Periorbital infections after Dermabond closure of traumatic lacerations in three children.

PURPOSE: To report the occurrence of periorbital infections in 3 children treated with the tissue adhesive 2-octyl cyanoacrylate (Dermabond) after traumatic periorbital laceration. METHODS: We retrospectively reviewed the records of consecutive patients referred to Vanderbilt Children's Hospital for the treatment of periorbital infections to identify cases associated with the use of Dermabond. The clinical features and outcomes of each case were reviewed. We performed a meta-analysis of published cases to identify any association of tissue adhesive with wound infection rate. RESULTS: The review identified 3 patients, all of whom were younger than 3 years of age and developed cellulitis within 24 hours of wound closure. Broad-spectrum intravenous antibiotic therapy was started in less than 3 hours in all cases. Cultures were obtained in 2 of the 3 cases; both grew Streptococcus pyogenes. Two cases required surgical intervention, including one with necrotizing fasciitis. In the meta-analysis, the wound infection rate was 1.8% in tissue adhesive closure and 0.3% in standard wound closure (odds ratio 6.0; 95% confidence interval 0.7-50.3, P = 0.06). CONCLUSIONS: The development of periorbital cellulitis after the closure of periorbital lacerations with Dermabond should alert the physician to the possibility of periorbital infection, including necrotizing fasciitis. The literature review suggests a trend toward an increased infection rate with tissue adhesive closure. We propose that ineffective wound sterilization before tissue adhesive wound closure may be a contributing factor.

The influence of Derrick T. Vail Sr, MD, and Edward M. Jackson, MD, on the creation of the American Board of Ophthalmology and the Specialist Board System in the United States.

The claim that Derrick T. Vail Sr, MD, was the innovator behind the formation of the American Board of Ophthalmology rests on an interpretation of a single paragraph in a speech he delivered in 1908. Using the technique of historical literary criticism, we identified fundamental flaws in this interpretation based on a misunderstanding of the context of the speech and his intent. Historical review of the period, including the writings and actions of others in leadership roles, supports our contention. Vail was an influential figure at the time but was only briefly involved in the activities that led to the formation of the American Board of Ophthalmology. On the other hand, Edward M. Jackson, MD, provided inspirational and persistent leadership during the 12 years needed to bring the board into existence. He should be considered the founder of the American Board of Ophthalmology.

J Donald M Gass MD: father of macular diseases, and one of the ten most influential ophthalmologists of the 20th century.

John Donald MacIntyre Gass, MD was one of the most significant figures to emerge in ophthalmology in the last 100 years. There could be few ophthalmologists who cannot attribute part of their increase in understanding of retinal disease to the influence of Don Gass. His insights opened up opportunities for many new effective therapies. He has influenced ophthalmic thought worldwide, if not by his presence as a visitor, then through his scientific publications, his outstanding books and the international fellows he trained. Like many distinguished physicians, Don Gass's clinical acumen was well grounded in his understanding of ocular pathology. This experience was gained under the mentorship of Lorenz E Zimmerman, MD, who trained a number of distinguished ophthalmologists, who subsequently became professors. Professor Gass passed away on February 26, 2005 at the age of 76 years from pancreatic carcinoma. With the demise of Don Gass, the world of ophthalmology has lost an extraordinary physician of great talent, commonsense and humility. On the other hand it has gained a generation of young ophthalmologists inspired by his example.

Morphogenic and genetic differences between Candida albicans strains are associated with keratomycosis virulence.

PURPOSE: To correlate the morphogenic and molecular traits that affect fungal virulence in human corneas. METHODS: C. albicans wild-type strains SC5314 and VE175 were compared using in vitro growth kinetics, filamentation assays, and microarray analysis. Corneal virulence was assessed ex vivo by inoculating C. albicans onto superficially scarified human corneas that were processed after 1 and 3 days to measure hyphal penetration. For comparison, DSY459, a C. albicans homozygous deletion mutant deficient in secreted aspartyl proteinases (SAP) 4, 5, and 6, was evaluated. RESULTS: C. albicans strain SC5314 was highly filamentous in vitro and more invasive in human corneal explants while VE175 demonstrated limited filamentation and less corneal invasion. Among 6,655 C. albicans genes, 9.0% significantly (p<.05) differed by 2 fold or more between SC5314 and VE175. Genes involved in fungal filamentation that were upregulated in strain SC5314 compared to VE175 included SAP5, SAP6, and other hypha-associated genes. Compared to wild-type strains, DSY459 had intermediate filamentation and stromal penetration. CONCLUSIONS: Fungal genes involved in filamentation likely contribute to virulence differences between wild-type strains of C. albicans. The corneal pathogenicity of C. albicans involves the morphogenic transformation of yeasts into hyphae.

First-time failure rates of candidates for board certification: an educational outcome measure.

BACKGROUND: Few objective standards are available to assess the educational effectiveness of ophthalmology residency programs. As a possible measure, we evaluated the first-time failure (FTF) rate in the examinations of the American Board of Ophthalmology, defined as a first-attempt failure in the written examination or a first-attempt failure in the oral examination after having passed the written examination on the first attempt. METHOD: We tracked data on all residents who graduated between June 30, 1999, and December 31, 2003, from commencement of training to certification, including rates of overall FTF, written and oral FTF, and program FTF. Performance was analyzed for several factors, including program size. RESULTS: The FTF rate was 28% overall and ranged from 0% to 89% across 118 programs (median, 27%). Programs with fewer than 16 graduates per 5 years were significantly more likely to have higher FTF rates than larger programs. Thirty-two programs accounted for 50% of the FTF rate. CONCLUSIONS: The FTF rate is a potentially useful measure. However, the small size of many programs contributes to some imprecision. Therefore, this measure should be used in conjunction with other factors when assessing the educational effectiveness of ophthalmology residency programs. Although the eventual certification rate was high, graduates from a few programs appeared inadequately prepared to take the examinations.

Improving diabetic retinopathy screening ratios using telemedicine-based digital retinal imaging technology: the Vine Hill study.

OBJECTIVE: To evaluate the impact of a telemedicine, digital retinal imaging strategy on diabetic retinopathy screening rates in an inner-city primary care clinic. RESEARCH DESIGN AND METHODS: This retrospective cohort study included all diabetic patients aged > or = 18 years (n = 495) seen at Vine Hill Community Clinic between 1 September 2003 and 31 August 2004. Patients were offered ophthalmology referral or digital screening. Patients choosing referral received the next available (within 3 months) appointment at the Vanderbilt Eye Clinic; patients choosing digital screening were screened during the visit. RESULTS: Retinal screening was documented for 293 (59.2%) patients, a significant improvement compared with the 23% baseline rate. Of 293 patients screened, 92 (31.4%) were screened in ophthalmology, and 201 (68.6%) were digitally screened. Among the 201 digitally screened patients, 104 (51.7%) screened negative and were advised to rescreen in 1 year, 75 (37.3%) screened positive and were nonurgently referred to ophthalmology, and 22 (11.0%) screened positive for sight-threatening eye disease and were urgently referred for ophthalmological follow-up. Digital imaging technical failure rate was 0.5%. Referral status was associated with race/ethnicity (chi2 = 7.9, P < 0.02) with whites more likely to screen negative than non-whites (62.4 vs. 47.8%, respectively). Sight-threatening disease among non-whites (14.7%) was more than double that observed for whites (5.9%). CONCLUSIONS: Digital imaging technology in the primary care visit can significantly improve screening rates over conventional methods, increase access to recommended diabetic eye care, and focus specialty care on medically indigent patients with greatest need.

The failure rate of candidates for board certification: an educational outcome measure.

BACKGROUND: Because most residents eventually become board certified, the overall certification rate for the American Board of Ophthalmology (ABO) is not a discriminating educational outcome measure. We have evaluated two related measures: (1) first-time failure (FTF) in the written examination, or FTF in the oral examination after passing the written examination the first time, and (2) failure to certify within 2 years of graduation (FC2). METHODS: We used the tracking system at the ABO to access and analyze information from 1998-2005 on resident performance from program match to certification. RESULTS: Ninety-seven percent of graduates entered the certification process. The FTF rate was 28%. The program FTF rate ranged from 0% to 89% (median, 28%). Programs with fewer than 16 graduates per 5 years were significantly more likely to have higher FTF rates than larger programs. The FC2 rate was 21%. Thirty-two programs accounted for 50% of the FTFs and 27 for 50% of the FC2s. Residents who voluntarily transferred programs performed significantly worse than nontransferring residents by both measures. CONCLUSION: The FTF and FC2 rates are potentially useful outcome measures. However, the small size of many programs contributes to some imprecision. The rates should be used only in conjunction with other factors when assessing programs. These data provide an insight into the state of ophthalmic education in the United States. Although the eventual certification rate was high, graduates from a substantial minority of programs appeared inadequately prepared to sit the Board's examinations.