Treatment of Steroid-Resistant Nodular Episcleritis With Tacrolimus: A Case Report

A 46-year-old male, with no chronic medical illness, complained of pain, tearing, and redness for one-month duration, with no photophobia, discharge, or decrease in visual acuity. Examination revealed a small, painful, red swelling in the left sclera. Slit-lamp examination using a narrow bright slit beam revealed edema of the episcleral layer and injection of the superficial episcleral blood vessels. The rest of the anterior segment exam and fundoscopy were normal. The laboratory investigations and systemic workup were normal. The patient was initially treated with prednisolone acetate (Pred Forte) 1% every three hours per day for one week, and then four times per day for another week, and tapered gradually over eight weeks with systemic nonsteroidal anti-inflammatory drugs (NSAIDs) as diclofenac sodium for eight weeks with mild improvement of clinical symptoms, but the size of the lesion remained without any change and the patient started to have a relapse of symptoms at the end of the course. Topical tacrolimus drops of 0.1% concentration were prepared in the pharmacy under complete sterile precautions and were used four times per day for the following six weeks duration instead of the initial therapy (steroids and NSAIDs). Tacrolimus drops were then tapered gradually over another six weeks duration. The patient showed dramatic suppression of inflammation and exceptional remission of symptoms with complete resolution of the episcleritis. Topical tacrolimus is very effective in the treatment of nodular episcleritis, which is resistant to steroid therapy. Patients with nodular episcleritis suffer from prolonged bouts of inflammation that are characteristically more painful than the diffuse type and may be associated with other systemic diseases. The case is steroid-resistant nodular episcleritis, which did not respond to the usual treatment and showed a good response to treatment with tacrolimus, which was first introduced in episcleritis. Tacrolimus is being used in other ocular diseases, but its use in episcleritis is unique.

The use of medicinal plants in common ophthalmic disorders: A systematic review with meta-analysis

Purpose

This study aimed to assess and compile the available research articles about medicinal plants used for ocular diseases.

Principal results

A total of 2949 articles were retrieved, 35 full-text articles were assessed for eligibility, and seven studies (4 observational and three experimental) with low to moderate quality were eligible and involved in the systematic review, with a total of 600 plants from 4 countries. Among the 600 plants, only 24 (4%) were used to assess the status. Both the fixed and random models of the studies showed that the included studies tended to predict the results for the observational studies (OR = 0.062, CI = 0.043-0.090 OR = 0.039, CI = 0.012-0.122) for different plants used for ocular diseases. High heterogeneity (estimated as I² = 87.078, Tau² = 1.161 and Q-value = 23.217 with a p-value of 0.000), while for experimental studies (I² = 94.928, Tau² = 23.211 and Q-value = 39.434 with a p-value of 0.000) and publication bias were reported.

Conclusion

Few articles representing approximately 600 plants of low to moderate quality reported using medicinal plants for ocular diseases. The meta-analysis confirmed the systematic review findings regarding the plants' traditional use with high heterogeneity and publication bias. A considerable gap was proven in the use of medicinal plants in ocular diseases requiring intensive research.

Optimal Steps for designing and implementing the extracurriculars through the integrative medical approach

Extracurriculars are those that fall outside the scope of the academic curriculum. The purpose of the work is to outline the steps of planning extracurriculars, practice these steps in the medical program, and evaluate these steps.

Methods

Using Kern's steps with some modifications, we did some extracurricular reforms. Assessment of the current situation/needs and identification of gaps have been occurred by a questionnaire that revealed low students' satisfaction (36.1%) about the current extracurriculars with points of weakness that have been addressed in the improvement plan. A list of extracurriculars was prepared and aligned with modules and learning outcomes. Allocation of resources and implementation of these extracurriculars were performed. The evaluation was done through a questionnaire that was fulfilled by 404 students.

Results

Students' satisfaction was 66.8% in the second questionnaire compared to 36% in the initial questionnaire with a significant association. Further analysis of the respondents who revealed satisfaction showed that 95 out of 140 (67.8%) were high-grade achievers, 88 out of 134 (65.7%) for moderate, and 87 out of 130 (66.9%) in low-grade achievers. A comparison of the student's satisfaction in the three phases revealed a significant p-value (0.004), but no significance in students' satisfaction within phases of the program between males and females.

Conclusion

Well-structured extracurriculars might contribute to the achievement of the mission, vision, and goals of the program. Extracurricular activities might be flexible and undergo periodic changes related to the nature of the curriculum. Following the cycle of developing extracurricular activities in designing, implementing, monitoring, evaluating, and reporting, the extracurricular activities will be more efficient in enhancing the learning climate and making the learning process more enjoyable, especially in a solid medical integrated curriculum.

The efficacy of self-directed learning versus problem-based learning for teaching and learning ophthalmology: a comparative study

INTRODUCTION

Self-directed learning (SDL) and problem-based learning (PBL) are fundamental tools to achieve lifelong learning in an integrated medical curriculum. However, the efficacy of SDL in some clinical courses is debated.

AIM

The aim of the study was to measure the effectiveness of SDL for an ophthalmology course in comparison with PBL.

METHODS

A cross-sectional study was conducted with fifth-year medical students enrolled in an ophthalmology course. SDL comprised four case-based scenarios guided by several questions. PBL comprised three sessions. An ear, nose, and throat (ENT) course was selected for comparison as a control. At the end of the course, 30 multiple-choice questions (MCQs) for both SDL and PBL were assessed and analyzed against their counterparts in the ENT course by an independent t-test.

RESULTS

For the SDL component of the ophthalmology course, the number and percentages of students attaining high (n = 6/60, 10%) and moderate (n = 15/60, 28.3%) scores on an MCQs written exam were evaluated. For the PBL component, high scores were seen for 23.3% (n = 14/60), and moderate scores for 33.3% (n = 20/60) of the participants. For the SDL component of the ENT course, the number and percentages of students attaining high (n = 14/60, 23.3%) and moderate (n = 17/60, 28.3%) scores were recorded. For the PBL component, high (16/60, 26.6%) and moderate (17/60, 28%) scores were recorded. Significant p-values were obtained between the results for SDL and PBL in the ophthalmology course (p = 0.009), as well as between SDL results for both courses (p = 0.0308). Moreover, differences between the SDL results of ophthalmology and the PBL results of ENT (p = 0.0372) were significant.

CONCLUSION

SDL appears to be less valuable for promotion of self-readiness. Periodic discussions in small groups or by panel discussion are strongly recommended for students to enhance readiness with SDL.

A rare and fatal complication of oesophagoscopy. Anaesthetic implications

A 3.5-year-old child developed a tight oesophageal stricture following ingestion of caustic soda. At the end of the fourth anaesthetic for oesophageal dilatation, laryngospasm and difficulty in mask ventilation was followed by cyanosis, bradycardia, and cardiac arrest. Chest X ray showed a large pneumopericardium, which was immediately aspirated, but unfortunately resuscitation was unsuccessful. It was presumed that during attempted manual ventilation of the lungs in the presence of a closed glottis, air had been accidentally forced into the pericardium through a small tear in the fragile oesophagus.