Practice Locations of Michigan Ophthalmologists as a Model to Compare Practice Patterns of DO and MD Surgical Subspecialists.

CONTEXT: While existing data demonstrate that osteopathic physicians (ie, DOs) in primary care are more likely than allopathic physicians (ie, MDs) to practice in rural areas, no data exist on practice patterns of DO surgical subspecialists, such as ophthalmologists. Michigan has a relatively high number of DOs and, formerly, the most osteopathic ophthalmology residency programs in the United States. Analyzing the distribution of ophthalmologists in Michigan may reveal patterns and predict trends about the geographic distribution of DO surgical subspecialists across the country. OBJECTIVE: To compare geographic distributions of DO and MD ophthalmologists in Michigan and identify differences in community size and type (eg, urbanized area, urban cluster, or rural area) of practice. METHODS: A list of Michigan's ophthalmologists practicing in 2018 was developed using the Centers for Medicare and Medicaid Services, the American Osteopathic College of Ophthalmology, and the American Medical Association data sets. DOs and MDs were then analyzed by determining where each ophthalmologist practiced, identifying the size and type of community in which they practiced, and finally by comparing the percentage of DOs and MDs who practiced in various community sizes and each community type as defined by the US Census Bureau. A χ2 analysis was used to determine whether a difference existed in practice locations. RESULTS: A total of 643 ophthalmologists practiced in Michigan in 2018, including 85 DOs and 558 MDs. A greater proportion of DOs worked in rural areas and urban clusters (57 [67%]), whereas a greater proportion of MDs worked in urbanized areas (368 [66%]). Of DOs, 28 (33%) practiced in cities with a population of at least 50,000 vs 371 MDs (66%). Fourteen DOs (16%) practiced in communities with a population of at least 100,000 vs 207 MDs (37%). χ2 analysis showed a significant difference in the geographic distribution of ophthalmologist DOs and MDs (P<.01). CONCLUSION: Higher proportions of DOs practice ophthalmology in smaller, more rural Michigan communities compared with MDs, implying that a subgroup exists that tends to serve underserved areas.

Isolated cranio-orbitofacial neurofibroma mimicking vascular malformation.

Isolated neurofibromas in the absence of systemic neurofibromatosis are known as solitary or localized neurofibromas. When present in the orbit, these lesions may appear clinically and radiographically similar to other tumors, complicating diagnosis and management. Key radiographic signs may guide clinicians to the correct diagnosis when the presentation and patient demographic data obfuscate the disease entity. We present a case of a large multi-lobulated neurofibroma misdiagnosed as a lymphangioma. A brief review of these tumors emphasizing key radiographic features is also included.

Factors associated with multiple recurrences of nonspecific orbital inflammation aka orbital pseudotumor.

OBJECTIVE: To assess clinical characteristics of patients at risk for recurrent nonspecific orbital inflammation (NSOI). METHODS: This was a retrospective comparison study with a 24-month follow-up, in a clinic-based population in rural India. The medical records at two eye care centers were searched from March 2001-2014. A total of 153 patients with recurrent NSOI, 107 of whom had a single recurrence (Group 1) and 46 of whom had multiple recurrences (Group 2). Clinical and demographic data were compared between both groups. Comparisons of mean values were done with multiple 2-tailed independent T tests, and differences in proportions were compared using Chi-squared tests. A multivariate logistic regression model was used to determine which factors were predictive of patients having multiple recurrences. RESULTS: Several factors were independently related to multiple recurrences (P < 0.05 for all): age ≤16 years (2.5 OR, 95% CI 1.3-3.6), bilateral disease (3.2 OR 95% CI 1.4-5.1), presence of optic disc edema or T-sign on B-scan ultrasonography (3.9 OR 95% CI 1.8-6.2), sclerosing variant (8.5 OR 95% CI 5.4-11.3), corticosteroid taper <4 weeks long (2.8 OR 95% CI 1.1-4.2), autoimmune disease among 1st degree relatives (2.2 OR 95% CI 1.2-3.3). In patients with recurrent disease, the interval between the initial episode and the first recurrence was predictive of further recurrences: ≤3 months (3.2 OR, 95% CI 2.0-4.5) and ≥12 months (0.21 OR, 95% CI 0.01-0.39). CONCLUSION: Younger patients and those with bilateral disease are more apt to have recurrences of NSOI. Other factors that increase the risk of multiple recurrences include a T-sign, optic disc edema, poor initial response to steroids, a sclerosing variant, a recurrence within 3 months, and those who underwent a rapid steroid taper.

Isolated Neurofibroma of the Orbit: Case Report and Literature Review.

PURPOSE: To summarize the clinical, radiographic, and intraoperative characteristics of isolated neurofibromas of the orbit (INFO) in the literature and report a case of INFO. METHODS: Case report and a systematic review of the literature. RESULTS: A total of 45 patients were identified from 18 previous studies. There was no sex predilection and mean ages were between 32.3 and 40.0 years with a standard deviation of 9.8 to 19.5 years, median age was 32 to 38 years with a range of 1.5 to 82 years. On CT imaging, INFO reveals homogeneous precontrast radiodensity similar to that of extraocular muscles. On MR imaging, INFO appears hypointense to orbital fat and isointense to brain on precontrast T1-weighted images. On T2-weighted images, they have been described as being predominantly hyperintense with possible hypointense intralesional islands. To the best of our knowledge, our case identifies the youngest patient with the myxoid histologic variant of INFO. CONCLUSIONS: Patients with orbital neurofibromas should be evaluated for the presence of systemic neurofibromatosis, and the plexiform variant is a commonly associated subtype. The myxoid variant can be part of a lesser known condition called NAME syndrome (nevi, atrial myxoma, myxoid neurofibroma, and ephelides) which may warrant echocardiography in patients to evaluate for associated cardiac tumors.

Dyslipidemia and its Association with Meibomian Gland Dysfunction: A Systematic Review.

PURPOSE: To perform a systematic review of the literature examining the association between meibomian gland dysfunction (MGD) and dyslipidemia. METHODS: A systematic literature search was performed using the Medline database. A total of four studies directly relevant to our search are reviewed here. RESULTS: In a series of four studies, all but one found that the prevalence of dyslipidemia was significantly higher in those with MGD compared to those without. Factors such as age, total cholesterol, LDL, HDL, and triglycerides demonstrated a significant association whereas sex, BMI, serum creatinine, and serum glucose did not. Various subsets within the MGD group, such as males between the ages of 24-64, were found to have higher total cholesterol levels compared to controls, highlighting the association of dyslipidemia with sex and age. CONCLUSION: While each study carried its own limitations preventing a causal relationship from being established, it is evident that a strong positive correlation exists between dyslipidemia and MGD. As such, eye care practitioners, through the detection of MGD, may be identifying patients with dyslipidemia who were previously believed to have normal serum lipid profiles. This may imply that eye care providers have a role in detecting a well-known risk factor for cardiovascular disease. Additionally, if prospective studies can demonstrate a temporal relationship with MGD preceding dyslipidemia, clinicians could consider lipid-lowering agents as management for both conditions.

Critical flicker fusion frequency in demyelinating and ischemic optic neuropathies.

PURPOSE: Critical flicker fusion (CFF) frequency is a well-studied test for evaluating demyelinating optic neuritis (ON). Its use in evaluating other optic neuropathies is not well established. The purpose of this study was to compare CFF in ON and non-arteritic anterior ischemic optic neuropathy (NAION). METHODS: We performed a retrospective review to compare multiple variables for eyes with ON or NAION using two-sided T tests and Chi-square tests. A multivariate linear regression was performed for the dependent variable CFF. A receiver operating characteristic (ROC) curve was used to define a CFF threshold for distinguishing these entities. RESULTS: Unaffected eyes had an average CFF value of 31.5 Hz. CFF values for ON (20.7 Hz ± 7.36) and NAION (24.3 Hz ± 9.03) were not significantly different from each other (P = 0.06). However, the CFF for ON, 18.27 Hz ± 9.29, was significantly lower than for NAION, 23.92 Hz ± 7.02, P = 0.02 when limiting the comparison to moderate and severe disease. An ROC curve demonstrates that a CFF value of ≤24 Hz is 71% sensitive for ON and that a value >24 Hz is 74% specific for excluding ON. A multivariate linear regression model demonstrated that ON contributed to approximately an 8 Hz decrease in CFF compared to NAION. Patients with a CFF of ≤24 Hz have a 2.89 odds ratio (95% CI 1.76-4.01) of having ON. CONCLUSION: CFF values in eyes with ON were significantly lower compared to eyes with NAION when evaluating moderate and severe disease. Twenty-four hertz may be a useful CFF threshold value when trying to distinguish between these two entities.

Association of Intraocular Pressure With Human Immunodeficiency Virus.

PURPOSE: Prior studies have shown an association between human immunodeficiency virus (HIV) and reduced intraocular pressures (IOP). The purpose of this study was to determine if patients with HIV on highly active antiretroviral therapy (HAART) had any difference in their IOP compared with patients without HIV or with HIV who are not on HAART. DESIGN: Retrospective cross-sectional study. METHODS: We included 400 patients from our academic eye center between 2000 and 2016. Group 1 (G1) consisted of patients with HIV on HAART (n = 176), Group 2 (G2) consisted of patients with HIV who were not on HAART (n = 48), and Group 3 (G3) consisted of controls without HIV (n = 176). An analysis of variance (ANOVA) was performed to compare mean IOP values. Multivariate linear and logistic regression models were performed to assess factors impacting IOP. Difference in IOP was the primary outcome being measured. RESULTS: The mean IOPs in mm Hg were 13.7 ± 5.1 (G1), 13.1 ± 3.6 (G2), and 17.3 ± 3.8 (G3), P < .01. In regression modeling, having a CD4 count ≤700 cells/mm3 contributed to a 2.1 mm Hg decrease in IOP. Patients with HIV were 7 times more likely to have an IOP ≤10 mm Hg, and patients with a CD4 count ≤700 cells/mm3 were 13 times more likely to have an IOP ≤10 mm Hg. CONCLUSIONS: Absolute CD4 counts may play a role in IOP fluctuations. This association was found in patients with HIV regardless of whether patients were on HAART.

Depression and burden among the caregivers of visually impaired patients: a systematic review.

Caregiving has evolved as an important issue not only for those receiving care, but for those providing it as well. While caregiving allows those with disabilities to better adapt, it has been shown to take a toll on the caregiver on various levels, such as invoking depression and burden. The purpose of this study was to perform a systematic review of the literature pertaining to depression and burden among caregivers of patients with visual impairment. A comprehensive literature search using multiple databases was conducted to include all articles on burden of care or depression among the caregivers of the visually impaired. Nine studies were included in this review. There was demonstrable association of depression and burden with the caregivers of the visually impaired. Communication theory, emotional contagion, and care burden were cited as factors associated with depression in these studies. A number of other elements were also identified to play a role in depression and burden, such as providing greater hours of supervision to the patient, multiple chronic conditions in the patient or caregiver, patient not completing vision rehabilitation, and female gender of the caregiver. By identifying those at risk for decreased quality of life outcomes, health care providers may be able to alter the management of the visually impaired, such as advocating the use of vision rehabilitation clinics in order to minimize the caregiver burden and depression.

Optical coherence tomography findings of bilateral foveal leukemic infiltration.

We report a case of a 59-year-old man with a history of atypical chronic myelogenous leukemia who presented with a several-week history of decreased vision in both eyes. His clinical examination revealed bilateral foveal infiltration, which was also demonstrated on optical coherence tomography. After a failed induction with imatinib (Gleevec(®)), he was treated with omacetaxine (Synribo(®)) with an appropriate hematologic response. As his leukemia improved with chemotherapy, his retinal lesions regressed as demonstrated by serial optical coherence tomography and fundus photographs, with near complete restoration of foveal architecture.

Burden and Depression among Caregivers of Visually Impaired Patients in a Canadian Population.

Purpose/Background. This study reports the degree of burden and the proportion at risk for depression among individuals who provide care to visually impaired patients. Study Design. This is clinic-based, cross-sectional survey in a tertiary care hospital. Methods. Caregivers were considered unpaid family members for patients whose sole impairment was visual. Patients were stratified by vision in their better seeing eye into two groups: Group 1 had visual acuity between 6/18 and 6/60 and Group 2 were those who had 6/60 or worse. Burden was evaluated by the Burden Index of Caregivers and the prevalence of being at risk for depression was determined by the Center for Epidemiologic Studies Depression scale. Results. 236 caregivers of 236 patients were included. Total mean BIC scores were higher in Group 2. Female caregivers, caregivers providing greater hours of care, and caregivers of patients who have not completed vision rehabilitation programs are at higher risk for depression.

Burden and Depression in Caregivers of Blind Patients in New York State.

PURPOSE: To describe the degree of burden of care and the proportion at risk of depression among individuals caring for legally blind patients. METHODS: We performed a cross-sectional study of 486 individuals providing care to their family members who were legally blind. Best-corrected visual acuity of the better-seeing eye in patients determined group placement: Group 1, 20/200-10/200; group 2, 10/200 to light perception (LP); group 3, no light perception (NLP); group VF, visual field loss to <20 central degrees. Burden was evaluated using the Burden Index of Caregivers (BIC-11) and the prevalence at risk of depression was determined by the Center for Epidemiologic Studies Depression (CES-D) scale. RESULTS: Total mean BIC-11 scores ranged from 8.78 ± 4.82 (group 1) to 12.03 ± 5.22 (group 3; p = 0.04). Daily hours spent on close supervision, intensity of caregiving and presence of multiple chronic illnesses in caregivers were the significant covariates affecting BIC-11 scores (p < 0.05). The prevalence of caregivers at risk of depression increased with vision loss from 6.9% (group 1) to 17.9% (group 3; p < 0.05). Female caregivers had an odds ratio (OR) of 2.89 for depression (95% confidence interval, CI, 1.07-3.97; p = 0.04). Caregivers with ≥2 comorbidities had OR 4.24 (95% CI 2.41-6.11) for risk of depression (p < 0.01). CONCLUSION: Burden of care was highest among caregivers who provided greater hours of supervision. Patients with more limitations in their activities of daily living had caregivers who reported higher burden. Female caregivers and caregivers with multiple chronic illnesses were at higher risk of depression.

Dyslipidemia and its association with meibomian gland dysfunction.

Abnormal serum lipid levels significantly increase the risk for cardiovascular disease. Furthermore, abnormal compositions of cholesterol in glandular secretions have been hypothesized as an etiology for meibomian gland dysfunction, yet this relationship has not been well studied in clinical settings. The primary purpose of this study was to determine if there is an association between dyslipidemia and meibomian gland dysfunction (MGD). The secondary purpose was to identify the factors, if any, that play a role in this association. A case-control study was performed between October 2013 and February 2015 which recruited 109 patients with MGD and 115 control patients without MGD. All participants were of Indian descent and had no history of dyslipidemia. Basic demographic information was collected as well as fasting levels of serum glucose, creatinine, triglycerides, total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). To calculate differences between groups, Z test or Student t test were used. A stepwise logistic regression model was used to calculate the estimates of odds ratios (ORs), where MGD was the dependent variable, making the independent variables consist of sex, age, body mass index (BMI), triglycerides ≥150 mg/dL, total cholesterol ≥200 mg/dL, LDL ≥130 mg/dL, or HDL ≤40 mg/dL, serum glucose, and serum creatinine. Dyslipidemia, defined by either a fasting total cholesterol level of ≥ 200 mg/dL, triglycerides ≥150 mg/dL, LDL ≥130 mg/dL, or HDL ≤40 mg/dL, was detected in 70 cases (64 %) and 21 controls (18 %), P < 0.001. Mean levels of triglycerides, total cholesterol, LDL, and HDL were 98.5 ± 42.1, 203.1 ± 13.2, 126.1 ± 10.2, and 53.3 ± 4.2 mg/dL, respectively, in cases and 82.3 ± 36.5, 156.6 ± 14.5, 92.2 ± 12.4, 45.8 ± 2.6 mg/dL, respectively, in controls. All differences were statistically significant (P < 0.05). MGD was significantly associated with age >65 years (OR 2.1; 95 % CI 1.2-3.2, P = 0.04), serum triglyceride concentration ≥150 mg/dL (OR 3.2; 95 % CI 1.9-4.4; P = 0.03), total cholesterol ≥200 mg/dL (OR 14.3; 95 % CI 8.2-20.7, P < 0.01), and LDL ≥130 mg/dL (OR 9.1; 95 % CI 6.6-13.2, P < 0.01). Adults from northern rural India with MGD are more likely to have abnormal serum lipid levels compared to age- and sex-matched adults without MGD. Eye care providers may have a role in discovering undiagnosed dyslipidemia, an important risk factor for cardiovascular illness.

Nosocomial keratitis caused by methicillin-resistant Staphylococcus aureus: case report and preventative measures.

A 47-year-old African-American woman was admitted to the intensive care unit of our community hospital for respiratory failure secondary to severe decompensated heart failure, requiring intubation. In the ensuing days, she developed a methicillin-resistant Staphylococcus aureus (MRSA) infection of the cornea, despite no growth of MRSA in multiple blood, sputum, and urine cultures. This unexpected corneal infection complicated her hospital stay, and increased morbidity and disease-related cost. Risk factors, warning signs, and preventative measures for MRSA keratitis secondary to lagophthalmos (inability to completely close one's eyelids) are outlined in this case report. Implementing simple precautions such as taping eyelids shut or using artificial lubrication may reduce patient morbidity and disease-related costs. These recommendations are directed to non-ophthalmic clinicians who provide care to patients in settings where MRSA colonization is widespread.

Prevalence and factors predictive of intraocular fungal infection in patients with fungemia at an academic urban tertiary care center.

OBJECTIVE: To report the prevalence and to identify factors predictive of intraocular infection in patients with fungemia receiving prophylactic antifungal therapy. METHODS: A retrospective review of patients who received prophylactic antifungal therapy and a dilated fundus examination at an academic urban tertiary care center from 2000 to 2007. Basic demographic information, fungal species grown, antifungal agent(s) used, number of positive blood culture specimens, visual acuity, visual symptoms, and known risks of disseminated candidiasis were noted. Logistic regression analysis was used to determine the factors significantly associated with intraocular fungal infection. RESULTS: A total of 132 patients with positive fungemia culture were requested to have ophthalmology consults. The prevalence of ocular infection was 6.9% (N=9). All nine patients were infected with Candida species. Undergoing gastrointestinal (GI) surgery within the prior 6 months was significantly related to developing intraocular infection, with an odds ratio of 18.5 (95% confidence interval, 15.1-24.3; P=0.002). Having ≥3 positive fungal blood cultures was also a significant risk factor, with an odds ratio of 2.6 (95% confidence interval, 1.8-3.7; P=0.03). Among 40 patients having GI surgery, eight (20.0%) had intraocular fungal disease, compared with one of 92 patients (1.1%) not having GI surgery. Among 125 patients with a negative baseline examination result, two of 32 patients (6.3%), who had recent GI surgery, subsequently developed fungal ocular disease, compared with 0 of 93 patients (0%), who did not have recent GI surgery. CONCLUSION: Recent GI surgery and higher numbers of positive fungal blood culture specimens may be predictive of candida ocular infections. Normal baseline fundoscopy examination results in patients with such risks may require repeat evaluations to detect delayed manifestations.

The first cataract surgeons in Anglo-America.

We tried to identify the earliest cataract surgeons in the English-speaking areas of America. In 1751, couching was performed on the Caribbean island of Montserrat by John Morphy. William Stork of England, who couched cataracts, practiced in Jamaica in 1760 and then in cities from Annapolis to Boston between 1761 and 1764. Frederick William Jericho of Germany, upon completion of his training at Utrecht, published his 1767 treatise on his preferred surgical technique of extracapsular cataract extraction. Jericho had practiced in the Leeward Islands by 1776 and then in cities from Charleston to Boston between 1783 and 1785. The French surgeon Lewis Leprilete was the first to advertise cataract extraction in the United States in 1782 and probably passed on the skill to his protégé, Nathaniel Miller of Massachusetts. Leprilete was also the first to publicize Benjamin Franklin's invention of bifocals. These pioneers exposed American doctors and the public to cataract surgery. Shortly after their arrival, evidence emerges of other surgeons performing these procedures in America.

Pseudo third cranial nerve palsy secondary to orbital ectopic lacrimal gland cyst: management with functional endoscopic sinus surgery.

An otherwise healthy 13-month-old girl was noted by her pediatrician to have developed a left head turn. The patient was referred to a pediatric ophthalmologist, who noticed signs of incomplete third cranial nerve palsy. Magnetic resonance imaging revealed the presence of an abnormal lesion in the inferonasal orbit that was abutting the ethmoid sinus. After consultation with an ENT specialist, the decision was made to remove the lesion via functional endoscopic sinus surgery because this approach was deemed to provide adequate access while limiting morbidity. Histology of the excised lesion identified it as true ectopic lacrimal gland tissue with cysts. We recognize and comment on the fact that in many reported cases of ectopic lacrimal gland cyst, the tissue was not ectopic at all but instead represented an extension of normal lacrimal gland tissue.

A rare cause of submandibular swelling in a 12-year-old child: pleomorphic adenoma.

Pleomorphic adenoma is rare in pediatric populations, where viral and congenital problems are the usual culprits responsible for submandibular masses. We report the case of a 12-year-old child who presented with a painless right submandibular mass that had developed over the course of 4 months. The patient denied fever, erythema, and edema. The mass was diagnosed as a branchial cleft cyst before complete excision was performed. The pattern and etiology of a pleomorphic adenoma in children differs from those in adults. In children, it requires prompt and correct diagnosis to keep morbidity and mortality at a minimum.

Burden and depression in the caregivers of blind patients in India.

PURPOSE: Several studies have examined the rates of depression in caregivers of patients with debilitating neurologic diseases. This study describes the degree of burden and the prevalence of depression among individuals caring for legally blind patients. To the best of our knowledge, no prior studies in the ophthalmic literature have reported this relationship. DESIGN: Clinic-based, cross-sectional study. PARTICIPANTS: We included 522 individuals in Rampur, India, providing care to their close family relatives who were legally blind. Visual acuities varied from 20/200 in the best eye, to no light perception (NLP) in each eye. METHODS: Several surveys were completed by the caregivers of patients whose sole impairment was visual, allowing us to quantitatively and selectively assess burden and depression among caregivers of blind patients. MAIN OUTCOME MEASURES: The Burden Index of Caregivers (BIC) was used to measure care burden and the Center for Epidemiologic Studies Depression scale was applied to determine depression. RESULTS: Caregivers of patients with NLP experience higher burden than caregivers of patients with lesser degrees of blindness. Daily hours spent on close supervision and the intensity of care-giving were the definitive factors linked to high BIC scores (P<0.01). The prevalence of caregiver depression increased with degree of visual impairment from 16% in the 20/200 group to 48% in the NLP cohort (P<0.01). Independently related variables for depression in caregivers were daily hours required for close supervision of the patient, intensity of care-giving, low household income, and the caregiver being the parent of a blind adult child (P<0.01). CONCLUSIONS: Severity of blindness in patients directly correlated with burden in caregivers. More severe forms of blindness meant patients require more help with their activities of daily living and additional hours of close supervision per day, both of which increase care burden. The same 2 factors also increase risk of caregiver depression along with low household income and the caregiver being the parent of a blind adult child. Awareness of the extent of burden and depression among caregivers of blind individuals is required by vision health personnel to identify at risk caregivers and implement effective interventions and support strategies.