Postoperative Horner Syndrome After Lung Transplantation.

BACKGROUND: Horner syndrome arises from a disruption along the oculosympathetic efferent chain and can be caused by a variety of pathological and iatrogenic etiologies. We present 3 cases of postoperative Horner syndrome after bilateral lung transplantation. METHODS: The electronic health records of 3 patients with iatrogenic Horner syndrome after lung transplantation were examined, including notes from each patient's medical history, operative and postoperative records, and ophthalmology consultation results. A literature review was performed. RESULTS: All 3 of our patients displayed anisocoria and ptosis, symptoms consistent with Horner syndrome, and the patients from Cases 1 and 2 showed reversal of anisocoria after an application of topical apraclonidine. CONCLUSIONS: Ophthalmologists should be aware of the risk of Horner syndrome after lung transplantation.

Reversible Nyctalopia and Bilateral Optic Neuropathy due to Combined Vitamin A, Zinc, and Copper Deficiency: A Case Report.

Introduction: Combined nutritional deficiency is an uncommon cause of vision loss in the USA. Notably, vitamin A deficiency can produce nyctalopia but rarely causes bilateral central vision loss. The combination of these symptoms is unusual, although likely underreported. Case Presentation: We report an exceptionally rare case of bilateral central vision loss and nyctalopia caused by combined vitamin A, zinc, and copper deficiency, likely following bariatric surgery and alcohol use. Following mineral and vitamin supplementation, the patient's vision improved significantly and returned to baseline within 1 month. Vision loss resulting from this specific multicombination of vitamin and mineral deficiency has never been reported previously in the English-language ophthalmic literature. Conclusion: Given rising rates of bariatric surgery and alcohol use in the USA and abroad, clinicians should be aware that the combination of progressive nyctalopia and bilateral central vision loss may be produced by combined nutritional deficiency. Screening and supplementation of both vitamin and mineral deficiency may result in dramatic reversal of visual loss in such cases.

Rhino-orbital Mucormycosis Treated Successfully with Posaconazole without Exenteration.

Mucormycosis is a rare and often fatal opportunistic angioinvasive infection seen mostly in immunocompromised patients, such as those with diabetes mellitus, cancer, or renal failure. Ophthalmic manifestations of orbital mucormycosis include ocular pain, periocular oedema, visual loss, ophthalmoplegia, proptosis, and ptosis. Although therapy for orbital mucormycosis consists of maximally tolerated doses of antifungal agents (e.g., amphotericin B) and extensive surgical debridement, treatment remains ineffective in up to 20% of cases. We describe two patients with rhino-orbitalmucormycosis who were successfully treated with posaconazole in conjunction with intravenous (IV) amphotericin B and sinus surgical debridement. These cases highlight several unusual early manifestations of orbital mucormycosis, including disc oedema and amaurosis fugax, as well as the applicability of a new extended-spectrum antifungal agent in management of orbital zygomycosis.

Branch retinal artery occlusions after balloon sinuplasty due to formation of a traumatic pseudoaneurysm in the internal carotid artery and embolization treatment.

PURPOSE: To describe a case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after a balloon sphenoid sinuplasty procedure. OBSERVATIONS: A 62-year-old female with no significant past medical history underwent an elective outpatient balloon sinuplasty of the right frontal sinus and bilateral sphenoid sinuses. Shortly after the balloon sinuplasty device was inflated in the left sphenoid sinus, acute, severe, pulsatile bleeding was encountered from the posterior wall of the sinus. The patient underwent emergent catheter angiography and a traumatic pseudoaneurysm was noted in the left internal carotid artery that required endovascular embolization. After the procedures, the patient's visual acuity was 20/40 in the right eye and 20/200 in the left eye. The pupil exam revealed a left relative afferent pupillary defect. Visual field testing showed a central scotoma and an inferior nasal quadrant defect in the left eye. On fundus exam, there were multiple retinal emboli seen with ischemic retinal whitening in the left superior macular and superior temporal segments consistent with multifocal branch retinal artery occlusions in the left eye. CONCLUSIONS AND IMPORTANCE: The dilation of paranasal sinuses using a balloon instrument is a fairly new technique in the surgical management of chronic sinonasal inflammatory disease, and serious adverse effects have not been widely reported. To our knowledge, this is the first case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after balloon sinuplasty to be reported in the English language ophthalmic literature.

Impact of COVID-19 pandemic on ophthalmology medical student teaching: educational innovations, challenges, and future directions.

Graduate medical education (GME) in ophthalmology has faced and overcome many challenges over the past years, and 2020 has been a game-changer. Although the severe acute respiratory syndrome coronavirus pandemic disrupted medical education globally, ophthalmic educators rapidly transformed their curricula to novel and effective virtual learning formats. Thus, while the COVID-19 outbreak has been one of the most significant challenges faced in the history of medical education, it has also provided an impetus to develop innovative teaching practices, bringing with it unprecedented success in allowing medical students to continue their education in ophthalmology despite these challenges. We review and appraise novel educational interventions implemented by various institutions in response to the COVID-19 pandemic, highlighting their effectiveness, challenges and proposing future directions beyond the pandemic. Many of these innovations will persist even after the end of the pandemic because they have proven that face-to-face learning is not required for all aspects of the ophthalmic GME curriculum. As ophthalmic educators harness the power of educational technology it is critical that their novel educational initiatives are incorporated into competency-based curricula with assessments mapped to the competencies. Future research should focus on evaluating the impact of this transformation to virtual learning environments on student performances as well as implementing longitudinal assessment strategies for clinical competence in workplace-based practice.

Advancing ophthalmology medical student education: International insights and strategies for enhanced teaching.

Enhancing medical student education in ophthalmology can lead to improved eye health care delivery and patient outcomes across all primary care and specialty disciplines. There has been a resurgence of interest in delivering high-quality ophthalmic medical student education. This educational revival is both timely and topical. A general consensus has emerged that, rather than focusing solely on increasing teaching time, strategies are needed to focus on how to optimize the limited time allotted to ophthalmology. All physicians should be prepared to provide competent and confident ophthalmic care based on exciting innovations in ophthalmic curricula content, teaching methodologies, instructional design, learning objectives, and assessment methods. We provide an update on new and innovative ophthalmic teaching and learning practices. We critically appraise and summarize novel educational strategies from around the world that can be universally applicable in enhancing ophthalmology teaching in medical school curricula. It is our hope that, although there is marginalization of ophthalmology training, these strategies can be used to further improve teaching and learning in the limited time available in medical curricula and provide an impetus for further research and innovations in teaching ophthalmology to medical students.

Vertebrobasilar ischemia (VBI) related neuro-ophthalmic syndromes after routine activities involving hyperextension or rotation of the neck (hairdresser syndrome).

BACKGROUND: Vertebrobasilar insufficiency (VBI) after rotation or hyperextension of the neck during otherwise routine activities is uncommon "hairdresser syndrome" (HDS). We report three such cases presenting with neuro-ophthalmic complaints (Horner syndrome, ophthalmoplegia, and transient vision loss). METHODS: A retrospective review was performed of the electronic health records of three patients seen in the neuro-ophthalmology clinic of Houston Methodist Hospital with acute neuro-ophthalmological signs after neck hyperextension. A literature review was also performed. RESULTS: While various ischemic signs of VBI have been previously documented, to our knowledge, these are the first cases in the English ophthalmic literature to describe the presenting neuro-ophthalmologic signs of HDS. CONCLUSION: Clinicians should consider the possibility of neck hyperextension as a potential mechanism and precipitating event for acute neuro-ophthalmic presentations of VBI. Patients with a history of occupational (e.g., carpenter), recreational (e.g., bow hunter), or cosmetic (hairdresser) neck hyperextension (i.e., possible HDS) should undergo structural and vascular neuroimaging of both the head and neck (e.g., CT/CTA or MRI/MRA) to look for evidence of posterior fossa ischemia and/or vertebrobasilar lesion (e.g., occlusion, dissection, FMD, and pseudoaneurysm).

Shewanella algae keratitis.

A 75-year-old male with a right eye history of chronic dry eye syndrome, glaucoma status post tube shunt, and Fuchs dystrophy status post Descemet stripping endothelial keratoplasty followed by penetrating keratoplasty (PKP) presented with a 2.7 × 4.2 mm corneal ulcer, culture positive for Shewanella algae and Klebsiella oxytoca. A topical antibiotic regimen of gentamicin 14 mg/mL and vancomycin 50 mg/mL was administered according to culture sensitivities. There was concurrent use of loteprednol 0.5% (Lotemax Gel, Bausch and Lomb, Rochester, NY, USA) and later addition of erythromycin 0.5% ointment. The corneal ulcer improved with antibiotic therapy but was complicated by poor patient follow-up. Descemetocele formation prompted PKP in the right eye. The graft was successful and visual acuity improved from a low of light perception to maximum of 20/200 Snellen.

Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement.

The current resident selection process for ophthalmology has undergone little change over the last several years and remains highly dependent on the traditional selection factors (i.e., grades, honors, letters of recommendation, and an interview). Unfortunately, these selection factors have not been shown to be consistently predictive of future resident performance. In addition, the Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the USA and the current selection process does not directly recruit for these competencies. We propose an implementation strategy to re-engineer and improve the resident selection process in ophthalmology and potentially develop assessments that would be predictive of actual downstream resident performance that would encompass the ACGME related competencies. An intra-departmental Task Force for the ACGME Competencies reviewed a PubMed literature search regarding resident selection. A content expert (AGL) gleaned selected "good practices" from the literature review and summarized the results. Specific recommendations were reviewed for topicality to ophthalmology and where possible for feasibility, reliability, and validity. We summarize several good practices identified from the literature review and propose an implementation matrix for aligning the resident application process with the ACGME competencies that might include: using a standardized and consolidated academic score for the cognitive domains; converting the letter of recommendation format into a letter of evaluation; standardizing the letters of evaluation, including the "Dean's letter"; using behavior specific interview techniques with standardized questions; and developing a specialty based consensus for the selection of traits specific to ophthalmology that might predict success. The resident selection process for ophthalmology might be improved by implementation of specific good practices from the literature. Ophthalmology should strive to develop applicant selection tools that might be useful for predicting residency performance and that would align with the ACGME competency mandate for tools to predict future performance as a physician.

Teaching and assessing competency in retinal lasers in ophthalmology residency.

BACKGROUND AND OBJECTIVE: The Accreditation Council for Graduate Medical Education has mandated that residency programs teach and assess six specific competencies (ie, medical knowledge, patient care, communication and interpersonal skills, professionalism, practice-based learning, and systems-based learning). To the authors' knowledge, there is no standardized and widely used curriculum for teaching and assessing resident competencies in retinal lasers. METHODS: The pertinent literature on resident education in retinal lasers is reviewed and specific "good practices" for teaching and assessing laser competency are presented. RESULTS: Development and deployment of educational tools that teach and assess laser competency simultaneously; are reliable, reproducible, and valid; have low faculty time burden; and are affordable, generalizable, and fair are recommended. CONCLUSION: Retinal laser competency can be taught and assessed in ophthalmology residency training programs. Future research will be needed to provide evidence that these teaching and assessment tools produce improved educational and patient outcomes and provide verifiable, reliable, and valid evidence of resident competence in retinal lasers.

The Iowa ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency.

PURPOSE: To describe an ophthalmology wet laboratory (OWL) curriculum for residents in training. METHODS: Systematic literature review and selection of best practices for use in the OWL learning plan from a single academic ophthalmology program. RESULTS: A pretest and posttest of cognitive skills, objective wet laboratory structured assessment of skill and technique, and summative global evaluation form were developed as part of a systematic OWL curriculum. CONCLUSION: The Iowa OWL curriculum may form the basis for successfully utilizing the wet laboratory to teach and assess aspects of resident surgical competence in cataract surgery.

Teaching and assessing professionalism in ophthalmology residency training programs.

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.

Teaching and assessing systems-based competency in ophthalmology residency training programs.

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residency programs, including ophthalmology, teach and assess specific competencies, including systems-based learning. We review the pertinent literature on systems-based learning for ophthalmology and recommend specific "good practices" to manage the ACGME mandate. Tools are required that both teach and assess systems based learning competency simultaneously, that are reliable and valid, that have low faculty burden, and that are affordable, practical, and fair. Future research should provide evidence that these interventions produce improved educational and patient outcomes and show proof of competence in systems based learning among residents and clinicians in practice.

Structured journal club as a tool to teach and assess resident competence in practice-based learning and improvement.

PURPOSE: To describe the use of the journal club as a tool to teach and assess competency in practice-based learning (PBL) and improvement among residents in ophthalmology. DESIGN: Interventional case series. PARTICIPANTS: Ophthalmology residents. SETTING: Three academic ophthalmology residency programs in the United States. METHODS: A survey was performed of self-assessed skills in PBL among residents in ophthalmology training before and after the implementation of a structured review checklist during a traditional resident journal club. The survey had 5 domains, including (A) appraise and assimilate evidence, (B) read a journal article critically, (C) use a systematic and standardized checklist, (D) apply knowledge of study designs and statistical methods, and (E) maintain a self-documented written record of compliance. The respondents scored their ability (range, 1-5). RESULTS: The use of a structured journal club tool was associated with a statistically significant improvement in self-assessed ability in all 5 domains. CONCLUSIONS: Although validity, reliability, and long-term efficacy studies are necessary, the structured journal club is one method of teaching and assessing resident competency in PBL and improvement.

Teaching and assessing surgical competency in ophthalmology training programs.

BACKGROUND AND OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence. PATIENTS AND METHODS: An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence. RESULTS: "Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation. CONCLUSION: An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.

A systematic review of best practices in teaching ophthalmology to medical students.

Ophthalmic medical student education is a cornerstone to improving eye health care globally. We review the current state of the literature, listing barriers to potential best practices for undergraduate ophthalmology teaching and learning within medical curricula. We describe recent advances and pedagogical approaches in ophthalmic education and propose specific recommendations for further improvements and research. Future research should concentrate on developing teaching and learning innovations that may result in a more time- and resource-effective models for interactive and integrated learning. As well as demonstrating that a competency-based approach results not just in better eye health, but also improvements in patient care, education, and medical care in general. By optimizing teaching available through improved evidence-based education, the ultimate goal is to increase medical students' knowledge and produce graduates who are highly trained in eye examination skills, resulting in improved patient eye care through timely diagnosis, referrals, and treatment.

Using the Journal Club to teach and assess competence in practice-based learning and improvement: a literature review and recommendation for implementation.

The traditional journal club has historically been used to teach residents about critically reading and reviewing the literature in order to improve patient care. The Accreditation Council for Graduate Medical Education competencies mandate requires that ophthalmology residency programs both teach and assess practice-based learning and improvement. A systematically conducted review of the literature regarding the use of the journal club in resident medical education was performed to define specific recommendations for implementation of a journal club tool. Selected best practices for a successful journal club were gleaned from the existing medical literature. These include the following: 1) the use of a structured review checklist, 2) explicit written learning objectives, and 3) a formalized meeting structure and process. The journal club might prove to be an excellent tool for the assessment of competencies like practice-based learning which may be difficult to assess by other means. Future study is necessary to determine if journal club can improve educational outcomes and promote lifelong competence in practice-based learning.

Acute bilateral optic disk edema with a macular star figure in a 12-year-old girl.

A 12-year-old girl developed headaches and bilateral optic disk edema due to malignant hypertension. Optic disk edema in most of these cases is probably on the spectrum of ischemic optic neuropathy rather than increased intracranial pressure.