Wills Eye Hospital Research Articles

Editorial introductions

Editorial introductions

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents.

To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents. This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course. A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessment's mean score was statistically significant before and after training (P = .038). A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

Economic Evaluation of a Home-Based Age-Related Macular Degeneration Monitoring System

Medicare recently approved coverage of home telemonitoring for early detection of incident choroidal neovascularization (CNV) among patients with age-related macular degeneration (AMD), but no economic evaluation has yet assessed its cost-effectiveness and budgetary impact. To evaluate a home-based daily visual-field monitoring system using simulation methods and to apply the findings of the Home Monitoring of the Eye study to the US population at high risk for wet-form AMD. In this economic analysis, an evaluation of the potential cost, cost-effectiveness, and government budgetary impact of adoption of a home-based daily visual-field monitoring system among eligible Medicare patients was performed. Effectiveness and visual outcomes data from the Age-Related Eye Disease Study 2 Home Monitoring of the Eye study, treatment data from the Wills Eye Hospital Treat & Extend study, and AMD progression data from the Age-Related Eye Disease Study 1 were used to simulate the long-term effects of telemonitoring patients with CNV in one eye or large drusen and/or pigment abnormalities in both eyes. Univariate and probabilistic sensitivity analysis and an alternative scenario using the Treat & Extend study control group outcomes were used to examine uncertainty in these data and assumptions. Home telemonitoring of patients with AMD for early detection of CNV vs usual care. Incremental cost-effectiveness ratio, net present value of lifetime societal costs, and 10-year nominal government expenditures. Telemonitoring of patients with existing unilateral CNV or multiple bilateral risk factors for CNV (large drusen and retinal pigment abnormalities) incurs $907 (95% CI, -$6302 to $2809) in net lifetime societal costs, costs $1312 (95% CI, $222-$2848) per patient during 10 years from the federal government's perspective, and results in an incremental cost-effectiveness ratio of $35 663 (95% CI, cost savings to $235 613) per quality-adjusted life-year gained. Home telemonitoring of patients with AMD who are at risk for CNV was cost-effective compared with scheduled examinations alone. Monitoring patients with existing CNV in one eye is cost saving, but monitoring is generally not cost-effective among patients with low risk of CNV, including those with no or few risk factors. With Medicare coverage, monitoring incurs budgetary expenditures for the government but is cost-saving for patients at high risk of AMD. Monitoring could be cost saving to society if monitoring reduced the frequency of scheduled examinations or led to a reduction of one or more injections of ranibizumab.

Editorial introductions

Current Opinion in Ophthalmology was launched in 1990. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of Ophthalmology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editor and Section Editor for this issue. EDITOR Allen C. HoAllen C. HoDr Allen C. Ho is an Attending Surgeon of the Retina Service and Director of Retina Research of Wills Eye Hospital, USA. He is Professor of Ophthalmology at Thomas Jefferson University School of Medicine, USA. Dr Ho is a founding member of Mid Atlantic Retina. He is author of multiple textbooks including Age Related Macular Degeneration Diagnosis and Treatment, The Wills Eye Hospital Color Atlas and Synopsis of Retinal Disease and is Editor-in-Chief of Current Opinion in Ophthalmology and Chief Medical Editor of Retina Today, a global publication that features new therapies for retinal disease. He is a member of the Scientific Editorial Boards of Retina Cases and Brief Reports, Ophthalmic Surgery, Lasers and Imaging, Retinal Physician, and Ocular Surgery News. Dr Ho has been an invited lecturer at numerous national and international ophthalmic meetings around the world. He is a recipient of multiple clinical research grants investigating new treatments for macular diseases sponsored by the National Eye Institute and received the American Academy of Ophthalmology's Achievement Award and Senior Achievement Award and the American Society of Retina Specialists Crystal Apple Award. Dr Ho is Principal Investigator at Wills Eye Institute of several collaborative clinical trials evaluating new treatments for age-related macular degeneration, surgical retina and diabetic retinopathy. He maintains special interests in macular diseases, diabetic retinopathy, surgical retinal diseases and clinical trials investigating new treatments for vitreoretinal diseases. SECTION EDITOR Natalie A. AfshariNatalie A. AfshariNatalie A. Afshari is Stuart I. Brown MD Chair in Ophthalmology in Memory of Donald P. Shiley, Chief of Cornea and Refractive Surgery, Vice Chair of Education, and Professor of Ophthalmology at the Shiley Eye Institute, University of California, San Diego. Prior to this, she was Professor of Ophthalmology and Director of Centers of Excellence at the Duke University Eye Center. She received her medical degree from Stanford University and her residency training at Harvard University, Massachusetts Eye and Ear Infirmary. She then completed a two-year fellowship in cornea and refractive surgery at Harvard University. Dr Afshari is the recipient of the Senior Achievement Award and the Secretariat Award by the American Academy of Ophthalmology and has been named a Gold Fellow of the Association for Research in Vision and Ophthalmology. She has received the inaugural Top Ten Women in Medicine award by Triangle News, Women Who Mean Business award by San Diego Business Journal, and the Teacher of the Year award at the Duke University Eye Center. She has also been recognized in the Best Doctors in America in each listing for the past decade, and was named in the US News & World Report's Top Doctors List. Dr Afshari is the co-editor of a new two-volume cornea book called “Principles and Practice of Cornea”. She is also on the editorial boards of Investigative Ophthalmology and Visual Science and American Journal of Ophthalmology. She has previously served on the EyeNet editorial board, BCSC Cornea text book committee, and the American Academy of Ophthalmology council representing the American Society of Cataract and Refractive Surgery. She was co-chair of the cornea program committee for the Association for Research in Vision and Ophthalmology and co-director of Cornea Subspecialty Day for the American Academy of Ophthalmology. She is currently the chair of the American Society of Cataract and Refractive Surgery FDA Committee. Her NIH research grant is on the study of Fuchs dystrophy, and she investigates the intricacies of endothelial keratoplasty and regeneration of cornea. When not researching or practicing, Dr Afshari donates her time and surgical expertise as an international volunteer. She has traveled to West Africa, Central America, and Mexico to help patients who might otherwise go untreated.

A Clinical Vision Research Training and Mentoring Program as a Model for Ophthalmology and Other Medical Specialties: Implementation and Evaluation

Background Over the past 50 years, there has been a decline in the number of physicians pursuing careers in clinical research. In ophthalmology, the need for clinician-investigators continues to grow with the increasing eye-care demands of the aging population. Expert panels have recommended exposing medical students early in their training to structured, didactic curricula with clinical research experience and mentoring opportunities. Methods To address this need, the Department of Research, Wills Eye Hospital, developed an 8-week Clinical Vision Research Training and Mentoring Program for undergraduate and medical students. The curriculum included an 11-hour lecture series on topics in research methods in ophthalmology and a 10-hour scientific writing workshop series. The program also involved hands-on participation in vision research projects and shadowing in one of Wills' subspecialty services. Students completed 40-question pre- and posttests on ophthalmology and research methodology. Scores were analyzed using a paired-sample t-test. The program also utilized a satisfaction survey. Results During 2014 and 2015, a total of 34 students out of 56 applicants were accepted to the Clinical Vision Research Training and Mentoring Program. Students scored significantly higher on the posttest (mean [M] = 79.78%, standard deviation [SD] = 6.25) than on the pretest (M = 71.43%, SD = 8.43); p&lt; 0.001. Using a satisfaction survey, students strongly agreed that they were satisfied with the program and that the lecture series and manuscript writing workshops enhanced their learning. Conclusions The Wills Eye Clinical Vision Research Training and Mentoring Program provided an evidence-based foundation in research methods and manuscript development for students interested in careers in ophthalmology. Students emerged with clinical research skills and an increased understanding and appreciation of vision research. Results of the pre- and posttest analysis indicate that lecture material supplemented with hands-on experience can lead to better understanding of ophthalmology. This pilot program can serve as a research training and mentoring model for ophthalmology and other medical and surgical specialties.

Tumors and Related Lesions of the Pigmented Epithelium.

Several tumors and pseudotumors can arise from the iris pigment epithelium (IPE), ciliary pigment epithelium (CPE), and retinal pigment epithelium (RPE), including cysts of the IPE, solitary congenital hypertrophy of the RPE (CHRPE), multifocal CHRPE ("bear tracks"), congenital simple hamartoma of the RPE, combined hamartoma of the retina and RPE, and acquired epithelioma of IPE, CPE, and RPE. This article describes examples of pigment epithelial tumors and pseudotumors by reviewing the literature and cases on file in the Oncology Service at Wills Eye Hospital. Solitary CHRPE, traditionally believed to be stationary, can show growth in diameter in 83% and can spawn elevated nodular tumors that can progressively enlarge, cause complications, and even evolve into malignant epithelioma (adenocarcinoma). Multifocal CHRPE (congenital grouped pigmentation) has no relationship to familial adenomatous polyposis or Gardner syndrome, despite its similarity to the pigmented fundus lesions seen with those conditions. Congenital simple hamartoma of the RPE is a specific lesion that involves the fovea and does not tend to cause complications. Combined hamartoma, an idiopathic proliferation of RPE cells, blood vessels, and glial cells, is also believed to be a relatively stable lesion but can cause vision loss due to traction. Acquired tumors (adenoma, adenocarcinoma) have features distinct from melanoma clinically and histopathologically. Torpedo maculopathy is a small stable lesion with typical features, resembling a torpedo. There are several intriguing tumors and pseudotumors of the pigmented epithelium that have major clinical and histopathologic importance.

Turning Patient Engagement into Scientific Disruption

Turning Patient Engagement into Scientific Disruption

Disc-damage Likelihood Scale (DDLS) as a Clinical Indicator of the Presence of a Relative Afferent Pupillary Defect (RAPD).

To evaluate clinical parameters and their relationship to the presence of a relative afferent pupillary defect (RAPD). Retrospective chart review of 672 consecutive patients who presented to the Glaucoma Service at Wills Eye Hospital from January 1 through May 29, 2012. Swinging flashlight method (SFM) was used to test for RAPDs. Records of visual acuity, intraocular pressure (IOP), disc-damage likelihood scale (DDLS), cup/disc (C/D) ratio, visual field mean deviation (MD), optical coherence tomography (OCT), and Heidelberg retinal tomography (HRT) asymmetries were examined. We measured the prevalence of RAPDs as clinical asymmetries increase, calculated cut-off points for clinical asymmetries that optimized sensitivity and specificity in detecting RAPDs, and determined values of clinical asymmetries above which a RAPD always exists. Upon exclusion, we studied 409 patients, 175 (42.8%) with RAPDs and 234 (57.2%) without. Age, visual acuity, IOP, DDLS, C/D ratio, MD, retina nerve fiber layer thickness by OCT, HRT C/D, and HRT rim area asymmetries all correlated with RAPD status (OCT and HRT parameters did not include enough patients for multivariable analysis or cut-off determination). Multivariable analysis indicated that IOP, DDLS, and MD asymmetries were significantly correlated with RAPD status (P-value<0.05). Although the optimal cut-off values for the variables retained in the final multivariable model had low sensitivity and moderate specificity, DDLS had the highest specificity of 0.86. IOP, DDLS, and MD asymmetries had the best correlation with RAPD status, and increased asymmetries in these parameters were associated with higher likelihood of RAPDs. DDLS score had the highest specificity in predicting a RAPD, and DDLS asymmetry scores ≥6 identified all cases of RAPDs.

Improving access to vision screening in urban Philadelphia elementary schools

The Wills Eye Vision Screening Program for Children is a community-based vision screening program for children in urban Philadelphia elementary schools that aims to provide vision screening, remedy refractive error by providing glasses, and refer children with suspected nonrefractive eye disease for eye care. Children in grades K-5 from 45 Philadelphia elementary schools were screened for distance and near visual acuity, stereopsis, and color vision from January 2014 to June 2015. Children who failed were assessed by an on-site optometrist. Two pairs of eyeglasses were provided at no cost. Children with suspected, nonrefractive disease were referred to Wills Eye Hospital Pediatric Ophthalmology and contacted by a social worker to schedule an appointment. Over 84days, 10,726 children were screened for vision problems at 45 schools. A total of 1,321 children (12%) had refractive error and 1,015 children (77%) returned the consent form and received two pairs of glasses. Of the 509 children (5%) referred to Wills Eye, 177 returned consent forms and were not being followed by an ophthalmologist. Of these, 127 children (72%) completed an eye examination at Wills. The program described herein can provide comprehensive vision screening, with eyeglasses and/or referrals, to children within an underserved community.

Survival of Primary Penetrating Keratoplasty in Children

To review the indications and outcomes of children undergoing primary penetrating keratoplasty and identify prognostic factors for graft survival. Retrospective, interventional case series. Medical records of every child 12 years of age or younger who underwent primary penetrating keratoplasty at Wills Eye Hospital Cornea Service between 2007 and 2015 were reviewed. Survival of the primary graft was analyzed using the Kaplan-Meier survival method. Forty-six eyes of 35 children underwent primary keratoplasty during the study period. The mean age at the time of primary keratoplasty was 24.6 ± 39.9months. The mean follow-up duration was 36.4 ± 28.8months. Congenital opacity was the most common diagnosis for primary keratoplasty (89.1%). The overall mean graft survival time was 45.2 ± 5.8months, with a survival rate of 75.7% at 1 year. The 1-year graft survival rate was 51.9% and 90.7% in eyes with and without glaucoma, respectively. Cox proportional hazards regression analysis demonstrated that the presence of glaucoma (P= .014) and concurrent operation during primary keratoplasty (P= .049) were independent prognostic factors for poor graft survival. On the other hand, age of primary keratoplasty (P= .626) and operation before or after primary keratoplasty (P= .800 and P= .104, respectively) were not associated with poorer graft survival. Half of our patients were able to achieve ambulatory vision at the last follow-up. Although pediatric penetrating keratoplasty is challenging, successful transplantation with good graft survival can be obtained. Better understanding of prognostic factors can possibly improve graft survival in the future.

The Association between Diabetes and Herpes Simplex Eye Disease

ABSTRACTPurpose: To evaluate the association between diabetes mellitus (DM) and presence and severity of Herpes simplex eye disease (HSED).Methods: We conducted two sub-studies. We included the patients seen on the Cornea Service of the Wills Eye Hospital from January 2008 to August 2012. Study 1 included 541 patients with HSED and 3226 controls. Study 2 involved 40 diabetic and 120 non-diabetic ocular surface HSED patients. Severity of ocular surface HSED was graded as mild, moderate, or severe, based on best-corrected visual acuity (BCVA). Patients were excluded if they had fewer than two office visits or had non-Herpes simplex-related vision-threatening conditions. Diabetes was graded as: diet group (DM controlled with diet), oral group (DM controlled with oral medications), and insulin group (DM control required insulin).Results: Five of 541 (0.93%) HSED patients had type 1 DM, similar to 19/3246 (0.59%) controls (p = 0.375); 48 of 541 (8.88%) HSED patients had type 2 DM, similar to 287/3246 (8.84%) controls (p = 0.981). Using multinomial logistic regression analyses, the probability/risk of being in the severe ocular surface HSED group as opposed to the mild ocular surface HSED group were not statistically significantly different between DM patients and those without DM (p = 0.120; OR, 1.900; 95% CI, 0.846–4.266).Conclusions: There may not be a positive association between type 2 DM and HSED.

Outcomes of Wound Dehiscence Post-Penetrating Keratoplasty.

Penetrating keratoplasties (PKs) carry a lifetime risk of developing wound dehiscence, which can lead to severe consequences to vision. To better understand the risk, we analyzed the characteristics and outcomes of a series of patients with wound dehiscence post-PK. Data were collected retrospectively on 31 eyes from 30 patients with a history of wound dehiscence repair post-PK between January 1, 2009, and April 30, 2014, and followed up at the Cornea Service at Wills Eye Hospital. Only patients who had surgical repair of an open wound dehiscence were included, excluding those with wound slippage but no aqueous leak. The mean age at wound dehiscence was 56 years with a mean time from PK to dehiscence of 9.8 years. Among the 31 eyes, 26 (26/31, 84%) had trauma-induced dehiscence, while 5 had unknown causations or no reported trauma. The mean size of dehiscence was 153 ± 66 degrees. Visual outcomes ranged from 20/50 to no light perception, with a majority between 20/100 and hand motion (18/30, 60%). Twenty eyes (20/26, 76%) lost their lens at dehiscence. All 10 phakic eyes lost their lenses. Five patients retained their lens implants and had a better mean visual outcome (average = 20/400) than the 10 patients who lost their implants (average = 20/800) (1 lens status was unknown postdehiscence). Wound dehiscence is a lifelong risk after PK regardless of the age, indication for corneal transplant, and time since transplant. A better visual outcome was associated with retained pseudophakia and clear corneas.

Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care.

Glaucoma is the leadi ng cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma. The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence. This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios. Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04-1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08-1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56. A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

In Vivo Assessment of Macular Vascular Density in Healthy Human Eyes Using Optical Coherence Tomography Angiography

To quantify density of macular vascular networks over regions of interest in healthy subjects using optical coherence tomography angiography (OCTA). Prospective cross-sectional study. Setting was the Retina and Oncology Services of Wills Eye Hospital. Subjects with no known systemic disease and without retinal pathology were included. OCTA was performed on a 3× 3-mm region centered on the macula and en face angiograms of the superficial and deep vascular networks were acquired. Vascular density was calculated using an automated image thresholding method over regions of interest. Foveal and parafoveal vascular density were calculated. The differences between vascular networks, sexes, and fellow eyes and correlation between vascular density, signal strength, and age, as well as reproducibility of measurements, were evaluated. A total of 198 healthy eyes were imaged, from which 163 eyes of 122 subjects were included based on image quality criteria. In the parafoveal region, deep vascular density was significantly higher than the superficial (52% ± 2.4% vs 46% ± 2.2%; P < .001), whereas the opposite was found in the foveal region (27% ± 5.2% vs 32% ± 3.2%; P < .001). All vascular density measurements were statistically similar in fellow eyes and there was no sex difference (P > .05). There was a negative correlation between vascular density and age that persisted upon adjusting for signal strength. Vascular density measurements were highly correlated between separate imaging sessions with intraclass correlation coefficients of over 0.85 for all assessments. Calculation of vascular density using OCTA is a reproducible and noninvasive method to quantitate individual networks within the macula. Understanding normal values and their correlations could affect clinical evaluation of the macula in healthy patients and disease states.

The Impact of Visual Field Clusters on Performance-based Measures and Vision-Related Quality of Life in Patients With Glaucoma

To investigate how visual field (VF) clusters affect performance-based measures of the ability to perform activities of daily living and subjective measures of vision-related quality of life (QoL) in patients with glaucoma. Prospective, cross-sectional study. setting: Institutional - Wills Eye Hospital. 322 eyes of 161 patients with moderate-stage glaucoma. VF tests were conducted using the Humphrey 24-2 Swedish Interactive Thresholding Algorithm standard perimeter. The VFs of each patient were divided into 5 clusters: nasal, temporal, central, paracentral, and peripheral. The score for each cluster was the averaged total deviation scores of all tested points within the cluster. Each cluster score was correlated with performance-based measures of visual function and subjective assessment of vision-related QoL. The Compressed Assessment of Ability Related to Vision, the National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25), and the Modified Glaucoma Symptom Scale. The central VF cluster in the better eye was positively correlated with all Compressed Assessment of Ability Related to Vision (performance-based measure) subscales. The strongest correlation for the better eye was between the central VF cluster and total Compressed Assessment of Ability Related to Vision score (0.39, P < .001). The inferior VF hemisphere in both eyes was positively correlated with most Compressed Assessment of Ability Related to Vision subscales. Central VF clusters in the better eye were positively correlated with a majority of the NEI VFQ-25 subscales. There were no significant correlations between VF clusters and Modified Glaucoma Symptom Scale subscales. Scores of central VF defects in the better eye and inferior hemisphere defects in both eyes were positively correlated with performance-based measures of the ability to perform activities of daily living. Glaucoma patients with central defects in the better eye were more likely to have reduced scores on assessments of vision-related QoL.

Relationships Between Measures of the Ability to Perform Vision-Related Activities, Vision-Related Quality of Life, and Clinical Findings in Patients With Glaucoma.

To our knowledge, few studies have combined an objective measure of vision-related performance (VRP) and subjective measures of vision-related quality of life (VRQoL) with clinically related visual parameters, particularly in a large, prospective, cohort study setting. To examine the relationships between clinical visual assessments and both a VRP and 2 self-reported VRQoL measurements. Patients (N = 161) with moderate-stage glaucoma recruited from the Glaucoma Service at Wills Eye Hospital, Philadelphia, Pennsylvania, were enrolled from May 2012 to May 2014 in an ongoing prospective, 4-year longitudinal observational study. This report includes cross-sectional results from the baseline visit. Patients received a complete ocular examination, automated visual field (VF) test and Cirrus optical coherence tomographic scan. Contrast sensitivity was measured with the Pelli-Robson and the Spaeth-Richman Contrast Sensitivity (SPARCS) tests. Vision-related performance was assessed by the Compressed Assessment of Ability Related to Vision (CAARV) test. Vision-related QoL was assessed by the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) and a modified Glaucoma Symptom Scale (MGSS). Correlations between clinical measures and CAARV, NEI-VFQ-25, and MGSS scores. A total of 161 patients were enrolled in the study. The strongest correlation was found between SPARCS score in the better eye and total CAARV score (r = 0.398; 95% CI, 0.235-0.537; P < .001). The CAARV score also correlated with the Pelli-Robson score (r = 0.353; 95% CI, 0.186-0.499; P = .001), VF mean deviation (r = 0.366; 95% CI, 0.200-0.510; P < .001), and VA (r = -0.326, 95% CI = -0.476 to -0.157; P = .003) in the better eye. There were more statistically significant correlations between contrast sensitivity tests and VF mean deviation with VRQoL measurements than with other clinical measures (visual acuity, intraocular pressure, Disc Damage Likelihood Scale, and mean retinal nerve fiber layer thickness). The MGSS scores were lower (worse) in women compared with men (P = .03 for binocular, P = .01 for better eye, and P = .05 for the worse eye). Structural measures (eg, Disc Damage Likelihood Scale, and retinal nerve fiber layer thickness) were generally not informative with respect to VRP or VRQoL. Contrast sensitivity tests and VF mean deviation were associated with both objective measures of the ability to act and subjective measurements of VRQoL. The strongest correlation was between SPARCS score (contrast sensitivity) in the better eye and total CAARV score. Therefore, measurement of contrast sensitivity should be considered when evaluating patients' VRQoL. The results of this study were limited by the patient population and apply only within the bounds of the tested cohort.

Long-term outcomes in patients initially responsive to selective laser trabeculoplasty.

To determine the long-term effects of selective laser trabeculoplasty (SLT) on intraocular pressure (IOP) and the number of medications used up to 5y following treatment in glaucoma patients receiving maximally tolerated medical therapy (MTMT). The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the charts of glaucoma patients who underwent SLT after receiving MTMT. Eyes that did not achieve their target pressure within 3mo following SLT were excluded from the study. Changes in mean IOP and number of glaucoma medications used were analyzed at 1, 3, and 5y following SLT. Seventy-five eyes of 67 patients were included in the study. Fifteen eyes that received SLT failed to achieve their target pressure within 3mo and were excluded from the study. The average follow-up time was 37.4mo (±14.4). Mean IOP was significantly reduced 1y after treatment (P=0.005). It was also reduced 3, 5y after treatment without reaching statistical significance (P=0.20 and P=0.072, respectively). There was a significant decrease in mean number of medications used 1, 3, 5y after treatment (P<0.001, P<0.001, and P=0.039, respectively). In the span of 5y, 2 eyes (2.7%) underwent repeat SLT, 7 eyes (9.3%) underwent glaucoma surgery and an additional 3 eyes (4.0%) underwent both. SLT significantly reduced the number of glaucoma medications used 5y following treatment in glaucoma patients receiving MTMT. SLT may delay operating-room surgery.

Long-Term Results of the Boston Keratoprosthesis for Unilateral Corneal Disease.

To report the results of unilateral implantation of a Boston keratoprosthesis (BKPro) in patients with good visual acuity in the fellow eye. A retrospective analysis of 37 eyes of 37 patients who underwent an optical BKPro and had a preoperative best-corrected visual acuity (BCVA) of 20/40 or better in the fellow eye at Wills Eye Hospital from September 2005 to November 2013 was performed. Patients were excluded if they had less than 1 year of postoperative follow-up. The mean follow-up after BKPro implantation was 31.7 months (range, 12-78 months; SD, 21). Twenty-eight patients underwent a BKPro for failed penetrating keratoplasty, and 9 patients underwent a primary BKPro. The most common complications were elevated intraocular pressure and retroprosthetic membrane formation in 16 eyes (43%) each. The mean final BCVA (1.0 ± 0.8 logMAR; median, 1.0 logMAR) was statistically better than the mean preoperative BCVA (1.8 ± 0.2 logMAR; median, 1.8 logMAR) (P < 0.001). The probability of postoperative BCVA of 20/200 or better was 54.1% with an average 45.1 ± 4.7 (confidence interval: 35.9-54.3) months of follow-up. The probability of postoperative BCVA of 20/40 or better was 37.8% with an average 51.8 ± 4.9 (confidence interval: 42.0-61.5) months of follow-up. Half of the patients in our study achieved the minimum visual acuity required for binocular functioning, whereas one-third of the patients achieved a BCVA somewhat similar to that of the contralateral eye. The complications were similar to those reported previously with good retention of the device. BKPro implantation is a reasonable option for patients with good vision in the fellow eye.

Inpatient Ophthalmology Consultation for Fungemia: Prevalence of Ocular Involvement and Necessity of Funduscopic Screening.

To determine the generalizability of recent data assessing the necessity of ophthalmic consultation for fungemic patients, we examined the prevalence, microbial profile, and treatment of fungal chorioretinitis and endophthalmitis among patients with positive fungal cultures referred for ophthalmologic consultation at a tertiary care medical center. Retrospective cross-sectional study. All inpatient ophthalmology consultations from Wills Eye Hospital at Thomas Jefferson University between January 1, 2006 and December 31, 2012 were retrospectively reviewed and cross-referenced to a microbiologic database of positive fungal blood cultures. This included 227 adult consecutive inpatients with positive fungal blood cultures (n= 215) or suspected fungemia (n= 12). Clinical data were extracted from records held by the microbiology laboratory and inpatient records. Patients were deemed to have ocular fungal involvement if dilated fundus examination demonstrated evidence of chorioretinitis or endophthalmitis. Two hundred and twenty-seven consultations were requested to evaluate patients for ocular manifestations of fungemia. Eleven patients (4.8%, 95% CI 2.4%-8.5%) were diagnosed with fungal chorioretinitis or endophthalmitis. Of these 11 patients, 5 had visual symptoms, 2 were asymptomatic, and 4 were unable to communicate. A total of 5 patients (2.2%) received intravitreal injections following funduscopic screening. An additional 11 patients (4.8%) had nonspecific fundus lesions considered to be inconsistent with ocular fungal involvement. The most common fungal species identified were Candida albicans (n= 85), Candida glabrata (n=63), and Candida parapsilosis (n= 44). The current study found a low rate of disseminated ocular involvement in patients with positive fungal cultures referred for ophthalmologic consultation. However, 2 patients with ocular fungal involvement denied visual symptoms and over half of affected patients were asymptomatic or unable to communicate. As the presence and severity of ocular involvement in fungemic patients may dictate the mode and duration of antifungal treatment, funduscopic screenings may still have an important role.

Editorial introductions

Editorial introductions