Matthew Gardiner

Effects of caffeinated coffee consumption on intraocular pressure, ocular perfusion pressure, and ocular pulse amplitude: a randomized controlled trial

PurposeTo examine the effects of caffeinated coffee consumption on intraocular pressure (IOP), ocular perfusion pressure (OPP), and ocular pulse amplitude (OPA) in those with or at risk for primary open-angle glaucoma (POAG).MethodsWe conducted a prospective, double-masked, crossover, randomized controlled trial with 106 subjects: 22 with high tension POAG, 18 with normal tension POAG, 20 with ocular hypertension, 21 POAG suspects, and 25 healthy participants. Subjects ingested either 237 ml of caffeinated (182 mg caffeine) or decaffeinated (4 mg caffeine) coffee for the first visit and the alternate beverage for the second visit. Blood pressure (BP) and pascal dynamic contour tonometer measurements of IOP, OPA, and heart rate were measured before and at 60 and 90 min after coffee ingestion per visit. OPP was calculated from BP and IOP measurements. Results were analysed using paired t-tests. Multivariable models assessed determinants of IOP, OPP, and OPA changes.ResultsThere were no significant differences in baseline IOP, OPP, and OPA between the caffeinated and decaffeinated visits. After caffeinated as compared with decaffeinated coffee ingestion, mean mm Hg changes (±SD) in IOP, OPP, and OPA were as follows: 0.99 (±1.52, P<0.0001), 1.57 (±6.40, P=0.0129), and 0.23 (±0.52, P<0.0001) at 60 min, respectively; and 1.06 (±1.67, P<0.0001), 1.26 (±6.23, P=0.0398), and 0.18 (±0.52, P=0.0006) at 90 min, respectively. Regression analyses revealed sporadic and inconsistent associations with IOP, OPP, and OPA changes.ConclusionConsuming one cup of caffeinated coffee (182 mg caffeine) statistically increases, but likely does not clinically impact, IOP and OPP in those with or at risk for POAG.

Solar Exposure and Residential Geographic History in Relation to Exfoliation Syndrome in the United States and Israel

IMPORTANCE Residential (geographic) history and extent of solar exposure may be important risk factors for exfoliation syndrome (XFS) but, to our knowledge, detailed lifetime solar exposure has not been previously evaluated in XFS. OBJECTIVE To assess the relation between residential history, solar exposure, and XFS. DESIGN, SETTING, AND PARTICIPANTS This clinic-based case-control study was conducted in the United States and Israel. It involved XFS cases and control individuals (all ≥ 60-year-old white individuals) enrolled from 2010 to 2012 (United States: 118 cases and 106 control participants; Israel: 67 cases and 72 control participants). MAIN OUTCOMES AND MEASURES Weighted lifetime average latitude of residence and average number of hours per week spent outdoors as determined by validated questionnaires. RESULTS In multivariable analyses, each degree of weighted lifetime average residential latitude away from the equator was associated with 11% increased odds of XFS (pooled odds ratio [OR], 1.11; 95% CI, 1.05-1.17; P < .001). Furthermore, every hour per week spent outdoors during the summer, averaged over a lifetime, was associated with 4% increased odds of XFS (pooled OR, 1.04; 95% CI, 1.00-1.07; P = .03). For every 1% of average lifetime summer time between 10 am and 4 pm that sunglasses were worn, the odds of XFS decreased by 2% (OR, 0.98; 95% CI, 0.97-0.99; P < .001) in the United States but not in Israel (OR, 1.00; 95% CI, 0.99-1.01; P = .92; P for heterogeneity = .005). In the United States, after controlling for important environmental covariates, history of work over water or snow was associated with increased odds of XFS (OR, 3.86; 95% CI, 1.36-10.9); in Israel, there were too few people with such history for analysis. We did not identify an association between brimmed hat wear and XFS (P > .57). CONCLUSIONS AND RELEVANCE Lifetime outdoor activities may contribute to XFS. The association with work over snow or water and the lack of association with brimmed hat wear suggests that ocular exposure to light from reflective surfaces may be an important type of exposure in XFS etiology.

Achieving Target Refraction after Cataract Surgery

PURPOSE To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institutions Comprehensive Ophthalmology Service. DESIGN Retrospective study. PARTICIPANTS We examined 1275 eye surgeries for this study. METHODS All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. MAIN OUTCOME MEASURES The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. RESULTS We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. CONCLUSIONS This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.

The incidence of intraocular foreign bodies and other intraocular findings in patients with corneal metal foreign bodies.

PURPOSE To review the findings of dilated fundus examinations (DFEs) in patients with the diagnosis of corneal metal foreign body (CMFB) and to assess the likelihood of concomitant intraocular foreign body (IOFB) in this clinical setting. DESIGN Retrospective, case review series. PARTICIPANTS All 288 cases with a new diagnosis of CMFB that had a documented DFE in the emergency department at Massachusetts Eye and Ear Infirmary from January 1, 2008, to December 31, 2008. In addition, all 9 separate cases of metal IOFB seen in the same time period were also reviewed. METHODS The medical records of all patients were individually reviewed. MAIN OUTCOME MEASURES The DFE findings of each visit were analyzed in addition to mechanism of injury, visual acuity and anterior segment abnormalities. RESULTS Of the 288 CMFB cases, all but 1 presented without corneal or conjunctival laceration. The etiologies of the injuries included low- and high-velocity impact. Best-corrected visual acuity ranged between 20/15 and 20/150. The anterior chamber (AC) reaction ranged from quiet to 4+ cells. None of the DFEs revealed an IOFB. Only 1 case had a posterior segment abnormality related to the injury-commotion retinae in the setting of an explosion. There were 14 cases with unrelated DFE findings. Among the separate 9 cases of metal IOFB reviewed, all had a history of high-velocity injury and evidence of corneal or conjunctival laceration. In 1 of the 9 cases, the IOFB was protruding from the cornea; in 2 cases, IOFBs were seen on DFE. Six cases were diagnosed by computed tomography. All documented AC examinations for this group of patients had significant findings such as 4+ cells, hyphema, or lens fragments. CONCLUSIONS The finding of IOFB on a DFE for patients with a CMFB without clinical evidence of penetrating injury is very rare. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Bacterial conjunctivitis in children: a current review of pathogens and treatment.

Acute conjunctivitis can have numerous etiologies, including infectious, both bacterial and viral, and noninfectious, such as allergies or toxins. Typical signs of acute infectious conjunctivitis include conjunctival hyperemia and mucopurulent discharge causing foreign body sensation, tearing, and matting of the eyelids. Other less commons signs include subconjunctival hemorrhage, palpebral papillary reaction, and chemosis. Numerous studies have shown that, in children, bacterial conjunctivitis is more common than viral. One of the frequently quoted studies was published in 1993 by Weiss et al, which reported that almost 78% of 95 patients with conjunctivitis who were assessed by a pediatric ophthalmologist had a bacterial cause. Before this, Gigliotti et al showed similar findings, reporting that 65% of 99 conjunctivitis cases were bacterial whereas only 20% were viral. Acute bacterial conjunctivitis is a significant healthcare concern in the United States in both the pediatric and adult population. In 2005, it was estimated that there were 1,356,693 outpatient visits for conjunctivitis in children <15 years old. The total annual direct cost of treating conjunctivitis by pediatricians in 2005 was

Ocular Blast Injuries in Mass-Casualty Incidents: The Marathon Bombing in Boston, Massachusetts, and the Fertilizer Plant Explosion in West, Texas

130,988,709. In addition to direct costs involving physician visits and medications, there are significant indirect costs related to missed school and time lost from work for those who care for ill children. These were estimated to be an additional

Fingernail-induced corneal abrasions: case series from an ophthalmology emergency department.

33,021,908. The purpose of this study is to highlight the importance of bacterial conjunctivitis in children and to review common pathogens and potential treatments, paying special attention to newer therapies in light of increasing antibiotic resistance.

Assessing Resident Cataract Surgery Outcomes Using Medicare Physician Quality Reporting System Measures

PURPOSE To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. DESIGN Multicenter, cross-sectional, retrospective, comparative case series. PARTICIPANTS Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. METHODS Ocular and systemic trauma data were collected from medical records. MAIN OUTCOME MEASURES Types and severity of ocular and systemic trauma and associations with mechanisms of injury. RESULTS In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. CONCLUSIONS Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Orbital Fractures and Ocular Injury: Is a Postoperative Ophthalmology Examination Necessary?

Purpose: Fingernail-induced corneal abrasions are one of the most common eye injuries that present to the emergency department, and yet there is little literature available to offer guidelines for management. We analyzed the treatment used in cases of fingernail-induced corneal abrasions that presented to the Massachusetts Eye and Ear Infirmary Emergency Department and studied its relationship to the development of complications such as recurrent erosion syndrome and infection. Methods: We performed a retrospective review of 99 patients who presented to the Massachusetts Eye and Ear Infirmary Emergency Department with fingernail-induced corneal abrasions between January 1, 2009 and December 31, 2009. We followed the patients for 12 months and documented demographics, nature of the injury, treatment, and complications. Results: The average age was 29.4 (range, 2–89) years. Forty-four percent (n = 44) were female and 56% (n = 55) were male. Of the 99 subjects, 39 had a full 12 month follow-up, and 7 developed a complication from the injury. Compared with the 32 subjects without complications, there was no difference in age or gender. However, there was a significant difference in that adults scratched by another adult were more highly represented in the group with complications (43%, n = 3/7 vs. 3%, n = 1/32; P = 0.0017). There was no significant difference in outcome by treatment used. Conclusions: This is the largest fingernail-induced corneal abrasion study completed to date. Patients are at risk of developing complications, but there is scant evidenced-based literature available for treating this common injury. Prospective trials should be performed to better optimize and standardize treatments.

Inadvertent filtering bleb due to corneal stromal wick syndrome.

OBJECTIVES To assess resident cataract surgery outcomes at an academic teaching institution using 2 Physician Quality Reporting System (PQRS) cataract measures, which are intended to serve as a proxy for quality of surgical care. DESIGN A retrospective review comparing cataract surgery outcomes of resident and attending surgeries using 2 PQRS measures: (1) 20/40 or better best-corrected visual acuity following cataract surgery and (2) complications within 30 days following cataract surgery requiring additional surgical procedures. SETTING An academic ophthalmology center. PARTICIPANTS A total of 2487 surgeries performed at the Massachusetts Eye and Ear Infirmary from January 1, 2011 to December 31, 2012 were included in this study. RESULTS Of all 2487 cataract surgeries, 98.95% achieved a vision of at least 20/40 at or before 90 days, and only 0.64% required a return to the operating room for postoperative complications. Of resident surgeries, 98.9% (1370 of 1385) achieved 20/40 vision at or before 90 days follow-up. Of attending surgeries, 99.0% (1091 of 1102) achieved 20/40 vision at or before 90 days (p = 1.00). There were no statistically significant differences between resident and attending cases regarding postoperative complications needing a return to the operating room (i.e., 0.65%, or 9 of 1385 resident cases vs 0.64%, or 7 of 1102 attending cases; p = 1.00). CONCLUSIONS Using PQRS Medicare cataract surgery criteria, this study establishes new benchmarks for cataract surgery outcomes at a teaching institution and supplemental measure for assessing resident surgical performance. Excellent cataract outcomes were achieved at an academic teaching institution, with results exceeding Medicare thresholds of 50%. There appears to be no significant difference in supervised trainee and attending cataract surgeon outcomes using 2 PQRS measures currently used by Medicare to determine physician reimbursement and quality of care.