Bias Reduction Practices in Underrepresented Groups in Ophthalmology Resident Recruitment.

Importance: Best recruitment practices for increasing diversity are well established, but the adoption and impact of these practices in ophthalmology residency recruitment are unknown. Objective: To describe the adoption of bias reduction practices in groups underrepresented in ophthalmology (URiO) residency recruitment and determine which practices are effective for increasing URiO residents. Design, Setting, and Participants: This cross-sectional survey study used an 18-item questionnaire included in the online survey of the Association of University Professors in Ophthalmology (AUPO) Residency Program Directors. Data collection occurred from July 2022 to December 2022. The data were initially analyzed on January 16, 2023. Participants included residency program directors (PDs) in the AUPO PD listserv database. Main Outcomes and Measures: Descriptive analysis of resident selection committee approaches, evaluation of applicant traits, and use of bias reduction tools. Primary outcome was diversity assessed by presence of at least 1 resident in the last 5 classes who identified as URiO, including those underrepresented in medicine (URiM), lesbian, gay, bisexual, transgender, queer, intersex, and asexual plus, or another disadvantaged background (eg, low socioeconomic status). Multivariate analyses of recruitment practices were conducted to determine which practices were associated with increased URiO and URiM. Results: Among 106 PDs, 65 completed the survey (61.3%). Thirty-nine PDs used an interview rubric (60.0%), 28 used interview standardization (43.0%), 56 provided at least 1 bias reduction tool to their selection committee (86.2%), and 44 used postinterview metrics to assess diversity, equity, and inclusion efforts (67.7%). Application filters, interview standardization, and postinterview metrics were not associated with increased URiO. Multivariate logistic regression analysis showed larger residency class (odds ratio [OR], 1.34; 95% CI, 1.09-1.65; P = .01) and use of multiple selection committee bias reduction tools (OR, 1.47; 95% CI, 1.13-1.92; P = .01) were positively associated with increased URiO, whereas use of interview rubrics (OR, 0.72; 95% CI, 0.59-0.87; P = .001) and placing higher importance of applicant interest in a program (OR, 0.83; 95% CI, 0.75-0.92; P = .02) were negatively associated. URiM analyses showed similar associations. Conclusions and Relevance: Ophthalmology residency interviews are variably standardized. In this study, providing multiple bias reduction tools to selection committees was associated with increased URiO and URiM residents. Prioritizing applicant interest in a program may reduce resident diversity. Interview rubrics, while intended to reduce bias, may inadvertently increase inequity.

Transient Vision Loss Associated with Prefilled Aflibercept Syringes: A Case Series and Analysis of Injection Force.

Objective: To describe cases of significant vision loss following intravitreal aflibercept using pre-filled syringes (PFS) and to study the relationship between syringe design, injection speed, and injection force. Design: Retrospective case series and experimental study. Subjects: 12 patients who received intravitreal aflibercept PFS. Methods: All retina specialists (N=13) at Oregon Health & Science University and the Veterans Affairs Portland Medical Center were queried in December 2020 to report episodes of significant vision loss following aflibercept PFS use. Chart review was completed for all affected patients for demographics and pertinent ocular history. Using a commercially available force measuring system, injection force was measured for aflibercept PFS, ranibizumab PFS, and a tuberculin syringe at various injection speeds. Main Outcome Measures: Number of significant vision loss episodes following aflibercept PFS use; average injection force (Newton, N) at various injection speeds across different syringes. Results: Ten specialists (76.9%) reported a perceived increase in post-injection vision loss with aflibercept PFS. Three specialists had no cases of vision loss. 16 events of light perception or worse vision immediately following aflibercept PFS use were reported. Chart review was available for 12 of these events. The indication for aflibercept was exudative age-related macular degeneration (N=8), diabetic macular edema (N=3), and central serous chorioretinopathy (N=1). The median age of affected patients was 71 years (range 49-94). Two patients were being treated for glaucoma (N=1) or ocular hypertension (N=1); one patient was a glaucoma suspect. Anterior chamber paracentesis was performed in four patients to normalize intraocular pressure (IOP) promptly. Laboratory experiments demonstrated that higher injection speeds were associated with higher injection forces for all syringe types. Injection forces were consistently greater with aflibercept PFS than with the ranibizumab PFS or tuberculin syringes (p < 0.0001). Conclusions: Retina specialists within our institutions have noted numerous cases of severe transient vision loss with aflibercept PFS use. Some affected patients have reported increased injection-related anxiety. The average injection force may be greater with the aflibercept PFS when compared to other intravitreal anti-VEGF options. Additional clinical studies are needed to better understand how syringe design and fluid dynamics may contribute to post-injection vision loss.

Three-Year Safety Results of SAR422459 (EIAV-ABCA4) Gene Therapy in Patients With ABCA4-Associated Stargardt Disease: An Open-Label Dose-Escalation Phase I/IIa Clinical Trial, Cohorts 1-5.

PURPOSE: To report on the safety of the first 5 cohorts of a gene therapy trial using recombinant equine infectious anemia virus expressing ABCA4 (EIAV-ABCA4) in adults with Stargardt dystrophy due to mutations in ABCA4. DESIGN: Nonrandomized multicenter phase I/IIa clinical trial. METHODS: Patients received a subretinal injection of EIAVABCA4 in the worse-seeing eye at 3 dose levels and were followed for 3 years after treatment. MAIN OUTCOME MEASURES: The primary end point was ocular and systemic adverse events. The secondary end points were best-corrected visual acuity, static perimetry, kinetic perimetry, total field hill of vision, full field electroretinogram, multifocal ERG, color fundus photography, short-wavelength fundus autofluorescence, and spectral domain optical coherence tomography. RESULTS: The subretinal injections were well tolerated by all 22 patients across 3 dose levels. There was 1 case of a treatment-related ophthalmic serious adverse event in the form of chronic ocular hypertension. The most common adverse events were associated with the surgical procedure. In 1 patient treated with the highest dose, there was a significant decline in the number of macular flecks as compared with the untreated eye. However, in 6 patients, hypoautofluorescent changes were worse in the treated eye than in the untreated eye. Of these, 1 patient had retinal pigment epithelium atrophy that was characteristic of tissue damage likely associated with bleb induction. No patients had any clinically significant changes in best-corrected visual acuity, static perimetry, kinetic perimetry, total field hill of vision, full field electroretinogram, or multifocal ERG attributable to the treatment. CONCLUSIONS: Subretinal treatment with EIAV-ABCA4 was well tolerated with only 1 case of ocular hypertension. No clinically significant changes in visual function tests were found to be attributable to the treatment. However, 27% of treated eyes showed exacerbation of retinal pigment epithelium atrophy on fundus autofluorescence. There was a significant reduction in macular flecks in 1 treated eye from the highest dose cohort. Additional follow-up and continued investigation in more patients will be required to fully characterize the safety and efficacy of EIAV-ABCA4.

Erratum: Addendum: Outcomes of a Five-Year Formal Ophthalmology Residency Mentorship Program.

[This corrects the article DOI: 10.1055/s-0042-1756133.].

Outcomes of a Five-Year Formal Ophthalmology Residency Mentorship Program.

Objective: This article describes a formal ophthalmology residency mentorship program, identifies its strengths and weaknesses over 5 years of implementation, and proposes strategies to improve qualitative outcomes of the mentorship program. Design: Cross-sectional anonymous online survey. Subjects: All current and former mentees and mentors at the Casey Eye Institute (CEI) residency program from 2016 to 2021. Methods: All eligible participants were contacted via email to complete a survey to describe and analyze their experiences with the CEI's formal residency mentorship program. Results: Of the 65 surveyed participants, 82% preferred in-person meetings and met up from 2 to 3 times (44%) to 4 to 6 times (38.5%) annually at 15 minutes to 1 hour (48%) or 1 to 2 hours (42%) duration. Sixty-two percent of meetings were initiated by mentors, 8% by mentees, and 32% shared responsibilities equally. Participants also identified the three most important qualities for successful mentor-mentee relationship as personality (33.6%), communication styles (29.2%), and extracurricular interests/hobbies (16.8%). Mentees valued career advising, networking, and wellness support over academic and research mentorship. Subjective outcomes showed 25% of the mentee and 43% of the mentors agreed the mentorship program was a valuable experience. Comparably, 14% of the mentees and 38% of the mentors prioritized the relationship. There was a strong correlation between participants who prioritized the relationship and acknowledged it as a valuable experience (p < 0.01). Eighteen percent of the mentees and 43% of the mentors found the relationship effective and met their expectations. Twenty-one percent of the mentees and 38% of the mentors believed they had the tools and skills necessary to be effective in their respective roles. Conclusion: Our survey identified that weaknesses of the mentorship program include ineffective communications, inadequate preparation in their respective roles, and lack of priority focus on the relationship. We propose strategies to strengthen our program through creating workshops to clarify roles and responsibilities, emphasizing accountability with a contract statement, and implementing a new matching algorithm to customize participants' experience. Additional studies from other residencies with formal mentorship programs are warranted to identify, strategize, and foster high-quality mentorship.

Multimodal Imaging in a Case with Bilateral Choroidal Folds.

We highlight the use of multimodal imaging to diagnose and report what is, to our knowledge, a novel presentation of bilateral choroidal neovascularization (CNV) and prominent macular choroidal folds (CFs) in a patient with pattern dystrophy. An 81-year-old Caucasian male presented with painless, blurry central vision in both eyes. Color fundus photography, spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), fundus autofluorescence, and brightness scan ultrasonography supported the diagnosis of pattern dystrophy with bilateral CNV and CF. In the right eye, visually significant CNV worsened post-bevacizumab treatment but responded well to aflibercept. During 4-year follow-up, Snellen visual acuity remained excellent in both eyes at 20/20, including the treatment-naïve left eye. CFs remained markedly stable in both eyes.

MULTIMODAL IMAGING OF PHOTIC MACULOPATHY FROM ARC WELDING.

PURPOSE: Photic retinal toxicity induced by exposure to arc welding can lead to irreversible vision loss. Serial multimodal imaging is characterized in a patient with outer retinal damage secondary to welder's maculopathy. METHODS: A single case was retrospectively reviewed. RESULTS: Spectral domain optical coherence tomography acutely revealed disruption of the ellipsoid zone, hyperreflective bands through the outer nuclear layer, and outer retinal cavitation consistent with phototoxicity. Subsequently, disruption and hypertrophy of the subfoveal retinal pigment epithelium developed. Autofluorescence depicted central hypoautofluorescence. CONCLUSION: We report serial multimodal imaging in welder's maculopathy to better characterize the evolution of lesions. Multimodal imaging including spectral domain optical coherence tomography in arc welding phototoxicity may share features with other forms of phototoxicity such as hand-held laser maculopathy.

Comparative effectiveness and harms of intravitreal antivascular endothelial growth factor agents for three retinal conditions: a systematic review and meta-analysis.

Intravitreal antivascular endothelial growth factor (VEGF) agents are widely used to treat ocular conditions but the benefits and harms of these treatments are uncertain. We conducted a systematic review to compare the effects of aflibercept, bevacizumab and ranibizumab on best-corrected visual acuity (BCVA) changes, quality of life and ocular or systemic adverse events in patients with neovascular age-related macular degeneration (NVAMD), diabetic macular oedema (DME) and central or branch retinal vein occlusion (RVO). We searched published and unpublished literature sources to February 2017 for randomised controlled trials and cohort or modelling studies reporting comparative costs in the USA. Two reviewers extracted data and graded the strength of the evidence using established methods. Of 17 included trials, none reported a clinically important difference (≥ 5 letters) in visual acuity gains between agents. Nine trials provide high-strength evidence of no difference between bevacizumab and ranibizumab for NVAMD. Three trials provide moderate-strength evidence of no difference between bevacizumab and ranibizumab for DME. There was low-strength evidence of similar effects between aflibercept and ranibizumab for NVAMD, aflibercept and bevacizumab for RVO and all three agents for DME. There was insufficient evidence to compare bevacizumab and ranibizumab for RVO. Rates of ocular adverse events were low, and systemic harms were generally similar between groups, although 1 DME trial reported more arterial thrombotic events with ranibizumab versus aflibercept. Overall, no agent had a clear advantage over another for effectiveness or safety. Aflibercept and ranibizumab were significantly less cost-effective than repackaged bevacizumab in two trials. Systematic review registration number: CRD42016034076.

Sensitivity and Specificity of OCT Angiography to Detect Choroidal Neovascularization.

PURPOSE: To determine the sensitivity and specificity of optical coherence tomography angiography (OCTA) in the detection of choroidal neovascularization (CNV) in age-related macular degeneration (AMD). DESIGN: Prospective case series. SUBJECTS: Prospective series of seventy-two eyes were studied, which included eyes with treatment-naive CNV due to AMD, non-neovascular AMD, and normal controls. METHODS: All eyes underwent OCTA with a spectral domain (SD) OCT (Optovue, Inc.). The 3D angiogram was segmented into separate en face views including the inner retinal angiogram, outer retinal angiogram, and choriocapillaris angiogram. Detection of abnormal flow in the outer retina served as candidate CNV with OCTA. Masked graders reviewed structural OCT alone, en face OCTA alone, and en face OCTA combined with cross-sectional OCTA for the presence of CNV. MAIN OUTCOME MEASURE: The sensitivity and specificity of CNV detection compared to the gold standard of fluorescein angiography (FA) and OCT was determined for structural SD-OCT alone, en face OCTA alone, and with en face OCTA combined with cross-sectional OCTA. RESULTS: Of 32 eyes with CNV, both graders identified 26 true positives with en face OCTA alone, resulting in a sensitivity of 81.3%. Four of the 6 false negatives had large subretinal hemorrhage (SRH) and sensitivity improved to 94% for both graders if eyes with SRH were excluded. The addition of cross-sectional OCTA along with en face OCTA improved the sensitivity to 100% for both graders. Structural OCT alone also had a sensitivity of 100%. The specificity of en face OCTA alone was 92.5% for grader A and 97.5% for grader B. The specificity of structural OCT alone was 97.5% for grader A and 85% for grader B. Cross-sectional OCTA combined with en face OCTA had a specificity of 97.5% for grader A and 100% for grader B. CONCLUSIONS: Sensitivity and specificity for CNV detection with en face OCTA combined with cross-sectional OCTA approaches that of the gold standard of FA with OCT, and it is better than en face OCTA alone. Structural OCT alone has excellent sensitivity for CNV detection. False positives from structural OCT can be mitigated with the addition of flow information with OCTA.

Screening for Diabetic Retinopathy Using a Portable, Noncontact, Nonmydriatic Handheld Retinal Camera.

BACKGROUND: Diabetic retinopathy (DR) is a leading cause of low vision and blindness. We evaluated the feasibility of using a handheld, noncontact digital retinal camera, Pictor, to obtain retinal images in dilated and undilated eyes for DR screening. We also evaluated the accuracy of ophthalmologists with different levels of training/experience in grading these images to identify eyes with vision-threatening DR. METHODS: A prospective study of diabetic adults scheduled to have dilated eye exams at Duke Eye Center from January to May 2014 was conducted. An imager acquired retinal images pre- and postdilation with Pictor and selected 1 pre- and 1 postdilation image per eye. Five masked ophthalmologists graded images for gradability (based on image focus and centration) and the presence of no, mild, moderate, or severe nonproliferative DR (NPDR) or proliferative DR (PDR). Referable disease was defined as moderate or severe NPDR or PDR on image grading. We evaluated feasibility based on the graders' evaluation of image gradability. We evaluated accuracy of identifying vision-threatening disease (severe NPDR or PDR documented on dilated clinical examination) based on the graders' sensitivity and specificity of grading referable disease. RESULTS: Images were gradable in 86-94% of predilation and 94-97% of postdilation photos. Compared to the dilated clinical exam, overall sensitivity for identifying vision-threatening DR was 64-88% and specificity was 71-90%. CONCLUSIONS: Pictor can capture retinal images of sufficient quality to screen for DR with and without dilation. Single retinal images obtained using Pictor can identify eyes with vision-threatening DR with high sensitivity and acceptable specificity compared to clinical exam.

Normotensive Glaucoma Follow-Up with Incidental Finding of Choroidal Neovascular Membrane: a Teaching Case Report.

Behind cataracts, glaucoma is the second leading cause of blindness worldwide. Patients with glaucoma are followed at regular intervals for testing to confirm stability of the disease; however, providers may need to divert from planned glaucoma testing when clinical findings suggest progression of comorbid ophthalmic conditions. This case report describes a patient presenting for a routine glaucoma follow-up appointment who was subsequently diagnosed with an acute choroidal neovascular membrane due to conversion from non-neovascular to neovascular age-related macular degeneration. The case highlights the management of normotensive glaucoma and both non-neovascular and neovascular macular degeneration.

Assessment of Different Sampling Methods for Measuring and Representing Macular Cone Density Using Flood-Illuminated Adaptive Optics.

PURPOSE: To describe a standardized flood-illuminated adaptive optics (AO) imaging protocol suitable for the clinical setting and to assess sampling methods for measuring cone density. METHODS: Cone density was calculated following three measurement protocols: 50 × 50-µm sampling window values every 0.5° along the horizontal and vertical meridians (fixed-interval method), the mean density of expanding 0.5°-wide arcuate areas in the nasal, temporal, superior, and inferior quadrants (arcuate mean method), and the peak cone density of a 50 × 50-µm sampling window within expanding arcuate areas near the meridian (peak density method). Repeated imaging was performed in nine subjects to determine intersession repeatability of cone density. RESULTS: Cone density montages could be created for 67 of the 74 subjects. Image quality was determined to be adequate for automated cone counting for 35 (52%) of the 67 subjects. We found that cone density varied with different sampling methods and regions tested. In the nasal and temporal quadrants, peak density most closely resembled histological data, whereas the arcuate mean and fixed-interval methods tended to underestimate the density compared with histological data. However, in the inferior and superior quadrants, arcuate mean and fixed-interval methods most closely matched histological data, whereas the peak density method overestimated cone density compared with histological data. Intersession repeatability testing showed that repeatability was greatest when sampling by arcuate mean and lowest when sampling by fixed interval. CONCLUSIONS: We show that different methods of sampling can significantly affect cone density measurements. Therefore, care must be taken when interpreting cone density results, even in a normal population.

Retinal detachment associated with ocular toxoplasmosis.

PURPOSE: To assess the frequency of retinal detachment (RD) and associated clinical features in ocular toxoplasmosis. METHODS: A review of the medical records of patients diagnosed with ocular toxoplasmosis and follow-up of 6 months or more was conducted. All patients were seen at the Casey Eye Institute at the Oregon Health & Science University over a 9-year period (2003-2012). Demographic data, presence of RD and/or vitritis, and treatments were reviewed. Main outcome measures were the rate of RD in ocular toxoplasmosis, degree of vision loss, and final anatomical status of the retina. Disease- and treatment-related factors associated with poor visual outcome were also analyzed. RESULTS: Thirty-five eyes of 28 patients with ocular toxoplasmosis and sufficient follow-up were studied. Median age of patients was 40 years (range, 7-93 years). Median follow-up time was 22.5 months (range, 6-96 months). Four of thirty-five eyes (11.4%) developed RD with a frequency of 0.06 RD events per patient-year of follow-up in this sample in a single center. Of four patients with RD, three underwent pars plana vitrectomy and one underwent laser retinopexy. Two of the 4 patients had recurrent RD requiring scleral buckle. At final follow-up, all patients who underwent surgical repair had attached retinas; however, 3 of 4 patients had severe vision loss (20/200 or worse). CONCLUSION: Retinal detachment occurred in 11% of eyes in this study that led to severe vision loss despite successful RD repair.

Injection frequency and anatomic outcomes 1 year following conversion to aflibercept in patients with neovascular age-related macular degeneration.

BACKGROUND/AIM: To evaluate the clinical, anatomic and functional effects of conversion to aflibercept following ranibizumab and/or bevacizumab in patients with neovascular age-related macular degeneration (AMD). METHODS: A retrospective review of patients with neovascular AMD treated with intravitreal ranibizumab and/or bevacizumab who were switched to aflibercept was performed. The primary outcome was change in injection frequency in the year following the change. Secondary outcomes included change in central macular thickness (CMT) at 6 months and 1 year, presence of intraretinal and subretinal fluid at 6 months and visual acuity at 1 year. RESULTS: A total of 109 eyes with neovascular AMD were switched to aflibercept and met inclusion criteria. Overall, aflibercept injection frequency was unchanged with patients receiving 7.4 antivascular endothelial growth factor (VEGF) injections the year prior to conversion compared with 7.2 aflibercept injections in the year following (p=0.47). However, the change to aflibercept was associated with improvement in CMT from 324 to 295 µm (p=0.0001) at 6 months and 299 µm (p=0.0047) at 1 year. There was no effect on visual acuity at 1 year. In a subgroup analysis, patients who had received ≥10 anti-VEGF injections in the year prior had fewer injections (11.1 to 8.4, p<0.0001) and clinic visits (13.9 to 9.6, p<0.0001) as well as a significant decrease in CMT (-35 µm, p=0.02). CONCLUSIONS: In our population, switching to aflibercept therapy was not associated with a change in injection frequency nor improved visual acuity, but was associated with improved CMT at 6 months and 1 year. In patients who received at least 10 anti-VEGF injections in the year prior, transitioning to aflibercept was associated with a reduced injection frequency and CMT, suggesting potential cost savings in this population.