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.

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.

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.

Herpes Zoster Optic Neuropathy.

BACKGROUND: Herpes zoster optic neuropathy (HZON) is a rare manifestation of herpes zoster ophthalmicus (HZO). The aim of our study was to better characterize the clinical features, therapeutic choices, and visual outcomes in HZON. METHODS: A retrospective chart review was performed at multiple academic eye centers with the inclusion criteria of all eyes presenting with optic neuropathy within 1 month of cutaneous zoster of the ipsilateral trigeminal dermatome. Data were collected regarding presenting features, treatment regimen, and visual acuity outcomes. RESULTS: Six patients meeting the HZON inclusion criteria were identified. Mean follow-up was 2.75 months (range 0.5-4 months). Herpes zoster optic neuropathy developed at a mean of 14.1 days after initial rash (range 6-30 days). Optic neuropathy was anterior in 2 eyes and retrobulbar in 4 eyes. Other manifestations of HZO included keratoconjunctivitis (3 eyes) and iritis (4 eyes). All patients were treated with systemic antiviral therapy in addition to topical and/or systemic corticosteroids. At the last follow-up, visual acuity in 3 eyes had improved relative to presentation, 2 eyes had worsened, and 1 eye remained the same. The 2 eyes that did not receive systemic corticosteroids had the best observed final visual acuity. CONCLUSION: Herpes zoster optic neuropathy is an unusual but distinctive complication of HZO. Visual recovery after HZON is variable. Identification of an optimal treatment regiment for HZON could not be identified from our patient cohort. Systemic antiviral agents are a component of HZON treatment regimens. Efficacy of systemic corticosteroids for HZON remains unclear and should be considered on a case-by-case basis.

CPD? What happened to CME? CME and beyond.

Continuing medical education (CME) has been evolving into continuing professional development (CPD) and more recently into competency-based continuing professional development (CBCPD). We will describe this progression and the consequent changes in CPD programs developed by educators, appraise emerging challenges in CPD, propose strategies to overcome them and conclude by recommending research in CPD as the best way to consistently guide effective CPD programs and systems aligned with the public healthcare needs and expectations.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery. METHODS: An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. RESULTS: The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard 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 for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

Evaluation of Horner Syndrome in the MRI Era.

BACKGROUND: To identify the etiologies of adult Horner syndrome (HS) in the MRI era using a targeted evaluation approach and to assess the value and yield of targeted imaging. METHODS: A retrospective chart review was performed of 200 adult outpatients with HS, confirmed with cocaine eyedrop testing. Patients were divided into subgroups based on the presence or absence of symptoms and those who did or did not receive additional testing with hydroxyamphetamine drops. Imaging was obtained based on pharmacologic localization and/or clinical evaluation. The etiology of HS and the yield of imaging were determined in all subgroups. RESULTS: Imaging showed causative lesions in 24 of 179 (12.84%) imaged patients with HS, and 13 (69.0%) were determined "idiopathic." Of the patients who underwent testing with hydroxyamphetamine drops (132 patients), 86 had a postganglionic localization with an imaging yield of 8.1%, and 46 had preganglionic cause with an imaging yield of 21.7%. Fifty-three patients (26.5%) never noticed ptosis/anisocoria before examination, and the imaging yield in this subgroup was 2.8%. Eighteen of the 200 patients (9.0%) had serious pathology, including carotid artery dissection, brain, or neck mass, and 6 of these (31.6%) had acute symptoms and/or pain. CONCLUSIONS: HS is most often idiopathic with serious pathology being relatively infrequent. When determining etiology, the absence of symptoms is not predictive of the pathology. However, acute onset of symptoms and/or pain are possible indicators for serious pathology. Localizing the lesion using hydroxyamphetamine drops whenever obtainable and available is still an efficient way to target imaging evaluation.

Optic Neuropathy As the Initial Presenting Sign of N-methyl-d-aspartate (NMDA) Encephalitis.

A 52-year-old woman presented with painless vision loss for 3 months. She was in custody for allegedly robbing a bank and had recently been diagnosed with paranoid schizophrenia. She had 20/100 VA OD, a 2+RAPD, and optic atrophy. Extensive diagnostic workup including MRI, Fluorescein Angiography, Infectious Disease Panel, lumbar puncture, and leptomeningeal biopsy were unrevealing. Vision in her right eye declined to NLP and her left eye declined to 20/200 VA. Anti N-methyl-D-aspartate (NMDA) Autoimmune Encephalitis was diagnosed based on CSF serology and clinical suspicion. Her clinical course improved as she was treated with corticosteroids and rituximab.

Recovery of ocular motor cranial nerve palsy after herpes zoster ophthalmicus.

OBJECTIVE: To report the course of ocular motor cranial nerve palsy due to herpes zoster. METHODS: A retrospective chart review identified patients with ocular motor cranial nerve palsy occurring at the time of herpes zoster ophthalmicus. Patients were seen by a single neuro-ophthalmologist from 1994 to 2012. RESULTS: Twenty-one patients were identified; 3 were excluded because of incomplete follow-up. Nine (50%) had complete recovery and 8 (44%) had partial recovery but no diplopia in primary gaze (mean time = 10 weeks). One patient with complete ophthalmoplegia had persistent diplopia in primary position for recovery. CONCLUSION: Ophthalmoplegia secondary to herpes zoster ophthalmicus has good long-term prognosis for recovery.

Cat scratch neuroretinitis: the role of acute and convalescent titers for diagnosis.

Cat scratch neuroretinitis (CSN) is a clinical diagnosis supported by serological testing. We present 2 cases of CSN in which initial acute titers were negative or equivocal for Bartonella henselae while convalescent titers were shown to be positive. We report these cases to emphasize that a single acute negative titer is insufficient to exclude the diagnosis of CSN and that convalescent titers should be obtained in patients for whom there is a high clinical suspicion of the disease.

The ophthalmology surgical competency assessment rubric for lateral tarsal strip surgery.

PURPOSE: To produce an internationally valid tool to assess skill in performing lateral tarsal strip surgery. METHODS: A panel of 7 content experts adapted a previously published tool for assessing lateral tarsal strip surgery by using a modified Dreyfus scale of skill acquisition and providing behavioral descriptors for each level of skill in each category. The tools were then reviewed by 11 international content experts for their constructive comments. RESULTS: Experts' comments were incorporated, establishing face and content validity. CONCLUSIONS: The tool International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubric for Lateral Tarsal Strip Surgery has face and content validity. It can be used globally to assess lateral tarsal strip surgical skill. Reliability and predictive validity still need to be determined.

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.

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.

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.