Purpose To determine if a structured surgical wet laboratory curriculum for ophthalmology residents reduced the rate of posterior capsule rupture (PCR) in phacoemulsification cataract surgery. Setting James A. Haley Veterans' Hospital, Tampa, FL. Design Retrospective cohort study. Methods The study assessed resident-performed phacoemulsification cataract cases from 2011 to 2017, after the creation of a wet laboratory course. Primary outcome measure was PCR. If present, timing of complication, dropped lens fragments, and the need for anterior vitrectomies were noted. Self-reported rates of PCR prior to institution of a wet laboratory course (2010–2011) were compared with cases done by residents who completed the course (2011–2017). Results A total of 3,445 cases were reviewed of which 2.44% (84 cases) noted PCR. Of these, 19% (16) had dropped lens fragments, and 60.7% (51) required anterior vitrectomy. Sixty-nine cases documented timing of PCR with the majority, 58%, occurring during phacoemulsification. When comparing rates of PCR in cases done prior to the presence of a wet laboratory course versus after, there was a significant reduction observed (5.20% before vs. 2.44% after). Conclusion In the presence of a wet laboratory curriculum, the rate of PCR decreased dramatically. The average rate was lower than those reported at other training programs (2.6–9.9%). Most PCR occurred during phacoemulsification, suggesting need for further focused instruction in this step.

A 65-year-old man developed bilateral vision loss 4 months after magnetic resonance imaging demonstrated no lesion in the vicinity of the optic chiasm, hypothalamus, and suprasellar tissues. Repeat computed tomography 3 months later showed a predominantly cystic mass of the suprasellar cistern with extension into the anterior third ventricle, which histologically was a craniopharyngioma. The clinical course of this case fuels the controversy whether craniopharyngiomas arise from embryonic rests or can be acquired. From a clinical perspective, it raises questions about when to obtain imaging studies dedicated to the chiasm and the appropriate interval in which a scan should be repeated to exclude structural causes of bilateral vision loss.

Purpose The aim of the study is to demonstrate whether resident performance on the United States Medical Licensing Exam (USMLE) Step 1 and the Ophthalmology Knowledge Assessment Program (OKAP) correlates to American Board of Ophthalmology Written Qualifying Examination (ABO-WQE). Design This is a retrospective cohort study. Participants Forty-one residents who completed their postgraduate training between 1999 and 2011 from our institution were included in the study. Methods Percentiles on the USMLE Step 1, OKAP, and ABO-WQE first attempt were recorded and analyzed for possible correlations among scores across examinations using Pearson rank correlation, chi-square analysis, Fisher exact test, and Student t-test. Results The percentile score on the USMLE Step 1 was the only standardized test that had a statistically significant association with the percentile score on the ABO-WQE (Pearson rank coefficient = 0.45, p = 0.01). Not achieving a score of 20th percentile on the OKAP examination among second-year residents had the highest statistical association with failing the ABO-WQE on first attempt (p = 0.001) with an odds ratio of 20.4, and the relative risk of failing the ABO-WQE was 11.3; however, the relative risk of passing if the cutoff was achieved was only 1.8, and a positive predictive value for failing the ABO-WQE on first attempt of 0.47. Conclusions Percentile scores on the OKAP are not indicative of percentile scores on the ABO-WQE. While OKAP examinations in the second and third year appear to separate out residents at risk of failing the ABO-WQE, there is a large disparity between the risk of passing and failing which is likely due to the inadequate prognostic value of the test. It is likely OKAP examinations may be a useful tool to identify residents who are at low risk for failing the ABO-WQE on first attempt, but much less useful for identifying residents who are at high risk for failing the ABO-WQE.

CONTEXT:Neonatal conjunctivitis is associated with poor prenatal care worldwide.PURPOSE:Data on neonatal conjunctivitis is scarce in Malawi. This study describes risk factors associated with conjunctivitis in neonates born in a large tertiary care hospital in Blantyre, Malawi.MATERIALS AND METHODS:Medical records of a retrospective cohort of 231 neonates diagnosed with conjunctivitis from January 2006 to December 2009 at a large tertiary hospital in Malawi were reviewed. All subjects were clinically diagnosed with ophthalmia neonatorum. Data were collected on patient demographics and clinical features. The frequencies were calculated of various risk factors in neonates with ophthalmia neonatorum and their mothers as well as the treatments administered.RESULTS:Mean age of the mother was 23.45 years (range, 15-40 years), and the mean number of previous deliveries was 2.3 (range, 1-7) children. Nearly, 80% of mothers delivered preterm infants via spontaneous vaginal delivery. The mean birth weight of neonates was 2869.6 grams (1100-5000 grams). Among mothers, premature rupture of membranes was the leading risk factor (24%) followed by sepsis during labor (9%), and history of sexually transmitted infections (STI) (7%). Neonates presented with low Apgar scores (19%), fever (8%), and/or meconium aspiration (5%). Providers treated patients empirically with a varied combination of benzyl penicillin, gentamicin, tetracycline eye ointment, and saline eye wash. Tetracycline with a saline eyewash was used frequently (34%) compared with combinations of benzyl penicillin and gentamicin.CONCLUSIONS:Improving prenatal care to reduce sepsis, traumatic deliveries, and early diagnosis of STI with appropriate treatment may potentially reduce vertical transmission of neonatal conjunctivitis in this understudied population.

Purpose:To report a case of worsening normal-tension glaucoma immediately following ventriculoperitoneal (VP) shunt placement to lower cerebrospinal fluid pressure (CSFP). Methods:The clinical records of the patient were reviewed retrospectively. Observations were made and collated as the case progressed. Results:A 93-year-old white woman previously diagnosed with normal-tension glaucoma underwent placement of a VP shunt with a Codman-Hakim programmable valve for normal pressure hydrocephalus. Shortly after the procedure, progressive visual field loss was noted in both eyes and new optic disc hemorrhages were seen in the patient’s right eye. The hemorrhages resolved, but the patient had recurrent complaints of poor gait, memory, and mentation. The CSFP was lowered by reprogramming the Codman-Hakim valve. The patient’s visual fields again worsened in both eyes and a new disc hemorrhage was seen in the right eye. A year later, a new disc hemorrhage was seen in the patient’s left eye. The CSFP was raised by reprogramming the VP shunt. Before the placement of the VP shunt, no optic disc hemorrhages had been observed. Conclusion:This case suggests that relatively low CSFP is a contributor to worsening normal-tension glaucoma, probably by increasing translaminar pressure gradient of the optic nerve.

Transverse (lateral) sinus thrombosis is a well-known complication of acute otitis media and mastoiditis in the pediatric and adult population. Thrombosis involving the transverse sinus can ultimately cause elevation of intracranial pressure (ICP) as a result of decreased cerebrospinal fluid absorption. If treatment to lower ICP is not undertaken, it can lead to ophthalmological complications including irreversible vision loss. The following case report describes an 11-year-old girl who was diagnosed with AOM by her pediatrician and subsequently presented to the emergency department complaining of nausea, vomiting, headache, and diplopia.

The diagnosis of feigned vision loss in adults taxes the doctor-patient relationship because the relationship should be based on trust, honesty, and the mutual desire to improve the medical condition. Even under ideal circumstances, physicians rarely have a complete understanding of the factors that lead patients to simulate disease they do not have. We describe the historical figure of John Howard Griffin (1920-1980) who likely perpetuated feigned vision loss for a decade. His writings provide a unique perspective on motivation (or inspiration) behind factitious disease.

A 38-year-old woman developed bilateral carotid cavernous fistulae (CCF) following a motor vehicle collision. Her initial ophthalmologic findings included periorbital edema, palsies of the left oculomotor and abducens nerves, and residual dilated pupils. She subsequently developed significant optic disc edema and retinal vascular dilation bilaterally. Patients with similar injuries typically require neurosurgical or vascular intervention. In this case, the patient's signs resolved spontaneously by 21 months after onset, leaving no residual ocular deficits.

Tilted optic disks are a common finding in the general population. An expression of anomalous human development, the tilted disk appears rotated and tilted along its axes. Visual sequelae described with tilted optic disks include myopia, astigmatism, visual field loss, deficient color vision, and retinal abnormalities. Although the natural course of tilted optic disks is nonprogressive, the anomaly can be mistaken for tumors of the anterior visual pathway, edema of the optic nerve head, or glaucoma. A thorough examination of patients with tilted disk includes refraction, dilated fundus examination, and visual field testing. At times, neuroimaging may be necessary to arrive at the correct diagnosis. Until normative data are validated for tilted disks, the role of new imaging technologies for the optic nerve head is limited. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted disks may be the most critical factors in avoiding misdiagnosis.

The authors describe the case of a 76-year-old man in whom reversible sudden blindness developed after a percutaneous balloon compression rhizotomy for trigeminal neuralgia. His eye became tense and swollen with intraocular pressures of 66 mm Hg. Acetazolamide was administered, and visual acuity (20/50) returned within several months. Despite correct needle placement, the intraocular pressure rose acutely because of transient occlusion of the orbital venous drainage through the cavernous sinus; this was reversed with aggressive medical treatment. In cadaveric studies (dried skull and formalin-fixed head), the authors studied the mechanism of optic nerve penetration. Their findings showed that excessive cranial angulation of the needle with penetration of the inferior orbital fissure can directly traumatize the optic nerve in the orbital apex. Direct trauma to the optic nerve can therefore be prevented by early and repeated confirmation of the needle trajectory with lateral fluoroscopy before penetration of the foramen ovale.

Introduction: Percutaneous approaches to the skull base are routinely performed in the treatment of trigeminal neuralgia. Despite their quasi absence from the scientific literature, immediate postoperative complications of these approaches have been reviewed several times by the senior author in the context of legal actions against the surgeon who performed the procedure. The most common complication involved immediate postoperative blindness.

Purpose The diagnoses of both anterior ischemic optic neuropathy (AION) and optic neuritis are clinical ones with significant overlap of symptoms and signs. This study investigates the presence and character of pain at the onset of AION, in order to evaluate this symptom as a differentiating diagnostic feature between optic neuritis and AION. Methods Forty-one consecutive patients over 45 years of age with a clinical syndrome consistent with AION were questioned about the presence and character of associated pain. Methods Pain was reported by 12% (5 of 41) of the patients with AION. This is contrasted with data compiled on 448 patients enrolled in the optic neuritis treatment trial, of whom 92.2% complained of pain. Methods While there is overlap in the incidence and character of pain in AION and optic neuritis, its presence/absence remains a useful differentiating feature.