Hilary A. Beaver

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.

Screening elderly patients in an outpatient ophthalmology clinic for dementia, depression, and functional impairment

PURPOSE To determine the feasibility of screening for depression, dementia, and functional impairment in an ophthalmology outpatient clinic. DESIGN Prospective pilot survey study. PARTICIPANTS Fifty consecutive ophthalmology clinic outpatients. METHODS Consecutive patients more than 64 years of age with visits to the comprehensive eye clinic and the neuroophthalmology clinic at the University of Iowa were assessed. Suitable subjects were asked to complete a short questionnaire on instrumental activities of daily living, to answer a single question on depression, and to complete a clock drawing task in the office waiting room or examination room. RESULTS The 50 questionnaires reviewed showed that most respondents were functional (94%) in instrumental activities of daily living, had normal clock drawing results (80%), and were not depressed (80%). A significant minority, however, were identified by the screening to have functional impairment (6%), abnormal clock drawing results (20%), or depression (20%), and these patients were offered geriatric assessment. The tests were rapid (fewer than 5 minutes to perform) and easy to administer. CONCLUSIONS Screening for geriatric syndromes in the eye clinic was rapid, easy to perform, and detected a significant number of patients with functional disability, depression, and possible dementia.

Acute bilateral optic disk edema with a macular star figure in a 12-year-old girl.

A 12-year-old girl developed headaches and bilateral optic disk edema due to malignant hypertension. Optic disk edema in most of these cases is probably on the spectrum of ischemic optic neuropathy rather than increased intracranial pressure.

The ACGME Outcome Project in Ophthalmology: Practical Recommendations for Overcoming the Barriers to Local Implementation of the National Mandate

The Accreditation Council for Graduate Medical Education (ACGME) Outcome project is a well-defined, 10-year, ambitious national mandate to improve resident education through the teaching and assessing of six general competencies (i.e., patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice). Over the past 5 years a Task Force at the University of Iowa has deployed 10 major competency assessment tools: 1) the University of Iowa residency curriculum; 2) direct observation using the Ophthalmic Clinical Exercise (OCEX); 3) journal club; 4) multi-source evaluation; 5) a modified Dreyfus scale faculty global evaluation form; 6) the Iowa Cataract surgical curriculum; 7) the Iowa Ophthalmic Laser curriculum; 8) traditional written and oral examinations; 9) self reflection exercises and projects; and 10) learner portfolio. We report our 5-year experience with an implementation matrix for translating the national ACGME mandate into local compliance. We identify the barriers encountered by our Task Force in local implementation and propose practice solutions based upon our experience for overcoming the cultural, institutional, financial, and other barriers to success. We hope that our institutional work and experience will stimulate other programs to participate more fully in the ACGME Outcomes Project.

Painful ophthalmologic disorders and eye pain for the neurologist

Neurologists should be aware of the following causes of eye pain: (1)ocular and orbital disorders with or without visible pathology of the eye (eg,redness, corneal opacity, or proptosis); (2) ophthalmologic syndromes associated with headache; and (3) headache syndromes associated with ophthalmologic findings.

An Update on Eye Pain for the Neurologist

Pain in and around the eye with or without an associated headache is a common presenting complaint to the neurologist. Although the main causes for eye pain are easily diagnosed by simple examination techniques that are readily available to a neurologist, sometimes the etiology is not as obvious and may require a referral to an ophthalmologist. This article summarizes and updates our prior review in Neurologic Clinics on this topic and includes (1) ocular and orbital disorders that produce eye pain with a normal examination, (2) neurologic syndromes with predominantly ophthalmologic presentations, and (3) ophthalmologic presentations of selected headache syndromes.

HIV and cannot see

A 55-year-old HIV-positive man presented with acute vision loss in the right eye and altered mental status. Ophthalmic evaluation revealed light perception vision OD with a right relative afferent pupillary defect, conjunctival chemosis, large mutton-fat keratitic precipitates, and diffuse cream-colored vitreous cells. Magnetic resonance imaging of the brain and orbit with and without contrast with fat saturation showed choroidal thickening OD, multifocal deep periventricular and deep ganglionic enhancing lesions, and a suprasellar mass. Brain biopsy showed diffuse large B-cell lymphoma. Intrathecal chemotherapy with methotrexate and cytarabine and whole brain radiation therapy failed. His mental status deteriorated. He developed pancytopenia, neutropenic fever, and septic shock and subsequently expired under palliative care.

Microbial keratitis as the manifestation of trigeminal amyloidoma at initial presentation.

Amyloidosis is characterized by the deposition of extracellular, insoluble proteinaceous, fibrillar material. It can be classified as primary, in cases without underlying disease, or secondary, in cases with an associated chronic disease (e.g., multiple myeloma, rheumatoid arthritis, osteomyelitis, or tuberculosis). Isolated amyloidoma rarely involves the central nervous system but has been reported to occur in the orbit, spine, pituitary gland, jugular foramen, cerebellopontine angle, and cerebral white matter. In the literature, only five reports could be found of amyloidoma involving the trigeminal ganglion. This is a report of a case of trigeminal nerve amyloidoma that had initial symptoms of microbial keratitis secondary to trigeminal neuropathy. A review of the literature on amyloidoma of the trigeminal nerve is included.

The Value of Maintenance of Certification

21. Cook DA, Holmboe ES, Sorensen KJ, Berger RA, Wilkinson JM. Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions. JAMA Intern Med. 2015;175(1):35-42. 22. US Department of Health and Human Services. Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. http://www.hhs.gov/about/news/2015 /01/26/better-smarter-healthier-in-historic -announcement-hhs-sets-clear-goals-and-timeline -for-shifting-medicare-reimbursement-from -volume-to-value.html. Published January 26, 2015. Accessed July 24, 2015.

Herpes zoster ophthalmicus: Pre-eruption phase sine herpete

a Department of Ophthalmology, Baylor College of Medicine, Houston, TX, United States Department of Ophthalmology & Visual Sciences, University of Texas Medical Branch, Galveston, TX, United States c Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, United States d Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, United States e Section of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, TX, United States Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States