University of Toronto's redesigned ophthalmology curriculum and eye dissection lab.

OBJECTIVE: To present a multifaceted approach to ophthalmology undergraduate medical education and to assess the efficacy of an eye dissection laboratory in enhancing medical student learning. DESIGN: Curriculum review, validation, and student feedback evaluations. PARTICIPANTS: Year 2 medical students enrolled in the University of Toronto's Doctor of Medicine Program. METHODS: Student feedback evaluations were compiled from the University of Toronto undergraduate medical education student surveys before 2012-2016 and following introduction of the redesigned foundations ophthalmology curriculum at the University of Toronto (2017-2018). Students who participated in the Eye Dissection Lab as part of the newly designed curriculum completed the pre- and postsession satisfaction and overall interest in ophthalmology questionnaires and a knowledge-based test. RESULTS: Analysis of 1640 student evaluations demonstrated an increase in ophthalmology curriculum rating following the launch of the foundations ophthalmology curriculum (p = 0.015). Among the 335 students who completed the eye dissection lab, there was a significant increase in the average scores for the satisfaction questionnaire, knowledge-based test, and level of interest in the field of ophthalmology from before and after the session, with improvements in scores noted in 91%, 42%, and 36% of the educational parameters of the participants, respectively (p < 0.001). CONCLUSIONS: The newly designed foundations ophthalmology curriculum and the eye dissection lab at the University of Toronto serve as effective means for enhancing ophthalmology teaching in medical schools across Canada.

Acute Angle Closure Following Implantable Collamer Lens for Myopia.

We report a case of acute angle closure with significantly elevated intraocular pressure 9 hours after implantation of a phakic intraocular lens for high myopia.

Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic after intravitreal injection.

IMPORTANCE: Treatment with intravitreal (IVT) injections has increased during the last several years as evidence has accumulated demonstrating the efficacy of anti-vascular endothelial growth factor agents in the treatment of neovascular age-related macular degeneration (AMD) and various retinal vascular diseases. Although IVT injections are generally safe, infectious endophthalmitis is a rare but devastating complication, and the risk of morbidity and vision loss from endophthalmitis is high. OBJECTIVE: To examine the change in antibiotic resistance of ocular surface flora with repeated prophylactic use of antibiotics after IVT injection for AMD. DESIGN AND SETTING: Prospective, nonrandomized cohort study in 2 tertiary academic hospitals. PARTICIPANTS: Patients 65 years and older with newly diagnosed AMD were recruited by 7 retinal specialists from July 1, 2010, through December 31, 2011. INTERVENTION: The study group received topical moxifloxacin hydrochloride for 3 days after each monthly IVT injection. MAIN OUTCOME MEASURE: Resistance to moxifloxacin and ceftazidime in cultured isolates at baseline and monthly for 3 months by change in minimal inhibitory concentration (MIC) of culture isolates was studied. RESULTS: The study group consisted of 84 patients, and the control group had 94 patients. In the study group, the baseline adjusted MIC increased (from 1.04 to 1.25 µg/mL; P = .01) as did the MIC for 50% of isolates (MIC50) (from 0.64 to 1.00 µg/mL) and the MIC for 90% of isolates (MIC90) (from 0.94 to 4.00 µg/mL). In both groups, the culture-positive rate did not change significantly when adjusted for baseline. No significant change was found in the MIC level, culture-positive rate, MIC50 level, and MIC90 level in the control group. Subgroup analysis found diabetes mellitus to be noncontributory to both the MIC and culture-positive rate. No endophthalmitis or adverse events were reported. CONCLUSIONS AND RELEVANCE: Repeated use of topical moxifloxacin after IVT injection significantly increases antibiotic resistance of ocular surface flora. We recommend that routine use of prophylactic antibiotics after IVT injection be discouraged. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01181713.

Long-term follow-up of 42 patients with small ciliary body tumors with ultrasound biomicroscopy.

PURPOSE: To establish the growth behavior of small ciliary body tumors in a relatively large cohort of patients over an extended period. DESIGN: Retrospective, noncomparative case series. METHODS: Ciliary body tumors less than 4 mm in size within the penetration power of ultrasound biomicroscopy (UBM) were included. Tumor height was assessed by ultrasound biomicroscopy. Tumor growth was defined as an increase in height of at least 20% from baseline, as measured on 2 consecutive UBM readings. The data were collected longitudinally, and a statistical analysis was performed. RESULTS: Forty-two patients were included in the study with a median follow-up of 9.0 years (range, 1.0 to 17.2 years). The median age was 59 years (range, 17 to 82 years). Median initial tumor height was 2.05 mm (range, 1.11 to 3.80 mm). The overall average rate of growth was 0.0014 mm per year (P = .68). The 5- and 10-year accumulative tumor growth rates were 12% and 29%, respectively. In the first 3 years after diagnosis, the growth rate of ciliary body lesions with an initial tumor thickness less than or equal to 2 mm was 0.054 mm per year (P = 0.0001); thereafter, tumor size appeared to stabilize. Tumors with an initial thickness greater than 2 mm showed a small but significant rate of regression of 0.0125 mm per year (P = 0.04). CONCLUSIONS: Most small tumors of the ciliary body show little growth over an extended period and can be managed conservatively without invasive diagnostic interventions. However, long-term follow-up is required. Indications for treatment include growth in height or lateral extension, extrascleral extension or the need for cataract surgery.

Small ciliary body tumors: ultrasound biomicroscopic assessment and follow-up of 42 patients.

PURPOSE: Detecting and following small tumors of the ciliary body is a particular challenge because of their location. Recently high-frequency ultrasound biomicroscopy (UBM) has been used to assist in this task. The aim of this study was to evaluate this subset of small ciliary body tumors through the use of UBM. DESIGN: Retrospective, noncomparative case series. METHODS: Forty-two patients with small ciliary body tumors (less than 4 mm) from our institution were included in the study with a median follow-up of 4.3 years. UBM was used to assess tumor characteristics including height, location, and internal and external features. The data were collected longitudinally, and statistical analysis was performed. RESULTS: Median initial tumor height was 2.05 mm (range 1.1 to 3.8 mm) as measured by UBM. By 5 years after diagnosis, five tumors (12%) exhibited growth. The overall mean growth rate was 0.026 mm per year (P = .00007). The most rapid period of growth was in the first year after diagnosis (growth rate 0.128 mm per year), after which the mean tumor size appeared to stabilize. CONCLUSIONS: UBM is a valuable tool for detecting and following small ciliary body tumors (less than 4 mm), as these lesions may go undetected by other methods. Despite the potential for local extension into the iris or choroid, few of the tumors in this study exhibited growth, suggesting that many of these tumors can be managed conservatively. UBM can be used to assess various internal tumor features; however, arriving at a specific diagnosis without histologic correlation is difficult.

Stereotactic radiotherapy in the treatment of juxtapapillary choroidal melanoma: preliminary results.

PURPOSE: To evaluate the preliminary results of stereotactic radiotherapy in the management of patients with juxtapapillary choroidal melanoma. METHODS & MATERIALS: A retrospective, consecutive case series of 28 patients with choroidal melanoma located within 2 mm of the optic nerve who were treated with stereotactic radiotherapy at Princess Margaret Hospital, Toronto, between October 1998 and May 2001. RESULTS: Median age was 62 years. Median tumor height was 4.6 mm and median maximum tumor diameter was 9.4 mm. The prescribed radiation dose was 70 Gy in five fractions over 10 days and median follow-up was 18.5 months. Posttreatment, 2 patients developed local tumor regrowth and 3 patients developed liver metastases. Actuarial rates of local tumor control, metastases, and survival at 18 months were 96%, 10%, and 94%, respectively. Actuarial rates of radiation-induced neovascular glaucoma, cataract, retinopathy, and optic neuropathy at 18 months were 20%, 29%, 30%, and 37%, respectively. A higher radiation dose to the lens was associated with an increased risk of cataract (p = 0.02). CONCLUSIONS: Stereotactic radiotherapy offers a noninvasive alternative to enucleation and brachytherapy in the management of juxtapapillary choroidal melanoma. However, further efforts are needed to optimize local tumor control and minimize radiation-induced complications.

Anterior chamber depth in plateau iris syndrome and pupillary block as measured by ultrasound biomicroscopy.

PURPOSE: To quantitatively analyze the anterior chamber depth (ACD) in patients with pupillary block and plateau iris syndrome. DESIGN: Retrospective, consecutive, observational case series. METHODS: We measured the ACD in 318 eyes of 318 patients who had been diagnosed by ultrasound biomicroscopy as having either pupillary block or plateau iris syndrome. Pupillary block patients were all preiridotomy and plateau iris patients were all postiridotomy. Anterior chamber depth was measured axially from the internal corneal surface to the lens surface using the ultrasound instrument's internal measuring capability. RESULTS: The mean ACD in patients with plateau iris syndrome (n = 181) was significantly smaller than the hypothesized normal ACD (2.04 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with pupillary block (n = 137) was also significantly smaller than the hypothesized normal ACD (2.17 +/- 0.30 mm vs 3.0 mm, P =.0001). The mean ACD in patients with plateau iris syndrome was significantly smaller than the ACD in patients with pupillary block (2.04 +/- 0.30 mm vs 2.17 +/- 0.30 mm, P =.001). CONCLUSIONS: Review of the literature suggests that patients with plateau iris have a normal or deeper axial ACD compared with pupillary block. This study found that the ACD associated with plateau iris syndrome is shallower than normal and also shallower than in pupillary block.

Outcomes of repeat penetrating keratoplasty and risk factors for graft failure.

PURPOSE: To compare repeat penetrating keratoplasty (PKP) with primary PKP with respect to patient characteristics, survival rates, and risk factors for graft failure. METHODS: Retrospective, consecutive, noncomparative case series of 116 patients who underwent repeat PKP and who were identified from a cohort of 696 PKPs performed by one surgeon over a 7.5-year period. RESULTS: Compared with patients who underwent primary PKP, regraft patients were 5 years older, had a higher rate of peripheral anterior synechiae (PAS), were more likely to require intraocular pressure (IOP)-lowering medications prior to surgery, were more likely to develop postoperative corneal neovascularization, were less likely to be phakic, and were more likely to undergo PKP in conjunction with a lens procedure. There was no difference between the two groups with respect to the distribution of original diagnoses leading to PKP and the rate of graft rejection. Two- and 5-year survival rates for repeat PKP were 63.9% and 45.6%, respectively. In a multivariate analysis, the original diagnosis leading to corneal transplantation, the presence of preoperative PAS, intraoperative anterior vitrectomy, and postoperative corneal neovascularization were identified as risk factors for graft failure in patients undergoing a regraft. CONCLUSIONS: Patients undergoing PKP for the first and second time share common risk factors for graft failure, namely, the original diagnosis leading to corneal transplantation, the presence of preoperative PAS, and the occurrence of postoperative corneal neovascularization. The difference in graft survival rates between the two groups can be partially explained on the basis of higher rates of the latter two risk factors among regrafts.