Flipped classroom approach to global outreach: cross-cultural teaching of horizontal strabismus to Chinese ophthalmology residents.

AIM: To evaluate the flipped classroom model for teaching horizontal strabismus didactics in an ophthalmology residency program in China as part of a visiting professorship from the United States. METHODS: Residents from an ophthalmology residency program in China were invited to participate in flipped classroom sessions taught by an experienced American ophthalmology faculty in 2018. Residents were instructed to watch a pre-class video lecture prior to the in-class-case-based activity. Content tests (5 Ophthalmic Knowledge Assessment Program style questions) and surveys were administered before and after the classroom sessions (100% response rate). These results were compared to that of an American cohort who were taught the same content. RESULTS: The Chinese cohort of 12 residents preferred the flipped classroom to the traditional classroom at higher rates than the American cohort of 40 residents (92% vs 55%, P=0.04) and felt that all ophthalmology topics would be appropriate for the flipped classroom teaching style (P-values between 0.008 and <0.001). In both Chinese and American cohorts, we found that the exotropia curriculum saw a small but significant improvement in performance following the flipped classroom session (P=0.025 for Chinese residents; P=0.001 for US residents), whereas scores in both groups for the esotropia course did not significantly improve. CONCLUSION: This is the first study to evaluate the flipped classroom model implemented by a visiting ophthalmology professor in a global outreach setting. The flipped classroom sessions are viewed favorably by the Chinese residents relative to the US cohort with a modest impact on knowledge. Decreased in-person interpreter requirement and increased student engagement make this model valuable in cross-cultural visiting professorship settings. Finally, the flipped classroom may lend itself well to a virtual format to prevent the transmission of COVID-19, although such a format requires further study.

The flipped-classroom approach to teaching horizontal strabismus in ophthalmology residency: a multicentered randomized controlled study.

BACKGROUND: The flipped-classroom involves watching prerecorded lectures at home followed by group learning exercises within the classroom. This study compares the flipped classroom approach with the traditional classroom for teaching horizontal strabismus didactics in ophthalmology residency. METHODS: In this multicenter, randomized controlled survey study from October 2017 to July 2018, 110 ophthalmology residents were taught esotropia and exotropia sequentially, randomized by order and classroom style. Flipped classroom participants were assigned a preclass video lecture prior to the in-class case-based activity. The traditional classroom included a preparatory reading assignment and an in-person lecture. Residents completed three identical 5-question assessments (pretest, post-test, and 3-month retention) and surveys for each classroom. The primary outcome measured residents' preferences for classroom styles; the secondary outcome compared knowledge acquisition. RESULTS: In our study cohort, the flipped classroom resulted in greater at-home preparation than the traditional classroom (P = 0.001) and was preferred by 33 of 53 residents (62%); 45 of 53 (85%) wished to see the flipped classroom used at least 25% of the time. The exotropia flipped classroom scored higher than traditional classroom on the pretest (3.71/5 [74%] vs 2.87/5 [57%]; P < 0.001) and post-test (4.53/5 [91%] vs 4.13/5 [83%]; P = 0.01) but not the 3-month retention test (3.53/5 [71%] vs 3.37/5 [67%]; P = 0.48). The esotropia classroom styles did not differ on pre- or post-test but demonstrated higher scores for the traditional classroom at 3-month retention (3.43/5 [69%] vs 2.92/5 [58%]; P = 0.03). Advantages cited for flipped classroom include being interactive and engaging while incentivizing better classroom preparation. CONCLUSIONS: The flipped classroom method was received favorably by trainees and may complement traditional methods of teaching.

Ophthalmologic disorders and risk factors in children with autism spectrum disorder.

PURPOSE: To report the results of our review of all children with autism spectrum disorder (ASD) who underwent complete pediatric ophthalmologic examination at our institution over a 10-year period. METHODS: The medical records of all children (0-17 years of age) with a diagnosis of ASD seen at University of California, Davis, over a 10-year period were reviewed retrospectively. Demographic data, birth history, genetic testing results, neuropsychiatric comorbidities, and ophthalmologic findings were extracted from the record. Multiple logistic regression was used to identify risk factors for ophthalmologic disorders. RESULTS: A total of 2,555 children with ASD were seen at the university over the study period, of whom 380 (15%) were evaluated in the ophthalmology clinic. Eye examination revealed an ophthalmic diagnosis in 71% of children, of which the most common were significant refractive error (42%), strabismus (32%), and amblyopia (19%). Optic neuropathy occurred in 14 children (4%). Cerebral palsy was a significant risk factor for refractive error (OR = 3.22; P = 0.016), strabismus (OR = 3.59; P = 0.012), amblyopia (OR = 3.49; P = 0.0097), and optic neuropathy (OR = 14.0; P = 0.0009). CONCLUSIONS: Ophthalmic disorders were found in 71% of children with ASD evaluated at our university-based ophthalmology clinic. The rates of significant refractive error, strabismus, amblyopia, and optic neuropathy exceeded those of the general pediatric population. ASD and cerebral palsy may have additive risk for these disorders.

The flipped-classroom approach to teaching horizontal strabismus in ophthalmology residency: a pilot study.

PURPOSE: To compare the flipped classroom (home pre-taped lectures followed by in-class group exercise) to the traditional classroom (home reading assignment followed by in-class lecture) for horizontal strabismus didactics in ophthalmology residency. METHODS: All PGY2-4 residents from four U.S. ophthalmology residencies without prior residency flipped-classroom experience were invited to esotropia and exotropia sessions sequentially, with random order and assignment to flipped and traditional classrooms. Content test scores before and after the two classrooms were compared. Surveys were administered to assess participant experience. RESULTS: A total of 40 residents attended each session. Likert scale evaluation of preparatory material and classroom activity did not differ between sessions; however, divided by year of training, 70% of senior residents (PGY3-4) and 39% of first-year (PGY2) residents preferred the flipped classroom over the traditional classroom. Pre- and post-test scores for the flipped classroom exceeded those of the traditional classroom for the exotropia course (P = 0.01 and P = 0.001, resp.) but not for the esotropia course. There was significant improvement between pre- and post-tests for both styles of learning. CONCLUSIONS: The flipped classroom had a favorable effect on test scores for only one of the two strabismus subjects but was preferred over the traditional classroom among PGY3-4 residents.

Strabismus surgery for Medicare-aged patients: more than a decade of insights.

BACKGROUND: The psychosocial and functional impact of strabismus among the elderly is increasingly important as life expectancy increases and factors that enhance the quality of life become more significant. The purpose of this study was to characterize the demographics, presenting complaints, health status, underlying etiology, and outcomes of strabismus surgery in three age cohorts of Medicare-aged patients. METHODS: The medical records of patients at least 65 years of age who underwent strabismus surgery between 2004 and 2015 in a university-based strabismus practice were reviewed retrospectively. RESULTS: A total of 110 patients were identified and divided into three age cohorts for analysis: young-old (age 65-74), middle-old (age 75-84), and old-old (age 85+). At least 75% of patients in all cohorts cited diplopia as their chief complaint (P = 0.87). There was no difference in sex distribution, type of deviation, underlying etiology, or preoperative American Society of Anesthesiologists physical status classification scores between the cohorts (P = 0.68, P = 0.53, P = 0.71, P = 0.93, resp.). By the 6- to 8-week postoperative visit, 63% of all patients reported complete resolution of their presenting chief complaint, 23% reported some improvement, and 11% reported no improvement, with no difference between the cohorts (P = 0.12). CONCLUSIONS: Given the functional and psychosocial impact of strabismus in the elderly, this study lends support to consideration of surgery as a viable option to successfully treat strabismus among the oldest age cohorts.

Icare ONE Home Tonometry in Children With and Without Known Glaucoma.

PURPOSE: The Icare ONE (Finland Oy) rebound tonometer may have promise for home tonometry in children with glaucoma. The purpose of this study was: (1) to assess the feasibility of Icare ONE home tonometry in a small number of children with and without glaucoma and (2) to characterize diurnal intraocular pressure (IOP) variations in children with and without glaucoma. METHODS: Patients were recruited from Duke pediatric ophthalmology clinic. Parents underwent in-clinic training for Icare ONE tonometry. Parents were instructed to record the subject's IOP using Icare ONE at 6 time intervals daily for 10 sequential days. RESULTS: Eight normal subjects (16 eyes) and 10 subjects (10 eyes) with glaucoma were included. All parents successfully performed Icare ONE home tonometry. In-clinic Icare ONE IOP exceeded Goldmann applanation in both groups. Normal subjects (mean age, 11.8 y) had a mean daily IOP range of 4.8 ± 4.6 mm Hg for right eyes and 5.2 ± 1.7 mm Hg for left eyes, and demonstrated relative peaks in the morning and relative troughs in the evening. Subjects with glaucoma (mean age, 12.4 y) had a mean daily IOP range of 8.6 ± 8.2 mm Hg, and demonstrated an even distribution of relative peaks and troughs throughout the day. CONCLUSIONS: Icare ONE home tonometry seems feasible in a small number of children. Normal eyes demonstrated smaller daily IOP ranges than glaucomatous eyes. Normal eyes were also more likely to show a relative early morning IOP peak and a late evening IOP trough. It is likely that the limited sampling in this study limits its generalizability to all children with glaucoma or to normal children.

Sildenafil for pediatric orbital lymphangioma.

IMPORTANCE: Orbital lymphangiomas, congenital hamartomas of the lymphovascular tissue, are often associated with significant ocular complications and can be challenging to treat. To date, therapeutic approaches have demonstrated variable results and have significant ocular and systemic risks. We present 2 cases of pediatric orbital lymphangioma that responded to treatment with oral sildenafil. OBSERVATIONS: This is a report of a series of 2 patients at the University of California-Davis Medical Center treated between March 2011 and October 2012. The first patient was a 12-month-old male infant whose extensive orbital and facial lymphangioma responded to sildenafil after repeated sclerosing and drainage procedures failed to achieve remission. The second patient was a 12-year-old boy whose orbital lymphangioma and associated ocular pain improved with sildenafil, making enucleation unnecessary. CONCLUSIONS AND RELEVANCE: These reported cases demonstrate promise for sildenafil as a noninvasive therapy for pediatric lymphangioma. Larger clinical trials are needed to clarify the optimal length of treatment, use as monotherapy, and long-term adverse effects.

Treatment of neuro-ophthalmic and orbitofacial manifestations of neurofibromatosis type 1.

PURPOSE OF REVIEW: Optic pathway gliomas (OPGs) and orbitofacial plexiform neurofibromas are two of the more common ophthalmic manifestations of neurofibromatosis type 1. This article reviews recent advances in the treatment of these challenging lesions. RECENT FINDINGS: Recent advances in the treatment of OPGs include chemotherapeutic, radiation-based, and surgical interventions. Chemotherapy continues to be the mainstay of treatment of these lesions, but the effects on visual outcome are variable. Fractionated radiotherapy and gamma knife treatment have been studied as an alternative to conventional radiotherapy and have demonstrated fewer vision and life-threatening side-effects. Surgical resection can be undertaken through multiple approaches depending upon the extent of the lesion. The management of the orbitofacial neurofibroma is primarily surgical, and the systematic surgical approach to these lesions is discussed. SUMMARY: OPGs and orbitofacial neurofibromas are clinically diverse. Although the advances in the treatment of both are promising, recent studies demonstrate the great variety in treatment approaches and suggest a need for standardized outcome metrics for research that can ultimately contribute to guidelines for treatment.

Longitudinal reproducibility of optical coherence tomography measurements in children.

PURPOSE: To evaluate the longitudinal reproducibility of optical coherence tomography (OCT) measurements in normal and glaucomatous eyes of children. METHODS: In this 2-setting prospective study, OCT-3 was used to obtain fast retinal nerve fiber layer (RNFL) and macular thickness scans. In the first study setting, the normal eyes of healthy children were scanned on presentation, at 2 weeks, and 3 years, with axial length measured at the first and last examinations. In the second setting, OCT scans of patients in the pediatric glaucoma clinic were performed over 4 years as clinically indicated. Eyes were classified as "normal" (normal eyes and those with physiologic cupping but normal intraocular pressure [IOP]); "mild glaucoma" (increased IOP and a normal optic nerve appearance); or "advanced glaucoma" (severe cupping or progressive glaucoma). Intraclass correlation coefficients were used to evaluate the reproducibility of measurements on the same day and over time. RESULTS: In the first setting, 8 normal eyes were included. Axial length increased 0.11 ± 0.04 mm/year over an average of 3.3 years (P = 0.03); there was no statistically significant change in RNFL thickness (P = 0.30). In our second setting, 27 normal eyes and 37 eyes with glaucoma were included. Intraclass correlation coefficients across the 3 visits for total macular volume were 0.80-0.91 and for average RNFL were 0.73-0.95. CONCLUSIONS: Global OCT measurements in children were reproducible over years and were not affected by normal increase in axial length. OCT shows promise as an objective tool for longitudinal assessment of children.

Icare ONE rebound versus Goldmann applanation tonometry in children with known or suspected glaucoma.

PURPOSE: To compare Icare ONE tonometry by clinic examiner and parent/guardian to Goldmann applanation in children with known/suspected glaucoma; to evaluate the trend in intraocular pressure (IOP) with 4 repeated measurements using Icare ONE; and to evaluate the feasibility of instructing parents on the use of the Icare ONE device in the clinic setting. DESIGN: Nonrandomized, prospective clinical study. METHODS: Patients with known or suspected glaucoma were recruited from the Duke pediatric glaucoma clinic. Parent(s) of all subjects gave informed consent (and children gave assent) for participation in this research study. IOP was measured using Icare ONE by clinic examiner and parent/guardian, then using Goldmann applanation (masked physician). Each parent/guardian completed an ease-of-use survey. RESULTS: Sixty eyes (60 children) were included. Absolute value of mean IOP difference (ICare ONE clinic examiner vs Goldmann applanation) was 3.3 ± 4.0 mm Hg (P = .001). Icare ONE IOP by clinic examiner was within 3 mm Hg of Goldmann applanation in 68% (n = 41 eyes). In eyes with >3 mm Hg difference, Icare ONE was higher than Goldmann applanation in 84%. IOP demonstrated a statistically significant downward trend with repeated sequential measurements with Icare ONE (P = .0053, r(2) = 0.9894). All parents accomplished Icare ONE tonometry on at least 1 eye; 98% reported it was "easy to learn to use." CONCLUSION: Icare ONE tonometry appears accurate and well-tolerated compared to Goldmann applanation, and holds promise for clinic and home tonometry in children. IOP trends downward with successive measurements using Icare ONE, demonstrating a possible effect from presumed patient relaxation.

Periodic unilateral eyelid retraction in a pediatric patient.

A healthy 11-year-old girl presented with right upper eyelid retraction since birth. An evaluation including thyroid function studies and neuroimaging was negative, and the patient was scheduled for a right levator recession to address the eyelid malposition. Intraoperatively, after the induction of inhalational general anesthesia, the patient displayed cyclic right upper eyelid retraction. Occurring in intervals of exactly 48 seconds, these cycles involved a rapid elevation of the right eyelid from a position of half-closure to a retracted position just above the superior limbus. There was no change in pupil size or eye position during these cyclic spasms, and the contralateral eyelid was unaffected. The patient underwent an uncomplicated levator recession, which improved the upper eyelid retraction. Postoperative testing, including external motility video and infrared pupillometry, demonstrated no cyclic variation in eyelid position, eye position, or pupil size in the waking state. This is a unique case of unilateral eyelid retraction with periodic spasms under conditions of anesthesia without a preexisting oculomotor paresis; it represents an unusual variation on congenital eyelid retraction and classically described cyclic oculomotor palsy.

Complete elimination is a difficult goal for trachoma programs in severely affected communities.

The World Health Organization has distributed millions of doses of azithromycin to control the ocular chlamydial infection that causes trachoma. Theoretically, a loftier goal of elimination is feasible. Here, we demonstrate that, although local elimination of infection in the most severely affected communities is difficult, it is possible with biannual antibiotic distributions.