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Thyroid hormones are essential during developmental myelination and may play a direct role in remyelination and repair in the adult central nervous system by promoting the differentiation of oligodendrocyte precursor cells into mature oligodendrocytes. Since tri-iodothyronine (T3) is believed to mediate the majority of important thyroid hormone actions, liothyronine (synthetic T3) has the potential to induce reparative mechanisms and limit neurodegeneration in multiple sclerosis (MS). We completed a phase 1b clinical trial to determine the safety and tolerability of ascending doses of liothyronine in individuals with relapsing and progressive MS. A total of 20 people with MS were enrolled in this single-center trial of oral liothyronine. Eighteen participants completed the 24-week study. Our study cohort included mostly women (11/20), majority relapsing MS (12/20), mean age of 46, and baseline median EDSS of 3.5. Liothyronine was tolerated well without treatment-related severe/serious adverse events or evidence of disease activation/clinical deterioration. The most common adverse events included gastrointestinal distress and abnormal thyroid function tests. No clinical thyrotoxicosis occurred. Importantly, we did not observe a negative impact on secondary clinical outcome measures. The CSF proteomic changes suggest a biological effect of T3 treatment within the CNS. We noted changes primarily in proteins associated with immune cell function and angiogenesis. Liothyronine appeared safe and was well tolerated in people with MS. A larger clinical trial will help assess whether liothyronine can promote oligodendrogenesis and enhance remyelination in vivo, limit axonal degeneration, or improve function. [ABSTRACT FROM AUTHOR]

Purpose: To estimate payments for glaucoma care among Medicare beneficiaries from 2002 to 2009. Design: Database study. Participants: Data from a 5% random sample of Medicare billing information from 2002 to 2009. Methods: Medicare beneficiaries, aged 65 years or older, with both Parts A and B fee-for-service (FFS) enrollment comprised the annual denominator. For each year, we included those with a defined glaucoma diagnostic code linked to a glaucoma visit, diagnostic test, or laser/surgical procedure. Open-angle, angle-closure, and other glaucoma were categorized separately. Claims were classified into glaucoma care, other eye care, and other medical care. Main Outcome Measures: Cost of glaucoma care in the Medicare Fee-for-Service Population. Results: In 2009, total glaucoma payments by Medicare were $37.4 million for this subset, for an overall estimated cost of $748 million, or 0.4% of an estimated cost of $192 billion for all Medicare FFS payments. Office visits comprised approximately one half, diagnostic testing was approximately one-third, and surgical and laser procedures were approximately 10% of glaucoma-related costs. Coded open-angle glaucoma (OAG) and OAG suspects accounted for 87.5% of glaucoma costs, whereas cost per person was highest in “other glaucoma.” In 2009, <3% of patients with OAG underwent incisional surgery and approximately 5% had laser trabeculoplasty. Laser iridotomy was the highest cost category among patients with angle-closure glaucoma, whereas office visits was the highest cost category among the “other glaucoma” group. The total cost of nonglaucoma eye care for patients with glaucoma was 67% higher than their glaucoma care costs; these were chiefly costs for cataract surgery and treatment of retinal diseases. From 2002 to 2009, FFS glaucoma care costs calculated in 2009 dollars were stable and cost per person per year in 2009 dollars decreased from $242 to $228 (P = 0.01 by test for linear trend). Conclusions: Annual glaucoma care costs per person decreased in constant dollars from 2002 to 2009. Cataract and retinal eye care for patients with glaucoma substantially exceeded the cost of their glaucoma care each year. Visit payments represented the largest category of costs. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To determine the prevalence of diagnosed glaucoma in the Medicare population and to assess regional variations and trends. Design: Retrospective, cross-sectional study. Participants: A 5% random sample of Medicare beneficiaries aged ≥65 years, excluding those in health maintenance organizations. Methods: All claims with a glaucoma diagnosis code submitted by ophthalmologists, optometrists, or ambulatory surgery centers were used to estimate prevalence of the diagnosis of glaucoma for each year from 2002 to 2008. Regional variation in diagnosed glaucoma was examined in 9 large geographic regions and in 179 smaller subregions, controlling for patient characteristics and provider supply. Main Outcome Measures: The prevalence of diagnosed open-angle glaucoma suspect (OAG-s), open-angle glaucoma (OAG), angle-closure glaucoma suspect (ACG-s), and angle-closure glaucoma (ACG), trends over time, and regional variations in prevalence. Results: The overall prevalence increased from 10.4% in 2002 to 11.9% by 2008, largely owing to increase in diagnosed OAG-s (from 3.2% to 4.5%; P<0.001). The relative prevalence of diagnosed OAG compared with diagnosed ACG was 32:1. In 2008, multivariable models showed that the New England and Mid-Atlantic regions had 1.7 times more diagnosed OAG-s than the reference region (East South Central; New England: odds ratio [OR], 1.66; 95% confidence interval [CI], 1.58–1.75; Mid-Atlantic: OR, 1.66; 95% CI, 1.59–1.73). The odds of diagnosed OAG was 36% higher in New England (OR, 1.36; 95% CI, 1.30–1.42) and 31% higher in the Mid-Atlantic (OR, 1.31; 95% CI, 1.26–1.36) than in the reference region. The New England and Mid-Atlantic regions had the highest odds of diagnosed ACG-s and the Mid-Atlantic region had the highest odds of diagnosed ACG. Among 179 subregions, the New York area had high diagnosis rates of all glaucoma types. Conclusions: The relative prevalence of diagnosed ACG compared with diagnosed OAG was lower than expected from population-based data, possibly owing to failure to perform gonioscopy. Substantial regional differences in diagnosed rates existed for all types of glaucoma, even after adjusting for patient characteristics and provider concentration, suggesting possible overdiagnosis in some areas and/or underdiagnosis in other areas. Regionally higher diagnosis rates in the New York area deserve further study. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To evaluate the physical functioning of Ethiopian trichiasis surgery patients before and 6 months after surgery. Design: Nested cohort study. Methods: This study was nested within the Surgery for Trichiasis, Antibiotics to Prevent Recurrence (STAR) clinical trial conducted in Ethiopia. Demographic information, ocular examinations, and physical functioning assessments were collected before and 6 months after surgery. A single score for patients'' physical functioning was constructed using Rasch analysis. A multivariate linear regression model was used to determine if change in physical functioning was associated with change in visual acuity. Results: Of the 438 participants, 411 (93.8%) had both baseline and follow-up questionnaires. Physical functioning scores at baseline ranged from −6.32 (great difficulty) to +6.01 (no difficulty). The percentage of participants reporting no difficulty in physical functioning increased by 32.6%; the proportion of participants in the mild/no visual impairment category increased by 8.6%. A multivariate linear regression model showed that for every line of vision gained, physical functioning improves significantly (0.09 units; 95% CI: 0.02–0.16). Conclusions: Surgery to correct trichiasis appears to improve patients'' physical functioning as measured at 6 months. More effort in promoting trichiasis surgery is essential, not only to prevent corneal blindness, but also to enable improved functioning in daily life. [Copyright &y& Elsevier]

The authors discuss the importance of Medicare's coverage of a screening benefit for glaucoma. They provide an overview of the prevalence of glaucoma in the U.S. They cite several reasons why the glaucoma screening benefit failed to be used in any meaningful way. They also mention the need to identify an effective alternative to the current glaucoma screening benefit in the Medicare population.

Objective: To estimate endophthalmitis incidence after cataract surgery nationally and at the state level in 2003 and 2004 and to explore risk factors. Design: Analysis of Medicare beneficiary claims data. Participants: We evaluated billed claims for cataract surgery and endophthalmitis diagnosis and treatment for all Medicare fee-for-service beneficiaries in 2003-2004. Methods: Cataract surgeries were identified by procedure codes and merged with demographic information. Cataract annual surgical volume was calculated for all surgeons. Presumed postoperative endophthalmitis cases were identified by International Classification of Diseases-9 Clinical Modification Codes on claims within 42 days after surgery. Endophthalmitis rates and 95% confidence intervals (CI) were calculated at state and national levels. Logistic regression was used to investigate the association between developing endophthalmitis and surgery location and surgeon factors. Main Outcome Measures: Endophthalmitis incidence and risk factors. Results: We included 4006 cases of presumed endophthalmitis, which occurred after 3 280 966 cataract surgeries. The national rate in 2003 was 1.33 per 1000 surgeries (95% CI, 1.27–1.38) and decreased to 1.11 per 1000 (95% CI, 1.06–1.16) in 2004. Males (relative risk [RR], 1.23; 95% CI, 1.15–1.31), older individuals (RR, 1.53; 95% CI, 1.38–1.69; ≥85 compared with 65–74 years), blacks (RR, 1.17; 95% CI, 1.03–1.33), and Native Americans (RR, 1.72; 95% CI, 1.07–2.77) had increased risk of disease. After adjustment, surgeries by surgeons with low annual volume (RR, 3.80; 95% CI, 3.13–4.61 for 1–50 compared with ≥1001 annual surgeries) and less experience (RR, 1.41; 95% CI, 1.25–1.59 for 1–10 compared with ≥30 years), and surgeries performed in 2003 (RR, 1.20; 95% CI, 1.13–1.28) had increased endophthalmitis risk. Conclusions: Endophthalmitis rates are lower than previous yearly US estimates, but remain higher than rates reported from a series of studies from Sweden; patient factors or methodologic differences may contribute to differences across countries. Patient age, gender, and race, and surgeon volume and years of experience are important risk factors. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To determine the sensitivity of time domain optical coherence tomography (OCT) in detecting conversion to neovascular age-related macular degeneration (AMD) in eyes at high risk for choroidal neovascularization (CNV), compared with detection using fluorescein angiography (FA) as the gold standard. Design: Prospective, multicenter, observational study. Participants: Individuals aged ≥50 years with nonneovascular AMD at high risk of progressing to CNV in the study eye and evidence of neovascular AMD in the fellow eye. Methods: At study entry and every 3 months through 2 years, participants underwent best-corrected visual acuity, supervised Amsler grid testing, preferential hyperacuity perimetry (PHP) testing, stereoscopic digital fundus photographs with FA, and OCT imaging. A central Reading Center graded all images. Main Outcomes Measures: The sensitivity of OCT in detecting conversion to neovascular AMD by 2 years, using FA as the reference standard. Secondary outcomes included comparison of sensitivity, specificity, positive predictive value, and negative predictive value of OCT, PHP, and supervised Amsler grid relative to FA for detecting incident CNV. Results: A total of 98 participants were enrolled; 87 (89%) of these individuals either completed the 24-month visit or exited the study after developing CNV. Fifteen (17%) study eyes had incident CNV confirmed on FA by the Reading Center. The sensitivity of each modality for detecting CNV was: OCT 0.40 (95% confidence interval [CI], 0.16–0.68), supervised Amsler grid 0.42 (95% CI, 0.15–0.72), and PHP 0.50 (95% CI, 0.23–0.77). Treatment for incident CNV was recommended by the study investigator in 13 study eyes. Sensitivity of the testing modalities for detection of CNV in these 13 eyes was 0.69 (95% CI, 0.39–0.91) for OCT, 0.50 (95% CI, 0.19–0.81) for supervised Amsler grid, and 0.70 (95% CI, 0.35–0.93) for PHP. Specificity of the OCT was higher than that of the Amsler grid and PHP. Conclusions: Time-domain OCT, supervised Amsler grid, and PHP have low to moderate sensitivity for detection of new-onset CNV compared with FA. Optical coherence tomography has greater specificity than Amsler grid or PHP. Among fellow eyes of individuals with unilateral CNV, FA remains the best method to detect new-onset CNV. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [Copyright &y& Elsevier]

Objective: To determine whether year of residency is associated with intraoperative phacoemulsification complication rates. Design: Retrospective cohort study. Participants: One attending physician supervised 691 resident-performed phacoemulsification procedures on 492 patients. Second- and third-year residents performed 228 and 463 cases, respectively. Methods: All resident-performed phacoemulsification procedures performed between October 2003 and June 2008 and supervised by one attending surgeon (SR) were considered for this study. Data were collected on the residency year of the physician performing the surgery, preoperative risk indicators, and intraoperative complications, including anterior and posterior capsular tears with or without vitreous loss, zonular dialysis or dehiscence, burns, nuclear fragment loss, and Descemet''s membrane tear. Cases were classified as difficult if they had 1 or more preoperative risk indicators including: pseudoexfoliation; proliferative diabetic retinopathy; prior vitrectomy; a 4+ dense, white, or brunescent cataract; current Flomax (Boehringer-Ingelheim, Ingelheim, Germany) use, pre-existing zonular dialysis; and intraoperative use of Trypan blue, iris hooks, or pupil dilator. Intraoperative complications are presented as rate per 100 surgeries (95% confidence intervals [CIs]). Main Outcome Measures: Intraoperative complication rates and case difficulty. Results: Fifty-three patients experienced at least 1 complication, with 25 cases experiencing multiple complications. Intraoperative complication rates were similar among second- and third-year resident groups (7.9% vs. 7.6%; P = 0.88). Similarly, vitreous loss rates among second- and third-year residents were comparable (4.8% vs. 3.0%; P = 0.27). Risk indicators were more common among third-year cases (24.6% vs. 15.8%; P = 0.008). Having 1 or more risk indicators increased the odds of an intraoperative complication (odds ratio [OR], 3.09; 95% CI, 1.73–5.49). After controlling for risk indicators, second-year resident surgeries still had a similar risk of intraoperative complications as third-year resident surgeries (OR, 1.15; 95% CI, 0.6–2.19). Conclusions: The year of residency did not significantly influence intraoperative complication rates, even after controlling for differences in case difficulty. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [Copyright &y& Elsevier]

Purpose Endophthalmitis is a rare but sight-threatening infection after cataract surgery. Roughly one third of eyes remain blind after treatment. We report United States population-based data on microbiological investigations and treatment patterns plus risk factors for poor outcomes. Design Retrospective cohort study. Participants Medicare beneficiaries from 5 states in whom endophthalmitis developed within 6 weeks after cataract surgery in 2003 and 2004. Methods We identified endophthalmitis cases occurring after cataract surgery using Medicare billing claims. We contacted treating physicians and requested they complete a questionnaire on clinical and microbiological data and submit relevant medical records. Two independent observers reviewed materials to confirm that cases met a standardized definition. Main Outcome Measures Positive culture results, vitrectomy status, microbiology spectrum, and final visual acuity. Results In total, 615 cases met our case definition. Initial visual acuity was counting fingers or worse for 72%. Among 502 cases with known culture results, 291 (58%) had culture positive results. Twelve percent had positive results for streptococci. More than 99% of cases were treated with intravitreal vancomycin. Vitrectomy was performed in 279 cases (45%), including 201 cases with initial acuity better than light perception. Rates of vitrectomy varied across states, with California having the highest rate and Michigan having the lowest (56% and 19% of cases, respectively). Overall, 43% of individuals achieved visual acuity of 20/40 or better. Poor initial acuity (adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04–1.12 per 0.10 logarithm of the minimum angle of resolution units), older age at diagnosis (OR, 1.22; 95% CI, 1.03–1.45 per 5-year increase), and more virulent organisms were important predictors of poor final visual acuity. Cases with streptococci infection were 10 times more likely to have poor final acuity than coagulase-negative staphylococci cases (adjusted OR, 11.28; 95% CI, 3.63–35.03). Vitrectomy was not predictive of final visual acuity (adjusted OR, 1.26; 95% CI, 0.78–2.04). Conclusions Population-based data on the microbiology of acute postoperative endophthalmitis in the United States after cataract surgery are consistent with prior reports. Vitrectomy usage is higher than that recommended from the Endophthalmitis Vitrectomy Study, with no evidence of increased benefit. [ABSTRACT FROM AUTHOR]