Pediatric Ophthalmology Provider and Staff Attitudes and Patient Satisfaction in Telehealth Implementation During COVID-19.

Purpose:Describe a comprehensive overview of a telehealth implementation process that highlights attitudes and satisfaction scores toward telehealth from patients, providers, and staff in an academic pediatric ophthalmology practice during the early months of the coronavirus disease 2019 (COVID-19) pandemic.Methods:The electronic medical record data for telehealth and in-person visits, as well as a patient experience survey in pediatric ophthalmology were retrospectively reviewed for March 1 to July 31, 2020 and March 1 to July 31, 2019. Patient experience survey results were retrospectively reviewed. All current providers and staff were invited to participate in an anonymous and voluntary survey focused on attitudes at the time of telehealth implementation.Results:During March 1 to July 31, 2020, there was significant increase in telehealth visits (n = 1,006) compared with the same period in 2019 (n = 22). Evaluation and management (E & M) codes (n = 527) were the most commonly used billing codes, and strabismus, nystagmus, and irregular eye movement (n = 496) were the most common telehealth primary diagnoses. The telehealth attitudes survey showed more positive responses from providers than staff. The patient experience survey showed more favorable scores for telehealth visits compared with clinic visits. However, only about 50% of the respondents were satisfied with the technology in terms of ease and quality of connection during their telehealth visits.Conclusions:Telehealth was a satisfactory alternative to clinic visits in our academic pediatric ophthalmology practice during the early phase of the COVID-19 pandemic. Providers and staff had largely positive attitudes toward telehealth; however, future efforts should include strategies to increase staff buy in. Patients had high satisfaction scores with telehealth visits despite connection challenges.

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.

Outcomes of Bilateral Cataract Surgery in Infants 7 to 24 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry.

PURPOSE: To evaluate outcomes of bilateral cataract surgery in children aged 7 to 24 months and compare rates of adverse events (AEs) with other Toddler Aphakia and Pseudophakia Study (TAPS) registry outcomes. DESIGN: Retrospective clinical study at 10 Infant Aphakia Treatment Study (IATS) sites. Statistical analyses comparing this cohort with previously reported TAPS registry cohorts. PARTICIPANTS: Children enrolled in the TAPS registry between 2004 and 2010. METHODS: Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement at age 7 to 24 months with 5 years of postsurgical follow-up. MAIN OUTCOME MEASURES: Visual acuity (VA), occurrence of strabismus, AEs, and reoperations. RESULTS: A total of 40 children (76 eyes) who underwent bilateral cataract surgery with primary posterior capsulectomy were identified with a median age at cataract surgery of 11 months (7-23); 68% received a primary IOL. Recurrent visual axis opacification (VAO) occurred in 7.5% and was associated only with the use of an IOL (odds ratio, 6.10; P = 0.005). Glaucoma suspect (GS) was diagnosed in 2.5%, but no child developed glaucoma. In this bilateral cohort, AEs (8/40, 20%), including glaucoma or GS and VAO, and reoperations occurred in a similar proportion to that of the published unilateral TAPS cohort. When analyzed with children aged 1 to 7 months at bilateral surgery, the incidence of AEs and glaucoma or GS correlated strongly with age at surgery (P = 0.011/0.004) and glaucoma correlated with microcornea (P = 0.040) but not with IOL insertion (P = 0.15). CONCLUSIONS: Follow-up to age 5 years after bilateral cataract surgery in children aged 7 to 24 months reveals a low rate of VAO and very rare glaucoma or GS diagnosis compared with infants with cataracts operated at < 7 months of age despite primary IOL implantation in most children in the group aged 7 to 24 months. The use of an IOL increases the risk of VAO irrespective of age at surgery.

Outcomes of Bilateral Cataracts Removed in Infants 1 to 7 Months of Age Using the Toddler Aphakia and Pseudophakia Treatment Study Registry.

PURPOSE: To evaluate outcomes of bilateral cataract surgery in infants 1 to 7 months of age performed by Infant Aphakia Treatment Study (IATS) investigators during IATS recruitment and to compare them with IATS unilateral outcomes. DESIGN: Retrospective case series review at 10 IATS sites. PARTICIPANTS: The Toddler Aphakia and Pseudophakia Study (TAPS) is a registry of children treated by surgeons who participated in the IATS. METHODS: Children underwent bilateral cataract surgery with or without intraocular lens (IOL) placement during IATS enrollment years 2004 through 2010. MAIN OUTCOME MEASURES: Visual acuity (VA), strabismus, adverse events (AEs), and reoperations. RESULTS: One hundred seventy-eight eyes (96 children) were identified with a median age of 2.5 months (range, 1-7 months) at the time of cataract surgery. Forty-two eyes (24%) received primary IOL implantation. Median VA of the better-seeing eye at final study visit closest to 5 years of age with optotype VA testing was 0.35 logarithm of the minimum angle of resolution (logMAR; optotype equivalent, 20/45; range, 0.00-1.18 logMAR) in both aphakic and pseudophakic children. Corrected VA was excellent (<20/40) in 29% of better-seeing eyes, 15% of worse-seeing eyes. One percent showed poor acuity (≥20/200) in the better-seeing eye, 12% in the worse-seeing eye. Younger age at surgery and smaller (<9.5 mm) corneal diameter at surgery conferred an increased risk for glaucoma or glaucoma suspect designation (younger age: odds ratio [OR], 1.44; P = 0.037; and smaller cornea: OR, 3.95; P = 0.045). Adverse events also were associated with these 2 variables on multivariate analysis (younger age: OR, 1.36; P = 0.023; and smaller cornea: OR, 4.78; P = 0.057). Visual axis opacification was more common in pseudophakic (32%) than aphakic (8%) eyes (P = 0.009). Unplanned intraocular reoperation occurred in 28% of first enrolled eyes (including glaucoma surgery in 10%). CONCLUSIONS: Visual acuity after bilateral cataract surgery in infants younger than 7 months is good, despite frequent systemic and ocular comorbidities. Although aphakia management did not affect VA outcome or AE incidence, IOL placement increased the risk of visual axis opacification. Adverse events and glaucoma correlated with a younger age at surgery and glaucoma correlated with the presence of microcornea.

Outcomes of Unilateral Cataracts in Infants and Toddlers 7 to 24 Months of Age: Toddler Aphakia and Pseudophakia Study (TAPS).

PURPOSE: To evaluate outcomes of unilateral cataract surgery in children 7 to 24 months of age. DESIGN: Retrospective case series at 10 Infant Aphakia Treatment Study (IATS) sites. PARTICIPANTS: The Toddler Aphakia and Pseudophakia Study is a registry of children treated by surgeons who participated in the IATS. METHODS: Children underwent unilateral cataract surgery with or without intraocular lens (IOL) placement during the IATS enrollment years of 2004 and 2010. MAIN OUTCOME MEASURES: Intraoperative complications, adverse events (AEs), visual acuity, and strabismus. RESULTS: Fifty-six children were included with a mean postoperative follow-up of 47.6 months. Median age at cataract surgery was 13.9 months (range, 7.2-22.9). Ninety-two percent received a primary IOL. Intraoperative complications occurred in 4 patients (7%). At 5 years of age, visual acuity of treated eyes was very good (≥20/40) in 11% and poor (≤20/200) in 44%. Adverse events were identified in 24%, with a 4% incidence of glaucoma suspect. An additional unplanned intraocular surgery occurred in 14% of children. Neither AEs nor intraocular reoperations were more common for children with surgery at 7 to 12 months of age than for those who underwent surgery at 13 to 24 months of age (AE rate, 21% vs. 25% [P = 0.60]; reoperation rate, 13% vs. 16% [P = 1.00]). CONCLUSIONS: Although most children underwent IOL implantation concurrent with unilateral cataract removal, the incidence of complications, reoperations, and glaucoma was low when surgery was performed between 7 and 24 months of age and compared favorably with same-site IATS data for infants undergoing surgery before 7 months of age. Our study showed that IOL implantation is relatively safe in children older than 6 months and younger than 2 years.

Bartonella presenting as branch retinal artery occlusion in a child.

Branch retinal artery occlusion (BRAO) is rare in children. Bartonella is a known cause of branch retinal artery occlusion in adults, but it is typically not considered in the differential diagnosis for pediatric BRAO. We present the case of a 12-year old boy with a BRAO caused by a Bartonella henselae infection. This is the youngest such case reported in the literature. Although rare, Bartonella infection may be an important and underrecognized cause of pediatric BRAO.

Data-Driven Scheduling for Improving Patient Efficiency in Ophthalmology Clinics.

PURPOSE: To improve clinic efficiency through development of an ophthalmology scheduling template developed using simulation models and electronic health record (EHR) data. DESIGN: We created a computer simulation model of 1 pediatric ophthalmologist's clinic using EHR timestamp data, which was used to develop a scheduling template based on appointment length (short, medium, or long). We assessed its impact on clinic efficiency after implementation in the practices of 5 different pediatric ophthalmologists. PARTICIPANTS: We observed and timed patient appointments in person (n = 120) and collected EHR timestamps for 2 years of appointments (n = 650). We calculated efficiency measures for 172 clinic sessions before implementation vs. 119 clinic sessions after implementation. METHODS: We validated clinic workflow timings calculated from EHR timestamps and the simulation models based on them with observed timings. From simulation tests, we developed a new scheduling template and evaluated it with efficiency metrics before vs. after implementation. MAIN OUTCOME MEASURES: Measurements of clinical efficiency (mean clinic volume, patient wait time, examination time, and clinic length). RESULTS: Mean physician examination time calculated from EHR timestamps was 13.8±8.2 minutes and was not statistically different from mean physician examination time from in-person observation (13.3±7.3 minutes; P = 0.7), suggesting that EHR timestamps are accurate. Mean patient wait time for the simulation model (31.2±10.9 minutes) was not statistically different from the observed mean patient wait times (32.6±25.3 minutes; P = 0.9), suggesting that simulation models are accurate. After implementation of the new scheduling template, all 5 pediatric ophthalmologists showed statistically significant improvements in clinic volume (mean increase of 1-3 patients/session; P ≤ 0.05 for 2 providers; P ≤ 0.008 for 3 providers), whereas 4 of 5 had improvements in mean patient wait time (average improvements of 3-4 minutes/patient; statistically significant for 2 providers, P ≤ 0.008). All of the ophthalmologists' examination times remained the same before and after implementation. CONCLUSIONS: Simulation models based on big data from EHRs can test clinic changes before real-life implementation. A scheduling template using predicted appointment length improves clinic efficiency and may generalize to other clinics. Electronic health records have potential to become tools for supporting clinic operations improvement.

Proptosis masquerading as buphthalmos following glaucoma drainage device surgery in a child with congenital glaucoma.

Glaucoma drainage devices are commonly used in the surgical treatment of children with glaucoma. We report a case of unusually large reservoir formation causing proptosis, exposure keratopathy, and motility deficits. This case highlights the importance of B-scan and axial length measurements in differentiating proptosis from buphthalmos in children with glaucoma. Reducing the reservoir improved the proptosis and resolved the motility and exposure issues.

Ophthalmic imaging in children: current practice patterns and perceived barriers.

Pediatric ophthalmologists were surveyed to determine current practice patterns regarding ophthalmic imaging for children and to identify perceived barriers to the adoption of imaging technologies in their practices. Some form of imaging was available in the majority of practices (94%), but its use varied widely among different clinical scenarios. The two most frequently perceived barriers to performing imaging in children were cooperation and lack of sufficient data supporting ophthalmic imaging in clinical practice.

Cerebrotendinous xanthomatosis: early diagnosis on the basis of juvenile cataracts.

Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid storage disease characterized by a broad spectrum of clinical manifestations, including bilateral juvenile cataracts. Untreated CTX leads to progressive permanent neurologic decline and early death. Although symptoms begin in early childhood, diagnosis and replacement therapy with chenodeoxycholic acid is often delayed until adulthood. Frequently bilateral juvenile cataracts present in early childhood which provides ophthalmologists an opportunity to aid in early diagnosis and initiate treatment. We report the case of a child presenting with juvenile bilateral cataracts leading to the diagnosis of CTX. The morphology of cataracts and the effect of systemic treatment on its progression are described.

Predictors of matching in an ophthalmology residency program.

PURPOSE: To examine the characteristics of US medical students applying for ophthalmology residency and to determine the predictors of matching. DESIGN: A retrospective case series. PARTICIPANTS: A total of 3435 medical students from the United States who applied to an ophthalmology residency program from 2003 to 2008 were included. METHODS: Matched and unmatched applicants were compared and stratified by predictor variables, including United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha (AOA) status, medical school reputation, and medical school geographic region. Differences in proportions were analyzed using the Fisher exact test. Logistic regression was used to determine the predictors of successful matching. MAIN OUTCOME MEASURES: Successful matching to an ophthalmology program. RESULTS: The majority of applicants (72%, 2486/3435) matched in ophthalmology. In multivariate analysis, AOA membership (odds ratio [OR], 2.6, P<0.0001), USMLE score (OR, 1.6; P<0.0001), presence of an ophthalmology residency at medical school (OR, 1.4; P = 0.01), top 25 medical school (OR, 1.4; P<0.03), top 10 medical school (OR, 1.6; P<0.02), and allopathic degree (OR, 4.0; P<0.0001) were statistically significant predictors of matching. Approximately 60% (1442/2486) of applicants matched to the same geographic region as their medical school. Applicants were more likely to match at a program in the same geographic region as their medical school than would be predicted by chance alone (P<0.0001). In multivariate analysis, higher USMLE score (OR, 0.9; P<0.0001) and top 10 medical school (OR, 0.7; P = 0.027) were statistically significant predictors of matching to outside the geographic region as one's medical school. CONCLUSIONS: The majority of applicants applying for an ophthalmology residency position match successfully. Higher performance on quantitative metrics seems to confer an advantage for matching. The majority of applicants match at a residency program within the same geographic region as one's medical school.

Association of community antibiotic consumption with clinically active trachoma in rural Ethiopia.

Community antibiotic utilization and its relationship with trachoma has been poorly characterized in areas with endemic trachoma. A survey of all drug-dispensing facilities in an area of rural Ethiopia was conducted. Antibiotic use was calculated using both retrospective and prospective methodology, and expressed as defined daily doses (DDDs). Overall antibiotic consumption estimates ranged from 2.91 to 3.07 DDDs per 1000 person days. Macrolide antibiotics accounted for 0.01 to 0.02 DDDs per 1000 person days. Each additional DDD of antibiotic use per 1000 person days was associated with a 15.0% (95% CI -19.7 to -10.3) decrease in the prevalence of clinically active trachoma among children under 10 years of age after adjusting for age, gender, altitude and the distance to nearest town. Increased background community antibiotic use may therefore be an aspect of socioeconomic development that can partially explain why trachoma prevalence has decreased in some areas in the absence of a trachoma program. The low volume of macrolide consumption in this area suggests that selection for nasopharyngeal pneumococcal macrolide resistance after mass azithromycin treatments likely has little clinical significance.

Incidence rates and risk factors for ocular complications and vision loss in HLA-B27-associated uveitis.

PURPOSE: To calculate the incidence rates of ocular complications and vision loss in HLA-B27-associated uveitis and to explore the effect of chronic inflammation on clinical outcomes. DESIGN: Retrospective longitudinal cohort study. METHODS: The clinical records of 99 patients (148 uveitis-affected eyes) with HLA-B27-associated uveitis seen at a tertiary care center were included. The main outcome measures were ocular complications (posterior iris synechiae, band keratopathy, posterior subcapsular [PSC] cataracts, ocular hypertension, hypotony, cystoid macular edema, and epiretinal membrane) and vision loss. Anterior chamber inflammation was defined as ≥1+ grade inflammation. Chronic uveitis was defined as persistent inflammation with relapse in <3 months after discontinuing treatment or requiring medications to suppress inflammation for >3 months after reviewing the patient's entire clinical course. RESULTS: The clinical course was most commonly acute/recurrent (75%) or chronic (20%). The most common complications to develop during follow-up were ocular hypertension (0.10/eye-year) and PSC cataracts (0.09/eye-year). In multivariate analysis, the presence of posterior synechiae at presentation, inflammation, corticosteroid-sparing therapy, corticosteroid injections, chronic disease, and male gender were associated with a statistically significant increased risk of developing vision loss (20/50 or worse). Chronic disease course was associated with a 7-fold increased risk of visual impairment (hazard ratio [HR] = 6.8, P < .0001). The presence of inflammation during follow-up was associated with an increased risk of developing visual impairment (HR = 6.2, P < .0001). In multivariate analysis, chronic disease course and topical corticosteroids were associated with an increased risk of developing any incident ocular complication (HR = 2.2, P = .04 and HR = 3.3, P = .01, respectively). CONCLUSIONS: Poorly controlled inflammation was associated with the development of ocular complications including vision loss. Patients with chronic inflammation were also at greater risk of complications.

Cigarette smoking as a risk factor for uveitis.

PURPOSE: To determine the association between tobacco smoking history and uveitis. DESIGN: Retrospective, case-control study. PARTICIPANTS: A total of 564 patients with ocular inflammation seen in the Proctor Foundation uveitis clinic between 2002 and 2009, and 564 randomly selected patients seen in the comprehensive eye clinic within the same time period. METHODS: A retrospective medical record review of all cases and controls. MAIN OUTCOME MEASURES: A logistic regression analysis was conducted with ocular inflammation as the main outcome variable and smoking as the main predictor variable, while adjusting for age, gender, race, and median income. RESULTS: The odds of a smoker having ocular inflammation were 2.2-fold that of a patient who had never smoked (95% confidence interval [CI], 1.7-3.0; P<0.001). All anatomic subtypes of uveitis were associated with a positive smoking history, with odds ratios (ORs) of 1.7 (95% CI, 1.2-2.4; P = 0.002) for anterior uveitis, 2.7 (95% CI, 1.4-5.6; P = 0.005) for intermediate uveitis, 3.2 (95% CI, 1.3-7.9; P = 0.014) for posterior uveitis, and 3.9 (95% CI, 2.4-6.1; P<0.001) for panuveitis. In patients with panuveitis and cystoid macular edema (CME), the OR was 8.0 (95% CI, 3.3-19.5; P<0.001) compared with 3.1 (95% CI, 1.8-5.2; P<0.001) for patients without CME. Patients with intermediate uveitis and CME also had a higher OR (OR 8.4; 95% CI, 2.5-28.8; P = 0.001) compared with patients without CME (OR 1.5; 95% CI, 0.6-3.8; P = 0.342). Patients with a smoking history were at greater odds of having infectious uveitis (OR 4.5; 95% CI, 2.3-9.0; P<0.001) than noninfectious uveitis (OR 2.1; 95% CI, 1.6-2.8; P<0.001), although both were associated with smoking. CONCLUSIONS: A history of smoking is significantly associated with all anatomic subtypes of uveitis and infectious uveitis. The association was greater in patients with intermediate uveitis and panuveitis with CME compared with those without CME. In view of the known risks of smoking, these findings, if replicated, would give an additional reason to recommend smoking cessation in patients with uveitis.