Low Acuity Research Articles

An economic evaluation of the Virtual Rural Generalist Service versus usual care in Western NSW Local Health District.

Evaluate the cost-effectiveness of the Virtual Rural Generalist Service (VRGS) model of care. A cost-consequence analysis of the VRGS model of care compared with usual care (treatment by local or locum [non-VRGS] doctors) from the perspective of the health care funder in 2022 prices. Twenty-nine rural and remote hospitals in the Western NSW Local Health District where the VRGS has been in operation (VRGS sites). Patients of any age who presented to an emergency department (ED) or were admitted to hospital at VRGS sites over the pre-VRGS period (1 February 2019 to 31 January 2020) or the post-VRGS period (1 July 2021 to 30 June 2022). The VRGS model of care, which provides 24-hour 7-days-a-week rural generalist doctors, both virtually and in person, to small rural and remote hospitals, predominantly for lower acuity ED presentations, daily ward rounds for inpatients admitted by a VRGS medical officer, and ad hoc inpatient medical reviews when local doctors need support or are unavailable. Incremental cost per incremental quality-of-care outcome, maintenance of health service activity levels, workforce sustainability (measured by changes in locum shifts), and service acceptability (as determined by thematic analysis of interviews). The cost per standard unit of health care (national weighted activity unit) was lower for the VRGS ($1047) than for usual care ($1753). VRGS doctors dealt with ED presentations of similar complexity to non-VRGS doctors, and admissions of significantly lower (40%) complexity. Health service activity remained stable from the pre-VRGS period to the post-VRGS period, only declining by 4% in the post-VRGS period, which was during the coronavirus disease 2019 pandemic. Locum shifts decreased from 1456 days in the pre-VRGS period to 609 days in the post-VRGS period, improving the sustainability of the workforce. Local doctors and managers found the VRGS to be acceptable, but thought it could be enhanced with additional investment in nursing and technical staff. Our economic evaluation of the VRGS showed that it provided lower cost care and equivalent quality-of-care outcomes when compared with usual care for ED presentations of the same complexity, and supported local clinical staff to maintain activity levels despite a pandemic. With additional investment in data capture and in nursing and technical staff to support the service, the VRGS has promise as a flexible service that can help sustain access to quality medical care in rural and remote communities.

Health service access and quality of care provided by the Western NSW Local Health District Virtual Rural Generalist Service: a retrospective analysis of linked administrative data.

To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS). Retrospective cohort study; analysis of emergency department and administrative hospital data. Twenty-nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds. All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022. Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality. During 2021-22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio-demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79-4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60-0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86-0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio-demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98-5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35-0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non-VRGS care (aOR, 0.78; 95% CI, 0.48-1.28) and when comparing combined (VRGS and non-VRGS) and non-VRGS care (aOR 1.21; 95% CI, 0.91-1.61). In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

Clinical Evaluation of Violet Light Filtration and High-Resolution Lathing on a Diffractive Extended Depth of Focus IOL.

This study is a prospective, randomized, subject/evaluator-masked clinical trial in a single-center clinical setting. The purpose of the study is to compare the clinical performance of Tecnis Symfony Optiblue IOL (models ZXR00V and ZXW150) with violet light filter (VLF) and manufacturing improvements versus Tecnis Symfony IOL (models ZXR00 and ZXT150) with ultraviolet light filter (UVF) in patients undergoing cataract surgery. Patients with cataracts aged ≥ 22years were randomly assigned 1:1 to bilateral implantation with ZXR00V/ZXW150 (VLF group) or ZXR00/ZXT150 (UVF group). Key endpoints at 6months postoperative included patient reported nighttime dysphotopsia symptoms, 25% low contrast visual acuity with glare, and patient satisfaction. Sixty patients were implanted with ZXR00V/ZXW150 (30) or ZXR00/ZXT150 (30). At 6months, the VLF group did not show a statistically significant differences in mean monocular photopic uncorrected distance visual acuity (UCDVA), best-corrected distance visual acuity (BCDVA), uncorrected near visual acuity (UCNVA) (40cm), or distance-corrected near visual acuity (DCNVA) (40cm) compared to the UVF group. At 1month, patients in the VLF group reported significantly less difficulty due to halo (p = 0.016) and starburst (p = 0.028) symptoms. By the 6months, dysphotopsia complaints were no longer significantly different between the groups. Although the VLF group trended toward better low contrast visual acuity and patient satisfaction, statistical significance was not reached. Managing the patients' expectations is key to achieving success. At the 1-month visit the patients who reported dysphotopsia complaints in the VLF group had significantly less difficulty with starbursts and halos as compared to the UVF group. By the 6-month visit, there was no significant difference between the two groups in the difficulty with starbursts and halos. ClinicalTrials.gov identifier, NCT06567834.

The Ability of a Virtual Implantation Device to Evaluate Two Intraocular Lens Designs.

To evaluate the ability of a novel device using virtual implantation to compare the visual performance of two different types of intraocular lenses (IOLs). In this prospective, masked, and randomized clinical trial, the visual performance of monofocal and lowadd bifocal IOLs was compared using a device for virtual implantation called VirtIOL. Eighty patients (< 50 years old with healthy eyes and without cataract) were enrolled in this study. Defocus curve and contrast sensitivity were measured using the Freiburg Vision and Contrast Test (FrACT). Expected defocus curves for the monofocal IOL and the bifocal IOL confirm the utility of the method. The monofocal IOL provided a slightly higher mean visual acuity at 0.00 diopter (D) (mean ± standard deviation: -0.18 ± 0.07 D) compared to the bifocal IOL (-0.16 ± 0.08 D), but also a slightly lower visual acuity from -1.25 to -4.00 D. The mean contrast sensitivity was significantly higher for the monofocal IOL at 7, 11, and 15 cycles per degree. The investigators attest a high usability of the method due to simple communication with the test patient and quick and uncomplicated change of test objects. The visual performance of the monofocal and bifocal IOLs was as expected, with greater depth of focus but reduced contrast sensitivity for the bifocal IOL. The VirtIOL device represents a promising tool to predict the visual performance of IOLs before implantation in patients. [J Refract Surg. 2024;40(12):e911-e915.].

Is There an Impending Epidemic of Myopia in Southeast Asia? An Appraisal of the Evidence

Predictions on the future prevalence of myopia suggest one of the Global Burden of Disease regions will develop an epidemic like in East Asia and Singapore in Southeast Asia. This paper analyses the available evidence on prevalence of myopia in this region, concluding that the bulk of the evidence suggests that the prevalence of myopia at the end of schooling is still modest, although two papers suggest that in young adults in Thailand and Indonesia, the prevalence of myopia may be approaching levels typical of the epidemic of myopia. It also analyses an indicator of expected years of education at school entry, as well as current educational levels of adults, using data from the calculation of the UN Human Development Index. It then analyses the results obtained by the countries of the Southeast Asian region in the PISA international surveys of student achievement. Neither of these educational indicators suggests an impending epidemic of myopia. There is a need for more data to clarify this uncertainty. It is suggested that future collection of data concentrate on determining the prevalence of myopia in young adults finishing their schooling. Even methodology as simple as determining levels of lowered visual acuity in senior school students should be sufficient to resolve the uncertainty. This group provides a sound basis for the prediction of future levels of myopia in the adult population, and avoids the impact of the high levels of myopia and high myopia associated with cataract development that occur in much of Southeast Asia.

Intersession repeatability of visual function and OCTA metrics in eyes with diabetic macular ischaemia.

To estimate inter-session coefficient of repeatability (CR) of visual function and OCTA metrics over 3 months in diabetic macular ischaemia (DMI) in stable laser-treated proliferative diabetic retinopathy (PDR) patients. This prospective study recruited patients with stable PDR for at least 6 months following pan-retinal photocoagulation with visual acuity of at least 54 ETDRS letters. DMI was confirmed on OCTA as FAZ area of at least 0.5 mm2 or parafoveal capillary dropout in at least one quadrant if the FAZ area was less than 0.5 mm2. Repeatability was assessed at baseline and 3 months by calculating the coefficients of repeatability (CR) and intraclass correlation coefficient (ICC). The Bland Altman (BA) plots including 95% CI bands for the bias (mean difference) and upper and lower limits of agreement (LOA) were used to visualise the agreement of the measurements. 88 eligible eyes of 63 participants were included in the analysis. The CR for best corrected visual acuity (BCVA) was 10.1 ETDRS letters (95% CI 8.5-11.7 ETDRS letters), and for low luminance visual acuity (LLVA) was 12.4 letters (95% CI 10.4-14.4). The ICC for BCVA and LLVA was 0.81 and 0.75 respectively. For Square Root of Foveal Avascular Zone (SQRT-FAZ) area, CR and ICC was 0.043 mm and 1.00 respectively. The Bland-Altman plots suggest that the level of agreement is wider for vascular density (VD) metrics compared to FAZ parameters. We recommend using the FAZ metrics for quantitative measurements of DMI outcomes due to the excellent repeatability of manually corrected FAZ area.

Effects of opening a vertical care area on emergency medicine resident clinical experience.

Challenging clinical environments faced by emergency departments (EDs) have led to operational changes including implementation of vertical care units and fast-track units. Little is known regarding the impact of such units on resident physician clinical education. A retrospective, observational study was performed at an urban quaternary care ED evaluating the effect of opening a vertical care unit with a triage physician directing lower acuity patients to be seen by physician associates (PAs)/advanced practice registered nurses (APRNs) on the following parameters: (1) percentage of patients seen by residents, (2) Emergency Severity Index (ESI) of patients seen by residents, (3) number of procedures performed by residents, (4) number of patients per shift seen by residents, (5) percentage of critical care patients seen by residents, and (6) percentage of behavioral health patients seen by residents. Comparing the implementation of the vertical care unit to the prior 3 months, postgraduate year (PGY)-1 residents had greater exposure to ESI Levels 1 and 2 (odds ratio [OR] 2.15) and more critical care (OR 2.58). PGY-2 and PGY-3 residents had a lower exposure to ESI 1 and 2 patients (PGY-2 OR 0.63, PGY-3 OR 0.61) and less critical care exposure (OR 0.64 for PGY-2 and OR 0.62 for PGY-3) after implementation. PGY-1 residents saw fewer behavioral health patients (OR 0.65) while the other two classes saw more (PGY-2 OR 1.64, PGY-3 OR 2.74). ESI 4 and 5 exposure decreased for all classes (PGY-1 OR 0.15, PGY-2 OR 0.86, PGY-3 OR 0.72). No significant difference was found in the proportion of patients treated by residents (p = 0.85) or the number of procedures performed by residents (p = 0.25) comparing the implementation of a vertical care unit to the prior 3 months. This study suggests no detrimental effects of vertical care unit implementation on multiple resident education outcomes including the number and acuity level of patients seen as well as procedure numbers of resident trainees. While the outcomes measured did not show significant negative effect for the resident compliment as a whole, we noted changes to the distribution of patient acuity based on PGY level. Similar assessments are recommended to determine the educational impact of comparable operational changes in other EDs.

Impact of the Astra Zeneca COVID-19 vaccine on an emergency department.

To assess the impact of the AstraZeneca (AZ) vaccine roll-out on an ED. Primary outcomes are ED length of stay (LOS), investigation ordering and costs. Secondary measures are compliance with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) Vaccine-Induced Thrombotic Thrombocytopaenia Syndrome (VITT) guidelines. This retrospective observational study examined a level 5 ED in Sydney, Australia. Triages mentioning the AZ vaccine between 7 July 2021 and 8 November 2021 were reviewed. Cases were limited to a single day of the week. Researchers reviewed clinical notes to identify patients that presented due to AZ vaccine concern and abstracted relevant data. Costings were calculated using an ED activity-based funding algorithm. One thousand three hundred and fifty cases were identified, with 167 analysed (12%) and 97 presented (7%). Median LOS was 195 min (IQR: 152-232 min, 95% CI [184, 217]). Median age was 43 years (IQR: 35-65 years, 95% CI [44, 51]). Median Australian Triage Category was 4. Ninety-eight percent were discharged directly home. Ninety-four percent underwent pathology and 41% radiology. Compliance with the THANZ guidelines was 16%. No findings were related to VITT. AZ vaccine concern contributed 12% of August ED caseload. Over the 16-week study period a cost of AUD$486 747.99 was extrapolated. A high number of young, low acuity patients presented to the ED with AZ vaccine concerns and were associated with financial and workload implications. The quantity of ED presentations appears to be associated with vaccine administration rates. There was poor compliance with the THANZ guidelines, and they appear to have contributed to the high volume of investigations.

Ranked Importance of Visual Function Outcome Measures in Choroideremia Clinical Trials.

Clinical trials of novel therapies for choroideremia require robust and clinically meaningful visual function outcome measures. Best-corrected visual acuity (BCVA) is mostly insensitive to changes in disease state, until late stages, and hence also to potential therapeutic gains after gene therapies. While the insensitivity of BCVA as an effective outcome measure is common wisdom, its low importance has not been rigorously demonstrated in the literature. This work uses statistical techniques to rank the relative importance of potential functional outcome measures in choroideremia. Retrospective dominance analysis was performed on data from a longitudinal interventional clinical trial performed at the Oxford Eye Hospital. Functional data from the untreated eye were analyzed and correlated with an anatomic measure of disease progression in the form of blue fundus autofluorescence area of the surviving outer retinal island. Each functional measure was then ranked in terms of variable importance. Microperimetry was the functional measure ranking first in terms of variable importance, followed by time since baseline visit, Pelli-Robson contrast sensitivity, high spatial frequency contrast sensitivity function, and low luminance visual acuity. Early Treatment Diabetic Screening chart BCVA under standard lighting conditions was ranked lowest among the panel of test modalities. Clinical trials in choroideremia for early and mid-stage disease would be justified in moving away from using standard BCVA as a clinical trial outcome measure as we have shown its sensitivity to be relatively low compared to microperimetry. We have also demonstrated how functional measures rank in terms of importance.

Randomised controlled trial of HOYA one-day multifocal contact lenses: The HOMCL trial

Trial designDouble-masked crossover RCT (Research Registry: #8136) comparison of a new HOYA one-day disposable multifocal contact lens (HOMCL) with Alcon DAILIES TOTAL1® Multifocal (ADT1). MethodsSixty presbyopic participants from three countries attended for baseline measurements and fitting of both lens types and then for a fortnight completed daily diaries of symptoms with habitual optical correction, and VF-14 questionnaire. Participants collected either HOMCL or ADT1, when the vision was measured again, and they wore this product for a fortnight, completing daily diaries and VF-14. Participants then collected the other type and had vision and symptoms recorded in the same way. ResultsThere were no serious adverse events. Primary outcomes were no significant differences between the lens types in willingness to purchase nor stated preference; no significant differences in the daily symptom ratings of comfort; statistically significant findings with the daily symptom ratings and VF-14 of better near vision with HOMCL and better distance vision with ADT1. Secondary outcomes were better high contrast distance visual acuity with ADT1 (<1 line), better low contrast distance visual acuity with ADT1; faster Wilkins rate of reading test with HOMCL; no significant differences in near visual acuity, wearing time, or number of lenses required during fitting process. Exploratory analyses were better handling scores with ADT1; and some, but not all of the dry eye data indicating better acceptance of HOMCL by patients with relatively dry eyes. For all measures, there were some participants who preferred/performed better with each lens type. ConclusionsThe differences between the performance of the two products were small. There was a trend in some clinical measurements and the daily diary data and VF-14 questionnaire, for HOMCL to outperform ADT1 for near vision and vice versa for distance vision.

Pupillary Peaking & Presence of Dysphotopsias Following Glaucoma Tube Shunt Surgery

ABSTRACT Purpose To describe the presence of pupillary peaking and dysphotopsias in a sample of eyes following glaucoma drainage device (GDD) surgery. Methods Cross-sectional analysis of 68 glaucoma patients with GDD, 45 patients with glaucoma and no GDD, and 50 control patients was conducted in a single academic center. Patients with an appropriate diagnosis that met the inclusion criteria were asked to enroll in the study. All patients received an 8-item dysphotopsia questionnaire and were age-matched. Photographs of pupils were taken to assess pupillary peaking. One-way analysis of variance (ANOVA) testing was performed for statistical analysis. Results Of the 68 patients with GDD, 25 (36.76%) had pupillary abnormalities with peaking most commonly occurring in the direction of the tube entry superotemporally, and 50 (73.53%) had reported one or more dysphotopsias. In patients reporting one or more dysphotopsias, the rate of lines, crescents, ghost images, and shadows was significantly higher when compared to glaucoma patients without GDD and control patients (p < .01). This corresponded to a lower best-corrected visual acuity in the GDD group compared to the glaucoma and control groups (p < .001). Conclusions Over a third of glaucoma patients receiving GDD had pupillary abnormalities, and nearly 3 out of 4 patients with GDD reported one or more dysphotopsias when compared to glaucoma patients without GDD and an age-matched control group. Glaucoma specialists and patients should be aware of these complications when proceeding with GDD surgery.

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

Evaluation of parameters for early detection of pediatric keratoconus

BackgroundKeratoconus in children is often more severe and rapidly progressive compared to adults. While Scheimpflug imaging (Pentacam) improves screening, there are no established pediatric guidelines. Due to challenges in diagnosis, we aimed to correlate clinical factors with abnormal imaging results to aid in the development of screening protocols.MethodsA single-center retrospective cohort analysis of patients 3–18 years screened for keratoconus with ophthalmic examination and initial Scheimpflug imaging between 2021 to 2023. Scheimpflug indices including final D, ART max, and calculated CAIRO 8, which is a corneal metric combining pachymetry, ART max, and elevation, were compared to published pediatric ranges for normal and keratoconus corneas.ResultsSeventy-eight patients (11.8 ± 3.9 years) were screened with the majority referred due to high and/or progressive astigmatism (74 patients, 94%). Forty-nine patients (63%) were male and 48 (62%) self-reported Hispanic ethnicity. Average astigmatism was 4.9 ± 1.8 D and 86% had with-the-rule astigmatism. Fourteen patients (18%) had corneal findings on slit lamp. Average LogMAR CDVA was 0.243 ± 0.274 D. By Pentacam, 55 (70%) patients had ≥ 1 indeterminate or keratoconus value. Patients stratified as keratoconus by all parameters were older (15 vs. 11 years, p = 0.015–0.02), had worse visual acuity (p < 0.0001), and were more likely to have oblique astigmatism (0.0002—< 0.0001) and corneal abnormalities on examination (p < 0.00001) compared to eyes with normal or indeterminate indices.ConclusionsOlder age, lower visual acuity, oblique astigmatism, and corneal findings were more commonly found in patients with abnormal screening Pentacam. Most patients clinically suspicious for keratoconus had ≥ 1 indeterminate/abnormal indices. Future studies will follow these patients to identify clinical risk factors for progression.

New risk factors and predictions of the development of retinal vein occlusion after cardiac surgeries with the use of artificial circulation

Background. Cardiovascular diseases are one of the risk factors for the development of retinal vein occlusion (RVO). Cardiac interventions with artificial circulation (AC) can be associated with perioperative complications, including retinal vessel occlusion. The actual task of modern ophthalmology is to determine the frequency of retinal vessel occlusions, clinical features, risk factors, the role of markers of inflammation and endothelial dysfunction in RVO in patients with cardiovascular diseases after surgeries with artificial circulation. The purpose of the study was to investigate new risk factors and predict the development of retinal vein occlusions after cardiac surgeries using artificial circulation. Materials and methods. Three hundred and ninety-four patients (638 eyes) were under observation. Of them, 220 people (405 eyes) had cardiovascular diseases and underwent heart surgeries with the use of AC. In these patients, we determined the nature, frequency and features of the development and clinical course of RVO after cardiac surgery with AC in the early and late periods of observation (3 and 6 months). Also, a study was conducted of 174 patients (233 eyes) with cardiovascular diseases who underwent cardiac surgeries with AC, and the serum levels of markers of inflammation (IL-6 and IL-8) and endothelial dysfunction (VE-cadherin) were determined before and after operations depending on the time of RVO occurrence. The main group included 126 patients (137 eyes) who were diagnosed with occlusion of the central retinal vein (CRV) or its branches after surgery with AC; the comparison group — 43 patients (86 eyes) who did not have retinal vein occlusion during the entire observation period; the control group — 5 patients (10 eyes) who had the same degree and duration of the underlying disease, indications for surgery with AC, but were examined before the operation, and within 180 days after it, and did not have RVO. The patients were examined by an ophthalmologist 2, 7, 30, 60, 90 and 180 days after cardiac surgery. The content of IL-6, IL-8 and VE-cadherin in blood serum was determined by the enzyme immunoassay (Bender MedSystems, Austria). Statistical data were processed using the Statistica 10 program (StatSoft Inc., USA), regression analysis was performed with the help of the GLZ software package. Results. As a result of the research, it was found that the frequency of retinal vein occlusions after cardiac surgeries with the use of artificial circulation was 0.99 % on the 2nd day, 3.95 % on the 7th day, 10.2 % after 3 months, 1.4 % after 6 months. The conducted discriminant analysis showed that the type of occlusion was determined by age, lower visual acuity, and the order of occlusion of the CRV branches. An increase in the macular volume of the retina was also significant, reflecting the development of macular edema. The regression model for predicting the type of occlusion based on visual acuity, the order of occlusion of the CRV branches and age had a prediction accuracy of 82.5 %. Cardiac surgeries with the use of AC caused an increase in interleukin content in the early period (IL-6 on days 2 and 7, and IL-8 — up to day 30), while the content of VE-cadherin was slightly increased during almost the entire observation period. In the presence of RVO, IL-6 content was significantly higher at all stages of occlusion development, IL-8 content — up to 30 days, and VE-cadherin content — mostly after 7 days. Regression analysis showed that after 1–2 days, the occurrence of RVO was directly related to the content of IL-6 and IL-8 in the blood, on days 3–7 — to the content of only IL-8, on days 8–30 — to the content of all markers, and later — to the content of IL-6 and VE-cadherin. The prediction accuracy for the presence or absence of RVO in the corresponding term according to the calculated regression models is at least 78 % (p &lt; 0.001), which proves the influence of markers on the development of RVO. Conclusions. The conducted study shows the importance of acute inflammation and endothelial dysfunction in the occurrence of RVO when using AC, which justifies the use of preventive measures in the early stages of limiting the activity of the inflammatory process, in the later stages — preventing the development of endothelial dysfunction.

Were there any missing mediators between visual impairment and anxiety symptoms? Results from Chinese Longitudinal Healthy Longevity Survey.

Visual impairment, encompassing low visual acuity and visual field loss, significantly impacts the older adult population worldwide, leading to increased disability and mortality risks. Recent studies suggest a strong association between visual impairment and anxiety, particularly among older adults. This study aims to explore the relationship between visual impairment and anxiety symptoms in older adult individuals in China, and to investigate potential mediating factors. Data for this study were derived from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), including 11,702 participants aged 65 and older. Visual impairment was assessed through self-reported visual function, while anxiety symptoms were measured using the 7-item Generalized Anxiety Disorder scale (GAD-7). Additional assessments included sleep quality and duration, exercise status, and dietary diversity. Logistic regression models and mediation analysis were employed to explore associations and mediating effects. The findings indicate that visual impairment is significantly associated with increased anxiety symptoms among the older adult (OR = 1.51, 95% CI: 1.32-1.72, p < 0.001). Mediation analysis revealed that sleep quality, dietary diversity score (DDS), and plant-based DDS significantly mediated the relationship between visual impairment and anxiety. In contrast, sleep duration, exercise, and animal-based DDS did not show significant mediating effects. Visual impairment is a crucial predictor of anxiety symptoms in the older adult. Improving sleep quality and promoting a diverse plant-based diet may mitigate anxiety symptoms in this population. Interventions targeting these areas could enhance the mental health and quality of life of older adult individuals with visual impairment.

Treatment Options in Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP): Case Presentation and Review of the Literature

ABSTRACT Purpose To outline the therapeutic approach for a rare case of Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) and examine the current management recommendations of this uncommon condition. Methods-Results Literature review on the current treatment options in BDUMP cases. An 82-year-old woman was referred to our clinic due to bilateral visual loss. She was treated elsewhere with anti-vascular endothelial growth factors (anti-VEGF) in both eyes for presumed choroidal neovascularization (CNV) without improvement. Her past medical history (PMH) entailed colon cancer, treated with surgical resection and adjuvant chemotherapy 15 years ago. The patient presented with low visual acuity in both eyes, multiple oval orange patches in the fundus with striking hyperfluorescent pattern in fluorescein angiography (FA), giraffe pattern in fundus autofluorescence (FAF) and rapidly progressive cataracts. Intravitreal dexamethasone implants were administered with mild improvement and subretinal fluid absorption. Conclusions The management strategy in BDUMP should focus on the systemic, often occult malignancy. There is no standard treatment protocol for BDUMP; however, plasmapheresis in combination with primary malignancy treatment seems to yield promising results in current literature reports. Anti-VEGF injections failed to control BDUMP sequelae, however intravitreal dexamethasone implants may offer temporary relief.

A Cross-Sectional Analysis of ALS/ BLS Care in Low Acuity 9-1-1 Response by Geography and Insurance Status Utilizing the 2019 NEMSIS Dataset

Purpose. The objective of this study was to examine the relationship between patient acuity and level of EMS care adjusting for rurality and insurance. Methods. Data were obtained from the National Emergency Services Information System (NEMSIS) database for 2019. EMS responses (n = 4,375,568) were analyzed comparing patient acuity and CMS Service level, Advanced Life Support (ALS) vs Basic Life Support (BLS), to assess for associations in acuity and CMS Service level using logistic regression. Results. Overall, there was a decreased odds of advanced life service use at low acuity EMS responses (OR=0.443, 95% CI=0.440-0.445). Sub analysis exploring the interaction between CMS Service Level, Rurality demonstrates an overall trend of decreasing odds of low acuity EMS responses among rural areas and BLS care (OR=0.492, 95% CI=0.486,0.498) and ALS care (OR=0.198, 95% CI=0.197,0.200). When analyzing trends among public vs all other insurance and rural vs urban settings, there were decreases in low acuity ALS care in the rural setting; ALS and Pub Insurance (OR 0.447, 0.444-0.450, p&lt;0.001), ALS and Rural (OR 0.198, CI 0.197-0.914, p&lt;0.001) among low acuity responses. The results indicate that acuity and service level vary according to insurance and rurality. In the low acuity call type, we see decreased odds of ALS use compared BLS use in those with public insurances compared to other insurance. There is also a geographic component to these results where the use of Advance Life Support services declined with decreases in urbanicity. Discussion. These results potentially highlight that rural areas utilize less emergency medical response resources in low acuity responses. As such, EMS programs like community paramedicine, could be potentially effective interventions to close gaps in access to care for rural residents.

Microperimetry Sensitivity Correlates to Structural Macular Changes in Adolescents with Achromatopsia Unlike Other Visual Function Tests.

Objectives: Achromatopsia (ACHM) is a rare autosomal, recessively inherited disease that is characterized by cone dysfunction, for which several gene therapies are currently on trial. The aim of this study was to find correlations between the morphological macular changes identified using optical coherence tomography (OCT) and some visual functional parameters. Visual acuity (VA), contrast sensitivity (CS), and macular sensitivity obtained by means of microperimetry were assessed. Methods: Adolescents with ACHM underwent macular microperimetry (S-MAIA device) in mesopic condition, macular OCT, best corrected visual acuity (BCVA), low luminance visual acuity (LLVA), near vision acuity (NVA), and CS measurement. Results: Eight patients (15 eyes) with ACHM were analyzed. The mean age was 17 ± 2.7 years, and genetic variants involved the CNGA3 gene (37.5%) and CNGB3 gene (62.5%). OCT staging significantly correlated with microperimetry sensitivity parameters, namely the sensitivity of the central foveal point (p = 0.0286) and of the first and second perifoveal rings (p = 0.0008 and p = 0.0014, respectively). No correlations were found between OCT staging and VA measurements, nor with CS value. Conclusions: Among the extensive evaluated visual function tests, only microperimetry sensitivity showed a correlation with morphological macular changes identified at OCT. Microperimetry sensitivity may thus represent a useful visual function tool in natural ACHM history studies considering the upcoming research on gene therapies for the treatment of ACHM.

Psychiatric Sequelae in Adult Open Globe Injury Patients

Background: The aim of this study was to investigate psychiatric sequelae in open globe injury patients and to identify the risk factors associated with these sequelae. Methods: After a complete ophthalmologic examination, Davidson Trauma Scale (DTS), State-Trait Anxiety Inventory (STAI), and Zung Depression Scale (ZDS) scores were administered to all patients. Patients were divided into 5 groups according to final best corrected visual acuity (BCVA): group 1 (no perception of light, NPL), group 2 [perception of light (PL) or hand movements (HM)], group 3 (1/200 to 19/200), group 4 (20/200 to 20/50), and group 5 (20/40 or above). Results: A total of 113 patients with open globe injuries were included. The mean ZDS scores were 78.5±35.9 in group 1, 66.2±24.5 in group 2, and 27.6±2.1 in group 5. In group 1, 8 patients (66.7%) had moderate depression. In group 2, 20 patients (60.6%) had mild depression. All patients in group 4 and group 5 had ZDS scores in the normal range. There is a statistically significant difference between the groups in terms of ZDS scores. In univariate analysis, depression (ZDS) and trauma (DTS) scores were associated with younger age (P=0.016 and P=0.003, respectively) and lower final visual acuity level (P&lt;0.001, for both). In multivariate analysis adjusted for age and sex, a lower final visual acuity level (P&lt;0.001, for both) was also associated. Conclusions: In conclusion, high anxiety and depression scores can be seen in open globe injury patients. Patients with young age and lower final visual acuity should be carefully screened, and the presence of a psychiatric pathology should be investigated. Amelioration of psychiatric pathologies may improve patient compliance with treatment and clinical success.

Contribution of the Association of CT scan and Ocular Trauma Score in Open Globe Ocular Injuries: Mohammed VI University Hospital Experience

Objective: The aim of this study was to assess the association between oculo-orbital CT scan results and Ocular Trauma Score (OTS) in open globe injuries. Methods: In 65 eyes with open globe injuries undergoing oculo-orbital CT, they were classified into 5 major types: intraocular foreign body/air, scleral irregularity with decreased globe volume, lens dislocation, abnormal vitreous density, choroid layer thickening, and choroidal detachment. The association between different types and the number of CT findings with OTS stages was evaluated. Results: The average age of patients was 37 ± 15.8 years. The most common CT findings were the presence of intraocular foreign bodies (63.1%), severe scleral irregularity (18.5%), and abnormal vitreous density (23.1%). The most frequent OTS stages were III (47.7%) and II (21.5%). Univariate analysis showed that severe scleral irregularity (OR = 0.015; p = 0.001), abnormal vitreous density (OR = 0.095; p &lt; 0.004), choroidal layer thickening (OR = 0.211; p = 0.006), and foreign body (OR = 9.50; p = 0.004) were associated with more advanced OTS stages (I and II). The discovery of more anomalies on CT was associated with severe ocular injuries, namely OTS I (p &lt; 0.001) with corresponding low final visual acuity. Conclusion: CT results can aid in predicting OTS stage and visual prognosis in open globe eye injuries.