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Ailin Song,1 Nicholas A Johnson,1 Delaram Mirzania,1,2 Alexandria M Ayala,1 Kelly W Muir,3,4 Atalie C Thompson3,5 1Duke University School of Medicine, Durham, NC, USA; 2Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Health, Ann Arbor, MI, USA; 3Department of Ophthalmology, Duke University, Durham, NC, USA; 4Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA; 5Wake Forest Baptist Health, Winston Salem, NC, USACorrespondence: Atalie C Thompson, Wake Forest Baptist Health, Janeway Tower, 6 th Floor, 1 Medical Center Blvd, Winston Salem, NC, 27103, USA, Tel +1 650-868-8050, Email ataliethompson@gmail.comBackground: Early detection of ophthalmic conditions such as diabetic retinopathy (DR) and glaucoma is crucial to preventing vision loss. Previous studies have evaluated teleretinal screening programs for DR in well-insured populations. The purpose of this retrospective study was to evaluate a teleretinal screening program in a population of uninsured and underinsured patients seen in a Federally Qualified Health Center (FQHC).Methods: We conducted a retrospective chart review of patients (age ≥ 18) who underwent teleretinal imaging (TRI) at a FQHC between January 2015 and September 2019. TRI gradings and patient demographic and clinical information were abstracted. Factors associated with referral for a dilated eye exam by an ophthalmologist, adherence to recommended follow-up dilated eye exam, and ophthalmology visit attendance were examined.Results: 3130 TRIs were graded in 2216 eyes (1107 patients). 65.2% (N = 722) self-identified as Hispanic and 56.3% (N = 623) required interpreter services. Follow-up dilated fundus examination (DFE) was recommended for 388 TRIs, 49% (N = 190) of which were completed within 1 year. Adherence to the recommended ophthalmology exam was not associated with any baseline clinical or demographic characteristics (p > 0.05). Older age, male sex, hypertension, proteinuria, and higher A1c were significantly associated with greater odds of ophthalmology referral based on TRI (all p < 0.05), after adjusting for covariates. Less severe diabetic retinopathy, no insurance coverage, and Hispanic ethnicity were associated with lower odds of attending an ophthalmology visit, regardless of follow-up recommendations based on TRI (all p < 0.05).Conclusion: In an FQHC serving predominantly uninsured and underinsured patients, only 49% of recommended DFE were completed within one year. Less severe diabetic retinopathy, lack of insurance coverage, and Hispanic ethnicity were associated with a lower likelihood of having a DFE regardless of recommendation. These results suggest that greater system-level efforts are needed to increase adherence to follow-up eye exams after TRI to ensure sight-saving care for underserved populations.Keywords: teleretinal screening, teleophthalmology, uninsured, underinsured, adherence, ophthalmology referral

Purpose: To describe the clinical features of a conjunctival apocrine hidrocystoma that developed 6 decades after a strabismus surgery and review existing literature on apocrine hidrocystomas of the conjunctiva and caruncle., Methods: Case report and review of literature on conjunctival apocrine hidrocystomas., Results: A 71-year-old man with a history of strabismus surgery as a child presented with a cystic lesion on the nasal conjunctiva and caruncle for 1 year. Excision of the lesion showed a unilocular cavity lined by a double layer of cells with the hallmark finding of apical decapitations, confirming a diagnosis of apocrine hidrocystoma. Seven additional cases of conjunctival and caruncular apocrine hidrocystomas were reviewed. All cases presented after 50 year of age. Most cases presented nasally or within the caruncle and had a pigmented appearance. No other reported cases had a history of trauma or surgery. All cases were treated with surgical excision without recurrence., Conclusions: History of strabismus surgery or conjunctival trauma may lead to ectopic deposition of apocrine glands that may contribute to the formation of an apocrine hidrocystoma., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To examine the long-term outcome of the staged excision via the square procedure for the treatment of periocular thin cutaneous melanoma., Methods: A retrospective chart review of 95 periocular cutaneous melanoma-in-situ and microinvasive melanoma tumors that were treated with the square procedure between April 1, 1994 and December 31, 2018 at the University of Michigan. Demographic and clinical data were evaluated., Results: Of 95 cases, 19 (20%) were atypical junctional melanocytic proliferation with features of early melanoma-in-situ, 63 (66.3%) were melanoma-in-situ and 13 (13.7) were microinvasive melanoma with Breslow depth less than 1 mm. Tumor-free margins were achieved with a median margin of 10 mm (range 5-40 mm). Most cases (68.4%) required multiple excision stages. Surgical revision was necessary in 17.9% of cases and was associated with larger defect size. Local recurrence was noted in 8 patients (8.4%) at a median of 42 months postreconstruction. No tumor characteristics were found to predict recurrence., Conclusions: The square procedure for periocular melanoma offers an 8.4% recurrence rate, consistent with literature reports on similar staged excision approaches. The staged excision provides an excellent option for comprehensive margin review and tumor control with acceptable cosmetic results after reconstruction., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To evaluate presenting features and visual outcomes in eyes with acute syphilitic posterior placoid chorioretinopathy (ASPPC)., Design: Retrospective cohort study., Subjects: A total of 24 eyes of 17 adult patients with ASPPC., Methods: Chart review of patients with ASPPC who presented to the University of Michigan W. K. Kellogg Eye Center between January 1, 2012, and November 4, 2022. Demographic and clinical information, fundus photographs, fundus autofluorescence, and spectral-domain-OCT (SD-OCT) findings were reviewed., Main Outcome Measures: Clinical characteristics and visual acuity (VA) on presentation and follow-up examination., Results: The median age was 46 (interquartile range [IQR], 38-51) years. At presentation, 20 (83.3%) eyes had subjectively decreased vision, with a median initial VA of 0.54 (IQR, 0.35-1.00) logarithm of the minimum angle of resolution (logMAR); at 45 days, median logMAR VA was 0.096 (IQR, 0.02-0.17). Initial VA was positively associated with posterior pole-sparing lesions (coefficient estimate [CE], -0.75; 95% confidence interval [CI], -1.38 to -0.12); P = 0.03), and negatively associated with ellipsoid zone (EZ) disruption (CE, 0.72; 95% CI, 0.03-1.42; P = 0.04), subfoveal EZ disruption (CE, 0.62; 95% CI, 0.02-1.23; P = 0.046), and initial hyperreflective foci on SD-OCT (CE, 0.66; 95% CI, 0.09-1.23; P = 0.03). Female eyes were more likely (hazard ratio [HR], 3.36; 95% CI, 1.07-10.6; P = 0.04), and eyes with optic nerve abnormality were less likely (HR, 0.34; 95% CI, 0.12-0.96; P = 0.04), to achieve a VA ≥ 20/40 (logMAR, 0.30)., Conclusions: This study of patients with ASPPC showed that symptomatic eyes had an improvement from a median VA of 20/69 on presentation to a median VA of 20/25 at 45 days. Female sex and absence of optic nerve involvement were associated with higher probability of achieving ≥ 20/40. These findings provide refined guidance for counseling patients who present with decreased vision due to ASPPC., Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the risk factors and clinical outcomes in patients younger than 50 years with acute, treatment-naïve branch retinal vein occlusion (BRVO) with outcomes in patients 50 years or older. Methods: Patients diagnosed with acute, treatment-naïve BRVO at Duke Eye Center over a 9.5-year period who had BRVO with onset 3 months or less before presentation, BRVO with macular involvement, and 12 months or more of follow-up were included. Demographic data, presenting clinical features, risk factors, treatment patterns, and clinical outcomes were extracted during a retrospective review of medical records. Results: Of 302 patients identified, 23 were younger than 50 years (younger group) and 279 were 50 years or older (older group). Compared with older patients, younger patients had similar rates of hypertension ( P  = .275), diabetes mellitus ( P  = 1.000), smokers ( P  = .787), and open-angle glaucoma ( P  = .628). The younger group had a lower rate of hyperlipidemia than the older group (35% vs 59%) ( P  = .028). The 2 groups had similar presenting logMAR visual acuities (VAs) in the BRVO eye ( P  = .131). At the final follow-up, younger patients had significantly better logMAR VA in the BRVO-affected eye than older patients (mean 0.51 ± 0.65 vs 1.01 ± 1.20) ( P  = .016). The 2 groups had similar treatment burdens at 1 year ( P  = .516) and at the final follow-up ( P  = .782). Conclusions: Younger patients with acute, treatment-naïve BRVO have similar risk factors and treatment patterns as older patients, except for a lower rate of hyperlipidemia. Younger patients with BRVO may have similar presenting VA as older BRVO patients but better final VA, suggesting that age may be a potential prognostic factor., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Thomas is a consultant to Alimera, Allergan, Avesis, Eyepoint, and Genentech, and Novartis. Dr. Fekrat received patent royalties from Alcon and research support from Genentech and Optos and is a consultant to Glaukos and Bausch + Lomb. None of the other authors reported financial disclosures or conflicts., (© The Author(s) 2023.)

Prcis: Eyes with corneal striae had steeper cornea, induced astigmatism, and higher corneal hysteresis (CH), which implies a relationship between striae, corneal shape, and the cornea's resistance to deformation at low intraocular pressures (IOPs)., Background: Anterior corneal striae (ACS) are associated with low IOP. However, the clinical significance of ACS is unclear. Here, we aim to evaluate differences in eyes with striae compared with eyes without striae., Methods: Adults with ACS (cases) and without ACS (controls) ≥8 weeks after glaucoma surgery with an IOP ≤10 mm Hg were enrolled. Optical coherence tomography and optical biometry were performed. CH, defined as the difference in pressure between corneal indentation and reformation in response to an air jet, was obtained by the ocular response analyzer. Hypotony maculopathy (HM) was defined as optic disc swelling, vascular tortuosity attributed to hypotony, or clinical presence of chorioretinal folds confirmed on OCT., Results: One hundred sixteen eyes (76 cases, 40 controls) were included. Cases had a lower IOP compared with controls (6.5±2.3 vs. 8.5±1, P<0.0001). A 1 mm Hg increase in CH increased ACS odds [odds ratio (OR)=1.51, P=0.01]. A 1 D increase in the flattest presurgical and postsurgical corneal power increased ACS odds by 1.83 (P=0.01) and 1.41 (P=0.02), respectively. Astigmatism increased in eyes with ACS by 1.11 D (P<0.001). ACS odds were increased with every 1 minute increase in mitomycin-C duration (OR=1.58, P=0.047) and decreased with the use of topical glaucoma medication (OR=0.62, P=0.03). Visual acuity decreased from logarithm of the minimal angle of resolution 0.22 (20/33 Snellen) presurgery to 0.28 (20/38) postsurgery (P=0.008), independent of ACS. HM occurred in 19% of cases (P=0.05). A higher postsurgical CH increased HM odds (OR=1.8, P=0.003). HM predicted a 0.41 mm decrease in axial length (P<0.0001), independent of IOP., Conclusion: ACS were associated with a steeper cornea, induced astigmatism, and higher CH, suggesting a relationship between striae, corneal shape, and the cornea's ability to resist deformations at lower IOP. CH, HM, and axial length shortening were associated independently of IOP., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate differences in the retinal microvasculature and structure and choroidal structure among men and women with Alzheimer's disease (AD) compared with age-matched cognitively normal male and female controls., Design: Case-control study of participants ≥ 50 years of age., Participants: A total of 202 eyes of 139 subjects (101 cases and 101 controls)., Methods: All participants and controls underwent OCT and OCT angiography (OCTA), and parameters of subjects with AD were compared with those of cognitively normal controls., Main Outcome Measures: The foveal avascular zone (FAZ) area, vessel density (VD), and perfusion density (PD) in the superficial capillary plexus within the 3- and 6-mm circle and ring using Early Treatment Diabetic Retinopathy Study (ETDRS) grid overlay on OCTA; central subfield thickness (CST), retinal nerve fiber layer (RNFL) thickness, ganglion cell-inner plexiform layer (GCIPL) thickness, and choroidal vascularity index (CVI) on OCT., Results: No significant sex differences in VD or PD were found in the AD or control cohorts; however, there were greater differences in VD and PD among AD female participants than AD male participants compared with their respective controls. The CST and FAZ area were not different between male and female AD participants. Among controls, men had a thicker CST ( P < 0.001) and smaller FAZ area ( P  = 0.003) compared with women. The RNFL thickness, GCIPL thickness, and CVI were similar among male and female AD participants and controls., Conclusions: There may be a loss of the physiologic sex-related differences in retinal structure and microvasculature in those with AD compared with controls. Further studies are needed to elucidate the pathophysiological basis for these findings., (© 2021 by the American Academy of Ophthalmology.)

Glaucoma is the leading cause of irreversible blindness and disability worldwide. Nevertheless, the majority of patients do not know they have the disease and detection of glaucoma progression using standard technology remains a challenge in clinical practice. Artificial intelligence (AI) is an expanding field that offers the potential to improve diagnosis and screening for glaucoma with minimal reliance on human input. Deep learning (DL) algorithms have risen to the forefront of AI by providing nearly human-level performance, at times exceeding the performance of humans for detection of glaucoma on structural and functional tests. A succinct summary of present studies and challenges to be addressed in this field is needed. Following PRISMA guidelines, we conducted a systematic review of studies that applied DL methods for detection of glaucoma using color fundus photographs, optical coherence tomography (OCT), or standard automated perimetry (SAP). In this review article we describe recent advances in DL as applied to the diagnosis of glaucoma and glaucoma progression for application in screening and clinical settings, as well as the challenges that remain when applying this novel technique in glaucoma.

Purpose: To investigate the impact of time from symptom onset to presentation on the clinical course and outcomes of eyes with endophthalmitis., Design: Retrospective, longitudinal cohort study., Participants: One hundred thirty-three eyes of 130 patients with endophthalmitis., Methods: Adults diagnosed with endophthalmitis at the Duke Eye Center from January 1, 2009, through January 1, 2018, were identified using the Duke Enterprise Data Unified Content Explorer. Patient demographics, time of symptom onset, presenting clinical features, management, and outcomes were recorded by retrospective review. Patients were divided into those seeking medical care either early (within 2 days) or later (delayed, i.e., 3 days or longer) with regard to symptom onset. Clinical features, management, and visual outcomes of eyes with early or delayed presentation were compared., Main Outcome Measures: Mean corrected visual acuity (VA) at presentation and at 6 months., Results: In eyes with delayed presentation, VA was significantly worse on initial examination (delayed, 20/2941 vs. early, 20/1124; P = 0.009) and at 6 months (delayed, 20/547 vs. early, 20/173; P = 0.01). When controlling for time to presentation, VA before endophthalmitis was correlated significantly with VA at 6 months (Pearson r = 0.55; R 2  = 29%; P < 0.0001). Eyes with glaucoma drainage device-related endophthalmitis were more likely to have a delayed presentation (P = 0.03). Eyes with delayed presentation were more likely to have conjunctival injection on initial examination (delayed, 73% vs. early, 52%; P = 0.01). Visual acuity before endophthalmitis, pain, and patient-reported blurred vision were not associated with early or delayed presentation (P > 0.05)., Conclusions: Delayed presentation was associated with worse VA on initial examination and at 6 months in eyes with endophthalmitis. Presence of pain did not prompt earlier presentation. Visual acuity before endophthalmitis was associated with VA at 6 months, regardless of time to presentation. Further investigation may help to improve anticipatory guidelines for at-risk patients., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background and Objective: To investigate the effect of patient sex on presentation and outcomes of branch retinal vein occlusion (BRVO)., Patients and Methods: Retrospective chart review cohort study of 188 eyes with BRVO and cystoid macular edema (CME); 81 treatment-naïve eyes were selected for subgroup analysis., Results: Males had better visual acuity (VA) in the BRVO eye at baseline compared to females (log-MAR: 0.49 ± 0.47 vs. 0.62 ± 0.53; P = .04); this was not present at the final visit (males: 0.41 ± 0.40 vs. females: 0.59 ± 0.60; P = .10). In treatment-naïve eyes, both sexes had similar VA at baseline (males: 0.42 ± 0.29 vs. females: 0.59 ± 0.46; P = .09); however, at the final visit, males had better VA compared to females (0.38 ± 0.43 vs. 0.66 ± 0.67; P = .03). On average, males received more anti-VEGF injections when adjusting for follow-up (P = .04)., Conclusions: Significant sex differences in VA and treatment of eyes with BRVO and CME were noted. Further investigation is needed to understand sex differences in eyes with BRVO and CME. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:564-572.]., (Copyright 2020, SLACK Incorporated.)

Background and Objective: To evaluate the impact of sex differences on the presenting features, treatment patterns, and clinical outcomes in patients with central retinal vein occlusions (CRVO)., Patients and Methods: This retrospective, longitudinal cohort study included 476 patients diagnosed with CRVO over a 7-year period. Charts were reviewed and clinical data were abstracted., Results: The average age at CRVO onset was lower in males (63.8 years vs. 66.1 years; P = .048). More males (104/224, 54%) had an ischemic CRVO compared to females (113/252, 45%) at 12 months (P = .05). Males with CRVO had a greater central subfield thickness at the baseline (546.7 ± 306.8 μm vs. 438.4 ± 252.9 μm; P = .003) and final visits (343 ± 179.5 μm vs. 304.6 ± 176.2 μm; P = .005). Foveal avascular zone enlargement was more likely in males (39/102, 38% vs. 29/116, 25%; P = .04)., Conclusions: Sex differences exist in presenting features of patients with CRVO. Further inquiry may help provide individualized recommendations for management of CRVO. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:279-285.]., (Copyright 2020, SLACK Incorporated.)