The Decline of Basic Ophthalmology in General Medical Education: A Scoping Review and Recommended Potential Solutions.

OBJECTIVE: This literature review aims to explore research and conceptual pieces on the state of ophthalmology education and suggest potential ways to address current challenges. METHODS: A search was conducted in PubMed, ERIC, Web of Science, and Google Scholar with combinations of the following search terms: "ophthalmology education," "undergraduate medical education," "medical student," "United States," and "Canada." Eliminating irrelevant articles yielded 47 articles. Three were excluded because of region and focus, leaving 44. After examining the citations, we generated an additional 22 texts for review, totaling 66 articles. RESULTS: Four primary themes were identified: (1) challenges to ophthalmological education in the U.S. and Canada, (2) potential remedies for optimizing ophthalmology curriculum, (3) technology in ophthalmology education, and (4) innovative ophthalmology teaching approaches. Major challenges included the lack of a standardized curriculum and inadequate clinical exposure and skills training. A number of remedies were proposed, such as standardizing curriculum and furthering faculty involvement, utilizing technology as time-effective learning aids, and employing innovative teaching approaches such as service learning. CONCLUSION: In light of challenges in ophthalmology education, curriculum designers should consider Cognitive Load Theory (CLT) to assist students to remember meaningful exposures to ophthalmology knowledge and techniques. Based on CLT, we suggest two potential approaches to incorporating ophthalmology curriculum. The first is to embrace interdisciplinary collaborations and place ophthalmology knowledge in varied contexts to facilitate schema construction. The second is to incorporate ophthalmology diagnostics requirements into OSCEs and utilize simulation models for students to gradually increase the fidelity of tasks and devote cognitive resources fully to learning.

Sex Differences in Academic Rank, Scholarly Productivity, National Institutes of Health Funding, and Industry Ties Among Academic Cornea Specialists in the United States.

PURPOSE: This study analyzed sex differences among cornea specialists with regards to academic rank, scholarly productivity, National Institutes of Health (NIH) funding, and industry partnerships. DESIGN: Cross-sectional study. METHODS: This was a study of faculty at 113 US academic programs. Sex, residency graduation year, and academic rank were collected from institutional websites between January and March 2019. H-indices and m-quotients were collected from the Scopus database. The NIH Research Portfolio Online Reporting Tool and Centers for Medicare and Medicaid Services databases were queried for data on NIH funding and industry partnerships. RESULTS: Of the 440 cornea specialists identified, 131 (29.8%) were female. The proportions of females and males at each academic rank (assistant 69.5% vs 41.8%; associate 17.6% vs 21.0%; full professor 13.0% vs 37.2%) were not significant after adjusting for career duration (P = .083, .459, and .113, respectively). Females had significantly lower median h-indices (4.0 [interquartile range {IQR} 7.0] vs 11.0 [IQR 17.0], P < .001) and shorter median career duration (12.0 [IQR 11.0] vs. 25.0 [IQR 20.0] years, P < .001) than males but similar median m-quotients (0.5 [IQR 0.8] vs 0.5 [IQR 0.8], P = 1.00). Sex differences in h-indices were not seen at each academic rank or career duration interval. Among NIH-funded investigators, the median grant funding was $1.6M (IQR $2.2M) for females and $1.2M (IQR $4.6M, P = .853) for males. Overall, 25.5% of females and 58.6% of males (P = .600) had industry partnerships. CONCLUSION: Sex differences within academic ranks and h-indices are likely due to a smaller proportion of females with advanced career duration.

Analysis of Melanin Structure and Biochemical Composition in Conjunctival Melanocytic Lesions Using Pump-Probe Microscopy.

PURPOSE: We analyze melanin structure and biochemical composition in conjunctival melanocytic lesions using pump-probe microscopy to assess the potential for this method to assist in melanoma diagnosis. METHODS: Pump-probe microscopy interrogates transient excited-state photodynamic properties of absorbing molecules, which yields highly specific molecular information with subcellular spatial resolution. This method is applied to analyze melanin in 39 unstained, thin biopsy specimens of melanocytic conjunctival lesions. Quantitative features of the biochemical composition and structure of melanin in histopathologic specimens are assessed using a geometric representation of principal component analysis (PCA) and principles of mathematical morphology. Diagnostic power is determined using a feature selection algorithm combined with cross validation. RESULTS: Conjunctival melanomas show higher biochemical heterogeneity and different overall biochemical composition than primary acquired melanosis of the conjunctiva (PAM) without severe atypia. The molecular signatures of PAMs with severe atypia more closely resemble melanomas than other types of PAMs. Pigment organization in the tissue becomes more disorganized as diagnosis of the lesions worsen, but nevi are more inconsistent biochemically and structurally than other lesions. Relatively high sensitivity (SE) and specificity (SP) is achieved for differentiating between various melanocytic lesions, particularly PAMs without severe atypia and melanomas (SE = 89%; SP = 87%). CONCLUSIONS: Pump-probe microscopy is a powerful tool that can identify quantitative, phenotypic differences between various types of conjunctival melanocytic lesions. TRANSLATIONAL RELEVANCE: This study further validates the use of pump-probe microscopy as a potential diagnostic aid for histopathologic evaluation of conjunctival melanocytic lesions.

Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes.

PURPOSE: To describe a minimally invasive surgical technique and its clinical outcomes with the use of acellular nerve allograft to re-establish corneal sensibility in patients with neurotrophic keratopathy. METHODS: Acellular nerve allograft was coapted to an intact supraorbital, supratrochlear, or infraorbital nerve and transferred to the affected eye. Donor nerve pedicles were isolated through a transpalpebral or transconjunctival approach. Retrospective evaluation of preoperative and postoperative corneal sensibility, ocular surface, and best-corrected visual acuity was performed in all patients. Mean follow-up period was 6 months (range: 3-10 months). RESULTS: Corneal neurotization with acellular nerve allograft was successfully performed in 7 patients with restoration of corneal sensibility and corneal epithelial integrity. In vivo confocal microscopy demonstrated increased nerve density in corneal stroma at 4 months after surgery. CONCLUSIONS: The use of acellular nerve allograft allows for a minimally invasive approach to successful corneal neurotization.

Pediatric conjunctival melanoma arising from a compound nevus.

We present a rare case of conjunctival melanoma in a 9-year-old girl who presented with a conjunctival lesion of the left eye, growth of which was documented by patient photographs. Examination showed a raised pigmented lesion at the temporal limbus, with fine surrounding vessels. Enhanced depth imaging-optical coherence tomography showed no invasion into the sclera. The patient underwent excisional biopsy, and histopathology revealed conjunctival melanoma arising from a nevus with malignant cells that stained positively with markers HMB-45 and Ki-67. Systemic workup was negative for metastatic disease. Conjunctival nevi are the most common melanocytic conjunctival lesions in children and generally demonstrate physiologic growth during adolescence. Thus, there may be a greater risk of misdiagnosis of conjunctival melanoma in a child.

Ocular Surface Epithelial Atypia Mimicking Squamous Neoplasia in Association With Ulcerative Colitis.

PURPOSE: Inflammatory bowel disease may be associated with extraintestinal manifestations. We report a case of severe reactive epithelial atypia resembling ocular surface squamous neoplasia (OSSN) in a patient with ulcerative colitis (UC). METHODS: Case report. RESULTS: A 32-year-old woman presented with sequential, progressive keratoconjunctival lesions in the left and right eyes, and both lesions were excised. Anterior segment optical coherence tomography demonstrated features similar to OSSN, whereas histological examination revealed severe reactive epithelial atypia mimicking severe dysplasia. Shortly after treatment of the second eye, the patient was diagnosed with UC. Residual disease improved dramatically in response to systemic corticosteroids. CONCLUSIONS: Severe ocular surface epithelial atypia resembling OSSN may be seen in association with UC.

Advances in the management of conjunctival melanoma.

Malignant melanoma of the conjunctiva is a rare but serious condition. Over the last several years, there have been important advances in the classification, diagnosis, and treatment of this condition. Recent cytogenetic and immunohistochemical studies are increasing understanding of its tumorigenesis. Diagnosis, although still made via histopathology, has been aided with imaging techniques such as ultrasound biomicroscopy and anterior segment optical coherence tomography. Primary treatment consists of surgical excision. But adjuvant treatments with cryotherapy, topical chemotherapy, and radiation therapy have shown increased success. Sentinel lymph node biopsy has shown early promise of detecting micro-metastasis. Long term follow-up of patients with conjunctival melanoma with systemic surveillance is necessary to detect recurrences and metastases.

Anterior Segment Imaging in Ocular Surface Squamous Neoplasia.

Recent advances in anterior segment imaging have transformed the way ocular surface squamous neoplasia (OSSN) is diagnosed and monitored. Ultrasound biomicroscopy (UBM) has been reported to be useful primarily in the assessment of intraocular invasion and metastasis. In vivo confocal microscopy (IVCM) shows enlarged and irregular nuclei with hyperreflective cells in OSSN lesions and this has been found to correlate with histopathology findings. Anterior segment optical coherence tomography (AS-OCT) demonstrates thickened hyperreflective epithelium with an abrupt transition between abnormal and normal epithelium in OSSN lesions and this has also been shown to mimic histopathology findings. Although there are limitations to each of these imaging modalities, they can be useful adjunctive tools in the diagnosis of OSSN and could greatly assist the clinician in the management of OSSN patients. Nevertheless, anterior segment imaging has not replaced histopathology's role as the gold standard in confirming diagnosis.

Outcomes of intense pulsed light therapy for treatment of evaporative dry eye disease.

OBJECTIVE: To determine the clinical outcomes of intense pulsed light (IPL) therapy for the treatment of evaporative dry eye disease (DED). DESIGN: Multicentre cohort study. PARTICIPANTS: Patients with a diagnosis of meibomian gland dysfunction (MGD) and dry eye presenting to the ophthalmology clinic at either the Duke Eye Center, Durham, NC, or Matossian Eye Associates' private practice in Pennington, NJ, and Doylestown, PA. METHODS: Clinical data were reviewed from 100 patients with diagnosis of MGD and DED who underwent IPL therapy from September 2012 through December 2014 at 1 of 2 centres (Duke Eye Center or Matossian Eye Associates). Demographics, clinical history, examination findings (eyelid and facial vascularity, eyelid margin edema, meibomian gland oil flow, and quality score-all graded on a scale of 0 to 4), tear break up time (TBUT), and ocular surface disease index (OSDI) scoring data were collected from each visit. RESULTS: On average, patients underwent 4 IPL sessions. There was significant decrease in scoring of lid margin edema (mean = -0.3; range -1.5 to 0), facial telangiectasia (mean = -0.7; range -2.5 to 0), lid margin vascularity (mean = -1.2; range -2.5 to 0), meibum viscosity (mean = -1.1; range -3 to 0), and OSDI score (mean = -9.6), all with p < 0.001. There was a significant increase in oil flow score (mean = 0.9, range -0.5 to 2) and TBUT (mean = 3.4 seconds, range -2 to 7), both p < 0.001. No significant changes in intraocular pressure or acuity were noted. There were no cases of adverse ocular effects. CONCLUSIONS: IPL therapy for evaporative DED is a safe procedure. The positive change in objective clinical examination findings and subjective OSDI scoring data suggest that IPL is an effective treatment for patients with evaporative DED.

Fibrin adhesive in conjunction with epithelial ingrowth removal after laser in situ keratomileusis: long-term results.

PURPOSE: To describe the long-term results of fibrin adhesive use in the management of epithelial ingrowth after laser in situ keratomileusis (LASIK). SETTING: Private practice, Minneapolis, Minnesota, and an academic medical center, Durham, North Carolina, USA. DESIGN: Retrospective case series. METHODS: Patients with a history of LASIK had epithelial ingrowth removal with mechanical debridement and fibrin glue application. Visual outcomes and the presence or absence of epithelial ingrowth were evaluated again after 3 months and at the last follow-up. The main outcome measures were recurrence of epithelial ingrowth and visual acuity. RESULTS: Thirty-nine eyes of 38 patients were evaluated. After epithelial ingrowth removal and application of fibrin glue, 31 eyes (79.5%) had no recurrence of ingrowth at the final follow-up and 5 eyes (12.8%) had mild epithelial ingrowth not requiring removal. Three eyes (7.7%) had significant epithelial ingrowth at the 3-month follow-up that required subsequent removal and fibrin application. At the 3-month follow-up visit, 76.9% of eyes achieved 20/25 or better corrected distance visual acuity (CDVA) and 69.2% of eyes achieved 20/40 or better uncorrected distance visual acuity (UDVA). At the last follow-up visit (mean 26.6 ± 17.0 months [SD]), 84.6% of eyes had 20/25 or better CDVA and 74.4% of eyes had 20/40 or better UDVA. CONCLUSIONS: Fibrin adhesive in conjunction with manual epithelial removal prevented a clinically significant recurrence of epithelial ingrowth in the majority of eyes. Larger randomized studies are needed to compare the success of this technique with that of others. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Intense pulsed light therapy for the treatment of evaporative dry eye disease.

PURPOSE OF REVIEW: Evaporative dry eye disease is one of the most common types of dry eye. It is often the result of chronic meibomian gland dysfunction (MGD) and associated ocular rosacea. Evaporative dry eye and MGD significantly reduce patient's quality of life. Traditional treatments, such as artificial tears, warm compresses, and medications, such as topical cyclosporine, azithromycin, and oral doxycycline, provide some relief; however, many patients still suffer from dry eye symptoms. Intense pulsed light (IPL) therapy, which has been used extensively in dermatology to treat chronic skin conditions, is a relatively new treatment in ophthalmology for patients with evaporative dry eye disease. RECENT FINDINGS: There are very few studies published on the use of IPL in patients with dry eye disease. The present review describes the theoretical mechanisms of IPL treatment of MGD and ocular rosacea. Personal clinical experience and recently presented data are reported as well. SUMMARY: IPL therapy has promising results for evaporative dry eye patients. There are statistically significant improvements in clinical exam findings of dry eye disease. More importantly, patients report subjective improvement in their symptoms. More research is needed in this area to help understand the mechanism of dry eye disease and how it can be effectively treated.

Textural interface opacity after Descemet-stripping automated endothelial keratoplasty.

PURPOSE: To describe cases of interface haze, also known as textural interface opacity, after Descemet-stripping automated endothelial keratoplasty (DSAEK). SETTING: Department of Cornea, External Disease, and Refractive Surgery Service, Duke Eye Center, Durham, North Carolina, USA. DESIGN: Retrospective case series. METHODS: Patients' clinical and demographic characteristics, cornea donor information, surgical technique, histopathology, and anterior segment optical coherence tomography (OCT) were reviewed retrospectively and clinical outcomes reported. RESULTS: The interface haze that developed after DSAEK comprised 2 types of textural interface opacity; that is, total (11 cases) and partial (3 cases). The time of onset of textural interface opacity ranged from 1 day to 7 weeks postoperatively. Although most patients with textural interface opacity showed improvement, with a corrected distance visual acuity better than 20/50, 3 had persistent decreased visual acuity and required repeat DSAEK. Seven eyes had concurrent phacoemulsification with intraocular lens implantation and DSAEK. The corneal graft was inserted with an Endoserter device in 11 eyes, an insertion forceps in 2 eyes, and a cystotome needle in 1 eye. Histopathology of the grafts of eyes that required repeat DSAEK showed no inflammation, no foreign-body deposit, and no fibrosis. Anterior segment OCT showed increased hyperreflectivity in the interface. CONCLUSIONS: Although the etiology of textural interface opacity is unclear, it may be related to retained ophthalmic viscosurgical device (OVD) or an adhesive property of the OVD used during the surgery. Although most cases resolve with time, repeat DSAEK may be an effective treatment for refractory cases. FINANCIAL DISCLOSURE: Dr. Kim is a consultant to Ocular Systems, Inc. No other author has a financial or proprietary interest in any material or method mentioned.