Abstract Purpose To evaluate the long-term clinical outcomes in patients with combined pars plana vitrectomy (PPV) with anterior chamber intraocular lens (ACIOL) to intrascleral haptic fixation (ISHF) using the Agarwal technique with fibrin glue to secure the scleral flap of a posterior chamber intraocular lens. Methods Retrospective, consecutive, single-center, comparative case series. 83 eyes were studied. Patients with < 8 months of follow-up were excluded. Detailed pre-, intra-, and post-operative complications were analyzed using mixed model univariate analysis and t-test. Pre- and post-operative best corrected visual acuity (BCVA) was analyzed. Results Twenty-five subjects met entry criteria. Mean age at time of surgery was 70.4 ± 17.7 years in the ACIOL group (n = 12) and 54.6 ± 21.1 years in the ISHF group (n = 13; p = 0.03). Mean follow-up was 38.2 months. Incidence of corneal decompensation was similar in the ACIOL and ISHF lens group (p = 0.93). There was no difference in the BCVA mean change or cystoid macular edema (CME) at the final visit between the groups (p = 0.47; p = 0.08), but there was a trend toward increased CME in the ACIOL group. Conclusions PPV with concomitant placement of either ACIOL or ISHF lens result in improvement in BCVA. Both procedures are well tolerated and result in favorable outcomes with long-term follow-up though varying patient populations do not allow precise comparison between the two groups.

Diabetes mellitus is a multiorgan systemic disease impacting numerous ocular structures that results in significant ocular morbidity and often results in more frequent corneal and glaucoma surgeries for affected individuals. We hypothesize that the systemic metabolic and proteomic derangement observed in the progression of diabetes influences the composition of the aqueous humor (AH), which ultimately impacts the anterior segment health of the eye. To identify changes associated with diabetes progression, we mapped the metabolite profile and proteome of AH samples from patients with varying severities of type II diabetes (T2DM). Patients were classified as nondiabetic (ND or control), non-insulin-dependent diabetic without advanced features of disease (NAD-ni), insulin-dependent diabetic without advanced features (NAD-i), or diabetic with advanced features (AD). AH samples collected from the anterior chamber during elective ophthalmic surgery were evaluated for metabolite and protein expression changes associated with diabetic severity via gas chromatography/mass spectrometry and ultra-high performance liquid chromatography tandem mass spectrometry, respectively. Metabolic and proteomic pathway analyses were conducted utilizing MetaboAnalyst 4.0 and Ingenuity Pathway Analysis. A total of 14 control, 12 NAD-ni, 4 NAD-I, and 14 AD samples were included for analysis. Elevated levels of several branched amino acids (e.g., valine, leucine, isoleucine), and lipid metabolites (e.g., palmitate) were found only with increasing diabetic severity (i.e., the AD group). Similar proteomic trends were noted in amino acid and fatty acid metabolism and the unfolded protein/stress response. These results represent the first report of both metabolomic and proteomic evaluation of aqueous humor. Diabetes results in metabolic and proteomic perturbations detectable in the AH, and unique changes become manifest as T2DM severity worsens. Changes in AH composition may serve as an indicator of disease severity, risk assessment of anterior segment cells and structures, and potential future therapies.

PURPOSE:To report a case of bilateral iridoschisis with cataracts and corneal decompensation in a patient who underwent cataract extraction and superficial iridectomy followed by Descemet membrane endothelial keratoplasty (DMEK).OBSERVATIONS:A 58-year-old man with previously diagnosed iridoschisis, cataracts, and diabetes mellitus experienced progressive vision loss bilaterally due to corneal decompensation. Slit lamp examination revealed iridoschisis with iris fibrils contacting the corneal endothelium, stromal edema, and mild guttate changes bilaterally. Corneal findings were more severe in the right eye, including the presence of bullous keratopathy at the time of presentation. Cataract extraction with intraocular lens implantation and superficial iridectomy were performed in the right eye, followed by DMEK. These same procedures were performed subsequently in the left eye. Postoperatively, the patient had significant improvement in visual acuity and corneal edema.CONCLUSIONS AND IMPORTANCE:DMEK can be performed safely and successfully after staged cataract surgery with superficial iridectomy in eyes with endothelial decompensation caused by iridoschisis.

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In this issue of TRANSFUSION, the third1 of three studies1-3 investigating a possible link between repeated doses of adrenal corticosteroids and posterior subcapsular cataracts (PSCs) in granulocyte (neutrophil) donors is reported. Unfortunately, the overall findings of the three studies are neither in complete agreement nor are definitive, in terms of risk to healthy donors. Moreover, recommendations from the three studies are inconsistent as to how best to obtain informed consent for granulocyte donation. Accordingly, it is worthwhile to critically assess the findings of all three studies and to offer our suggestions as how to manage and counsel granulocyte donors. To collect the largest number of neutrophils for granulocyte transfusion therapy, it is mandatory to stimulate donors before leukapheresis with a combination of granulocyte–colony-stimulating factor (G-CSF) and corticosteroids (generally, dexamethasone)—although some blood centers prefer to avoid G-CSF, because it is not approved by the Federal Food and Drug Administration for this purpose, and to use corticosteroids alone.4 For decades, granulocyte donors have been given corticosteroids within several hours before each leukapheresis procedure, generally as a single oral dose of 8 mg of dexamethasone or as divided oral doses of up to 60 mg of prednisone.2 Although repeat granulocyte donors receive multiple individual doses of corticosteroids, sometimes extending over the course of several years, it has been widely assumed that the brief and interrupted doses would not lead to PSCs—a well-known complication of long-term corticosteroid therapy. The initial study from Iowa2 was prompted when a granulocyte donor reported to the Medical Director of the DeGowin Blood Center that his ophthalmologist had told him that he needed surgery for cataracts caused by the prednisone that he had received over the years as a granulocyte donor. Although an earlier editorial5 reviewed the available data about the possible relationship between corticosteroids and PSCs in granulocyte donors and offered guidance regarding informed consent for repeat granulocyte donation, information at that time was fairly sparse and in disagreement. Now that a third article has completed the “trilogy” and has provided some additional information, it is worthwhile to critically reassess the findings and to offer practice guidelines. In the study from the DeGowin Blood Center at the University of Iowa,2 11 donors who received corticosteroids for 17 to 46 granulocyte donations (mean, 26) were examined by an ophthalmologist using a slit lamp and indirect ophthalmoscopy, and they were compared with a control group of nine apheresis platelet (PLT) donors—all of whom had donated PLTs at least 15 times, but had never donated granulocytes with corticosteroid stimulation. The ophthalmologist was masked to donor identity (i.e., granulocyte vs. PLT donations). Four of 11 granulocyte donors (36%) and zero of nine PLT donors had PSCs (p = 0.068). Five of 22 granulocyte donor eyes versus 0 of 18 PLT donor eyes exhibited PSCs (significant difference at p = 0.040). PSCs were small, and vision was not affected. The development of PSCs was not related to the number of leukapheresis procedures or to steroid dose. Cortical and nuclear cataracts were found at similar frequencies in both granulocyte and PLT donors to suggest that lifestyle factors that might predispose to cataracts, but independent of corticosteroid therapy, were comparable. Because PSCs were found exclusively in granulocyte donors, all of whom received multiple doses of corticosteroids, and were clinically “silent” (i.e., detected only by formal ophthalmologic examination), the authors urged that additional studies be performed to either confirm or refute their findings. Concerned that granulocyte donors could be developing PSCs without visual complaints, the authors recommended use of G-CSF alone to stimulate donors for granulocyte collection until either the safety of corticosteroid stimulation could be confirmed or the risks clearly be defined. In a multicenter study from Burch and coworkers3 at the American Red Cross—prompted by the Iowa report—adrenal corticosteroids, given repeatedly to healthy individuals donating apheresis granulocytes for transfusion, were judged not to be associated with an increased risk of developing PSCs. Per study design, 89 pairs of donors—pairs consisting of granulocyte donors who received corticosteroids and donated five to 39 times (mean, 13 donations) who were matched with a control group of apheresis PLT donors who had not received corticosteroids—were examined for PSCs by digital retroillumination infrared photography of both lenses. Photographs were graded by experts who were masked as to donor identity (i.e., granulocyte or PLT donations). A subset of donors—33 donating granulocytes and 30 donating PLTs—were randomly selected at each study site for additional examination by ophthalmologists, who were masked as to donor identity. The primary outcome was the presence of PSCs in at least one lens of an individual donor. A great deal of care was taken to ensure comparability of the granulocyte and PLT donors enrolled, with the exception of corticosteroids used exclusively during granulocyte donation, and to make detection of PSCs as accurate and precise as possible. Six of 89 granulocyte donors (6.7%) and four of 89 PLT donors (4.5%) had photographic evidence of PSCs (p = 0.48); five of 33 granulocyte donors (15%) and three of 30 PLT donors (10%) had PSCs detected by ophthalmologists (p = 0.54). Two subjects had bilateral eye involvement; both were granulocyte donors. In all subjects with PSCs, involvement was minimal (i.e., <10% of the lens surface area). In granulocyte donors with PSCs, neither the cumulative dose of corticosteroids taken nor the length of time since the first corticosteroid-stimulated granulocyte donation were significantly associated with PSCs. Although significant differences were not found between matched granulocyte and PLT donors, worrisome trends “favored” the possible risk for PSCs in granulocyte donors given corticosteroids. A higher percentage of granulocyte donors versus PLT donors did exhibit PSCs both by retroillumination infrared photography and by direct ophthalmologic examination. Only granulocyte donors had bilateral involvement. Based on their study results,3 Burch and coworkers concluded that corticosteroids given for granulocyte donation were not a risk factor for developing PSCs and, offering the caveat that their study was not large enough to definitively exclude any possibility of PSCs risk with corticosteroid donor stimulation, they recommended that no changes be made in the current practice of giving corticosteroids to granulocyte donors. This recommendation was in conflict with the cautionary recommendation of the earlier Iowa study2 and created a dilemma for both practitioners and donors involved in granulocyte collection—hence the need for a third study to provide clarification. The “tie-breaker” study, performed at the Clinical Center of the National Institutes of Health,1 did not demonstrate a significant increased risk of PSCs with granulocyte donation. However, the study did provide sufficient data—when considered along with the previous findings from Iowa2 and the American Red Cross3—to suggest a likely association between corticosteroids given for granulocyte collection and PCSs. At the National Institutes of Health (NIH), 100 donors who had donated granulocytes four to 41 times (median, 12) were matched with 100 comparable PLT donors—83 of whom had donated only PLTs, whereas 17 had also donated granulocytes one to three times. Considerable care was taken to measure possible confounding factors such as other ocular conditions, history of corticosteroid use unrelated to granulocyte donations, diabetes, and so forth, and no significant differences were found. However, it is important to note that 39% of the “control group” PLT donors had received corticosteroids in the past, in doses judged to be moderate or high—a confounding factor that possibly diminished the ability of the authors to detect a significant difference in the frequency of PSCs between granulocyte and PLT donor groups. Ophthalmologic examination of dilated eyes was performed using a slit lamp and a Neitz retroillumination camera to take color photographs of the lenses of both eyes. Examinations and photographs were interpreted and graded by experts who were unaware of donor status. Among the 100 granulocyte donors, 10 individuals (10%) and 14 eyes (7%) had PSCs compared to four of 100 PLT donors (4%) and five eyes (2.5%)—resulting in an odds ratio (OR) of 2.67 with a p value 0.11.1 Importantly, and in contrast to the Iowa2 and American Red Cross3 studies, there was an increasing risk of PSCs with an increasing number of granulocyte donations—an estimated increased risk of 5% per donation (i.e., a “dose effect”). For four to nine granulocyte donations, the prevalence of PSCs was 8.6%, with prevalence of 9.5% for 10 to 19 donations and 13.0% for 20 or more donations (p = 0.06). The relationship of several underlying medical or social factors to the risk of developing PSCs was examined, and a history of ocular disease or surgery doubled the risk (OR, 2.26 with p = 0.19). The NIH study was designed to have 80% power to detect a 12% difference in PSCs between granulocyte and PLT donors, and although they found nearly a threefold increase in the OR of PSCs in granulocyte versus PLT donors, a significant difference was not achieved.1 However, the investigators concluded that the nearly threefold increased risk plus the biologic plausibility that donation-related corticosteroid exposure may be associated with PSCs, when considered together, suggest that granulocyte donors given corticosteroids are at increased risk of developing PSCs. Accordingly, they recommended that granulocyte donors should be advised to maintain an appropriate frequency of eye examinations.1 The standard for diagnosing PSCs is careful slit-lamp examination of the lens by a trained ophthalmologist. The presence of a cataract is documented using direct and retroillumination to identify opacities in the nucleus, cortex, or subcapsular regions. A two-dimensional view provided by a retroillumination camera cannot distinguish subcapsular opacities from opacities in other parts of the lens, although the morphology of the opacity may be suggestive of its location. PSCs tend to appear granular or plaque-like. The studies by Ghodsi and Strauss2 and Clayton and colleagues1 base their statistics on cataracts diagnosed by ophthalmic examination. The study by Burch and colleagues3 uses photographic methods to determine the presence of opacities. This could contribute to the different results among the studies. Indeed, Burch and colleagues3 showed a poor concordance between photographic diagnosis of opacities and those determined by ophthalmic examination of a randomly selected subset of subjects and controls. The difference in results could also be due to the possibility that the recruited patients are not representative of the total population of donors and controls. Eleven of 21 granulocyte donors and nine of 28 PLT donors recruited participated in the study by Ghodsi and Strauss.2 Eighty-nine of 124 donors and 89 of 121 controls were included in the study by Burch and coworkers.3 The study by Clayton and coworkers1 does not enumerate excluded patients, simply stating that 95% of patients contacted agreed to participate. One final difference is the exclusion of patients having undergone cataract extraction in the study by Burch and colleagues,3 while these patients were included in the statistics in the study by Clayton and colleagues.1 Patients with PSCs complain of glare or reduced vision in bright lighting conditions or when performing near tasks, because in these situations the pupil is constricted. Since the PSCs are typically axial, even minor PSCs can cause significant visual disability and, accordingly, are of substantial clinical importance. As pointed out in the study by Clayton and coworkers,1 it is most appropriate for comparisons to be person-based and not to count each eye of a patient as an independent item. Although a patient may develop a cataract in one or both eyes, a correlation between the two eyes would be expected. Although the three clinical studies1-3 are not in complete agreement, when the findings are considered in toto, an association between repeated corticosteroid administration to granulocyte donors and the development of PSCs in these individuals seems quite plausible. Accordingly, it is an issue with which those involved with granulocyte collections must deal. To this end, we offer the following recommendations. We cannot recommend using only G-CSF alone to stimulate granulocyte donors before leukapheresis. The problem created by dropping corticosteroids from the combined use of corticosteroid plus G-CSF for granulocyte donor stimulation (i.e., to use G-CSF alone) is to reduce granulocyte yields by about 25% from a mean of 6 × 1010 to 8 × 1010 per collection to only 4 × 1010 to 5 × 1010. This decrease in granulocyte dose per transfusion may diminish the efficacy of granulocyte transfusion therapy for infections in neutropenic patients. For decades, it has been presumed that transfusing higher doses of granulocytes would improve the antimicrobial effectiveness of granulocyte transfusions—particularly for severe fungal infections—but randomized clinical trials, in which granulocytes from donors stimulated with combined corticosteroid plus G-CSF were transfused, either are still ongoing or have not been completed as designed.6,7 Moreover, case reports and observational studies lacking randomized concurrent control subjects have given mixed results—sometimes with failure of granulocyte transfusions in severe fungal infections—despite transfusion of high doses of granulocytes. Thus, it is extremely important to transfuse the highest number of granulocytes possible during conduct of clinical trials properly designed to investigate the efficacy of granulocyte transfusions. The best granulocyte product for transfusion requires donor stimulation with combined corticosteroids and G-CSF4. There is no clear guideline to know the number or frequency of leukapheresis procedures (i.e., frequency of corticosteroid exposures) that place donors at significant risk of PSCs. Only one of the three studies1 found an increasing risk of PSCs with increasing numbers of leukapheresis procedures, and this “dose effect” finding did not quite reach clinical significance (p = 0.06). However, it is important for each collection facility to have a policy that limits the number of leukapheresis procedures for each granulocyte donor. Because there is no mandated or regulatory standard, the number of procedures permitted annually varies greatly from 24 procedures per year (based on the number of apheresis donations permitted annually) to eight to 12 leukapheresis procedures per year (based on a recent survey of major centers in the United States8) to eight procedures per year (based on the ongoing RING clinical trial in the United States).7 No lifetime limits have been established. As discussed previously,5 the use of corticosteroids in granulocyte donors leads to the question of disclosing the possibility of this adverse effect in the informed consent process. Laws and regulations for the protection of both regular donors and human research subjects require that these individuals be provided a description of any reasonably foreseeable harms or risks, other than minimal risks, associated with the donation process. Thus, the possible association between repeated corticosteroid administration and PSCs development should be addressed in the consent process. Additionally, consideration should be given to excluding individuals with underlying medical and ocular disorders that might predispose to cataract formation such as diabetes, therapeutic corticosteroid therapy for underlying disorders, history of ocular trauma and/or surgery, glaucoma, or uveitis. In agreement with the NIH recommendation,1 repeat granulocyte donors should be encouraged to have regular ocular examinations and their ophthalmologist should be made aware of any corticosteroid exposure. None.

CONSULTATION SECTION 537 Cataract Surgical Problem edited by Rupert M. Menapace, MD Cataract surgery in a 28-year-old man was complicated by posterior capsule rupture. The sulcus-placed 7.0 mm PMMA IOL is significantly decentered and tilted. The patient has myopic astigmatism and dysphotopsia. Gábor B. Scharioth, MD, Lisa Brothers Arbisser, MD, Thanh Hoang-Xuan, MD, Robert H. Osher, MD, Michael E. Snyder, MD, Marie-Jos e Tassignon, MD, PhD, FEBO, Andr e Dosso, MD, Nick Mamalis, MD

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.

The current resident selection process for ophthalmology has undergone little change over the last several years and remains highly dependent on the traditional selection factors (i.e., grades, honors, letters of recommendation, and an interview). Unfortunately, these selection factors have not been shown to be consistently predictive of future resident performance. In addition, the Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the USA and the current selection process does not directly recruit for these competencies. We propose an implementation strategy to re-engineer and improve the resident selection process in ophthalmology and potentially develop assessments that would be predictive of actual downstream resident performance that would encompass the ACGME related competencies. An intra-departmental Task Force for the ACGME Competencies reviewed a PubMed literature search regarding resident selection. A content expert (AGL) gleaned selected "good practices" from the literature review and summarized the results. Specific recommendations were reviewed for topicality to ophthalmology and where possible for feasibility, reliability, and validity. We summarize several good practices identified from the literature review and propose an implementation matrix for aligning the resident application process with the ACGME competencies that might include: using a standardized and consolidated academic score for the cognitive domains; converting the letter of recommendation format into a letter of evaluation; standardizing the letters of evaluation, including the "Dean's letter"; using behavior specific interview techniques with standardized questions; and developing a specialty based consensus for the selection of traits specific to ophthalmology that might predict success. The resident selection process for ophthalmology might be improved by implementation of specific good practices from the literature. Ophthalmology should strive to develop applicant selection tools that might be useful for predicting residency performance and that would align with the ACGME competency mandate for tools to predict future performance as a physician.

Journal of Cataract & Refractive Surgery 33(12):p 2153, December 2007. | DOI: 10.1016/j.jcrs.2007.07.039

Purpose To describe an ophthalmology wet laboratory (OWL) curriculum for residents in training. Methods Systematic literature review and selection of best practices for use in the OWL learning plan from a single academic ophthalmology program. Results A pretest and posttest of cognitive skills, objective wet laboratory structured assessment of skill and technique, and summative global evaluation form were developed as part of a systematic OWL curriculum. Conclusion The Iowa OWL curriculum may form the basis for successfully utilizing the wet laboratory to teach and assess aspects of resident surgical competence in cataract surgery.

The Accreditation Council for Graduate Medical Education has mandated that all residency training programs teach and assess 6 general competencies.1Lee A.G. Carter K.D. Managing the new mandate in resident education A blueprint for translating a national mandate into local compliance.Ophthalmology. 2004; 111: 1807-1812Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Lee A.G. The new competencies and their impact on resident training in ophthalmology.Surv Ophthalmol. 2003; 48: 651-662Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The American Board of Ophthalmology has recommended that a seventh competency in surgery be required. At the time of the writing of this letter, surgery still is included by the Accreditation Council for Graduate Medical Education in the patient care competency. Teaching and assessing resident surgical performance in ophthalmology poses special problems, including:1Live patient surgery produces unique ethical issues.2The availability of cases for residents is increasingly under threat.3The technical aspects of cataract microsurgery involve one operating surgeon (“one person driving”).4The increased use of topical anesthesia makes it difficult to provide meaningful and timely feedback to the operating resident.5Errors in an early stage of the procedure can lead to downstream complications or difficulty with other parts of the procedure.6Intraocular microsurgery has a narrow tolerance for intraoperative error.7Virtual simulated intraocular surgery, though promising, is not sufficiently advanced at this time to replace the wet laboratory or live patient surgical experience. To address the various technical, ethical, and practical issues of live surgery and surgical teaching, the residency review committee in ophthalmology has mandated that a wet laboratory experience be required by all ophthalmology programs. In this issue’s accompanying online-only article3Lee A.G. Greenlee E. Oetting T.A. et al.The Iowa ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency.Ophthalmology. 2007; 114: e21-e26Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar (available at http://aaojournal.org), we review the literature on the wet laboratory experience, glean best practices, and, based upon our experience, propose an implementation matrix for the ophthalmology wet laboratory (OWL) curriculum. The core of our strategy and our local implementation matrix for the ACGME competencies is listed in the article’s Table 1. Previous work has described the advantages of a criterion-referenced over a norm-referenced scale and has emphasized the Dreyfus model of expertise.4Dreyfus H.L. Intuitive, deliberative, and calculative models of expert performance.in: Zsambok C.E. Klein G. Naturalistic Decision Making. L. Erlbaum Associates, Mahwah, NJ1997: 17-28Google Scholar In the Dreyfus model, learners are expected to move through stages of expertise (i.e., novice, beginner, advanced beginner, proficient–competent, and expert). Using the Dreyfus model for the scoring rubric provides for formative feedback, allows the resident the opportunity for improvement, and includes specific behavioral anchors in the rubric to reinforce change over time. We also employ the Schön reflection model to improve learner understanding and motivation for learning.5Smith MK. Donald Schön: learning, reflection and change. Available at: http://www.infed.org/thinkers/et-schon.htm. Accessed March 29, 2006.Google Scholar The Schön model includes reflection on action (e.g., recognizing the need for further knowledge and learning), reflection in action (e.g., utilizing practice-based learning techniques, reviewing and synthesizing available evidence-based medicine), and knowledge in action (e.g., application of learning in the real-world patient context).5Smith MK. Donald Schön: learning, reflection and change. Available at: http://www.infed.org/thinkers/et-schon.htm. Accessed March 29, 2006.Google Scholar We include prerequisite reading material before entering the wet laboratory. As part of the wet laboratory experience, we emphasize the Ericsson deliberate practice model.6Ericsson K.A. Krampe R.T. Tesch-Roemer C. The role of deliberate practice in the acquisition of expert performance.Psychol Rev. 1993; 100: 363-406Crossref Google Scholar In this model, expertise is achieved by deliberate practice. Purposeful repetition, analysis of performance, and further refinement of technique are incorporated into the Ericsson model of deliberate practice for wet laboratory techniques. The University of Iowa Department of Ophthalmology Task Force on the Competencies (whose members are this letter’s authors) defined cognitive and skill domains for the OWL. The article’s Table 2 describes the Iowa OWL curriculum. Table 3 describes the Iowa OWL quiz for defining competency in selected cognitive domains for the wet laboratory. This quiz serves as the pretest and posttest for the cognitive portion of the OWL. Table 4 describes the Iowa Objective Wet Laboratory Structured Assessment of Skill and Technique scoring rubric. The Iowa Objective Wet Laboratory Structured Assessment of Skill and Technique is similar to other structured surgical assessment tools that have been proposed in other surgical specialties for assessing surgical skills and knowledge. The scoring rubric does not employ a norm-referenced scale (i.e., below average, average, above average, etc.) and instead uses a criterion-referenced scale that is behavior specific. The teaching of ophthalmic surgery to residents is a difficult and challenging task, with unique ethical, technical, and practical problems. We believe that the RRC (residency review committee) requirement for a wet laboratory experience and the Iowa OWL curriculum can be important methods for teaching and assessing surgical competence. The Iowa Ophthalmology Wet Laboratory Curriculum for Teaching and Assessing Cataract Surgical CompetencyOphthalmologyVol. 114Issue 7PreviewTo describe an ophthalmology wet laboratory (OWL) curriculum for residents in training. Full-Text PDF

PURPOSE: To evaluate the extent to which mutations in the optineurin (OPTN) glaucoma gene play a role in glaucoma in different populations.METHODS: Case-controlled study of OPTN sequence variants in individuals with or without glaucoma in populations of different ancestral origins and evaluate previous OPTN reports. We analyzed 314 subjects with African, Asian, Caucasian and Hispanic ancestries included 229 cases of primary open-angle glaucoma, 51 cases of juvenile-onset open-angle glaucoma, 33 cases of normal tension glaucoma, and 371 controls. Polymerase chain reaction-amplified OPTN coding exons were resequenced and case frequencies were compared to frequencies in controls matched for ancestry.RESULTS: The E50K sequence variant was identified in one individual from Chile with normal tension glaucoma, and the 691_692insAG variant was found in one Ashkenazi Jewish individual from Russia. The R545Q variant was found in two Asian individuals with primary open-angle glaucoma; one of Filipino ancestry and one of Korean ancestry. In addition to presenting OPTN allele frequencies for Caucasian and Asian populations that have been the subject of previous reports, we also present information for populations of Hispanic and black African ancestries.CONCLUSIONS: Our study contributes additional evidence to support the previously reported association of the OPTN E50K mutation with glaucoma. After finding an additional 691_692insAG OPTN variant, we can still only conclude that this variant is rare. Combined analysis of our data with data from more than a dozen other studies indicates no association of R545Q with glaucoma in most populations. Those same studies disagree in their conclusions regarding the role of M98K in glaucoma. Our analysis of the combined data provides statistically significant evidence of association of M98K with normal tension glaucoma in Asian populations, but not in Caucasian populations; however, the validity of this conclusion is questionable because of large differences in allele frequencies between and within populations. It is currently not possible to tell how much of the underlying cause of the allele frequency difference is attributable to demographic, technical, or ascertainment differences among the studies.

BACKGROUND AND OBJECTIVE:The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence.PATIENTS AND METHODS:An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence.RESULTS:"Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation.CONCLUSION:An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.

Purpose: To evaluate the safety and efficacy of the Ophtec capsular tension ring (CTR) in providing capsular support during and/or after cataract extraction in cases of a weak or partially broken ciliary zonule.Design: Phase III multicenter, nonrandomized, investigational device study. Participants: Twelve investigators at 9 sites enrolled 224 subjects and placed 255 CTRs.Methods: Capsular tension rings were placed in patients who were found to have a weakened or partially broken ciliary zonule comprising <34% of the circumference of the lens capsule. Two CTR models were evaluated, with noncompressed diameters of 12 mm and 13 mm. Patients were examined preoperatively, intraoperatively, and postoperatively at day 1 and months 1, 3, 6, and 12.Main Outcome Measures: Rate of successful stabilization of the capsular bag and intraocular lens (IOL) centration, complications, and adverse events.Results: Interim results from this ongoing study indicate that immediately after surgery 98.8% of IOLs were centered and 1.2% of the IOLs implanted (3/251) were not centered. Subsequently, the prevalence of decentered IOLs was 1.7% (4/236) 3 months after surgery, 3.8% (8/211) 6 months after surgery, and 2.3% (4/172) 12 months after surgery. The primary complication was posterior capsular opacification, which is unlikely to be a complication of CTR insertion. Neodymium:yttrium-aluminum-garnet laser capsulotomies have been performed in 12.8% of eyes by 12 months (22/172).Conclusions: Ophtec CTR models 275 and 276 safely provided capsular support during and after cataract surgery in cases where the zonule was weak or partially broken. (C) 2005 by the American Academy of Ophthalmology.

1) Course Objectives 2) Introduction a) Why did we develop this course b) Who are the instructors 3) Primer on the Competencies a) Why we must change b) Dreyfus Model c) Deliberate Practice 4) Defining the stages of Cataract Competency 5) Setting Expectations for each stage 6) Developing Resources for stage progression a) Know your audience b) Baby steps forward c) Deliberate practice d) Inventing resources 7) Measuring and documenting progression a) Formative Feedback b) Oasis c) Prove to the world you are teaching 8) Putting it together into a plan 9) Appendix a) General Ophthalmology Surgery Formative Feedback Form b) Specific Cataract Formative Feedback Form c) Surgical Consent Formative Feedback Form d) Dr Henderson’s Ophthalmology paper on OASIS e) Dr Lee’s Ophthalmology paper on the competencies

Purpose: To investigate the association of sequence variations in the optineurin (OPTN) gene in patients with open,angle glaucoma.Design: Prospective case control study.Methods: The OPTN gene was screened for sequence variations using a combination of single-strand conformational polymorphism analysis and automated DNA sequencing. A total of 1,299 subjects (1048 glaucoma patients and 251 controls) were screened for variations in the four portions of the gene that had been previously associated with glaucoma. A subset of these subjects (376 patients and 176 controls) was screened for variations in the entire coding sequence. Twenty-four percent of the patients and 35% of the controls were Japanese, whereas the remainder were predominantly Caucasian. Allele frequencies were compared with the Fisher exact test.Results: The OPTN sequence variations were not significantly associated with any form of high-tension open-angle glaucoma. One proband with familial normal, tension glaucoma was found to harbor the previously reported GIu50Lys variation. Another previously reported change, Met98Lys, was associated with normal-tension glaucoma in Japanese but not in Caucasian patients.Conclusions: This study provides some additional evidence for the association of the Glu50Lys OPTN sequence variation with familial normal tension glaucoma. However, because familial normal-tension glaucoma is so rare, this change seems to be responsible for less than 0.1% of all open-angle glaucoma. The Arg545Gln variation is likely to be a nondisease-causing polymorphism. The Met98Lys change may be associated with a fraction of normal-tension glaucoma in patients of Japanese ethnicity.

OBJECTIVE:To determine the prevalence and associated phenotype of myocilin (MYOC) coding sequence variations and a specific promoter polymorphism (MYOC.mt1) in patients with glaucoma and glaucoma suspects.METHODS:A consecutive, unselected series of 779 patients (652 with open-angle glaucoma and 127 glaucoma suspects) were recruited from a university medical center and clinically characterized. The coding sequences of the MYOC gene and the MYOC.mt1 locus in the promoter region were screened for sequence variations. We determined the prevalence of MYOC coding sequence mutations and the MYOC.mt1 promoter polymorphism. We also compared the clinical features of individuals with and without mutations and the MYOC.mt1 promoter polymorphism.RESULTS:Plausible disease-causing sequence variations (DCVs) in the MYOC gene were found in 3.0% of the entire group. Such variations were found in patients with most forms of open-angle glaucoma studied. Patients with primary open-angle glaucoma (POAG) who harbored coding sequence DCVs were clinically similar to patients without them. Patients who harbored the rarer allele of the MYOC.mt1 promoter polymorphism were no different in any measure of disease severity from those who harbored the more common allele.CONCLUSIONS:MYOC DCVs were found in approximately 3% of patients with glaucoma and glaucoma suspects. The 2 alleles of the MYOC.mt1 promoter polymorphism were equally distributed among patients with POAG and healthy control subjects. Patients with POAG who harbored the rarer allele of the MYOC.mt1 promoter polymorphism were no different from those with the more common variant in any measure of disease severity.CLINICAL RELEVANCE:Testing for the MYOC.mt1 promoter polymorphism appears to be of no value in the evaluation of patients with glaucoma.