[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To develop and assess the validity of an evaluation tool to assess quantitatively the hydrodissection and phacoemulsification portions of cataract surgery performed by residents. DESIGN: Case series. SETTING: Jules Stein Eye Institute, Olive View-UCLA Medical Center, and Veterans Administration Medical Center, Los Angeles, California, USA. METHODS: The UCLA ophthalmology faculty members were surveyed and the literature was reviewed to develop a grading tool consisting of 15 questions to evaluate surgical technique, including questions from the Global Rating Assessment of Skills in Intraocular Surgery and from the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric. Video clips of the hydrodissection and phacoemulsification portions of cataract surgery performed by 1 postgraduate year 2 (PGY2) resident, 1 PGY3 resident, 2 PGY4 residents, and an advanced surgeon were independently graded in a masked fashion by an 8-member faculty panel. RESULTS: Eleven of the 15 questions had a significant association with surgical experience level (P<.05, analysis of variance). Interobserver variability in grading yielded intraclass correlation coefficients between 0.28 and 0.72. The questions with the lowest interobserver variability were hydrodissection questions on instrument handling, flow of operation, and nucleus rotation. Nucleus cracking also had low variability. Less directly visible tasks, especially 3-dimensional tasks, had wider interobserver variability. CONCLUSIONS: Surgical performance can be validly measured using an evaluation tool. Improved videography and studies to identify the best questions for evaluating each step of cataract surgery may help ophthalmic educators more precisely measure training outcomes for improving teaching interventions. (C) 2014 ASCRS and ESCRS
Journal of Cataract and Refractive Surgery 09/2014; 40(9):1506-1513.e4. DOI:10.1016/j.jcrs.2013.11.048 · 2.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate the utility of corneal biopsy in the evaluation of infectious keratitis; to compare results of culture and histopathologic examination of the same specimens; to investigate potential factors related to positive biopsy results.
Retrospective, observational case series.
We reviewed medical records for all patients who underwent corneal biopsy because of infectious keratitis at the Jules Stein Eye Institute from June 1989 through June 2009. In general, biopsy specimens were both cultured and examined histopathologically. Lesion size, lesion progression, and interval from presentation to biopsy were analyzed as possible predictors of positive biopsies.
Organisms were identified in 20 of 48 (42%) consecutive biopsies (positive cultures in 9 of 47 cases [19%]; positive histopathologic examination in 19 of 47 cases [40%]). Culture and histopathologic results were concordant in 30 of 46 biopsies (65%) for which both techniques were performed; 10 of the 16 discordant cases were culture-negative/histopathology-positive, while the remaining 6 had positive but discordant results for the 2 techniques (cultures all showed bacteria; histopathologic examination showed fungi or cysts consistent with Acanthamoeba sp.). Corneal biopsy revealed microorganisms in 12 of 27 patients (44%) with negative cultures of corneal scrapings obtained at presentation. None of the potential risk factors was statistically associated with positive biopsies.
Corneal biopsy can be useful for identifying the cause of infectious keratitis in selected cases. Culture and histopathologic examination can provide complementary information, but discordant results may occur. Acanthamoebic and fungal infections are more likely to be identified by histopathologic examination.
American Journal of Ophthalmology 05/2012; 154(3):512-519.e2. DOI:10.1016/j.ajo.2012.03.014 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To develop and assess the validity of an evaluation tool to quantitatively assess the capsulorhexis portion of cataract surgery performed by residents.
University of California at Los Angeles (UCLA), Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA.
Masked prospective case series.
Ophthalmology faculty members at UCLA were surveyed and literature was reviewed to develop a grading tool comprising 12 questions to evaluate surgical technique, including 4 from the Global Rating Assessment of Skills in Intraocular Surgery and 2 from the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric. Video clips of continuous curvilinear capsulorhexis (CCC) performed by 2 postgraduate year (PGY) 3 residents, 2 PGY 4 residents, and 2 advanced surgeons were independently graded in a masked fashion by a 7-member faculty panel.
Four questions had low interobserver variability and a significant correlation with surgical skill level (intraclass correlation coefficient >0.75; P<.05, analysis of variance; 42 observations). The 4 questions were visual Likert-scale questions grading flow of operation, set up for regrasp, commencement of flap and formation, and circular completion of the CCC.
Surgical performance can be validly measured using an evaluation tool. However, not all evaluation questions produced reliable results. The reliability and accuracy of the measurements appear to depend on the form and content of the question. Studies to optimize assessment tools identifying the best questions for evaluating each step of cataract surgery may help ophthalmic educators more precisely measure outcomes for improving teaching interventions.
No author has a financial or proprietary interest in any material or method mentioned.
Journal of Cataract and Refractive Surgery 05/2012; 38(5):799-806. DOI:10.1016/j.jcrs.2011.11.046 · 2.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This is a prospective study in an urgent-care ophthalmic setting to investigate contact lens (CL) complications and their association with extended wear (EW).
Data on CL designs, care system(s), and ocular complications were collected over a 6-month period.
One thousand three hundred and sixty-nine patients presented to the Jules Stein Eye Institute urgent care with symptoms of eye problems. Of these, 56 were identified with diagnoses etiologically associated with CL wear, and 49 were studied. The five most common ocular diagnoses found in our study were in the following order: epithelial staining or abrasion/epithelial defect, conjunctival injection, papillae, corneal neovascularization, and presumed microbial keratitis (PMK). Fifteen of 49 patients were diagnosed with PMK. The mean number of complications was 3.43 per eye. Most of the patients (65%) reported some form of EW. Analysis of the patients with PMK showed an association with EW. There seemed to be no statistical difference in the number of complications per symptomatic eye with hydrogel and silicone hydrogel lenses although 13 of the 15 patients with PMK were silicone hydrogel wearers.
We studied various aspects of care and compliance in an urgent-care population and found that most of our urgent-care patients slept with CLs on their eyes. Symptomatic CL wear-related complications, and specifically MK, strongly correlate with EW with less relation to lens design, material, and wear modality. We therefore conclude that CL EW is a risk factor leading to urgent-care visits.
[Show abstract][Hide abstract] ABSTRACT: To determine incidence and risk factors for graft failure following penetrating keratoplasty (PK) in eyes with Ahmed valves (AV).
Retrospective, observational cohort study.
Patients who underwent PK after AV implantation (both performed at our institution through 2004) were studied. Intervals to graft failure (defined as either dysfunction [stromal thickening with retention of clarity] or decompensation [central microcystic edema or loss of clarity]) were analyzed using Kaplan-Meier technique. Risk factors for graft failure were analyzed using Cox proportional hazard models.
Included were 77 eyes (77 patients; first procedure 1993). Following PK, 40 eyes (52%) required increased numbers of glaucoma medications; 10 eyes (13%) required additional glaucoma drainage device(s). Graft failure at 1, 2, and 3 years was 42.4% (95% confidence interval: 32.0%-54.6%), 57.1% (45.6%-69.1%), and 59.1% (47.5%-71.2%), respectively. Prior PK (HR 2.38, P = .006) and stromal vessels (HR 2.90, P = .0005) were associated with increased risk of graft failure. Use of glaucoma medications (HR 0.27, P = .009) and evidence of lower intraocular pressures (IOP) during follow-up (excluding hypotony; HR 0.92, P = .010) were associated with reduced risk of graft failure. Endothelial rejection episodes were observed in 13 eyes (17%); however, rejection was not a risk factor for graft failure (P = .98).
Long-term survival of corneal grafts is poor in eyes with AV. The majority of graft failures are associated with progressive loss of endothelial function, without observed immunologic rejection. Despite the presence of an AV, escalation in glaucoma therapy often follows PK; graft failure may be related to poor IOP control.
American Journal of Ophthalmology 08/2010; 150(2):169-78. DOI:10.1016/j.ajo.2010.02.014 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine corneal levels of topically administered azithromycin and clarithromycin in a rabbit model.
Experimental animal study.
Corneas of New Zealand albino rabbits were treated with topical azithromycin (2 mg/ml or 4 mg/ml) or clarithromycin (10 mg/ml). Topical azithromycin was prepared from an intravenous solution and topical clarithromycin from a suspension for oral use. All rabbits received one drop every 2 hours on the right eye. Groups of rabbits were treated for the following intervals: 6, 12, 24, and 48 hours (four rabbits for each combination of time point, drug, and dose). Corneal tissue was removed 1 hour after the last application. To investigate stability of tissue azithromycin levels, an additional group of four rabbits was treated for 24 hours, but corneal tissue was not removed until 24 hours later. Samples were homogenized, and drug concentrations were measured using high-pressure liquid chromatography (HPLC) analysis and bioactivity assay.
Corneal concentrations of azithromycin increased with drug dosage and duration of application. Rabbits treated with azithromycin tolerated the drug well without signs of irritation. Clarithromycin was undetectable in corneal tissue by HPLC and bioactivity assay for all rabbits. Some rabbits treated with clarithromycin had signs of ocular surface irritation.
Measurable concentrations of azithromycin are achieved in corneal tissue after topical application in a rabbit model, and the drug is well tolerated. Azithromycin may be a useful antibiotic for the topical treatment of human corneal infections, but clarithromycin, in currently available formulations, may not be effective because of poor tissue penetration.
American Journal of Ophthalmology 11/2004; 138(4):547-53. DOI:10.1016/j.ajo.2004.04.071 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the presentation and management of the first identified case of ocular vaccinia infection associated with the current smallpox vaccination program.
Vaccinia virus was isolated by cell culture of a conjunctival swab. Direct staining with fluorescein isothiocyanate-labeled vaccinia antibody and polymerase chain reaction testing confirmed the diagnosis.
In February 2003, a 26-year-old woman developed right preseptal cellulitis and blepharoconjunctivitis following contact with a vaccinated member of the military. The preseptal cellulitis resolved with antibacterial therapy, and the conjunctival infection was treated successfully with a 14-day course of topical trifluridine and a single dose of intravenous vaccinia immune globulin.
To facilitate rapid diagnosis and appropriate treatment, clinicians must maintain a high index of suspicion for ocular smallpox vaccine-associated adverse reactions in vaccine recipients and their close contacts.
American Journal of Ophthalmology 04/2004; 137(3):554-6. DOI:10.1016/j.ajo.2003.09.013 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report a case of severe bilateral deep stromal neovascularization and opacification associated with unmonitored contact lens wear.
Observational case report.
A 46-year-old woman who had been using hydrogel contact lenses bought on the Internet without a prescription for 5 years was found to have dense, bilateral corneal opacities with deep stromal neovascularization.
The patient's contact lenses were found to be tight-fitting. Medical history and serological studies were negative for infectious or rheumatologic causes of interstitial keratitis.
The deep stromal neovascularization and the associated corneal opacification are most likely related to the unmonitored contact lens use and the lack of routine eye examinations. We believe it is critical that all contact lens wearers receive professional eye care on a regular basis regardless of where they obtain their contact lens supplies.
American Journal of Ophthalmology 12/2003; 136(5):957-8. DOI:10.1016/S0002-9394(03)00544-0 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infectious endophthalmitis is characterized by neutrophil migration into the eye. The purpose of this study was to determine whether systemic neutrophil depletion mitigates the ocular influx of neutrophils during the early phases of experimental endophthalmitis.
Endophthalmitis was induced in rats by intravitreal injection of Staphylococcus aureus. Animals received a single systemic dose of an anti-neutrophil-depleting antibody (dAb) or normal rabbit serum (NRS) 6 or 12 hours after intravitreal injection. Inflammation was graded both in vivo and by histopathology. Myeloperoxidase (MPO) was used as a biomarker of neutrophil infiltration. Bacterial clearance was evaluated by determining the amount of viable bacteria recovered from ocular specimens.
Rats that received dAb 6 hours after bacterial injection exhibited significantly lower clinical scores, MPO activity, fewer vitreous exudates, and higher vitreous bacterial counts at 24 hours (P < 0.05). As the neutrophil population returned in this group, measured by the number in the peripheral blood, increasing intraocular inflammation was observed. Rats receiving dAb 12 hours after vitreous injection also demonstrated significantly lower clinical scores, MPO activity and less vitreous exudates at the 24-hour time point (P < 0.05). No significant differences from the control were detected at any of the subsequent time points, except in bacterial counts and MPO activity.
Depletion of neutrophils early in the inflammatory response delayed the onset of severe ocular inflammation but also prevented adequate bacterial clearance. These results confirm the important role of neutrophils in ocular host defense during the early stages of experimental endophthalmitis.
[Show abstract][Hide abstract] ABSTRACT: To investigate the relationship between functional phenotype of and the associated human corneal infection.
This was an experimental pilot study of patients presenting with corneal infections at the Jules Stein Eye Institute with presumed infection during the period from 12/30/97 to 9/1/00. Thirteen patients were admitted to the study based on positive identification of the causative pathogen as and patient consent. Data were collected (including bacterial cultures, lens wear schedule and care, gender and age, completed history questionnaire, clinical photographs). Statistical analysis of possible correlations was performed. Phenotypes of were determined, and clinical factors associated with infection were explored.
Both invasive and cytotoxic phenotypes of were isolated in equal proportion. Cytotoxic strains and invasive strains were found to be associated with patients younger than 50 years of age and older than 50 years of age, respectively.
remains a significant pathogen in corneal infection, especially during contact lens wear. The age of the patient may influence the phenotype of causing infection. Since invasive and cytotoxic strains have different effects on corneal cells, treatment of the infection might require different approaches depending on this phenotype of the causative bacteria.
[Show abstract][Hide abstract] ABSTRACT: Among the many problems complicating contact lens wear, microbial keratitis is of most concern because of its potential for substantial morbidity. Three decades of basic and clinical research suggest that risk factors include poor care compliance and extended wear through one or multiple sleep cycles. Many believe the latter problem is caused in part or in whole to contact lens-induced hypoxia. New contact lenses, both rigid and soft, have been developed that allow oxygen delivery equivalent to the noncontact lens state, under open-eye conditions and close to the same even for closed-eye conditions. But will such lenses reduce the risk for microbial keratitis? The authors argue that until such a conclusion is reached through clinical trials, the question remains in doubt.
[Show abstract][Hide abstract] ABSTRACT: Although the risk of developing contact lens associated microbial keratitis is small, the potential consequences of this condition, such as vision loss, are serious. This paper presents an analysis of the risk factors that have been identified for contact lens induced microbial keratitis, which include extended wear, hypoxia, non-compliance, blepharitis, diabetes mellitus, epithelial trauma, steroid use, therapeutic lens use, tobacco use, and possibly travel to warm climates. By remaining mindful of these risk factors, practitioners can take action and offer advice to patients so as to optimize the safety of contact lens wear.
[Show abstract][Hide abstract] ABSTRACT: - PURPOSE: To describe a cluster of Mycobacterium chelonae keratitis cases involving patients who underwent laser in-situ keratomileusis (LASIK) at a single refractive surgery center. - DESIGN: Descriptive case series of four patients and cohort study to identify disease associations. - METHODS: Examination schedules, diagnostic tests, and therapy were based on best medical judgment. Isolates from three patients were compared by pulsed-field gel electrophoresis. Epidemiologic studies were per, formed to identify the source of infection. - RESULTS: Seven of eight eyes developed M. chelonae keratitis following bilateral simultaneous LASIK. Each patient was thought to have diffuse lamellar keratitis initially, but all seven eyes were noted to have opacities suggestive of infectious keratitis by 13 to 21 days after surgery. All eyes had undergone hyperopic LASIK over four days in April 2001 by one surgeon in a community, based refractive surgery center. A cohort study of all patients undergoing LASIK at the same center in April 2001 revealed that M. chelonae keratitis occurred only in persons undergoing correction of hyperopia (seven of 14 eyes vs. none of 217 eyes undergoing myopic LASIK, P < .001). The only difference identified between procedures was use of masks created from a soft contact lens in hyperopic LASIK. Three isolates (three patients) were indistinguishable by pulsed-field gel electrophoresis. Eyes were treated with a combination of antimicrobial agents, including topical azithromycin in three patients, with resolution of infection in all eyes over 6 to 14 weeks. The source of infection was not identified on environmental cultures. - CONCLUSION: Postoperative nontuberculous mycobacterial keratitis can occur in an epidemic fashion following LASIK Topical amikacin, azithromycin, clarithromycin, ciprofloxacin, or a combination of these agents, appears to be effective treatment for these infections.
American Journal of Ophthalmology 12/2001; 132(6):819-830. DOI:10.1016/S0002-9394(01)01267-3 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report fungal infection complicating Acanthamoeba keratitis.
Case report. A 45-year-old woman with contact lens-related bilateral Acanthamoeba keratitis developed corneal ulcer, corneal perforation, and mature cataract in the left eye, which was managed by penetrating keratoplasty, lensectomy, and vitrectomy.
Histopathologic examination of the keratoplasty specimen from the left eye revealed extensive lamellar stromal necrosis with the coexistence of both empty cysts and branching hyphae. Cultures from the keratoplasty specimen grew Scedosporium apiospermum.
Keratomycosis caused by S. apiospermum may complicate protracted Acanthamoeba keratitis.
American Journal of Ophthalmology 05/2001; 131(4):508-9. DOI:10.1016/S0002-9394(00)00827-8 · 3.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endophthalmitis is one of the most feared complications of ocular trauma or surgery. It is a complex pathogen- and host-mediated process that often results in significant vision loss. This review summarizes data from experimental models of staphylococcal endophthalmitis that address the host's immune response to intraocular staphylococci and those that investigate disease pathogenesis.
[Show abstract][Hide abstract] ABSTRACT: Peripheral ulcerative keratitis may be associated with a variety of autoimmune diseases. In some diseases, corneal involvement occurs after the systemic disease has been present for many years, whereas in others, it may be the first manifestation. Regardless of the time of presentation, the development of corneal ulceration in the setting of systemic autoimmune disease may represent progression of a potentially life threatening disease. The relatively rare incidence of these diseases has limited publications over the past year to a few case series that have further characterized the natural history of the diseases associated with peripheral ulcerative keratitis. Current laboratory research has been directed at describing the antigenic targets within the cornea of the abnormal immune response in these patients and also the mechanism of keratolysis that results in ulceration.
Current Opinion in Ophthalmology 01/2001; 11(6):468-71. DOI:10.1097/00055735-200012000-00014 · 2.50 Impact Factor