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Purpose: To investigate the prevalence of non-person-first language (PFL) in consecutive general ophthalmology referrals to a single tertiary ophthalmology clinic., Design: Retrospective cross-sectional study., Methods: Participants included Ophthalmology patients seen for their initial visit to a single tertiary ophthalmology clinic from July 2018 to December 2022. Ten randomly selected referrals from each day were screened for non-PFL as per the American Medical Association and American Psychological Association guidelines. Non-PFL was further categorized into general, diabetes, stigma, obesity, or ageism subcategories. The Chi-square test was used to evaluate associations between non-PFL use and referring provider gender and specialty, length of referral, and patient age and gender., Results: A total of 2625 referrals were included in the study and 136 (5.2%) used non-PFL, such as referring to a person with diabetes as a "diabetic". Error types included Diabetes (38.2%), Stigma (30.9%), General (23.5%), Disability (8.8%), and Obesity (4.4%). Year of referral was predictive of non-PFL (P = .0016), with most occurring in 2020 (9.5%). Non-PFL was significantly more likely to occur in long length referrals compared to medium and short length referrals (16.2% vs. 5.1% vs. 3.5%, P < .001). Referring provider specialty was also predictive of non-PFL (P < .001) with most received by Family Medicine (8.3%), Optometry (4.4%), Emergency Medicine (0.62%), Ophthalmology (4.2%), Others (2.9%). Patient gender (P = .5563), patient age (P = .3466), and referring provider gender (P = .9057) were not predictive of non-PFL., Conclusions: Non-PFL use was most prevalent in 2020, with the most common referral sources being Family Medicine and Optometry. The highest proportions of non-PFL errors made were diabetes and stigma errors. Increased use of PFL in physician-physician communication can decrease intersectional stigma and promote inclusive patient care for ophthalmology patients., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Direct ophthalmoscopy continues to be the "gold standard" method for retinal and optic nerve evaluation despite known challenges for learners to acquire this clinical skill and minimal opportunities for patient-facing practice. Here we review current literature regarding smartphone fundoscopy (SF) as an alternative learning tool that remains underutilized in Canadian medical schools. SF has significant advantages over direct ophthalmoscopy, such as enhanced learner visualization of ocular structure and pathologies, greater learner usability in comparison, and improved fundus assessment during more difficult ocular examinations such as with pediatric patients. Furthermore, SF provides opportunities for instructor exchange and feedback, group learning, increased learner confidence, and most important, an improved patient experience. Yet challenges remain with SF, including patient confidentiality during data capture and sharing and meaningful integration into an already limited and saturated curriculum. Our review finds SF to be a pedagogic tool with the potential to reinvigorate fundoscopy learning to improve competency in this important clinical skill., Competing Interests: Footnotes and Disclosure The authors have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background/objectives: Experimental investigation. Bing Chat (Microsoft) integration with ChatGPT-4 (OpenAI) integration has conferred the capability of accessing online data past 2021. We investigate its performance against ChatGPT-3.5 on a multiple-choice question ophthalmology exam., Subjects/methods: In August 2023, ChatGPT-3.5 and Bing Chat were evaluated against 913 questions derived from the Academy's Basic and Clinical Science Collection collection. For each response, the sub-topic, performance, Simple Measure of Gobbledygook readability score (measuring years of required education to understand a given passage), and cited resources were collected. The primary outcomes were the comparative scores between models, and qualitatively, the resources referenced by Bing Chat. Secondary outcomes included performance stratified by response readability, question type (explicit or situational), and BCSC sub-topic., Results: Across 913 questions, ChatGPT-3.5 scored 59.69% [95% CI 56.45,62.94] while Bing Chat scored 73.60% [95% CI 70.69,76.52]. Both models performed significantly better in explicit than clinical reasoning questions. Both models performed best on general medicine questions than ophthalmology subsections. Bing Chat referenced 927 online entities and provided at-least one citation to 836 of the 913 questions. The use of more reliable (peer-reviewed) sources was associated with higher likelihood of correct response. The most-cited resources were eyewiki.aao.org, aao.org, wikipedia.org, and ncbi.nlm.nih.gov. Bing Chat showed significantly better readability than ChatGPT-3.5, averaging a reading level of grade 11.4 [95% CI 7.14, 15.7] versus 12.4 [95% CI 8.77, 16.1], respectively (p-value < 0.0001, ρ = 0.25)., Conclusions: The online access, improved readability, and citation feature of Bing Chat confers additional utility for ophthalmology learners. We recommend critical appraisal of cited sources during response interpretation., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Objective: To characterize the neuro-ophthalmology publishing trends of the top general clinical ophthalmology and neurology journals and to report (i) the proportion of articles that are neuro-ophthalmology focused and (ii) the correlation between annual proportion of neuro-ophthalmology-focused articles and annual proportion of neuro-ophthalmologist journal editors., Design: Retrospective database review., Materials: Articles in the top 5 general clinical ophthalmology and neurology journals., Methods: Publications from 2012 through 2021 were retrieved from Embase and classified as teaching or nonteaching articles based on journal indexing. Duplicate screening was conducted to further categorize articles as either focused or not focused on neuro-ophthalmology., Results: The titles, abstracts, and (or) full texts of 34,660 articles were reviewed. The total proportions of nonteaching articles and teaching articles focused on neuro-ophthalmology were 3.4% and 13.8%, respectively. Neuro-ophthalmology contributions to nonteaching and teaching publications were greater among the ophthalmology journals (4.0% and 15.2%) than among the neurology journals (2.6% and 13.3%). There were no clear trends in the annual proportion of neuro-ophthalmology-focused articles across the 10-year period. The annual proportion of neuro-ophthalmologist journal editors was positively correlated with annual neuro-ophthalmology output for teaching articles (Pearson's r = 0.541; p < 0.001) but not articles unrelated to teaching (Pearson's r = 0.067; p = 0.598)., Conclusions: Our study found that there was a lower prevalence of neuro-ophthalmology papers in high-impact-factor general clinical ophthalmology and neurology journals over the last 10 years. It is important to have good representation of neuro-ophthalmology studies in such journals to promote best neuro-ophthalmic practices among all clinicians., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Empty sella often supports a diagnosis of raised intracranial pressure (ICP) but is also seen in normal individuals. This study's objective was to determine the prevalence of empty and partially empty sella in neuro-ophthalmology patients undergoing MRI for indications other than papilledema or raised ICP., Methods: Consecutive patients without papilledema or suspected raised ICP who underwent brain MRI between August 2017 and May 2021 were included in this study. Sagittal T1 images were evaluated by 2 independent, blinded neuroradiologists who graded the sella using the published criteria (Categories 1-5, with 1 being normal and 5 showing no visible pituitary tissue). Clinical parameters were also collected., Results: A total of 613 patients (309 men; average age 56.69 ± 18.06 years) were included in this study with optic neuropathy as the most common MRI indication. A total of 176 patients had moderate concavity of the pituitary gland (Category 3), 81 had severe concavity (Category 4), and 26 had no visible pituitary tissue (Category 5). Sella appearance was mentioned in 92 patients' radiology reports (15%). There was a statistically significant difference in age between composite Categories 1 and 2 (mean 52.89 ± 18.91; P < 0.001) and composite Categories 4 and 5 (mean 63.41 ± 15.44), but not the other clinical parameters., Conclusion: Empty sella is common in neuro-ophthalmology patients without raised ICP; 17.4% of patients have severe concavity or no pituitary tissue visible. An isolated finding of empty or partially empty sella on imaging is therefore of questionable clinical value in this patient population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by North American Neuro-Ophthalmology Society.)

Purpose: There are currently no available aids for authors when selecting ophthalmology journals to submit their manuscripts. We aim to provide comprehensive data on the duration from submission to various stages of the publication process and assess factors influencing time to publication in ophthalmology journals., Methods: A list of ophthalmology journals was obtained from the 2019 Web of Science Journal Citation Report. Journal characteristics, such as five-year impact factor, number of authors per article, journal type, and number of multi-institutional articles, were collected. The dates of submission, acceptance, electronic and print publication for all articles published in an ophthalmology journal in 2019 were determined., Results: In total, 56 journals and 8835 research articles were included. Of these articles, 3591 (40.6%) were open access and 4837 (54.7%) were multi-institutional. In 2019, most publications came from the United States of America (n = 1973), China (n = 1069) and Germany (n = 602). Significant associations were found between various predictors and a reduced mean number of days from submission to electronic publication: increased journal five-year impact factor ( p =  .026), more authors ( p =  .028), publishing in a hybrid journal (both open-access and subscription articles) versus an open-access journal ( p =  .021), and a reduced proportion of multi-institutional articles in a journal ( p =  .030)., Conclusions: There is a wide variation in the time to acceptance and publication in ophthalmology journals. Authors can expect a shorter time to publication when publishing in high-impact journals.

Background: To determine differential diagnosis and visual outcomes of patients with no light perception (NLP) vision related to neuro-ophthalmic conditions., Methods: Retrospective case series of patients seen at tertiary neuro-ophthalmology practices. Patients were included if they had NLP vision any time during their clinical course. Outcome measures were final diagnosis, treatment, and visual outcome., Results: Seventy-two eyes of 65 patients were included. The average age was 57.6 (range 18-93) years, and 58% were women. The Most common diagnosis (21 patients) was compressive optic neuropathy (CON) with meningioma being the most common culprit (12). Other diagnoses included optic neuritis (ON) (11 patients), infiltrative optic neuropathies (8), posterior ischemic optic neuropathy (7), nonarteritic anterior ischemic optic neuropathy (4), arteritic anterior ischemic optic neuropathy (3), ophthalmic artery occlusion (3), nonorganic vision loss (3), radiation-induced optic neuropathy (2), cortical vision loss (1), retinitis pigmentosa with optic disc drusen (1), and infectious optic neuropathy (1). Ten patients recovered vision: 7 ON, 2 infiltrative optic neuropathy, and 1 CON. Corticosteroids accelerated vision recovery in 7 of the 11 patients with ON to mean 20/60 (0.48 logMAR) over 9.0 ± 8.6 follow-up months. Eleven patients deteriorated to NLP after presenting with at least LP; their diagnoses included CON (3), ophthalmic artery occlusion (2), infiltration (2), ON (1), posterior ischemic optic neuropathy (1), arteritic anterior ischemic optic neuropathy (1), and radiation-induced optic neuropathy (1)., Conclusions: NLP vision may occur because of various diagnoses. Vision recovery was mainly seen in patients with ON. Serious systemic conditions may present or relapse with NLP vision, which clinicians should consider as an alarming sign in patients with known malignancies., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by North American Neuro-Ophthalmology Society.)

Background: Acute promyelocytic leukemia (APML) is a medical emergency that can initially present with neuro-ophthalmologic signs. Early recognition is crucial, and immediate treatment with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) can be life-saving. The goal of this study was to describe patients who first presented to neuro-ophthalmology and were subsequently diagnosed with APML., Methods: We retrospectively reviewed consecutive patients seen at a tertiary neuro-ophthalmology centre. Patients with an unknown diagnosis of APML at presentation who subsequently went on to receive this diagnosis were included. Clinical characteristics, neuro-ophthalmologic findings, and outcome were retrieved., Results: A total of 3 patients (2 women and 1 men) with a mean age of 30.7 (range 24-33) years were included in the study. Neuro-ophthalmologic diagnoses at presentation were severe hemorrhagic papilledema related to dural venous sinus thrombosis, hemorrhagic bilateral optic disc edema, and left homonymous hemianopia related to an occipital lobe hemorrhage. At diagnosis, the average hemoglobin was 83.7g/L (range 78-104), and the platelet count was 39.3 × 109/L (range 15-77). All patients were treated with ATRA and ATO. One patient developed papilledema and sixth nerve palsies related to this treatment, which resolved with acetazolamide. Clinical follow-up ranged from 6 to 12 months, and all patients were in clinical remission about systemic APML., Conclusion: Neuro-ophthalmologic symptoms may be the first manifestations of APML, and a complete blood count is an essential test in patients presenting with optic disc edema, especially if hemorrhagic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by North American Neuro-Ophthalmology Society.)

Improving quality of care and patient outcomes is a professional duty of all health care workers. Quality improvement is a part of health policy, an accreditation requirement of residency programs, and a recognized sub-specialty in academic medicine. Given the increasing need for ophthalmological services with our aging population, it is critical for ophthalmologists and their staff to develop the necessary skills in quality improvement to ensure access to care that is safe, patient-centered, effective, efficient, equitable, and timely. This narrative review outlines tools that are used in a recognized framework, including the creation of an aim statement, Ishikawa diagram, Pareto analysis, process maps, Plan-Do-Study-Act cycles, and run charts. We also discuss common challenges that occur when conducting quality initiatives. Two quality improvement projects conducted in the Department of Ophthalmology at University of Toronto are used as examples to illustrate these tools. The aim of the first project was to improve visual field test reliability and the aim of the second was to ensure secure email communication between residents and staff in caring for emergency patients. This primer provides the foundations ophthalmologists and their staff can use to support and guide their quality improvement efforts., (Copyright © 2019 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated., Evidence Acquisition: A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review., Results: Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters., Conclusions: Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.

Objective: To investigate what proportion of ophthalmologists have medical-only practices and the influence of career stage, sex, and time., Design: Population-based study of medical and surgical practice patterns among all ophthalmologists in Ontario, Canada, from April 1999 to March 2013., Participants: All active ophthalmologists in Ontario, Canada, providing universal health care for the provincial population of approximately 13 million., Methods: The IntelliHealth database operated by the Ministry of Health and Long Term Care, which has excellent accuracy for procedure performance, was used to obtain anonymized physician services. Ophthalmologists were categorized as surgical or medical-only based on billing claims data., Results: The proportion of medical-only versus surgical ophthalmologists changed little over the 14-year period, averaging 30.5% medical-only and 69.5% surgical. Recent graduates showed a decreasing trend toward performing surgery of 1.6% per year, whereas late-career ophthalmologists demonstrated an increasing trend of 1.5% per year. Female ophthalmologists were less likely to perform surgery than male ophthalmologists but showed an increasing surgical trend. Ophthalmologists performing surgery saw on average 1.6 times the number of yearly consultations and assessments than their medical peers. Late-career ophthalmologists saw significantly fewer patients than their younger counterparts in each year studied., Conclusions: A significant number of ophthalmologists have medical-only practices. The large majority of late-career ophthalmologists have transitioned to a medical-only practice. A decreasing trend in the proportion of young ophthalmologists performing surgery coincides with a growth of late-career surgical ophthalmologists, which may be limiting surgical opportunities for new graduates., (Copyright © 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: The past decade has seen significant paradigm shifts in the management of many retinal diseases. The goal of this study is to assess the effect these advances have had on the number of retinal specialists, and the differences in output between medical and surgical specialists at the population level., Design: Population-based analysis of surgical and medical retina therapeutic and diagnostic procedures among all ophthalmologists in Ontario, Canada, from April 1999 to March 2012., Participants: This study included all ophthalmologists with an Ontario license and receiving remuneration from the Ontario Health Insurance Plan (OHIP). Ophthalmologists were categorized as a surgical or medical retina specialist based on the type and volume of retina-specific procedures performed each year., Methods: The IntelliHealth database operated by the Ministry of Health and Long Term Care was used to obtain anonymized physician services, which has excellent accuracy for procedure performance., Results: The number of retina specialists grew from 9.7% to 14.4% of the ophthalmology workforce. The proportion of late-career retina specialists (>25 years since graduation) doubled but had no influence on procedure output. Almost all retina specialists (90%) practice in the region they graduated medical school, and most (65%) practice in counties with a population greater than 400,000 people. Over the study period, the mean number of photocoagulation and fluorescein angiography performed was significantly higher among surgical retina specialists. Scleral buckling declined by 55% over the study period, whereas the number of pars plana vitrectomies grew by 49%., Conclusions: The retina subspecialty is a growing area of ophthalmology and is mainly located in urban centres. There has been a dramatic shift in the types of procedures performed to treat medical and surgical diseases over the past decade. To our knowledge, this is the first study to quantify differences in diagnostic and procedure performance between the medical and surgical retina subspecialties., (Copyright © 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: Previous studies have shown that access to appropriate care is lacking in low-income and rural areas. The goal of this study was to assess the geographic variation in the number of ophthalmologists in Ontario from the 2000 to 2010 fiscal years., Design: Population-based analysis of the geographic distribution of Ontario ophthalmologists., Participants: All ophthalmologists who held an Ontario license and received payment through the Ontario Health Insurance Plan., Methods: Demographic information was obtained through Intellihealth Ontario's Medical Service Provider data source. Ontario counties were stratified into low-population (<100000), medium-population (100000-400000), and large-population (>400000) groups., Results: The ratio of ophthalmologists to population was greatest in low-population counties in 2000 (1:65601) and increased further in 2010 (1:75434). Only medium-sized counties saw an improvement in the ophthalmologist-to-population ratio over the study period. There was no statistical difference in the number of ophthalmologists per 100000 population between small, medium, and large counties. Counties with an ophthalmology residency program had a significantly higher number of ophthalmologists per population compared with those without one (1:18162 vs 1:44245)., Conclusions: Geographic disparities exist in the distribution of ophthalmologists in Ontario. The highest ratios of ophthalmologists to population are found in areas with an ophthalmology residency program. New strategies are needed to improve the overall numbers and distribution of ophthalmologists to meet the demands of the aging population and reduce the burden of vision loss in Canada., (Copyright © 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Twitter is a social media web site created in 2006 that allows users to post Tweets, which are text-based messages containing up to 140 characters. It has grown exponentially in popularity; now more than 340 million Tweets are sent daily, and there are more than 140 million users. Twitter has become an important tool in medicine in a variety of contexts, allowing medical journals to engage their audiences, conference attendees to interact with one another in real time, and physicians to have the opportunity to interact with politicians, organizations, and the media in a manner that can be freely observed. There are also tremendous research opportunities since Twitter contains a database of public opinion that can be mined by keywords and hashtags. This article serves as an introduction to Twitter and surveys the peer-reviewed literature concerning its various uses and original studies. Opportunities for use in ophthalmology are outlined, and a recommended list of ophthalmology feeds on Twitter is presented. Overall, Twitter is an underutilized resource in ophthalmology and has the potential to enhance professional collegiality, advocacy, and scientific research., (Copyright © 2012 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the publication volume of Canadian ophthalmology departments over a 5-year period, 2005-2009., Design: Systematic review of the literature., Methods: MEDLINE was searched for papers published from 2005 to 2009 where the designated affiliation corresponded to a Canadian ophthalmology department. The papers were sorted by year, university, and study design. A total impact score (the impact factor of the journal multiplied by the number of papers published in that journal per year) was also calculated for each university., Results: In the 5-year period there was an increasing trend in the total number of published ophthalmology papers. The University of Toronto had the highest number of published papers (224), followed by the University of British Columbia (143) and McGill University (120). The Canadian Journal of Ophthalmology published the most papers, followed by Investigative Ophthalmology and Visual Science. The most frequent study design category was basic science research and a total of 11 different randomized controlled trials were retrieved., Conclusions: The publication volume of Canadian ophthalmology researchers increased significantly from 2005 to 2009 with larger institutions accounting for the majority of published papers. Like researchers in other countries, Canadian ophthalmology researchers preferred to publish in domestic journals.

Ethan Waisberg,1 Jonathan A Micieli2,3 1UCD School of Medicine, University College Dublin, Belfield, Dublin, 4, Ireland; 2Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; 3Kensington Vision and Research Centre, Toronto, Ontario, CanadaCorrespondence: Jonathan A MicieliKensington Vision and Research Centre, 340 College Street, Suite 501, Toronto, Ontario, M5T 3A9, CanadaTel +1 416 928-1335Fax +1 416 928-5075Email jmicieli@kensingtonhealth.orgAbstract: Optic nerve cupping or enlargement of the cup-to-disc ratio is widely recognized as a feature of glaucoma, however it may also occur in non-glaucomatous optic neuropathies. The most well-recognized non-glaucomatous optic neuropathies that cause cupping include compressive optic neuropathies, arteritic anterior ischemic optic neuropathies, hereditary optic neuropathies, and optic neuritis. Cupping is thought to consist of two main components: prelaminar and laminar thinning. The former is a shallow form of cupping and related to loss of retinal ganglion cells, whereas the latter involves damage to the lamina cribrosa and peripapillary scleral connective tissue. Differentiating glaucomatous and non-glaucomatous optic nerve cupping remains challenging even for experienced observers. Classically, the optic nerve in non-glaucomatous causes has pallor of the neuroretinal rim, but the optic nerve should not be examined in isolation. The patient’s medical history, history of presenting illness, visual function (visual acuity, color vision and visual field testing) and ocular examination also need to be considered. Ancillary testing such as optical coherence tomography of the retinal nerve fiber layer and ganglion cell layer-inner plexiform layer may also be helpful in localizing the disease. In this review, we review the non-glaucomatous causes of cupping and provide an approach to evaluating a patient that presents with an enlarged cup-to-disc ratio.Keywords: optic disc cupping, misdiagnosis of glaucoma, nonglaucomatous cupping, differential diagnosis of glaucoma, optic disc pallor

Caberry W Yu,1 Matthew Yau,2 Natalie Mezey,1 Ishraq Joarder,3 Jonathan A Micieli4,5 1Faculty of Medicine, Queen’s University, Kingston, Canada; 2Faculty of Medicine, University of Toronto, Toronto, Canada; 3Faculty of Science, University of Toronto, Scarborough, Ontario, Canada; 4Department of Ophthalmology and Vision Sciences and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; 5Kensington Vision and Research Centre, Toronto, CanadaCorrespondence: Jonathan A MicieliKensington Vision and Research Centre, 340 College Street, Suite 501, Toronto, Ontario M5T 3A9, CanadaTel +1(416) 928-1335Fax +1(416) 928-5075Email jmicieli@kensingtonhealth.orgObjective: Immune checkpoint inhibitors (ICIs) are novel cancer therapies that may be associated with immune-related adverse events (IRAEs) and come to the attention of neuro-ophthalmologists. This systematic review aims to synthesize the reported ICI-associated IRAEs relevant to neuro-ophthalmologists to help in the diagnosis and management of these conditions.Methods: A systematic review of the literature indexed by MEDLINE, Embase, CENTRAL, and Web of Science databases was searched from inception to May 2020. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on ICIs and neuro-ophthalmic complications were included. Outcomes included number of cases and incidence of neuro-ophthalmic IRAEs.Results: Neuro-ophthalmic complications of ICIs occurred in 0.46% of patients undergoing ICI and may affect the afferent and efferent visual systems. Afferent complications include optic neuritis (12.8%), neuroretinitis (0.9%), and giant cell arteritis (3.7%). Efferent complications include myasthenia gravis (MG) (45.0%), thyroid-like eye disease (11.9%), orbital myositis (13.8%), general myositis with ptosis (7.3%), internuclear ophthalmoplegia (0.9%), opsoclonus-myoclonus-ataxia syndrome (0.9%), and oculomotor nerve palsy (0.9%). Pembrolizumab was the most common causative agent for neuro-ophthalmic complications (32.1%). Mortality was highest for MG (19.8%). Most patients (79.8%) experienced improvement or complete resolution of neuro-ophthalmic symptoms due to cessation of ICI and immunosuppression with systemic corticosteroids.Conclusion: While incidence of neuro-ophthalmic IRAEs is low, clinicians involved in the care of cancer patients must be aware of their presentation to facilitate prompt recognition and management. Collaboration between oncology and neuro-ophthalmology teams is required to effectively manage patients and reduce morbidity and mortality.Keywords: immune checkpoint inhibitors, cancer immunotherapy, CTLA-4 inhibitors, PD-1 inhibitors, PD-L1 inhibitors

Armin Farahvash,1 Jonathan A Micieli2– 4 1Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 2Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; 3Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; 4Kensington Vision and Research Centre, Toronto, Ontario, CanadaCorrespondence: Jonathan A Micieli Tel +1 (416) 928-1335Fax +1 (416) 928-5075Email jmicieli@kensingtonhealth.orgAbstract: Obstructive sleep apnea (OSA) is a disease of obstructed airways during sleep that significantly impacts the quality of life and increases the risk of various systemic diseases. OSA has been studied as a risk factor for a number of neuro-ophthalmic conditions and a strong relationship has been established with non-arteritic anterior ischemic optic neuropathy (NAION). The incidence of glaucoma and stroke have also been significantly associated with OSA and are conditions that may also be seen by neuro-ophthalmologists. Patients with NAION have a significantly higher incidence of OSA and OSA diagnosis significantly increases the risk for NAION development. Non-compliance with continuous positive airway pressure (CPAP) in OSA patients has also been found to be a risk factor for fellow-eye involvement and there is increasing evidence to suggest that every patient with NAION should be formally evaluated with polysomnography. The relationship between OSA and idiopathic intracranial hypertension (IIH) has also been studied, but the relationship between these two conditions is less clear. There is insufficient evidence to recommend routine eye examinations in OSA patients for papilledema and conducting a sleep study for a newly diagnosed IIH patient should be left to the discretion of the clinician based on other symptoms and risk factors of OSA.Keywords: ischemic optic neuropathy, non-arteritic anterior ischemic optic neuropathy, idiopathic intracranial hypertension, optic nerve, glaucoma, stroke

Jonathan A Micieli,1 Edmund Tsui2 1Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada; 2Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Background: The use of social media in ophthalmology remains largely unknown. Our aim was to evaluate the extent and involvement of ophthalmology journals, professional associations, trade publications, and patient advocacy and fundraising groups on social networking sites. Methods: An archived list of 107 ophthalmology journals from SCImago, trade publications, professional ophthalmology associations, and patient advocacy organizations were searched for their presence on Facebook, Twitter, and LinkedIn. Activity and popularity of each account was quantified by using the number of “likes” on Facebook, the number of followers on Twitter, and members on LinkedIn. Results: Of the 107 journals ranked by SCImago, 21.5% were present on Facebook and 18.7% were present on Twitter. Journal of Community Eye Health was the most popular on Facebook and JAMA Ophthalmology was most popular on Twitter. Among the 133 members of the International Council of Ophthalmology, 17.3% were present on Facebook, 12.8% were present on Twitter, and 7.5% were present on LinkedIn. The most popular on Facebook was the International Council of Ophthalmology, and the American Academy of Ophthalmology was most popular on Twitter and LinkedIn. Patient advocacy organizations were more popular on all sites compared with journals, professional association, and trade publications. Among the top ten most popular pages in each category, patient advocacy groups were most active followed by trade publications, professional associations, and journals. Conclusion: Patient advocacy groups lead the way in social networking followed by professional organizations and journals. Although some journals use social media, most have yet to engage its full potential and maximize the number of potential interested individuals. Keywords: social media, Twitter, Facebook, LinkedIn, ophthalmology