Evaluation of ophthalmology residents' self-assessments and peer assessments in simulated surgery.

OBJECTIVE: To evaluate the accuracy of ophthalmology residents' self-assessment and peer assessment of surgical skills in a simulation setting. DESIGN: Simulation laboratory assessment. PARTICIPANTS: Ophthalmology residents novice to cataract surgery. METHODS: A modified International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric: Phacoemulsification structured assessment tool for simulated cataract surgery was established by conventional Delphi method. Residents completed 10 independent simulated surgeries that were video-recorded. Two experts graded the videos using the assessment tool. Participants performed self-assessment of their own 10 videos, and peer assessment of 10 of their peers' videos. RESULTS: Nine cataract surgery experts provided feedback and modifications for the assessment tool. Agreement for the first round of the Delphi method ranged from 55.56% to 100%. Second round agreement was 80% or greater for all answers. The final assessment tool comprised (i) 4 procedural items scored from 0 (not performed) to 7 (competent), and (ii) a global rating scale (GRS) requiring yes/no answers to 4 performance-related questions. Eight residents participated in the study. There was excellent expert inter-rater reliability intraclass correlation ((ICC) = 0.844, 0.875, 0.809, 0.844) and fair to excellent inter-rater reliability between expert and peer scores (ICC = 0.702, 0.831, 0.521, 0.423), but systematic disagreement (ICC = -0.428, -0.038) or poor inter-rater reliability (ICC = 0.298, 0.362) between expert and self-scores. There was poor agreement for all GRS questions (κ statistic < 0.40) except 2 comparisons. CONCLUSIONS: In the simulation setting, experts were able to reliably assess trainees' performance using the assessment tool. Participants demonstrated inconsistency in assessing their own skills; however, they were adequate at assessing their peers' overall performance.

Measuring intraocular antibodies in eyes treated with anti-vascular endothelial growth factor.

OBJECTIVE: To characterize the total intraocular aqueous humour antibody profiles in cases receiving anti-vascular endothelial growth factor (anti-VEGF) for retinal vascular disease compared with controls without retinal pathology. DESIGN: Cross-sectional. PARTICIPANTS: 93 aqueous humour samples: 22 eyes undergoing cataract surgery (controls) and 71 eyes receiving intravitreal injections (IVI) (cases) for macular edema or neovascularization. METHODS: Antibody isotyping of aqueous humour was performed using Milliplex MAP Human Isotyping Multiplex Assay. Cases and controls were compared for several outcome measures. RESULTS: The primary outcome measure was total mean antibody isotype concentration quantified in the aqueous humour. Secondary outcomes included comparing aqueous humour concentrations with visual acuity, number of IVI received, type of anti-VEGF agent injected, and persistence intra-/subretinal fluid post injection. Mean immunoglobulin M (IgM) concentrations in cases were 19-fold higher compared with controls. Aqueous immunoglobulin G (IgG)1,2,3,4 and immunoglobulin A (IgA) were 2-4-fold higher in cases compared with controls. Disease-specific trends were observed, with diabetic retinopathy (DR) eyes containing the highest amounts of aqueous antibodies. Total number of injections correlated with higher titres of IgG1 (p < 0.001), IgG2 (p < 0.009), and IgG3 (p < 0.001) in all cases analyzed with the strongest correlations seen in DR eyes (r = 0.77, p < 0.001). Presence of aqueous humour antibodies correlated with worse post-IVI best-corrected visual acuity; IgG1 (p < 0.01), IgG2 (p < 0.005), IgG3 (p < 0.01), and IgA (p < 0.003) in all cases analyzed, with the strongest correlations seen in DR eyes (r = 0.74, p < 0.001). CONCLUSIONS: Intraocular antibodies are present in the aqueous humour at significantly higher concentrations in eyes receiving IVIs for retinal vascular diseases compared with controls.

Intraocular calcidiol: Uncovering a role for vitamin D in the eye.

Vitamin D has emerged as a potentially important molecule in ophthalmology. To date, all ophthalmic data pertaining to vitamin D has been restricted primarily to tear and serum analysis in human patients. Considering the isolated nature of the eye, we sought to determine the presence of intraocular vitamin D in ocular disease. METHODS: 25-Hydroxyvitamin D3 (25(OH)D3) concentrations were measured in the eye and blood of 120 participants undergoing ophthalmic procedures. Ocular localization of the 1,25-dihydroxyvitamin D3-generating (CYP27B1) and deactivating (CYP24A1) hydroxylases was performed by immunohistochemistry. Gene expression of CYP27B1, CYP24A1 and VEGF-A was measured in eyes from patients with and without disease. RESULTS: 25(OH)D3 was quantified in 112 ocular samples. In 40 cataract patient samples, the average 25(OH)D3 concentration was 0.057 ng/mL, compared to 72 retinal disease patient samples, average of 0.502 ng/mL (p < 0.001). Intraocular 25(OH)D3 did not correlate with serum levels of 25(OH)D3. There was no difference between the level of 25(OH)D3 measured in the aqueous and vitreous humour. The vitamin D-specific CYPs 27B1 and 24A1, strongly localized to complementary regions of the ciliary body, retinal pigment epithelium and neural retina. Gene expression analysis confirmed retinal CYP27B1 correlated strongly with VEGF-A in eyes from diabetic patients (r = 0.92, p < 0.001). CONCLUSIONS: Our data confirms that vitamin D is present in the humours of the human eye and that local synthesis/degradation is possible via the ocular CYP27B1 and CYP24A1. This argues for a functional role for local vitamin D production and signaling in the eye and suggests that vitamin D may be an important intraocular mediator in disease pathogenesis.

Evaluating the efficacy of an educational ergonomics module for improving slit lamp positioning in ophthalmology residents.

OBJECTIVE: To characterize changes in body positioning while performing a standardized slit lamp examination after exposure to an educational module on ergonomics. DESIGN: Prospective interventional pilot study. PARTICIPANTS: Ten ophthalmology residents. METHODS: An educational module discussing ergonomic issues in ophthalmology was created. In a standardized examination lane, participants were recorded performing 3 trials of an indirect slit lamp examination of a volunteer patient, adjusting equipment as they saw fit. Participants were then sent the module and within 2 weeks repeated the trial process. Data were processed using biomechanical software to obtain the Rapid Upper Limb Assessment (RULA) injury risk score, elbow and shoulder joint reaction moments, neck and trunk flexion angles, and spinal curvature magnitudes. RESULTS: The RULA injury risk scores decreased after completion of the module (95% CI 2.10-2.77), indicating a lesser risk for injury to the resident. Shoulder flexion and elbow abduction moments also decreased (95% CI -3.2 to -1.5 and -0.44 to -0.04, respectively), suggesting a more neutral body posture. The trunk flexion angle increased after completion of the module (95% CI -5.1 to -1.6), signifying a more upright trunk posture; this was confirmed by the lumbar spine curvature, which flattened postmodule (95% CI 6.6-940). CONCLUSIONS: These results suggest a promising ability for an educational module to mitigate some injury risk in this population during indirect slit lamp examination. It also delineated some awkward postures that persisted despite the module. These results will be reintegrated into the module to optimize its educational utility.

Cyanoacrylate tissue adhesive on a polyglactin scaffold in strabismus surgery: a laboratory study.

BACKGROUND: The use of cyanoacrylate tissue adhesives in strabismus surgery has been variously successful, depending primarily on achieving adequate bond strength and minimizing extraocular muscle slippage. We investigate a novel approach to this problem, involving cyanoacrylate tissue adhesive on a polyglactin 910 scaffold as a means to secure extraocular muscle to the sclera for strabismus surgery. METHODS: In this experimental laboratory study, butyl-cyanoacrylate was used to fix a polyglactin 910 scaffold to the sclera of cadaver eyes. After allowing for polymerization, a force was applied to the mesh until the polyglactin-sclera bond failed. The maximum load (g) required for bond failure was recorded. The effects of surface area of the polyglactin 910 mesh as well as time required for cyanoacrylate tissue adhesive polymerization on bond strength were investigated. RESULTS: All combination of variables tested, except for experiments involving polyglactin 910 mesh that is 30 mm(2) with a polymerization time of 15 seconds or 30 seconds and polyglactin 910 mesh that is 40 mm(2) with a polymerization time of 15 seconds, achieved a bond strength that was significantly greater than those forces seen in a physiologic setting (P > 0.05). Increasing area or time resulted in increasing bond strength. Area and time were found to be independent variables. CONCLUSIONS: The cyanoacrylate tissue adhesive-derived polyglactin-sclera bond achieved a maximum load greater than those seen in a physiologic setting. Our novel approach demonstrates a clinically feasible alternative to traditional means for bonding muscle to sclera in strabismus surgery.

10-Year Framingham risk in patients with retinal vein occlusion: a systematic review and meta-analysis.

OBJECTIVE: Cardiovascular risk factors predispose individuals to retinal vein occlusions (RVOs). Yet, the future risk for development of cardiovascular disease in persons with RVOs is uncertain. We performed a literature review and meta-analysis of studies to determine the 10-year Framingham risk for individuals with RVO. METHODS: A literature search was performed in MEDLINE and EMBASE. Studies were eligible if they included subjects with RVO and presented data on age, sex, smoking status, systolic blood pressure, total cholesterol, and high-density lipoprotein. The 10-year Framingham risk was calculated. Sensitivity analysis was performed and hypothesis testing was carried out using the upper tail z test with α = 0.05 to compare the estimated Framingham risk in RVO patients with the risk in the general Canadian population. Subgroup meta-analysis was carried out by Cochrane Collaboration Review Manager 4.5 software (Cochrane IMS, Copenhagen, Denmark). RESULTS: A final list of 6 articles was included. The estimated 10-year Framingham risk score in subjects with RVO was 10.1% (95% CI 9.9-10.2). Sensitivity analysis found Framingham risk score to be greatest in male smokers. The Framingham risk in subjects with RVO was significantly greater than the general Canadian population. In a subgroup analysis, the 10-year risk was significantly greater in subjects with RVO compared with control subjects. CONCLUSIONS: Patients with RVO have an increased 10-year risk for cardiovascular disease. This risk is greatest for male smokers (high risk). These patients may benefit from therapy aimed at controlling their risk factors. All individuals with an increased Framingham risk should be warned about vision loss as a potential complication of systemic atherosclerotic disease.

Fetal hepatic calcifications: prenatal diagnosis and outcome.

OBJECTIVE: The purpose of this study was to provide information on the causes and postnatal outcomes of fetal liver calcifications that were detected by ultrasound imaging. STUDY DESIGN: Cases with fetal liver calcifications that were encountered between 1992 and 2001 were evaluated. A detailed fetal ultrasound imaging for associated abnormalities, maternal STORCH (syphilis, cytomegalovirus, herpesvirus 1 and 2, rubella, and Toxoplasma ) analysis, parvovirus serologic condition, and parental cystic fibrosis mutations analysis were performed; amniocentesis was offered in all cases. All infants who were born alive were examined and followed up. RESULTS: Sixty-one pregnant women with fetal liver calcifications were identified. Forty of 61 patients had additional fetal abnormalities; 21 of 61 cases of fetal liver calcifications were isolated; 11/61 patients (18%) had abnormal karyotypes (trisomy 13, 4 patients; trisomy 21, 2 patients; trisomy 18, 1 patient; monosomy X (45,X), 1 patient; 4p-, 22q+, and 8p+, 1 patient). Ten of 11 patients with abnormal karyotypes had other abnormalities that were found on ultrasound imaging. Two patients had intrauterine infection, one patient had cytomegalovirus, and one patient had parvovirus B19 infection. Eighteen of 40 patients underwent pregnancy termination, one fetus died in utero, one newborn infant died, and two infants had neurologic sequelae. Of 21 patients with isolated liver calcifications, one fetus had parvovirus B19 infection and one infant had trisomy 21. The remainder of the infants each had a good outcome. CONCLUSION: Fetal liver calcifications are relatively common. Isolated cases have a good prognosis after aneuploidy and infection have been ruled out. However, additional major abnormalities present a risk for chromosomal abnormalities, mainly trisomy 13.