Perspectives of Resident and Attending Ophthalmologists on Common Ethical Dilemmas in Research.

Purpose To assess how resident and attending ophthalmologists perceive and evaluate ethically controversial scenarios regarding mentorship, authorship, and ethics compliance that may occur during research involving residents. Methods An online survey was developed and contained 14 controversial vignettes based on common research scenarios that can occur when conducting research with trainees. The scenarios were designed to capture issues regarding three themes: mentorship, authorship, and compliance with ethical guidelines. Resident and attending ophthalmologists at eight military and civilian academic residency programs in the United States were invited to participate. Respondents used a Likert scale to assess the ethicality of the situations in addition to self-reported demographic characteristics. Results The response rate was 35.6% (77/216), consisting of 37.7% ( n = 29) residents and 62.3% ( n = 48) attendings. More attending ophthalmologists responded than residents ( p = 0.004). Many respondents identified controversies around compliance (67.3%) and authorship (57.1%) as unethical, whereas situations regarding mentorship were largely viewed as neutral to ethical (68.0%). Responses to two scenarios, one regarding mentorship and one regarding authorship, significantly differed between residents and attendings ( p = 0.001 and p = 0.022, respectively). Conclusion Academic ophthalmologists' perceptions of the ethicality of common research scenarios varied. There is a need for more prescriptive guidelines for authorship and mentorship ethics at all training levels to ensure consistency, fairness, and integrity of research.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers.

BACKGROUND: Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited. OBJECTIVE: To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering. DESIGN: and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020. MAIN MEASURES: Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates. KEY RESULTS: Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered. CONCLUSIONS: In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Trends and Surgeon Variations in Early Regrafts After Endothelial Keratoplasty: Analysis of the National Medicare Data Set.

PURPOSE: The aims of this study were to determine national-level trends in early regraft rates and examine patient-level and surgeon-level characteristics associated with early regrafts. METHODS: This was a retrospective, cohort study. We identified beneficiaries aged 65 years or older in the 2011 to 2020 Medicare carrier claims data set who underwent Endothelial keratoplasty (EK) and subsequently underwent an early regraft. The incidence of early regraft for each year was calculated and patient-level and surgeon-level characteristics associated with regrafts were examined using a multivariable regression model. RESULTS: Of 114,383 EK procedures, 4119 (3.60%) were followed by an early regraft, with no significant variations in the rates between years ( P = 0.59). Factors associated with higher odds of early regraft were Black compared with White race (OR 1.151; 95% confidence interval (CI) 1.018-1.302) and the highest quartile of income versus the lowest quartile (OR 1.120; 95% CI 1.002-1.252). Factors associated with lower odds were female sex (OR 0.889; 95% CI 0.840-0.942), receiving surgery in a hospital-based outpatient department versus an ambulatory center (OR 0.813; 95% CI 0.740-0.894), and having a surgeon with the highest quartile of annual EK volume versus the lowest (OR 0.726; 95% CI 0.545-0.967). Early regraft rates among surgeons ranged from 0% to 58.8% with a median [interquartile range] of 3.13 [0-6.15]. CONCLUSIONS: We found no significant increases in the early regraft rates over the past decade in the United States. Patient male sex and Black race, ambulatory surgery center-based location of the surgery, and low surgeon EK volume were associated with early regrafts. Substantial surgeon variability in regraft rates may indicate opportunities for improvement through development of best practices on perioperative management and patient counseling.

Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review.

The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.

Baltimore pediatric ocular trauma study: Health disparities and outcomes in pediatric and adolescent open globe trauma.

Purpose Children represent approximately one-third of patients with serious ocular injuries. Our study evaluates associations between race and socioeconomic status in presentation and outcomes of pediatric and adolescent traumatic open globe injuries. Methods We conducted a retrospective chart review of traumatic open globe injuries in pediatric and adolescent patients presenting to Johns Hopkins Hospital and University of Maryland Medical Center between 2006 and 2020. Variables assessed included age, gender, parent-identified race, median household income, mechanism of injury, initial and final visual acuity (VA), and length of follow-up. Results Eighty patients ranging from 4 months to 17.7 years (mean 9.3 years) presented with traumatic open globe injury. Identifications were 28 White (35%), 38 Black (48%), and 5 Hispanic (6%). Initial presenting and final VA, pediatric ocular trauma score (POTS), and length of follow-up did not differ significantly among race, gender, or income. Black patients had higher rates of blunt trauma (odds ratio (OR) 3.81; 95% confidence interval (CI) 0.95-15.24, p = 0.07), uveal prolapse (OR 3.58; 95% CI 1.03-12.43; p = 0.049), and enucleation (OR 10.55; 95% CI 1.26-88.31). Hispanic patients presented at a younger age of 2.8 years mean age vs. 9.9 years (p = 0.004) for others. Conclusion Visual outcomes following traumatic open globe injury were independent of race, gender, or income. However, blunt trauma, uveal prolapse, and enucleation rates were higher in Black patients, and ocular trauma occurred at a younger age in Hispanic patients.

Global Current Practice Patterns for the Management of Hyphema.

Purpose: Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide. Methods: A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution. Results: For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution. Conclusion: Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.

Association Between Parental Leave and Ophthalmology Resident Physician Performance.

Importance: Although parental leave is essential in enhancing resident wellness and fostering inclusive workplace environments, residents may often feel discouraged from using parental leave owing to perceived stigma and concerns about possible negative effects on their training. Objective: To examine parental leave usage across multiple institutions and compare residency performance metrics between residents who took parental leave vs their peers who did not take leave. Design, Setting, and Participants: This was a retrospective cross-sectional analysis conducted from April 1, 2020, to July 28, 2022, of educational records. Multicenter data were obtained from 10 Accreditation Council for Graduate Medical Education (ACGME)-accredited ophthalmology programs across the US. Included ophthalmology residents graduated between 2015 and 2019. Data were analyzed from August 15, 2021, to July 25, 2022. Exposures: Performance metrics of residents who used parental leave during residency were compared with those of residents who did not take parental leave. Main Outcomes and Measures: Measures of performance included the Ophthalmic Knowledge Assessment Program (OKAP) scores, ACGME milestones scores, board examination pass rates, research activity, and surgical volumes. Results: Of the 283 ophthalmology residents (149 male [52.7%]) included in the study, 44 (15.5%) took a median (IQR) parental leave of 4.5 (2-6) weeks. There were no differences in average OKAP percentiles, research activity, average ACGME milestones scores, or surgical volume between residents who took parental leave and those who did not. Residents who pursued fellowship were less likely to have taken parental leave (odds ratio [OR], 0.43; 95% CI, 0.27-0.68; P < .001), and residents who practiced in private settings after residency were more likely to have taken parental leave (OR, 3.56; 95% CI, 1.79-7.08; P < .001). When stratified by sex, no differences were identified in performance between female residents who took parental leave compared with residents who did not take leave, except a mild surgical number difference in 1 subspecialty category of keratorefractive procedures (difference in median values, -2; 95% CI, -3.7 to -0.3; P = .03). Conclusions and Relevance: In this multicenter cross-sectional study, no differences in performance metrics were identified between residents taking parental leave compared with their peers. These findings may provide reassurance to trainees and program directors regarding the unlikelihood, on average, that taking adequate parental leave will affect performance metrics adversely.

Globe and Adnexal Trauma Terminology Survey.

Importance: Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings. Objective: To update terminology for globe and adnexal trauma. Design, Setting, and Participants: A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles. Main Outcomes and Measures: Expert consensus on ocular and adnexal terms. Results: A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology. Conclusions and Relevance: There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

Descemet membrane endothelial keratoplasty in eyes with COL8A2-associated corneal dystrophy.

Purpose: The p.(Leu450Trp) COL8A2 mutation, associated with an early-onset corneal endothelial dystrophy, can result in bullous keratopathy within the first few decades of life. People with this condition frequently experience anterior corneal changes in keratometry as the disease worsens, which may potentially affect refractive error after endothelial keratoplasty. We describe outcomes of the first cases of Descemet Membrane Endothelial Keratoplasty (DMEK) for patients with known mutations in this gene. Observations: Four eyes from two patients with COL8A2-associated corneal dystrophy underwent DMEK for this condition at a tertiary academic center. Preoperative and postoperative Scheimpflug imaging and manifest refraction was conducted. Mean central corneal thickness decreased from 713 µm preoperatively to 529 µm at one month. Despite long-standing corneal haze, all eyes reached between 20/20 and 20/30 best corrected visual acuity, and minimum postoperative central corneal thickness reached 482, 479, 479 and 533 µm. Refractive changes frequently occurred during the first postoperative year, with 3.6 D, 3.3 D, 3 D, and 0.8 D shifts in spherical equivalent taking place within this time period in the four eyes. Conclusions and Importance: In two patients with the p.(Leu450Trp) mutation in COL8A2 who underwent DMEK, resolution of corneal edema resulted in centrally thin corneas and refractive shifts postoperatively. Despite chronic edema, excellent visual acuity was achieved in all eyes.

The impact of COVID-19 on ophthalmology resident surgical experience: a retrospective cross-sectional analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to in-office and surgical procedures in the field of ophthalmology. The magnitude of the impact of the pandemic on surgical training among ophthalmology residents is not known. This study aims to quantify changes in average case logs among United States (U.S.) ophthalmology residency graduates prior to and during the COVID-19 pandemic. METHODS: Retrospective, cross-sectional analysis of aggregate, national data on case logs of U.S. ophthalmology residency graduates from 2012 to 2020. The yearly percent change in the average number of procedures performed in the Accreditation Council for Graduate Medical Education (ACGME) ophthalmology resident case logs were analyzed using linear regression on log-transformed dependent variables. The average percent change from 2019 to 2020 was compared to the average yearly percent change from 2012 to 2019 for procedures performed as the primary surgeon, and primary surgeon and surgical assistant (S + A), as well as procedures for which there are ACGME minimum graduating numbers. RESULTS: Across all procedures and roles, average case logs in 2020 were lower than the averages in 2019. While average total cases logged as primary surgeon increased yearly by 3.2% (95% CI: 2.7, 3.8%, p < 0.001) from 2012 to 2019, total primary surgeon case logs decreased by 11.2% from 2019 to 2020. Cataract (-22.0%) and keratorefractive (-21.1%) surgery experienced the greatest percent decrease in average primary surgeon cases logged from 2019 to 2020. Average total cases logged as S + A experienced an average yearly increase by 1.2% (95% CI: 0.9,1.6%, p < 0.001) prior to 2020, but decreased by 9.6% from 2019 to 2020. For ACGME minimum requirements, similar changes were observed. Specifically, the average case logs in YAG, SLT, filtering (glaucoma), and intravitreal injections had been increasing significantly prior to 2020 (p < 0.05 for all) but decreased in 2020. CONCLUSIONS: These findings demonstrate the vulnerability of ophthalmology residency programs to a significant interruption in surgical volume. There is a critical need for development of competency-based, rather than volume-based, requirements to evaluate readiness for independent practice.

Ghost and Honorary Authorship in Ophthalmology: A Cross-Sectional Survey.

PURPOSE: To evaluate the rates of ghost and honorary authorship in ophthalmology and to determine risk factors associated with ghost and honorary authorship. DESIGN: Cross-sectional survey. METHODS: Corresponding authors of articles published in Ophthalmology, JAMA Ophthalmology, and the American Journal of Ophthalmology from June 2019 to December 2020 were emailed an electronic survey. The rates of ghost and honorary authorship, demographic characteristics of the corresponding authors with and without ghost and honorary authorship, and risk factors for ghost and honorary authorship were evaluated. RESULTS: Corresponding authors (n = 830) were emailed a survey and 278 total responses (34.1%) were received; 227 responses (27.9%) were complete and included for analysis. Most respondents (n = 206, 90.7%) believed that the International Committee of Medical Journal Editors (ICMJE) guidelines for authorship adequately address criteria for authorship. Twenty-seven corresponding authors (11.9%) reported characteristics of their articles that indicated the presence of both ghost and honorary authorship (95% CI, 7.7%-16.1%). One hundred fifteen (50.7%) reported honorary authorship (44.2%-57.2%), and 37 (16.3%) indicated ghost authorship (11.5%-21.1%). Being a resident or fellow corresponding author increased the risk of honorary authorship (OR 11.75; 1.91-231.57; P = .03). There were no factors that predicted articles having ghost authors. CONCLUSIONS: While many authors believe the ICMJE guidelines for authorship comprehensively delineate fair authorship practices, listing authors on scientific publications honorarily and excluding authors who qualify for authorship are relatively common practices in ophthalmological research. Further investigation into the drivers of honorary and ghost authorship practices in ophthalmology, and the effectiveness of preventive measures are needed to ensure fair authorship attributions.

Corneal Edema and Keratoplasty: Risk Factors in Eyes With Previous Glaucoma Drainage Devices.

PURPOSE: To assess risk factors contributing to corneal decompensation following glaucoma drainage device (GDD) implantation. DESIGN: Retrospective case control study. METHODS: Records of 1610 eyes that underwent GDD implantation between June 1, 2009, and April 1, 2020, at the Johns Hopkins Wilmer Eye Institute were reviewed. Seventy-nine eyes (5%) developed corneal decompensation, of which 46 underwent keratoplasty. These 79 cases were matched with 220 controls. Cox proportional hazard models with robust standard error estimates to account for clustering at the matched-pair level were used to assess risk factors for corneal decompensation. Kaplan-Meier survival analysis analyzed time to corneal decompensation. RESULTS: The mean (SD) age of cases and controls was 68 (12.3) and 60.5 (15.9) years, respectively. The mean time from GDD implantation to corneal decompensation was 32 months, and the cumulative probability of developing decompensation at 3, 6, and 9 years was 4.7%, 9.2%, and 14.8%, respectively. Final visual outcomes in cases were worse, with a final mean ± SD visual acuity (logMAR) of 1.96±1.25 relative to a mean±SD visual acuity of 1.11±1.36 in controls (P < .001). In the multivariable model, significant risk factors for corneal decompensation were increased age (adjusted hazard ratio [AHR] 1.39, 95% CI 1.18, 1.63; P ≤ .001), history of Fuchs dystrophy or iridocorneal endothelial syndrome (AHR 9.18, 95% CI 5.35, 15.74; P ≤ .001), and postoperative complications such as hypotony (AHR 3.25, 95% CI 1.85, 5.72; P ≤ .001) and tube-cornea touch (AHR 6.37, 95% CI 3.77, 10.75; P ≤ .001). CONCLUSIONS: The risk of postoperative corneal decompensation is persistent over time. Patients receiving GDDs, particularly those with advanced age, preexisting corneal pathology, and postoperative complications, should be counseled regarding their increased risk for corneal decompensation.

Exposure of Ophthalmology Residents to Cornea and Keratorefractive Surgeries in the United States.

Purpose To describe the cornea and keratorefractive surgeries experience of U.S. ophthalmology residents. Methods Deidentified case logs of residents graduating in 2018 were collected from ophthalmology residency program directors in the United States. Using Current Procedure Terminology codes, case logs were reviewed in the categories of cornea and keratorefractive surgeries. Accreditation Council for Graduate Medical Education national graduating resident surgical case logs on cornea procedures published from 2010 to 2020 were also analyzed. Results Case logs were received for 152/488 (31.1%) residents from 36/115 (31.3%) ophthalmology residency programs. The most common procedures logged by residents as primary surgeons were pterygium removal (4.3 ± 4.2) and keratorefractive surgeries (3.6 ± 6.2). Residents logged an average of 2.4 keratoplasties as primary surgeon, performing an average of 1.4 penetrating keratoplasties (PKs) and 0.8 endothelial keratoplasties (EKs). As assistants, the most common procedures logged were keratorefractive surgeries (6.1 ± 4.9), EKs (3.8 ± 3.3), and PKs (3.5 ± 2.3). Medium or large residency class size was associated with higher cornea procedural volumes (odds ratio: 8.9; 95% confidence interval: 1.1-75.6; p < 0.05). Conclusion The most common cornea surgeries performed by residents include keratoplasty, keratorefractive, and pterygium procedures. Larger program size was associated with greater relative cornea surgery volume. More specific guidelines for logging of procedures could provide a more accurate assessment of resident exposure to critical techniques such as suturing as well as reflect trends in current practice such as the overall increase in EKs.

Use of Teleophthalmology for Evaluation of Ophthalmic Emergencies by Ophthalmology Residents in the Emergency Department.

Background:Utilizing telemedicine is one approach to reduce the ever-increasing burden of patients on emergency departments (EDs) and consulting physicians. Utilization of telemedicine services in the ED may also benefit resident education.Materials and Methods:Ten first-year ophthalmology residents were trained to use a Topcon 3D Optical Coherence Tomography (OCT)-1 Maestro to capture OCT images and fundus photos in patients presenting to the ED with urgent ophthalmic concerns. Findings were communicated to the supervising ophthalmologist. Retrospective chart review was conducted to obtain patient characteristics and final ophthalmologist diagnosis. Residents rated ease of use, technical reliability, and educational value through a survey.Results:From December 1, 2019, to December 1, 2020, the device was used in 109 patient encounters, capturing 887 images (average 8.1 images per encounter). Patients on whom the device was used were on average 48.5 years old (±17.2, range 17-90) and 59.6% were female. The imaging device was utilized most commonly for evaluating papilledema (n = 21, 18.6%), new-onset visual acuity/visual field defects (n = 12, 10.6%), retinal detachment/tear (n = 8, 7.1%), and ophthalmic trauma workup (n = 8, 7.1%). Eight residents completed the survey and most (n = 7) agreed or strongly agreed that the device helped them diagnose patients more accurately. Technical issues such as machine malfunction, image artifacts, and problems syncing with the electronic health record and computer were noted by survey respondents.Conclusions:The most common use of teleophthalmology in the ED setting was evaluation of papilledema; the majority of residents perceived an educational benefit from this tool. Efforts should be made to address the technical challenges to increase the utility of this device.

Global Current Practice Patterns for the Management of Open Globe Injuries.

PURPOSE: To determine global current practice patterns for the management of open globe injuries and identify areas of variation. DESIGN: Cross-sectional survey. METHODS: An online survey assessed global management paradigms for open globe injuries from August 2020 to January 2021. Responses were collected from experts at eye trauma centers and emergency departments worldwide who manage ≥1 open globe injury per month. The survey assessed the use/selection of antibiotics and steroids, procedural and imaging decisions, and admission practices for open globe injuries. RESULTS: Responses were received from representatives of 36 of 42 institutions (85.7%), of which 33 (78.6%) had sufficient trauma volume to be included. Included responses were distributed across North America (n=12, 36.4%), Asia (n=12, 36.4%), South America (n=4, 12.1%), Africa (n=3, 9.1%), Europe (n=1, 3.0%), and Australia (n=1, 3.0%). Preoperative systemic antibiotics for open globe injuries were administered by 75.8% (n = 25/33) of institutions, while 30.3% (n = 10/33) administered preoperative topical antibiotics. Intraoperative ophthalmic antibiotics for open globe injuries were used by 54.5% (n = 18/33) of experts. Most institutions also administered postoperative systemic antibiotics (n = 23 [69.7%]) and topical steroids (n = 29 [87.9%]), although specific medication choices diverged. At 19 responding centers (61.3% of the 31 that had trainees), residents participated in surgical repairs. Many institutions discharged patients after repair, but 54.5% (n = 18/33) of locations routinely admitted them for observation. CONCLUSIONS: Preferred management practices for open globe injuries vary widely. To ensure the highest standard of care for all patients, evidence-based international guidelines for the treatment of these injuries are needed.

Trends in Early Graft Failure Leading to Regrafting After Endothelial Keratoplasty in the United States.

PURPOSE: The purpose of this study was to report trends in the prevalence of early graft failure after endothelial keratoplasty in the United States. METHODS: Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) graft volumes were collected from records maintained by 6 major eye banks in the United States from January 1, 2013, to December 31, 2018. The prevalence and presumed cause of early graft failures (defined as a graft with persistent edema or regrafted within 8 weeks after keratoplasty) each year were sourced from surgeon-reported adverse events. Failed graft cases from the 3 eye banks were compared with nonfailures at the donor and recipient levels to perform subset analysis of factors associated with early graft failure. RESULTS: A total of 51,887 endothelial keratoplasty tissues were distributed during the study period; 72% were DSAEK grafts. The total number of early graft failures reported was 168 of 14,284 (1.18%) for DMEK and 322 of 37,603 (0.86%) for DSAEK. Early DMEK failures decreased from 2013 (7.69%) to 2018 (0.68%). In generalized linear mixed model analyses adjusting for donor tissue characteristics, recipient age, and diagnosis, an association of borderline significance was found between higher donor age and early failure [odds ratio (95% confidence interval): 1.03 (1.00-1.05); unit change of 1 yr] and DSAEK [odds ratio 1.02 (1.00-1.04); unit of change 1 yr] cases. CONCLUSIONS: The proportion of early graft failures in DMEK decreased over time and was comparable with failure rates in DSAEK at the end of the study period. The surgical learning curve might have played a role.

Global Current Practice Patterns for the Management of Exogenous Endophthalmitis: A Survey by the American Society of Ophthalmic Trauma.

OBJECTIVE: To investigate the global practice patterns for the management of exogenous endophthalmitis. METHODS: This cross-sectional study was conducted to assess global practice patterns for the management of exogenous endophthalmitis. An online survey comprised of questions regarding the management of exogenous endophthalmitis was distributed to institutions who are members of International Globe and Adnexal Trauma Epidemiology Study Group (IGATES) or invited affiliates of the American Society of Ophthalmic Trauma and the Asia Pacific Ophthalmic Trauma Society. Responses were gathered from August 2020 to January 2021. RESULTS: Of 42 institutions, 36 responses were received (86% response rate), of which 33 (79%) were included in the analysis. Included centers were from Asia (36%), North America (36%), South America (12%), Africa (9%), Europe (3%), and Australia (3%). Oral antibiotics were administered in 19 (58%) institutions, with moxifloxacin as the preferred agent (n = 9, 27%). The preferred method for obtaining cultures was vitreous tap (n = 25, 76%). Most institutions (n = 26, 79%) routinely administered intravitreal vancomycin and ceftazidime, while intravitreal steroids were routinely administered at 11 centers (33%). Indications for performing vitrectomy included; decreased visual acuity (n = 14, 39%); all cases of exogenous endophthalmitis (n = 4, 12%); non-response to medical therapy (n = 4, 12%); or no view of the fundus (n = 4, 12%), indicating significant variation in surgical indications. More than half (n = 17, 52%) of responding institutions routinely admitted patients with exogenous endophthalmitis to the hospital. Institutions in the United States were less likely to administer oral antibiotics (27% vs. 73%, P = .024) and to admit patients (9% vs. 73%, P < .001) compared to other countries. CONCLUSIONS: This study highlights the global variations in the management of exogenous endophthalmitis, especially as it pertains to surgical indications. Further establishment of evidence-based guidelines may be beneficial to provide more uniform guidance to optimize outcomes.

Prevalence of incivility between ophthalmology and emergency medicine residents during interdepartmental consultations.

OBJECTIVES: Since incivility is linked to adverse effects in patient care and health care worker well-being, evaluation of the prevalence of incivility during the formative years of residency training is warranted. The aim of this study was to determine the perceived presence and degree of incivility between emergency medicine (EM) and ophthalmology residents during emergency department (ED) consultations. METHODS: We conducted a single-site, survey-based study, targeted to ophthalmology and EM residents. The survey we distributed included questions adapted from validated and widely used surveys measuring incivility in the workplace (Workplace Incivility Scale) and incivility within the ED. RESULTS: Ophthalmology (13/15, 86.7%) and EM (42/48, 87.5%) residents participated, with an overall response rate of 55 of 63 (87.3%). Most residents (47/55, 85.5%) reported some degree of incivility during consultations, with a greater proportion of females reporting incivility (100%) than males (77.4%, p = 0.033). A total of 52.7% of respondents reported occurrence of incivility on a quarterly basis; 21.8% reported monthly, 10.9% weekly, and none daily. Incivilities were reported most commonly during nonurgent consults (85.5%). The two most common incivilities reported by trainees were when the other party paid little attention to their statements or opinions (80% of residents) or doubted their professional judgment (74.5% of residents). More female trainees reported jokes being told at their expense compared to males (15.8% vs. 0%, p = 0.049). Residents most often attributed incivility to stress (78.2%), loss of empathy/burnout (63.6%), or attempts to shift responsibility to another party (60.0%). Among EM residents surveyed, incivility was identified as occurring most often during consultations with surgical specialties. CONCLUSIONS: Incivility during interdepartmental consultations between EM and ophthalmology is commonly reported by physicians-in-training. It occurs more often during consultations deemed as nonurgent and is more commonly reported by females. Given its associations with adverse outcomes, interventions to decrease incivility early in training may be warranted.

Prevalence, Patterns, and Characteristics of Eye Injuries in Professional Mixed Martial Arts.

PURPOSE: To describe the frequency and type of eye injuries in fighters in mixed martial arts (MMA) competition. METHODS: Fight result data were collected from the Nevada Athletic Commission database from 2001 to 2020. Any fighters in a professional mixed martial arts (MMA) contest with an eye injury were included. Main outcome measures included frequency and rate of eye injuries per fight and the types of eye injuries. Secondary outcome measures were gender, laterality, decision type, and length of no-contact recommended. RESULTS: Of the 256 MMA events in the database, 187 events (73.3%) had at least one eye injury. Of a total 2208 fights at these events, there were 363 fighters who sustained 369 eye injuries, with the yearly rate of eye injuries per 100 fighters ranging from 2.56 to 12.22. The most common injuries were eyebrow and eyelid lacerations (n=160, 43%), lacerations around the eye (n=98, 27%), and orbital fractures (n=62, 17%). Most eye injuries were right sided (n=197, 53.3%) and the majority of fighters with eye injuries lost their match (n=228, 62.8%). Fifty-seven fighters were recommended for further ophthalmology clearance after the match. The most common reasons for recommended ophthalmology follow-up was orbital fracture (n=25, 44%) and retinal injury (n=7, 12%). Forty-three fighters received no-contact requirements relating to their injury for an average of 8.9 weeks (range 1-24 weeks). CONCLUSION: Ophthalmic injuries in professional MMA were prevalent, were most often lacerations surrounding the eye, and often accompanied the fighter losing their match.