Ophthalmology Resident Oculofacial Surgery Case Exposure: An ACGME Case Log Analysis.

PURPOSE: The authors quantified trends in resident oculofacial surgery exposure between 2009 and 2018, reviewed specific procedure volume, and correlated procedure volume with program characteristics. METHODS: The authors requested de-identified case logs of residents graduating US ophthalmology residency programs in 2018 from all 118 programs. Current Procedural Terminology codes of all oculofacial procedures were analyzed. Current Procedural Terminology codes were grouped into 25 unique categories that the authors created in addition to the 11 Accreditation Council for Graduate Medical Education categories. RESULTS: One hundred and sixty-six of 488 (34%) US ophthalmology residents graduating in 2018 provided case logs (32.2% of programs). According to Accreditation Council for Graduate Medical Education case logs, residents graduating in 2018 completed significantly fewer eye removal/implant procedures, lacrimal surgeries, "other orbital" procedures, entropion/ectropion repairs, and temporal artery biopsies as primary surgeon than residents graduating in 2009, yet significantly more eyelid laceration repairs, chalazion excisions, tarsorrhaphies, ptosis repairs, and blepharoplasty/reconstruction procedures ( p < 0.05). No difference was found between the total number of oculofacial cases between 2009 and 2018 ( p = 0.051). The most frequently logged procedure per resident in the sample was blepharoplasty/reconstruction (17.2 ± 15) followed by "other oculoplastic" (12.7 ± 10.6). The least commonly performed procedures included temporal artery biopsy (1.5 ± 2.2) and "other orbital" (1.9 ± 3.1). Program size, location, and presence of oculofacial fellowship program all impacted case volume. CONCLUSIONS: Oculofacial surgery has the second highest case number requirement for residents per Accreditation Council for Graduate Medical Education guidelines. However, resident exposure to oculofacial surgery cases greatly varies in each ophthalmology residency program.

The EmpaTeach intervention for reducing physical violence from teachers to students in Nyarugusu Refugee Camp: A cluster-randomised controlled trial.

BACKGROUND: School-based violence prevention interventions offer enormous potential to reduce children's experience of violence perpetrated by teachers, but few have been rigorously evaluated globally and, to the best of our knowledge, none in humanitarian settings. We tested whether the EmpaTeach intervention could reduce physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. METHODS AND FINDINGS: We conducted a 2-arm cluster-randomised controlled trial with parallel assignment. A complete sample of all 27 primary and secondary schools in Nyarugusu Refugee Camp were approached and agreed to participate in the study. Eligible students and teachers participated in cross-sectional baseline, midline, and endline surveys in November/December 2018, May/June 2019, and January/February 2020, respectively. Fourteen schools were randomly assigned to receive a violence prevention intervention targeted at teachers implemented in January-March 2019; 13 formed a wait-list control group. The EmpaTeach intervention used empathy-building exercises and group work to equip teachers with self-regulation, alternative discipline techniques, and classroom management strategies. Allocation was not concealed due to the nature of the intervention. The primary outcome was students' self-reported experience of physical violence from teachers, assessed at midline using a modified version of the ISPCAN Child Abuse Screening Tool-Child Institutional. Secondary outcomes included student reports of emotional violence, depressive symptoms, and school attendance. Analyses were by intention to treat, using generalised estimating equations adjusted for stratification factors. No schools left the study. In total, 1,493 of the 1,866 (80%) randomly sampled students approached for participation took part in the baseline survey; at baseline 54.1% of students reported past-week physical violence from school staff. In total, 1,619 of 1,978 students (81.9%) took part in the midline survey, and 1,617 of 2,032 students (79.6%) participated at endline. Prevalence of past-week violence at midline was not statistically different in intervention (408 of 839 students, 48.6%) and control schools (412 of 777 students, 53.0%; risk ratio = 0.91, 95% CI 0.80 to 1.02, p = 0.106). No effect was detected on secondary outcomes. A camp-wide educational policy change during intervention implementation resulted in 14.7% of teachers in the intervention arm receiving a compressed version of the intervention, but exploratory analyses showed no difference in our primary outcome by school-level adherence to the intervention. Main study limitations included the small number of schools in the camp, which limited statistical power to detect small differences between intervention and control groups. We also did not assess the test-retest reliability of our outcome measures, and interviewers were unmasked to intervention allocation. CONCLUSIONS: There was no evidence that the EmpaTeach intervention effectively reduced physical violence from teachers towards primary or secondary school students in Nyarugusu Refugee Camp. Further research is needed to develop and test interventions to prevent teacher violence in humanitarian settings. TRIAL REGISTRATION: clinicaltrials.gov (NCT03745573).

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

INTRODUCTION: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. METHODS: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. RESULTS: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. DISCUSSION: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. CONCLUSION: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.

Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition.

BACKGROUND: In 2015 the US President's Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90-90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). METHODS: We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. RESULTS: We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. CONCLUSIONS: This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.

Understanding the implications of the Sustainable Development Goals for health policy and systems research: results of a research priority setting exercise.

BACKGROUND: Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals. OBJECTIVES: To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals. METHODS: We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30-36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings. RESULTS: Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures. CONCLUSIONS: To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

Preventing violence against children in schools (PVACS): protocol for a cluster randomised controlled trial of the EmpaTeach behavioural intervention in Nyarugusu refugee camp.

BACKGROUND: We aim to test the effectiveness of the EmpaTeach intervention to prevent physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. EmpaTeach is a 10-week, 14-session, classroom management and cognitive-behavioural therapy-based intervention for groups of teachers for delivery by lay personnel in resource-constrained settings. METHODS: We will conduct a two-arm cluster randomized controlled trial (RCT) with parallel assignment and an approximately 1:1 allocation ratio. All primary and secondary schools in Nyarugusu will be invited to participate. Whole schools will be stratified according to whether they are Congolese or Burundian, and primary or secondary schools, then randomised to active intervention or wait-list control conditions via a public meeting with headteachers. We will collect survey data from n = 500 teachers and at least n = 1500 students before the intervention, soon after, and at least 6 months after the end of the intervention. The primary outcome measure will be students' self-reports of experience of physical violence from school staff in the past week, measured using a modified version of the International Society for the Prevention of Child Abuse and Neglect Screening Tool-Child Institutional at the first follow-up after the intervention. Secondary outcomes include emotional violence, depressive symptoms and educational test scores. Analysis will be intention to treat, using repeat cross-sectional data from individuals. DISCUSSION: If successful, the EmpaTeach intervention would represent one of a handful of proven interventions to reduce violence from teachers to students in any setting. IRC provides an immediate platform for scale up of the intervention via its current work in more than 40 conflict-affected countries. TRIAL REGISTRATION: NCT03745573 , registered November 19, 2018 at clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03745573 .

Identifying health policy and systems research priorities for the sustainable development goals: social protection for health.

BACKGROUND: There is an established body of evidence linking systems of social protection to health systems and health outcomes. The Sustainable Development Goals (SDGs) provide further emphasis on this linkage as necessary to achieving health and non-health goals. Existing literature on social protection and health has focused primarily on cash transfers. We sought to identify potential research priorities concerning social protection and health in low and middle-income countries, from multiple perspectives. METHODS: Priority research questions were identified through two sources: 1) research reviews on social protection interventions and health, 2) interviews with 54 policy makers from Ministries of Health, multi-lateral or bilateral organizations, and NGOs. Data was collated and summarized using a framework analysis approach. The final refining and ranking of the questions was completed by researchers from around the globe through an online platform. RESULTS: The overview of reviews identified 5 main categories of social protection interventions: cash transfers; financial incentives and other demand side financing interventions; food aid and nutritional interventions; parental leave; and livelihood/social welfare interventions. Policy-makers focused on the implementation and practice of social protection and health, how social protection programs could be integrated with other sectors, and how they should be monitored/evaluated. A collated list resulted in 31 priority research questions. Scale and sustainability of social protection programs ranked highest. The top 10 research questions focused heavily on design, implementation, and context, with a range of interventions that included cash transfers, social insurance, and labor market interventions. CONCLUSIONS: There is potentially a rich field of enquiry into the linkages between health systems and social protection programs, but research within this field has focused on a few relatively narrowly defined areas. The SDGs provide an impetus to the expansion of research of this nature, with priority setting exercises such as this helping to align funder investment with researcher effort and policy-maker evidence needs.

Cup-to-Disc Ratio Asymmetry in U.S. Adults: Prevalence and Association with Glaucoma in the 2005-2008 National Health and Nutrition Examination Survey.

PURPOSE: To describe the prevalence of vertical cup-to-disc ratio (vCDR) asymmetry in U.S. adults and assess the utility of vCDR asymmetry in the diagnosis of glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 5359 subjects aged ≥40 years from the 2005-2008 National Health and Nutrition Examination Survey (NHANES). METHODS: Subjects completed retinal photography and had vCDR determined in both eyes, with vCDR asymmetry calculated as the absolute value of the difference between the 2 eyes. Frequency Doubling Technology perimetry was used to assess for visual field (VF) defects. Subjects were categorized as having "disc defined glaucoma" if either disc demonstrated glaucomatous features, and VF data were combined with optic disc grading to determine "disc plus field defined glaucoma." MAIN OUTCOME MEASURES: Association between vCDR asymmetry and disc plus field defined glaucoma. RESULTS: In U.S. adults without glaucoma, the 50th, 97.5th, and 99.5th percentiles of vCDR asymmetry are 0.05, 0.19, and 0.26, respectively. Vertical cup-to-disc ratio asymmetry ≥0.20 occurs in 2.1% of U.S. adults without glaucoma. The prevalence of vCDR asymmetry ≥0.20 among white, black, and Hispanic adults without glaucoma is 2.4%, 0.7%, and 1.8%, respectively. The odds of vCDR asymmetry ≥0.20 are 1.44 times higher per 10-year increase in age (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.20-1.72; P < 0.01). Each 0.10 increase in vCDR asymmetry was associated with a 2.57 times higher adjusted odds of disc plus field defined glaucoma (OR, 2.57; 95% CI, 1.43-4.61; P < 0.01). The sensitivity and specificity of vCDR asymmetry ≥0.20 for disc plus field defined glaucoma are 22.7% and 97.7%, respectively, whereas the positive likelihood ratio is 9.9 and the positive predictive value (PPV) is 7.0%. At a higher vCDR asymmetry cutoff of ≥0.30, the PPV increases to 37.7%. CONCLUSIONS: Vertical cup-to-disc ratio asymmetry is predictive of prevalent glaucoma, but the PPV remains low even at high degrees of asymmetry. Vertical cup-to-disc ratio asymmetry should initiate a more comprehensive glaucoma workup, especially in individuals with additional risk factors, but it is not appropriate as a screening metric for glaucoma.

Contraceptive Implant Discontinuation in Huambo and Luanda, Angola: A Qualitative Exploration of Motives.

Introduction The Government of Angola is engaged in ongoing efforts to increase access to contraceptives, in particular contraceptive implants (CIs). Discontinuation of CIs, however, has been identified as being a challenge to this work, hindering the improvement of contraceptive prevalence, and in turn, maternal and child health. The objective of this study was to understand motives for contraceptive implant discontinuation in Luanda and Huambo, Angola. Methods We conducted 45 in-depth interviews and six focus groups amongst former and current contraceptive implant clients and family planning nurses in eight clinics across the provinces of Huambo and Luanda. Data collectors transcribed and translated key information from Portuguese into English. We used a combined deductive/inductive approach to code and analyze data. Results Participants described adverse side effects, desire for pregnancy, partner dissatisfaction, quality of care, alternative or lack of information, and religion as motives for discontinuation. Adverse side effects, including prolonged bleeding, amenorrhea, and headaches were most commonly cited by both clients and providers. Discussion Motives for discontinuation reflect existing findings from other studies in similar settings, in particular the influence of adverse side effects and desire for pregnancy as motivating factors. We contextualize these findings in the Angolan setting to tease out the relationship between cultural norms of ideal family size and the perceived role of women in regards to fertility and child-bearing. We suggest that programs enter into dialog with communities to address these concerns, rather than working exclusively on improving service delivery and quality.

Association Between Hay Fever and High Myopia in United States Adolescents and Adults.

OBJECTIVES: To investigate the relationship between hay fever and refractive error in a representative sample of adolescents and adults in the United States. METHODS: This cross-sectional study included 5,744 participants aged ≥12 years from the 2005 to 2006 National Health and Nutrition Examination Survey who participated in the allergy questionnaire, completed objective refraction and keratometry in both eyes, and had immunoglobulin E (IgE) serology. The primary predictor variable, refractive error, was classified as emmetropia (-0.99 to +0.99 diopters [D]), low myopia (-1.00 to -2.99 D), moderate myopia (-3.00 to -5.99 D), high myopia (≥-6.00 D), or hyperopia (≥1.00 D). Covariates included age, gender, race, asthma, eczema, total serum IgE ≥120 kU/L, corneal steepness, and corneal astigmatism. The primary outcome was hay fever. RESULTS: The study population's mean age was 41.7 years; 48.8% of subjects were men and 51.2% were women. The prevalence of hay fever was 12.1% overall. High myopes had 2.7 times higher odds of hay fever compared to emmetropes (OR 2.67, CI, 1.57-4.51, P=0.001), which was independent of demographics, atopic conditions, IgE serology, and keratometry measurements. CONCLUSIONS: The association between hay fever and high myopia identified in this large cross-sectional study remains speculative and was not mediated through corneal steepness or corneal astigmatism. Further prospective studies may help elucidate the directionality of the association between hay fever and high myopia.

Exploring pathways for building trust in vaccination and strengthening health system resilience.

BACKGROUND: Trust is critical to generate and maintain demand for vaccines in low and middle income countries. However, there is little documentation on how health system insufficiencies affect trust in vaccination and the process of re-building trust once it has been compromised. We reflect on how disruptions to immunizations systems can affect trust in vaccination and can compromise vaccine utilization. We then explore key pathways for overcoming system vulnerabilities in order to restore trust, to strengthen the resilience of health systems and communities, and to promote vaccine utilization. METHODS: Utilizing secondary data and a review of the literature, we developed a causal loop diagram (CLD) to map the determinants of building trust in immunizations. Using the CLD, we devised three scenarios to illustrate common vulnerabilities that compromise trust and pathways to strengthen trust and utilization of vaccines, specifically looking at weak health systems, harmful communication channels, and role of social capital. Spill-over effects, interactions and other dynamics in the CLD were then examined to assess leverage points to counter these vulnerabilities. RESULTS: Trust in vaccination arises from the interactions among experiences with the health system, the various forms of communication and social capital - both external and internal to communities. When experiencing system-wide shocks such as the case in Ebola-affected countries, distrust is reinforced by feedback between the health and immunization systems where distrust often lingers even after systems are restored and spills over beyond vaccination in the broader health system. Vaccine myths or anti-vaccine movements reinforce distrust. Social capital - the collective value of social networks of community members - plays a central role in increasing levels of trust. CONCLUSIONS: Trust is important, yet underexplored, in the context of vaccine utilization. Using a CLD to illustrate various scenarios helped to explore how common health and vaccine vulnerabilities can reinforce and spill over distrust through vicious, reinforcing feedback. Restoring trust requires a careful balance between eliminating vulnerabilities and strengthening social capital and interactions among communication channels.

Choroidal Nevus in the United States Adult Population: Racial Disparities and Associated Factors in the National Health and Nutrition Examination Survey.

PURPOSE: To describe the prevalence of choroidal nevus in the US population and identify possible associated factors. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 5575 participants aged ≥40 years from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) who underwent retinal imaging examination. METHODS: Predictor variables included a spectrum of demographic, ophthalmic, dermatologic, systemic, socioeconomic, or occupational factor variables available in NHANES. MAIN OUTCOME MEASURES: Choroidal nevus on retinal imaging. RESULTS: The prevalence of choroidal nevus was 4.7% overall and increased with age (4.7%, 3.1%, 5.4%, 6.6%, and 7.5% in subjects aged 40-49, 50-59, 60-69, 70-79, and ≥80 years, respectively). The prevalence was 5.0% in men, 4.4% in women, 5.6% in whites, 2.7% in Hispanics, 0.6% in blacks, and 2.1% in others. After adjusting for age and race, the odds of choroidal nevus were 10-fold higher in whites than in blacks, 5-fold higher in Hispanics than in blacks, 4-fold higher in others than in blacks, and 2-fold higher in whites than in Hispanics. Choroidal nevus was associated with hypertension (odds ratio [OR], 1.40; 95% confidence interval [CI], 0.99-1.98); psoriasis (OR, 3.90; 95% CI, 1.57-9.66); lower high-density lipoprotein (OR, 0.99; 95% CI, 0.98-0.99); higher uric acid (OR, 1.13; 95% CI, 1.04-1.22); working in installation, maintenance, or repairs (OR, 1.42; 95% CI, 1.03-1.96); and having never worked (OR, 1.56; 95% CI, 1.03-2.37; P = 0.04). There was no association with visual symptoms, visual functioning, visual acuity, refractive error, visual field, diabetic retinopathy, age-related macular degeneration, or elevated cup-to-disc ratio on retinal imaging. There was no association with skin melanoma, other cancers, lung/liver/kidney/thyroid disease, alcohol/drug use, income/education, hemoglobin A1C, C-reactive protein, lactate dehydrogenase, electrolytes, or urine albumin. CONCLUSIONS: Among US adults, the prevalence of choroidal nevus located within two 45° areas centered on the macula and optic disc is 4.7%. The prevalence increases with age, is highest among whites (5.6%), is lowest among blacks (0.6%), and has been previously under-recognized among Hispanics (2.7%). Extrapolating to the entire fundus, the true prevalence of choroidal nevus is even higher but difficult to accurately estimate. Possible associations with cardiovascular, renal, autoimmune, and occupational risk factors warrant further investigation.

Association between visual field defects and quality of life in the United States.

PURPOSE: To investigate the association between visual field defects and quality of life in the United States population. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 5186 participants in the 2005 through 2008 National Health and Nutrition Examination Survey 40 years of age and older without a self-reported history of age-related macular degeneration or prior refractive surgery who had undergone frequency doubling technology perimetric testing. METHODS: Frequency doubling technology perimetry was performed in both eyes. Results from the better eye were used to categorize subjects as normal or having mild, moderate, or severe visual field loss. Subjects completed surveys about their visual and physical functioning ability. MAIN OUTCOME MEASURES: Disability pertaining to 6 vision-related activities, 2 visual function questions, and 5 physical functioning domains. RESULTS: Eighty-one percent of subjects had normal visual fields and 10%, 7%, and 2% demonstrated mild, moderate, and severe visual field defects, respectively. Subjects with greater severity of visual field defects had greater difficulty with vision-related activities. Subjects with severe visual field defects demonstrated the greatest odds of difficulty with all 6 activities. The 2 activities impacted most adversely were daytime driving in familiar places (odds ratio [OR], 12.4; 95% confidence interval [CI], 6.1-25.1) and noticing objects off to the side when walking (OR, 7.7; 95% CI, 4.7-12.7). Subjects with severe visual field defects had greater odds of worrying about eyesight (OR, 3.4; 95% CI, 2.0-5.8) and being limited by vision in the time spent on daily activities (OR, 5.1; 95% CI, 3.0-8.5). Subjects with severe visual field defects demonstrated the greatest odds of difficulty with 3 physical function domains, including activities of daily living (OR, 2.45; 95% CI, 1.37-4.38), instrumental activities of daily living (OR, 2.45; 95% CI, 1.37-4.38), as well as leisure and social activities (OR, 3.29; 95% CI, 1.87-5.77). CONCLUSIONS: Greater severity of visual field abnormality was associated with significantly greater odds of disability with vision-related function and physical function. These findings support the necessity of routine screening to find those who may benefit from therapy to prevent progressive glaucomatous vision loss.

Techniques and Preferences for Nonvalved Aqueous Shunts: A Survey of American Glaucoma Society Members.

PURPOSE: To assess practice patterns and opinions of glaucoma specialists regarding indications, surgical technique, and postoperative management for nonvalved aqueous shunts. DESIGN: Anonymous online survey study. PARTICIPANTS: American Glaucoma Society (AGS) members. METHODS: An anonymous online survey was distributed to glaucoma specialists via the AGS forum from June to August 2022. MAIN OUTCOME MEASURES: Survey questions and responses were assessed in 4 sections: (1) general demographics and practice patterns; (2) nonvalved tubes vs. trabeculectomy; (3) nonvalved tubes vs. valved tubes; and (4) nonvalved tube techniques. RESULTS: There were 132 respondents; nonvalved tubes were reported to be performed more often than trabeculectomy by 61% of respondents within 5 years of completing training and 23% of respondents with more than 15 years since completing training. The most frequently preferred types of nonvalved tubes were Baerveldt-350 (41%), Baerveldt-250 (27%), and ClearPath-250 (18%). In patients with lower target intraocular pressure (IOP), 92% of respondents preferred trabeculectomy over nonvalved tube; 33% cited a cutoff of < 12 mmHg, and 31% cited a cutoff of < 15 mmHg. In patients with higher preoperative IOP, 50% of respondents preferred valved over nonvalved tubes; 29% cited a cutoff of > 40 mmHg, and 38% cited a cutoff of > 30 mmHg. The most frequently used ligature was 7-0 Vicryl (69%). The most frequently used strategies for early IOP lowering were fenestrations without wicks (70%) and with wicks (22%), with one 10-0 Nylon being the most used wick technique (22%). Overall, 37% of respondents use a ripcord; among ripcord users, 55% use it for hypotony prevention (3-0 Prolene most common for this purpose at 35%), and 40% use it for optional early IOP lowering (4-0 Nylon most common for this purpose at 21%). If IOP is too high at postoperative week 4, 38% of respondents do not open the tube early. CONCLUSIONS: We demonstrate significant heterogeneity regarding specific indications, surgical technique, and postoperative management for nonvalved tubes. Future work is needed to identify and develop standardized guidelines alongside best practices. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Case study and pilot results: Stepwise approach to teach a resident tube shunt surgery.

Purpose: To illustrate the utility of a previously published stepwise rubric for evaluating a resident's progress learning aqueous tube shunt surgery. Method: Using a stepwise rubric, a single PGY3 ophthalmology resident and attending glaucoma surgeon evaluated the resident's performance after each aqueous tube shunt surgery. The rubric subdivides the surgery into 12 consecutive steps and scores the resident's proficiency in each step with either a 0 (observation), 2 (novice), 3 (beginner), 4 (advanced beginner), or 5 (competent). Results: The resident's cumulative score increased significantly throughout the 17 surgeries performed, with the resident's self-evaluated score and attending's score increasing from 12 to 27 and 14 to 27 from the first to last surgery, respectively. Scores were consistent between the resident and attending; for any given surgery, the resident's own score never deviated from the attending's score by more than 1 point. The resident completed at least 50% of the steps in 11 of the 17 cases. While some surgical steps were mastered earlier on ("tube tying" and "suture implantation"), other steps were more challenging to master ("tunnel in sclera and enter the AC" and "close conjunctiva", as demonstrated by fewer overall attempts or never attaining a score of '5' despite multiple attempts. Conclusions and Importance: This study demonstrates the utility of the stepwise rubric in tracking resident surgical scores chronologically via self and attending assessment. The ability to compare their own scores to that of an attending allows the resident to learn how to effectively evaluate their own performance. Most importantly, statistics obtained for each step provides the resident with personalized and real-time feedback for learning specific surgical steps. In conclusion, the stepwise rubric is a useful add-on to a resident's aqueous tube shunt surgery education.

Outcomes of slow coagulation transscleral cyclophotocoagulation in a predominantly African American glaucoma population.

Purpose: To evaluate outcomes of slow coagulation transscleral cyclophotocoagulation (SC-TSCPC) in a primarily African American patient population with glaucoma. Methods: A retrospective chart review was performed for 104 consecutive cases of SC-TSCPC by a single surgeon between November 6, 2019-September 7, 2023. Power ranged from 1150 to 1500 mW, duration was 4 s, and number of spots ranged from 10 to 25. Exclusion criteria were diagnosis of neovascular glaucoma, prior CPC, visual acuity (VA) of no light perception or unable to be assessed due to patient's mental status, aphakia, or follow-up <3 months. The primary outcome measure was surgical success defined as an intraocular pressure (IOP) of 6-21 mmHg with a ≥20 % reduction from baseline, no glaucoma re-operation, and no loss of light-perception. Secondary outcome measures included VA, glaucoma medication use, and post-surgical complications. Analysis was also stratified by lens status as literature suggests a greater IOP-lowering effect in pseudophakic eyes after CPC. Results: There were 28 eligible patients (6 phakic, 22 pseudophakic) included in this analysis. Mean follow-up was 11.6 ± 8.3 months, and 14 patients had postoperative year 1 data available. The mean age was 75.2 ± 13.9 years, 42.9 % were female, and 92.9 % were African American, reflective of the demographics of the local community. The cumulative success rate was 68.5 % at 1 year and did not differ significantly between phakic and pseudophakic patients. Mean VA worsened from 20/600 preoperatively to 20/1050 at last follow-up (P = 0.04) and was marginally worse in the phakic group (P = 0.15). Mean IOP decreased from 31.1 ± 13.2 mmHg on 4.0 ± 1.5 medications preoperatively to 13.8 ± 7.1 mmHg on 2.6 ± 1.5 medications at last follow-up (P < 0.001; P < 0.01), with a more pronounced effect among pseudophakic patients. 85.7 % of patients had prolonged anterior chamber (AC) inflammation beyond 1 month, which persisted in 10.7 % at last follow-up. The cystoid macular edema (CME) rate was 21.4 %, with 10.7 % persistent at last follow-up. Conclusions: SC-TSCPC is an effective, non-incisional IOP-lowering procedure in phakic and pseudophakic eyes that may not otherwise be ideal candidates for incisional glaucoma surgery. Pseudophakic eyes may experience larger reductions in IOP, however, laser settings can be titrated on a case-by-case basis depending on individual patients' goals. There was a higher incidence of prolonged AC inflammation and CME in our cohort compared to similar studies which report rates of 12.7 % and 2.7 %, respectively. Although the significance of such complications may differ based on the visual potential of each patient, these findings support existing literature that African American patients can have greater incidence of inflammation and subsequent sequalae after ocular surgery.

Bleb revision with Tenon's transposition flap: Case report.

INTRODUCTION: To describe the use and technique of a Tenon's transposition flap without overlying conjunctiva to cover bare sclera following bleb excision and tube shunt implantation. PRESENTATION OF CASE: A 76-year-old man with severe stage primary open-angle glaucoma in both eyes presented with a nonfunctioning trabeculectomy with a thin-walled, cystic bleb overhanging the cornea. A Baerveldt-350 Glaucoma Implant in the ciliary sulcus was recommended for further lowering of intraocular pressure, along with concurrent excision of the bleb due to patient dissatisfaction with the cosmesis of the bleb and to prevent future bleb-associated complications. Conjunctiva could be closed without tension over the new tube entry site; however, a defect remained at the prior trabeculectomy site. A Tenon's transposition flap without overlying conjunctiva was created to cover this site. By postoperative week 6, new conjunctiva had grown over the Tenon's transposition graft, appearing as if there had never been a bleb. DISCUSSION: This case illustrates the use of a Tenon's transposition flap to cover bare sclera following bleb excision. This technique proves valuable when conjunctiva is limited, offering an alternative when adjacent conjunctiva cannot be mobilized. CONCLUSION: In cases requiring non-water-tight coverage of bare sclera with limited available conjunctiva, a Tenon's transposition flap can be used, permitting new conjunctiva to safely grow over bare Tenon's. This technique is useful during a variety of scenarios, including tube shunt and trabeculectomy revisions, where conjunctival closure may be difficult.

Baerveldt-350 with 3-0 Prolene Ripcord to Minimize Hypotony-Associated Complications after Spontaneous Ligature Dissolution.

PURPOSE: To describe the technique and demonstrate the utility and outcomes of using a thick 3-0 Prolene ripcord in the lumen of a Baerveldt-350 aqueous shunt until after the ligature suture dissolves. DESIGN: Single-center, noncontrolled, retrospective case series. PARTICIPANTS: A total of 50 eyes from 50 patients with glaucoma undergoing placement of Baerveldt-350 aqueous shunts with 3-0 Prolene ripcords. METHODS: A retrospective chart review was performed for all eyes of adult patients that had undergone a Baerveldt-350 aqueous shunt placement by a single surgeon at a single academic center between October 1, 2019 and June 30, 2022. MAIN OUTCOME MEASURES: Data collected included demographic and clinical characteristics of the patients, preoperative and postoperative clinical data including intraocular pressure (IOP) and glaucoma medications, postoperative timepoints of ligature suture dissolution, and timepoints of 3-0 Prolene ripcord removal or whether they were permanently left in place. RESULTS: In total, 50 eyes from 50 patients were included; mean age was 69.5 years, 54.0% of patients were female, 92% of patients were Black, and 66% of eyes had primary open-angle glaucoma. Twenty-six of 50 (52%) eyes had ripcord removal at the soonest postoperative visit after spontaneous ligature dissolution, 19/50 (38%) eyes had delayed ripcord removal, and 5/50 (10%) eyes had no ripcord removal. There were no cases of hypotony-associated complications (shallow anterior chamber, hypotony maculopathy, choroidal effusion, suprachoroidal hemorrhage) in this subgroup of eyes that underwent no ripcord removal. CONCLUSIONS: Our results demonstrate that routine use of a 3-0 Prolene ripcord to partially occlude the lumen of a Baerveldt-350 is a useful strategy to minimize sudden hypotony-associated complications when the ligature suture dissolves. This strategy allows for a more controlled postoperative course and a safe 2-step decrease in IOP (1: when the ligature dissolves, and 2: when the ripcord is removed). FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Same-quadrant Baerveldt Glaucoma Implant-250 to Baerveldt Glaucoma Implant-350 exchange.

Purpose: In eyes with a prior failed aqueous shunt (or "tube") requiring additional intraocular pressure (IOP) control, options include angle surgery, cyclodestruction, second tube, tube revision, or tube exchange. We present a case of a same-quadrant tube exchange of a Baerveldt-250 (BGI-250) to BGI-350. Observations: The patient is a 71-year-old African American female with severe-stage primary open angle glaucoma of both eyes, and this case focuses on the right eye. This eye had prior cataract surgery with iStent, prior BGI-250 in the anterior chamber (AC), and prior iStent removal with gonioscopy assisted transluminal trabeculotomy (GATT). The visual acuity (VA) was 20/150, and the IOP was 26 mmHg on 3 IOP-lowering medications. The prior superotemporal BGI-250 had its "wings" on top of the superior and lateral rectus muscles and its tube tip in the AC. The implant was removed in its entirety including the superficial and deep layers of its capsule. The new BGI-350 was stented with a 3-0 polypropylene ripcord, ligated with a 7-0 polyglactin suture, and implanted with its wings under the rectus muscles and the tube tip in the sulcus. For early IOP-lowering prior to ligature dissolution, 2 needle stab fenestrations and an additional 7-0 polyglactin wick was used. The capsule from the prior BGI-250 was used as a patch graft for the new BGI-350. The ligature dissolved at postoperative week (POW) 6. By POW8, the IOP was 18 mmHg on 3 IOP-lowering medications and frequent topical steroid, the AC was quiet, and the ripcord was removed. A slow steroid taper finished at postoperative month (POM) 6. By POM 12, the VA was still at baseline 20/150, and the IOP was 14 mmHg on 3 IOP-lowering medications. Conclusions & importance: Patients with a prior failed tube requiring additional IOP-lowering can undergo a same-quadrant tube exchange. BGI-350s may offer more IOP-lowering than BGI-250s, but the IOP-lowering achieved in this patient's case could be attributable to differences in postoperative management in addition to endplate size; longer follow-up is needed. A tube exchange offers the opportunity to reposition the tube tip from the AC to the sulcus and to use the prior tube's capsule as a patch graft for the new tube.