Tedi Begaj

Purpose: West Nile virus (WNV) can cause anterior/intermediate uveitis with characteristic multifocal chorioretinal lesions. Literature on acute manifestations is robust; however there is limited data describing the full spectrum of uveitic manifestations of WNV, treatments in the acute and chronic phase, as well as long-term sequelae. Methods: A retrospective observational study from three academic uveitis practices. Patients diagnosed with WNV based on serologic and imaging findings were selected; data collected included demographics, ocular and systemic co-morbidities, ophthalmic examination findings, and treatment. Results: Eleven patients were included between 2015 to 2023, with a mean follow-up of 128 weeks (∼ 2.5 years). The average patient was a 60-year-old Caucasian (64%) woman (55%); 27% of patients had diabetes. Fifty-five percent presented with 20/20-20/40 Snellen visual acuity. Importantly, 73% of patients in this cohort were hospitalized due to encephalitis or meningitis. Acute findings included anterior inflammation (8 [36.4%] eyes), vitreous inflammation (9 [40.9%] eyes), cystoid macular edema (CME) (6 [27.3%] eyes), non-occlusive retinal vasculitis (5 [22.7%]), and 1 (4.5%) eye with occlusive retinal vasculitis. Two (9.1%) eyes developed secondary peripheral retinal neovascularization requiring anti-vascular endothelial growth factor treatment or laser panretinal photocoagulation. Eight (36.4%) eyes were initially treated with systemic steroids, and 4 (18.2%) eyes required immunomodulatory therapy (IMT) for recurrent CME and retinal vasculitis. Conclusion: WNV uveitis often has a self-limited course but can be intractable in some patients, with long-term control needed for CME and retinal vasculitis with systemic IMT. Ophthalmologists must be aware of the rarer complications that may require intervention.

Purpose: To describe the long-term follow-up of an immunocompetent patient with cytomegalovirus (CMV) retinitis. Methods: A single case was analyzed and a literature review performed. Results: A 47-year-old woman presented with a paracentral scotoma in the left eye. Examination showed parafoveal retinitis. An aqueous fluid tap was positive for CMV on polymerase chain reaction; however, there was no recent surgery or local or systemic immunosuppression. A thorough workup, including pan imaging, was unremarkable. The retinitis resolved with oral valganciclovir and adjuvant intravitreal ganciclovir and foscarnet injections. At the 3-year follow-up, the patient’s disease was inactive without development of systemic illness. Conclusions: In patients presenting with retinitis, the diagnostic use of aqueous polymerase chain reaction is critical, especially in atypical cases in which the retinitis might be associated with CMV.

Objective: To determine the rate of Medicare opt-out among optometrists and ophthalmologists and to contrast the differences in the characteristics and geographic distribution of these populations. Design: A retrospective cross-sectional study. Setting: Using a publicly available Centers for Medicare & Medicaid Services (CMS) data set, we collated data for ophthalmologists and optometrists who opted out in each year between 2005 and 2023. We calculated the rate of opt-out annually in each year window and cumulatively from 2005 to 2023. Comparative analysis was used to identify clinician characteristics associated with opt-out. Main outcomes and measures: Both annual and cumulative rate of ophthalmologist and optometrist opt-out from Medicare. Results: The estimated prevalence of Medicare opt-outs was 0.52% (77/14,807) for ophthalmologists and 0.38% (154/40,526) for optometrists. Ophthalmologists opting out were predominantly male (67.5%), had a longer practice duration (average 31.8 years), and were more often located in urban areas (83.1%), compared to optometrists (53.2% male, average 19.6 years in practice, 59.1% in urban areas, p = 0.04, p<0.001, p75% of identified clinicians were in private practice. Geographical distribution across the US showed variable opt-out rates, with the top 3 states including Oklahoma (3.4%), Arizona (2.1%), and Kansas (1.6%) for ophthalmology and Idaho (4.3%), Montana (3.1%), and Wyoming (1.4%) for optometry. Conclusions and relevance: Few ophthalmologists and optometrists opt-out of Medicare but this trend has significantly increased since 2012. Of those who disenrolled from Medicare, 83% of ophthalmologists were in urbanized areas while 41% of optometrists were in non-urbanized areas. Because reasons for Medicare opt-out cannot be solely determined by administrative data, further investigation is warranted given the potential impact on healthcare accessibility.

Purpose: To determine how often ChatGPT is able to provide accurate and comprehensive information regarding clinical vitreoretinal scenarios. To assess the types of sources ChatGPT primarily uses and to determine whether they are hallucinated. Methods: This was a retrospective cross-sectional study. The authors designed 40 open-ended clinical scenarios across four main topics in vitreoretinal disease. Responses were graded on correctness and comprehensiveness by three blinded retina specialists. The primary outcome was the number of clinical scenarios that ChatGPT answered correctly and comprehensively. Secondary outcomes included theoretical harm to patients, the distribution of the type of references used by the chatbot, and the frequency of hallucinated references. Results: In June 2023, ChatGPT answered 83% of clinical scenarios (33/40) correctly but provided a comprehensive answer in only 52.5% of cases (21/40). Subgroup analysis demonstrated an average correct score of 86.7% in neovascular age-related macular degeneration, 100% in diabetic retinopathy, 76.7% in retinal vascular disease, and 70% in the surgical domain. There were six incorrect responses with one case (16.7%) of no harm, three cases (50%) of possible harm, and two cases (33.3%) of definitive harm. Conclusion: ChatGPT correctly answered more than 80% of complex open-ended vitreoretinal clinical scenarios, with a reduced capability to provide a comprehensive response.

A 47-year-old man presented with a sudden decrease in vision in the right eye and a history of binocular diplopia, bilateral cranial nerve 6 palsies, and an undifferentiated pontine mass. Examination revealed a large optic nerve head mass with optic disc hyperemia, scattered dot hemorrhages, a placoid lesion in the posterior pole, and a mass protruding out of the optic nerve head. What would you do next?

Purpose: Although pivotal trials have demonstrated efficacy of anti–vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment. Methods: Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti–vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated. Results: A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline (P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage. Conclusion: This neovascular age-related macular degeneration cohort received on average eight anti–vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.