Predictors of Ophthalmology Resident Performance From Medical Student Application Materials.

OBJECTIVE: To determine whether elements in ophthalmology residency applications are predictors of future resident performance. DESIGN: This multi-institutional, cross-sectional, observational study retrospectively reviewed the residency application materials of ophthalmology residents who graduated from residency from 2006 through 2018. Resident performance was scored by 2 faculty reviewers in 4 domains (clinical, surgical, academic, and global performance). Correlation between specific elements of the residency application and resident performance was assessed by Spearman correlation coefficients (univariate) and linear regression (multivariate) for continuous variables and logistic regression (multivariate) for categorical variables. SETTING: Seven ophthalmology residency programs in the US. PARTICIPANTS: Ophthalmology residents who graduated from their residency program. RESULTS: High-performing residents were a diverse group, in terms of sex, ethnicity, visa status, and educational background. Residents with United States Medical Licensing Examination Step 1 scores higher than the national average for that year had significantly higher scores in all 4 performance domains than those who scored at or below the mean (all domains P < 0.05). Residents who had honors in at least 4 core clerkships and who were members of Alpha Omega Alpha Medical Honor Society also had higher scores in all 4 performance domains (all domains P ≤ 0.04). Step 1 score (ρ=0.26, P < 0.001) and the difference between Step 1 score and the national average for that year (ρ=0.19, P = 0.009) positively correlated with total resident performance scores. Residents who passed the American Board of Ophthalmology Written Qualifying Examination or Oral Examination on their first attempt had significantly higher Step 1/2 scores (P ≤ 0.005), Ophthalmology Knowledge Assessment Program scores (P = 0.001), and resident performance scores (P ≤ 0.004). CONCLUSIONS: In this new landscape of increasing numbers of applicants to residency programs and changing of the Step 1 score to pass/fail, our findings may help guide selection committees as they holistically review applicants to select exceptional future residents in ophthalmology.

Orbital Vasculitides-Differential Diagnosis.

PURPOSE OF REVIEW: The orbit is subject to a variety of vascular insults that manifest with both specific and nonspecific patterns of vision compromise. The aim of the following review is to highlight the ophthalmic clinical features of systemic vasculitides that most frequently involve the orbit and differentiate them from the most common non-vasculitic orbital disorders. RECENT FINDINGS: New studies continue to explore the autoimmune nature of vasculitic disease and seek to determine optimal use of newer therapies such as biologic agents. The pattern of ocular involvement in the context of clinical history allows the knowledgeable physician to distill a differential diagnosis into a specific or likely cause. Establishing a diagnosis in a timely fashion allows for a custom-tailored approach to therapy.

Online Ratings of ASOPRS Surgeons: What Do Your Patients Really Think of You?

PURPOSE: To characterize patient evaluations of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) surgeons on a popular online physician rating website in an effort to determine which factors play a role in determining the likelihood of a patient recommending an ASOPRS surgeon to family and friends. METHODS: After obtaining approval and access from Healthgrades.com, the website database was searched for 612 U.S.-based ASOPRS members using their name as published on http://www.asoprs.org/ as of May 2015. For each surgeon, the total number of ratings and average ratings were recorded under each category. The evaluator recommendation, defined as the response to the questions of "likelihood of recommending Dr. X to family and friends," constituted the main outcome measure. Variables from each surgeon were compared using unpaired t tests, with statistical significance set at p < 0.05. Correlations were analyzed using Spearman correlation (rs), with coefficients of greater than or equal to 0.40 or less than or equal to -0.40 considered significant. RESULTS: Five-hundred nineteen members (85%) had at least 1 rating while 222 members (36%) had 10 or more ratings. The mean number of ratings for all rated members was 11.4 (range, 1-77; standard deviation [SD] = 11.1) and mean evaluator recommendation score was 4.16 (range, 1-5; SD = 0.79). There was a strong negative correlation between total wait time and evaluator recommendation score (rs = -0.409, p < 0.001). The average number of ratings and rating scores for all categories were not significantly different when comparing male with female members. University-employed members had significantly fewer ratings (8.46; range, 1-52; SD = 9.3) compared with other members (11.9; range, 1-77; SD = 11.3) (p < 0.016). There were no differences in any other rating score when comparing those university-employed members with other members. CONCLUSION: Online patient-reported evaluations of ASOPRS surgeons appear high in many categories. Long wait times correlate strongly with lower recommendation scores. Further study is required to determine how online patient reviews correlate to objective outcome measures, and how these reviews affect surgeon selection by patients.

Cogan's syndrome and other ocular vasculitides.

The clinical presentation of Cogan's syndrome has been classified as typical and atypical. Like other forms of ocular vasculitis, Cogan's syndrome has been found to have autoimmune origins with antibodies against the cornea, inner ear, and endothelial antigens. Antineutrophil cytoplasmic antibody (ANCA) and rheumatoid factor (RF) have been associated with Cogan's syndrome as well as ocular-involving vasculitides not as strongly associated with the audiovestibular manifestations such as granulomatosis with polyangiitis and rheumatoid arthritis. The mainstay of therapy has been corticosteroids although other methods have been described in recalcitrant disease and to prevent development of systemic sequelae.

Ocular vasculitis.

Vasculitis is the inflammation of blood vessels that leads to loss of perfusion and ischemia with necrosis. When this occurs in the orbit, the consequences are typically very conspicuous and can be devastating with decreased quality of life and loss of vision. Systemic vasculitides are often related to ophthalmic disorders, which can serve as the first diagnostic manifestation of potentially life-threatening disease. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (e.g., granulomatosis with polyangiitis), Behcet's disease, rheumatoid arthritis, sarcoidosis, and systemic lupus erythematosus are a few of the diseases commonly associated with ocular vasculitis. Collaboration between ophthalmologists and rheumatologists is important in the successful diagnosis and treatment of patients with vasculitis.

Cyclic (alternate day) vertical deviation--possible forme fruste of ocular neuromyotonia.

PURPOSE: Cyclic ocular deviations are relatively uncommon and are seldom seen in adults. We report 3 adult patients with cyclic hypotropia that has clinical characteristics similar to neuromyotonia, suggesting a possible common etiology. METHODS: Three consecutive patients with 48-hour cyclic hypotropia underwent full neuro-ophthalmologic, oculoplastics, and orthoptic evaluations as well as appropriate medical and neurologic studies. Examinations were arranged on consecutive days on multiple visits to document the cyclic pattern. RESULTS: All 3 patients had sustained contraction of a vertically acting extraocular muscle lasting 24 hours and demonstrated characteristics of ocular neuromyotonia. The contraction was absent for the next 24 hours. Two of the patients had thyroid eye disease; the third patient had unilateral ophthalmoparesis and had subsequent frameless robotic radiosurgery for a cavernous sinus schwannoma. Regular cycles lasting 6, 9, or 14 months were documented by all 3 patients. In 2 patients, treatment with carbamazepine and gabapentin effectively reduced or eliminated the cycle. The cyclic deviation in the third patient resolved spontaneously. CONCLUSIONS: On the basis of the response of these patients to membrane-stabilizing medications and the behavior noted as the cycle broke each day, we propose that cyclic vertical strabismus and ocular neuromyotonia may be related conditions with similar underlying physiology.

A unique association of granuloma of the lower eyelid to prior trauma.

A 5-year-old girl presented with a mass of the lower eyelid causing lower eyelid retraction and traction in upgaze. The patient had a recent history of minor trauma to the area. An orbitotomy was performed with lateral canthotomy and cantholysis to allow for dissection of the lesion, which was found in the anterior lamella of the lower eyelid. Pathologic review showed non-necrotizing granulomatous inflammation with granulation tissue. Reports of granulomas of the oral mucosa secondary to trauma are common in the dental literature. This is a unique case in that it is the first report of a subcutaneous granuloma of the eyelid arising secondary to trauma.

Orbital inflammatory pseudotumors: etiology, differential diagnosis, and management.

Orbital inflammation is typically an idiopathic process that occasionally may be identified with a specific local or systemic disease as the causative agent. Orbital inflammatory pseudotumor (also known as idiopathic orbital inflammation syndrome, orbital pseudotumor, nonspecific orbital inflammation, and orbital inflammatory syndrome) is defined as an idiopathic tumor-like inflammation consisting of a pleomorphic cellular response and a fibrovascular tissue reaction. Various rheumatologic disorders are associated with orbital inflammation and must be ruled out in cases of orbital inflammatory pseudotumor, including Wegener's granulomatosis, giant cell arteritis, systemic lupus erythematosus, dermatomyositis, and rheumatoid arthritis. The mainstay of therapy is corticosteroid therapy, although there is an increasing trend toward use of antimetabolites, alkylating agents, cytotoxic agents, and other immunosuppressive agents.

Survey of oculoplastic surgeons regarding clinical use of tear production tests.

PURPOSE: To determine by a survey of ophthalmic plastic surgeons with specific expertise in blepharoplasty surgery the perceived role of Schirmer testing and other evaluation features in determining patient predisposition to postoperative dry-eye complaints. METHODS: A literature review of tear production tests was performed. An anonymous survey was mailed to all members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. The survey included questions on practice patterns, the role of different objective tests, and the occurrence of postblepharoplasty dry-eye or exposure complaints. RESULTS: Forty-eight percent (263 of 544) of those surveyed responded. All responding physicians perform a clinical history and examination to preoperatively evaluate for dry eye, 36% perform no additional tear production tests, 33% perform a test if indicated by signs or symptoms, 29% always perform a test, and 1% perform a test only if multiple procedures were planned. Schirmer testing with anesthetic is the predominant test used by physicians who perform tear production tests (89%), followed by Schirmer test without anesthetic (10%), and phenol red thread test (1%). Nevertheless, 74% of physicians felt that Schirmer testing should not be a medical standard of care in evaluating blepharoplasty patients. CONCLUSIONS: The preoperative evaluation of blepharoplasty patients may be severely limited in specialties that perform Schirmer testing or other tear production tests without the benefit of a directed clinical history and slit lamp examination. Current tear production tests are unreliable in detecting dry eye. The ideal approach to the evaluation of the blepharoplasty patient remains controversial.

Outcomes in children with nasolacrimal duct obstruction: Significance of persistent symptoms while stents are in place.

To evaluate the correlation between persistent symptoms while stents are in place and final outcome in children with nasolacrimal duct obstruction (NLDO). A retrospective observational case series, with medical record review that included indications for surgery, surgical procedure, presence of symptoms while stents were in place, and final outcome after stent removal. Twenty-eight children with NLDO had nasolacrimal duct stents placed in 42 eyes. Twenty-one of the 42 eyes (50%) had minimal or no signs or symptoms of NLDO while stents were in place, and 18 of 21 (86%) were symptom-free after stent removal. Twenty-one of the 42 eyes (50%) remained symptomatic while stents were in place. Eleven of these 21 eyes (52%) had good outcomes after stent removal. Ten (48%) of these patients had persistent symptoms after stent removal requiring further treatment. The prognosis for a good outcome is excellent if symptoms of NLDO resolve while stents are in place. The prognosis is poorer if symptoms of NLDO persist, but more than half of such patients still have good outcomes. Careful counseling of parents regarding these outcomes should be performed before considering additional interventions.

Evolution of eyelid surgery.

Cosmetic rejuvenation of the periorbital area has been an area of continual advancement in surgical knowledge over the past century. It is anticipated that some new currently described advances will be incorporated into continuing practice patterns, with advances in nonsurgical rejuvenation and surgical techniques.

Conjunctival pyogenic granulomas after strabismus surgery.

PURPOSE: To measure the incidence and evaluate treatment of pyogenic granulomas after strabismus surgery. DESIGN: Retrospective observational case series. PARTICIPANTS: Four hundred seventy-nine strabismus surgical patients. METHODS: Incidence was determined by review of 472 consecutive patients who underwent strabismus surgery from January 6, 1999 to December 29, 2000. Outcomes were evaluated in 7 additional patients who underwent surgical excision of pyogenic granulomas over a 6-year period from July 5, 1995 to September 19, 2001 (exclusive of the years 1999-2000). MAIN OUTCOME MEASURE: Development and resolution of pyogenic granulomas. RESULTS: Pyogenic granulomas developed in 10 of 472 patients (2.1%). None of these patients had more than 1 pyogenic granuloma, despite having had surgery before or after the event. Treatment of pyogenic granulomas with topical corticosteroids was successful in 90% of patients. Surgical excision was successful in the group of 7 additional patients who did not respond to corticosteroids. CONCLUSIONS: Conjunctival pyogenic granulomas are a potential complication of strabismus surgery. Treatment with topical steroids is an effective initial treatment for most patients with pyogenic granulomas. Surgical excision is effective in patients who do not improve with topical medication. Patients with multiple surgeries do not seem to be at increased risk for pyogenic granulomas, and the occurrence of a pyogenic granuloma does not seem to increase the risk of developing pyogenic granulomas in future surgeries.

Pharmacokinetics of intravenously administered azithromycin in pediatric patients.

BACKGROUND: The objective of this study was to characterize the pharmacokinetics and tolerance of a single intravenous (IV) azithromycin dose in children. METHODS: Subjects were stratified into 4 age groups: 0.5-2 years; >2-<6 years; 6-<12 years; and 12-<16 years. Each subject received a single 10 mg/kg dose (500 mg maximum) infused in 1 hour. Serial venous blood samples were obtained for a 168-hour period, and laboratory safety evaluations were performed immediately preceding azithromycin administration and at the conclusion of the study. Serum azithromycin concentrations were quantified with a validated high performance liquid chromatography method with mass spectrometric detection. Pharmacokinetic indices were calculated for each subject by noncompartmental techniques. RESULTS: Thirty-two subjects (6.7 +/- 5.0 years, 11 boys) participated. Mean serum concentration-time data were comparable for the 4 age groups. For all subjects with evaluable data, the mean area under the curve from 0 to 72 hours (AUC0-72) was 8.2 microg . h/mL (n = 26), the maximum concentration (Cmax) was 2.4 microg/mL and the elimination half-life (t1/2) was 65.2 hours (n = 25). The AUC0-72 and Cmax were not associated with age. The dose was well-tolerated with no serious adverse events. CONCLUSION: The disposition of azithromycin after a single 10-mg/kg IV dose (maximum labeled adult dose of 500 mg) is comparable in pediatric patients between 0.5 and 16 years of age. These pharmacokinetic data can be used to guide dose selection for future therapeutic trials of IV azithromycin in pediatric patients.