Assessment of fellowship programs in the Department of Ophthalmology and Visual Sciences, Philippine General Hospital

Objective@#The purpose of this study was to describe the perceptions and satisfaction of the graduates and trainees of the fellowship programs of the Philippine General Hospital - Department of Ophthalmology and Visual Sciences (PGH DOVS). @*Methods@#A uniform survey was conducted among all graduates and ongoing trainees of the External Disease and Cornea, Medical and Surgical Vitreo-Retina, Glaucoma, Orbit and Oculoplastics, and Pediatric Ophthalmology and Strabismus fellowship programs. The survey link was emailed to all the participants.@*Results@#Response rate was 74%. Majority of graduates were clustered in the National Capital Region (NCR) (56.4%), and Luzon excluding NCR (46.4%). Majority of the graduates perceived that the objectives of their fellowship program were met (60%). Overall, 65.4% of the fellows assessed their training as completely adequate. Strengths identified were volume of patients, level of independence, and consultant supervision. Weaknesses identified were the lack of specialized instruments, lack of inter-department exposures, and difficulties in the conduct of research.@*Conclusion@#Majority were satisfied with their training and would recommend their training program to others despite the difficulties and deficiencies identified. Some of the perceived weaknesses observed by the graduates have been addressed since their graduation from their program. This is the first attempt to assess post-residency fellowship programs in ophthalmology in the Philippines.

Effects of visual impairment on the quality of life of children aged 8 to 18 years in a tertiary referral center

Background@#Vision impairment impacts children’s physical well-being, psychological state, and productivity. The Impact of Vision Impairment for Children (IVI_C) is a vision-specific pediatric instrument designed to assess the effects of visual impairment on the quality of life (QoL) in children aged 8 to 18 years who have no additional disabilities. It measures quality of life to assess the needs of children with low vision and outcomes of interventions by deriving answers from both children and their caregivers. @*Objectives@#The primary objective of the study was to determine the effect of visual impairment on the quality of life of children aged 8 to 18 years. @*Methods@#This was an observational, analytical, cross-sectional study conducted at the Outpatient Department of the University of the Philippines-Philippine General Hospital, Sentro Oftalmologico Jose Rizal (SOJR), General and Pediatric Ophthalmology Clinics. We included children 8 to 18 years of age with best corrected visual acuity of less than or equal to 20/40 in the better-seeing eye for the visually impaired (VI) group. The control group included children aged 8 to 18 years with best corrected visual acuity of 20/20 to 20/30 in both eyes. Participants underwent a complete ophthalmologic examination, including the determination of visual acuity using the Early Treatment Diabetic Retinopathy Study( ETDRS ) chart prior to administration of the Filipino version of IVI_C questionnaire. After the ophthalmologic examination and prior to end of the medical consultation, the investigator administered the questionnaire to the children and their parents. @*Results@#A total of 133 participants were included in the study, 67 in the visually impaired group and 66 in the control group. Participants had a median age of 10 years (range, 8 to 18), and 54% were female. Overall QoL scores and sub-scores across domains were significantly lower in the visually impaired group compared to the control group. The mean total and domain IVI_C scores progressively declined with increasing severity of visual impairment. The mean (±SD) total score ranged from 56 ± 6 in the mildly impaired to 42 ± 8 in the severe bilateral impairment group. On multivariate analysis, the significant predictors of quality of life were visual impairment and age. Quality of life of children with visual impairment is lower by 33.59 points (95% CI -35.82 to -31.36) than those in the control group. The QoL score increased by 0.579 per one unit increase in age. This model explained 87.05% of the variance in the IVI_C scores (p < 0.01). @*Conclusion@#Children with visual impairment have significantly decreased IVI_C and quality of life scores, overall and across domains. Lower scores are associated with increased severity of visual impairment.

Time reduction of new patient consultation at the Department of Ophthalmology and Visual Sciences of a Philippine Tertiary Hospital

Objective@#To decrease the total time spent of new patients on a General Clinic consult at the Department of Ophthalmology and Visual Sciences of a Philippine Tertiary Hospital. @*Methods@#A time quality management team was formed. The description of the process of a General Clinic new patient consult was elucidated and was consolidated in a data collection form. Convenience sampling of the population was done. The collection and analysis of the data were done with institution of interventions to address the factors causing the prolonged consultation visit; then, pre-intervention analysis, post-intervention analysis and comparison were done. @*Results@#Thirty-five new patients were tracked prior to and after intervention. Among the identified causes for prolonged new patient consult were delay in temporary chart, front of chart and blue card issuance, insufficient examination tools and resident dedicated to the General Clinic, unnecessary examination and patient not being around when called. Most causes were addressed. A mean decrease of 68±112 minutes or approximately 18% in total time stay was noted. @*Conclusion@#This study showed that the total consultation time of a new patient in General Clinic decreased. This was achieved with the help of most of the personnel involved in the system after identifying factors causing the prolonged consultation visit and instituting interventions to address these identified factors. The improvement in health service delivery was taken as a step by step process. A preliminary step was demonstrated in this paper for future interventions for better service delivery.

Refractive changes after intraocular lens implantation in post-cataract extraction children in a Philippine Tertiary Hospital

Objective@#To determine refractive changes in children post-cataract extraction and intraocular lens (IOL) implantation at a Philippine tertiary hospital. @*Methods@#This is a retrospective cohort study involving patients aged 1 to 10 years in the Department of Ophthalmology of a Philippine tertiary hospital who underwent cataract extraction and IOL implantation between 2004 to 2013. @*Results@#We included 55 eyes of 34 patients in the analysis. Thirty-eight eyes (69%) eyes underwent primary IOL implantation. The mean duration of follow-up was 3.5 ± 2.1 years. The median refractive changes were -2.00 (-2.50, -0.50) diopters (D) for the 1- to 3-year-old group, -1.25 (-1.50, -0.25) D for the 4- to 7-year-old group, and -1.00 (-1.63, -0.25) D for the 8- to 10-year-old group. Only the 1- to 3-year-old group had significant difference between the initial post-operative refraction and the latest follow-up refraction (p<0.001). For the primary implantation group, patients in the 1- to 3-year-old group had the highest median refractive change at -2.00 (-3.125, -1.00) D while patients in the 8- to 10-year-old group had the highest median refractive change at -2.12 (-2.56, -1.69) D in the secondary implantation group. Refractions of eyes with IOL-implanted and normal eyes showed a median difference of -1.00 (-0.25, -3.5) D. @*Conclusion@#The determination of the power of IOL implants in pediatric patients who underwent cataract extraction remains challenging despite availability of recommendations.

Factors affecting visual outcomes of children with open globe injury

Objective@#This study described the demographics of pediatric patients who sustained open globe injuries, determined the visual outcome of open globe injuries in pediatric patients and the factors associated with final visual acuity. @*Methodology@#The medical charts of 195 patients aged 0-18 years seen for open globe injury in a Philippine tertiary hospital for three years were reviewed. @*Results@#The average age of patients was 7.9 years with 41% belonging to the 5-9 years old group. Seventy-five percent (75%) of the patients were males. Ninety-five percent (95%) of the open globe injuries were accidental, mostly from play (67%). The most common agents of injury were metallic objects (42%) followed by wooden objects (24%). The cornea was injured in 80% of the cases, cornea and sclera in 10%, sclera in 7%, and globe rupture in 3%. Eighty-six percent (86%) of the patients underwent surgery. Initial visual acuity was associated with the presence of complication and the site of injury. Final visual acuity was associated with the initial visual acuity, the interval from injury to consultation, the site of injury, and the presence of complications. @*Conclusions@#The majority of the injuries were accidental and thus avoidable. The education of parents and caregivers on proper storage of potentially harmful objects at home and proper supervision of children at play are important in addition to early consultation after the injury as well as a timely intervention.

Clinical profile of amblyopic children at a Philippine tertiary hospital

Objective@#To describe the clinical profile of patients with amblyopia seen at a Philippine tertiary hospital. @*Methodology@#This was a cross-sectional study utilizing a chart review of children ages 6 months to 18 years old diagnosed with amblyopia at a Philippine tertiary hospital. Records with complete entry of history and ocular examinations were included. Verbal children with best-corrected visual acuity in both eyes of less than 6/15 or a 2 line difference between eyes were considered amblyopic. Response to alternate occlusion or refixation patterns was used as a basis for diagnosing amblyopia in pre-verbal children. Patients with visual deprivation amblyopia such as from cataract who had undergone lens extraction and optical correction were included. @*Results@#There were 334 patients included in the study. The mean age was 5±3 years with 52% being male. Deprivation type of amblyopia was present in 192 (58%) patients, strabismic type in 81 (24%), and refractive type in 61 (18%). No sex predilection was observed. Majority of the patients were 3-6 years old on initial consult. Cataract was the most common cause of deprivation amblyopia affecting 127 (66%) patients. Strabismic amblyopia was present in 58 patients with 74% being esotropic. Anisometropic refractive amblyopia was more common at 37 (58%) than isometropic refractive amblyopia. @*Conclusion@#Visual deprivation amblyopia was the most common cause of amblyopia in a Philippine tertiary hospital.

Difference in optic nerve parameters and retinal nerve fiber layer thickness in the eyes of normal and amblyopic Filipino children

Background@#Optical coherence tomography (OCT) can accurately assess the optic nerve and retinal fiber layer (RNFL) to closely look at the anatomical ocular pathology of amblyopia. @*Objectives@#This study aimed to determine and compare optic nerve parameters and RNFL in amblyopic and normal Filipino children using OCT. @*Methodology@#Forty-two eyes of 21 normal participants and 40 eyes of 20 amblyopic participants underwent complete eye examinations and OCT scanning of optic nerve and RNFL. The following data were collected: age, refraction, intraocular pressure, optic nerve parameters (including rim area-vertical cross-section, average nerve width, disc diameter, cup diameter, rim length, vertical integrated rim area, horizontal integrated rim width, disc area, rim area, cup area, cup to disk area ratio, cup-to-disk horizontal ratio, cup to disc vertical ratio), and peripapillary RNFL. @*Results@#There was a statistically significant difference between normal and amblyopic groups with regard to the following parameters: cup area, rim area, cup-disc area ratio, cup-disc horizontal ratio, cup-disc vertical ratio, superior RNFL, and inferior RNFL. The rim area was significantly smaller in amblyopic eyes compared to normal whereas the cup-disc area ratio, cup area, cup-disc vertical and horizontal ratios were significantly larger in amblyopic eyes. The RNFL inferiorly and superiorly were also thinner in amblyopic eyes. @*Conclusion@#As measured by OCT, some optic nerve parameters and RNFL thickness in Filipino children were significantly different in amblyopic eyes compared to normal.

Postoperative changes in alignment in patients surgically corrected for Esotropia and Exotropia in a Tertiary Government Hospital

Objective@#To compare the postoperative alignment of patients surgically corrected for esotropia or exotropia 6 weeks and 6 months after surgery.@*Method@#This retrospective study reviewed clinical records of patients who underwent horizontal muscle surgery at the University of the Philippines-Philippine General Hospital from 2010 to 2014. The changes in alignment from 1 week to 6 weeks and from 1 week to 6 months after surgery were compared for overcorrection, undercorrection, and adequate correction groups. ANOVA and Pearson correlation were used.@*Results@#Twenty two esotropia and 10 exotropia patients were included. Overcorrected esotropia patients had an esotropic change in alignment (15.50+13.44 PD after 6 weeks, p=0.026; 25+18.38 PD after 6 months, p=0.008). Under corrected esotropia patients had an exotropic change in alignment (-1.25+5.91 PD after 6 weeks, p=0.026;-4.38+14.16 PD after 6 months, p=0.008). Undercorrected exotropia patients had an esotropic change in alignment (6.67+6.35 PD after 6 weeks, p=0.028; 6+9.85 PD after 6 months, p=0.024). The presence of vertical deviations in esotropia caused an exotropic change in alignment after 6 months (p=0.03).@*Conclusion@#Although an exotropic drift is more commonly reported, fusional vergences may account for postoperative alignment changes towards orthotropia.

Visual outcomes of Amblyopia Therapy

Objective@#To determine the visual outcome of amblyopia treatment and describe the relationship between age of onset and consult, compliance as measured by a patch diary, amblyopia subtype, and severity with the final visual outcome.@*Methods@#Thirty-two consecutive, newly-diagnosed cases of amblyopia, aged 3-8 years on initial consult, with no history of prior amblyopia treatment, were included. Patching was done based on current AAO recommendations and patients were followed up monthly for 6 months. Treatment success was defined as best corrected visual acuity (BCVA) better than 20/30 (0.17LogMAR), or a 3-line improvement from baseline, or stable isoacuity for at least 3 months. Treatment failure was defined as no improvement of BCVA after 3 months of occlusion therapy or a regression of 2 lines. Descriptive and correlation statistics were performed comparing age of onset and consult, amblyopia subtype, severity, and compliance with the main outcome measure of BCVA at 6 months. @*Results@#Sixteen (50%) attained treatment success. Patients seen earlier (age 2-5 years) had higher rates of success (75%) than those seen later (age 6-8 years) (35%). A moderately strong negative correlation (r=-0.48, p=0.01) existed between severity of amblyopia and final BCVA at 6 months. overall compliance to patching was 88±18%, with good compliance in the success group (92%) compared to fair compliance in the failure group (84%) and a moderate correlation between compliance and BCVA (r=0.37, p=0.05). @*Conclusion@#Treatment success was related to severity, compliance, and younger age of treatment. In the presence of good compliance, severity was a strong prognostic variable.

Correlation of the in-training examination in ophthalmology with the written certifying examination of the Philippine Board of Ophthalmology

Objective@#This study determined the correlation between the performance in the Philippine Board of Ophthalmology (PBO) written qualifying examinations and the Ophthalmology In-Training Proficiency Examinations (OPEX).@*Methods@#PBO written certifying examinations and the OPEX scores of residency graduates covering the years 2005 to 2010 and 2004 to 2009 respectively were retrieved for this study. ANOVA statistical test compared OPEX scores through residency (Y1, Y2, Y3, and Y4) and determined if the number of times the OPEX was taken reflected significant differences in the PBO scores of the different groups. Pearson’s test determined the correlation between OPEX and PBO written examination scores. @*Results@#Of the 165 subjects included in the study, 5 took the OPEX four times during their residency, 87 thrice, 39 twice, and 34 once. Mean OPEX scores for the different levels of residency training was observed to be statistically different from each other (p < 0.001). Mean PBO scores improved with increase in the number of times that OPEX was taken during residency (p < 0.001). Significant positive correlation was observed between the PBO scores and OPEX scores for all year levels of residency, average OPEX scores and terminal OPEX scores (r = 0.57 to 0.73, p < 0.0001) with the highest correlation noted between terminal OPEX and PBO scores. Based on the number of OPEX taken, significant correlation was strongest for the group with three OPEX taken (r = 0.73, p < 0.001). @*Conclusions@#There is a positive correlation between residents’ performance in the OPEX to their future performance in the written certifying examinations of the PBO.

Mobius sequence with prenatal exposure to misoprostol

Objective@#To present 3 cases of Möbius sequence exposed in utero to misoprostol and discuss their clinical presentations, etiopathogenesis, and management. @*Methods@#Medical records of 3 patients with Möbius sequence and prenatal exposure to misoprostol were reviewed. Clinical findings were compared with those reported in the literature.@*Results@#Lack of facial-muscle movement, lagophthalmos with secondary exposure keratitis, decreased ability to crease forehead, and shallow nasolabial fold imply facial-nerve dysfunction. Small- and large-angle esotropia and apparent orthotropia with abduction limitation showed varying degrees of abducens nerve involvement. Two patients had early prenatal exposure to misoprostol during the first 3 months of gestation.@*Conclusion@#A history of misoprostol exposure should be routinely elicited from parents of children with Möbius sequence. Associated deficiencies in Möbius sequence and its variants require a multidisciplinary approach.