Rethinking the Hydroxychloroquine Dosing and Retinopathy Screening Guidelines.

PURPOSE: To describe the rationale for revising the hydroxychloroquine (HCQ) dosing and screening guidelines and to identify the barriers to more effective guidelines in the future. DESIGN: Literature review. METHODS: A PubMed query of studies on HCQ dosing and HCQ retinopathy (HCQR) screening was conducted with a selective review of the English language literature. RESULTS: Three iterations of the American Academy of Ophthalmology HCQ dosing and HCQR screening guidelines have been published without including prescribing physicians on the writing committees. This may contribute to prescribing physicians' low adherence to the guidelines. As ancillary tests have improved, asymptomatic HCQR is being detected earlier, leading to a higher reported prevalence of HCQR and a drop in the ceiling for safe dosing. These trends put stricter constraints on prescribers and their patients, who may have had well-controlled autoimmune disease on HCQ doses that were previously considered to be below the high-risk threshold for HCQR. Indeed, stopping HCQ at the earliest sign of HCQR should be reconsidered; for cases of early HCQR, dose reduction and more intensive monitoring for retinopathy may strike a more appropriate balance between HCQ risk and benefits. A prospective study using the Diabetic Retinopathy Clinical Research Retina Network with standardized collection of data, HCQ blood levels, centralized grading of ancillary tests, and community and academic ophthalmologists would provide a stronger evidence base for future HCQ guidelines. CONCLUSIONS: The HCQ dosing and screening guidelines should be updated and a prospective study of HCQ dosing and HCQR should be initiated with the joint efforts of ophthalmologists and prescribing physicians.

Placing Bundled Payments in Perspective: A Survey of the New England Ophthalmological Society.

OBJECTIVE: To determine ophthalmologists' views on the Medicare bundled payment model for specialty physicians in the outpatient setting. DESIGN AND METHODS: The New England Ophthalmology Society (NEOS) was emailed an anonymous survey. Views of bundled payments and demographic characteristics were analyzed. RESULTS: Of responding members, 72% (115/160) strongly opposed bundled payments; 68% (108/160) believed bundled payments will lead to financial losses, and the majority did not support including costs of prescription drugs (69%, 109/159) or preoperative (77%, 123/159) or postoperative complications (59%, 94/159) in the bundle. Respondents who held office in a medical society, were in private practice, solely billed for income, and had mostly conservative political views were significantly more likely to oppose bundling. CONCLUSION: The majority of NEOS ophthalmologists were opposed to bundled payments. Personal beliefs and practice type may influence the level of ophthalmologist support of bundled payments.

Solitary myofibroma of the sclera.

PURPOSE: To report a novel case of solitary myofibroma involving the sclera. METHODS: Case report and review of the literature. RESULTS: A 19-year-old woman had an expanding and painful epibulbar mass clinically diagnosed as nodular scleritis that did not respond to anti-inflammatory therapy. A biopsy showed a proliferation of spindle-shaped cells that reacted strongly positively with immunoperoxidase stains for vimentin and smooth-muscle actin. The diagnosis of solitary myofibroma was made. Six months postoperatively, the patient was well, and the lesion had not recurred. CONCLUSIONS: Myofibroma should be considered in the differential diagnosis of an epibulbar mass, especially in the setting that would mimic nodular scleritis.

Reversible carotid artery narrowing in morning glory disc anomaly.

A 14-year-old boy with morning glory disc anomaly (MGDA) and normal visual and neurologic function displayed marked carotid artery narrowing on magnetic resonance angiography (MRA). This narrowing disappeared on a follow-up MRA six months later. Optic coherence tomography and scanning laser polarimetry disclosed a normal retinal nerve fiber layer in the eye with MGDA. MGDA has been reported in association with irreversible carotid artery stenosis leading to moya moya disease. This case suggests that mild cases of MGDA may be associated with reversible carotid artery narrowing owing to vasospasm.

Factors influencing the need for enhancement after laser in situ keratomileusis.

PURPOSE: To confirm that enhancements after primary laser in situ keratomileusis (LASIK) are effective in dealing with residual refractive errors, and to determine if any variables prior to or during the primary LASIK procedure predisposed eyes to require subsequent enhancement. METHODS: A retrospective study of eyes undergoing primary LASIK with the VISX S2 or S3 laser and Hansatome microkeratome between January 1, 2000 and January 1, 2002 was done. Of the 393 eyes of 207 patients, 58 eyes (14%) underwent enhancement within a 16-month window of the primary procedure. Statistical comparisons were made between enhanced (n = 37) and non-enhanced (n = 148) patients, and enhanced (n = 48) and non-enhanced (n = 303) eyes, treated for myopia only. RESULTS: In comparing the primary LASIK parameters of enhanced to non-enhanced eyes in myopic patients, no significant difference was found in right vs left eye, season of the primary treatment, preoperative astigmatism, pachymetry, or amount of attempted astigmatism correction. A multivariate logistic regression analysis revealed that male gender, patient age over 45 years, and a history of recent rigid contact lens use within 6 months of primary LASIK were significantly associated with the need for enhancement. CONCLUSION: Enhancements were an effective way of dealing with residual refractive errors after primary LASIK. Age greater than 45 years or a history of recent rigid contact lens use were significantly associated with the need for enhancement in patients with myopia or myopic astigmatism.