Garvin H. Davis

A Comparison of Two-Way Text Versus Conventional Paging Systems in an Academic Ophthalmology Department

Alphanumeric paging systems are unidirectional without prioritization capabilities. Newer electronic communication devices such as two-way text paging systems are capable of bidirectional paging and prioritization. While previous studies have evaluated alphanumeric paging systems in academic hospital settings, bidirectional two-way text paging systems have not been investigated. The goal of this study was to evaluate efficiency and impact on patient care delivery of a two-way text paging system compared to conventional one-way alphanumeric pagers. This unmasked, crossover prospective study was divided into three phases. In phase one, surveys were distributed to all ophthalmology attending physicians, residents, clinical technicians, and secretaries to assess the conventional alphanumeric paging system. In phase two, these participants used two-way text pagers without instruction (unstructured format) that they subsequently compared to the alphanumeric system with devised surveys assessing (on a scale of 0 to 100) time saved, increased daily efficiency, facilitation in patient care, and overall impression (helpfulness).In phase three, participants used a specific communication prioritization protocol (structured format) with the two-way text pagers with subsequent comparison and assessment with the same surveys. Compared to traditional alphanumeric pagers, new digital two-way text pagers were found to be statistically (p < 0.0001) more helpful by participants in all categories: as a time saver (80.33 vs. 56.95) p < 0.0001, increased daily efficiency (78.15 vs. 57.13) p < 0.0001, facilitation in patient care (78.79 vs. 56.95) p < 0.0001, and overall impression (helpfulness) (61.82 vs. 84.33) p < 0.0001. When compared to the alphanumeric pager, the two-way text pager was found to decrease subjectively call backs (73.6% to 45.6%, p < 0.0001), reduce interruptions of learning activities (43.63% to 26.6%, p < 0.0001) and enabled better patient care (59.8% to 42.2%, p < 0.0001). No significant statistical difference was found between the structured and unstructured system. Two-way text paging (structured versus unstructured guidance) was preferred over the conventional one-way alphanumeric paging system in every participant category. Two-way text paging is an effective alternative to alphanumeric paging, demonstrating saved time, increased daily efficiency, reduced call backs and interruptions of educational activities, and facilitation in patient care.

Risk factors associated with retinal hemorrhage in suspected abusive head trauma

Purpose To determine risk factors associated with retinal hemorrhage (RH) in pediatric abusive head trauma (AHT) suspects. Methods Records of children aged 0–3 years hospitalized for suspected AHT from January 2007 to November 2011 were retrospectively reviewed in this case–control study. Children were classified into case and control groups based on RH presence. Medical history, presenting symptoms, reasons, and characteristics of injury were recorded. Logistic regression analysis was performed to identify risk factors. Results A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories). Conclusions Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.

Management of Endogenous Endophthalmitis

Endogenous endophthalmitis is a potentially blinding ocular infection resulting from hematogenous spread from a remote primary source. Endogenous endophthalmitis accounts for only 2–8% of cases of endophthalmitis and usually occurs in the setting of at least a relatively immunocompromised state. Causes include both gram-positive and gram-negative bacteria and fungi. Streptococcal species are the most commonly implicated bacterial organisms; Candida species are the most commonly implicated fungal organisms. Endogenous mold endophthalmitis is rare and typically occurs in the setting of relative immunocompromise or intravenous drug use. Early diagnosis of endogenous endophthalmitis requires a high degree of suspicion and is critical if vision is to be preserved. Therapeutic management includes hospitalization and delivery of broad-spectrum systemic and intravitreal antibiotics. Vitrectomy may be appropriate in some cases. The prognosis of patients with endogenous endophthalmitis is disappointing; even with aggressive treatment, useful vision (i.e., ability to count fingers or better) is preserved in only about 40% of patients.

Surgical repair of large cyclodialysis clefts.

Purpose To describe a new surgical technique to effectively close large (>180 degrees) cyclodialysis clefts. Methods Our method involves the use of procedures commonly associated with repair of retinal detachment and complex cataract extraction: phacoemulsification with placement of a capsular tension ring followed by pars plana vitrectomy and gas tamponade with light cryotherapy. We also used anterior segment optical coherence tomography (OCT) as a noninvasive mechanism to determine the extent of the clefts and compared those results with ultrasound biomicroscopy (UBM) and gonioscopy. Results This technique was used to repair large cyclodialysis clefts in 4 eyes. All 4 eyes had resolution of hypotony and improvement of visual acuity. One patient had an intraocular pressure spike requiring further surgical intervention. Anterior segment OCT imaging in all 4 patients showed a more extensive cleft than UBM or gonioscopy. Conclusions This technique is effective in repairing large cyclodialysis clefts. Anterior segment OCT more accurately predicted the extent of each cleft, while UBM and gonioscopy both underestimated the size of the cleft.

Viral Retinitis in the Cancer Patient

Viral retinitis is a vision-threatening infection of the retina that can occur in both immunocompetent and immunocompromised patients and is primarily caused by the human herpesvirus family of viruses. Prompt recognition and treatment are critical for optimal outcomes. This chapter focuses on cytomegalovirus (CMV) retinitis, acute retinal necrosis (ARN), and progressive outer retinal necrosis (PORN). Presentations of CMV retinitis range from an indolent/granular retinitis to a fulminant/edematous retinitis characterized by necrosis and hemorrhage. ARN is a vaso-occlusive necrotizing retinitis that is usually secondary to herpes zoster or HSV. PORN is characterized by primary involvement of the outer retina, minimal to no vitreous inflammation, and extremely rapid progression. Treatment of CMV retinitis consists of improving the patient’s immune status and then administering induction and maintenance antiviral therapy. For ARN, intravenous acyclovir is the standard initial treatment; oral acyclovir is then employed for variably prolonged periods. Because of PORN’s poor prognosis, a multidisciplinary approach with an infectious disease consultation is favored. In patients with viral retinitis, argon laser photocoagulation posterior to the edge of necrosis may be performed as prophylaxis against retinal detachment, which is the major cause of visual loss after acute manifestations have resolved. Retinal detachments in patients with CMV retinitis have been approached with scleral buckling, gas pneumatic retinopexy, and vitrectomy with either gas or silicone oil tamponade. Visual prognosis is guarded for patients with CMV retinitis or ARN and extremely poor for patients with PORN.

Diagnostic Vitrectomy and the Cancer Patient: Special Considerations

The term diagnostic vitrectomy is used to refer to biopsy of the vitreous or the uvea. In patients with a history of cancer, there is a low clinical threshold for diagnostic vitrectomy as vitritis can represent recurrence of lymphoma or leukemia or an opportunistic infection. The most common clinical scenarios in which diagnostic vitrectomy is performed in cancer patients are new-onset vitreous cellularity in a patient with lymphoma in remission or newly diagnosed lymphoma; vitritis in a patient with recent bone marrow transplantation; atypical retinitis or choroiditis; and atypical iris, ciliary body, or choroidal lesions. In addition, choroidal biopsy is sometimes done to obtain material for cytogenetic studies in patients with uveal melanoma. Vitreous biopsy can be performed successfully with either a two-port or three-port approach; specifics of the technique depend on the vitrector gauge. Uveal biopsy can be performed with fine-needle aspiration biopsy or with transretinal choroidal biopsy with a sutureless vitrectomy system, an approach that is gaining favor. Collaboration and good communication between the ophthalmologist and a pathologist well versed in the handling and analysis of vitreous samples are essential for successful diagnostic vitrectomy.