Evaluation of Ophthalmology Residency Program Web Sites

Objective This article evaluates the current availability of information on residency program Web sites that may be of interest to residency applicants.

Design Cross-sectional analysis of 117 Accreditation Council for Graduate Medical Education (ACGME)-accredited ophthalmology residency program Web sites from October 17, 2018 to December 17, 2018.

Methods Programs were identified through the ACGME-specialty search, and the URL links provided by the program were evaluated for directing the user to the institution, department, or residency program. If a link was not functional or not provided, programs were identified through a Google search. Web sites were evaluated for having information on how to apply, application requirements and eligibility, and providing a link to the San Francisco (SF) Match. Educational content included: didactic instruction, rotation overview, research requirement information, active and/or past research, institutional conferences, academic conferences, call schedules, and charitable work. Recruitment content included current residents and faculty and their biographies, graduate placement, salary, benefits, surrounding area information, message from the Program Director, Chair, and/or Chief Residents, surgical statistics, affiliated hospital information, selection criteria, and association links. Data was stratified by program size, geographic region, and top 20 hospitals in ophthalmology by the U.S. News & World Report.

Results Nonfunctional links were provided by 16.2% of programs, and 3.4% did not provide a link. Application instructions were presented by 83% of programs and 77% provided a link to the SF Match. Greater than 80% provided didactic instruction, rotation overviews, research expectations of residents, and faculty and resident listings. Up to half of programs listed information about application requirements and eligibility, call schedules, surgical statistics, academic conferences, charitable work, salary, and selection criteria. A message to applicants was displayed by 48% of programs, and 16% of programs provided association links. Programs with more than 15 residents provided more educational content than programs with less than 12 (p = 0.042). Differences in recruitment content were observed among programs in the Northeast and West, (p = 0.003) and programs in the South and West (p = 0.037). No other differences were observed.

Conclusion The Internet is frequently consulted during the residency application process. Many programs provide basic information, but this can be further optimized to maximize the utility of residency Web sites.

Vision loss with pembrolizumab treatment: A report of two cases

BACKGROUND

Vision loss and other ocular toxicities are rare, but detrimental, side effects of immune checkpoint inhibitors. Herein, we report two patients who developed vision loss while on pembrolizumab treatment.

CASES PRESENTATION

Case 1 - A 58-year-old man was started on pembrolizumab for advanced melanoma. He was tolerating the treatment well. After receiving 14 cycles of pembrolizumab, he developed acute bilateral vision loss and occipital headaches. An emergent ophthalmologic evaluation revealed bilateral shallow choroidal effusion with bilateral focal exudative retinal detachment. After excluding other possible etiologies, inflammatory process secondary to pembrolizumab was suspected. Pembrolizumab was stopped, and the patient was started on a course of systemic and topical steroids. His vision improved within days and he recovered completely within two months. Calculated Naranjo Nomogram score was 7 indicating a "probable" correlation; Case 2 - A 57-year-old man with stage IIIC melanoma was started on adjuvant pembrolizumab. After a few weeks of treatments, he reported minor bilateral vision changes that progressively worsened over a period of six months. An ophthalmologic evaluation revealed bilateral posterior uveitis with right optic disc edema. Pembrolizumab-related inflammatory changes were suspected, and he was started on systemic and topical steroids. His symptoms improved within a few weeks and steroids were tapered. He was re-challenged with pembrolizumab and his symptoms quickly re-occurred. Pembrolizumab was stopped indefinitely and the patient again treated with systemic and topical steroids. His symptoms resolved and his vision returned to baseline within two months. The Naranjo Nomogram score was 9 indicating a "definite" correlation.

CONCLUSIONS

Vision loss is a serious complication that may occur at any point during treatment with PD-1 inhibitors. Vision loss is very distressing to the patients and their families. It is prudent for practitioners to recognize early vision abnormalities in patients receiving PD-1 antagonists to prevent permanent vision loss.

Bisphosphonate-induced orbital inflammation in a patient on chronic immunosuppressive therapy

Background

To report a case of orbital inflammation after bisphosphonate infusion in a patient who was already receiving immunosuppressive therapy.

Case presentation

A 56-year-old woman presented to the ophthalmology clinic with acute onset of right eye pain 24 h after receiving her first Zolendronic acid infusion. She has a past medical history of chronic inflammatory demyelinating polyneuropathy, Sjogren’s syndrome, and systemic lupus erythematosus that have been controlled with immunosuppressive therapy for three years. Clinical ophthalmic exam and MRI studies were significant for right orbital inflammation. The patient was started on oral prednisone with rapid resolution of symptoms.

Conclusions

This is the first case report of a patient receiving chronic immunosuppressive therapy to develop orbital inflammation after Zoledronic acid infusion. In addition, it demonstrates that corticosteroids can be an effective first line therapy in treating orbital inflammation in similar patients. Physicians should be aware of this rare but serious potential side effect of bisphosphonates, and have bisphosphonate-related orbital inflammation on their differential for proper initiation of treatment.

Deep lateral wall orbital decompression following strabismus surgery in patients with Type II ophthalmic Graves' disease

PURPOSE

Surgical management of ophthalmic Graves' disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves' disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia.

METHODS

A case series of four Type II ophthalmic Graves' disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas.

RESULTS

None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD.

CONCLUSIONS

While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves' disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.

A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography

Purpose/Aim: Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure of unknown etiology. A subset of patients has shown benefit from endovascular dural venous sinus stenting (DVSS). We sought to identify a population of IIH patients who underwent DVSS to assess outcomes.

MATERIALS AND METHODS

A retrospective study was performed to identify IIH patients with dural sinus stenosis treated with DVSS. Outcome measures included dural sinus pressure gradients, peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography and improvement in symptoms.

RESULTS

Seventeen patients underwent DVSS. Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient.

CONCLUSIONS

Our series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis.

Farris-Tang retractor in optic nerve sheath decompression surgery

PURPOSE

Our purpose is to introduce the use of the Farris-Tang retractor in optic nerve sheath decompression surgery.

METHODS

The procedure of optic nerve sheath fenestration was reviewed at our tertiary care teaching hospital, including the use of the Farris-Tang retractor.

RESULTS

Pseudotumor cerebri is a syndrome of increased intracranial pressure without a clear cause. Surgical treatment can be effective in cases in which medical therapy has failed and disc swelling with visual field loss progresses. Optic nerve sheath decompression surgery (ONDS) involves cutting slits or windows in the optic nerve sheath to allow cerebrospinal fluid to escape, reducing the pressure around the optic nerve. We introduce the Farris-Tang retractor, a retractor that allows for excellent visualization of the optic nerve sheath during this surgery, facilitating the fenestration of the sheath and visualization of the subsequent cerebrospinal fluid egress. Utilizing a medial conjunctival approach, the Farris-Tang retractor allows for easy retraction of the medial orbital tissue and reduces the incidence of orbital fat protrusion through Tenon's capsule.

CONCLUSION

The Farris-Tang retractor allows safe, easy, and effective access to the optic nerve with good visualization in optic nerve sheath decompression surgery. This, in turn, allows for greater surgical efficiency and positive patient outcomes.

Cytokine profiles in clinical subtypes of ophthalmic Graves' disease

PURPOSE

To examine the association of cytokines in the two clinical subtypes of ophthalmic Graves' disease by comparing cytokine expression in the fat and ethmoid tissue of type I and type II patients.

METHODS

Patients needing orbital decompression or eyelid surgery were identified and enrolled into a prospective study. Patients were assigned to the type I or type II subclassification, based on the presence of diplopia. Orbital fat, sinus tissue or muscle removed during surgery was evaluated. The mRNA expression profiles of Th1 cytokines (TNF-alpha/beta, IFN-gamma, IL-2) and Th2 cytokines (IL-4, IL-5, IL-6, IL-10) were analyzed using real time PCR.

RESULTS

30 patients were enrolled in the study: 5 type I (80% female), 14 type II (71% female) and 11 controls (73% female). There were 14 decompressions (3 type I and 11 type II), 17 lid procedures (2 type I, 4 type II and 11 controls) and 10 ethmoidectomies (3 type I and 7 type II). The average ages were 45, 56 and 66 in the type I, type II and control groups, respectively. There was more TNF-alpha (p value 0.009) and IL-6 (p value 0.04) in ethmoid sinus cells of type II patients compared to ethmoid sinus cells of type I patients and a trend of higher expression of all cytokines in type II patients.

CONCLUSIONS

There is a trend towards greater mRNA expression of both Th1 and Th2 cytokines in both orbital fat and ethmoidal sinus tissue of type II patients compared to type I patients.

Diplopia and ptosis following injection of local anesthesia without hyaluronidase

In a university ophthalmology department, a cluster of postoperative diplopia and ptosis cases occurred in the initial 3 months after hyaluronidase (Wydase) became unavailable for use with injection anesthesia. These cases suggest that hyaluronidase, when used with injection anesthesia, may protect extraocular muscles and nerves from the toxic effects of local anesthetic agents. The spreading action of hyaluronidase facilitates uniform diffusion of anesthetic agents. This prevents elevated extracellular tissue pressure, a cause of ischemic damage to extraocular muscles or nerves. Hyaluronidase may also prevent focal accumulations and concentrations of local anesthetic agents, which at high enough levels may cause myotoxic or neurotoxic damage, fibrosis, and contracture of extraocular muscles or nerves.