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.

Ophthalmic Trauma Malpractice in the Ophthalmic Mutual Insurance Company Database.

PURPOSE: To review ophthalmic trauma malpractice claims in the Ophthalmic Mutual Insurance Company (OMIC) database to determine the frequency and causes of litigation. METHODS: A retrospective case series analysis of ophthalmic trauma claims from 2009 to 2019 was completed. Cases were selected only if the injury was secondary to trauma (e.g., fall, gunshot wound, paintball injury, etc.); iatrogenic traumatic surgical injuries were excluded. RESULTS: 31 closed cases associated with 40 total claims related to ophthalmic trauma out of 2565 claims (1.56%) in the OMIC database were analysed. 13 of the 31 cases (41.9%) were decided for the plaintiff. In decisions for the plaintiff, the median settlement amount was $330,000 (range $125,000-$1,000,000). The most frequent initial diagnoses were corneal abrasion (n = 10), hyphema (n = 5) and open-globe injury (n = 5), and the most common final diagnoses were endophthalmitis (n = 8), intraocular foreign body (n = 7) and retinal detachment (n = 7). The most common causes of malpractice litigation were a delay in referral or follow-up (n = 11) and failure to get appropriate imaging (n = 8). In the 13 cases decided for the plaintiff, experts concluded nine did not meet standard of care. CONCLUSIONS: Ophthalmic trauma malpractice claims are very uncommon in the United States, however, the payout is higher than non-trauma settlements, and approximately 40% of cases were decided for the plaintiff. Care could be improved with a careful history and complete ophthalmic examination (with dilated fundoscopy), imaging in appropriate patients, meticulous documentation, and early sub-specialist referral when the diagnosis or management plan was unclear.

Evaluation and Management of Blepharoptosis.

Drooping of the upper eyelid margin, aka blepharoptosis or "ptosis," is common. Whether the ptosis is severe or mild, congenital or acquired, aponeurotic or neuropathic or myopathic, proper management always begins with a detailed history and evaluation of the patient. The information gathered will direct the surgeon in choosing the technique most likely to give the best result. This article will briefly review common causes of ptosis, the evaluation of the ptosis patient as well as the two most common types of surgical intervention.

Ghost and Honorary Authorship in Ophthalmology: A Cross-Sectional Survey.

PURPOSE: To evaluate the rates of ghost and honorary authorship in ophthalmology and to determine risk factors associated with ghost and honorary authorship. DESIGN: Cross-sectional survey. METHODS: Corresponding authors of articles published in Ophthalmology, JAMA Ophthalmology, and the American Journal of Ophthalmology from June 2019 to December 2020 were emailed an electronic survey. The rates of ghost and honorary authorship, demographic characteristics of the corresponding authors with and without ghost and honorary authorship, and risk factors for ghost and honorary authorship were evaluated. RESULTS: Corresponding authors (n = 830) were emailed a survey and 278 total responses (34.1%) were received; 227 responses (27.9%) were complete and included for analysis. Most respondents (n = 206, 90.7%) believed that the International Committee of Medical Journal Editors (ICMJE) guidelines for authorship adequately address criteria for authorship. Twenty-seven corresponding authors (11.9%) reported characteristics of their articles that indicated the presence of both ghost and honorary authorship (95% CI, 7.7%-16.1%). One hundred fifteen (50.7%) reported honorary authorship (44.2%-57.2%), and 37 (16.3%) indicated ghost authorship (11.5%-21.1%). Being a resident or fellow corresponding author increased the risk of honorary authorship (OR 11.75; 1.91-231.57; P = .03). There were no factors that predicted articles having ghost authors. CONCLUSIONS: While many authors believe the ICMJE guidelines for authorship comprehensively delineate fair authorship practices, listing authors on scientific publications honorarily and excluding authors who qualify for authorship are relatively common practices in ophthalmological research. Further investigation into the drivers of honorary and ghost authorship practices in ophthalmology, and the effectiveness of preventive measures are needed to ensure fair authorship attributions.

Defect of the Eyelids.

Eyelid defects disrupt the complex natural form and function of the eyelids and present a surgical challenge. Detailed knowledge of eyelid anatomy is essential in evaluating a defect and composing a reconstructive plan. Numerous reconstructive techniques have been described, including primary closure, grafting, and a variety of local flaps. This article describes an updated reconstructive ladder for eyelid defects that can be used in various permutations to solve most eyelid defects.

Tear Trough Incision for External Dacryocystorhinostomy.

PURPOSE: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. METHODS: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon's preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. RESULTS: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). CONCLUSIONS: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients.

The anterior eyelid crease approach to the orbit.

PURPOSE OF REVIEW: The anterior lid crease approach to the orbit allows the surgeon access to the superior orbital compartments through an upper eyelid incision giving excellent exposure with minimal damage to normal structures. Because the incision is in the lid crease, scarring is minimal. This route into the orbit has gained popularity in recent years and has been used by multiple different surgical subspecialties. RECENT FINDINGS: Historically, the eyelid approach to the orbit has been used mainly by ophthalmic plastic surgeons for removal of intraconal and extraconal orbital tumors, orbital fracture repair and optic nerve sheath fenestration. In recent years, other surgical subspecialties have adopted this technique for surgical access to adjacent structures such as the skull base and frontal sinuses. In addition, adjunctive devices, such as the endoscope, are being employed along with the eyelid crease incision to further improve surgical outcomes by decreasing wound size and increasing visualization of the orbital anatomy. SUMMARY: The use of upper eyelid crease for access to the orbit allows excellent surgical exposure to the superior orbit and adjacent structures with outstanding cosmetic outcome.

Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach.

OBJECTIVE: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess. DESIGN: Case series. SETTING: Tertiary pediatric hospital. PATIENTS: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy. INTERVENTION: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed. MAIN OUTCOME MEASURES: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications. RESULTS: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach. CONCLUSIONS: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.