Orbital floor fractures in Taiwan: A 10-year nationwide population-based study.

PURPOSE: To characterize the epidemiology, associated complications, and risk factors of orbital floor fractures in a nationwide longitudinal health insurance database. MATERIALS AND METHODS: Claims data from a million randomly selected registered residents from the Taiwan National Health Insurance Research Database were analyzed between 2001 and 2011 as part of a retrospective cohort review. Patients were identified using the International Classification of Disease-9 diagnosis codes for orbital floor fracture (closed: 802.6; open: 802.7). The cases were categorized as surgical or nonsurgical based on the procedure codes and compared statistically. RESULTS: From 2001 to 2011, 663 patients were diagnosed with orbital floor fractures out of a total population at risk of 9,836,431 person-years (average incidence: 6.78 persons/100,000/year) with overall increasing incidence. Surgical treatments were performed in 213 (32%) patients. Patients who received surgical treatment were younger than those who did not (mean age 25.3 ± 13.6 years vs. 34.2 ± 18.6 years, P < 0.001). The diagnosis with diplopia was a significantly associated factor for surgical treatment (2.2% in nonsurgery group vs. 6.6% in surgery group, P = 0.007). Male gender (adjusted hazard ratios [aHR] = 2.1, 95% confidence interval [CI]: 1.79-2.49) and low monthly income (aHR = 1.76, 95% CI: 1.16-2.67) were the risk factors for orbital floor fracture. CONCLUSION: The incidence of orbital floor fractures increased in the Taiwanese population between 2001 and 2011. Men and low income patients were at increased risk of orbital floor fracture. More research is necessary to clarify what factors are driving the escalating incidence of orbital fractures in this national population.

Visual Outcomes and Patient Satisfaction After Bilateral Refractive Lens Exchange with a Trifocal Intraocular Lens in Patients with Presbyopia.

INTRODUCTION: Refractive lens exchange (RLE) patients represent a unique population with a different baseline and set of expectations compared to their cataract counterparts. Visual outcomes and patient satisfaction following RLE with bilateral implantation of a trifocal intraocular lens (IOL) were assessed in a cohort of patients with presbyopia and without cataract. METHODS: Charts of patients with presbyopia who underwent femtosecond laser-assisted RLE with bilateral implantation of the PanOptix trifocal IOL (toric and non-toric) at a single-surgeon, private practice center from September 2019 to August 2020 were retrospectively reviewed. Eyes with prior keratorefractive surgery, amblyopia, or underlying pathology were excluded. Primary endpoints included corrected and uncorrected visual acuity at distance (CDVA and UDVA), intermediate (DCIVA and UIVA), and near (DCNVA and UNVA) at 6 months. Secondary endpoints included residual refractive error, patient-reported satisfaction, spectacle independence, and visual disturbance profile as assessed by a validated questionnaire at 6 months. RESULTS: Seventy-eight eyes of 39 patients (mean age 56 ± 6 years; 79% female) were included. Most eyes were hyperopic (mean SE 2.35 ± 1.81). Postoperatively, 100% and 92% of eyes were within ± 1.00 D and ± 0.50 D of emmetropia, respectively. One hundred percent, 97%, and 97% of patients achieved UDVA, UNVA, and UIVA of logMAR 0.1 or better. Starbursts were the most frequent (67%) and bothersome (41%) visual disturbance cited, but nearly half (41%) of patients rated them as absent or "not bothersome at all." Overall, 77% of patients reported achieving complete spectacle independence with 87% and 90% of patients stating they were satisfied with their vision and would recommend the same procedure to others, respectively. CONCLUSIONS: RLE with bilateral implantation of the PanOptix IOL is a safe and effective procedure with good patient satisfaction. Because of their relatively clear native lenses and visually demanding needs compared to their cataract counterparts, surgeons should take extra precautions to counsel RLE patients on the limitations of trifocal technology.

Implants and spacers for paralytic ectropion: Literature review and assessment of a thin-profile porous polyethylene implant.

Purpose: There is no ideal treatment paradigm for paralytic ectropion. This study evaluated lower eyelid spacers and the efficacy of a novel lower eyelid thin profile, bio-integratable, porous polyethylene. Methods: A retrospective review of 15 consecutive patients who underwent thin-profile porous polyethylene implantation and canthoplasty for paralytic ectropion was carried out. A comprehensive literature review of spacers for paralytic ectropion and retraction using the Pubmed database with search terms "[implant or graft or spacer] and [paralytic ectropion or paralytic retraction]," "graft and paralysis and ectropion," "implant and paralysis and ectropion," "graft and paralysis and retraction," and "implant and paralysis and retraction" was carried out. Results: The mean patient age was 69 years (range: 50-88). Lagophthalmos improved from a mean of 5.7 mm (SD = 3.3, range 3-14 mm) to 1.4 mm (SD = 1.1, range 0-3.5 mm), P < 0.0001. MRD 2 improved from a mean of 6.7 mm (SD = 2.3, range 2-12 mm) to 4.2 mm (SD = 0.9, range 3-6 mm), P = 0.0005. No patients needed additional lower eyelid surgery. There were no implant exposures at a mean follow-up of 7.6 months (SD = 7.9, range 0.7-21.6 months). Detailed literature review revealed that hard palate and ear cartilage are the most reported spacers, each with unique disadvantages. Conclusion: The thin-profile porous polyethylene implant is a useful addition to the management of symptomatic paralytic ectropion. Meaningful comparison of lower eyelid spacers is difficult because of variations in surgical technique, spacer size, and poorly reported outcome data. No spacer proves superior.

Central Toxic Keratopathy in Siblings After Laser-Assisted Keratomileusis: Case Report and Literature Review.

PURPOSE: The purpose of this study was to report an isolated case of 2 siblings who developed central toxic keratopathy (CTK) after undergoing laser-assisted keratomileusis (LASIK) on the same day. METHODS: This was a case report and literature review. RESULTS: Two sisters with no significant medical history underwent uncomplicated LASIK on the same day. Postoperative day 1 slitlamp examination findings were unremarkable. One week later, both patients returned for routine examination and were found to have a reduction in visual acuity, hyperopic shift, bilateral central opacification at the interface, and characteristic posterior stromal "mud cracks" or macrostriae most consistent with the entity CTK. The patients reported only mild ocular discomfort with minimal signs of inflammation. None of the other LASIK patients from the same surgery day nor any previous or following days thereafter developed any complications. The siblings were closely followed and treated with a short course of prophylactic topical antibiotics and rapid steroid taper, along with aggressive lubrication and long-term systemic treatment including oral doxycycline, vitamin C, and coenzyme Q10. Three months later, both patients had resolution of CTK with an uncorrected visual acuity of 20/20 or better in both eyes. CONCLUSIONS: CTK is a rare, noninflammatory but potentially sight-threatening entity most commonly associated with excimer laser ablation procedures. Its pathophysiology is poorly understood but likely multifactorial. Its isolated presentation in this case of 2 siblings suggests a possible underlying genetic predisposition, which has not been previously described. With careful monitoring and early supportive treatment, patients can have a complete and rapid resolution.

Increase in Pediatric Pseudotumor Cerebri Syndrome Emergency Department Visits, Inpatient Admissions, and Surgeries During the COVID-19 Pandemic.

BACKGROUND: Pediatric pseudotumor cerebri syndrome (PTCS) is a vision-threatening condition that is associated with female sex and obesity in pubertal and postpubertal children. It is unknown whether the increase in childhood obesity during the COVID-19 pandemic has affected the rates and characteristics of pediatric PTCS. METHODS: We conducted a retrospective study of children evaluated for PTCS (inpatient or emergency department) at our children's hospital before (March 19, 2015 to March 19, 2020) and during (March 20, 2020 to February 20, 2021) the pandemic. We compared the monthly number of inpatient and emergency department encounters for pediatric PTCS before and during the pandemic. In addition, anthropometric and ophthalmologic characteristics of children evaluated for pediatric PTCS before and during the pandemic were compared. RESULTS: A total of 36 encounters in the 5 years before the pandemic and 26 encounters in the 11 months during the pandemic were identified. The median monthly number of encounters for pediatric PTCS was significantly higher during the pandemic compared with the 5 years before the pandemic (2 vs 0, P = 0.0021). Compared with prepandemic patients, children evaluated during the pandemic were older (median age 16 vs 14 years, P = 0.02), with higher rates of obesity (85% vs 66%, P = 0.05) and lower likelihood of reporting Caucasian race (4% vs 31%, P = 0.02). Pandemic patients had worse presenting visual acuity (median logMAR 0.14 vs 0.05, P = 0.05) and were more likely to have fulminant presentation (23% vs 6%, P = 0.04) and require surgical intervention (23% vs 6%, P = 0.04). CONCLUSIONS: At our children's hospital, the rate of inpatient admissions and emergency department visits for pediatric PTCS increased during the pandemic. The severity of disease and frequency of surgical treatment also increased. Racial and ethnic minorities seem to be disproportionately affected. These changes may be related to increasing rates of childhood obesity during the pandemic.

Microinvasive Glaucoma Surgical Training in United States Ophthalmology Residency Programs.

PURPOSE: The emergence of microinvasive glaucoma surgeries (MIGS) has expanded glaucoma management options. Resident experience with these novel procedures is unclear as no residency minimums exist for them, nor are they part of Accreditation Council for Graduate Medical Education (ACGME) procedure logs. The purpose of this study was to assess resident experience with MIGS in ACGME ophthalmology residency programs across the United States. METHODS: This was a cross-sectional survey study of resident MIGS experience. A survey was mailed to program directors of ACGME-accredited ophthalmology residency programs (N = 118) in January 2017. Descriptive analyses were used to characterize the respondent demographics. Chi-square, paired t-tests, and McNemar's tests were used to analyze the geographical distribution and frequency of MIGS experience. RESULTS: A total of 30 out of 118 (25%) residency program directors across all geographic regions responded. Most incorporated both MIGS lecture (87%) and wet lab (73%) didactics into their curriculum. Only 27% felt that MIGS should be part of ACGME requirements. The most common MIGS taught were iStent (70%), endoscopic cyclophotocoagulation (50%), and trabectome (40%). Few residents had completed MIGS procedures as the primary surgeon by graduation. Eleven out of 30 program directors (37%) did not feel that the experience was adequate for independent practice. CONCLUSION: This study suggests that residents are exposed to some MIGS procedures during training, but program directors did not feel that the experience was adequate for independent practice. Further research is necessary to understand the barriers to integrating MIGS training into residency programs.

Quantitative assessment of secondary white matter injury in the visual pathway by pituitary adenomas: a multimodal study at 7-Tesla MRI.

OBJECTIVE: The objective of this study was to investigate microstructural damage caused by pituitary macroadenomas by performing probabilistic tractography of the optic tracts and radiations using 7-T diffusion-weighted MRI (DWI). These imaging findings were correlated with neuro-ophthalmological results to assess the utility of ultra-high-field MRI for objective evaluation of damage to the anterior and posterior visual pathways. METHODS: Probabilistic tractography employing 7-T DWI was used to reconstruct the optic tracts and radiations in 18 patients with adenomas and in 16 healthy volunteers. Optic chiasm compression was found in 66.7% of the patients and visual defects in 61.1%. Diffusion indices were calculated along the projections and correlated with tumor volumes and results from neuro-ophthalmological examinations. Primary visual cortical thicknesses were also assessed. RESULTS: Fractional anisotropy was reduced by 21.9% in the optic tracts (p < 0.001) and 17.7% in the optic radiations (p < 0.001) in patients with adenomas. Patients showed an 8.5% increase in mean diffusivity of optic radiations compared with healthy controls (p < 0.001). Primary visual cortical thickness was reduced in adenoma patients. Diffusion indices of the visual pathway showed significant correlations with neuro-ophthalmological examination findings. CONCLUSIONS: Imaging-based quantification of secondary neuronal damage from adenomas strongly correlated with neuro-ophthalmological findings. Diffusion characteristics enabled by ultra-high-field DWI may allow preoperative characterization of visual pathway damage in patients with chiasmatic compression and may inform prognosis for vision recoverability.

Health literacy assessment and patient satisfaction in surgical practice.

BACKGROUND: Limited health literacy has been associated with poorer health outcomes and increased morbidity and mortality. Though caring for surgical patients requires communication about complex topics, there is limited literature on health literacy competency in this population. The objective of this study was to assess health literacy in an adult surgical outpatient clinic population, to explore potential determinants of adequate health literacy, and to assess patient satisfaction with physician-patient communication. MATERIALS AND METHODS: A prospective cross-sectional study was performed and anonymous data including health literacy, demographics, and patient satisfaction with provider communication were collected. The study population included adult patients who visited an outpatient surgical practice over a one-month period. Health literacy was assessed using the Newest Vital Sign while the satisfaction questions came from the Outpatient Satisfaction Survey (Press-Ganey Associates, Chicago, IL). RESULTS: 148 patients participated in the study. The mean age was 49 years, 41% of those who gender identified were male, and 76% were White/Caucasian. 34 (27%) of those who answered the question had received a four-year undergraduate/university degree. 55 (37%) of the patients were identified as having low health literacy. More years of education was significantly associated with adequate health literacy and those patients who were more educated and had adequate health literacy were more satisfied with provider communication. CONCLUSION: Patients on average were highly satisfied with provider communication in this outpatient surgical clinic. Higher education levels were associated with better health literacy and patients with both characteristics were more satisfied with provider communication.

Association Between Eyelid Laxity and Obstructive Sleep Apnea.

Importance: While much has been reported on the relationship between floppy eyelid syndrome and obstructive sleep apnea (OSA), the diagnostic criteria of floppy eyelid syndrome are often subjective and vague. Objective: To evaluate the association between OSA and quantitative markers of eyelid laxity or secondary ocular surface disease in a sleep clinic population. Design, Setting, and Participants: This investigation was a cross-sectional observational study at the Center for Sleep Medicine at Icahn School of Medicine at Mount Sinai. Participants were individuals referred for overnight polysomnography from March 1 to August 30, 2015. Main Outcomes and Measures: Eyelid laxity and ocular surface disease were assessed on bedside ophthalmologic examination. The presence and severity of OSA were determined from polysomnography results. Initial correlation between OSA and ocular surface and eyelid markers was calculated through bivariate linear regression analysis, and the association between ocular symptoms was obtained through bivariate ordered logistic regression. Analysis was repeated adjusting for known associations between OSA and sex, age, body mass index, and medical comorbidities through multivariable analysis. Results: In total, 201 individuals (402 eyes) were enrolled in the study. Their mean (SD) age was 53.2 (13.5) years, 43.3% (n = 87) were female, 56.7% (n = 114) were of white race/ethnicity, 26.9% (n = 54) were black/African American, 4.0% (n = 8) were Asian, 8.0% (n = 16) were multiracial or other, and 4.5% (n = 9) were of unknown race/ethnicity, with 21.9% (n = 44) of all individuals self-identifying as Hispanic and 75.1% (n = 151) self-identifying as non-Hispanic. After adjustment, no association was observed between OSA severity and an eyelid laxity score (regression coefficient, 0.85; 95% CI, -0.33 to 0.62; P = .40) or an ocular surface score (regression coefficient, 1.09; 95% CI, -0.32 to 0.29; P = .93). Through subset analysis, male sex was associated with a higher ocular surface score, while older age and diabetes were associated with a higher eyelid laxity score. Only one patient (0.5%) exhibited findings of floppy eyelid syndrome. Conclusions and Relevance: Among individuals referred for overnight polysomnography, quantitative markers of eyelid laxity were not associated with the presence or severity of OSA. Subset analysis suggests that prior studies may have been limited by confounding variables or the technique of identifying eyelid laxity.

Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization.

BACKGROUND: Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS: We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS: Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.