Paediatric vision screening in the primary care setting in Ontario.

OBJECTIVES: Early intervention is critical to prevent treatable causes of vision loss in children. The objectives of the current study are: (1) to assess how well primary care physicians in Ontario follow the vision screening guidelines for children as recommended by the Canadian Paediatric Society and the Rourke Baby Record and (2) to identify barriers to vision screening in the primary care setting. DESIGN: Cross-sectional survey. METHODS: A 19-question survey was mailed out to 1000 randomly selected family physicians (family MDs), 1000 general practitioners (GPs) and 1000 paediatricians in Ontario as listed in the 2013 Canadian Medical Directory. RESULTS: A total of 719 completed surveys were included in the analysis (449 from family MDs/GPs and 270 from paediatricians). Vision screening was reported to be performed by 65% of family MDs/GPs and 52% of general paediatricians at every well child visit. While red reflex was reported to be checked by 94% of all physicians in children under 3, it was only performed by 25% of respondents for children over 3. Thirty seven percent of all physicians reported never performing a visual acuity test in any age group. When asked about the obstacles preventing them from performing vision screening, lack of training (family MDs/GPs: 50%, paediatricians: 42%), time constraints (family MDs/GPs: 42%; paediatricians: 40%) and inadequate reimbursement (family MDs/GPs: 17%; paediatricians: 15%) were the most commonly cited reasons. CONCLUSIONS: Strategies to improve vision screening are necessary given that early intervention is crucial to prevent treatable causes of vision loss in children.

Pediatric orbital cellulitis in the Haemophilus influenzae vaccine era.

PURPOSE: To evaluate the microbiology of pediatric orbital cellulitis in blood cultures and abscess drainage cultures following the introduction of the Haemophilus influenzae serotype b (Hib) vaccine. METHODS: The medical records of all pediatrics patients (aged <18 years) at a tertiary pediatric hospital during the period January 2000 to July 2011 with a computed tomography orbital imaging querying "orbital cellulitis," "periorbital cellulitis," "preseptal cellulitis," or "post-septal cellulitis" were retrospectively reviewed. The records, microbiology, and radiology of these patients were reviewed to assess the rates and complications of H. influenzae orbital cellulitis, including bacteremia and meningitis. RESULTS: A total of 149 patients were diagnosed with preseptal or orbital cellulitis, of whom 101 (mean age, 7.2 ± 4.0) had true orbital cellulitis. No patients grew H. influenzae from blood cultures. Of the 101 patients, 30 (29.7%) required surgical drainage and had abscess drainage fluid sent for microbiology. Of these, 18 (64.3%) had a positive culture: 4 (13.3%) grew H. influenzae from their abscess drainage fluid samples; 1 grew H. influenzae alone; and 3 had mixed growth that included H. influenzae. The patients positive for H. influenzae were significantly older and had significantly larger abscesses. CONCLUSIONS: Although there were no cases of H. influenzae bacteremia or meningitis in our cases of orbital cellulitis, abscess drainage fluid microbiology indicated that H. influenzae remains a cause of orbital cellulitis. H. influenzae abscess volume was significantly larger than other bacterial abscesses and was associated with abscesses of mixed bacterial growth in older children.

The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention.

PURPOSE: To assess the effect of adding orbital computerized tomography (CT) findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. METHODS: The medical records of patients with orbital CT at a tertiary pediatric hospital from January 2000 to March 2011 were reviewed retrospectively. CT images of cases with radiology report of postseptal orbital involvement were further reviewed by a neuroradiologist. RESULTS: Of 101 cases of orbital cellulitis, 71 (mean age, 7.1 ± 4.0) were successfully managed with systemic antibiotics alone; 30 patients (mean age, 7.2 ± 4.3) required surgical intervention. Bony destruction on CT was significantly associated with surgical intervention (P = 0.02), and the size of the subperiosteal abscess (SPA) was significantly correlated with management outcome. Patients who were managed with systemic antibiotics alone had a mean SPA volume of 2.1 ± 2.4 mL; those who had undergone surgical intervention had a mean SPA volume of 14.3 mL ± 16.8 mL (P < 0.0001). If SPA volume is <3.8 mL, then the probability of surgery is 12%; if SPA is >3.8 mL, the probability of surgery is 71% (P < 0.0001). CONCLUSIONS: Adding radiological characteristics such as presence of bony destruction on CT and size of SPA to the Chandler orbital cellulitis classification scheme increases the ability to more accurately predict which patients will require surgical intervention.

Virtual reality ophthalmic surgical simulation as a feasible training and assessment tool: results of a multicentre study.

OBJECTIVE: To compare performance on the Eyesi surgical simulator by users with different levels of experience in ophthalmology. DESIGN: Multicentre cross-sectional study. PARTICIPANTS: Four medical students, 4 ophthalmic medical technologist trainees, 36 ophthalmology residents, 3 fellows, and 18 staff ophthalmologists. METHODS: Subjects were recruited at the 2007 Canadian Ophthalmological Society Meeting and in the departments of ophthalmology at the University of Toronto, University of Ottawa, and University of Western Ontario. Subjects performed a standardized 20-minute session on the Eyesi simulator. The protocol consisted of a practice trial in the anterior segment module, followed by 3 scored trials in the anterior forceps, antitremor, and capsulorhexis modules. RESULTS: In the forceps module, participants with greater experience achieved significantly higher total scores than those who were less experienced: staff ophthalmologists (Group D) = 67.9 (SD 18.4), senior residents and fellows (Group C) = 67.6 (SD 21.1), junior residents (Group B) = 52.9 (SD 29.4), medical students and ophthalmic medical technologist trainees (Group A) = 27.8 (SD 29.4) (p = 0.011), with lower total task time (p = 0.044) and fewer injuries to the cornea (p = 0.001) and lens (p = 0.026). In the antitremor module, subjects in Group D achieved significantly higher (p = 0.004) total scores (46.7, SD 21.6) than Groups C (45.8, SD 25.1), B (41.2, SD 29.4), and A (8.5, SD 9.2) with lower total task time (p = 0.005) and fewer errors (p = 0.003). In the capsulorhexis module there was also a positive correlation between experience and total scores achieved (p = 0.065). CONCLUSIONS: Subjects' level of training is a reliable predictor of their performance on the Eyesi anterior forceps and antitremor modules (p < 0.05), indicating the modules' construct validity.