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PURPOSE To compare objectively measured changes in plus disease after bevacizumab and laser for Type 1 retinopathy of prematurity. METHODS ROPtool (a computer program) analyzed fundus images at baseline, 1 week, and subsequent examinations. RESULTS Six infants (9 eyes) were treated with bevacizumab and 7 (12 eyes) with laser. One week after treatment, bevacizumab compared with laser resulted in a greater median percent change from pretreatment in tortuosity (-53.8 vs. -0.2%, P < 0.001) and overall plus disease (-20.1 vs. -3.1%, P < 0.001). Change in dilation did not differ (-3.5 vs. -5.5%, P = 0.48). After week 1, all median ROPtool parameters continued to decrease for both groups. At last follow-up (median 3, range: 2-10 weeks), both bevacizumab and laser significantly decreased tortuosity (-54.3 and -23.8%), dilation (-8.7 and -7.5%), and overall plus disease (-27.3 and -10.3%). CONCLUSION Improvement in plus disease, in particular tortuosity, likely occurs more quickly after bevacizumab compared with laser, particularly at 1 week after treatment. These results guide clinical expectations for plus disease resolution after both treatment modalities.

OBJECTIVE: To evaluate the association between retinopathy of prematurity and vitreous findings in premature infants detected by handheld spectral-domain optical coherence tomography. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Consecutive sample of 92 premature infants requiring retinopathy of prematurity screening at two academic neonatal intensive care units, between July 2015 and March 2018. METHODS: Infants underwent handheld spectral domain optical coherence tomography at the time of routine retinopathy of prematurity examinations. Two masked, trained graders analyzed right eye vitreoretinal findings including semi-automated quantification of punctate hyperreflective vitreous opacities within 5 foveal/parafoveal B-scans (Vitreous Opacity Ratio). MAIN OUTCOME MEASURES: Excluding post-treatment data, vitreous findings were compared to clinical retinopathy of prematurity diagnoses. RESULTS: Agreement between image graders for all vitreoretinal findings was 91% (kappa=0.86 [95% confidence interval, 0.82–0.90], P

To characterize how prior incisional glaucoma surgery affects the intraocular pressure (IOP) elevation immediately following intravitreal anti-VEGF injections (IVI). Single institution, experimental study. Patients with a history of incisional glaucoma surgery who were receiving anti-VEGF injections were recruited as well as control eyes. Pre- and post-injection IOP measurements were compared as well as time to recovery to within 5 and 10 mmHg of baseline IOP. Ten eyes with a history of glaucoma surgery and 29 control eyes receiving anti-VEGF injections were included. The most common indication for intravitreal anti-VEGF injection was proliferative diabetic retinopathy in both surgical and control eyes (50% vs 45%, p = 1.00). Post-injection IOP was significantly decreased compared to baseline IOP after anti-VEGF injection in surgical versus control eyes (26.5 ± 8.9 mmHg vs 44.2 ± 8.5 mmHg, respectively, p

BackgroundThe flipped-classroom involves watching prerecorded lectures at home followed by group learning exercises within the classroom. This study compares the flipped classroom approach with the traditional classroom for teaching horizontal strabismus didactics in ophthalmology residency.MethodsIn this multicenter, randomized controlled survey study from October 2017 to July 2018, 110 ophthalmology residents were taught esotropia and exotropia sequentially, randomized by order and classroom style. Flipped classroom participants were assigned a preclass video lecture prior to the in-class case-based activity. The traditional classroom included a preparatory reading assignment and an in-person lecture. Residents completed three identical 5-question assessments (pretest, post-test, and 3-month retention) and surveys for each classroom. The primary outcome measured residents' preferences for classroom styles; the secondary outcome compared knowledge acquisition.ResultsIn our study cohort, the flipped classroom resulted in greater at-home preparation than the traditional classroom (P=0.001) and was preferred by 33 of 53 residents (62%); 45 of 53 (85%) wished to see the flipped classroom used at least 25% of the time. The exotropia flipped classroom scored higher than traditional classroom on the pretest (3.71/5 [74%] vs 2.87/5 [57%]; P&nbsp

Purpose To describe normative values for choroidal thickness in newborns and characterize their relationship to vitreoretinal features. Methods Term newborns underwent awake, handheld swept-source optical coherence tomography (SS-OCT) in this prospective cohort study. An automated segmentation algorithm followed by manual adjustments measured choroidal thickness at the fovea and five perifoveal locations. Two masked, trained graders, with a third mediating disagreements, analyzed scans for vitreoretinal findings. OCT vitreoretinal findings, including dome-shaped macula, subretinal fluid, punctate hyperreflective vitreous opacities, persistent inner retinal layers, foveal ellipsoid zone, tractional and non-tractional vitreous bands, epiretinal membrane, cystoid macular edema, vessel elevation, scalloped retinal layers, hyporeflective vessels, and retinal spaces, were assessed and correlated with foveal choroidal thickness using a generalized linear mixed model. Results Fifty-nine eyes of 39 infants (mean gestational age, 39.5 weeks; 18 male, 46%) were included. Mean foveal choroidal thickness was 455.5 ± 93.9 µm. Choroid was thinner inferonasally (343.6 ± 106.2 µm) compared to superonasally (368.4 ± 92.9 µm; P = 0.03) and superotemporally (369.6 ± 100.6 µm; P = 0.02). Thinner foveal choroidal thickness was associated with absence of a foveal ellipsoid zone (437.1 ± 78.5 µm vs. 553.7 ± 93.9 µm; P = 0.02). Choroidal thickness was not significantly associated with other OCT findings. Conclusions We identified an association between thinner choroid and foveal immaturity. Additional study is needed to determine whether choroidal development impacts visual outcomes. Translational Relevance Handheld SS-OCT achieved normative measurements for choroidal thickness across the macula in term newborns, providing a foundation for future investigations into the role of choroidal development in infancy.

Purpose To describe dome-shaped macula and associated clinical findings in premature infants. Methods This prospective, observational cohort study included a consecutive sample of premature infants screened for retinopathy of prematurity (ROP) with 9-month follow-up. Handheld spectral domain optical coherence tomography (SD-OCT) was performed at the time of ROP screening. Images were assessed for dome-shaped macula, cystoid macular edema, epiretinal membrane, vitreous bands, and punctate hyperreflective vitreous opacities. Dome height measurements were performed in a subset of images. Teller visual acuity and cycloplegic refraction were performed at an adjusted age of 8-10 months. Results Of 37 infants (74 eyes; 49% male; mean gestational age 27.8 ± 3.2 weeks; mean birth weight 949 ± 284 g), 24/37 (65%) demonstrated dome-shaped macula in at least one eye (13 both eyes, 5 right eye only, and 6 left eye only). Of the 74 eyes, 26 (35%) could be reliably measured, with a mean dome height of 139.0 ± 72.3 μm (range, 54–369 μm). Presence of dome-shaped macula was associated with a diagnosis of ROP (P = 0.02; OR, 3.03; 95% CI, 1.18-7.82) and pre-plus or plus disease (P = 0.02; OR, 4.20; 95% CI, 1.05-16.78). Infants with dome-shaped macula had lower birth weight compared with those without (877 vs 1081 g; P = 0.04). No associations with other demographics, OCT findings, and 9-month refractive outcomes were found. Conclusions Dome-shaped macula was frequently identified by handheld SD-OCT in premature infants, especially those with lower birth weight and severe ROP. The long-term clinical significance of this finding is unknown.

Objective To objectively measure sleep and activity levels and examine their relationship to burnout, depression, anxiety, and stress in ophthalmology residents. Design A cohort study of ophthalmology residents at the University of Washington from July 1, 2017 to June 30, 2018. Setting Single-center academic institution. Participants Fourteen ophthalmology residents at the University of Washington enrolled between July 1, 2017 and June 30, 2018. Results Data were collected from 14 residents, ages 27 to 34. Wrist actigraphy allowed for objective measurement of resident sleep and activity, though adherence to wrist actigraphy usage dropped significantly over time. Residents recorded significantly less sleep on call compared to when they were off call, with mean (SD) 3.6 (2.0) hours on primary call, 5.6 (1.8) hours on secondary call, and 6.7 (1.4) hours off call. Lower average sleep on call was associated with higher emotional exhaustion (r = −0.69, p = 0.04), lower personal accomplishment (r = 0.82, p = 0.007), higher anxiety (r = −0.90, p = 0.001), and higher stress (r = −0.75, p = 0.02). Higher daily activity was associated with higher sense of personal accomplishment (r = 0.57, p = 0.04). Average nightly sleep, average sleep while not on call, and daily sedentary time was not associated with any subset of burnout. Conclusions The association between objectively measured sleep while on call and burnout, depression, and anxiety are consistent with findings from prior studies which relied on subjective measures of sleep. The direction of causality – whether poor sleep caused burnout, burnout caused poor sleep, or both – could not be assessed in the present study. However, these results are consistent with the hypothesis that poor sleep on call contributes to resident burnout and that physical activity may reduce aspects of burnout. The use of wrist actigraphy to objectively measure sleep and activity patterns may help focus and evaluate interventions aimed at decreasing resident burnout.

PURPOSE: To compare vitreous opacity density in infants born at term and in infants born prematurely using an investigational handheld swept-source optical coherence tomography (SS-OCT). METHODS: Infants born at term underwent imaging once between 12 and 48 hours after birth; infants born prematurely were imaged at each routine retinopathy of prematurity (ROP) examination. Three masked, trained graders analyzed images. Semiautomated methods were used to quantify vitreous opacity density, which was correlated with ROP severity based on indirect ophthalmoscopy, other SS-OCT findings, and medical comorbidities. RESULTS: Between April 2018 and June 2019, 251 SS-OCT imaging sessions were performed on 78 infants (49% female; 36% preterm, with mean birth weight of 1018 ± 338 g and gestational age of 28.6 ± 3.2 weeks). All SS-OCT sessions produced images of adequate quality. Punctate vitreous opacities were present in 25 of 28 term infants (89%) and 41 of 50 premature infants (82%). Dice coefficient and F1 scores for intergrader agreement were 0.99 ± 0.03 and 0.77 ± 0.31, respectively. Vitreous opacity density was 0.118 ± 0.187 in prematurely born infants and 0.031 ± 0.118 in infants born at term (P = 0.009). In the former, vitreous opacity density was associated with ROP zone (P = 0.044) and stage (P = 0.031), intraventricular hemorrhage (P = 0.028), subchorionic hemorrhage (P = 0.026), and African American race (P = 0.023). In the latter, vitreous opacity density was associated with maternal diabetes (P = 0.049). CONCLUSIONS: Our investigational handheld SS-OCT achieved high-quality vitreoretinal images. In our study cohort, punctate vitreous opacities were a frequent finding in infants born at term and those born prematurely, with increased density in those born prematurely, particularly those with severe ROP.

This anonymous survey identifies a sexual harassment prevalence of 59% among ophthalmologists responding through the Women in Ophthalmology listserv. The authors urge implementation of sexual harassment policies within our professional societies, accreditation councils and workplaces.

To determine the incidence of retinopathy of prematurity (ROP) in Gansu, China by combining bedside examinations with remote RetCam (Clarity Medical Systems, Pleasanton, CA, USA) diagnosis.ROP screening via indirect ophthalmoscopy followed by RetCam imaging was performed from 2014 to 2015. Three ROP-experienced ophthalmologists interpreted images remotely. Incidence of ROP was determined by combining bedside and telemedicine diagnoses.Of 139 examined infants and 137 complete records, 20 (14.6%) patients developed ROP, with 11 (8.0%) stage 1, six (4.4%) stage 2, and three (2.2%) stage 3 based on combined diagnoses. Perinatal asphyxia was significantly associated with ROP incidence (p = 0.01). ROP incidence by combined diagnosis (20/137 or 14.6%) versus clinician diagnosis alone (21/137 or 15.3%, p = 0.50) was similar. Telemedicine changed diagnoses in 4/21 (19.0%) ROP cases.Telemedicine may be helpful in confirming ROP incidence and may serve as a training and support model for less experienced and professionally isolated ROP examiners.

Background To determine accuracy of partial coherence interferometry (PCI) in patients with large inter-eye axial eye length (AEL) difference. Methods Patients undergoing cataract surgery at two academic medical centers with an inter-eye axial eye length (AEL) difference of > 0.30 mm were identified and were matched to control patients without inter-eye AEL difference > 0.30 mm on the basis of age, sex, and AEL. The expected post-operative refraction for the implanted IOL was calculated using SRK/T, Holladay II, and Hoffer Q formulae. The main outcome measures were the refractive prediction error and the equivalence of the refractive outcomes between the subjects and controls. Results Review of 2212 eyes from 1617 patients found 131 eyes of 93 patients which met inclusion criteria. These were matched to 131 control eyes of 115 patients. The mean AEL was 24.92 ± 1.50 mm. The mean absolute error (MAE) ranged from 0.47 D to 0.69 D, and was not statistically different between subjects and controls. The refractive prediction error was equivalent between the cases and controls, with no significant difference between the MAE for any formula, nor in the number of cases vs. controls with a refractive prediction error of at least 0.50 D or 1.00 D. Conclusions Among eyes in our study population, good-quality PCI data was equally accurate in patients with or without an inter-eye AEL difference > 0.30 mm. Confirmatory AEL measurements using different AEL measuring modalities in patients with a large inter-eye AEL difference may not be necessary.

Purpose To compare retinal vascular parameters acquired by handheld swept-source optical coherence tomography angiography (SS-OCTA) between nonsedated preterm and full-term infants. Methods Preterm and full-term infants at the University of Washington Medical Center were enrolled. Retinal angiograms (nominal size ∼7 × 7 mm2) were obtained at each routine retinopathy of prematurity (ROP) screening session for preterms and once during the first 72 hours of life for full-terms. Macular vessel area density and nonperfusion area were evaluated on the binarized vasculature map in both small (1.5 × 1.5 mm) and large (3 × 3 mm) quadrants. Average vessel diameter and tortuosity values were obtained from each large vessel branch (length >200 µm). All vascular analyses used previously published algorithms. Results Handheld SS-OCTA captured 31 of 55 (56%) high-quality volumes on 8 awake preterm infants (gestational age 28 ± 4 weeks, birth weight 891 ± 314 g, postmenstrual age at first imaging session 37 ± 2 weeks) and 48 of 54 (89%) volumes on 12 awake full-term infants (gestational age 39 ± 1 weeks, birth weight 3405 ± 329 g). Signal-to-noise ratio was 5.08 ± 1.52 dB in preterm and 4.90 ± 1.12 dB in full-term infants. Preterm infants had higher mean large vessel tortuosity compared to full-term infants (P = 0.004). The large nasal quadrant vessel area density of infants with stage 3 and/or pre-plus or worse ROP was higher than other preterm infants (P = 0.007). Conclusions Although inadequate image quality limited usable imaging sessions, handheld SS-OCTA achieved adequate signal-to-noise ratio in nonsedated infants for quantitative retinal vascular parameter analysis. Translational relevance Large- and small-vessel parameters were associated with prematurity and ROP severity, respectively.

Purpose To compare the flipped classroom (home pre-taped lectures followed by in-class group exercise) to the traditional classroom (home reading assignment followed by in-class lecture) for horizontal strabismus didactics in ophthalmology residency. Methods All PGY2-4 residents from four U.S. ophthalmology residencies without prior residency flipped-classroom experience were invited to esotropia and exotropia sessions sequentially, with random order and assignment to flipped and traditional classrooms. Content test scores before and after the two classrooms were compared. Surveys were administered to assess participant experience. Results A total of 40 residents attended each session. Likert scale evaluation of preparatory material and classroom activity did not differ between sessions; however, divided by year of training, 70% of senior residents (PGY3-4) and 39% of first-year (PGY2) residents preferred the flipped classroom over the traditional classroom. Pre- and post-test scores for the flipped classroom exceeded those of the traditional classroom for the exotropia course (P = 0.01 and P = 0.001, resp.) but not for the esotropia course. There was significant improvement between pre- and post-tests for both styles of learning. Conclusions The flipped classroom had a favorable effect on test scores for only one of the two strabismus subjects but was preferred over the traditional classroom among PGY3-4 residents.

Importance Handheld spectral-domain optical coherence tomography (SD-OCT) can provide insights into the complex interactions occurring at the vitreoretinal interface in retinopathy of prematurity (ROP) to enhance our understanding of ROP pathology. Objective To characterize vitreous bands in premature infants with use of handheld SD-OCT. Design, Setting, and Participants Prospective cohort study conducted from July 7, 2015, to February 28, 2017, at 2 university-based neonatal intensive care units. Seventy-three premature infants who required routine ROP screening examination were recruited. Informed consent was obtained from all legal guardians. Trained graders who were masked to the clinical assessment analyzed each SD-OCT scan of the right eye for vitreoretinal findings. A third trained grader mediated disagreements. Main Outcomes and Measures Associations between the presence of vitreous bands in premature infants with ROP diagnoses and the presence of other vitreoretinal SD-OCT findings were investigated. Results Of the 73 infants recruited, 6 infants’ parents withdrew their children from the study, and 2 infants were too hemodynamically unstable for imaging, leaving a total of 65 participants. Of these, 32 (49%) were female, 36 (55%) were white, 10 (15%) were Hispanic, 3 (5%) were Native American, 4 (6%) were African American, 4 (7%) were Asian/Pacific Islander, and 8 (12%) were other. The mean (SD) gestational age was 28 (2.7) weeks, the mean (SD) birth weight was 997 g (286 g), and the mean (SD) postmenstrual age at imaging was 34 (3) weeks (mean [SD] total of 3 [2] imaging sessions). Comparing the 24 infants (37%) who had a right eye vitreous band at any time with the 41 (63%) who did not, no difference in mean birth weight, gestational age, postmenstrual age at imaging, sex, or race/ethnicity was identified. No associations with ROP stage (eg, in 6 [25%] infants with vitreous bands vs 4 [9.8%] in those without;P = .23), presence of plus disease (2 [8%] vs 2 [5%];P = .84), or type 1 ROP (3 [12%] vs 3 [7%];P = .66) were identified. Vitreous bands were associated with epiretinal membrane detected on SD-OCT (P = .001) with an odds ratio of 9.4 (95% CI, 2.8-31.3) in 15 [62%] infants with vitreous bands vs 6 [15%] in those without. Vitreous bands were also associated with cystoid macular edema (in 15 [62%] infants with vitreous bands vs 1 [27%] in those without;P = .005) with an odds ratio of 4.5 (95% CI, 1.5-13.3). Conclusions and Relevance In this study, the development of vitreous bands was associated with both cystoid macular edema and epiretinal membrane. These findings suggest a tractional pathogenesis to these entities among premature infants. This study did not find a direct association between vitreous bands and severe ROP. Additional study is needed to determine whether vitreous bands represent subclinical hyaloidal organization leading to retinal detachment in advanced ROP.

Purpose This study aimed to understand patients' perceptions about potential benefits and harms of accessing their own ophthalmology clinic notes via an electronic patient portal as part of the OpenNotes initiative. Methods The authors conducted a cross-sectional, in-person survey of ophthalmology patients at three US eye clinics. The paper survey was self-administered or administered with assistance from study staff before or after patients' clinical visits. The authors used descriptive statistics to summarise patient characteristics and patient attitudes about accessing their ophthalmology notes online. Chi-square and t-tests were performed to assess differences in patient responses between clinic locations. Results Four hundred and fifty-one patients responded (response rate 65%). Most patients thought that accessing doctors' notes online was a good idea (95%), wanted to view their clinic notes online (94%), and agreed online access would increase their understanding of their eye problems (95%) and help them better remember their care plan (94%); 14% said online access would increase their worry; 43% had privacy concerns; and 96% indicated they would show or discuss their notes with at least one other person. Non-white patients were more likely than white patients to perceive online clinic notes as a useful tool, but they were also more likely to worry and to express greater privacy concerns. Conclusions Patients at three US eye clinics were strongly in favour of online access to ophthalmology notes and were optimistic this access would improve their understanding and self-care. Ophthalmologists should consider offering online access to their notes to enhance doctor-patient communication and improve clinical outcomes.

Purpose: To evaluate the correlation between lamina cribrosa (LC) morphology and glaucoma severity in patients with primary forms of open-angle glaucoma (OAG) using enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT) and Humphrey visual field test (HVF). Subjects and Methods: Patients with OAG (n = 166), divided into normal-tension glaucoma (NTG) and high-tension glaucoma (HTG) groups (n = 66 and n = 100), were imaged using SD-OCT to obtain horizontal B-scan images of the optic nerve head (ONH). Laminar depth (LD) and laminar thickness (LT) were measured at the center of ONH. Results: The mean (±standard deviation) values of LD, LT, and visual field mean deviation (MD) were 555.4 ± 142.3 μm, 179.9 ± 49.7 μm, and − 5.7 ± 6.4 dB, respectively. In the multivariate linear regression analysis, LD, LT, and intraocular pressure (IOP) were significantly correlated with MD (P = 0.007, P = 0.037, and P = 0.004, respectively). In the subgroup analyses, only LD was associated with MD in the NTG group (n = 66), whereas LT and IOP were correlated with MD in the HTG group (n = 100). Neither axial length nor central corneal thickness was associated with LD or LT. Conclusions: Glaucoma severity, as measured by HVF MD, shows significant correlations with LD and LT, with greater severity associated with increasing LD and decreasing LT. Normal- and high-tension OAG patients have different associations with LD and LT, which implies that the pathogenesis of these two entities might be different.