Educational Impact Drives Feasibility of Implementing Daily Assessment in the Workplace.

Construct: Authors investigated the perspectives of stakeholders on feasibility elements of workplace-based assessments (WBA) with varying designs. Background: In the transition to competency-based medical education, WBA are taking a more prominent role in assessment programs. However, the increased demand for WBA leads to new challenges for implementing suitable WBA tools with published validity evidence, while also being feasible and useful in practice. Despite the availability of published WBA tools, implementation does not necessarily occur; a more fulsome understanding of the perspectives of stakeholders who are ultimately the end-users of these tools, as well as the system factors that both deter or support their use, could help to explain why evidence-based assessment tools may not be incorporated into residency programs. Approach: We examined the perspectives of two groups of stakeholders, surgical teachers and resident learners, during an assessment intervention that varied the assessment tools while keeping the assessment process constant. We chose diverse exemplars from published assessment tools that each represented a different response format: global rating scales, step-by-step surgical rubrics, and an entrustability scale. The primary purpose was to investigate how stakeholders are impacted by WBA tools with varying response formats to better understand their feasibility for assessment of cataract surgery. Secondarily, we were able to explore the culture of assessment in cataract surgery education including stakeholders' perceptions of WBA unrelated to assessment form design. Semi-structured interviews with teachers and a focus group with the residents enabled discussion of their perspectives on dimensions of the tools such as acceptability, demand, implementation, practicality, adaptation, and integration. Findings: Three themes summarize teachers' and residents' experiences with the assessment tools: (1) Feedback is the priority; (2) Forms informing coaching; and (3) Forcing the conversation. The tools helped to facilitate the feedback conversation by serving as a reminder to initiate the conversation, a framework to structure the conversation, and a memory aid for providing detailed feedback. Surgical teachers preferred the assessment tool with a design that best aligned with their approach to teaching and how they wanted to provide feedback. Orientation to the tools, combined with established remediation pathways, may help preceptors to better use assessment tools and improve their ability to give critical feedback. Conclusions: Feedback, more so than assessment, dominated the comments provided by both teachers and residents after using the various WBA tools. Our typical assessment design efforts focus on the creation or selection of a robust assessment tool according to good design and measurement principles, but the current findings would encourage us to also prioritize the coaching relationship and include efforts to design WBA tools to function as a mediator to augment teaching, learning, and feedback exchange within that relationship in the workplace.

Association between phosphodiesterase-5 inhibitors and nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: Use of phosphodiesterase-5 (PDE-5) inhibitors has been reported to be a risk factor for development of nonarteritic anterior ischemic optic neuropathy (NAION) in males, based largely on a number of case reports. The objective of our study was to determine whether men who use this class of medications are more likely than a matched control group to develop NAION. METHODS: A pharmacoepidemiological nested case-control study was used to examine the above association in a health claims database of physician diagnoses and prescription medication dispensing. Cases of NAION were matched with corresponding controls and correlated with the use of PDE-5 inhibitors. A conditional logistic regression model was used to estimate rate ratios for development of NAION with use of PDE-5 inhibitors. RESULTS: A total of 1,109 cases of NAION were found and matched to 1,237,290 controls identified within the database. Cases were more likely to have hyperlipidemia, diabetes, hypertension, myocardial infarction, and cerebrovascular accident in the year preceding their NAION. The adjusted rate ratio for any use of PDE-5 inhibitor in the year before the NAION was 1.01 (95% confidence interval [CI], 0.79-1.28); recent use of a PDE-5 inhibitor in the 30 days before the NAION also had no significant association, with an adjusted rate ratio of 0.96 (95% CI, 0.75-1.23). Results for individual PDE-5 inhibitors did not achieve statistical significance. CONCLUSIONS: Our results do not suggest any association between having a prescription filled for PDE-5 inhibitor medication and receiving a diagnosis code for NAION. This is consistent with other studies in the literature that have failed to elucidate a plausible mechanism by which these drugs might compromise circulation at the optic nerve head.

Trephination for canalicular obstruction: experience in 45 eyes.

PURPOSE: To evaluate efficacy of a trephination procedure for resolution of primary canalicular obstruction or obstruction secondary to failed dacryocystorhinostomy (DCR). METHODS: Retrospective review of patients in a single surgeon's practice who underwent trephination with Crawford tube insertion between 2001 and 2011, with a minimum follow-up period of 12 months. Indications for surgery included symptomatic patients either with primary canalicular obstruction or secondary obstruction after a failed DCR. RESULTS: Trephination was carried out on 45 eyes of 43 patients; 78% were female, and average age at trephination was 61.0 years (range 32 to 89). Thirty-two eyes had previous DCR (75% endonasal, 25% external); mean interval of trephination after DCR was 1.4 years (range 0.3-9.1). Crawford stent tubes were left in-situ in 2 patients; in the remainder, tubes were removed at a mean interval of 5.6 months (range 0.3-20.6). The vast majority of presenting canalicular obstructions were in the common canalicus (73%). Sixteen eyes (36%) underwent a single trephination, and 29 eyes (64%) required repeat intervention; of these, 16 eyes had DCR (3 endonasal, 13 external) and 13 eyes had either repeat trephination with stenting (10 eyes) or repeat stenting alone (3 eyes). When separated into those with primary versus secondary obstruction, re-operation rate was similar in both groups (63% versus 69%). No patients developed complications after trephination. CONCLUSIONS: Trephination is a simple and effective intervention for canalicular obstruction that allowed 64% of patients, through one or two procedures, to avoid the morbidity of DCR.

Acute Vision Loss as an Ophthalmic Complication of Dental Procedures.

Introduction: Acute vision loss has been previously described as a complication of dental procedures through a variety of mechanisms. The vision loss is typically transient, although permanent loss has been reported. Physicians, including ophthalmologists, typically lack formal education around dental procedures and may be uninformed about the risks to ocular or periocular structures as well as the types of complications that can arise. We aimed to summarize literature describing the various mechanisms by which dental procedures can lead to vision loss in order to equip physicians (primary care, emergency medicine, and ophthalmologists) with a better understanding of the mechanisms by which dental procedures can lead to acute vision loss. Methods: A literature search (1950 to 2020) identified articles discussing acute vision loss as a complication of dental procedures. Results: Dental procedures can result in a variety of ophthalmological conditions through ischemic, infectious, compressive, and anesthetic-related etiologies. Conclusions: While the majority of vision loss is transient and requires little management, there are vision and life-threatening complications that can arise and would require assessment and appropriate treatment.

Evaluation of ophthalmology clerkships across teaching sites at the University of British Columbia.

OBJECTIVE: Clerkship at the University of British Columbia (UBC) Medical School encompasses a variety of models: traditional rotation-based clerkship; distributed rotation-based clerkship at sites across the province; and a longitudinal integrated community clerkship. The purpose of this study was to: (i) Evaluate the undergraduate ophthalmology clerkship experience at UBC to compare outcomes and experiences across the various sites and models; and (ii) Apply educational theories to evaluation outcomes in order to improve curriculum design for clerkship programs. DESIGN: Cross-sectional evaluation of the ophthalmology clerkship program at UBC. METHODS: Using a logic model, we identified inputs, activities, and outputs of the ophthalmology clerkship experience at each site at UBC. Site directors and administrators were contacted for information regarding program curriculum and delivery, and outcomes were described using written exam and clinical assessment scores as well as student and instructor feedback (questionnaires with narrative responses). RESULTS: Site directors and administrators from all clerkship sites participated in the study. Clerkship experiences across all sites (rotation-based and integrated community clerkship) were found to be unique in contexts and clinical activities. There were no significant differences noted between outcomes in the rotation-based sites. CONCLUSION: Clerkship experiences can be delivered in various contexts and through varied clinical settings, yet provide an equivalent student learning experience. As longitudinal and distributed clerkship models gain traction in medical education around the world, there are lessons for undergraduate medical education both in ophthalmology and in other areas.

Correlation in Severity Between Glaucoma and Erectile Dysfunction.

PURPOSE: To examine the association between open-angle glaucoma and erectile dysfunction (ED), and investigate the correlation in severity between these 2 conditions. METHODS: Cross-sectional study with patient questionnaire and retrospective chart review. A total of 167 male patients over 40 years of age who attended ophthalmology clinic visits in Vancouver, British Columbia, Canada, participated in the study by providing written consent and responding to the survey. Patients with previous radiation or surgical prostate treatment were excluded, leaving final sample sizes of 61 glaucoma patients and 67 control patients. Presence and severity of ED was determined using a validated patient questionnaire (the International Index of Erectile Function questionnaire). Presence of glaucoma was based on previous clinical diagnosis, and severity was graded based on visual field index using a 30-2 visual field test with the SITA Standard protocol. Bivariate analysis examined the presence of ED in glaucoma patients versus controls. Risk factors including dyslipidemia, diabetes, hypertension, and smoking were adjusted for using multiple logistic regression. The association between glaucoma and ED severity was assessed with correlation and scatterplot analysis. RESULTS: Glaucoma was found to be a significant risk factor for ED in our population, with an odds ratio of 2.58 (95% confidence interval, 1.15-5.83). Severity of glaucoma and ED were significantly correlated (r=0.365, P=0.007). CONCLUSIONS: Our results demonstrate that there is a positive association between the presence of ED and the diagnosis of glaucoma and a positive association between the severity of ED and the severity of glaucoma.

Association between glaucoma, glaucoma therapies, and erectile dysfunction.

PURPOSE: To examine the association between (1) glaucoma and erectile dysfunction (ED) and (2) topical ß-blocker (BB) use and ED. METHODS: A comprehensive, province-wide database of physician visits and diagnoses and prescription drug dispensing was used to identify cases of ED (1380) and find corresponding controls (13,800). A conditional logistic regression model was used to estimate rate ratios for 2 main exposures: (1) diagnosis of glaucoma and (2) use of a prescription of a topical BB before the index date. A variety of risk factors were adjusted for. RESULTS: Cases were more likely to have coronary artery disease, chronic obstructive pulmonary disease, and diabetes. A crude rate ratio of the current diagnosis of ED in a population with at least 2 separate diagnoses of glaucoma was 1.34 and when adjusted for a number of variables (including oral BB use), this ratio was 1.37 [95% confidence interval (CI), 1.06-1.76]. Use of topical BB in the 30 days before the diagnosis of ED did not have a significant association with a diagnosis of ED, with crude and adjusted rate ratios of 1.05 and 1.10, respectively (95% CI, 0.61-1.99). Topical ocular prostaglandin use was also not associated with ED, with crude and adjusted rate ratios of 0.96 and 0.93, respectively (95% CI, 0.57-1.53). CONCLUSIONS: Our results confirmed an association between ED and glaucoma that cannot be attributed to topical BB use. Given that most cardiovascular and metabolic risk factors were adjusted for, further research in this area will be necessary to elucidate the nature of this association and potential causation.

Periocular mass lesions secondary to dermatologic fillers: report of 3 cases.

OBJECTIVE: To describe findings in patients who received dermal fillers and later developed peri-ocular mass lesions. DESIGN: Retrospective case series. PARTICIPANTS: Patients who presented with peri-ocular masses secondary to dermal filler use. METHODS: Retrospective chart review. RESULTS: Three patients with remote filler injection (hyaluronic acid and polyalkylimide), not volunteered on initial history, presented with peri-orbital swelling and/or inflammation that was suspicious in each case for more serious pathology. CONCLUSIONS: It is important for the injecting physician, the ophthalmologist, and the patient to recognize this complication to permit appropriate investigation and management.

Statin use and risk for cataract: a nested case-control study of 2 populations in Canada and the United States.

BACKGROUND: In current literature the association between statin use and cataracts is inconsistent and controversial. We sought to further examine the effect of statin use on the risk of cataract and need for surgical intervention in 2 North American populations. METHODS: This retrospective nested case-control study derived data from the British Columbia (BC) Ministry of Health databases from 2000-2007 and the IMS LifeLink database from 2001-2011 to form 2 patient cohorts. The BC cohort was comprised of female and male patients; 162,501 patients were matched with 650,004 control subjects. The IMS LifeLink cohort was comprised of male patients aged 40-85 years; 45,065 patients were matched with 450,650 control subjects. Patients with statin use for > 1 year before the initial ophthalmology visit were identified. Diagnosis and surgical management of cataract were followed. Conditional logistic regression models were used to analyze data. RESULTS: For the BC cohort, the crude rate ratio (RR) for use of any statin was 1.30, and the adjusted RR was 1.27 (95% confidence interval, 1.24-1.30). The adjusted RRs for each individual statin were all statistically significant. For the IMS LifeLink cohort, the crude RR for use of any statin was 1.13, and the adjusted RR was 1.07 (95% confidence interval, 1.04-1.10). CONCLUSIONS: This study demonstrates that statin use is significantly associated with cataract requiring surgical intervention. This relationship was consistent in both North American cohorts. Further assessment of this relationship is recommended, especially because of increased statin use and the importance of acceptable vision in old age when cardiovascular disease is common.

Optical coherence tomography-based measurement of drusen load predicts development of advanced age-related macular degeneration.

PURPOSE: To determine whether baseline drusen load, as measured using spectral-domain optical coherence tomography (SD OCT), is a useful predictor of development of advanced age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. METHODS: setting: Academic clinical practice. study population: All patients with non-neovascular AMD and no retinal pigment epithelial (RPE) atrophy at baseline who were seen between 2007 and 2012 in a single academic retina practice. A minimum of 1 year of follow-up was required. observation: Drusen load (area and volume) was assessed using automated SD OCT software algorithms. main outcome measure: RPE atrophy area, assessed using an automated SD OCT software algorithm, and the development of neovascular AMD. RESULTS: Eighty-three patients met the inclusion criteria with a mean age of 80 years and a mean follow-up time of 2.8 years. Repeated-measures analysis of variance showed an association between drusen area (P = .005) and drusen volume (P = .001) and the development of RPE atrophy. We also found an association between drusen area (P = .001) and drusen volume (P = .001) and the development of neovascular AMD. CONCLUSIONS: Drusen load, as measured using SD OCT, is associated with the development of RPE atrophy and neovascular AMD. SD OCT assessments of drusen load are simple and practical measurements that may be useful in stratifying the risk of developing advanced AMD. These measurements have potential applications in both routine clinical care and clinical trials.