Survival and characteristics of retinopathy of prematurity in micro-premature infants.

OBJECTIVE: To describe the risk and nature of retinopathy of prematurity (ROP) in micro-premature infants (≤26 weeks' gestational age [GA]). METHODS: Retrospective analysis of prospectively collected data from infants born at 22-26 weeks' GA over a 5-year period. RESULTS: A total of 502 infants were identified, of whom 414 survived to discharge (82.5%). The Vermont Oxford Network database documented clinical follow-up data and ROP outcomes for all 414 patients; complete ROP clinical records were available for 294 of the infants who survived (70.8%). Forty infants were born between 22 and 23 weeks' GA (group A, 13.6%), and 254 were born between 24 and 26 weeks' GA (group B, 86.4%). Survival for group A infants was worse than that of group B infants (66.2% vs 85.4%; p < 0.01). Survival of group A infants improved during the study period (R2 = 0.625). Overall, 59.9% of infants developed any ROP and 8.5% developed type 1 ROP. Group A infants were more likely to develop ROP (90.0% vs 48.6%; p < 0.01) and type 1 ROP (30.0% vs 5.1%; p < 0.01) than group B infants. Group A infants developed ROP at an earlier age (32 + 6 weeks vs 33 + 3 weeks; p = 0.02) and were more likely to have zone I disease on presentation (65.0% vs 20.5%; p < 0.01), but there was no difference in the corrected gestational age of peak severity of ROP (35 + 2 weeks vs 34 + 5 weeks; p = 0.36). CONCLUSION: The most premature infants, born at 22-23 weeks' GA, develop ROP at an earlier age, are more likely to present with posterior disease, and have a high risk of disease requiring treatment.

Prospective evaluation of medical student accuracy conducting direct ophthalmoscopy with an unmodified iPhone X.

PURPOSE: To evaluate fundus examination accuracy of medical students when using an unmodified iPhone X or a direct ophthalmoscope in comparison to a staff ophthalmologist's retinal examination. METHODS: In this prospective comparative analysis, patients underwent dilated fundus examination by novice medical trainees using either an unmodified iPhone X or standard direct ophthalmoscope. The primary outcome was the mean difference and degree of agreement in cup-to-disc ratio between student examination and the staff ophthalmologist's cup-to-disc observation. RESULTS: A total of 18 medical students conducted 230 retinal examinations, 117 with the iPhone X and 113 with the direct ophthalmoscope. A greater proportion of students were unable to report cup-to-disc ratio using the iPhone X (81.2%) vs direct ophthalmoscope (30.1%). Student examination of cup-to-disc ratio led to a systematic bias (95% limits of agreement) of + 0.16 (-0.22 to + 0.54) and + 0.10 (-0.36 to + 0.56) with the iPhone X and direct ophthalmoscope, respectively. iPhone X and direct ophthalmoscope student observation concordance for optic disc colour (88.7 and 82.4%, respectively) and contour (68.3 and 74.2%, respectively) demonstrated low agreement with staff ophthalmologist findings. Student iPhone X observations demonstrated lower agreement with staff findings compared to direct ophthalmoscope observations for spontaneous venous pulsations (Cohen's Kappa = -0.044 vs 0.099). CONCLUSION: Amongst medical trainees, optic disc visualization using an unmodified iPhone X was inferior to the direct ophthalmoscope. When able to visualize the optic nerve head, there was no significant difference in reported cup-to-disc ratio between modalities. However, both modalities demonstrated poor reliability in comparison to staff ophthalmologist findings.

Development and validation of the Iris Glare, Appearance, and Photophobia questionnaire for patients with iris defects.

PURPOSE: To validate the Iris Glare, Appearance, and Photophobia (Iris GAP) questionnaire, a new symptom-based and appearance-based quality-of-life measure for patients with iris defects. SETTING: Single tertiary glaucoma clinic in Toronto, Ontario, Canada. DESIGN: Prospective cohort study. METHODS: Patients with varying degrees of iris defects were enrolled. Patients completed the Iris GAP questionnaire and the glare and driving subscales of the Refractive Status and Vision Profile (RSVP) questionnaire. Test-retest reliability, defined by Cronbach α and intraclass correlation coefficients (ICCs), was evaluated with repeat testing 2 weeks later. RESULTS: The study included 73 patients with iris defects, 68 controls with no iris defects, 77 patients with peripheral iridotomies (PIs) or transillumination defects (TIDs), and 22 patientswith surgically repaired irides (n = 22). Iris GAP scores ranged from 0 to 32 with a 97% completion rate. Iris GAP had high test-retest reliability (Cronbach α = 0.866, ICC = 0.953, P < .0005). Iris GAP scores were reliably distinguishable between patients with iris defects, repaired iris defects, and PIs and TIDs and controls (1-way analysis of variance, P < .0005). In pairwise comparisons, the major defect group had statistically significant higher scores than any of the other groups ( P < .005 for each). The control and repaired groups had the lowest scores, whereas the PI/TID group had intermediate scores. 9 patients underwent iris repair between tests and had a mean difference of 8.2 ± 6.2 points between their preoperative and postoperative scores ( P = .004). Iris GAP scores positively correlated with RSVP scores ( R2 = 0.73). CONCLUSIONS: Iris GAP can reliably evaluate symptomatology and patient-reported appearance in patients with iris defects.

Surgical management of a live intravitreal nematode.

PURPOSE: To describe a novel surgical technique for the removal of a live intravitreal nematode. OBSERVATIONS: We describe the surgical management of a 35-year-old man with a live intravitreal nematode in his left eye. A 23-gauge pars plana limited core vitrectomy was performed to release the nematode from the surrounding vitreous strands. After creating a peritomy, a 20-gauge full thickness sclerotomy was created with a microvitreoretinal blade. The tip of a 20-gauge angiocath needle was cut obliquely and inserted through the sclerotomy. The external portion of the needle was attached to the viscous fluid extraction tubing for the Constellation vitrectomy machine (Alcon). Gentle aspiration pulled the nematode into the angiocath. The nematode was transferred to a syringe for parasitologic evaluation. CONCLUSIONS AND IMPORTANCE: The novel surgical technique described allows for aspiration of an intravitreal nematode in a controlled fashion. This technique can be used to manage this rare, but visually significant condition.

Comparison of the Ahmed and Baerveldt glaucoma shunts with combined cataract extraction.

OBJECTIVE: To compare the surgical outcomes of combined phacoemulsification with either Ahmed glaucoma valve (AGV) or Baerveldt glaucoma implant (BGI). DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 104 eyes that underwent combined phacoemulsification with either AGV (PhacoAGV; n = 57) or BGI (PhacoBGI; n = 47) implantation. METHODS: Failure was defined as uncontrolled intraocular pressure (IOP; <5 mm Hg, ≥18 mm Hg, or <20% reduction), additional glaucoma surgery, vision-threatening complications, or progression to no-light-perception vision. RESULTS: The PhacoAGV group was older (p = 0.03), had poorer baseline visual acuity (VA; p = 0.001), and had fewer previous glaucoma surgeries (p = 0.04). Both groups had similar baseline IOP (PhacoAGV: 26.4 ± 8.3 mm Hg; PhacoBGI: 25.7 ± 7.3; p = 0.66) and glaucoma medications (PhacoAGV: 3.8 ± 1.0; PhacoBGI: 3.6 ± 1.5; p = 0.54). At 2 years, failure rates were 44% in the PhacoAGV group and 23% in the PhacoBGI group (p = 0.02). Both groups had similar mean IOP reduction (PhacoAGV: 45%; PhacoBGI: 47%, p = 0.67) and medication use reduction (PhacoAGV: 47%; PhacoBGI: 58%, p = 0.38). The PhacoBGI group had higher IOP and medication use up to 1 month (p < 0.05). Both groups improved in VA from baseline (p < 0.05) and had similar overall complication rates (p = 0.31). The PhacoBGI group required more overall interventions (p < 0.0005). CONCLUSIONS: This comparative study found no difference in IOP, glaucoma medications, or complication rates between PhacoAGV and PhacoBGI at 2 years, despite BGIs being implanted in patients at higher risk for failure. The PhacoAGV group had higher failure rates at 2 years. Both groups had significant improvements in VA due to removal of their cataracts. The PhacoBGI group required more interventions, but most of these were minor slit-lamp procedures.

Teaching binocular indirect ophthalmoscopy to novice residents using an augmented reality simulator.

OBJECTIVE: To compare the traditional teaching approach of binocular indirect ophthalmoscopy (BIO) to the EyeSI augmented reality (AR) BIO simulator. DESIGN: Prospective randomized control trial. PARTICIPANTS: 28 post-graduate year one (PGY1) ophthalmology residents. METHODS: Residents were recruited at the 2012 Toronto Ophthalmology Residents Introductory Course (TORIC). 15 were randomized to conventional teaching (Group 1), and 13 to augmented reality simulator training (Group 2). 3 vitreoretinal fellows were enrolled to serve as experts. Evaluations were completed on the simulator, with 3 tasks, and outcome measures were total raw score, total time elapsed, and performance. RESULTS: Following conventional training, Group 1 residents were outperformed by vitreoretinal fellows with respect to all 3 outcome measures. Following AR training, Group 2 residents demonstrated superior total scores and performance compared to Group 1 residents. Once the Group 1 residents also completed the AR BIO training, there was a significant improvement compared to their baseline scores, and were now on par with Group 2 residents. CONCLUSIONS: This study provides construct validity for the EyeSI AR BIO simulator and demonstrates that it may be superior to conventional BIO teaching for novice ophthalmology residents.

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey.

BACKGROUND: The purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication. METHOD: Survey questions addressed four domains: survival, delayed or obscured recurrence detection, delayed adjuvant therapy, and aesthetics. The survey was administered to 1160 Ontario plastic and general surgeons and radiation and medical oncologists. Data were compared to published guidelines. RESULTS: The overall response rate was 48%, with 57% of respondents treating breast cancer. Of those treating breast cancer, 75% are affiliated with an academic center. Immediate breast reconstruction (IBR) is not available to 28%. Autologous reconstruction is thought to interfere with recurrence detection by 23% (oncologists 30%, surgeons 19%, p = 0.04). For patients not expected to require radiation therapy, IBR is not supported by 30%. Autologous IBR is believed to delay delivery of adjuvant chemotherapy by 45% (oncologists 55%, surgeons 41%, p = 0.02). Up to 42% of respondents believe delays in adjuvant therapy delivery following IBR are due to insufficient health care resources (ie. coordinating an oncologic and reconstructive surgeon). Radiation therapy following reconstruction is believed to have negative aesthetic outcomes, and increase the need for revision surgery. CONCLUSIONS: Unfavourable beliefs about certain clinical actions do not align with recent provincial guideline recommendations. Insufficient healthcare resources are perceived to be a significant barrier to IBR and timely care.