious conditions. Patients with autoimmune conditions, such as rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, and polyangiitis with granulomatosis, may develop scleritis flares that may require topical and systemic therapy. Initial therapy typically involves oral nonsteroidal anti-inflammatory drugs (NSAIDs); however, it is important to address the underlying condition, particularly if systemic. Other treatment regimens typically involve either local or systemic steroids or the use of immunomodulatory agents, which have a wide range of efficacy and documented use in the literature. There is a myriad of immunomodulatory agents used in the treatment of scleritis including antimetabolites, calcineurin inhibitors, biologics, and alkylating agents. In this review, we highlight the various subtypes of noninfectious scleritis and explore each of the mainstay agents used in the management of this entity. We explore the use of steroids and NSAIDs in detail and discuss evidence for various immunomodulatory agents.

Ophthalmology Residency Match in the Covid-19 Era: Applicant and Program Director Perceptions of the 2020-2021 Application Cycle.

OBJECTIVE: To evaluate the experiences and preferences of ophthalmology residency applicants and program directors (PDs), with emphasis on the effect of COVID-19 as well as recent changes on the application process. DESIGN: Cross-sectional, online survey. PARTICIPANTS: All applicants to the Bascom Palmer Eye Institute ophthalmology residency program, and all United States ophthalmology residency PDs, during the 2020-2021 application cycle. METHODS: An online survey was distributed to applicants and program directors of the 2020-2021 ophthalmology residency application cycle.Main Outcome Measures: Applicant demographics, application submissions, interview experiences, financial considerations, match results, and suggestions for improvement of the application process. RESULTS: Responses were obtained from 205 applicants (34.9% response rate) and 37 PDs (30.3%). A successful match into an ophthalmology residency was achieved by 144 (83.7%) applicants. Applicants applied to (mean ± SD) 79.7 ± 22.8 ophthalmology residency programs, received 13.1 ± 8.9 invitations to interview, and attended 11.1 ± 5.8 interviews. Most applicants (N = 126; 71.2%) and PDs (N = 22; 78.6%) expressed a preference for in-person interviews over virtual interviews. If given a choice regarding the future direction for interviews, most applicants were unsure (N = 68; 38.4%) or would prefer to hold interviews virtually (N = 62; 35.0%); PDs felt that interviews should go back to being in-person (39.3%) or were unsure (28.6%). Most PDs (N = 21; 72.4%) reported an increased number of applications received by their respective programs this year compared to previous years. While applicants (N = 108; 61.0%) mostly felt that there should not be a cap on the number of applications, 19 (67.9%) PDs supported a limit on application numbers. Applicants spent an average (SD) of $2320.96 ($1172.86) on the application process this year, which is significantly less than 2018-2019 data. CONCLUSIONS: The ophthalmology residency application process was especially complex during the COVID-19 pandemic. Although many applicants and PDs were glad that interviews were held virtually this year, they were less certain regarding future years. The virtual format led to a significantly lower financial burden for applicants and may lead some to prefer this format in the future; if a hybrid model is offered for virtual/in-person interviews, these two interview modes should be compared equally.

Factors affecting the resolution of acute non-infectious anterior scleritis.

BACKGROUND/AIMS: Tumor necrosis factor alpha (TNF-⍺) inhibitors are increasingly being used to treat scleritis, however, their efficacy has not been compared to older treatments. Additionally, few studies have assessed differences in the course of scleritis among different patient groups. We identify demographic factors, comorbidities and treatments associated with the resolution of acute scleritis. METHODS: The records of patients with non-infectious anterior scleritis who presented between 1 January 2013 and 1 January 2018 were retrospectively reviewed. RESULTS: A total of 141 patients (169 eyes) with anterior scleritis were identified. 92.9% had diffuse anterior scleritis, 5.0% had nodular anterior scleritis and 2.1% had necrotising scleritis. Topical corticosteroids were used in 66.7% of patients, systemic non-steroidal anti-inflammatory drugs (NSAIDs) in 48.9% and systemic corticosteroids in 37.6%. Non-corticosteroid immunomodulatory therapies were required in 37.6% of patients. In a Cox proportionate hazards model, factors positively associated with the resolution of an episode of scleritis included NSAID use (HR=2.145; 95% CI 1.200 to 3.832), Hispanic race (HR=2.991; 95% CI 1.115 to 7.341) and lupus erythematous (HR=6.175; 95% CI 1.774 to 21.489). Bilateral scleritis was negatively associated with resolution (HR=0.437; 95% CI 0.196 to 0.972). TNF-⍺ inhibitors (HR=3.346; 95% CI 1.277-8.763), NSAID use (HR=2.558; 95% CI 1.383 to 4.729), lupus erythematosus (HR=5.251; 95% CI 1.478 to 18.659) and Hispanic race (HR=3.198; 95% CI 1.022 to 10.005) were significantly positively associated with steroid sparing resolution. CONCLUSION: Patient characteristics including a lupus diagnosis and Hispanic race were associated with faster times to symptom resolution and steroid sparing resolution, as were treatments including systemic NSAIDs and TNF-⍺ inhibitors. Due to limitations in the available data, this analysis did not account for disease severity. Future prospective studies will further elucidate the relationship between these factors and patient outcomes.

The Association Between Mental Health Disorders and Non-Infectious Scleritis: A Prevalence Study and Review of the Literature.

Chronic inflammatory diseases can cause significant psychosocial stress in affected patients. Few studies have examined the psychological effects of ocular inflammatory disease and no studies have examined the psychological effects of scleritis. In this study we evaluate the prevalence of mental health disorders in scleritis patients and we conduct a comprehensive review of the literature on the mental health effects of ocular inflammatory diseases. 162 patients (195 eyes) presenting to a tertiary care center with scleritis were identified. At least one comorbid mental health disorder was diagnosed in 35 patients (21.6%), most commonly major depression in 11.7%, generalized anxiety disorder in 9.3%, and substance use disorder in 6.2%. There were no significant differences in the length of an episode of scleritis or in the probability of symptom resolution between patients with a mental health disorder and other patients. In a review of the literature, 30 manuscripts met the inclusion criteria. The majority of manuscripts (83.3%) were focused on uveitis patients. Eight of these studies were focused on patients with uveitis in the context of systemic disease. The most commonly reported mental health disorders reported were anxiety and depression. An average of 31.3% of patients with ocular inflammatory disease had depression and 35.0% had anxiety. Similar to other chronic illnesses, ocular inflammatory disease may be a significant psychosocial stressor. Future studies will further elucidate the relationship between these diseases and mental health.

COVID-19 and the Ophthalmology Residency Match: Data from Applicants' Perspectives.

Background The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on medical education, particularly for those applying to residency programs in 2020 to 2021. This study describes the challenges for potential ophthalmology residency applicants so that residency leadership can make informed decisions about changes to the process. Methods A survey was distributed electronically via social media and medical school ophthalmology interest groups from June 18, 2020 to July 2, 2020 to individuals interested in applying to ophthalmology residency in the United States. Survey questions included demographics and perceived impacts of COVID-19 on ability, confidence, intention to apply, and perceptions toward changes in the application process for the 2020 to 2021 ophthalmology residency application cycle. Results One-hundred sixteen total responses were received. Eighty-six responses (74%) were from individuals intending to apply in the 2020 to 2021 application cycle. Most respondents (86%) felt that their application would be affected by COVID-19 with 51% feeling less confident. Only four (5%) felt that they could adequately compile a rank list following a video interview, and over half (51%) anticipated applying to more programs than they originally intended. Academic plans of seven (8%) respondents were significantly altered via deferral of application or cancellation of a research year. Thirty-nine (45%) students reported delayed ophthalmology electives, with less than half (41%) feeling that they had adequate clinical exposure to be prepared for residency. Conclusion The COVID-19 pandemic has had a substantial impact on the 2020 to 2021 ophthalmology residency application cycle. As stakeholders begin to approach this cycle, these findings will help them make effective and informed decisions to create the best overall experience for all involved.

Ophthalmic Medication Expenditures and Out-of-Pocket Spending: An Analysis of United States Prescriptions from 2007 through 2016.

PURPOSE: To estimate temporal trends in total and out-of-pocket (OOP) expenditures for ophthalmic prescription medications among adults in the United States. DESIGN: Retrospective, longitudinal cohort study. PARTICIPANTS: Participants in the 2007 through 2016 Medical Expenditure Panel Survey (MEPS) 18 years of age or older. The MEPS is a nationally representative survey of the noninstitutionalized, civilian United States population. METHODS: We estimated trends in national and per capita annual ophthalmic prescription expenditures by pooling data into 2-year cycles and using weighted linear regressions. We also identified characteristics associated with greater total or OOP expenditures with multivariate weighted linear regression. Costs were adjusted to 2016 United States dollars using the gross domestic product price index. MAIN OUTCOME MEASURES: Trends in total and OOP annual expenditures for ophthalmic medications from 2007 through 2016 as well as factors associated with greater expenditures. RESULTS: From 2007 through 2016, 9989 MEPS participants (4.2%) reported ophthalmic medication prescription use. Annual ophthalmic medication use increased from 10.0 to 12.2 million individuals from 2007 and 2008 through 2015 and 2016. In this same period, national expenditures for ophthalmic medications increased from $3.39 billion to $6.08 billion and OOP expenditures decreased from $1.34 to $1.18 billion. Per capita expenditure increased from $338.72 to $499.42 (P < 0.001), and per capita OOP expenditure decreased from $133.48 to $96.67 (P < 0.001) from 2007 and 2008 through 2015 and 2016, respectively. From 2015 through 2016, dry eye (29.5%) and glaucoma (42.7%) medications accounted for 72.2% of all ophthalmic medication expenditures. Patients who were older than 65 years (P < 0.001), uninsured (P < 0.001), and visually impaired (P < 0.001) were significantly more likely to have greater OOP spending on ophthalmic medications. CONCLUSIONS: Total ophthalmic medication expenditure in the United States increased significantly over the last decade, whereas OOP expenses decreased. Increases in coverage, copayment assistance, and use of expensive brand drugs may be contributing to these trends. Policy makers and physicians should be aware that rising overall drug expenditures ultimately may increase indirect costs to the patient and offset a decline in OOP prescription drug spending.

NEUROSARCOIDOSIS MASQUERADING AS A CENTRAL NERVOUS SYSTEM TUMOR.

PURPOSE: To report a case of neurosarcoidosis with an isolated brain lesion mimicking a low-grade glioma. METHODS: A 38-year-old woman presented with 2 weeks of blurry vision in the left eye. Ophthalmic examination, visual field testing, fluorescein angiography, laboratory testing, and MRI of the brain were performed. RESULTS: Ophthalmic examination revealed left-sided optic nerve infiltration, and MRI of the brain demonstrated a solitary lesion in the brain. The visual symptoms and ophthalmic examination improved significantly with initiation of high-dose oral prednisone. Because the MRI appearance was concerning for malignancy, a brain biopsy was performed. Pathology demonstrated gliosis consistent with a low-grade central nervous system (CNS) glioma. One year later, after initial loss to ophthalmic follow-up, the right optic nerve became involved, and the patient was again treated successfully for presumed ocular sarcoidosis. At this time, serial neuroimaging demonstrated enlargement of the CNS lesion, prompting rebiopsy. Rebiopsy demonstrated a noncaseating granuloma, confirming the diagnosis of neurosarcoidosis. The patient was treated with 20 mg of methotrexate weekly and a prednisone taper with improvement in visual and neurologic symptoms. CONCLUSION: The authors present an unusual case of neurosarcoidosis masquerading as a CNS glioma. In cases of solitary CNS granulomas, radiographically differentiating neurosarcoidosis from a glioma can be challenging. In this case, serial ophthalmic examination identifying sequential involvement of both optic nerves helped to identify the underlying cause of the CNS disease as sarcoidosis.