Understanding choroidal nevus risk factors for transformation into melanoma.

A choroidal nevus is a common intraocular tumor in the United States, found in approximately 5% of Caucasian adults. The three main risks of melanocytic choroidal nevus include vision loss from a subfoveal nevus, development of subretinal fluid, and transformation of nevus into melanoma, a malignant counterpart. We explore clinical risk factors that predict benign melanocytic choroidal nevus transformation into a malignant choroidal melanoma. Based on a large analysis of 2,355 cases that were monitored longitudinally using multimodal imaging, the most recent list of clinical features includes tumor Thickness greater than 2 mm on ultrasonography, subretinal Fluid on optical coherence tomography, Symptomatic vision loss 20/50 or worse, Orange pigment on fundus autofluorescence, Melanoma hollow on ultrasonography, and DIaMeter greater than 5 mm on fundus photography. These factors are remembered with a mnemonic of the capital letters TFSOM-DIM for "To Find Small Ocular Melanoma Doing Imaging." Analysis of these factors demonstrated a Kaplan-Meier mean five-year risk of 1% with no risk factors, 11% with any one factor, 22% with any two factors, 34% with any three factors, 51% with any four factors, and 55% with any five factors. There was no patient with six risk factors. Of those with combinations of four risk factors, six of 15 combinations yielded a 70%-100% rate of transformation; of those with combinations of five risk factors, two of five combinations yielded a 70%-100% rate of transformation. Choroidal nevus carries a risk for evolving into melanoma, and understanding of clinical and imaging features predictive of this outcome is highly important.

Patient perspectives on ocular oncology care at hybrid telehealth satellite offices.

OBJECTIVE: To assess patient satisfaction with the hybrid telehealth model in patients undergoing follow-up care in ocular oncology. DESIGN: Retrospective survey study. PARTICIPANTS: All patients who visited 1 of 2 satellite telehealth offices between July 2021 and October 2022 for their follow-up ocular oncology appointment. METHODS: A 13-question online survey was completed for outcome measures of patient demographics, patient satisfaction with the satellite offices, and overall patient experience with telehealth. RESULTS: The survey response rate was 32% (203 of 632). The mean patient age was 65 years (median, 65 years), and 119 patients (58%) were female. A comparison (suburban satellite vs urban in-person office) revealed that the suburban satellite office had less difficulty in travel (3% vs 47%; p < 0.001) and less time commitment (<1 hour) for travel to the office (58% vs 23%; p < 0.001). On a scale (i.e., poor, fair, good, or excellent), the percentage of patients reported the following parameters as good or excellent: ease of finding satellite office (95%), check-in (94%), and time spent waiting for the doctor (72%). On a scale (i.e., extremely dissatisfied to extremely satisfied), the percentage of patients reported being extremely satisfied to the following parameters: the staff (81%) and the office overall (65%). Most patients (90%) would use this telehealth model for future visits (p < 0.0001), and 86% would recommend it to a friend (p < 0.0001). CONCLUSION: In this study on a hybrid telehealth satellite office model for ocular oncology follow-up examinations, patient satisfaction was high, most patients would use this form of examination in the future.

Virtual versus In-Person Ophthalmology Interviews: Perceptions of U.S. Ophthalmology Fellowship Applicants in 2022-2023.

Purpose Despite easing restrictions on social distancing and travel since the beginning of coronavirus disease 2019 pandemic, virtual interviews remain a widely used format for ophthalmology fellowship interviews. This study aims to evaluate the relative benefits and drawbacks of in-person versus virtual interviews during a cycle where both formats were prevalent. Methods A prospective cross-sectional study surveyed all fellowship applicants ( N = 311) who applied to Wills Eye Hospital and Bascom Palmer Eye Institute during the 2022 to 2023 application cycle. Results A total of 59 (19%) applicants responded to the survey, with the majority being male (53.0%) and between the ages of 20 and 35 (91.3%). There was no statistically significant difference between the number of virtual and in-person interviews attended or the total number of interviews attended. The highest ranked limitations of the virtual interview process were limited exposure to details of the program structure, limited opportunity to exhibit applicants' strengths to the program, and limited exposure to the fellows. The highest ranked strengths were less pressure during interviews, greater scheduling flexibility, and ability to interview at more fellowship programs. The highest ranked limitations of the in-person interview process were more pressure during interviews, inability to interview at all desired fellowship programs, and decreased scheduling flexibility. The highest ranked strengths based on median rankings were greater exposure to details of the program structure, greater ability to exhibit an applicant's strengths to the program, and greater exposure to the geographic location/city. Conclusion While both in-person and virtual interviews have their own benefits and limitations, virtual interviews appear to be more cost-effective and time-efficient while in-person interviews provide better opportunities to assess program fit and culture. A hybrid format that combines the ideal aspects of both formats may be an optimal solution.

Fracture-Dislocations of the Elbow: A Comparison of Monteggia and Terrible Triad Fracture Patterns.

Fracture-dislocations of the elbow are a spectrum of injuries that have varying outcomes and complications, such as limited range of motion and long-term pain. The Monteggia fracture-dislocation and terrible triad fracture-dislocation are 2 such injury patterns that occur secondary to different mechanisms. This study sought to compare complication profiles and patient outcomes associated with these 2 distinct injury patterns. A retrospective chart review of all adult patients treated by 1 of 3 orthopedic traumatologists at a major academic center for operative fixation for either a Monteggia fracture-dislocation or a terrible triad elbow fracture-dislocation over a 12-year period was performed. Data collected included demographics, surgical data, patient-reported pain and elbow stiffness, elbow range of motion, presence of elbow joint contracture, nerve injuries, healing complications, and need for reoperation. The review included 105 patients, 58 with Monteggia injury and 47 with terrible triad injury, who had complete follow-up and radiographic imaging available. At latest follow-up, the 2 groups had similar rates of pain, reoperation, and ultimate elbow range of motion in flexion, extension, pronation, and supination. Elbow contractures requiring operative release were more commonly associated with terrible triad injury, and the incidence of nonunion was significantly greater in Monteggia fractures. A Monteggia fracture-dislocation portends a higher risk of ulna nonunion, whereas terrible triad injury is associated with elbow contracture. Despite their unique complications, both patterns ultimately have high rates of reoperation as their unique complications are both indications for operative repair. Patients should be appropriately counseled on the complication profile of their unique injury pattern. [Orthopedics. 2023;46(3):158-163.].

Outpatient lower extremity fracture surgery: should we be concerned?

PURPOSE: With rising healthcare costs and insurance push against non-emergent hospital admission, lower extremity fracture treatment is shifting toward outpatient procedures over inpatient hospitalizations. This study compares outcomes for fractures treated as inpatient versus outpatient. METHODS: We conducted a retrospective review of lower extremity fracture patients. We collected demographics, injury information, hospital course, and complication data. Length of stay was categorized as "inpatient" and "outpatient" based a 24-h hospital stay cutoff. Data analysis included differences between cohorts with regards to readmissions and complications. RESULTS: We identified 229 patients who met inclusion criteria. Inpatient versus outpatient status was predictive of in-hospital complications; however, inpatient versus outpatient status did not predict 1-year readmission. CONCLUSION: Outpatient surgery is safe and effective. As the population increases and ages, low-risk surgeries should be considered for outpatient rather than inpatient stays to lower costs, save resources, and reduce complications.

Barriers to Follow-Up Retinal Care During the COVID-19 Pandemic: A Survey Study.

BACKGROUND AND OBJECTIVE: To characterize patient-identified barriers to care in those non-compliant with retina appointments during the coronavirus disease 2019 (COVID-19) pandemic. PATIENTS AND METHODS: Inclusion criteria included non-compliant patients from March 1, 2020 to May 1, 2020. Ultimately, 1,345 patients were invited to complete a 14-question survey. A retrospective chart review correlated clinical and demographic information. Univariate logistic regression, independent-samples t-test, and Pearson correlation coefficient identified differences among subgroups. RESULTS: Of the 1,345 patients, 181 (13.5%) completed the survey. The most significant barriers to care included fear of COVID (76/181; 42.0%), wait times (21/181; 11.6%), and costs (11/181; 6.1%). Patients who got their COVID information from the Centers for Disease Control and Prevention (7.8 ± 2.4) and televised news (8.0 ± 2.0) had higher levels of fear. Finally, patients with diabetic retinopathy and higher Charlson Comorbidity Index scores had greater concerns of COVID (P = .034 and P = .047, respectively). CONCLUSION: This survey study suggests fear of COVID-19 is a prominent new barrier to retinal care. Identifying those at risk for loss to follow-up can guide practices as the pandemic continues. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:526-533.].

Female Editorial Authorship Trends in High-Impact Ophthalmology Journals.

IMPORTANCE: Individuals with perceived experience and expertise are invited by editorial boards to provide commentary through editorials. Female representation among editorialists is not yet defined. OBJECTIVE: To determine female representation as editorial authors in 3 high-impact general ophthalmology journals. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study investigates the proportion of female authorship in editorials published between 2005 to 2009 and 2015 to 2019 in 3 journals: Ophthalmology, JAMA Ophthalmology, and American Journal of Ophthalmology. Data were collected from April to June 2020. MAIN OUTCOMES AND MEASURES: Proportions of female first and senior (last or solo) authors between 2005 to 2009 compared with 2015 to 2019. Secondary outcome measures include representation by sex across degree types and subspecialties. Comparisons were made for all editorialists and ophthalmologist editorialists. RESULTS: Of 814 editorial articles, there were 1179 (first and senior) authors identified. Women held 301 (25.5%) of these authorships, including 116 of 365 first authorships (32.9%) and 185 of 814 senior authorships (23.9%). Overall, female first and senior authorships grew by 68.0% between 2005 to 2009 and 2015 to 2019 (85 of 469 [18.1%] vs 216 of 710 [30.4%]; difference, 12.3%; 95% CI, 7.4-317.2; P < .001). Between 2005 to 2009 and 2015 to 2019, first and senior authorships by women increased (first: 33 of 133 [24.8%] vs 83 of 232 [35.8%]; difference, 11.0%; 95% CI, 1.4-320.6; P = .03; senior: 52 of 336 [15.5%] vs 133 of 478 [27.8%]; difference, 12.3%; 95% CI, 6.8-317.9; P < .001). JAMA Ophthalmology most substantially contributed to the increase in female first and senior authorships (13.8% and 16%), although the test for homogeneity among the 3 journals was not significant. The proportion of female ophthalmologist first authors was greater than the proportion of American Board of Ophthalmology-certified female ophthalmologists (81 of 281 [28.9%] vs 123 of 672 [18.3%]; difference, 10.6%; 95% CI, 5.3-315.9; P < .001). CONCLUSIONS AND RELEVANCE: The proportion of female senior authors increased by 68.0% between 2005 to 2009 and 2015 to 2019, but female authors represented only 25.5% of editorialists. Compared with male ophthalmologists, female ophthalmologists were more commonly first than senior authors. Additionally, female authors were more likely to be nonophthalmologists or to hold nonmedical, non-PhD degrees. While the swelling rank of female editorialists has paralleled the rising proportion of female ophthalmologists over time, parity by sex has yet to be attained. Greater awareness of disparities and strategies to mitigate them may help equalize representation.

Geographic Access Disparities of Clinical Trials in Neovascular Age-Related Macular Degeneration in the United States.

To identify geographic and socioeconomic variables predictive of residential proximity to neovascular age-related macular degeneration (nAMD) clinical trial locations. DESIGN: Retrospective, cross-sectional study. METHODS: Census tract-level data from public datasets and trial-level data from ClinicalTrials.gov were analyzed. We calculated the driving distance (>60 miles) and time (>60 minutes) from the population-weighted US census tract centroid to the nearest clinical trial site. RESULTS: We identified 42 trials studying nAMD across 829 unique clinical trial sites in the United States. In a multivariable model, driving distance >60 miles had a significant association with rural location (adjusted odds ratio [aOR] 5.54; 95% confidence interval [CI] 3.86-7.96, P < .0001) and with Midwest (aOR 2.30; 95% CI 1.21-4.38, P = .01) and South (aOR 2.43; 95% CI 1.21-4.91, P = .01) as compared to the Northeast region, and with some college or an associate's degree, as compared to a bachelor's degree (aOR 1.02; 95% CI 1.01-1.04, P = .0007, and aOR 1.05; 95% CI 1.00-1.10, P = .04, respectively). Lower odds of traveling >60 miles to the nearest nAMD trial site were associated with census tracts with a higher percentage of blacks (aOR 0.98; 95% CI 0.97-0.99, P < .0001), Hispanics (aOR 0.97; 95% CI 0.95-0.99, P = .002), and Asians (aOR 0.90; 95% CI 0.88-0.93, P < .0001), as compared to whites, and with a lower percentage of the population <200% of the federal poverty level. Similar predictors were found in time traveled >60 minutes. CONCLUSIONS: There are geographic access disparities of clinical trial sites for nAMD in the United States.

Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance.

PURPOSE: This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS: A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS: Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION: Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE: Level III.

Geographic Access Disparities to Clinical Trials in Diabetic Eye Disease in the United States.

PURPOSE: To identify geographic and socioeconomic variables predictive of residential proximity to diabetic eye disease clinical trial locations. DESIGN: Cross-sectional, retrospective study. PARTICIPANTS: De-identified census tract-level data from public datasets and trial-level data from ClinicalTrials.gov. METHODS: Using public data from ClinicalTrials.gov, we identified all active interventional clinical trials in diabetic eye disease since 2017. After geolocating every trial site, we used an origin-destination cost-matrix to calculate the driving distance and travel time from the population-weighted United States census tract centroid to the nearest site. We then used public databases to identify census tract-level socioeconomic factors predictive of driving distance and time. MAIN OUTCOME MEASURES: Driving distance > 60 miles and time traveled > 60 minutes to the nearest clinical trial site. RESULTS: In a multivariate model, driving distance of more than 60 miles had a significant association with rural versus urban location (adjusted odds ratio, 5.22; 95% confidence interval [CI], 3.75-7.26; P < 0.001), percentage of population at less than 200% of federal poverty level compared with the fourth quartile (first quartile: adjusted odds ratio, 0.40 [95% CI, 0.29-0.55]; second quartile: adjusted odds ratio, 0.60 [95% CI, 0.47-0.77]; third quartile: adjusted odds ratio, 0.76 [95% CI, 0.63-0.91]; P < 0.001) and the Midwest (adjusted odds ratio, 2.15; 95% CI, 1.13-4.07; P = 0.02), South (adjusted odds ratio, 2.71; 95% CI, 1.23-5.99; P = 0.01), and West (adjusted odds ratio, 3.01; 95% CI, 1.21-7.54; P = 0.02) regions as compared with the Northeast. Driving distance was associated with county-level prevalence of diabetes in the univariate model (odds ratio, 1.12; 95% CI, 1.06-1.19; P < 0.001), although it was nonsignificant in the multivariate model. Similar predictors were found for time traveled in minutes. CONCLUSIONS: Geographic maldistributions of clinical trial sites exist for diabetic eye disease in the United States. Those with higher travel burden are more likely to reside in a census tract that is rural, low income, and from areas outside the Northeast.

Virtual Ophthalmology Fellowship Interviews: Perceptions of U.S. Ophthalmology Fellowship Applicants in 2020.

Objective This study aimed to evaluate the experiences and preferences of ophthalmology fellowship applicants utilizing a virtual interview format. Design Present study is a cross-sectional study. Subjects All fellowship applicants to Wills Eye Hospital during 2020 to 2021 application cycle were included. Methods A nonvalidated, online survey was conducted, and surveys were distributed at the conclusion of the interview process after rank list submission. Main Outcome Measures Applicant demographics, application submissions, interview experiences, financial considerations, and suggestions for improvement of the virtual interview process were the primary outcomes of this cross-sectional study. Results Survey responses were received from 68 fellowship applicants (34% response rate). Thirty (44%) applicants preferred in-person interviews, 25 (36%) preferred virtual interviews, and 13 (19%) would like to prefer the option to choose either. Fifty-five of 68 (80%) applicants attended the same range of interviews for which they received interview invitations. Reduced costs were reported as the highest ranked strength of virtual interviews in 44 (65%) applicants, with a majority of respondents (68%) spending less than U.S. $250 throughout the entire process. The highest ranked limitation for virtual interviews was limited exposure to the culture/environment of the program in 20 (29%) respondents. On a scale of 0 to 100, the mean (standard deviation [SD]) satisfaction level with the fellowship application process was 74.6 (18.3) and mean (SD) perceived effectiveness levels of virtual interviews was 67.4 (20.4). Conclusion Respondents were generally satisfied with virtual interviews and noted reduced costs and increased ability to attend more fellowship interviews as the strengths of the virtual interview format. Limited exposure to the culture/environment of the program was cited as the most important limitation.

A Focused Gap Year Program in Orthopaedic Research: An 18-Year Experience.

INTRODUCTION: Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate. METHODS: From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year. RESULTS: One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons. CONCLUSION: Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.

Displaced Radial Shaft Fracture: The Dorsal (Thompson) Approach to the Forearm.

This video demonstrates a displaced radial shaft fracture repaired through a dorsal (Thompson) approach to the forearm. The patient is an 18-year-old man who sustained a left elbow dislocation and ipsilateral radial shaft fracture (OTA/AO: 22-B2) while playing basketball. The patient underwent a closed reduction of the elbow joint and was indicated for operative repair of the radius. Ultimate fixation included a compression plate and nonlocking screws through a dorsal approach to the radius. Anatomic reduction and stable fixation was obtained. The posterior interosseus nerve was identified and protected throughout the procedure. A dorsal (Thompson) approach to a radial shaft fracture is advantageous for fractures involving the proximal and middle-third of the radius. This approach can also be used when there is soft tissue damage (open wounds) on the dorsal aspect, which require debridement.

Posteromedial Approach to Tibial Plateau Fracture Nonunion.

Tibial plateau fractures can involve planes that require reduction and stabilization from a posterior approach. This includes posteromedial, posterolateral, and posterior column shear type injuries. This video outlines the prone posteromedial approach to the tibial plateau for posterior column fracture exposure, reduction, and fixation.

Trifocal choroidal melanoma in an eye with oculodermal melanocytosis: A case report.

We report a case of trifocal choroidal melanoma (three separate tumors) in a 48-year-old Caucasian female who had been followed for oculodermal melanocytosis since childhood. At presentation, no tumor was present and annual examination was advised. Seventeen years later, three choroidal melanocytic lesions were detected in the right eye. Growth of each was documented, enucleation was performed, and histopathology revealed three independent choroidal melanomas. The patient developed extensive liver and bone metastases and subsequently died. Oculodermal melanocytosis is a risk factor for the development of uveal melanoma and a potential marker for worse prognosis. Careful long-term follow-up is required.