To identify strategies for effective curriculum development and implementation in United States (US) ophthalmology residency training programs. A literature review was conducted for all English-language PubMed/Medline articles relating to ophthalmology residency education or curriculum/curricula. Despite ACGME-defined program requirements outlining curricular goals for US ophthalmology residency training programs, there is no comprehensive, national curriculum with detailed plans for instruction of necessary topics within the 36-month residency training period. Several articles identify a need for detailed curricula on various topics, propose ideas on how residency programs could create curricula, and explore ways of assessing resident competence. There is a paucity of literature evaluating how ophthalmology residents best learn various ophthalmology topics. We need to develop an intentional, comprehensive, and timely national curriculum for ophthalmology residency programs in the US, with detailed plans on how to meet curricular objectives and consideration of the most effective teaching strategies for different ophthalmology concepts.

A 68-year-old diabetic male with Fuchs endothelial corneal dystrophy cataract underwent combined DMEK and cataract surgery of the left eye. Post-operative course was complicated by a partial graft detachment on POD 3, treated with a re-bubbling procedure. The patient subsequently developed a corneal infiltrate, cultured by aqueous sample, that was found to be C. parapsilosis. Oral fluconazole and voriconazole, topical voriconazole 1%, and amphotericin B as well as intracameral and intrastromal voriconazole and amphotericin B were employed. By post-operative day 45, symptoms and signs of DMEK stromal C. parapsilosis keratitis had resolved, and a corneal scar remained. Best corrected visual acuity, at post-operative month 4, was 20/25-2 without correction. Post-DMEK fungal stromal keratitis is a rare post-operative complication. We present a case of C. parapsilosis DMEK stromal keratitis and describe diagnostic and therapeutic modalities that allowed for resolution of the infection, without explantation of the patient's graft, and preservation of visual acuity.

Question Can noninvasive retinal imaging parameters from optical coherence tomography angiography and enhanced depth imaging optical coherence tomography serve as novel biomarkers for the diagnosis of Parkinson disease (PD)? Findings In this cross-sectional study of eyes of 69 participants with PD and 137 healthy control participants, individuals with PD had decreased retinal vessel and perfusion densities, increased total choroidal area and choroid luminal area, and decreased choroidal vascularity index compared with age- and sex-matched control patients. Meaning Results of this study suggest that noninvasive retinal imaging parameters warrant further investigation as potential biomarkers in PD. This cross-sectional study compares the changes in optical coherence tomography parameters and choroidal structural parameters among adults with Parkinson disease and cognitively healthy individuals. Importance Noninvasive retinal imaging may detect structural changes associated with Parkinson disease (PD) and may represent a novel biomarker for disease detection. Objective To characterize alterations in the structure and microvasculature of the retina and choroid in eyes of individuals with PD and compare them with eyes of age- and sex-matched cognitively healthy control individuals using optical coherence tomography (OCT) and OCT angiography (OCTA). Design, Setting, and Participants This cross-sectional study was conducted at the Duke Neurological Disorders Clinic in Durham, North Carolina. Individuals aged 50 years or older with a diagnosis of PD were eligible for inclusion and underwent an evaluation and diagnosis confirmation before enrollment. Control individuals aged 50 years or older and without subjective cognitive dysfunction, a history of tremor, or evidence of motor dysfunction consistent with parkinsonism were solicited from the clinic or the Duke Alzheimer's Disease Prevention Registry. Individuals with diabetes, glaucoma, retinal pathology, other dementias, and corrected Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity worse than 20/40 Snellen were excluded. Data were analyzed between January 1, 2020, and March 30, 2020. Exposures All participants underwent OCT and OCTA imaging. Main Outcomes and Measures Generalized estimating equation analysis was used to characterize the association between imaging parameters and PD diagnosis. Superficial capillary plexus vessel density (VD) and perfusion density (PFD) were assessed within the ETDRS 6 x 6-mm circle, 6 x 6-mm inner ring, and 6 x 6-mm outer ring, as was the foveal avascular zone area. Peripapillary retinal nerve fiber layer thickness, macular ganglion cell-inner plexiform layer thickness, central subfield thickness, subfoveal choroidal thickness, total choroidal area, luminal area, and choroidal vascularity index (CVI) were measured. Results A total of 124 eyes of 69 participants with PD (39 men [56.5%]; mean [SD] age, 71.7 [7.0] years) and 248 eyes of 137 control participants (77 men [56.2%]; mean [SD] age, 70.9 [6.7] years) were analyzed. In the 6 x 6-mm ETDRS circle, VD (beta coefficient = 0.37; 95% CI, 0.04-0.71; P = .03) and PFD (beta coefficient = 0.009; 95% CI, 0.0003-0.018; P = .04) were lower in eyes of participants with PD. In the inner ring of the 6 x 6-mm ETDRS circle, VD (beta coefficient = 0.61; 95% CI, 0.20-1.02; P = .003) and PFD (beta coefficient = 0.015; 95% CI, 0.005-0.026; P = .004) were lower in eyes of participants with PD. Total choroidal area (beta coefficient = -1.74 pixels(2); 95% CI, -3.12 to -0.37 pixels(2); P = .01) and luminal area (beta coefficient = -1.02 pixels(2); 95% CI, -1.86 to -0.18 pixels(2); P = .02) were greater, but CVI was lower (beta coefficient = 0.5%; 95% CI, 0.2%-0.8%; P < .001) in eyes of individuals with PD. Conclusions and Relevance This study found that individuals with PD had decreased retinal VD and PFD as well as choroidal structural changes compared with age- and sex-matched control participants. Given the observed population differences in these noninvasive retinal biomarkers, further research into their clinical utility in PD is needed.

PURPOSE To present a case series of Urrets-Zavalia syndrome (UZS) that developed after Descemet membrane endothelial keratoplasty (DMEK). METHODS A retrospective chart review was performed to identify patients who underwent DMEK by a single surgeon at the Duke Eye Center from 2017 to 2019 and subsequently developed UZS. Demographic data, preoperative history, operative notes, and postoperative course were reviewed. RESULTS We describe 5 cases of UZS after DMEK (ages 19-74 years; 3 men and 2 women). Onset of UZS was noted at postoperative week 1 (n = 1), 2 (n =3), or 4 (n = 1). Four patients had an underlying diagnosis of Fuchs endothelial dystrophy and 1 had posterior polymorphous corneal dystrophy. Sixty percent (n = 3) of patients had an elevated intraocular pressure on postoperative day 0 or 1, and 40% (n = 2) of patients also had a pupillary block. One patient developed UZS after a rebubbling procedure for partial graft detachment and another developed UZS after repeat DMEK transplantation. Of the 3 patients who underwent bilateral combined DMEK and cataract surgery, 1 developed UZS in the second eye, whereas 2 developed UZS in the first eye. Most patients experienced monocular diplopia or had cosmetic concerns because of their mydriatic pupils. Two patients had spontaneous improvement in mydriasis. CONCLUSIONS UZS after DMEK is rare, with only 2 cases in the literature: Holtmann et al and Isac et al. We present the largest case series of UZS after DMEK to date. Postoperative elevation in intraocular pressure is a common contributing factor. Evaluation of more patients may elucidate additional risk factors for this condition.

Press Ganey patient satisfaction scores are increasingly being used as a physician quality metric. In this retrospective review of over 25,000 patient surveys for 61 ophthalmologists, pediatric ophthalmologists and neuro-ophthalmologists received significantly lower patient satisfaction scores than their peers, suggesting that the problem for which a patient seeks care may affect whether he or she is satisfied with the care received. These findings should be taken into account when considering the validity of Press Ganey scores as an equitable, modifiable measure of physician performance, especially when considering factoring these scores into physician evaluation and reimbursement.

PURPOSE:To describe a case of anterior ischemic optic neuropathy as a presenting sign of granulomatosis with polyangiitis.OBSERVATIONS:A previously healthy 50-year-old female developed right eye, then left eye, redness and pruritis and was diagnosed with allergic versus viral conjunctivitis. Five days later, she noted an acute decline in vision in the right eye, corresponding with a decrease on Snellen testing from 20/30 to 20/100 with correction. She was noted to have a right relative afferent pupillary defect, 2+ pallid disc edema, and OCT (Spectralis, Heidelberg Engineering, Carlsbad, CA) findings of significant retinal nerve fiber thickening. Review of systems revealed a three-month history fatigue, right-sided headaches, jaw claudication, bronchitis, cough without hemoptysis, and epistaxis, as well as interval development of a petechial rash across her body, migratory polyarthralgias, fevers, and tachycardia. ESR and CRP were markedly elevated, and the patient was admitted to the hospital for a systemic vasculitis workup. She was started on IV methylprednisolone. Her vision improved dramatically with steroids, measuring 20/50 with correction in the right eye after 24 hours and returning to baseline after five days. An extensive workup including imaging, bloodwork, and biopsies led to a diagnosis of granulomatosis with polyangiitis, with PR3-positive ANCA.CONCLUSIONS:Ocular findings, including anterior ischemic optic neuropathy, may be the presenting signs for patients with granulomatosis with polyangiitis. Prompt recognition and treatment with high-dose steroids and immunomodulatory therapy is important for visual recovery.IMPORTANCE:Prompt recognition of potential vasculitis-related vision loss can lead to timely initiation of vision-saving treatment.

Journal of Cataract & Refractive Surgery 46(7):p 1059-1060, July 2020. | DOI: 10.1097/01.j.jcrs.0000694664.06264.3b

PURPOSE:To investigate the relationship between intraocular pressure (IOP) and big bubble (BB) formation in a model of deep anterior lamellar keratoplasty (DALK).DESIGN:Ex-vivo.METHODS:Corneoscleral buttons from human donors were loaded onto an artificial anterior chamber connected to a column of balanced salt solution. A surgeon-in-training learned to perform DALK via the BB technique using swept-source microscope-integrated optical coherence tomography (SS-MIOCT) with heads-up display (HUD). DALK procedures were performed at 6 different IOPs (5, 10, 15, 20, 30, or 40 mm Hg; n = 6 per group) in a randomized fashion, with the surgeon-in-training masked to the pressure and guided by SS-MIOCT with HUD. For a subset of corneas within each pressure group, DALK was performed on matching donor tissue at a control IOP. BB diameter was recorded, and a diameter exceeding the trephine diameter was considered optimal.RESULTS:Wilcoxon rank sum test showed a difference in BB diameter among the different pressure groups (mean ± SD of 7.75 ± 1.60, 8.33 ± 1.99, 10.9 ± 0.92, 9.08 ± 1.07, 6.67 ± 3.33, and 3.42 ± 3.77 mm in the 5, 10, 15, 20, 30, and 40 mm Hg groups, respectively; P = 0.0014). Per Tukey test, this difference was attributable to comparisons between the 40 mm Hg group and the 5, 10, 15, or 20 mm Hg groups (P = 0.04, 0.02, 0.0001, 0.004, respectively).CONCLUSIONS:In this ex-vivo model of DALK, the BB technique guided by SS-MIOCT with HUD yielded bubbles of optimal diameters only at physiologic pressures (10‒20 mm Hg). Extremely high IOP (40 mm Hg) resulted in BBs of significantly smaller diameter than BBs obtained at physiologic and low (5 mm Hg) IOPs.

Grewal, Dilraj S. MD; Bhullar, Paramjit K. BS; Pasricha, Neel D. BA; Carrasco-Zevallos, Oscar M. BS; Viehland, Christian BS; Keller, Brenton BS; Shen, Liango BS; Izatt, Joseph A. PhD; Kuo, Anthony N. MD; Toth, Cynthia A. MD; Mruthyunjaya, Prithvi MD, MHSEditor(s): Williams, George A. Author Information

We report the first use of swept-source microscope-integrated optical coherence tomography (SS-MIOCT) capable of live four-dimensional (4D) (three-dimensional across time) imaging intraoperatively to directly visualize tube shunt placement and trabeculectomy surgeries in two patients with severe open-angle glaucoma and elevated intraocular pressure (IOP) that was not adequately managed by medical intervention or prior surgery. We performed tube shunt placement and trabeculectomy surgery and used SS-MIOCT to visualize and record surgical steps that benefitted from the enhanced visualization. In the case of tube shunt placement, SS-MIOCT successfully visualized the scleral tunneling, tube shunt positioning in the anterior chamber, and tube shunt suturing. For the trabeculectomy, SS-MIOCT successfully visualized the scleral flap creation, sclerotomy, and iridectomy. Postoperatively, both patients did well, with IOPs decreasing to the target goal. We found the benefit of SS-MIOCT was greatest in surgical steps requiring depth-based assessments. This technology has the potential to improve clinical outcomes.

BACKGROUND AND OBJECTIVE: To assess regional changes in choroidal thickness in the affected temporal hemifield of eyes with branch retinal artery occlusion (BRAO) compared to the unaffected temporal hemifield of the same eye and to fellow eyes. PATIENTS AND METHODS: Six eyes of six patients with unilateral BRAO with fellow eyes serving as controls. Using optical coherence tomography, choroidal thickness was measured at 49 points and averaged for each hemifield. RESULTS: In BRAO eyes, choroidal thickness was greater in the affected hemifield (209.5 µm ± 13.9 µm) compared to the unaffected hemifield (181.3 µm ± 8.9 µm; P = .001). In fellow-eyes, there was no difference between the two hemifields (180.3 µm ± 18.1 µm vs. 193.7 µm ± 16 µm; P = .39). The choroid was thicker in the affected BRAO eye hemifield compared to the corresponding fellow eye hemifield (209.5 µm ± 13.9 µm vs. 180.3 µm ± 18.1 µm; P = .01), whereas no difference was observed among unaffected BRAO eye hemifield and corresponding fellow eye hemifield (181.3 µm ± 8.9 µm vs. 193.7 µm ± 16 µm; P = .1). Subfoveal choroidal thickness between BRAO and fellow eyes was similar (185.5 µm ± 25.7 µm vs. 194.5 µm ± 20.8 µm; P = .4). CONCLUSION: The choroid was 15.6% thicker in the affected hemifield of BRAO eyes compared to the unaffected hemifield of same eye and 16.2% thicker than the corresponding hemifield in fellow eyes. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:811–818.]

Aplastic anemia is a life-threatening hematologic disorder resulting from autoimmune destruction of hematopoietic stem cells. Pancytopenia and failure of bone marrow cause severe bleeding, which may lead to ocular comorbidities. Although the prevalence of ocular hemorrhage in aplastic anemia has been established,1Mansour A.M. Lee J.W. Yahng S.A. et al.Ocular manifestations of idiopathic aplastic anemia: retrospective study and literature review.Clin Ophthalmol. 2014; 8: 777-787Crossref PubMed Scopus (22) Google Scholar reports of these hemorrhages preceding and aiding in the diagnosis of aplastic anemia are rare. We report a novel case of bilateral, symmetric, macular preretinal hemorrhages causing acutely decreased vision as a presenting symptom and key diagnostic feature of aplastic anemia. A 60-year-old male with a history of hypertension, hyperlipidemia, type 2 diabetes, obstructive sleep apnea, and suspected glaucoma presented with an acute decrease in his central vision bilaterally. He also had been experiencing concomitant petechial rashes, gingival bleeding, lethargy, and weakness. His best-corrected visual acuity was 20/400 OD and 20/200 OS. Intraocular pressure, pupillary response, and anterior segment exam were normal in both eyes. Ophthalmoscopic exam revealed remarkably symmetric bilateral circular preretinal hemorrhages at the fovea, each approximately 1-disc area in size, and in the superonasal macula bilaterally (Fig. 1A). The right eye also demonstrated an inferotemporal disc hemorrhage. There were rare scattered dot blot hemorrhages throughout the periphery in both eyes. Fluorescein angiography revealed bilateral blockage corresponding to the areas of hemorrhage, but no associated leakage (Fig. 1B). Optical coherence tomography of the macula demonstrated bilateral subinternal limiting membrane hemorrhage with central thickening (556 µm OD, 479 µm OS), without subretinal hemorrhage (Fig. 1C). The patient was hospitalized for his systemic symptoms and was found to be pancytopenic with a platelet count of 4000/µL. Bone marrow biopsy demonstrated hypocellularity consistent with aplastic anemia of unknown cause despite extensive diagnostic testing. The patient was monitored closely, and 3 months after initial presentation, his platelet count was 51 000/µL, the preretinal hemorrhages had resolved, and his vision had improved to 20/40 OD and 20/30 OS. Aplastic anemia is a rare, idiopathic failure of the bone marrow. Our patient presented with both ophthalmic manifestations as well as systemic symptoms consistent with aplastic anemia. In a retrospective study of patients with aplastic anemia, 23.7% of patients with funduscopic exams had retinal hemorrhages, of which 81% were bilateral.1Mansour A.M. Lee J.W. Yahng S.A. et al.Ocular manifestations of idiopathic aplastic anemia: retrospective study and literature review.Clin Ophthalmol. 2014; 8: 777-787Crossref PubMed Scopus (22) Google Scholar Other retinal findings included central retinal vein occlusion-like picture, optic disc edema, cotton wool spots, and macular edema. Other reports have also described retrobulbar2Grové J.D. Meyer D. Aplastic anemia presenting as spontaneous orbital hemorrhage.Orbit. 2008; 27: 391-393Crossref PubMed Scopus (5) Google Scholar and subhyaloid3Ghosh S. Biswas P.N. Mukhopadhyay S. et al.Posthepatitis aplastic anaemia presenting only with bilateral vision loss.J Indian Med Assoc. 2007; 105: 524,26,43Google Scholar hemorrhages, and one report characterized a patient with nerve fibre layer, intraretinal, and intragel hemorrhages.4Wechsler D.Z. Tay T.S. McKay D.L. Life-threatening haematological disorders presenting with ophthalmic manifestations.Clin Exp Ophthalmol. 2004; 32: 547-550Crossref PubMed Scopus (19) Google Scholar Although retinal hemorrhages are relatively common among patients with this uncommon disease, our case is unique due to its presentation prior to the diagnosis of aplastic anemia, highly symmetric appearance, and sparsity of hemorrhages outside of the macula. Although premacular subhyaloid hemorrhages have been treated with drainage into the vitreous cavity via Nd:YAG laser,5Ranganath A. Mariatos G. Thakur S. Bilateral macular haemorrhages secondary to hepatitis-associated aplastic anaemia, treated with Nd:YAG laser posterior hyaloidotomy.BMJ Case Rep. 2011 Dec 1; https://doi.org/10.1136/bcr.08.2011.4715Crossref PubMed Scopus (6) Google Scholar this patient was observed closely, and his vision improved markedly due to reabsorption of the hemorrhages and an increase in platelet count during a 3-month period. Our case demonstrates that bilateral preretinal hemorrhages can be a presenting manifestation of aplastic anemia and that an ophthalmic examination can be of vital importance in the prompt diagnosis of this life-threatening disease. The authors have no proprietary or commercial interest in any materials discussed in this article.