Outcomes of treatment of fungal keratitis at the University of Iowa Hospitals and Clinics: a 10-year retrospective analysis.

PURPOSE: To evaluate the outcomes of medical and surgical management of fungal keratitis at a tertiary care eye center. METHODS: A retrospective review was performed of the medical records of all patients with a diagnosis of microbiologically or histopathologically confirmed fungal keratitis at the University of Iowa Hospitals and Clinics from July 1, 2001, through June 30, 2011. The main outcome measure was a microbiological cure with either medical therapy alone or medical therapy combined with therapeutic keratoplasty (TKP). The secondary outcome measures were graft survival of the TKPs and subsequent optical keratoplasties (OKPs) and visual outcome. RESULTS: Seventy-three eyes met the inclusion criteria. A microbiological cure was achieved in 72 eyes (98.6%). Forty-one eyes (56.2%) were treated with medical therapy alone, and 32 (43.8%) eyes required 1 TKP (29 eyes) or 2 TKPs (3 eyes). Among the 32 eyes treated with TKP, 17 (53.1%) maintained a clear graft. Among 15 eyes with failed grafts, 12 eyes ultimately achieved clear grafts after a total of 19 OKP procedures. Among 41 eyes treated with medical therapy alone, all 3 eyes treated with OKP remained clear. The final median best-corrected visual acuity was 20/30 in the medical therapy group and 20/40 in the TKP group. CONCLUSIONS: A high microbiological cure rate can be achieved in eyes with fungal keratitis; however, TKP is often needed to achieve this objective. A good final visual outcome can be achieved in most cases, but multiple keratoplasty procedures may be required.

Reverse optic capture of the single-piece acrylic intraocular lens in eyes with posterior capsule rupture.

BACKGROUND AND OBJECTIVE: To evaluate the clinical results of reverse optic capture (ROC) with single-piece posterior chamber intraocular lenses (PC-IOLs) in cases of phacoemulsification cataract and IOL surgery with posterior capsular rupture. PATIENTS AND METHODS: Preoperative diagnosis, intraoperative events, surgical parameters, intraoperative and postoperative complications, and preoperative and postoperative visual acuity and refraction of 16 eyes that underwent ROC were reviewed and analyzed. The fellow eye of 12 patients undergoing uneventful phacoemulsification without optic capture served as the control group. RESULTS: Over a mean of 19 months' follow-up, 94% of eyes in the ROC group and 92% in the control group achieved a best-corrected visual acuity of 20/25 or better. Ninety-four percent of eyes in the ROC group and 100% in the control group had postoperative spherical equivalent ± 1.00 D of the intended refraction. Refraction was stable between 1 month and final follow-up in both groups. In all eyes with ROC, the IOL remained well centered with a securely captured optic. There were no vision-threatening complications throughout the follow-up. CONCLUSION: The comparable outcomes in both groups suggests that optic capture of a single-piece acrylic IOL through an anterior capsulorhexis merits consideration for IOL placement in selected cases of insufficient posterior capsule support.

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.

Construct validity of a surgical simulator as a valid model for capsulorhexis training.

PURPOSE: To compare the performance on the EYESi surgical simulator capsulorhexis training module between medical students and residents and experienced cataract surgeons. SETTING: Department of Ophthalmology, University of Iowa, Iowa City, Iowa, USA. DESIGN: Comparative case series. METHODS: The study comprised medical students and residents at the University of Iowa and experienced cataract surgeons. Neither group had experience with the simulator. Each participant completed 4 trials on the capsulorhexis module. RESULTS: The 7 experienced surgeons achieved statistically significantly better total scores than the 16 medical students and residents on the easy level and the medium level of the capsulorhexis module (P = .004 and P = .000007, respectively). Experienced surgeons achieved significantly better scores in all parameters at the medium level, with better centering (P = .001), less corneal injury (P = .02), fewer spikes (P = .03), less time operating without a red reflex (P = .0005), better roundness of the capsulorhexis (P = .003), and less time completing tasks (P = .008). CONCLUSION: The surgical simulator capsulorhexis module showed significant construct validity (P<.05).

Cataract surgery in the patient that cannot lie flat.

PURPOSE OF REVIEW: At times a patient requiring cataract surgery cannot be positioned flat rendering the case challenging. In addition, sometimes the medical condition that limits the patient's ability to lie supine also carries an increased risk of being placed under general anesthesia making topical anesthesia a safer option. The surgeon must often use ingenuity in positioning in order to carry out a successful surgery. This review will highlight different techniques employed for cataract surgery in a patient that cannot lie supine. RECENT FINDINGS: There is a small amount of published literature describing techniques of cataract surgery in the patient who cannot lie supine. We hope to highlight the various techniques that have been described in the literature. SUMMARY: Cataract surgery can become more complex when the patient cannot be positioned with their head flat on the operating table. With creative alterations to normal positioning, successful phacoemulsification can be executed.

Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates.

PURPOSE: To determine whether institution of a structured surgical curriculum for ophthalmology residents decreased the rate of sentinel surgical complications. SETTING: Veterans Affairs Medical Center, Des Moines, Iowa, USA. METHODS: A retrospective review was performed of third-year ophthalmic resident quality-assurance surgical outcomes data at a single residency-training site from 1998 to 2008. The primary outcome measure was defined as a sentinel event; that is, a posterior capsule tear (with or without vitreous loss) or vitreous loss (from any cause) occurring during a resident-performed case. The study population was divided into 2 groups. Group 1 comprised surgical cases of residents trained before the surgical curriculum change (academic years 1998 to 2003) and Group 2, surgical cases of residents trained with the enhanced curriculum (academic years 2004 to 2008). Data from 1 year (academic year 2003 to 2004) were excluded because the transition to the enhanced curriculum occurred during that period. The data were analyzed and adjusted for surgical experience. RESULTS: In Group 1 (before institution of surgical curriculum), there were 823 cases with 59 sentinel complications. In Group 2 (after institution of surgical curriculum), there were 1009 cases with 38 sentinel complications. There was a statistically significant reduction in the sentinel complication rate, from 7.17% before the curriculum changes to 3.77% with the enhanced curriculum (P = .001, unpaired 2-tailed t test). CONCLUSION: Implementation of a structured surgical curriculum resulted in a statistically significant reduction in sentinel event complications, even after adjusting for surgical experience.

Reconciling medications at admission: safe practice recommendations and implementation strategies.

BACKGROUND: Fifty hospitals collaborated in a patient safety initiative developed and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. METHODS: A consensus group identified safe practices and suggested implementation strategies. Four collaborative learning sessions were offered, and teams monitored their progress and shared successful strategies and lessons learned. Reports from participating teams and an evaluation survey were then used to identify successful techniques for reconciling medications. RESULTS: For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. DISCUSSION: Adoption of the reconciling safe practices proved challenging. The process of writing medication orders at patient transfer points is complex. The hospitals' experiences demonstrated that implementing the proposed safe practices requires a team effort with leadership support and vigilant measurement.