Predictors of matching into an ophthalmology fellowship for international medical graduates: a San Francisco match analysis.

PURPOSE: To describe the characteristics and outcomes of international medical graduates (IMGs) applying for ophthalmology fellowship match. METHODS: Design Case control study. Setting San Francisco Fellowship Match data between 2010 and 2017. Participants IMGs applying for ophthalmology fellowships. Main outcome(s) and measure(s) Applicant characteristics for IMGs were stratified by their match outcome and compared using Chi-Square and Mann-Whitney U test. A multivariable logistic regression model was used to assess the effect of applicant characteristics on their match outcomes. RESULTS: 22.62% (785/3471) of the fellowship match applicants were IMGs of which 35.92% (n = 282) matched. This rate was 58% lower than the 86.4% match rate for US-MG (p < 0.001). Factors associated with higher odds of matching among IMGs were graduating from a US residency (Odds Ratio (OR):2.330; 95% Confidence Interval (CI):1.433-3.789), higher USMLE Step 3 score (OR:1.019; 95% CI: 1.006-1.032), applying to more programs (OR:1.035; 95% CI: 1.017-1.053), ranking more programs (OR:1.200; 95% CI: 1.096-1.313) and having a higher percentage of programs ranked (OR:1.021; 95% CI: 1.014-1.028). CONCLUSIONS: Fellowship match rates for IMGs were significantly lower than for US-MGs. IMGs graduating from an ophthalmology residency in the US, scoring higher Step 3 scores, distributing more applications, and ranking more programs had increased odds of matching. This information may assist IMG fellowship applicants and their mentors when they consider pursuing an ophthalmology fellowship program in the US.

Ophthalmology Surgical Assessment of Tube Shunt Glaucoma Surgery.

PURPOSE: To develop an internationally standardized and validated tool to assess skill in performing tube shunt surgery. DESIGN: A panel of 6 glaucoma surgeons developed a tool for assessing tube shunt surgery using a modified Dreyfus scale for skill acquisition. The tool was reviewed by a panel of 10 international content experts, and their comments were incorporated into the final rubric. PARTICIPANTS: A different panel of 8 international glaucoma specialists independently graded videos of surgical procedures performed by 6 surgeons at various levels of ophthalmic training. MAIN OUTCOME MEASURES: Inter-rater reliability for each step in the rubric was calculated. RESULTS: The tube shunt rubric contained 13 steps specific to tube shunt surgery and 7 global indices. The Cronbach α statistic, a measure of internal reliability, ranged from 0.75 to 0.97, indicating strong internal reliability for all 13 steps. CONCLUSIONS: The tube shunt assessment tool has face validity, content validity, and interobserver reliability, and can be used to assess tube shunt surgery skills. Further studies are required to determine predictive and construct validity.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for Open Globe Surgical Management.

Background/Aims: To produce an internationally developed rubric to assess surgical competency in open globe management. Methods: An international expert panel of seven ophthalmologist educators developed a standardized competency-based rubric. The steps to perform an open globe repair were outlined. Based on a modified Dreyfus model, the experts agreed on the steps of surgery and certain global indices. They then assigned descriptors for the competency expected of a novice, beginner, advanced beginner, and competent surgeon. The tool was then vetted by another panel of ten ophthalmologists. The main outcome measure was the final version of the tool as agreed upon by the expert review panel. Results: The steps of open globe repair and key global indices were established. Descriptive wording for each step and global indices for novice, beginner, advanced beginner, and competent surgery were listed. All the expert comments were integrated to establish face and content validity. Conclusion: This standardized rubric to evaluate resident competency should be used globally in training programs to assess open globe repair surgical skills. Using a modified Dreyfus model, four different levels of training competency were defined allowing a non-biased, objective, numerical and simple assessment.

Complete Response of a Patient With a Mismatch Repair Deficient Aggressive Pituitary Adenoma to Immune Checkpoint Inhibitor Therapy: A Case Report.

BACKGROUND AND IMPORTANCE: Aggressive pituitary adenomas (APAs) are pituitary tumors that are refractory to standard treatments and carry a poor prognosis. Current treatment guidelines are not standardized but combine surgical resection, radiation therapy, and chemotherapy. Temozolomide is the only chemotherapeutic agent with documented effectiveness and is recommended for APA in European Society of Endocrinology clinical guidelines. CLINICAL PRESENTATION: A 57-year-old man presented with visual deterioration and bitemporal hemianopsia. MRI of the brain demonstrated a sellar mass suspected to be pituitary macroadenoma with displacement of the stalk and optic nerve impingement. The patient underwent stereotactic endoscopic transsphenoidal resection of the mass. Postoperative MRI demonstrated gross total resection. Pathology revealed a sparsely granulated corticotroph adenoma with malignant transformation. Immunohistochemistry showed loss of expression of MLH1 and PMS2 in the tumor cells. Proton therapy was recommended given an elevated Ki67 index and p53 positivity. Before radiotherapy, there was no radiographic evidence of residual tumor. Temozolomide therapy was initiated after surveillance MRI showed recurrence at 16 months postoperatively. However, MRI demonstrated marked progression after 3 cycles. Next-generation sequencing using the MSK-IMPACT platform identified somatic mutations in MLH1 Y548lfs*9 and TP53 R337C . Immunotherapy with ipilimumab/nivolumab was initiated, and MRI demonstrated no residual tumor burden 34 months postoperatively. CONCLUSION: APA is a tumor with frequent recurrence and a short median expected length of survival. Here, we demonstrate the utility of immunotherapy in a single case report of APA, with complete resolution of recurrent APA and improved survival compared with life expectancy.

Pharmacologic Mydriasis Secondary to Topical Glycopyrronium Tosylate Cloths: Clinical Characterization From a Multicenter Analysis.

BACKGROUND: Topical glycopyrronium tosylate (GT) is an anticholinergic medication for treatment of axillary hyperhidrosis. Pharmacologic mydriasis and anisocoria from topical GT has been reported and may be underrecognized. This study aims to clinically characterize patients presenting with pharmacologic mydriasis from exposure to this medication. METHODS: This study is a retrospective observational case series. A multicenter chart review of 16 patients diagnosed with pharmacologic mydriasis secondary to topical GT was performed. RESULTS: Eight patients (50.0%) were age 18 years and younger, and 14 patients (87.5%) were female. Unilateral mydriasis (anisocoria) occurred in 14 patients (87.5%). Fourteen patients (87.5%) did not initially volunteer topical GT as a "medication," and the history of topical GT exposure needed to be elicited with further questioning. Hand hygiene details were known for 12 patients, and all reported that they did not wash their hands after GT application. Six patients (37.5%) were soft contact lens users. One patient had possible exposure through a family member's use of the medication. Ocular symptoms were common (blurry vision [11 patients, 68.8%] and eye dryness [7 patients, 43.8%]), but systemic anticholinergic symptoms were uncommon (such as constipation [1 patient, 6.3%] and urinary symptoms [3 patients, 18.8%]). CONCLUSIONS: Mydriasis associated with topical GT seems to be a consequence of local exposure rather than systemic toxicity. Because patients may not volunteer topical GT as a medication, eliciting a history of exposure often requires further specific questioning. Soft contact lens wear and poor postapplication hand hygiene seem to be associated with mydriasis in GT use.

Pearls & Oy-sters: Pivoting Treatment Regimens of Pediatric Atypical Teratoid Rhabdoid Tumors to Optimize Care in Adult ATRT: A Case Report.

Atypical teratoid rhabdoid tumor (ATRT) is a highly malignant embryonal tumor of the CNS, largely affecting pediatric patients, with exceedingly rare cases in adults at an estimated annual incidence of 1/1,000,000. We report a unique case of ATRT in a 43-year-old female patient who first presented with progressive focal headaches. Imaging revealed a sellar mass with suprasellar extensions, which was partially removed via a transsphenoidal resection. The tumor aggressively recurred just 1 month postoperatively. Her care team pursued a novel treatment plan by using a slightly modified COG ACNS 0332 regimen, which involved radiation, followed by 4 cycles of monthly chemotherapy including vincristine, cyclophosphamide, and cisplatin. Hematopoietic stem cells were collected between radiation and chemotherapy in the event that the patient required stem cell salvage therapy postadjuvant chemotherapy. The MRIs taken at 2 and 4 months postrecurrence indicated a substantial decrease in tumor volume, with corresponding clinical improvements to cranial nerve deficits. Given the scarcity of literature on adult cases of ATRT and the lack of a standard of care for these cases, discussing the efficacy of our patient's treatment plan may aid clinical decision making for adult ATRT cases.

Ophthalmology foundation Ophthalmic Surgical Competency Assessment Rubric (OSCAR) for pterygium surgery.

Background: Pterygium surgery is a procedure commonly performed by ophthalmologists. Valid, objective methods are needed to assess competence in this procedure. Methods: A panel of 5 specialists consisting of members from different regions of the world including Pakistan, United States, Iran, Mongolia and Peru was formed to create a rubric for assessment of pterygium surgery by residents. The assessment rubric was developed using the standard template of Ophthalmology Surgical Competency Assessment Rubrics (OSCARs) previously published. The rubric was designed using a modified Dreyfus model of skill acquisition on a four-point behavioral scale. Results: The rubric consisted of 14 essential steps in pterygium surgery and 5 global indices. The content and face validity of the rubric was refined by repeatedly reviewing the rubric on Googledocs and considering critiques by a panel of 10 cornea specialists from around the world. Each step was divided into four levels, from novice to competent. The skill required for each level was described specifically to help decrease rater subjectivity. Conclusions: The OSCAR for pterygium surgery has face-validity and can be used effectively for both teaching and assessing ophthalmology residents in training programs across the world.

Online Faculty Development on Curriculum Design in Simulation-based Education by International Collaboration - An Example from the Democratic Republic of the Congo.

PURPOSE: Faculty development for procedural specialists is intended to improve clinical education and surgical/procedural skills. Despite challenging in under-resourced settings, this may be enhanced by developing international collaboration agreements and supported by online learning experiences. The Congolese Society of Ophthalmology and the International Council of Ophthalmology agreed to collaborate on implementing an online educational program to form a community of practice (CoP) of ophthalmologists educators and enhance competence in curriculum design and simulation-based education (SBE) on cataract surgery. METHODS: Ten Congolese ophthalmologists, faculty for the "Centre de Formation Ophthalmologique pour l'Afrique Centrale" (CFOACF), participated in a group-mentored 12-webinar modular program on curriculum design, in 2019. Considering the geo-social-cultural learning environment, we developed a curriculum framework incorporating social constructivism and experiential learning principles to facilitate the implementation of learning. Educational strategies included flipped, practice-based and social learning, group mentoring, and individual and collective reflection opportunities. A CoP was virtually nurtured using WhatsApp. Program evaluation relied on (a) feedback survey per module and 3 months upon conclusion, (b) individual declarative knowledge assessment, and (c) group assignment to test competence improvement. RESULTS: The CFOACF formed a virtual CoP, commented on an enjoyable opportunity to develop scholar teaching competence, expressed intention in systematically building educational curricula design that includes active learning strategies and effective feedback and showed individual learning and team-competence improvement. CONCLUSION: This first iteration of our online faculty development program nurtured the formation of a CoP of ophthalmologists' educators and enabled to practice a scholar teaching approach, especially applied to SBE.

The Ophthalmology Surgical Competency Assessment Rubric for Intravitreal Injections (ICO-OSCAR:IVI).

(1) Background: Intravitreal injections (IVIs) are the most commonly performed intraocular procedure worldwide. Ensuring correct learning is essential to avoid complications. Our purpose was to develop an internationally valid tool to assess skill in performing IVIs. (2) Methods: A panel of six content experts designed a rubric for assessing the IVI procedure by using a modified Dreyfus scale of skill acquisition, dividing it into steps and providing objective behavioral descriptors for each level of skill in each category, following the International Council of Ophthalmology (ICO) guidance. The rubric draft was then critically reviewed by 12 international content experts, and their constructive comments were considered for the final rubric. (3) Results: The Ophthalmology Surgical Competency Assessment Rubric for IVI (ICO-OSCAR:IVI) is the proposed tool for assessing healthcare professionals training to perform IVI. (4) Conclusions: The ICO-OSCAR:IVI is the result of the consensus of an international expert panel. The methodology used for its development provides this rubric with face and content validity. It can be used globally to assess healthcare professionals training to perform IVI, as well as the impact of different teaching methods on performance. Further studies are required to establish intra- and inter-rater reliability, as well as the predictive validity of this tool.

Online Faculty Development: An African Lusophone Ophthalmic Society Experience During the COVID-19 Pandemic.

PURPOSE: Faculty development for procedural specialists aims at developing both their medical education and surgical competence. This has been challenging during the COVID-19 pandemic, especially in under-resourced settings and African Lusophone ophthalmology community has been no exception. The Mozambican College of Ophthalmology (MOC) and the Continuing Professional Development Committee of the International Council of Ophthalmology (ICO) established a collaboration to enhance simulation-based clinical teaching competence in cataract surgery. METHODS: Ten Mozambican ophthalmologists experienced in teaching cataract surgery participated in a group mentoring assisted 6 month/11 flipped-learning online experience on curriculum design, which included practice-based and social learning strategies, continuous bidirectional feedback, individual and group reflection opportunities, and the demonstration of declarative and procedural competencies. Program evaluation consisted of pre and post-test knowledge assessment; individual homework, informed by curated reading and a recorded lesson; feedback surveys for each module and one month after the program's conclusion, and a longitudinal project on creating a simulation-based education session on one step of cataract surgery. RESULTS: Participants a) highlighted the opportunity to advance their scholarly teaching skills as facilitators; b) showed an increase in knowledge post-test, expressed commitment to improve their learning experiences´ design, include interactive educational methods, and provide constructive feedback; and c) formed a sustained community of practice of ophthalmologists educators (CoP). CONCLUSION: This online faculty development program, assisted by group mentoring, held during the COVID-19 pandemic, facilitated the development of a CoP and was effective in enhancing teaching competence in curriculum design to apply in simulation-based learning environments.

The Ophthalmology Surgical Competency Assessment Rubric for External Dacryocystorhinostomy Surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tool for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for external dacryocystorhinostomy (ExDCR). METHODS: An international panel of content experts, representing Argentina, India, U.A.E., United Kingdom, and the U.S.A. was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardized OSCAR template as a baseline, developing explicit behavioral descriptors (the behavior and performance expected for each step) that were reviewed and modified with successive models. Learners were scored on a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. The tool was then reviewed by a secondary panel of international content experts, representing Brazil, India, Iran, Singapore, United Kingdom, and the U.S.A. RESULTS: The final OSCAR ExDCR tool was developed in alignment with the ICO-OSCAR standard. Nineteen agreed and weighted stems were produced. Specific comments with regards to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity. CONCLUSIONS: The OSCAR ExDCR is skill and behavior based, has ICO agreed standards for assessment, and provides learners with specific targets for improvement. Although the OSCAR tool has face and content validity, further development could better elucidate its precise role.

The International Council of Ophthalmology Ophthalmic clinical evaluation exercise.

Purpose: Fifteen years after the publication of the Ophthalmic Clinical Evaluation Exercise (OCEX), it was deemed necessary to review and revise it, and to validate it for an international audience of ophthalmologists. This study to revise the OCEX and validate it for international use. Methods: The OCEX rubric was changed to a modified Dreyfus scale; a behavioral descriptor was created for each category. An international panel of ophthalmic educators reviewed the international applicability and appropriateness of the tool. Results: A tool for assessing and giving feedback on four aspects of clinical competence during the ophthalmic consultation (interview skills, examination, interpersonal and communication skills, and case presentation) was revised. The original scoring tool was improved to a new behavioral one, and relevant comments and suggestions from international reviewers were incorporated. The new tool has face and content validity for an international audience. Conclusion: The OCEX is the only tool for workplace assessment and feedback specifically for ophthalmology residents and the ophthalmic consultation. This improved and simplified version will facilitate its use and implementation to diverse programs around the world.

Fellowship Match Outcomes in the U.S. From 2010 to 2017: Analysis of San Francisco Match.

PURPOSE: To describe applicant characteristics and outcomes associated with the ophthalmology fellowship match. DESIGN: Retrospective case-control study. METHODS: This study took place in San Francisco and matched data for ophthalmology fellowship applicants in the USA. The study population was registrants for the 2010-2017 ophthalmology fellowship match cycles. The match rate took place during the 8-year study period. Applicant characteristics were stratified by match status and factors associated with matching to ophthalmology fellowship positions. RESULTS: Between 2010 and 2017, most applicants (2,558/3,471; 73.7%) were matched into ophthalmology fellowship programs. No difference over time in the proportion of applicants that matched for fellowship was identified (P = .41). On average, ophthalmology residents who were matched into fellowships had higher step 1 (difference: 9; 99% confidence interval [CI]: 6.8-10.9; P < .001), step 2 (difference: 9.5; 99% CI: 7-12; P < .001), and step 3 (difference: 7.4; 99% CI: 5-9.7; P <.001) scores than those who did not match. Applicants who matched also had a greater number of application distributions (difference: 9.6; 99% CI: 7.9-11.2; P < .001), and ranked programs on the match list (difference: 6.2; 99% CI: 5.8-6.7; P < .001). Among applicants who matched, 15% matched at the same institute, 29% matched in the same state, and 45% matched in the same region. On multivariable analysis, factors associated with an increased likelihood of matching into an ophthalmology fellowship program included graduates from the US versus graduates from non-US residency programs (odds ratio [OR]: 2.09; 99% CI: 1.27-3.44; P <.001), increasing percentage of applications ranked (number of ranked programs and/or number of applications distributed) (OR: 1.02; 99% CI: 1.02-1.03; P < .001) as well as having ranked more programs (OR: 1.24; 99% CI: 1.17-1.31; P < .001). Medical graduate status outside of the US (OR: 0.58; 99% CI: 0.36-0.93; P < .001) was associated with decreased odds of matching for fellowship. CONCLUSIONS: From 2010 to 2017, approximately three-quarters of residents applying for an ophthalmology fellowship position matched. Factors associated with increased likelihood of matching included the applicant's graduating from a U.S. residency, graduating from a U.S. medical school, ranking more programs, and having a higher percentage of applications ranked (number of programs ranked by applicant and/or number of applications distributed). The information gained from this study may help applicants as they consider applying to fellowship programs.

Ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) for trabeculectomy.

BACKGROUND/AIMS: To develop, test and determine whether a surgical-competency assessment tool for simulated glaucoma surgery is valid. METHODS: The trabeculectomy ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) was assessed for face and content validity with a large international group of expert eye surgeons. Cohorts of novice and competent surgeons were invited to perform anonymised simulation trabeculectomy surgery, which was marked using the Sim-OSSCAR in a masked fashion by a panel of four expert surgeons. Construct validity was assessed using a Wilcoxon rank-sum test. Krippendorff's alpha was calculated for interobserver reliability. RESULTS: For the Sim-OSSCAR for trabeculectomy, 58 of 67 surgeons (86.6%) either agreed or strongly agreed that the Sim-OSSCAR is an appropriate way to assess trainees' surgical skill. Face validity was rated as 4.04 (out of 5.00). Fifty-seven of 71 surgeons (80.3%) either agreed or strongly agreed that the Sim-OSSCAR contents represented the surgical technique of surgical trabeculectomy. Content validity was rated as 4.00. Wilcoxon rank-sum test showed that competent surgeons perform better than novices (p=0.02). Interobserver reliability was rated >0.60 (Krippendorff's alpha) in 19 of 20 steps of the Sim-OSSCAR. CONCLUSION: The Sim-OSSCAR for trabeculectomy, a newly developed and validated assessment tool for simulation glaucoma surgery, has validity and reliability. It has the potential to play a useful role in ophthalmic surgical education.

Ophthalmic Simulated Surgical Competency Assessment Rubric for manual small-incision cataract surgery.

PURPOSE: To develop and test the validity of a surgical competency assessment tool for simulated small-incision cataract surgery (SICS). SETTING: Participating ophthalmologists contributed from 8 countries. DESIGN: Qualitative and quantitative development and evaluation of face and content validity of an assessment rubric, and evaluation of construct validity and reliability. METHODS: The SICS Ophthalmic Simulated Surgical Competency Assessment Rubric (Sim-OSSCAR) was developed and assessed for face and content validity by an international group of experienced ophthalmologists. Groups of novice and competent surgeons from 4 countries were recorded performing surgery, and masked assessments were performed by 4 expert surgeons, to determine construct validity and reliability. RESULTS: The Sim-OSSCAR for SICS was assessed by a panel of 12 international experts from 8 countries. In response to the question, "Do you think the OSSCAR represents the surgical techniques and skills upon which trainees should be assessed?," all respondents either agreed or strongly agreed. Face validity was rated as 4.60 (out of 5.0). The content was iteratively agreed to by the panel of experts; final content validity was rated as 4.5. Interobserver reliability was assessed, and 17 of 20 items in the assessment matrix had a Krippendorff α correlation of more than 0.6. A Wilcoxon rank-sum test showed that competent surgeons perform better than novices (P = .02). CONCLUSIONS: This newly developed and validated assessment tool for simulation SICS, based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric, has good face and content validity. It can play a role in ophthalmic surgical education.