Primary Care Provider Familiarity and Compliance With Preferred Practice Patterns for Comprehensive Eye Examinations.

PURPOSE: To assess primary care practitioners' (PCPs) familiarity with American Academy of Ophthalmology Preferred Practice Pattern (PPP) guidelines on the frequency of comprehensive eye examinations (CEEs), and to explore their opinions and practices on counseling and referring patients for CEEs. DESIGN: Cross-sectional study. METHODS: Between February 1, 2019, and June 25, 2019, an anonymous survey was emailed to clinicians holding an MD, DO, PA, or NP degree, and residents at Brigham and Women's Hospital and the University of Oklahoma. Descriptive statistics of participants' responses were reported. RESULTS: Regarding patient counseling on CEEs, 15.4% of PCPs reported "always," 48.1% "usually," and 36.5% "seldom" or "never" doing so. Few PCPs (11.1%) reported being able to describe the guidelines, and 63.9% were unaware of their existence. A strong majority of PCPs (90.7%) correctly referred a type 2 diabetic patient at their time of diagnosis, but a similar majority (77.8%) prematurely referred a newly diagnosed type 1 diabetic patient. One in 7 PCPs (13.4%) would refer a patient with family history of glaucoma only upon developing visual/ocular symptoms. Compared to other providers, PAs/NPs were more likely to recommend unnecessary CEEs for low-risk individuals (P = .009), whereas residents counseled patients less frequently (P = .003), were less likely to be familiar with PPP guidelines (P = .026), and were less likely to recommend appropriate follow-ups for patients with family history of glaucoma (P = .004). CONCLUSIONS: PCPs' awareness of and familiarity with AAO CEE guidelines is variable and improves with provider age and experience. Efforts to improve PCP guideline awareness may be especially well suited to residents and mid-level practitioners.

Active Learning to Characterize the Full Contrast Sensitivity Function in Cataracts.

Background: To characterize contrast sensitivity function (CSF) in cataractous and pseudophakic eyes compared to healthy control eyes using a novel quantitative CSF test with active learning algorithms. Methods: This is a prospective observational study at an academic medical center. CSF was measured in eyes with visually significant cataract, at least 2+ nuclear sclerosis (NS) and visual acuity (VA) ≥ 20/50, in pseudophakic eyes and in healthy controls with no more than 1+ NS and no visual complaints, using the Manifold Contrast Vision Meter. Outcomes included Area under the Log CSF (AULCSF) and CS thresholds at 1, 1.5, 3, 6, 12, and 18 cycles per degree (cpd). A subgroup analysis as performed on cataract eyes with VA ≥ 20/25. Results: A total of 167 eyes were included, 58 eyes in the cataract group, 77 controls, and 32 pseudophakic eyes with respective median AULCSF of 1.053 (0.352) vs 1.228 (0.318) vs 1.256 (0.360). In our multivariate regression model, cataract was associated with significantly reduced AULCSF (P= 0.04, ß= -0.11) and contrast threshold at 6 cpd (P= 0.01, ß= -0.16) compared to controls. Contrast threshold at 6 cpd was significantly reduced even in the subgroup of cataractous eyes with VA ≥ 20/25 (P=0.02, ß=-0.16). Conclusion: The novel qCSF test detected disproportionate significant contrast deficits at 6 cpd in cataract eyes; this remained significant even in the cataractous eyes with VA ≥ 20/25. CSF testing may enhance cataract evaluation and surgical decision-making, particularly in patients with subjective visual complaints despite good VA.

Optimization of cataract surgery follow-up: A standard set of questions can predict unexpected management changes at postoperative week one.

PURPOSE: There is limited evidence to inform the optimal follow-up schedule after cataract surgery. This study aims to determine whether a standardized question set can predict unexpected management changes (UMCs) at the postoperative week one (POW1) timepoint. SETTING: Massachusetts Eye and Ear, Harvard Medical School. DESIGN: Prospective cohort study. METHODS: Two-hundred-and-fifty-four consecutive phacoemulsification cases having attended an examination between postoperative days 5-14. A set of 7 'Yes' or 'No' questions were administered to all participants by a technician at the POW1 visit. Patient answers along with perioperative patient information were recorded and analyzed. Outcomes were the incidence of UMCs at POW1. RESULTS: The incidence of UMCs was zero in uneventful cataract cases with unremarkable history and normal postoperative day one exam if no positive answers were given with the question set demonstrating 100% sensitivity (p<0.0001). A test version with 5 questions was equally sensitive in detecting UMCs at POW1 after cataract surgery. CONCLUSION: In routine cataract cases with no positive answers to the current set of clinical questions, a POW1 visit is unlikely to result in a management change. This result offers the opportunity for eye care providers to risk-stratify patients who have had cataract surgery and individualize follow-up.

Bilateral maculopathy associated with Pierre Robin sequence.

Pierre Robin sequence has been associated with a number of ocular complications, including myopia, strabismus, Möbius syndrome, nasolacrimal duct obstruction, glaucoma, cataract, microphthalmos, coloboma of choroid, and retinal detachment. We report a 10-day-old boy who presented with micrognathia, glossoptosis, and cleft palate as well as multiple congenital anomalies. Ophthalmic examination was notable for bilateral maculopathy, with focal areas of retinal and retinal pigment epithelial atrophy. The association of Pierre Robin sequence and maculopathy has been reported only twice previously.

Small-incision Descemet stripping automated endothelial keratoplasty: a comparison of small-incision tissue injector and forceps techniques.

PURPOSE: To describe a novel, small-incision, no-fold Descemet stripping automated endothelial keratoplasty (DSAEK) graft injector and to compare complications, visual acuity, and endothelial cell loss with a forceps technique. METHODS: An Institutional Review Board-approved, interventional, nonrandomized, consecutive case series analysis of 175 eyes undergoing DSAEK for Fuchs dystrophy and bullous keratopathy. The injector arm is prospective, and the forceps arm is retrospective. Seventy grafts were performed with a DSAEK graft injector, and 105 grafts were performed using a small-incision forceps technique. Preoperative and postoperative visual acuities at 3 and 6 months, 6-month endothelial cell counts, and complications, including graft dislocation, failure, and rejection, were recorded. Fifty-seven of 232 eyes met exclusion criteria for previous incisional corneal or glaucoma surgery. RESULTS: There were 4 eyes (5.7%) in the injector group and 29 eyes (27.6%) in the forceps group that required a re-bubble procedure because of graft detachment. One graft (1.4%) failed in the injector group and 7 grafts (6.5%) failed in the forceps group. Excluding eyes with other ocular comorbidities (43), in the injector group 74% were 20/40 or better at 6 months and 100% were 20/60 or better. In the forceps group, 72% were 20/40 or better at 6 months and 98% were 20/60 or better. Six-month postoperative endothelial cell counts were available for 84 (46 injector and 38 forceps) eyes, with an average cell loss of 28.3% in the injector group and 44.1% in the forceps group. CONCLUSIONS: DSAEK is an effective treatment of endothelial dysfunction. Surgical technique is important to limit endothelial cell loss and prevent complications, such as graft dislocation. The injector device has several advantages over the trifold forceps technique, including decreased endothelial cell loss, graft dislocation rate, and graft failure rate, and it reduces the DSAEK learning curve. DSAEK graft injectors likely will have a role in the future of endothelial keratoplasty.

Three-millimeter incision descemet stripping endothelial keratoplasty using sodium hyaluronate (healon): a survey of 105 eyes.

PURPOSE: To report a Descemet stripping automated endothelial keratoplasty (DSAEK) insertion technique using sodium hyaluronate (Healon) and describe complication rates, visual acuity, and endothelial cell counts. METHODS: A retrospective analysis of 105 eyes in 91 patients undergoing DSAEK. Ninety-three eyes had Fuchs endothelial dystrophy, 11 had bullous keratopathy, and 1 had iridocorneal endothelial (ICE) syndrome. We noted pre- and postoperative visual acuity at 3 and 6 months, endothelial cell counts, and complications, including graft detachment rates. Thirty-six of 141 eyes met exclusion criteria of prior incisional corneal, glaucoma, or retinal surgery. RESULTS: Because of graft detachment, 29 of 105 eyes (28%) required a re-bubble procedure at day 1 or week 1. Five of 105 grafts (4.8%) failed. Of note, in the last 35 cases, there were no graft failures and 5 detachments (14%). Twenty-eight percent of patients were 20/40 or better preoperatively compared with 49% at 3 months and 52% at 6 months. Excluding eyes with other ocular comorbidities (34), 62% were 20/40 or better at 3 months and 72% were 20/40 or better at 6 months. Postoperative endothelial cell counts were available for 52 eyes with an average cell loss of 44% at an average of 9.4 months. CONCLUSIONS: DSAEK is an effective treatment for endothelial dysfunction, but the learning curve is steep. Anterior chamber stability, graft positioning, and small incision insertion are advantages to our technique. Disadvantages include a relatively high endothelial loss and dislocation rate. Minimizing endothelial cell loss and graft dislocation continue to be important goals for successful DSAEK.

Structures of nitric oxide synthase isoforms complexed with the inhibitor AR-R17477 suggest a rational basis for specificity and inhibitor design.

The high level of amino acid conservation and structural similarity of the substrate-binding sites of the oxygenase domains of the nitric oxide synthase (NOS) isoforms (eNOSoxy, iNOSoxy, nNOSoxy) make the interpretation of the structural basis of inhibitor isoform specificity a challenge, and provide few clues for the design of new selective compounds. Crystal structures of iNOSoxy and nNOSoxy complexed with the neuronal NOS-specific inhibitor AR-R17447 suggest that specificity is provided by the interaction of the chlorophenyl group with an isoform-unique substrate access channel residue (L337 in rat neuronal NOS, N115 in mouse inducible NOS). This is confirmed by biochemical analysis of site-directed mutants. Inhibitors combining guanidinium-like structural motifs with long chains specifically targeting this residue are good candidates for rational isoform-specific drug design. Based on this finding, modifications of AR-R17447 to improve the specificity for the human isoforms are suggested.