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Background: Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment., Methods: We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences., Results: Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience., Conclusions: We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees' surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective.

Purpose: To describe a surgical technique of Descemet membrane endothelial keratoplasty (DMEK) using an endothelium-in pull-through technique with novel infusion forceps and report 6-month clinical outcomes., Methods: This is a retrospective case series of 33 cases with Fuchs endothelial corneal dystrophy who underwent either DMEK alone (n = 5), DMEK combined with phacoemulsification (n = 27), or DMEK combined with intraocular lens exchange (n = 1) performed by surgeons at the beginning of the DMEK learning curve. Best-corrected visual acuity (BCVA), manifest refraction, central corneal thickness, endothelial cell density, intraoperative and postoperative complications, and need for additional surgeries including rebubbling were evaluated through 6 months postoperatively., Results: Preoperative BCVA was 0.37 ± 0.34 logarithm of the minimum angle of resolution and improved to 0.09 ± 0.10 logarithm of the minimum angle of resolution at 6 months (P < 0.001). Eighty-two percent of eyes obtained a BCVA of 20/25 or better. Central corneal thickness decreased significantly at 6 months (P < 0.001). Endothelial cell loss was 29.1% at 6 months (available for 20 of 33 eyes). All surgeries were uneventful. Six eyes required rebubbling for graft detachments. There were no primary or secondary graft failures at 6 months., Conclusions: DMEK with infusion microforceps is efficacious and safe in eyes with Fuchs endothelial corneal dystrophy and could offer a more controlled surgery, making it suitable for both novice and experienced DMEK surgeons., Competing Interests: A. S. Jun: co-inventor of DMEK spoon and infusion microforceps. The remaining authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To examine the incidence, characteristics, and economic burden of orbital floor fractures in the United States., Design: Retrospective, longitudinal study of the Nationwide Emergency Department Sample (NEDS)., Participants: Patients in the Emergency Department (ED)., Methods: The NEDS, a representative sample of all hospital-based EDs in the US, was used to identify and describe ED visits with a primary diagnosis of orbital floor fracture from 2006 to 2017. Linear regression was used to estimate the trends in annual incidence and inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission., Main Outcome Measures: Incidence, injury mechanisms, demographics, clinical characteristics, disposition, and economic burden., Results: From 2006 to 2017, there were an estimated 350 379 ED visits in the US with a primary diagnosis of orbital floor fracture. The incidence increased by 47% over the study period (P < 0.001): from 7.7 (95% confidence interval [CI], 6.9-8.5) to 11.3 (95% CI, 10.0-12.6) per 100 000 population. The majority were male (67%), aged 21 to 44 years (46%), and from low-income households (32%). The most common cause was assault (43%), which was most frequent in young adults (65%) and increased modestly over time (3.5 to 4.5 per 100 000 population; P = 0.02). The second most common cause was falls (26%), most frequent in patients aged ≥65 years (86%) and more than doubled over time (1.6 to 3.5 per 100 000 population; P < 0.001). The rate of inpatient admission was 14%, with a higher likelihood for patients aged ≥65 years (odds ratio [OR], 2.21; 95% CI, 1.99-2.46; P < 0.001) and falls (OR, 1.54; 95% CI, 1.27-1.86; P < 0.001). The total inflation-adjusted ED charges over the study period exceeded $2 billion, with the mean charge per visit increasing 48% (P < 0.001): from $5881 (95% CI, 5499-6263) to $8728 (95% CI, 8074-9382)., Conclusions: Orbital floor fractures are becoming an increasingly common and costly injury in the United States. Preventive strategies aimed at reducing assault and falls will be crucial to mitigate the burden of orbital floor fractures on the healthcare system., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To estimate the financial impact of coronavirus disease 2019 (COVID-19)-related shutdowns on ophthalmic surgery performed at hospital outpatient departments (HOPDs) in the United States., Setting: Nationally representative sample of U.S. hospital payment and cost data., Design: Retrospective review and economic impact analysis., Methods: The Nationwide Ambulatory Surgery Sample (NASS) was used to identify ophthalmic surgical procedures and associated charges, which were performed at HOPDs. The highest volume elective ophthalmic procedures were identified. The total hospital cost and payment amount was calculated for each procedure using the Hospital Outpatient Prospective Payment System (OPPS) maintained by the Centers for Medicare & Medicaid Services. Net facility income (estimated payments less OPPS rates) was determined for each elective surgical procedure category and stratified by hospital teaching status., Results: In 2017, elective cataract, strabismus, and keratoplasty surgeries were performed 1 230 992 times at HOPDs. The total cost of these elective surgeries was 2350 million U.S. dollars (USD), with a total hospital payment of 3624 to 3786 million USD. This led to an estimated net income of 1278 to 1440 million USD overall to U.S. hospitals in the NASS dataset from elective ophthalmic surgery (approximately 107 to 120 million USD per month), with a larger proportion performed in teaching hospitals., Conclusions: The cessation of elective ophthalmic surgeries at HOPDs during COVID-19 resulted in a significant loss of income for hospitals in the United States and teaching experiences for trainees at academic medical centers., (Copyright © 2020 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To report a case of herpes zoster ophthalmicus (HZO) reactivation after recombinant zoster vaccination., Methods: A 78-year-old woman, with a history of HZO 20 years ago, was referred for progressive corneal thinning in her left eye that started 1 week after her second dose of recombinant zoster vaccination., Results: At presentation, visual acuity was counting fingers. Corneal sensation was markedly decreased. Slit lamp examination revealed a temporal paracentral epithelial defect 1.5 × 2.0 mm in size with 40% thinning and surrounding stromal inflammation suggestive of stromal keratitis with ulceration. The patient was started on oral valacyclovir, topical erythromycin ointment, and hourly topical lubrication. A bandage contact lens was placed and was replaced 1 week later with self-retained cryopreserved amniotic membrane ring. The ring was removed in the following week when the thinned area was epithelialized with no further evidence of stromal lysis., Conclusions: HZO reactivation after recombinant zoster vaccination is uncommon but possible. Ophthalmologists should remain aware of potential risks of zoster vaccination and take special precautions in patients with HZO history., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose : As ophthalmic elective surgeries resume amidst the COVID-19 pandemic, protocols for testing patients for SARS-CoV-2 is important due to the transmissibility of the virus. Here, we describe the protocol our institution has implemented for screening asymptomatic patients before proceeding to elective ophthalmic surgery. Methods: A retrospective chart review analyzed the number of elective surgeries, results of SARS-CoV-2 testing, and the effect of a positive result on surgery scheduling. Results : We display the screening protocol our institution used to test for SARS-CoV-2. Through its implementation, we found 2 asymptomatic patients who were positive for SARS-CoV-2 resulting in cancellation of their surgeries.  Conclusion : Because of the possibility of positive COVID-19 status in asymptomatic patients and the risk this poses to patients and staff, we recommend testing all asymptomatic patients for SARS-CoV-2 prior to elective surgeries.

Purpose: To evaluate long-term rates of repeated keratoplasty after endothelial keratoplasty (EK), and to explore risk factors associated with graft failure., Design: Retrospective, cohort study., Methods: Population-based using 2010-2019 Medicare carrier claims., Study Population: Medicare beneficiaries aged ≥65 years who underwent endothelial keratoplasty (EK) procedures. Main outcome measures were 1) occurrence of repeated keratoplasty for the overall cohort as well as stratified by clinical indication, and 2), risk factors associated with repeated keratoplasty. The probability of undergoing repeated keratoplasty for different indications was estimated using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards regression model was constructed to determine patient and physician factors associated with the risk of repeated keratoplasty., Results: A total of 94,829 Medicare EK procedures (N = 71,040 unique patients) were included in the analysis. Over the study period, 11,013 of 94,829 EK procedures were followed by repeated keratoplasty. The overall probability of receiving a repeated keratoplasty was 6.1% at 6 months, 7.6% at 1 year, 14.3% at 5 years and 16.9% at 8 years. The probability of repeated keratoplasty was highest for procedures performed for prior failed grafts: 10.2% at 1 year, 29.9% at 8 years. Whereas 6.4% and 11.4% of grafts performed for Fuchs' endothelial dystrophy (FED) required repeated keratoplasty at 1 and 8 years of follow-up, respectively. For bullous keratoplasty and/or corneal edema, 8.6% and 22% of grafts underwent repeated keratoplasty at 1 and 8 years, respectively. In a multivariate analysis, patient factors associated with increased risk of repeated keratoplasty were black (hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.20-1.38) or Asians (HR: 1.26; 95% CI: 1.10-1.45) having a glaucoma diagnosis (HR: 1.53; 95% CI: 1.46-1.60), prior glaucoma surgery (HR: 1.26; 95% CI: 1.18-1.35), and concurrent glaucoma surgery (HR: 1.31; 95% CI: 1.20-1.44). Surgeons with higher EK volumes had a decreased risk of repeated keratoplasty. Physicians who graduated medical school >30 years previously had increased risk of repeated keratoplasty compared to those who graduated within 10 years (HR: 1.16; 95% CI: 1.10-1.23)., Conclusions: Blacks or Asians, comorbid glaucoma, concurrent or prior glaucoma surgery, and lower volumes of surgery are associated with increased risk of repeated keratoplasty. Racial disparities identified in this study warrant further investigation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To present a case of epithelial ingrowth in the graft-host interface after Descemet membrane endothelial keratoplasty (DMEK) surgery that was successfully treated with a yttrium aluminum garnet (YAG) laser., Methods: A 53-year-old white woman underwent uncomplicated combined cataract and DMEK surgery in her right eye. At her regularly scheduled 6-month follow-up visit, an asymptomatic dense white interface opacity was observed. Confocal imaging confirmed the presence of epithelial cells. After initial close observation, the opacity was noted to be slowly growing and the patient underwent YAG laser treatment for the opacity., Results: The patient remained stable 4 months postlaser treatment with no recurrence of epithelial ingrowth., Conclusions: YAG laser treatment may be a safe and effective way to treat early-stage epithelial ingrowth in the interface after DMEK surgery.

Purpose: To determine national-level incidence rates of major postoperative complications following endothelial keratoplasty (EK) procedures and to stratify these rates based on EK indications over an 8-year period using Medicare claims data., Design: Retrospective, cohort study., Methods: Setting: population-based; study population: Medicare beneficiaries aged ≥65 years who underwent EK procedures; main outcome measurements: 1) occurrence of major postoperative complications (i.e., endophthalmitis, choroidal hemorrhage, infectious keratitis, cystoid macular edema [CME], retinal detachment [RD], or RD surgery) following EK surgery; 2) time-to-event analysis for glaucoma surgery; and 3) occurrence of graft complications., Results: A total of 94,829 EK procedures (n = 71,040 unique patients) were included in the analysis. Of the total, 29% of patients had pre-existing glaucoma. The overall 90-day cumulative incidence of postoperative endophthalmitis and choroidal hemorrhage following EK was 0.03% and 0.05%, respectively. The overall 1-year cumulative rates of RD or RD surgery, infectious keratitis, and CME were 1.0%, 0.8%, and 4.1%, respectively. Approximately 7.6%, 12.2%, and 13.8% of all eyes in this study needed glaucoma surgery at 1-, 5-, and 8-years of follow-up, respectively. The probability of glaucoma surgery among patients with pre-existing glaucoma was 29% vs. 8% among those without pre-existing glaucoma at 8 years. The cumulative probabilities of developing any graft complications were 13%, 23.2%, and 27.1% at 1, 5, and 8 years, respectively, of follow-up. On average, patients undergoing EK procedures for a prior failed graft had the highest rate of complications, whereas those with Fuchs' corneal endothelial dystrophy had the lowest., Conclusions: The incidence of major postoperative complications including endophthalmitis, retinal detachment, and choroidal hemorrhage following EK procedures is low. A high proportion of eyes undergoing EK eventually require glaucoma surgery and experience graft-related complications. Postoperative outcomes are typically worse for patients undergoing EK for prior failed grafts than for those undergoing EK for Fuchs' corneal endothelial dystrophy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To describe applicant characteristics and outcomes associated with the ophthalmology fellowship match., Design: Retrospective case-control study., Methods: This study took place in San Francisco and matched data for ophthalmology fellowship applicants in the USA. The study population was registrants for the 2010-2017 ophthalmology fellowship match cycles. The match rate took place during the 8-year study period. Applicant characteristics were stratified by match status and factors associated with matching to ophthalmology fellowship positions., Results: Between 2010 and 2017, most applicants (2,558/3,471; 73.7%) were matched into ophthalmology fellowship programs. No difference over time in the proportion of applicants that matched for fellowship was identified (P = .41). On average, ophthalmology residents who were matched into fellowships had higher step 1 (difference: 9; 99% confidence interval [CI]: 6.8-10.9; P < .001), step 2 (difference: 9.5; 99% CI: 7-12; P < .001), and step 3 (difference: 7.4; 99% CI: 5-9.7; P <.001) scores than those who did not match. Applicants who matched also had a greater number of application distributions (difference: 9.6; 99% CI: 7.9-11.2; P < .001), and ranked programs on the match list (difference: 6.2; 99% CI: 5.8-6.7; P < .001). Among applicants who matched, 15% matched at the same institute, 29% matched in the same state, and 45% matched in the same region. On multivariable analysis, factors associated with an increased likelihood of matching into an ophthalmology fellowship program included graduates from the US versus graduates from non-US residency programs (odds ratio [OR]: 2.09; 99% CI: 1.27-3.44; P <.001), increasing percentage of applications ranked (number of ranked programs and/or number of applications distributed) (OR: 1.02; 99% CI: 1.02-1.03; P < .001) as well as having ranked more programs (OR: 1.24; 99% CI: 1.17-1.31; P < .001). Medical graduate status outside of the US (OR: 0.58; 99% CI: 0.36-0.93; P < .001) was associated with decreased odds of matching for fellowship., Conclusions: From 2010 to 2017, approximately three-quarters of residents applying for an ophthalmology fellowship position matched. Factors associated with increased likelihood of matching included the applicant's graduating from a U.S. residency, graduating from a U.S. medical school, ranking more programs, and having a higher percentage of applications ranked (number of programs ranked by applicant and/or number of applications distributed). The information gained from this study may help applicants as they consider applying to fellowship programs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to describe the transition of ophthalmology education to a virtual curriculum during the COVID-19 pandemic. We highlight innovative solutions ophthalmic educators implemented for medical students, residents, and fellows., Recent Findings: Clinical and surgical ophthalmology volume abruptly decreased in March 2020 as a result of the COVID-19 public health crisis. All didactics, grand rounds, and journal clubs shifted to an online format. Ophthalmic educators collaborated with other institutions in the United States and abroad on shared virtual curricula and seminars, and simulation-based training tools were better emphasized for surgical skill acquisition. We share the latest literature written by ophthalmic educators on successful adaptation of these new instructional strategies., Summary: The COVID-19 pandemic transformed ophthalmology education overnight and accelerated the adoption of innovative e-virtual learning resources for trainees. These changes will undoubtedly remain part of the new paradigm of medical education in the post-COVID era.

Background: Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation., Methods: The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage., Results: A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4 ± 9.5 months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P < 0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage., Conclusions: When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine costs and prescribing patterns of postoperative eye drops for cataract surgery and estimate potential savings of generic or therapeutic drug substitutions., Design: Retrospective, cross-sectional analysis., Participants: Medicare beneficiaries aged ≥65 years with Part D coverage who underwent cataract surgery in 2016., Methods: Medicare Part D claims were used to extract information on eye drop prescriptions that were filled during the postoperative period of cataract surgery. Savings from generic or therapeutic drug substitutions were estimated for brand medications., Main Outcome Measures: Total cost of postoperative eye drops for cataract surgery and physician and patient factors associated with medication cost., Results: Postoperative eye drops were prescribed in 2016 to 88% of 591 733 Medicare beneficiaries who underwent cataract surgery during that calendar year, with brand medications accounting for 57.5% of prescription volume. The overall cost totaled more than $167 million, 76.5% of which was attributable to use of brand medications. The mean costs of medications were $228 and $324 for those undergoing 1 and 2 surgeries, respectively. Topical antibiotics (89%) were the most commonly prescribed drug class by volume, followed by topical steroids (86%) and nonsteroidal anti-inflammatory drugs (66%), and accounted for 26%, 37%, and 36% of the total cataract surgery eye drop cost, respectively. Use of therapeutic and generic alternatives could have resulted in cost savings of as much as $118 million, or 70% of the total cost of postoperative eye drops. In adjusted analysis, patient factors associated with increased eye drop cost included older age, female gender, and race or ethnicity. Physician characteristics associated with increased eye drop cost included female gender, greater number of years in practice, practicing in metropolitan versus nonmetropolitan areas, and practicing in the Northeast versus the South and in the South versus the Midwest., Conclusions: The cost to the Centers for Medicare and Medicaid Services for eye drops prescribed for postoperative use after cataract surgery in 2016 was approximately $170 million. In the absence of evidence of clinical superiority of expensive versus less costly options, substantial opportunity exists to improve the value of care delivered to Medicare beneficiaries., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to investigate the risk of cataract development among patients with juvenile idiopathic arthritis (JIA)-associated uveitis treated with topical corticosteroids., Design: Retrospective cohort study., Participants: We included 75 patients with JIA-associated uveitis observed from July 1984 through August 2005 at a single academic center., Methods: Clinical data on these patients were collected by chart review and were analyzed., Main Outcome Measures: Incidence of new-onset cataract. Risk factors for cataract development were assessed with attention paid to the use of topical corticosteroids., Results: Over a median follow-up of 4 years, the incidence of new-onset cataract was 0.04/eye-year (EY; 95% confidence interval [CI], 0.02-0.09). Of the 60 eyes in 40 patients who received topical corticosteroid therapy, there was a dose-dependent increase in the rate of cataract development among eyes receiving topical corticosteroids. The incidence of cataract was 0.01/EY for eyes treated with <3 drops daily and 0.16/EY (P = 0.0006 for log-rank test) for eyes treated with >3 drops daily. Among eyes receiving <2 drops daily, the incidence of cataract was 0/EY (95% CI [1 sided], 0.03/EY). Presence of posterior synechiae, active uveitis, and use of topical corticosteroids at presentation were significantly associated with cataract development after controlling for confounding variables. Use of topical corticosteroids was associated with cataract formation independent of uveitis activity. Using longitudinal data analysis and controlling for duration of uveitis, presence and degree of active uveitis, and concomitant use of other forms of corticosteroids in a time-updated fashion, treatment with <3 drops daily of topical corticosteroid was associated with an 87% lower risk of cataract formation compared with eyes treated with >3 drops daily (relative risk, 0.13; 95% CI, 0.02-0.69; P = 0.02)., Conclusions: In our cohort, topical corticosteroid use was associated with an increased risk of cataract formation independent of active uveitis or presence of posterior synechiae. However, chronic use of topical corticosteroids dosed at <3 drops daily seemed to be associated with a lower risk of cataract development relative to eyes receiving higher doses over follow-up in the setting of suppressed uveitis., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2020. Published by Elsevier Inc.)

Importance: Open globe injuries can lead to substantial visual morbidity and lifelong sequelae. Interventions to reduce the burden of open globe injuries in the United States require a better understanding of these injuries through well-designed epidemiologic investigations., Objective: To examine the incidence, common injury mechanisms, and economic burden of open globe injuries in the United States., Design, Setting, and Participants: This retrospective, cross-sectional study of US nationwide emergency department (ED) data assessed all ED visits of patients with a primary diagnosis of open globe injury in the Nationwide Emergency Department Sample (NEDS) from January 1, 2006, to December 31, 2014. Data analysis was performed from August 29, 2018, to November 11, 2019., Main Outcomes and Measures: Annual incidence of open globe injuries by age, sex, mechanism of injury, and concomitant diagnosis, as well as median charges associated with open globe injuries and variables associated with hospitalization., Results: A total of 124 989 ED visits for open globe injuries were assessed, with an incidence of 4.49 per 100 000 population in the United States from 2006 to 2014 (mean [SD] age of study participants, 37.7 [22.5] years; 94 078 [75.3%] male). The incidence was highest in 2006 (5.88 per 100 000 population) and decreased by 0.3% per month between 2006 and 2014 (incidence rate ratio, 0.99; 95% CI, 0.99-0.99; P < .001). Open globe injuries occurred in 37 060 individuals (30.6%) of low socioeconomic status. The most common injury mechanism was being struck by or against an object or person (40 119 of all 124 989 injury mechanisms [32.1%]). Open globe injuries associated with falls increased 6.6% between 2006-2010 and 2011-2015 (95% CI, 1.04-1.08; P < .001) and were the most common injury mechanism in individuals older than 70 years. The total cost associated with open globe injuries was $793 million. The cost of ED visits increased from $865 during 2006-2010 to $1557 during 2011-2015. Inpatient costs similarly increased from $21 527 during 2006-2010 to $30 243 during 2011-2015., Conclusions and Relevance: The incidence of open globe injuries in the United States decreased from 2006 to 2014. Although the data are from 5 to 13 years ago, these findings appear to provide valuable information for targeting preventive measures toward individuals at highest risk; targeting young men with lower socioeconomic status and individuals 70 years or older at an increased risk of falls may help lower the incidence of open globe injuries.

Purpose: To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits., Design: Retrospective, trend study., Methods: Setting: National Hospital Ambulatory Medical Care Survey 2007-2015., Patient Population: Eye-related ED patients who underwent CT or MRI., Main Outcome Measure(s): Population-based CT/MR imaging rates and independent factors associated with imaging., Results: An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted., Conclusions: Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To examine barriers and facilitators to adoption of Descemet membrane endothelial keratoplasty (DMEK) for treatment of endothelial dysfunction., Methods: Anonymous electronic surveys were emailed to surgeons ordering corneal transplant tissue in the past 18 months from 2 eye banks in the United States (US)., Results: Of 365 surgeons emailed, 118 (32%) completed the survey. Most respondents were located at an urban site (59%), were in private practice (64%), and had been in practice for >10 years (53%). Participants performing DMEK (n = 70) were more likely to have been in practice for ≤10 years than those not performing DMEK (56% vs. 35%, respectively, P = 0.03). Among respondents not performing DMEK (n = 48, 41%), the most frequently reported barriers were technical difficulty (n = 30, 63%), a lack of experience (n = 29, 60%), low surgical volume (n = 20, 42%), and risk of postoperative complications (n = 19, 40%). Most (n = 46, 96%) respondents not performing DMEK were interested in doing so, with the following reported as helpful resources: wet laboratory courses (n = 35, 73%), eye bank-prepared tissue: preloaded/prestripped (n = 32, 67%), back-up tissue in case of inadvertent graft damage (n = 29, 60%), higher surgical volume to support the learning curve (n = 28, 58%), and surgical mentorship (n = 22, 46%). Only a minority wanted more data to highlight superiority over other EK procedures (n = 12, 25%)., Conclusions: There is substantial interest in learning to perform DMEK among the surgical community. Barriers identified in this survey may be addressed to help surgeons increase DMEK adoption.

Purpose: To estimate ophthalmologist-level variation in cataract surgery billing and evaluate patient and ophthalmologist characteristics associated with complex cataract surgery coding., Setting: Cross-sectional study., Design: Retrospective case series., Methods: Medicare beneficiaries aged 65 years or older who had cataract surgery between January 1, 2016, and December 31, 2017, were included. Billing of cataract surgery as complex versus routine and patient and physician characteristics associated with billing of cataract surgery as complex were evaluated., Results: An estimated 3.5 million cataract procedures were performed on Medicare beneficiaries in 2016 and 2017. Men (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.75-1.82), patients 75 years or older (versus those aged 65 to 74 years: OR, 1.35; 95% CI, 1.33-1.36), and racial minorities (blacks versus whites: OR, 1.80; 95% CI, 1.75-1.85) had increased odds of having cataract surgery coded as complex. The mean rate of coding for complex cataract surgery by individual surgeons (n = 10 075) in the United States was 11.2%, with significant variation. A high-risk clinical diagnosis code was associated with 40.0% of complex cataract surgeries. Adjusted for patient characteristics, ophthalmologists who graduated from medical school within the past 10 years (OR, 1.35; 95% CI, 1.22-1.49) were more likely to code for complex cataract surgery. Higher volume ophthalmologists were less likely to code for complex cataract surgery than low-volume ophthalmologists., Conclusions: There was marked variation among ophthalmologists in the use of complex cataract surgery. Some variability might represent inaccurate coding and was not entirely based on differences in referral patterns for more complex patients., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background: To determine which resident and program characteristics correlate with ophthalmic knowledge, as assessed by resident Ophthalmic Knowledge Assessment Program (OKAP) performance., Methods: An online survey was sent in June 2017 to all US ophthalmology residents who took the OKAP in April 2017., Results: The survey response rate was 13.8% (192/1387 residents). The mean respondent age was 30.4 years, and 57.3% were male. The mean [SD] self-reported 2017 OKAP percentile was 61.9 [26.7]. OKAP performance was found to have a significant positive correlation with greater number of hours spent/week studying for the OKAPs (p = 0.007), with use of online question banks (p < 0.001), with review sessions and/or lectures arranged by residency programs (p < 0.001), and with OKAP-specific didactics (p = 0.002). On multivariable analysis, factors most predictive of residents scoring ≥75th percentile were, higher step 1 scores (OR = 2.48, [95% CI: 1.68-3.64, p < 0.001]), presence of incentives (OR = 2.75, [95% CI: 1.16-6.56, p = 0.022]), greater number of hours/week spent studying (OR = 1.09, [95% CI:1.01-1.17, p = 0.026]) and fewer hours spent in research 3 months prior to examination (OR = 1.08, [95% CI: 1.01-1.15, p = 0.020]. Lastly, residents less likely to depend on group study sessions as a learning method tended to score higher (OR = 3.40, [95% CI: 1.16-9.94, p = 0.026])., Conclusions: Programs wishing to improve resident OKAP scores might consider offering incentives, providing effective access to learning content e.g. online question banks, and adjusting the curriculum to highlight OKAP material. Step 1 scores may help educators identify residents who might be at risk of not performing as well on the OKAP.

Purpose: To describe epidemiological trends, risk factors, and hospital-associated charges for patients presenting with hyphema to emergency departments (EDs) throughout the United States (U.S.)., Methods: Cross-sectional analysis of all hyphema-related ED cases in the U.S. Nationwide Emergency Department Sample (NEDS) between 2006 and 2015 to determine population-based incidence rates, patient demographics, visit characteristics and associated charges., Results: Between 2006 and 2015, there were a total of 16,222 cases with hyphema as primary visit diagnosis (0.52 ED visits per 100,000 population). The mean (SD) age at presentation was 37.4 (24.8) years, and males accounted for 66.2% of these cases. Trauma (n = 4,994, 30.8%) was the most frequently identified etiology, with sports-related injuries as important contributor. On multivariate analysis, traumatic hyphema was more likely for patients aged 5-14 years (Odds ratio [OR] = 1.88 [95% Confidence interval [CI]: 1.04-3.40, p = 0.04]) than 0-4 years, males (OR = 1.33 [95% CI: 1.09-1.62, p = 0.01]), in May through September (OR = 1.66-1.93 [95% CI: 1.08-3.05, p = 0.005-0.03]),and for those in the highest income quartile (OR = 1.42 [95% CI: 1.10-1.83, p = 0.01]). Visits were less likely for patients aged ≥55 years (OR = 0.49 [95% CI: 0.25-0.994, p = 0.03]) than 0-4 years. During the study period, hyphema accounted for $21 million in ED associated and $9 million in inpatient charges., Conclusion: ED visits with hyphema as primary diagnosis occur at an annual rate of 0.52 per 100,000 population. Young males are particularly at risk and there has been an increase in the number of sports-related injuries which may represent a modifiable cause. Hyphema management costs $3 million in hospital-related charges annually.

Purpose of Review: To provide a consolidated update regarding preoperative evaluation for cataract surgery., Recent Findings: Visual acuity alone is a poor gauge of cataract disability. Modalities such as wave front aberrometry, lens densitometry, and light-scatter assessments can quantify optical aspects of cataract and may prove clinically useful in surgical evaluation. Advances in biometry are driving improvements in refractive outcomes, which in turn have increased patient expectations. Future advances in biometry technology may include three-dimensional imaging of the cornea and lens. Screening for ocular comorbidities has become increasingly important, particularly to guide lens selection. Risk stratification systems can help guide surgical decisions and may decrease intraoperative complication rate. A comprehensive medical history and physical is currently mandated for all Medicare patients undergoing cataract surgery but may be of limited utility for low-risk patients., Summary: Rising patient expectations and a growing number of surgical choices have expanded the cataract preoperative evaluation. A systematic and comprehensive examination which includes identifying any ocular comorbidity is essential for surgical planning and counseling on visual prognosis. New technologies will continue to inform, but not replace, sound clinical judgment.

Purpose: To describe the impact of a physician assistant (PA) in an academic ophthalmology consult service., Design: Evaluation research., Methods: A PA was integrated into our ophthalmology consult service to enhance resident education. First-year resident annual surgical logs before and after the introduction of the PA were reviewed. Residents were anonymously surveyed for their perceptions regarding the impact of the PA integration on their residency experience. Consult wait time was compared for residents and the PA. Internal financial metrics for the PA were reviewed for a cost scenario analysis using 2016 national salary data for PAs., Results: The PA made approximately 28 days per year for each first-year resident available for alternative clinical assignments, which resulted in a 75% increase in total first-year resident annual surgical volume. The majority of residents (93%) strongly agreed that having a PA improved both their ophthalmic education (by enabling them to spend time on other clinical assignments) and their service-to-education balance on the consult rotation. Adjusted median consult wait time for residents was 28 minutes longer (P < .001) than for the PA. A PA would likely need to see an average of 8-12 patients per day to be cost neutral to a consult service., Conclusions: Integrating a PA into an ophthalmology consult service can optimize the resident clinical service-to-education balance, reduce consult wait time, and be financially feasible. PAs trained in ophthalmology present a unique opportunity for all institutions that require clinical ophthalmology expertise., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Corneal dystrophies are a rare group of hereditary disorders, that are bilateral, non-inflammatory, and progressive. Clinically, they can be classified based on the anatomic layer of the cornea affected. Refractive surgery and phototherapeutic keratectomy (PTK) can be performed with caution in patients with certain corneal dystrophies, but should be avoided in others. For epithelial basement membrane dystrophy, photorefractive keratectomy (PRK) is the procedure of choice for treatment of refractive error, and PTK may be performed for the treatment of recurrent erosions or irregular astigmatism. PRK and laser-assisted in situ keratomileusis (LASIK) have been associated with exacerbation of combined granular-lattice corneal dystrophy. LASIK and PRK appear to be safe in mild forms of posterior polymorphous corneal dystrophy, whereas LASIK should be avoided in Fuchs dystrophy. The safety of refractive surgery and PTK in the remainder of epithelial, Bowman layer, and stromal dystrophies has yet to be established., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Photorefractive keratectomy (PRK) is a refractive procedure gaining popularity that eliminates the risk of ectasia and flap complications that can occur after laser in situ keratomileusis. Post-operative discomfort is a major drawback after PRK and thus the management of pain and discomfort following PRK is of great importance. We summarize corneal pain pathways and summarize current approaches to pain management after PRK., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To assess the rate of development of esotropia following the diagnosis of pseudoesotropia among young children., Methods: Retrospective records review of children diagnosed during an eye examination with pseudoesotropia prior to age 5 years with a reassessment for strabismus completed after age 5 years., Results: Thirty-one patients met the inclusion criteria. The median age at diagnosis of pseudoesotropia was 1.3 years. Fourteen were boys (45%). Six (19.4%) children were subsequently diagnosed with esotropia (95% confidence interval: 7.5 to 37.5%)., Conclusion: Even when experienced examiners find no misalignment in young children, a small number will later be found with esotropia. Serial examinations and parent education about this possibility need to be considered.

Purpose: We sought to investigate the risk of cataract development among patients with juvenile idiopathic arthritis (JIA)-associated uveitis treated with topical corticosteroids., Design: Retrospective cohort study., Participants: We included 75 patients with JIA-associated uveitis observed from July 1984 through August 2005 at a single academic center., Methods: Clinical data on these patients were collected by chart review and were analyzed., Main Outcome Measures: Incidence of new-onset cataract. Risk factors for cataract development were assessed with attention paid to the use of topical corticosteroids., Results: Over a median follow-up of 4 years, the incidence of new-onset cataract was 0.04/eye-year (EY; 95% confidence interval [CI], 0.02-0.09). Of the 60 eyes in 40 patients who received topical corticosteroid therapy, there was a dose-dependent increase in the rate of cataract development among eyes receiving topical corticosteroids. The incidence of cataract was 0.01/EY for eyes treated with < or = 3 drops daily and 0.16/EY (P = 0.0006 for log-rank test) for eyes treated with >3 drops daily. Among eyes receiving < or = 2 drops daily, the incidence of cataract was 0/EY (95% CI [1 sided], 0.03/EY). Presence of posterior synechiae, active uveitis, and use of topical corticosteroids at presentation were significantly associated with cataract development after controlling for confounding variables. Use of topical corticosteroids was associated with cataract formation independent of uveitis activity. Using longitudinal data analysis and controlling for duration of uveitis, presence and degree of active uveitis, and concomitant use of other forms of corticosteroids in a time-updated fashion, treatment with < or = 3 drops daily of topical corticosteroid was associated with an 87% lower risk of cataract formation compared with eyes treated with >3 drops daily (relative risk, 0.13; 95% CI, 0.02-0.69; P = 0.02)., Conclusions: In our cohort, topical corticosteroid use was associated with an increased risk of cataract formation independent of active uveitis or presence of posterior synechiae. However, chronic use of topical corticosteroids dosed at < or = 3 drops daily seemed to be associated with a lower risk of cataract development relative to eyes receiving higher doses over follow-up in the setting of suppressed uveitis., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effectiveness of immunosuppressive drug therapy in the treatment of ocular mucous membrane pemphigoid (MMP)., Design: Retrospective cohort study., Participants: Ninety-four patients with biopsy-proven ocular MMP seen at the Pemphigoid Clinic at Wilmer Eye Institute from July 1984 through November 2006., Methods: Data recorded included demographics, use and doses of immunosuppressive drugs, response to therapy, and side effects associated with drug use., Main Outcome Measures: Outcome measures included: (1) ocular control, defined as resolution of inflammation and cessation of cicatrization of the conjunctiva; (2) ocular remission, defined as ocular control for 3 months or more after the cessation of immunosuppressive drug therapy; and (3) ocular relapse, defined as the recurrence of ocular disease in either eye after a remission., Results: By 1 year of treatment, 82.9% of patients had complete control of the inflammation, and of these, 86.3% achieved a remission at some point during follow-up. The incidences of ocular control, remission, and relapse were 1.03 (95% confidence interval [CI], 0.78-1.33), 0.50 (95% CI, 0.37-0.67), and 0.04 (95% CI, 0.02-0.09) events per person-years (PY), respectively. Among patients initially treated with prednisone and cyclophosphamide (n = 44), 91% of patients achieved a remission within 2 years after the initiation of immunosuppressive drug therapy. Characteristics at presentation associated with failing to achieve remission in the univariate analysis were trichiasis (relative risk [RR], 0.28; 95% CI, 0.08-097), prior eyelid surgery (RR, 0.11; 95% CI, 0.02-0.78), and esophageal involvement (RR, 0.29; 95% CI, 0.10-0.83). After adjusting for confounding, an initial treatment regimen containing cyclophosphamide and prednisone was associated with a greater likelihood of achieving ocular remission (RR, 8.53; 95% CI, 2.53-28.86; P = 0.001) when compared with other initial treatment regimens. Infections, hematuria, and anemia were the most common side effects observed in patients receiving cyclophosphamide therapy. The rate of discontinuing cyclophosphamide resulting from side effects was 0.20/PY; however, 74% of these patients still achieved remission despite early discontinuation of cyclophosphamide., Conclusions: In patients with ocular MMP, most achieved ocular disease control with immunosuppressive drug therapy. Treatment with cyclophosphamide and prednisone was strongly associated with the development of ocular remission., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.