Purpose This study compares the clinical features and physician selection of either Regional Anesthesia (peribulbar or retrobulbar block) with Monitored Anesthesia Care (RA-MAC) or General Anesthesia (GA) for open globe injury repair. Design A non-randomized, comparative, retrospective case series at a University Referral Center. Participants All adult repairable open globe injuries receiving primary repair between January 1st, 2004 and December 31st, 2014 (11 years). Exclusion criteria were patients less than 18 years of age and those treated with primary enucleation. Methods Data was gathered via retrospective chart review. Main Outcome Measures Data collected from each patient was age, gender, injury type, location, length of wound, presenting visual acuity, classification of anesthesia used, duration of the procedure performed, months of clinical follow-up, and final visual acuity. Results During the 11 years study period, 448 patients were identified who had open globe injuries with documented information on zone of injury. Globe injury repair was performed using RA-MAC in 351/448 (78%) patients and general anesthesia in 97/448 (22%) patients. Zone 1, 2 and 3 injuries were recorded in 241, 135, and 72 patients respectively. The rates in specific zones, of RA-MAC versus GA were as follows: Zone 1 – 213/241 (88%) vs 28/241 (12%), Zone 2 – 104/135 (77%) vs 31/135 (23%) and Zone 3 – 34/72 (47%) vs 38/72 (53%). Open globe injuries repaired under RA-MAC had significantly shorter wound length (p<0.001), more anterior wound location (p<0.001) and shorter operative times (p<0.001). RA-MAC cases also had a better presenting and final visual acuity (p<0.001). Neither class of anesthesia conferred a greater visual acuity improvement (p=0.06). The use of GA did not cause any delay in the time elapsed from injury until surgical repair (p=0.74). Conclusions RA-MAC is a reasonable alternative to GA for the repair of open globe injuries in selected adult patients. RA-MAC was selected more often for Zone 1 and Zone 2 injuries. For eyes with Zone 3 injuries, there are equal selection ratio for RA-MAC and GA.

BackgroundA major obstacle that academic institutions face is the steep learning curve for cornea fellows initially learning to perform Descemet Stripping Endothelial Keratoplasty (DSEK). The purpose of this study is to evaluate the outcomes of complex DSEK performed by cornea fellow supervised by an attending surgeon at an academic institution.MethodsPatients who underwent a complex DSEK procedure performed by a cornea fellow during the years 2009-2013 were included. All the surgeries were supervised by the same cornea attending. All patients had a minimum follow-up of 6 months. Charts were reviewed for demographic data, intraoperative and postoperative complications and clinical outcomes. Corneal graft survival was calculated using the Kaplan-Meier analysis.ResultsFifty-seven eyes of 55 patients (mean age 77.5 ± 8.5 years) were included in the study with a mean follow-up time of 16.4 ± 15.6 months. Previous graft failure, presence of a tube and history of trabeculectomy were the leading diagnoses to define the surgery as complex. No intraoperative complications occurred. In 21.1% of cases a corneal graft detachment was documented in the first postoperative day. Mean visual acuity improved from 1.06 LogMAR (20/230) preoperatively to 0.39 LogMAR (20/50, p < 0.001) by the sixth postoperative month and to 0.52 LogMAR (20/65, p < 0.001) at the last follow-up visit. Graft failure rate was 29.8%. Kaplan-Meier analysis found a 67.2% graft survival rate at 20 months.ConclusionsComplex DSEK can be performed successfully with an acceptable postoperative complication rate by cornea fellows during their training period when supervised by an experienced attending.

A 56-year-old female complained of diplopia immediately after surgical excision of a recurrent left skull base tuberculum meningioma. She was found to have a left sixth nerve palsy, which was subsequently treated with botulinum toxin injection to the medial rectus muscle. Three months post injection, the patient had partial recovery of the sixth nerve palsy and new-onset ocular neuromyotonia.

To review the outcomes of vitreoretinal surgery (VRS) performed by supervised first-year fellows-in-training. Methods: A retrospective review was performed of consecutive VRS cases performed by 4 consecutive first-year fellows under direct attending supervision in a tertiary-care teaching hospital. Main outcomes were rates of surgical complications including vitreous hemorrhage (VH) and retinal detachment (RD). Results: One hundred thirty-five cases were reviewed. Common indications for surgery included rhegmatogenous retinal detachment (RRD, 31.9%), VH (26.7%), tractional retinal detachment (TRD, 25.9%), and combined TRD/RRD (5.2%). The mean logarithm of the minimal angle of resolution visual acuity improved from preoperative 1.48 to 0.98 (P < .0001). Forty-three cases were performed for RRD repair. Grade C proliferative vitreoretinopathy was present preoperatively in 34.9% (15 of 43). The mean duration of symptoms prior to RD repair was 40.1 days. The primary reattachment rate was 81.4% (35 of 43). Sixty-six vitrectomies were performed for proliferative diabetic retinopathy. Eleven (16.7%) patients experienced early VH, and 9 (13.6%) had delayed VH. Postoperative RD occurred in 6 (9.1%) patients all of whom initially presented with TRD. Outcomes of surgeries performed by beginning fellows (months 1-4) were compared to those performed by more experienced first-year fellows (months 5-12). Complication rates were found to be similar between the groups. Conclusion: With appropriate supervision, VRS can be safely performed by beginning fellows-in-training. Despite complex pathology, surgical outcomes of the first-year fellow cases compare favorably to published results.