Cassie A. Ludwig, MD, MS is a Vitreoretinal Surgeon and Assistant Professor in Ophthalmology at the Byers Eye Institute, Department of Ophthalmology, at the Stanford University School of Medicine. Dr. Ludwig graduated summa cum laude from Duke University with training in Biology, followed by medical school and residency at Stanford University where she was inducted into the Alpha Omega Alpha Honor Medical Society and received numerous awards for her research including the prestigious Heed Fellowship. Subsequently, she underwent a 2-year vitreoretinal surgery fellowship at Massachusetts Eye and Ear at Harvard Medical School where she was honored with the Ronald G. Michels Fellowship Foundation Award for outstanding fellows as well as Harvard's Thomas J. Madden Fellowship in Retina. She became interested in myopia while treating patients at Stanford as a resident and has continued to pursue her mission to improve our means of treating and preventing high and pathological myopia and their sequelae as a member of the vitreoretinal surgery faculty.

Dr. Ludwig specializes in the management of vitreoretinal diseases including retinal tears and detachments, myopic macular degeneration, myopic traction maculopathy, diabetic retinopathy, retinal vascular occlusions, trauma, age-related macular degeneration, macular telangiectasia, and complex medical and surgical retina problems.

Dr. Ludwig’s surgical interests include complex retinal detachment repair related to high myopia, proliferative vitreoretinopathy or traumatic injuries, complex macular holes including myopic macular holes, epiretinal membranes (macular pucker), and dislocated lenses.

She is passionate about providing patient-centered care while training and mentoring the next generation of vitreoretinal surgeons.

Clinical Focus

  • Retina Specialist

Academic Appointments

  • Assistant Professor - University Medical Line, Ophthalmology

Administrative Appointments

  • Ophthalmology Liason, LGBTQ+ Health Program (2023 - Present)

Honors & Awards

  • Thomas J. Madden Fellowship in Retina, Harvard University, Massachusetts Eye and Ear (2022)
  • Ronald G. Michels Fellowship Foundation Award, Ronald G. Michels Fellowship Foundation (2021)
  • Heed Fellowship, Society of Heed Fellows (2020)
  • Marmor-Blumenkranz Ophthalmology Residents Research Prize, Stanford University, Byers Eye Institute (2019, 2020)
  • Resident Winner, Young Ophthalmology Video Competition, American Academy of Ophthalmology (2019)
  • Travel Grant, National Eye Institute (2018)
  • GME Research Day Award, Best in Show, California Pacific Medical Center (2017)
  • Spectrum/TL1 Clinical Research Training Program, NIH (2015)
  • Scholarship, Duke University Bassett Society (2013)

Boards, Advisory Committees, Professional Organizations

  • Member, Vit-Buckle Society (2023 - Present)
  • Member, The American Society of Retina Specialists (2023 - Present)
  • Member, Retina World Congress (2023 - Present)
  • Member, International Myopia Institute (2020 - Present)
  • Member, Alpha Omega Alpha Honor Medical Society (2019 - Present)
  • Member, Women in Ophthalmology (2018 - Present)
  • Member, American Academy of Ophthalmology (2017 - Present)
  • Member, Association for Research in Vision and Ophthalmology (2015 - Present)
  • Member, Phi Beta Kappa Society (2009 - Present)

Professional Education

  • Fellowship, Harvard University, Massachusetts Eye and Ear, Vitreoretinal Surgery (2022)
  • Board Certification: American Board of Ophthalmology, Ophthalmology (2021)
  • Residency, Stanford University, Byers Eye Institute, Ophthalmology (2020)
  • Internship, California Pacific Medical Center, Internal Medicine (2017)
  • Master's Degree, Stanford University School of Medicine, Epidemiology and Clinical Research (2016)
  • Medical Education, Stanford University School of Medicine, Health Services and Policy Research; Neuroscience, Behavior & Cognition (2016)
  • Bachelor of Science, Duke University, Biology, Religion, and Neuroscience (2011)

Current Research and Scholarly Interests

My research at present focuses on better understanding high and pathologic myopia and their retina sequelae (retinal detachments, myopic traction maculopathy, myopic macular degeneration) through informatics and data-driven research. My goal is to make discoveries within the field of Ophthalmology that will impact the rest of medicine, taking advantage of our ready access to the only visible portion of the central nervous system.

All Publications

  • Epidemiology of rhegmatogenous retinal detachment in commercially insured myopes in the United States. Scientific reports Ludwig, C. A., Vail, D., Al-Moujahed, A., Callaway, N. F., Saroj, N., Moshfeghi, A., Moshfeghi, D. M. 2023; 13 (1): 9430


    Myopia is a known risk factor for rhegmatogenous retinal detachment (RRD). Given global trends of increasing myopia, we aimed to determine the absolute risk (incidence rate) of RRD in non-myopes, myopes and high myopes in the United States over ten years. We performed a retrospective cohort study of 85,476,781 commercially insured patients enrolled in the Merative Marketscan Research Database. The incidence rate of RRD in phakic patients inthe United States was 39-fold higher in high myopes than non-myopes (868.83 per 100,000 person-years versus 22.44 per 100,000 person-years)and three-fold higher in myopes than non-myopes (67.51 per 100,000 person-yearsversus22.44 per 100,000 person-years). The incidence rate was significantly higher in males in each category (P<0.01). Combined, the incidence rate of RRD in phakic patients inthe United States from 2007 to 2016was 25.27 RRDs per 100,000 person-years, a rate higherthan those in prior published studies in North America, South America, Europe, Asia, and Australia.The absolute risk of myopia and high myopia increased from 2007 to 2016. Therisk of RRD in phakichigh myopes rosewith increasing age. Notably, the magnitude of increased risk of RRD in myopes varied substantially according to the minimum follow-up period in our models and should be accounted for when interpreting data analyses.

    View details for DOI 10.1038/s41598-023-35520-x

    View details for PubMedID 37296124

  • Differences in anterior peripheral pathologic myopia and macular pathologic myopia by age and gender. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie Ludwig, C. A., Boucher, N., Saroj, N., Moshfeghi, D. M. 2021

    View details for DOI 10.1007/s00417-021-05217-w

    View details for PubMedID 34019150

  • Automatic Identification of Referral-Warranted Diabetic Retinopathy Using Deep Learning on Mobile Phone Images. Translational vision science & technology Ludwig, C. A., Perera, C., Myung, D., Greven, M. A., Smith, S. J., Chang, R. T., Leng, T. 2020; 9 (2): 60


    Purpose: To evaluate the performance of a deep learning algorithm in the detection of referral-warranted diabetic retinopathy (RDR) on low-resolution fundus images acquired with a smartphone and indirect ophthalmoscope lens adapter.Methods: An automated deep learning algorithm trained on 92,364 traditional fundus camera images was tested on a dataset of smartphone fundus images from 103 eyes acquired from two previously published studies. Images were extracted from live video screenshots from fundus examinations using a commercially available lens adapter and exported as a screenshot from live video clips filmed at 1080p resolution. Each image was graded twice by a board-certified ophthalmologist and compared to the output of the algorithm, which classified each image as having RDR (moderate nonproliferative DR or worse) or no RDR.Results: In spite of the presence of multiple artifacts (lens glare, lens particulates/smudging, user hands over the objective lens) and low-resolution images achieved by users of various levels of medical training, the algorithm achieved a 0.89 (95% confidence interval [CI] 0.83-0.95) area under the curve with an 89% sensitivity (95% CI 81%-100%) and 83% specificity (95% CI 77%-89%) for detecting RDR on mobile phone acquired fundus photos.Conclusions: The fully data-driven artificial intelligence-based grading algorithm herein can be used to screen fundus photos taken from mobile devices and identify with high reliability which cases should be referred to an ophthalmologist for further evaluation and treatment.Translational Relevance: The implementation of this algorithm on a global basis could drastically reduce the rate of vision loss attributed to DR.

    View details for DOI 10.1167/tvst.9.2.60

    View details for PubMedID 33294301

  • Democratizing Health Care in the Metaverse: How Video Games can Monitor Eye Conditions Using the Vision Performance Index: A Pilot Study. Ophthalmology science Ahmed, Y., Reddy, M., Mederos, J., McDermott, K. C., Varma, D. K., Ludwig, C. A., Ahmed, I. K., Khaderi, K. R. 2024; 4 (1): 100349


    In a world where digital media is deeply engrained into our everyday lives, there lies an opportunity to leverage interactions with technology for health and wellness. The Vision Performance Index (VPI) leverages natural human-technology interaction to evaluate visual function using visual, cognitive, and motor psychometric data over 5 domains: field of view, accuracy, multitracking, endurance, and detection. The purpose of this study was to describe a novel method of evaluating holistic visual function through video game-derived VPI score data in patients with specific ocular pathology.Prospective comparative analysis.Patients with dry eye, glaucoma, cataract, diabetic retinopathy (DR), age-related macular degeneration, and healthy individuals.The Vizzario Inc software development kit was integrated into 2 video game applications, Balloon Pop and Picture Perfect, which allowed for generation of VPI scores. Study participants were instructed to play rounds of each video game, from which a VPI score was compiled.The primary outcome was VPI overall score in each comparison group. Vision Performance Index component, subcomponent scores, and psychophysical inputs were also compared.Vision Performance Index scores were generated from 93 patients with macular degeneration (n = 10), cataract (n = 10), DR (n = 15), dry eye (n = 15), glaucoma (n = 16), and no ocular disease (n = 27). The VPI overall score was not significantly different across comparison groups. The VPI subcomponent "reaction accuracy" score was significantly greater in DR patients (106 ± 13.2) versus controls (96.9 ± 11.5), P = 0.0220. The VPI subcomponent "color detection" score was significantly lower in patients with DR (96.8 ± 2.5; p=0.0217) and glaucoma (98.5 ± 6.3; P = 0.0093) compared with controls (101 ± 11). Psychophysical measures were statistically significantly different from controls: proportion correct (lower in DR, age-related macular degeneration), contrast errors (higher in cataract, DR), and saturation errors (higher in dry eye).Vision Performance Index scores can be generated from interactions of an ocular disease population with video games. The VPI may offer utility in monitoring select ocular diseases through evaluation of subcomponent and psychophysical input scores; however, future larger-scale studies must evaluate the validity of this tool.Proprietary or commercial disclosure may be found after the references.

    View details for DOI 10.1016/j.xops.2023.100349

    View details for PubMedID 37869021

    View details for PubMedCentralID PMC10587622

  • Limitations of Assessing Barriers in Diabetic Retinopathy Screening-Reply. JAMA ophthalmology Wang, S. Y., Ludwig, C. A., Ravindranath, R. 2024

    View details for DOI 10.1001/jamaophthalmol.2024.0320

    View details for PubMedID 38512268

  • Characterizing Macular Neovascularization in Myopic Macular Degeneration and Age-Related Macular Degeneration Using Swept Source OCTA. Clinical ophthalmology (Auckland, N.Z.) Sayah, D. N., Garg, I., Katz, R., Zhu, Y., Cui, Y., Zeng, R., Tandias, R., Moon, J. Y., Vingopoulos, F., Wescott, H. E., Baldwin, G., Wang, K., Elze, T., Ludwig, C. A., Vavvas, D. G., Miller, J. W., Husain, D., Kim, L. A., Patel, N. A., Miller, J. B. 2023; 17: 3855-3866


    Visual prognosis and treatment burden for macular neovascularization (MNV) can differ between myopic macular degeneration (MMD) and age-related macular degeneration (AMD). We describe and compare MNV associated with MMD and AMD using swept-source (SS)-OCTA.Adult patients with documented MNV associated with MMD or AMD were consecutively recruited. Qualitative and quantitative features were assessed from 6x6mm angiograms, including the MNV area and vessel density (VD). Descriptive statistics and linear regression analyses were carried out.Out of 75 enrolled eyes with diagnosed MNV (30 MMD-MNV and 45 AMD-MNV; mean age 55±19 and 75±8 years, respectively), 44 eyes had discernible MNV (11 MMD-MNV and 33 AMD-MNV) on SS-OCTA at the time of the study and were included in the analysis. The MMD-MNV group exhibited a three-fold smaller sized MNV (p=0.001), lower greatest linear dimension (p=0.009) and greatest vascular caliber (p<0.001) compared to AMD-MNVs, and had a higher prevalence of tree-in-bud pattern. Eyes with AMD showed a higher prevalence of type 1 MNVs with medusa pattern. There was no difference in the location of the MNV, shape's regularity, margins, presence of core vessel, capillary fringe, peripheral loops, or perilesional dark halo (p>0.05) between both conditions. After adjustment, decreased MNV area and increased VD were associated with the tree-in-bud pattern, whereas the diagnosis did not significantly influence those parameters.While larger studies are warranted, this study is the first to describe and compare MMD-MNV and AMD-MNV using SS-OCTA, providing relevant clinical insight on MNV secondary to MMD and AMD. These findings also further validate OCTA as a powerful tool to detect and characterize MNV non-invasively.

    View details for DOI 10.2147/OPTH.S440575

    View details for PubMedID 38105914

    View details for PubMedCentralID PMC10725687

  • Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening. JAMA ophthalmology Ravindranath, R., Bernstein, I. A., Fernandez, K. S., Ludwig, C. A., Wang, S. Y. 2023


    Regular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates.To evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization.This retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022.The associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions.The primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression.Of the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96).This study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

    View details for DOI 10.1001/jamaophthalmol.2023.5287

    View details for PubMedID 37971726

  • Risk of Stroke, Myocardial Infarction, and Death After Retinal Artery Occlusion. JAMA ophthalmology Wai, K. M., Knapp, A., Ludwig, C. A., Koo, E., Parikh, R., Rahimy, E., Mruthyunjaya, P. 2023


    Importance: Patients with retinal artery occlusions (RAOs) are recommended to have emergent stroke workup, although the true risk of death and subsequent vascular events post-RAO is not clear.Objective: To determine short-term and long-term rates of stroke, myocardial infarction (MI), and death in patients after RAO compared with a control cohort.Design, Setting, and Participants: This retrospective cohort study used aggregated electronic health records from January 1, 2003, through April 14, 2023, from TriNetX, a network with data from more than 111 million patients. Patients with RAO and a cataract control group were identified and matched for age, sex, race, and comorbidities, including hypertension, diabetes, hyperlipidemia, and smoking status. Patients were excluded if they had a stroke or MI within 2 years before the diagnosis of RAO or cataract.Exposure: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis code for RAO or age-related cataract.Main Outcomes and Measures: Rate of death, stroke, and MI at 2 weeks, 30 days, 1 year, 5 years, and 10 years after RAO compared with matched controls.Results: There were a total of 34 874 patients with at least 1 year of follow-up in the RAO cohort. The mean (SD) age at the RAO event was 66 (15.2) years. The rate of death after RAO diagnosis was higher than after cataract diagnosis at 2 weeks (0.14% vs 0.06%; relative risk [RR], 2.45; 95% CI, 1.46-4.12; risk difference [RD], 0.08%; 95% CI, 0.04%-0.13%; P<.001), 30 days (0.29% vs 0.14%; RR, 2.10; 95% CI, 1.49-2.97; RD, 0.15%; 95% CI, 0.08%-0.22%; P<.001), 1 year (3.51% vs 1.99%; RR, 1.78; 95% CI, 1.61-1.94; RD, 1.41%; 95% CI, 1.17%-1.66%; P<.001), 5 years (22.74% vs 17.82%; RR, 1.28; 95% CI, 1.23-1.33; RD, 4.93%; 95% CI, 4.17%-5.68%; P<.001), and 10 years (57.86% vs 55.38%; RR, 1.05; 95% CI, 1.02-1.07; RD, 2.47%; 95% CI, 1.25%-3.69%; P<.001). Risk of stroke after RAO was higher at 2 weeks (1.72% vs 0.08%; RR, 21.43; 95% CI, 14.67-31.29; RD, 1.64%; 95% CI, 1.50%-1.78%; P<.001), 30 days (2.48% vs 0.18%; RR, 14.18; 95% CI, 10.94-18.48; RD, 2.31%; 95% CI, 2.14%-2.47%; P<.001), 1 year (5.89% vs 1.13%; RR, 5.20; 95% CI, 4.67-5.79; RD, 4.64%; 95% CI, 4.37%-4.91%; P<.001), 5 years (10.85% vs 4.86%; RR, 2.24; 95% CI, 2.09-2.40; RD, 6.00%; 95% CI, 5.50%-6.50%; P<.001), and 10 years (14.59% vs 9.18%; RR, 1.59; 95% CI, 1.48-1.70; RD, 5.41%; 95% CI, 4.62%-6.21%; P<.001). Risk of MI after RAO was higher at 2 weeks (0.16% vs 0.06%; RR, 3.00; 95% CI, 1.79-5.04; RD, 0.11%; 95% CI, 0.06%-0.16%; P<.001), 30 days (0.27% vs 0.10%; RR, 2.61; 95% CI, 1.78-3.83; RD, 0.17%; 95% CI, 0.10%-0.23%; P<.001), 1 year (1.66% vs 0.97%; RR, 1.72; 95% CI, 1.51-1.97; RD, 0.59%; 95% CI, 0.42%-0.76%; P<.001), 5 years (6.06% vs 5.00%; RR, 1.21; 95% CI, 1.12-1.31; RD, 1.07%; 95% CI, 0.64%-1.50%; P<.001), and 10 years (10.55% vs 9.43%; RR, 1.12; 95% CI, 1.04-1.21; RD, 1.13%; 95% CI, 0.39%-1.87%; P=.003).Conclusions and Relevance: This study showed an increased risk of death, stroke, and MI in patients with RAO at both short-term and long-term intervals after RAO compared with a matched control population diagnosed with cataract. These findings suggest a potential need for multidisciplinary evaluation and long-term systemic follow-up of patients post-RAO.

    View details for DOI 10.1001/jamaophthalmol.2023.4716

    View details for PubMedID 37883068

  • Risk of Stroke, Myocardial Infarction, Deep Vein Thrombosis, Pulmonary Embolism, and Death after Retinal Vein Occlusion. American journal of ophthalmology Wai, K. M., Ludwig, C. A., Koo, E., Parikh, R., Mruthyunjaya, P., Rahimy, E. 2023


    To examine rates of stroke, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE), and death in patients after retinal vein occlusion (RVO) compared to controls.Retrospective cohort study.An aggregated electronic health records research network, TriNetX (Cambridge, MA, USA), was used to identify patients with diagnosis of RVO and a control group of patients with cataract. Patients were excluded if they had history of stroke, MI, DVT, or PE within 2 years of diagnosis of RVO or cataract. Propensity score matching was performed to control for baseline demographics and medical comorbidities. Main outcomes included relative risk (RR) of death, stroke, MI, DVT, and PE after RVO compared to matched controls.45304 patients were included in each cohort. There was elevated risk of death in the RVO cohort compared to the control cohort at 1 (RR: 1.30, p<0.01), 5 (RR: 1.22, p<0.01), and 10 years (RR:1.08, p<0.01). There was elevated risk of stroke at 1 (RR:1.61, p<0.01), 5 (RR:1.31, p<0.01), and 10 years (RR: 1.18, p<0.01). There was elevated risk of MI at 1 (RR:1.26, p<0.01) and 5 years (RR:1.13, p<0.01), but not at 10 years (RR:1.06, p=0.12). There was mildly elevated risk of DVT at 1 year (RR: 1.65, p<0.01), but not at 5 (RR: 0.94, p=0.94) or at 10 years (RR: 1.05, p=0.37), There was no elevated risk of PE at 1 (RR: 0.98, p=0.80), 5 (RR: 0.95, p=0.42), or 10 years (RR: 0.85, p=0.40).There is an increased rate of death, stroke, and MI after RVO compared to matched controls. We emphasize the need for long term systemic evaluation after RVO.

    View details for DOI 10.1016/j.ajo.2023.08.022

    View details for PubMedID 37660963

  • Comparison of Ophthalmologist and Large Language Model Chatbot Responses to Online Patient Eye Care Questions. JAMA network open Bernstein, I. A., Zhang, Y. V., Govil, D., Majid, I., Chang, R. T., Sun, Y., Shue, A., Chou, J. C., Schehlein, E., Christopher, K. L., Groth, S. L., Ludwig, C., Wang, S. Y. 2023; 6 (8): e2330320


    Importance: Large language models (LLMs) like ChatGPT appear capable of performing a variety of tasks, including answering patient eye care questions, but have not yet been evaluated in direct comparison with ophthalmologists. It remains unclear whether LLM-generated advice is accurate, appropriate, and safe for eye patients.Objective: To evaluate the quality of ophthalmology advice generated by an LLM chatbot in comparison with ophthalmologist-written advice.Design, Setting, and Participants: This cross-sectional study used deidentified data from an online medical forum, in which patient questions received responses written by American Academy of Ophthalmology (AAO)-affiliated ophthalmologists. A masked panel of 8 board-certified ophthalmologists were asked to distinguish between answers generated by the ChatGPT chatbot and human answers. Posts were dated between 2007 and 2016; data were accessed January 2023 and analysis was performed between March and May 2023.Main Outcomes and Measures: Identification of chatbot and human answers on a 4-point scale (likely or definitely artificial intelligence [AI] vs likely or definitely human) and evaluation of responses for presence of incorrect information, alignment with perceived consensus in the medical community, likelihood to cause harm, and extent of harm.Results: A total of 200 pairs of user questions and answers by AAO-affiliated ophthalmologists were evaluated. The mean (SD) accuracy for distinguishing between AI and human responses was 61.3% (9.7%). Of 800 evaluations of chatbot-written answers, 168 answers (21.0%) were marked as human-written, while 517 of 800 human-written answers (64.6%) were marked as AI-written. Compared with human answers, chatbot answers were more frequently rated as probably or definitely written by AI (prevalence ratio [PR], 1.72; 95% CI, 1.52-1.93). The likelihood of chatbot answers containing incorrect or inappropriate material was comparable with human answers (PR, 0.92; 95% CI, 0.77-1.10), and did not differ from human answers in terms of likelihood of harm (PR, 0.84; 95% CI, 0.67-1.07) nor extent of harm (PR, 0.99; 95% CI, 0.80-1.22).Conclusions and Relevance: In this cross-sectional study of human-written and AI-generated responses to 200 eye care questions from an online advice forum, a chatbot appeared capable of responding to long user-written eye health posts and largely generated appropriate responses that did not differ significantly from ophthalmologist-written responses in terms of incorrect information, likelihood of harm, extent of harm, or deviation from ophthalmologist community standards. Additional research is needed to assess patient attitudes toward LLM-augmented ophthalmologists vs fully autonomous AI content generation, to evaluate clarity and acceptability of LLM-generated answers from the patient perspective, to test the performance of LLMs in a greater variety of clinical contexts, and to determine an optimal manner of utilizing LLMs that is ethical and minimizes harm.

    View details for DOI 10.1001/jamanetworkopen.2023.30320

    View details for PubMedID 37606922

  • Effect of Next Generation Oral Hypoglycemic Agents on Diabetic Retinopathy Progression: A National Cohort Study Wai, K., Ahluwalia, A., Abrant, A., Ludwig, C., Parikh, R., Mruthyunjaya, P., Rahimy, E. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2023
  • Ischemic optic neuropathy with and without optic disc drusen Gong, X., Pugazhendhi, S., Zhu, P., Ludwig, C., Wang, S., Liao, Y. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2023
  • Unpredictability of Axial Elongation in Infants undergoing Cataract Surgery Abrant, A., Oke, I., McClatchey, S., Mruthyunjaya, P., Moshfeghi, D. M., Ludwig, C., Lambert, S. R. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2023
  • Biometric Variations in High Myopia Associated with Different Underlying Ocular and Genetic Conditions. Ophthalmology science Ghoraba, H. H., Ludwig, C. A., Moshfeghi, D. M. 2023; 3 (1): 100236


    Purpose: To report different biometric measurements in high myopia associated with different underlying ocular and genetic conditions.Design: Retrospective study.Subjects: Patients with high myopia.Methods: We searched the Stanford Research Repository tool to identify patients with the diagnosis of high myopia who were seen by a single provider at Byers Eye Institute at Stanford from January 2019 to March 2022. We performed a chart review and included eyes that had high myopia and ocular biometric measurements at any time point after January 2019. We divided our cohort into 5 different groups: (1) isolated high myopia (IHM) (control group); (2) retinopathy of prematurity (ROP); (3) familial exudative vitreoretinopathy; (4) Marfan syndrome; and (5) Stickler syndrome.Main Outcome Measures: Biometric measurements.Results: A total of 246 patients (432 eyes) were included as follows: 202 patients (359 eyes) in the IHM group, 17 patients (27 eyes) in the ROP group, 7 patients (12 eyes) in the familial exudative vitreoretinopathy group, 8 patients (14 eyes) in the Marfan group, and 12 patients (20 eyes) in the Stickler group. The ROPgroup showed significantly shorter axial lengths, shallower anterior chambers, and thicker lenses compared with the IHM group. The Marfan group showed significantly flatter corneas and thicker lenses compared with the IHM group. The Stickler group showed significantly longer axial lengths compared with the IHM group.Conclusions: High myopia is associated with variable biometric measurements according to underlying ocular or genetic conditions. Retinopathy of prematurity-associated high myopia is primarily lenticular, while Stickler syndrome-associated high myopia is axial. Marfan syndrome-associated high myopia is derived from both axial and lenticular mechanisms.

    View details for DOI 10.1016/j.xops.2022.100236

    View details for PubMedID 36545263

  • Sudden monocular vision loss after sneezing as captured on widefield swept source optical coherence tomography-angiography. Retinal cases & brief reports Moon, J. Y., Garg, I., Miller, J. B., Ludwig, C. A. 2022


    PURPOSE: We report an unusual case of likely combined retinal artery occlusion and retinal vein occlusion following a sneeze. Widefield swept source optical coherence tomography-angiography (WF-SS-OCTA) was used to analyze retinal changes at one-month follow-up.METHODS: The patient reported visual symptoms in his left eye immediately after sneezing five times in a row. Fundus examination showed an embolus along the superior arcade. Stroke workup revealed moderate carotid artery stenosis and a subtherapeutic INR. At one-month follow-up, fundus photography and SS-OCTA were obtained.RESULTS: Fundus photography showed superior retinal whitening and arteriole attenuation, an inferior perifoveal cotton wool spot, and inferotemporal intraretinal hemorrhages. SS-OCTA showed loss of the deep capillary plexus superiorly and inferotemporally, most consistent with combined retinal artery and retinal vein occlusion.CONCLUSION: We report the first case of sneeze-induced combined retinal artery and retinal vein occlusion. The retina is a uniquely accessible window that provides insight into human physiology, and SS-OCTA is a powerful tool that can give further insight into the pathophysiology of an occlusion.

    View details for DOI 10.1097/ICB.0000000000001395

    View details for PubMedID 36729527

  • Trends in Leadership and Award Recognition Among Women in the American Society of Retina Specialists JOURNAL OF VITREORETINAL DISEASES Reeves, M. R., Pasricha, M., Ludwig, C. A., Chandramohan, A., Azad, A. D., Li, A. S., Rosenblatt, T. R., Sears, C., Kossler, A. L., Do, D., Pan, C. K. 2022; 6 (5): 374-380
  • Trends in Leadership and Award Recognition Among Women in the American Society of Retina Specialists. Journal of vitreoretinal diseases Reeves, M. R., Pasricha, M. V., Ludwig, C. A., Chandramohan, A., Azad, A. D., Li, A. S., Rosenblatt, T. R., Sears, C. M., Kossler, A. L., Do, D. V., Pan, C. K. 2022; 6 (5): 374-380


    This work evaluates trends in achievement of women in the retina field, through an analysis of gender representation in the American Society of Retina Specialists (ASRS).This retrospective, longitudinal study spans 1983 to 2020. Historical data classified by male or female gender were collected from ASRS's overall membership, board of directors and officers, and recipients of the 4 society awards. The proportion of each benchmark held by women was compared with prior decades since the founding of ASRS using the Fisher's exact test.Women's representation increased from 11% of ASRS members in 2007 to 19.7% in 2020. From 2010 to 2019, women received a higher proportion of society awards (21.1%) compared with membership prior to the start of that decade. In 2020, women were proportionally well represented in board of director positions (21.9%) and held a significantly higher proportion of board positions than in the period 1983 to 1989 (P = .02). From 1983 to 2020, women held 4.3% (1 of 23) of presidencies.Although the number of women in retina is increasing, women remain underrepresented in the leadership of ASRS. Interventions to increase exposure to female mentorship and improve childcare benefits are warranted to engage female ophthalmology trainees in retina and ultimately society leadership.

    View details for DOI 10.1177/24741264211021019

    View details for PubMedID 37006904

    View details for PubMedCentralID PMC9954927

  • Representation of Women in Ophthalmology Subspecialty Societies over 20 OPHTHALMOLOGY Azad, A. D., Chandramohan, A., Li, A. S., Rosenblatt, T. R., Reeves, M. R., Veerappan-Pasricha, M., Ludwig, C. A., Nguyen, A., Winges, K. M., Wang, S. Y., Pan, C. K., Moss, H. E., Do, D. V., Fountain, T. R., Kossler, A. L. 2022; 129 (5): 587-590
  • Ocular Penetrance and Safety of the Dopaminergic Prodrug Etilevodopa. Translational vision science & technology Gao, Q., Ludwig, C. A., Smith, S. J., Schachar, I. H. 2021; 10 (12): 5


    Purpose: Animal models have demonstrated the role of dopamine in regulating axial elongation, the critical feature of myopia. Because frequent delivery of dopaminergic agents via peribulbar, intravitreal, or intraperitoneal injections is not clinically viable, we sought to evaluate ocular penetration and safety of the topically applied dopaminergic prodrug etilevodopa.Methods: The ocular penetration of dopamine and dopaminergic prodrugs (levodopa and etilevodopa) were quantified using an enzyme-linked immunosorbent assay in enucleated porcine eyes after a single topical administration. The pharmacokinetic profile of the etilevodopa was then assessed in rats. A four-week once-daily application of etilevodopa as a topical eye drop was conducted to establish its safety profile.Results: At 24hours, the studied prodrugs showed increased dopaminergic derivatives in the vitreous of porcine eyes. Dopamine 0.5% (P = 0.0123) and etilevodopa 10% (p = 0.370) achieved significant vitreous concentrations. Etilevodopa 10% was able to enter the posterior segment of the eye after topical administration in rats with an intravitreal half-life of eight hours after single topical administration. Monthly application of topical etilevodopa showed no alterations in retinal ocular coherence tomography, electroretinography, caspase staining, or TUNEL staining.Conclusions: At similar concentrations, no difference in ocular penetration of levodopa and etilevodopa was observed. However, etilevodopa was highly soluble and able to be applied at higher topical concentrations. Dopamine exhibited both high solubility and enhanced penetration into the vitreous as compared to other dopaminergic prodrugs.Translational Relevance: These findings indicate the potential of topical etilevodopa and dopamine for further study as a therapeutic treatment for myopia.

    View details for DOI 10.1167/tvst.10.12.5

    View details for PubMedID 34609478

  • Fall risk in patients with pseudophakic monovision. Canadian journal of ophthalmology. Journal canadien d'ophtalmologie Rosenblatt, T. R., Vail, D., Ludwig, C. A., Al-Moujahed, A., Pasricha, M. V., Ji, M. H., Callaway, N. F., Moshfeghi, D. M. 2021


    OBJECTIVE: Vision changes can precipitate falls in the elderly resulting in significant morbidity and mortality. We hypothesized that pseudophakic monovision and ensuing anisometropia and aniseikonia impact elderly fall risk. This study assessed fall risk in patients with pseudophakic monovision, pseudophakic single vision distance (classic cataract surgery), and cataracts with no surgery.DESIGN: Retrospective single-institution cohort study PARTICIPANTS: Patients with bilateral cataracts diagnosed at 60 years of age or older who underwent bilateral cataract surgery (monovision or single vision distance) or did not undergo any cataract surgery (n = 13 385). Patients with unilateral surgery or a fall prior to cataract diagnosis were excluded.METHODS: Data were obtained from the Stanford Research Repository. Time-to-fall analysis was performed across all 3 groups. Primary outcome was hazard ratio (HR) for fall after second eye cataract surgery or after bilateral cataract diagnosis.RESULTS: Of 13 385 patients (241 pseudophakic monovision, 2809 pseudophakic single vision, 10 335 no surgery), 850 fell after cataract diagnosis. Pseudophakic monovision was not associated with fall risk after controlling for age, sex, and myopia. Pseudophakic single-vision patients had a decreased time to fall compared with no-surgery patients (log rank, p < 0.001). Older age at cataract diagnosis (HR =1.05, 95% confidence interval [CI] 1.04-1.06, p < 0.001) or at time of surgery (HR = 1.05, 95% CI 1.03-1.07, p < 0.001) increased fall risk, as did female sex (HR = 1.29, 95% CI 1.10-1.51, p = 0.002) and preexisting myopia (HR = 1.31, 95% CI 1.01-1.71, p = 0.046) among nonsurgical patients.CONCLUSIONS: Pseudophakic monovision did not impact fall risk, but pseudophakic single vision may increase falls compared with patients without cataract surgery.

    View details for DOI 10.1016/j.jcjo.2021.07.010

    View details for PubMedID 34419423

  • Comparison between wide-field digital imaging system and the red reflex test for universal newborn eye screening in Brazil. Acta ophthalmologica da Cunha, L. P., Cavalcante Costa, M. A., de Miranda, H. A., Reis Guimaraes, J., Aihara, T., Ludwig, C. A., Rosenblatt, T., Callaway, N. F., Pasricha, M., Al-Moujahed, A., Vail, D., Ji, M. H., Kumm, J., Moshfeghi, D. M. 2021


    PURPOSE: To compare neonatal eye screening using the red reflex test (RRT) versus the wide-field digital imaging (WFDI) system.METHODS: Prospective cohort study. Newborns (n=380, 760 eyes) in the Maternity Ward of Irmandade Santa Casa de Misericordia de Sao Paulo hospital from May to July 2014 underwent RRT by a paediatrician and WFDI performed by the authors. Wide-field digital imaging (WFDI) images were analysed by the authors. Validity of the paediatrician's RRT was assessed by unweighted kappa [kappa] statistic, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).RESULTS: While WFDI showed abnormalities in 130 eyes (17.1%), RRT was only abnormal in 13 eyes (1.7%). Wide-field digital imaging (WFDI) detected treatable retina pathology that RRT missed including hyphema, CMV retinitis, FEVR and a vitreous haemorrhage. The sensitivity of the paediatrician's RRT to detect abnormalities was poor at 0.77% (95% confidence interval, CI, 0.02%-4.21%) with a PPV of only 7.69% (95% CI, 1.08%-38.85%). Overall, there was no agreement between screening modalities (kappa=-0.02, 95% CI, -0.05 to 0.01). The number needed to screen to detect ocular abnormalities using WFDI was 5.9 newborns and to detect treatable abnormalities was 76 newborns.CONCLUSION: While RRT detects gross abnormalities that preclude visualization of the retina (i.e. media opacities and very large tumours), only WFDI consistently detects subtle treatable retina and optic nerve pathology. With a higher sensitivity than the current gold standard, universal WFDI allows for early detection and management of potentially blinding ophthalmic disease missed by RRT.

    View details for DOI 10.1111/aos.14759

    View details for PubMedID 34032022

  • Visual acuity and progression of macular atrophy in patients receiving intravitreal anti-VEGF for age-related macular degeneration. European journal of ophthalmology Ji, M. H., Callaway, N. F., Ludwig, C. A., Vail, D., Al-Moujahed, A., Rosenblatt, T. R., Leng, T., Sanislo, S. R., Moshfeghi, D. M. 2021: 11206721211001708


    PURPOSE: Whether intravitreal anti-vascular endothelial growth factors (VEGFs) cause retinal atrophy is still a subject of debate. We reported 13 eyes that received several injections of anti-VEGF for wet age-related macular degeneration (AMD) with good visual acuity despite geographic atrophy on imaging.METHODS: This is a case series study conducted at Byers Eye Institute at Stanford University. Patients of three retina specialists with wet AMD who received six or more intravitreal injection of anti-VEGFs with visual acuity of 20/60 or better and incomplete RPE and outer retina atrophy (iRORA) or complete RPE and outer retinal atrophy (cRORA) were enrolled in this case series. Different imaging modalities were reviewed by three retina specialists comparing the baseline with the most recent exam.RESULTS: About 13 eyes of 10 patients met the selection criteria. Eleven eyes were classified as iRORA and 2 as cRORA. Despite the development of macular atrophy on imaging after an average of 38.1 injections, eyes maintained stable visual acuity.CONCLUSION: The discrepancy between structural and functional findings in this cohort suggests that patients treated by anti-VEGF drugs exhibit divergent clinical outcomes for currently unknown reasons. The authors propose anti-VEGF may affect melanosomes within RPE without disrupting RPE and photoreceptors function completely. This requires further investigation.

    View details for DOI 10.1177/11206721211001708

    View details for PubMedID 33781106

  • Key factors in a rigorous longitudinal image-based assessment of retinopathy of prematurity. Scientific reports Rosenblatt, T. R., Ji, M. H., Vail, D., Ludwig, C. A., Al-Moujahed, A., Pasricha, M. V., Callaway, N. F., Kumm, J., Moshfeghi, D. M. 2021; 11 (1): 5369


    To describe a database of longitudinally graded telemedicine retinal images to be used as a comparator for future studies assessing grader recall bias and ability to detect typical progression (e.g. International Classification of Retinopathy of Prematurity (ICROP) stages) as well as incremental changes in retinopathy of prematurity (ROP). Cohort comprised of retinal images from 84 eyes of 42 patients who were sequentially screened for ROP over 6 consecutive weeks in a telemedicine program and then followed to vascular maturation or treatment, and then disease stabilization. De-identified retinal images across the 6 weekly exams (2520 total images) were graded by an ROP expert based on whether ROP had improved, worsened, or stayed the same compared to the prior week's images, corresponding to an overall clinical "gestalt" score. Subsequently, we examined which parameters might have influenced the examiner's ability to detect longitudinal change; images were graded by the same ROP expert by image view (central, inferior, nasal, superior, temporal) and by retinal components (vascular tortuosity, vascular dilation, stage, hemorrhage, vessel growth), again determining if each particular retinal component or ROP in each image view had improved, worsened, or stayed the same compared to the prior week's images. Agreement between gestalt scores and view, component, and component by view scores was assessed using percent agreement, absolute agreement, and Cohen's weighted kappa statistic to determine if any of the hypothesized image features correlated with the ability to predict ROP disease trajectory in patients. The central view showed substantial agreement with gestalt scores (kappa=0.63), with moderate agreement in the remaining views. Of retinal components, vascular tortuosity showed the most overall agreement with gestalt (kappa=0.42-0.61), with only slight to fair agreement for all other components. This is a well-defined ROP database graded by one expert in a real-world setting in a masked fashion that correlated with the actual (remote in time) exams and known outcomes. This provides a foundation for subsequent study of telemedicine's ability to longitudinally assess ROP disease trajectory, as well as for potential artificial intelligence approaches to retinal image grading, in order to expand patient access to timely, accurate ROP screening.

    View details for DOI 10.1038/s41598-021-84723-7

    View details for PubMedID 33686091

  • Liquid biopsy proteomics of uveal melanoma reveals biomarkers associated with metastatic risk. Molecular cancer Velez, G., Nguyen, H. V., Chemudupati, T., Ludwig, C. A., Toral, M., Reddy, S., Mruthyunjaya, P., Mahajan, V. B. 2021; 20 (1): 39

    View details for DOI 10.1186/s12943-021-01336-4

    View details for PubMedID 33627107

  • Higher prevalence of fundus haemorrhages in early-screened (NEST Study) as compared to late-screened (SUNDROP Study) newborn populations. The British journal of ophthalmology Ludwig, C. A., Jabbehdari, S., Ji, M., Vail, D., Al-Moujahed, A., Rosenblatt, T., Azad, A. D., Veerappan, M., Callaway, N. F., Moshfeghi, D. M. 2021


    BACKGROUND/AIMS: To determine whether timing of ophthalmic screening influences prevalence of neonatal fundus haemorrhages. We compared the prevalence of fundus haemorrhages in two populations: term newborns screened early (less than 72 hours) and preterm newborns screened late (4-11 weeks). Additionally, we reviewed the literature on timing and prevalence of newborn haemorrhages.METHODS: Retrospective observational cohort study. Infants who underwent wide-angle ophthalmic digital imaging over one overlapping year in the Newborn Eye Screen Testing (NEST) or Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) programme were included. The PubMed database was filtered to include English-language articles dating back to 1950. Nine articles were selected for review based on inclusion of the prevalence of newborn fundus haemorrhages at multiple time points.RESULTS: A total of 202 patients received early imaging in the NEST cohort and 73 patients received late imaging in the SUNDROP cohort. In the NEST cohort, 20.2% of newborns had haemorrhages. In contrast, we found haemorrhages in only one case or 1.4% of the SUNDROP cohort. Using prevalence data from nine additional studies, we developed a predicted probabilities model of newborn haemorrhages. Per this model, the probability of seeing a haemorrhage if you screen an infant at 1 hour is 18.8%, at 2 weeks is 2.9% and at 1 month is 0.28%.CONCLUSION: We found a significant difference in the prevalence of fundus haemorrhages between the early-screened NEST cohort and the late-screened, preterm SUNDROP cohort. Likely, this difference is due to the transient nature of most newborn haemorrhages.

    View details for DOI 10.1136/bjophthalmol-2020-317908

    View details for PubMedID 33514529

  • Multimodal Imaging Features of Optic Disc Drusen. American journal of ophthalmology Yan, Y., Ludwig, C. A., Liao, Y. J. 2021


    PURPOSE: Identify key en face multimodal imaging features of optic disc drusen (ODD).DESIGN: Retrospective cross-sectional study.METHODS: .SETTING: Single academic center.PATIENT OR STUDY POPULATION: 786 patients (age 10-82 years) with diagnostic codes for ODD or the term "optic disc drusen" in clinical notes extracted using natural language processing.INTERVENTION OR OBSERVATION PROCEDURES: Color fundus image, green-light and blue-light fundus autofluorescence (FAF), near-infrared reflectance (NIR), and enhanced-depth imaging optical coherence tomography (EDI-OCT).MAIN OUTCOME MEASURES: Ophthalmic imaging characteristics and sensitivity of en face imaging compared with EDI-OCT.RESULTS: 38 (61 eyes) of 786 patients had high-quality EDI-OCT and en face multimodal imaging. Green-light FAF had the highest sensitivity (96.8%) and showed homogeneously hyperautofluorescence while blue-light FAF differentiated superficial and deep ODD by the heterogeneous brightness of FAF. Blue-light FAF (93.5%) and NIR (91.8%) were also sensitive and provided important features including the location, size, and depth of ODD and morphology of the optic disc and ODD-associated features such as horizontal hyperreflective lines and peripapillary hyperreflective ovoid mass-like structures (PHOMS), respectively. Color fundus imaging had the lowest sensitivity (82%). There was good inter-rater reliability for all en face imaging modalities (P < .0001 for all).CONCLUSIONS: Green-light FAF had the highest sensitivity in diagnosis of ODD, while blue-light FAF and NIR provided more information regarding the severity, location, depth, and size of ODD. In eyes that are negative on green-light FAF, EDI-OCT can be performed and provides the highest-resolution characterization of the entire optic disc to rule out ODD.

    View details for DOI 10.1016/j.ajo.2020.12.023

    View details for PubMedID 33485838

  • Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): Truly Mobile Teleophthalmology OPHTHALMIC SURGERY LASERS & IMAGING RETINA Pasricha, M., Ludwig, C. A., Moshfeghi, D. M. 2021; 52 (1): 11–12


    [Ophthalmic Surg Lasers Imaging Retina. 2021;52:11-12.].

    View details for DOI 10.3928/23258160-20201223-03

    View details for Web of Science ID 000623529700002

    View details for PubMedID 33471909

  • Statins and the progression of age-related macular degeneration in the United States. PloS one Ludwig, C. A., Vail, D., Rajeshuni, N. A., Al-Moujahed, A., Rosenblatt, T., Callaway, N. F., Veerappan Pasricha, M., Ji, M. H., Moshfeghi, D. M. 2021; 16 (8): e0252878


    To study the effect of statin exposure on the progression from non-exudative to exudative age-related macular degeneration (AMD).Retrospective cohort study of commercially insured patients diagnosed with non-exudative AMD (n = 231,888) from 2007 to 2015. Time-to-event analysis of the association between exposure to lipid-lowering medications and time from non-exudative AMD to exudative AMD diagnosis was conducted. Outcome measures included progression to exudative AMD, indicated by diagnosis codes for exudative AMD or procedural codes for intravitreal injections.In the year before and after first AMD diagnosis, 11,330 patients were continuously prescribed lipid-lowering medications and 31,627 patients did not take any lipid-lowering medication. Of those taking statins, 21 (1.6%) patients were on very-high-dose lipophilic statins, 644 (47.6%) on high-dose lipophilic statins, and 689 (50.9%) on low-dose lipophilic statins. We found no statistically significant relationship between exposure to low (HR 0.89, 95% CI 0.83 to 1.38) or high-dose lipophilic statins (HR 1.12, 95% CI 0.86 to 1.45) and progression to exudative AMD. No patients taking very-high-dose lipophilic statins converted from non-exudative to exudative AMD, though this difference was not statistically significant due to the subgroup size (p = .23, log-rank test).No statistically significant relationship was found between statin exposure and risk of AMD progression. Interestingly, no patients taking very-high-dose lipophilic statins progressed to exudative AMD, a finding that warrants further exploration.

    View details for DOI 10.1371/journal.pone.0252878

    View details for PubMedID 34347799

  • Risk of Retinal Artery Occlusion in Patients with Migraine. American journal of ophthalmology Al-Moujahed, A., Tran, E. M., Azad, A., Vail, D., Ludwig, C. A., Pasricha, M. V., Rosenblatt, T. R., Callaway, N. F., Moshfeghi, D. M. 2020


    PURPOSE: To determine if migraine is associated with increased risk of retinal artery occlusion (RAO).DESIGN: Retrospective cohort study METHODS: Setting: A large insurance claims database.PARTICIPANTS: Patients with migraine and matched controls without migraine between 2007 to 2016.PROCEDURES: Cox proportional hazard regression models were used to investigate the association between migraine and risk of all RAO, central RAO (CRAO), branch RAO (BRAO), and "other" RAO, which includes transient and partial RAO.MAIN OUTCOME MEASURES: Incidence of all RAO, including CRAO, BRAO, and other RAO, following first migraine diagnosis.RESULT: There were 418,965 patients with migraine who met study criteria and were included in the analysis with the appropriate matched controls. Among the 418,965 patients with migraine, 1,060 (0.25%) were subsequently diagnosed with RAO, whereas only 335 (0.08%) of the patients without migraine were diagnosed with RAO. The hazard ratio (HR) for incident all RAO in patients with migraine compared with those without migraine was 3.48 (95% Confidence Interval (CI): 3.07 - 3.94; P <0.0001]. This association was consistent across all types of RAO, including CRAO (HR = 1.62; 95% CI: 1.15 - 2.28; P=0.004) BRAO (HR 2.09; 95% CI 1.60 - 2.72; P <0.001), and other types of RAO (HR 4.61; 95% CI 3.94 - 5.38; P <0.001). Patients with migraine with aura had a higher risk for incident RAO compared with those with migraine without aura (HR = 1.58; 95% CI: 1.40 - 1.79; P <0.001). This association was consistent for BRAO (HR = 1.43; 95% CI 1.04 - 1.97; P <0.03) and other types of RAO (HR = 1.67; 95% CI 1.45 - 1.91; P <0.001), but was not statistically significant for CRAO (HR = 1.18; 95% CI 0.75 - 1.87; P = 0.475). Significant risk factors for this association included increased age, male sex, acute coronary syndrome, valvular disease, carotid disease, hyperlipidemia, hypertension, retinal vasculitis and/or inflammation, and systemic lupus erythematosus.CONCLUSIONS: Migraine is associated with increased risk of all types of RAO and migraine with aura is associated with increased risk of RAO compared with migraine without aura.

    View details for DOI 10.1016/j.ajo.2020.11.004

    View details for PubMedID 33359716

  • Reply to Comment on: Racial, Ethnic, and Socioeconomic Disparities in Retinoblastoma Enucleation: A Population-Based Study, SEER 18 2000-2014 AMERICAN JOURNAL OF OPHTHALMOLOGY Rajeshuni, N., Whittemore, A. S., Ludwig, C. A., Mruthyunjaya, P., Moshfeghi, D. M. 2020; 217: 351
  • Morning glory optic nerve in Aicardi syndrome: Report of a case with fluorescein angiography. European journal of ophthalmology Al-Moujahed, A., Callaway, N. F., Ludwig, C. A., Rayess, N., Wood, E., Moshfeghi, D. M. 2020: 1120672120942702


    BACKGROUND: Aicardi syndrome is an X-linked condition that is associated with multiple ophthalmic malformations. Here, we report the first published fluorescein angiography (FA) study of a morning glory optic nerve in a patient with Aicardi syndrome and contralateral persistent fetal vasculature (PFV).CASE DESCRIPTION: A 12-day old full-term baby girl with a normal neurological exam was referred for evaluation of microphthalmia. The posterior segment of the right eye demonstrated chorioretinal lacunae typical of Aicardi syndrome and microphthalmos with a stalk consistent with PFV. The right eye imaging could not be captured due to the severe microphthalmos and cataract, however, fluorescein angioscopy was performed. The left eye demonstrated a morning glory appearing optic disc with peripapillary chorioretinal lacunae. Fluorescein angiography of the eye showed and late staining in the areas of ellipsoid chorioretinal lacunae emanating from the optic nerve and extensive peripapillary staining and late leakage of the optic nerve.CONCLUSION: Patients with Aicardi syndrome can have morning glory optic nerve anomaly and PFV. Using FA under anesthesia to detect these abnormalities help in estimating the extend of the disease and its complications, which allows for better management of the complications.

    View details for DOI 10.1177/1120672120942702

    View details for PubMedID 32674592

  • Evaluation of Racial, Ethnic, and Socioeconomic Associations With Treatment and Survival in Uveal Melanoma, 2004-2014. JAMA ophthalmology Rajeshuni, N., Zubair, T., Ludwig, C. A., Moshfeghi, D. M., Mruthyunjaya, P. 2020


    Importance: Identifying disparities in uveal melanoma (UM) treatment patterns and survival across racial, ethnic, and socioeconomic (SES) groups reveals possible inequities in ophthalmologic health care.Objective: To examine the association of race, ethnicity, and SES with UM treatment and survival.Design, Setting, and Participants: A retrospective cohort analysis of 28% of the US population using the Surveillance, Epidemiology, and End Results (SEER) 18 registries from January 1, 2004, to December 31, 2014, was conducted. Data analysis was performed from April to July 2018. SEER identified 4475 individuals using International Classification of Diseases for Oncology, Third Edition site and morphology codes.Exposures: Race, ethnicity, and SES estimated by tertile using Yost Index composite scores.Main Outcomes and Measures: Treatment odds ratios (ORs), 1-year and 5-year survival estimates, mortality hazard ratios (HRs), and Kaplan-Meier survival curves. Hypothesis was formulated before data collection.Results: Multivariate analyses of 4475 individuals (2315 [51.7%] men; non-Hispanic white, 4130 [92.3%]; nonwhite, 345 [7.7%]) showed that patients who were nonwhite (OR, 1.45; 95% CI, 1.12-1.88) and socioeconomically disadvantaged (lower SES: OR, 2.21; 95% CI, 1.82-2.68; middle SES: OR, 1.86; 95% CI, 1.56-2.21) were more likely to receive primary enucleation. No interactions were observed between race/ethnicity, SES, and stage at diagnosis. From 2004 to 2014, rates of primary enucleation decreased across all racial/ethnic and SES groups, but disparities persisted. Socioeconomically disadvantaged patients had lower 5-year all-cause survival rates (lower SES: 69.2%; middle SES: 68.1%; and upper SES: 73.8%), although disease-specific survival did not vary significantly by racial/ethnic or SES strata. Mortality risk was associated with older age at diagnosis (56-68 years: HR, 1.70; 95% CI, 1.44-2.01; ≥69 years: HR, 3.32; 95% CI, 2.85-3.86), advanced stage of UM (stage 2: HR, 1.40; 95% CI, 1.19-1.65; stage 3: HR, 2.26; 95% CI, 1.87-2.73; and stage 4: HR, 10.09; 95% CI, 7.39-13.77), and treatment with primary enucleation (HR, 2.14; 95% CI, 1.88-2.44) with no racial/ethnic or SES variation.Conclusions and Relevance: In this study, SEER data from 2004 to 2014 suggest that nonwhite and socioeconomically disadvantaged patients with UM are more likely to be treated with primary enucleation, although no such variation appears to exist in disease-specific survival. These differences reveal opportunities to address issues regarding treatment choice in UM.

    View details for DOI 10.1001/jamaophthalmol.2020.2254

    View details for PubMedID 32614376

  • Effective Field of View of Wide-Field Fundus Camera for Retinopathy of Prematurity Screening Ji, M. H., Bodnar, Z., Callaway, N. F., Ludwig, C. A., Kumm, J., Rosenblatt, T., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
  • Absolute Risk of Rhegmatogenous Retinal Detachment in High Myopes in the United States Ludwig, C. A., Vail, D., Callaway, N. F., Al-Moujahed, A., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
  • Progression of Dry to Wet Age-related Macular Degeneration in Patients Receiving Intensive Statin Treatment Al Moujahed, A., Ludwig, C. A., Davila, J., Vail, D., Callaway, N. F., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
  • The association between pentosan polysulfate sodium exposure and drug-induced maculopathy Pasricha, M., Ludwig, C. A., Davila, J., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2020
  • Retinopathy of prematurity and neurodevelopmental outcomes in premature infants. Eye (London, England) Al-Moujahed, A., Azad, A., Vail, D., Ludwig, C. A., Callaway, N. F., Moshfeghi, D. M. 2020

    View details for DOI 10.1038/s41433-020-0941-x

    View details for PubMedID 32398837

  • Re: Ludwig et al.: Pentosan polysulfate sodium exposure and drug-induced maculopathy in commercially insured patients in the United States (Ophthalmology. 2020;127:535-543) Reply OPHTHALMOLOGY Ludwig, C. A., Vail, D., Moshfeghi, D. M. 2020; 127 (5): E36
  • Resolution of optic disc pit-associated macular retinoschisis after topical carbonic anhydrase inhibitor treatment: Report of a case. European journal of ophthalmology Al-Moujahed, A., Callaway, N. F., Vail, D., Ludwig, C. A., Ji, M. H., Moshfeghi, D. M. 2020: 1120672120904664


    BACKGROUND: Optic disc pits frequently lead to visual deterioration due to macular retinoschisis or serous retinal detachment. Here, we report a case of optic disc pit-associated macular retinoschisis due to intraretinal fluid accumulation that resolved with improvement in visual acuity after treatment with topical dorzolamide.CASE DESCRIPTION: A 56-year-old otherwise healthy female with no ocular history presented with 2weeks of slowly worsening blurry vision in her right eye. Visual acuity was 20/30 in the right eye. Posterior segment examination revealed posterior vitreous detachment, an optic disc pit at 9 o'clock, macular edema and foveoschisis with fluid extending from the optic nerve, and a normal peripheral retina. Optical coherence tomography imaging of the macula showed central subfield thickness of 526m. The patient preferred no surgical intervention, so topical dorzolamide 2% three times daily was initiated. Over the next 2 years, the central subfield thickness steadily declined from 526 to 262m, and her vision improved to 20/20 with improvement in the macular retinoschisis.CONCLUSION: Our report presents a case of resolution of optic disc pit-associated macular retinoschisis due to intraretinal fluid accumulation with possible role for dorzolamide as a potential treatment option.

    View details for DOI 10.1177/1120672120904664

    View details for PubMedID 32019335

  • Von Hippel-Lindau Syndrome Phenotype With Prominent Vitreoretinal Neovascularization Treated With Early PPV: A Case Series and Literature Review OPHTHALMIC SURGERY LASERS & IMAGING RETINA Zubair, T., Callaway, N. F., Ludwig, C., Tang, P. H., Shields, R. A., Ji, M. H., Vail, D., Powers, M. A., Moshfeghi, D. M. 2020; 51 (2): 109–15


    To describe a case series of three patients in one family with Von Hippel-Lindau (VHL) disease who presented with vitreoretinal neovascularization and resulting tractional retinal detachments (TRDs). This vitreoretinal phenotype of VHL may benefit from early surgical intervention.Descriptive case series of three patients in one family with VHL disease. A review of the literature regarding surgical intervention for VHL was performed.All three patients developed prominent intravitreal neovascularization with fibrovascular growth within the vitreous secondary to a retinal capillary hemangioma. Two subjects with intravitreal neovascularization were treated with laser and cryotherapy but eventually developed a TRD. The final vision in these two patients was light perception and 20/300. The eye that was preemptively treated with vitrectomy to remove the vitreous sustaining the neovascularization had visual acuity of 20/50 after surgery.Intravitreal neovascularization with fibrovascular proliferation may be an indication for vitrectomy prior to the development of retinal detachment. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:109-115.].

    View details for DOI 10.3928/23258160-20200129-07

    View details for Web of Science ID 000516809400007

    View details for PubMedID 32084284

  • Surgical timing and presence of a vitreoretinal fellow on postoperative adverse events following pars plana vitrectomy EUROPEAN JOURNAL OF OPHTHALMOLOGY Shields, R. A., Ludwig, C. A., Powers, M. A., Tijerina, J. D., Schachar, I. H., Moshfeghi, D. M. 2020; 30 (1): 81–87
  • Timing and Reoperation Rate of Rhegmatogenous Retinal Detachments Occurring During Major Ophthalmology Meetings. Ophthalmic surgery, lasers & imaging retina Vail, D. n., Al-Moujahed, A. n., Callaway, N. F., Ji, M. H., Ludwig, C. A., Moshfeghi, D. M. 2020; 51 (6): 328–37


    To investigate whether surgical management of newly diagnosed rhegmatogenous retinal detachment (RRD) varies if patients are diagnosed during a major national ophthalmology conference.This retrospective cohort study included 34,759 patients with incident RRD, of whom, 1,246 (3.6%) were diagnosed during dates of three national ophthalmology conferences, and 1,170 (3.4%) underwent surgery during conference dates. The authors identified patients with primary repair with cryotherapy, laser, scleral buckle, pneumatic retinopexy, or pars plana vitrectomy. Multinomial logistic regression models were used to determine patients' likelihood of receiving each type of repair within 30 days of their diagnosis depending on whether they were diagnosed during a national ophthalmology conference. Linear regression models were used to determine the relationship between the date patients were diagnosed and how long they waited to receive a repair. Main outcome measures included days between diagnosis with RRD and RRD repair, receiving repair on the same day of diagnosis, and reoperation rate within 30 days of the primary repair.Mean time from diagnosis to repair was 1.5 days (standard deviation: ± 2.4 days), and 71% of patients underwent repair within a day of diagnosis. Repairs were followed by a second surgery within 30 days in 11.1% of patients. Patients diagnosed during conferences waited 0.23 days longer between diagnosis and repair compared with patients diagnosed outside of conference dates (P = .001). Patients diagnosed with RRD during conferences were less likely to receive surgical repair within a day of diagnosis compared to patients diagnosed during non-conference dates (P = .037). Patients who were diagnosed with RRD during a conference date and also received surgery during a conference date were more likely to undergo a second surgery within 30 days of the primary procedure (P = .006) CONCLUSIONS: Patients diagnosed with RRD during national ophthalmology conference dates waited slightly longer for surgery, were slightly less likely to receive surgery within a day, and were more likely to undergo a second surgery within 30 days of the primary procedure. The "national meeting effect" phenomenon is present in ophthalmology, albeit to a lesser degree that is likely not visually significant. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:328-337.].

    View details for DOI 10.3928/23258160-20200603-03

    View details for PubMedID 32579691

  • Intravitreal methotrexate and fluocinolone acetonide implantation for Vogt-Koyanagi-Harada uveitis. American journal of ophthalmology case reports Park, J. G., Callaway, N. F., Ludwig, C. A., Mahajan, V. B. 2020; 19: 100859


    To report a case of intravitreal methotrexate treatment and fluocinolone acetonide (Retisert®) implantation in a patient with Vogt-Koyanagi-Harada syndrome (VKH).A 34-year-old male was referred for worsening vision and bilateral panuveitis consistent with VKH. He was treated with prednisone, mycophenolate mofetil, prednisolone acetate eye drops, and injections of triamcinolone and adalimumab. He failed to improve with these therapies and developed multiple adverse effects, including hepatotoxicity, severe eye pain, cataracts, and cystoid macular edema. We treated him with intravitreal methotrexate injections in both eyes, which rapidly improved his eye pain, inflammation, and vision. He subsequently underwent fluocinolone acetonide (Retisert®) implantation, cataract extraction with intraocular lens insertion, and Ahmed tube placement for long-term intraocular pressure control. His vision improved from hand motions to 20/30, intraocular pressure remained stable at 17, there was complete resolution of his panuveitis and uveitic macular edema, and his systemic medications were able to be discontinued./Importance: This case demonstrates intravitreal methotrexate may successfully treat intraocular inflammation, pain, and macular edema in VKH. Excellent long-term vision and reduction of adverse effects of systemic medications were also achieved with subsequent fluocinolone acetonide implantation. Combining these two targeted therapies may be an effective strategy in treating VKH in patients who have severe pain and cannot tolerate systemic therapy.

    View details for DOI 10.1016/j.ajoc.2020.100859

    View details for PubMedID 32793845

    View details for PubMedCentralID PMC7415829

  • Sex Differences in the Repair of Retinal Detachments in the United States. American journal of ophthalmology Callaway, N. F., Vail, D. n., Al-Moujahed, A. n., Ludwig, C. n., Ji, M. H., Mahajan, V. B., Pershing, S. n., Moshfeghi, D. M. 2020


    To determine differences between women and men in the repair of rhegmatogenous retinal detachments (RRD) in the United States.Retrospective cohort study.SETTING: A large insurance claims database.Subjects with an incident RRD between 2007-2015.Demographic data, comorbid ocular conditions associated with RRD,systemic comorbidities,and surgical intervention (pneumatic retinopexy (PR), pars plana vitrectomy (PPV), laser barricade, or scleral buckle (SB)) were collected.Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex.The study period included 133 million eligible records with 61,071 cases of incident RRD meeting inclusion criteria among which 43% (n = 26,289) were women. Women had 34% reduced odds of receipt of surgical repairof an RRD (OR 0.66, 95% CI 0.59 - 0.73, p<0.001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients that received repair, women were more often delayed (0.17 days, p = 0.04). Women were more likely to undergo primary laser barricade (RRR 1.68, p < 0.001), primary SB (RRR 1.15, p < 0.001), and PR (RRR 1.07, p < 0.04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85 - 0.96, p=0.002) after adjustment.Insured women are less likely than insured men to receive surgical intervention for an RRD. If the odds of repair were equal between women and men in the U.S. then 781 more women would receive surgery each year, or 7,029 more during the study period. Women are more likely to have the repair performed with scleral buckle and laser barricade. The reason for thesesex differences in RRD repair remains unknown and requires further investigation.

    View details for DOI 10.1016/j.ajo.2020.06.039

    View details for PubMedID 32640255

  • Conserved regression patterns of retinopathy of prematurity after intravitreal ranibizumab: A class effect. European journal of ophthalmology Ji, M. H., Moshfeghi, D. M., Shields, R. A., Bodnar, Z. n., Ludwig, C. A., Callaway, N. F., Orazi, L. n., Amorelli, G. M., Lepore, D. n. 2020: 1120672120945101


    To determine if fluorescein angiographic (FA) findings after intravitreal ranibizumab (IVR) for retinopathy of prematurity (ROP) conform to a class effect previously described with bevacizumab.Single-center retrospective case series of all infants treated with 0.2 mg (0.02 mL) IVR for Type 1 ROP from July 2016 to November 2018. FA were obtained at 40, 52, 62, and 72 weeks of postmenstrual age (PMA) using wide-angle photography. FA images were analyzed and the peripheral avascular areas measured with ImageJ using a reference disc diameter (DD). Based on the extent of the avascular area and tortuosity of the retinal vessels all eyes were classified into four categories: complete vascular maturity (vascularization within 2 DD of the ora serrata), VAA (avascular area >2 DD of the ora serrata), VAT (avascular area >2 DD of the ora serrata and posterior tortuosity), and reactivation (recurrence of stage disease).About 13 infants were enrolled and 24 eyes were available in this study. None of the eyes reached complete vascular maturity at an average PMA of 60 weeks, 7 (29%) eyes presented with VAA, 8 (33%) with VAT, and 9 (37.5%) reactivated. The reactivated eyes presented with the largest area of peripheral ischemia, followed by the VAT and then the VAA groups (p = 0.02).IVR conforms to the previously described regression patterns following intravitreal bevacizumab for ROP indicative of a class effect. Follow-up using FA might help to optimize the management of these infants after injection of the drug.

    View details for DOI 10.1177/1120672120945101

    View details for PubMedID 32722932

  • Racial, Ethnic, and Socioeconomic Disparities in Retinoblastoma Enucleation: A Population-Based Study, SEER 18 2000-2014 AMERICAN JOURNAL OF OPHTHALMOLOGY Rajeshuni, N., Whittemore, A. S., Ludwig, C. A., Mruthyunjaya, P., Moshfeghi, D. M. 2019; 207: 215–23
  • Pilot Study to Assess Safety and Usability of the Kyron NPWT System PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Karki, B., Rai, S., Nakarmi, K., Laminchhane, A., Maharjan, N., Giri, P., Pathak, K., Spielman, A., Kung, T. H., Ludwig, C. A. 2019; 7 (8)
  • Birth-related subconjunctival and retinal haemorrhages in the Newborn Eye Screening Test (NEST) Cohort. Eye (London, England) Ji, M. H., Ludwig, C. A., Callaway, N. F., Moshfeghi, D. M. 2019

    View details for DOI 10.1038/s41433-019-0523-y

    View details for PubMedID 31285570

  • Gender Differences in Surgical Intervention Rate and Timing for Rhegmatogenous Retinal Detachments Among US Commercially Insured Patients From 2007-2015 Callaway, N. F., Vail, D., Pershing, S., Ludwig, C. A., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • High-Dose Statins and Progression of Age-Related Macular Degeneration in Commercially Insured Patients, 2007 to 2016 Ludwig, C. A., Rajeshuni, N., Vail, D., Callaway, N. F., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Regression patterns of Retinopathy of Prematurity after intravitreal injection of Ranibizumab Ji, M. H., Moshfeghi, D., Shields, R. A., Bodnar, Z., Ludwig, C. A., Callaway, N. F., Leng, T., Sanislo, S., Orazi, L., Amorelli, G., Lepore, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Traumatic chorioretinitis sclopetaria: Risk factors, management, and prognosis. American journal of ophthalmology case reports Ludwig, C. A., Shields, R. A., Do, D. V., Moshfeghi, D. M., Mahajan, V. B. 2019; 14: 39–46


    Purpose: To describe new cases of sclopetaria and evaluate the risk factors, management, and visual prognosis of all reported cases in the literature.Observations: We performed a retrospective, observational case series. This study included six cases (median age 23, interquartile range 33) of sclopetaria. Additionally, literature searches were conducted in the PubMed and Cochrane Library databases to uncover risk factors associated with all published cases of sclopetaria. Main outcome measure was best corrected visual acuity (BCVA) worse than 20/20. Sixty-seven cases (71 eyes) of sclopetaria have been reported, of which 59 cases (61 eyes) met inclusion criteria in this study. Most were young (median age 19.5 years) men (51/59, 88.1%). Thirty-seven eyes were observed while 24 underwent immediate surgery including six pars plana vitrectomies and three scleral buckles. Compared to initial presentation, BCVA improved in 31/48 (64.6%) eyes, remained stable in 12/48 eyes (25.0%), and worsened in 5/48 eyes (10.4%). Ten patients (16.4%) achieved a final BCVA of 20/20 with median follow up time of seven months. In a multivariate model, location of sclopetaria in the macula, temporal retina, or immediate orbital foreign body removal predicted poor final BCVA with an area under receiver operating characteristic curve of 0.767.Conclusions and importance: Traumatic chorioretinitis sclopetaria is rare, but reports have increased dramatically over the past two decades. While pars plana vitrectomy may be required for the management of retinal detachments and non-clearing vitreous hemorrhage, close observation is appropriate in most cases. Visual prognosis is poor with most patients attaining 20/200 vision or worse.

    View details for PubMedID 30834355

  • Postoperative Adverse Events, Interventions, and the Utility of Routine Follow-Up After 23-, 25-, and 27-Gauge Pars Plana Vitrectomy. Asia-Pacific journal of ophthalmology (Philadelphia, Pa.) Shields, R. A., Ludwig, C. A., Powers, M. A., Tran, E. M., Smith, S. J., Moshfeghi, D. M. 2019


    PURPOSE: To evaluate the utility of standard postoperative visit (POV) intervals in pars plana vitrectomy (PPV) as a function of adverse events (AEs) identified.DESIGN: Retrospective case review.METHODS: The medical records of all patients undergoing 23-, 25-, and 27-gauge PPV from January 1, 2016 to December 31, 2016 were reviewed. Each POV was assessed as a standard (s-POV), physicianadjusted (a-POV), or patient-initiated visit (p-POV). Preoperative features, diagnoses, and surgical procedures were evaluated to determine protective and risk factors for AEs.RESULTS: A total of 256 patients (310 PPVs) were included in this study. The most common cumulative postoperative AEs were elevated intraocular pressure (>30 mm Hg) (12.3%), cystoid macular edema (6.1%), and retinal detachment (5.8%). Patients with the diagnosis of macular hole or epiretinal membrane had the lowest relative risk of AEs [0.30; 95% confidence interval (CI), 0.12-0.75 and 0.36; 95% CI, 0.21-0.63, respectively]. There was no difference in time to AE among different vitrectomy gauge sizes (P = 0.733). Patients in a-POV and p-POV groups had a statistically significant higher incidence of AEs in the POV day 5-10 window (P = 0.004).CONCLUSIONS: The utility of standard POVs in detecting AEs is dependent on the indication for PPV. Specifically patients undergoing isolated macular surgery (epiretinal membrane peel or macular hole repair) had the lowest relative risk of postoperative AEs and may warrant a less-intensive follow-up regimen.

    View details for PubMedID 30628767

  • Colour change in the newborn iris: 2-year follow-up of the Newborn Eye Screening Test study. Acta ophthalmologica Jabbehdari, S. n., Sinow, C. n., Ludwig, C. A., Callaway, N. F., Moshfeghi, D. M. 2019

    View details for DOI 10.1111/aos.14321

    View details for PubMedID 31811709

  • The effect of statin exposure on choroidal neovascularization in nonexudative age-related macular degeneration patients EYE Rajeshuni, N., Ludwig, C. A., Moshfeghi, D. M. 2019; 33 (1): 163–65
  • Characteristics of Ophthalmology Trials Registered in, 2007-2018. American journal of ophthalmology Turner, B. n., Rajeshuni, N. n., Tran, E. M., Ludwig, C. A., Tauqeer, Z. n., Weeks, B. n., Kinde, B. n., Pershing, S. n. 2019


    To perform a comprehensive analysis of characteristics of ophthalmology trials registered in study METHODS: All 4,203 ophthalmologic clinical trials registered on between October 1, 2007, and April 30, 2018 were identified using Medical Subject Heading (MeSH) terms. Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratio and 95% confidence intervals were determined for characteristics associated with early discontinuation.The majority of trials were multi-armed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). Thirty-three percent utilized a data monitoring committee (DMC), and 50.6% incorporated blinding. 51.6% were funded by industry, while 2.6% by the National Institute of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH=15.5%, Other=3%, Industry=1.5%; p<0.001) or pediatric disease (NIH=20.9%, Other=5.9%, Industry=1.4%; p<0.001). Industry-sponsored trials (69.6% of phase 3 trials) and were significantly more likely to be randomized (Industry=68.7%, NIH=58.9%, Other=60.8%; p<0.001) and blinded (Industry=57.2%, NIH=42.7%, Other=43.5%; p<0.001). 359 trials (8.5%) were discontinued early and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (HR 0.72; 95% CI 0.55-0.95; p=0.021) and/or had a DMC (HR 0.71, 95% CI 0.55-0.92, p=0.010).Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, while Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically-sound trials with deliberate funding allocation.

    View details for DOI 10.1016/j.ajo.2019.11.004

    View details for PubMedID 31730839

  • Lipid-Lowering Medications are Associated with Lower Risk of Retinopathy and Ophthalmic Interventions among U.S. Patients with Diabetes. American journal of ophthalmology Vail, D. n., Callaway, N. F., Ludwig, C. A., Saroj, N. n., Moshfeghi, D. M. 2019


    To evaluate the impact of lipid-lowering medications on diabetic retinopathy and diabetic complications requiring intervention in the U.S.Retrospective cohort analysis.Administrative insurance claims drawn from the Truven MarketScan Commercial Claims and Encounters database.Beneficiaries with Type 2 diabetes mellitus (T2DM).Any signs of diabetic retinopathy, as measured by diagnosis codes for non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), diabetic macular edema (DME), and procedure codes for retinopathy treatments (anti-VEGF injections, laser therapy, and vitrectomy).We analyzed a population of 269,782 patients diagnosed with T2DM between 2008 and 2015. 99,233 (37%) of patients were undergoing treatment with lipid-lowering medications. Approximately 6% of patients on lipid-lowering medications had a diagnosis code for NPDR, PDR, or DME, or a procedural code for intravitreal injections, PPV, or laser in their record following diagnosis with diabetes, compared to 6.5% of patients who did not take lipid-lowering medications (p<0.01). In adjusted time-to-event analyses, patients who took lipid-lowering medications prior to diagnosis with T2DM were less likely to progress to any retinopathy diagnosis (HR 0.60, 95% CI 0.55-0.65) and less likely to receive any treatment for retinopathy (HR 0.81, 95% CI 0.78-0.84). These findings were significant at the aggregate level, as well as at the level of individual diagnosis (NPDR HR 0.63, 95% CI 0.57-0.69; PDR HR 0.45, 95% CI 0.37-0.54; DME HR 0.39, 95% CI 0.33-0.45), and at the level of each treatment category (anti-VEGF injection HR 0.81, 95% CI 0.78-0.84; laser HR 0.62, 95% CI 0.47-0.81; vitrectomy HR 0.71, 95% CI 0.59-0.85).We find consistent evidence that patients on lipid-lowering medications are less likely to develop NPDR, PDR, or DME, and modest evidence that these patients are less likely to receive intravitreal injections of anti-VEGF medication, laser treatments, or vitrectomy. Our study validates the findings of studies that have used claims databases in East Asia in relatively homogeneous populations to estimate an association between statin use and retinopathy, replicating them in a U.S. context in a large commercial claims database.

    View details for DOI 10.1016/j.ajo.2019.05.029

    View details for PubMedID 31194953

  • Postoperative Adverse Events, Interventions, and the Utility of Routine Follow-Up After 23-, 25-, and 27-Gauge Pars Plana Vitrectomy ASIA-PACIFIC JOURNAL OF OPHTHALMOLOGY Shields, R. A., Ludwig, C. A., Powers, M. A., Tran, E. T., Smith, S. J., Moshfeghi, D. M. 2019; 8 (1): 36–42
  • Pentosan Polysulfate Sodium Exposure and Drug-Induced Maculopathy in Commercially Insured Patients in the United States. Ophthalmology Ludwig, C. A., Vail, D. n., Callaway, N. F., Pasricha, M. V., Moshfeghi, D. M. 2019


    To determine the association and cumulative dose-response pattern between pentosan polysulfate sodium (PPS) use for interstitial cystitis (IC) and maculopathy.Large, multicenter, retrospective cohort study of commercially insured patients in the MarketScan database (Truven Health Analytics, San Jose, CA).Two hundred twenty-seven thousand three hundred twenty-five patients with IC who were enrolled continuously in the MarketScan database.Cox proportional hazards models (controlling for patient gender, age at index diagnosis of IC, and diagnosis with diabetes mellitus) followed up patients from index diagnosis of IC for 5 years, or until patients discontinued insurance coverage, or until patients' first diagnosis with a maculopathy. As a sensitivity analysis, we re-estimate all models after excluding all patients with diabetes. To assess for dose response, we calculated the total days of PPS prescriptions filled and created a categorical variable indicating total exposure.The primary outcome measure was association between binary PPS exposure and any maculopathy. Secondary outcome measures included exposure between binary and categorical, time-dependent, exposure to PPS and to drusen, nonexudative age-related macular degeneration (AMD), exudative AMD, hereditary maculopathy, and toxic maculopathy.The most common diagnoses of maculopathy in patients with IC were exudative AMD (1.5%), drusen (0.8%), nonexudative AMD (0.3%), toxic maculopathy (0.1%), and hereditary dystrophy (0.04%). In unadjusted analyses, the percentage of patients who filled a PPS prescription and were diagnosed later with a maculopathy (2.37%) was very similar to the percentage of patients who did not fill a prescription (2.77%). Survival models using a binary variable indicating PPS exposure showed no significant associations between PPS exposure and diagnosis of drusen, nonexudative AMD, exudative AMD, toxic maculopathy, hereditary dystrophy, or an aggregate variable of any maculopathy. Similarly, there was no dose-dependent relationship between PPS exposure and diagnosis of any maculopathy. These findings remained stable in sensitivity analysis models that excluded patients with diabetes mellitus.In this large, commercial claims database analysis, no association was found between PPS exposure and subsequent diagnosis of maculopathy.

    View details for DOI 10.1016/j.ophtha.2019.10.036

    View details for PubMedID 31899034

  • A novel classification of high myopia into anterior and posterior pathologic subtypes GRAEFES ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY Ludwig, C. A., Shields, R. A., Chen, T. A., Powers, M. A., Parke, D., Moshfeghi, A. A., Moshfeghi, D. M. 2018; 256 (10): 1847–56
  • The effect of statin exposure on choroidal neovascularization in nonexudative age-related macular degeneration patients. Eye (London, England) Rajeshuni, N., Ludwig, C. A., Moshfeghi, D. M. 2018

    View details for PubMedID 30120400

  • A novel classification of high myopia into anterior and posterior pathologic subtypes. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie Ludwig, C. A., Shields, R. A., Chen, T. A., Powers, M. A., Wilkin Parke, D. 3., Moshfeghi, A. A., Moshfeghi, D. M. 2018


    PURPOSE: High myopia and pathologic myopia are common causes of visual morbidity. Myopic pathology can affect all regions of the retina, though there is currently no classification system to distinguish anterior (peripheral) and posterior (macular) pathology. We hypothesize that these classifications are characterized by distinct demographic and refractive features, highlighting the disparity in types of pathologic myopia.METHODS: Institutional retrospective cohort study. The Stanford University Medical Center Clinical Data Warehouse was used to identify patients with high myopia by ICD-9 and ICD-10 codes. Predetermined ICD diagnoses were then used to classify patients with high myopia into isolated high myopia (IHM), anterior pathologic myopia (APM), posterior pathologic myopia (PPM), and combined pathologic myopia (CPM). A cohort of this population was then manually reviewed to gather refractive data and confirm accuracy of ICD coding.RESULTS: Patients (3274) were identified with high myopia. Overall, 22.1% individuals met criteria for APM, 10.7% for PPM, 17.0% for CPM, and 50.2% for IHM. We identified a significantly higher frequency of females with PPM compared to APM (62.3 vs. 48.3%; OR, 1.73; 95% CI, 1.34 to 2.25), Asian patients with PPM as compared to APM (42.9 vs. 33.3%; OR, 1.50; 95% CI, 1.16 to 1.95), and younger patients with APM compared to PPM (median 45.3 vs. 63.4years). The refractive error was significantly more myopic in the CPM (median -9.8D; interquartile range,IQR 6.7) and PPM (median -10.5D; IQR 9.8) subgroups as compared to the APM (median -8.1D; IQR 3.5), and IHM (median - 8.2D; IQR 4.1) subgroups (p=0.003).CONCLUSIONS: High myopia may be divided into four distinct subgroups based on presence and location of pathology, which is associated with differences in age, gender, race, and refractive error.

    View details for PubMedID 30030628

  • Outcomes of Vitrectomy in Von Hippel-Lindau Disease Powers, M., Shields, R. A., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
  • A Novel Classification of High Myopia into Anterior and Posterior Pathologic Subtypes Ludwig, C., Shields, R. A., Chen, T., Powers, M. A., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
  • Postoperative complications following 23, 25, and 27-gauge pars plana vitrectomy and the utility of routine follow-up Shields, R., Powers, M. A., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
  • Effect of Statin Exposure on Choroidal Neovascularization in Nonexudative Age-Related Macular Degeneration Patients Rajeshuni, N., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
  • Automatic identification of referral-warranted diabetic retinopathy using deep learning on mobile phone images Leng, T., Greven, M., Smith, S., Ludwig, C., Chang, R., Gargeya, R. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2018
  • Validity of the Red Reflex Exam in the Newborn Eye Screening Test Cohort. Ophthalmic surgery, lasers & imaging retina Ludwig, C. A., Callaway, N. F., Blumenkranz, M. S., Fredrick, D. R., Moshfeghi, D. M. 2018; 49 (2): 103–10


    The validity of the red reflex exam has yet to be tested against new methods of wide-angle imaging that may improve early detection of neonatal ocular pathology. The authors aimed to determine the validity of the pediatrician's red reflex exam using 130° wide-angle external and fundus digital imaging as a gold standard.This was a prospective cohort study of 194 healthy, term newborns enrolled in the Newborn Eye Screening Test study at Lucile Packard Children's Hospital from July 25, 2013, to July 25, 2014. Red reflex screening was performed by a pediatrician in the newborn nursery and wide-angle fundus digital imaging was performed by a neonatal intensive care unit-certified nurse. The main outcome measure was the validity of the pediatrician's red reflex exam (unweighted kappa [κ] statistic, sensitivity, specificity).Compared to no subjects with abnormal red reflex exams reported in the pediatrician's notes, 49 subjects demonstrated one or multiple ocular abnormalities on 130° wide-angle fundus imaging (κ = 0.00). The pediatrician's red reflex exam had a sensitivity of 0.0% (95% CI, 0.0%-7.3%) and specificity of 100.0% (95% CI, 97.5%-100.0%) for the detection of ocular abnormalities.This study demonstrates the ability of wide-angle fundus imaging to detect fundus abnormalities not otherwise identified by standard newborn red reflex screening prior to hospital discharge. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:103-110.].

    View details for DOI 10.3928/23258160-20180129-04

    View details for PubMedID 29443359

  • Peripapillary Pigmentation and Optic Disc Morphology in Newborns with Treatment Warranted Retinopathy of Prematurity Chen, T., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
  • The Epidemiology of Retinopathy of Prematurity in the United States. Ophthalmic surgery, lasers & imaging retina Ludwig, C. A., Chen, T. A., Hernandez-Boussard, T. n., Moshfeghi, A. A., Moshfeghi, D. M. 2017; 48 (7): 553–62


    Retinopathy of prematurity (ROP) is a leading cause of blindness in premature and low birth weight infants. Here, the authors examine the incidence of ROP in the United States and evaluate risk factors associated with ROP development.The National Healthcare Cost and Utilization Project Kids' Inpatient Database was queried for all newborns with and without ROP. Adjusted odds ratios were constructed for predictors of ROP using multivariate logistic regression modeling.The incidence of ROP increased from 14.70% in 2000 to 19.88% in 2012. Multivariate regression analysis indicated that female gender, birth weight, and gestational age predicted ROP. The frequency of ROP was 2.40% in newborns weighing more than 2,500 grams (g) and 30.22% in newborns with a birth weight between 750 g and 999 g.The authors' report examines a nationwide cohort of ROP infants and reveals an increase in the incidence of ROP from 2000 to 2012. This trend is inversely related to a simultaneous decline in newborn mortality. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:553-562.].

    View details for DOI 10.3928/23258160-20170630-06

    View details for PubMedID 28728176

  • Predictors of treatment-warranted retinopathy of prematurity in the SUNDROP cohort: influence of photographic features. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie Ludwig, C. A., Greven, M. A., Moshfeghi, D. M. 2017


    The Stanford University Network for the Diagnosis of Retinopathy of Prematurity (SUNDROP) initiative-an ongoing telemedicine-based initiative for in-hospital screening of high-risk infants for treatment-warranted ROP (TW-ROP)-has been shown to be a safe, reliable, and cost-effective supplement to the efforts of ROP specialists. We utilized data collected in the SUNDROP initiative to determine demographic (birth weight, sex, multiplicity), weight gain, and ocular imaging (media haze, peripapillary atrophy, fundus pigmentation) predictors of TW-ROP.This was a retrospective nested case-control study. Cases and controls were selected from a cohort of 843 low birth weight, premature newborns who survived to an estimated gestational age of 31 weeks and underwent screening through the SUNDROP initiative. Infants were screened at one of six neonatal intensive care units from December 1, 2005, to April 1, 2016. Cases (n = 37) were newborns with TW-ROP who underwent retinal ablative therapy. Two controls (n = 74) without TW-ROP were matched to each case by gestational age. One reviewer graded media haze, presence of peripapillary atrophy, and fundus pigmentation in images taken at the baseline exam for each newborn. The main outcome measure was association of TW-ROP with predictive factors.In the SUNDROP trial, 37 out of 843 (4.4%) newborns developed TW-ROP. In a multivariable model, birth weight (OR, 0.32; 95% CI, 0.15-0.70) was inversely associated with TW-ROP. In contrast to prior reports, we found no significant difference in sex, multiplicity, or fundus pigmentation at baseline exam in those with TW-ROP as compared to controls. High levels of media haze (>2, scale 0 to 5) were found in the majority of cases (67.6%, 25/37) and controls (65.7%, 44/67). Presence of peripapillary atrophy did not improve prediction of the development of TW-ROP compared to birth weight and weight gain rate alone.The finding of high levels of media haze at baseline ROP screening exams is novel. This study supports the current model for detection of TW-ROP using birth weight, gestational age, and weight gain rate. We found no significant difference between newborns with TW-ROP and controls in baseline presence of media haze, fundus pigmentation or peripapillary atrophy.

    View details for PubMedID 28782073

  • Training time and quality of smartphone-based anterior segment screening in rural India. Clinical ophthalmology (Auckland, N.Z.) Ludwig, C. A., Newsom, M. R., Jais, A. n., Myung, D. J., Murthy, S. I., Chang, R. T. 2017; 11: 1301–7


    We aimed at evaluating the ability of individuals without ophthalmologic training to quickly capture high-quality images of the cornea by using a smartphone and low-cost anterior segment imaging adapter (the "EyeGo" prototype).Seven volunteers photographed 1,502 anterior segments from 751 high school students in Varni, India, by using an iPhone 5S with an attached EyeGo adapter. Primary outcome measures were median photograph quality of the cornea and anterior segment of the eye (validated Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department [FOTO-ED] study; 1-5 scale; 5, best) and the time required to take each photograph. Volunteers were surveyed on their familiarity with using a smartphone (1-5 scale; 5, very comfortable) and comfort in assessing problems with the eye (1-5 scale; 5, very comfortable). Binomial logistic regression was performed using image quality (low quality: <4; high quality: ≥4) as the dependent variable and age, comfort using a smartphone, and comfort in assessing problems with the eye as independent variables.Six of the seven volunteers captured high-quality (median ≥4/5) images with a median time of ≤25 seconds per eye for all the eyes screened. Four of the seven volunteers demonstrated significant reductions in time to acquire photographs (P1=0.01, P5=0.01, P6=0.01, and P7=0.01), and three of the seven volunteers demonstrated significant improvements in the quality of photographs between the first 100 and last 100 eyes screened (P1<0.001, P2<0.001, and P6<0.01). Self-reported comfort using a smartphone (odds ratio [OR] =1.25; 95% CI =1.13 to 1.39) and self-reported comfort diagnosing eye conditions (OR =1.17; 95% CI =1.07 to 1.29) were significantly associated with an ability to take a high-quality image (≥4/5). There was a nonsignificant association between younger age and ability to take a high-quality image.Individuals without ophthalmic training were able to quickly capture a high-quality magnified view of the anterior segment of the eye by using a smartphone with an attached imaging adapter.

    View details for PubMedID 28761328

  • Retinotomy Closure Following Subretinal Stem Cell Transplant With a 30-Gauge Needle. Ophthalmic surgery, lasers & imaging retina Ludwig, C. A., Leng, T. 2016; 47 (9): 869-873


    The authors report two cases of posterior retinotomy closure following subretinal stem cell transplantation for age-related macular degeneration with a 30-gauge needle - a larger bore needle than those used in prior studies. Partial retinotomy closure was seen on optical coherence tomography within 24 hours in one patient, whereas complete closure occurred by the 5-month and 1-year follow-up visits. A trace retinal hemorrhage occurred in one case, with resolution by 12 weeks. These findings demonstrate the likelihood of uncomplicated, spontaneous retinotomy closure following subretinal stem cell transplantation with a 30-gauge needle. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:869-873.].

    View details for DOI 10.3928/23258160-20160901-12

    View details for PubMedID 27631485

  • Posterior Segment Predictors of Treatment Warranted Retinopathy of Prematurity Ludwig, C., Greven, M., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2016
  • Media haze and development of treatment warranted retinopathy of prematurity Greven, M., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2016
  • What colour are newborns' eyes? Prevalence of iris colour in the Newborn Eye Screening Test (NEST) study. Acta ophthalmologica Ludwig, C. A., Callaway, N. F., Fredrick, D. R., Blumenkranz, M. S., Moshfeghi, D. M. 2016; 94 (5): 485-488


    This study aims to assess the birth prevalence of iris colour among newborns in a prospective, healthy, full-term newborn cohort.The Newborn Eye Screening Test (NEST) study is a prospective cohort study conducted at Lucile Packard Children's Hospital at Stanford University School of Medicine. A paediatric vitreoretinal specialist (DMM) reviewed images sent to the Byers Eye Institute telemedicine reading centre and recorded eye colour for every infant screened. Variables were graphed to assess for normality, and frequencies per subject were reported for eye colour, sex, ethnicity and race.Among 192 subjects screened in the first year of the NEST study with external images of appropriate quality for visualization of the irides, the birth prevalence of iris colour was 63.0% brown, 20.8% blue, 5.7% green/hazel, 9.9% indeterminate and 0.5% partial heterochromia. The study population was derived from a quaternary care children's hospital. We report the birth prevalence of iris colour among full-term newborns in a diverse prospective cohort.The study demonstrates a broad range of iris colour prevalence at birth with a predominance of brown iris coloration. Future studies with the NEST cohort will assess the change in iris colour over time and whether the frequencies of eye colour change as the child ages.

    View details for DOI 10.1111/aos.13006

    View details for PubMedID 27061128

  • Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-Year Results of the Newborn Eye Screen Test Study. Ophthalmology Callaway, N. F., Ludwig, C. A., Blumenkranz, M. S., Jones, J. M., Fredrick, D. R., Moshfeghi, D. M. 2016; 123 (5): 1043-1052


    To report the birth prevalence, risk factors, characteristics, and location of fundus hemorrhages (FHs) of the retina and optic nerve present in newborns at birth.Prospective cohort study at Stanford University School of Medicine.All infants who were 37 weeks postmenstrual age or older and stable were eligible for screening. Infants with known or suspected infectious conjunctivitis were excluded.Infants born at Lucile Packard Children's Hospital (LPCH) from July 25, 2013, through July 25, 2014, were offered universal newborn screening via wide-angle digital retinal photography in the Newborn Eye Screen Test study. Maternal, obstetric, and neonatal factors were obtained from hospital records. The location, retinal layer, and laterality of FH were recorded by 1 pediatric vitreoretinal specialist.Birth prevalence of FH. Secondary outcomes included rate of adverse events, risk factors for FH, hemorrhage characteristics, and adverse events.The birth prevalence of FH in this study was 20.3% (41/202 infants). Ninety-five percent of FHs involved the periphery, 83% involved the macula, and 71% involved multiple layers of the retina. The fovea was involved in 15% of FH cases (birth prevalence, 3.0%). No cases of bilateral foveal hemorrhage were found. Fundus hemorrhages were more common in the left eye than the right. Fundus hemorrhages were most commonly optic nerve flame hemorrhages (48%) and white-centered retinal hemorrhages (30%). Retinal hemorrhages were found most frequently in all 4 quadrants (35%) and more often were multiple than solitary. Macular hemorrhages most often were intraretinal (40%). Among the risk factors examined in this study, vaginal delivery compared with cesarean section (odds ratio [OR], 9.34; 95% confidence interval [CI], 2.57-33.97) showed the greatest level of association with FH. Self-identified ethnicity as Hispanic or Latino showed a protective effect (OR, 0.43; 95% CI, 0.20-0.94). Other study factors were not significant.Fundus hemorrhages are common among newborns. They often involve multiple areas and layers of the retina. Vaginal delivery was associated with a significantly increased risk of FH, whereas self-identified Hispanic or Latino ethnicity was protective against FH in this study. The long-term consequences of FH on visual development remain unknown.

    View details for DOI 10.1016/j.ophtha.2016.01.004

    View details for PubMedID 26875004

  • Mobile Health in the Retinal Clinic Population: Access to and Interest in Self-Tracking. Ophthalmic surgery, lasers & imaging retina Ludwig, C. A., Callaway, N. F., Park, J. H., Leng, T. 2016; 47 (3): 252-257


    Implementation of mobile health-tracking programs for retinal pathology requires both access to mobile devices and patient motivation to participate in self-tracking. The authors' study aimed to evaluate the prevalence of smartphone and tablet ownership and patient interest in self-tracking among a retinal clinic population.This is an institutional, prospective, cross-sectional survey of 103 retinal clinic outpatients. Consenting patients underwent a one-on-one interview conducted in the examination room during their waiting period by one researcher.Overall, 75 of 103 participants (72.2%) reported either owning a smartphone and/or tablet or having access at their household to a device that could be used to track eye health. The majority of participants (69 of 103 participants; 67%) reported interest in using a mobile application (smartphone or tablet) to track their eye health.These data suggest strong patient interest in the use of mobile devices to track eye health. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:252-257.].

    View details for DOI 10.3928/23258160-20160229-08

    View details for PubMedID 26985799

  • A novel smartphone ophthalmic imaging adapter: User feasibility studies in Hyderabad, India INDIAN JOURNAL OF OPHTHALMOLOGY Ludwig, C. A., Murthy, S. I., Pappuru, R. R., Jais, A., Myung, D. J., Chang, R. T. 2016; 64 (3): 191-200


    To evaluate the ability of ancillary health staff to use a novel smartphone imaging adapter system (EyeGo, now known as Paxos Scope) to capture images of sufficient quality to exclude emergent eye findings. Secondary aims were to assess user and patient experiences during image acquisition, interuser reproducibility, and subjective image quality.The system captures images using a macro lens and an indirect ophthalmoscopy lens coupled with an iPhone 5S. We conducted a prospective cohort study of 229 consecutive patients presenting to L. V. Prasad Eye Institute, Hyderabad, India. Primary outcome measure was mean photographic quality (FOTO-ED study 1-5 scale, 5 best). 210 patients and eight users completed surveys assessing comfort and ease of use. For 46 patients, two users imaged the same patient's eyes sequentially. For 182 patients, photos taken with the EyeGo system were compared to images taken by existing clinic cameras: a BX 900 slit-lamp with a Canon EOS 40D Digital Camera and an FF 450 plus Fundus Camera with VISUPAC™ Digital Imaging System. Images were graded post hoc by a reviewer blinded to diagnosis.Nine users acquired 719 useable images and 253 videos of 229 patients. Mean image quality was ≥ 4.0/5.0 (able to exclude subtle findings) for all users. 8/8 users and 189/210 patients surveyed were comfortable with the EyeGo device on a 5-point Likert scale. For 21 patients imaged with the anterior adapter by two users, a weighted κ of 0.597 (95% confidence interval: 0.389-0.806) indicated moderate reproducibility. High level of agreement between EyeGo and existing clinic cameras (92.6% anterior, 84.4% posterior) was found.The novel, ophthalmic imaging system is easily learned by ancillary eye care providers, well tolerated by patients, and captures high-quality images of eye findings.

    View details for DOI 10.4103/0301-4738.181742

    View details for Web of Science ID 000376126800003

    View details for PubMedID 27146928

  • The Future of Automated Mobile Eye Diagnosis Journal of Mobile Technology in Medicine Ludwig, C. A., Shan, M. X., Nguyen, N. H., Choi, D. Y., Ku, V., Lam, C. 2016; 5 (2): 44–50

    View details for DOI 10.7309/jmtm.5.2.7

  • Altered Innervation Pattern in Ligaments of Patients with Basal Thumb Arthritis. Journal of wrist surgery Ludwig, C. A., Mobargha, N., Okogbaa, J., Hagert, E., Ladd, A. L. 2015; 4 (4): 284-291


    Purpose The population of mechanoreceptors in patients with osteoarthritis (OA) lacks detailed characterization. In this study, we examined the distribution and type of mechanoreceptors of two principal ligaments in surgical subjects with OA of the first carpometacarpal joint (CMC1). Methods We harvested two ligaments from the CMC1 of eleven subjects undergoing complete trapeziectomy and suspension arthroplasty: the anterior oblique (AOL) and dorsal radial ligament (DRL). Ligaments were divided into proximal and distal portions, paraffin-sectioned, and analyzed using immunoflourescent triple staining microscopy. We performed statistical analyses using the Wilcoxon Rank Sum test and ANOVA with post-hoc Bonferroni and Tamhane adjustments. Results The most prevalent nerve endings in the AOL and DRL of subjects with OA were unclassifiable mechanoreceptors, which do not currently fit into a defined morphological scheme. These were found in 11/11 (100%) DRLs and 7/11 (63.6%) AOLs. No significant difference existed with respect to location within the ligament (proximal versus distal) of mechanoreceptors in OA subjects. Conclusion The distribution and type of mechanoreceptors in cadavers with no to mild OA differ from those in surgical patients with OA. Where Ruffini endings predominate in cadavers with no to mild OA, unclassifiable corpuscles predominate in surgical patients with OA. These findings suggest an alteration of the mechanoreceptor population and distribution that accompanies the development of OA. Clinical Relevance Identification of a unique type and distribution of mechanoreceptors in the CMC1 of symptomatic subjects provides preliminary evidence of altered proprioception in OA.

    View details for DOI 10.1055/s-0035-1564982

    View details for PubMedID 26649261

  • Newborn Retinal Hemorrhages: One-year Results of the Newborn Eye Screening Test (NEST) Study Callaway, N., Ludwig, C., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2015
  • Fundus Hemorrhages in a Term Newborn and Preterm Population: Does Examination Timing Influence Findings? Moshfeghi, D. M., Ludwig, C. A., Callaway, N. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2015
  • Validity of the Newborn Eye Exam in the Newborn Eye Screening Test (NEST) Cohort Ludwig, C. A., Callaway, N., Moshfeghi, D. M. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2015
  • Intracranial fat migration: A newly described complication of autologous fat repair of a cerebrospinal fluid leak following supracerebellar infratentorial approach. International journal of surgery case reports Ludwig, C. A., Aujla, P., Moreno, M., Veeravagu, A., Li, G. 2015; 7C: 1-5


    Intracranial fat migration following autologous fat graft and placement of a lumbar drain for cerebrospinal fluid leak after pineal cyst resection surgery has not been previously reported.The authors present a case of a 39-year-old male with a history of headaches who presented for removal of a pineal cyst from the pineal region. He subsequently experienced cerebrospinal fluid leak and postoperative Escherichia coli (E. Coli) wound infection, and meningitis, which were treated initially with wound washout and antibiotics in addition to bone removal and primary repair with primary suture-closure of the durotomy. A lumbar drain was left in place. The cerebrospinal fluid leak returned two weeks following removal of the lumbar drain; therefore, autologous fat graft repair and lumbar drain placement were performed. Three days later, the patient began experiencing right homonymous hemianopia and was found via computed tomography and magnetic resonance imaging to have autologous fat in the infra‑ and supratentorial space, including intraparenchymal and subarachnoid spread. Symptoms began to resolve with supportive care over 48 hours and had almost fully resolved within one week.This is the first known report of a patient with an autologous fat graft entering the subarachnoid space, intraparenchymal space, and ventricles following fat graft and lumbar drainage.This case highlights the importance of monitoring for complications of lumbar drain placement.

    View details for DOI 10.1016/j.ijscr.2014.12.008

    View details for PubMedID 25557086

  • Idiopathic pigmented vitreous cyst. Acta ophthalmologica Ludwig, C. A., Leng, T. n. 2015

    View details for PubMedID 26095667

  • Acute lung injury in patients with subarachnoid hemorrhage: a nationwide inpatient sample study. World neurosurgery Veeravagu, A., Chen, Y., Ludwig, C., Rincon, F., Maltenfort, M., Jallo, J., Choudhri, O., Steinberg, G. K., Ratliff, J. K. 2014; 82 (1-2): e235-41


    Subarachnoid hemorrhage (SAH) causes significant morbidity and mortality. Pulmonary complications may be particularly frequent, but national data is lacking on the outcomes associated with acute respiratory distress syndrome (ARDS) in SAH patients. The aim of this study is to determine national trends for SAH patients with ARDS.The Nationwide Inpatient Sample Database (NIS) was utilized to sample 193,209 admissions for SAH with and without ARDS from 1993 to 2008 using ICD-9-CM coding. A multivariate stepwise regression analysis was performed.The incidence of ARDS in SAH has increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in SAH patients and in SAH patients with ARDS has decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76% respectively. Multivariate analysis showed that the predictors of developing ARDS in SAH patients include older age, larger hospital size, and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and hematologic, renal, or neurological dysfunction. Predictors of mortality in SAH patients include age and hospital complications such as coronary artery disease, ARDS, cancer, and hematologic, or renal dysfunction.SAH patients are at increased risk of developing ARDS and the identification of certain risk factors may alert and aid the practitioner in preventing worsening disease.

    View details for DOI 10.1016/j.wneu.2014.02.030

    View details for PubMedID 24560705

  • Ultrastructure and Innervation of Thumb Carpometacarpal Ligaments in Surgical Patients With Osteoarthritis CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Mobargha, N., Ludwig, C., Ladd, A. L., Hagert, E. 2014; 472 (4): 1146-1154


    BACKGROUND: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. QUESTIONS/PURPOSES: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. METHODS: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. RESULTS: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. CONCLUSIONS: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. CLINICAL RELEVANCE: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.

    View details for DOI 10.1007/s11999-013-3083-7

    View details for Web of Science ID 000332576400016

    View details for PubMedID 23761171

  • Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World neurosurgery Veeravagu, A., Ludwig, C., Camara-Quintana, J. Q., Jiang, B., Lad, N., Shuer, L. 2013; 80 (1-2): 222 e5-222 e13

    View details for DOI 10.1016/j.wneu.2012.12.016

    View details for PubMedID 23247021

  • Traumatic epistaxis: Skull base defects, intracranial complications and neurosurgical considerations. International journal of surgery case reports Veeravagu, A., Joseph, R., Jiang, B., Lober, R. M., Ludwig, C., Torres, R., Singh, H. 2013; 4 (8): 656-661


    Endonasal procedures may be necessary during management of craniofacial trauma. When a skull base fracture is present, these procedures carry a high risk of violating the cranial vault and causing brain injury or central nervous system infection.A 52-year-old bicyclist was hit by an automobile at high speed. He sustained extensive maxillofacial fractures, including frontal and sphenoid sinus fractures (Fig. 1). He presented to the emergency room with brisk nasopharyngeal hemorrhage, and was intubated for airway protection. He underwent emergent stabilization of his nasal epistaxis by placement of a Foley catheter in his left nare and tamponade with the Foley balloon. A six-vessel angiogram showed no evidence of arterial dissection or laceration. Imaging revealed inadvertent insertion of the Foley catheter and deployment of the balloon in the frontal lobe (Fig. 2). The balloon was subsequently deflated and the Foley catheter removed. The patient underwent bifrontal craniotomy for dural repair of CSF leak. He also had placement of a ventriculoperitoneal shunt for development of post-traumatic hydrocephalus. Although the hospital course was a prolonged one, he did make a good neurological recovery.The authors review the literature involving violation of the intracranial compartment with medical devices in the settings of craniofacial trauma.Caution should be exercised while performing any endonasal procedure in the settings of trauma where disruption of the anterior cranial base is possible.

    View details for DOI 10.1016/j.ijscr.2013.04.033

    View details for PubMedID 23792475

    View details for PubMedCentralID PMC3710897

  • Biopsy versus resection for the management of low-grade gliomas. Cochrane database of systematic reviews Veeravagu, A., Jiang, B., Ludwig, C., Chang, S. D., Black, K. L., Patil, C. G. 2013; 4: CD009319-?


    Low-grade gliomas (LGG) constitute a class of slow-growing primary brain neoplasms. Patients with clinically and radiographically suspected LGG have two initial surgical options, biopsy or resection. Biopsy can provide a histological diagnosis with minimal risk but does not offer a direct treatment. Resection may have additional benefits such as increasing survival and delaying recurrence, but is associated with a higher risk for surgical morbidity. There remains controversy about the role of biopsy versus resection and the relative clinical outcomes for the management of LGG.To assess the clinical effectiveness of biopsy compared to surgical resection in patients with a new lesion suspected to be a LGG.The following electronic databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11), MEDLINE (1950 to week 3 November 2012), EMBASE (1980 to Week 46 2012). Unpublished and grey literature including Metaregister, Physicians Data Query,,, and were also queried for ongoing trials.Patients of any age with a suspected intracranial LGG receiving biopsy or resection within a randomized clinical trial (RCT) or controlled clinical trial (CCT) were included. Patients with prior resections, radiation therapy, or chemotherapy for LGG were excluded. Outcome measures included overall survival (OS), progression free survival (PFS), functionally independent survival (FIS), adverse events, symptom control, and quality of life (QoL).A total of 2764 citations were searched and critically analyzed for relevance. This effort was undertaken by three independent review authors.No RCTs of biopsy or resection for LGG were identified. Twenty other studies were retrieved for analysis based on pre-specified selection criteria. Ten studies were retrospective or literature reviews. Three studies were prospective but were limited to tumor recurrence or the extent of resection. One study was a population-based parallel cohort and not an RCT. Four studies were RCTs, however patients were randomized with respect to varying radiotherapy regimens to assess timing and dose of radiation. One RCT was focused on high-grade gliomas and not LGG. One last RCT evaluated diffusion tensor imaging (DTI)-based neuro-navigation for surgical resection.Currently there are no randomized clinical trials or controlled clinical trials available on which to base clinical decisions. Therefore, physicians must approach each case individually and weigh the risks and benefits of each intervention until further evidence is available. Future research could focus on randomized clinical trials to determine outcomes benefits for biopsy versus resection.

    View details for DOI 10.1002/14651858.CD009319.pub2

    View details for PubMedID 23633369

  • From the Patient’s Point of View: Patient-Centered Outcomes in Spine Surgery Cureus Ludwig, C. A., Veeravagu, A., Zhang, M., Maltenfort, M. G., Dowzicky, P., Ratliff, J. K. 2013; 5 (4): e114
  • Radiosurgery for Intramedullary Spinal Cord Tumors Tumors of the Central Nervous System: Pineal, Pituitary, and Spinal Tumors Veeravagu, A., Ludwig, C. A., Jiang, B., Chang, S. D. Springer Netherlands. 2013; 1: 213–221