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.

Fixed High Energy Versus Standard Titrated Energy Settings for Selective Laser Trabeculoplasty.

PRCIS: Fixed high-energy selective laser trabeculoplasty (SLT) is associated with a greater reduction in intraocular pressure (IOP) compared with the standard titrated approach at up to 36 months postprocedure. PURPOSE: There is no consensus on ideal SLT procedural laser energy settings. This study aims to compare fixed high-energy SLT to the standard titrated-energy approach within the setting of a residency training program. PATIENTS: Patients over the age of 18 years received SLT between 2011 and 2017, a total of 354 eyes. Patients with a prior history of SLT were excluded. METHODS: Retrospective review of clinical data from 354 eyes that underwent SLT. Eyes that underwent SLT using fixed high energy (1.2 mJ/spot) were compared with those with the standard titrated approach starting at 0.8 mJ/spot and titrating to "champagne" bubbles. The entirety of the angle was treated using a Lumenis laser set to the SLT setting (532 nm). No repeat treatments were included. MAIN OUTCOME MEASURE: IOP and glaucoma medications. RESULTS: In our residency training program, fixed high-energy SLT was associated with a reduction in IOP compared with a baseline of -4.65 (±4.49, n = 120), -3.79 (±4.49, n = 109), and -4.40 (±5.01, n =119) while standard titrated-energy was associated with IOP reduction of -2.07 (±5.06, n = 133), -2.67 (±5.28, n = 107), and -1.88 (±4.96, n = 115) at each respective postprocedural time point (12, 24, and 36 months). The fixed high-energy SLT group had significantly greater IOP reduction at 12 months and 36 months. The same comparison was performed for medication naïve individuals. For these individuals, fixed high-energy SLT resulted in IOP reductions of -6.88 (±3.72, n = 47), -6.01 (±3.80, n = 41), and -6.52 (±4.10, n = 46) while standard titrated-energy had IOP reductions of -3.82 (±4.51, n = 25), -1.85 (±4.88, n = 20), and -0.65 (±4.64, n = 27). For medication naïve individuals, fixed high-energy SLT resulted in a significantly greater reduction in IOP at each respective time point. Complication rates (IOP spike, iritis, and macular edema) were similar between the two groups. The study is limited by overall poor response to standard-energy treatments, whereas high-energy treatments showed similar efficacy to those in literature. CONCLUSION: This study demonstrates that fixed-energy SLT produces at least equivalent results compared with the standard-energy approach, without an increase in adverse outcomes. Particularly in the medication naïve subpopulation, fixed-energy SLT was associated with a significantly greater IOP reduction at each respective time point. The study is limited by overall poor response to standard-energy treatments, with our results showing decreased IOP reduction compared with those of previous studies. These poor outcomes of the standard SLT group may be responsible for our conclusion that fixed high-energy SLT results in a greater reduction in IOP. These results may be useful when considering optimal SLT procedural energy in future studies for validation.

Hydrus Microstent implantation with OMNI Surgical System Ab interno canaloplasty for the management of open-angle glaucoma in phakic patients refractory to medical therapy.

Purpose: To report a series of 8 phakic eyes of 8 patients with open angle glaucoma with uncontrolled intraocular pressure on maximum tolerable medical therapy receiving Hydrus Microstent implants combined with concomitant OMNI Surgical System ab interno canaloplasty. Observations: 8 phakic eyes underwent Hydrus Microstent implantation with OMNI Surgical System ab interno canaloplasty. 2 patients underwent concurrent Kahook Dual Blade goniotomy and 1 patient underwent a concurrent micropulse transscleral cyclophotocoagulation. 6 out of 8 eyes achieved successful intraocular pressure reduction. Only 1 achieved success without the need for additional medical therapy. 1 required Neodymium-doped yttrium aluminum garnet laser to clear iris obstruction of the Hydrus inlet and 1 required selective laser trabeculoplasty for additional intraocular pressure lowering. 2 out of 8 eyes required subsequent incisional glaucoma surgery for unacceptable intraocular pressure levels despite maximum tolerable medical therapy. Conclusions and Importance: The Hydrus Microstent combined with OMNI Surgical System ab interno canaloplasty can safely and successfully reduce intraocular pressure in phakic patients with open-angle glaucoma with uncontrolled intraocular pressure on maximum tolerable medical therapy with a low complication rate and rapid visual recovery.

Clinical Outcomes of Ab Interno Placement versus Ab Externo Placement of XEN45 Gel Stents.

PURPOSE: To compare the effectiveness of ab interno versus ab externo placement of XEN45 gel stents in patients with open-angle glaucoma. DESIGN: Single-center, noncontrolled, retrospective, comparative case series. PARTICIPANTS: Eighty-nine eyes of 89 patients with open-angle glaucoma who underwent XEN45 gel stent implantation. METHODS: Patients underwent either ab interno (group 1) or ab externo (group 2) placement of a XEN45 stent between 2017 and 2020 by a single surgeon. Outcomes were recorded at each follow-up visit from postoperative day 1 up to 24 months, with median follow-up lengths of 12 months and 8 months for groups 1 and 2, respectively. MAIN OUTCOME MEASURES: The primary outcome measure was the surgical success rate at 8 months. Secondary measures were postoperative intraocular pressure (IOP) and medication usage, complication rates, and bleb revision rates. RESULTS: Success rates at 8 months were 72% in group 1 (n = 29) and 74% in group 2 (n = 60). There was no difference in the median time to failure between groups (P = 0.98). The mean baseline IOPs were 22.8 ± 7.5 on 3.8 ± 0.9 medications in group 1 and 25.3 ± 10.7 on 3.7 ± 1 medications in group 2. At the last follow-up among eyes with surgical success, the mean IOPs were 12.5 ± 3.8 on 2.2 ± 1.4 medications in group 1 and 12.2 ± 2.1 on 1.8 ± 1.3 medications in group 2. The adjusted mean IOPs and numbers of medications used were significantly lower after XEN45 stent implantation at all postoperative time points compared with baseline in both groups (P < 0.05). There were no significant differences in postoperative adjusted mean IOPs or medications used between the groups at any of the follow-up time points. Complication rates and bleb revision rates were comparable between both groups (P > 0.05). CONCLUSIONS: The ab externo approach of XEN45 stent placement demonstrates comparable effectiveness to the ab interno approach in patients with open-angle glaucoma, although this study was underpowered to detect a difference in success rates between groups.

Hyphema in Open-Globe Versus Closed-Globe Injuries in Operation Iraqi Freedom and Enduring Freedom: 2001-2011.

INTRODUCTION: The goal of this study is to update the incidence of hyphema in Operation Iraqi (OIF) and Enduring Freedom (OEF). We wanted to assess associated ocular injuries and final visual acuity (VA) in open-globe versus closed-globe injuries with a hyphema. MATERIALS AND METHODS: We performed a retrospective review of the Walter Reed Ocular Trauma Database (WRTOD) to identify U.S. Service members and DoD civilians with hyphema who were evacuated to Walter Reed Army Medical Center between 2001 and 2011. Primary outcome measures were the final VA and differences in concomitant ocular injuries in open-globe hyphema and closed-globe hyphema. RESULTS: 168 of 890 eyes (18.9%) in the WROTD had a hyphema. Closed-globe injuries were noted in 64 (38.1%) eyes and open-globe injuries in 104 (61.9%) eyes. A final VA of less than 20/200 was noted in 88 eyes (51.8%). Eyes with hyphema were more likely to have traumatic cataract formation (odds ratio (OR) 6.2, 95% confidence interval (CI) 4.2-9.2, P < 0.001), retinal detachment (OR 4.2, CI 2.8-6.4, P < 0.001), angle recession (OR 8.1, CI 2.9-24.3, P < 0.001), and final VA of less than 20/200 (OR 3.7, CI 2.6-5.4, P < 0.001). Traumatic cataract formation (OR 7.4, CI 2.9-18.7, P < 0.001), retinal detachment (OR 6.1, CI 2.1-17.5, P < 0.001), and a final VA less than 20/200 (OR 6.1, CI 2.4-15.4 P < 0.001) were statistically more likely to occur with an open-globe hyphema than with a closed-globe hyphema. CONCLUSIONS: Close follow-up in patients with hyphema is important due to the associated development of traumatic cataract and retinal detachment and poor final visual outcome.

Trabectome-Initiated Gonioscopy-Assisted Transluminal Trabeculotomy.

Introduction: To introduce a trabectome-initiated gonioscopy-assisted transluminal trabeculotomy (TIGATT) procedure and to report preliminary results. Materials and Methods: A preliminary case series of eight patients who have undergone the newly proposed TIGATT procedure is presented. TIGATT is a new concept that modifies established techniques by replacing the initial goniotomy incision of gonioscopy-assisted transluminal trabeculotomy (GATT) with an ab interno trabeculectomy ablation utilizing the trabectome. All surgeries were performed by a single surgeon (W.I.K.) between November 2014 and October 2015 in adults with primary open-angle glaucoma. Recorded outcome measures were intraocular pressure (IOP), number of medications, and complications. Results: Eight patients with an age range of 63-93 yr underwent TIGATT with at least 3 mo of follow-up. Five of the eight initial patients had follow-up to 2 yr. The mean pre-operative IOP was 25 mmHg (standard deviation [SD] 7.0) on four medications (SD 1.1). The mean post-operative IOP at 3 mo was 14 mmHg (SD 1.8) on two medications (SD 1.3). The average decrease in IOP was 9.9 mmHg (SD 7.5) with an average decrease in medications of two (SD 1.4) at 3 mo. At 2 yr, the mean post-operative IOP was 14 mmHg (SD 3.2) on one medication (SD 1.1). The average decrease in IOP was 7.8 mmHg (SD 3.1) with an average decrease in medications of two (SD 1.8). There were two treatment failures that required further glaucoma surgery and one patient was lost to follow-up. Conclusions: The preliminary results and safety profile for TIGATT are promising and appear at least comparable with previously published results for both GATT and trabectome. Initiating the transluminal trabeculotomy with trabectome clearly exposes Schlemm's canal and facilitates threading the microcatheter into the canal. Additionally, if the 360-degree trabeculotomy cannot be completed because of an incompletely patent Schlemm's canal, the patient will at least have a trabectome ablation that can serve as their glaucoma surgery.

Oocyst-Shedding Patterns of Three Eimeria Species in Chickens and Shedding Pattern Variation Depending on the Storage Period of Eimeria tenella Oocysts.

Various species of Eimeria have different prepatent times and predilection sites, but their life cycles in infected poultry are similar. Practically speaking, chickens can be continuously exposed to various Eimeria species through environmental contamination. Furthermore, storage condition of the oocysts influences subsequent challenge infectivity, since coccidian oocysts contain a polysaccharide energy source known as amylopectin that is required for sporulation of oocysts and survival of the sporozoites. Here analysis of the oocyst-shedding patterns of 3 Eimeria species ( Eimeria acervulina, Eimeria maxima, and Eimeria tenella) and the effects of different oocyst storage time (64, 143, 225, and 332 days) on subsequent propagation patterns were evaluated. Based on the analysis of oocyst-shedding patterns and infectious lesions evaluated by oocyst counts and histopathology, respectively, the peak points of oocyst production and infectious lesion generation in animals infected with E. acervulina were observed to occur earlier in comparison to E. maxima- and E. tenella-infected animals. Prolonged storage of E. tenella oocysts decreased oocyst excretion (measured as oocysts per gram of feces [OPG]) and lengthened the peak period. Chickens infected with the freshest oocysts (Group A) had the highest fecal oocyst output, and animals in this group reached their peak at 7 days post-infection (dpi), which is similar to the normal pattern of oocyst output in fresh isolates. Infection with oocysts stored for longer periods showed a 1-day delay in the fecal oocyst peak count (8 dpi), and these infections also resulted in fewer OPG compared to Group A. Therefore, these results indicate that the storage period is important in affecting the peak point and pattern of oocyst shedding.

Implantation of a CyPass Supraciliary Stent Combined With Targeted iStent Trabecular Microbypass Stents in a Phakic Patient With Primary Open-angle Glaucoma.

PURPOSE: To report the first successful implantation of a CyPass supraciliary stent combined with 2 targeted iStent trabecular microbypass stents in a phakic primary open-angle glaucoma patient with markedly elevated intraocular pressures (IOP) on maximum tolerable medical therapy. METHODS: Case report. RESULTS: A 52-year-old phakic male patient with primary open-angle glaucoma with uncontrolled IOP in the right eye (OD) of 36 mm Hg on maximal topical pharmacotherapy. The patient underwent implantation of a single CyPass supraciliary stent combined with the targeted implantation of 2 iStent trabecular microbypass stents, 1 right facing stent and 1 left facing stent. Postoperatively, off of all glaucoma medications, the IOP decreased to 10 mm Hg on day 1 and continued to be controlled between 10 to 13 mm Hg until postoperative month 6, with only 1 glaucoma medication added after postoperative month 5. In addition, there were no postoperative complications to date. CONCLUSIONS: The combined implantation of a CyPass supraciliary stent and iStent trabecular microbypass stents can successfully lower IOP and decrease medication burden with minimal risk for complications.

The Efficacy of Two Trabecular Bypass Stents Compared to One in the Management of Open-Angle Glaucoma.

OBJECTIVES: To compare the outcomes of combined cataract surgery with two trabecular microbypass stents compared to one in patients with open-angle glaucoma. METHODS: Patients with primary open-angle glaucoma were included. Primary outcome measures were intraocular pressure (IOP), postoperative medications, and postoperative adverse events. RESULTS: The average patient age was 73.2 years. Thirty-nine eyes had phacoemulsification and one stent implanted (Group 1); 30 eyes had phacoemulsification and two stents implanted (Group 2). A significant reduction in mean IOP from baseline to 12 months was noted for both Group 1 (16.67 ± 4.1 mm Hg to 14.45 ± 3.8 mm Hg; p < 0.0251) and Group 2 (18.33 ± 3.99 mm Hg to 14.31 ± 1.8 mm Hg; p < 0.0014). Group 2 had a greater percent decrease in IOP at 12 months than Group 1, but this difference was not statistically significant. Only Group 2 demonstrated a statistically significant reduction in medication burden at 12 months. There were no serious complications in either group thought to be caused by the microbypass stents. CONCLUSIONS: Both groups demonstrated a significant reduction in IOP at 12 months. Group 2 showed a greater percent decrease in IOP; however, it was not statistically significant. Only Group 2 demonstrated a statistically significant reduction in medication burden.

Endothelial transient receptor potential conical channel (TRPC)-3 activation induces vasogenic edema formation in the rat piriform cortex following status epilepticus.

Transient receptor potential canonical channel (TRPC) is a nonselective cation channel permeable to Ca(2+), which express in many cell types, including neurons. However the alterations in TRPC receptor expressions in response to status epilepticus (SE) have not been explored. Therefore, the present study was designated to elucidate the roles of TRPC3 in neuronal death and vasogenic edema within the rat piriform cortex (PC) following SE. In non-SE animals, TRPC3 immunoreactivity was abundantly detected in the PC. Following SE, TRPC3 immunoreactivity was increased in neurons. Furthermore, TRPC3 expression was detected in endothelial cells that did not contain it in non-SE animals. Loss of SMI-71 (a blood-brain barrier antigen) immunoreactivity was also observed in TRPC3 positive endothelial cells. In addition, FJB positive neurons and vasogenic edema were noticeably detected in the PC. To directly determine whether TRPC3 activation is correlated to SE-induced vasogenic edema formation and neuronal damages in the PC, the effect of Pyr-3 (a TRPC3 antagonist) on SE-induced insults were investigated. Pyr-3 infusion effectively attenuated vasogenic edema in the PC as compared to the vehicle. Therefore, our findings indicate that TRPC3 activation/overexpression induced by SE may involve BBB disruption and neuronal damages in the rat PC following SE. Therefore, the present study was TRPC3 may play an important role in SE-induced vasogenic edema formation through BBB disruptions in the rat PC.

Long-term effect of phacoemulsification on intraocular pressure using phakic fellow eye as control.

PURPOSE: To investigate the long-term effect of phacoemulsification on intraocular pressure (IOP) in patients with ocular hypertension and open-angle glaucoma. SETTING: Three multispecialty ophthalmology practices and one glaucoma specialty group. DESIGN: Retrospective comparative case series. METHODS: Review of medical records of patients with open-angle glaucoma or ocular hypertension who had had unilateral phacoemulsification (without other prior or concurrent ophthalmic procedure) with the fellow eye remaining phakic at least 3 years postoperatively. RESULTS: Preoperatively, the IOP in the surgical and fellow eyes in the 29 patients was 15.66 mm Hg ± 3.33 (SD) and 15.64 ± 4.23 mm Hg (P=.98), respectively. Postoperatively, it was 13.56 ± 2.04 mm Hg and 14.92 ± 2.85 mm Hg, respectively, at 4.5 months (P=.06); 14.88 ± 3.20 mm Hg and 15.27 ± 3.19 mm Hg, respectively, at 1 year (P=.67); 14.16 ± 2.61 mm Hg and 14.95 ± 2.79 mm Hg, respectively, at 2 years (P=.37); and 14.68 ± 3.44 mm Hg and 14.68 ± 2.68 mm Hg at 3 years (P=1.00), respectively. There was no significant difference in the mean number of IOP-lowering medications used in the surgical eyes (1.96 ± 1.40) and fellow eyes (2.08 ± 1.44) postoperatively (P=.77). CONCLUSIONS: In a cohort of ocular hypertensive and glaucoma patients, uncomplicated phacoemulsification had no significant IOP-lowering effect compared with the phakic fellow eye for up to 3 years postoperatively. There was also no difference between the mean number of postoperative IOP-lowering medications used in the surgical and fellow eyes. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Resolution of lymphoma-associated open-angle glaucoma by rituximab.

PURPOSE: To report a patient who developed open-angle glaucoma, secondary to bilateral perilimbal conjunctival lymphoid infiltrates without intraocular involvement that resolved after treatment with systemic rituximab. METHODS: Observational case report. RESULTS: Review of historic, clinical, and photographic data of a 67-year-old woman with non-Hodgkin lymphoma of the axillary and cervical lymph nodes and bilateral perilimbal conjunctival lymphoid infiltrates who presented for treatment of uncontrolled chronic open-angle glaucoma on maximum medical therapy. The elevated intraocular pressures and conjunctival lesions resolved after treatment of the systemic lymphoma with rituximab. The patient was followed for a period of 6 years without recurrence of the conjunctival lesions, with low normal intraocular pressures without progressive optic nerve damage off all glaucoma treatments. CONCLUSIONS: Open-angle glaucoma can result as a consequence of isolated conjunctival lymphoid tumors and can resolve with successful treatment of lymphoid lesions. The mechanism of glaucoma may be obstruction of aqueous outflow to the episcleral and conjunctival veins either by compression from a mass effect or direct infiltration that is relieved with resolution of the conjunctival lymphoid lesions. We believe this is a unique presentation of glaucoma associated with lymphoid tumors that has not been reported earlier.

The effect of additional propofol on intubation conditions.

STUDY OBJECTIVE: To evaluate whether an additional dose of propofol prior to intubation improves intubation conditions. DESIGN: Prospective, randomized, double-blinded clinical study. SETTING: Operating room in university hospital. PATIENTS: 102 ASA physical status I and II patients undergoing elective surgery with general anesthesia. INTERVENTIONS: Patients received different doses of propofol (Groups A and B, 1.5 mg/kg; Group C, 2 mg/kg) preceded by fentanyl (1.5 µg/kg). In Group B, additional propofol (0.5 mg/kg) was administered 45 seconds after rocuronium. Intubation was performed 90 seconds after administration of rocuronium 0.6 mg/kg. Intubation conditions and hemodynamic variables were compared among the three groups. MEASUREMENTS AND MAIN RESULTS: Intubation conditions were acceptable in 61.8% of Group A patients, 58.8% of Group C patients, and 91.1% of Group B patients (P = 0.005). Mean arterial pressure (MAP) three minutes after intubation was significantly lower in Group C (P = 0.006 vs. Groups A and B), while MAP did not differ between Group A and Group B. CONCLUSIONS: Administration of an additional dose of propofol (0.5 mg/kg) prior to intubation may significantly improve intubation conditions without increasing the frequency of hypotension.

Development of a foot-and-mouth disease NSP ELISA and its comparison with differential diagnostic methods.

The gene encoding the nonstructural protein (NSP) of O/SKR/2000 foot-and-mouth disease virus (FMDV) was constructed to express under the polyhedron promoter of baculovirus. The expression of NSP was confirmed by indirect immunofluorescence assay (IFA) and Western blotting. The expressed NSP was applied as a diagnostic antigen for indirect-trapping ELISA (I-ELISA). An I-ELISA using monoclonal antibody (Mab) against 3A as trapping antibody was developed to differentiate infected from vaccinated cattle. The diagnostic efficiency of Mab linked I-ELISA was compared and evaluated with baculovirus expressed 3ABC I-ELISA from USDA and Mab (3A) linked E. coli expressed 3ABC I-ELISA from IZSLE through retrospective sero-surveillance. Compared with the two different I-ELISA methods, Mab (3A) linked I-ELISA using baculovirus expressed NSP showed the same level of sensitivity and specificity, indicating that this method is suitable for a differential diagnostic method in cattle.