The evolution of refractive surgery training.

PURPOSE OF REVIEW: Although refractive surgery is one of the most commonly performed ophthalmic procedures, there is a relative paucity of literature on residency and fellowship refractive surgery education. The purpose of this article is to review the current state and recent updates to refractive surgery education and to evaluate the safety and visual outcomes of trainee performed refractive procedures. RECENT FINDINGS: Currently, there is no standard refractive surgery curriculum in the United States apart from required mandatory minimum refractive requirements for residents and fellows. Our survey of residency programs confirms that refractive training is extremely varied, ranging from a dedicated refractive rotation with direct surgical experience to only didactics or observation of procedures. There is a proposed standardized framework for refractive surgery training for the military, which may be a starting point in developing a more comprehensive refractive surgery curriculum in residency education. Multiple studies have reinforced the safety of resident and fellow performed refractive surgery. SUMMARY: Refractive surgery is an increasingly popular procedure and a more comprehensive refractive education is paramount. Future studies are needed to determine how best to provide the fundamental training and surgical experience for trainees in the fast-changing landscape of refractive surgery.

EPIRETINAL MEMBRANE WITH FOVEAL HERNIATION: Visual and Surgical Outcomes.

PURPOSE: Foveal herniation occurs when neuroretinal tissue protrudes through and above the level of an epiretinal membrane. This study describes the visual symptoms and spectral domain optical coherence tomography findings associated with foveal herniation and evaluates the postoperative visual, anatomical, and surgical outcomes. METHODS: A multicenter retrospective review of patients diagnosed with epiretinal membrane identified 59 patients with preoperative foveal herniation on spectral domain optical coherence tomography. Data regarding visual symptoms, preoperative and postoperative best-corrected visual acuity (BCVA), central retinal thickness, macular volume, and size of foveal herniation were collected, and statistical analysis was performed. RESULTS: A total of 58 of the 59 patients with foveal herniation underwent surgical epiretinal membrane peeling, with foveal contour restored in 53.5% of patients after surgery. Average BCVA improved from 20/80 to 20/40 Snellen equivalent at most-recent postoperative visit (P < 0.0001). The average central retinal thickness decreased from 632 µm to 432 µm (P < 0.0001) and the average macular volume decreased from 11.3 mm3 to 9.5 mm3 (P < 0.0001) at 3 months postoperatively. Preoperatively, greater herniation height was associated with worse BCVA (P = 0.008), greater central retinal thickness (P = 0.01), retinoschisis, cystoid macular edema, foveolar detachment, ellipsoid zone abnormality, and external limiting membrane abnormalities (P < 0.05). Postoperatively, there was a decrease in retinoschisis, cystoid macular edema, foveolar detachment, ellipsoid zone, and external limiting membrane abnormality (P < 0.05) on spectral domain optical coherence tomography. CONCLUSION: Patients with larger foveal herniation height had greater preoperative central retinal thickness, worse preoperative and postoperative BCVA, and more intraretinal abnormalities on spectral domain optical coherence tomography. Surgical epiretinal membrane peeling in patients with foveal herniation resulted in a significant improvement in patients' BCVA and microstructural abnormalities.

High-Fidelity Simulation Scenario: Pyridoxine-Dependent Epilepsy and Treatment.

Introduction: Treatment of seizures in the neonatal patient is urgent and time sensitive. Effective and timely treatment of this life-threatening condition is vital in preventing mortality and long-term morbidity. This simulation-based curriculum involves the identification and management of a seizure in a 4-day-old neonate with pyridoxine-dependent epilepsy. The target audience is emergency medicine and pediatric residents, pediatric emergency medicine fellows, and medical students. Methods: The primary objectives for this simulation are to (1) rapidly initiate stabilization techniques for a seizing neonate, (2) recognize the importance of checking a glucose level in a seizing neonate, (3) demonstrate understanding of antiepileptic medications and dosing, and (4) identify status epilepticus and initiate pyridoxine once initial seizure management has failed. The goals of this simulation are for residents to treat a seizing infant in an emergency department setting, identify status epilepticus, develop a differential diagnosis that includes vitamin B6 deficiency, and correctly administer pyridoxine. Requirements of this simulation include a high-fidelity patient simulator, medical supplies, a patient simulator operator, and one actor. Results: This simulation case was performed at the simulation lab at the State University of New York Upstate Medical University with emergency medicine and pediatric residents. Feedback evaluations for the case showed that it improved resident education and clinical skills. Discussion: This simulation case was well received and helped residents develop a systematic approach to seizure management of a newborn. Residents reported increased confidence in treating a seizing neonate and increased comprehension of pyridoxine-dependent epilepsy.