Objective The intravitreal injection (IVI) of pharmacological agents is the most commonly performed ocular procedure and is associated with a host of complications. The majority of IVI-related complications data is derived from randomized controlled clinical trials, which report a high adverse event rate. The nature of these protocol-driven trials limit their applicability to the diverse circumstances seen in routine clinical practice. The goal of this study is to determine the prevalence of patient reported IVI-related complications, their risk factors, and the manner in which patients presented in a tertiary eye care center. Design A retrospective, IRB-approved review. Subjects, Participants and/or Controls 44,734 injections in 5,318 unique patients at the Cleveland Clinic Cole Eye Institute from 2012-2016. Methods, Intervention, or Testing Intravitreal injection. Main Outcome Measures Complication occurrence within 15 days of injection. Results From 2012-2016, a total of 44,734 injections were performed in 5,318 unique patients. Overall, complication rates were low, representing 1.9% of all injections, with 1031 unique complications in 685 (12.9%) patients. The most common minor complications, or those not requiring intervention, were irritation (n=312) and subconjunctival hemorrhage (n=284). The most common serious complications, or those requiring intervention, were corneal abrasion (n=46) and iritis (n=31). The majority of complications (66%) were adequately managed by a telephone/Epic electronic message encounter only. Importantly, no injection protocol parameter, such as type of anesthesia, preparation, or post-injection medication, increased the risk of a complication. However, patient sex, age, number of previous injections, and provider strongly influenced the risk of patient-reported complications. Conclusions Overall, complication rates seen in routine clinical practice were low compared to clinical trial reporting. Providers should feel confident in the safety and administration of IVI during times when follow-up office visits and resources may be limited. When performing an IVI, factors such as a patient’s sex, age, number of previous injections, and provider must be taken into account to ensure the best possible outcomes.

Background: Recently, a skeletal maturity system using knee radiographs, named the modified Roche-Wainer-Thissen (RWT) system, has been developed using 7 discrete radiographic parameters. While the system has been shown to significantly outperform the Greulich and Pyle atlas, the effect of rotational variation of the knee radiograph on skeletal maturity determinations has not been studied. Methods: Normal knee computed tomography scans of 12 male children ages 10 to 16 years and 8 female children ages 8 to 14 years were obtained retrospectively, converted into 3-dimensional reconstructions, and then used to simulate knee radiographs in 5 different rotational positions. Images were graded using the modified RWT system, and 1-way repeated measures analysis of variance was used to compare skeletal age in the patella centered view versus the other positions. We next retrospectively found 85 pediatric patients with both bilateral standing anteroposterior hip to ankles and separate knee radiograph within 6 months of each other. The skeletal maturity values from the 2 different radiographs were compared in 39 males between the ages of 10 and 16 years and 46 females between 8 and 14 years of age using paired t test and Wilcoxon-signed rank test. Results: On the computed tomography scan-based images, there was no statistically significant effect of rotational position on the modified RWT score using repeat measures analysis of variance (P = 0.210). Only the width ratio of the tibial epiphysis and metaphysis and the width ratio of the fibular epiphysis and metaphysis were statistically different between rotational positions (P < 0.05). Comparing clinical full length versus knee radiographs, we found a small difference of 0.069 years which trended towards a statistically significant difference (P = 0.009). Conclusions: This retrospective study supports the resilience of the RWT model to rotational variation, reassuring clinicians that bone age estimation can be performed in a slightly rotated knee x-ray within a reasonable margin of error. These results can minimize the number of radiographs needed to assess skeletal maturity limiting radiation exposure and expedite clinical flow. Level of Evidence: Level-III-diagnostic study.

Background:The recently described optimized Oxford skeletal maturity system utilizes anteroposterior (AP) hip radiographs to accurately, rapidly, and reliably estimate skeletal maturity. However, in the real-world setting, significant positional variation in AP hip radiographs may influence the accuracy of optimized Oxford skeletal age estimates. We sought to evaluate the consistency of skeletal age estimations using the optimized Oxford system between differently rotated radiographs. Methods: Thirty normal computerized tomography scans of males (15 children, 9 to 15 y) and females (15 children, 8 to 14 y) were obtained retrospectively, converted into 3D reconstructions, and then used to produce simulated hip radiographs in five different rotational positions. The optimized Oxford system was applied to the 150 simulated AP hip radiographs (5 differently rotated views of 30 hips) to produce a skeletal age estimate for each. Results: Rotational position did not have a statistically significant effect on the skeletal age (P = 0.84) using 1-way repeated measures analysis of variance. Of the 5 radiographic parameters in the optimized Oxford system, only greater trochanter height showed significant rotational variation after Greenhouse-Geisser correction (F 2.58, 74.68 = 5.98, P < 0.001). However, post hoc analyses showed that the greater trochanter height obtained at the most centered position was not different from the other 4 rotational positions (P > 0.05 for all). Conclusion: The optimized Oxford skeletal maturity system is resilient to rotational variation. Mildly to moderately rotated radiographs obtained in the modern clinical setting can be used for skeletal age estimation by this method, broadening the clinical usage of this system.