Creation of an asynchronous faculty development curriculum on well-written narrative assessments that avoid bias.

BACKGROUND: The COVID-19 pandemic in parallel with concerns about bias in grading resulted in many medical schools adopting pass/fail clinical grading and relying solely on narrative assessments. However, narratives often contain bias and lack specificity. The purpose of this project was to develop asynchronous faculty development to rapidly educate/re-educate > 2000 clinical faculty spread across geographic sites and clinical disciplines on components of a well-written narrative and methods to minimize bias in the assessment of students. METHODS: We describe creation, implementation, and pilot data outcomes for an asynchronous faculty development curriculum created by a committee of volunteer learners and faculty. After reviewing the literature on the presence and impact of bias in clinical rotations and ways to mitigate bias in written narrative assessments, the committee developed a web-based curriculum using multimedia learning theory and principles of adult learning. Just-in-time supplemental materials accompanied the curriculum. The Dean added completion of the module by 90% of clinical faculty to the department chairperson's annual education metric. Module completion was tracked in a learning management system, including time spent in the module and the answer to a single text entry question about intended changes in behavior. Thematic analysis of the text entry question with grounded theory and inductive processing was used to define themes of how faculty anticipate future teaching and assessment as a result of this curricula. OUTCOMES: Between January 1, 2021, and December 1, 2021, 2166 individuals completed the online module; 1820 spent between 5 and 90 min on the module, with a median time of 17 min and an average time of 20.2 min. 15/16 clinical departments achieved completion by 90% or more faculty. Major themes included: changing the wording of future narratives, changing content in future narratives, and focusing on efforts to change how faculty teach and lead teams, including efforts to minimize bias. CONCLUSIONS: We developed a faculty development curriculum on mitigating bias in written narratives with high rates of faculty participation. Inclusion of this module as part of the chair's education performance metric likely impacted participation. Nevertheless, time spent in the module suggests that faculty engaged with the material. Other institutions could easily adapt this curriculum with provided materials.

Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department.

BACKGROUND: Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration. METHODS: An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked. RESULTS: Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students. CONCLUSIONS: Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Myopic Shift 5 Years after Intraocular Lens Implantation in the Infant Aphakia Treatment Study.

PURPOSE: To report the myopic shift at 5 years of age after cataract surgery with intraocular lens (IOL) implantation for infants enrolled in the Infant Aphakia Treatment Study (IATS). METHODS: Refractions were performed at 1 month and every 3 months postoperatively until age 4 years and then at ages 4.25, 4.5, and 5 years. The change in refraction over time was estimated by linear mixed model analysis. RESULTS: Intraocular lens implantation was completed in 56 eyes; 43 were analyzed (median age, 2.4 months; range, 1.0-6.8 months). Exclusions included 11 patients with glaucoma, 1 patient with Stickler syndrome, and 1 patient with an IOL exchange at 8 months postoperatively. The mean rate of change in a myopic direction from 1 month after cataract surgery to age 1.5 years was 0.35 diopters (D)/month (95% confidence interval [CI], 0.29-0.40 D/month); after age 1.5 years, the mean rate of change in a myopic direction was 0.97 D/year (95% CI, 0.66-1.28 D/year). The mean refractive change was 8.97 D (95% CI, 7.25-10.68 D) at age 5 years for children 1 month of age at surgery and 7.22 D (95% CI, 5.54-8.91 D) for children 6 months of age at surgery. The mean refractive error at age 5 years was -2.53 D (95% CI, -4.05 to -1.02). CONCLUSIONS: After IOL implantation during infancy, the rate of myopic shift occurs most rapidly during the first 1.5 years of life. Myopic shift varies substantially among patients. If the goal is emmetropia at age 5 years, then the immediate postoperative hypermetropic targets should be +10.5 D at 4 to 6 weeks and +8.50 D from 7 weeks to 6 months. However, even using these targets, it is likely that many children will require additional refractive correction given the high variability of refractive outcomes.

Comparison of Visual Outcomes in Coats' Disease: A 20-Year Experience.

PURPOSE: To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice. DESIGN: Single-center retrospective cohort study. PARTICIPANTS: Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015. METHODS: Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015). MAIN OUTCOME MEASURES: Visual acuity (VA). RESULTS: Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P = 0.03), but remained stable for decade 2 eyes (P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P < 0.001). CONCLUSIONS: The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

Update on congenital cataract surgery management.

PURPOSE OF REVIEW: The basic procedure of pediatric cataract surgery has not dramatically changed over the past few years. Recent multicenter study results along with technological innovations, however, have increased our understanding and armamentarium of techniques and devices used to improve outcomes. RECENT FINDINGS: We review surgical techniques that have been recently applied to the management of pediatric cataracts and describe newer intraocular lenses that have become available for use in the pediatric population. The 5-year results of the Infant Aphakia Treatment Study, including visual outcomes and complications, as well as other studies comparing intraocular lens implants with contact lenses for infants have shaped our management of congenital cataract. We also discuss how ocular imaging with optical coherence tomography has enhanced our understanding of the microstructural effects on pediatric eyes after cataract surgery and touch on other future innovations. SUMMARY: We review updates in the management of congenital cataract, which remains a major cause of preventable childhood blindness.

Temporary Lumbar Drain as Treatment for Pediatric Fulminant Idiopathic Intracranial Hypertension.

Fulminant idiopathic intracranial hypertension (FIIH) is a subtype of idiopathic intracranial hypertension (IIH) characterized by rapid, severe, progressive vision loss. Surgical intervention is often performed either as a cerebrospinal fluid (CSF) shunt procedure or an optic nerve sheath fenestration or, at times, both. These surgical procedures carry a significant risk of morbidity and failure. We present 2 patients in whom a temporary lumbar drain was successfully used in the management of medically undertreated pediatric FIIH, and circumvented the need for surgical intervention.

Congenital fibrovascular pupillary membranes: clinical and histopathologic findings.

PURPOSE: To report the clinical and histopathologic findings associated with congenital fibrovascular pupillary membranes. DESIGN: Case series. PARTICIPANTS: Seven infants were included, 6 with a unilateral congenital pupillary membrane and 1 with classic persistent fetal vasculature (PFV). METHODS: Patients underwent a membranectomy, pupilloplasty, or lensectomy. Histopathologic examination was performed on the excised membranes. MAIN OUTCOME MEASURES: Visual acuity and pupil size. RESULTS: Four of the 6 patients with a unilateral congenital pupillary membrane had 1 or more recurrences after a membranectomy and pupilloplasty. The most recent pupil size ranged from 2 to 5 mm in the affected eye. When last tested, the vision in the affected eye was excellent in 4 of the 6 patients. The 2 patients without recurrences of the pupillary membranes underwent multiple iris sphincterotomies at the time of the initial surgery. Histopathologic examination of 2 primary pupillary membranes showed fibrovascular tissue that did not stain for neuron-specific enolase. Smooth muscle actin was only present in vascular walls. In contrast, histopathology of a recurrent pupillary membrane revealed collagenized fibrovascular tissue that was immunoreactive for smooth muscle actin. Finally, histopathology of the retrolenticular membrane excised from an infant with classic PFV was similar to the latter aside from hypercellularity. CONCLUSIONS: Congenital fibrovascular pupillary membranes in infants are likely a variant of PFV that may recur if incompletely excised. The risk of these membranes recurring may be reduced by excising as much as the membrane as possible and enlarging the pupil with iris sphincterotomies. A lensectomy should be avoided if possible.

Complications, adverse events, and additional intraocular surgery 1 year after cataract surgery in the infant Aphakia Treatment Study.

PURPOSE: To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation. DESIGN: Prospective, randomized clinical trial. PARTICIPANTS: The Infant Aphakia Treatment Study (IATS) is a randomized, multicenter (n = 12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract. INTERVENTION: Infants underwent cataract surgery with or without placement of an IOL. MAIN OUTCOME MEASURES: The rate, character, and severity of intraoperative complications (ICs), adverse events (AEs), and additional intraocular surgeries (AISs) during the first postoperative year in the 2 groups were analyzed. RESULTS: There were more patients with ICs (28% vs. 11%; P = 0.031), AEs (77% vs. 25%; P<0.0001), and AISs (63% vs. 12%; P<0.0001) in the IOL group than the contact lens group. Iris prolapse was the most common IC. The most common AE was visual axis opacification, and the most common additional intraocular reoperation was a clearing of visual axis opacification. CONCLUSIONS: The rates of ICs, AEs, and AISs 1 year after surgery were numerically higher in the IOL group, but their functional impact does not clearly favor either treatment group. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Update on pediatric cataract surgery and intraocular lens implantation.

PURPOSE OF REVIEW: Cataract surgery is the most commonly performed intraocular surgery in the pediatric population worldwide. Although the basic surgical techniques have not significantly changed over the last several years, there are many related issues under continual debate and research. These include use of local perioperative anesthesia, capsular management, type and power of intraocular lenses (IOLs), sutured IOLs, and risk of subsequent glaucoma. This review will primarily focus on postsurgical outcomes and IOL-related controversies. RECENT FINDINGS: The just completed Infant Aphakia Treatment Study aims to answer questions regarding visual outcomes with primary IOL implantation versus contact lens use in children less than 7 months old with a unilateral congenital cataract. But correct IOL selection is controversial as recent studies highlight difficulties with biometry measurement and IOL calculations in the entire pediatric population. We also discuss the risk of late suture breakage and dislocation with sutured IOLs and the risks of aphakic glaucoma. SUMMARY: Worldwide experiences with pediatric cataract surgery and IOL implantation are constantly evolving. Expectations of good outcomes by the patients, families, and surgeons are also increasing therefore continued efforts to improve techniques and formulas specific to the pediatric population are critical.

A global partnership in medical education between Duke University and the National University of Singapore.

Duke University and the National University of Singapore (NUS) have partnered to launch a new medical school that brings the American style of postbaccalaureate medical education to Asia. The new institution, called the Duke-NUS Graduate Medical School (GMS) and located in Singapore adjacent to the Singapore General Hospital, admitted its inaugural class of students representing citizens of seven nations in August 2007. The project represents an investment of more than $350 million from three ministries of the Singapore government, and a commitment on Duke's part to provide senior leadership and recruit faculty from Duke, from other international locales, and from within Singapore itself. Graduating students who complete the four-year Duke curriculum will receive an MD degree awarded jointly by Duke and NUS, thereby distinguishing this school from medical education in most Asian institutions that award an MBBS degree after a five-year period of study that follows directly from secondary school. The emphasis of the Duke-NUS GMS is to prepare physician-scientists for academic careers, with plans for 20% of each class to complete a combined MD/PhD degree. This article describes events leading up to this partnership and details of the relationship, including curriculum, organizational structure, milestones, and goals.

Safety and efficacy of silicone rod frontalis suspension surgery for childhood ptosis repair.

PURPOSE: To evaluate the safety and efficacy of silicone rod frontalis suspension surgery for childhood ptosis. METHODS: The authors retrospectively studied 89 consecutive children (110 eyelids) who had silicone rod frontalis suspension surgery for ptosis at Duke University Eye Center from 1983 to 2004. Marginal reflex distance1 (MRD1) elevation of 2 mm or more (vs preoperative MRD1) was considered satisfactory. MRD1 was measured as the vertical distance from the corneal light reflex in primary gaze to the upper eyelid margin. The postoperative eyelid symmetry (< or = 1 mm = satisfactory) was the difference between the MRD1 of the surgical and fellow eyelid. RESULTS: Median age at surgery was 45 months (range: 3 to 223 months) and median follow-up was 17 months (range: 1 to 88 months). Ptosis types (number of eyelids) were unilateral congenital (53), bilateral congenital (30), third nerve palsy (16), Marcus Gunn jaw wink (7), trauma (2), and myasthenia gravis (2). Median MRD1 elevation was 2 mm or greater for all ptosis types, whereas satisfactory postoperative symmetry occurred in 60% of unilateral and 100% of bilateral congenital ptosis cases (last follow-up). Complications occurred in 10 eyelids (9%) and reoperation occurred in 10 eyelids (9%). CONCLUSION: The use of silicone rod frontalis suspension surgery for ptosis repair in pediatric patients is modestly effective, with few complications and easy removal and adjustment.

Is it a match? a novel method of evaluating medical school success.

BACKGROUND: Medical education program evaluation allows for curricular improvements to both Undergraduate (UME) and Graduate Medical Education (GME). UME programs are left with little more than match rates and self-report to evaluate success of graduates in The Match. OBJECTIVE: This manuscript shares a novel method of program evaluation through a systematic assessment of Match outcomes. DESIGN: Surveys were developed and distributed to Program Training Directors (PTDs) at our institution to classify residency programs into which our UME graduates matched using an ordinal response scale and open-ended responses. Outcomes-based measures for UME graduates were collected and analyzed. The relationship between PTD survey data and UME graduates' outcomes were explored. Open-ended response data were qualitatively analyzed using iterative cycles of coding and identifying themes. RESULTS: The PTD survey response rate was 100%. 71% of our graduates matched to programs ranked as 'elite' (36%) or 'top' (35%) tier. The mean total number of 'Honors' grades achieved by UME graduates was 2.6. Data showed that graduates entering elite and top GME programs did not consistently earn Honors in their associated clerkships. A positive correlation was identified between USMLE Step 1 score, number of honors, and residency program rankings for a majority of the programs. Qualitative analysis identified research, faculty, and clinical exposure as necessary characteristics of 'elite' programs:. Factors considered by PTDs in the rating of programs included reputation, faculty, research, national presence and quality of graduates. CONCLUSIONS: This study describes a novel outcomes-based method of evaluating the success of UME programs. Results provided useful feedback about the quality of our UME program and its ability to produce graduates who match in highly-regarded GME programs. The findings from this study can benefit Clerkship Directors, Student Affairs and Curriculam Deans, and residency PTDs as they help students determine their competitiveness forspecialties and specific residency programs.

Efficacy and Safety of Low-Dose Iodine Plaque Brachytherapy for Juxtapapillary Choroidal Melanoma.

PURPOSE: To evaluate low- vs high-dose plaque brachytherapy for juxtapapillary choroidal melanoma. DESIGN: Retrospective interventional case series. METHODS: Setting: Single institution. STUDY POPULATION: Forty-seven patients with juxtapapillary choroidal melanoma. INTERVENTION: Iodine-125 plaque brachytherapy. Eyes were divided into apex low-dose (LD) and high-dose (HD) groups (≤ or > median apex dose 84.35 Gy). Main outcome measures were time to distant failure, local failure, death, enucleation, radiation retinopathy, optic neuropathy, and best-corrected visual acuity (BCVA). RESULTS: Freedom from distant failure rates were 96% and 95% in apex LD and HD groups at 5 years and 77% and 95% at 10 years, respectively (P = .84). Freedom from local failure rates were 90% in the apex LD group vs 89% in the HD group at 5 and 10 years (P = .96). Apex LD and HD groups did not differ for time to death or enucleation. Five- and 10-year freedom from radiation retinopathy and optic neuropathy rates were higher in the apex LD than HD group. Loss of ≥3 BCVA lines, final BCVA 20/40 or better, and final BCVA 20/200 or worse were more favorable in the 5 mm LD compared to HD group. Visual acuity outcomes did not differ between apex LD and HD groups. CONCLUSIONS: Low-dose iodine-125 plaque brachytherapy (67.5-81 Gy at tumor apex) provides safe and effective tumor control for juxtapapillary choroidal melanoma and may be associated with reduced radiation toxicity. Larger trials are needed to determine the optimal therapeutic dose for juxtapapillary choroidal melanoma.

Optical coherence tomography as a tool for monitoring pediatric pseudotumor cerebri.

PURPOSE: To evaluate optical coherence tomography (OCT) measurement of peripapillary retinal nerve fiber layer (RNFL) and macular thickness in children with pseudotumor cerebri. METHODS: Prospective observational series of children with pseudotumor cerebri compared against controls matched for age and gender. We included 11 pediatric subjects with clinical pseudotumor cerebri and 37 normal controls. Subjects underwent a complete eye examination including stereo disk photographs and OCT. Peripapillary RNFL and macular thickness were evaluated using the Stratus OCT 3000. The peripapillary RNFL was evaluated with two protocols: Fast RNFL Map protocol with values divided in eight sections, made up of four quadrants, each with an inner and outer ring, and Fast RNFL Thickness (3.4) protocol, using values presented for four quadrants. A Fast Macular Thickness Map was also obtained, and results reported similarly included eight sections, made up of four quadrants, each with an inner and outer ring. RESULTS: The Fast RNFL Map protocol showed an increased RNFL thickness (pseudotumor cerebri vs controls) in the temporal and superior quadrants. The Fast RNFL Thickness (3.4) protocol showed a thicker average RNFL for pseudotumor cerebri eyes compared with controls (125.7 vs 106.5 microm, p < 0.0001). The Fast Macular Thickness Map showed an increased RNFL thickness in the nasal quadrant for the inner ring. The macular volumes for pseudotumor cerebri versus control eyes were 7.21 versus 6.97 mm(3), respectively (p = 0.005). CONCLUSIONS: OCT shows increased RNFL and macular thickness in pseudotumor cerebri and may be a useful clinical tool in these children.

Anisometropia at Age 5 Years After Unilateral Intraocular Lens Implantation During Infancy in the Infant Aphakia Treatment Study.

PURPOSE: To report the prevalence of anisometropia at age 5 years after unilateral intraocular lens (IOL) implantation in infants. DESIGN: Prospective randomized clinical trial. METHODS: Fifty-seven infants in the Infant Aphakia Treatment Study (IATS) with a unilateral cataract were randomized to IOL implantation with an initial targeted postoperative refractive error of either +8 diopters (D) (infants 28 to <48 days of age) or +6 D (infants 48-210 days of age). Anisometropia was calculated at age 5 years. Six patients were excluded from the analyses. RESULTS: Median age at cataract surgery was 2.2 months (interquartile range [IQR], 1.2, 3.5 months). The mean age at the age 5 years follow-up visit was 5.0 ± 0.1 years (range, 4.9-5.4 years). The median refractive error at the age 5 years visit of the treated eyes was -2.25 D (IQR -5.13, +0.88 D) and of the fellow eyes +1.50 D (IQR +0.88, +2.25). Median anisometropia was -3.50 D (IQR -8.25, -0.88 D); range -19.63 to +2.75 D. Patients with glaucoma in the treated eye (n = 9) had greater anisometropia (glaucoma, median -8.25 D; IQR -11.38, -5.25 D vs no glaucoma median -2.75; IQR -6.38, -0.75 D; P = .005). CONCLUSIONS: The majority of pseudophakic eyes had significant anisometropia at age 5 years. Anisometropia was greater in patients that developed glaucoma. Variability in eye growth and myopic shift continue to make refractive outcomes challenging for IOL implantation during infancy.

Is there a latent period for the surgical treatment of children with dense bilateral congenital cataracts?

BACKGROUND: It generally is accepted that cataract surgery during the first 6 weeks of life is associated with the best visual outcomes for children with dense unilateral congenital cataracts. The latent period for children with dense bilateral congenital cataracts has not been clearly defined. METHODS: The best-corrected visual acuity (BCVA) at 4 to 6 years of age was collected retrospectively on a series of 43 children with dense bilateral congenital cataracts from 4 institutions. All of the children underwent a lensectomy, posterior capsulotomy, and anterior vitrectomy at 36 weeks of age or younger. RESULTS: Cataract surgery was performed at a mean age of 11.5 weeks for the better-seeing eye. BCVA was assessed when the children were a mean of 5.3 years of age. The visual acuities of 26 (60%) were 20/40 or better, 12 (28%) were 20/50 to 20/80, and 5 (12%) were 20/100 or worse. There was a trend for worse BCVA with increasing age at the time of surgery (r = 0.28, P = 0.07). We noted that a BCVA of 20/100 or worse occurred only among eyes undergoing surgery when infants were older than 10 weeks (10 weeks: 5/22 = 23%, P = 0.049). Children with preoperative nystagmus had worse visual outcomes; only 38% of children with preoperative nystagmus achieved a BCVA of 20/40 or better compared with 74% of children without preoperative nystagmus (P = 0.03). CONCLUSION: Previous reports have proposed that cataract surgery during the first 5 to 8 weeks of life is associated with better visual outcomes in children with dense bilateral congenital cataracts. Our results would suggest that good visual outcomes can be achieved beyond this age, but the incidence of poor visual outcomes increases if cataract surgery is delayed beyond 10 weeks of age. The absence of preoperative nystagmus is a better predictor of a good visual outcome than the age at surgery.

Comparison of the rate of refractive growth in aphakic eyes versus pseudophakic eyes in the Infant Aphakia Treatment Study.

PURPOSE: To compare the rate of refractive growth (RRG) between aphakic eyes and pseudophakic eyes in the Infant Aphakia Treatment Study (IATS). SETTING: Twelve clinical sites across the United States. DESIGN: Randomized clinical trial. METHODS: Patients randomized to unilateral cataract extraction with contact lens correction versus intraocular lens (IOL) implantation in the IATS had their rate of refractive growth (RRG3) calculated based on the change in refraction from the 1-month postoperative examination to age 5 years. The RRG3 is a logarithmic formula designed to calculate the RRG in children. Two-group t tests were used to compare the mean refractive growth between the contact lens group and IOL group and outcomes based on age at surgery and visual acuity. RESULTS: Longitudinal refractive data were studied for 108 of 114 patients enrolled in the IATS (contact lens group, n = 54; IOL group, n = 54). The mean RRG3 was similar in the contact lens group (-18.0 diopter [D] ± 11.0 [SD]) and the IOL group (-19.0 ± 9.0 D) (P = .49). The RRG3 value was not correlated with age at cataract surgery, glaucoma status, or visual outcome in the IOL group. In the aphakia group, only visual outcome was correlated with refractive growth (P = .01). CONCLUSIONS: Infants' eyes had a similar rate of refractive growth after unilateral cataract surgery whether or not an IOL was implanted. A worse visual outcome was associated with a higher RRG in aphakic, but not pseudophakic, eyes. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Pediatric optic nerve sheath decompression.

PURPOSE: To review our experience with optic nerve sheath decompression for pediatric pseudotumor cerebri. DESIGN: Retrospective chart review. PARTICIPANTS: Seventeen eyes in 12 children younger than 16 years of age. All patients were either unresponsive or intolerant to medication. INTERVENTION, METHODS, OR TESTING: An optic nerve sheath fenestration was performed. MAIN OUTCOME MEASURES: Optic nerve appearance, visual acuity, color vision, and visual fields. RESULTS: The average age at surgery was 10.1 years of age. The average follow-up was 39.6 months. Headache was the most common presenting symptom. All patients showed improvement in optic nerve edema. Visual acuity improved or stayed the same in all surgical eyes (P = 0.0078). One patient required a neurosurgical lumbar peritoneal shunt, and 2 patients required acetazolamide on the last follow-up appointment. No patient had postoperative infection, loss of vision, or strabismus develop. Five of the patients in this study required sheath decompression on the other eye. CONCLUSIONS: Optic nerve sheath decompression in children is safe, and the results are similar to those obtained in adults. Close follow-up is required, because 5 of 12 patients in this study required a contralateral optic nerve sheath decompression.

Posttraumatic abducens to oculomotor nerve misdirection.

INTRODUCTION: Paradoxical patterns of extraocular muscle, eyelid, or pupillary movements can occur following injury between divisions of the oculomotor nerve, trigeminal and abducens nerves, and trigeminal and oculomotor nerves. We report three cases of unusual ocular motility and eyelid movements that are a result of aberrant connections between the abducens and oculomotor nerves. METHODS: Three patients with unusual eye movement abnormalities after trauma were studied. A complete ophthalmic examination plus neuroradiologic evaluation were performed. RESULTS: Each patient manifested an aberrant connection between the 6th and 3rd cranial nerves resulting in third nerve function during sixth nerve stimulation. Two patients demonstrated complete third nerve palsies except for adduction on attempted abduction. The third showed improved bilateral ptosis on abduction. CONCLUSIONS: The neuroanatomical abnormalities involve intraorbital structures in one patient and central nervous system pathways in the others. Explanations such as retrograde regeneration, ephaptic transmission, or denervation supersensitivity do not appear to explain these unusual eye movements. The most likely mechanism involves some form of peripheral neuronal misdirection. These rare sixth to third nerve misdirection cases add support to the "neuronal misdirection hypothesis" of aberrant eye movements after trauma.