Successful management of epithelial ingrowth after sequential intracameral 5-fluorouracil and Descemet-stripping automated endothelial keratoplasty.

To describe the successful treatment of epithelial ingrowth using combined surgical excision with intracameral adjuvant 5-fluorouracil (5-FU) followed by Descemet-stripping automated endothelial keratoplasty (DSAEK). A 71-year-old man presented with epithelial ingrowth after clear corneal phacoemulsification. He underwent surgical excision of the membrane together with pars plana vitrectomy, air fluid exchange, and intracameral 5-FU. This treatment resulted in corneal decompensation for which DSAEK was performed 6 months later. Despite interface haze, the postoperative corrected distance visual acuity returned to 20/40 three months after DSAEK. There was no clinical evidence of recurrence of the epithelial ingrowth 9 months after the surgical removal. Intracameral 5-FU can be used in conjunction with surgical excision and subsequent DSAEK to successfully treat epithelial ingrowth.

Histopathological analysis of retinopathy of prematurity after intravitreal bevacizumab.

We report the case of a premature infant with end-organ failure who developed high-risk retinopathy of prematurity (ROP) bilaterally and was treated with intravitreal bevacizumab (IVB) injection therapy with regression noted on follow-up clinical examination. The infant died 3 weeks after IVB injection therapy. Histopathological analysis was conducted on bilateral globes and revealed persistent preretinal vessels.

Implementation of competency-based medical education: are we addressing the concerns and challenges?

CONTEXT: Competency-based medical education (CBME) has emerged as a core strategy to educate and assess the next generation of physicians. Advantages of CBME include: a focus on outcomes and learner achievement; requirements for multifaceted assessment that embraces formative and summative approaches; support of a flexible, time-independent trajectory through the curriculum; and increased accountability to stakeholders with a shared set of expectations and a common language for education, assessment and regulation. OBJECTIVES: Despite the advantages of CBME, numerous concerns and challenges to the implementation of CBME frameworks have been described, including: increased administrative requirements; the need for faculty development; the lack of models for flexible curricula, and inconsistencies in terms and definitions. Additionally, there are concerns about reductionist approaches to assessment in CBME, lack of good assessments for some competencies, and whether CBME frameworks include domains of current importance. This study will outline these issues and discuss the responses of the medical education community. METHODS: The concerns and challenges expressed are primarily categorised as: (i) those related to practical, administrative and logistical challenges in implementing CBME frameworks, and (ii) those with more conceptual or theoretical bases. The responses of the education community to these issues are then summarised. CONCLUSIONS: The education community has begun to address the challenges involved in implementing CBME. Models and guidance exist to inform implementation strategies across the continuum of education, and focus on the more efficient use of resources and technology, and the use of milestones and entrustable professional activities-based frameworks. Inconsistencies in CBME definitions and frameworks remain a significant obstacle. Evolution in assessment approaches from in vitro task-based methods to in vivo integrated approaches is responsive to many of the theoretical and conceptual concerns about CBME, but much work remains to be done to bring rigour and quality to work-based assessment.

Nonimmunologic graft failure after Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for presumed amantadine-induced corneal edema.

CONTEXT: With one exception, a case report of amantadine-induced corneal toxicity has described reversible corneal edema. OBJECTIVE: To report a patient with unrecognized amantadine-induced corneal edema. DESIGN: Patient with schizophrenia and tardive dyskinesia developed bilateral corneal edema while receiving chronic amantadine hydrochloride. Both eyes underwent successful phakic Descemet's stripping automated endothelial keratoplasty, and histopathologic examination of the excised host tissue was performed. RESULTS: Despite initial clearing of the donor lenticules, both eyes later experienced nonimmunologic graft failure, probably related to continued amantadine corneal toxicity. After discontinuation of the amantadine, one graft demonstrated partial clearing. Histopathology demonstrated endothelial cell loss. Specular microscopy demonstrated pleomorphism and disruption of the orderly hexagonal array. CONCLUSIONS: Chronic amantadine hydrochloride therapy may be responsible for irreversible corneal edema and may lead to graft failure in unrecognized cases.

Retinal hemorrhages in children following fatal motor vehicle crashes: a case series.

OBJECTIVE: To demonstrate the severity of ocular findings in young children who died of injuries due to motor vehicle crashes. METHODS: Case series of 10 children younger than 3 years who were fatally injured in motor vehicle crashes between January 1, 1994, and December 31, 2002. All children underwent autopsy that included eye examination. All available medical and autopsy records, pathology slides and photographs, and police and traffic department reports were reviewed for each case. RESULTS: Eight patients had retinal hemorrhages, which extended into the periphery in 13 eyes and were bilateral in 7 patients. Three patients had elevated circular retinal folds. Six patients had hemorrhages below the internal limiting membrane, but no patients had deeper splitting of the retina. Nine patients had optic nerve sheath hemorrhages. CONCLUSION: The association of extensive, sometimes severe, ocular hemorrhages with fatal accidental trauma, compared with previous reports of accidental trauma with no or few hemorrhages, indicates the severity of injury required to cause hemorrhages of this magnitude.

Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse.

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.

Massive extraocular extension and parotid lymph node metastasis of uveal melanoma.

A 22-year-old man, diagnosed with unilateral glaucoma and treated with trabeculectomy 6 years earlier, presented with an epibulbar nodule of 6 months' duration. MRI displayed intra- and extraocular tumor, and gross invasion of the medial rectus muscle. Biopsy demonstrated uveal melanoma, and staging revealed enhancing ipsilateral parotid lymph nodes. Orbital exenteration and parotidectomy with selective neck dissection were performed. The tumor infiltrated superficial parotid nodes and extended into the parotid gland. The site of tumor origin is speculative, but a ring melanoma of the anterior chamber angle is suspected. Lymph node metastasis of uveal melanoma is rare; to our knowledge, this is the most advanced of the few reported cases.

Staphylococcus hominis endophthalmitis associated with a capsular hypopyon.

PURPOSE: To report a case of Staphylococcus hominis endophthalmitis associated with a capsular hypopyon. DESIGN: Interventional case report. METHODS: A 51-year-old man presented with chronic postcataract extraction inflammation and underwent vitrectomy, partial capsulectomy, and intravitreal antibiotic injections, followed by explantation of the intraocular lens and capsule. RESULTS: A capsular hypopyon in the absence of an anterior chamber hypopyon was noted. Cultures of the vitreous and capsule revealed Staphylococcus hominis, a coagulase-negative gram-positive organism. CONCLUSIONS: We are unaware of previous reports of endophthalmitis caused by Staphylococcus hominis, and could find none in a computerized search using MEDLINE. This case adds Staphylococcus hominis to the list of causative organisms in chronic endophthalmitis and illustrates the rare finding of a capsular hypopyon.