The effect of mandatory post-call relief on sleep and wellness in ophthalmology residents.

BACKGROUND: Multiple duty hour reforms have been implemented to optimize resident wellness through increasing opportunities for sleep recovery, but few studies have recorded objectively measured sleep or shown direct sleep and wellness benefits from such interventions. This study seeks to determine whether mandatory post-call relief policies with a partial night float system improved resident sleep, activity, and burnout among ophthalmology residents taking home call. METHODS: We conducted a two group cohort study of ophthalmology residents at the University Washington comparing post graduate year-2 (PGY-2) resident sleep, activity, and burnout between the optional post-call relief group from July 1, 2017 to June 30, 2019 to the mandatory post-call relief group from July 1, 2019 to June 30, 2021. RESULTS: Of twenty total residents participating in the survey portion, 18 residents participated in the sleep and activity tracking portion of the study, 9 in in the optional post-call relief cohort, and 9 in the mandatory post-call relief cohort. The mandatory post-call relief group recorded longer total sleep on call than the optional post-call relief group (p < 0.001). There was no difference in overnight sleep recorded on call (median 3.4 h), but residents recorded more time napping in the mandatory post-call relief cohort (p < 0.001). There was no significant difference between cohorts in amount of sleep while not on call. Residents in the mandatory post-call relief cohort recorded higher average daily steps, higher exercise time, and lower sedentary time than residents in the optional post-call relief cohort (p < 0.001). They also recorded lower median emotional exhaustion on the Maslach Burnout Inventory and lower stress in the Depression and Anxiety Stress Scale in the mandatory post-call relief cohort (p = 0.008). CONCLUSIONS: Implementation of mandatory post-call relief policies with a partial night-float system among PGY-2 residents was associated with more post-call naps with more overall physical activity, lower emotional exhaustion scores, and lower stress scores, despite no changes to overnight sleep on call or total sleep. Although sample size limits interpretation of data, implementation of mandatory post call relief could be considered to improve post-call sleep in programs with home call.

Neuro-Sweet Disease Causing Orbital Inflammation.

Neuro-Sweet disease is a rare condition causing encephalitis or meningitis in addition to the erythematous skin plaques of Sweet syndrome. Neuro-Sweet disease has been associated with several ocular manifestations, including ocular movement disorders, episcleritis, conjunctivitis, uveitis, and optic disc oedema. The author reports a patient with orbital inflammation, cranial neuropathies, and a skin rash in the setting of myelodysplastic syndrome. Biopsy of her skin lesion confirmed the diagnosis of neuro-Sweet disease. To the author's knowledge, this is the first reported case of neuro-Sweet disease causing orbital inflammation. Her ocular inflammation resolved with the use of systemic corticosteroid treatment.

Resident Sleep During Traditional Home Call Compared to Night Float.

Purpose This article aims to compare resident sleep while on night float with a traditional home call. Methods We conducted a crossover observational study assessing sleep patterns of seven postgraduate year-2 ophthalmology residents at the University of Washington from 2019 to 2021 using the Fitbit Alta HR device. Overnight call was scheduled from 5 p.m. to 8 a.m. on weekdays, and 8 a.m. to 8 a.m. on weekends. The residency program implemented a partial night float rotation, during which two to three nights of consecutive call were assigned to a resident without other clinical duties. Sleep was recorded using the Fitbit Alta HR for residents while on a 5-week partial night float rotation, on 10-week home call rotations, with postcall relief, and for stretches of seven or more days without call responsibilities. Mixed model regression analysis was used to compare average sleep on home call, night float, and periods without call. Results Sleep data were recorded for a total of 1,015 nights, including 503 nights on home call rotation and 230 nights on night float rotation. Residents slept more during periods away from call compared to either night float or home call rotations ( p < 0.001). Residents experienced increased average overall sleep during 10-week rotations on night float compared to home call ( p = 0.008). While there was no difference in overnight sleep on call between night float and home call ( p = 0.701), residents experienced more sleep overall while on call on night float compared to home call due to more sleep being recorded during postcall naps ( p = 0.016). Conclusion Implementing a night float system can increase resident sleep by allowing for more sleep recovery during time away from clinical duties.

Postcataract surgical inflammation.

PURPOSE OF REVIEW: To describe the epidemiology, pathogenesis, and recent developments in the diagnosis and management of postcataract surgery inflammation. RECENT FINDINGS: In patients with pre-existing uveitis, control of inflammation with topical and/or systemic therapy for 3 months preoperatively continues to be important in lessening the risk of postoperative inflammation and complications. During cataract surgery, intraocular lens selection in these patients is important. Recent literature suggests that modern intraocular lenses (IOLs), particularly hydrophilic or hydrophobic acrylic lenses, generally have good uveal biocompatibility in uveitic patients. The postoperative course can be complicated by inflammation and cystoid macular edema (CME), and in uveitic patients, intensive perioperative steroid treatment can lessen these complications. Recent studies show that in uveitic patients, the improvement in CME and inflammation after intravitreal triamcinolone is better than after orbital floor triamcinolone injection, but that a single intraoperative orbital floor injection of triamcinolone is as effective as a 4-week course of postoperative oral prednisolone. Although postoperative inflammation in uveitic patients may be due to recurrence of uveitis, one must recognize other important potential causes of postoperative inflammation and treat accordingly. SUMMARY: Most patients with postcataract inflammation have good visual outcomes provided that the cause is recognized and that there is adequate perioperative planning in patients predisposed to inflammation.

Inefficiencies in Residency Matching Associated with Gale-Shapley Algorithms.

Purpose: To investigate emerging trends and increasing costs in the National Residency Matching Program (NRMP) and San Francisco Residency and Fellowship Match Services (SF Match) associated with the current applicant/program Gale-Shapley-type matching algorithms. Design: A longitudinal observational study of behavioral trends in national residency matching systems with modeling of match results with alternative parameters. Methods: We analyzed publicly available data from the SF Match and NRMP websites from 1985 to 2020 for trends in the total number of applicants and available positions, as well the average number of applications and interviews per applicant for multiple specialties. To understand these trends and the algorithms' effect on the residency programs and applicants, we analyzed anonymized rank list and match data for ophthalmology from the SF Match between 2011 to 2019. Match results using current match parameters, as well as under conditions in which applicant and/or program rank lists were truncated, were analyzed. Results: Both the number of applications and length of programs' rank lists have increased steadily throughout residency programs, particularly those with competitive specialities. Capping student rank lists at 7 programs, or less than 80% of the average 8.9 programs currently ranked, results in a 0.71% decrease in the total number of positions filled. Similarly, capping program rank lists at 7 applicants per spot, or less than 60% of the average 11.5 applicants ranked per spot, results in a 5% decrease in the total number of positions filled. Conclusion: While the number of ophthalmology positions in the US has increased only modestly, the number of applications under consideration has increased substantially over the past two decades. The current study suggests that both programs and applicants rank more choices than are required for a nearly-complete and stable match, creating excess cost and work for both applicants and programs. "Stable-marriage"-type algorithms induce applicants and programs to rank as many counter-parties as possible to maximize individual chances of optimizing the match.

Accuracy of partial coherence interferometry in patients with large inter-eye axial length difference.

BACKGROUND: To determine accuracy of partial coherence interferometry (PCI) in patients with large inter-eye axial eye length (AEL) difference. METHODS: Patients undergoing cataract surgery at two academic medical centers with an inter-eye axial eye length (AEL) difference of > 0.30 mm were identified and were matched to control patients without inter-eye AEL difference > 0.30 mm on the basis of age, sex, and AEL. The expected post-operative refraction for the implanted IOL was calculated using SRK/T, Holladay II, and Hoffer Q formulae. The main outcome measures were the refractive prediction error and the equivalence of the refractive outcomes between the subjects and controls. RESULTS: Review of 2212 eyes from 1617 patients found 131 eyes of 93 patients which met inclusion criteria. These were matched to 131 control eyes of 115 patients. The mean AEL was 24.92 ± 1.50 mm. The mean absolute error (MAE) ranged from 0.47 D to 0.69 D, and was not statistically different between subjects and controls. The refractive prediction error was equivalent between the cases and controls, with no significant difference between the MAE for any formula, nor in the number of cases vs. controls with a refractive prediction error of at least 0.50 D or 1.00 D. CONCLUSIONS: Among eyes in our study population, good-quality PCI data was equally accurate in patients with or without an inter-eye AEL difference > 0.30 mm. Confirmatory AEL measurements using different AEL measuring modalities in patients with a large inter-eye AEL difference may not be necessary.

Gender Differences in Case Volume Among Ophthalmology Residents.

IMPORTANCE: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. OBJECTIVE: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency. DESIGN, SETTING, PARTICIPANTS: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018. MAIN OUTCOMES AND MEASURES: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status. RESULTS: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (ß = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (ß = -8.0 [95% CI, -14.0 to -2.1]; P = .008). CONCLUSIONS AND RELEVANCE: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.

Humphrey Matrix perimetry in optic nerve and chiasmal disorders: comparison with Humphrey SITA standard 24-2.

PURPOSE: To compare the Humphrey Matrix 24-2 perimetry (Matrix; Carl Zeiss Meditec, Inc., Dublin, CA) with the standard automated perimetry Humphrey Visual Field Analyzer using SITA (Swedish Interactive Threshold Algorithm) program 24-2 (SAP; Carl Zeiss Meditec, Inc.) in neuro-ophthalmic disorders affecting the optic nerve and chiasm. METHODS: Matrix and SAP were performed on 93 patients with neuro-ophthalmic disorders affecting the optic nerve and optic chiasm. Three readers compared the total and pattern deviation probability plots and judged the similarity and the extent of the visual field defects. The sensitivity and specificity of both perimeters were calculated. RESULTS: Concordance was good in 61%, fair in 30%, and poor in 9% of the total deviation plots. For the pattern deviation, concordance was good in 52%, fair in 34%, and poor in 14%. The extent of field loss was equal in 50%, 23% more extensive with Matrix, and 27% more extensive with SAP for total deviation plots. For the pattern deviation, the extent was equal in 47%, 20% more extensive with Matrix and 33% more extensive with SAP. The sensitivity for detecting defects was 84% (SAP) and 77% (Matrix) for total deviation and 80% (SAP) and 79% (Matrix) for pattern deviation (no significant difference, P > 0.05). The specificity was 84% (SAP) and 86% (Matrix) for total deviation and 68% (SAP) and 74% (Matrix) for pattern deviation (no significant difference, P > 0.05). CONCLUSIONS: The new Humphrey Matrix 24-2 testing strategy provides a visual field testing method for optic nerve and chiasmal disorders that has fair to good concordance with the Humphrey SITA Standard 24-2 program. Both tests have similar sensitivity and specificity.

Sensitivity and specificity of the Humphrey Matrix to detect homonymous hemianopias.

PURPOSE: To compare the sensitivity and specificity of the Humphrey Matrix frequency-doubling perimeter (Carl Zeiss Meditec, Inc., Dublin, CA) to that of standard automated perimetry (SAP) in detecting homonymous hemianopic visual field defects. METHODS: Thirty-three patients with homonymous hemianopias and 50 normal subjects were tested with SAP with the Humphrey Visual Field Analyzer (SITA standard program 24-2) and Humphrey Matrix frequency-doubling perimetry, program 24-2 (Matrix) on the same day. Patients with hemianopias had lesions of the retrochiasmal visual system that were documented by magnetic resonance imaging or by computed tomography. To be classified as a hemianopic visual field defect, the abnormal test location had to be homonymous, respect the vertical meridian, and have no additional scattered abnormal points that obscured the hemianopic pattern. The sensitivity and specificity of SAP and Matrix in detecting hemianopic defects were calculated. The chi(2) test was used to test for differences between groups. RESULTS: The sensitivity for hemianopic defects by total deviation probability plots was 75% for SAP and 59% for Matrix (not statistically significant, P = 0.29). The sensitivity of hemianopic defects by pattern deviation probability plots was 88% for SAP and 69% for Matrix (not statistically significant, P = 0.13). The specificity of total deviation probability plots was 84% for SAP and 86% for Matrix. The specificity of the pattern deviation probability plots was 68% for SAP and 74% for Matrix. CONCLUSIONS: Although there was no statistically significant difference between the Matrix and SAP in the detection of hemianopias, the sensitivity of SAP was higher, probably because of the obscuration of defects by scattered abnormal test locations with the Matrix.

That's a wrap.

Muslin-induced optochiasmatic arachnoiditis is a rare complication following surgical repair of an intracranial aneurysm but should be suspected in any delayed visual loss after aneurysm repair in which muslin was used. A 52-year-old male underwent clipping and muslin wrapping of a ruptured aneurysm of an anterior communicating artery. Eight months following surgery, the patient developed progressive visual loss, resulting in a bitemporal hemianopsia. Neuroimaging confirmed a suprasellar mass but no recurrent aneurysm. The patient was treated with prednisone and had significant improvement of his vision. Muslin wrapping of aneurysms should probably be avoided in aneurysms near the optic apparatus.

Effect of surgical case order on cataract surgery complication rates and procedure time.

PURPOSE: To determine whether surgical warm-up affects cataract surgery complication rates and surgical case times. SETTING: University of Washington Medicine Eye Institute, Harborview, Seattle, Washington, USA. DESIGN: Retrospective case-control study. METHODS: Patients who had phacoemulsification from June 2010 to December 2011 were consecutively reviewed. Case order for each surgeon was evaluated, comparing intraoperative complication rates and case times for attending and resident surgeons for the first case of the day (considered the warm-up case) versus subsequent cases. Simple (AMA Current Procedural Terminology code 66984) and complex (code 66982) phacoemulsification surgeries were included. Excluded were patients who had cataract surgery combined with another surgery. Pearson chi-square tests and 2-tailed independent-sample t tests were used to analyze data. RESULTS: The study reviewed 1424 patients. Cataract surgery complication rates were not statistically different between the first cases of the day and subsequent cases (3.3% versus 4.0%) (P = .552). There was, however, a significant difference in mean case time between these groups. The mean case time for simple phacoemulsification by resident physicians was 49.45 minutes ± 19.38 (SD) for first cases and 42.27 ± 15.78 minutes for subsequent cases (P = .021) and by attending physicians, 32.54 ± 12.91 minutes and 26.69 ± 9.17 minutes, respectively (P <. 0001). CONCLUSION: Surgical case order might not affect complication rates of cataract surgery; however, the first case of the day was longer than subsequent cases, suggesting that a preoperative warm-up exercise might decrease cataract surgery time. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Role of molecular diagnostics in ocular microbiology.

Although microbial culture remains the gold standard for diagnosis of many ocular infections, the technique is limited by low yield, inability to detect certain organisms, and potentially long delays to results. DNA-based molecular diagnostic techniques use detection of specific nucleic acid sequences as evidence for presence of suspected pathogens. The polymerase chain reaction (PCR) is a powerful molecular biology technique that allows for detection of fewer than 10 copies of pathogen genome. Recent technical advances in PCR have permitted quantitation of pathogen load using quantitative PCR (qPCR), and have permitted multiplexing of primer sets. Use of pan-bacterial and pan-fungal primers for ribosomal DNA sequences has allowed diagnosis of bacterial and fungal infections using molecular techniques. In this review, we highlight recent advances in the application of PCR to the diagnosis of anterior segment and posterior segment ocular infectious diseases.