TOPIC:The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking. CLINICAL RELEVANCE:Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes. METHODS:A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS:Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment. DISCUSSION:Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

TOPIC:This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE:Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS:PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS:Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS:The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S):The author(s) have no proprietary or commercial interest in any materials discussed in this article.

INTRODUCTION:Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting.MATERIALS AND METHODS:We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record.RESULTS:From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record.CONCLUSIONS:Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.

TOPIC:Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE:This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS:Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS:Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION:Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Acute angle-closure glaucoma (AACG) is a medical emergency that can cause permanent visual deficits without prompt recognition. From 2006 to 2011, nearly 12 million visits to emergency departments (ED) in the United States were ophthalmologic in nature, making it crucial for emergency physicians to be familiar with the diagnosis and treatment of ophthalmologic emergencies. AACG can be precipitated by several mechanisms including pupillary block, anticholinergic medications, and sympathomimetic medications. We present a rare case of angle-closure glaucoma status post pneumatic retinopexy with cryotherapy due to migration of an intravitreal gas bubble into the anterior chamber with emphasis on understanding how retinal surgery types lead to significant differences in management.

Introduction: Simulation has been used in medicine to train clinicians to manage a variety of clinical scenarios. A key adaptation of the use of simulation in military healthcare occurred in 2015 with the development of the STOMP (Simulation Training for Operational Medical Providers) curriculum, a specific curriculum designed for the intern (PGY-1) trained physicians being sent into the military to practice primary care. Despite showing the curriculum’s influence on self-perceived comfort scores, no study has determined whether simulation is an effective means of improving general medical officer (GMO) physicians’ skills compared to other traditional styles of education. Specifically, this study sought to determine whether simulation-based education (SBE) of ophthalmologic skills improves GMO physicians’ clinical performance, as compared to traditional didactic-based instruction. Methods: The study, conducted at Naval Medical Center Portsmouth, included GMO physicians who were enrolled in the 2019 STOMP class. Following a brief overview of the study, GMO physicians who elected to participate in the study were randomized to either SBE or lecture-based training for three commonly used ophthalmological procedures: slit lamp exam, tonometry, and corneal foreign body removal. After completing the simulation and lecture-based education training sessions, participants' procedural performance was evaluated utilizing a locally developed performance checklist, and completion time for each of the three procedures was recorded. Data were analyzed using the t-test and Mann-Whitney test. A significance level of 0.05 was considered to be statistically significant. Results: Of the 50 consented participants, 46 completed the study. The mean overall completion scores for the performance checklists were significantly higher for the SBE group (n=26) compared to the lecture group (n=20) [80% (95% CI 78-82%) vs 41% (95% CI 35-47%), respectively]. Time to completion of the individual tasks was also significantly shorter for the SBE group compared to the lecture group (with mean differences ranging from 27 to 126 seconds, all p<.05). Conclusions: Simulation-based training appeared to be more effective at teaching three ophthalmological procedures (slit lamp exam, tonometry, and corneal foreign body removal) to GMO physicians compared to didactic-based instruction alone.

IMPORTANCE The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions. OBJECTIVE To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. DESIGN, SETTING, AND PARTICIPANTS This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019. INTERVENTIONS Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied. MAIN OUTCOMES AND MEASURES Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult. RESULTS There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act. CONCLUSIONS AND RELEVANCE While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.

INTRODUCTION:Diplopia and strabismus are known complications after corneal refractive surgery (CRS). Within the U.S. Armed Forces, refractive surgery is used to improve the operational readiness of the service member, and these complications could cause significant degradation to their capability. This study was performed in order to identify the incidence of strabismus and diplopia following CRS within the U.S. Military Health System.METHODS:A retrospective review of all patients who underwent photorefractive keratectomy (PRK) or laser-assisted in situ keratomileusis (LASIK) in the Department of Defense from January 2006 through September 2013 was designed and approved by the Naval Medical Center Portsmouth Institutional Review Board. The military health system data mart was queried for all patients who underwent one of these procedures and subsequently had an International Classification of Disease-9 code for any strabismus or diplopia through 2014 allowing at least 1 year of follow-up. We then calculated the incidence of both diplopia and strabismus for these procedures as the primary measure and the overall prevalence as a secondary measure.RESULTS:A total of 108,157 patients underwent PRK or LASIK during our study period with 41 of these patients subsequently having a diagnosis of diplopia or strabismus. After chart review, 16 of these patients were excluded resulting in 25 patients for inclusion in either the strabismus (23 patients, 0.02%) or diplopia (3 patients, 0.003%) cohorts with one patient having both. Of the 23 patients with postoperative strabismus, 4 were new cases giving an incidence of 0.004% and 2 new cases of diplopia for an incidence of 0.002%.CONCLUSION:Diplopia and strabismus are rare complications after CRS in the U.S. military population. These procedures continue to increase the operational readiness of our service members with minimal risk of these potentially debilitating complications. Overall, this study provides support for the continued use of PRK and LASIK despite study limitations related to the use of large databases for retrospective review. Future prospective studies using delineated preoperative and postoperative examinations with sensorimotor testing included may be able to resolve the limitations of this study.

There should be no doubt in any physician's mind that governmental regulation, on the state and federal level, has a tremendous impact on how physicians practice and on the care that patients receive.

Acute acquired comitant esotropia secondary to smart-phone use is a newly described phenomenon. This case report describes a boy with acute acquired comitant esotropia due to prolonged smartphone use who had improvement in binocular function after cessation of near work for several weeks. [J Pediatr Ophthalmol Strabismus. 2018;55:e42-e44.].

This article will review the recent literature and discuss the unique aspects to the presentation, evaluation, and treatment of pediatric ocular trauma.

Orbital penetrating injuries are an unfortunately common occurrence; however, those from marine animals are rare. Injuries from marine animals can be quite profound and there are no known reports of complete visual recovery after an orbital penetrating injury. Complications range from secondary infection to a carotid-cavernous fistula, which can complicate the management of these patients. We report a case of penetrating orbital injury from a needlefish with complete return of visual function after surgical removal of foreign debris and an extended course of antibiotics.

To the Editors: Clinical success for strabismus surgery requires utmost care in the surgical technique, which, although crucial, is of secondary importance to the surgical planning. To carefully plan for strabismus surgery, the surgeon must take into consideration many factors. Tracking all relevant information can be confusing. This is particularly true in complex patients or those having reoperations. However, it is imperative to assess all of these variables before, during, and after surgery. As an example, consider the case of a hypothetical but not unusual 65-year-old patient with a right hypotropia and bothersome vertical diplopia due to thyroid eye disease with previous orbital decompressions. Her ocular surgical history includes bimedial recession of 4 mm with infraplacement, recession of the left inferior rectus, posterior fixation of the right inferior rectus, three injections of botulinum toxin to the left inferior rectus to temporize diplopia prior to stabilization allowing surgical intervention, bilateral refractive surgeries, two glaucoma surgeries (glaucoma drainage device in the right eye and trabeculectomy in the left eye), and recent cataract surgeries. Aside from detailed refractive status and alignment measurements not discussed here, taking into consideration such a complex surgical history can be challenging. To this end, over the years a technique has been developed by the senior staff, fellows, and residents of the Ratner Children’s Eye Center of the Shiley Eye Institute at the University of California, San Diego, in which the relevant information for surgical decision making is presented to the surgeon in a straightforward manner on a one-page template shown in Figure A (available in the online version of this article). The technique emphasizes visual simplicity and helps even the most complicated strabismus cases be more visually apparent while ensuring that all relevant data are presented. The template includes the pertinent systemic and ophthalmologic information. Of most importance is a simplified illustration of the expected location of the extraocular muscles if a strabismus surgery (or any other ocular/periocular surgery) was previously performed using a special “code” for each surgical intervention shown handdrawn as it would be in a clinical setting (Figures B-C, available in the online version of this article, with Figure Ca being the template of the patient discussed above). Additionally, the “sensory” component of a strabismus evaluation is part of the preoperative worksheet. Then the surgical plan or plans are added. Sometimes this will include an “if/then” algorithm in case a predictable or unexpected variation in the surgical process is found. In general, strabismus surgeons have trained and become visual learners based on the repetition of examining patients and performing eye surgery. This preoperative planning worksheet takes advantage of this visualization skill, allowing the patterns of strabismus to be “seen” on the page and visualizing previous surgery. Recently it was found that the self-reported error rate in strabismus surgery is 1 in 2,506 cases.1 As suggested by the authors, strabismus surgeons should adapt more error-prevention strategies. We feel that displaying the surgical plan as shown here in the operating room serves that purpose. Although this might be unnecessary in straightforward cases with no surgical history and low complexity, it simplifies even the most complicated cases and improves surgical decision making.

*Department of Ophthalmology, Ratner Children's Eye Center, Shiley Eye Institute, University of California San Diego, San Diego, California; and †Department of Ophthalmology, Naval Medical Center San Diego, San Diego, California. Reprint requests: Kyle E. Miller, MD, Department of Ophthalmology, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134; e-mail: [email protected] The author has no financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.retinajournal.com). The submitted manuscript is a work of authorship prepared as part of my official duties as an officer or employee of the US Government and therefore in the public domain.

We report the case of a 21-month-old girl who was found to have familial exudative vitreoretinopathy after genetic testing revealed a genetic deletion at 7q22. She had previously been followed for exotropia; however, fundus examinations in the office were thought to be normal. After the pediatric geneticist identified the link between 7q22 deletions and vitreoretinopathies an examination under anesthesia was performed. Fluorescein angiography during this examination confirmed the presence of avascular areas of the retina.

PURPOSE To evaluate the frictional force created by different knots used in adjustable suture strabismus surgery.METHODS To allow the simulation of strabismus surgery suture tying methods a model using 6-0 polyglactin 910 suture was created. Three different knots were evaluated: (1) the sliding noose knot with a double wrap of suture, (2) the cinch knot with a single throw on both sides of the pole suture, (2) and a single-throw square knot. (Bow-tie knots were not included.) A digital force meter was used to measure the force (gram-force [gf]) required to overcome the static friction created by the knot. Each simulation was repeated with new suture material 5 times and the force required after subsequent repositioning was also recorded.RESULTS The force to overcome static friction of the sliding noose knot was 240 gf [95% CI, 187-284 gf]; of the cinch knot, 150 gf [95% CI, 123-167 gf]; and of the square knot, 110 gf [95% CI, 95-121 gf]. Subsequent movement of each knot along the same suture required progressively less force, with the sliding noose maintaining the most static friction.CONCLUSIONS The sliding noose knot generates the most frictional force and also maintains the most friction after subsequent repositioning. Important consideration should be given to multiple repositioning movements, because the force required for each subsequent repositioning decreases.

BACKGROUND Multiple procedures have been described to treat a large-angle esodeviation: with an associated abduction deficit. We report a plication augmentation of the Hummelsheim procedure for the management of esotropia and severe abduction deficit due to abducens nerve palsy or type 1 Duane syndrome.METHODS The medical records of patients operated on using the plication augmentation Hummelsheim procedure at two tertiary centers were retrospectively reviewed. The surgery involved ipsilateral lateral rectos plication, half muscle transposition of the vertical rectus muscles to the paralytic plicated lateral rectos, Foster augmentation sutures, and ipsilateral medial rectus recession or botulinum toxin injection if it was found to be tight on intra-operative forced duction testing. Pre- and postoperative deviations, ocular motility findings, and complications were noted.RESULTS A total of 13 patients were included, all of whom had an esotropia with profound abduction deficit (-4 or more). Postoperative deviations ranged from 14(Delta) of esotropia to 14(Delta) of exotropia, with significant improvement of the abductive motion. No patient developed anterior segment ischemia.CONCLUSIONS The plication augmentation Hummelsheim procedure resulted in correction of even very large esodeviations and improvement of the abduction force. This procedure may also better preserve the blood supply to the anterior segment compared to other surgical approaches.

Rupture of the long head of the biceps is usually seen in older adults, in conjunction with rotator cuff tears or tenosynovitis secondary to chronic subacromial impingement; it is rarely seen as a result of trauma. We present the case of a young active patient who denied prodromal symptoms but ruptured the long head of the biceps brachii tendon (LHB) while performing 25-pound biceps curls. Upon examination, the patient was noted to have a readily apparent biceps defect and decreased strength. He was brought to the operating room, where open subpectoral tenodesis of the LHB was performed. At the 6-week follow-up evaluation, the patient had regained full range of motion. By 6 months, he had regained his previous strength. This case demonstrates an unusual presentation of a LHB rupture in a young healthy man with no prodromal symptoms.