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Health care teams are most effective at addressing complex problems and improving health outcomes for underserved populations when team members bring diverse life experiences and perspectives to the effort. With rates of visual impairment expected to increase in the United States by 2050, especially among minority populations, diversification of the ophthalmology workforce will be critical in reducing disparities in access to and quality of vision health care. Currently, ophthalmology is less diverse with respect to race, ethnicity, and gender than graduating medical classes and other medical specialties, as well as the general US population. In addition, data on diversity in sexual orientation and gender identity, socioeconomic status, and disability are lacking in ophthalmology. The Minority Ophthalmology Mentoring and Rabb-Venable Excellence in Ophthalmology Programs are examples of initiatives to increase racial and ethnic diversity in the workforce and can serve as models for increasing other aspects of inclusiveness. Other strategies for improving vision health care for all Americans include continuing to support existing diversity programs and creating new ones; addressing unconscious and implicit bias in medical school, residency, and faculty selections; conducting holistic reviews of medical school and residency applications; diversifying selection committees and leadership; and encouraging faculty development of underrepresented groups.

The purpose of this retrospective pilot study was to examine the short-term effect of simultaneous Ahmed Glaucoma Valve implantation and cyclophotocoagulation on postoperative outcomes in patients with neovascular glaucoma.Patient charts were selected for inclusion in this study if they carried a diagnosis of neovascular glaucoma and underwent Ahmed glaucoma valve implantation only, Ahmed glaucoma valve implantation with cyclophotocoagulation, or cyclophotocoagulation only. A total of 55 eyes of 54 patients were selected for data collection and analysis. Main outcome measures included 1-, 3-, and 6-month intraocular pressure and occurrence of the hypertensive phase. Other outcomes included visual acuity, surgical complication rate, and a number of 6-month postoperative ophthalmic medications.A significantly lower intraocular pressure was seen in the group that received Ahmed glaucoma valve implantation + cyclophotocoagulation compared to the Ahmed glaucoma valve-only group at 3 and 6 months (Simultaneous Ahmed glaucoma valve implantation and cyclophotocoagulation significantly lowered intraocular pressure at 3 and 6 months compared to Ahmed glaucoma valve implantation alone in patients with neovascular glaucoma.Neovascular glaucoma is difficult to manage medically and surgically. When surgery is performed, intraocular pressure often remains elevated postoperatively despite aggressive medical management. This study examines a novel method to lower intraocular pressure after Ahmed glaucoma valve implantation in patients with neovascular glaucoma.Ford RL, Knight ORJ, Klifto MR

The purpose of this study was to report a case of corneal transparency for 7 months after the formation and persistence of a Descemet fluid cleft.We report the case of a 64-year-old woman undergoing anterior chamber reformation 2 months after Baerveldt implantation of the right eye. During the procedure, the ophthalmic viscoelastic was inadvertently injected into the posterior stroma, nearly isolating the corneal endothelial cell layer, and creating a Descemet fluid cleft filled with viscoelastic. The patient was managed conservatively and monitored near monthly for corneal decompensation.The cornea remained centrally clear for 207 days after the initial anterior chamber reformation until the collapse of the viscoelastic cleft. When the cleft completely collapsed, the cornea became diffusely edematous, and the patient underwent cataract removal and intraocular lens placement without need for Descemet stripping endothelial keratoplasty to maintain vision. During these 7 months, the patient's best-corrected visual acuity remained stable at 20/25 +2 or better. Intraocular pressure was also stable, averaging 18.2 mm Hg.We hypothesize that corneal transparency can be maintained in the absence of endothelial cell function provided that aqueous humor cannot reach the cornea and disrupt the arrangement of the interfibrillar space.

The proportions of individuals who are underrepresented in medicine (URiM) in ophthalmology lag behind their proportions within the US population. Diversity trends have been studied in other specialties, but literature examining trends in ophthalmology is lacking. In this study, we investigate trends in the racial and ethnic demographics of ophthalmology residents and residency applicants.Trend study.Demographic data of all residency programs across all specialties were extracted from Accreditation Council for Graduate Medical Education yearly reports from 2011 to 2019. Data from 2016 to 2019 on ophthalmology match applicants were analyzed using the 2020 Ophthalmology Residency Match Summary Report and the 2020 Association of University Professors of Ophthalmology Residency GenderEthnicity Summary. Linear trends were examined by the Cochran-Armitage test.From 2011 to 2019, the raw percentage of URiM ophthalmology residents increased from 4.7% (66/1419) to 5.8% (85/1473) (P.001) whereas that of surgical specialties decreased from 9.9% (2164/21,967) to 9.1% (2370/26,082) (P.001). The percentage of URiM ophthalmology match applicants increased from 5.9% (43/726) of all applicants to 11.8% (87/741) from 2016 to 2019 (P.001), and the percentage of URiMs matching into ophthalmology increased from 4.9% (23/467) of all participants to 10.8% (52/484) from 2016 to 2019 (P.001).Although there has been a positive trend in the percentage of URiMs applying and matching into ophthalmology, a lack of racial and ethnic diversity relative to other specialties persists. Strategies are needed to increase diversity in the field.

Examine trends in the proportion of underrepresented minority (URM) residents from 2011 to 2019 across all specialties and investigate differences between surgical and non-surgical specialties.Cross-sectional study.N/A.The authors extracted data on the proportion of URM residents in all specialties from the Accreditation Council for Graduate Medical Education yearly reports.There was a statistically significant decline in the proportion of URM residents in surgical specialties (p0.01) from 2011 (9.9%) to 2019 (9.1%) and a significant increase in the proportion of URM residents in non-surgical specialties (p0.01) from 2011 (9.6%) to 2019 (10.2%).This study emphasizes the need to increase recruitment of URMs in medicine, especially in surgical specialties. Findings from this study can inform much-needed initiatives to address barriers to entry for diverse applicants within specialties that lack diversity and have shown minimal improvement over time.

Prcis Patients with chronic kidney disease are at increased risk for choroidal effusion development following glaucoma surgery. Purpose Choroidal effusion is a postoperative complication of glaucoma surgery that results from a transudative fluid collection in the suprachoroidal space. Kidney disease alters bodily fluid dynamics through a variety of mechanisms. The relationship between chronic kidney disease and choroidal effusion following glaucoma surgery has not previously been studied. The purpose of this study was to determine the relationship between chronic kidney disease and choroidal effusion development after glaucoma surgery. Patients and methods This retrospective cohort study consisted of 86 eyes from 86 patients who received glaucoma filtering surgery or transscleral cyclophotocoagulation within the study timeframe. Forty-three patients had chronic kidney disease and 43 patients did not have kidney disease. The main outcome of this study was the development of choroidal effusion measured by Pearson's chi-squared test and multivariate analyses using a binomial regression with a log link. Results Ten patients (23.3%) in the chronic kidney disease group developed choroidal effusion while two patients (4.7%) in the no-kidney disease group developed choroidal effusion (relative risk, 5.0; 95% confidence interval 1.16 to 21.5; P=0.013). The association between chronic kidney disease and choroidal effusion showed mixed results in the multivariate analyses, with some analyses showing a significant association and others showing no significant association. Conclusions In both the univariate analysis and multivariate analysis, chronic kidney disease was found to be significantly associated with choroidal effusion after glaucoma surgery.

PRéCIS:: This study addresses the paucity of literature examining glaucoma patients' distance from clinic on postoperative follow-up outcomes. Greater distance from clinic was associated with higher likelihood of loss to follow-up and missed appointments.To investigate the relationship of patient travel distance and interstate access to glaucoma surgery postoperative follow-up visit attendance.Retrospective longitudinal chart review of all noninstitutionalized adult glaucoma patients with initial trabeculectomies or drainage device implantations between April 4, 2014 and December 31, 2018. Patients were stratified into groups on the basis of straight-line distance from residence to University of North Carolina at Chapel Hill's Kittner Eye Center and distance from residence to interstate access. Corrective procedures, visual acuity, appointment cancellations, no-shows, and insurance data were recorded. Means were compared using 2-tailed Student t-test, Pearson χ, analysis of variance, and multivariate logistical regression determined odds ratios for loss to follow-up.In total, 199 patients met all inclusion criteria. Six-month postoperatively, patients50 miles from clinic had greater odds of loss to follow-up compared with patients25 miles (odds ratios, 3.47; 95% confidence interval, 1.24-4.12; P0.05). Patients50 miles from clinic had significantly more missed appointments than patients 25 to 50 miles away, and patients25 miles away (P=0.008). Patients20 miles from interstate access had greater loss to follow-up than those10 miles (t(150)=2.05; P0.05). Mean distance from clinic was 12.59 miles farther for patients lost to follow-up (t(197)=3.29; P0.01). Patients with Medicaid coverage had more missed appointments than those with Medicare plans (t(144)=-2.193; P0.05).Increased distance from clinic and interstate access are associated with increased missed appointments and loss to follow-up. Glaucoma specialists should consider these factors when choosing surgical interventions requiring frequent postoperative evaluations.

IMPORTANCE: Diversity in the ophthalmology profession is important when providing care for an increasingly diverse patient population. However, implicit bias may inadvertently disadvantage underrepresented applicants during resident recruitment and selection. OBJECTIVE: To evaluate the association of the redaction of applicant identifiers with the review scores on ophthalmology residency applications as an intervention to address implicit bias. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, 46 faculty members reviewed randomized sets of 462 redacted and unredacted applications from a single academic institution during the 2019-2020 ophthalmology residency application cycle. INTERVENTIONS: Applications electronically redacted for applicant identifiers, including name, sex or gender, race and ethnicity, and related terms. MAIN OUTCOMES AND MEASURES: The main outcome was the distribution of scores on redacted and unredacted applications, stratified by applicant’s sex, underrepresentation in medicine (URiM; traditionally comprising American Indian or Alaskan Native, Black, and Hispanic individuals) status, and international medical graduate (IMG) status; the application score β coefficients for redaction and the applicant and reviewer characteristics were calculated. Applications were scored on a scale of 1 to 9, where 1 was the best score and 9 was the worst score. Scores were evaluated for a significant difference based on redaction among female, URiM, and IMG applicants. Linear regression was used to evaluate the adjusted association of redaction, self-reported applicant characteristics, and reviewer characteristics with scores on ophthalmology residency applications. RESULTS: In this study, 277 applicants (60.0%) were male and 71 (15.4%) had URiM status; 32 faculty reviewers (69.6%) were male and 2 (0.4%) had URiM status. The distribution of scores was similar for redacted vs unredacted applications, with no difference based on sex, URiM status, or IMG status. Applicant’s sex, URiM status, and IMG status had no association with scores in multivariable analysis (sex, β = –0.08; 95% CI, –0.32 to 0.15; P = .26; URiM status, β = –0.03; (95% CI, –0.36 to 0.30; P = .94; and IMG status, β = 0.39; 95% CI, –0.24 to 1.02; P = .35). In adjusted regression, redaction was not associated with differences in scores (β = −0.06 points on a 1-9 scale; 95% CI, –0.22 to 0.10 points; P = .48). Factors most associated with better scores were attending a top 20 medical school (β = −1.06; 95% CI, –1.37 to –0.76; P

A 64-year-old man who presented with photopsia was found to have elevated intraocular pressure in one eye and optic disc swelling in the other eye. He was initially diagnosed with neurocysticercosis and later metastatic lung adenocarcinoma. The purpose of this paper is to report a rare case of bilateral glare as the first sign of diffusely metastatic cancer and to raise clinical suspicion for systemic malignancy in the presence of multiple ocular manifestations.

Background: To evaluate a method for treating uncorrected refractive error in adults in the developing world. Design: Prospective, cross-sectional study in outpatient community health centres. Participants: Eight hundred and forty subjects aged 18 and older from rural villages in Haiti and Belize. Methods: Undilated refractive error screening exams were conducted over a 5-day period in rural Haiti and Belize using portable autorefractors. Isometropic, spherical, ready-made spectacles were provided to patients with bilateral refractive error, astigmatism 1 dioptre in each eye and visual acuity worse than 6/9 in each eye. Visual acuity was measured with and without corrective spectacles. Main Outcome Measures: The mean visual improvement and median final visual acuity after treatment with ready-made glasses. Results: Eight hundred and forty patients aged 18 and older were screened with autorefractors. One hundred and eighty-nine subjects (22.5%) were found to have visually significant bilateral refractive error. Fifty-eight per cent (110/189) of these patients met criteria for treatment with ready-made spectacles. Visual acuity improved an average of 4.2 lines in the better eye and 4.1 lines in the worse eye with corrective glasses. The median visual acuity in the better eye was 6/6 after treatment.

Purpose To evaluate the sensitivity and specificity of measurements of retinal nerve fiber layer (RNFL) thickness in early to moderate glaucoma using Stratus time-domain and Cirrus spectral-domain optical coherence tomography (OCT; Carl Zeiss Meditec, Dublin, CA). Design Evaluation of diagnostic test or technology. Participants Fifty-four glaucoma subjects with early to moderate visual field defects and 50 age-matched normal subjects. Testing Three peripapillary RNFL scans of 1 eye of each subject using Stratus and Cirrus OCT. Main Outcome Measures Sensitivity and specificity of average, quadrant, and clock-hour RNFL thickness. Results The average age±standard deviation in the normal and glaucoma groups was 62.9±12.7 years (range, 40–84 years) and 67.6±11.4 (range, 42–85 years), respectively ( P = 0.05). The glaucoma group consisted of 34 early (average mean deviation, −3.20±1.22 dB) and 20 moderate (average mean deviation, −8.05±1.87 dB) glaucomas. Cirrus OCT sensitivity and specificity for average RNFL abnormal at the 5% level were 83% and 88%, respectively, and at the 1% level were 65% and 100%, respectively. Stratus OCT sensitivity and specificity for average RNFL abnormal at the 5% level were 80% and 94%, respectively, and at the 1% level were 61% and 100%, respectively. For 1 or more abnormal quadrants at the 5% level, the sensitivity and specificity for Cirrus OCT were 98% and 80%, respectively, and at the 1% level were 87% and 92%, respectively. For 1 or more quadrants abnormal at the 5% level, the sensitivity and specificity for Stratus OCT were 96% and 76%, respectively, and at the 1% level were 74% and 94%, respectively. Cirrus OCT sensitivity and specificity using a criterion of 1 or more abnormal clock hours at the 5% level were 100% and 72%, respectively, and at the 1% level were 85% and 94%, respectively. Stratus OCT sensitivity and specificity for 1 or more abnormal clock hours at the 5% level were 98% and 66%, respectively, and at the 1% level were 85% and 90%, respectively. Conclusions The sensitivity and specificity of various RNFL parameters using the Cirrus OCT for glaucoma with early to moderate visual field defects are excellent and are equivalent to Stratus OCT. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

This article reviews recently published studies and important clinical trials of novel drug delivery systems for glaucoma and evaluates the potential of these systems to provide sustained therapeutic benefits.The efficacy of topical medications to lower intraocular pressure (IOP) is limited by poor patient adherence, low bioavailability of drug and the potential for local and systemic side effects. Recent studies highlight the potential for sustained drug delivery through innovative delivery platforms. Nanoparticle-based formulations, drug-eluting contact lenses, punctum inserts and bioadhesive matrices placed in the conjunctival sac can enhance drug delivery by increasing precorneal residence time, enhancing corneal permeation and lowering the systemic absorption of drug. Periocular injections and surgically implanted drug reservoirs could offer even greater duration of drug delivery, particularly when the drug is packaged within stable vehicles.Novel platforms for providing sustained drug delivery in glaucoma continue to evolve. The ability to incorporate effective commercially available drugs into more stable compounds is an important element. Although more research is needed to establish their clinical efficacy, novel delivery systems will allow for more targeted medical therapy and for the opportunity to further explore neuroprotective and gene-based therapies.

Objective To determine the effect of race, demographic, and ocular variables on optic nerve head and retinal nerve fiber layer (RNFL) thickness measurements using spectral-domain optical coherence tomography. Methods In a cross-sectional observational study, 284 normal subjects aged 18 to 84 years were evaluated at 7 sites using Cirrus HD-OCT. Disc area, rim area, average cup-disc ratio, vertical cup-disc ratio, cup volume, and average, temporal, superior, nasal, and inferior RNFL thicknesses were calculated. The main outcome measures were associations between Cirrus HD-OCT optic nerve head and RNFL measurements and age, sex, and race. Results The 284 subjects self-identified as being of European (122), Chinese (63), African (51), or Hispanic (35) descent. After adjusting for the effect of age, there was a statistically significant difference among racial groups for all optic nerve head and RNFL parameters (all P ≤ .005) except rim area (P = .22). Rim area, average cup-disc ratio, vertical cup-disc ratio, and cup volume were moderately associated with disc area (r 2 = 0.15, 0.33, 0.33, and 0.37, respectively). After a linear adjustment for disc area, there was no statistically significant difference among racial groups for any optic nerve head parameter. Individuals of European descent had thinner RNFL measurements except in the temporal quadrant. Conclusions There are racial differences in optic disc area, average cup-disc ratio, vertical cup-disc ratio, cup volume, and RNFL thickness as measured by Cirrus HD-OCT. These differences should be considered when using Cirrus HD-OCT to assess for glaucomatous damage in differing population groups.

To determine the agreement between peripapillary retinal nerve fiber layer (RNFL) thickness measurements from Stratus time domain optical coherence tomography (OCT) and Cirrus spectral domain OCT (Carl Zeiss Meditec, Dublin, CA) in normal subjects and subjects with glaucoma.Evaluation of diagnostic test or technology.A total of 130 eyes from 130 normal subjects and subjects with glaucoma were analyzed. The subjects were divided into groups by visual field criteria: normal (n = 29), glaucoma suspect (n = 12), mild glaucoma (n = 41), moderate glaucoma (n = 18), and severe glaucoma (n = 30).Peripapillary RNFL thickness was measured with Stratus Fast RNFL and Cirrus 200 x 200 Optic Disc Scan on the same day in 1 eye of each subject to determine agreement. Two operators used the same instruments for all scans.Student paired t testing, Pearson's correlation coefficient, and Bland-Altman analysis of RNFL thickness measurements.The average age of the glaucoma group was significantly more than that of the normal group: 68.3+/-12.3 years versus 55.7+/-12.1 years, respectively. For Stratus OCT, the average RNFL thickness (mean +/- standard deviation) was 99.4+/-13.2 microm, 94.5+/-15.0 microm, 79.0+/-14.5 microm, 62.7+/-10.2 microm, and 51.0+/-8.9 microm for the normal, suspect, mild, moderate, and severe groups, respectively. For Cirrus OCT, the corresponding measurements were 92.0+/-10.8 microm, 88.1+/-13.5 microm, 73.3+/-11.8 microm, 60.9+/-8.3 microm, and 55.3+/-6.6 microm. All Stratus-Cirrus differences were statistically significant by paired t testing (P0.001) except for the moderate group (P = 0.11). For average RNFL, there was also a highly significant linear relationship between Stratus minus Cirrus difference and RNFL thickness (P0.001). Bland-Altman plots showed that the systematic difference of Stratus measurements are smaller than Cirrus at thinner RNFL values but larger at thicker RNFL values.RNFL thickness measurements between Stratus OCT and Cirrus OCT cannot be directly compared. Clinicians should be aware that measurements are generally higher with Stratus than with Cirrus except when the RNFL is very thin, as in severe glaucoma. This difference must be taken into account if comparing Stratus measurements with Cirrus measurements.

BACKGROUND AND OBJECTIVE Measurements performed on fundus images using current software are not accurate. Accurate measurements can be obtained only by calibrating a fundus camera using measurements between fixed retinal landmarks, such as the dimensions of the optic nerve, or by relying on a calibrated model eye provided by a reading center. However, calibrated spectral domain OCT (SD-OCT) could offer a convenient alternative method for the calibration of any fundus image. PATIENTS AND METHODS The ability to measure exact distances on SD-OCT fundus images was tested by measuring the distance between the center of the fovea and the optic nerve. Calibrated SD-OCT scans measuring 6 × 6 × 2 mm centered on the fovea and the optic nerve were analyzed in 50 healthy right eyes. The foveal center was identified using cross-sectional SD-OCT images, and the center of the optic nerve was identified manually. The SD-OCT scans were registered to each other, and the distances between the center of the optic nerve and fovea were calculated. The overlay of these SD-OCT fundus images on photographic fundus images was performed. RESULTS Any image of the fundus could be calibrated by overlaying the SD-OCT fundus image, and the measurements were consistent with previously defined calibration methods. The mean distance between the center of the fovea and the center of the optic nerve was 4.32 ± 0.32 mm. The line from the center of the optic nerve to the foveal center had a mean declination of 7.67 ± 3.88°. Mean horizontal displacement and vertical displacement were 4.27 ± 0.29 mm and 0.58 ± 0.29 mm, respectively. CONCLUSIONS The overlay of the SD-OCT fundus image provides a convenient method for calibrating any image of the fundus. This approach should provide a uniform standard when comparing images from different devices and from different reading centers. [Ophthalmic Surg Lasers Imaging 2008;39:S15-S20.]

Although glaucoma is classified as an optic nerve disease, pathologically it is characterized by the death of retinal ganglion cells (RGCs) and their axons. Traditionally, loss of RGCs has been judged based on damage to the optic nerve head (ONH) and visual field (VF) deficits. Because these assessments do not exactly reflect the extent to which the RGC population is affected, it became evident that any method enabling measurement of RGCs would advance both early detection and longitudinal monitoring of glaucoma. Advances in ocular imaging techniques, particularly the advent of optical coherence tomography (OCT), have enabled assessment of RGC axons by measuring the thickness of the peripapillary retinal nerve fiber layer (RNFL). In addition to peripapillary RNFL, OCT devices can measure the thickness of the whole retina, particularly in the macular area. Decreases in macular thickness that are believed to be due to loss of RGCs and that correlate with both RNFL thickness and VF defects have been reported in glaucomatous eyes.1–8 However, measuring the whole macular thickness as a surrogate for glaucoma has the disadvantage of taking into account cell layers (i.e., outer retinal layers) that are not affected in glaucoma, thus obscuring the actual contribution of the RGC layer to the process. Since its introduction, OCT has undergone several improvements, the latest of which is spectral domain (SD) technology. More recent advances in segmentation algorithms by several research groups have made possible the visualization and measurement of individual retinal layers with OCT in the macular region.6,9–18 Anatomically, the human retina contains more than 1 million RGCs, with substantial interindividual variability; approximately 50% of the cells are concentrated within 4.5 mm of the fovea.19 Although there is no variability in the RGC population in this small parafoveal area, there is, in contrast, considerable variability in the entire retina, resulting in variability in the number of axons in the peripapillary region.19 Glaucoma preferentially affects the ganglion cell complex (GCC), which is the sum of the three innermost layers: the RNFL, which is composed of axons; the ganglion cell layer (GCL), which is composed of cell bodies; and the inner plexiform layer (IPL), which contains the RGC dendrites. A few recent studies20–22 have shown that measurement of macular GCC thickness has the same glaucoma diagnostic performance as RNFL thickness. However, it is possible that including the RNFL in the measurement may affect the diagnostic ability of GCC thickness. An underlying assumption here is that the ganglion cell structure differs less in a normal population than do other diagnostically important structures such as the RNFL and the ONH. As such, the potential sensitivity of a measurement that is compared with that in a normal population could be higher because the difference would more likely be the result of pathologic change than of normal variation. This is a working hypothesis because until the advent of SD-OCT, we have been unable to study this in a reliable way. Furthermore, it is also hypothesized that the normal ganglion cell structure has symmetries that could be exploited in attempting to detect loss; an example would be a temporal defect in the anatomy corresponding to a nasal step in the VF. Including the RNFL in the measurement would make exploiting such symmetries in the analyses impossible. The purpose of this study was to demonstrate the capability of the ganglion cell analysis (GCA) developed for Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA) to automatically segment macular layers, to measure the thickness of the complex ganglion cell–inner plexiform layer, referred to in this study as GCIPL, and to assess its intervisit reproducibility.