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Cycloplegic and mydriatic agents for routine ophthalmologic examination: a survey of pediatric ophthalmologists.

INTRODUCTION: We have used a mixture of tropicamide 1% and cyclopentolate 2% for routine cycloplegia in children. Because our hospital pharmacy expressed reluctance to prepare this mixture, we were interested in the current standard of care among pediatric ophthalmologists. METHODS: A survey was mailed to all members and associate members of the American Association for Pediatric Ophthalmology and Strabismus. Responses were tabulated from 522 respondents (62%). RESULTS: Mixtures were used by 22% of respondents for neonates and by 40% for older children. The most popular mixtures were cyclopentolate and phenylephrine for neonates and cyclopentolate, phenylephrine, and tropicamide for older children. CONCLUSION: Although a commercially available mixture (Cyclomydril; Alcon, Ft. Worth, TX) has found wide acceptance for treatment of neonates, ophthalmologists seeking stronger concentrations for older children must rely on alternate sources. There would appear to be a market for such a product.

Child, Preschool↗

Ophthalmology and vision science research. Part 4: avoiding rejection--structuring a research paper from introduction to references.

As part of an ongoing series, this fourth article is the second of 2 related articles that deal with the basics of producing a high-quality manuscript. Although ophthalmology and vision science are the principal focus of this series, the general concepts essential to producing a quality manuscript are applicable to diverse fields of research. This article provides guidelines on how to present research findings in a structured form using the Introduction, Methods, Results, and Discussion (IMRaD) style. The components to be included, and equally important excluded, from each section are elucidated in detail. Commonly omitted or inaccurately or incompletely presented components of the manuscript, such as statistical analysis and references, are highlighted. The necessity to carefully refine manuscripts before submission is discussed. This article concludes by illustrating methods of appropriately dealing with referees' comments and resubmitting manuscripts. Although researchers may have to deal with rejection as part of the process, we hope that this series provides an easy-to-follow structure to maximize manuscript quality and improve the prospect of scientific publication.

Biomedical Research↗

Ophthalmology and vision science research: part 2: How to commence research--Eureka or that's a little unusual?

Understanding the key elements that increase the likelihood of project success is fundamental for those embarking on research. The first article in this series placed scientific journals in perspective in relation to Journal Impact Factors and citation indices. This second article in a series primarily aimed at those commencing research, particularly in the area of ophthalmology and vision science, delineates the interrelated components that are required to complete a research project. Successful research projects seldom emerge from serendipitous observation, and most evolve through a combination of inspiration, careful planning, and a great deal of industry. Beginning researchers must first be clear about their reason(s) for pursuing research and should identify potential mentors and collaborators at the outset. This article discusses methods of identifying suitable projects and mentors. Ten component areas necessary to complete a research project are addressed, with reference to relevant published literature, under the following topic areas: mentors and collaborators; finding a research topic; confirming suitability of the topic; defining the research question; developing the hypothesis; key considerations in study design; threats to study validity; study sample size; benefits and limitations of clinical science; completing to publication. This guide is intended to be applicable to all embarking on research, but particularly to those with an interest in the visual system. The final 3 articles in this series will deal with writing a research paper to publication standard, working successfully with the journal review process, and refining electronic literature searches.

Biomedical Research↗

Ophthalmology and vision science research: Part 3: avoiding writer's block--understanding the ABCs of a good research paper.

Completion of a scientific manuscript for submission to a peer-reviewed journal is a daunting task for clinicians and scientists early in their careers. In an ongoing series, this third article is the first of 2 related articles that deal with the basics of producing a high-quality research manuscript. Although ophthalmology and vision science are the principal focus of this series, the general concepts essential to producing a quality manuscript are applicable to diverse fields of research. This article highlights the exponential growth in the scientific literature over the past 40 years, considers why it is important to publish completed research, and discusses the necessity of identifying the key messages of the research, and their context, in relation to the published literature. The ethics of publishing biomedical research and scientific misconduct, such as duplicate publication or plagiarism, are outlined. To avoid later conflict, there is a critical need for coworkers to carefully address authorship order and inclusion early in the manuscript process. Internationally agreed guidelines are identified to guide this process. The importance of choosing the correct journal for a specific article and the nature of basic citation indices are discussed. The article concludes by elaborating and contrasting different scientific writing styles and emphasizing the considerable importance of developing a representative title and applying clarity and appropriate structure to the abstract.

Authorship↗

Ophthalmology and vision science research: part 5: surfing or sieving--using literature databases wisely.

Literature databases are an ever-expanding resource available to the field of medical sciences. Understanding how to use such databases efficiently is critical for those involved in research. However, for the uninitiated, getting started is a major hurdle to overcome and for the occasional user, the finer points of database searching remain an unacquired skill. In the fifth and final article in this series aimed at those embarking on ophthalmology and vision science research, we look at how the beginning researcher can start to use literature databases and, by using a stepwise approach, how they can optimize their use. This instructional paper gives a hypothetical example of a researcher writing a review article and how he or she acquires the necessary scientific literature for the article. A prototype search of the Medline database is used to illustrate how even a novice might swiftly acquire the skills required for a medium-level search. It provides examples and key tips that can increase the proficiency of the occasional user. Pitfalls of database searching are discussed, as are the limitations of which the user should be aware.

Biomedical Research↗

Trends in the nature of provision in ophthalmology services and resources and barriers to education in ophthalmic nursing: 3rd National UK survey.

Over the last decade in the United Kingdom (UK), the roles of nurses have become increasingly specialised to support a more efficient and effective health service. In ophthalmology, the changes are most visible in the growing number of patients being treated as day case and the greater nursing contribution to patient outcomes. To support this change there is a continuing need for educational institutions to create opportunities to meet the training needs of nurses working in both specialised areas and at the advance level of practice. This article reports on a 3rd national survey the aims of which were to investigate trends in the nature and provision of ophthalmic services and the resources and barriers to education in ophthalmic nursing. The results demonstrate that over the three surveys there has been a significant increase of pre-operative assessment units and a significant decrease of designated ophthalmic wards. Between the second and third survey, the results indicate fewer difficulties with funding but there has been an increase of respondents stating a lack of training institutions offering ophthalmic courses. The survey shows that at a time when nurses need to acquire ophthalmic nursing skills and knowledge there appear to be fewer opportunities for them to access ophthalmic courses.

Adult↗

New antimicrobials in ophthalmology.

This article discusses the newest antibiotics, antivirals, and antifungals and their application in ophthalmology. The literature is reviewed to present the latest research on topical antibiotics, with particular attention to the newest classes of fluoroquinolones, new oral and topical antifungals, and new oral antivirals. Data comparing in vitro susceptibilities and minimum inhibitory concentrations of the antibiotics and antifungals are presented in tabular form.

Anti-Bacterial Agents↗

Botulinum toxin in ophthalmology.

Since its introduction into clinical medicine in 1980, botulinum toxin has become a major therapeutic drug with applications valuable to many medical sub-specialties. Its use was spearheaded in ophthalmology where its potential applications have expanded to cover a broad range of visually related disorders. These include dystonic movement disorders, strabismus, nystagmus, headache syndromes such as migraine, lacrimal hypersecretion syndromes, eyelid retraction, spastic entropion, compressive optic neuropathy, and, more recently, periorbital aesthetic uses. Botulinum toxin is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. When used appropriately it will weaken the force of muscular contraction, or inhibit glandular secretion. Recovery occurs over 3 to 4 months from nerve terminal sprouting and regeneration of inactivated proteins necessary for degranualtion of acetylcholine vesicles. Complications are related to chemodenervation of adjacent muscle groups, injection technique, and immunological mechanisms.

Botulinum Toxins, Type A↗

Operative stretchers. Use in ophthalmologic procedures.

Operative stretchers have been used at Holy Spirit Hospital for more than 500 ophthalmologic procedures. Most of those procedures have been extracapsular cataract extraction with intraocular lens implants performed as ambulatory surgery procedures. We also have used these stretchers for the inpatient procedures such as scleral buckling. Because the stretchers eliminate the need to clean and remake a stationary OR bed between each procedure, we have decreased the downtime between cases. We have recently started using the operative stretchers in selected plastic and otolaryngology procedures. We have six operative stretchers in use and, at times, need more.

Beds↗

Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach.

PURPOSE: To report retrieval of a medial rectus muscle completely detached from the globe and lost in the orbital tissue in four eyes. METHOD: A lost medial rectus muscle was retrieved in four eyes of four patients with either a transcutaneous medial orbitotomy approach or a transnasal endoscopic ethmoid sinus approach. RESULTS: The lost medial rectus muscle was successfully retrieved in all four patients. One patient lost the medial rectus muscle secondary to trauma, and the other three cases resulted from complications of strabismus surgery. The mean preoperative angle of exotropia was 44 prism diopters. The endoscopic approach was attempted in three patients, and the medial rectus muscle was successfully found in two of these patients. In one case in which the endoscopic approach was used, an image guidance system was used to aid in finding the lost medial rectus muscle. The endoscopic approach was abandoned in one case in which the medial rectus muscle could not be identified after extensive searching, but the muscle was subsequently found by means of the transcutaneous medial orbitotomy approach. A transcutaneous medial orbitotomy alone was used to find the lost medial rectus muscle in one of the cases. The postoperative ocular deviation for primary position at distance fixation was a mean of 24 prism diopters of exotropia. With one additional operation in two patients, the mean ocular deviation was less than 12 prism diopters. CONCLUSION: We successfully retrieved a lost medial rectus muscle in four patients with the use of nontraditional strabismus surgical techniques. We effectively combined techniques taken from both ophthalmology and otorhinolaryngology to help solve this difficult problem.

Adult↗

Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group.

PURPOSE: Most uveitis case series have come from tertiary care centers, and the relative frequencies of disorders they report may reflect referral bias. We sought information about the types of uveitis encountered in the general practice of ophthalmology. METHODS: We prospectively examined 213 consecutive cases of general uveitis, defined as intraocular inflammation other than cytomegalovirus retinopathy, seen by a group of community-based comprehensive ophthalmologists. This group of cases was compared with 213 consecutive cases of general uveitis examined by a uveitis specialist at a university referral center in the same community. All cases were categorized by anatomic site of inflammation and disease course, and, if possible, they were assigned a specific diagnosis. Cases of cytomegalovirus retinopathy and masquerade syndrome seen during the same intervals were recorded separately. RESULTS: The distribution of general uveitis cases by anatomic site of disease was significantly different between the community-based practices (anterior, 90.6%; intermediate, 1.4%; posterior 4.7%; panuveitis, 1.4%) and the university referral practice (anterior, 60.6%; intermediate, 12.2%; posterior, 14.6%; panuveitis, 9.4%; P < .00005). A cause or clinical syndrome could be assigned to 47.4% of cases in the community-based practices, and to 57.8% of cases in the university referral practice (P = .03). HLA-B27-associated anterior uveitis, cytomegalovirus retinopathy, and toxoplasmic retinochoroiditis were among the five most common forms of uveitis in both practice settings. CONCLUSION: The relative frequencies with which various forms of uveitis are seen in a tertiary referral center do not necessarily reflect the experience of ophthalmologists from the community in which the center is located. Anterior uveitis and disorders of sudden onset constitute a greater proportion of cases seen by community-based comprehensive ophthalmologists.

Adolescent↗

Vision standards for driving in Canada and the United States. A review for the Canadian Ophthalmological Society.

We review the vision requirements for driving with the goal of revising current Canadian Ophthalmological Society (COS) recommendations for vision standards for driving. The report comprises two sections. In the first section we report the results of a survey of transportation authorities in Canada and the United States conducted on behalf of the COS to determine the current standards and medical review procedures. The results suggest that although the standards in Canada are more consistent than those in the United States, few of the standards in either country are evidence-based. In the second section we review the recent literature on visual function and driving. We conclude from this review that adequate contrast sensitivity is as important as, if not more important than, good visual acuity for driving and that there is little evidence to support a monocular standard for acuity, contrast sensitivity or visual field. Although there is evidence that the extent of a visual field defect is related to the ability to perform driving tasks, there is little evidence to suggest a relation between the location of the visual field defect and fitness to drive.

Automobile Driving↗

Department of Ophthalmology at the New York University Medical Center, 1960-2001. A personal journey.

This autobiographical narrative describes many of the activities of the Department of Ophthalmology at New York University Medical Center that took place under the stewardship of Goodwin M. Breinin, who was chairman from 1958 to 2000. The author recalls his 40 years of collaborative research during this period, exploring the visual system with many faculty members at New York University and participating in departmentally sponsored studies elsewhere.

Academic Medical Centers↗

Diving and hyperbaric ophthalmology.

Exposure of the human body to ambient pressures greater than that at sea level may result in various disorders, some of which have ocular manifestations. Additionally, some eye disorders and postoperative states may be adversely affected by the underwater environment or other hyperbaric exposures. The prevalence of recreational, military, and commercial diving, as well as the medical use of hyperbaric oxygen therapy, requires that ophthalmologists be familiar with the effects of the hyperbaric environment on the normal and diseased eye. The ophthalmology and diving medical literatures were surveyed for publications relating to the ophthalmic aspects of diving and hyperbaric exposures. Underwater optics, underwater refractive correction, and ophthalmic aspects of a fitness-to-dive evaluation are summarized. The evaluation and management of ocular manifestations of decompression sickness and arterial gas embolism are reviewed and guidelines for diving after ocular surgery are proposed.

Barotrauma↗

"Eyes" on the thrones: imperial ophthalmologic nicknames.

Several Greek and Byzantine sovereigns are known in history by nicknames that are of ophthalmologic origin; the sobriquets derive from characteristics of their eyes or their actions in relation to the eyes. The first was Antigonos I Monophthalmus (the One-eyed), who was the most eminent successor of Alexander the Great and Sovereign of Eastern Mediterranean Asia. He obtained his nickname at an early age when he lost one eye fighting at the seige of Perinthos, as a general of King Philip of Macedon (father of Alexander the Great). Several Byzantine emperors also have a number of similar nicknames, such as Anastasius I Dicoros (with Heterochromia Iridis), Alexius V Ducas Murtzuphlus (with Scowling Eyebrows), and Andronicus I Comnenus Misophaes (Hater of Sunlight, since he blinded a great number of his opponents). To these must be added the Byzantine Empress Zoe Carvounopsina (with Coal-black Eyes).

Byzantium↗

Developing specialty-wide standards of practice: the experience of ophthalmology.

In 1986, the American Academy of Ophthalmology (AAO) developed national guidelines for the diagnosis and treatment of major eye disease. A core committee of 10 AAO members detailed the framework and goals for the guidelines and wrote a series of broad criteria outlining the ophthalmologist's moral and ethical responsibilities. Several panels of AAO-physician experts were formed to develop guidelines for specific conditions. The panels were formed according to subspecialty and were assigned well-defined issues, such as the diagnosis and management of chronic, adult-onset open-angle glaucoma. Process and structure standards were developed first; outcome standards are scheduled for future development. The first five sets of practice guidelines have been approved by the AAO's Governing Council. These include standards for the comprehensive eye exam, as well as four disease-specific guidelines--open-angle glaucoma, glaucoma suspect, diabetic eye disease, and cataract.

Clinical Protocols↗

[Imaging of neuro-ophthalmological emergencies].

MRI often is mandatory in the diagnostic work-up of visual loss, visual field alterations and oculomotor problems. It is performed emergently in patients with painful diplopia associated to mydriasis, to exclude aneurysm, or in patients with painful Horner syndrome to exclude dissection of the internal carotid artery. CT scan in emergency remains useful in case of acute lateral hemianopsia or acute post traumatic visual loss. Progressive neuro-ophthalmological symptoms may require imaging examination in a short delay to define the therapeutic strategy: monocular transient blindness (dissection or carotid stenosis), progressive visual loss (optic nerve compression), bitemporal hemianopsia (optic chiasm lesion), painful visual loss (optic neuritis). A very precise clinical indication is helpful for the choice of imaging protocol and to improve its diagnosis value.

Acute Disease↗

Future impact of manpower needs on ophthalmology training programs.

Current projections for ophthalmology manpower needs in the year 2000 suggest that the number of new ophthalmologists trained should be frozen at 500 a year. Factors that would cause a need to train more ophthalmologists would be a shorter workweek or workyear, an increased length of time for each patient visit, universal comprehensive health insurance, an earlier age of retirement, and an increased incidence of eye disease. The factor that would most likely reduce the need for new ophthalmologists would be the transfer of primary eye care delivery to nonophthalmologists. Modulation of resident numbers should be based on peer-judged program quality, not on geography or government edict.

Forecasting↗