Cystoid macular edema from cancer-associated retinopathy.

PURPOSE: This article reviews the diagnosis and management of a patient with cancer-associated retinopathy (CAR) secondary to small cell lung cancer who developed a rare presentation of CAR, cystoid macular edema (CME). CAR is a rare cause of unexplained, often rapid, visual acuity and visual field loss. CASE REPORT: A 67-year-old man with a recent history of photopsias and simultaneous dimming of vision presented to our clinic. Four months before, he had been diagnosed with small cell lung cancer. Retinal examination was normal, but the visual field was severely constricted. He was referred for an electroretinogram and an evaluation by a retina specialist because of a strong suspicion of CAR, which was confirmed. Despite a lack of strong clinical evidence for the treatment of CAR, and no clinical recommendations for CME found in CAR, our patient's CME was initially treated with diclofenac QID and, subsequently, a sub-tenon injection of triamcinolone. Since his diagnosis of CME, he has been chronically managed with diclofenac QID to treat his edema, with relatively stable visual acuity. His visual fields remain highly constricted. CONCLUSIONS: CAR is a rare form of painless bilateral vision loss in patients with a history of cancer. Our patient developed CME from his CAR, and was treated with diclofenac and sub-tenon injections of triamcinolone. Despite potential options for treatment, none have demonstrated much efficacy, and the visual prognosis is typically poor.

Handwriting with a preferred retinal locus for AMD with scotomas.

PURPOSE: Individuals with macular scotomas from age-related macular degeneration frequently have difficulty writing legibly. The purpose of this study was to investigate the causes of this difficulty by documenting the location of the retinal image of the pen used for writing in relation to the scotoma and fixational preferred retinal locus (fPRL). METHODS: Subjects with macular scotomas from age-related macular degeneration and visually normal age-matched controls wrote words while observing their hand, pen, and text in a scanning laser ophthalmoscope. Scanning laser ophthalmoscope video images were analyzed to find the retinal positions of the subject's scotoma, fixation area, and pen tip. RESULTS: Control subjects placed their fovea and scotoma subjects placed their fPRL on or very close to the pen tip for both cursive writing and printing. Scotoma subjects' written text sloped downward at a greater angle than controls'. Text angle was negatively correlated with fPRL eccentricity, visual acuity, and the amount the scotoma obscured the writing guides. When printing, control subjects placed their fovea precisely in the center of printing box guides, whereas scotoma subjects exhibited highly dispersed placement of the fPRL. CONCLUSIONS: The principal finding is that, because the retinal locations of the pen tip and the fPRL or fovea are coincident or very close, the fPRL and fovea are "monitoring" the pen tip and its location on the page. It is the PRL determined by asking subjects to fixate (i.e., the fPRL) that is used when handwriting, not a separate "handwriting" PRL. The poor handwriting performance of those with macular scotomas seems to be primarily caused by difficulty in placing letters in the appropriate location probably because of reduced visual acuity of the fPRL and scotoma obscuration of the area on which to write.

Are Internal Medicine Residents Meeting the Bar? Comparing Resident Knowledge and Self-Efficacy to Published Palliative Care Competencies.

BACKGROUND: There is a need for improved primary palliative care (PC) education and resident comfort with providing end-of-life care. OBJECTIVE: Utilize a new instrument derived from published PC competencies to assess baseline Internal Medicine (IM) resident knowledge and self-efficacy in PC to identify educational gaps and create new PC curricula. DESIGN: We created a 2-part instrument including a Knowledge Test (KT) and a Self-Efficacy Inventory (SEI) addressing 18 PC resident competencies across 5 domains: Pain and Symptom Management (PSM), Communication (COMM), Psychosocial, Spiritual, and Cultural Aspects of Care (PSC), Terminal Care and Bereavement (TCB), and Palliative Care Principles and Practice (PCPP). SETTING/SUBJECTS: The instrument was emailed to IM residents at our institution during academic years 2015-2016 and 2016-2017. MEASUREMENTS: Basic descriptive statistics were performed for the KT and SEI. Mean Rank Analysis and One-way ANOVA were utilized for the KT and SEI, respectively. Congruence was calculated between knowledge and self-efficacy. RESULTS: The mean score on the KT was 73% (range 33-80%). There was no significant difference in knowledge among post-graduate year cohorts. Self-efficacy scores were lower for interns overall and in PCPP, TCB, and COMM domains. Knowledge was concordant with self-efficacy in 42% of participants, higher than self-efficacy in 10% of participants, and lower than self-efficacy in 48% of participants. CONCLUSIONS: For approximately half of respondents, high self-efficacy in PC did not correlate with high PC knowledge. A more focused curriculum is needed to help IM residents facilitate mastery of PC competencies by graduation.

A New Competency-Based Instrument to Assess Resident Knowledge and Self-Efficacy in Primary Palliative Care.

CONTEXT: There is a need to improve both primary palliative care (PPC) education and its assessment in graduate medical education (GME). We developed an instrument based on published palliative care (PC) competencies to assess resident competency and educational interventions. OBJECTIVES: To describe the development and psychometric properties of a novel, competency-based instrument to measure resident knowledge and self-efficacy in PPC. METHODS: We created a 2-part instrument comprised of a knowledge test (KT) and a self-efficacy inventory (SEI) addressing 18 consensus, core PC resident competencies across 5 domains: pain and symptom management; communication; psychosocial, spiritual, and cultural aspects of care; terminal care and bereavement; and PC principles and practice. The instrument was distributed to 341 internal medicine residents during academic years 2015 to 2016 and 2016 to 2017. A standard item analysis was performed on the KT. Internal consistency (Cronbach α) and variable relationships (factor analysis) were measured for the SEI. RESULTS: One hundred forty-four residents completed the survey (42% response). For 15 KT items, difficulty ranged from 0.17 to 0.98, with 7 items ranging 0.20 to 0.80 (typical optimum difficulty); discrimination ranged from 0.03 to 0.60 with 10 items ≥0.27 (good to very good discrimination). Cronbach α was 0.954 for 35 SEI items. Factor analysis of combined 2015 to 2016 items yielded 4 factors explaining the majority of variance for the entire set of variables. CONCLUSION: Our instrument demonstrates promising psychometric properties and reliability in probing the constructs of PC and can be further utilized in PC GME research to assess learners and evaluate PPC educational interventions.