Antibiotic Protocols for Endophthalmitis Prophylaxis Following Open-Globe Repair: A Survey of U.S. Residency Programs.

Purpose To assess the various approaches to endophthalmitis prevention following traumatic open-globe injury (OGI) repair. Methods A research electronic data capture (REDCap) questionnaire evaluating the usage of antibiotics and steroids in patients with OGI was distributed to program directors of all U.S. ophthalmology residency programs using the Association of University Professors of Ophthalmology program directors' listserv. Completed questionnaires were analyzed for treatment patterns. Results The REDCap questionnaire was distributed to 111 programs, with 32 residency programs responding. Two responses were excluded. Ninety percent (27/30) of included programs used perioperative intravenous (IV) antibiotics, with 78% (21/27) of those giving one dose only. At the time of surgery, 27% (8/30) of programs gave intravitreal antibiotics and 60% (18/30) gave subconjunctival antibiotics. Postoperatively, 100% (30/30) gave topical antibiotics and 97% (29/30) gave topical steroids. Only 53% of responders discharged patients on oral antibiotics. Of the three programs who did not use IV antibiotics, all three gave intravitreal therapy and one also discharged patients on oral antibiotics. Conclusion There is a large variation in practice patterns for endophthalmitis prophylaxis among residency programs. Further investigation is needed to compare rates of endophthalmitis between these protocols and establish a safe and minimally burdensome standard of care.

Outcomes of resident-performed laser-assisted vs traditional phacoemulsification.

PURPOSE: To compare the effectiveness of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification cataract surgery (CPS) by resident surgeons. SETTING: Parkland Memorial Health and Hospital System, Dallas, Texas, USA. DESIGN: Prospective randomized study. METHODS: All surgeries to be performed by postgraduate year 3 and year 4 residents from October 2015 through June 2017 were eligible for inclusion. Patients were required to complete postoperative day 1, week 1, month 1, and month 3 visits. Specular microscopy was performed preoperatively and postoperatively. Surgeries were filmed, and each step was timed and compared. Surgeon and patient surveys were filled out postoperatively. RESULTS: Of the 135 eyes of 96 subjects enrolled in the study, 64 eyes received FLACS and 71 eyes received CPS. There was no significant difference in corrected distance visual acuity (CDVA), either preoperatively or at the postoperative day 1, week 1, month 1, or month 3 visits (P = .469, .539, .701, .777, and .777, respectively). Cumulated dissipated energy and irrigation fluid usage were not different between FLACS and CPS (P = .521 and .368, respectively), nor was there a difference in the reduction of endothelial cell counts postoperatively (P = .881). Wound creation (P = .014), cortical cleanup (P = .009), and IOL implantation (P = .031) were faster in the CPS group. Survey results indicated that the overall patient experience was similar for FLACS and CPS. CONCLUSIONS: This first prospective randomized trial evaluating resident-performed FLACS shows that, in resident hands, FLACS provides similar results to CPS regarding visual acuity, endothelial cell loss, operative time, patient satisfaction, and surgical complication rate.

Comparison of 1-field, 2-fields, and 3-fields fundus photography for detection and grading of diabetic retinopathy.

AIM: To evaluate the sensitivity and specificity of 1-, 2-, and 3-fields, nonmydriatic (NM), 45° color photography compared with mydriatic ophthalmoscopy for detection of diabetic retinopathy (DR). METHODS: Masked, comparative case series was performed utilizing a group of 128 diabetic patients (256 eyes) with various stages of DR who underwent both 3-fields NM color photography and ophthalmologic examination. In a blinded manner, the same optometrist who read the original 3-fields images for a patient read the 1- and 2-fields photographs on separate dates later. RESULTS: The sensitivity and specificity of digital retinal photography compared with dilated ophthalmoscopy were, respectively: 88% and 76% for 1-field; 94% and 69% for 2-fields; and 100% and 79% for 3-fields. The proportion of agreement between fundus photography reading and exam DR diagnosis were 58% for 1-field, 58% for 2-fields, and 77% for 3-fields. Kappa and Cramer's V statistics for 1-, 2-, and 3-fields were 0.55 and 0.60, 0.52 and 0.57, and 0.72 and 0.74, respectively. Three-fields measurement of DR was most similar to the dilated ophthalmological exam overall and across all DR severity levels. CONCLUSIONS: Compared to 1- and 2-fields fundus photography, 3-fields is superior for detecting vision-threatening DR. One- and 2-fields have reasonable sensitivity for DR screening.

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.

Pupil-Involving Third Cranial Nerve Paresis at High Altitude.

Blomquist, Preston H. Pupil-involving third cranial nerve paresis at high altitude. High Alt Med Biol. 19:286-287, 2018.-Although sixth cranial nerve palsies are a well-recognized entity at high altitude, other cranial nerve palsies due to altitude are much more uncommon. A case of a 55-year-old woman is presented who flew from Dallas, Texas (elevation 176 m) to Breckenridge, Colorado, where she hiked up to 3600 m above sea level. She developed a pupil-involving right third cranial nerve paresis that resolved over the next 3 months. In the absence of significant abnormalities on neuroimaging and serum laboratories, the etiology is presumed to be due to high altitude.

Supervised resident manual small-incision cataract surgery outcomes at large urban United States residency training program.

PURPOSE: To examine the outcomes of resident-performed manual small-incision cataract surgery (SICS) in an urban academic setting. SETTING: Parkland Memorial Hospital, Dallas, Texas, USA. DESIGN: Retrospective case series. METHODS: Manual SICS was used only in selected cases for which phacoemulsification was expected to be difficult, namely for mature or brunescent cataracts, traumatic cataracts, and pseudoexfoliation syndrome or other causes of zonular weakness. All manual SICS cases performed by resident physicians as the primary surgeon over a 5-year period were reviewed. Postoperative visual acuity, intraoperative complications, and early postoperative complications were the main outcomes measured. RESULTS: For the 52 cases identified, the mean preoperative visual acuity was 2.165 logarithm of the minimum angle of resolution (logMAR) ± 0.141 (SD) (95% confidence interval) (slightly better than had motion acuity), improving to 0.278 ± 0.131 logMAR (Snellen 20/38) corrected visual acuity postoperatively. Of the 52 cases, the most frequent intraoperative complications were iris prolapse (5 cases [9.6%]) and zonular dialysis (4 cases [7.7%]), with vitreous loss occurring in 1 case (1.9%). The most frequent postoperative complications were cystoid macular edema (3 cases [5.8%]), retained ophthalmic viscosurgical device (2 cases [3.8%]), intraocular lens displacement (2 cases [3.8%]), and microhyphema (2 cases [3.8%]). CONCLUSIONS: Although the more advanced wound construction in manual SICS might be challenging to surgeons unfamiliar with the technique, it was a safe and efficacious technique in the hands of learning residents. With several advantages over phacoemulsification, such as cost and ability to remove very dense nuclei, manual SICS will play a valuable role in modern cataract surgery.

Use of Intravenous Vancomycin and Cefepime in Preventing Endophthalmitis After Open Globe Injury.

PURPOSE: The choice and route of antibiotic prophylaxis in the setting of open globe injury remains controversial. We investigated the utility of intravenous vancomycin and cefepime prophylaxis in preventing endopthalmitis after open globe injury. METHODS: The charts of 224 patients who presented to Parkland Memorial Hospital and Children's Medical Center in Dallas, Texas, between June 1, 2009 and June 30, 2013, with open globe injury and who were treated with prophylactic intravenous vancomycin and cefepime were retrospectively reviewed. Data collection included time from injury to presentation, mechanism of injury, details of ophthalmological examination, timing of open globe repair, and length of follow-up. All patients were treated with intravenous vancomycin and cefepime for 48 h after presentation. RESULTS: The primary outcome measure was rate of endophthalmitis, and the secondary outcome measure was identification of risk factors for developing endophthalmitis. Out of 224 patients who presented after open globe injury, 3 patients had signs of endophthalmitis on initial exam before starting antibiotics, and 2 patients developed endophthalmitis after initiation of vancomycin and cefepime (0.9%). Delayed time from injury to presentation was a risk factor for post-traumatic endophthalmitis (P = 0.0002). The association between presence of intraocular foreign body and post-traumatic endophthalmitis was approaching significance (P = 0.064). CONCLUSIONS: When intravenous vancomycin and cefepime are used prophylactically after open globe injury, the rate of endophthalmitis is low.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease.

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease.

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

Outcomes of manual extracapsular versus phacoemulsification cataract extraction by beginner resident surgeons.

PURPOSE: To evaluate the safety and efficacy of phacoemulsification cataract extraction and manual extracapsular cataract extraction (ECCE) performed by beginning resident surgeons. SETTING: Dallas Veterans Affairs Medical Center, Dallas, Texas, USA. DESIGN: Retrospective cohort study. METHODS: A review was performed of each resident's series of initial cataract surgery procedures as a late first-year or second-year resident. Data were collected for cases performed over almost a 6-year period during which initially the first primary surgeon cases were ECCE and later, the first primary surgeon cases were phacoemulsification. For each case, the following data were gathered: technique of cataract extraction, laterality, resident, vitreous loss or dropped nucleus, placement of posterior chamber intraocular lens (IOL), and need for reoperation within 90 days of surgery. RESULTS: Complications occurred in 6 (2.5%) of 244 cases in which phacoemulsification was performed by a beginner resident primary surgeon and in 7 (4.1%) of 172 cases in which ECCE was used (P=.40). Posterior chamber IOLs were placed in all but 2 phacoemulsification cases and 4 ECCE cases (P=.24). Moreover, 3 cases in the phacoemulsification group and 1 case in the ECCE group required a reoperation within 90 days (P=.65). CONCLUSION: Phacoemulsification cataract extraction can be taught safely and effectively to residents with no cataract surgery experience as a primary surgeon.

A multicenter analysis of the ophthalmic knowledge assessment program and American Board of Ophthalmology written qualifying examination performance.

OBJECTIVE: To compare the performance on the American Board of Ophthalmology Written Qualifying Examination (WQE) with the performance on step 1 of the United States Medical Licensing Examination (USMLE) and the Ophthalmic Knowledge Assessment Program (OKAP) examination for residents in multiple residency programs. DESIGN: Comparative case series. PARTICIPANTS: Fifteen residency programs with 339 total residents participated in this study. The data were extracted from the 5-year American Board of Ophthalmology report to each participating program in 2009 and included residency graduating classes from 2003 through 2007. Residents were included if data were available for the USMLE, OKAP examination in ophthalmology years 1 through 3, and the WQE score. Residents were excluded if one or more of the test scores were not available. METHODS: Two-sample t tests, logistic regression analysis, and receiver operating characteristic (ROC) curves were used to examine the association of the various tests (USMLE, OKAP examination year 1, OKAP examination year 2, OKAP examination year 3, and maximum OKAP examination score) as a predictor for a passing or failing grade on the WQE. MAIN OUTCOME MEASURES: The primary outcome measure of this study was first time pass rate for the WQE. RESULTS: Using ROC analysis, the OKAP examination taken at the third year of ophthalmology residency best predicted performance on the WQE. For the OKAP examination taken during the third year of residency, the probability of passing the WQE was at least 80% for a score of 35 or higher and at least 95% for a score of 72 or higher. CONCLUSIONS: The OKAP examination, especially in the third year of residency, can be useful to residents to predict the likelihood of success on the high-stakes WQE examination.

Resident experience with toric and multifocal intraocular lenses in a public county hospital system.

PURPOSE: To study the outcomes of toric and multifocal intraocular lens (IOL) implantation performed by resident surgeons. SETTING: Parkland Health and Hospital System, Dallas, Texas, USA. DESIGN: Case series. METHODS: Patients seen between July 2008 and May 2011 and meeting inclusion criteria (including >1.0 diopter [D] of astigmatism in toric group and <0.75 D astigmatism in multifocal group) were offered implantation of the study IOLs. Major outcomes were uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) and, for the multifocal IOL, near visual acuity. Residents were surveyed about their knowledge regarding these IOLs. RESULTS: Seventy-nine eyes of 60 patients received an Alcon Acrysof toric IOL. Eighteen eyes of 10 patients received an Alcon Acrysof Restor IOL. In the toric group, 57% of eyes achieved a postoperative UDVA of 20/25 or better and 90% achieved 20/40 or better. The CDVA was 20/25 or better in 92% of eyes. The mean refractive cylinder was 1.69 D preoperatively and 0.38 D postoperatively. In the multifocal group, 78% of patients achieved a UDVA of 20/25 or better and 94% achieved 20/40 or better. All patients had a CDVA of 20/25 or better. Near vision was Jaeger 3 or better in 94%. The survey showed that residents have a strong comfort level with preoperative and surgical techniques for premium IOLs after their experience in the residency setting. CONCLUSION: Residents in public county hospitals can be taught to use premium IOLs with good success rates, comparable to those in other published studies. FINANCIAL DISCLOSURE: Dr. McCulley is a consultant to Alcon Laboratories, Inc., and Dr. Aggarwal is on the speaker's bureau for Alcon Laboratories, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Risk factors for vitreous complications in resident-performed phacoemulsification surgery.

PURPOSE: To identify risk factors for intraoperative vitreous complications in resident-performed phacoemulsification surgery. SETTING: Two urban public county hospitals. DESIGN: Case series. METHODS: Phacoemulsification cataract surgeries performed by residents between January 4, 2005, and January 8, 2008, were retrospectively reviewed. Clinical characteristics of patients with and without intraoperative vitreous complications were compared and independent factors associated with vitreous complications identified using univariate and multivariate analysis. RESULTS: Of 2434 cases meeting inclusion criteria, there were 92 vitreous complications (3.8%). On univariate analysis, significant preoperative risk factors for vitreous complications included older age (P=.020), poor preoperative corrected distance visual acuity (CDVA) (P=.007), left eye (P=.043), history of trauma (P=.045), prior pars plana vitrectomy (P=.034), dementia (P=.020), phacodonesis (P=.014), zonule dehiscence (P<.0001), posterior polar cataract (P=.037), white/mature cataract (P=.005), dense nuclear sclerotic cataract (P=.0006), and poor red reflex (P=.002). Factors that remained significant on multivariate analysis were older age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), poor preoperative CDVA (OR, 1.52; 95% CI, 1.14-2.03), left eye (OR, 1.63; 95% CI, 1.05-2.51), prior pars plana vitrectomy (OR, 1.88; 95% CI, 1.01-3.51), dementia (OR, 3.65; 95% CI, 1.20-11.17), and zonule dehiscence (OR, 8.55; 95% CI, 3.92-18.63). CONCLUSION: Elements of the preoperative history and examination can identify patients at higher risk for intraoperative complications during resident-performed phacoemulsification surgery.

Ocular complications of systemic medications.

Systemic medications can have adverse effects on the eyes that range from dry eye syndrome, keratitis and cataract to blinding complications of toxic retinopathy and optic neuropathy. This review focuses on major drugs with common ocular side effects and highlights more recently recognized associations with systemic medications. Recommendations for ocular monitoring are given for medications with frequent and/or severe adverse ocular effects.

Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery.

PURPOSE: To validate the Najjar-Awwad cataract surgery risk score for residents, which has been proposed to predict surgical complexity and risk. SETTING: Two urban public county hospitals. DESIGN: Case series. METHODS: Phacoemulsification cataract surgeries performed by residents between January 2005 and April 2008 were retrospectively reviewed. The cataract risk score was calculated retrospectively. Intraoperative complications included posterior and anterior capsular tears, vitreous prolapse, dropped nucleus, and conversion to manual extracapsular cataract extraction. RESULTS: Of the cases performed by 33 residents, 1833 met the inclusion criteria. There were 120 complications (6.5%); the rate of complications involving vitreous prolapse or loss (including dropped nucleus) was 3.2%. Significant risk factors in the risk score associated with intraoperative complications were dense nuclear sclerosis (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.32-3.26; P = .004) and poor red reflex (OR, 2.10; 95% CI, 1.45-3.06; P = .00007). Cataract risk scores ranged from 3 to 16. The score was less than 5 in 85 cases (4.6%) and less than 7 in 885 cases (48.3%). The OR for complications increased significantly when the risk score was higher than 6 (OR, 2.11; 95% CI, 1.42-3.14; P = .0002). CONCLUSIONS: Although the Najjar-Awwad cataract surgery risk score can be used to predict intraoperative complications at the time of cataract surgery, the complication rate did not significantly increase until the score reached 7. There were few cases with scores lower than 5 in these county hospital populations. Beginning surgeons should be given cases with a risk score of less than 7.

Ophthalmic Manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis and Relation to SCORTEN.

PURPOSE: To evaluate the severity of ocular involvement of patients with Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap, and to investigate the relationship of the SCORTEN (a severity-of-illness score for SJS and TEN based on a minimal set of well-defined variables calculated within 24 hours of admission) with eye disease in this patient population. DESIGN: Retrospective observational case series. METHODS: Charts of all patients admitted to the Parkland Memorial Hospital Burn Center with a preliminary diagnosis of SJS, SJS/TEN overlap, or TEN between 1998 and 2008 were reviewed. Patients were included for study if they met clinical criteria, had positive diagnostic skin biopsy, and had dermatologic and ophthalmologic consultations. Eighty-two patients with a diagnosis of SJS, SJS/TEN overlap, or TEN met inclusion criteria. Ocular manifestations were classified as mild, moderate, or severe. Admission data were used to calculate the SCORTEN. Main outcome measure was the severity of ocular involvement with respect to diagnosis and SCORTEN. RESULTS: Overall, 84% of patients had ocular involvement (71% SJS, 90% TEN, 100% SJS/TEN overlap). There was no difference in the severity of acute ocular complications among groups. While the SCORTEN value did correlate well with mortality rate (correlation coefficient 0.97, P = .005), there was no correlation between the SCORTEN value and severity of eye involvement in the acute setting. There was also no association of any individual diagnosis of SJS/overlap/TEN with the severity of eye involvement, although eye findings are more common in TEN (P = .03). CONCLUSIONS: Ocular damage in the acute setting was more frequent in patients with epidermal detachment >10% of the total body surface area. The SCORTEN value did not correlate with the severity of eye involvement in the acute setting.