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We are all beginning to see the light at the end of the pandemic tunnel, but it is important to realize that this welcoming glow will not magically erase the emotional toll of COVID-19. This pandemic blew in like a hurricane, leaving us all shaken and bruised. Now as the storm loses steam, we’re relieved to see it subside, but we’re left in its devastating aftermath, grappling with how to deal with both the short and long-term effects of its trauma. Not only has there been a loss of life, there have been many other losses as well. Symptoms of depression often rise after a 

, and I, like many clinicians, believe a second wave – a mental health pandemic – is here.

The disease of depression is known to impact more than 17.3 million American 

, and research indicates the number of adults experiencing symptoms of depression in the U.S. has tripled because of 

. In fact, it is estimated that over 1 in 4 U.S. adults now report such 

.Treating depression can be tough, so it is critical that people have knowledge of 

their treatment options available to them.It can be life changing.

While COVID-19 has exacerbated symptoms for patients who were already struggling with depression, it has also meant new diagnoses, particularly in those who have experienced intense social isolation and loss, even if they don’t have a medical history of the disease. As depression rates continue to rise across the board, 2020 Census Bureau data reveals cases are rising most in younger adults, those who are more likely to be single and living 

. This is something I’ve witnessed in my own practice. 

Studies have also found that 24% of those who had actual COVID infection developed a psychiatric disorder in the 6 months following their infection, and this was the first psychiatric diagnosis for 36% of those 

. These rates are higher than what would be expected in people with similar illness such as the flu, and there is speculation that the infection itself may have its own neuropsychiatric effects.

We sometimes classify depression as either exogenous or endogenous, but both are equally treatable. Exogenous depression is triggered by external stressors, like COVID-19, whereas endogenous depression seems to come out of the blue and is considered primarily biological. Sometimes exogenous depression can be overlooked due to the seemingly situational origin of symptoms.We have certainly seen a rise in patients suffering from exogenous depression brought about by pandemic-inflicted circumstances like interpersonal loss, opportunity loss, and economic hardship.But dismissing these symptoms as situational and not worthy of treatment creates a problem for patients in need.

Do not Assume Pandemic Depression Will Disappear with a Vaccine

Stress can lead to brain changes that underlie depression, and such changes will remain long after vaccines roll out. Since cases are expected to rise, it is important that we not only listen, but actively screen for depression so diagnosis and treatment are not delayed. To facilitate this process, we should lean into available screening tools at our fingertips, like the Patient Health Questionnaire (PHQ-9), a common tool used to screen, diagnose, monitor, and measure the severity of 

. A patient can easily complete the PHQ-9 prior to their appointment or even in the waiting room, and it can be quickly scored by clinicians.

Once we accept that cases of exogenous depression are likely to remain even after protocols lift, the conversation can shift to the importance of discussing all treatment options with patients.

The reality is that drug therapy simply does not work for all patients – and it is important that we shift our thinking to consider TMS (Transcranial Magnetic Stimulation) sooner in the patient 

. It is a safe and effective treatment option for adult patients struggling with either exogenous or endogenous depression and has minimal systemic side effects. 

I’ve supported thousands of patients through depression – many of whom were among the estimated 6.2 million who do not benefit from antidepressant 

- with TMS therapy, an FDA-cleared, insurance covered, non-invasive treatment that uses MRI-strength magnetic pulses to stimulate specific areas of the brain associated with mood.

After 12 years of treating depressed patients with TMS therapy, my practice is one of the larger providers in the country. We have administered more than 100,000 treatments across 12 locations, and as we navigate this mental health pandemic, I’d urge you to keep these best practices top of mind.

With TMS, we are seeing better response and remission rates than patients experience on their second, third or fourth antidepressant. In fact, research indicates the likelihood of remission drops in depressed patients who are unresponsive to multiple antidepressant 

. This makes TMS an especially appealing option for those struggling with chronic and persistent depression, as well as first episodes.

In conclusion, current depression rates within the U.S. are increasing to staggering levels. As the hurricane of COVID passes, we are left dealing with its devastating impact on mental health in America. To fight this new pandemic, physicians must increase screening efforts and raise patient awareness of safe and effective treatments beyond drug therapy. Physicians would be wise to mitigate the damage by teaching patients about non-drug treatment options like TMS early on. The sooner the better for everyone.

Dr. Todd Hutton is the Medical Director at 

. Dr. Hutton is a board certified Psychiatrist and a Distinguished Fellow of the American Psychiatric Association. He is an Adjunct Clinical Professor of Psychiatry at the USC Keck School of Medicine where he teaches residents in Psychiatry. Dr. Hutton completed his advanced TMS Therapy Fellowship at Duke University Medical Center. He was also elected the 

Articles

Dr. Todd Hutton gives tips for how to best handle the ongoing mental health crisis.

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As One Pandemic Ends, My Tips on How To Navigate This Next One

If the COVID-19 pandemic has caused a lost year of healthcare for chronic disease patients, as so many clinicians describe in their practice, then it may take even more years to understand the total effect of such significant lapses in care between the beginning and the eventual end of the distance-driving health crisis.

And some chronic diseases are less forgiving than others; that lost year may make all the difference. In the case of millions of US patients with 

Consider that about one-third of all adults aged ≥40 years old with diabetes suffer from at least 1 symptom of diabetic retinopathy (DR), and that about 5% of all diabetic patients may suffer severe vision loss. Now consider that, per the Centers for Disease Control and Prevention (CDC) last year, 

more than 34 million Americans have diabetes

, and another 88 million have prediabetes.

Couple all that with context: new diabetes cases significantly decreased from 2008-2018 among adults, yet significantly increased among pediatric and adolescent persons. And new cases are notably greater among non-Hispanic blacks and people of Hispanic origin than that of non-Hispanic Asians and non-Hispanic whites—a trend which shows that greater US diabetes burden is falling on groups with lesser healthcare access and treatment retention across other chronic conditions.

The average diabetes patient—of which there are 1 for every 10 people in America—is getting younger, and more distant from clinicians, at a time when a global pandemic has already done unprecedented harm to in-person care rates and screenings.

Katherine Talcott, MD, of the Cleveland Clinic’s Cole Eye Institute, explained to 

 the multitude of ways in which COVID-19 has harmed the patients of her ophthalmology practice.

“A lot of our patients with diabetes who had been coming in have been lost to follow-up in the last year, and they have a lot worse macular edema or their diabetes is worse,” 

An epidemic of its own right, diabetes is worsening in the US, and its comorbid effects bleeds into other specialties of care. As covered in a series of research topics and presentations at the 

Association of Research in Vision and Ophthalmology (ARVO) 2021 Virtual Meeting

 last week, there is a trend heading toward a greater convergence between diabetic and related ophthalmic care.

But what is that current dynamic? And how will it change to improve the state of a patient’s diabetes, and associated visual wellbeing?

Research from the CDC, presented at ARVO 2021 by Elizabeth Lundeen, PhD, MPH, of the Division of Diabetes Translation, showed visually-impaired persons from a 2018 national health survey were 48% more likely to have diabetes than the general population.

The findings, which also illustrated significant ties between cardiovascular-associated risk factors including smoking and visual impairment, came as little surprise to Lundeen, who noted the “strong correlation” between cardiovascular, cardiometabolic, and visual health. Previous CDC research even depicted a similar relationship between stroke, cardiovascular events, and visual impairment.

“Cardiovascular health and vision health show a lot of the same risk factors, actually,” 

. “For example, a well-known risk factor for glaucoma would be (high) blood pressure—which is also a risk factor for cardiovascular disease. And age-related macular degeneration shares a lot of risk factors with cardiovascular disease.”

In fact, all 7 targeted risk factors for cardiovascular disease—even when controlled for patient demographics—were more likely to present in visually-impaired patients: smoking; physical activity; excessive alcohol intake; obesity; hypertension; high cholesterol; as well as diabetes.

The correlation is not always consistent; in fact, new ARVO research even suggested that currently available ophthalmic therapies may benefit regardless of comorbid diabetes or cardiovascular risk factors.

Talcott reported her team’s assessment of 

 which observed patients’ diabetic macular edema (DME) resolution and time to resolution when treated with intravitreal aflibercept, with consideration to baseline factors including HbA1c, hypertension, hyperlipidemia, smoking status, and more.

What they found was that ophthalmic status factors, including baseline central subfield thickness (CST) and best-corrected visual acuity (BCVA), were more influential in DME patient likelihood and time to disease clearance with aflibercept than cardiovascular risk factors were.

In fact, to Talcott’s surprise, diabetes severity at baseline did not affect treatment-based DME clearance at all—despite it being the disease which leads to DME development in the first place.

“I think it’s interesting,” she said. “Some of the preconceptions we have as clinicians as to how individual patients might do, don’t necessarily pan out when you conduct these large studies.”

The surprise of the findings speaks to the nature of collaborative care among ophthalmologists and prescribers managing the same patients with diabetes and vision impairment—a partnership in the US health system which clinicians themselves agree is subpar.

The connection between cardiovascular and cardiometabolic risk factors in visually impaired persons is not just correlative; it’s been proven causative enough that experts like Allen Ho, MD, considers such factors in the itinerary of diabetic retinopathy (DR) care.

, is significantly impacted by diet, exercise, smoking status, blood pressure, and A1c levels.

“You can be seeing well and just drop off a cliff the next day,” Ho, director of Retina Research at the Wills Eye Hospital said. “If you don’t know your A1c, that’s a risk factor for vision loss right there. It’s like driving with your eyes closed, is what I tell (patients.”

That’s reason enough for improved communication between providers with mutual interest in those risk factors—at least communication from a better mindset. Ho described the current ophthalmology-diabetes specialist connection as something mandated, and possible punitive: missing eye exam referrals for newly-diagnosed diabetics can result in penalties to physicians.

Unfortunately for clinicians like Talcott, collaborative care usually bookends a patient’s diabetes status: referral and monitoring at the beginning of their diagnosis, then reactive response when comorbid disease like DME or DR is in full effect.

“I think that we all tend to, unfortunately, focus on our problems and forget about other parts of the body,” she said. “But when we see patients who have disease that’s out of control, that usually means their diabetes is not well-controlled in other reasons as well.”

A promising connector, it could be suggested, may be the advancement which both specialties may be most interested in: drug classes which treat diabetes, DME, DR, all the same.

Not only are researchers beginning to interpret the absolute value of already-established drug classes like anti-VEGF injections, which Talcott’s team showed in the case of aflibercept benefits ophthalmic disease regardless of diabetes severity. They are also venturing into consideration of diabetic agents for the management of DME and DR.

Ashay D. Bhatwadekar, PhD, RPh, associate professor at the Eugene and Marilyn Glick Eye Institute, 

presented animal model findings at ARVO 2021

 indicating gluclose-lowering SGLT-2 inhibitor dapagliflozin—a dynamic add-on agent in cardiometabolic, cardiovascular, and renal outcome risk reduction—may provide anti-inflammatory and anti-angiogenic benefit to patients with DR.

The scientific rationale of Bhatwadekar’s work was based on the valuation of SGLT-2 in glucose rates among patients with diabetes, and believing that it correlates enough with DR pathology to consider dapagliflozin for treatment.

But the broader rationale of the research was simpler than that: dapagliflozin has shown benefit in numerous comorbid outcomes in patients with diabetes. Why not diabetic retinopathy?

“Considering its use into cardiovascular conditions, I think that kind of multi-regimented use you see makes sense that you look into seeing it in diabetic retinopathy,” he explained to 

The early-stage findings were hopeful enough for Bhatwadekar to discuss progression into human trials comparing outcomes, symptoms, and levels of DR among patients treated with and without dapagliflozin. But implementation of SGLT-2 inhibitors for the direct treatment of DR or DME—or even other glycemic control drug classes, including GLP-1 agonists—is a long time away still.

What may benefit experts most in bridging the gaps between diabetes and ophthalmology in the short term may be improved screening, mixed with referral and communication that’s more “carrot” than “stick,” as Ho put it.

“We tend to communicate in a way that, in an era of digital medicine, I think can improve,” Ho said. “Even detection of diabetic retinopathy, there are devices now involving artificial intelligence (AI) that keep patients from coming in to get their eyes dilated.”

Patient-centered detection and screening tools, which are currently available at most physician’s offices and pharmacies, may soon come to smartphones, Ho suggested. At-home AI-enabled detection may provide streamlined referrals and allocation of care.

Lundeen echoed Ho’s suggestions of improved screening integration in ophthalmology, with the addendum that it may be better managed by a host of stakeholders: general practitioners, endocrinologists, and cardiologists all worker to assure vision health monitoring is a universal touchpoint in routine care.

On the other end, ophthalmologists should be looking to integrate chronic disease prevention strategies into their routine practice.

“There are opportunities to better integrate healthcare—both general healthcare being more attentive to vision health, and vice versa,” she said.

Ho suggested that even patients could be more cognizant of the risk factors associated with diabetes, including chronic ophthalmic disease, before even being approached with the matter by a clinician. Improved awareness campaigns, led by notable affected figures, could help to educate the millions at risk, rather than the thousands dedicated to treating them.

Sometimes the elephant in the room goes unnoticed if it’s been there for too long. Diabetes is not always at the forefront of a treating ophthalmologist’s priority list, because the vision-related byproducts of diabetes already are. More than any comprehensive therapy, referral strategy, technology or campaign, the continued discussion and research of diabetes' total effect on a patient among experts should be what leads to better outcomes in ophthalmology.

“I think there’s a lot of overlap that we just don’t think about, and it’s part of the questions that we don’t think about asking,” Talcott said. “There’s definitely a lot more we could be doing to better communicate and understand how different organs are related in diabetes.”

Research at ARVO 2021 highlighted a gamut of interplaying diabetes and vision loss risk factors, and even treatments for both. But experts depict a referral and care process that lacks whole diabetes care.

Conference

Ophthalmology

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Diabetic Vision Loss Care Lacks Specialty Collaborations

non-steroidal anti-inflammatory drugs (NSAIDs)

, such as ibuprofen, was thought to increase disease severity in patients with COVID-19.

Investigators, led by Prof Ewen M Harrison, Centre for Medical Informatics, Usher Institute, University of Edinburgh, conducted a prospective, multi-center cohort study and found that the use of NSAIDs were not associated with higher mortality or increased severity of COVID-19.

The goal of the study was to characterize the safety of NSAIDs, while identifying if pre-existing NSAIDs use was associated with an increased severity of COVID-19.

Investigators used the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) Clinical Characterization Protocol (CCP) for Severe Emerging Infection in the study, which was activated for COVID-19 in January 2020.

Eligibility for the study included patients of any age admitted to the hospital with a confirmed or highly suspected SARS-CoV-2 Infection leading to COVID-19 between January – August 2020.

Data on admission, hospital stay, and discharge were collected, as well as demographic data including age, sex, and comorbidities. Information on current NSAIDs medication or medication taken within the past 2 weeks from the study were also collected.

The primary outcome included in-hospital morality, while the secondary outcomes were admission to critical care, use of invasive mechanical ventilation, use of non-invasive ventilation, use of supplementary oxygen, and occurrence of acute kidney injury.

Logistic regression estimated the effects of NSAIDs and adjusted for confounding variables. Investigators also used propensity score matching to estimate the treatment effect of NSAIDs and accounted for covariate differences in the populations.

The study included 78,674 patients enrolled 255 healthcare facilities in the United Kingdom between January – August 2020. The patient population represented 60% of the total people admitted to the hospital with COVID-19.

Of the patients, 72,179 had death outcomes for matching. Demographics included 38,151 male (56.1%) and 29,564 (43.5%) female patients.

The study cohort included 4211 (5.8%) patients recorded as taking systemic NSAIDs before they were admitted to hospital. Propensity score matching created balanced groups of NSAIDs users and non-NSAIDs users, with 4205 patients in each group.

Investigators found 1279 (30.4%) of 4211 patients in the NSAIDs group died versus 21 256 (31.3%) of 67,698 patients in the non-NSAIDs group.

After matching, the team found NSAIDs use was not associated with worse in-hospital mortality with an odds ratio (OR) of 0.95 (95% CI, 0.84 – 1.07, P = 0.35).

Patients taking NSADS were also not more likely to require critical care admission, (OR 1.01; 95% CI, 0.81 – 1.17; P = .89), invasive ventilation (OR 0.96; 95% CI, 0.80 – 1.17; P = .69), or non-invasive ventilation (OR 1.12; 95% CI, 0.96 – 1.32); P = 0.14), compared to those not taking NSAIDs.

Investigators also found they were not more likely to require supplementary oxygen (OR 1.00; 95% CI, 0.89 – 1.12; P = 0.97) or sustain acute kidney injury (OR 1.08; 95% CI, 0.92 – 1.26; P = 0.33) compared to those not taking NSAIDs.

The use of ibuprofen was not associated with increased mortality compared with those not taking any NSAIDs (OR 0.90; 95% CI, 0.71 – 1.13; P = .36) or those taking other NSAIDs (OR 0.82; 95% CI, 0.66 – 1.03; P = .082).

Investigators concluded that patients admitted to the hospital with COVID-19 and were also taking NSAIDs did not have more severe disease than those not taking NSAIDs.

“For clinicians and patients, our findings should provide reassurance that NSAIDs can be used as indicated in the community without increasing the severity of COVID-19,” investigators wrote.

Non-steroidal anti-inflammatory drug use and outcomes of COVID-19 in the ISARIC Clinical Characterisation Protocol UK cohort: a matched, prospective cohort study

,” was published online in The Lancet Rheumatology.

New data show NSAIDs treatment not associated with worse in-hospital mortality rates compared to patients not treated with NSAIDs. 

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No Link Found Between Non-Steroidal Anti-Inflammatory Treatment and Severe COVID-19 Outcomes 

Shockwaves were sent through both the public and the 

report showed suicides were actually down during the duration of the COVID-19 pandemic.

Conventional wisdom from both laypersons and psychiatrists is that the pandemic and the mitigation measures put in place like social distancing and shelter-in-place orders, while effective in combatting the virus, would have a negative impact on the collective mental health of the country.

As the deadly virus ravages communities throughout the country with some estimates having a 20% overall increase in deaths year over year and political and economic strife took hold, it would be hard to believe suicides could decrease.

And while it is undoubtedly true that there will be mental health problems on a wide-scale in the years to come, why did suicides actually decline during such a divisive and difficult time?

From a psychiatric standpoint, the most reasonable explanation is that people, even those with mental health concerns, can really focus during the course of a disaster or traumatic event, but eventually the disaster only exacerbates those types of problems and there is concern that suicides could rise in the subsequent years.

“In a state of acute stress, people are somehow dealing with it like in war, there are less suicides because you're just trying to make ends meet,” Christoph Correll, MD, professor of Psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, said in an interview with 

. “But also, people are not using the help that they should. So, we're basically creating a mental health crisis, every day.”

Ultimately, suicides can be a lagging indicator of a mental health crisis.

And Correll said clinicians are already starting to see some evidence that the mental health crisis might be difficult to manage in years to come.

On March 31, Farida B. Ahmad, MPH, National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), and Robert N. Anderson, PhD, National Center for Health Statistics, Mortality Statistics Branch, Division of Vital Statistics, published new data in 

 showing the totality of US deaths in 2020.

Provisional estimates indicate a 17.7% increase in the number of deaths in 2020 (the increase in the age-adjusted rate was 15.9%) compared with 2019.

Obviously, the biggest difference between 2019 and 2020 was COVID-19 deaths, which went from 0-345,323, but there was also an increase in mortality from heart disease, unintentional injuries, stroke, Alzheimer disease, and diabetes in 2020.

The researchers identified 44,834 suicides in 2020, a reduction from the 47,511 suicides in 2019.

Certain conditions that are easier to quantify are already showing the impact of the pandemic.

An example of this can be seen in patients with eating disorders, patients who came back to psychiatric services weighing much less than they were before the pandemic.

One explanation for this is people generally have checks in place in friends, family, and co-workers.

But during the pandemic, most of these checks weren’t in place, leading many patients to engage in reckless or dangerous behaviors that are associated with their disorder.

“We see that in the UK, whether it's physical or mental disorders, the use of care is going down,” Correll said. “But that doesn't mean people are healthier. It just means there, they're even doing less than during normal times and that's really problematic, because they should have more attention and get more help, but they get less.”

“Resilience is one of the major factors that come into play regarding suicide risk, and really just mental health and I think this past year has really tested all of us and our resilience,” Anum Iqbal Baig, MD, Charles R. Drew University of Medicine & Science said in an interview with 

. “I think it's challenging. I think some people do have the potential to thrive and maybe can get ahead, but I think during this time, social support and feeling of connection and having access to multiple resources are some of the things that determine that.”

It is challenging to attribute 1 prevailing factor in suicide trends since each patient with suicide ideation suffers from different circumstances and characteristics, including history of past suicide attempts, developmental history, social support, and access to lethal means.

“It's a difficult one to answer because there are just so many factors involved,” Baig said. “Especially, you know, there are multiple factors that determine a patient's risk for suicide, which we always evaluate.”

Baig also said while she was completing her residency in the early part of the pandemic, when was part of a substance abuse rotation.

“I noticed that the patients were really not doing well,” she said. “During that time in July, we were extremely busy. We were doing a lot of telepsychiatry at the time, and I really noticed that a lot of patients were relapsing. A lot of patients were very depressed and with the pandemic going on a lot of them lost loved ones.”

While suicides could rise in future years, there are some ways to mitigate the damage.

For one, education can be a key factor moving forward, both for patients and clinicians to help identify early warning signs of suicide ideation. In addition, there should be a public push in instilling hope that the pandemic and other problems are only temporary and there is reason to believe once the threat of COVID-19 has decreased substantially.

Also, an increase in funding to mental health services can help limit some of the damage that may occur.

“At the moment, the resources are going a lot into physical health and, and vaccination and, and we're turning a little bit of a blind eye to the growing mental health pandemic that will basically come,” Correll said.

But the pandemic might offer a chance in psychiatry to destigmatize mental illness, which in part could lead to more patients seeking help earlier.

“We're now not talking just about a subgroup that is depressed or anxious, we’re talking about mental well-being or lack thereof, and stress and depression and sadness is my much more common place. And it's a unifying feature for all of us,” Correll said.

A recent JAMA study shows a decrease in suicide deaths between 2019-2020, despite a 17% overall increase in mortality.

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Drop in Suicides Won't Result in Complacency in Psychiatry

Association for Research in Vision and Ophthalmology (ARVO) 2021 Virtual Meeting

 this week showed investigative gene therapy AGTC-501 provided notable efficacy and safety mark benefit in patients with 

The six-moth findings, presented by author Paul Yang, MD, PhD, of the Casey Eye Institute at Oregon Health & Science University, lead to hope for even greater and more concrete outcomes as the agent is assessed through 5 years in the patients aged ≥6 years old with the rare vision loss disease.

In a DocTalk podcast interview conducted during ARVO 2021, Yang joined to discuss the newest phase 1/2 findings, as well as the properties of benefit being assessed in AGTC-501.

Yang also explained the reason for expansive gene therapy research in XLRP, the role of advocacy and awareness-building in gene therapy research for rare disease, and what he would define as the modern ocular gene therapy care team.

Six Month Findings from a Phase 1/2 Clinical Study of Subretinal Gene Therapy Drug AGTC-501 for X-Linked Retinitis Pigmentosa Show Clinically Meaningful Improvement in Macular Sensitivity

Podcasts

A podcast interview with study author Paul Yang, MD, PhD, on the current research and future implementation of the agent.

Pediatrics

Rare Disease Report®

Gene Therapy AGTC-501 Hits Phase 1/2 Marks for Rare Pediatric Blindness

Data from the KITE study shows that ≥50% of brolucizumab patients maintained a 12-week interval schedule through 52 weeks.


Diabetic Macular Edema

Brolucizumab Comparable to Aflibercept for DME

Patients who utilized virtual and in-person visits had comparable numbers of follow-ups, referrals, and outpatient surgeries.

Hospital Medicine

Telehealth Could Be Feasible Alternative in Ophthalmology

New data show rheumatoid arthritis and immunosuppressive treatment associated with more severe risks of COVID-19, including hospitalization and death. 

Rheumatoid Arthritis

Arthritis

Rheumatoid Arthritis Linked to Adverse COVID-19 Outcomes 

The companies announce plans to submit a Biologics License Agreement for the mRNA-based vaccine.

Vaccination

 Pfizer-BioNTech Hoping for Full FDA Approval for COVID-19 Vaccine

The CDC currently recommends every pregnant woman screened for hepatitis C virus.

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No Link Found Between Non-Steroidal Anti-Inflammatory Treatment and Severe COVID-19 Outcomes

Drop in Suicides Won't Result in Complacency in Psychiatry

Gene Therapy AGTC-501 Hits Phase 1/2 Marks for Rare Pediatric Blindness