The effect of post-traumatic-stress-disorder on intra-operative analgesia in a veteran population during cataract procedures carried out using retrobulbar or topical anesthesia: a retrospective study.

BACKGROUND: A growing proportion of veterans treated at the Veterans Health Administration (VA) have a history of post-traumatic-stress-disorder (PTSD), and there exists a higher rate of PTSD amongst veterans than the general population. The purpose of this study is to determine the correlation between PTSD and intra-operative analgesia, intra-operative time, and anesthesia type for cataract surgery in a veteran population. Secondary objectives are to determine if patient age, and first or second eye surgery affect intra-operative pain control or are correlated with type of anesthesia modality. METHODS: A retrospective study of 330 cataract surgeries performed by resident physicians between January and September 2012 at the Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville and Murfreesboro Campuses was completed. Three hundred and thirty veteran patients were selected if their cataract surgery was performed between January and September 2012. Combined cases were excluded. The primary outcome evaluated was intra-operative analgesia. Secondary outcomes included history of post-traumatic-stress-disorder, anesthesia type, first or second eye, pain control, intra-operative heart rate and blood pressure, age, and case complexity. Data was analyzed using an unpaired two-sample Welch's t-test assuming unequal variance and Z test of comparison of proportions. RESULTS: Patients with post-traumatic-stress-disorder reported higher pain scores, had longer operative times, and were more likely to have received a retrobulbar block. Operative time was not associated with an increased pain score, irrespective of anesthesia type, when controlled for PTSD. Complex cases had longer operative times, more sedation, and higher pain scores. P < 0.05 was used consistently. CONCLUSIONS: Post-traumatic stress disorder and anxiety are more prevalent in the veteran population. Our data suggests that a history of post-traumatic-stress-disorder was correlated with higher pain scores, longer operative times, and with having received a retrobulbar block. Patients without a history of PTSD were more likely to have received topical anesthesia with or without sedation. The veteran population requires more sedation to allay anxiety and perceptions of discomfort, which may account for longer surgical times. The veteran population is a special population and it is important to investigate how PTSD in the veteran population affects intra-operative analgesia.

Predictors of Ophthalmology Resident Performance From Medical Student Application Materials.

OBJECTIVE: To determine whether elements in ophthalmology residency applications are predictors of future resident performance. DESIGN: This multi-institutional, cross-sectional, observational study retrospectively reviewed the residency application materials of ophthalmology residents who graduated from residency from 2006 through 2018. Resident performance was scored by 2 faculty reviewers in 4 domains (clinical, surgical, academic, and global performance). Correlation between specific elements of the residency application and resident performance was assessed by Spearman correlation coefficients (univariate) and linear regression (multivariate) for continuous variables and logistic regression (multivariate) for categorical variables. SETTING: Seven ophthalmology residency programs in the US. PARTICIPANTS: Ophthalmology residents who graduated from their residency program. RESULTS: High-performing residents were a diverse group, in terms of sex, ethnicity, visa status, and educational background. Residents with United States Medical Licensing Examination Step 1 scores higher than the national average for that year had significantly higher scores in all 4 performance domains than those who scored at or below the mean (all domains P < 0.05). Residents who had honors in at least 4 core clerkships and who were members of Alpha Omega Alpha Medical Honor Society also had higher scores in all 4 performance domains (all domains P ≤ 0.04). Step 1 score (ρ=0.26, P < 0.001) and the difference between Step 1 score and the national average for that year (ρ=0.19, P = 0.009) positively correlated with total resident performance scores. Residents who passed the American Board of Ophthalmology Written Qualifying Examination or Oral Examination on their first attempt had significantly higher Step 1/2 scores (P ≤ 0.005), Ophthalmology Knowledge Assessment Program scores (P = 0.001), and resident performance scores (P ≤ 0.004). CONCLUSIONS: In this new landscape of increasing numbers of applicants to residency programs and changing of the Step 1 score to pass/fail, our findings may help guide selection committees as they holistically review applicants to select exceptional future residents in ophthalmology.

Evaluation of Two-Dimensional (2D) versus Three-Dimensional (3D) Video Tutorials in Cataract Surgery for New Trainees.

Purpose Microscopic ophthalmic surgery requires an understanding of three-dimensional (3D) spaces within the eye. Recently, there has been an increase in 3D video training tools in health care. Studies have evaluated the efficacy of 3D tutorials in general surgery, but little has been published within ophthalmology. We present a randomized study evaluating differences in surgically naïve trainees after watching either a 2D or 3D phacoemulsification tutorial. Design This was a double-blind, randomized study. A group of third and fourth year medical students at our institution were randomized with stratified randomization based on prior surgical courses to control for differences in baseline surgical skill. The two study arms were watching 2D or 3D instructional videos on phacoemulsification (Richard Mackool). Methods Participants received a preliminary survey and participated in an hour-long microscopic surgery session. During the session, participants performed tasks evaluating baseline microscopic spatial awareness and surgical skill. The students were then instructed to watch either a 2D or 3D video on phacoemulsification based on their randomized study arm. During the postintervention session, participants performed the biplanar incision and capsulorhexis steps of cataract surgery discussed in the video on model eyes. Students were evaluated on speed and overall capsulorhexis quality. Results Thirty-one students qualified for the study and completed the microscopic surgery session. Students in both groups had similar baseline speed and quality of preintervention microscopic tasks ( p > 0.05 for all tasks). Postintervention, students randomized to the 3D video performed significantly faster than the 2D group for biplanar incision (11.1 ± 5.5 s vs. 20.7 ± 10.5 s, p = 0.001). There were no statistically significant differences found between the groups in capsulorhexis timing ( p = 0.12) or quality score ( p = 0.60). Conclusions 3D video surgical training tutorials may improve speed of certain steps of cataract surgery for surgically naïve ophthalmology trainees. Given the limited sample size of this study, further investigation of their effectiveness is warranted.

Factors Influencing Fellowship Training Among Ophthalmology Residents: A Pilot Study.

Objective: There has been an increase in ophthalmology fellowship training programs and applicants. The current ophthalmology literature lacks any recent study examining factors influencing residents' decisions to pursue subspecialty fellowship training. Methods: An anonymous, 16-item survey was distributed to residents from a convenience sample of ophthalmology residency programs by their program directors or administrators. Results: A total of 72 residents and 9 interns from 9 distinct programs completed the survey. Eighty-two percent of respondents reported they have either applied or will apply for a fellowship position. Gender and race showed no significant association with fellowship application. Respondents perceived that obtaining a fellowship position would be easier (61%) than obtaining an ophthalmology residency. The desire for additional clinical and surgical training were the 2 primary factors for the pursuit of fellowship training. Half of those pursuing fellowship training (49%) indicated they still desired to practice comprehensive ophthalmology. None of the respondents indicated they wished to practice in a rural area. Conclusion: The data collected in this pilot study elicited factors and variable associations that provide a sound basis for informing revisions and improvements to the data collection tool for a follow-up prospective, longitudinal study involving all ACGME ophthalmology training programs. The results indicate some of the essential factors associated with the pursuit of fellowship training by the current generation of residents. The results also highlight potential trends related to residents' views of their training and desired practice patterns.

Long-term potency, sterility, and stability of vancomycin, ceftazidime, and moxifloxacin for treatment of bacterial endophthalmitis.

PURPOSE: To determine the long-term potency, sterility, and stability of vancomycin, ceftazidime, and moxifloxacin prepared in single-use polypropylene syringes for intravitreal injection. METHODS: Experimental study. Vancomycin 1 mg/0.1 mL, ceftazidime 2 mg/0.1 mL, and moxifloxacin 160 µg/0.1 mL were compounded and prepared in 1-mL polypropylene syringes and stored at 4 °C, -20 °C, and -80 °C. Antibiotic potency, sterility, pH, osmolality, and concentration were tested at baseline and at 1, 2, 4, 8, 12, and 24 weeks after preparation. RESULTS: Potency, sterility, and stability were preserved for all 3 antibiotics at all temperatures out to 24 weeks, although there was a trend toward reduced potency at Week 24 for vancomycin and ceftazidime stored at 4°C. The largest zones of inhibition for Staphylococcus epidermidis and S. aureus were consistently demonstrated by moxifloxacin. CONCLUSION: Vancomycin, ceftazidime, and moxifloxacin prepared in single-use polypropylene syringes retain potency, sterility, and stability out to 24 weeks when stored at -20 °C or -80 °C. The results of this study may have important implications for the current management of endophthalmitis.

Distance Surgical Mentorship for Ophthalmologists in Northern Peru.

This article was migrated. The article was marked as recommended. Purpose: To evaluate the quality of live distance surgical mentorship as an alternative way to provide continuing professional development (CPD) to practicing ophthalmologists. An activity which could be particularly beneficial to surgeons in remote locations where CPD is difficult to access. Methods: Orbis paired ophthalmologists from the Regional Institute of Ophthalmology (IRO) in Trujillo, Peru and a senior ophthalmologist from Vanderbilt Eye Institute in Tennessee, USA (LW). One week in advance, the Peruvian surgeon sent the mentor patient information confidentially via Cybersight.org, Orbis' telemedicine platform. The mentor reviewed the preoperative information to determine if the case was appropriate for remote guidance and formulated questions to help guide the educational experience. The mentor and mentee also consulted on specific learning objectives. The mentor observed live phacoemulsification surgery over the Internet using audio-visual equipment and Zoom desktop video conferencing software, allowing her to see through the operating microscope in real-time and have constant voice contact with the local surgeon. Post-mentorship a survey was administered to gauge acceptability of the CPD method, as well as their self-assessment on its impact on their skill development. Results: Latency experienced was well within the suggested margin of acceptability and the video quality was broadcast-grade, allowing the mentor to clearly see the anatomy and instrument manipulation. Seven surgeons over four sessions performed twelve phacoemulsification surgeries in Peru, 91.67% of those 12 patients achieved postoperative best corrected visual acuity ≥6/18. Four surgeons completed the survey and 100% agreed or strongly agreed that their objectives had been met and that the CPD had increased their confidence and their surgical skills. The step in the procedure most commonly reported for improvement was nuclear cracking (75% of respondents), followed by hydrodissection, quadrant removal and wound closure (50% each). Conclusions: Distance surgical mentorship in phacoemulsification is an acceptable form of CPD for consultant ophthalmologists. We describe a program with positive user feedback and experiences of improved confidence and microsurgical skill among participants.

Rate of Unverifiable Publications Among Ophthalmology Residency Applicants Invited to Interview.

Importance: Unverifiable publications in applications for ophthalmology residencies could be a serious concern if they represent publication dishonesty. Objective: To determine the rate of unverifiable publications among applicants offered an interview. Design: Retrospective review of 322 ophthalmology residency applications for entering classes 2012 to 2017 at Vanderbilt University School of Medicine, Nashville, Tennessee. Interventions: Full-length publications reported in the applications were searched in PubMed, Google, Google Scholar, and directly on the journal's website. Applications were deemed unverifiable if there was no record of the publication by any of these means or if substantial discrepancies existed, such as incorrect authorship, incorrect journal, or a meaningful discrepancy in title or length (full-length article vs abstract). Main Outcomes and Measures: Inability to locate publication with search, incorrect author position, applicant not listed as an author, article being an abstract and not a published paper, substantial title discrepancy suggesting an alternative project, and incorrect journal. Results: Of the 322 applicants offered interviews during the 6-year study period, 22 (6.8%) had 24 unverifiable publications. Two hundred thirty-nine of these applicants (74.2%) reported at least 1 qualifying publication; of this group, 22 (9.2%) had an unverifiable publication. The applications with unverifiable publications were evenly distributed across the years of the study (range, 2-6 per cycle; Pearson χ25 = 3.65; P = .60). Two applicants had 2 unverifiable publications each. Two of the 22 applicants (9.1%) with unverifiable publications were graduates of medical schools outside the United States. Among the unverifiable publications, the most common reason was inability to locate the publication (13 [54%]). Additional issues included abstract rather than full-length publication (5 [20.8%]), incorrect author position (4 [16.7%]), applicant not listed as an author on the publication (1 [4.2%]), and substantial title discrepancy (1 [4.2%]). One listed publication had an incorrect author position and incorrect journal (1 [4.2%]). Conclusions and Relevance: Unverifiable publications among ophthalmology residency applicants is a persistent problem. Possible strategies to modify the review process include asking applicants to provide copies of their full-length works or the relevant PMCID (PubMed Central reference number) or DOI (digital object identifier) for their publications.

Probability of Success in the Ophthalmology Residency Match: Three-Year Outcomes Analysis of San Francisco Matching Program Data.

OBJECTIVE: To develop a probability model of matching into a US ophthalmology residency program using San Francisco Matching Program (SF Match) data. DESIGN: Retrospective data analysis of de-identified application and matching data. PARTICIPANTS: Registrants for the 2013, 2014, and 2015 ophthalmology residency matches conducted by the SF Match. METHODS: Descriptive statistics of candidates, comparison of continuous and categorical variables between matched and nonmatched candidates, and linear regression modeling were performed. A recursive partitioning method was used to create a probability of matching algorithm. MAIN OUTCOME MEASURES: Probability of successfully matching based on quantifiable candidate characteristics. RESULTS: Over the 3-year period, 1,959 individuals submitted an average of 64 applications and received a mean of nine interview invitations. The overall match rate was 71%, with 78% matching at one of their top five choices. Successful matches were more likely to occur in US medical school graduates (78% vs 20%, p < 0.001) and applicants on their first attempt (76% vs 29%, p < 0.001). The association between matching and number of programs applied became negative with > 48 applications. Probability of matching was "high" (> 80%) among US graduates with a step 1 United States Medical Licensing Examination (USMLE)score>243(regardless of number of programs applied to), a step 1 USMLE score of 231 to 243 who applied to at least 30 programs, and first-time applicants with a step 1 score >232. No international medical graduates or repeat applicants had a "high" probability of matching. CONCLUSIONS: Although advice must be individualized for each candidate, applicants for ophthalmology residency who fall into a "high" probability of matching group are likely to be successful with applications to 45 or fewer programs. Applying to 80 or more programs should be considered for international medical graduates and/or applicants who are previously unmatched. Modification of the match application data form may allow more detailed analysis of variables such as Alpha Omega Alpha or Gold Humanism Honor Society membership, research activity, and composite evaluation on a standardized letter of recommendation.

Xanthoma disseminatum with bilateral epibulbar involvement.

PURPOSE: To describe the ocular involvement in xanthoma disseminatum. DESIGN: Case report and literature review. METHODS: Histopathologic study of excised conjunctival tumor and clinical follow-up. RESULTS: A 29-year-old woman with normal serum lipoproteins developed widespread xanthomas of the skin, throat, and episclera. There were no signs of recurrence 12 months after removal of the conjunctival xanthomas. CONCLUSIONS: Xanthoma disseminatum is a rare condition for which there is no medical treatment. The distinction between the normolipemic xanthomatoses awaits a better understanding of their pathogenesis. Surgical removal of episcleral xanthomas can be successful, but long-term follow-up of such patients has been limited.

Effect of ibopamine on aqueous humor production in normotensive humans.

PURPOSE: Ibopamine is a prodrug of epinine (deoxyepinephrine) that exhibits activity at dopaminergic and adrenergic receptors. Topical ocular application has been shown to cause mydriasis without cycloplegia and to increase the rate of aqueous humor flow in normotensive human eyes. Mydriasis can interfere with the measurement of aqueous flow. In this study ibopamine's effect on aqueous humor production was measured while making allowance for the potential artifact caused by its mydriatic effect. METHODS: The effects of topical ibopamine on pupillary diameter, aqueous humor flow measured by fluorophotometry, and intraocular pressure were studied in 24 healthy, blue-eyed humans. Ibopamine was administered with and without the alpha-adrenergic antagonist dapiprazole, and its effects were compared with those of tropicamide, with and without dapiprazole in a double-masked, randomized, crossover design. RESULTS: Ibopamine dilated the pupil from a diameter of 3.7 +/- 0.64 (mean +/- SD, n=24) to 7.7 +/- 0.70 mm. Ibopamine, during its peak mydriasis, was associated with a very large increase in the rate of clearance of topically applied fluorescein from the cornea and anterior chamber, an effect that was not associated with tropicamide during its peak mydriasis. The mydriatic effect of ibopamine was completely blocked by dapiprazole, and the increase in fluorescein clearance was partially blocked. When mydriasis was blocked, ibopamine increased fluorescein clearance by 13% (P<0.0001), which was interpreted as an increased rate of aqueous humor production. Compared with placebo and with the tropicamide control, ibopamine decreased intraocular pressure, despite its stimulation of aqueous humor flow. CONCLUSIONS: Ibopamine is in a specific class of drug, along with pilocarpine, epinephrine, and bimatoprost that in humans increases the rate of aqueous humor flow as measured by fluorophotometry. This effect is partly responsible for its ability to increase intraocular pressure in persons suspected to have abnormally low aqueous humor outflow facility. The transient apparent doubling of aqueous humor flow, measured by fluorescein clearance after administration of ibopamine is an artifact of increased fluorescein clearance through the dilated pupil while accommodation is active.

Pupillary response to four concentrations of pilocarpine in normal subjects: application to testing for Adie tonic pupil.

PURPOSE: To determine the amount of pupillary constriction to four different concentrations of pilocarpine in normal human subjects and to determine if pupillary constriction correlates with bioavailability of the instilled concentrations. The amount of pupillary constriction to dilute pilocarpine is utilized as a diagnostic test for Adie tonic pupil as distinguished from a normal pupil response. DESIGN: Twenty healthy volunteers had automated binocular infrared pupillography in the dark after instillation of four different concentrations of dilute pilocarpine. Ocular penetration of eye drops was also assessed using 2% fluorescein sodium as a tracer. METHODS: Prospective institutional double-masked study of both eyes of twenty healthy volunteers, ten with brown irides, ten with blue irides, between the ages of 20-40 years. RESULTS: A pilocarpine dose-dependent curve showed decreased pupil size within 15 minutes, peaking at 30-60 minutes. No difference was noted between right and left eyes, iris color, or corneal permeability. CONCLUSIONS: Normal pupils constrict to dilute concentrations of pilocarpine (0.25% or 0.125%), but constrict insignificantly to concentrations of 0.0313% or 0.0625%. Pupil constriction with 0.0625% pilocarpine should distinguish an Adie pupil from normal. This confirms the utility of this simple office diagnostic procedure.