Endophthalmitis following cataract surgery: visual outcomes, microbial spectrum and complications.

PURPOSE OF REVIEW: The aim of this study was to update visual outcomes, microbial spectrum and complications in eyes with endophthalmitis following cataract surgery. RECENT FINDINGS: A single-institution, retrospective review of eyes treated for endophthalmitis following cataract surgery between 2 January 2014 and 10 January 2017. This study included 112 cases of endophthalmitis following cataract surgery, 58 of which were culture-positive (51.8%). The most isolated organisms were coagulase-negative Staphylococci (56.9%). Oral flora were present in 17.2% of cases. At 6 months, 71.7% of patients achieved visual acuity of at least 20/200 and 51.7% achieved at least 20/40 or better. Visual acuity was better in culture-negative vs. culture-positive cases (∼20/290 vs. ∼20/80, P   =  0.03), and in nonoral flora-associated vs. oral flora-associated culture-positive cases (∼CF vs. ∼20/150, P   <  0.01). SUMMARY: Following postcataract surgery endophthalmitis, approximately 70% of eyes achieved vision of 20/200 or better and half achieved vision of 20/40 or better 6 months after treatment. Poor visual outcomes were seen in eyes with positive bacterial cultures and with oral flora.

Likelihood of germline mutation with solitary retinoblastoma based on tumour location at presentation.

BACKGROUND/AIMS: To evaluate the likelihood of germline mutation in patients presenting with solitary retinoblastoma based on tumour location at first examination. METHODS: Retrospective analysis of solitary unilateral retinoblastoma for likelihood of germline mutation (family history of retinoblastoma and/or genetic testing indicating germline RB1 mutation and/or development of additional new or bilateral tumours) based on tumur location at presentation (macular vs extramacular). RESULTS: Of 480 consecutive patients with solitary retinoblastoma, 85 were in the macula (18%) and 395 were extramacular (82%). By comparison (macular vs extramacular tumours), macular tumours had smaller basal diameter (12.7 mm vs 18.9 mm, p<0.001) and smaller tumour thickness (6.1 mm vs 10.7 mm, p<0.001). Patients with macular tumours demonstrated greater likelihood for germline mutation (23% vs 12%, OR=2.18, p=0.011), specifically based on family history of retinoblastoma (13% vs 2%, OR=4.64, p=0.004), genetic testing showing germline RB1 mutation (27% vs 15%, OR=2.04 (95% CI 1.04 to 4.01), p=0.039), development of new tumours (13% vs 3%, OR=5.16 (95% CI 2.06 to 12.87), p=0.001) and/or development of bilateral disease (9% vs 2%, OR=4.98 (95% CI 1.70 to 14.65), p=0.004). CONCLUSIONS: Among patients with solitary unilateral retinoblastoma, those presenting with macular tumour (compared with extramacular tumour) show 2.18 times greater likelihood for germline mutation and an even higher likelihood of development of subsequent tumours. Solitary macular retinoblastoma should raise an index of suspicion for likely germline mutation and multifocal disease.

Likelihood of Germline Mutation With Solitary Unilateral Retinoblastoma Based on Patient Age at Presentation: Analysis of 482 Consecutive Patients.

PURPOSE: To evaluate the likelihood of germline retinoblastoma in patients presenting with solitary unilateral retinoblastoma, based on age at presentation. METHODS: This retrospective case series of 482 consecutive patients presenting with solitary unilateral retinoblastoma analyzed the likelihood of germline retinoblastoma, defined as family history of retinoblastoma, germline retinoblastoma mutation documented on genetic testing, and/or development of bilateral disease and/or additional new tumors. This analysis was based on age at presentation (0 to 12 months vs older than 12 to 24 months vs older than 24 to 36 months vs older than 36 months) and a sub-study was conducted on infant age at presentation (0 to 3 months vs older than 3 to 6 months vs older than 6 to 9 months vs older than 9 to 12 months). RESULTS: Of the overall group (482 consecutive patients) with solitary unilateral retinoblastoma, there were significantly different findings in the youngest age group (0 to 12 months old) with greater family history of retinoblastoma (10% vs 2% vs 1% vs 2%, P = .004), smaller median basal diameter (18.0 vs 20.0 vs 20.0 vs 20.0 mm, P = .014), smaller median tumor thickness (8.7 vs 10.0 vs 11.5 vs 10.0 mm, P = .002), greater macular tumor location (33% vs 16% vs 10% vs 8%, P < .001), and greatest likelihood of germline mutation (29% vs 17% vs 8% vs 9%, P = .001). By comparison, patients 1 year and younger (vs older than 1 year) demonstrated a 2.96 odds ratio (OR) (P = .001) for likelihood of germline retinoblastoma. For those classified as infants (1 year and younger) (n = 132 consecutive patients), the youngest patients (0 to 3 months old) demonstrated the greatest likelihood for germline mutation (61% vs 20% vs 24% vs 22%, P = .009) and greatest odds ratio (5.52, P = .002) compared to patients older than 3 to 12 months. CONCLUSIONS: The youngest patients with solitary unilateral retinoblastoma showed the greatest likelihood of germline disease when evaluating all patients (1 year and younger vs older than 1 year of age) (OR = 2.96) and the substudy of infants (3 years and younger vs older than 3 to 12 months old) (OR = 5.52). [J Pediatr Ophthalmol Strabismus. 2021;58(6):355-364.].

Intra-arterial chemotherapy for retinoblastoma in 341 consecutive eyes (1,292 infusions): comparative analysis of outcomes based on patient age, race, and sex.

PURPOSE: To evaluate tumor control and globe salvage following intra-arterial chemotherapy (IAC) for retinoblastoma based on International Classification of Retinoblastoma (ICRB) and patient demographics. METHODS: The medical records of 313 patients (341 eyes) treated with IAC were reviewed retrospectively. Chemotherapy agents included melphalan, topotecan, and carboplatin. Comparative analysis was performed for tumor control and globe salvage based on ICRB and patient demographics including age (≤12 vs >12 months), race (white vs nonwhite), and sex. RESULTS: Of the 341 eyes treated with 1,292 consecutive infusions of IAC as primary or secondary therapy for retinoblastoma, Kaplan-Meier 5-year estimates of globe salvage was 74%. Of those treated with IAC as primary therapy (n = 160 eyes; 655 infusions), 5-year globe salvage overall was 76%: and more specifically, 100% for groups B and C, 86% for group D, and 55% for group E. Of those treated with IAC as secondary therapy (n = 207 eyes; 859 infusions), 5-year globe salvage was 71%. Comparative analysis by race and sex demonstrated no differences in outcomes, but analysis by age revealed that younger patients had a higher rate of globe salvage (77% vs 72%; P < 0.001). Complications (per catheterization) included retina ischemia (1%), choroidal ischemia (1%), neovascularization of the disk, retina, iris (NVI), glaucoma (about 1% each), and central/peripheral systemic ischemia (<1%). Younger patients showed less NVI (P = 0.028), white patients showed less retinal ischemia (P = 0.037), and no difference by sex. There were no patients with metastatic disease or death. CONCLUSIONS: Our results suggest that IAC provides substantial tumor control for advanced and/or recurrent retinoblastoma with a high rate of globe salvage and few complications. There was little difference in outcomes per age, race, and sex.

Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period.

Aims: To evaluate whether the incidence, microbial spectrum, and visual outcomes of endophthalmitis following intravitreal injections have changed over time.Methods: Retrospective cohort study of endophthalmitis in eyes receiving intravitreal injection of anti-vascular endothelial growth factor between 2009-2012 and 2016-2017 at a single, large retina practice.Results: A total of 283,315 injections resulted in 96 suspected infectious endophthalmitis cases. Comparing 2009-2012 and 2016-2017, the rate of suspected endophthalmitis changed from 1 in 2,663 injections to 1 in 3,195 injections (p = .37). Visual outcomes 6 months after endophthalmitis were significantly better during the latter period (p = .04), with an average loss of 6.3 lines of VA in 2009-2012 compared to a loss of 3.6 lines in 2016-2017. In multivariate analysis, a "no-talking" policy during injections resulted in a trend towards a decrease in endophthalmitis incidence (p = .08). Cessation of post-injection topical antibiotic use did not independently decrease endophthalmitis incidence (p = .24) when the effect of a "no-talking" policy was taken into account. A lower rate of endophthalmitis was seen after prefilled vs. conventionally prepared ranibizumab syringe use for injection (0.014% vs. 0.035%, respectively), though this difference did not meet statistical significance (p = .16).Conclusion: The incidence of endophthalmitis after intravitreal injection decreased and visual outcomes improved between the periods of 2009-2012 and 2016-2017. A "no-talking" policy during injections was associated with a trend toward a decrease in endophthalmitis rate.

Sensing everyday activity: Parent perceptions and feasibility.

Mobile and wearable sensors provide a unique opportunity to capture the daily activities and interactions that shape developmental trajectories, with potential to revolutionize the study of development (de Barbaro, 2019). However, developmental research employing sensors is still in its infancy, and parents' comfort using these devices is uncertain. This exploratory report assesses parent willingness to participate in sensor studies via a nationally representative survey (N = 210) and live recruitment of a low-income, minority population for an ongoing study (N = 359). The survey allowed us to assess how protocol design influences acceptability, including various options for devices and datastream resolution, conditions of data sharing, and feedback. By contrast, our recruitment data provided insight into parents' true willingness to participate in a sensor study, with a protocol including 72 h of continuous audio, motion, and physiological data. Our results indicate that parents are relatively conservative when considering participation in sensing studies. However, nearly 41 % of surveyed parents reported that they would be at least somewhat willing to participate in studies with audio or video recordings, 26 % were willing or extremely willing, and 14 % reported being extremely willing. These results roughly paralleled our recruitment results, where 58 % of parents indicated interest, 29 % of parents scheduled to participate, and 10 % ultimately participated. Additionally, 70 % of caregivers stated their reason for not participating in the study was due to barriers unrelated to sensing while about 25 % noted barriers due to either privacy concerns or the physical sensors themselves. Parents' willingness to collect sensitive datastreams increased if data stayed within the household for individual use only, are shared anonymously with researchers, or if parents receive feedback from devices. Overall, our findings suggest that given the correct circumstances, mobile sensors are a feasible and promising tool for characterizing children's daily interactions and their role in development.

Endophthalmitis after Cataract Surgery: Changes in Management Based on Microbiologic Cultures.

PURPOSE: To assess the utility of microbiologic culture data for the management of endophthalmitis after cataract surgery. DESIGN: Retrospective, single-center, cohort study. PARTICIPANTS: All patients treated for endophthalmitis after cataract surgery between January 1, 2014, and December 31, 2017, at a single institution. METHODS: Endophthalmitis cases were determined from billing records and confirmed with chart review. A change in clinical management was defined as additional intravitreal antibiotic injections or pars plana vitrectomy. MAIN OUTCOME MEASURES: A change in clinical management within 2 weeks of initial endophthalmitis culture and treatment; visual acuity (VA). RESULTS: A total of 111 eyes of 111 patients were treated for endophthalmitis after cataract surgery, of which 57 (51%) were culture-positive. After initial treatment of endophthalmitis, a change in clinical management after vitreous culture occurred in 9 of 111 eyes (8%), including 6 of 57 (11%) culture-positive eyes compared with 3 of 54 (6%) culture-negative eyes (P = 0.49). Change in clinical management for culture-positive eyes was based on declining vision (3 eyes), worsening clinical examination results (2 eyes), and retinal detachment (1 case). Change in clinical management for culture-negative endophthalmitis eyes was based on worsening clinical examination results (2 eyes) and declining vision (1 eye). No additional interventions were initiated on the basis of positive culture results. At final follow-up, mean logarithm of the minimum angle of resolution (logMAR) VA was 1.09 (∼20/250) for the culture-positive eyes compared with 0.59 (∼20/80) for culture-negative eyes (adjusted difference, 0.394; 95% confidence interval, 0.02-0.77, P = 0.03). Rhegmatogenous retinal detachments (RRDs) or retinal tears occurred in 19 of 111 eyes (17%) after developing endophthalmitis, and culture-positive eyes developed a secondary RRD in 11 of 57 eyes (19%) compared with 3 of 54 (6%) culture-negative eyes (P = 0.03). CONCLUSIONS: After endophthalmitis related to cataract surgery, vitreous cultures may have prognostic value for final visual outcomes but have a limited effect on clinical management.

Outcomes and Complications of In-Office Laser Demarcation of Peripheral Rhegmatogenous Retinal Detachments.

BACKGROUND AND OBJECTIVE: To evaluate the outcomes of in-office laser demarcation (LD) for peripheral rhegmatogenous retinal detachments (RRDs). PATIENTS AND METHODS: This was a retrospective analysis of peripheral RRDs treated with LD. Patient demographics, visual acuity (VA), and RRD characteristics were recorded. Complications requiring additional procedures were recorded. Multiple logistic regression was used to characterize the association of RRD anatomy to treatment complications. RESULTS: A total of 112 eyes of 107 patients were analyzed with mean follow-up of 20 ± 12 months. VA at baseline and last follow-up was equivalent (0.16 logMAR, Snellen equivalent 20/29). Ninety-five (84.8%) eyes were successfully treated without an additional procedure. In multivariate analysis, the presence of VH (odds ratio [OR] = 4.0; 95% confidence interval [CI], 1.1-17; P = .04) and RRDs in the inferior 6 clock hours (OR = 6.2; 95% CI, 1.5-29; P = .01) were associated with complications. CONCLUSIONS: LD is successful in treating peripheral RRDs. RRD characteristics less conducive to laser include presence of VH and inferior RRD. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:428-434.].

Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment.

PURPOSE: To determine the incidence and timing of delayed retinal breaks and retinal detachments (RDs) after acute posterior vitreous detachment (PVD) and associated risk factors. DESIGN: Retrospective case-control study. PARTICIPANTS: Acute PVD eyes treated between October 2015 and August 2018 at a single academic retina practice. METHODS: Eyes with a PVD diagnosis and history of extended ophthalmoscopic examination on presentation were identified using diagnostic billing codes. The number of eyes with a history of laser retinopexy, cryotherapy for retinal tear, or RD repair was determined using procedural billing codes, and the duration between initial and treatment visits was measured. Records of eyes with a delayed retinal break or RD and of a reference group comprising the first 100 presenting eyes with no initial or delayed retinal break or RD were reviewed to determine and compare the presence of select risk factors on initial examination. MAIN OUTCOME MEASURES: Development of a delayed retinal break or RD. RESULTS: Of 7999 eyes with acute PVD, 1280 (16.0%) showed a retinal break and 499 (6.2%) showed an RD on presentation. Delayed retinal breaks and RDs were found in 209 (2.6%) and 80 (1.0%) eyes, respectively. Of delayed breaks, 116 (55.5%) were found in 6 weeks or less and 93 (44.5%) were found more than 6 weeks after presentation. Of delayed RDs, 26 (32.5%) were found in 6 weeks or less and 54 (67.5%) were found more than 6 weeks after presentation. Compared with the reference group, vitreous hemorrhage (hazard ratio, 2.53 [P < 0.001] and 2.80 [P = 0.001]) and male gender (hazard ratio, 1.36 [P = 0.03] and 1.87 [P = 0.02]) were risk factors for delayed retinal breaks and RDs, respectively. Pseudophakia (hazard ratio, 2.10; P = 0.004) was also a risk factor for delayed RD; older age (odds ratio, 0.96; P = 0.01) was slightly protective. Vitreous hemorrhage was a risk factor for earlier retinal breaks (≤6 weeks vs. >6 weeks; odds ratio, 3.58; P < 0.001). CONCLUSIONS: Clinically significant rates of newly detected retinal breaks and RDs may occur after acute PVD, suggesting that repeat examination may be prudent in these patients.

Trends in Retina Specialist Imaging Utilization from 2012 to 2016 in the United States Medicare Fee-for-Service Population.

PURPOSE: To characterize temporal trends and regional variance in retinal imaging utilization in the United States Medicare fee-for-service population from 2012-2016. DESIGN: Cross-sectional, retrospective database analysis. METHODS: This study addresses office or operating-room based retinal imaging. Our study population included retina specialists, defined as ophthalmologists performing either intravitreal anti-vascular endothelial growth factor injections or posterior segment laser photocoagulation and no neodymium-doped yttrium aluminum garnet laser capsulotomy. We recorded fundus photography, optical coherence tomography (OCT), intravenous fluorescein angiography (IVFA), indocyanine-green angiography, and ophthalmic ultrasound (B-scan) billed in the Medicare fee-for-service population from 2012-2016. Imaging obtained on any platform or device was eligible for inclusion (eg, posterior pole imaging vs ultrawidefield imaging). The main outcome measure was the relative utilization of retinal imaging modalities. RESULTS: National relative utilization of OCT increased from 61.5% in 2012 to 70.5% in 2016 (P < .001), while IVFA fell from 20.9% to 15.1% over the same interval (P < .001). Fundus photography decreased from 14.6% in 2012 to 11.7% in 2016 (P < .001). By 2016, the Midwest region had the highest relative utilization of OCT (75.2%) and lowest of IVFA (12.0%), while the West region had the lowest OCT (68.4%) and highest IVFA (17.0%). CONCLUSIONS: Among retina specialists, OCT usage increased while the utilization of fundus photography and IVFA has declined. The Midwest region had the highest utilization of OCT and lowest of IVFA.

Changes in Management Based on Vitreous Culture in Endophthalmitis After Intravitreal Anti-vascular Endothelial Growth Factor Injection.

PURPOSE: To assess whether vitreous culture results affect the clinical management of patients with acute endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection. DESIGN: Retrospective case series. METHODS: Setting: Single-center. STUDY POPULATION: Patients who developed endophthalmitis after intravitreal injection of aflibercept, bevacizumab, or ranibizumab between January 1, 2016, and May 31, 2018. OBSERVATION: A change in clinical management was defined as additional intravitreal antibiotic injections or pars plana vitrectomy. MAIN OUTCOME MEASURES: A change in clinical management within 2 weeks of initial endophthalmitis culture and treatment; visual acuity. RESULTS: Of 204,986 intravitreal anti-VEGF injections performed, 60 cases (0.0293%) of endophthalmitis were identified, 18 of which were culture-positive. Six of 60 eyes (10%) had a change in clinical management. A change in clinical management was initiated in 3 of 18 (17%) culture-positive cases compared to 3 of 42 (7%) culture-negative cases (P = .357). Changes in management for culture-positive cases were performed based on declining vision (2 cases) and worsening clinical examination (1 case). Changes in management for culture-negative endophthalmitis cases were performed based on declining vision (1 case) and worsening clinical examination (2 cases). No additional interventions were initiated based on positive-culture results. Comparing vision loss from baseline by culture result, at final follow-up, oral flora-associated culture-positive cases lost 17.5 lines, non-oral flora-associated culture-positive cases lost 9.1 lines, and culture-negative cases lost 2.5 lines of vision (P < .001). CONCLUSION: Following endophthalmitis from intravitreal injection of anti-VEGF agents, vitreous culture data may help prognosticate visual outcomes but appear to have a limited effect on clinical management.

"I meant that med for Baylee not Bailey!": a mixed method study to identify incidence and risk factors for CPOE patient misidentification.

Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.