Michael Waisbourd

Purpose: To investigate the effect of change in body mass index (BMI) on intraocular pressure (IOP) in a large cohort of apparently healthy volunteers who underwent an annual comprehensive screening examinations. Methods: This study included individuals who were enrolled in the Tel Aviv Medical Center Inflammation Survey (TAMCIS) and had IOP and BMI measurements at their baseline and follow up visits. Relationships between BMI and IOP and the effect of change in BMI on IOP were investigated. Results: A total of 7,782 individuals had at least one IOP measurement at their baseline visit, and 2,985 individuals had ≥2 visits recorded. The mean (SD) IOP (right eye) was 14.6 (2.5) mm Hg and mean (SD) BMI was 26.4 (4.1) kg/m². IOP positively correlated with BMI levels (r = 0.16, p2) and ≥2 visits, a change in BMI between the baseline and first follow-up visits correlated positively with a change in the IOP (r = 0.23, p = 0.029). Subgroup analysis of subjects who had a reduction of at least 2 BMI units showed a stronger positive correlation between change in BMI and change in IOP (r = 0.29, p2 of BMI was associated with a reduction of 1 mm Hg in IOP. Conclusions: BMI loss correlated with reduction in IOP, and this correlation was more pronounced among morbidly obese individuals.

To report clinical outcomes following ocular injury from foam dart (nerf) blasters - a spring-loaded toy guns that fire foam-coated darts or bullets at a relatively low velocity. These guns gained popularity in recent years among children and adolescents. Eleven patients with ocular injuries from foam dart blasters were included in this retrospective, single-center study. Visual acuity (VA), intraocular pressure (IOP), and anterior segment, glaucoma-related, and vitreoretinal complications were recorded at each visit. The average age at presentation was 13.4 years and 82% were male. Mean initial VA was 6/12 (range 6/6 – 1/18); On initial examination, nine patients (82%) had hyphema, three (27%) had corneal abrasions, three (27%) had vitreous hemorrhage, and two (18%) had traumatic mydriasis. Four patients (36%) experienced glaucoma-related complications, including three (27%) with angle recession and three (27%) with increased IOP. Three patients (27%) were diagnosed with posterior segment injuries, including three (27%) with commotio retinae and one (9%) with severe retinal photoreceptor damage. No patients required surgical intervention. Conclusion: Foam dart blasters can cause severe blunt ocular trauma and permanent visual loss, illustrating the need for eye protection when handling these toys. What is Known: • Foam dart blasters, a blanket term for spring-loaded toy guns that fire foam-coated darts or bullets at a relatively low velocity, have gained popularity in recent years among pediatric populations, with an increase in associated ocular injuries. • To date, scattered case reporting provides insufficient insight into the full clinical spectrum of injury and prognosis of foam dart blasters related ocular injury. What is New: • This case series characterizes the myriad foam dart blasters injuries that may afflict the eye, most of which are self-limiting, but some of which may result in poor visual outcomes and lifelong disability in pediatric patients. • We strongly recommend that all users wear eye protection while using foam dart blasters.

Purpose: To report clinical outcomes following ocular injury from Nerf guns - a spring-loaded toy guns that fire foam-coated darts or bullets at a relatively low velocity. These guns gained popularity in recent years among children and adolescents. Methods: Eleven patients with ocular injuries from Nerf guns were included in this retrospective, single-center study. Visual acuity (VA), intraocular pressure (IOP), and anterior segment, glaucoma-related, and vitreoretinal complications were recorded at each visit.Results: The average age at presentation was 13.4 years and 82% were male. Mean initial VA was 6/12 (range 6/6 – 1/18); On initial examination, nine patients (82%) had hyphema, three (27%) had corneal abrasions, three (27%) had vitreous hemorrhage, and two (18%) had traumatic mydriasis. Four patients (36%) experienced glaucoma-related complications, including three (27%) with angle recession and three (27%) with increased IOP. Three patients (27%) were diagnosed with posterior segment injuries, including three (27%) with commotio retinae and one (9%) with severe retinal photoreceptor damage. No patients required surgical intervention. Conclusion: Foam dart blasters (i.e. Nerf guns) can cause severe blunt ocular trauma and permanent visual loss, illustrating the need for eye protection when handling these toys.

Background: The purpose of this study was to investigate the feasibility and effectiveness of an innovative telemedicine community-based intervention to increase detection of previously undiagnosed ocular diseases in high-risk populations in Israel. Methods: A team comprising an ocular technician, a project manager, and a driver was sent to underserved areas in Israel. Patient demographics, ocular, and medical information were recorded. Visual acuity (VA), intraocular pressure and fundus photographs were obtained. The data were transferred to the Ophthalmology Reading Center in Tel-Aviv Medical Center, where it was interpreted by an ophthalmologist. A letter was sent to the patients indicating examination results. It instructed them to return for a follow-up examination if indicated. Results: A total of 124 individuals underwent telemedicine remote screening examinations in 10 locations. The mean age was 79.9 ± 7.2 years, with female predominance of 67%. The major pathologies detected were (1) reduction in VA >6/12 in at least one eye (n = 48, 38.7%); (2) glaucoma suspicion in the optic disk (n = 18, 14.5%); (3) ocular hypertension >21 mmHg (n = 15, 12.1%); (4) age-related macular degeneration (AMD; n = 15, 12.1%); (5) diabetic retinopathy (n = 6, 4.8%); (6) visually significant cataract (n = 6, 4.8%); and (7) other pathologies (n = 11, 8.9%); 97.7% of the patients reported high satisfaction rates (they were satisfied or very satisfied from the project model). Conclusions: Our pilot telemedicine screening project effectively detected ocular diseases in underserved areas in Israel and helped improve access to eye care. This project has the potential of reaching a national level, allow for early diagnosis, and prevent vision loss and blindness in underserved areas.

Purpose: The purpose of this study was to assess patient interest and willingness to pay (WTP) for teleophthalmology services, whose benefits include improved healthcare access and potential cost savings. Patients and Methods: Cross-sectional study of 215 patients attending a single tertiary center to assess their interest in teleophthalmology. Comparisons between those interested and those not interested were conducted; logistic regression was used to evaluate the effect of price on interest. Results: Two thirds (66.5%) of patients were interested in teleophthalmology instead of in-person clinic visits. Those interested were significantly younger than uninterested patients (48.8± 22.7 vs 62.4± 18.3 years) and were more likely to miss work to attend clinic, own both a computer and smartphone, have experience with video conferencing, and use the internet frequently (all P< 0.05). Interested patients were also more likely to indicate time and cost savings, as well as improved follow-up testing, compared to uninterested patients (both P< 0.001). Overall, 70.4% of interested patients expressed WTP out-of-pocket for teleservices, especially at low (<$14 US dollars) and moderate-high (>$28) price points. Higher level of education was associated with WTP (OR=2.31, 95% CI 1.05– 5.06; P=0.037). Conclusion: Most patients were interested in teleophthalmology services, especially if they were young, would otherwise miss work, and were familiar with electronics, video conferencing, and internet use. Most interested patients expressed WTP out-of-pocket. Targeting factors related to teleophthalmology interest may increase patient use and enhance communication, thereby improving healthcare access and follow-up.

To ascertain determinants of unreadable fundus images for participants enrolled in the Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study. Individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening (Visit 1) included fundus photography, assessing family history of glaucoma, and intraocular pressure (IOP) measurements. Participants with an unreadable image in at least one eye were deemed unreadable and invited to return for a confirmatory eye exam (Visit 2). Nine hundred and six participants completed the Visit 1 eye screening and 17.1% (n=155/906) were “unreadable.” In the multivariable logistic regression analysis, older age, male gender, smoking, and worse visual acuity were significantly associated with an unreadable fundus image finding at the eye screening (P<0.05). Of the 89 participants who were invited for the confirmatory eye exam solely for unreadable images and attended Visit 2, 58 (65.2%) were diagnosed with at least one ocular pathology. The most frequent diagnoses were cataracts (n=71; 15 visually significant, 56 non-visually significant), glaucoma suspects (n=27), and anatomical narrow angle (n=10). Understanding the causes of unreadable fundus images will foster improvements in telemedicine techniques to optimize the predictive accuracy, efficiency, and cost in ophthalmology. A high proportion of participants with unreadable images (65.2%) in our study were diagnosed with some ocular pathology, indicating that the finding of an unreadable fundus image warrants a referral for a comprehensive follow-up eye exam.

Importance: This study evaluates two rapid electrophysiological glaucoma diagnostic tests that may add a functional perspective to glaucoma diagnosis.Background: This study aimed to determine the ability of two office‐based electrophysiological diagnostic tests, steady‐state pattern electroretinogram and short‐duration transient visual evoked potentials, to discern between glaucomatous and healthy eyes.Design: This is a cross‐sectional study in a hospital setting.Participants: Forty‐one patients with glaucoma and 41 healthy volunteers participated in the study.Methods: Steady‐state pattern electroretinogram and short‐duration transient visual evoked potential testing was conducted in glaucomatous and healthy eyes. A 64‐bar‐size stimulus with both a low‐contrast and high‐contrast setting was used to compare steady‐state pattern electroretinogram parameters in both groups. A low‐contrast and high‐contrast checkerboard stimulus was used to measure short‐duration transient visual evoked potential parameters in both groups.Main Outcome Measures: Steady‐state pattern electroretinogram parameters compared were MagnitudeD, MagnitudeD/Magnitude ratio, and the signal‐to‐noise ratio. Short‐duration transient visual evoked potential parameters compared were amplitude and latency.Results: MagnitudeD was significantly lower in glaucoma patients when using a low‐contrast (P = 0.001) and high‐contrast (P < 0.001) 64‐bar‐size steady‐state pattern electroretinogram stimulus. MagnitudeD/Magnitude ratio and SNR were significantly lower in the glaucoma group when using a high‐contrast 64‐bar‐size stimulus (P < 0.001 and P = 0.010, respectively). Short‐duration transient visual evoked potential amplitude and latency were not significantly different between the two groups.Conclusions and relevance: Steady‐state pattern electroretinogram was effectively able to discern between glaucomatous and healthy eyes. Steady‐state pattern electroretinogram may thus have a role as a clinically useful electrophysiological diagnostic tool.

To evaluate the use of short-duration transient visual evoked potentials (VEP) and color reflectivity discretization analysis (CORDA) in glaucomatous eyes, eyes suspected of having glaucoma, and healthy eyes. The study included 136 eyes from 136 subjects: 49 eyes with glaucoma, 45 glaucoma suspect eyes, and 42 healthy eyes. Subjects underwent Humphrey visual field (VF) testing, VEP testing, as well as peripapillary retinal nerve fiber layer optical coherence tomography imaging studies with post-acquisition CORDA applied. Statistical analysis was performed using means and ranges, ANOVA, post-hoc comparisons using Turkey's adjustment, Fisher's Exact test, area under the curve, and Spearman correlation coefficients. Parameters from VEP and CORDA correlated significantly with VF mean deviation (MD) (P<0.05). In distinguishing glaucomatous eyes from controls, VEP demonstrated area under the curve (AUC) values of 0.64-0.75 for amplitude and 0.67-0.81 for latency. The CORDA HR1 parameter was highly discriminative for glaucomatous eyes vs controls (AUC=0.94). Significant correlations are found between MD and parameters of short-duration transient VEP and CORDA, diagnostic modalities which warrant further consideration in identifying glaucoma characteristics.