The impact of COVID-19 on ophthalmology resident surgical experience: a retrospective cross-sectional analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant disruption to in-office and surgical procedures in the field of ophthalmology. The magnitude of the impact of the pandemic on surgical training among ophthalmology residents is not known. This study aims to quantify changes in average case logs among United States (U.S.) ophthalmology residency graduates prior to and during the COVID-19 pandemic. METHODS: Retrospective, cross-sectional analysis of aggregate, national data on case logs of U.S. ophthalmology residency graduates from 2012 to 2020. The yearly percent change in the average number of procedures performed in the Accreditation Council for Graduate Medical Education (ACGME) ophthalmology resident case logs were analyzed using linear regression on log-transformed dependent variables. The average percent change from 2019 to 2020 was compared to the average yearly percent change from 2012 to 2019 for procedures performed as the primary surgeon, and primary surgeon and surgical assistant (S + A), as well as procedures for which there are ACGME minimum graduating numbers. RESULTS: Across all procedures and roles, average case logs in 2020 were lower than the averages in 2019. While average total cases logged as primary surgeon increased yearly by 3.2% (95% CI: 2.7, 3.8%, p < 0.001) from 2012 to 2019, total primary surgeon case logs decreased by 11.2% from 2019 to 2020. Cataract (-22.0%) and keratorefractive (-21.1%) surgery experienced the greatest percent decrease in average primary surgeon cases logged from 2019 to 2020. Average total cases logged as S + A experienced an average yearly increase by 1.2% (95% CI: 0.9,1.6%, p < 0.001) prior to 2020, but decreased by 9.6% from 2019 to 2020. For ACGME minimum requirements, similar changes were observed. Specifically, the average case logs in YAG, SLT, filtering (glaucoma), and intravitreal injections had been increasing significantly prior to 2020 (p < 0.05 for all) but decreased in 2020. CONCLUSIONS: These findings demonstrate the vulnerability of ophthalmology residency programs to a significant interruption in surgical volume. There is a critical need for development of competency-based, rather than volume-based, requirements to evaluate readiness for independent practice.

Teleophthalmology in the Era of COVID-19: Characteristics of Early Adopters at a Large Academic Institution.

Introduction: COVID-19 led to rapid policy changes to expand telemedicine adoption. We examined rates of early telemedicine adoption among surgical departments at a large academic institution and compared provider characteristics associated with teleophthalmology. Methods: With data from departmental and electronic medical records across surgical departments at Johns Hopkins Medicine, we performed a retrospective analysis using the Fisher test and binomial logistic regression. Results: Telemedicine adoption in ophthalmology was disproportionately lower than other surgical departments. Providers who were female [odds ratio, OR, 2.42 (95% confidence interval, CI, 1.03-5.67)], clinical assistants, clinical associates, or instructors [OR 12.5 (95% CI 2.63-59.47)], associate professors [OR 4.38 (95% CI 1.42-13.52)], practiced for ≥36 years [OR 0.20 (95% CI 0.06-0.66)], cornea [OR 0.13 (95% CI 0.04-0.47)], glaucoma [OR 0.18 (95% CI 0.04-0.93)] or retina [OR 0.04 (95% CI 0.01-0.17)] specialists, or had a MD/MBBCh/MBBS [OR 0.30 (95% CI 0.10-0.94)] or second degree [OR 0.28 (95% CI 0.08-0.99)] were significantly more or less likely to adopt. When adjusted, cornea [adjusted OR 0.10 (95% CI 0.02-0.57)] or retina [adjusted OR 0.01 (95% CI 0.002-0.12)] specialists or providers who practiced for 12-18 years [adjusted OR 0.22 (95% CI 0.05-0.91)] or ≥36 years [adjusted OR 0.13 (95% CI 0.03-0.68)] were significantly more or less likely to adopt. Discussion: Subspecialty among other provider characteristics influences the likelihood of teleophthalmology adoption. As the pandemic continues, strategies to reduce adoption barriers are needed to ensure the provision of health care services.

Underlying Ehlers-Danlos syndrome discovered during neuro-ophthalmic evaluation of concussion patients: a case series.

BACKGROUND: The Ehlers-Danlos syndromes are a heterogenous group of diseases that cause connective tissue defects. At present, there are no published reports focusing upon the neuro-ophthalmic symptoms that might occur in EDS patients after mild traumatic brain injury. The demographics and clinical course of seven patients with subclinical EDS and mild traumatic brain injury are presented. CASE PRESENTATION: This series describes patients with Ehlers Danlos Syndrome whose diagnosis was discovered in a neuro-ophthalmic clinic for brain injury. Patient demographics and neuro-ophthalmological symptoms are presented. CONCLUSIONS: Patients with subclinical EDS and brain injury may experience a slower, less complete recovery course. Heightened awareness of undiagnosed or underlying Ehlers Danlos Syndrome is important for patients and providers.

Supervision and autonomy of ophthalmology residents in the outpatient clinic in the United States II: a survey of senior residents.

BACKGROUND: A balance between autonomy and supervision can be difficult to obtain in medical education. In this study, we sought to determine whether the presence and level of supervision of ophthalmology resident outpatient clinic correlates with metrics of resident success, professionalism and stress. METHODS: A survey was emailed to all US ophthalmology program directors requesting it be forwarded to PGY4 residents. Questions included whether their program provided a resident-hosted outpatient clinic, and if so, whether residents were mandated to discuss every patient with faculty. Residents were assigned to three categories based on this question (0: no clinic, 1: mandated faculty input, 2: discretionary faculty input). Success metrics included numbers of manuscripts submitted, OKAP scores and success in obtaining fellowships. Professionalism metrics included rating comfort obtaining informed consent, breaking bad news, managing time in clinic, and confidence in providing care in various settings. Residents affirming participation in a continuity clinic also provided perceptions of the level of supervision and how the clinic affected stress. RESULTS: Category 1 residents perceived somewhat too much supervision, while category 2 residents felt that they had somewhat insufficient supervision. The majority of residents in either category did not feel that the continuity clinic affected their overall stress, although those who reported a change in stress usually indicated that the presence of the clinic increased stress. There were no other statistically significant differences between the responses from any category. CONCLUSIONS: The presence of a resident-hosted continuity clinic neither adds nor detracts from the success or sense of professionalism of ophthalmology residents. However, when such a clinic is present, the degree of supervision appears to correlate inversely with resident perception of autonomy. These results suggest that the decision of a training program to offer a clinic hosted by residents offering comprehensive continuity care can be informed primarily by faculty and trainee philosophy and personal preferences without comprising education quality, clinical efficiency, residents' perception of stress or their success in fellowship matching.

Resident and program characteristics that impact performance on the Ophthalmic Knowledge Assessment Program (OKAP).

BACKGROUND: To determine which resident and program characteristics correlate with ophthalmic knowledge, as assessed by resident Ophthalmic Knowledge Assessment Program (OKAP) performance. METHODS: An online survey was sent in June 2017 to all US ophthalmology residents who took the OKAP in April 2017. RESULTS: The survey response rate was 13.8% (192/1387 residents). The mean respondent age was 30.4 years, and 57.3% were male. The mean [SD] self-reported 2017 OKAP percentile was 61.9 [26.7]. OKAP performance was found to have a significant positive correlation with greater number of hours spent/week studying for the OKAPs (p = 0.007), with use of online question banks (p < 0.001), with review sessions and/or lectures arranged by residency programs (p < 0.001), and with OKAP-specific didactics (p = 0.002). On multivariable analysis, factors most predictive of residents scoring ≥75th percentile were, higher step 1 scores (OR = 2.48, [95% CI: 1.68-3.64, p < 0.001]), presence of incentives (OR = 2.75, [95% CI: 1.16-6.56, p = 0.022]), greater number of hours/week spent studying (OR = 1.09, [95% CI:1.01-1.17, p = 0.026]) and fewer hours spent in research 3 months prior to examination (OR = 1.08, [95% CI: 1.01-1.15, p = 0.020]. Lastly, residents less likely to depend on group study sessions as a learning method tended to score higher (OR = 3.40, [95% CI: 1.16-9.94, p = 0.026]). CONCLUSIONS: Programs wishing to improve resident OKAP scores might consider offering incentives, providing effective access to learning content e.g. online question banks, and adjusting the curriculum to highlight OKAP material. Step 1 scores may help educators identify residents who might be at risk of not performing as well on the OKAP.

Neurological and spinal manifestations of the Ehlers-Danlos syndromes.

The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders characterized by joint hypermobility, skin extensibility, and tissue fragility. This communication briefly reports upon the neurological manifestations that arise including the weakness of the ligaments of the craniocervical junction and spine, early disc degeneration, and the weakness of the epineurium and perineurium surrounding peripheral nerves. Entrapment, deformation, and biophysical deformative stresses exerted upon the nervous system may alter gene expression, neuronal function and phenotypic expression. This report also discusses increased prevalence of migraine, idiopathic intracranial hypertension, Tarlov cysts, tethered cord syndrome, and dystonia, where associations with EDS have been anecdotally reported, but where epidemiological evidence is not yet available. Chiari Malformation Type I (CMI) has been reported to be a comorbid condition to EDS, and may be complicated by craniocervical instability or basilar invagination. Motor delay, headache, and quadriparesis have been attributed to ligamentous laxity and instability at the atlanto-occipital and atlantoaxial joints, which may complicate all forms of EDS. Discopathy and early degenerative spondylotic disease manifest by spinal segmental instability and kyphosis, rendering EDS patients prone to mechanical pain, and myelopathy. Musculoskeletal pain starts early, is chronic and debilitating, and the neuromuscular disease of EDS manifests symptomatically with weakness, myalgia, easy fatigability, limited walking, reduction of vibration sense, and mild impairment of mobility and daily activities. Consensus criteria and clinical practice guidelines, based upon stronger epidemiological and pathophysiological evidence, are needed to refine diagnosis and treatment of the various neurological and spinal manifestations of EDS. © 2017 Wiley Periodicals, Inc.

CT in the Evaluation of Acute Injuries of the Anterior Eye Segment.

OBJECTIVE: Slit-lamp ophthalmologic examination and ocular B-scan sonography of the globe are frequently constrained by technical limitations in the setting of traumatic orbital injury. The main purpose of this study was to evaluate the diagnostic performance of CT in acute anterior segment ocular injuries as an adjunctive diagnostic modality. MATERIALS AND METHODS: We retrospectively identified 122 patients who presented to the emergency department from April 2011 through April 2016 with recent direct trauma to the anterior segment of the eye. Deidentified multiplanar thin-slice CT images were reviewed by two subspecialty board-certified neuroradiologists for the presence of anterior segment rupture and hyphema, as well as lens, ciliary body, and lacrimal gland injury. The CT findings were compared to slit-lamp, B-scan ultrasound, or operative data as the reference standard. RESULTS: The neuroradiologists' CT evaluation showed high sensitivity of 87.2% (95% CI, 74.3-95.2%) and specificity of 97.3% (95% CI, 90.7-99.7%) in diagnosing anterior globe rupture with high interrater agreement (κ = 0.876; 95% CI, 0.787-0.965). Detection of lens dislocation and anterior hyphema showed a sensitivity and specificity of 88.0% and 90.7% and 77.4% and 88.4%, respectively. A shallow anterior chamber was detectable with a sensitivity of 89.2% and specificity of 87.1%. This critically important sign predicted anterior globe rupture in 39 of 47 patients (odds ratio, 68.25; p < 0.0001). CONCLUSION: Subtle ocular findings are readily detectable at CT and can provide valuable information to the ophthalmologist concerning acute trauma to the ocular anterior segment.

The consequence of spatial visual processing dysfunction caused by traumatic brain injury (TBI).

OBJECTIVE: A bi-modal visual processing model is supported by research to affect dysfunction following a traumatic brain injury (TBI). TBI causes dysfunction of visual processing affecting binocularity, spatial orientation, posture and balance. Research demonstrates that prescription of prisms influence the plasticity between spatial visual processing and motor-sensory systems improving visual processing and reducing symptoms following a TBI. RATIONALE: The rationale demonstrates that visual processing underlies the functional aspects of binocularity, balance and posture. The bi-modal visual process maintains plasticity for efficiency. Compromise causes Post Trauma Vision Syndrome (PTVS) and Visual Midline Shift Syndrome (VMSS). Rehabilitation through use of lenses, prisms and sectoral occlusion has inter-professional implications in rehabilitation affecting the plasticity of the bi-modal visual process, thereby improving binocularity, spatial orientation, posture and balance Main outcomes: This review provides an opportunity to create a new perspective of the consequences of TBI on visual processing and the symptoms that are often caused by trauma. It also serves to provide a perspective of visual processing dysfunction that has potential for developing new approaches of rehabilitation. CONCLUSIONS: Understanding vision as a bi-modal process facilitates a new perspective of visual processing and the potentials for rehabilitation following a concussion, brain injury or other neurological events.

Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs.

BACKGROUND: The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States. METHODS: A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored. RESULTS: The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated. CONCLUSIONS: The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.

Research: Validity of Measurements when Reusing Icare Probes.

BACKGROUND: It has been reported that reusing Icare tonometer probes may not pose a considerable risk of transmission of infection, thereby supporting this practice under extraordinary circumstances, such as mass glaucoma screenings in developing countries. The present study sought to determine whether reusing the probes reduced the validity of pressure readings. METHODS: Thousands of measurements were made with the same Icare probe on a purpose-built calibration device. A second set of measurements was made during which the Icare probe head was wiped with an alcohol pad between each reading. RESULTS: Statistically different readings were observed between the no-wipe and wipe groups for most of the settings evaluated. In addition, statistically significant readings were noted for a few of the settings as the number of readings increased for either group. However, these differences would not be considered clinically significant. CONCLUSION: This study suggests that reusing Icare tonometer probes, even for hundreds of measurements, would not reduce the clinical utility of the pressure readings. For mass screenings in developing countries where cost savings is crucial, considering the reuse of Icare tonometer probes seems reasonable.

Benchmarking the Wilmer general eye services clinics: baseline metrics for surgical and outpatient clinic volume in an educational environment.

BACKGROUND: The Wilmer General Eye Services (GES) at the Johns Hopkins Hospital is the clinic where residents provide supervised comprehensive medical and surgical care to ophthalmology patients. The clinic schedule and supervision structure allows for a progressive increase in trainee responsibility, with graduated autonomy and longitudinal continuity of care over the three years of ophthalmology residency training. This study sought to determine the number of cases the GES contributes to the resident surgical experiences. In addition, it was intended to create benchmarks for patient volumes, cataract surgery yield and room utilization as part of an educational initiative to introduce residents to metrics important for practice management. METHODS: The electronic surgical posting system database was explored to determine the numbers of cases scheduled for patients seen by residents in the GES. In addition, aggregated residents' self-reported Accreditation Council for Graduate Medical Education (ACGME) surgical logs were collected for comparison. Finally transactional databases were queried to determine clinic volumes of new and established patients. The proportion of resident surgeries (1(st) surgeon and assistant) provided by GES patients, cataract surgery yield and new patient rates were calculated. Data was collected from July 1(st), 2014 until March 31(st), 2015 for all 16 residents (6 third year, 5 second year and 5 first year). RESULTS: The percentage of cataract, oculoplastics, cornea and glaucoma surgeries in which a resident was 1(st) surgeon and the patient came from the GES was 91.3, 76.1, 65.6, and 93.9 respectively. The new patient rate was 28.1% and room utilization was 50.4%. Cataract surgery yield was 29.2 DISCUSSION: The GES provides a significant proportion of primary surgeon opportunities for the residents, and in some instances, the majority of cases. Compared to benchmarks available for private practices, the new patient rate is high while the cataract surgery yield is low. The room utilization is lower than the 85% preferred by the hospital system. These are the first benchmarks of this type for an academic resident ophthalmology practice in the United States. CONCLUSIONS: Our study suggests that resident-hosted clinics can provide the majority of surgical opportunities for ophthalmology trainees, particulary with regard to cataract cases. However, because our study is the first academic resident practice to publish metrics of the type used in private practices, it is impossible to determine where our clinic stands compared to other training programs. Therefore, the authors strongly encourage ophthalmology training programs to explore and publish practice metrics. This will permit the creation of a benchmarking program that could be used to quantify efforts at enhancing ophthalmic resident education.

A comparison of commercial and custom-made electronic tracking systems to measure patient flow through an ambulatory clinic.

BACKGROUND: Understanding how patients move through outpatient clinics is important for optimizing clinic processes. This study compares the costs, benefits, and challenges of two clinically important methods for measuring patient flow: (1) a commercial system using infrared (IR) technology that passively tracks patient movements and (2) a custom-built, low cost, networked radio frequency identification (RFID) system that requires active swiping by patients at proximity card readers. METHODS: Readers for both the IR and RFID systems were installed in the General Eye Service of the Wilmer Eye Institute. Participants were given both IR and RFID tags to measure the time they spent in various clinic stations. Simultaneously, investigators recorded the times at which patients moved between rooms. These measurements were considered the standard against which the other methods were compared. RESULTS: One hundred twelve patients generated a total of 252 events over the course of 6 days. The proportion of events successfully recorded by the RFID system (83.7%) was significantly greater than that obtained with the IR system (75.4%, p < 0.001). The cause of the missing events using the IR method was found to be a signal interruption between the patient tags and the check-in desk receiver. Excluding those data, the IR system successfully recorded 94.4% of events (p = 0.002; OR = 3.83 compared to the RFID system). There was no statistical difference between the IR, RFID, and manual time measurements (p > 0.05 for all comparisons). CONCLUSIONS: Both RFID and IR methods are effective at providing patient flow information. The custom-made RFID system was as accurate as IR and was installed at about 10% the cost. Given its significantly lower costs, the RFID option may be an appealing option for smaller clinics with more limited budgets.

Outcomes and Complications in Patients With Hypermobile Ehlers-Danlos Syndrome Who Have Undergone Laser In Situ Keratomileusis Surgery.

PURPOSE: The purpose of this study was to determine the safety and outcomes of myopic laser in situ keratomileusis (LASIK) in patients who were secondarily diagnosed with hypermobile Ehlers-Danlos syndrome (EDS). METHODS: We conducted a case series study on patients with hypermobile EDS who underwent myopic LASIK surgery. Visual acuity, manifest refraction, a full dilated eye examination, biometry measurements, and Scheimpflug imaging were performed in the Wilmer outpatient clinic. RESULTS: There were 24 eyes of 12 patients included in this study. All participants were White women with a mean age of 46.58 years (SD 8.91 years). Participants were seen at an average of 13.83 years (SD 4.3 years, range 6-21 years) after undergoing LASIK. None of the patients in the series had a diagnosis of hypermobile EDS before LASIK surgery. Overall, 92% of patients were happy they got LASIK. The uncorrected distance visual acuity was 20/20 or better in 68% of eyes, and the best-corrected visual acuity was 20/20 or better in 92% of eyes. Manifest refraction was within 1 diopter of plano in 79% of patients. Dry eye symptoms were present in 83% of patients, and 46% of eyes had either punctate epithelial erosions or decreased tear break-up time. One of the 12 patients developed corneal ectasia in both eyes. CONCLUSIONS: Patients with hypermobile EDS are generally satisfied with myopic LASIK correction, with good visual acuity outcomes and low rates of myopic regression. However, the risk of corneal ectasia may prevent laser vision correction from being a viable treatment option in these patients. Further studies are needed to make a definitive recommendation.

Identification and Prediction of Clinical Phenotypes in Hospitalized Patients With COVID-19: Machine Learning From Medical Records.

BACKGROUND: There is significant heterogeneity in disease progression among hospitalized patients with COVID-19. The pathogenesis of SARS-CoV-2 infection is attributed to a complex interplay between virus and host immune response that in some patients unpredictably and rapidly leads to "hyperinflammation" associated with increased risk of mortality. The early identification of patients at risk of progression to hyperinflammation may help inform timely therapeutic decisions and lead to improved outcomes. OBJECTIVE: The primary objective of this study was to use machine learning to reproducibly identify specific risk-stratifying clinical phenotypes across hospitalized patients with COVID-19 and compare treatment response characteristics and outcomes. A secondary objective was to derive a predictive phenotype classification model using routinely available early encounter data that may be useful in informing optimal COVID-19 bedside clinical management. METHODS: This was a retrospective analysis of electronic health record data of adult patients (N=4379) who were admitted to a Johns Hopkins Health System hospital for COVID-19 treatment from 2020 to 2021. Phenotypes were identified by clustering 38 routine clinical observations recorded during inpatient care. To examine the reproducibility and validity of the derived phenotypes, patient data were randomly divided into 2 cohorts, and clustering analysis was performed independently for each cohort. A predictive phenotype classifier using the gradient-boosting machine method was derived using routine clinical observations recorded during the first 6 hours following admission. RESULTS: A total of 2 phenotypes (designated as phenotype 1 and phenotype 2) were identified in patients admitted for COVID-19 in both the training and validation cohorts with similar distributions of features, correlations with biomarkers, treatments, comorbidities, and outcomes. In both the training and validation cohorts, phenotype-2 patients were older; had elevated markers of inflammation; and were at an increased risk of requiring intensive care unit-level care, developing sepsis, and mortality compared with phenotype-1 patients. The gradient-boosting machine phenotype prediction model yielded an area under the curve of 0.89 and a positive predictive value of 0.83. CONCLUSIONS: Using machine learning clustering, we identified and internally validated 2 clinical COVID-19 phenotypes with distinct treatment or response characteristics consistent with similar 2-phenotype models derived from other hospitalized populations with COVID-19, supporting the reliability and generalizability of these findings. COVID-19 phenotypes can be accurately identified using machine learning models based on readily available early encounter clinical data. A phenotype prediction model based on early encounter data may be clinically useful for timely bedside risk stratification and treatment personalization.

Post-traumatic headaches and vision: A review.

BACKGROUND: Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. OBJECTIVES: To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. METHODS: We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. RESULTS: Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. CONCLUSION: Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.

Ehlers-Danlos syndromes and their manifestations in the visual system.

Ehlers-Danlos syndrome (EDS) is a rare, genetically variable, heterogenous group of (currently recognized) thirteen connective tissue disorders characterized by skin hyperextensibility, tissue fragility, and generalized joint hypermobility. In addition to these commonly recognized phenotypes, recent studies have notably highlighted variable ophthalmic features in EDS. In this review, we comprehensively gather and discuss the ocular manifestations of EDS and its thirteen subtypes in the clinical setting.

Use of the Cogan lid twitch to identify myasthenia gravis.

BACKGROUND: To evaluate the reliability of the Cogan lid twitch (CLT) test in a neuro-ophthalmology clinic. METHODS: CLT testing was performed on adult patients presenting to the neuro-ophthalmology clinic by the neuro-ophthalmologist. The patients were instructed to look straight ahead, up, down, and straight ahead again. The upper eyelids were carefully evaluated immediately following this movement for the presence of a brief upward twitch of the upper eyelid, which would indicate a positive CLT test. The test was repeated as needed. We evaluated the findings from the ophthalmologic examination along with results of available tests, such as serologic findings, MRIs, and CTs. RESULTS: Of 117 patients evaluated, 24 had myasthenia gravis (MG), and 18 of these patients had a positive lid twitch. Of the 98 patients who did not display a positive Cogan twitch, 6 had MG. We calculated the specificity of the CLT to be 99%, with a sensitivity 75% and false-positive rate 1%. CONCLUSION: The CLT test is a specific and sensitive test to use in a neuro-ophthalmology clinic to evaluate for MG.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement.

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.

Parental Leave Policy for Ophthalmology Residents: Results of a Nationwide Cross-Sectional Study of Program Directors.

BACKGROUND: Many residents become parents during residency and the adequacy of parental leave is integrally related to resident wellness. OBJECTIVE: To understand current parental leave policies in ophthalmology residency programs and program director perceptions of the impact of parental leave on trainees. DESIGN: Cross-sectional study. SETTING: Multicenter among all U.S. ophthalmology residency programs. PARTICIPANTS: Ophthalmology residency program directors during the 2017 to 2018 academic year. RESULTS: Sixty-eight percent (82/120) program directors participated in this study. The majority of programs had written maternity leave policies (89%) and partner leave policies (72%). The typical duration of maternity leave taken ranged from 4 to 6 weeks while typical partner leave duration taken ranged from 1 day to 2 weeks. Residents who take leave may need to extend training at 72% of programs. Program directors perceived that parental leave negatively impacts resident scholarly activities and surgical skills and volume. Male program directors, relative to female program directors, perceived that becoming a childbearing parent negatively impacts resident dedication to patient care. Program directors raised concerns including local support and policy, extension of residency, impact on residents, impact on programs, consistency and fairness, and desire for national policy change. CONCLUSIONS: Parental leave practices vary significantly among ophthalmology training programs with residents typically taking less leave than permitted. Program directors are challenged to accommodate parental leave while balancing resident training and wellness for all trainees in their program.