Retrospective Optimization of the Hawkeye Orbital Fracture Prioritization and Evaluation Algorithms for Triaging Ophthalmic Care.

Objectives: Many orbital fracture patients are transferred to tertiary care centers for immediate ophthalmology consultation, though few require urgent ophthalmic evaluation or intervention. This overutilizes limited resources and overburdens patients and the health care system with travel and emergency department (ED) expenses. A simple, easy-to-use, clinical decision-making tool is needed to aid local EDs and triage services in effectively identifying orbital fracture patients who need urgent ophthalmic evaluation. Design: Single center, retrospective cohort study. Subjects: Orbital fracture patients aged ≥ 18 years who presented to the study institution's emergency department and received an ophthalmology consultation. Methods: Ocular injuries that required close monitoring or an intervention within the first few hours after presentation were termed urgent. Two Hawkeye Orbital Fracture Prioritization and Evaluation (HOPE) algorithms were developed to identify orbital fracture patients needing urgent evaluation; including 1 algorithm incorporating computerized tomography (CT) scans interpreted by ophthalmology (HOPE+CT). Algorithms were compared with 3 previously published protocols: the University of Texas Health Science Center at Houston (UTH), the South Texas Orbital Fracture Protocol (STOP), and Massachusetts Eye and Ear (MEE) algorithms. Main Outcome Measures: Correct triage of patients with orbital fractures who have urgent ocular or orbital conditions. Results: In the study institution's ED, 134 adult patients (145 orbits) were seen with orbital fractures in 2019. Eighteen (13.4%) had ocular or orbital conditions categorized as urgent. The HOPE tool resulted in 100% sensitivity and 78.4% specificity. The HOPE+CT tool resulted in 100.0% sensitivity and 94.0% specificity. The UTH algorithm was 91.7% sensitive and 76.5% specific. South Texas Orbital Fracture Protocol and MEE were both 100% sensitive but only 35.1% and 32.8% specific, respectively. Conclusions: The HOPE and HOPE+CT algorithms were superior or equal to the UTH, STOP, and MEE algorithms in terms of specificity while detecting all urgent cases. Implementation of a triage protocol that uses the HOPE or HOPE+CT algorithms could improve resource utilization and reduce health care costs through identification of orbital fracture patients needing urgent evaluation. An online tool that deploys the HOPE+CT algorithm in a user-friendly interface has been developed and is undergoing prospective validation before public dissemination. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Flipped ophthalmology classroom augmented with case-based learning.

BACKGROUND: Although the flipped classroom model provides an effective way to teach ophthalmology to medical students, there are concerns that it overburdens the learner. The purpose of this study was to assess medical students' perceptions of a case-based flipped classroom style compared with a traditional didactic lecture series and to evaluate the effects of case-based learning on students' confidence in managing common ophthalmic complaints. METHODS: We created an interactive, case-based flipped classroom ophthalmology curriculum. Paired pre- and post-clerkship surveys were distributed to students on the first and last day of the 2-week clerkship. Questions were formatted as statements using a 6-point Likert scale to assess students' prior exposure to a flipped classroom, perceptions of the flipped classroom curriculum, and confidence in evaluating ophthalmic complaints. RESULTS: A total of 75 students were included during the period July 2019 to March 2020. Pre-clerkship questionnaires revealed no preference for either teaching modality. Wilcoxon signed-rank testing comparing pre- and post-clerkship data revealed a significant increase in students' favoring the case-based flipped-classroom model. Participants reported significant reductions in pressure to perform, course burden, and overall anxiety as well as increased confidence in triaging common eye complaints. CONCLUSIONS: The case-based flipped classroom modality prioritizes key learning objectives while increasing student participation and confidence. The reproducibility and accessibility of standardized prepared video lectures and cases may help institutions to better incorporate ophthalmology into preexisting rotations.

A Comparison of the Flipped Classroom Model for Medical Student Education in Ophthalmology before and during the COVID-19 Pandemic.

Background The coronavirus disease 2019 (COVID-19) pandemic has necessitated a shift of medical education to online learning in lieu of traditional clinic-based rotations. The flipped classroom model, which has been shown to be an effective approach to the medical student ophthalmology curriculum, shows promise as a method of learning that can be shared virtually. As such, the aim of this study was to investigate the effectiveness of a flipped classroom approach to the primary care-focused ophthalmology clerkship delivered entirely online in the face of the COVID-19 pandemic. Methods Medical students who completed the 2-week introductory clinical ophthalmology clerkship from July 2019 to July 2020 were included in this study. The curriculum centers on a flipped classroom model and was delivered in person prior to March 2020, after which it transitioned to an online format for 5 months. A survey was administered to students completing this rotation, which utilized 6-point Likert scales to assess students' interest in the field of ophthalmology, perceptions of the flipped classroom curriculum, and confidence in evaluating ophthalmic complaints. The cohort that completed in-person learning was then compared with the cohort that completed online learning. Results A total of 112 responding students were included in our analysis, with 68/82 students from the in-person cohort and 44/66 students in the online cohort responding to the survey. Students who participated in the online virtual clerkship were equally likely to feel comfortable evaluating eye complaints than those who participated in the in-person clerkship, and more likely to report that the course enhanced their interest in ophthalmology. However, online students were less likely to feel comfortable using the direct ophthalmoscope compared with those in the in-person cohort. Conclusion Regardless of its mode of delivery, the flipped classroom model is able to impart confidence in evaluating ophthalmic complaints and interest in the field of ophthalmology to medical students. While online learning can never serve as a full replacement for learning physical examination skills and other important clinical experiences, there are aspects of the virtual flipped classroom that do not compromise student's learning and engagement and may be implemented into curricula even after clinical activities are allowed to resume.

Photophobia: shared pathophysiology underlying dry eye disease, migraine and traumatic brain injury leading to central neuroplasticity of the trigeminothalamic pathway.

BACKGROUND: Photophobia is a potentially debilitating symptom often found in dry eye disease (DE), migraine and traumatic brain injury (TBI). METHODS: We conducted a review of the literature via a PubMed search of English language articles with a focus on how photophobia may relate to a shared pathophysiology across DE, migraine and TBI. RESULTS: DE, migraine and TBI are common conditions in the general population, are often comorbid, and share photophobia as a symptom. Across the three conditions, neural dysregulation of peripheral and central nervous system components is implicated in photophobia in various animal models and in humans. Enhanced activity of the neuropeptide calcitonin gene-related peptide (CGRP) is closely linked to photophobia. Current therapies for photophobia include glasses which shield the eyes from specific wavelengths, botulinum toxin, and inhibition of CGRP and its receptor. Many individuals have persistent photophobia despite the use of these therapies, and thus, development of new therapies is needed. CONCLUSIONS: The presence of photophobia in DE, migraine and TBI suggests shared trigeminothalamic pathophysiologic mechanisms, as explained by central neuroplasticity and hypersensitivity mediated by neuropeptide CGRP. Treatment strategies which target neural pathways (ie, oral neuromodulators, transcutaneous nerve stimulation) should be considered in patients with persistent photophobia, specifically in individuals with DE whose symptoms are not controlled with traditional therapies.

Periorbital botulinum toxin A improves photophobia and sensations of dryness in patients without migraine: Case series of four patients.

PURPOSE: Individuals receiving botulinum toxin A (BoNT-A) injections in the head and neck for migraine treatment have reported decreases in photophobia and sensations of dryness, independent of ocular surface parameters. We hypothesized that patients without migraine but with similar ocular neuropathic-like symptoms would also experience symptomatic improvement with periocular BoNT-A injections, independent of ocular surface changes. OBSERVATIONS: We identified four individuals without a history of migraine but with neuropathic ocular pain (symptoms of dryness, burning, and photophobia that were out of proportion to ocular surface findings and unresponsive to ongoing dry eye (DE) therapies). Individuals underwent 1 session of periocular BoNT-A injections. Validated questionnaires (Visual Light Sensitivity Questionnaire-8, Dry Eye Questionnaire-5) assessed photophobia and DE symptoms pre- and 1-month post-injections. All four reported improvements in frequency and severity of photophobia and eye discomfort following BoNT-A injections. Tear film parameters (phenol red thread test, tear break-up time, corneal staining, and Schirmer test) and eyelid (palpebral fissure height and levator palpebrae superioris function) and eyebrow (position) anatomy were also evaluated before and after injections. Despite a unanimous improvement in symptoms, there were no consistent changes in ocular surface parameters with BoNT-A injections across individuals. CONCLUSIONS: Periocular BoNT-A shows promise in reducing photophobia and sensations of dryness in individuals with neuropathic-like DE symptoms without a history of migraine, independent of tear film, eyelid, or eyebrow parameters.

Transcorneal Cryotherapy and Descemet Membrane Endothelial Keratoplasty to Treat Epithelial Downgrowth and Corneal Decompensation After Cataract Surgery.

PURPOSE: Epithelial downgrowth is a vision-threatening complication of intraocular surgery or penetrating ocular trauma, and although various therapeutic interventions have been performed to treat this disease, success has been limited. We present a case of corneal decompensation secondary to epithelial downgrowth after uncomplicated clear corneal cataract surgery in the left eye, treated successfully with sequential transcorneal cryotherapy to destroy epithelial cell nests followed by Descemet membrane endothelial keratoplasty (DMEK) to restore corneal clarity and vision. METHODS: We applied a transcorneal cryotherapy probe using a double freeze-thaw technique at -80°C to the entire cornea, with care taken to spare the limbus except at the superior temporal quadrant overlying the clear corneal incision where treatment was applied intentionally. The same procedure was performed 2 weeks later to ensure complete ablation of epithelial nest cells. Uncomplicated DMEK surgery using standard technique was performed 1 week later to restore corneal clarity. RESULTS: Visual acuity at presentation was 20/40. Endothelial cell densities were 2138 cells/mm (22% loss) and 1720 cells/mm (37% loss) at 3- and 12-months after DMEK, respectively. Two years after surgery, the best-corrected visual acuity remained 20/20 and the patient had no evidence of recurrence or limbal stem cell deficiency. CONCLUSIONS: The use of sequential cryotherapy as a targeted intervention to destroy invasive corneal epithelial cells followed by staged DMEK surgery to replace damaged corneal endothelium was, in this case, an effective treatment for endothelial decompensation secondary to epithelial downgrowth and may be a potential alternative for the management of this disease.

Individuals with migraine have a different dry eye symptom profile than individuals without migraine.

BACKGROUND: Many individuals with migraine report symptoms of dry eye (DE). However, it is not known whether DE profiles are similar between individuals with and without migraine. To bridge this gap, we evaluated symptoms and signs of DE, including symptoms suggestive of nerve dysfunction, in a large group of individuals with DE symptoms, and compared profiles between individuals with migraine and those without migraine or headache. METHODS: Prospective cross-sectional study of individuals with DE symptoms seen at the Miami VA. RESULTS: Of 250 individuals, 31 met International Classification of Headache Disorders criteria for migraine based on a validated screen. Individuals with migraine were significantly younger (57 vs 62 years) and more likely to be female (26% vs 6%) than controls. Individuals with migraine had more severe DE symptoms and ocular pain compared with controls (mean Ocular Surface Disease Index 53.93 ± 21.76 vs 36.30 ± 22.90, p=0.0001; mean Neuropathic Pain Symptom Inventory modified for the Eye 39.39 ± 23.33 vs 21.86 ± 20.17, p=0.0001). The difference in symptom profile occurred despite similar ocular surface parameters between the groups. CONCLUSIONS: Individuals with migraine had a different DE symptom yet a similar DE sign profile when compared with controls without migraine. This suggests that DE symptoms in individuals with migraine may be driven by nerve dysfunction as opposed to ocular surface abnormalities.

Photophobia and sensations of dryness in patients with migraine occur independent of baseline tear volume and improve following botulinum toxin A injections.

BACKGROUND: To evaluate the efficacy of botulinum toxin A (BoNT-A) in reducing photophobia and dry eye symptoms in individuals with chronic migraine. Additionally, we aimed to evaluate tear film volume as a potential contributor to symptoms in these patients. METHODS: Retrospective review of 76 patients who received BoNT-A for chronic migraine between 23 August 2017 and 13 December 2017 at the Miami Veterans Affairs Medical Center Neurotoxin Clinic. Demographic data and all comorbidities were queried via chart review. Standardised validated surveys were administered to assess symptoms prior to and after BoNT-A injection. Preinjection tear volumes were obtained using the phenol red thread (PRT) test. RESULTS: Preinjection migraine, photophobia and dry eye symptom scores were all significantly correlated, p<0.05, and none were associated with preinjection PRT results. After BoNT-A, improvements in migraine, photophobia and dry eye symptoms were also significantly correlated, p<0.05 and similarly did not associate with preinjection PRT results. Photophobia scores significantly improved following BoNT-A, while dry eye symptoms significantly improved in those with severe symptoms at baseline (DEQ-5 score ≥12), p=0.027. In logistic regression analysis of all individuals with dry eye symptoms (DEQ-5 ≥6), individuals with more severe dry eye symptoms were more likely improve, OR 1.27, 95% CI 1.06 to 1.51, p<0.01. CONCLUSIONS: BoNT-A significantly improved photophobia in patients being treated for migraine and also improved dry eye symptoms in patients with severe symptoms at baseline, independent of baseline tear film volume. These improvements may be due to modulation of shared trigeminal neural pathways.