Daniel G. Ezra

Skills Acquisition and Assessment after a Microsurgical Skills Course for Ophthalmology Residents

OBJECTIVE To assess the impact of a skills course on microsurgical skills acquisition and to investigate the validity of a video-based modified Objective Structured Assessment of Technical Skill (OSATS) assessment tool that has not previously been applied to ophthalmic surgery. DESIGN Prospective longitudinal cohort study. PARTICIPANTS Fourteen residents were recruited from 20 attendees at the Moorfields Eye Hospital microsurgical skills course for residents. METHODS Each resident performed a standardized microsurgical task consisting of the placement of a 10-0 nylon corneal suture into a model eye using an operating microscope with standardized equipment in a standardized environment. Objective measurements were made using the Imperial College Surgical Assessment Device (ICSAD). This is a motion-tracking device returning 3 parameters for economy of movement: total path length, time, and number of individual hand movements. A concurrent video recording was made of each task by 2 independent observers who were masked to the time of the recording relative to the course and the identity of the resident. Video footage was marked in accordance with the OSATS video scoring template. MAIN OUTCOME MEASURES Each resident had motion-tracking analysis performed during corneal suturing before and after the course (total path length, time, and number of individual hand movements), along with concurrent OSATS video scores. RESULTS Skills improvement after the course was found to be statistically significant for all 3 ICSAD economy of movement parameters: path length, P = 0.001; hand movements, P = 0.012; and time, P = 0.009. Differences in the combined OSATS scores of the 2 raters before and after the course were found to be significant (P = 0.039). Interrater reliability of OSATS scorers was 0.78 (alpha Cronbach). Correlations between the OSATS scores and each of the ICSAD parameters were found to be significant (P<0.001). CONCLUSIONS A video-based OSATS scoring system has significant correlation with the ICSAD motion-tracking parameters, demonstrating concurrent validity between the 2 assessment tools. These data also demonstrate that surgical skill, as measured by a validated motion-tracking system, is significantly improved after a 1-day microsurgical skills course. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The associations of floppy eyelid syndrome: a case control study.

OBJECTIVE To describe the demographic features of a large series of patients with floppy eyelid syndrome (FES) and to investigate the associations of the condition with keratoconus, obstructive sleep apnea-hypopnea syndrome (OSAHS), and a variety of upper and lower eyelid features. DESIGN Case control study. PARTICIPANTS The test group comprised 102 patients with FES. A control group of 102 patients were recruited from a diabetic retinopathy clinic and matched on a 1:1 basis on age, gender, and body mass index (BMI). METHODS A full medical and ophthalmic history was taken. Patients also underwent a full ocular examination, including an assessment of upper and lower lid laxity and upper lid levator function. Keratoconus grading was made using the Oculus Instruments Pentacam imaging system (Oculus Optikgerate GmbH, Wetzlar, Germany). Patients were screened for OSAHS using the Epworth daytime somnolence score. Matched statistical analysis of dichotomous data was made using Mantel-Haenszel methods for odds ratios and McNemars test. Analysis of continuous data was performed using a matched t test and tests for symmetry of larger tables were made using the McNemar-Bowker test. MAIN OUTCOME MEASURES The significance of association of FES with keratoconus, OSAHS, smoking history, medial and lateral canthal laxity of the upper and lower lids, levator function, lash ptosis, and dermatochalasis. RESULTS Significant associations were found between FES and OSAHS (P = 0.0008), keratoconus (P<0.0001), lash ptosis (P<0.0001), dermatochalasis (P = 0.02), upper lid medial canthal laxity (P = 0.02), upper lid distraction (P = 0.001), palpebral aperture (P = 0.004), and levator function (P = 0.005). CONCLUSIONS Floppy eyelid syndrome seems to be a condition strongly associated with OSAHS and keratoconus. As well as providing a platform for an etiologic hypothesis for the condition, these findings should also encourage clinicians to be aware of these associations and to direct further treatment. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Teprotumumab for thyroid-associated ophthalmopathy

BACKGROUND Thyroid‐associated ophthalmopathy, a condition commonly associated with Graves’ disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin‐like growth factor I receptor (IGF‐IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy. METHODS We conducted a multicenter, double‐masked, randomized, placebo‐controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF‐IR, in patients with active, moderate‐to‐severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid‐associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves’ ophthalmopathy–specific quality‐of‐life questionnaire. Adverse events were assessed. RESULTS In the intention‐to‐treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P<0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P<0.001). Differences between the groups increased at subsequent time points. The only drug‐related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes. CONCLUSIONS In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997.)

Floppy eyelid syndrome: stretching the limits.

Floppy eyelid syndrome is a distressing condition that can cause significant morbidity and vision loss. Many systemic and ocular associations have been proposed, most notably keratoconus and obstructive sleep apnea-hypopnea syndrome. Although conservative treatments can sometimes be effective, a wide variety of surgical treatments to tighten the upper eyelid have been described. The underlying pathogenesis remains elusive, although progress has been made in the identification of extracellular matrix changes in the tarsal plate. This systematic review discusses the issues surrounding ambiguities in the definition of floppy eyelid syndrome as well as what is currently known about its clinical features, ocular and systemic associations, pathological changes, and proposed theories of pathogenesis. In addition a critical discussion of the proposed surgical treatments and their reported success rates and follow-up times is provided.

Doxycycline prevents matrix remodeling and contraction by trichiasis-derived conjunctival fibroblasts.

PURPOSE Trachoma is a conjunctival scarring disease, which is the leading infectious cause of blindness worldwide. Elimination of blinding trachoma is being held back by the high rate of trichiasis recurrence following surgery. There is currently no treatment available to suppress the profibrotic state and reduce recurrence. Although the mechanisms underlying trichiasis development are unknown, the profibrotic phenotype has been linked to matrix metalloproteinase (MMP) expression. Doxycycline, a well-known tetracycline antibiotic, can act as a broad MMP inhibitor and has showed some success in preventing fibrosis in various clinical contexts. The purpose of this work was to assess the antiscarring properties of doxycycline in an in vitro model of trichiasis fibroblast-mediated tissue contraction. METHODS Primary cultures of fibroblasts were established from conjunctival samples obtained from normal donors or during surgery for trachomatous trichiasis. The effect of doxycycline on matrix contraction was investigated in our standard collagen gel contraction model. Cell morphology and matrix integrity were assessed using confocal reflection microscopy. Quantitative real time polymerase chain reaction and a FRET-based assay were used to measure MMP expression and activity, respectively. RESULTS Doxycycline treatment successfully suppressed the contractile phenotype of trichiasis fibroblasts, matrix degradation, and significantly altered the expression of MMP1, MMP9, and MMP12 associated with the profibrotic phenotype. CONCLUSIONS In view of the results presented here and the wider use of doxycycline in clinical settings, we propose that doxycycline might be useful as a treatment to prevent recurrence following trichiasis surgery.

Factors associated with quality of life and mood in adults with strabismus

Background/Aims To explore the factors associated with the mood and quality of life (QoL) of patients with strabismus due to undergo realignment surgery. Methods A cross-sectional study was undertaken with adult patients. Along with demographic, clinical and psychosocial process variables, the Hospital Anxiety and Depression Scale and AS-20 QoL measures were administered. Regression models were used to identify the factors associated with QoL and mood. Results Of the 220 participants, 11% were experiencing clinical levels of depression, and 24% clinical anxiety. This is in line with other forms of facial disfigurement but higher than other chronic diseases. Although mood and QoL were associated with age and diplopia, it was beliefs and cognitions which were more consistently associated with well-being. This included feelings of social anxiety and avoidance, a belief that strabismus has negative consequences, poor understanding of strabismus, social support, fear of negative evaluation and the perceived visibility of their condition. Conclusions Psychosocial rather than clinical characteristics were identified as determinants of well-being in this population. It is important for clinicians planning surgery to be aware of these factors which could influence outcomes. Longitudinal studies need to be conducted to explore the direction of causality before interventions to improve well-being are developed and evaluated.

High-speed camera characterization of voluntary eye blinking kinematics

Blinking is vital to maintain the integrity of the ocular surface and its characteristics such as blink duration and speed can vary significantly, depending on the health of the eyes. The blink is so rapid that special techniques are required to characterize it. In this study, a high-speed camera was used to record and characterize voluntary blinking. The blinking motion of 25 healthy volunteers was recorded at 600 frames per second. Master curves for the palpebral aperture and blinking speed were constructed using palpebral aperture versus time data taken from the high-speed camera recordings, which show that one blink can be divided into four phases; closing, closed, early opening and late opening. Analysis of data from the high-speed camera images was used to calculate the palpebral aperture, peak blinking speed, average blinking speed and duration of voluntary blinking and compare it with data generated by other methods previously used to evaluate voluntary blinking. The advantages of the high-speed camera method over the others are discussed, thereby supporting the high potential usefulness of the method in clinical research.

Corneal wedge excision in the treatment of high astigmatism after penetrating keratoplasty.

Purpose: To report 5 cases of high astigmatism after penetrating keratoplasty (PK) treated with corneal wedge excisions. Methods: We report our experience of 5 patients treated with corneal wedge excisions for high astigmatism after PK. A thin sliver of cornea measuring between 0.1 and 0.2 mm in thickness was excised from just inside the graft-recipient interface. The length of the incision centered at the axis of the flatter meridian of the cornea and was extended over a range of 60-90 degrees. The wound was closed with interrupted 10-0 nylon sutures placed every 15 degrees. We also report, for the first time, both pre- and postoperative corneal topography in 3 of our patients who underwent wedge excisions. Results: The mean preoperative astigmatism was 15.2 D (range, 8.5-29.1 D). Postoperatively, after wedge excision, the mean astigmatism was reduced to 2.3 D (range, 1.9-3.7 D). The mean reduction in astigmatism was 12.9 D (range, 6.3-25.4 D). Conclusions: Corneal wedge resection is an effective treatment for high astigmatism after PK. It may prove particularly useful in cases of high astigmatism or where other treatments are not appropriate. We believe that there is still a role for wedge resection as one of many tools to be used in the treatment of high post-PK astigmatism.

The impact of strabismus on quality of life in adults with and without diplopia: a systematic review

Strabismus affects approximately 4% of the adult population and can cause substantial physical disturbance and changes to appearance. This article aims to examine the impact of strabismus in adults both with and without diplopia, focusing primarily on quality of life (QoL). We highlight the value of measuring QoL, assess the ways in which it can be measured, and the impact the disease, diplopia, and surgery have on the patient. QoL differs for strabismus patients based on their diplopia status. Patients with diplopia tend to have more concerns relating to functional QoL, whereas patients without diplopia have primarily psychosocial concerns. Two diplopia-specific questionnaires have been designed to assess QoL and the perceived severity of symptoms. Further research is needed to identify the variables which influence QoL so that appropriate support can be given to all patients with strabismus to improve their QoL.

Appearance concerns in ophthalmic patients

AimsThis study aimed to determine the psychosocial and appearance-related concerns of a sample of ophthalmic patients by measuring a range of psychological, social, and demographic factors.MethodsStandardized psychological measures including anxiety, depression, appearance-related distress, self-discrepancy, appearance salience and valence were administered to 98 participants attending ophthalmic outpatient clinics in either London, Bristol, Sheffield or Bradford. Differences between groups were explored using t-tests and ANOVA, relationships between all variables were investigated using Pearsons correlation coefficient.ResultsAlthough mean scores for psychological adjustment were within the normal range, some participants were experiencing considerable levels of generalized anxiety. Being older, male, and married or living with a partner was related to significantly better adjustment. Better adjustment was also related to a less visible area of concern, greater disguisability of the affected area, a more positive evaluation of their own appearance, less engagement in comparing themselves with others, greater feelings of being accepted by others, appearance being less important to their self-concept, and a smaller discrepancy between the persons ideal and actual appearance.ConclusionsA majority of ophthalmic patients adjust positively to the demands placed on them. By identifying the variables that are associated with successful adaptation, the specific psychological interventions and appropriate systems of support can be put in place to help those who are adversely affected.