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Sulfur mustard (SM) is a cytotoxic, vesicating, chemical warfare agent, first used in 1917; corneas are particularly vulnerable to SM exposure. They may develop inflammation, ulceration, neovascularization (NV), impaired vision, and partial/complete blindness depending upon the concentration of SM, exposure duration, and bio-physiological conditions of the eyes. Comprehensive in vivo studies have established ocular structural alterations, opacity, NV, and inflammation upon short durations (<4 min) of SM exposure. In this study, detailed analyses of histopathological alterations in corneal structure, keratocytes, inflammatory cells, blood vessels, and expressions of cyclooxygenase (COX)-2, matrix metalloproteinase (MMP)-9, vascular endothelial growth factor (VEGF), and cytokines were performed in New Zealand white rabbits, in a time-dependent manner till 28 days, post longer durations (5 and 7 min) of ocular SM exposure to establish quantifiable endpoints of injury and healing. Results indicated that SM exposure led to duration-dependent increases in corneal thickness, opacity, ulceration, epithelial-stromal separation, and epithelial degradation. Significant increases in NV, keratocyte death, blood vessels, and inflammatory markers (COX-2, MMP-9, VEGF, and interleukin-8) were also observed for both exposure durations compared to the controls. Collectively, these findings would benefit in temporal delineation of mechanisms underlying SM-induced corneal toxicity and provide models for testing therapeutic interventions., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To determine changes in the clinical treatment of pediatric patients taking vigabatrin for seizure control in response to results of electroretinogram (ERG) performed for retinal toxicity screening., Methods: The authors retrospectively reviewed the medical records of patients who received ERGs at Children's Hospital of Colorado from 2009 to 2012. Age, indication for ERG, ERG data, and clinical management of vigabatrin were extracted from the records. ERGs were interpreted according to LKC Technologies normative values. A physician trained in ERG analysis interpreted each ERG., Results: One hundred seventy ERGs were performed during the study period, and 147 ERGs were available for analysis. Every patient received general anesthesia for the procedure. Thirty-three ERGs were performed in 29 patients specifically as screening for retinal toxicity due to vigabatrin use, and 30 were available for analysis. Within this cohort, only 2 ERGs were normal (6.6%), and 28 were abnormal (93.3%). In patients who received abnormal results, 1 patient discontinued vigabatrin in response to the screening., Conclusions: In this study cohort, clinical management generally did not change in response to an abnormal screening result. Given the need for general anesthesia in the pediatric population receiving ERG testing, and minimal change in clinical decision-making in the face of abnormal results, ERG screening for retinal toxicity due to vigabatrin in the pediatric cohort should be reconsidered. [ J Pediatr Ophthalmol Strabismus . 2021;58(3):174-179.] .

Introduction: Wilms tumor (WT) is the most common renal malignancy of children and can be seen in WAGR syndrome (WT, aniridia, genitourinary anomalies, and intellectual disability). WAGR results from a contiguous gene deletion within the 11p13 region, encompassing the WT1 gene, often responsible for WT development, and the PAX6 gene, responsible for aniridia. Aniridia, a pan-ocular disease resulting from iris hypoplasia, is thought to increase the risk for WT development if their genetic alteration spans both the WT1 and the PAX6 genes on 11p13. Case Description: We describe a unique case of a patient with aniridia secondary to a heterozygous PAX6 nonsense mutation who developed WT despite no additional identifiable germline genetic drivers for this disease. Discussion: Isolated mutations in PAX6 previously have not been associated with increased risk of WT development case raises the question of if surveillance for WT should be continued in patients with aniridia with an isolated PAX6 mutation identified.

Purpose: Deep phenotyping is an emerging trend in precision medicine for genetic disease. The shape of the face is affected in 30-40% of known genetic syndromes. Here, we determine whether syndromes can be diagnosed from 3D images of human faces., Methods: We analyzed variation in three-dimensional (3D) facial images of 7057 subjects: 3327 with 396 different syndromes, 727 of their relatives, and 3003 unrelated, unaffected subjects. We developed and tested machine learning and parametric approaches to automated syndrome diagnosis using 3D facial images., Results: Unrelated, unaffected subjects were correctly classified with 96% accuracy. Considering both syndromic and unrelated, unaffected subjects together, balanced accuracy was 73% and mean sensitivity 49%. Excluding unrelated, unaffected subjects substantially improved both balanced accuracy (78.1%) and sensitivity (56.9%) of syndrome diagnosis. The best predictors of classification accuracy were phenotypic severity and facial distinctiveness of syndromes. Surprisingly, unaffected relatives of syndromic subjects were frequently classified as syndromic, often to the syndrome of their affected relative., Conclusion: Deep phenotyping by quantitative 3D facial imaging has considerable potential to facilitate syndrome diagnosis. Furthermore, 3D facial imaging of "unaffected" relatives may identify unrecognized cases or may reveal novel examples of semidominant inheritance.

Sulfur mustard (SM), a potent vesicating chemical warfare agent, and its analog nitrogen mustard (NM), are both strong bi-functional alkylating agents. Eyes, skin, and the respiratory system are the main targets of SM and NM exposure; however, ocular tissue is most sensitive, resulting in severe ocular injury. The mechanism of ocular injury from vesicating agents' exposure is not completely understood. To understand the injury mechanism from exposure to vesicating agents, NM has been previously employed in our toxicity studies on primary human corneal epithelial cells and ex vivo rabbit cornea organ culture model. In the current study, corneal toxicity from NM ocular exposure (1%) was analyzed for up to 28 days post-exposure in New Zealand White male rabbits to develop an acute corneal injury model. NM exposure led to conjunctival and eyelid swelling within a few hours after exposure, in addition to significant corneal opacity and ulceration. An increase in total corneal thickness and epithelial degradation was observed starting at day 3 post-NM exposure, which was maximal at day 14 post-exposure and did not resolve until 28 days post-exposure. There was an NM-induced increase in the number of blood vessels and inflammatory cells, and a decrease in keratocytes in the corneal stroma. NM exposure resulted in increased expression levels of cyclooxygenase-2, Interleukin-8, vascular endothelial growth factor and Matrix Metalloproteinase 9 indicating their involvement in NM-induced corneal injury. These clinical, biological, and molecular markers could be useful for the evaluation of acute corneal injury and to screen for therapies against NM- and SM-induced ocular injury., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Research Objective: Military personnel are at greater risks of head and facial traumas and permanent blindness from orbital compartment syndrome in modern warfare. Rapid treatment must be implemented with a low-risk surgical remedy: lateral canthotomy and cantholysis (LCC). Traditional training of LCC is primarily performed using an animal tissue trainer (ATT); however, limitations to these types of trainers exist. Therefore, our research objectives were focused on highlighting the effectiveness, benefits, and vision-saving potential of learning LCC on a synthetic trainer., Methods: Participants included 22 second-year medical students and 6 healthcare professionals. A pre-quiz assessed baseline knowledge. Next, an experienced ophthalmologist provided an overview and instruction. Subjects were randomized to either the synthetic trainer or the ATT and then switched to the other model for comparison. After performing LCC procedures on both models, a post-quiz and survey were administered., Results: Participants found the synthetic trainer easier to use than the ATT model (p < 0.01). There was no statistically significant preference (p = 0.23), or preference of practical eye anatomy (p = 0.26) between the trainers. Post-quiz results demonstrated an overall improvement from pre-quiz scores for participants (p < 0.001)., Conclusions: The synthetic trainer is comparable to the traditional swine model for training LCC procedures, and should be considered as a future training platform., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Red and blue are the historical tactical lighting hues of choice to ensure light discipline and to preserve dark adaptation. As yet, no scientifically ideal hue for use in Special Operations medicine has been identified. We propose red/green polychromatic light as a superior choice that preserves visual function for tactical medical tasks in austere settings., Methods: Thirty participants were enrolled in this institutional review board-approved study. Participants completed four vision tasks in low-light settings under various lighting conditions. The Pelli-Robson Near Contrast Sensitivity test (PR), tumbling E visual acuity test, Farnsworth D-15 color-vision test (FD15), and pseudoisochromatic plate (PiP) testing was performed under white, green, or red light illumination and also red/green and red/green/yellow lights. PR and tumbling E tests were performed using blue and blue/red lights., Results: The test results for each light were compared against a white-light standard. Contrast sensitivity as measured by PR testing showed no statistical difference when white light was used compared with red/green or red/green/yellow light, and the differences between red, green, blue, and blue/red all were statistically different from when white light was used. When measuring visual acuity, blue light was the only color for which there was a statistically significant decrease in visual acuity in comparison with white. There was no reduction in visual acuity with any other lights compared with white. Performance on FD15 testing with all single-hue and multihue lights was significantly worse than with white light for measuring color-vision perception. Color discrimination as measured by PiP testing showed red and green light was significantly worse than with white light, whereas test results when green/red and green/red/yellow lights were used were not statistically different from white., Conclusion: Red/Green/yellow and red/green were superior light sources and performance results only were worse than white light on FD15 testing., (2018.)

Background: Amniotic membrane grafts (AMGs) are used, with mixed results, as a platform for ocular healing and to reduce pathologic scarring. This study evaluated wound tensile strength and histopathologic changes after strabismus surgery with AMGs in 20 New Zealand white rabbits., Methods: All subjects underwent 4 mm inferior rectus hang-back recessions to both eyes. The right eyes served as controls. Ten left eyes (group 1) received processed dehydrated amniotic membrane allografts (Ambiodry2, IOP Inc, Costa Mesa, CA) and ten left eyes (group 2) received cryopreserved human amniotic membrane allografts (AmnioGraft, Bio-Tissue, Miami, FL) between the sclera and muscle insertion and between the muscle and repositioned conjunctiva. At postoperative month 1, tensile strengths of the muscle-globe and conjunctiva-globe attachments were measured, and histopathologic analysis of each eye was performed., Results: In group 1 the mean tensile strength of the muscle-globe attachments was 441.4 ± 274.4 g; of the conjunctiva-globe attachments, 640.3 ± 266.4 g. In the control eyes, the comparable values were 365.8 ± 199.8 g and 595.2 ± 315.3 g, respectively (P = 0.19, P = 0.13). In group 2 the mean tensile strengths were 456 ± 297.5 g and 608.2 ± 306.7 g, compared with control values of 352.7 ± 114.8 g and 583.8 ± 347.1 g (P = 0.43, P = 0.45)., Conclusions: There was no significant change in tensile strength of the muscle insertion using AMGs. In a rabbit model, AMGs do not reduce inflammation or improve scar formation 1 month after strabismus surgery., (Published by Elsevier Inc.)

Lewisite (LEW), a potent arsenical vesicating chemical warfare agent, poses a continuous risk of accidental exposure in addition to its feared use as a terrorist weapon. Ocular tissue is exquisitely sensitive to LEW and exposure can cause devastating corneal lesions. However, detailed pathogenesis of corneal injury and related mechanisms from LEW exposure that could help identify targeted therapies are not available. Using an established consistent and efficient exposure system, we evaluated the pathophysiology of the corneal injury in New Zealand white rabbits following LEW vapor exposure (at 0.2 mg/L dose) for 2.5 and 7.5 min, for up to 28 day post-exposure. LEW led to an increase in total corneal thickness starting at day 1 post-exposure and epithelial degradation starting at day 3 post-exposure, with maximal effect at day 7 postexposure followed by recovery at later time points. LEW also led to an increase in the number of blood vessels and inflammatory cells but a decrease in keratocytes with optimal effects at day 7 postexposure. A significant increase in epithelial-stromal separation was observed at days 7 and 14 post 7.5 min LEW exposure. LEW also caused an increase in the expression levels of cyclooxygenase-2, IL-8, vascular endothelial growth factor, and matrix metalloproteinase-9 at all the study time points indicating their involvement in LEW-induced inflammation, vesication, and neovascularization. The outcomes here provide valuable LEW-induced corneal injury endpoints at both lower and higher exposure durations in a relevant model system, which will be helpful to identify and screen therapies against LEW-induced corneal injury., (© The Author 2017. Published by Oxford University Press on behalf of the Society of Toxicology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments., (2017.)

Background: WINROP (weight, insulin-like growth factor 1, neonatal, retinopathy of prematurity) is a web-based retinopathy of prematurity (ROP) risk algorithm that uses postnatal weight gain as a surrogate of insulin-like growth factor-1 (IGF-1) to predict the risk of severe ROP in premature infants. The purpose of this study was to validate the web-based algorithm WINROP in detecting severe (type 1 or type 2) ROP in a North American cohort of infants., Methods: The records of consecutive infants who underwent ROP examinations between 2008 and 2011 were reviewed retrospectively. Infants were classified into categories of "alarm" (at risk for developing severe ROP) and "no alarm" (minimal risk for severe ROP)., Results: A total of 483 were included. Alarm occurred in 241 neonates (50%), with the median time from birth to alarm of 2 weeks. WINROP had a sensitivity of 81.8% (95% CI, 67.3%-91.8%) and specificity of 53.3% (95% CI, 48.5%-58.0%) for identifying infants with severe ROP. Eight of the 44 infants with severe ROP were not detected (5 with type 1 and 3 with type 2). Of these 8 infants, 7 (88%) had birth weight in excess of the 70 th pecentile. With additional weight data entry, sensitivity of WINROP rose to 88.6%., Conclusions: Very preterm infants (gestational age of ≤27 weeks) with relatively high birth weight for gestational age may not be detected by WINROP as high risk for developing severe ROP., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Non-organic visual loss (NOVL), defined as a decrease in visual acuity or field without an identifiable organic cause, can be challenging to diagnose, especially in patients whose NOVL is superimposed on some component of true organic pathology. Exposure to combat puts soldiers at risk of emotional distress and physical trauma, which can contribute to the development of NOVL with conversion disorder or malingering. This case series describes six patients with NOVL who sustained ocular or non-ocular injuries while serving in combat operations in Iraq and Afghanistan, and highlights diagnostic pearls and components of inter-disciplinary management in the unique military context.

Ocular injury by lewisite (LEW), a potential chemical warfare and terrorist agent, results in edema of eyelids, inflammation, massive corneal necrosis and blindness. To enable screening of effective therapeutics to treat ocular injury from LEW, useful clinically-relevant endpoints are essential. Hence, we designed an efficient exposure system capable of exposing up to six New-Zealand white rabbits at one time, and assessed LEW vapor-induced progression of clinical ocular lesions mainly in the cornea. The right eye of each rabbit was exposed to LEW (0.2 mg/L) vapor for 2.5, 5.0, 7.5 and 10.0 min and clinical progression of injury was observed for 28 days post-exposure (dose-response study), or exposed to same LEW dose for 2.5 and 7.5 min and clinical progression of injury was observed for up to 56 days post-exposure (time-response study); left eye served as an unexposed control. Increasing LEW exposure caused corneal opacity within 6 h post-exposure, which increased up to 3 days, slightly reduced thereafter till 3 weeks, and again increased thereafter. LEW-induced corneal ulceration peaked at 1 day post-exposure and its increase thereafter was observed in phases. LEW exposure induced neovascularization starting at 7 days which peaked at 22-35 days post-exposure, and remained persistent thereafter. In addition, LEW exposure caused corneal thickness, iris redness, and redness and swelling of the conjunctiva. Together, these findings provide clinical sequelae of ocular injury following LEW exposure and for the first time establish clinically-relevant quantitative endpoints, to enable the further identification of histopathological and molecular events involved in LEW-induced ocular injury.

Purpose: The Colorado retinopathy of prematurity (ROP) prediction model (CO-ROP), developed using a cohort of infants from Colorado, calls for ROP examination of infants meeting all of the following criteria: gestational age of ≤30 weeks, birth weight of ≤1500 g, and a net weight gain of ≤650 g between birth and 4 weeks of age. The purpose of this study was to perform an external validation to assess the sensitivity and specificity of the CO-ROP model in a larger cohort of babies screened for ROP from four academic institutions in the United States., Methods: The medical records of neonates screened for ROP according current national guidelines was conducted at 4 US academic centers were retrospectively reviewed. Sensitivity, specificity, and respective 95% confidence intervals in detecting ROP using CO-ROP were calculated for type 1, type 2, and any grade of ROP., Results: A total of 858 cases were included. The CO-ROP algorithm had a sensitivity of 98.1% (95% CI, 93.3%-99.8%) for type 1 ROP, 95.6% (95% CI 78.0-99.9%) for type 2 ROP, and 95.0% (95% CI, 93.1-97.4%) for all grades of ROP. The CO-ROP model would have reduced the total number of infants screened by 23.9% compared to current 2013 screening guidelines., Conclusions: CO-ROP demonstrated high sensitivity in predicting ROP and would have greatly reduced the number of infants needing examination., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Special Operations Forces (SOF) medical personnel function worldwide in environments where endemic anthrax (caused by Bacillus anthracis infection) may present in one of three forms: cutaneous, pulmonary, or gastrointestinal. This report presents a rare periocular anthrax case from Haiti to emphasize the need for heightened diagnostic suspicion of unusual lesions likely to be encountered in SOF theaters., (2016.)

Purpose: To evaluate the toxic effects and associated mechanisms in corneal tissue exposed to the vesicating agent, nitrogen mustard (NM), a bifunctional alkylating analog of the chemical warfare agent sulfur mustard., Methods: Toxic effects and associated mechanisms were examined in maximally affected corneal tissue using corneal cultures and human corneal epithelial (HCE) cells exposed to NM., Results: Analysis of ex vivo rabbit corneas showed that NM exposure increased apoptotic cell death, epithelial thickness, epithelial-stromal separation, and levels of vascular endothelial growth factor, cyclooxygenase 2, and matrix metalloproteinase-9. In HCE cells, NM exposure resulted in a dose-dependent decrease in cell viability and proliferation, which was associated with DNA damage in terms of an increase in p53 ser15, total p53, and H2A.X ser139 levels. NM exposure also induced caspase-3 and poly ADP ribose polymerase cleavage, suggesting their involvement in NM-induced apoptotic death in the rabbit cornea and HCE cells. Similar to rabbit cornea, NM exposure caused an increase in cyclooxygenase 2, matrix metalloproteinase-9, and vascular endothelial growth factor levels in HCE cells, indicating a role of these molecules and related pathways in NM-induced corneal inflammation, epithelial-stromal separation, and neovascularization. NM exposure also induced activation of activator protein 1 transcription factor proteins and upstream signaling pathways including mitogen-activated protein kinases and Akt protein kinase, suggesting that these could be key factors involved in NM-induced corneal injury., Conclusions: Results from this study provide insight into the molecular targets and pathways that could be involved in NM-induced corneal injuries laying the background for further investigation of these pathways in vesicant-induced ocular injuries, which could be helpful in the development of targeted therapies.

Purpose: To describe a novel retinopathy of prematurity (ROP) screening model incorporating birth weight, gestational age, and postnatal weight gain that maintains sensitivity but improves specificity in detecting all grades of ROP compared to current 2013 screening guidelines., Methods: The medical records of 499 neonates from a single tertiary referral center who met the 2013 screening guidelines for ROP were retrospectively reviewed. Weekly weights were analyzed using standard logistic regression to determine the age at which the weekly net weight gain best predicted the development of ROP, which was designated as the postnatal weight gain criterion. The 2013 birth weight and gestational age criteria were included in an "and" fashion to form the CO-ROP model. Sensitivities and specificities in detecting high grade (type 1 and 2) and all grades of ROP were calculated., Results: The CO-ROP model screens infants with a gestational age at birth of ≤30 weeks and birth weight of ≤1500 g and net weight gain of ≤650 g between birth and 1 month of age. In our cohort, CO-ROP had a sensitivity of 100% (95% CI, 92.1%-100.0%) for high-grade (type 1 and 2) ROP and 96.4% (95% CI, 92.3%-98.7%) for all grades of ROP. It would reduce the number of infants screened by 23.7% compared to 2013 guidelines. Calibrating the model to detect only high-grade ROP would result in a 45.9% reduction in the total number of infants screened., Conclusions: CO-ROP is a simple model that maintains a statistically similar sensitivity in detecting all grades of ROP while significantly reducing the total number of required ROP screenings compared to 2013 guidelines. The study had a small sample size but shows promise for future research and clinical efforts., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Success in Special Operations Forces medicine (SOFMED) depends on maximizing visual capability without compromising the provider or casualty when under fire. There is no single light that has been deemed "ideal" for all SOFMED environments., Methods: We used the Farnsworth-Munsell (FM) hue test to determine color vision of normal subjects under white, red-green, and blue flashlights to determine color discrimination. Then we used a timed color-determination visual test to determine how quickly normal subjects can identify color correctly. We had subjects perform a simulated surgery illuminated by a normal white-light source, then by red-green or blue light-emitting diode (LED) tactical light., Results: The total error score for white light was 49.714, 272.923 for red/green light, and 531.4 for blue light. The subjective perception of simulated trauma wounds was not substantially different with red-green LED tactical light when compared with white LED light. However, simulated surgery under the blue LED was more difficult compared with simulated surgery under the red-green LED light., Conclusion: Red-green was a superior light source for SOFMED and military first responders in this study, especially, where light was required to allow accurate and efficient application of Tactical Combat Casualty Care to injured personnel., (2016.)

Eye injuries are common in forward areas of operations. Definitive diagnosis and care may be limited not by provider skill but rather by available equipment. The ability to treat simple trauma such as corneal foreign bodies at the Role 1 level has advantages including rapid return to duty, decreased cost of treatment, and, most important, decreased risk of delayed care. We propose the device such as a hand-held portable slit lamp should be made available for appropriate Special Operations Medical Forces (SOFMED) or aviation providers., (2014.)

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings., (2013.)

Purpose: To report the demographics and outcomes in children (<18 years of age) who developed hyphema from ocular trauma and were subsequently cared for at a tertiary medical center., Methods: The medical records of consecutive patients seen at Children's Hospital Colorado diagnosed with traumatic hyphema between September 1, 2003, and December 31, 2011, were retrospectively reviewed. The following data were recorded: patient age, parent/guardian-reported ethnicity, sex, injury location, visual acuity, and intraocular pressure (IOP) at presentation and follow-up., Results: A total of 138 cases of unilateral hyphema were included, with 88% occurring in boys (mean age, 10.1 years; range, 1-19). Over 90% of injuries occurred in the home setting, with the most common mechanisms of injury being general play, projectiles from guns, and sports injuries occurring during games or practice. Only 3 patients had visual acuity <20/40 at 1 month's follow-up, and no patient experienced a rebleeding event. Most of the 33 patients with elevated IOP were managed medically; 4 (12%) required surgery., Conclusions: The majority of children with traumatic hyphema in this patient cohort were injured in the home setting. Very few patients underwent surgery for ocular hypertension, but higher IOP at presentation was associated with the need for surgical intervention. Outpatient care with activity restriction and topical medications usually led to resolution of hyphema without serious complications or visual loss., (Copyright © 2013 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Objectives: To present a case report of an intraorbital training munition during combat simulation., Methods: A 36-year-old National Guardsman presented to our hospital after being struck in the right orbit with a training munition during combat exercises at Fort Carson, Colorado. The clinical findings, treatment course, and outcome of the case are discussed with review of the literature., Results: An anterior orbitotomy and retinal detachment repair was performed on the patient. The training munition was recovered through the entrance wound in the upper eyelid. At 1 month postoperative, the patient?s vision was 20/20 with correction. No complications were noted., Conclusions: This case report is serves as an example of the ocular morbidity associated with training munitions as well as a reminder of the importance of compliance with protective eyewear during training exercises. While surgical excision is this case was straightforward, intraorbital foreign bodies can pose a significant surgical challenge., (2013.)

Retinal hemorrhages in children in the absence of risk factors are regarded to be pathognomonic of shaken baby syndrome or other nonaccidental injuries. The physician must decide whether the retinal hemorrhages in children without risk factors are due to abuse or cardiopulmonary resuscitation with chest compression (CPR-CC). The objective of this study was to determine if CPR-CC can lead to retinal hemorrhages in children. Twenty-two patients who received in-hospital CPR-CC between February 15, 1990, and June 15, 1990, were enrolled. Pediatric ophthalmology fellows carried a code beeper and responded to calls for cardiopulmonary arrest situations. At the scene of CPR-CC, an indirect funduscopic examination was conducted for presence of retinal hemorrhages in the posterior pole. Follow-up examinations were performed at 24 and 72 hours. Of the 22 patients, 6 (27%) had retinal hemorrhages at the time of CPR-CC. Of these 6 patients, 5 had risk factors for retinal hemorrhages. The sixth patient had no risk factors and may have represented the only true case of retinal hemorrhages due to CPR-CC. Retinal hemorrhages are uncommon findings after CPR-CC. Retinal hemorrhages that are found after CPR-CC usually occur in the presence of other risk factors for hemorrhage with a mild hemorrhagic retinopathy in the posterior pole.

Background and Purpose: To elucidate the experience of pediatric ophthalmologists across the United States who care for infants with retinopathy of prematurity (ROP)., Methods: Seven hundred and ten surveys were mailed to U.S. members of the American Association of Pediatric Ophthalmology and Strabismus, and 283 (40%) of 710 surveys were completed. Surveys were reviewed and statistical analysis was completed by the authors., Results: There was no uniformity of contract compensation or method for determining the value of ROP care. Almost half of the respondents felt they would generate more income if they did not perform ROP screening. Eighty percent of respondents that were happy with their ROP compensation had a contract for those services. One third of respondents had their malpractice insurance provided by the hospital. Retina specialists performed 40% of inpatient ROP screening and 53% of treatment. Most respondents continued to care for infants with ROP once discharged., Conclusions: In the United States, there is no uniform experience regarding compensation for ROP care, or a methodology for determining the value of services and coverage of liability insurance. These findings are consistent with previous studies. Lack of uniform compensation and high liability pose a threat to the future of ROP care.

There are no effective and approved therapies against devastating ocular injuries caused by vesicating chemical agents sulfur mustard (SM) and nitrogen mustard (NM). Herein, studies were carried out in rabbit corneal cultures to establish relevant ocular injury biomarkers with NM for screening potential efficacious agents in laboratory settings. NM (100nmol) exposure of the corneas for 2h (cultured for 24h), showed increases in epithelial thickness, ulceration, apoptotic cell death, epithelial detachment microbullae formation, and the levels of VEGF, cyclooxygenase-2 (COX-2) and matrix metalloproteinase-9 (MMP-9). Employing these biomarkers, efficacy studies were performed with agent treatments 2h and every 4h thereafter, for 24h following NM exposure. Three agents were evaluated, including prescription drugs dexamethasone (0.1%; anti-inflammatory steroid) and doxycycline (100nmol; antibiotic and MMP inhibitor) that have been studied earlier for treating vesicant-induced eye injuries. We also examined silibinin (100μg), a non-toxic natural flavanone found to be effective in treating SM analog-induced skin injuries in our earlier studies. Treatments of doxycycline+dexamethasone, and silibinin were more effective than doxycycline or dexamethasone alone in reversing NM-induced epithelial thickening, microbullae formation, apoptotic cell death, and MMP-9 elevation. However, dexamethasone and silibinin alone were more effective in reversing NM-induced VEGF levels. Doxycycline, dexamethasone and silibinin were all effective in reversing NM-induced COX-2 levels. Apart from therapeutic efficacy of doxycycline and dexamethasone, these results show strong multifunctional efficacy of silibinin in reversing NM-induced ocular injuries, which could help develop effective and safe therapeutics against ocular injuries by vesicants., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Unlabelled: Identification and management of injuries to the eyes and ocular adnexa is commonly encountered by frontline medical personnel. This brief review is intended for the Special Forces Medic of all branches and describes the clinical presentation of common ophthalmic and periocular trauma with appropriate management strategies. Prompt recognition of these wounds facilitates early treatment and optimized visual outcomes for affected Soldiers and civilians alike., Keywords: trauma, eye, ophthalmology, vision, open globe., (2012.)

Embryogenesis of a congenital nasolacrimal duct (NLD) cyst is attributed to the failure of the Hasner membrane of the NLD system to cannulate. Prenatal diagnosis of congenital NLD cysts supports the argument for a developmental error, with a postnatal prevalence of 6%. The role of a genetic basis for this malformation has never been ascribed. We present a set of monozygotic twins with bilateral congenital NLD cysts as an argument for a genetic basis of this entity. A case report and literature review were performed. We present two cases of bilateral congenital NLD cysts occurring in a set of monozygotic twins. Patients were delivered at 37 weeks via cesarean section. The pregnancy was complicated by preterm labor at 33 weeks requiring administration of terbutaline and betamethasone. At presentation, twin A had bilateral eye discharge, erythema, and swelling medial to the medial canthi as well as nasal obstruction. Computed tomography (CT) showed classic bilateral cystic masses in the inferior meatus. The diagnosis of bilateral infected congenital dacryocystoceles was made. Twin B initially presented with only bilateral eye discharge and CT showed a dilated NLD system. Twin B subsequently developed early signs of bilateral dacryocystoceles the following day. Both patients underwent lacrimal probing and endoscopic marsupialization of the dacryocystoceles. Biopsies were consistent with dacryocystocele. Dacryocystocele is a common presentation of unresolved neonatal NLD obstruction. This case report in a set of identical twins is an argument for a genetic basis for the formation of this lesion.

Introduction and Purpose: We evaluated the impact of developmentally-at-risk status on the results of photorefractive screening with iScreen®., Patients and Methods: We sequentially recruited 169 children (aged 2-5 years) to participate in a blinded, prospective study of a photoscreening device. The principle investigator examined the children after photoscreening. Using established standards for amblyogenic factors, the principle investigator and photoscreen interpreters separately made a determination of "normal" or "needs referral" for each child. Sensitivity, specificity, positive predictive value, and negative predictive value for the photoscreening device were determined., Results: Overall, sensitivity was 85% with a positive predictive value of 98%, and specificity was 87% with a negative predictive value of 47%. Developmentally-at-risk status in 34 children (three refused imaging) did not reduce sensitivity (89%) or specificity (100%) when compared with 130 children (two refused imaging) who did not have developmentally-at-risk factors (sensitivity = 84% and specificity = 80%)., Conclusion: The efficacy of photorefractive screening in young children with developmentally-at-risk status is comparable to results found in normal children.

Objective: To determine if there was any uniform experience across the United States relative to retinopathy of prematurity (ROP) services provided, reimbursement, and malpractice insurance coverage., Methods: An online pediatric ophthalmology listserv poll queried pediatric ophthalmologists regarding ROP screening, reimbursement, malpractice insurance, and call and consult coverage., Results: Compensation for providing ROP services is quite variable around the United States. The Southern respondents reported the highest contract income while the Northeast reported the lowest. The mean annual contract income was $63 753 and the median annual contract income was $39 000. There was an even distribution between physicians vs hospitals providing malpractice coverage. There was also a fairly even distribution between physicians who do and do not provide consult and call coverage., Conclusions: Nationwide, there is no standard rate of compensation for ROP in-hospital care, coverage of liability insurance, or providing additional consult or on-call services. Income generation performing ROP screening examinations is roughly half what a pediatric ophthalmologist can generate by seeing patients in the clinic or performing surgery.

Purpose: To describe a case of an incidental finding of bilateral corectopia detected by photo screening which ultimately led to the diagnosis of multiple sclerosis., Methods: Case presentation and literature review., Results: Corectopia may be congenital or acquired. Midbrain corectopia is commonly caused by infarction and demyelinating disease can cause autonomic pupil abnormalities resulting in corectopia., Conclusion: A careful history and ocular examinatin can aid in determining the etiology of corectopia. Additional genetics or neurologic consultation may be necessary to diagnosis systemic disease.

Retrobulbar hemorrhage is an uncommon, but potentially devastating complication associated with facial trauma. It can rapidly fill the orbit and cause an "orbital compartment syndrome" that subsequently cuts off perfusion to vital ocular structures, leading to permanent visual loss. Treatment must be initiated within a limited time in order to prevent these effects; however, specialty consultation is not always available in remote field environments. This article addresses the mechanism, diagnosis, and treatment ofretrobulbar hemorrhage via lateral canthotomy and cantholysis, and recommends that 18D medical sergeants be properly trained to evaluate and perform this sight-saving procedure in emergent settings where upper echelons of care are not immediately available.

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.

The National Guard has extensive capabilities that are impossible to attain in active duty units, largely because its citizen Soldiers bring their civilian expertise in addition to their military occupational specialties. While deploying to Afghanistan as the flight surgeon for a forward deployed Special Forces (SF) battalion, this Colorado Army National Guardsman also provided basic ophthalmology care in theater in the absence of an assigned ophthalmologist. The SF Battalion Preventive Medicine (PM) NCO was also an experienced eye technician in civilian life. Emergency eye surgery was provided for allied, coalition and host nationals in accordance with the Rules of Engagement. Elective eye surgery was an excellent method to build rapport and trust in keeping with the Special Forces "winning the hearts and minds" philosophy.

Purpose: To develop and validate a new parental questionnaire addressing symptoms and health-related quality of life (HRQL) in childhood nasolacrimal duct obstruction (NLDO)., Design: Cross-sectional study., Participants: Children ages 6 to younger than 48 months with and without clinical signs of NLDO., Methods: A new questionnaire was developed using semistructured interviews with parents of children with NLDO and through discussions with expert clinicians. Questionnaires were completed by parents of children with and without NLDO. Cronbach's alpha was calculated as a measure of internal-consistency reliability. Factor analysis was used to evaluate a priori subscales: symptoms and HRQL. Discriminant construct validity was assessed by comparing questionnaire scores between children with and without NLDO and between affected and unaffected eyes of children with unilateral NLDO. Instrument responsiveness was determined by comparing presurgical and postsurgical intervention scores in a subset of NLDO patients who underwent surgical treatment., Main Outcome Measure: The NLDO questionnaire score., Results: Eighty-seven children were enrolled, 56 with and 31 without NLDO. All but 2 questions on the questionnaire showed a good distribution of responses, a high correlation with the rest of the questionnaire, and excellent discrimination between patients with and without NLDO. Cronbach's alpha values were good for the overall questionnaire (0.95), and for 2 predetermined subscales: symptoms (0.95) and HRQL (0.85). On a 0 to 4 scale, NLDO patients had worse scores compared with non-NLDO patients for both symptoms (mean difference, 2.1; 95% confidence interval [CI], 1.9-2.3) and HRQL (mean difference, 1.2; 95% CI, 0.9-1.5) subscales. The NLDO patients had worse scores before intervention compared with after intervention for both the symptoms (mean difference, 2.2; 95% CI, 1.6-2.9) and HRQL (mean difference, 1.4; 95% CI, 0.8-2.1) subscales. Finally, NLDO patients had worse symptom scores for affected eyes compared with unaffected eyes (mean difference, 2.3; 95% CI, 1.9-2.6)., Conclusions: This novel NLDO questionnaire is useful in quantifying parental perception of symptoms and HRQL in childhood NLDO. The questionnaire may have a role in future clinical studies of NLDO.

Purpose: To compare postmortem orbital findings in pediatric accidental head injury to Shaken Baby Syndrome (SBS)., Design: Retrospective study., Setting: Institutional., Study Population: Thirty-six patients underwent postmortem modified exenteration with sectioning of the orbital contents; 18 victims of SBS and 18 cases of fatal accidental head trauma., Observation Procedure: In all cases of children who died from accidental head trauma, the orbital tissues were separated to expose the optic nerve sheath. Patients with gross evidence of hemorrhage within the sheath were included. All cases of SBS were included. After accidental head injury, exenteration was performed only if optic nerve sheath hemorrhage was suspected on gross examination. All children younger than 18 years old with head injury as primary cause of death were included. SBS is defined as having at least two of the following: (1) typical abnormal findings on neuroimaging, (2) typical skeletal injury, (3) retinal hemorrhages, (4) history of abusive shaking with or without blunt head trauma, or (5) an inadequate history to explain the observed injuries., Main Outcome Measure: Presence or absence of orbital hemorrhage., Results: Orbital tissue injury is more common in SBS than accidental head trauma without orbital fracture. In addition, optic nerve sheath and optic nerve intradural hemorrhage are also significantly more common in SBS (P < .0001)., Conclusions: Our study reports new evidence of injury to orbital tissues in SBS and supports the concept that these finding are due to unique acceleration-deceleration forces of this type of abusive head injury.

Introduction: Statistical Process Control (SPC) techniques were originally used for evaluating quality in manufacturing. The SPC chart consists of data plotted in a time sequence with the mean and upper and lower control limits (approximates +/- 3 standard deviations), graphically showing trends in the data. We employed SPC charts to analyze one and two muscle surgery for simple horizontal strabismus of 25 prism diopters (PD) or less., Methods: We reviewed the records of 47 patients, 18 years and younger with consistent preoperative strabismus measurements of 25 PD or less, who underwent pure horizontal rectus muscle recession, resection, or both. SPC charts were used to compare the differences in preoperative and postoperative measurements of one muscle versus two muscle esotropia and exotropia using the QI analyst software package., Results: The average preoperative measurements for esotropia were 19.6 PD of one muscle cases, and 23.8 PD for two muscle cases. For exotropia, these values were 16.7 PD for one muscle cases and 20.6 PD for two muscle cases. The average postoperative measurements for esotropia were 5.4 PD for one muscle cases, and 10.0 PD for two muscles cases. For exotropia, the values were 2.2 PD for one muscle cases, and 11.0 PD for two muscle cases. SPC charts displaying pre- and postoperative measurements for one and two muscle surgery for both esotropia and exotropia showed normal statistical fluctuation. Interestingly, two muscle postoperative measurements for both esotropia and exotropia had higher upper control limits (UCL) than one muscle measurements. Those patients requiring additional surgery, or whose postoperative measurements were greater than 15 PD were considered failed cases. The differences in failure rates between one muscle and two muscle cases were not "statistically significant" [p less than 0.05]., Conclusion: One muscle horizontal rectus surgery should be considered as an option when planning surgical treatment for medium angle strabismus. Statistical process control may be a valuable method to analyze variability in many ophthalmologic procedures, with the goal of minimizing variability to achieve better outcome.

A 9-month-old infant presented with Horner syndrome. Magnetic resonance imaging of his head and neck was unremarkable, but magnetic resonance imaging of his chest revealed ectopic cervical thymus. The patient's condition has been managed with imaging studies and close clinical follow-up.

Introduction: This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects., Methods: After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties., Results: The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024)., Conclusions: The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.

Purpose: As part of a larger study intended to evaluate the management of strabismus in adults, we documented and compared patient and provider perspectives on the various factors that may contribute to treatment outcome and value of strabismus care., Methods: By completing a questionnaire, 170 patients with strabismus (ages 19 to 87 years) and 11 strabismus specialists who performed surgery on these patients each indicated the relative weight of several disease- and treatment-related contributors to the outcome and value of care. In addition, each respondent rated the severity of the strabismus before and after surgery., Results: Overall severity ratings improved as a result of surgery. The improvement perceived by the physicians was 5.1 +/- 1.7 on a 10-point scale and was larger than the 2.6 +/- 3.6 points improvement perceived by the patients ( P < 0.001). Patients and physicians expressed different views on the relative contributions to outcome and value (overall P < 0.001). Both groups indicated "the condition," "the physician," and "the procedures" as the largest contributors, but "condition" was perceived as more important by the physicians than by the patients ( P < 0.001), and "physician" was more important to the patients than to the physicians ( P < 0.001)., Conclusion: Although in approximate agreement on the main contributors to outcome and value, discrepancies exist between perspectives of patients and physicians on the relative weights of those contributors. Public information, education, and counseling may bring these perspectives better in line and ultimately improve both quality and patient satisfaction.

Over two centuries ago, the Greek military historian Xenophon wrote the first systematic book on leadership, Anabasis, or March Up Country. According to management guru Peter Drucker, it is still the best book on the subject. Physician executives can learn timeless lessons from Xenophon.

Purpose: To evaluate children 6 years old and younger, lactating mothers, and women of childbearing age for vitamin A deficiency in the districts of Kabul City, Afghanistan., Methods: A set number of patients selected randomly in all 13 districts of the city limits were examined between August and September 2000 for ocular signs of vitamin A deficiency., Results: Night blindness, Bitot's spot, corneal ulceration, and corneal scars were seen in increased amounts as defined by the World Health Organization among the sampled population., Conclusions: Vitamin A deficiency is a moderate to severe public health problem in children and lactating mothers in Kabul City, Afghanistan.

Purpose: Although originally developed to evaluate quality in manufacturing, statistical process control (SPC) techniques may be applicable to other frequently performed standardized processes. SPC analysis has rarely been used in medicine. We employed SPC charts to analyze the outcomes of one- and two-muscle horizontal strabismus surgery for esotropia and exotropia., Methods: During a 33-month period between October 1, 1998 and July 1, 2001, we evaluated 95 patients undergoing strabismus surgery on either one or two previously unoperated eye muscles in one or both eyes. SPC charts were used to evaluate the success and validity of our surgical guidelines for horizontal recession and resection procedures. Data were divided into 2 groups, patients with esotropia and patients with exotropia, for computerized statistical analysis using QI Analyst (SPSS, Chicago, IL)., Results: Our results after horizontal strabismus surgery, both esotropia and exotropia repair, appear to follow the laws of statistical fluctuation or normal random variation. Our dose-response schedule produced a resultant ocular alignment or exit angle that appeared to be in statistical control, ie, variation from orthotropia that can be expected simply from normal random chance error with only a limited number of outliers., Conclusion: The resultant ocular alignment or exit angle after one- or two-muscle strabismus surgery may be described by standard models of statistical fluctuation. SPC may be a valuable method to analyze the variability of the results of many ophthalmologic procedures or treatments over time with the ultimate goal of producing better patient outcomes by decreasing variability.

Purpose: Tear substitutes are one of the primary treatment modalities for dry eye conditions. The goal of this research was to determine the least costly preserved artificial tear product for treating patients with mild dry eye conditions., Methods: Eight manufacturers' samples of artificial tears were examined to determine the effect of bottle angle on the dispensing drop size, the average drop volume, the number of drops per bottle, the measured volume of a bottle compared with its advertised volume, and the approximate cost per year for dry eye treatment. Drop sizes (mass) were determined by weighing to the nearest milligram. The retail cost was assessed to determine the most economical tear substitute., Results: For all samples tested, a smaller drop was produced when the bottle was held at a 45-degree angle as compared with a 90-degree angle from horizontal. At a 45-degree angle, Natural Tears Formula by Murine and Artificial Tears by Heath Pride produced the smallest drops, less than 0.030 g, closest to the volume of the lacrimal lake. Smaller drop size produced accordingly more drops per bottle. The measured total bottle volume averaged 3.5% more than the volumes stated on the labels. The most inexpensive sample based on cost per year of treatment was Natural Tears Formula by Murine at $11.29 annually., Conclusions: Cost comparison of commercial over-the-counter artificial tears is an important factor to patients being treated for a dry eye condition. Several factors are important when considering the economics of article tear substitutes: drop size, number of drops per bottle, the volume of the bottle, and the cost of treatment per year. Because this information may not be readily available to patients, it is of great importance that physicians educate their patients to make treatment of dry eye as affordable as possible. The least expensive artificial tear treatments could require prolonged use of the same bottle, which may be associated with contamination of the contents of that bottle over time. The potential contamination with the long-term use of artificial tears in a bottle is significant. Patients using the least expensive artificial tear treatments should be advised against prolonged use of the same bottle.