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PURPOSE: To describe tumor response and cranial nerve function outcomes after administration of anti-PD-1 to patients with cutaneous squamous cell carcinoma (CSCC) with perineural spread to cranial nerves (CN) extending into the cavernous sinus. METHODS: Electronic patient records from a single institution were queried for patients with CSCC of the head and neck causing diplopia (ICD-10 H53.2) who were treated with anti-PD-1. Data extracted included demographics, duration of anti-PD-1 therapy, immune-mediated adverse reactions, tumor response per adapted RECIST v1.1, and changes in CN function and symptoms (e.g., pain). All patients were prescribed cemiplimab 350 mg IV q3 weeks. RESULTS: Four patients met inclusion criteria. They had varying degrees of pain and sensory deficits in branches of the trigeminal nerve (CN V). One, 2, 3 and 1 patients had baseline involvement of CN III, IV, VI and VII, respectively. MRI confirmed perineural cavernous sinus involvement in all patients. Duration of anti-PD-1 therapy ranged 15-60 weeks. All patients experienced an objective anti-tumor response to anti-PD-1; partial response n = 2, complete response n = 2. At a median follow-up of 22 months, responses were ongoing in all patients. All patients demonstrated improvement in ocular motility deficits and pain with resolution of symptoms in 3 and 1 patients, respectively. CONCLUSION: Administration of anti-PD-1 to patients with CSCC with perineural spread into the cavernous sinus can generate durable anti-tumor regressions and restore CN function, while sparing the morbidity associated with surgical resection and/or radiotherapy. Our findings add to emerging literature supporting this treatment approach for this patient population.
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Carcinoma de Células Escamosas , Seno Cavernoso , Neoplasias Cutáneas , Humanos , Carcinoma de Células Escamosas/patología , Resultado del Tratamiento , Neoplasias Cutáneas/patología , Seno Cavernoso/patología , Estudios Retrospectivos , DolorRESUMEN
OBJECTIVES: The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. DESIGN: A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. SETTING: Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. PATIENTS: Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). CONCLUSIONS: The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.
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Cuidados Críticos , Respiración Artificial , Humanos , Niño , Adolescente , Recién Nacido , Lactante , Preescolar , Reino Unido/epidemiologíaRESUMEN
Mpox is an emerging zoonotic infection with potentially severe ocular and periocular consequences, particularly in immunocompromised patients. This report summarizes 2 cases of fulminant mpox presenting in patients with AIDS. In the first case, confluent lesions resulted in orbital compartment syndrome and total eyelid necrosis. In the second case, eyelid involvement was accompanied by corneal melt and perforation. Despite aggressive medical and surgical treatment, both patients developed permanent loss of vision and ultimately expired.
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Mpox , Humanos , Cara , PárpadosRESUMEN
Acellular porcine urinary bladder matrix promotes wound healing and is also used to stimulate hair growth. A 64-year-old female presented with acute-onset OD pain and decreased visual acuity after subcutaneous injection of acellular porcine urinary bladder matrix at the hairline. Fundus examination revealed multiple emboli at retinal arcade branch points, and fluorescein angiography demonstrated corresponding areas of peripheral nonperfusion. Two weeks later, external examination revealed new swelling of the right medial canthus without erythema or fluctuance, which was felt to possibly represent recruitment of vessels after occlusion in the facial vasculature. At 1-month follow up, visual acuity of the OD improved with resolution of right medial canthal swelling. Fundus examination was normal with no visible emboli. Herein, the authors present a case of retinal occlusion and medial canthal swelling following injection of acellular porcine urinary bladder matrix for hair restoration, which to the authors knowledge has not been previously reported.
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Aparato Lagrimal , Oclusión de la Arteria Retiniana , Femenino , Porcinos , Animales , Oclusión de la Arteria Retiniana/diagnóstico , Oclusión de la Arteria Retiniana/etiología , Vejiga Urinaria , Angiografía con Fluoresceína , CabelloRESUMEN
PURPOSE: To characterize demographics and trends in oculoplastics-related emergency department (ED) visits. METHODS: The authors conducted a retrospective, multiyear study of the nationwide ED sample database. The nationwide ED sample was queried for oculoplastics-related International Classification of Disease-ninth revision codes identified from a comprehensive list and categorized based on anatomic location, urgency, and trauma status. Demographics, clinical characteristics, procedure requirement, and cost data were analyzed. Variables associated with inpatient admission were assessed using univariate and multivariate logistic regression. RESULTS: The authors identified an estimated 4.2 million ED visits in the United States with oculoplastics-related primary diagnoses, of which pathology was 80.8% eyelid/adnexal, 17.4% orbital, and 1.74% lacrimal. Overall, 31.3% of the visits were deemed to be nonurgent. Orbital pathology was more likely to be caused by trauma (70.6%), to be urgent (98.0%), and to require a procedure (45.6%) (p < 0.001). While less than 5% of all patients required hospitalization, predictors for inpatient admission were urgent diagnoses (odds ratio, 14.9; CI, 13.7-16.1), presentation to a level 1 trauma center (odds ratio, 3.19; CI, 2.7-3.79), and presence of orbital pathology (odds ratio, 6.09; CI 5.73-6.47). Incidence of ED visits decreased in all categories; however, total inflation-adjusted charges increased. CONCLUSIONS: Over half of oculoplastics-related ED visits are for trauma, with orbital pathology being less common but requiring a high level of care. Although trends show a potentially decreasing incidence of oculoplastics-related ED visits, increasing costs and high proportion of nonurgent visits pose an opportunity for mitigating periocular trauma and increasing outpatient access to care, respectively.
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Servicio de Urgencia en Hospital , Hospitalización , Bases de Datos Factuales , Humanos , Incidencia , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: To present a protocol for audiologic monitoring in the setting of teprotumumab treatment of thyroid eye disease, motivated by 4 cases of significant hearing loss, and review the relevant literature. METHODS: Cases of hearing loss in the setting of teprotumumab were retrospectively elicited as part of a multi-institutional focus group, including oculoplastic surgeons, a neurotologist and an endocrinologist. A literature review was performed. RESULTS: An aggregate of 4 cases of teprotumumab-associated hearing loss documented by formal audiologic testing were identified among 3 clinicians who had treated 28 patients. CONCLUSIONS: Teprotumumab may cause a spectrum of potentially irreversible hearing loss ranging from mild to severe, likely resulting from the inhibition of the insulin-like growth factor-1 and the insulin-like growth factor-1 receptor pathway. Due to the novelty of teprotumumab and the lack of a comprehensive understanding of its effect on hearing, the authors endorse prospective investigations of hearing loss in the setting of teprotumumab treatment. Until the results of such studies are available, the authors think it prudent to adopt a surveillance protocol to include an audiogram and tympanometry before, during and after infusion, and when prompted by new symptoms of hearing dysfunction.
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Anticuerpos Monoclonales Humanizados , Pérdida Auditiva , Pérdida Auditiva/inducido químicamente , Pérdida Auditiva/diagnóstico , Humanos , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
In-situ hybridization provides a convenient and reliable method to detect human papillomavirus (HPV) infection in formalin-fixed paraffin-embedded tissue. Cases of conjunctival papillomas, conjunctival intraepithelial neoplasia (CIN), conjunctival carcinoma in situ (cCIS), and invasive squamous cell carcinoma (SCC), in which low-risk (LR) and/or high-risk (HR) HPV types were evaluated by RNA or DNA in-situ hybridization, were retrospectively identified. LR HPV types were frequently detected in conjunctival papillomas (25/30, 83%), including 17/18 (94%) with RNA probes, compared to 8/12 (75%) with DNA probes. None of the CIN/cCIS or SCC cases were positive for LR HPV by either method. HR HPV was detected by RNA in-situ hybridization in 1/16 (6%) of CIN/cCIS cases and 2/4 (50%) of SCC cases, while DNA in-situ hybridization failed to detect HPV infection in any of the CIN/cCIS lesions. Reactive atypia and dysplasia observed in papillomas was generally associated with the detection of LR HPV types. Collectively, our findings indicate RNA in-situ hybridization may provide a high-sensitivity approach for identifying HPV infection in squamous lesions of the conjunctiva and facilitate the distinction between reactive atypia and true dysplasia. There was no clear association between HPV infection and atopy in papillomas or dysplastic lesions.
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Alphapapillomavirus , Carcinoma in Situ , Carcinoma de Células Escamosas , Neoplasias de la Conjuntiva , Papiloma , Infecciones por Papillomavirus , Alphapapillomavirus/genética , Carcinoma in Situ/diagnóstico , Carcinoma de Células Escamosas/patología , Conjuntiva/patología , Neoplasias de la Conjuntiva/diagnóstico , Neoplasias de la Conjuntiva/genética , ADN Viral/genética , Humanos , Papiloma/complicaciones , Papiloma/patología , Papillomaviridae/genética , ARN , Estudios RetrospectivosRESUMEN
PURPOSE: To present the application of computer-assisted surgery (CAS) in pre-operative planning, intra-operative navigation, and post-operative assessment as an adjunct tool in orbital surgery. METHODS: An IRB-approved, retrospective review was performed to identify patients who had undergone orbital surgery by a single surgeon from July 2013 to December 2019 with attention to pre-operative virtual surgical planning, intra-operative navigation, and post-operative assessment. The reasons and methods of CAS use were classified. RESULTS: The use of computer-assisted technologies was identified in 91 cases out of 464 orbital surgeries (19.6%). This included 23 (25.3%) orbital decompression surgeries, 39 (42.9%) fracture repairs, and 25 (27.5%) orbital tumors. In all cases, pre-, intra-, and post-operative CAS allowed for increased operative efficiency and safety with good outcomes. CONCLUSIONS: Use of CAS in orbital surgery can allow for complex radiographic analysis and in select cases is a great tool to add to the orbital surgeon's armamentarium.
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Fracturas Orbitales , Neoplasias Orbitales , Procedimientos de Cirugía Plástica , Cirugía Asistida por Computador , Humanos , Órbita/diagnóstico por imagen , Órbita/cirugía , Fracturas Orbitales/diagnóstico por imagen , Fracturas Orbitales/cirugía , Neoplasias Orbitales/diagnóstico por imagen , Neoplasias Orbitales/cirugía , Procedimientos de Cirugía Plástica/métodosRESUMEN
Late-onset orbital hemorrhage is a rare complication of alloplastic implant use in orbital wall reconstruction following trauma. The authors report 3 patients with chocolate cysts presenting 3 to 9 years after orbital fracture repair with porous polyethylene implants. All patients were managed by implant removal and evacuation of cyst contents. Complete excision of the cyst was performed in 1 patient, while partial excision of the capsule was performed in 2 patients. Improvement of symptoms associated with the mass effects of the cyst was noted after surgical intervention. The authors also report the first case of orbital volume expansion from a chocolate cyst associated with a nonbarriered porous polyethylene implant. Delayed hemorrhage with capsule formation, although extremely rare, is a possible complication following orbital fracture repair with porous polyethylene implants.
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Chocolate , Quistes , Fracturas Orbitales , Implantes Orbitales , Quistes/etiología , Quistes/cirugía , Humanos , Fracturas Orbitales/cirugía , Polietileno , Porosidad , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Floppy eyelid syndrome is a disorder in which the tarsal plate is easily distensible and is currently treated with conservative or surgical measures. Human tarsal plate contains type I collagen, which is crosslinked in corneal tissue as a treatment for keratoconus. We hypothesized that collagen crosslinking would similarly stiffen tarsal plate tissue and investigated this in porcine and human tarsal plate specimens. METHODS: Riboflavin-sensitized porcine and human tarsus samples were irradiated with ultraviolet-A light. Porcine experiments were analyzed with gross photographs, anterior segment optical computed tomography (AS-OCT) imaging, and tensile testing. A prospective study of human tarsus was performed on samples from patients undergoing wedge resection for floppy eyelid syndrome and was analyzed with AS-OCT and tensile testing. RESULTS: 73 porcine adnexa and 9 patients (16 eyelids) who underwent wedge excision were included in the study. Grossly, greater stiffness was observed in crosslinked porcine tissue. AS-OCT imaging in porcine tissue showed a distinct hyperreflective band in crosslinked specimens whose area and intensity increased with longer treatment time (P = 0.003); this band was also visible in crosslinked human specimens. Tensile testing was performed, but results were not statistically significant. CONCLUSIONS: AS-OCT imaging, which has not been previously described for tarsal plate, showed a characteristic change in crosslinked porcine and human specimens. Tissue stiffness was increased grossly, but changes in tensile properties were not statistically significant. Further study is warranted to determine relevance as a potential treatment for floppy eyelid syndrome.
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Colágeno Tipo I/metabolismo , Reactivos de Enlaces Cruzados , Enfermedades de los Párpados/tratamiento farmacológico , Párpados/metabolismo , Fármacos Fotosensibilizantes/uso terapéutico , Riboflavina/uso terapéutico , Adulto , Animales , Enfermedades de los Párpados/diagnóstico por imagen , Enfermedades de los Párpados/metabolismo , Párpados/diagnóstico por imagen , Humanos , Estudios Prospectivos , Porcinos , Resistencia a la Tracción , Tomografía de Coherencia Óptica , Rayos UltravioletaRESUMEN
BACKGROUND: This study explored the implementation of Chicago Urban Resiliency Building (CURB), a randomized clinical trial designed as an Internet-based primary care depression prevention intervention for urban African American and Latino adolescents. METHODS: We utilized a mixed methods analysis to explore four aims. First, we estimated the percent of at-risk adolescents that were successfully screened. Second, we examined clinic site factors and performance. Third, primary care providers (n = 10) and clinic staff (n = 18) were surveyed to assess their knowledge and attitudes about the intervention. Fourth, clinic staff (nursing and medical assistant) interviews were analyzed using thematic analysis to gather perspectives of the implementation process. RESULTS: We found that the estimated percent of at-risk adolescents who were successfully screened in each clinic varied widely between clinics with a mean of 14.48%. Daily clinic communication was suggestive of greater successful screening. Feasibility of screening was high for both primary care providers and clinic staff. Clinic staff exit interviews indicated the presence of community barriers that inhibited successful implementation of the intervention. CONCLUSION: This study shares the challenges and successes for depression screening and implementing Internet-based mental health interventions for urban racial/ethnic minority adolescents in primary care settings.
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Negro o Afroamericano/psicología , Depresión/diagnóstico , Depresión/prevención & control , Hispánicos o Latinos/psicología , Internet , Grupos Minoritarios/psicología , Atención Primaria de Salud/métodos , Adolescente , Adulto , Anciano , Actitud del Personal de Salud , Chicago , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Desarrollo de Programa , Factores de Riesgo , Población UrbanaRESUMEN
PURPOSE: In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma. METHODS: A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity. RESULTS: Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026). CONCLUSIONS: The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.
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Fracturas Orbitales/patología , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Órbita/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
PURPOSE: To evaluate the usage of preoperative digital anatomic implant evaluation in internal orbital fractures. METHODS: An IRB-approved review of cases of orbital fracture repair was conducted and cases where digital implant modeling was performed were selected for comprehensive review. The surgical time of these cases was also compared with surgeon and implant matched controls. RESULTS: A total of 25 patients and 26 orbits underwent preoperative virtual fitting and were reviewed. There were no complications or revision surgeries needed. Postoperative assessment demonstrated accuracy to the preoperative target with an average maximum deviation of 1.9 mm. CONCLUSIONS: Preoperative digital fracture assessment, implant manufacturer and size selection, and virtual cutting guide creation provides additional tools for orbital surgeons to achieve anatomic restoration without significant differences in operating time.
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Órbita/cirugía , Fracturas Orbitales/cirugía , Implantes Orbitales , Procedimientos de Cirugía Plástica/métodos , Ajuste de Prótesis/métodos , Cirugía Asistida por Computador/métodos , Interfaz Usuario-Computador , Adolescente , Adulto , Femenino , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Órbita/diagnóstico por imagen , Fracturas Orbitales/diagnóstico , Diseño de Prótesis , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
BACKGROUND: Medical educators, residents and administrators have increasing access to a large quantity of electronic resources. This content can augment and improve our teaching methods but can be difficult to consolidate and present. A multitude of electronic learning management systems are available to help organize and serve this content though never with small residency programs as the target userbase. As our residency program in Ophthalmology looked to consolidate our electronic resources and update our education methods, we evaluated and built an electronic learning management platform. RESULTS: Faculty were interviewed to determine features they would find useful in curriculum management system and then various systems were investigated for features, cost and ease of use. CONCLUSIONS: Our solution has been both cost-effective and successful. Resident satisfaction is high and faculty utilization has been increasing. We present many customizations that increased success. Consideration of the specific needs of a program is paramount to choosing a cost effective solution that will be well received.
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Internado y Residencia/métodos , Oftalmología/educación , Entrenamiento Simulado , Curriculum , Evaluación Educacional , Humanos , Internado y Residencia/normas , Enseñanza , Interfaz Usuario-ComputadorRESUMEN
PURPOSE: To determine the exposure rate after enucleation using the smooth surface tunnel (SST) and SST-EZ porous polyethylene (PP) orbital implants (Stryker Kalamazoo, MI, U.S.A.). METHODS: The authors performed an institutional review board-approved retrospective review of 150 consecutively placed SST and SST-EZ PP implants after enucleation. Patient records were reviewed for comorbidities, surgical details, follow-up length, and presence of implant exposure. All prior published studies on porous orbital implant insertion were reviewed, and the exposure rate for patients undergoing enucleation with primary implant insertion was studied for comparison. RESULTS: Of the 150 implants, 30 were excluded due to follow up of less than 8 weeks. Of the remaining 120 implants, 4 (3.3%) became exposed during the follow-up period (mean, 2.1 years), 2 of which were in children who underwent chemotherapy for retinoblastoma. The authors calculated a 7.1% exposure rate for all porous implant materials placed primarily after enucleation from 58 previously published studies. CONCLUSIONS: The SST and SST-EZ PP implants are well tolerated when placed at the time of enucleation. The theoretical advantage of a smooth anterior surface may indeed lead to a lower rate of exposure compared with standard unwrapped porous materials as demonstrated by the relatively low exposure rate using this implant.
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Enucleación del Ojo , Implantes Orbitales , Polietileno , Complicaciones Posoperatorias , Materiales Biocompatibles Revestidos , Oftalmopatías/cirugía , Femenino , Humanos , Lactante , Persona de Mediana Edad , Porosidad , Implantación de Prótesis , Estudios RetrospectivosRESUMEN
The National Confidential Enquiry into Patient Outcome and Death reviewed the barriers and facilitators in the process of the transition of children and young people with chronic health conditions into adult health services. The report focuses on five issues - developmentally appropriate healthcare, the involvement of children and young people and their parents or carers in transition planning, communication and coordination of care, the organisation of transition services and leadership - and makes recommendations for practice.
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Comunicación , Liderazgo , Adolescente , Adulto , Niño , Humanos , Enfermedad CrónicaRESUMEN
The National Confidential Enquiry into Patient Outcome and Death reviewed the quality of care provided to adults who presented to hospital following an epileptic seizure. Clinical and organisational changes are highlighted that aim to improve patient care and outcomes.
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Epilepsia , Convulsiones , Adulto , Humanos , Epilepsia/terapia , Hospitales , Convulsiones/terapiaRESUMEN
The dacryocystorhinostomy procedure creates a direct passageway between the lacrimal sac and nasal cavity, bypassing any nasolacrimal duct obstruction. Use of a continuous positive airway pressure device after dacryocystorhinostomy can cause nasolacrimal air regurgitation. Here, we report a case of air regurgitation after dacryocystorhinostomy that was successfully treated with placement of a Mini Monoka device, a silicone stent used in nasolacrimal surgery to prevent closure of the passageway, in a patient using a continuous positive airway pressure machine. Following the procedure, the patient was able to resume use of her continuous positive airway pressure device. CITATION: Srivatsan S, Mirza M, Imayama I, Setabutr P, Mahoney NR. Use of a nasolacrimal stent to treat air regurgitation after dacryocystorhinostomy in a patient using a continuous positive airway pressure device. J Clin Sleep Med. 2023;19(12):2123-2124.
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Dacriocistorrinostomía , Obstrucción del Conducto Lagrimal , Conducto Nasolagrimal , Femenino , Humanos , Dacriocistorrinostomía/métodos , Conducto Nasolagrimal/cirugía , Obstrucción del Conducto Lagrimal/terapia , Presión de las Vías Aéreas Positiva Contínua , StentsRESUMEN
BACKGROUND/AIMS: To assess surgical patterns in ophthalmology by subspecialty in the USA. METHODS: Ophthalmic surgeons were categorised as comprehensive/subspecialist based on billed procedures in the 2017-2018 Medicare Provider Utilization and Payment Data. Poisson regression models assessed factors associated with physicians performing surgeries in the core domain (eg, cataract extractions) and subspecialty domain. Models were adjusted for provider gender, time since graduation, geographical region, practice setting and hospital affiliation. RESULTS: There were 10 346 ophthalmic surgeons, 74.7% comprehensive and 25.3% subspecialists. Cataract extractions were performed by 6.0%, 9.9%, 21.0%, 88.1% and 95.3% of specialists in surgical retina, neuro-ophthalmology/paediatrics, oculoplastics, glaucoma and cornea, respectively. Retina specialists were more likely to perform cataract surgery if they were 20-30 or>30 years in practice (relative risk: 2.20 (95% CI: 1.17 to 4.12) and 3.74 (95% CI: 1.80 to 7.76), respectively) or in a non-metropolitan setting (3.78 (95% CI: 1.71 to 8.38)). Among oculoplastics specialists, male surgeons (2.71 (95% CI: 1.36 to 5.42)), those in practice 10-20 years or 20-30 years (1.93 (95% CI: 1.15 to 3.26) and 1.91 (95% CI: 1.11 to 3.27), respectively) and in non-metropolitan settings (3.07 (95% CI: 1.88 to 5.02)) were more likely to perform cataract surgery. Only 26 of the 2620 subspecialists performed surgeries in two or more subspecialty domains. CONCLUSIONS: There is a trend towards surgical subspecialisation in ophthalmology in the USA whereby some surgeons focus their surgical practice on subspecialty procedures and rarely perform surgeries in the core domain.