Perceptions of Justice in Clinical Learning Environments: Development and Validation of an Organizational Justice Measure for Medical Trainees.

PURPOSE: This study aimed to develop an instrument to measure medical trainees' perceptions of justice in clinical learning environments. METHOD: Between 2019 and 2023, the authors conducted a multiyear, multi-institutional, multiphase study to develop a 16-item justice measure with 4 dimensions: interpersonal, informational, procedural, and distributive. The authors gathered validity evidence based on test content, internal structure, and relationships with other variables across 3 phases. Phase 1 involved drafting items and gathering evidence that items measured intended dimensions. Phase 2 involved analyzing relevance of items for target groups, examining interitem correlations and factor loadings in a preliminary analysis, and obtaining reliability estimates. Phase 3 involved a confirmatory factor analysis and collecting convergent and discriminant validity evidence. RESULTS: In phase 1, 63 of 91 draft items were retained following a content validation exercise gauging how well items measured targeted dimensions (mean [SD] item ratings within dimensions, 4.16 [0.36] to 4.39 [0.34]) on a 5-point Likert scale (with 1 indicating not at all well and 5 indicating extremely well). In phase 2, 30 items were removed due to low factor loadings (i.e., < 0.40), and 4 items per dimension were selected (factor loadings, 0.42-0.89). In phase 3, a confirmatory factor analysis supported the 4-dimension model (χ2 = 610.14, P < .001; comparative fit index = 0.90, Tucker-Lewis Index = 0.87, root mean squared error of approximation = 0.11, standardized root mean squared residual = 0.06), with convergent and discriminant validity evidence showing hypothesized positive correlations with a justice measure (r = 0.93, P < .001), trait positive affect (r = 0.46, P < .001), and emotional stability (r = 0.33, P < .001) and negative correlations with trait negative affect (r = -0.39, P < .001). CONCLUSIONS: Results indicate the measure's potential utility in understanding justice perceptions and designing targeted interventions.

The status of women in academic ophthalmology: Authorship of papers, presentations, and academic promotions.

As the field of ophthalmology has evolved in the last several decades, so has the gender distribution of ophthalmologists. We conducted a narrative review to further characterise the status of women in the realm of publication, presentations, editorial positions, grants, academic promotion, and financial compensation. While the proportion of women publishing, presenting, and filling academic and editorial roles has increased over time, it still does not match that of men. Women are more likely to be first authors instead of senior authors, have lower average h-indices, and are awarded fewer grants. The magnitude of some of these differences is smaller when adjusted for women's shorter career duration on average. Despite increased representation of women in ophthalmology, women continue to receive less compensation for the same work. This review highlights that more can be done to improve gender parity in ophthalmology.

Visual Autism.

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder characterized by deficits in social communication and restricted, repetitive behaviors. It affects approximately 2.2% of children. Both genetic and environmental risk factors have been identified for ASD. Visual comorbidities are relatively common among children with ASD. Between 20 and 44% of ASD children have visually significant refractive error, on-third have strabismus, and one-fifth have amblyopia. In addition, ASD is 30 times more common in children with congenital blindness. It is unknown whether the association of ASD with visual morbidity is causal, comorbid, or contributing. Structural and functional abnormalities have been identified in MRIs of ASD children, and ASD children have been noted to have aberrant eye tracking. ASD children with visually significant refractive errors and poor spectacle compliance (present in 30% of ASD children) offer the opportunity for investigation into how improved visual acuity influences ASD behaviors. In this review, we focus on what is known of the visual system, refractive surgery, and ASD.

Differences in Trainee Evaluations of Faculty by Rater and Ratee Gender.

PURPOSE: To examine whether gender differences exist in medical trainees' (residents' and fellows') evaluations of faculty at a number of clinical departments. METHOD: The authors conducted a single-institution (University of Minnesota Medical School) retrospective cohort analysis of 5,071 trainee evaluations of 447 faculty (for which trainee and faculty gender information was available) completed between July 1, 2019, and June 30, 2022. The authors developed and employed a 17-item measure of clinical teaching effectiveness, with 4 dimensions: overall teaching effectiveness, role modeling, facilitating knowledge acquisition, and teaching procedures. Using both between- and within-subject samples, they conducted analyses to examine gender differences among the trainees making ratings (rater effects), the faculty receiving ratings (ratee effects), and whether faculty ratings differed by trainee gender (interaction effects). RESULTS: There was a statistically significant rater effect for the overall teaching effectiveness and facilitating knowledge acquisition dimensions (B = -0.28 and -0.14, 95% CI: [-0.35, -0.21] and [-0.20, -0.09], respectively, P < .001, medium corrected effect sizes between -0.34 and -0.54); female trainees rated male and female faculty lower than male trainees on both dimensions. There also was a statistically significant ratee effect for the overall teaching effectiveness and role modeling dimensions (B = -0.09 and -0.08, 95% CI: [-0.16, -0.02] and [-0.13, -0.04], P = .01 and < .001, respectively, small to medium corrected effect sizes between -0.16 and -0.44); female faculty were rated lower than male faculty on both dimensions. There was not a statistically significant interaction effect. CONCLUSIONS: Female trainees rated faculty lower than male trainees and female faculty were rated lower than male faculty on 2 teaching dimensions each. The authors encourage researchers to continue to examine the reasons for the evaluation differences observed and how implicit bias interventions might help to address them.

Impact of Ocular Conditions and Improvements After Refractive Surgery in Quality of Life for Children With Neurodevelopmental Disorders.

PURPOSE: This study aims to characterize the eye-related quality of life of children with neurodevelopmental and ocular disorders at baseline and after refractive surgery. DESIGN: Prospective interventional case series. METHODS: We enrolled children and adolescents 5 to 18 of age with neurodevelopmental disorders undergoing refractive surgery (6 for pre-/postsurgical assessment and 14 for baseline analysis). Eye-related quality of life was measured using the Pediatric Eye Questionnaire (PedEyeQ). Baseline levels of adaptive functioning and social behaviors were measured using the Adaptive Behavioral Assessment System (ABAS-3) and Social Responsiveness Scale (SRS-2). We assessed the correlation between baseline PedEyeQ scores, number of ocular comorbidities, magnitude of refractive error, and ABAS-3 and SRS-2 scores. RESULTS: At baseline, 14 patients demonstrated decreased median eye-related quality of life (<60/100) in 5 of 9 PedEyeQ domains, moderate deficiencies in social behaviors (SRS-2 median 71, range 49-90), and low adaptive functioning (ABAS-3 median percentile for age of 0.100). Baseline PedEyeQ scores did not correlate with magnitude of refractive error or adaptive functioning scores but did correlate with number of ocular comorbidities and social behavior scores. Six patients have undergone refractive surgery without complication. Postoperatively, 11 of 11 eyes were within ±1.5 diopters spherical equivalent. Four of 6 patients exhibited clinically significant improvements in PedEyeQ scores after surgery. CONCLUSIONS: Even in the presence of significant social and adaptive impairments, quality of life in children with neurodevelopmental disorders is decreased by ocular disorders. Refractive surgery is associated with clinically significant improvements in eye-related quality of life.

Visual Acuity Outcomes and Loss to Follow-up in the Treatment of Amblyopia in Children From Lower Socioeconomic Backgrounds.

PURPOSE: To compare visual acuity outcomes and loss to follow-up after initiation of treatment for unilateral amblyopia in children from different socioeconomic backgrounds. METHODS: Medical records of children diagnosed as having unilateral amblyopia at an initial encounter between 2015 and 2018 were reviewed. Medicaid and private insurance were used as proxies for socioeconomic status (SES). Data points were collected at the patients' initial, follow-up, and final visits. Visual acuity improvement was the primary outcome variable in patients with at least one follow-up appointment. In a separate analysis, failure to attend a single follow-up appointment was examined for associations with SES, race, sex, and distance traveled to appointments. RESULTS: Seventy-three patients met the inclusion criteria; of these, 28 had Medicaid and 45 had private insurance. Visual acuity improved by 2.86 lines in the Medicaid group and 2.98 lines in the private insurance group (P = .84). Number of missed appointments and distance traveled did not correlate with visual acuity improvement. In the loss to follow-up subanalysis, 40 of 141 (28.4%) patients with Medicaid and 11 of 107 (10.3%) patients with private insurance failed to attend a single follow-up visit (P = .001). No association was found between loss to follow-up and race, sex, or distance traveled. CONCLUSIONS: Visual acuity outcomes of treatment for amblyopia did not differ between patients with Medicaid and patients with private insurance who followed up. However, patients with Medicaid were much more likely to be immediately lost to follow-up. Measures should be taken by eye care providers and pediatricians to increase follow-up in patients from low SES populations. [J Pediatr Ophthalmol Strabismus. 2022;59(2):110-117.].

Income Disparities in Outcomes of Horizontal Strabismus Surgery in a Pediatric Population.

PURPOSE: To examine postoperative outcomes in pediatric patients undergoing strabismus surgery to determine the potential impact of socioeconomic disparities on ophthalmic outcomes. METHODS: This study included 284 children undergoing strabismus surgery at a tertiary institution with at least 11 months of follow-up and no prior strabismus surgery or other neurologic or ophthalmologic conditions. Demographics, insurance, operative parameters, and appointments scheduled/attended were collected via chart review. Ocular alignment was recorded preoperatively and postoperatively at 3, 12, and 24 months. Two-sided t tests and chi-squared analyses were used to compare demographic and operative parameters. Logistic regression was employed to determine predictive factors for ophthalmic outcomes. RESULTS: There was no difference in failure rates between patients with Medicaid and patients with private insurance 24 months postoperatively (45.9% vs 50.5%, respectively, P = .46). Patients with Medicaid were more likely to not follow up postoperatively (28.2% vs 9.6%, respectively, P < .01), whereas patients with private insurance were more likely to complete more than three follow-up appointments in 24 months (21.5% vs 39.0%, respectively, P < .01). Postoperative attendance was linked to Medicaid status (P < .01) but not travel time, neighborhood income levels, or social deprivation index factors. CONCLUSIONS: There was no difference in failure rates between patients with Medicaid and patients with private insurance. Medicaid status was significantly predictive of loss to follow-up. [J Pediatr Ophthalmol Strabismus. 2022;59(3):156-163.].

Development of a taxonomy of unprofessional behavior in clinical learning environments using learner-generated critical incidents.

PURPOSE: Few studies have examined medical residents' and fellows' (trainees) direct experience of unprofessional behavior in clinical learning environments (CLE). The purpose of this study was to create a taxonomy of unprofessional behavior in CLEs using critical incidents gathered from trainees. METHOD: In step 1 (data collection), the authors collected 382 critical incidents from trainees at more than a dozen CLEs over a six-year period (2013-2019). In step 2 (model generation), nine subject matter experts (SMEs) sorted the incidents into homogenous clusters and this structure was tested with principal components analysis (PCA). In step 3 (model evaluation), two new groups of SMEs each re-sorted half of the incidents into the PCA-derived categories. RESULTS: A 13-component solution accounted for 62.46% of the variance in the critical incidents collected. The SMEs who re-sorted the critical incidents demonstrated good agreement with each other and with the 13-component PCA solution. The resulting taxonomy included 13 dimensions, with 48.7% of behaviors focused on displays of aggression or discriminatory conduct. CONCLUSIONS: Critical incident methodology can provide unique insights into the dimensionality of unprofessional behavior in the CLE. Future research should leverage the taxonomy created to inform professionalism assessment development in the CLE.

Assessing the Clinical Requirement of 2.5% Phenylephrine for Diagnostic Pupil Examination.

Purpose: To evaluate whether the standard dilating drop regimen consisting of phenylephrine, tropicamide, and proparacaine produces clinically significant improvement in pupil size compared to tropicamide and proparacaine during diagnostic eye examination. Methods: Sixty-three adult patients at Washington University School of Medicine Eye Clinic were enrolled in this prospective, randomized trial. Each patient received one of two dilating drop regimens: phenylephrine + tropicamide + proparacaine (PE+T+PP), which is considered the standard therapy, or tropicamide + proparacaine (T+PP). Main outcome measures were the proportion of pupils able to achieve successful clinical examination without need for additional dilating drops and change in predilation to postdilation pupil size. Comparisons were made using McNemar's test, repeated measures analysis of variance, and Fisher's test to determine whether PE is a necessary component of the standard eye examination. Results: There were no statistically significant differences between the PE+T+PP and T+PE treatment groups in predilation to postdilation changes in average resting pupil size (1.58 ± 0.66 and 2.61 ± 0.79; P = 0.57) or constricted pupil size (2.52 ± 0.93 and 3.56 ± 0.96; P = 0.15). There was no statistically significant difference between patients who obtained a successful dilated pupil examination between those receiving PE+T+PP and those receiving T+PP as determined by the examining physicians (Fisher's, P = 0.67). Conclusion: The addition of phenylephrine to tropicamide and proparacaine did not improve pupillary dilation size or ability to conduct a clinical examination. A single dilating agent using tropicamide should be considered in clinical practice.

Crowdsourced Assessment of Surgical Skill Proficiency in Cataract Surgery.

OBJECTIVE: To test whether crowdsourced lay raters can accurately assess cataract surgical skills. DESIGN: Two-armed study: independent cross-sectional and longitudinal cohorts. SETTING: Washington University Department of Ophthalmology. PARTICIPANTS AND METHODS: Sixteen cataract surgeons with varying experience levels submitted cataract surgery videos to be graded by 5 experts and 300+ crowdworkers masked to surgeon experience. Cross-sectional study: 50 videos from surgeons ranging from first-year resident to attending physician, pooled by years of training. Longitudinal study: 28 videos obtained at regular intervals as residents progressed through 180 cases. Surgical skill was graded using the modified Objective Structured Assessment of Technical Skill (mOSATS). Main outcome measures were overall technical performance, reliability indices, and correlation between expert and crowd mean scores. RESULTS: Experts demonstrated high interrater reliability and accurately predicted training level, establishing construct validity for the modified OSATS. Crowd scores were correlated with (r = 0.865, p < 0.0001) but consistently higher than expert scores for first, second, and third-year residents (p < 0.0001, paired t-test). Longer surgery duration negatively correlated with training level (r = -0.855, p < 0.0001) and expert score (r = -0.927, p < 0.0001). The longitudinal dataset reproduced cross-sectional study findings for crowd and expert comparisons. A regression equation transforming crowd score plus video length into expert score was derived from the cross-sectional dataset (r2 = 0.92) and demonstrated excellent predictive modeling when applied to the independent longitudinal dataset (r2 = 0.80). A group of student raters who had edited the cataract videos also graded them, producing scores that more closely approximated experts than the crowd. CONCLUSIONS: Crowdsourced rankings correlated with expert scores, but were not equivalent; crowd scores overestimated technical competency, especially for novice surgeons. A novel approach of adjusting crowd scores with surgery duration generated a more accurate predictive model for surgical skill. More studies are needed before crowdsourcing can be reliably used for assessing surgical proficiency.

Gender Differences in Case Volume Among Ophthalmology Residents.

IMPORTANCE: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. OBJECTIVE: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency. DESIGN, SETTING, PARTICIPANTS: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018. MAIN OUTCOMES AND MEASURES: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status. RESULTS: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (ß = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (ß = -8.0 [95% CI, -14.0 to -2.1]; P = .008). CONCLUSIONS AND RELEVANCE: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.

New advances in amblyopia therapy II: refractive therapies.

The treatment of anisometropic or ametropic amblyopia has traditionally enjoyed a high treatment success rate. Early initiation and consistent use of spectacle correction can completely resolve amblyopia in a majority of patients. For those with anisometropic amblyopia that fail to improve with glasses wear alone, patching or atropine penalisation can lead to equalisation of visual acuity. However, successful treatment requires full-time compliance with refractive correction and this can be a challenge for a patient population that often has one eye with good acuity without correction. Other barriers for a select population with high anisometropic  or ametropic amblyopia include rejection of glasses for various reasons including discomfort, behavioural or sensory problems, postural issues and visually significant aniseikonia. When consistent wear of optical correction proves difficult and patching/atropine remains a major obstacle, surgical correction of refractive error has proven success in achieving vision improvement. Acting as a means to achieve spectacle independence or reducing the overall needed refractive correction, refractive surgery can offer a unique treatment option for this patient population. Laser surgery, phakic intraocular lenses and clear lens exchange are three approaches to altering the refractive state of the eye. Each has documented success in improving vision, particularly in populations where glasses wear has not been possible. Surgical correction of refractive error has a risk profile greater than that of more traditional therapies. However, its use in a specific population offers the opportunity for improving visual acuity in children who otherwise have poor outcomes with glasses and patching/atropine alone.

New advances in amblyopia therapy I: binocular therapies and pharmacologic augmentation.

Amblyopia therapy options have traditionally been limited to penalisation of the non-amblyopic eye with either patching or pharmaceutical penalisation. Solid evidence, mostly from the Pediatric Eye Disease Investigator Group, has validated both number of hours a day of patching and days per week of atropine use. The use of glasses alone has also been established as a good first-line therapy for both anisometropic and strabismic amblyopia. Unfortunately, visual acuity equalisation or even improvement is not always attainable with these methods. Additionally, non-compliance with prescribed therapies contributes to treatment failures, with data supporting difficulty adhering to full treatment sessions. Interest in alternative therapies for amblyopia treatment has long been a topic of interest among researchers and clinicians alike. Incorporating new technology with an understanding of the biological basis of amblyopia has led to enthusiasm for binocular treatment of amblyopia. Early work on perceptual learning as well as more recent enthusiasm for iPad-based dichoptic training have each generated interesting and promising data for vision improvement in amblyopes. Use of pharmaceutical augmentation of traditional therapies has also been investigated. Several different drugs with unique mechanisms of action are thought to be able to neurosensitise the brain and enhance responsiveness to amblyopia therapy. No new treatment has emerged from currently available evidence as superior to the traditional therapies in common practice today. But ongoing investigation into the use of both new technology and the understanding of the neural basis of amblyopia promises alternate or perhaps better cures in the future.

Probability of Success in the Ophthalmology Residency Match: Three-Year Outcomes Analysis of San Francisco Matching Program Data.

OBJECTIVE: To develop a probability model of matching into a US ophthalmology residency program using San Francisco Matching Program (SF Match) data. DESIGN: Retrospective data analysis of de-identified application and matching data. PARTICIPANTS: Registrants for the 2013, 2014, and 2015 ophthalmology residency matches conducted by the SF Match. METHODS: Descriptive statistics of candidates, comparison of continuous and categorical variables between matched and nonmatched candidates, and linear regression modeling were performed. A recursive partitioning method was used to create a probability of matching algorithm. MAIN OUTCOME MEASURES: Probability of successfully matching based on quantifiable candidate characteristics. RESULTS: Over the 3-year period, 1,959 individuals submitted an average of 64 applications and received a mean of nine interview invitations. The overall match rate was 71%, with 78% matching at one of their top five choices. Successful matches were more likely to occur in US medical school graduates (78% vs 20%, p < 0.001) and applicants on their first attempt (76% vs 29%, p < 0.001). The association between matching and number of programs applied became negative with > 48 applications. Probability of matching was "high" (> 80%) among US graduates with a step 1 United States Medical Licensing Examination (USMLE)score>243(regardless of number of programs applied to), a step 1 USMLE score of 231 to 243 who applied to at least 30 programs, and first-time applicants with a step 1 score >232. No international medical graduates or repeat applicants had a "high" probability of matching. CONCLUSIONS: Although advice must be individualized for each candidate, applicants for ophthalmology residency who fall into a "high" probability of matching group are likely to be successful with applications to 45 or fewer programs. Applying to 80 or more programs should be considered for international medical graduates and/or applicants who are previously unmatched. Modification of the match application data form may allow more detailed analysis of variables such as Alpha Omega Alpha or Gold Humanism Honor Society membership, research activity, and composite evaluation on a standardized letter of recommendation.

Assessing the utility of 2.5% phenylephrine for diagnostic pupillary dilation.

OBJECTIVE: To evaluate whether the addition of phenylephrine to tropicamide produces any clinically significant change in pupil size during diagnostic eye examination. METHODS: Twenty healthy adults at the Washington University School of Medicine Eye Clinic were enrolled in this prospective, nonrandomized, crossover trial. Each had 3 dilating eye drop regimens administered to the left eye on separate days. Tropicamide (T) + proparacaine (PP) + phenylephrine (PE) (T+PP+PE) was considered the standard therapy, to which tropicamide alone (T alone) and tropicamide + proparacaine (T+PP) were compared against. Main outcome measures were postdilation pupil size and proportion of pupils able to achieve adequate clinical pupil dilation of >7 mm. Comparisons were made using Wilcoxon signed-ranked tests and McNemar's test. RESULTS: Mean postdilation pupil size was 7.94 ± 0.78 mm, 7.64 ± 0.78 mm, and 7.48 ± 0.77 mm for T+PP+PE, T+PP, and T alone, respectively. T+PP+PE was statistically superior to T+PP (p = 0.004) and T alone (p < 0.001) with respect to postdilation pupil size. The proportion of pupils able to achieve adequate pupil dilation of >7 mm was 90%, 80%, and 70% for T+PP+PE, T+PP, and T alone, respectively. No statistical difference was observed in each regimen's ability to achieve adequate pupil dilation of >7 mm (T+PP+PE and T+PP: p = 0.47; T+PP+PE and T alone: p = 0.13). CONCLUSION: The addition of phenylephrine eye drops to tropicamide produced larger pupil dilation, but the magnitude of benefit was marginal and clinically insignificant in this young, healthy cohort. A single-dilating-agent regimen using tropicamide could be considered in routine clinical practice.

Functional connectivity alterations in a murine model of optic neuritis.

The basis for neuronal dysfunction following inflammatory demyelination of the central nervous system (CNS) remains poorly understood. We characterized the network response to white matter injury in the anterior visual pathway using an experimental model of optic neuritis (ON), as ON is often an early manifestation of immune-mediated CNS demyelination in multiple sclerosis (MS). Optical intrinsic signal imaging was performed before and after the induction of ON in mice to measure changes in cortical network functional connectivity. We observed a greater loss of connectivity between homotopic visual cortices in ON mice compared to controls. Further, decreases in homotopic visual cortex connectivity were associated with visual acuity loss in ON mice. These results demonstrate that network connectivity changes resulting from ON can be modeled in an experimental murine system. Future studies will identify the mechanisms that cause neuronal dysfunction due to white matter injury seen in MS.

Assessing Progression of Resident Proficiency during Ophthalmology Residency Training: Utility of Serial Clinical Skill Evaluations.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residency programs document progression of competency-based outcomes. The Ophthalmic Clinical Evaluation Exercise (OCEX) assesses clinical skills in ophthalmology residents during patient encounters. Although OCEX has been validated for assessing several of the ACGME-mandated competencies, it was unclear whether OCEX can measure the development of proficiency during residency. This study evaluated whether OCEX can discriminate skill levels across years in training. METHODS: In 2017, the authors performed a retrospective analysis on modified OCEX evaluations collected for 22 residents over 3 years at 2 residency programs. OCEX subcomponent scores were averaged to generate a mean score for each evaluation, followed by linear regression analysis for mean scores over time for individual residents. One-way ANOVA with repeated measures was used to compare scores aggregated over an academic year between resident classes. The authors also surveyed internal faculty evaluators and nationwide ophthalmology residency program directors on their use of OCEX. RESULTS: Mean OCEX scores for individual residents and resident class averages showed variable trajectories over the course of residency. There was no consistent effect of increasing level of training on scores. Surveys of evaluators and program directors indicated different interpretations of the grading scale anchors and irregular participation by faculty. CONCLUSION: This dataset suggests that, despite clear behavioral anchors and faculty development on the use of the tool, evaluators still apply inconsistent grading standards that limit the OCEX from accurately monitoring longitudinal development of resident clinical performance in real-world practice.

Obtaining Lissamine Green 1% Solution for Clinical Use.

PURPOSE: With new compounding pharmacy laws, the only economically feasible approach to using lissamine is through dye-impregnated strips. This research aims to determine the concentration of lissamine that can be obtained using a single commercially available lissamine strip. With the optimal vital staining requiring 1% concentration of lissamine, we sought to obtain this concentration using supplies in an ordinary ophthalmology clinic. METHODS: A standard curve was generated using compounded lissamine green 1% solution. Serial dilutions were made with 3 different diluents and measured using a spectrophotometer at a wavelength of 633 µm. Combinations of the number of strips, amount of solvent, and absorption time were performed to obtain a 1% solution. Cost analyses were performed to select the most economical method. RESULTS: Single lissamine strips wetted with any of the diluents produced 0.17% ± 0.05% (95% confidence interval) lissamine solution, a 5-fold weaker concentration than the optimal for vital staining. Combinations of 4 strips in 200 µL (4 drops) for 1 minute and 2 strips in 200 µL for 5 minutes were found to reach concentrations of 1%. Cost analysis showed that the 2 strip/4 drops/5 minutes method costs $0.67 and the 4 strips/4 drops/1 minute method $1.27. CONCLUSIONS: Use of a single lissamine strip leads to suboptimal concentrations for vital staining. With only the addition of disposable microcentrifuge tubes to the clinical setting, ophthalmologists can make 1% solutions of lissamine. This solution is both more economical and in compliance with both state and national compounding laws.