Publications by authors named "William J Feuer"

248 Publications

FACTORS INFLUENCING CAREER DECISIONS AND SATISFACTION AMONG NEWLY PRACTICING OPHTHALMOLOGISTS.

Am J Ophthalmol 2021 Jun 19. Epub 2021 Jun 19.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

Purpose: To describe the career choices of newly practicing ophthalmologists and explore factors influencing career decisions and satisfaction.

Methods: A cross-sectional study was conducted using data from an electronic survey of ophthalmologists who completed training within the prior 5 years. The survey included questions about demographic information, medical education, current practice, factors affecting career choices, and career satisfaction. Statistical comparisons were made based on gender, type of practice, subspecialty training, and practice area.

Results: Surveys were completed by 696 (32%) newly practicing ophthalmologists, including 276 (40%) women, 179 (29%) academicians, and 465 (67%) subspecialists. A higher proportion of female respondents entered academics than male respondents (36% vs 26%, P = .009). Female and male respondents pursued fellowship training with similar frequency (64% vs 68%, P = .32), but men were more likely to seek vitreoretinal fellowships (30% vs 11%, P < .001) and women were more likely to undertake fellowships in pediatric ophthalmology (21% vs 8%, P < .001), uveitis (10% vs 2%, P = .002), and neuro-ophthalmology (6% vs 2%, P = .042). A total of 514 (83%) respondents reported being happy with work life.

Conclusions: The career choices of newly practicing ophthalmologists differ based on gender, type of practice, subspecialty training, and practice area. Many factors affect career decisions, and they have varying influence on subgroups within ophthalmology. Ophthalmologists have high levels of career satisfaction. This information may prove useful when developing workforce strategies to meet future eye care needs.
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http://dx.doi.org/10.1016/j.ajo.2021.06.011DOI Listing
June 2021

Treatment Outcomes of Slow Coagulation Transscleral Cyclophotocoagulation In Pseudophakic Patients with Medically Uncontrolled Glaucoma.

Am J Ophthalmol 2021 Apr 20;229:90-99. Epub 2021 Apr 20.

Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

Purpose: Reporting treatment outcomes of slow coagulation transscleral cyclophotocoagulation (TSCPC) as an initial surgical intervention in pseudophakic patients with glaucoma.

Design: Retrospective case series.

Methods: This single academic center study reviewed 74 pseudophakic patients who had a diagnosis of glaucoma and no previous glaucoma surgeries (mean age 82.6 ± 12.5 years; mean follow-up 18.7 ± 9.1 months). The intervention used was slow coagulation continuous wave TSCPC (1250-mW power and 4-second duration). The primary outcome measure was surgical success defined as an intraocular pressure (IOP) of 6-21 mm Hg with a ≥20% reduction from baseline, no reoperation for glaucoma, and no loss of light-perception vision. Secondary outcome measures included glaucoma medication use, visual acuity (VA), and complications.

Results: IOP decreased from 27.5 ± 9.8 mm Hg preoperatively to 16.1 ± 6.3 mm Hg postoperatively (P < .001). The preoperative number of glaucoma medications was 4.1 ± 0.9 and 3.1 ± 1.3 post-TSCPC (P < .001). The cumulative probabilities of success at 1 and 2 years were 60.6 % and 58.5%, respectively. When patients were divided into 2 groups based on their baseline IOP being >21 mm Hg (high group) or ≤21 mm Hg (low group), success rates at 2 years were 64.9% and 45.5%, respectively (P = .144). The mean logarithm of the minimum angle of resolution VA changed from 0.70 ± 0.64 to 1.04 ± 0.87 at the last follow-up visit (P = .01). No serious complications were observed and most of the complications were mild and transient.

Conclusions: Slow coagulation TSCPC has good efficiency, especially in patients with baseline IOP >21 mm Hg, and safety profile as an initial surgical intervention in pseudophakic patients with glaucoma. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.
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http://dx.doi.org/10.1016/j.ajo.2021.04.003DOI Listing
April 2021

Tube Versus Trabeculectomy IRIS Registry 1-Year Composite Outcome Analysis with Comparisons to the Randomized Controlled Trial.

Am J Ophthalmol 2021 07 28;227:87-99. Epub 2021 Feb 28.

Bascom Palmer Eye Institute, Miami, Florida, USA.

Purpose: This study compared 1-year results for the composite treatment outcome from the Tube Versus Trabeculectomy (TVT) randomized controlled trial (RCT) to those from an IRIS (Intelligent Research In Sight) Registry cohort of analogous eyes.

Design: Retrospective clinical study with comparison to an RCT.

Methods: Subjects' eyes in the IRIS Registry received either a glaucoma drainage implant (tube) or underwent trabeculectomy after a previous trabeculectomy and/or cataract extraction and had data for 1-year follow-up analyses.

Outcome: Eyes were classified as failing if they had hypotony (intraocular pressure (IOP) ≤5 mm Hg) or inadequate IOP control (IOP >21 mm Hg or not reduced at least 20% below baseline) on 2 consecutive follow-up visits after 3 months, a reoperation for glaucoma, or no light perception vision and as successful otherwise. Failure risk was compared by treatment, demographic, and clinical variables and was compared to analogous failure risks from the TVT RCT.

Results: The TVT IRIS Registry cohort included 419 eyes, 236 tube eyes (56.3%) and 183 trabeculectomy eyes (43.7%). In this cohort, there was no significant failure risk difference (12.3% for tube eyes and 16.4% for trabeculectomy eyes, P = 0.231). Comparing the studies, there was a significantly greater risk of failure in the TVT IRIS Registry tube eyes than in the TVT RCT tube eyes (3.8%; P <.001). Reasons for treatment failure included reoperations for glaucoma (none in the TVT RCT at 1 year).

Conclusions: Our results were different from those in the TVT RCT. Possible reasons include non-Baerveldt tubes, greater severity among tube eyes, and practice patterns that reflect real-world data, which are different than those in RCTs.
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http://dx.doi.org/10.1016/j.ajo.2021.02.023DOI Listing
July 2021

Treatment Outcomes of Primary Transscleral Cyclophotocoagulation.

Ophthalmol Glaucoma 2021 Jan 8. Epub 2021 Jan 8.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To report treatment outcomes of primary transscleral cyclophotocoagulation (TSCPC) in glaucomatous eyes.

Design: Retrospective noncomparative study.

Participants: Forty-eight eyes with a diagnosis of glaucoma and no previous incisional ocular surgery.

Methods: Continuous-wave TSCPC was applied to the ciliary body.

Main Outcome Measures: The primary outcome measure was surgical success defined as an IOP ≤ 21 mmHg and reduced by 20% or more from baseline, IOP > 5 mmHg, no reoperation for glaucoma, and no loss of light perception vision. Secondary outcome measures included visual acuity (VA) and complications.

Results: Glaucoma eyes were stratified into 2 groups: (1) those with pretreatment IOP >21 mmHg (high group) and (2) those with pretreatment IOP ≤ 21 mmHg (low group). Mean ± standard deviation (SD) IOP at baseline was 30.6 ± 6.3 mmHg in the high group and 16.2 ± 2.8 mmHg in the low group. Mean ± SD number of glaucoma medications at baseline was 4.1 ± 0.8 in the high group and 3.6 ± 1.1 in the low group. Based on our success criteria, the cumulative probability of success during the first year of follow-up was 58.3% in the high group and 28.1% in the low group (P = 0.052). Postoperative mean IOP was significantly lower than baseline IOP in the high group at 1-, 3-, 6-, 12-, and 18-month postoperative visits (P < 0.05). No significant change was observed in IOP at follow-up visits after 1 month in the low IOP group. Throughout the first year of follow-up, both groups required fewer glaucoma medications compared with baseline at the 1-, 3-, 6-, and 12-month postoperative visits (P < 0.05). The most frequent cause of postoperative decrease in VA was cataract in 9 eyes. Decrease in vision resulting from glaucoma was observed in 3 eyes. Complications included prolonged inflammation (11 eyes), iris neovascularization (2 eyes), cystoid macular edema (4 eyes), and hyphema (1 eye). No severe or long-term complications were observed.

Conclusions: Continuous-wave TSCPC was effective in lowering IOP in glaucoma patients without prior incisional ocular surgery whose disease was recalcitrant to medical therapy, particularly those with baseline IOP of more than 21 mmHg.
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http://dx.doi.org/10.1016/j.ogla.2020.12.014DOI Listing
January 2021

Conjunctival Vessels in Diabetes Using Functional Slit Lamp Biomicroscopy.

Cornea 2021 08;40(8):950-957

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL.

Purpose: This study used functional slit lamp biomicroscopy (FSLB) to quantify conjunctival microvessel parameters in individuals with and without diabetes and examined whether these metrics could be used as surrogate markers of diabetes-related complications.

Methods: A cross-sectional study of 98 controls (C), 13 individuals with diabetes without complications (D-C), and 21 with diabetes and related complications (D+C), which included retinopathy, nephropathy, neuropathy, and cardiovascular-, peripheral vascular-, and cerebrovascular diseases, was performed. Bulbar conjunctival metrics (venule diameter, length, axial velocity [Va], cross-sectional velocity [Vs], flow [Q], and branching complexity) were measured using FSLB (digital camera mounted on traditional slit lamp).

Results: The mean age was 60 ± 11 years, and demographics were similar across the groups. Va and Vs significantly differed between groups. Va was 0.51 ± 0.17 mm/s, 0.62 ± 0.17 mm/s, and 0.45 ± 0.17 mm/s in the C, D-C, and D+C groups, respectively (P = 0.025). Similarly, Vs was 0.35 ± 01.12, 0.43 ± 0.13, and 0.32 ± 0.13 mm/s in the C, D-C, and D+C groups, respectively (P = 0.031). Black individuals had increased Va, Vs, and Q compared with White individuals (P < 0.05), but differences in velocities persisted after accounting for race. Among patients with diabetes, Va and Vs correlated with number of organ systems affected (Va: ρ = -0.42, P = 0.016; Vs: ρ = -0.41, P = 0.021). Va, Vs, and Q significantly (P ≤ 0.005) discriminated between diabetic patients with and without complications (area under the receiver operating curve for Va = 0.81, Vs = 0.79, Q = 0.81).

Conclusions: Bulbar conjunctival blood flow metrics measured by FSLB differed between controls, diabetic patients without complications, and diabetic patients with complications. FSLB is a quick, easily accessible, and noninvasive alternative that might estimate the burden of vascular complications in diabetes.
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http://dx.doi.org/10.1097/ICO.0000000000002623DOI Listing
August 2021

The Tube Versus Trabeculectomy IRIS® Registry Study: Cohort Selection and Follow-up and Comparisons to the Randomized Controlled Trial.

Am J Ophthalmol 2021 04 8;224:43-52. Epub 2020 Dec 8.

Bascom Palmer Eye Institute, Miami, Florida, USA.

Purpose: To assess the feasibility of replicating a randomized controlled trial (RCT) with a cohort of eyes, from IRIS® Registry data, analogous to the Tube Versus Trabeculectomy (TVT) RCT cohort and compare characteristics and follow-up.

Design: Comparison of RCT and IRIS Registry cohorts and follow-up.

Methods: We identified a cohort of IRIS Registry eyes (2013-2017) that received either a glaucoma drainage implant (tube) or trabeculectomy after a previous trabeculectomy and/or cataract extraction; extracted clinical and demographic characteristics for baseline surgery and follow-up visits through 1 year; and compared treatment groups in the IRIS Registry cohort and this cohort to the TVT RCT cohort.

Results: The IRIS Registry cohort included 419 eyes: 183 (43.7%) trabeculectomy; 236 (56.3%) tube. There were significant differences between treatment groups, including race (White: trabeculectomy 61.8%, tube 44.9%; Black: trabeculectomy 20.8%, tube 35.6%; P = .003) and the percentage of follow-up visits completed (trabeculectomy 88.4%, tube 83.8%, P = .004). There were also significant differences between the TVT IRIS Registry cohort and the TVT RCT cohort in the percentage of follow-up visits completed (IRIS Registry 85.6%, RCT 96.1%, P < .001) and in the probability of having a 1-year follow-up visit (IRIS Registry 81.4%, RCT 89.2%, P = .011).

Conclusion: The TVT IRIS Registry cohort had several significant treatment group differences at baseline, whereas there had been none in the TVT RCT cohort. Follow-up in the TVT IRIS Registry cohort was inferior to that of the TVT RCT. Some data needed to refine the selection of eyes for the cohort were not available in the IRIS Registry.
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http://dx.doi.org/10.1016/j.ajo.2020.11.014DOI Listing
April 2021

Investigating Vascular Complexity and Neurogenic Alterations in Sectoral Regions of the Retina in Patients With Cognitive Impairment.

Front Physiol 2020 9;11:570412. Epub 2020 Nov 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States.

Evidence is accumulating that cognitive function, and visual impairment may be related. In this pilot study, we investigated whether multifractal dimension and lacunarity analyses performed in sectoral regions of the retina may reveal changes in patients with cognitive impairment (CI) that may be masked in the study considering the whole retinal branching pattern. Prospective age-matched subjects ( = 69) with and with no CI and without the presence of any ophthalmic history were recruited (age > 55+ years). The Montreal Cognitive Assessment (MoCA) was used to measure CI, and full-field electroretinogram (ERG) was performed. Also, visual performance exams were conducted using the Rabin cone contrast test (CCT). Quantification of the retinal structure was performed in retinal fundus images [45 field of view (FOV), optic disk centered] with excellent quality for all individuals [19 healthy controls (HC) and 20 patients with CI] after evaluating the inclusion and exclusion criteria in all study participants recruited ( = 69). The skeletonized vasculature network that comprised the whole branching pattern observable in the full 45° FOV was obtained for each image and divided into nine equal regions (superotemporal, superior, superonasal, macular, optic disk, nasal, inferotemporal, inferior, and inferonasal). The multifractal behavior was analyzed by calculating the generalized dimension Dq (Do, D1, and D2), the lacunarity parameter (Λ), and singularity spectrum f(α) in the nine sectoral skeletonized images as well as in the skeletons that comprised the whole branching pattern observable in the full 45° FOV. The analyses were performed using the ImageJ program together with the FracLac plug-in. Independent sample -tests or Mann Whitney test and Pearson correlation coefficient were used to find associations between all parameters in both groups. The effect size (Cohen's ) of the difference between both groups was also assessed. A -value < 0.05 was considered statistically significant. Significant correlations between multifractal and Λ parameters with the MoCA and implicit time ERG-parameter were observed in the regional analysis. In contrast, no trend was found when considering the whole retinal branching pattern. Analysis of combined structural-functional parameters in sectoral regions of the retina, instead of individual retinal biomarkers, may provide a useful clinical marker of CI.
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http://dx.doi.org/10.3389/fphys.2020.570412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680898PMC
November 2020

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Ophthalmology 2020 09;127(9):e81-e82

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.04.025DOI Listing
September 2020

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Ophthalmology 2020 09;127(9):e79-e80

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.04.014DOI Listing
September 2020

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Ophthalmology 2020 10 29;127(10):e92-e93. Epub 2020 Jul 29.

Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ophtha.2020.05.019DOI Listing
October 2020

Separation and thickness measurements of superficial and deep slabs of the retinal nerve fiber layer in healthy and glaucomatous eyes.

Ophthalmol Glaucoma 2020 Jan-Feb;3(1):66-75. Epub 2019 Nov 20.

Department of Ophthalmology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States.

Purpose: Describe a new method to analyze retinal nerve fiber layer (RNFL) thickness maps.

Design: Cross-sectional study.

Subjects: RNFL thickness maps of healthy and glaucomatous eyes.

Methods: Optical coherence tomography (OCT) RNFL raster scans from 98 healthy and 50 glaucomatous eyes were analyzed. The RNFL thickness maps were separated into superficial (SNFL) and deep (DNFL) slabs through a partial thickness plane set at the modal thickness (mode). Association between mode and OCT signal strength (SS), age, axial length, and visual field mean deviation (VFMD) was tested (Pearson coefficient, ). Thicknesses of inferior and superior SNFL regions (i-,s-SNFL), and inferior, superior, nasal, and temporal DNFL regions (i-,s-,n-,t-DNFL) were calculated. The regions thicknesses were compared between healthy and glaucomatous eyes (t-test) and between glaucomatous eyes with early, moderate, and severe disease (ANOVA and linear regressions of thickness on VFMD). Diagnostic accuracy and correlation with VFMD of RNFL regions thicknesses were calculated as the area under the receiver operating characteristic curve (AUC) and Pearson respectively. <0.05 was considered significant.

Main Outcome: Thickness of regions in SNFL and DNFL slabs.

Results: The mode was not associated with SS, age, axial length, or VFMD, it circumscribed the thicker RNFL around the optic disc of healthy and glaucomatous eyes, and it was used to separate the SNFL and DNFL slabs of RNFL thickness maps. The thickness of the SNFL slab was less in glaucomatous eyes than in healthy eyes (<0.001). S-SNFL and i-SNFL thicknesses (respectively) were 86.0±8.2μm and 87.3±9.6μm in healthy eyes vs. 66.1±9.1μm and 63.4±8.2μm in glaucomatous eyes (<0.001 for both). The thickness of the DNFL slab was similar between groups (=0.19). T-DNFL thickness was 37.0±5.3μm in healthy eyes vs. 33.9±5.0μm in glaucomatous eyes (<0.001); thicknesses of all other DNFL regions were similar. The SNFL regions only thinned with progressively worse glaucoma severity, had excellent AUCs (AUC≥0.95, <0.001), and correlated strongly with VFMD (≥0.60, <0.001).

Conclusions: Glaucomatous RNFL thinning is predominantly detected within a slab with thickness greater than the mode. SNFL thickness has great AUC and correlation with VFMD in glaucomatous eyes. The usefulness for diagnosis and monitoring of glaucoma needs further study.
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http://dx.doi.org/10.1016/j.ogla.2019.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337289PMC
November 2019

Comparing Treatment Outcomes from the Tube Versus Trabeculectomy and Primary Tube Versus Trabeculectomy Studies.

Ophthalmology 2021 02 2;128(2):324-326. Epub 2020 Jul 2.

Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota.

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http://dx.doi.org/10.1016/j.ophtha.2020.06.059DOI Listing
February 2021

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Ophthalmology 2020 07;127(7):e45-e46

Department of Ophthalmology, University of California, Davis, Sacramento, California.

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http://dx.doi.org/10.1016/j.ophtha.2020.02.033DOI Listing
July 2020

Visual Field Outcomes in the Tube Versus Trabeculectomy Study.

Ophthalmology 2020 09 4;127(9):1162-1169. Epub 2020 Mar 4.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To describe visual field (VF) outcomes in the Tube Versus Trabeculectomy (TVT) Study.

Design: Cohort analysis of patients in a multicenter randomized clinical trial.

Participants: A total of 122 eyes of 122 patients, with 61 eyes in both the tube shunt and trabeculectomy groups.

Methods: The TVT Study is a multicenter randomized clinical trial comparing the safety and efficacy of tube shunt surgery (350-mm Baerveldt implant) and trabeculectomy with mitomycin C (MMC) (0.4 mg/ml for 4 minutes) in patients with previous cataract or glaucoma surgery. Enrolled patients underwent perimetry at baseline and annual follow-up visits. The VFs were included if the false-positive rate was ≤20% and false-negative rate was ≤35%. The VFs were excluded if visual acuity <20/400 or loss of ≥2 Snellen lines from baseline was attributed to an etiology other than glaucoma. Longitudinal linear mixed-effects models with best linear unbiased predictions (BLUPs) were applied to estimate rates of change in mean deviation (MD) for each treatment group.

Main Outcome Measure: Rate of MD change during follow-up period.

Results: A total of 436 reliable VFs were analyzed, with an average of 3.6 VFs per eye. Baseline MD was -13.07 ± 8.4 decibels (dB) in the tube shunt group and -13.18 ± 8.2 dB in the trabeculectomy group (P = 0.99). The rate of change in MD was -0.60 dB/year in the tube group and -0.38 dB/year in the trabeculectomy group (P = 0.34). The 95% confidence intervals for the rates of MD change were -0.77 to -0.44 dB/year in the tube group and -0.56 to -0.20 dB/year in the trabeculectomy group. No significant difference in MD slope was seen when patients were categorized by percentage of visits with intraocular pressure (IOP) <18 mmHg or by average IOP. Univariable and multivariable risk factor analyses identified history of diabetes, elevated IOP, and worse MD as baseline factors associated with more rapid VF loss.

Conclusions: Slow rates of VF loss were observed after randomized surgical treatment in the TVT Study, but no significant difference in the rate of VF loss was seen after tube shunt implantation and trabeculectomy with MMC. Patients with diabetes, higher IOP, and more severe VF loss at baseline were at higher risk for VF progression.
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http://dx.doi.org/10.1016/j.ophtha.2020.02.034DOI Listing
September 2020

Ophthalmology Resident Surgical Competence: A Survey of Program Directors.

Ophthalmology 2020 08 20;127(8):1123-1125. Epub 2020 Feb 20.

Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ophtha.2020.02.017DOI Listing
August 2020

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Ophthalmology 2020 04;127(4):e26

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1016/j.ophtha.2019.11.023DOI Listing
April 2020

Long-term PERG monitoring of untreated and treated glaucoma suspects.

Doc Ophthalmol 2020 10 9;141(2):149-156. Epub 2020 Mar 9.

Mc Knight Vision Research Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 1638 NW 10th Ave., Room 101, Miami, FL, 33136, USA.

Purpose: To investigate long-term structural and functional progression of untreated and treated glaucoma suspects (UGS and TGS).

Methods: Retrospective analysis of serial steady-state pattern electroretinogram (PERG), mean retinal nerve fiber layer thickness (RNFLT), and standard automated perimetry mean deviation (SAP-MD) in UGS (N = 20) and TGS (N = 18). Outcome measures were the rates of change (linear regression slopes) of PERG amplitude, PERG phase, mean RNFLT, and SAP-MD over 9.8 ± 1.3 years (15.6 ± 4.2 visits).

Results: The number of patients with significant (P < 0.05) progression slopes for PERG amplitude, PERG phase, RNFLT, and SAP-MD was, respectively, UGS: 5, 0, 4, 2; TGS: 8, 2, 6, 5. In UGS, outcome measures were not correlated with each other. In TGS, both PERG amplitude and RNFLT were significantly (P < 0.05) correlated with SAP-MD (R ≥ 0.58), while PERG amplitude and RNFLT were not correlated with each other (R = 0.43, P = 0.064). The rate of change of SAP-MD was predicted (P < 0.05) by a linear combination of RNFLT slope and PERG amplitude slope.

Conclusions: Results substantiate and extend previous results showing that steady-state PERG amplitude progressively decreased over time in a proportion of glaucoma suspects, with relatively steeper slope in TGS compared to UGS. RNFLT progression also had a steeper slope in TGS compared to UGS; however, progressions of PERG amplitude and RNFLT were not significantly correlated. Both PERG progression and RNFLT progression independently contribute to prediction of visual field progression.
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http://dx.doi.org/10.1007/s10633-020-09760-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483546PMC
October 2020

Age-Related Changes in Choroidal Thickness and the Volume of Vessels and Stroma Using Swept-Source OCT and Fully Automated Algorithms.

Ophthalmol Retina 2020 02 1;4(2):204-215. Epub 2019 Oct 1.

Department of Bioengineering, University of Washington, Seattle, Washington; Department of Ophthalmology, University of Washington, Seattle, Washington. Electronic address:

Purpose: To determine age-related changes in choroidal thickness and the volume of choroidal vessels and stroma using automated algorithms based on structural swept-source OCT (SS-OCT) scans.

Design: Prospective and observational study.

Participants: The study included 144 normal participants with ages ranging from 20 to 88 years.

Methods: A previously reported strategy was used to automatically segment the choroid using SS-OCT structural images. Attenuation correction was applied on B-scans to enhance the choroidal contrast and facilitate more accurate automatic segmentation of the 3-dimensional choroidal vessel and stroma. The parameters that we investigated included mean choroidal thickness (MCT), choroidal vessel volume (CVV), choroidal stroma volume (CSV), choroid vascularity index (CVI), and the choroidal stroma-to-vessel volume ratio (CSVR). Correlations between MCT and choroidal vessel metrics of CVV, CSV, CVI, and CSVR were studied. Regional distributions of MCT and CVI were analyzed using a grid centered on the fovea. Age-related changes in MCT, CVV, CSV, and CVI were studied in the entire scanning region, as well as in the subregions of the grids.

Main Outcome Measures: Age-related changes in MCT, CVV, CSV, and CVI using 6×6-mm and 12×12-mm SS-OCT scans.

Results: The automated choroid segmentations were validated against manual segmentations, and MCT measurements were shown to be in good agreement (P < 0.0001). Choroidal vessel volume and CSV showed significant correlations with MCT (all P < 0.0001). Interestingly, CVI and CSVR were constant, with little variation among all participants regardless of age and MCT (61.1±1.8% and 0.64±0.05, respectively). Measurements on 12×12-mm and 6×6-mm scans showed excellent agreement in all scan regions (all P < 0.0001). While choroidal thickness and choroidal volume, which includes both choroidal vessels and stroma, decrease with age (all P < 0.0001), the CVI and CSVR vary little among all ages in all regions.

Conclusions: Whereas MCT, CVV, and CSV decrease with age, the CVI and CSVR remain constant in all regions with age. Ongoing studies are using these automated algorithms on SS-OCT structural datasets to investigate the diagnostic usefulness of these choroidal parameters in a myriad of ocular and systemic diseases.
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http://dx.doi.org/10.1016/j.oret.2019.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812781PMC
February 2020

Retinal Nonperfusion in Proliferative Diabetic Retinopathy Before and After Panretinal Photocoagulation Assessed by Widefield OCT Angiography.

Am J Ophthalmol 2020 05 13;213:177-185. Epub 2020 Mar 13.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: Widefield swept source optical coherence tomography angiography (WF SS-OCTA) imaging was compared with ultra-widefield (UWF) fluorescein angiography (FA) imaging to better understand changes in retinal nonperfusion before and after panretinal photocoagulation (PRP) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR).

Design: Prospective, observational, consecutive case series.

Methods: Participants with treatment-naïve PDR were imaged using the SS-OCTA 12- × 12-mm scan pattern at baseline and at 1 week, 1 month, and 3 months after PRP. UWF FA was obtained at baseline and 3 months after PRP. Selected eyes were imaged using 5 SS-OCTA 12- × 12-mm scans to create a posterior pole montage, and 5 eyes also underwent SS-OCTA imaging at 6 months and 1 year. Areas of retinal nonperfusion (RNP) were drawn independently by 2 masked graders, and analysis of variance (ANOVA) tests were used to compare areas of RNP over time. Main outcome measurements consisted of areas and boundaries of RNP visualized using WF SS-OCTA and UWF FA.

Results: From January 2018 through January 2019, WF SS-OCTA was performed on 20 eyes with treatment-naïve PDR from 15 patients. Areas of RNP identified on UWF FA images co-localized with RNP areas visualized on WF SS-OCTA images. There were no statistically significant changes in RNP area on WF SS-OCTA images through 3 months after PRP. Even eyes that were severely ischemic at baseline had no significant changes in RNP area 1 year after PRP.

Conclusions: RNP in PDR can be identified at baseline and imaged serially after PRP using WF SS-OCTA. Retinal perfusion in PDR does not change significantly after PRP. The ability of WF SS-OCTA to longitudinally evaluate RNP areas provides additional justification for adopting WF SS-OCTA as the sole imaging modality for clinical management of PDR.
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http://dx.doi.org/10.1016/j.ajo.2020.01.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962743PMC
May 2020

Early Results of Goniotomy with the Kahook Dual Blade, a Novel Device for the Treatment of Glaucoma.

Clin Ophthalmol 2019 2;13:2369-2376. Epub 2019 Dec 2.

Glaucoma Associates of Texas, Dallas, Texas, USA.

Purpose: To report the outcomes of patients who underwent goniotomy with the Kahook Dual Blade (KDB) either as a standalone procedure or in combination with cataract extraction.

Patients And Methods: This retrospective chart review included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016 at Glaucoma Associates of Texas. KDB goniotomy was combined with cataract surgery in 100 eyes. The main outcome measures were postoperative intraocular pressure (IOP) and number of IOP lowering medications.

Results: Preoperatively, mean IOP was 17.1 ± 4.7 mmHg (range 8-34 mmHg) and mean number of IOP lowering medications was 2.4 ± 1.3 (range 0-6). Postoperatively, mean IOP was 14.9 mmHg, 13.9 mmHg, 14.1 mmHg, 14.4 mmHg, and 14.7 mmHg at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.004). Mean numbers of IOP lowering medications were 0.8, 1.0, 1.0, 1.0, and 1.6 at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.001). The cumulative reoperation rates for uncontrolled IOP after KDB were 0%, 1.0%, 2.1%, and 4.6% at 3, 6, 9, and 12 months, respectively. Eyes with a preoperative IOP >21 mmHg were significantly more likely to undergo reoperation (p = 0.038, log-rank test). There were no serious complications at any time point in the follow-up period.

Conclusion: The Kahook Dual Blade results in a reduction in IOP and use of glaucoma medications after one year of follow-up. Further prospective studies are needed to fully characterize safety and efficacy.
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http://dx.doi.org/10.2147/OPTH.S224643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896929PMC
December 2019

Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 3 Years of Follow-up.

Ophthalmology 2020 03 9;127(3):333-345. Epub 2019 Oct 9.

Department of Ophthalmology, University of California, Davis, Sacramento, California.

Purpose: To report 3-year results of the Primary Tube Versus Trabeculectomy (PTVT) Study.

Design: Unmasked multicenter randomized clinical trial.

Participants: Two hundred forty-two eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 in the tube group and 117 in the trabeculectomy group.

Methods: Patients were enrolled at 16 clinical centers and were assigned randomly to treatment with a tube shunt (350-mm Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC; 0.4 mg/ml for 2 minutes).

Main Outcome Measures: The primary outcome measure was the rate of surgical failure, defined as intraocular pressure (IOP) of more than 21 mmHg or reduced less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision. Secondary outcome measures included IOP, glaucoma medical therapy, visual acuity, and surgical complications.

Results: The cumulative probability of failure after 3 years of follow-up was 33% in the tube group and 28% in the trabeculectomy group (P = 0.17; hazard ratio, 1.39; 95% confidence interval, 0.9-2.2). Mean ± standard deviation IOP was 14.0±4.2 mmHg in the tube group and 12.1±4.8 mmHg in the trabeculectomy group at 3 years (P = 0.008), and the number of glaucoma medications was 2.1±1.4 in the tube group and 1.2±1.5 in the trabeculectomy group (P < 0.001). Serious complications requiring reoperation or producing loss of 2 or more Snellen lines developed in 3 patients (2%) in the tube group and 9 patients (8%) in the trabeculectomy group (P = 0.11).

Conclusions: There was no significant difference in the rate of surgical failure between the 2 surgical procedures at 3 years. Trabeculectomy with MMC achieved lower IOP with use of fewer glaucoma medications compared with tube shunt surgery after 3 years of follow-up in the PTVT Study. Serious complications producing vision loss or requiring reoperation occurred with similar frequency after both surgical procedures.
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http://dx.doi.org/10.1016/j.ophtha.2019.10.002DOI Listing
March 2020

Graft-size selection and anisometropia reduction in penetrating keratoplasty (PKP).

PLoS One 2019 20;14(6):e0218199. Epub 2019 Jun 20.

Bascom Palmer Eye Institute, Department of Ophthalmology, Miller School of Medicine at the University of Miami, Miami, Florida, United States of America.

Purpose: To compare the amount of myopia induced by same-size donor-to-host penetrating keratoplasty with that of the amount of myopia induced by over-sized donor-to-host penetrating keratoplasty.

Setting: Tertiary referral academic center.

Design: Retrospective cohort study.

Methods: Charts from patients who underwent penetrating keratoplasty by the same technique at Bascom Palmer Eye Institute between Nov 1, 2002, and January 1, 2006, were reviewed. The patients underwent optical penetrating keratoplasty using 12 interrupted 10-0 nylon sutures and a 12-bite continuous 10-0 nylon suture by a single surgeon (R.K.F.). The surgical technique used would be considered standard of care at most institutions. The Institutional Review Board, University of Miami Human Subjects Research Office, approved the study protocol. The donor graft was over-sized by 0.25mm in eyes when the intended final refractive target was greater than -1.00 diopters spherical equivalent (SE). The same-size donor graft was used when the intended final refractive target was less than -1.00 diopters SE. The selection of donor graft size was entirely based upon clinical parameters, meaning that the intended final refractive target was determined per each patient's fellow eye refraction, with the intention of reducing anisometropia. All patients received postoperative refraction and corneal topography. These measurements were performed at 6-8 weeks when the initial removal of sutures commenced, then at 6 months, then after completion of selective suture removal, then again at 12 months.

Results: At 12 months, the over-sized group resulted in -1.35 diopters (SD = 2.25) SE of refraction, and the same-size group resulted in -0.14 diopters (SD = 2.42) SE. This approached statistical significance (p = 0.052) in comparison to -1.00 diopters spherical equivalent.

Conclusions: Using a donor graft that is over-sized by 0.25mm results in refraction of -1.00 diopters SE or more of myopia. Using a same-size donor-graft results in refraction of less than -1.00 diopters SE. Therefore, careful graft-size selection can result in a more favorable clinical outcome-namely, reduction in anisometropia-in patients undergoing penetrating keratoplasty.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218199PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586274PMC
February 2020

Warning: Do Not Treat Intermediate AMD with Laser Therapy.

Ophthalmology 2019 06;126(6):839-840

Miami, Florida.

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http://dx.doi.org/10.1016/j.ophtha.2018.12.016DOI Listing
June 2019

Reply.

Ophthalmology 2019 04;126(4):e32-e33

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1016/j.ophtha.2018.11.024DOI Listing
April 2019

Assessing nonsedated handheld cone flicker electroretingram as a screening test in pediatric patients: comparison to sedated conventional cone flicker electroretinogram.

J AAPOS 2019 02 6;23(1):34.e1-34.e5. Epub 2019 Jan 6.

Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To assess the RETeval (LKC Technologies, Gaithersburg, MD) handheld electroretingram (ERG) device as a screening tool for cone dysfunction in pediatric patients by comparing it to conventional ERG.

Methods: Patients scheduled for ERG under general anesthesia (GA) underwent three tests: (1) RETeval standard 30 Hz cone flicker ERG using skin electrodes prior to GA, (2) E3 Diagnosys (Diagnosys LLC, Lowell, MA) conventional complete standard protocol full-field ERG using bipolar contact lens electrodes and handheld stimulus under GA, and (3) repeat RETeval testing under GA. The 30 Hz cone flicker amplitudes and implicit times from the three methods were compared. Negative and positive predictive values were calculated by applying a previously established 5 μV amplitude cut-off.

Results: Thirty patients ≤18 years of age were enrolled. Impaired conventional ERGs were found in 18 patients. Compared to conventional ERG under GA, RETeval cone flicker amplitudes were smaller before GA (mean difference, -42.2 ± 45.3 μV) and under GA (-37.1 ± 44.5 μV), likely due to skin electrode; and implicit times were shorter before GA (-1.06 ± 2.83 ms) and longer under GA (1.28 ± 4.12 ms), likely due to GA. Comparing RETeval responses before and under GA, the amplitudes were lower (-3.05 ± 6.82 μV), and implicit times were shorter (-2.25 ± 3.28 μV) before GA. Overall, the positive predictive value of the RETeval was 85%; the negative predictive value, 90%.

Conclusions: The unsedated handheld RETeval 30 Hz cone flicker ERG is a feasible screening test for detecting cone dysfunction in pediatric patients. Full-protocol ERG is needed when screening ERG is reduced, equivocal, or clinically warranted.
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http://dx.doi.org/10.1016/j.jaapos.2018.09.009DOI Listing
February 2019

Detecting Glaucoma Progression Using Guided Progression Analysis with OCT and Visual Field Assessment in Eyes Classified by International Classification of Disease Severity Codes.

Ophthalmol Glaucoma 2019 Jan - Feb;2(1):36-46. Epub 2018 Nov 15.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Palm Beach Gardens, Florida.

Purpose: To compare the detection and rates of progressive retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL) loss with spectral-domain (SD) OCT and visual field (VF) loss using Guided Progression Analysis (GPA; Carl Zeiss Meditec, Dublin, CA) in glaucomatous eyes classified using International Classification of Diseases (ICD) diagnosis codes.

Design: Retrospective cohort study.

Participants: Glaucoma patients with at least 3 years of follow-up and a minimum of 4 SD OCT and 5 reliable VF examinations.

Methods: Glaucoma severity was classified using ICD, 10th Edition, Clinical Modification, diagnosis codes. Rates of RNFL, macular GCIPL, and VF loss were calculated, and progression estimates were compared using generalized estimating equations and McNemar's tests.

Main Outcome Measures: Progressive RNFL, GCIPL, and VF loss assessed by GPA criteria.

Results: A total of 147 eyes of 116 patients (mean age, 69.9±8.5 years) were included with mean follow-up of 69.67±18.64 months. Overall, 38 of 147 eyes (25.9%) showed RNFL progression, 35 eyes (23.8%) showed GCIPL progression, and 20 eyes (13.6%) showed VF progression. Progression by all 3 methods was noted in 10 eyes (7.0%). Eyes with mild (n = 62) and severe (n = 46) glaucoma showed significantly more progression on SD OCT compared with VF (P < 0.001 and P = 0.004). Retinal nerve fiber layer, GCIPL, and VF progressors showed faster rates of loss in average RNFL, GCIPL, and VF mean deviation compared with nonprogressors (mean ± standard error: -1.47±0.30 μm/year vs. -0.03±0.12 μm/year [P = 0.0001], -1.68±0.34 μm/year vs. -0.29±0.07 μm/year [P = 0.0001], and -1.07±0.20 dB/year vs. -0.19±0.04 dB/year [P = 0.0001], respectively).

Conclusions: Spectral-domain OCT progression was significantly more common than VF progression in glaucomatous eyes classified with mild and severe disease. Structure and function should be monitored closely across the entire spectrum of glaucoma severity.
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http://dx.doi.org/10.1016/j.ogla.2018.11.004DOI Listing
November 2018

Automated instrument designed to determine visual photosensitivity thresholds.

Biomed Opt Express 2018 Nov 18;9(11):5583-5596. Epub 2018 Oct 18.

Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA.

The Ocular Photosensitivity Analyzer (OPA), a new automated instrument to quantify the visual photosensitivity thresholds (VPT) in healthy and light sensitive subjects, is described. The OPA generates light stimuli of varying intensities utilizing unequal ascending and descending steps to yield the VPT. The performance of the OPA was evaluated in healthy subjects, as well as light sensitive subjects with achromatopsia or traumatic brain injury (TBI). VPT in healthy, achromatopsia, and TBI subjects were 3.2 ± 0.6 log lux, 0.5 ± 0.5 log lux, and 0.4 ± 0.6 log lux, respectively. Light sensitive subjects manifested significantly lower VPT compared to healthy subjects. Longitudinal analysis revealed that the OPA reliably measured VPT in healthy subjects.
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http://dx.doi.org/10.1364/BOE.9.005583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238927PMC
November 2018

Effect of prostaglandin analogs on matrix metalloproteinases and tissue inhibitor of metalloproteinases in eyelid muscle specimens.

Clin Ophthalmol 2018 11;12:2039-2046. Epub 2018 Oct 11.

Bascom Palmer Eye Institute, Miami, FL, USA,

Purpose: To characterize the effect of prostaglandin analogs (PAs) on tissue specific expression of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs) in levator aponeurosis resections (LAR) and conjunctiva-Muller muscle resections (CMMR).

Methods: Specimens from LAR and CMMR of PA users and non-users were analyzed for tissue specific expression of MMP-3, MMP-7, MMP-9 and TIMP-2 using immunohistochemistry. PA use, marginal reflex distances, levator function and palpebral fissure were documented through chart review. The associations between MMP expression, PA exposure time and ocular characteristics were evaluated with a two-factor analysis of variance and multiple correlation analysis.

Results: We observed a tissue specific pattern of expression of MMPs and TIMP-2 in relation to PA exposure between CMMR and LAR specimens. There was increased MMP-7 and TIMP-2 expression in muscle compared to collagen and adipose tissue (≤0.005), as well as a statistically significant difference in the relationship of MMP-3, MMP-9 and TIMP-2 levels to PA exposure in the two types of muscles (all ≤0.011). Adipose tissue had a PA-dependent reduced expression of MMP-3 (<0.022), which was seen in both LAR and CMMR. Decreased expression of MMP-3 in collagen correlated with increased dermatochalasis (<0.045) and steatoblepharon (<0.018).

Conclusion: PA exposure may affect MMP and TIMP expression in a tissue specific manner, and decreased expression of certain MMPs in collagen correlates to increased clinical measures of prostaglandin associated periorbitopathy (PAP). Further studies with larger samples are needed to ascertain if the changes associated with PAP are due to MMP/TIMP changes or to structural changes.
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http://dx.doi.org/10.2147/OPTH.S178106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188183PMC
October 2018
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