United States

Background
Meibomian gland disease (MGD) is classically diagnosed using clinical symptoms and eyelid exam. Advancements in meibomian gland imaging can offer an additional, quantitative measure for disease correlation. This study examines whether a patient’s diagnosis of MGD correlates with the severity of meibomian gland dropout assessed through Meibography. 
Methods
Meibography images from 319 lower eyelids of patients with dry eye disease (DED) were collected. Three different graders assigned each image a Meiboscore using a previously validated scale (score 0 = no dropout, score 3 = severe dropout). The mean of the 3 gradings was used to assign a Meiboscore to each eyelid. A retrospective medical records review was performed to determine which cases of DED were made in conjunction with MGD. Diagnosis of MGD was made only based on clinical exam without consideration of Meibography images. 
Results
Of the 319 images included in the study, 46% (148 images) of them came from patients with only DED and 54% (171 patients) came from patients with both DED and MGD. There was no significant difference in age (p=0.73) or gender (p=0.45) between the two groups. The mean Meiboscore for patients diagnosed with DED without associated MGD is 1.81 ± 0.82, while the mean Meiboscore for patients with diagnoses of DED and MGD is 1.63 ± 0.844 (p=0.045, level of significance &lt;0.05). 
Conclusion
Patients diagnosed with DED without diagnosed MGD exhibit significantly more gland dropout than patients with associated MGD. This suggests that patients with DED may be underdiagnosed with MGD. As Meibography becomes more accessible in clinical settings, revision of MGD diagnostics is needed to incorporate Meibography into established criteria. Determining the cause of dry eye disease through meibography can be used in conjunction with techniques like meibum expression and tear analysis to help tailor treatments. For example, can the Meiboscore in combination with other clinical information help us determine if a meibomian gland expression, probing or IPL treatment be most suitable for a particular patient? To decrease the variability in capturing and scoring images, future research should focus on standardizing these measures.


AMA Research Challenge 2023

Identifying the Underdiagnosis of Meibomian Gland Disease
Through Meibography

Background
Meibomian gland disease (MGD) is classically diagnosed using clinical symptoms and eyelid exam. Advancements in meibomian gland imaging can offer an additional, quantitative measure for disease correlation. This study examines whether a patient’s diagnosis of MGD correlates with the severity of meibomian gland dropout assessed through Meibography. 
Methods
Meibography images from 319 lower eyelids of patients with dry eye disease (DED) were collected. Three different graders assigned each image a Meiboscore using a previously validated scale (score 0 = no dropout, score 3 = severe dropout). The mean of the 3 gradings was used to assign a Meiboscore to each eyelid. A retrospective medical records review was performed to determine which cases of DED were made in conjunction with MGD. Diagnosis of MGD was made only based on clinical exam without consideration of Meibography images. 
Results
Of the 319 images included in the study, 46% (148 images) of them came from patients with only DED and 54% (171 patients) came from patients with both DED and MGD. There was no significant difference in age (p=0.73) or gender (p=0.45) between the two groups. The mean Meiboscore for patients diagnosed with DED without associated MGD is 1.81 ± 0.82, while the mean Meiboscore for patients with diagnoses of DED and MGD is 1.63 ± 0.844 (p=0.045, level of significance <0.05). 
Conclusion
Patients diagnosed with DED without diagnosed MGD exhibit significantly more gland dropout than patients with associated MGD. This suggests that patients with DED may be underdiagnosed with MGD. As Meibography becomes more accessible in clinical settings, revision of MGD diagnostics is needed to incorporate Meibography into established criteria. Determining the cause of dry eye disease through meibography can be used in conjunction with techniques like meibum expression and tear analysis to help tailor treatments. For example, can the Meiboscore in combination with other clinical information help us determine if a meibomian gland expression, probing or IPL treatment be most suitable for a particular patient? To decrease the variability in capturing and scoring images, future research should focus on standardizing these measures.

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Pediatric Keratoconus (KCN) is believed to progress more rapidly to cornea transplant surgery (CTS) than adults. This study evaluated children with KCN to identify potential topographic indicators for evaluation for Corneal Collagen Cross-Linking (CXL) in order to halt or lessen the progression of KCN.

A retrospective study was conducted on 27 patients, ages 12-18, that were diagnosed with KCN based on slit-lamp findings, loss of vision, and corneal topography. A total of 50 eyes were included in this study with CXL performed in 33 eyes and 17 untreated. Cross-linked and untreated eyes were compared on anterior mean keratometry (AKm), posterior mean keratometry (PKm), and thinnest pachymetry (TTP) using a two-tailed t-test.

At initial presentation, treated eyes had a mean AKm of 48.4, PKm of -7.3, and TTP of 454.4, whereas untreated eyes had means of 44.8, -6.6, and 495.8, respectively. Additionally, the mean difference for AKm was 3.59 (P = 0.028, 95% CI ±3.18), PKm was -0.637 (P=0.024, 95% CI ± 0.55), and TTP was -41.46 (P=0.022, 95% CI ± 35.23). None of the cross-linked eyes progressed to CTS.

Children with KCN often present with more advanced disease and are at a greater risk of progression than adults. Earlier treatment with CXL may halt or slow progression of KCN. Our results indicate that pediatric KCN patients presenting with steeper AKm and PKm, as well as thinner corneas, should be considered for CXL.

Topographic Findings in the Eyes of Children Treated with Collagen Cross-Linking for Keratoconus

Background
Ocular funduscopic examinations is rarely performed at bedside by non-ophthalmology providers, resulting in diagnostic errors and worse patient outcomes when the correct diagnosis is delayed. This is particularly a concern in emergency departments (ED) where ophthalmologists are not always available for consultation. The goal of this study is to evaluate the short-term impact of the implementation of a non-mydriatic (without pharmacologic dilation of the pupils) fundus camera in a busy ED based in a metropolitan quaternary care center hospital.

Methods
Quality improvement project involving the systematic prospective collection of data from patients who had ocular fundus photographs taken in the ED for visual complaints, headaches, neurologic symptoms, hypertensive crisis. We collected demographic information, indication for fundus photographs and final diagnosis, who ordered photographs, timing of photographs and whether photographs had an impact on the patients’ length of ED stay and final outcomes.

Results
Since the camera was introduced in our ED 6 weeks ago, 148 patients had photographs taken (ordered by ED in 83.9%, ophthalmology in 8.9%, neurology in 7.2%). The reasons included visual complaint 33.5%, headache 20.5%, papilledema 8.9%, hypertension 1.3%, diabetes 0.6%, other neurologic complaints 34.9%. Photographs could be interpreted remotely, avoiding an ophthalmology or neurology consultation in 17.8%. It took less than 5 minutes to obtain photographs (60.2% high quality; 75.2% able to exclude emergent findings. The photographs accelerated the management/disposition of patients with acute disorders in 29.5%, including 8 acute central retinal arterial occlusions, 3 giant cell arteritis, 18 papilledema from intracranial hypertension.

Conclusion
Incorporating a non-mydriatic ocular fundus camera into the ED workflow can be used as a substitute for the funduscopic examination in most cases, allowing for remote fundus interpretation by ophthalmologists who can provide real time recommendations without seeing patients in person. These positive preliminary results obtained only 6 weeks after implementation of the camera suggest that this strategy reduces the overall hospital stay and accelerates the diagnosis of urgent vision- or life-threatening conditions, resulting in improved patients’ outcomes. Further data will be collected over the next few months and results of the first 3 months will be presented at the conference.

Implementation of a Non-mydriatic Ocular Fundus Camera in a Large Emergency Department

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**Abstract:**



Intraocular Pressure Reduction comparing Cataract Extraction and Hydrus Microstent Implantation with Cataract Extraction, Canaloplasty, and Hydrus Microstent Implanation

Automated identification of RIPLs, a potential imaging biomarker of cardiovascular disease

Introduction:
This study explores the feasibility of 3D bioprinting cornea models and contact lenses using digital light processing (DLP) and extrusion printing methods. The goal is to compare the efficiency and results of the BIONOVAX DLP printer and the BIOX6 extrusion printer for potential applications in ophthalmology.

Methods:
Mouse contact lens designs were created using FreeCAD software, and two different materials were used: PEGDA hydrogel for the DLP printer and GelMA collagen-based gel for the extrusion printer. Multiple prints were performed, optimizing parameters to achieve a viable lens structure. Cell viability was assessed by printing with glioblastoma cells and imaging the constructs.

Results:
The BIOX6 printer achieved a more accurate and scalable base curve compared to the BIONOVAX printer. However, the filament diameter of BIOX6 was smaller. BIONOVAX demonstrated a lens thickness of less than 100 microns, while BIOX6 achieved a thickness of 0.21 mm. Print speed differed significantly, with BIONOVAX completing prints in an average of 30 seconds and BIOX6 requiring around 3 minutes.

Conclusion:
BIOX6 showed potential for printing viable lens structures with cells, while BIONOVAX offered higher reliability. Further optimization is needed to enhance the efficiency and replicability of 3D bioprinting. Future research aims to explore different ink properties, optimize lens design, and assess the viability of drug delivery through 3D bioprinted lenses for ocular pathologies like diabetic retinopathy.

Printing the Vision: Advancements in 3D Bioprinting for Cornea and Contact Lens Constructs

Background: Central retinal artery occlusion (CRAO) is associated with painless, unilateral vision loss causing retinal hypoperfusion and ganglion cellular damage. This life-threatening emergency is relatively rare in pediatric populations with causes including trauma, cardiac emboli, and hypercoagulable states. Current evidence-based management for pediatric CRAO is limited, suggesting a critical need to document these isolated presentations. Furthermore, though the patient’s vision is unlikely to be preserved, swift action is essential to prevent death or other comorbidities following CRAO presentation.

Methods: A PubMed search of CRAO in the pediatric population was conducted. Inclusion criteria included patients under 18 years of age at the time of CRAO occurrence with documented fundus findings displaying diffuse central whitening. Branch retinal artery occlusions were excluded. Reporting of CRAO was verified through direct fundus visualization and aided by optical coherence tomography (OCT), fundus photography, and fundus fluorescein angiography. Etiology of CRAO, age, initial and final visual acuity (VA), laterality, follow-up period, workup treatment, and outcome were obtained. A following novel CRAO presentation was included in the study. 

Results: Thirty patients met our inclusion criteria. The mean age of these patients at the initial visit was 11 ± 4.2 years. Visual acuity of 6 patients improved during follow-up, 2 worsened, 8 were unchanged, and 12 patients did not have documented follow-up visual acuity. Average presenting VA was 2.4 ± 0.76 (20/50), and average final VA was 1.54 ± 1.25. The mean LogMAR VA change was -0.26 ± 0.77 over a mean follow-up duration of 18.75 ± 33.01 months. The most common etiologies were thrombotic (8), idiopathic (8), iatrogenic (5), local neoplastic (3), and embolic (3). Notably, pediatric cardiac embolic and systemic thrombotic etiologies were much more common than in the adult population. In contrast, vasculitic and carotid embolic etiologies, the most common causes of adult CRAO, were not seen. The most frequently reported abnormal diagnostic tests were head imaging (16), CBC (complete blood count)/basic metabolic panel (BMP) (11), urinalysis (10), erythrocyte sedimentation rate (ESR)/ C-reactive protein (CRP) (9), and carotid ultrasound or angiogram (7). 

Conclusion: In this review, the most common etiologies of pediatric CRAO were of thrombotic and iatrogenic origin. Our study recommends an initial age-appropriate workup including a magnetic resonance imaging (MRI) of the brain and orbit followed by cardiac imaging, systemic thrombotic workup with head imaging, CBC/BMP, urinalysis, and ESR/CRP.


Systematic Review of Central Retinal Artery Occlusion in Children and Novel Case Presentation

Quantification and Analysis of Laser Peripheral Iridotomies from 2000 to 2021- A National Study

Background

Retinal vascular occlusions (RAVO), such as retinal vein occlusion (RVO) and retinal artery occlusion (RAO), have been shown to be associated with cognitive impairment, including dementia. The purpose of our study is to examine the risk of dementia among patients with retinal vascular occlusion.

Methods

Demographic, clinical, and ophthalmic information was collected for subjects with and without retinal vascular occlusions. 503 subjects with retinal vascular occlusion and 1006 subjects without retinal vascular occlusion (comparison group) seen in an eye clinic were included. Among subjects with retinal vascular occlusions, 432 had retinal vein occlusion (RVO) and 71 had retinal artery occlusion (RAO). Among subjects with retinal vein occlusion, 200 had central RVO (CRVO) and 232 had branch RVO (BRVO). Subjects in the comparison group were age- and sex-matched to those with vascular occlusion. Logistic regression was used to analyze the odds of all-cause dementia, vascular dementia, and Alzheimer’s disease after adjusting for race, ethnicity, diabetes, hypertension, hyperlipidemia, stroke, coronary heart disease, diabetic retinopathy, age-related macular degeneration, and glaucoma.

Results

Subjects with RAVO had increased odds for all-cause dementia (Odds ratio (OR)=2.04, p=0.001) and vascular dementia (OR=2.66, p=0.011). Subjects with RVO had increased odds for all-cause dementia (OR=2.34, p<0.001) and vascular dementia (OR=3.27, p=0.006) relative to the comparison group. Subjects with CRVO (OR=2.34, p=0.013) or BRVO (OR=2.72, p=0.006) had increased odds for all-cause dementia relative to the comparison group. There was no significant association between RAO and the odds for all-cause dementia (OR=1.03, p=0.963).

Conclusion

Central retinal vein occlusions increase the odds of all-cause dementia by over two-fold. Branch retinal vein occlusions increase the odds of all-cause dementia by nearly three-fold. These associations were not seen among patients with retinal arterial occlusions. Retinal vein occlusions also increase the odds of vascular dementia by approximately three-fold.

Risk Factors for Dementia in Patients with Retinal Vein Occlusions

Posterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: A Scoping Review

Background
Cutibacterium, as a ubiquitous, commensal gram-positive organism, represents a diagnostic challenge for arthroplasty surgeons. The characteristics of Cutibacterium culture positivity in THA and TKA are not well understood.

Methods
1: Retrospective chart review of patients with Cutibacterium culture following THA or TKA. 
2: Patient baseline characteristics and lab results were analyzed using T-test and chi-squared analysis. 
3: Those who underwent subsequent surgery were evaluated at one year using MSIS ORT.

Results
Of those with Cutibacterium-positive cultures, 10 of 21 THAs (47.6%) preoperatively met MSIS infection criteria, while 7 of 8 TKAs preoperatively met MSIS criteria (87.5%) (p= 0.13). Mean ESR was 36.4 mm/h for THA and 51.5 mm/h for TKA (p = 0.21), with mean CRP of 35.2 mg/dL for THA and 36.8 mg/dL for TKA (p = 0.95). Mean cell count and percent polymorphonuclear (PMNs) leukocytes from intra-articular aspiration was 27,055 with 68% PMNs for THA and 22,194 with 73.9% PMNs for TKA (p = 0.72 and p = 0.70, respectively). Mean cell count and percent PMNs was 24,143 (range of 95 to 128,205) with 58.9% PMNs for monomicrobial infections and 25,903 with 78.8% PMNs for polymicrobial infections. Of patients who underwent surgical intervention following positive periprosthetic Cutibacterium culture and had one-year follow-up (n =22), 16 (72%) had successful outcomes at one year. Only ASA was significantly different between the success and failure groups.

Conclusion
1) Cutibacterium PJI could lead to more subtle clinical and laboratory changes compared to other microbial species.
2) Patients with Cutibacterium-positive cultures following TKA or THA may not meet MSIS infection criteria.
3) Inflammatory markers and fluid characteristics of Cutibacterium-positive THAs and TKAs were elevated but had more subtle changes compared to accepted values for more virulent microbial species.
4) Patients who undergo surgical intervention following a positive periprosthetic Cutibacterium culture often have successful outcomes at one year.


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Identifying the Underdiagnosis of Meibomian Gland Disease Through Meibography

Next from AMA Research Challenge 2023

Topographic Findings in the Eyes of Children Treated with Collagen Cross-Linking for Keratoconus