Ryan K. Wong

Retinopathy of Prematurity Residency Training

Dear Editor: Retinopathy of prematurity (ROP) is a vasoproliferative retinal disease that is a major cause of blindness in children.1 According to a national survey, approximately 37% of ophthalmologists who screen for ROP are general ophthalmologists without fellowship training.2 This raises the question of whether residency training is adequate to produce ophthalmologists competent in ROP care, especially in light of studies demonstrating variable diagnostic competency for ROP by less experienced board-eligible ophthalmologists.3,4 Because ROP is a rapidly progressive disease that can result in blindness, basic competency in ROP should be expected of all ophthalmologists-in-training. Through a web-based survey of ophthalmology residency program directors and third-year residents across the United States, we sought to characterize the quality and extent of ROP training during ophthalmology residency. All ophthalmology residency programs listed in the San Francisco Match database were invited to participate in the spring of 2010. Out of 117 program directors, 42 (36%) indicated willingness to participate, allowing us to contact 139 of 446 (31%) third-year residents. These individuals were sent an anonymous survey approved by the institutional review board. Thirty three of 42 (79%) program directors and 82 of 139 (59%) third-year residents completed the survey. This yielded a total of 114 responders representing 42 of 117 (36%) ophthalmology residency programs from throughout the United States. Supplementary Figure 1 (available at http://aaojournal.org) displays the estimated number of exams performed by residents. The estimates made by program directors and by residents were similar (Fisher exact test of independence, P = 0.2). Seventy five of 114 (66%) responders—program directors and residents—estimated that residents perform ≤20 ROP exams during residency. In particular, 22 of 114 (19%) responders reported zero exams, and only 12 of 114 (11%) estimated that residents perform >50 exams. The number of exams directly supervised by an attending ophthalmologist is depicted in Supplementary Figure 2 (available at http://aaojournal.org.); 55 of 94 (59%) responders estimated that an attending directly supervises all bedside ROP examinations performed by residents, whereas 28 of 94 (30%) estimated that attending supervision occurred during less than one-third of exams. The estimates by program directors and residents were again highly concordant (P = 0.96). Fourteen of 82 (17%) residents felt confident with their ROP examination skills at the end of residency. Supplementary Figure 3 (available at http://aaojournal.org) demonstrates that residents who felt confident versus not confident had performed a greater number of exams (P = 0.0002). Only 5 of 114 (4%) survey participants reported a formal assessment of competency in ROP at their institution. Anecdotally, it has been our observation that some residents believe the presence of fellows may interfere with their clinical experience. Twenty nine of 42 (69%) programs were associated with either a pediatric, medical retina, or surgical retina fellowship, or a combination thereof. Supplementary Figure 4 (available at http://aaojournal.org) illustrates the estimated number of ROP exams performed by residents at programs with versus without fellowship programs. Residents at programs with associated fellowships performed significantly fewer examinations (P = 0.039). Notably, the percentage of responders who estimated doing ≤20 exams during residency was 43% (9 of 21) in programs lacking fellows, compared with 71% (66 of 93) in programs with fellows. Because the standard of care for treatment-requiring ROP involves laser photocoagulation of the peripheral retina, we asked residents and program directors to estimate the number of laser procedures performed by a resident. Seventy three of 94 (78%) responders estimated that residents perform zero laser procedures, and 19/94 (20%) estimated that residents perform 1-5 laser procedures. The key findings of this study are as follows: (1) most residents receive limited or no exposure to ROP examination and treatment during residency; (2) ROP exams are sometimes performed by residents without direct attending supervision; and (3) residents at programs with pediatric ophthalmology or retina fellows perform fewer exams than those without fellows. Although this survey study is limited by the low overall response rate, these findings raise concerns about the adequacy of ROP training during residency. Interestingly, a recent study on ROP training during fellowship also demonstrated similar deficiencies, including limited supervision of exams by attending.5 We therefore encourage residency program directors to scrutinize the ROP training paradigm at their institutions and establish formal training expectations with attending physicians. We hope these survey results will provide the basis for improvements in ROP care and limit or even reverse the decline in ophthalmologists who care for infants with ROP.

5-Fluorouracil for epithelial downgrowth after Descemet stripping automated endothelial keratoplasty.

Purpose: To report the use of intracameral 5-fluorouracil (5-FU) to treat epithelial downgrowth after performing a Descemet-stripping automated endothelial keratoplasty (DSAEK). Methods: We describe the case of a 79-year-old woman who underwent a DSAEK for pseudophakic Fuchs endothelial corneal dystrophy. The patient required 2 repeat DSAEKs for graft failure and persistent, visually significant interface haze. Six months after the third and most recent DSAEK, the patient was followed up and found to have a visual acuity of 20/100. On examination, the patient continued to have a persistent interface haze. However, the patient also had a cellular anterior chamber reaction despite the administration of frequent topical corticosteroids, and subtle findings of a translucent, membranous growth over the iris. Argon laser photocoagulation of the area resulted in a whitening response, characteristic of epithelial growth. Results: Epithelial downgrowth was diagnosed, and intracameral 5-FU was administered. One month after the injection was given, the patients examination results and vision improved to 20/60. Six months after the single injection, the patient had a clear DSAEK graft without interface haze, a quiet chamber, and 20/30 visual acuity. Conclusions: Epithelial downgrowth that occurs after performing a DSAEK can be treated successfully using intracameral 5-FU.

Association between assisted reproductive technology and advanced retinopathy of prematurity.

Purpose To investigate the associations between assisted reproductive technology (ART) and severe retinopathy of prematurity (ROP) requiring treatment. Methods Retrospective analyses of inborn preterm infants screened for severe ROP at the Weill Cornell Medical Center Neonatal Intensive Care Unit at the New York-Presbyterian Hospital by single factor logistic regression and multifactor models. Results Of 399 ethnically diverse infants, 253 were conceived naturally and 146 by ART. Eight (3.16%) patients conceived naturally, and 11 (7.53%) with ART required laser treatment. In multifactor analyses, significant risks for severe ROP requiring treatment included both gestational age (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.23–0.52; P < 0.001) and ART ([OR] 4.70; [CI], 1.52–4.57; P = 0.007). Conclusions ART is associated with severe ROP requiring treatment in this cohort. This is the first report that demonstrates a statistically significant association between ART and severe ROP requiring treatment in infants in the US.

Iris cyst after iris-sutured intraocular lens implantation in a child

Iris cysts are uncommon in childhood and can present diagnostic and therapeutic challenges. We present the case of a 5-year-old boy with Marfan syndrome who, 9 months after an uncomplicated lensectomy with iris-sutured intraocular lens (IOL), developed a translucent epithelial inclusion cyst. The cyst was observed without treatment and no complications developed. To our knowledge, this is the first case of an iris cyst in a child after implantation of an iris-sutured IOL. This potential complication should be considered when implanting IOLs in children.

Acute retinal necrosis and cystic encephalomalacia in a premature neonate.

PURPOSE To report a case of an infant born at 30 weeks gestational age (GA) who, at 37 weeks GA, presented with bilateral acute retinal necrosis (ARN) syndrome and herpes simplex virus (HSV) encephalomalacia. METHODS Observational case report. RESULTS A premature infant was found to have ARN based on dilated funduscopic examination and positive HSV serologies. Herpes simplex virus encephalomalacia was diagnosed base on magnetic resonance imaging (MRI). CONCLUSION To our knowledge, this is the youngest reported patient with ARN. This case demonstrates that neonatal ARN may present with posterior chorioretinal lesions and highlights the importance of considering HSV infection of the central nervous system with MRI findings of cystic encephalomalacia.