Devin D. Mackay

Teaching Ophthalmoscopy to Medical Students (TOTeMS) II: A One-Year Retention Study

OBJECTIVE: We previously demonstrated that medical students (MS) performed more accurately and preferred using photographs than direct ophthalmoscopy to examine the ocular fundus. We hypothesized that these differences would persist over time. BACKGROUND: Learning direct ophthalmoscopy is challenging, and MS long-term retention of ophthalmoscopy skills is poor. DESIGN/METHODS: One year after initial training, second-year MS were randomized and reevaluated on their ability to examine the ocular fundus using either fundus photographs or direct ophthalmoscopy on eye simulators. Positive and negative affect, preferences, and clinical experiences with ocular fundus examination were assessed. RESULTS: 107/119 students (90%) who participated in the original study completed this one-year retention study. Students answered 34/48 (71%) questions correctly using photographs and 31/48 (65%) correctly using ophthalmoscopy (p<.01). Both photograph and ophthalmoscopy groups answered five fewer questions correctly on average than one year prior (p<.001). Students rated photographs as “easier than ophthalmoscopy” (8/10 vs. 6/10, respectively; p<.001). Students’ positive affect scores were higher in the photograph group (26.5) than in the ophthalmoscopy group (23.2; p=.03). Students tested on simulators reported lower positive affect than one year ago (decrease of 6.4 points, p<0.001). Students’ self-reported median frequency of fundus examination over the preceding year was <10% (IQR 0-20%). Ocular fundus examination was not performed because of discomfort with the examination (38%), discouragement by their preceptor (20%), and insufficient time (15%). 79% of students felt uncomfortable with ophthalmoscopy, and 44% stated that they would not perform ophthalmoscopy during a general physical examination. 76% stated they would prefer using photographs instead of ophthalmoscopy for fundus examination. CONCLUSIONS: Students preferred photographs for examining the ocular fundus and were more accurate using photographs vs. direct ophthalmoscopy one year after training. The increasing availability of non-mydriatic ocular fundus photography may allow more frequent and accurate examination of the ocular fundus by MS and non-ophthalmologists in many clinical settings. Study Supported by: Research to Prevent Blindness, NIH/NEI P30-EY06360, K23-EY019341 Disclosure: Dr. Mackay has nothing to disclose. Dr. Garza has nothing to disclose. Dr. Bruce has received personal compensation for activities with Kaiser Permanente. Dr. Bruce has received research support from Pfizer, Inc. and Teva Neuroscience. Dr. Bidot has nothing to disclose. Dr. Kelly has nothing to disclose. Dr. Graubart has nothing to disclose. Dr. Newman has received personal compensation for activities with Santhera. Dr. Biousse has received personal compensation in an editorial capacity for Up To Date.

Teaching Video NeuroImages: periodic alternating nystagmus evident only in darkness.

An 81-year-old man with retinitis pigmentosa had severe, slowly progressive visual loss that began at age 20. Intermittent nystagmus was observed for 1 decade. Examination revealed severe retinal atrophy and periodic alternating nystagmus (PAN) that occurred only in darkness (video on the Neurology® Web site at www.neurology.org).

Hemodialysis graft-induced intracranial hypertension.

Intracranial hypertension is rarely associated with peripheral hemodialysis shunts, presumably in association with central venous stenosis.1,2 Hemodialysis Reliable Outflow (HeRO) grafts (CryoLife, Inc., Kennesaw, GA) are designed to bypass preexisting central venous stenosis by connecting the brachial artery with the venous circulation through the ipsilateral internal jugular vein (IJV) (figure, C and D).3 We report a case of intracranial hypertension immediately after placement of a HeRO graft, review similar cases in the medical literature, and discuss possible pathophysiology.

Periodic alternating gaze deviation and nystagmus in posterior reversible encephalopathy syndrome

A 73-year-old man with benign prostatic hypertrophy, but no history of hypertension, presented with acute urinary retention and severe headache followed by sudden loss of vision.

Nonarteritic anterior ischemic optic neuropathy: untreatable at present?

Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in patients aged over 50 years and results from ischemic damage to the anterior optic nerve. Proposed treatments for NAION presumably target thrombosis, blood vessels or disc edema or may have a neuroprotective effect. However, no controlled prospective clinical trials have shown benefit for any medical or surgical treatments. Most of the literature on the treatment of NAION consists of retrospective or prospective case series and case reports. IONDT is the only large multicenter prospective randomized controlled trial performed for NAION and it found no benefit for surgical intervention. There is a debate over the utility of steroids, both oral and intravitreal, and over the use of intravitreal injections of antivascular endothelial growth factor agents. Similarly, therapies aimed at secondary prevention of fellow eye involvement in NAION remain of unproven benefit.