Kenneth B. Simons

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

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.

Floppy Eyelid Syndrome and Blepharochalasis

Floppy eyelid syndrome and blepharochalasis may represent a spectrum of one underlying disease. Two patients with floppy eyelid syndrome and one with blepharochalasis shared important clinical similarities. All three patients displayed eyelid laxity associated with papillary conjunctivitis and ocular surface abnormalities. Histopathologic findings were similar in the three cases, characterized by chronic conjunctival inflammation with normal tarsal collagen. In all three patients surgical horizontal eyelid shortening led to improvement in symptoms and findings.

Mycobacterium fortuitum Keratitis

Two of four cases of Mycobacterium fortuitum keratitis occurred after corneal surgery with contact lens wear, one was associated with extended contact lens wear alone, and one occurred after a foreign body injury. All cases were characterized by pain, conjunctival hyperemia, stromal inflammation, and ulceration. Diagnosis was made by culture and acid-fast staining of corneal scrapings. On the basis of published experience with amikacin for the treatment of nonocular M. fortuitum infections, three patients were treated with topical amikacin. Two patients responded clinically, but histopathologic examination of a penetrating keratoplasty specimen in one of the two disclosed persistent infection. One patient was cured of early disease by debridement alone. Rapid diagnosis and absence of corticosteroid use were the two most important determinants of successful therapy. In advanced cases, infection may be cured and useful vision restored by penetrating keratoplasty.

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.

Ligneous conjunctivitis: an autosomal recessive disorder.

Two siblings, a boy and a girl, developed a chronic, bilateral conjunctivitis with large recurrent pseudomembranes. The diagnosis of ligneous conjunctivitis was made by excisional biopsies in both. The family was referred for genetic counseling after the second child developed the disorder. On the basis of this family and previous reports, we believe that ligneous conjunctivitis is a genetic disorder inherited in an autosomal recessive pattern and that genetic counseling should be offered to the parents of affected children.

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.

Vitreous in Lattice Degeneration of Retina

A localized pocket of missing vitreous invariably overlies lattice degeneration of the retina. Subjects with lattice also have a higher rate of rhegmatogenous retinal detachment, which is usually a complication of retinal tears. The latter are in turn a result of alterations in the central vitreous--that is, synchysis senilis leading to posterior vitreous detachment. In order to determine if there is either an association or a deleterious interaction between the local and central lesions of the vitreous in eyes with lattice, a comparison was made in autopsy eyes with and without lattice the degree of synchysis and rate of vitreous detachment. Results show no association between the local and central vitreous lesions, indicating that a higher rate of vitreous detachment is not the basis for the higher rate of retinal detachment in eyes with lattice. Also, there was no suggestion of deleterious interaction between the local and central vitreous lesions, either through vitreodonesis as a basis for precocious vitreous detachment, or through a greater degree of synchysis as a basis for interconnection of local and central lacunae (which could extend the localized retinal detachment in eyes with holes in lattice degeneration).

Endophthalmitis from Mycobacterium bovis–Bacille Calmette-Guérin after intravesicular Bacille Calmette-Guérin injections for bladder carcinoma

PURPOSE To present clinical and histologic findings of intraocular infection with Mycobacterium bovis-bacille Calmette-Guérin after intravesicular bacille Calmette-Guérin injections for treatment of bladder carcinoma. METHODS A 77-year-old man was initially seen with visual acuity of 20/200, focal retinitis, vasculitis, and progressive vitreous opacity in the right eye and visual acuity of light perception, intraocular inflammation, and a dense cataract in the left eye 14 months after intravesicular injection of live bacille Calmette-Guérin organisms. RESULTS Vitreous cultures in the right eye demonstrated growth of bacille Calmette-Guérin organisms. Bilateral loss of light perception occurred despite systemic antimy-cobacterial therapy. Histopathologic examination demonstrated nongranulomatous inflammation and acid-fast bacilli in both eyes. CONCLUSION Delayed endogenous endophthalmitis may develop after intravesicular bacille Calmette-Guérin injection that may not respond to systemic agents. Intravitreal therapy may be indicated.

Comparison of Lesions Predisposing To Rhegmatogenous Retinal Detachment By Race of Subjects

Because rhegmatogenous retinal detachments are thought to be much less common in blacks than in whites, we compared the incidence of various lesions known to cause or predispose to this condition (synchysis senilis, posterior vitreous detachment, breaks, tears, and holes of the peripheral fundus, and lattice degeneration of the retina) in a series of postmortem eyes on the basis of race. Our statistical analysis also included trauma, myopia, and chorioretinitis. The series included 322 black subjects and 2,012 white subjects. The subjects ranged in age from 20 to 93 years at the time of death. Although the initial data showed a racial difference in the incidence of synchysis senilis of grade 3 (50% destruction) or higher and posterior vitreous detachment (P = .033 and P = .021, respectively), we found no difference when the data were age-corrected.

Magnetic resonance imaging of craniopharyngioma.

Craniopharyngiomas are common tumors located in the suprasellar region. Contrast enhancement, cyst formation, and calcification are the three characteristic features of craniopharyngiomas on computed tomographic scan. More than 90% of suprasellar craniopharyngiomas exhibit at least two of these three features, thus providing easy radiologic detection. We treated a 41-year-old man in whom a large suprasellar craniopharyngioma producing severe visual loss was not detected by computed tomography but was easily identified with magnetic resonance imaging. Thus, despite high-resolution computed tomographic scan, large suprasellar craniopharyngiomas can be missed. Magnetic resonance imaging may be superior to computed tomography in detecting these tumors.