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Objective: To evaluate SCImago’s top ranked ophthalmology journals, comparing them with the top medical and surgical journals. Methods: Data over 20 years was extracted for the top-ranked 20 ophthalmology, top 5 medical, and top 5 surgical journals based on SCImago Journal Ranking (SJR). Trends in SJR, self-citations, external citations per document, uncited documents, international collaboration, citations per document, and total citations were identified. ANCOVA analysis was utilized to further characterize average trends over time between medicine, ophthalmology and surgery. Results and Discussion: The fields of medicine, ophthalmology, then surgery had the highest SJR while medicine, surgery, then ophthalmology had the highest h-indices. Medicine had 1.01 uncited per cited article, compared to 0.54 and 0.43 for ophthalmology and surgery. Percent of self-citation was 5.9% for ophthalmology, 5.0% for surgery, and 0.56% for medicine; however, self-citations per article were the highest for surgery. International collaboration was highest for ophthalmology (19.14%) compared to surgery (16.75%) and medicine (8.00%). Medicine increased disproportionately in SJR (p= 0.0037), citations per document (p Conclusion: Ophthalmology has a lower h-index compared to surgery and medicine but was comparable when using more qualitative measures including SJR and uncited articles. Ophthalmology has the highest number of self-citations and the greatest level of international collaboration.

Grant A Justin,1,2 Mohammed Soleimani,3 Sidra Zafar,4 Kasra Cheraqpour,5 Catherine Green,6 Mohammad Moin,7 N Venkatesh Prajna,8 Karl C Golnik,9 Fasika A Woreta4 1Department of Vitreoretinal Surgery, Duke Eye Center, Durham, NC, USA; 2Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 3Department of Ocular Trauma and Emergency, Tehran University of Medical Sciences, Tehran, Iran; 4Wilmer Eye Institute, Johns Hopkins Medical Institute, Baltimore, MD, USA; 5Department of Eye Research, Tehran University of Medical Sciences, Tehran, Iran; 6Glaucoma Unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; 7Department of Ophthalmology, Amee ud Din Medical College, Lahore, Pakistan; 8Department of Cornea and Refractive Eye Services, Aravind Eye Hospital, Madurai, India; 9Department of Ophthalmology, University of Cincinnati, The Cincinnati Eye Institute, Cincinnati, OH, USACorrespondence: Grant A Justin, Department of Vitreoretinal Surgery, Duke Eye Center, Durham, NC, USA, Tel +1 609-468-2468, Email grant.a.justin@gmail.comBackground/Aims: To produce an internationally developed rubric to assess surgical competency in open globe management.Methods: An international expert panel of seven ophthalmologist educators developed a standardized competency-based rubric. The steps to perform an open globe repair were outlined. Based on a modified Dreyfus model, the experts agreed on the steps of surgery and certain global indices. They then assigned descriptors for the competency expected of a novice, beginner, advanced beginner, and competent surgeon. The tool was then vetted by another panel of ten ophthalmologists. The main outcome measure was the final version of the tool as agreed upon by the expert review panel.Results: The steps of open globe repair and key global indices were established. Descriptive wording for each step and global indices for novice, beginner, advanced beginner, and competent surgery were listed. All the expert comments were integrated to establish face and content validity.Conclusion: This standardized rubric to evaluate resident competency should be used globally in training programs to assess open globe repair surgical skills. Using a modified Dreyfus model, four different levels of training competency were defined allowing a non-biased, objective, numerical and simple assessment.Keywords: open globe, resident education, surgical competency

To determine global current practice patterns for the management of open globe injuries and identify areas of variation.Cross-sectional survey.An online survey assessed global management paradigms for open globe injuries from August 2020 to January 2021. Responses were collected from experts at eye trauma centers and emergency departments worldwide who manage ≥1 open globe injury per month. The survey assessed the use/selection of antibiotics and steroids, procedural and imaging decisions, and admission practices for open globe injuries.Responses were received from representatives of 36 of 42 institutions (85.7%), of which 33 (78.6%) had sufficient trauma volume to be included. Included responses were distributed across North America (n=12, 36.4%), Asia (n=12, 36.4%), South America (n=4, 12.1%), Africa (n=3, 9.1%), Europe (n=1, 3.0%), and Australia (n=1, 3.0%). Preoperative systemic antibiotics for open globe injuries were administered by 75.8% (n = 25/33) of institutions, while 30.3% (n = 10/33) administered preoperative topical antibiotics. Intraoperative ophthalmic antibiotics for open globe injuries were used by 54.5% (n = 18/33) of experts. Most institutions also administered postoperative systemic antibiotics (n = 23 [69.7%]) and topical steroids (n = 29 [87.9%]), although specific medication choices diverged. At 19 responding centers (61.3% of the 31 that had trainees), residents participated in surgical repairs. Many institutions discharged patients after repair, but 54.5% (n = 18/33) of locations routinely admitted them for observation.Preferred management practices for open globe injuries vary widely. To ensure the highest standard of care for all patients, evidence-based international guidelines for the treatment of these injuries are needed.

To investigate the global practice patterns for the management of exogenous endophthalmitis. This cross-sectional study was conducted to assess global practice patterns for the management of exogenous endophthalmitis. An online survey comprised of questions regarding the management of exogenous endophthalmitis was distributed to institutions who are members of International Globe and Adnexal Trauma Epidemiology Study Group (IGATES) or invited affiliates of the American Society of Ophthalmic Trauma and the Asia Pacific Ophthalmic Trauma Society. Responses were gathered from August 2020 to January 2021. Of 42 institutions, 36 responses were received (86% response rate), of which 33 (79%) were included in the analysis. Included centers were from Asia (36%), North America (36%), South America (12%), Africa (9%), Europe (3%), and Australia (3%). Oral antibiotics were administered in 19 (58%) institutions, with moxifloxacin as the preferred agent (n = 9, 27%). The preferred method for obtaining cultures was vitreous tap (n = 25, 76%). Most institutions (n = 26, 79%) routinely administered intravitreal vancomycin and ceftazidime, while intravitreal steroids were routinely administered at 11 centers (33%). Indications for performing vitrectomy included; decreased visual acuity (n = 14, 39%); all cases of exogenous endophthalmitis (n = 4, 12%); non-response to medical therapy (n = 4, 12%); or no view of the fundus (n = 4, 12%), indicating significant variation in surgical indications. More than half (n = 17, 52%) of responding institutions routinely admitted patients with exogenous endophthalmitis to the hospital. Institutions in the United States were less likely to administer oral antibiotics (27% vs. 73%, P = .024) and to admit patients (9% vs. 73%, P This study highlights the global variations in the management of exogenous endophthalmitis, especially as it pertains to surgical indications. Further establishment of evidence-based guidelines may be beneficial to provide more uniform guidance to optimize outcomes.

To analyze the top 100 cited papers on ophthalmic trauma.A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma.The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2).This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

BACKGROUND/PURPOSE To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

We report use of cyanoacrylate (N-butyl-Cyanoacrylate) in previously failed retinal reattachment surgeries for chorio-retinal colobomas. We report the surgical technique, its challenges, and long-term outcomes in three patients who underwent the surgery.A chart review of patients with chorio-retinal colobomas and retinal detachment repair with cyanoacrylate at a tertiary eye care center in Nepal. Cyanoacrylate was used to seal colobomatous retinal breaks in eyes which had undergone multiple retinal surgeries with failed outcome.Three eyes that were operated using cyanoacrylate were included. All three patients had attached retina and none of the patients required a long-term tamponading agent. None of the patients underwent head positioning following the surgery. All of the patients had a visual acuity gain of 3/60 or more at the end of 8 months. No adverse or inflammatory reactions were noted.We demonstrate that cyanoacrylate is safe and less resource-demanding without a requirement of second surgery to remove a tamponading agent. It could be helpful in eyes with persistent retinal detachment in colobomatous eyes. Because we were able to achieve favorable outcomes without head positioning, we believe it may also be helpful in patients who are not suitable for positioning because of bodily or bony deformities and in retinal detachment with other coexisting trauma.

Sarah C Miller,1 Prajna Meeralakshmi,2 Michael J Fliotsos,3 Grant A Justin,4 Yoshihiro Yonekawa,5 Ariel Chen,1 Annette K Hoskin,6,7 Richard J Blanch,8– 10 Kara M Cavuoto,11 Rebecca Low,12 Ximin Li,1,13 Matthew Gardiner,14 TY Alvin Liu,1 Ankoor S Shah,14 James D Auran,15 Rupesh Agrawal,12,16– 18 Fasika A Woreta1 On behalf of The International Globe and Adnexal Trauma Epidemiology Study (IGATES)1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Aravind Eye Hospital, Madurai, India; 3Department of Ophthalmology, Yale New Haven Hospital, New Haven, CT, USA; 4Vitreoretinal Surgery Service, Duke Eye Center, Durham, NC, USA; 5Wills Eye Hospital, Mid Atlantic Retina, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA; 6Save Sight Institute, University of Sydney, Sydney, Australia; 7Lions Eye Institute, University of Western Australia, Perth, Australia; 8Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England; 9University Hospitals Birmingham, NHS Foundation Trust, Birmingham, England; 10Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, England; 11Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA; 12Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore; 13Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 14Massachusetts Eye and Ear Infirmary, Boston, MA, USA; 15Columbia University Irving Medical Center, New York City, NY, USA; 16Singapore Eye Research Institute, Singapore; 17Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; 18Duke NUS Medical School, SingaporeCorrespondence: Fasika A Woreta, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21205, USA, Tel +410-961-2868, Fax +410-614-9632, Email fworeta1@jhmi.edu Rupesh Agrawal, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore Eye Research Institute, Lee Kong Chian School of Medicine, Nanyang Technological University, Duke NUS Medical School, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore, Tel +6563571000, Email Rupesh_agrawal@ttsh.com.sgPurpose: Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide.Methods: A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution.Results: For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution.Conclusion: Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.Keywords: current practices, hyphema, trauma, sickle cell, anterior segment

BACKGROUND AND OBJECTIVE: The goal of this study was to determine the anatomic outcome of traumatic retinal detachment (RD) from combat ocular trauma. MATERIALS AND METHODS: Retrospective study of patients sustaining a traumatic RD in Operation Iraqi Freedom and Operation Enduring Freedom who were evacuated to Walter Reed Army Medical Center from 2001 to 2011. The Fisher exact test, Wilcoxon rank sum test, and Agresti and Coull methods were used for analyses. RESULTS: There were 143 eyes of 134 patients in which a traumatic RD developed, of a total of 890 eyes of 652 patients in the Walter Reed Ocular Trauma Database. Based on our results, predictors for failure to reattach the retina include maculaoff status ( P = .0002), open-globe injury ( P = .03), proliferative vitreoretinopathy postoperatively ( P = .002), and presence of hyphema ( P = .02). Intraocular foreign body and time to initial retinal surgery did not increase risk for failure. Thirty-four percent (34%) of eyes failed to be reattached. CONCLUSIONS: Traumatic RD due to injury sustained in a combat zone resulted in poor prognosis, with 82.09% of eyes with RD having a best-corrected visual acuity worse than 20/200. The anatomic success of RD repair was shown to be 65.71%, likely owing to the severity of the injuries, concomitant systemic injuries, and delayed surgical intervention. [ Ophthalmic Surg Lasers Imaging Retina 2022;53:493–501.]

To analyze the 100 most cited articles pertaining to endophthalmitis using bibliometric analysis. An all-time Web of Science literature search and refined to peer-reviewed articles in the field of ophthalmology with the keyword “endophthalmitis” was completed. Total citation count of articles published pertaining to endophthalmitis, topic, incidence rate, publishing journals, year published, language, country of origin, number of authors, names of the first and last authors, study type, and number of patients/eyes studied. The top 100 most cited articles pertaining to endophthalmitis had a mean citation count of 362.92, with a range of 175 to 3583. They were published in 20 peer-reviewed journals, with Ophthalmology publishing the most (n = 42). Thirteen different countries were represented, with the majority (n = 77) originating from the USA. The most common study type was clinical experiences (n = 52), though eight of the top ten were clinical trials. The number of patients varied widely, represented by a mean of 9680, but with a median of only 229. The majority (n = 67) examined the incidence of endophthalmitis which included 24 articles after anti-vascular endothelial growth factor injections, 18 after ocular surgeries/procedures, 15 after intraocular steroid injections, eight after chemotoxic drug use, and three after ocular injuries. This bibliographic study serves as a unique historical analysis of the top 100 cited scholarly articles pertaining to endophthalmitis with many of the articles related to post-procedural endophthalmitis.

Ophthalmic disease in people living with HIV (PLWH) and at-risk controls in Sub-Saharan Africa was evaluated. PLWH were more likely to have ophthalmic disease at enrollment, but there was no difference in incidence once enrolled.

Michael J Fliotsos,1 Donovan Stephen Reed,2 Gregory Giles,3 Adam HH Altman,2 Joseph A Santamaria,2 Sidra Zafar,1 Darrel K Carlton,3 Anthony J Johnson,3 Brett W Davies,2 Gary L Legault,3,4 Fasika A Woreta,1 Grant A Justin3,4 1Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of Ophthalmology, Wilford Hall Eye Center, San Antonio, TX, USA; 3Department of Ophthalmology, Brooke Army Medical Center, San Antonio, TX, USA; 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USACorrespondence: Michael J FliotsosWilmer Eye Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USATel +1-260-409-7314Email michael.fliotsos@yale.eduPurpose: To describe the frequency and type of eye injuries in fighters in mixed martial arts (MMA) competition.Methods: Fight result data were collected from the Nevada Athletic Commission database from 2001 to 2020. Any fighters in a professional mixed martial arts (MMA) contest with an eye injury were included. Main outcome measures included frequency and rate of eye injuries per fight and the types of eye injuries. Secondary outcome measures were gender, laterality, decision type, and length of no-contact recommended.Results: Of the 256 MMA events in the database, 187 events (73.3%) had at least one eye injury. Of a total 2208 fights at these events, there were 363 fighters who sustained 369 eye injuries, with the yearly rate of eye injuries per 100 fighters ranging from 2.56 to 12.22. The most common injuries were eyebrow and eyelid lacerations (n=160, 43%), lacerations around the eye (n=98, 27%), and orbital fractures (n=62, 17%). Most eye injuries were right sided (n=197, 53.3%) and the majority of fighters with eye injuries lost their match (n=228, 62.8%). Fifty-seven fighters were recommended for further ophthalmology clearance after the match. The most common reasons for recommended ophthalmology follow-up was orbital fracture (n=25, 44%) and retinal injury (n=7, 12%). Forty-three fighters received no-contact requirements relating to their injury for an average of 8.9 weeks (range 1– 24 weeks).Conclusion: Ophthalmic injuries in professional MMA were prevalent, were most often lacerations surrounding the eye, and often accompanied the fighter losing their match.Keywords: ophthalmic trauma, eye trauma, mixed martial arts, boxing, MMA, combat sports

Introduction American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. Methods We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. Results Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. Conclusion Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

Purpose: This work reports the association of obstructive sleep apnea (OSA) and cotton-wool spots (CWS) seen in patients with nonproliferative diabetic retinopathy (DR). Methods: A random sample of patients diagnosed with DR between January 1, 2015 and December 31, 2018, were selected from medical-billing codes. Dilated funduscopic examination findings and medical history were analyzed by reviewing medical records. Results: CWS were present in 12 of 118 patients without OSA, compared with 11 of 32 patients with OSA (10.2% vs 34.4%, respectively; P = .002). OSA was more common in men (68.8%, P = .03) and associated with a higher body mass index (30.0 ± 5.0 without OSA vs 33.6 ± 5.5 with OSA, P < .001). When comparing those with and without OSA, there was no association with age; glycated hemoglobin A1c; stage of DR; insulin dependence; presence of diabetic macular edema; smoking status; or a history of hypertension, hyperlipidemia, cardiovascular disease, or other breathing disorder. Conclusions: The presence of OSA is associated with CWS in patients with DR, as well as male sex and a higher body mass index. Further research is needed to determine the ophthalmologist’s role in the timely referral of patients with CWS for OSA evaluation.

Background Open globe injury (OGI) is one of the most devastating form of ocular trauma. The aim of the study is to identify the epidemiology and predict visual outcomes in traumatic open globe injuries using ocular trauma score (OTS) and correlate with final visual acuity (VA) at 3 months. Methods Patients older than 5 years, presenting to B.P. Koirala Lions Centre for Ophthalmic Studies (BPKLCOS) from March 2016- March 2017 with OGI that met inclusion criteria were evaluated. Patient profile, nature and cause of injury, and time to presentation were recorded. Patients were managed accordingly and followed up to 3 months. An OTS score for each patient was calculated and raw scores were categorized accordingly. The VA after 3 months were compared to the predicted OTS values. Results Seventy-three eyes of 72 patients were examined. 76 % were male, and the mean age was 26.17 years (median, 23.5 years). The mean time from injury to presentation was Conclusions OTS can be an accurate predictive tool for final visual acuity even with a short follow up period of 3 months; with poor presenting visual acuity, delayed presentation, posterior zones of injury, need for intravitreal injections, endophthalmitis, and globe rupture associated with poorer prognosis.

To describe the presentation, features, and outcomes of patients with Vogt-Koyanagi-Harada disease (VKH) seen by uveitis specialists in Oklahoma. Clinical data were collected for 26 patients (52 eyes) diagnosed with VKH and seen between 1992 and 2018. Main outcome measures included rates of visual loss, ocular complications, and remission. There were 11 Native American (NA) patients (11/26, 42.3%) and 15 non-Natives (n-NA). NA VKH patients were significantly more likely to present at a younger age (18.6 years) than n-NA VKH patients (30.1 years) (p = 0.023). NA patients were less likely to have meningismus (0.00 vs. 42.9%; 0.048) or systemic symptoms (50.0% vs. 93.3%; p = 0.023) than n-NA patients, but more likely to develop cataracts (100.0% vs. 66.7%; p = 0.003). There were similar rates of macular edema, epiretinal membrane, subretinal fibrosis, and recurrent uveitis between the two groups. Oral corticosteroid use was similar between both groups (72.7% vs. 86.7%; p = 0.61). VKH may manifest with earlier disease course in NA patients than n-NA patients, particularly regarding ocular findings. However, NA patients were less likely to have systemic symptoms than n-NA patients.

BACKGROUND AND OBJECTIVE: To determine the risk factors associated with developing proliferative vitreoretinopathy (PVR) from combat ocular injuries in U.S. service members. PATIENTS AND METHODS: Retrospective review of associated risk factors and outcomes of PVR within the Walter Reed Ocular Trauma Database. Ocular injuries in U.S. service members wounded during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2011 were assessed, and of these all cases of PVR were studied. Principal outcome measures were the risk factors associated with PVR development and rate of final visual acuity (VA) less than 20/200. RESULTS: Eight hundred ninety eyes of 651 U.S. service members were evaluated. A total of 76 eyes (8.5%) of 66 patients developed PVR. Five patients had bilateral PVR. Nineteen patients had bilateral eye injuries. Sixty-one eyes (80.2%) had a final VA less than 20/200. PVR was found to be a significant risk factor for a poor final VA ( P < .001). Retinal detachment (RD) was found in 52 eyes (68.4%) of patients. In patients with a RD, intraocular foreign bodies (IOFBs) ( P < .001), unsuccessful repair ( P = .002), and macular hemorrhage ( P = .04) were significant risk factors for the development of PVR. Time to initial retina surgery was not found to be a risk factor for PVR development ( P = .5). Time to initial retina surgery was available in 41 patients and the time to surgery on average was 22.56 days (range: 3 to 87 days). CONCLUSIONS: PVR occurs frequently in combat trauma and is a significant cause of poor final VA. In patients with PVR and RD, injuries caused by an IOFB, macular hemorrhage, or unsuccessful repair were significant risk factors for the development of PVR. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:556–563.]

To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes.There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1-2 (20/15 - 20/200), while 29.9% of patients had final VA grades of 3-5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%.Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

Introduction There is a growing trend of multidrug-resistant organisms (MDRO). The goal of this study was to characterize MDRO at a single center from ophthalmic cultures to better understand how treatments were tailored and to assess effect on visual acuity. Materials and Methods The MDRO data were collected by the Multidrug-Resistant Organism Repository and Surveillance Network from the Brooke Army Medical Center clinical laboratory. Both patient- and isolate-specific data were collected and qualitatively analyzed. Primary outcome measures were organism and type of resistance, anatomic location of isolate, initial and final antibiotic choice, and visual acuity. Results Thirty-one bacterial culture samples were analyzed from 29 patients. Twenty-two (72%) were Gram-positive and all were methicillin-resistant Staphylococcus aureus (MRSA). Nine (29%) were Gram-negative and of these five were Pseudomonas spp. Fourteen (45%) isolates were cultured from the cornea, nine (29%) from the lid, four (13%) from the conjunctiva, and four (13%) from other locations. The majority (66.6%) required adjustment of initial antibiotics following ocular culture results. Sixteen adult patients had recorded initial and final visual acuities. Fifteen of those 16 patients had stable or improved visual acuities following treatment of the infection, but five patients had a final visual acuity less than 20/200. Conclusion This study demonstrated a high frequency of corneal MDRO infections and specifically MRSA and Pseudomonas spp. isolates. Antibiotic treatments frequently required adjustment. Further prospective study of visual outcomes from ophthalmic MDRO cultures is needed.

BACKGROUND AND OBJECTIVE: To report and analyze the causes and outcomes of vitreoretinal surgery and medical retina malpractice litigation. PATIENTS AND METHODS: The WestLaw database was reviewed for all vitreoretinal malpractice litigation in the United States between 1930 and 2014. RESULTS: One hundred forty-two retina cases were included. Overall, 64.1% of cases were resolved in favor of defendants. Eighty-three (58.5%) cases were resolved via jury trial, 30.1% of which were associated with plaintiff verdicts with mean adjusted jury award of $5,222,894 (median, $691,974). Eight cases (5.6%) resulted in settlements with mean adjusted indemnity of $726,003 (median: $437,165). Jury awards were higher than settlement awards ( P = .04). Commonly litigated scenarios included retinal detachment (46.5%) and retinopathy of prematurity (9.2%). CONCLUSIONS: The complexity of treating vitreoretinal problems and the high potential for vision loss inherent in many diagnoses make treating retinal problems high-risk. Many cases in this series resulted in multi-million-dollar plaintiff awards. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:272–278.]

Introduction Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI. Materials and Methods A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher’s exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI. Results When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99). Conclusions Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI.

Mya Abousy,1 Andy Schilling,1 Mary Qiu,2 Grant A Justin,3 Fatemeh Rajaii,1 Ximin Li,1 Fasika A Woreta1 1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of Ophthalmology, University of Chicago Medicine, Chicago, IL, USA; 3Department of Ophthalmology, Walter Reed National Military Medical Center, Bethesda, MD, USACorrespondence: Fasika A Woreta, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA, Email fworeta1@jhmi.eduPurpose: To describe ophthalmology resident experience with ophthalmic trauma cases in the U.S. Methods: We analyzed Accreditation Council for Graduate Medical Education (ACGME) case log data and de-identified case logs from US ophthalmology residency programs for residents graduating in 2018.  Current Procedural Terminology (CPT) codes documented as “Globe Trauma” and  trauma-related “Oculoplastic and Orbit” codes including lid lacerations and lateral canthotomies were analyzed.Results: 38 residency programs provided case logs (response rate: 32.2%). Residents performed an average of 7.24± 4.37 open globe repairs, 8.66± 6.94 lid laceration repairs, 0.49± 1.4 orbital fracture repairs, 1.22± 1.81 lateral canthotomies, and 0.28± 0.69 anterior chamber washouts as primary surgeon. On average, the most logged “Globe Trauma” procedure was open globe repair as primary surgeon. The more common trauma-related “Oculoplastic and Orbit” procedure was lid laceration repair as primary surgeon.  42.8% of residents did not log any lateral canthotomy procedures. Medium programs performed significantly more canthotomies than large programs (F(2166) = 6.35, p = 0.002), and large programs performed significantly more orbital fracture repairs than small and medium programs (F(2166) = 4.45, p = 0.013).Conclusion: Significant variation in globe trauma volume exists across programs. ACGME guidelines require a minimum of four globe trauma procedures for graduation, but procedures like anterior chamber paracentesis count towards this requirement. Open globe repairs, simple lid lacerations, and lateral canthotomies are basic skills every graduating resident should be competent in. Updating ACGME case log requirements for ophthalmic trauma and increasing opportunities for wet lab simulations may assist in ensuring graduating ophthalmology residents’ competency in performing these procedures.Keywords: globe trauma, ACGME, education, residency, surgical education

To evaluate the rates of ghost and honorary authorship in ophthalmology and to determine risk factors associated with ghost and honorary authorship.Cross-sectional survey.Corresponding authors of articles published in Ophthalmology, JAMA Ophthalmology, and the American Journal of Ophthalmology from June 2019 to December 2020 were emailed an electronic survey. The rates of ghost and honorary authorship, demographic characteristics of the corresponding authors with and without ghost and honorary authorship, and risk factors for ghost and honorary authorship were evaluated.Corresponding authors (n = 830) were emailed a survey and 278 total responses (34.1%) were received; 227 responses (27.9%) were complete and included for analysis. Most respondents (n = 206, 90.7%) believed that the International Committee of Medical Journal Editors (ICMJE) guidelines for authorship adequately address criteria for authorship. Twenty-seven corresponding authors (11.9%) reported characteristics of their articles that indicated the presence of both ghost and honorary authorship (95% CI, 7.7%-16.1%). One hundred fifteen (50.7%) reported honorary authorship (44.2%-57.2%), and 37 (16.3%) indicated ghost authorship (11.5%-21.1%). Being a resident or fellow corresponding author increased the risk of honorary authorship (OR 11.75; 1.91-231.57; P = .03). There were no factors that predicted articles having ghost authors.While many authors believe the ICMJE guidelines for authorship comprehensively delineate fair authorship practices, listing authors on scientific publications honorarily and excluding authors who qualify for authorship are relatively common practices in ophthalmological research. Further investigation into the drivers of honorary and ghost authorship practices in ophthalmology, and the effectiveness of preventive measures are needed to ensure fair authorship attributions.

PURPOSE To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. RESULTS Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). CONCLUSIONS Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Purpose To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. Methods The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. Results One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). Conclusion Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

ImportanceOcular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings.ObjectiveTo update terminology for globe and adnexal trauma.Design, Setting, and ParticipantsA 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma–related peer-reviewed articles.Main Outcomes and MeasuresExpert consensus on ocular and adnexal terms.ResultsA total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology.Conclusions and RelevanceThere was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

To analyze the 100 most cited articles pertaining to endophthalmitis using bibliometric analysis.An all-time Web of Science literature search and refined to peer-reviewed articles in the field of ophthalmology with the keyword "endophthalmitis" was completed. Total citation count of articles published pertaining to endophthalmitis, topic, incidence rate, publishing journals, year published, language, country of origin, number of authors, names of the first and last authors, study type, and number of patients/eyes studied.The top 100 most cited articles pertaining to endophthalmitis had a mean citation count of 362.92, with a range of 175 to 3583. They were published in 20 peer-reviewed journals, with Ophthalmology publishing the most (n = 42). Thirteen different countries were represented, with the majority (n = 77) originating from the USA. The most common study type was clinical experiences (n = 52), though eight of the top ten were clinical trials. The number of patients varied widely, represented by a mean of 9680, but with a median of only 229. The majority (n = 67) examined the incidence of endophthalmitis which included 24 articles after anti-vascular endothelial growth factor injections, 18 after ocular surgeries/procedures, 15 after intraocular steroid injections, eight after chemotoxic drug use, and three after ocular injuries.This bibliographic study serves as a unique historical analysis of the top 100 cited scholarly articles pertaining to endophthalmitis with many of the articles related to post-procedural endophthalmitis.

Purpose The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI). Methods This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory. Results Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009) Conclusions Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population’s overall clinical presentation and daily functions.

To review ophthalmic trauma malpractice claims in the Ophthalmic Mutual Insurance Company (OMIC) database to determine the frequency and causes of litigation.A retrospective case series analysis of ophthalmic trauma claims from 2009 to 2019 was completed. Cases were selected only if the injury was secondary to trauma (e.g., fall, gunshot wound, paintball injury, etc.); iatrogenic traumatic surgical injuries were excluded.31 closed cases associated with 40 total claims related to ophthalmic trauma out of 2565 claims (1.56%) in the OMIC database were analysed. 13 of the 31 cases (41.9%) were decided for the plaintiff. In decisions for the plaintiff, the median settlement amount was $330,000 (range $125,000-$1,000,000). The most frequent initial diagnoses were corneal abrasion (n = 10), hyphema (n = 5) and open-globe injury (n = 5), and the most common final diagnoses were endophthalmitis (n = 8), intraocular foreign body (n = 7) and retinal detachment (n = 7). The most common causes of malpractice litigation were a delay in referral or follow-up (n = 11) and failure to get appropriate imaging (n = 8). In the 13 cases decided for the plaintiff, experts concluded nine did not meet standard of care.Ophthalmic trauma malpractice claims are very uncommon in the United States, however, the payout is higher than non-trauma settlements, and approximately 40% of cases were decided for the plaintiff. Care could be improved with a careful history and complete ophthalmic examination (with dilated fundoscopy), imaging in appropriate patients, meticulous documentation, and early sub-specialist referral when the diagnosis or management plan was unclear.

To describe and assess the cataract experience of ophthalmology residents throughout the United States (U.S.). Cataract procedures logged by graduating ophthalmology residents nationwide and published by the Accreditation Council for Graduate Medical Education (ACGME) from 2009 to 2020 were analyzed using linear regression on log-transformed response variables with robust variance. As primary surgeon, average numbers logged for phacoemulsification increased yearly by an average of 4.1% prior to 2019 and then decreased by 22.1% in 2019 for an overall average yearly increase of 2.9% (95% CI: 0.5, 5.4%, p = .03), non-phacoemulsification extracapsular extraction decreased yearly by an average of 4.6% (95% CI: −7.7, −1.5%, p = .01), other cataract/intraocular lens surgeries decreased yearly by an average of 8.4% (95% CI: −10.1, −6.6%, p < .001), anterior vitrectomies decreased yearly by an average of 12.5% (95% CI: −14.9, −10.1%, p < .001), and laser capsulotomies increased yearly by an average of 6.0% prior to 2019 and then decreased by 3.0% for an overall average yearly increase of 5.3% (95% CI: 4.5, 6.2%, p < .001). As assistant, average numbers logged in all ACGME minimum categories showed decreasing trends. Over the last decade, the average numbers of phacoemulsification and laser capsulotomies logged by residents as primary surgeon increased while other ACGME cataract minimum procedures decreased. Surgical volume in 2019–20 was lower due to the coronavirus disease-19 pandemic but higher than from 2009 to 2013.