To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify... more To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify stressors, and propose methods for reducing and preventing burnout in our academic leaders.Cross-sectional study.One-hundred thirty-one chairs of academic departments of ophthalmology in the United States and Canada.Confidential surveys mailed to ophthalmology chairs.Questionnaires assessed demographics, potential stressors, satisfaction with personal life, self-efficacy, burnout as measured by the Maslach Burnout Inventory–Human Services Survey (MBI-HSS), and quality of life.Questionnaires were returned from 101 chairs, a response rate of 77%. Each chair had served an average of 9.4 years. They worked an average of 62 hours each week, spending 41% on patient care, 36% on administrative duties, 13% on teaching, and 9% on research. There was no difference in hours worked each week in chairs who had served >10 years from those who had been chair <5 years. The most frequently identified stressors were faculty retention, Residency Review Committee/Accreditation Council for Graduate Medical Education issues, department or hospital budgets, and compliance issues. Seventy percent of chairs reported they are currently satisfied with their positions compared with 79% who reported feeling that way 5 years ago. Nine chairs (9%) were considered to have burnout based on their MBI-HSS surveys, and 9 (9%) chair’s scores showed no characteristics of burnout. Fifty-six percent had scores consistent with low personal achievement, the highest risk factor for burnout. Overall, the MBI-HSS revealed moderate subscale scores for emotional exhaustion, low for depersonalization, and low for personal accomplishment.The overall prevalence of burnout in chairs of academic departments of ophthalmology is similar to burnout rates seen in chairs of other academic departments. The MBI-HSS scores for ophthalmology chairs showed high levels of emotional exhaustion, moderate levels of depersonalization, and moderate levels of personal accomplishment. Because the cost of burnout can be high, both in terms of a chair’s psychological well-being and the actual cost associated with replacing a chair, it is important that strategies are put in place to reduce burnout in our academic leaders.
We report a novel and simple application of skin conductance response (SCR) testing for diagnosis... more We report a novel and simple application of skin conductance response (SCR) testing for diagnosis of a new-onset iatrogenic Harlequin syndrome in an infant. Isolated ipsilateral facial pallor, complicated by thermally induced systemic sympathetic vasodilatation, and preferential lateral decubitus positioning, mimics harlequin colour change. Correct diagnosis as Harlequin syndrome with facial sympathetic interruption was demonstrated by diminution of SCR.
The authors present a case report of Duane retraction syndrome (DRS) associated with Rubinstein-T... more The authors present a case report of Duane retraction syndrome (DRS) associated with Rubinstein-Taybi syndrome (RTS). RTS is a multisystem condition characterized by psychomotor developmental delay, broad thumbs and great toes, short stature, and characteristic facies with a beaked nose. DRS is an ocular disorder characterized by retraction of the globe with narrowing of the palpebral fissure in attempted adduction, with abduction and/or adduction deficiency, and, frequently, upshoot or downshoot of the affected eye on adduction. The case report described represents the first reported case of DRS associated with RTS, an association not previously recognized. This association raises the possibility that the abnormal CNS development in RTS may occasionally involve the ocular motor nerves.
To identify common perceptions and ideas about preparation and planning for retirement of chairs ... more To identify common perceptions and ideas about preparation and planning for retirement of chairs of academic departments of ophthalmology, determining areas of particular stress and proposing ways to better prepare for retirement. Cross-sectional study. One-hundred sixteen chairs of academic departments of ophthalmology in the United States. A confidential online survey emailed to ophthalmology chairs. Surveys assessed demographics; current work schedule; perceptions, preparation, and planning for retirement; and retirement training for faculty and residents. Ninety-six department chairs responded to the survey (82% response rate). Most chairs anticipate retiring around age 70. Significantly, only 9% are looking forward to retirement. Reasons for delaying retirement include keeping active (37%), income/insurance/benefits (20%), and maintaining lifestyle (17%). The most common concern is financing retirement (46%). Forty percent anticipate their reason for retirement will be because of age or health, whereas 20% anticipate fatigue or burnout. Nearly half of the respondents have no specific plan upon retirement. Most respondents anticipate pursuing other interests (43%); 32% intend to spend time with family, vacationing, and travelling. Younger respondents are more concerned with the financial aspects of retirement while more senior respondents appear to delay retirement to keep active or because they enjoy their work. Retirement is a source of stress for many ophthalmology department chairs and many indicate financial preparation is their major concern. Despite this, the major reason for putting off retirement is a desire to keep active. Developing a retirement plan eases stress and engenders a feeling of confidence about the future.
Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting ... more Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting in a highly variable degree of chemosis and enlargement of the preorbital fat pads, eyelid retraction, proptosis, restrictive strabismus, torticollis, and, rarely, compressive or congestive optic neuropathy. Although most patients with thyroid eye disease are best treated conservatively, those more severely affected may benefit from orbital decompression, strabismus surgery, or eyelid retraction repair after stabilization has occurred. Botulinum A toxin, high-dose intravenous corticosteroids, and radiation treatment are therapeutic options in select cases. Compressive or congestive optic neuropathy and severe corneal exposure warrant consideration of surgical intervention on an urgent basis without waiting for stabilization. Epidemiology and risks and benefits of high-dose steroids and radiation therapy are reviewed along with recommendations to improve conservative as well as surgical management of this disease. Strategies to manage strabismus and optimize outcomes are provided.
Journal of Autism and Developmental Disorders, 2013
To determine the incidence of ophthalmologic disorders in children with autism and related disord... more To determine the incidence of ophthalmologic disorders in children with autism and related disorders. Retrospective chart review. Four hundred and seven children diagnosed with autism or a related disorder between 1998 and 2006. one hundred and fifty-four of these children completed a comprehensive ophthalmology exam by a pediatric ophthalmologist. Ophthalmologic pathology was found in 40% of patients with autism or a related disorder with 29% having significant refractive errors, 21% demonstrating strabismus, and 10% having amblyopia. Children with autism or a related disorder will frequently have an ophthalmologic abnormality. Since cooperation with vision screening is understandably limited in these children, a comprehensive eye examination by a pediatric ophthalmologist is recommended for all such children.
In a prospective observational study, we previously reported that weaning (tapering or gradually ... more In a prospective observational study, we previously reported that weaning (tapering or gradually reducing) treatment in children treated with 6 to 8 hours of daily patching for amblyopia resulted in a 4-fold reduction in odds of recurrence. We now report the association of additional factors with recurrence or regression of amblyopia in this same cohort.Prospective, nonrandomized, observational study.Sixty-nine children aged <8 years with successfully treated anisometropic or strabismic amblyopia (improved ≥3 logarithm of the minimum angle of resolution [logMAR] lines).Patients were enrolled at the time they stopped patching for amblyopia. Patients were classified according to whether patching was stopped abruptly or weaned before cessation. They were followed off treatment for 52 weeks to assess recurrence of amblyopia.Recurrence of amblyopia defined as a ≥2–logMAR level reduction of visual acuity from enrollment (cessation of patching) confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted with a ≥2–logMAR level reduction of visual acuity, even if it was not confirmed by a second examination.The risk of recurrence was higher with better visual acuity at the time of cessation of treatment (adjusted risk ratio [RR], 0.68 per line of worse visual acuity; 95% confidence interval [CI], 0.51–0.90), a greater number of lines improved during the previous treatment (adjusted RR, 1.5 per line increase; 95% CI, 1.1–2.0), and a history of recurrence (adjusted RR, 2.7; 95% CI, 1.5–4.9). Orthotropia or excellent stereoacuity at the time of patching cessation did not appear to have a protective effect on the risk of recurrence.The higher risk of recurrence in the most successfully treated children with amblyopia and absence of protection from orthotropia and excellent random dot stereoacuity suggests that careful and prolonged follow-up is needed for all children who have been previously treated for amblyopia.
An 11-year-old boy had a one-month history of horizontal diplopia. Three years earlier, he had un... more An 11-year-old boy had a one-month history of horizontal diplopia. Three years earlier, he had undergone allogeneic bone marrow transplantation complicated by graft versus host disease. The patient had esotropia and bilateral optic disk edema. A magnetic resonance imaging scan disclosed no intracranial lesion. The opening pressure of the lumbar puncture was 500 mm of water. Pseudotumor cerebri secondary to cyclosporine was diagnosed. The patient improved with resolution of his esotropia and diplopia within five days of discontinuing his cyclosporine. The optic disk edema resolved within three months. Cyclosporine must be added to the list of medications with a known association with pseudotumor cerebri.
The authors retrospectively analyzed the visual outcome and incidence of complications of 181 con... more The authors retrospectively analyzed the visual outcome and incidence of complications of 181 consecutive cases of phacoemulsification performed by eight third-year ophthalmology residents. A posterior chamber intraocular lens was implanted in 179 of these eyes. Vitreous loss occurred in 5.5% of cases. The overall incidence of posterior capsule rupture was 9.9%; of the 18 posterior capsular ruptures, 72% were detected during cortical removal and 22% during nuclear emulsification. Postoperative follow-up for 177 eyes was at least 2 months, and 70% were followed for 6 months or longer. Final best corrected visual acuity of 20/40 or better was obtained in 92.6% of eyes. These results are comparable with previous reports of residents&#39; experience in performing planned extracapsular cataract extraction. With appropriate training and faculty supervision, residents learning to perform phacoemulsification and intraocular lens implantation can achieve acceptable results.
Background: An abnormal head posture may be adopted for ocular or nonocular reasons. The most com... more Background: An abnormal head posture may be adopted for ocular or nonocular reasons. The most common ocular reasons are to maintain binocularity and to obtain the best possible visual acuity. Patients with undercorrected or overcorrected refractive errors have been reported to adopt a variety of head positions, thought to be an attempt to obtain the best possible visual acuity. Methods: Five patients with symmetric high hyperopia (at least +5.00 D) and an abnormal head posture are presented. Results: All five patients demonstrated an abnormal head posture of chin down for fixation without the spectacle correction in place. This abnormal head posture was eliminated by occlusion of either eye and also by wearing of the refractive correction. No patient demonstrated significant strabismus. Conclusion: An abnormal head posture when not wearing spectacle correction can occur in children who have high hyperopia and insignificant strabismus. This may be a mechanism by which the best visual acuity is obtained (indicated by the disappearance of the abnormal head posture on wearing of the glasses) and also to maintain binocularity (indicated by the disappearance of the abnormal head posture under monocular testing conditions). The presence of a chin-down abnormal head posture should alert the examiner to the possible presence of high hyperopia and therefore the necessity for a cycloplegic refraction.
Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable s... more Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable success outcomes ranging from 43% to 82%. Previous studies showed that correcting the restricted duction seen in thyroid eye disease, rather than the deviation as is done in other types of strabismus surgery, resulted in markedly improved success rates. Other investigators have recommended a change in the approach to the surgical management of dysthyroid ophthalmopathy.Retrospective comparison of sequential case series.The data of 86 patients were retrospectively reviewed, including 52 in the deviation correction group and 34 in the duction correction group, with 74 deviation correction operations and 47 duction correction operations. A successful outcome, defined as postoperative deviation less than or equal to 5Δ, was seen in 72% of deviation corrections operations and 66% of duction correction operations (p = 0.55).In our study, no difference in outcome between surgical corrections of restricted duction versus deviation was demonstrated.
To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify... more To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify stressors, and propose methods for reducing and preventing burnout in our academic leaders.Cross-sectional study.One-hundred thirty-one chairs of academic departments of ophthalmology in the United States and Canada.Confidential surveys mailed to ophthalmology chairs.Questionnaires assessed demographics, potential stressors, satisfaction with personal life, self-efficacy, burnout as measured by the Maslach Burnout Inventory–Human Services Survey (MBI-HSS), and quality of life.Questionnaires were returned from 101 chairs, a response rate of 77%. Each chair had served an average of 9.4 years. They worked an average of 62 hours each week, spending 41% on patient care, 36% on administrative duties, 13% on teaching, and 9% on research. There was no difference in hours worked each week in chairs who had served >10 years from those who had been chair <5 years. The most frequently identified stressors were faculty retention, Residency Review Committee/Accreditation Council for Graduate Medical Education issues, department or hospital budgets, and compliance issues. Seventy percent of chairs reported they are currently satisfied with their positions compared with 79% who reported feeling that way 5 years ago. Nine chairs (9%) were considered to have burnout based on their MBI-HSS surveys, and 9 (9%) chair’s scores showed no characteristics of burnout. Fifty-six percent had scores consistent with low personal achievement, the highest risk factor for burnout. Overall, the MBI-HSS revealed moderate subscale scores for emotional exhaustion, low for depersonalization, and low for personal accomplishment.The overall prevalence of burnout in chairs of academic departments of ophthalmology is similar to burnout rates seen in chairs of other academic departments. The MBI-HSS scores for ophthalmology chairs showed high levels of emotional exhaustion, moderate levels of depersonalization, and moderate levels of personal accomplishment. Because the cost of burnout can be high, both in terms of a chair’s psychological well-being and the actual cost associated with replacing a chair, it is important that strategies are put in place to reduce burnout in our academic leaders.
We report a novel and simple application of skin conductance response (SCR) testing for diagnosis... more We report a novel and simple application of skin conductance response (SCR) testing for diagnosis of a new-onset iatrogenic Harlequin syndrome in an infant. Isolated ipsilateral facial pallor, complicated by thermally induced systemic sympathetic vasodilatation, and preferential lateral decubitus positioning, mimics harlequin colour change. Correct diagnosis as Harlequin syndrome with facial sympathetic interruption was demonstrated by diminution of SCR.
The authors present a case report of Duane retraction syndrome (DRS) associated with Rubinstein-T... more The authors present a case report of Duane retraction syndrome (DRS) associated with Rubinstein-Taybi syndrome (RTS). RTS is a multisystem condition characterized by psychomotor developmental delay, broad thumbs and great toes, short stature, and characteristic facies with a beaked nose. DRS is an ocular disorder characterized by retraction of the globe with narrowing of the palpebral fissure in attempted adduction, with abduction and/or adduction deficiency, and, frequently, upshoot or downshoot of the affected eye on adduction. The case report described represents the first reported case of DRS associated with RTS, an association not previously recognized. This association raises the possibility that the abnormal CNS development in RTS may occasionally involve the ocular motor nerves.
To identify common perceptions and ideas about preparation and planning for retirement of chairs ... more To identify common perceptions and ideas about preparation and planning for retirement of chairs of academic departments of ophthalmology, determining areas of particular stress and proposing ways to better prepare for retirement. Cross-sectional study. One-hundred sixteen chairs of academic departments of ophthalmology in the United States. A confidential online survey emailed to ophthalmology chairs. Surveys assessed demographics; current work schedule; perceptions, preparation, and planning for retirement; and retirement training for faculty and residents. Ninety-six department chairs responded to the survey (82% response rate). Most chairs anticipate retiring around age 70. Significantly, only 9% are looking forward to retirement. Reasons for delaying retirement include keeping active (37%), income/insurance/benefits (20%), and maintaining lifestyle (17%). The most common concern is financing retirement (46%). Forty percent anticipate their reason for retirement will be because of age or health, whereas 20% anticipate fatigue or burnout. Nearly half of the respondents have no specific plan upon retirement. Most respondents anticipate pursuing other interests (43%); 32% intend to spend time with family, vacationing, and travelling. Younger respondents are more concerned with the financial aspects of retirement while more senior respondents appear to delay retirement to keep active or because they enjoy their work. Retirement is a source of stress for many ophthalmology department chairs and many indicate financial preparation is their major concern. Despite this, the major reason for putting off retirement is a desire to keep active. Developing a retirement plan eases stress and engenders a feeling of confidence about the future.
Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting ... more Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting in a highly variable degree of chemosis and enlargement of the preorbital fat pads, eyelid retraction, proptosis, restrictive strabismus, torticollis, and, rarely, compressive or congestive optic neuropathy. Although most patients with thyroid eye disease are best treated conservatively, those more severely affected may benefit from orbital decompression, strabismus surgery, or eyelid retraction repair after stabilization has occurred. Botulinum A toxin, high-dose intravenous corticosteroids, and radiation treatment are therapeutic options in select cases. Compressive or congestive optic neuropathy and severe corneal exposure warrant consideration of surgical intervention on an urgent basis without waiting for stabilization. Epidemiology and risks and benefits of high-dose steroids and radiation therapy are reviewed along with recommendations to improve conservative as well as surgical management of this disease. Strategies to manage strabismus and optimize outcomes are provided.
Journal of Autism and Developmental Disorders, 2013
To determine the incidence of ophthalmologic disorders in children with autism and related disord... more To determine the incidence of ophthalmologic disorders in children with autism and related disorders. Retrospective chart review. Four hundred and seven children diagnosed with autism or a related disorder between 1998 and 2006. one hundred and fifty-four of these children completed a comprehensive ophthalmology exam by a pediatric ophthalmologist. Ophthalmologic pathology was found in 40% of patients with autism or a related disorder with 29% having significant refractive errors, 21% demonstrating strabismus, and 10% having amblyopia. Children with autism or a related disorder will frequently have an ophthalmologic abnormality. Since cooperation with vision screening is understandably limited in these children, a comprehensive eye examination by a pediatric ophthalmologist is recommended for all such children.
In a prospective observational study, we previously reported that weaning (tapering or gradually ... more In a prospective observational study, we previously reported that weaning (tapering or gradually reducing) treatment in children treated with 6 to 8 hours of daily patching for amblyopia resulted in a 4-fold reduction in odds of recurrence. We now report the association of additional factors with recurrence or regression of amblyopia in this same cohort.Prospective, nonrandomized, observational study.Sixty-nine children aged <8 years with successfully treated anisometropic or strabismic amblyopia (improved ≥3 logarithm of the minimum angle of resolution [logMAR] lines).Patients were enrolled at the time they stopped patching for amblyopia. Patients were classified according to whether patching was stopped abruptly or weaned before cessation. They were followed off treatment for 52 weeks to assess recurrence of amblyopia.Recurrence of amblyopia defined as a ≥2–logMAR level reduction of visual acuity from enrollment (cessation of patching) confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted with a ≥2–logMAR level reduction of visual acuity, even if it was not confirmed by a second examination.The risk of recurrence was higher with better visual acuity at the time of cessation of treatment (adjusted risk ratio [RR], 0.68 per line of worse visual acuity; 95% confidence interval [CI], 0.51–0.90), a greater number of lines improved during the previous treatment (adjusted RR, 1.5 per line increase; 95% CI, 1.1–2.0), and a history of recurrence (adjusted RR, 2.7; 95% CI, 1.5–4.9). Orthotropia or excellent stereoacuity at the time of patching cessation did not appear to have a protective effect on the risk of recurrence.The higher risk of recurrence in the most successfully treated children with amblyopia and absence of protection from orthotropia and excellent random dot stereoacuity suggests that careful and prolonged follow-up is needed for all children who have been previously treated for amblyopia.
An 11-year-old boy had a one-month history of horizontal diplopia. Three years earlier, he had un... more An 11-year-old boy had a one-month history of horizontal diplopia. Three years earlier, he had undergone allogeneic bone marrow transplantation complicated by graft versus host disease. The patient had esotropia and bilateral optic disk edema. A magnetic resonance imaging scan disclosed no intracranial lesion. The opening pressure of the lumbar puncture was 500 mm of water. Pseudotumor cerebri secondary to cyclosporine was diagnosed. The patient improved with resolution of his esotropia and diplopia within five days of discontinuing his cyclosporine. The optic disk edema resolved within three months. Cyclosporine must be added to the list of medications with a known association with pseudotumor cerebri.
The authors retrospectively analyzed the visual outcome and incidence of complications of 181 con... more The authors retrospectively analyzed the visual outcome and incidence of complications of 181 consecutive cases of phacoemulsification performed by eight third-year ophthalmology residents. A posterior chamber intraocular lens was implanted in 179 of these eyes. Vitreous loss occurred in 5.5% of cases. The overall incidence of posterior capsule rupture was 9.9%; of the 18 posterior capsular ruptures, 72% were detected during cortical removal and 22% during nuclear emulsification. Postoperative follow-up for 177 eyes was at least 2 months, and 70% were followed for 6 months or longer. Final best corrected visual acuity of 20/40 or better was obtained in 92.6% of eyes. These results are comparable with previous reports of residents&#39; experience in performing planned extracapsular cataract extraction. With appropriate training and faculty supervision, residents learning to perform phacoemulsification and intraocular lens implantation can achieve acceptable results.
Background: An abnormal head posture may be adopted for ocular or nonocular reasons. The most com... more Background: An abnormal head posture may be adopted for ocular or nonocular reasons. The most common ocular reasons are to maintain binocularity and to obtain the best possible visual acuity. Patients with undercorrected or overcorrected refractive errors have been reported to adopt a variety of head positions, thought to be an attempt to obtain the best possible visual acuity. Methods: Five patients with symmetric high hyperopia (at least +5.00 D) and an abnormal head posture are presented. Results: All five patients demonstrated an abnormal head posture of chin down for fixation without the spectacle correction in place. This abnormal head posture was eliminated by occlusion of either eye and also by wearing of the refractive correction. No patient demonstrated significant strabismus. Conclusion: An abnormal head posture when not wearing spectacle correction can occur in children who have high hyperopia and insignificant strabismus. This may be a mechanism by which the best visual acuity is obtained (indicated by the disappearance of the abnormal head posture on wearing of the glasses) and also to maintain binocularity (indicated by the disappearance of the abnormal head posture under monocular testing conditions). The presence of a chin-down abnormal head posture should alert the examiner to the possible presence of high hyperopia and therefore the necessity for a cycloplegic refraction.
Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable s... more Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable success outcomes ranging from 43% to 82%. Previous studies showed that correcting the restricted duction seen in thyroid eye disease, rather than the deviation as is done in other types of strabismus surgery, resulted in markedly improved success rates. Other investigators have recommended a change in the approach to the surgical management of dysthyroid ophthalmopathy.Retrospective comparison of sequential case series.The data of 86 patients were retrospectively reviewed, including 52 in the deviation correction group and 34 in the duction correction group, with 74 deviation correction operations and 47 duction correction operations. A successful outcome, defined as postoperative deviation less than or equal to 5Δ, was seen in 72% of deviation corrections operations and 66% of duction correction operations (p = 0.55).In our study, no difference in outcome between surgical corrections of restricted duction versus deviation was demonstrated.
Uploads