Ocular Mucous Membrane Pemphigoid: The Effect of Risk Factors at Presentation on Treatment Outcomes.

PURPOSE: Analyze the influence of risk factors at presentation in the long-term immunosuppressive therapy (IMT) outcomes of ocular mucous membrane pemphigoid (OMMP). DESIGN: Retrospective multicenter study. PARTICIPANTS: Patients with OMMP seen at the Duke Eye Center, Tecnologico de Monterrey, and Hospital Clinic of Barcelona from 1990 to 2022. METHODS: Data at presentation on demographics, direct immunofluorescence, ocular findings, sites of extraocular manifestations (EOMs), and previous treatments in patients with a clinical or laboratory diagnosis of OMMP, were analyzed with multivariable analysis and Kaplan-Meier plots to identify factors associated with adverse outcomes. MAIN OUTCOME MEASURES: (1) Inflammatory control (no conjunctival inflammation in both eyes at 3 months on IMT); (2) relapse (new-onset inflammation after absolute control in either eye); (3) progression (≥ 1 cicatrizing stage progression in either eye); and (4) vision loss (≥ 2 Snellen lines). RESULTS: A total of 117 patients (234 eyes), 61% (71/117) of whom were women, with a mean age of 66.6 (SD: 12.4) years (range: 37-97 years) and median follow-up of 34 months (interquartile range: 16-66 months; range: 3-265 months), were enrolled. Inflammatory control was achieved in 57% of patients (67/117), with high-risk EOM (HR-EOM), including esophageal, nasopharyngeal, and/or genital involvement (adjusted odds ratio [aOR]: 12.51; 95% confidence interval [CI]: 2.61-59.99; P = 0.002) and corneal scarring (aOR: 3.06; 95% CI, 1.15-8.14; P = 0.025), as significant risk factors for persistent inflammation. Disease relapse, progression, and vision loss occurred in 20% of patients (23/117), 12% of patients (14/117), and 27% of patients (32/117), respectively. Baseline corneal scarring was a risk factor for relapse (adjusted hazard ratio: 4.14; 95% CI: 1.61-10.62; P = 0.003), progression (aOR: 11.46; 95% CI: 1.78-73.75; P = 0.010), and vision loss (aOR: 3.51; 95% CI: 1.35-9.10; P = 0.010). HR-EOM was associated with stage progression (aOR, 34.57; 95% CI, 6.57-181.89; P<0.001) and vision loss (aOR, 8.42; 95% CI, 2.50-28.42; P = 0.001). No significant differences were found between IMT regimes and relapse (P = 0.169). CONCLUSIONS: Ocular mucous membrane pemphigoid presenting with HR-EOMs and corneal scarring has an increased risk of stage progression and vision loss. Corneal scarring and severe inflammation at baseline were associated with an increased risk of relapse. A disease progression staging system incorporating both the HR-EOMs and corneal involvement is required to predict the visual outcome of OMMP better. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Considerations for the Identification and Management of Geographic Atrophy: Recommendations from an Expert Panel.

Newly approved treatments for patients with geographic atrophy are changing the treatment paradigm, highlighting the need for eye care providers (ECPs) to have a set of recommendations on how to best manage GA patients. Here, we outline how to identify various stages of age-related macular degeneration including geographic atrophy (GA) by examining optimal management scenarios implicating various ECPs and reviewing treatment considerations for patients with GA. Early identification of GA will lead to optimal patient outcomes, while a standardized management scenario will reduce clinical burden among ECPs treating patients with GA.

Automated Eye Tracking Enables Saccade Performance Evaluation of Patients with Concussion History.

SIGNIFICANCE: Automated eye tracking could be used to evaluate saccade performance of patients with concussion history, providing quantitative insights about the degree of oculomotor impairment and potential vision rehabilitation strategies for this patient population. PURPOSE: To evaluate the saccade performance of patients with concussion history based on automated eye-tracking test results. METHODS: We conducted a retrospective study of patients with concussion history, primarily from sports participation, who underwent oculomotor testing based on an eye-tracking technology at the Duke Eye Center vision rehabilitation clinic between June 30, 2017, and January 10, 2022. Patients' saccade test results were reviewed, including saccade fixation and saccade speed/accuracy ratio. The outcomes were compared with age-matched normative population data derived from healthy individuals. Multiple linear regression analyses were performed to identify factors associated with saccade performance among patients with concussion history. RESULTS: On hundred fifteen patients with concussion history were included in the study. Patients with concussion, on average, had fewer fixations on self-paced horizontal and vertical saccade tests and lower horizontal and vertical saccade speed/accuracy ratios compared with normative ranges. Among patients with concussion history, multiple linear regression analyses showed that older age was associated with fewer fixations on horizontal and vertical saccade tests, whereas male sex was associated with more fixations on horizontal and vertical saccade tests (all P < .01). In addition, older age was associated with lower horizontal saccade speed/accuracy ratio, after adjusting for sex, number of concussion(s), and time from most recent concussion to oculomotor testing ( P < .001). CONCLUSIONS: Patients with concussion history had lower saccade performance based on eye tracking compared with healthy individuals. We additionally identified risk factors for lower saccade performance among patients with concussion history. These findings support the use of saccade test results as biomarkers for concussion and have implications for post-concussion rehabilitation strategies.

Geographic Atrophy Management Consensus (GA-MAC): a Delphi panel study on identification, diagnosis and treatment.

BACKGROUND/AIMS: With a paradigm shift in geographic atrophy (GA) treatments now available, establishing consensus on the identification and diagnosis of the disease along with considerations for management of patients with GA will assist eye care professionals (ECP) in their day-to-day practices, leading to improved patient outcomes. METHODS: A modified Delphi panel process (Geographic Atrophy Management Consensus) consisting of three total surveys and one virtual live meeting held between survey 2 and survey 3. Data were collected from July to October 2022. Participants included expert members of the eye care community that have demonstrated outstanding leadership among peers: a steering committee with three ECPs and a 15-member panel divided between five optometrists, five comprehensive ophthalmologists and five retina specialists. Consensus on statements related to the management of patients with GA was calculated using the RAND/UCLA Appropriateness Method. RESULTS: At the conclusion of the third survey, consensus was reached on 91% of the 77 statements. Critical consensus topics include: (1) optical coherence tomography as the favoured method to diagnose and monitor GA, (2) preferred practice patterns regarding referral of patients to retina specialists and (3) treatment criteria given the advent of emerging therapeutics for GA. CONCLUSIONS: Generating awareness of early signs of disease development, progression and identifying the best tools to evaluate GA establishes ideal management and referral strategies. Given the paradigm shift in GA management driven by approved therapies, coupled with the fact that the disease is progressive resulting in devastating vision loss, these strategies are critical to ensure best overall outcomes.

Functional glycoproteomics by integrated network assembly and partitioning.

The post-translational modification (PTM) of proteins by O-linked ß-N-acetyl-D-glucosamine (O-GlcNAcylation) is widespread across the proteome during the lifespan of all multicellular organisms. However, nearly all functional studies have focused on individual protein modifications, overlooking the multitude of simultaneous O-GlcNAcylation events that work together to coordinate cellular activities. Here, we describe Networking of Interactors and SubstratEs (NISE), a novel, systems-level approach to rapidly and comprehensively monitor O-GlcNAcylation across the proteome. Our method integrates affinity purification-mass spectrometry (AP-MS) and site-specific chemoproteomic technologies with network generation and unsupervised partitioning to connect potential upstream regulators with downstream targets of O-GlcNAcylation. The resulting network provides a data-rich framework that reveals both conserved activities of O-GlcNAcylation such as epigenetic regulation as well as tissue-specific functions like synaptic morphology. Beyond O-GlcNAc, this holistic and unbiased systems-level approach provides a broadly applicable framework to study PTMs and discover their diverse roles in specific cell types and biological states.

Younger Age and Longer Case Times Associated With Emergency Department Visits After Cataract Surgery.

PURPOSE: To characterize the frequency, reasons, hospital costs, and risk factors for emergency department (ED) visits within 30 days of cataract surgery. DESIGN: Retrospective cohort study. METHODS: A retrospective review of all cataract surgeries at Duke Health between 2013 and 2021 was conducted. Demographics, case characteristics (length, complexity by billing codes, anesthesia type), ED visit findings, and hospital costs were collected. Logistic regression models were used to determine the odds of ED visits based on several risk factors. RESULTS: Of 34 246 patients (57 656 eyes) undergoing cataract surgery at Duke Health from 2013 to 2021, a total of 607 patients (1.77%) had 680 ED visits within 30 days of surgery. The most common ED diagnosis was cardiovascular (24.4%), whereas ocular complaints constituted 15.4% of visits. The most common ocular diagnoses were high intraocular pressure, rebound iritis, and posterior vitreous detachment. Hospital costs were lowest for ocular diagnoses (mean $467.72) and highest for trauma diagnoses (mean $4660.55). Risk factors for ED visits included case lengths greater than 30 minutes (OR 2.1, 95% CI 1.56-2.83, P < .001), the combination of Monitored Anesthesia Care (MAC) and retrobulbar anesthesia or general anesthesia (OR 2.98, 95% CI 1.73-5.12, P < .001), and age less than 70 years (OR 1.39, 95% CI 1.16-1.65, P < .001). CONCLUSIONS: ED visits within 30 days of cataract surgery are uncommon. Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of ED visits.

Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives.

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis.

Meibomian Gland Dysfunction: A Dermatological Perspective on Pathogenesis and Treatment Outlook.

Meibomian glands are modified oil-producing glands that produce meibum and can become dysfunctional and negatively affect the lipid layer in the tear film, resulting in ocular surface diseases such as evaporative dry eye. Abnormal keratin production and aggregation at the meibomian gland orifice has been implicated in the pathogenesis of meibomian gland dysfunction (MGD). Current treatments largely ignore the role of keratin proteins. This review paper synthesizes various publications on hyperkeratinization and its role in MGD pathogenesis and proposes a novel treatment strategy for MGD that involves the use of keratolytic agents commonly used in dermatological treatments.

The corneal endothelium: clinical review of endothelial cell health and function.

The endothelial cell is a critical structure within the cornea and is responsible for maintaining corneal clarity through its pump function. Endothelial cells are lost over time naturally but can be injured medically, surgically, or as a part of various dystrophies. Monitoring of endothelial cells can be performed clinically or more formally with specular microscopy. In cases of significant compromise, endothelial cells can be transplanted by various endothelial keratoplasty techniques. The future pipeline is bright for possible endothelial cell regeneration and rehabilitation. This article reviews these topics in depth to provide a comprehensive look at the structure and function of the endothelial cell, etiologies of endothelial cell damage, detailed review of iatrogenic causes of endothelial cell loss, and management strategies.

Refractive Outcomes Using Intraoperative Aberrometry for Highly Myopic, Highly Hyperopic, and Post-refractive Eyes.

PURPOSE: To evaluate whether intraoperative aberrometry improves the accuracy of refractive outcomes after cataract surgery in highly myopic, highly hyperopic, and post-refractive eyes. METHODS: This single-center, retrospective review compared the spherical equivalent of postoperative refraction to that predicted by the Barrett Universal II formula versus Optiwave Refractive Analysis (ORA) (Alcon Laboratories, Inc) for highly myopic and hyperopic eyes and to the Barrett True K formula versus ORA for post-refractive eyes. The number and magnitude of lens changes were analyzed and used to determine in how many cases refractive surprises were affected by ORA, with additional subanalysis of outcomes based on average keratometry values. RESULTS: ORA led to a change in the lens power implanted in 48% (96 of 198) of eyes, and prevented hyperopic surprise in 27% (15 of 55) and excess myopia in 46% (19 of 41). Steeper keratometry values correlated with more frequent changes on ORA-recommended implanted intraocular lens (P = .0031). ORA led to a similar percentage of eyes falling within ±0.50, ±0.75, and ±1.00 diopters compared to the Barrett Universal II and Barrett True K formulas. In post-refractive eyes, ORA led to a similar mean absolute error when compared to the Barrett True K formula (P = .62). For highly myopic eyes with an axial length of greater than 27 mm, ORA demonstrated a trend toward lower mean absolute error when compared to the Barrett Universal II formula (P = .076). CONCLUSIONS: ORA demonstrated similar refractive results to the Barrett True K formula in post-refractive eyes and to the Barrett Universal II formula in highly myopic and hyper-opic eyes and may provide additional benefit for eyes with steeper corneas or an axial length of greater than 27 mm. [J Refract Surg. 2021;37(9):609-615.].

Posterior lamellar keratoplasty: techniques, outcomes, and recent advances.

Over the past 2 decades, posterior lamellar keratoplasty (PLK) has emerged as an alternative to penetrating keratoplasty in the treatment of corneal endothelial disorders. The reasons for this trend include the search for a safer procedure to replace diseased endothelium that provides faster and better visual rehabilitation and reduces the need for postoperative care. Different surgical techniques, surgical instruments, devices, and lasers have been introduced to overcome technical difficulties, thus improving clinical outcomes. Yet, surgeons and eye banks must address the complications and limitations that arise during the transition to these new techniques. This review discusses the most significant aspects of the evolution of PLK, including a detailed description of current techniques and the direction of future treatment for corneal endothelial disease with the use of laser-assisted surgery, bioengineered corneas, cell therapy, and new pharmacologic therapy.

Retrospective review of Duke men's basketball eye care: annual screenings and traumatic injuries.

OBJECTIVES: 1) To assess the utility of performing eye screenings for healthy basketball players. 2) To describe the traumatic injuries sustained by competitive college basketball players. METHODS: The eye screening examinations of the Duke University Men's Basketball players over six seasons were reviewed retrospectively. Traumatic basketball-related eye injuries amongst Duke University Men's Basketball players over 16 seasons were also reviewed and described. RESULTS: Forty-four total players underwent screening examinations. Thirteen (29.5%) of athletes had uncorrected or under-corrected refractive errors. One athlete was found to have a severe monocular visual deficit secondary to a traumatic injury in childhood, which was significantly mitigated by a contact lens referral. Eight traumatic ocular injuries in eight different athletes, 8.6% of the total roster players in this interval, required ophthalmologic consultation. Most injuries, 7/8, resulted in no permanent visual impairment. However, two severe episodes of injury required operative intervention, and one episode involving a giant retinal dialysis and traumatic optic nerve head avulsion caused severe, permanent visual loss. Most injuries did not result in significant competition time loss, with a median time loss of 5 days (range 0 to 240 days). CONCLUSION: Screening eye examinations in healthy athletes are beneficial for the identification and treatment of refractive errors. Traumatic basketball-related eye injuries are common and result in a wide array of injuries. Although most basketball-related eye injuries do no result in permanent visual loss, given the potential for severe injury, many basketball-related eye injuries require expert ophthalmic consultation.

When ophthalmology goes virtual amid a pandemic: content analysis of the 2020 #ASCRSVirtualMeeting.

PURPOSE: To assess the use and impact of the social media platform Twitter during the 2020 ASCRS Virtual Meeting. SETTING: Social media platform Twitter.com. DESIGN: Retrospective review. METHODS: Retrospective analysis of Twitter use during the ASCRS Virtual Meeting in May 2020. All tweets and associated metadata pertaining to the conference were compiled starting from when the virtual meeting was announced (April 8, 2020) to 2 weeks postconference (May 31, 2020). Two coders independently coded all tweets and excluded tweets if they were irrelevant or no longer available. RESULTS: A total of 501 tweets were reviewed, of which 48.5% of tweets came from private accounts, 23.1% from academic institutions, 14.4% from ASCRS accounts, 12.4% from industry, and 1.6% from professional organizations; 146 tweets (29.1%) were shared before, 303 tweets (60.5%) during, and 52 tweets (10.4%) after the conference. A total of 315 tweets (62.9%) promoted conference events, 137 tweets (27.3%)) were about research studies, 136 tweets (27.1%) were social posts, 115 tweets (23.0%) were from industry sponsors, 22 tweets (4.4%) were self-promotion, and 5 tweets (1.0%5) were not categorized. Twitter impressions on the ASCRS account increased by 79% in 2020 compared with the 2019 annual meeting. CONCLUSIONS: To the author's knowledge, this is the first study to describe how Twitter users engaged with a virtual ophthalmology meeting through social media during the coronavirus pandemic. Findings from this study offer insight into how the ophthalmology community can use social media during conferences and highlight opportunities for networking through social media for both virtual and in-person conferences in the future.

Case Series of Urrets-Zavalia Syndrome After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To present a case series of Urrets-Zavalia syndrome (UZS) that developed after Descemet membrane endothelial keratoplasty (DMEK). METHODS: A retrospective chart review was performed to identify patients who underwent DMEK by a single surgeon at the Duke Eye Center from 2017 to 2019 and subsequently developed UZS. Demographic data, preoperative history, operative notes, and postoperative course were reviewed. RESULTS: We describe 5 cases of UZS after DMEK (ages 19-74 years; 3 men and 2 women). Onset of UZS was noted at postoperative week 1 (n = 1), 2 (n =3), or 4 (n = 1). Four patients had an underlying diagnosis of Fuchs endothelial dystrophy and 1 had posterior polymorphous corneal dystrophy. Sixty percent (n = 3) of patients had an elevated intraocular pressure on postoperative day 0 or 1, and 40% (n = 2) of patients also had a pupillary block. One patient developed UZS after a rebubbling procedure for partial graft detachment and another developed UZS after repeat DMEK transplantation. Of the 3 patients who underwent bilateral combined DMEK and cataract surgery, 1 developed UZS in the second eye, whereas 2 developed UZS in the first eye. Most patients experienced monocular diplopia or had cosmetic concerns because of their mydriatic pupils. Two patients had spontaneous improvement in mydriasis. CONCLUSIONS: UZS after DMEK is rare, with only 2 cases in the literature: Holtmann et al and Isac et al. We present the largest case series of UZS after DMEK to date. Postoperative elevation in intraocular pressure is a common contributing factor. Evaluation of more patients may elucidate additional risk factors for this condition.

Real-world opioid prescribing after cataract surgery among patients who received intracameral phenylephrine and ketorolac 1.0%/0.3.

OBJECTIVE: To examine opioid prescribing following cataract surgery among patients who did or did not receive Omidria (phenylephrine and ketorolac intraocular solution 1.0%/0.3%) referred to as "P/K". METHODS: The retrospective study compared adults over 65 without recent opioid use in the MarketScan databases who had a cataract-related surgical procedure between 1 January 2015 and 31 July 2019. Opioid prescription fills in the initial 2 and 7 days following surgery were compared between patients who did or did not receive P/K during surgery. RESULTS: We identified 218,672 older adults with cataract-related surgical procedures, of whom 5145 received P/K during surgery. Within 2 days of surgery, 0.50% of P/K patients and 0.68% of non-P/K patients received at least one opioid prescription. Pill counts in the first prescription post-surgery were lower for patients who received P/K than those who did not receive P/K (20 vs 45 respectively, p = .015). Findings were similar when a 7 day window was used. The reduction in opioids prescribed to patients who received P/K occurred despite the P/K-treated patients having a significantly higher incidence of preoperative comorbidities or risk factors for surgical complexity than patients who did not receive P/K (46.6% vs 31.3%, p < .001). CONCLUSIONS: Patients without recent opioid use who received P/K during cataract surgery, despite greater incidence of preoperative comorbidities and higher risk for surgical complexity, were prescribed fewer opioid pills following surgery than patients who did not receive P/K.

Pooled Efficacy and Safety Profile of Netarsudil Ophthalmic Solution 0.02% in Patients With Open-angle Glaucoma or Ocular Hypertension.

PRECIS: In pooled phase III analyses, once-daily netarsudil 0.02% resulted in intraocular pressure (IOP) reduction that was noninferior to twice-daily timolol 0.5%, with minimal treatment-related serious or systemic adverse events (AEs). Ocular AEs were generally tolerable. PURPOSE: The purpose of this study was to assess the efficacy and safety of the Rho kinase inhibitor netarsudil in patients with open-angle glaucoma or ocular hypertension. PATIENTS AND METHODS: Pooled analysis of data from the ROCKET-1 to 4 phase III studies of once-daily (PM) netarsudil or twice-daily timolol in patients with open-angle glaucoma or ocular hypertension. The primary efficacy measure was mean IOP at 8:00 AM, 10:00 AM, and 4:00 PM at week 2, week 6, and month 3 in patients with baseline IOP <25 mm Hg. RESULTS: In the pooled primary efficacy population (netarsudil, n=494; timolol, n=510), once-daily netarsudil was noninferior to twice-daily timolol at all 9 timepoints through month 3. Mean treated IOP ranged from 16.4 to 18.1 mm Hg among netarsudil-treated patients and 16.8 to 17.6 mm Hg among timolol-treated patients. In the pooled safety population (n=839 in each treatment group), treatment-related serious AEs occurred at similar frequencies in each treatment group (netarsudil, 0.1%; timolol, 0%). The most common ocular AE, conjunctival hyperemia (netarsudil, 54.4%; timolol, 10.4%), was graded as mild in 77.6% (354/456) of affected netarsudil-treated patients. CONCLUSIONS: Once-daily netarsudil resulted in IOP lowering that was noninferior to twice-daily timolol, with tolerable ocular AEs that were generally mild and self-resolving. As a first-in-class agent in the United States, with a novel mechanism of action, netarsudil may provide a useful therapeutic option for patients who would benefit from IOP lowering.