Summary Rapamycin increases lifespan in mice, but whether this represents merely inhibition of lethal neoplastic diseases, or an overall slowing in multiple aspects of aging is currently unclear. We report here that many forms of age-dependent change, including alterations in heart, liver, adrenal glands, endometrium, and tendon, as well as age-dependent decline in spontaneous activity, occur more slowly in rapamycin-treated mice, suggesting strongly that rapamycin retards multiple aspects of aging in mice, in addition to any beneficial effects it may have on neoplastic disease. We also note, however, that mice treated with rapamycin starting at 9 months of age have significantly higher incidence of testicular degeneration and cataracts; harmful effects of this kind will guide further studies on timing, dosage, and tissue-specific actions of rapamycin relevant to the development of clinically useful inhibitors of TOR action.

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PURPOSE To analyze the reasons for patient dissatisfaction after phacoemulsification with multifocal intraocular lens (IOL) implantation and the outcomes after intervention. SETTING Emory Eye Center, Atlanta, Georgia, USA. METHODS This retrospective review comprised eyes of patients dissatisfied with visual outcomes after multifocal IOL implantation. Outcomes analyzed included type of visual complaint, treatment modality for each complaint, and degree of clinical improvement after intervention. RESULTS Thirty-two patients (43 eyes) reported unwanted visual symptoms after multifocal IOL implantation, including in 28 eyes (65%) with an AcrySof ReSTOR IOL and 15 (35%) with a ReZoom IOL. Thirty patients (41 eyes) reported blurred vision, 15 (18 eyes) reported photic phenomena, and 13 (16 eyes) reported both. Causes of blurred vision included ametropia (12 eyes, 29%), dry eye syndrome (6 eyes, 15%), posterior capsule opacification (PCO) (22 eyes, 54%), and unexplained etiology (1 eye, 2%). Causes of photic phenomena included IOL decentration (2 eyes, 12%), retained lens fragment (1 eye, 6%), PCO (12 eyes, 66%), dry-eye syndrome (1 eye, 2%), and unexplained etiology (2 eyes, 11%). Photic phenomena attributed to PCO also caused blurred vision. Thirty-five eyes (81%) had improvement with conservative treatment. Five eyes (12%) did not have improvement despite treatment combinations. Three eyes (7%) required IOL exchange. CONCLUSIONS Complaints of blurred vision and photic phenomena after multifocal IOL implantation were effectively managed with appropriate treatment. Few eyes (7%) required IOL exchange. Neodymium:YAG capsulotomy should be delayed until it has been determined that IOL exchange will not be necessary.

Objectives: To analyze outcomes of resident-performed phacoemulsifications and to assess the resident phacoemulsification learning curve. Methods: Retrospective chart review of residentperformed phacoemulsification cases at the Atlanta Veterans Affairs Medical Center, Decatur, Georgia, from July 1, 1999, through June 30, 2002. Outcomes measured included postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), intraoperative complications, and adjusted phacoemulsification times (total phacoemulsification time multiplied by phacoemulsification power used). Results: We analyzed 680 cases. Postoperative mean UCVA was 20/39, and mean BSCVA was 20/25 (Ն 20/20 in 44.0% of cases and Ն20/40 in 97.8%). There were no differences in visual acuity outcomes over the course of residency training. Intraoperative complications occurred in 34 cases (5.0%), with a significant reduction in vitreous loss rates after the first 80 resident cases (5.1% vs 1.9%; P=.03). Mean adjusted phacoemulsification time was 0.68 minutes, with a significant reduction in adjusted phacoemulsification time after the first 80 cases (0.87 vs 0.52 minutes; P Ͻ.001). Conclusions: Quality visual outcomes after phacoemulsification can be attained throughout residency training; however, surgical competency, when measured by complication rates and phacoemulsification efficiency, continues to improve significantly with increasing surgical experience well beyond the first 80 resident phacoemulsification cases.

Purpose Several small-scale studies have reported associations between keratoconus (KCN) and an array of systemic diseases but no large-scale study has fully investigated this topic. The purpose of this study is to determine whether an association exists between common systemic diseases, sociodemographic factors, and KCN among a large, diverse group of insured individuals in the United States. Design Retrospective longitudinal cohort study Participants 16,053 patients with KCN were matched 1:1 to 16,053 persons without KCN. Methods Persons with KCN were identified using International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) billing codes and matched by age, sex, and overall health to a control group with no record of KCN. A multivariable logistic regression assessed whether sociodemographic factors and certain systemic diseases affected the odds of KCN. Main Outcome Measures Odd ratios (OR) with 95% confidence intervals (CI) of KCN Results After adjustment for confounders, blacks (adjusted OR=1.57, CI: 1.38–1.79, p<0.001) had 57% higher odds and Latinos (adjusted OR=1.43, CI: 1.26–1.62, p<0.001) had 43% higher odds of being diagnosed with KCN compared with whites. Asians had 39% reduced odds (OR=0.61, CI: 0.50–0.75, p<0.001) of being diagnosed with KCN compared to whites. Patients with uncomplicated diabetes mellitus (DM) had 20% lower odds of KCN (adjusted OR=0.80, CI: 0.71–0.90, p=0.002) while patients with DM complicated by end-organ damage had 52% lower odds of having KCN (adjusted OR=0.48, CI: 0.40–0.58, p<0.001) compared to those without DM. Persons with collagen vascular disease had 35% lower odds of KCN (adjusted OR=0.65, CI: 0.47–0.91, p=0.01). Other conditions found to have increased odds of KCN included sleep apnea (adjusted OR=1.13, CI: 1.00–1.27, p=0.05), asthma (adjusted OR=1.31, CI: 1.17–1.47, p<0.001), and Down syndrome (adjusted OR=6.22, CI: 2.08–18.66, p<0.001). There was no association between KCN and allergic rhinitis, mitral valve disorder, aortic aneurysm, or depression (p>0.1, for all comparisons). Conclusions Clinicians caring for persons with KCN should inquire about difficulties with breathing or sleeping and, when appropriate, refer patients to undergo evaluation for conditions such as sleep apnea or asthma. Lower risk of KCN in those with DM, potentially due to corneal glycosylation, opens an interesting area of research.

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan’s syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Purpose To determine the frequency of visits to emergency departments (EDs) for non-urgent and urgent ocular conditions and risk factors associated with utilization of the ED for non-urgent and urgent ocular problems. Design Retrospective longitudinal cohort analysis Participants All enrollees age ≥ 21 years old in a U.S. managed care network from 2001-2014. Methods We identified all enrollees who presented to an ED with ocular conditions identified by International Classification of Diseases, 9th Revision billing codes. We designated each diagnosis as “urgent”, “non-urgent”, or “other”. We assessed the frequency of ED visits for urgent and non-urgent ocular conditions and how they changed over time. Next, we performed multivariable Cox regression modeling to determine factors associated with visiting an ED for urgent or non-urgent ocular conditions. Main Outcome Measures Hazard ratios (HR) with 95% confidence intervals (CI) of visiting an ED for urgent or non-urgent ocular conditions. Results Of the 11,160,833 enrollees eligible for this study, 376,680 (3.4%) had ≥1 ED visit for an eye-related problem over a mean ± standard deviation of 5.4 ± 3.3 years follow-up. Among the 376,680 enrollees who visited the ED for ocular conditions, 86,473 (23.0%) had ≥1 ED visits with a non-urgent ocular condition and 25,289 (6.7%) had ≥1 ED visit with an urgent ocular condition. ED utilization for non-urgent ocular problems was associated with younger age (p<0.0001 for all comparisons), black race or Latino ethnicity (p<0.0001 for both), male sex (p<0.0001), lower income (p<0.0001 for all comparisons), and those who frequently presented to an ED for non-ophthalmologic medical problems in a given year (p<0.0001). Enrollees with established eye care professionals had a 10% reduced hazard of visiting the ED for non-urgent ocular conditions (adjusted HR=0.90 [CI 0.88-0.92], p<0.0001). Conclusions Nearly one quarter of all enrollees in this managed care network who visited the ED for ocular problems were diagnosed with non-urgent conditions. Better educating and incentivizing patients to seek care for non-urgent ocular diseases in an office-based setting instead of an ED could potentially yield considerable cost savings without adversely affecting health outcomes and allow EDs to better serve patients with more severe problems.

PurposeHigh-quality, wide-field retinal imaging is a valuable method for screening preventable, vision-threatening diseases of the retina. Smartphone-based retinal cameras hold promise for increasing access to retinal imaging, but variable image quality and restricted field of view can limit their utility. We developed and clinically tested a smartphone-based system that addresses these challenges with automation-assisted imaging.MethodsThe system was designed to improve smartphone retinal imaging by combining automated fixation guidance, photomontage, and multicolored illumination with optimized optics, user-tested ergonomics, and touch-screen interface. System performance was evaluated from images of ophthalmic patients taken by nonophthalmic personnel. Two masked ophthalmologists evaluated images for abnormalities and disease severity.ResultsThe system automatically generated 100° retinal photomontages from five overlapping images in under 1 minute at full resolution (52.3 pixels per retinal degree) fully on-phone, revealing numerous retinal abnormalities. Feasibility of the system for diabetic retinopathy (DR) screening using the retinal photomontages was performed in 71 diabetics by masked graders. DR grade matched perfectly with dilated clinical examination in 55.1% of eyes and within 1 severity level for 85.2% of eyes. For referral-warranted DR, average sensitivity was 93.3% and specificity 56.8%.ConclusionsAutomation-assisted imaging produced high-quality, wide-field retinal images that demonstrate the potential of smartphone-based retinal cameras to be used for retinal disease screening.Translational RelevanceEnhancement of smartphone-based retinal imaging through automation and software intelligence holds great promise for increasing the accessibility of retinal screening.