 pandemic has changed clinical medicine, including ophthalmology, and has affected almost every aspect of American life.

No part of life has been immune to the effects of the pandemic, including American professional football.

Prior to the pandemic, innovative work was being done in the world of National Football League (NFL) refereeing; training NFL referees was changing to make the job more precise and objective.

Imagine my surprise when Walt Anderson, MD, a 24-year NFL officiating veteran, called me to talk about neuro-ophthalmology for the NFL. Anderson has been tasked with training and developing a new breed of NFL game officials. 



Cutting-edge neuro-ophthalmology: Combining artificial intelligence, eye tracking



The focus in his role as the league’s senior vice president of Officiating Training and Development is on education, and one of his goals is to bring the science of neuro-ophthalmology and the scientific method to the officiating role.

We all know the tired jokes about “blind” referees missing an infraction and offers for “free eye exams” after perceived errors. The truth is, however, that visual acuity probably has nothing to do with a blown officiating call on the field.



Anderson’s referee training approach includes real-world experience with astute scientific analysis combined with the power of careful slow-motion, repeated viewings of video replays. The process breaks down the mechanics of NFL officiating play by play.

So, what does this have to do with neuro-ophthalmology? In terms of the mechanics of the game for players, coaches, and more specifically, referees, football is an “on the field” opportunity to see both afferent and efferent neuro-ophthalmology in the real-world setting.

Amazingly, many of the details of the anatomy and mechanics of vision, visual field, saccades, pursuit, and the vestibulo-ocular reflex (VOR) have direct implications for the game. 

As a retired dentist, Anderson has a unique insight in to both the world of medicine/dentistry and the world of NFL football.



Technology 'perfect' for pediatric neuro-ophthalmology diagnoses

For example, the VOR—which acts to stabilize foveation during head or body motion—can degrade a referee’s ability to make the call on the run during a live-action play. Likewise, the visual field can make the difference between seeing a foul and missing the call.

Some of these scientific principles that are well known and intuitive to ophthalmologists are not as obvious to laypersons.

Experienced NFL referees know intuitively that they often have to move back from the snap when a play starts to increase their field of view to other aspects of the play that are known to evolve in a specific sequence.

They know to remain still after gaining line of sight on the play to reduce motion artifact from the VOR, and they know that running full tilt with a running back may not be the best way to maintain eyes on the ball.

Neuro-ophthalmic science provides the anatomy, physiology, and mechanics of vision and eye movement that pairs with the existing knowledge on play calling from years of NFL experience. The “know how” for the mechanics of football can be aligned with knowledge about neuro-ophthalmic systems.



For me, it has been an exciting and fascinating journey to go on the virtual field with Anderson and to learn the lingo and jargon of NFL referees. Likewise, for Anderson and his colleagues, they get a mini-medical school rotation to learn the jargon of neuro-ophthalmology and to put academic and scientific names on their referee experience and their advice on and off the field to NFL referees.

Maximizing visual field, minimizing foveal drift, improving saccadic search strategies, minimizing VOR degradation of foveation time, and maximizing binocular pursuit options in real time have made for fascinating and intriguing discussions between neuro-ophthalmology and the NFL referees.

As the pandemic continues to bring change and innovation to the game on the field, neuro-ophthalmology looks forward to continued work with Anderson and the NFL for improving the science of NFL officiating. 

Moreover, experience and expertise matter just as much for referees on the playing field as for clinicians in the neuro-ophthalmic clinic.




Lee is affiliated with the Blanton Eye Institute at Houston Methodist Hospital in Texas. He has no financial disclosures related to this content.

Articles

Science is being tapped by professional sports league to train and develop officials.

Neuro-ophthalmology, NFL connect for a touchdown

Utilization of a diabetic eye disease teleretinal screening program to detect 

 is not yet feasible. 

Instead, clinical examination remains the primary method of screening for the latter pathologies, concluded a team of investigators from Emory University in Atlanta, Georgia.

In a retrospective analysis of data collected from patients with type 1 or type 2 diabetes who had been screened via the Grady Health System’s teleretinal screening program, the investigators found only fair agreement between the results of screening based on nonmydriatic fundus camera images and clinical exam in regard to glaucoma diagnosis, slight agreement for detecting cataract, and slight agreement for detecting both pathologies combined.

Although the specificity and negative predictive value for the teleretinal screening program were both high for detecting glaucoma, cataract, and both together, its sensitivity and positive predictive value were low for all outcomes, according to investigators.



Retinal pathologies challenging to image with current technologies

The research was presented at the 2020 Association for Research in Vision and Ophthalmology meeting by Omar I. Ali, BS, an MPH candidate at Emory University’s Rollins School of Public Health and a medical student at Baylor College of Medicine in Houston, Texas. 

Yousuf M. Khalifa, MD, an associate professor of ophthalmology at Emory University School of Medicine, is the senior investigator in the study.



“Large teleretinal screening programs offer the potential to reduce the burden of eye disease through early detection and treatment,” Ali pointed out. “Such screening systems, however, should be both highly sensitive and highly specific when compared to the gold standard, which in our study was clinical examination.”

Ali also pointed out that additional research must be done on the best measures for accurate detection of glaucoma, because current telescreening programs differ on which aspects to give credence to, reflecting the general difficulty in diagnosing glaucoma clinically.

“In addition, further research is needed on the usefulness, cost-effectiveness, and accuracy of this type of screening system to better understand its role in a large healthcare system,” he said.

Astigmatism management software proving to be accurate, precise​ 




Although the use of teleretinal screening programs to detect diabetic retinopathy and reduce barriers to access has spread across many communities and the benefits have been well reported, there is less investigation of utilizing the screening program to detect secondary outcomes, such as cataract or glaucoma. 

According to Ali,the retrospective study was undertaken by investigators against that background.

Patients included in the study were identified from among those screened using a nonmydriatic camera via the Grady teleretinal screening program between January and October 2018.

Ali explained that the eligible patients had to meet the threshold for the primary outcome of having a positive screen for proliferative diabetic retinopathy (PDR) and/or 

. 

They also had to show evidence of cataract and/or glaucoma on the screening imaging, and have been seen in the clinic for follow-up of their primary outcome.

During the study period, a total of 7099 patients were screened through the teleretinal screening program, of which 394 screened positive for PDR and/or DME. Of the 394 patients, 299 were seen in clinic for follow-up, but only 16 of the 299 patients examined had glaucoma (n = 13) or cataract (n = 3) on screening.



Exploring pathogenic cytokines as biomarkers for DME

Agreement between the findings from the screening and clinical exam was calculated using K; values were 0.23 for glaucoma, 0.01 for presence of cataract, and 0.04 for the combined endpoint. The sensitivity of teleretinal screening for detecting any of the secondary outcomes ranged from 4.55% to 16.67%, and it had a positive predictive value of 50% for all three.

According to Ali, its specialty was greater than 98% and negative predictive value ranged from 71% to almost 95%.



Ali said it is likely that the true sensitivity of the current teleretinal system is much higher, especially given the literature report of a teleglaucoma program having high specificity and sensitivity.

The investigators were pleased with the results of their research, butalso acknowledged the limitations of the study. Further research is needed, Ali explained.

“Our study was limited, however, due to its sample size, loss to follow up, and requirement for patients having to screen positive for both the primary outcome, PDR and/or DME, and the secondary outcome of glaucoma or cataract,” Ali concluded. “Further studies with larger sample sizes and better follow-up are needed to better understand the role of teleretinal screening for secondary outcomes.”



Ali has no relevant financial relationships to disclose.

Programs use detection and treatment to ease burden of eye disease.

Teleretinal screening fails to do double duty for detecting glaucoma, cataracts


This article was reviewed by Yoshihiro Yonekawa, MD

With the nation’s opioid epidemic still a serious public health issue, Yoshihiro Yonekawa, MD, wanted to know to how retina specialists could contribute to a potential solution.

Yonekawa discussed a study of the mean number of opioid prescriptions written annually during the 2020 American Society of Retina Specialists (ASRS) virtual annual meeting. 

His observational, retrospective, cohort study of 1815 

 specialists in the 2019 ASRS directory found that male ASRS members were more likely to prescribe opioids, as were members who practice in southern US states.



Harnessing regeneration of retinal tissues: An option almost within reach



 However, the study results also showed that, as a whole, ASRS members prescribe opioids at a lower rate than the national mean of all prescribers (3.0% vs 6.8%, respectively).

In 2018, opioids were involved in 70% of all drug overdose deaths in the United States.

 

Although the overall opioid prescribing rate in the United States has been declining since 2012, the number of opioids prescribed per person is currently 3 times higher than it was in 1999.

“We wanted to know: Are retina surgeons contributing to the opioid addiction and overdose crisis through their prescribing patterns?” said Yonekawa, an adult and pediatric retina specialist at Wills Eye Hospital in Philadelphia, Pennsylvania. “And, if so, how are retina specialists trending over time?”

Jonathan Prenner, MD, clinical professor and chairman, Department of Ophthalmology, at Rutgers Robert Wood Johnson Medical School in New Jersey, noted during the discussion that retinal specialists “feel a little isolated from the opioid epidemic, given the closed ecosystem that we live in.”



COVID-19: ASRS survey details impact on retinal patients, practices

“As we all painfully know, the world is experiencing the coronavirus pandemic, and the smaller epidemics within it may be getting worse because of the viral public health crisis,” Yonekawa said. “The opioid epidemic was already a national issue, and the current pandemic may be making things worse. Postprocedural opioid prescription does play a role in this.”


Using the 2013-2016 Medicare Part D prescriber database, Yonekawa and his colleagues evaluated the opioid prescription patterns of 1815 ASRS members by dividing the US Census regions into 4 sections—Northeast, Midwest, South, and West. They then mapped the geographic variation in prescribing patterns. 

Finally, they performed a regression analysis to identify risk factors associated with a higher number of opioid prescriptions.

In the overall prescription patterns identified, 87% were men and 13% were women, although this does not necessarily represent the percentages of opioid prescribers, Yonekawa said. The majority of practices were located in the South (37%). 





Between 2013 and 2016, ASRS members wrote 918,076 opioid prescriptions. In 2016, ASRS members wrote 15,610 prescriptions with 70% of members writing at least 1. On average, ASRS members wrote 11 opioid prescriptions a year.

“About two-thirds of us wrote 1 to 10 opioid prescriptions, a quarter wrote 11 to 50 opioid prescriptions, and 6% wrote more than 50,” Yonekawa said. “This 6% accounted for 31% of the total number of opioid prescriptions.”

The total number of opioid prescriptions written by ASRS members did trend downward overtime, with an 18% decrease between 2013 and 2016. The highest number of prescriptions were written in Wisconsin, Tennessee, Texas, Oklahoma, Louisiana, Idaho, and South Dakota.

“Physicians in the South were more likely to prescribe more opioids, and this is a trend seen in other fields also,” Yonekawa said. “We’re not sure why, but it might be different practice patterns, perceptions toward opioids, and patient population.”

Although the researchers found that ASRS members wrote fewer opioid prescriptions than the national mean, they recommend retina specialists reconsider their prescribing habits given the high risk of addiction.



Effect of Omidira on pain and opioid usage during cataract surgery

Prenner said the percentage of ASRS members who prescribed opioids “was higher than I would have expected.” He also asked, “What factors did you find meaningful in terms of influencing prescribing patterns?” 

First, Yonekawa said, is that database is composed of Medicare recipients, “so younger patients are not fully accounted for, which means the actual numbers are likely much higher.” Southern-based retina physicians prescribe more opioids, but that is not unique as other specialties have similar breakdowns, he said.

“We’re not sure why that is,” Yonekawa said, but it may have to do with geographic practice patterns overall. In his practice, Yonekawa has stopped the use of opioids altogether.

For scleral buckling, which tends to be more uncomfortable than vitrectomy procedures, “we do a sub-Tenon’s block at the start or end of the case. Otherwise, we use over-the-counter medication, if necessary, Tylenol if it’s not contraindicated, and we tell patients to cycle it with nonsteroidal anti-inflammatory drugs as needed.”

Moreover, patients already on chronic pain medications, he said, usually are in close contact with their pain specialists.

“We communicate with the pain specialist and have them prescribe what they think is best so that they can monitor them closely, because we’re not pain experts,” Yonekawa said.



Yonekawa has no financial disclosures related to this content.

1. Drug Overdose Deaths. Centers for Disease Control and Prevention. Updated March 19, 2020. Accessed September 10, 2020. http://www.cdc.gov/drugoverdose/data/statedeaths.html

2 Overdose Death Maps. Centers for Disease Control and Prevention. Updated March 19, 2020. Accessed September 10, 2020. 

http://www.cdc.gov/drugoverdose/data/prescribing/overdose-death-maps.html

3. Guy GP, Zhang K, Bohm MK, et al. Vital signs: Changes in opioid prescribing in the United States, 2006-2015. 

. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4

Investigators looked at trends by geographic variation in practice patterns, perceptions toward opioids, and patient population

Ophthalmology Times: November 15, 2020

Neuro-ophthalmology, NFL connect for a touchdown

Teleretinal screening fails to do double duty for detecting glaucoma, cataracts

Analyzing opioid prescription patterns of US retina specialists