Wills Eye Research Articles

Prevalence of uncorrected refractive errors among school-age children in the School District of Philadelphia

To determine the prevalence and severity of uncorrected refractive errors in school-age children attending Philadelphia public schools. The Wills Eye Vision Screening Program for Children is a community-based pediatric vision screening program designed to detect and correct refractive errors and refer those with nonrefractive eye diseases for examination by a pediatric ophthalmologist. Between January 2014 and June 2016 the program screened 18,974 children in grades K-5 in Philadelphia public schools. Children who failed the vision screening were further examined by an on-site ophthalmologist or optometrist; children whose decreased visual acuity was not amenable to spectacle correction were referred to a pediatric ophthalmologist. Of the 18,974 children screened, 2,492 (13.1%) exhibited uncorrected refractive errors: 1,776 (9.4%) children had myopia, 459 (2.4%) had hyperopia, 1,484 (7.8%) had astigmatism, and 846 (4.5%) had anisometropia. Of the 2,492 with uncorrected refractive error, 368 children (14.8%) had more than one refractive error diagnosis. In stratifying refractive error diagnoses by severity, mild myopia (spherical equivalent of -0.50 D to<-3.00 D) was the most common diagnosis, present in 1,573 (8.3%) children. In this urban population 13.1% of school-age children exhibited uncorrected refractive errors. Blurred vision may create challenges for students in the classroom; school-based vision screening programs can provide an avenue to identify and correct refractive errors.

Vision-Related Quality of Life Associated with Unilateral and Bilateral Ocular Conditions

To present ophthalmic patient time-tradeoff vision utilities for quantifying vision-related quality-of-life when the fellow eye still has good vision. These utilities are important for performing reliable cost-utility analyses. Consecutive time-tradeoff vision utilities were obtained from ophthalmic patients with good vision (20/20-20/25) in one eye and vision ranging from 20/20 to no light perception in the fellow eye over a 15-year period from 2000 through2014. Five hundred eighty-six ophthalmic participant interviews from Wills Eye Hospital, New York Eye and Ear Hospital, and ophthalmology office practices in Pennsylvania and New Jersey. Participants underwent a full ophthalmic examination, after which time-tradeoff vision utilities were obtained by personal interview by the authors using a standardized, validated instrument. Time-tradeoff vision utilities. Mean time-tradeoff vision utilities were as follows in participants with good vision (20/20-20/25) in at least one eye and the following visions in the fellow eyes: no light perception, 0.79; counting fingers to light perception, 0.87; 20/200 to 20/400, 0.88; 20/60 to 20/100, 0.88; 20/30 to 20/50, 0.87; and 20/20 to 20/25, 0.94. In people with good vision (20/20-20/25) in one eye, the associated mean time-tradeoff vision utility is a remarkably consistent 0.87 to 0.88 when vision in the fellow eye ranges from 20/30 to light perception. Vision of 20/20 to 20/25 in the fellow eye results in a significantly higher associated utility of 0.94 (P < 0.01), whereas vision of no light perception in the fellow eye results in a significantly lower utility of 0.079 (P < 0.01). These utilities are important for calculating reliable patient value (quality-adjusted life-year) gains in ophthalmic cost-utility analysis populations in which there is unilateral and bilateral disease involvement.

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 U.S. 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.

Uveal Metastasis: Clinical Features and Survival Outcome of 2214 Tumors in 1111 Patients Based on Primary Tumor Origin.

PURPOSE:The purpose of this study is to evaluate patients with uveal metastasis based on primary tumor site.METHODS:Retrospective analysis from Wills Eye Hospital, Philadelphia, PA, USA, for uveal metastasis clinical features and outcomes based on the primary tumor site.RESULTS:There were 2214 uveal metastases diagnosed in 1111 consecutive patients. The demographics included mean age of 60 years (median 61 years), Caucasian race (88%), and female gender (64%). The tumor was unilateral (82%) and primary site was established before uveal metastasis (67%). The primary tumor originated in the breast (37%), lung (26%), kidney (4%), gastrointestinal (GI) tract (4%), cutaneous melanoma (2%), lung carcinoid (2%), prostate (2%), thyroid (1%), pancreas (1%), other sites (3%), and unknown (16%). Comparative analysis of the 5 most common primary sites (breast, lung, kidney, GI tract, and cutaneous melanoma), revealed metastasis at mean age (57, 62, 66, 61, 59 years), as unilateral tumor (74%, 86%, 85%, 93%, 85%), with mean number of metastasis/eye (1.9, 1.7, 1.0, 1.1, 2.0), and in females (99%, 46%, 26%, 25%, 30%). Choroidal metastases measured mean base (9.3, 10.2, 9.1, 11.0, 7.3 mm), mean thickness (2.4, 3.6, 4.4, 4.0, 2.9 mm), and demonstrated predominant color yellow (94%, 91%, 56%, 97%, 36%). Of the 769 patients with documented follow-up, mean patient survival was poor (22.2, 11.5, 8.6, 12.4, 11.4 months) and Kaplan–Meier analysis revealed 3-year survival (33%, 19%, 0%, 14%, 21%) and 5-year survival (24%, 13%, 0%, 14%, 21%). The worst survival was found in patients with pancreatic metastasis (mean 4.2 months) and best survival with lung carcinoid (92% at 5 years).CONCLUSION:In a tertiary referral service, uveal metastasis originates from cancer in the breast, lung, kidney, GI tract, cutaneous melanoma, or others. Overall prognosis is poor with 5-year survival at 23% and worst survival with pancreatic metastasis whereas best survival with lung carcinoid metastasis.

Pilot Study Assessing the Use of High-density Polyethylene (Su-Por) for Tube Shunt Patch Grafts.

To assess the viability of a manufactured high-density polyethylene patch graft material (Su-Por) for prevention of tube shunt exposure. Retrospective review of the first 11 patients from the Wills Eye Hospital Glaucoma Service to receive the high-density polyethylene patch graft during tube shunt surgery. Four patients (36.3%) experienced an extrusion of the Su-Por patch without a leak within 2.5 months of postoperative follow-up. All 4 patients developed either symptomatic or progressive extrusion. Operative repair was completed with Su-Por removal and replacement with a new human donor patch graft. No patient developed any sign of infection despite the extrusions. The remaining 7 patients had an uneventful postoperative course and continue to have no complications from the Su-Por patch with 9 months of follow-up. Given the high rate of extrusion of the Su-Por graft, this material seems to be an inadequate alternative for covering tube shunts. Harvested human tissue or other more flexible, manufactured grafts remain the standard of care for covering tube shunts.

Practice Patterns in the Management of Amblyopia: A Survey Study.

To characterize current practice preferences of pediatric ophthalmologists in the management of amblyopia and whether these are influenced by demographic variables. A 10-question survey was distributed to all pediatric ophthalmologists and fellows attending the Annual Joseph H. Calhoun Pediatric Ophthalmology Forum at Wills Eye Hospital in 2016. The questionnaire consisted of demographic information and clinical management of amblyopia using clinical scenarios commonly encountered in pediatric ophthalmology practice. Of the 133 pediatric ophthalmologists who attended, 74 completed the survey, all of which were included in the data analysis. Seventy-six percent of respondents prescribed refractive correction to a 3 year old with untreated anisometropic amblyopia prior to initiating occlusion therapy. For a child with coexisting exotropia, 57% recommended refractive and occlusion therapy until significant visual improvement, then surgery; however, 30% would perform surgery earlier. Fifty-seven percent stopped occlusion therapy at 10 years of age or older. Sixty-four percent estimated a patient patching compliance rate of 50% to 75%. There was no significant relationship (P < .05) between any of the demographic variables, indicating that no group was more or less likely to respond to the question in any way. This study highlights the lack of a unified approach to certain aspects of amblyopia management. Physician-related demographic variables did not significantly affect clinical decision-making; however, variation did exist among respondents, a finding that warrants further investigation. [J Pediatr Ophthalmol Strabismus. 2018;55(2):100-106.].

Optical Coherence Tomography Findings in Endogenous Fungal Chorioretinitis, Retinitis, and Endophthalmitis.

To describe spectral-domain optical coherence tomography (SD-OCT) findings in eyes with endogenous fungal chorioretinitis and endophthalmitis. Retrospective, observational case series of subjects at Wills Eye Hospital and William Beaumont Hospital were identified by screening OCT billing data and cross-referencing with patient charts. Clinical and imaging data were collected for each patient and reviewed. Twelve eyes of seven consecutive patients were identified, demonstrating two patterns of posterior ocular involvement: chorioretinal infiltration and superficial retinal/retinal vascular infiltration without choroidal involvement. Six of 12 eyes had follow-up imaging performed after antifungal treatment, which demonstrated decreased size of choroidal and/or retinal infiltrates. All patients with follow-up imaging had anatomic improvement by OCT of the lesions with treatment. In the future, OCT imaging may provide a method to assess therapeutic response and prognosis for visual recovery in patients with endogenous fungal ocular disease. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:894-901.].

Adjuvant Sunitinib in High-Risk Patients with Uveal Melanoma: Comparison with Institutional Controls

To compare overall survival in high-risk patients with primary uveal melanoma who received adjuvant sunitinib with institutional controls. Retrospective cohort. Selection criteria were (1) monosomy 3 and 8q amplification by cytogenetic or DecisionDx-UM Class 2 and (2) monosomy 3 and large tumor size (T3-4 by American Joint Committee on Cancer classification). Exclusion criteria were date of diagnosis before 2007 or after 2013 and age <18 years. A cohort of patients who intended to receive adjuvant sunitinib for 6 months was compared with institutional historical controls with the same risk factors. Kaplan-Meier and Cox proportional hazards models were used to analyze the outcome. Propensity score was used to adjust for nonrandom assignment to sunitinib. Overall survival. From the Wills Eye Hospital Oncology Service Uveal Melanoma Cytogenetic Database (N= 1172), 128 patients fulfilled the selection and exclusion criteria. Median follow-up was 52.7 months (range, 0.26-108 months). A total of 54 patients received sunitinib. Their median age was 56 years (range, 29-81 years), and 48% were men. A total of 74 historical controls in the same risk category were identified. Their median age was 62 years (21-80 years), and 48% were men. Patients in the sunitinib group had worse cytogenetic or molecular features (monosomy 3 and 8q amplification or class 2 87% vs. 57%; P < 0.001), had smaller tumor sizes (T3-4 56% vs. 83%; P= 0.001), and were younger. There were 51 deaths, 14 (26%) in the sunitinib group and 37 (50%) in the control group. In the univariate analysis, the sunitinib group had longer overall survival (hazard ratio, 0.53; 95% confidence interval, 0.29-0.99; P= 0.041). In multivariate Cox regression analysis, interaction between use of sunitinib and age as a dichotomous variable was highly significant (P= 0.003). The following variables were statistically associated with prediction of overall survival: cytogenetic/molecular status (P= 0.015), T-size category (P= 0.022), gender (P= 0.040), and adjuvant sunitinib in patients aged <60 years (P= 0.004). Results were confirmed by propensity score analysis. In this retrospective study, the use of sunitinib in the adjuvant setting was associated with better overall survival.

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.

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University. Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App. Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs $3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App. Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend $3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients' level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.

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.