Validation and Feasibility of the Postnatal Growth and Retinopathy of Prematurity Retinal Screening Criteria at a Level IV Tertiary Care Neonatal Intensive Care Unit.

OBJECTIVE: Retinopathy of prematurity (ROP) is detected in preterm infants by standardized screening programs, but in general, they have poor sensitivity. The Postnatal Growth and Retinopathy of Prematurity (G-ROP) algorithm uses weight gain to predict ROP superior reported sensitivity. Our objectives are to (1) independently validate the sensitivity of G-ROP criteria for the detection of ROP in infants born at >28 weeks' gestation in a tertiary care unit in the United States and (2) to calculate the cost savings associated with a potential reduction in examinations. STUDY DESIGN: This is a retrospective analysis of retinal screening examination data, with post-hoc application of G-ROP criteria to determine whether G-ROP criteria had acceptable sensitivity and specificity in diagnosing Type 1 and Type 2 ROP. All infants born at >28 weeks who were screened by current American Academy of Pediatric Ophthalmologists/American Academy of Pediatrics guidelines at Oklahoma Children's Hospital at the University of Oklahoma Health Sciences Center, between 2014 and 2019, were included. Subset analysis of infants screened by second tier criteria was also performed. Potential cost savings were estimated by analyzing frequency of billing codes. And by calculating the number of infants who could have potentially been spared examination. RESULTS: The G-ROP criteria had 100% sensitivity in detecting type 1 and 87.6% sensitivity in detecting type 2 ROP, which would have reduced infants screened by 50%. All infants in the second tier who would require treatment were detected. A cost saving of 49% was projected. CONCLUSION: The G-ROP criteria are easy to apply in real-world setting, thus establishing feasibility. The algorithm identified all cases of type 1 ROP; however, some cases of type 2 ROP were not detected. The annual savings in hospital examination cost by using these criteria would be 50%. Therefore, G-ROP criteria can safely be used to screen for ROP and may reduce the number of unnecessary examinations. KEY POINTS: · The G-ROP screening criteria are safe and predict 100% of treatment warranted ROP.. · Adoption of G-ROP criteria is feasible for level IV NICUs.. · Adoption of G-ROP screening guidelines will result in significant cost savings..

Surgical outcomes following strabismus surgery for abducens nerve palsy.

PURPOSE: To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries. METHODS: We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery. RESULTS: A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence. CONCLUSIONS: In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries.

Evaluation and Management of Symptomatic Vertical Strabismus and Diplopia.

The evaluation and management of vertical strabismus is more challenging and nuanced than that of horizontal strabismus. Vertical strabismus often results from a variety of restrictive or paretic causes, which can be further characterized as either acquired or congenital. In some cases, identifying the correct etiology of the strabismus can mean uncovering a potentially life-threatening condition, such as a brain tumor or stroke. The keys to identifying the correct diagnosis are, first and foremost, a careful history, and secondly, a detailed examination. The characteristics, etiologies, and evaluation of vertical strabismus will be reviewed here.

Learning From the 2021 Ophthalmology Match: Virtual Residency Matching During the COVID-19 Pandemic.

Background: The effect of virtual interviews on residency match outcomes during the COVID-19 pandemic is unknown. Examining the ophthalmology match may help inform all specialties undergoing virtual interviews. Objective: To determine the impact of allopathic applicant match characteristics in the first year of the virtual residency Match process. Methods: Using the Association of University Professors of Ophthalmology match database, a retrospective review was conducted of all allopathic applicants to ophthalmology residency programs in the United States from the 2016 through the 2021 match cycles. Demographic information, interview numbers, and match outcomes were compared between the 2016-2020 (in-person) and 2021 (virtual) cycles. Results: A total of 3343 allopathic applicants were analyzed. Applicants in the 2021 Match applied to significantly more programs than 2016-2020 applicants did (78.7±23.6 vs 73.1±22.7, P<.001). Among matched and unmatched applicants, there was no significant difference in the number of interviews granted or completed. There was a significant reduction in the match rate between the 2016-2020 and 2021 Match cycles (81.3% vs 76.6%, P=.0009). A subanalysis of applicants who went to medical schools with ophthalmology residency programs (N=2308) found that the home institution match rate was significantly higher for the 2021 Match compared to the aggregate 2016-2020 Matches (26.1% vs 20.6%, respectively, P=.015). Conclusions: Significantly more applicants to ophthalmology residency programs matched at their home institutions in the 2021 virtual match cycle compared to the previous 5 years without influencing the interview numbers granted and attended.

A case of brain hamartoma in a child leading to compressive optic neuropathy mimicking amblyopia.

Hamartomas are benign neoplastic malformations characterized by disorganized growths of tissue in their native location. They may grow in numerous sites throughout the body. We report the case of a 3-year-old boy with unilateral compressive optic neuropathy caused by a brain hamartoma that mimicked strabismic amblyopia. To our knowledge, this is the first case report in the literature of prechiasmal optic nerve compression from a brain hamartoma without ipsilateral bony defect or encephalocele.

A child with unilateral disk elevation.

A healthy 7-year-old girl underwent a routine eye examination and was referred for unilateral, left optic nerve swelling. Best-corrected visual acuity in the affected eye was 20/20 with full Ishihara color plates and no relative afferent pupillary defect. Initial extensive workup was normal for any cause of unilateral disk swelling. When the patient returned a few years later with decreased vision, a thickened, gray-white preretinal tissue with surrounding retinal contraction and a surrounding charcoal gray lesion had developed in her optic nerve. Spectral-domain optical coherence tomography over the optic nerve demonstrated distortion of the inner retinal architecture, a dense epiretinal membrane, and high internal reflectivity. Clinical examination and imaging revealed a diagnosis of combined hamartoma of the retina and retinal pigment epithelium.

Correlation of Ophthalmology Residency Application Characteristics with Subsequent Performance in Residency.

Purpose Only from reviewing applications, it is difficult to identify which applicants will be successful ophthalmology residents. The change of the USMLE Step 1 scoring to "Pass/Fail" removes another quantitative metric. We aimed to identify application attributes correlated with successful residency performance. This study also used artificial intelligence (AI) to evaluate letters of recommendation (LOR), the Dean's letter (MSPE), and personal statement (PS). Design Retrospective analysis of application characteristics versus residency performance was conducted. Participants Residents who graduated from the Dean McGee Eye Institute/University of Oklahoma Ophthalmology residency from 2004 to 2019 were included in this study. Methods Thirty-four attributes were recorded from each application. Residents were subjectively ranked into tertiles and top and bottom deciles based on residency performance by faculty present during their training. The Ophthalmic Knowledge Assessment Program (OKAP) examination scores were used as an objective performance metric. Analysis was performed to identify associations between application attributes and tertile/decile ranking. Additional analysis used AI and natural language processing to evaluate applicant LORs, MSPE, and PS. Main Outcome Measures Characteristics from residency applications that correlate with resident performance were the primary outcome of this study. Results Fifty-five residents and 21 faculty members were included. A grade of "A" or "Honors" in the obstetrics/gynecology (OB/GYN) clerkship and the presence of a home ophthalmology department were associated with ranking in the top tertile but not the top decile. Mean core clerkship grades, medical school ranking in the top 25 U.S. News and World Report (USNWR) primary care rankings, and postgraduate year (PGY)-2 and PGY-3 OKAP scores were predictive of being ranked in both the top tertile and the top decile. USMLE scores, alpha-omega-alpha (AOA) status, and number of publications did not correlate with subjective resident performance. AI analysis of LORs, MSPE, and PS did not identify any text features that correlated with resident performance. Conclusions Many metrics traditionally felt to be predictive of residency success (USMLE scores, AOA status, and research) did not predict resident success in our study. We did confirm the importance of core clerkship grades and medical school ranking. Objective measures of success such as PGY-2 and PGY-3 OKAP scores were associated with high subjective ranking.

What did he eat?

A 13-year-old boy reported acute horizontal binocular diplopia and headache. Ten days before these symptoms he suffered from a gastrointestinal infection. Ophthalmological examination revealed bilateral ophthalmoparesis and diffuse hyporeflexia. Magnetic resonance imaging of the brain was normal. Lumbar puncture revealed albumin-cytological dissociation. There were no anti-GQ1b antibodies, but serum anti-GM1 antibodies were detected. He received intravenous immunoglobulins and had fully recovered two weeks later. Miller Fisher syndrome and its atypical variants are uncommon in childhood; nevertheless, they should be considered in the differential diagnosis of bilateral acute ophthalmoparesis.

Ocular manifestations of mycoplasma-induced rash and mucositis.

A 13-year-old girl presented with a 5-day history of fever and cough followed by new-onset oral ulcers and conjunctival injection. Clinical examination revealed bilateral 360-degree subconjunctival hemorrhages, which later evolved to corneal epithelial defects, pseudo-membrane formation, and extensive oral mucosal ulceration. Mycoplasma pneumoniae serum IgG and IgM were positive. Treatment with topical prednisolone acetate, moxifloxacin, preservative-free artificial tears, and erythromycin ointment was initiated. A self-retaining amniotic membrane was placed. The ocular and oral lesions resolved within 2 weeks of treatment, and the patient's vision returned to baseline. Mycoplasma-induced rash and mucositis is a newly defined entity that mainly affects children and has a favorable prognosis with early detection and treatment.

Scope of telemedicine in neonatology.

There is a widespread shortage of physicians worldwide, especially in rural areas. This shortage is more prevalent when it comes to subspecialty care, even in developed countries. One way to provide access to specialty care is using technology via telemedicine. Telemedicine has evolved over the last two decades, and its use is becoming widespread in developed countries. However, its use in the neonatal population is still limited and practiced only in some centers. It is now apparent that telemedicine can be successfully used in the neonatal population for screening premature infants for retinopathy of prematurity, congenital heart disease, bedside clinical rounds, neonatal resuscitation with the support of a tertiary care hospital, and family support. This avoids unnecessary transfer and appears to provide the same quality of care that the baby would have received at the tertiary care facility. This approach also improves family satisfaction, as the baby and the mother are kept together, and reduces the cost of care. This review focuses on the use of telemedicine in neonatal care, concentrating on the main areas where telemedicine has been shown to be successful and effective, including the status of telemedicine in China.

Short-term Outcomes After Very Low-Dose Intravitreous Bevacizumab for Retinopathy of Prematurity.

Importance: Intravitreous bevacizumab (0.25 mg to 0.625 mg) is commonly used to treat type 1 retinopathy of prematurity (ROP), but there are concerns about systemic toxicity, particularly the risk of neurodevelopmental delay. A much lower dose may be effective for ROP while reducing systemic risk. Previously, after testing doses of 0.25 mg to 0.031 mg, doses as low as 0.031 mg were found to be effective in small cohorts of infants. Objective: To find the lowest dose of intravitreous bevacizumab effective for severe ROP. Design, Setting, and Participants: Between April 2017 and May 2019, 59 premature infants with type 1 ROP in 1 or both eyes were enrolled in a masked, multicenter, dose de-escalation study. In cohorts of 10 to 14 infants, 1 eye per infant received 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg of intravitreous bevacizumab. Diluted bevacizumab was prepared by individual research pharmacies and delivered using 300-µL syringes with 5/16-inch, 30-guage fixed needles. Analysis began July 2019. Interventions: Bevacizumab intravitreous injections at 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. Main Outcomes and Measures: Success was defined as improvement by 4 days postinjection and no recurrence of type 1 ROP or severe neovascularization requiring additional treatment within 4 weeks. Results: Fifty-five of 59 enrolled infants had 4-week outcomes completed; the mean (SD) birth weight was 664 (258) g, and the mean (SD) gestational age was 24.8 (1.6) weeks. A successful 4-week outcome was achieved for 13 of 13 eyes (100%) receiving 0.016 mg, 9 of 9 eyes (100%) receiving 0.008 mg, 9 of 10 eyes (90%) receiving 0.004 mg, but only 17 of 23 eyes (74%) receiving 0.002 mg. Conclusions and Relevance: These data suggest that 0.004 mg may be the lowest dose of bevacizumab effective for ROP. Further investigation is warranted to confirm effectiveness of very low-dose intravitreous bevacizumab and its effect on plasma vascular endothelial growth factor levels and peripheral retinal vascularization.

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.

Temporal Profile of Retinopathy of Prematurity in Extremely Premature Compared to Premature Infants.

PURPOSE: To compare the time course of retinopathy of prematurity (ROP) in premature (≥ 28 to 34 weeks' gestational age) and extremely premature (< 28 weeks' gestational age) infants. METHODS: This study was a retrospective single-center chart review that included 582 eyes (122 premature, 464 extremely premature) of 299 infants (65 premature, 234 extremely premature) diagnosed as having ROP who were born between January 1, 2010, and December 31, 2015. Data collected were analyzed with shared frailty models, chi-square, and Fisher's exact tests. RESULTS: Extremely premature infants were diagnosed as having ROP earlier than premature infants at 33.6 weeks (95% CI [confidence interval]: 33.4 to 33.9) versus 36.0 weeks (95% CI: 34.7 to 36.4, P < .0001). The time from diagnosis to spontaneous regression was more than 4 weeks longer for extremely premature infants than premature infants with stage 1 ROP (82.0 vs 50.0 days, P < .0001), and more than 6 weeks longer for extremely premature infants than premature infants with stage 2 ROP (99 vs 55 days, P < .0001). Extremely premature infants had more bilateral ROP (96.6% vs 87.1%, P < .01) and were three times more likely to require treatment than premature infants (29.7% vs 9.9%, P < .0001). On average, infants who required treatment weighed 137 grams less at birth (P < .0001) and gained 37.7 grams less per week than infants who underwent spontaneous regression (P < .0001). CONCLUSIONS: Extremely premature infants developed ROP earlier, had more bilateral ROP, took longer to achieve spontaneous regression, and required treatment more often than premature infants. Infants who required treatment had a lower birth weight and rate of weight gain than infants who underwent spontaneous regression. [J Pediatr Ophthalmol Strabismus. 2019;56(2):116-123.].

Assessment of Outcomes With a Sedation Protocol During Laser Photocoagulation in Preterm Infants With Retinopathy of Prematurity.

OBJECTIVES: To evaluate the success of a sedation protocol of fentanyl and midazolam infusions for infants undergoing laser photocoagulation for retinopathy of prematurity. METHODS: This retrospective study included infants receiving a sedation protocol for laser photocoagulation during a 4-year period. The primary objective was protocol success, defined as completion without interruption, absence of protocol dose deviations, and absence of interventions. Secondary objectives compared outcomes between those with and without opioid/benzodiazepine exposure. A logistic regression was used to assess the effect of prior opioid/benzodiazepine exposure on requirement for fentanyl infusion increases. RESULTS: Twenty-six infants were included. Seven (26.9%) had protocol success. Sixteen (61.5%) had protocol success, excluding dose deviations. Seventeen (65.4%) experienced ≥1 cardiopulmonary adverse events. Photocoagulation was completed in all cases. CONCLUSIONS: Most achieved protocol success, when eliminating dosing deviations. These data indicate that flexibility is needed in fentanyl and midazolam infusion titration, based on clinical response.

Divergence insufficiency alleviated by posterior fossa decompression with duraplasty in a patient with Chiari type 1.5 malformation.

The authors present a case of Chiari type 1.5 malformation with the uncommon presenting symptoms of esotropia and diplopia due to divergence insufficiency in a 12-year-old girl. Imaging at initial diagnosis revealed cerebellar herniation with extension of the tonsils to the C2 vertebral body, a retroflexed odontoid, and a small cervical syrinx. The patient was initially treated with an uncomplicated Chiari malformation decompression without dural opening. Repeat imaging revealed an adequate decompression. Three months postoperatively the patient's diplopia recurred and she underwent repeat posterior fossa decompression with dural opening and duraplasty. Following repeat decompression with dural opening and duraplasty, the patient's diplopia had not recurred by the 2-year follow-up.https://thejns.org/doi/abs/10.3171/2018.5.PEDS1886.