Purpose To determine predictors of reoperation and abnormal binocularity outcomes (including amblyopia and diplopia) following pediatric strabismus surgery. Design Retrospective cross-sectional study. Methods Setting: Review of a national insurance database. Study population: Children under age 18 years having strabismus procedures between 2007 and 2013. Interventions: Adjustable or fixed suture strabismus surgery, or botulinum toxin injection. Outcome measures: Reoperation or diagnosis of abnormal binocularity in the first postoperative year. Results Of 11,115 children having strabismus procedures, 851 (7.7%) underwent reoperation. The reoperation rate was 7.4% for fixed suture surgeries, 9.6% for adjustable suture surgeries (p=0.18), and 44.9% for botulinum injections (p<0.001). Age under 2 years was associated with higher reoperation and abnormal binocularity rates (p<0.001). For horizontal strabismus, the postoperative abnormal binocularity rate was 12.8% for fixed suture surgery and 26.5% for botulinum injection (p=0.005). Reoperation rates tended to be higher with adjustable sutures (odds ratio [OR] 1.69, 95% confidence interval [CI] 0.94 to 3.03, p=0.08), or botulinum toxin injection (OR 10.36, 95% CI 5.75 to 18.66, p<0.001) and lower with 3- or 4-muscle surgery (p=0.001). Esotropia, hyperopia, and botulinum injection were independently associated with higher rates of postoperative abnormal binocularity (p<=0.005). For vertical surgeries, predictors of reoperation were adjustable suture use (OR 2.51, p=0.10) and superior oblique surgery (OR 2.36, p<0.001). Conclusions Adjustable sutures were not associated with a lower reoperation rate in children. Younger age, esotropia, hyperopia, and botulinum injection were associated with postoperative abnormal binocularity. Superior oblique surgery and botulinum injection were associated with higher rates of reoperation.

Degenerative retinal disease leads to significant visual morbidity worldwide. Diabetic retinopathy and macular degeneration are leading causes of blindness in the developed world. While current therapies for these diseases slow disease progression, stem cell and gene therapy may also reverse the effects of these, and other, degenerative retinal conditions. Novel therapies being investigated include the use of various types of stem cells in the regeneration of atrophic or damaged retinal tissue, the prolonged administration of neurotrophic factors and/or drug delivery, immunomodulation, as well as the replacement of mutant genes, and immunomodulation through viral vector delivery. This review will update the reader on aspects of stem cell and gene therapy in diabetic retinopathy, age-related macular degeneration, retinitis pigmentosa and other less common inherited retinal dystrophies. These therapies include the use of adeno-associated viral vector-based therapies for treatment of various types of retinitis pigmentosa and dry age-related macular degeneration. Other potential therapies reviewed include the use of mesenchymal stem cells in local immunomodulation, and the use of stem cells in generating structures like three-dimensional retinal sheets for transplantation into degenerative retinas. Finally, aspects of stem cell and gene therapy in diabetic retinopathy, age-related macular degeneration, retinitis pigmentosa, and other less common inherited retinal dystrophies will be reviewed.

BackgroundSarcoidosis often involves pathological dysregulation of dependent factors of bone metabolism, e.g. calcitriol /calcium, and administration of high dose glucocorticoids (GCs) leading to low bone mineral density (LBMD). Traditional risk factors for LBMD include advancing age, female sex, low body mass index (BMI), smoking, white race and GCs. LBMD in sarcoidosis is presumed but not yet described.MethodsA retrospective chart review of biopsy-diagnosed patients with sarcoidosis for >1 year extracted and compared variables of prevalence, age (at chart review), sex, race, smoking status and designation of LBMD defined as osteopenia or osteoporosis with a T-score of ≤ -1 on DXA. Calculations were performed by non-parametric analyses using Fisher's exact for categorical data and Mann Whitney tests for continuous variables.Results269 charts were reviewed and 109 had documentation of biopsy. Of these 109, 61 patients (86.9% Black) had documentation of DXA, 38 (62.3%) with LBMD (30 with osteopenia and 8 with osteoporosis). Although patients with BMI ≥30 had a significantly lower incidence of LBMD vs. those with BMI <30, LBMD incidence exceeded reported in CDC data for overweight subjects. No differences (table) were seen in incident LBMD in patients age ≥ vs <65, in ever vs never smokers (no significant age difference between groups), nor in males vs females (despite females being significantly older than males with median 54 and 48 respectively).ConclusionsFactors protective against LBMD in the general population were not demonstrated in this retrospective sarcoidosis predominantly black cohort. A lower risk of LBMD was not conferred by age <65, male gender, or non-smoking status. While BMI appeared to confer protection, the prevalence in obese sarcoidosis patients supersedes that in CDC reported data. These trends suggest an abnormal signal of incident LBMD in this population differing from the general population. Lack of uniformity of documentation inherent in retrospective methods limits the assessment of important associative and causative influences such as duration and dose of GCs, biomarkers of bone metabolism (e.g. calcium, calcitriol, etc) and fracture risk which will be examined in our prospective sarcoid registry. Nevertheless these findings are important and support increased vigilance in GC use and perhaps consideration to initiate GC sparing agents earlier in the disease course, as well as routine DXA screening in sarcoidosis.AcknowledgementsThis research was funded by grant #T35HL105350 from the National Heart, Lung and Blood Institute.Disclosure of InterestM. Walker: None declared, A. Janot: None declared, H. Grewal: None declared, M. Yu: None declared, M. Lammi: None declared, L. A. Saketkoo Grant/research support from: ACR/EULAR Exchange Awardee

Pineles et al 1 studied binocular summation, defined as the improvement in visual acuity (VA) using binocular vision compared with the better eye alone. The authors reported that strabismus surgery was associated with average improvements in binocular summation of 0.8 letters for VA and of 1.5 and 2.6 letters for VA at 2.5% and 1.25% contrast, respectively. 1 The interpretation of the results might be aided by additional information. A more positive binocular summation value can result from better binocular vision, or from worse vision in the better eye. Consider a patient with a preoperative VA of 20/20, both binocularly and in the better eye. If the postoperative VA decreases to 20/25 binocularly and to 20/30 in the better eye, the patient will be reported to have an improvement in binocular summation of 1 line, despite the fact that the patient does not see as well. To address this possibility, it would be of value if the authors could report the mean preoperative and postoperative binocular and better-eye VA and contrast VA as well as the paired t-test value.

Purpose: Intravitreal injection therapy (IVIT) has transformed the management of many chorioretinal diseases. Although these treatments are effective, they can also be expensive. Using the Medicare Provider and Utilization Data Report (MPUDR), we aim to quantify the costs of these drugs to Medicare and to project future cost trends. Methods: Data were harvested from the MPUDR for all ophthalmology providers who delivered intravitreal injections (IVT) (CPT code 67028) during the years 2012-2016. Linear regression utilizing the MPUDR data was used to analyze cost trends and to project Medicare costs out to year 2026. Results: From 2012 to 2016, the total number of IVTs increased from 2 286 593 to 2 936 274 ( R2 = 0.98; P = .001). The per-beneficiary Medicare cost rose significantly from $3,148 to $3,945 ( R2 = 0.92; P = .03). The total cost to Medicare for IVIT increased from $1.68 billion to $2.73 billion ( R2 = 0.99; P < .005). IVIT accounts for 37% of all ophthalmology Medicare reimbursements. At the current rate, IVIT costs will exceed $5 billion per year by 2026. Conclusions: The total number of injections and costs for IVIT rose significantly from 2012 to 2016. At the current rate, Medicare reimbursement for brand-name drugs will make up a large proportion of future costs.