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Background A balance between autonomy and supervision can be difficult to obtain in medical education. In this study, we sought to determine whether the presence and level of supervision of ophthalmology resident outpatient clinic correlates with metrics of resident success, professionalism and stress. Methods A survey was emailed to all US ophthalmology program directors requesting it be forwarded to PGY4 residents. Questions included whether their program provided a resident-hosted outpatient clinic, and if so, whether residents were mandated to discuss every patient with faculty. Residents were assigned to three categories based on this question (0: no clinic, 1: mandated faculty input, 2: discretionary faculty input). Success metrics included numbers of manuscripts submitted, OKAP scores and success in obtaining fellowships. Professionalism metrics included rating comfort obtaining informed consent, breaking bad news, managing time in clinic, and confidence in providing care in various settings. Residents affirming participation in a continuity clinic also provided perceptions of the level of supervision and how the clinic affected stress. Results Category 1 residents perceived somewhat too much supervision, while category 2 residents felt that they had somewhat insufficient supervision. The majority of residents in either category did not feel that the continuity clinic affected their overall stress, although those who reported a change in stress usually indicated that the presence of the clinic increased stress. There were no other statistically significant differences between the responses from any category. Conclusions The presence of a resident-hosted continuity clinic neither adds nor detracts from the success or sense of professionalism of ophthalmology residents. However, when such a clinic is present, the degree of supervision appears to correlate inversely with resident perception of autonomy. These results suggest that the decision of a training program to offer a clinic hosted by residents offering comprehensive continuity care can be informed primarily by faculty and trainee philosophy and personal preferences without comprising education quality, clinical efficiency, residents’ perception of stress or their success in fellowship matching. Electronic supplementary material The online version of this article (10.1186/s12909-019-1620-0) contains supplementary material, which is available to authorized users.

Importance The description of racial and ethnic data in human trials is relatively unregulated, leading to potential confusion with and inconsistent reporting of these data. Objective To determine the frequency and use of racial and ethnic data in the ophthalmology literature in 2019. Design, Setting, and Participants This cross-sectional study included all full-length human studies published between January and December 2019 in theAmerican Journal of Ophthalmology,JAMA Ophthalmology, andOphthalmology. Main Outcomes and Measures Whether race or ethnicity was included in the data or analysis, how the categorization was described in the methods and results, specific racial and ethnic categories used, and whether and how the categories were determined. Results A total of 547 articles were identified during the study period, 484 (88% ± 2.7%) of which reported background demographic information, including patient age and sex. Only 233 (43% ± 4.1%) reported race and/or ethnicity. Of those articles, 72 (31% ± 5.9%) categorized it as race, 51 (22% ± 5.3%) ethnicity, 56 (24% ± 5.4%) race/ethnicity, 21 (9% ± 3.7%) race and ethnicity, 12 (5% ± 3.0%) descent, 12 (5% ± 2.9%) population, and 5 (2% ± 2.0%) ancestry; in 21 (9% ± 3.8%) it was not defined. Only 30 studies (13% ± 4.4%) described how it was determined in the methods or results, most frequently by self-report (77% ± 3.9%). A total of 78 races and/or ethnicities were defined. Conclusions and Relevance While most articles during the study period reported background demographic information, few included race and ethnicity and only a fraction of those described how these data were determined. The categories used were heterogeneous and often inconsistent. These findings suggest the need for increased and more standardized reporting of ethnic and racial demographic data in the ophthalmology literature.

Purpose There are no uniform standards to inform patients to what extent trainees are involved in their care. This may lead to inequities in sharing the potential risks associated with receiving care in an academic setting. This study was designed to determine patients' level of knowledge of the medical education system, their preferences regarding who provides treatment, and how strongly they would react if they found certain members of the care team were involved without their consent. Design This study is a prospective, nonrandomized, and observational survey of a convenience sample. Methods Consecutive patients referred for a cataract surgery evaluation to the Veteran's Affairs Ophthalmology Department in Lexington, KY between 2015 and 2017 were recruited. Results Ninety-six of 113 eligible patients (response rate 85%) completed the survey. About 33, 69, 33, and 49% of respondents recognized an intern, resident, fellow, and attending as a doctor, respectively. Three quarters (76.1%) felt it was important to be asked permission in advance of a resident assisting or performing surgery, and 21% indicated they would go elsewhere if they found that a resident would assist in, or perform their surgery. About 21, 21, and 58% of respondents would be upset or very upset if a resident was in the operating room, assisted in, or performed surgery without their permission, respectively. Conclusion This survey demonstrates an overall willingness of this specific, largely confined patient population to receive supervised care from training physicians provided they are fully informed and educated on the role of those involved in their care.

A prospective, nonrandomized, observational trial of 60 glaucoma patients to correlate visual acuity and visual field with ability to distinguish bottle cap color of commonly used ophthalmic medications was conducted. A total of 103 eyes from 60 patients (30 women) were evaluated. The mean logMAR acuity was 0.34±0.54 (approximately 20/45 Snellen acuity), average Humphrey Visual Field (HVF) mean deviation was -8.58±8.69 dB, mean Ishihara plates (out of 14) were 11.78±4.15, and bottle cap color score (out of 10) was 8.56±2.51. Multiple linear regression analysis revealed an independent correlation of visual acuity (P=0.0137) and Ishihara score (P0.05). Glaucoma patients with poor visual acuity, but not necessarily advanced visual field loss, are likely to have difficultly identifying the color of their bottle caps. Physicians should be cognizant of this potential issue when reviewing medications with patients.

Daniel B Moore,1 Rebecca F Neustein,2 Sarah K Jones,1 Alan L Robin,3 Kelly W Muir1,4 1Duke Eye Center, Duke University Medical Center, Durham, NC, 2Emory School of Medicine, Atlanta, GA, 3Department of Ophthalmology, Johns Hopkins School of Medicine and International Health, Bloomberg School of Public Health, Baltimore, MD, 4Health Services Research & Development, Durham VA Medical Center, Durham, NC, USA Abstract: As they grow older, most children with glaucoma must eventually face the transition to self-administering medications. We previously reported factors associated with better or worse medication adherence in children with glaucoma, using an objective, electronic monitor. Utilizing the same data set, the purpose of the current study was to determine whose report (the caregiver’s or the child’s) corresponded better with electronically monitored adherence. Of the 46 participants (22 girls), the mean age of children primarily responsible, and caregiver primarily responsible for medication administration was 15±2 and 10±2 years, respectively. For the children whose caregiver regularly administered the eyedrops, the caregiver’s assessment of drop adherence was associated with measured adherence (P=0.012), but the child’s was not (P=0.476). For the children who self-administered eyedrops, neither the child’s (P=0.218) nor the caregiver’s (P=0.395) assessment was associated with measured percent adherence. This study highlights potential errors when relying on self-reporting of compliance in patients and caregivers with pediatric glaucoma, particularly when the child is responsible for administering their own eyedrops. Frank discussions about the importance of medication adherence and how to improve compliance may help both the child and caregiver better communicate with the treating provider. Keywords: glaucoma, children, adherence

Purpose To estimate the cost of the match process for all ophthalmology applicants and the departmental costs at the University of Kentucky during the 2017 to 2018 match cycle. Design Financial analysis. Methods Using the available national match statistics for the 2017 to 2018 ophthalmology residency match and the mean of all residency interview costs available in the literature, the estimated mean and total match costs were calculated for all applicants, including application fees and interviews. Program costs were estimated based on direct interview costs, lost productivity, and fixed costs. Results Of 625 applicants, 475 matched into an ophthalmology residency position in 2017 to 2018. The mean estimated cost was US$6,613 for matched applicants, and all applicants spent US$4,646,950 on the match in aggregate. Our department spent an estimated US$179,327 over four interview days with 12 faculty volunteers, or an average of US$3,736 per each of 48 interviewed applicants. Conclusions and Relevance Matching into an ophthalmology residency position is expensive not only for the applicant but also the program. Reforms to the process would likely be beneficial to both parties.

Objective The main objective of the article is to determine the relative direct financial cost and benefit of an advanced practice provider (APP), optometrist, and faculty ophthalmologist compared with an ophthalmology resident. Design Single center cost–benefit financial analysis. Methods The direct total expenses, including mean salary and benefits; the cost/week, based upon calculated hours worked; and net revenue, based upon technical collections subtracted from total expenses were collected for all APPs, optometrists, faculty ophthalmologists, and ophthalmology residents at the University of Kentucky for the 2016 to 2017 academic year. Optometry and ophthalmology faculty collections were adjusted for clinical full-time equivalents. Results Total annual mean salary and benefits for 242 APPs, 4 optometrists, 17 faculty ophthalmologists, and 9 ophthalmology residents were $126,797, $117,021, $338,233, and $71,210, respectively. Assuming a 50-hour-work week, the calculated hourly costs were $48.77, $45.01, $130.09, and $27.39, respectively. Ophthalmology residents do not directly generate work relative value units or collections. On this basis, the net annual revenues were −$62,729, $122,757, $566,119, and −$71,210, respectively. Conclusions Ophthalmology residents are relatively inexpensive compared with potential substitute health care providers, although they are unable to generate direct revenue. Indirect costs and benefits are likely substantial, but currently incalculable. More candid analyses of the role and financial impact of trainees in health care are needed.

To evaluate optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) measurements in patients with active and quiescent uveitis with and without glaucoma and compare results to the published age-adjusted normative data.Comparative, retrospective pilot study.Consecutive patients with uveitis who underwent OCT RNFL measurements between December 2011 and October 2012 were identified: 76 uveitic eyes without glaucoma and 135 uveitic eyes with glaucoma.We conducted OCT of the RNFL.Global and sectoral RNFL thickness measurements.In 19 nonglaucomatous, uveitic eyes with active inflammation, mean global and all sectoral RNFL measurements were greater than the normative 95th percentile. The mean global RNFL OCT measurement was 140.5 microns in such eyes compared with 107.8 microns in the 57 nonglaucomatous, quiescent, uveitic eyes (P=0.008). These measurements were significantly higher than the average of 95.3 microns reported in normal eyes (P0.001). All mean sectoral measurements except superonasal were significantly higher in active compared with quiescent uveitic eyes (P=0.002-0.05). In glaucomatous eyes with both quiescent and active uveitis, the mean global RNFL measurements on OCT were 92.3 and 95.7 microns, respectively. These measurements were significantly higher than the mean global RNFL thickness (65.3 microns) reported in eyes with the same stage (moderate) of nonuveitic glaucoma.Uveitis is a major confounding factor in assessing the thickness of the RNFL. A significant thickening of the RNFL was found in patients with active uveitis and a greater RNFL thickness than anticipated in patients with uveitic glaucoma. These data raise concerns about the comparative value of RNFL scans as a method to detect and monitor glaucoma in uveitic eyes.

Background The purpose of this study is to evaluate the number of eyedrops available per bottle of a variety of commonly prescribed glaucoma medications. Methods Six bottles of each glaucoma medication were tested: three each in the vertical and horizontal orientations. Bottles were housed in a customized force gauge apparatus designed to mimic ballpoint fingertip contact with a bottle. At a standard rate, all drops were expressed from each bottle and counted with an automated drop counter. Simultaneously, bottle volume was measured and drop size and number were also estimated. The main outcome measures were: total number of drops, volume per bottle and drops per milliliter (mL) of glaucoma medication. Results A total of 192 bottles from 32 bottle designs and manufacturers were tested. Twenty-two of the 32 bottle designs had a significantly different mean number of drops in the vertical and horizontal positions, with 10 designs have more drops dispensed in the horizontal orientation and 12 in the vertical orientation. Six of the 32 bottle designs had a significantly different mean total bottle volume in the vertical and horizontal positions, with all designs having greater volume in the vertical position. An adjusted ratio of mean number of drops/mean bottle volume demonstrated a range from 20.9 drops/mL to 40.8 drops/mL. Conclusions There is significant variability in drops and volume available per bottle of glaucoma medication depending on both the bottle position and manufacturer. These data point to the need for circumspection in prescribing glaucoma medications and caution in evaluating therapeutic outcomes.

Purpose To evaluate the risk factors for and frequency of an acute intraocular pressure (IOP) elevation (spike) after phacoemulsification in patients with glaucoma. Setting Academic glaucoma clinics and operating rooms. Design Retrospective case series. Methods Charts of consecutive glaucoma patients without previous incisional glaucoma surgery having phacoemulsification by the same surgeon between August 1996 and July 2012 were reviewed to obtain demographic information, preoperative glaucoma medications, severity and treatment measures, intraoperative course, and postoperative outcomes. A postoperative IOP spike was defined as IOP greater than 50% above baseline IOP. Main outcome measures were the number of eyes with a postoperative IOP spike and risk factors associated with an IOP spike after phacoemulsification. Results Of 271 eyes (271 patients) included in the study, 45 (17%) had an IOP spike. Risk factors for postoperative IOP spike by multivariate analysis included longer axial length (AL) or associated characteristics (wider angle grade on gonioscopy, deeper anterior chamber, and male sex), higher number of preoperative IOP-lowering medications, previous laser trabeculoplasty, and lack of postoperative oral acetazolamide. One eye (0.4%) required trabeculectomy during the 90-day postoperative period. Conclusions A significant proportion of glaucoma patients having phacoemulsification had an IOP spike. Patients requiring a higher number of IOP-lowering medications or laser trabeculoplasty for IOP control preoperatively and those with a greater AL should be treated more aggressively with IOP-lowering medication in the immediate postoperative period. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Background. Optic disk hemorrhage is known to be a risk factor for glaucoma progression. Cataract surgery by phacoemulsification results in large intraocular pressure fluctuations. We aim to investigate whether phacoemulsification is associated with optic disc hemorrhage in patients with glaucoma. Methods. This is a retrospective review of consecutive university clinic based glaucoma patients undergoing phacoemulsification alone, with at least 3 visits in the year before and at least 5 visits in the year following phacoemulsification. The presence of optic disk hemorrhage was evaluated with slit lamp biomicroscopy at each clinic visit prior to and following phacoemulsification. Results. We evaluated 158 eyes of 158 subjects; 15 (9.5%) had ODH noted at least once during the 2-year study period. Four eyes had ODH identified on postoperative day 1, for a cross-sectional prevalence of 2.5%. Fourteen ODH episodes were noted preoperatively versus 12 episodes postoperatively (P=0.68). Aspirin use was associated with ODH (P=0.015). Conclusions. Our cross-sectional study found a prevalence of ODH immediately after CE that was similar to other published rates, and our longitudinal study did not find an increase in ODH in the year after phacoemulsification when compared to the year prior to surgery.

To determine the force requirements to dispense a single drop from commonly prescribed brand and generic topical glaucoma medications and correlate these findings with pinch strength in a representative patient population.Four bottles of each medication were tested: 2 in the vertical and 2 in the horizontal orientation. Bottles were housed in a customized force gauge apparatus designed to mimic ballpoint fingertip contact with a bottle tip. For all bottles, each of the first 10 dispensed drops was tested and then tests were performed in increments of 10 until the bottle was empty. For each tested drop, the maximum force and displacement were electronically measured. Concurrently, maximum pinch strength was measured on consecutive glaucoma patients.A total of 84 bottles from 21 bottle designs were tested. There was significant variability across the designs, with roughly a 7-fold (0.67 to 4.49 kgf) and 4-fold (0.81 to 3.00 kgf) difference in force requirements in the vertical and horizontal positions, respectively. Of 53 enrolled patients in the glaucoma clinic, the mean pinch strength was 5.05 (range, 1.23 to 10.4 kgf) and 4.82 (range, 1.47 to 10.67 kgf) kgf for the right and left hands, respectively.There is statistically significant variability in the force required to squeeze a drop from common glaucoma medications, and a representative sampling of clinic patients suggests that many likely struggle with the force requirements of several bottle designs. These data further support standardization of topical glaucoma drug delivery and design.

Sir Harold Ridley is recognised today as the inventor of intraocular lens implantation, one the most successful and common procedures in all of surgery. His story, however, is not largely one of triumph and public accolade. This paper reviews Ridley's invention of the intraocular lens and highlights the struggles he faced after his discovery.

Purpose To determine the accuracy of postoperative predicted refractive outcomes in surgically aphakic pediatric patients undergoing secondary intraocular lens (IOL) implantation. Comparisons were also made with other variables historically considered important in cataract surgery. Methods Retrospective review of 50 eyes from 35 consecutive pediatric patients (≤18 years of age) undergoing secondary IOL implantation within the ciliary sulcus or posterior capsular bag. All cases were performed by 1 of 2 surgeons and all refractions were performed manually using the retinoscope by an experienced pediatric ophthalmologist. Results The mean patient age at the time of the secondary implantation was 6.5 years of age (range, 0.58-15.04). The mean patient age at the time of the primary cataract extraction was 0.78 years (range, 0.08-5.77). For all patients, mean absolute value of prediction error was 1.64 D (SD 1.58 D). There were no significant associations between mean absolute value of prediction error and any of the variables measured including axial length, corneal mean curvature, bag or sulcus implantation, formula used, or age at primary and secondary surgery (p > 0.05). Conclusions The mean absolute value of prediction error observed in this study is consistent with previous pediatric primary and secondary IOL data in that it shows a considerable difference from that expected in adult populations. Our findings support the argument that methods currently employed to calculate IOL power may fail to accurately account for all the variations in the eyes of pediatric patients.

Sir Harold Ridley is recognised today as the inventor of intraocular lens implantation, one the most successful and common procedures in all of surgery. His story, however, is not largely one of triumph and public accolade. This paper reviews Ridley's invention of the intraocular lens and highlights the struggles he faced after his discovery.

Introduction The purpose of this study was to determine whether the outcomes following placement of a fluocinolone acetonide implant (Retisert®; Bausch & Lomb, Inc.) combined with an Ahmed™ glaucoma valve (New World Medical, Inc.) in eyes with uveitic glaucoma (UG Retisert) were different when compared to an Ahmed valve alone in eyes with uveitic glaucoma or primary open angle glaucoma (UG non-Retisert and POAG, respectively). Methods Retrospective, interventional study of consecutive uveitic and OAG eyes undergoing Ahmed valve (AV) implantation with or without combined Retisert insertion at a single academic center between 2009 and 2012. Surgical success was defined as intraocular pressure (IOP) between 5 and 18 mmHg and greater than 20% reduction of IOP at two consecutive visits without need for additional IOP-lowering medications or surgical procedures. Secondary outcome measures included IOP and number of glaucoma medications. Results Sixty eyes of 60 patients (22 UG Retisert, 16 UG non-Retisert, 22 POAG) were included. Mean ± standard deviation surgical success duration was significantly greater in UG Retisert eyes, 629 ± 53 days, compared to those with UG non-Retisert, 361 ± 37 days, and POAG, 472 ± 65 days (P = 0.034). At 24 months, the mean IOP was 11.7, 12.1, and 15.0 mmHg and the average patient was on 1.45, 0.71, and 2.00 medications in the UG Retisert, UG non-Retisert, and POAG valve groups, respectively. Conclusion Retisert implants when combined with AV in uveitic glaucoma had a longer duration of surgical success than uveitic or POAG treated with AV insertion alone. Electronic supplementary material The online version of this article (doi:10.1007/s40123-015-0041-3) contains supplementary material, which is available to authorized users.

Purpose To compare the surgical outcome visual acuity and complication rates among pediatric patients undergoing cataract surgery under local or general anesthesia in rural southern Ethiopia Methods This retrospective study included pediatric patients younger than years who underwent cataract surgery in rural southern Ethiopia during July August Local anesthesia was use in patients over the age of years unless they suffered from traumatic or bilateral cataract Clinical indices were collected before and following surgery including uncorrected visual acuity categorized into ambulatory better than hand motion and non ambulatory hand motion or light perception vision intraocular pressure cycloplegic refraction and ocular complications Results Ninety one eyes of consecutive patients male female were included in the study The average age at diagnosis was plusmn years Fifty five operations were performed under general anesthesia GA and using local anesthesia LA The percentage of patients with ambulatory UCVA improved significantly in both the GA vs p lt and LA groups vs lt No significant differences between the groups were noted regarding visual acuity results or complications Conclusions Our results suggest that the outcomes of pediatric cataract surgery performed under either local or general anesthesia were comparable LA should be considered a valid option for older children undergoing cataract surgery especially when medical resources are limited

PURPOSE The Parry-Romberg syndrome, or progressive hemifacial atrophy, is a slowly progressive marked facial deformity because of atrophy of subcutaneous fat and skin, cartilage, and bone wasting. Various ocular findings may be present in approximately 40% of cases of progressive hemifacial atrophy. We describe a novel case of a 42-year-old woman with progressive hemifacial atrophy and bilateral retinal dystrophy consistent with retinitis pigmentosa. METHODS Case report and literature review. RESULTS Clinical features, fundus photographs, visual fields, and electroretinographic findings are reported. CONCLUSION Progressive hemifacial atrophy can occur with retinitis pigmentosa.

Importance Measurement of retinal nerve fiber layer (RNFL) thickness using optical coherence tomography can aid in the diagnosis and management of glaucoma. We observed a previously unreported phenomenon in eyes with uveitis-associated glaucoma in which paradoxical changes in RNFL thickness were noted. Observations Four eyes of 3 patients with uveitis-associated glaucoma had a relatively normal RNFL measurement on presentation during periods of active uveitis and raised intraocular pressure. Subsequent control of uveitis and intraocular pressure was associated with a paradoxical thinning of the RNFL and increased cupping. Conclusions and Relevance Normal-appearing measurements of RNFL thickness in patients with uveitis should be interpreted cautiously in those with a raised intraocular pressure. Physicians should recognize that continued thinning of the RNFL and increased cupping, despite good intraocular pressure control in such eyes, may be due to resolution of edema of the RNFL.

To assess the prevalence of eye disease among malnourished children in a rural Ethiopian health center and evaluate correlations between xerophthalmia and grades of malnutrition. A retrospective, cross-sectional survey. An institution-based cross-sectional prospective study was performed at Bushulo Health Center in rural south Ethiopia and included all children age 6 months to 14 years receiving care for malnourishment from June 1st to July 30th, 2008. Data collection involved a combination of interviews with caretakers, ocular examination by a pediatric ophthalmologist and anthropometric measurements. One hundred and seventy-three children (average age at examination 2.9 ± 0.2 years) were treated for malnutrition (97 female, 76 male). One hundred and forty-nine patients had moderate malnutrition (86.03 %) and 24 had severe malnutrition (13.9 %). The following eye diseases were diagnosed--trachoma (12.1 %), blepharitis (13.3 %) and xerophthalmia (20.8 %). Severely malnourished children were more likely to suffer from xerophthalmia than moderately malnourished children (p < 0.0001). When comparing anthropometric measurements to the diagnosis of xerophthalmia, only weight percentile showed significance (p = 0.008). Xerophthalmia is a common global cause of pediatric blindness and is highly correlated with severe malnutrition. Continued efforts are necessary to improve nutrition and outcomes in these patients.

Primary congenital glaucoma is the most common type of infantile glaucoma, yet it remains a relatively rare disease. Treatment is principally surgical, and management lasts a lifetime. In the developing world, delayed diagnosis, limited treatment, and inadequate follow-up lead to a heavier burden on the patient and community. We highlight the epidemiology and genetics of the disease, its current management and prognosis, and the limitations facing both providers and patients in the developing world. Further efforts are necessary to provide effective, timely screening of children and allocate adequate resources to allow health care workers to reduce the rate of avoidable blindness in developing countries.

A 13-month-old girl presented with chronic keratoconjunctivitis with dermatitis. She was initially diagnosed with corneal abrasion and mild preseptal cellulitis and was treated with topical and oral antibiotics. After failing to respond to standard therapy, she was eventually identified as a victim of abuse. We discuss key findings that could have provoked earlier recognition.

The global society is aging at an increasing rate, with a continually larger proportion of the population consisting of those over the age of 65. Age-related vascular changes have been demonstrated in ocular tissue, and the incidence and prevalence of diseases such as macular degeneration, glaucoma and vascular occlusive diseases increase significantly with age. This article reviews the current body of literature examining age-associated ocular vascular changes, and summarizes the aggregate findings. We discuss the potential role of the aging vasculature in the etiology of age-associated ocular disease, focusing on glaucoma. Our working hypothesis is that although advancing age is a physiological phenomenon, there are stepwise hemodynamic and vascular changes that occur, predisposing the eye and other tissue beds to pathological conditions. Advancing age does not independently give rise to disease, but does generate increasingly vulnerable vascular beds that are susceptible to further insults. These results compel a need for further investigation of age-related changes in ocular physiology and pathophysiology.

Primary congenital glaucoma is an uncommon pediatric ocular disease contributing to a disproportionately high percentage of childhood blindness worldwide. This case report describes bilateral primary congenital glaucoma in monozygotic twins who first presented to an ophthalmologist in Ethiopia at 6 years of age. Both had severe, protracted disease, with only moderate improvement after surgical intervention. [J Pediatr Ophthalmol Strabismus 2010;41:124–126.]

Purpose To determine the accuracy of predicted postoperative refractive outcomes in pediatric patients having cataract surgery with intraocular lens (IOL) implantation and to compare them with other variables historically considered important in cataract surgery. Setting Tertiary care referral hospital. Methods This retrospective review comprised 203 eyes of 153 consecutive pediatric patients (≤18 years old) having cataract extraction with primary posterior chamber IOL implantation in the capsular bag. All cases were performed by 1 of 2 surgeons, and all refractions were performed manually by an experienced pediatric ophthalmologist using a retinoscope. Results In all patients, the mean absolute value (MAE) of the prediction error was 1.08 diopters (D) ± 0.93 (SD). Age at time of surgery and corneal (K) mean curvature were significantly correlated with the absolute value of the prediction error (P = .0006 and P = .0088, respectively). A multiple regression model showed that age at time of surgery and K mean curvature were the only 2 variables significantly associated with MAE; axial length, formula, surgeon, and A-scan type were not significantly associated with prediction error. Conclusions Data from 203 consecutive primary pediatric IOL implantations showed the heterogeneous nature of the variables involved in predictions of refractive outcomes in this population. The complexities of this issue support the need for specific methods of measurement and an IOL calculation formula for the pediatric population.

Endothelial progenitor cells (EPCs) can be isolated from adult peripheral and umbilical cord blood and expanded exponentially ex vivo. In contrast, human umbilical vein endothelial cells (HUVECs) or human aortic endothelial cells (HAECs) derived from vessel walls are widely considered to be differentiated, mature endothelial cells (ECs). However, similar to adult- and cord blood–derived EPCs, HUVECs and HAECs derived from vessel walls can be passaged for at least 40 population doublings in vitro. Based on this paradox, we tested whether EPCs reside in HUVECs or HAECs utilizing a novel single cell deposition assay that discriminates EPCs based on their proliferative and clonogenic potential. We demonstrate that a complete hierarchy of EPCs can be identified in HUVECs and HAECs derived from vessel walls and discriminated by their clonogenic and proliferative potential. This study provides evidence that a diversity of EPCs exists in human vessels and provides a conceptual framework for determining both the origin and function of EPCs in maintaining vessel integrity.

Importance In the past, resident physicians have provided care to indigent patients under the supervision of experienced physicians. General consensus exists regarding higher surgical costs of patient care at teaching hospitals. No study has examined the outcomes or the cost basis for resident physicians providing health care to an underserved population. Objectives To evaluate the visual results in uninsured patients undergoing cataract surgery performed by resident surgeons at a single institution and to determine the cost-effectiveness of care. Design and Setting A retrospective case series of consecutive uninsured patients undergoing cataract procedures performed by attending-supervised resident physicians at the University of Washington from July 1, 2005, through June 30, 2011. Data obtained included demographic information, preoperative and postoperative best-corrected visual acuity (BCVA) in the eye undergoing the procedure, and surgical complications. We calculated the costs of services rendered and normalized them to 2011 dollars. These data were incorporated into time–trade-off discounted utility values. Data were expressed as mean (SD). Participants One hundred forty-three consecutive patients. Exposure Cataract surgical procedures. Main Outcomes and Measures Costs of the surgical procedure and the utility value associated with the BCVA in the operated-on eye, Results The mean logMAR preoperative BCVA was 1.09 (0.74) (Snellen equivalent, 20/300). The best-recorded mean postoperative BCVA was 0.24 (0.42) (Snellen equivalent, 20/40), obtained at 3.77 (9.30) months. The final recorded mean BCVA was 0.27 (0.43) (Snellen equivalent, 20/40), obtained at a median (SD) follow-up of 16.32 (17.10) months. Four complications in 3 eyes required a second operation; 15 postoperative laser procedures were performed. The mean health care cost per patient was $3437.24 ($1334.68). Using these data, the mean utility value of cataract surgery in this population was 0.80 (0.12); the quality-adjusted life-years gained, 2.43 (1.87); and the discounted ratio of cost to utility, $1889.16 ($4800.62). Conclusions and Relevance These data support the success and cost-effectiveness of supervised, resident-performed cataract surgery in an underserved patient population. This study lends support for continuing this traditional scheme of surgical training and education. Further work must ensure that we remain aware of the balance between education and patient care.

Objective To evaluate the etiologies, management, and outcomes of pediatric cataracts in a rural sub-Saharan African setting. Methods A retrospective, consecutive case series of patients presenting to a tertiary referral center in southern Ethiopia during a 13-month period. All patients underwent clinical examination, were diagnosed as having cataract on the basis of standard clinical assessment, and immediately underwent surgical management. Visual acuity results were grossly divided into ambulatory and nonambulatory vision according to patient age and cooperation. Results Ninety-one eyes of 73 consecutive patients (57 boys and 16 girls) were included in the study. The mean (SEM) age at diagnosis was 7.1 (0.5) years (range, 0.5-15 years). Fifty-five patients had unilateral cataract and 18 had bilateral cataract. Cataracts were categorized according to the etiologic cause: congenital (n = 50), traumatic (n = 33), congenital glaucoma-related (n = 3), partially absorbed cataracts (n = 3), and congenital rubella infections (n = 2). At presentation, visual acuity ranged from 6/60 to light perception, with 13 eyes (14%) having ambulatory vision (better than hand motion). The mean postoperative visual acuity was significantly improved, ranging from light perception to 6/9. Seventy-five eyes (82%) achieved ambulatory vision. Of the 61 eyes with an implanted intraocular lens, 56 (92%) reached ambulatory visual acuity following surgery. This was significantly greater than preoperative visual acuity results (P Conclusions The underlying cause and management of pediatric cataracts in the developing world can differ significantly from that commonly reported in the literature. The effects of appropriate intervention on both visual outcome and associated survival statistics may be profound.

Objective To present the anatomic and functional results of surgical treatment for advanced primary congenital glaucoma (PCG) in a rural setting. Design Retrospective, observational case series. Participants Forty eyes of 22 consecutive patients diagnosed with PCG and who underwent surgical treatment. Methods All eyes underwent surgical treatment for PCG. Type of surgery and postoperative complications were noted. We examined anatomic and functional indices before and after the operation. Main Outcome Measures Visual acuity (VA), intraocular pressure (IOP), refractive spherical error, cup-to-disc ratio (CDR), and horizontal corneal diameter (HCD). Results Average age at the time of surgery was 3.3 years (range, 0.4–10) and the mean follow-up was 6 months (range, 1–11). 15% showed marked lens dislocation owing to the severe buphthalmos at presentation. Preoperative IOP was 54±2 mmHg, HCD was 15.1±0.3 mm, and CDR (when visible) was 0.8±0.02. Surgical intervention included 31 trabeculotomies, 6 Ahmed Glaucoma Valve implants, 1 goniotomy, and 2 eviscerations. Serious complications were noted in 4 eyes. Final postoperative IOP was 23±2 mmHg ( P P Conclusions Our surgical outcomes in children with advanced PCG demonstrated moderate overall improvement in IOP and modest improvement of VA. Deep deprivation amblyopia, severe disease manifestation at presentation, opaque corneas, and frequent lens dislocation limited the possible success. These data further signify the need for effective, timely screening of children and prompt recognition by health care workers to reduce the rate of avoidable blindness in developing countries. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Objective: To present the anatomic and functional results of surgical treatment for advanced primary congenital glaucoma (PCG) in a rural setting. Design: Retrospective, observational case series. Participants: Forty eyes of 22 consecutive patients diagnosed with PCG and who underwent surgical treatment. Methods: All eyes underwent surgical treatment for PCG. Type of surgery and postoperative complications were noted. We examined anatomic and functional indices before and after the operation. Main Outcome Measures: Visual acuity (VA), intraocular pressure (IOP), refractive spherical error, cup-todisc ratio (CDR), and horizontal corneal diameter (HCD). Results: Average age at the time of surgery was 3.3 years (range, 0.4–10) and the mean follow-up was 6 months (range, 1–11). 15% showed marked lens dislocation owing to the severe buphthalmos at presentation. Preoperative IOP was 54 2 mmHg, HCD was 15.1 0.3 mm, and CDR (when visible) was 0.8 0.02. Surgical intervention included 31 trabeculotomies, 6 Ahmed Glaucoma Valve implants, 1 goniotomy, and 2 eviscerations. Serious complications were noted in 4 eyes. Final postoperative IOP was 23 2 mmHg (P 0.0001). Patients were significantly more likely to have ambulatory VA (following objects or better) after operation (18% vs 64%; P 0.0001). Conclusions: Our surgical outcomes in children with advanced PCG demonstrated moderate overall improvement in IOP and modest improvement of VA. Deep deprivation amblyopia, severe disease manifestation at presentation, opaque corneas, and frequent lens dislocation limited the possible success. These data further signify the need for effective, timely screening of children and prompt recognition by health care workers to reduce the rate of avoidable blindness in developing countries. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. Ophthalmology 2011;118:231–235 © 2011 by the American Academy of Ophthalmology.

Endothelial progenitor cells (EPCs) can be isolated from adult peripheral and umbilical cord blood. EPCs are thought to originate from bone marrow, circulate in peripheral blood, and migrate to sites of angiogenesis. However, the number of circulating EPCs in peripheral blood is remarkably low, and recent genetic studies show that the contribution of bone marrow derived EPCs to newly formed vascular networks is minimal. Further, while endothelial cells (ECs) derived from vessel walls are widely considered to be differentiated mature ECs, these cells retain extensive proliferative potential and can be passaged for at least 40 population doubling in vitro. Based on these observations, we tested whether EPCs potentially reside in vessel walls utilizing a newly developed single cell deposition assay (Blood, 2004). Analogous to a paradigm established in the hematopoietic cell system, we can utilize this assay to reproducibly identify the following EPCs: (1) high proliferative potential - endothelial colony forming cells (HPP-ECFC), which form macroscopic colonies that form secondary and tertiary colonies upon replating, (2) low proliferative potential - endothelial colony forming cells (LPP-ECFC), which form colonies greater than 50 cells, but do not form secondary colonies upon replating, (3) endothelial cell clusters (EC-clusters) that contain less than 50 cells, and (4) mature terminally differentiated endothelial cells (EC), which do not divide. Utilizing this assay, we compared the clonogenic potential of 1000 single adult human dermal microvascular endothelial cells (HMVECds), human umbilical vein endothelial cells (HUVECs), human umbilical artery endothelial cells (HUAECs), human coronary artery endothelial cells (HCAECs), and human aortic endothelial cells (HAECs) to the potential of adult peripheral and umbilical cord blood derived EPCs. We conducted four independent experiments. Remarkably, we demonstrate that a complete hierarchy of EPCs can be identified in EC populations derived from every vessel wall tested (Table I and n=4). Further, we show that ECs derived from each vessel wall cell population tested contain more proliferative EPCs (LPP-ECFCs and HPP-ECFCs) compared to EPCs derived from adult peripheral blood. Percent of 1,000 Single Cells Plated | | Mature EC | EC-Cluster | LPP-ECFC | HPP-ECFC | |:--------- | --------- | ---------- | -------- | -------- | | HUVEC | 42±6 | 18±2 | 29±9 | 11±5 | | HAEC | 37±3 | 23±8 | 21±4 | 20±6 | | HMVECd | 65±9 | 21±6 | 12±4 | 2±0.6 | | HCAEC | 46±2 | 18±2 | 20±2 | 16±2 | | HUAEC | 41±1 | 10±1 | 27±4 | 21±2 | | Adult EPC | 81±9 | 9±1 | 12±8 | 0.2±0.2 | | Cord EPC | 50±20 | 7±2 | 20±10 | 23±9 | Thus, this study provides evidence that a diversity of EPCs exists in human vessels and provides a new conceptual framework for determining both the origin and function of EPCs in maintaining vessel integrity and contributing to new sites of angiogenesis.

We recently identified a novel hierarchy of human endothelial progenitor cells (EPCs), which are functionally defined by their proliferative and clonogenic potential (Blood, 2004). Emerging evidence suggests that EPCs may be used as angiogenic therapies, or as biomarkers to assess cardiovascular disease risk. Thus, identification of animal models, which phenocopy the human EPC hierarchy, is an important priority for preclinical testing of experimental therapeutics. Given the importance of the Rhesus Macaque as a preclinical model, we tested whether EPCs could be isolated from the peripheral blood of the Rhesus Macaque and compared to EPCs isolated from human adult peripheral blood. Mononuclear cells were isolated from 20 ml of Rhesus peripheral blood and cultured in EGM-2 medium, which promotes the formation of EPC colonies. After 7 days in culture, we identified approximately 20 endothelial cell colonies (n=9), which appeared identical to human EPC colonies. We subcultured the endothelial cell colonies into monolayers for immunophenotyping and functional analysis. Endothelial cells (ECs) derived from the Rhesus EPC colonies formed vessels in matrigel, and demonstrated uptake of acetylated LDL, which are characteristics of ECs. Similar to ECs derived from human EPCs, Rhesus ECs expressed the endothelial cell antigens, CD31, CD144, CD105, CD146, and Flk1. Importantly, Rhesus ECs did not express the hematopoietic cell specific antigens, CD45 and CD14. Similar to ECs derived from human peripheral blood EPC colonies, Rhesus ECs could be serially passaged for at least 40 population doublings without signs of cellular senescence. A hallmark of stem and progenitor cells is their ability to proliferate and give rise to functional progeny. Analogous to a paradigm established in the hematopoietic cell system, we recently developed a single cell deposition assay to reproducibly identify the following human EPCs: (1) high proliferative potential - endothelial colony forming cells (HPP-ECFC), which form macroscopic colonies that form secondary and tertiary colonies upon replating, (2) low proliferative potential - endothelial colony forming cells (LPP-ECFC), which form colonies greater than 50 cells, but do not form secondary colonies upon replating, (3) endothelial cell clusters (EC-clusters) that contain less than 50 cells, and (4) mature terminally differentiated endothelial cells (EC), which do not divide (Blood, 2004). To determine whether these different populations of EPCs could be identified in the ECs derived from Rhesus EPCs, we performed single cells deposition assays on 1,000 cells. All types of EPCs could be identified in the Rhesus ECs (Table I). Further, ECs derived from the Rhesus EPCs rapidly form chimeric vessels with human ECs derived from adult blood, implying that the molecular mechanisms critical for vessel formation are conserved between the two species. Finally, while the murine model is an animal model widely used for studying EPCs, a similar hierarchy of EPCs could not be established from the peripheral blood of mice. Thus, given the diversity of therapeutic applications of EPCs for treating a variety of human diseases, these studies establish the Rhesus Macaque as an important preclinical model. Percent of 1,000 Single Cells Plated Mature EC EC-Cluster LPP-ECFC HPP-ECFC Rhesus ECs 85.8±2.1 4.2±1.1 7.8±0.5 1.3±0.5 Human ECs 80.8±9.6 8.6±1.4 12.4±8.1 0.2±0.2

Background One barrier to patient adherence with chronic topical glaucoma treatment is an inadequate amount of medication available between prescription refills. We examined the self-reported prevalence of early exhaustion of glaucoma eye drops prior to a scheduled refill, and associated risk factors. Methods This cross-sectional survey was performed at a University-based clinical practice. Glaucoma patients at the University of Washington who were experienced with eye drop application and were on a steady regimen of self-administered glaucoma drops in both eyes took a survey at the time of clinic examination. The main outcome measure was self-reported early eye drop bottle exhaustion. Results 236 patients were eligible and chose to participate. In general, patients included were relatively healthy (mean 2.3 comorbid medical conditions). Sixty patients (25.4%) reported any problem with early exhaustion of eye drop bottles, and this was associated with visual acuity ≤ 20/70 in the better eye (P = .049). Twelve patients (5.1%) reported that they “often” (5–7 times per year), “usually” (8–11 times per year) or “always” ran out of eye drops prior to a scheduled refill. Patients affected by this higher level (≥5 times yearly) of eye drop bottle exhaustion were more likely to have poor visual acuity in their worse eye ≤ 20/70 (P = .015) and had significantly lower worse-eye logMAR (P = .043). Conclusions Self-reported early glaucoma bottle exhaustion regularly affected 5% of patients in our population and 25% reported early exhaustion at least once; the main risk factor was poor vision in at least one eye. These results may not be generalizable to a broad patient population, or to those inexperienced with eye drop self-administration. However, this pilot study compels further evaluation and consideration of early eye drop bottle exhaustion in glaucoma patients.

• The records of 886 patients who had appendectomy performed by the same surgeons within a five-year period were used to contrast appendiceal stump inversion vs simple ligation. Our analysis contrasted inversion vs simple ligation techniques as related to postoperative complications, hospital stay, and pathologic diagnosis. Adhesions requiring repeated operation to relieve bowel obstruction occurred in five of 87 patients with acute gangrenous appendicitis treated by inversion. Of 106 patients with acute gangrenous appendicitis treated with simple ligation, postoperative obstruction developed in none. No other statistically significant differences existed between the two techniques. These data suggest that simple ligation is at least as good as and probably better than inversion of the appendiceal stump. (Arch Surg1988;123:689-690)