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Computer simulation models for optimizing clinical workflow in pediatric ophthalmology
e22 the presence of a relationship between pupillary reaction and time of maximum cycloplegia. Methods: This was a prospective analytical study involving children aged 5-14 years. Cyclopentolate 1% was instilled three times at 10minute intervals. The spherical equivalent, pupillary reaction and pupillary diameter were recorded before the first drop and nine times after the last drop at 10-minute intervals. Time of maximum cycloplegia was determined from the time point at which the 95% confidence intervals of differences between mean spherical equivalent at each point and its final value was reached and remained within equivalence limit (0.25 D). Results: Sixty children were enrolled in this study. Mean age was 9.8 years (5-14). Time of maximum cycloplegia was reached at 30 minutes after the first instillation of cyclopentolate. Poor correlation was observed between pupillary reaction and time of maximum cycloplegia (r 5 –0.07). The mean pupillary diameter at 30 minutes was 3.7 1.3 mm, and further dilation occurred thereafter. Discussion: The maximum cycloplegia was reached at 30 minutes. Maximum cycloplegia and absence of pupillary reaction did not occur at the same time. It takes longer to reach maximum pupillary dilatation than to reach maximum cycloplegia. Conclusions: In most children with brown irises, maximum cycloplegia was reached 30 minutes after the first instillation of cyclopentolate. The absence of a pupillary reaction should not be used as an indicator of maximum cycloplegia. 079 Detection of optic disk drusen in children using B scan through the lens and avoiding the lens. Renuka Rajagopal Introduction: To assess if the detection rate of optic disk drusen in swollen optic disks in children varies if the B scan is performed through the lens or avoiding the lens. Methods: Retrospective review of the US machine database for all the patients who underwent Ultrasound for swollen disks in the Department of Pediatric Ophthalmology, Children's Hospital of Pittsburgh. Only the patients who had fundus pictures and B scan performed through and avoiding the lens were included in the study. Results: A total of 31 patients (62 eyes ) were included in the study. B scan detected optic disk drusen in 43.5% of the eyes. In 81.5% of these eyes, the drusen were not detected initially when the scanning was done through the lens but were detected on avoiding the lens. 10 of 16 (62.5%) patients with no drusen on Ultrasound ,had an identifiable cause for disk elevation. Discussion: B scan is a sensitive diagnostic tool for detecting a drusen. The rate of detection of the drusen is increased when the B scan is done avoiding the lens especially in a pediatric age group where the drusen are usually buried and not as calcified as those found in adults. Under such circumstances the reduced echogencity is absorbed by the more ultrasound absorbent pediatric lens, thus limiting the detection rates when scanning through the lens. Conclusions: Although various studies have reported that B scan being not as sensitive as OCT especially in buried drusen 50; however, B Scan is an indispensable and could be the only tools in pediatric age group where the cooperation for other tests is limited. Thus, it is crucial to maximize the information obtained in a shorter time frame available for testing. The technique of avoiding the lens can increase the rate of drusen detection. 080 Simultaneous versus sequential ptosis and strabismus surgery in children. Karen E. Revere, William R. Katowitz, Jonathan Li, James A. Katowitz, Gil Binenbaum
Volume 20 Number 4 / August 2016 Introduction: Coincident strabismus and ptosis are often addressed with separate surgeries, which increases anesthesia exposures. Advantages of a staged approach have not been clearly established. We sought to compare clinical outcomes of simultaneous versus sequential ptosis surgery and strabismus surgery in children. Methods: Retrospective cohort study of children requiring ptosis and strabismus surgery on same eye. Outcomes were ptosis success (MRD1 $2 mm, good lid contour, good lid crease); strabismus success (alignment \10D of orthophoria for comitant strabismus, improvement in head position or alignment for incomitant strabismus); surgical complications; reoperations. Results: Of 56 children studied (mean age, 64 months [range, 1-260]; mean follow-up, 27 months [3-112]), 38 had simultaneous surgery, 18 sequential. Strabismus surgery was performed first in all simultaneous and 6/18 sequential cases. 75% had congenital ptosis; 64% comitant strabismus. Ptosis surgery was 59% frontalis sling, 30% fasanella servat. There were no significant differences between simultaneous and sequential groups for surgical success, complications, or reoperations: lid height, 84%/89%; lid contour, 84%/94%; lid crease, 90%/100%; strabismus, 87%/78%; ptosis complications, 8%/17%; strabismus complications, 8%/0%; ptosis reoperation, 18%/17%; strabismus reoperation, 16%/6% (P . 0.28 for all outcomes [Fisher exact]). Discussion: This is the first comparative study of simultaneous versus sequential ptosis and strabismus surgery in children. There was no clinical advantage for sequential surgery. Despite a theoretical risk of increased complications, particularly with internal ptosis repair and strabismus procedures involving a superior muscle, no increased risk was seen. Conclusions: Performing ptosis and strabismus surgery together appears to be clinically effective, safe, and reduces anesthesia exposure during childhood. 081 Computer simulation models for optimizing clinical workflow in pediatric ophthalmology. Leah G. Reznick, Michelle R. Hribar, Sarah Read-Brown, Thomas R. Yackel, Michael F. Chiang Introduction: Pediatric ophthalmologists need to maximize clinical efficiency. This study demonstrates that timestamp data from EHRs may be applied to develop computer simulation models to identify scheduling templates which reduce patient wait times. Methods: Clinical workflow was mapped for a single pediatric ophthalmologist (LGR). EHR databases and audit logs were used to identify timestamps that best correlated with clinical activities during 1 year (2558 patient visits, 496,301 timestamps). EHR timestamps were validated against manually-observed timings by trained observers during 89 patient visits. Data were used to develop computer simulation models (Arena; Rockwell, Wexford, PA) to evaluate different scheduling policies for minimizing wait time. Results: EHR timestamp data were accurate within 3 minutes of manually observed times in 95/146 (65%) clinical activities. Over 1 year, EHR timestamp data showed mean wait time was 35.9 26.0 minutes/patient. Computer simulation models optimized patient wait times by scheduling patients for the shortest visit times earlier and longer times later in a half day clinical session. This model reduced wait times from 35.9 to 15 minutes/patient. This optimized schedule was implemented (2 half-day clinic sessions, 23 patients), and decreased mean wait time to 25 17 minutes/ patient (P 5 0.03).
Journal of AAPOS
Volume 20 Number 4 / August 2016 Discussion: EHR timestamp data, coupled with computer simulation modeling, can produce tools for managing clinical workflow. Additionally, we have used simulations to determine optimal number of ancillary staff and examination rooms. Conclusions: EHR timestamp data may be used to develop computer simulation models for testing alternative clinic configuration and scheduling policies, which have potential to improve efficiency of care delivery. 082 Strabismus measurements in adults before and after pupil dilation. Sean Rivera, Kim Merrill, Anna Schweigert, Andrea Kramer, Jill Anderson, Mike Lee, Erick Bothun Introduction: The goal of the study is to determine if pupil dilation affects strabismus measurements in adults, as this currently influences the examination sequence of standard clinical practice. Methods: Adult patients with strabismus were enrolled in the study and had a standard strabismus examination (visual acuity, motility, stereopsis, ocular alignment with alternate prism cover test) by a certified orthoptist. Pupils were then dilated with phenylephrine 2.5% and tropicamide 1%. Next, ocular alignment was measured at distance in primary gaze, 1/3 m and 1/3 m with a +3.00 add by a different orthoptist, masked to the initial measurements. To determine if the change was significant, the measurements were compared to published values of test–retest variability. Results: A total of 56 were enrolled, 12 with an exodeviation, 19 with an esodeviation, 19 with a hyperdeviation, 13 with a trochlear palsy, 4 with an abduscens palsy, and 11 with a mixed vertical/horizontal deviation. For horizontal measurements the mean change in prism diopters after dilation was 1.65 at distance (95% CI 0.77, P 5 0.99), 4.33 at near (95% CI 1.47, P 5 0.77), and 3.51 at near with +3.00 (95% CI 1.17, P 5 0.95). For vertical measurements the change was less with 0.76 at distance (95% CI 0.31, P 5 0.99), 1.33 at near (95% CI 0.53, P 5 0.99), and 1.16 at near with +3.00 (95% CI 0.67, P 5 0.99). Discussion: Pupil dilation does not seem to affect strabismus measurements in adults and age and presbyopia likely play a role. Conclusions: Pupil dilation does not need to influence the strabismus examination sequence in adults. 083 Bilateral multilayered retinal haemorrhages after a short distance accidental fall in an infant. Rehana Sadia, Jane L. Ashworth Introduction: A witnessed accidental short-distance fall in a 3 month old infant resulting in bilateral multilayered retinal hemorrhages. Methods: Case note review and RetCam images. Results: A 3-month-old infant accidentally fell from his mothers arms in a nursery group, which was witnessed by several other adults. CT and MR scan showed subdural hemorrhage and parietal bone fracture. Fundal examination and Retcam imaging showed multiple bilateral intraretinal and preretinal hemorrhages involving the posterior pole and midperiphery. Skeletal survey and coagulation profile was normal. Discussion: It is reported that retinal hemorrhages are virtually never seen in short distance falls; those that do occur are usually unilateral, located in the posterior pole and within a single retinal layer. Conclusions: This case adds to a small series of witnessed shortdistance falls associated with subdural and retinal hemorrhages. It highlights the diagnostic dilemma between accidental and nonaccidental head injury in infants and that multiple multilayered
Journal of AAPOS
e23 retinal hemorrhages can occur even in accidental short distance falls. 084 A population-based study of congenital nasolacrimal duct obstruction. Saraniya Sathiamoorthi, Brian Mohney, Ryan D. Frank Introduction: The purpose of this study was to describe the incidence, clinical characteristics and natural history of congenital nasolacrimal duct obstruction (CNLDO) in a population-based cohort of children. Methods: The medical records of all pediatric patients (\5 years) residing in a defined population who were diagnosed with CNLDO from January 1, 1995, through December 31, 2000, were retrospectively reviewed. Results: A total of 1,015 children were diagnosed with CNLDO during the 6-year period, yielding a birth prevalence of 9.8% or 1 in 11 births. The mean age at diagnosis was 15.3 weeks (range, birth to 60 months) and 520 (51.2%) were male. By a mean age of 5.0 months (range, 1 week to 65 months), 867 (85.4%) spontaneously resolved; 8 were lost to follow-up. Among the remaining 140 (13.8%) patients who were examined by an ophthalmologist, the cycloplegic refractive error was measured in 107 (76.4%), of which 8 (7.5%) had anisometropia of $1.00 D. Discussion: The incidence of CNLDO in this cohort was less than most prior reports, none of which were population-based. However, the rates of spontaneous resolution and anisometropia are similar to recent published findings. Conclusions: In this population-based cohort of children, CNLDO occurred in 1 in 11 live births with no gender predilection. Approximately 4 of 5 patients experienced a resolution of their symptoms by one year of age. Anisometropia was observed in 7.5% of those that underwent a cycloplegic refraction.
085 Rectus muscle plication for the treatment of anomalous head position and nystagmus. Theodor C. Sauer, Federico G. Velez, Stacy L. Pineles Introduction: Patients with nystagmus and head turn are traditionally treated by recession and resection of the rectus muscles as described by Kestenbaum and Anderson. Rectus muscle plication is a less invasive surgical option that minimizes the risk of anterior segment ischemia. Methods:A retrospective chart review of all patients with nystagmus and anomalous head position (AHP) who underwent plication of two horizontal rectus muscles as a treatment for AHP. Results: Six patients (4 males) met inclusion criteria and none were excluded. Age at the time of surgery ranged from 2 to 23 years. Plication amounts ranged from 3–8.5 mm on the medial rectus and 4.5–12 mm on the lateral rectus. Average preoperative horizontal AHP was 23.3 degrees and postoperative 5.0 degrees (P 5 0.007). Visual acuity improved from preoperative mean logMAR 0.58 (approximately 20/80) to postoperative 0.45 (20/60). One patient required an additional surgery for a residual exotropia despite full correction of the anomalous head posture. Discussion: We report 6 cases in which multiple rectus muscle plications were used for the treatment of AHP associated with nystagmus. To our knowledge, this is the first report detailing the use of variable amounts of plication and plication-only surgery in the treatment of AHP and nystagmus. Plication is a safer alternative to resection particularly in patients with previously operated rectus muscles at risk for anterior segment ischemia.
Volume 20 Number 4 / August 2016 Introduction: Coincident strabismus and ptosis are often addressed with separate surgeries, which increases anesthesia exposures. Advantages of a staged approach have not been clearly established. We sought to compare clinical outcomes of simultaneous versus sequential ptosis surgery and strabismus surgery in children. Methods: Retrospective cohort study of children requiring ptosis and strabismus surgery on same eye. Outcomes were ptosis success (MRD1 $2 mm, good lid contour, good lid crease); strabismus success (alignment \10D of orthophoria for comitant strabismus, improvement in head position or alignment for incomitant strabismus); surgical complications; reoperations. Results: Of 56 children studied (mean age, 64 months [range, 1-260]; mean follow-up, 27 months [3-112]), 38 had simultaneous surgery, 18 sequential. Strabismus surgery was performed first in all simultaneous and 6/18 sequential cases. 75% had congenital ptosis; 64% comitant strabismus. Ptosis surgery was 59% frontalis sling, 30% fasanella servat. There were no significant differences between simultaneous and sequential groups for surgical success, complications, or reoperations: lid height, 84%/89%; lid contour, 84%/94%; lid crease, 90%/100%; strabismus, 87%/78%; ptosis complications, 8%/17%; strabismus complications, 8%/0%; ptosis reoperation, 18%/17%; strabismus reoperation, 16%/6% (P . 0.28 for all outcomes [Fisher exact]). Discussion: This is the first comparative study of simultaneous versus sequential ptosis and strabismus surgery in children. There was no clinical advantage for sequential surgery. Despite a theoretical risk of increased complications, particularly with internal ptosis repair and strabismus procedures involving a superior muscle, no increased risk was seen. Conclusions: Performing ptosis and strabismus surgery together appears to be clinically effective, safe, and reduces anesthesia exposure during childhood. 081 Computer simulation models for optimizing clinical workflow in pediatric ophthalmology. Leah G. Reznick, Michelle R. Hribar, Sarah Read-Brown, Thomas R. Yackel, Michael F. Chiang Introduction: Pediatric ophthalmologists need to maximize clinical efficiency. This study demonstrates that timestamp data from EHRs may be applied to develop computer simulation models to identify scheduling templates which reduce patient wait times. Methods: Clinical workflow was mapped for a single pediatric ophthalmologist (LGR). EHR databases and audit logs were used to identify timestamps that best correlated with clinical activities during 1 year (2558 patient visits, 496,301 timestamps). EHR timestamps were validated against manually-observed timings by trained observers during 89 patient visits. Data were used to develop computer simulation models (Arena; Rockwell, Wexford, PA) to evaluate different scheduling policies for minimizing wait time. Results: EHR timestamp data were accurate within 3 minutes of manually observed times in 95/146 (65%) clinical activities. Over 1 year, EHR timestamp data showed mean wait time was 35.9 26.0 minutes/patient. Computer simulation models optimized patient wait times by scheduling patients for the shortest visit times earlier and longer times later in a half day clinical session. This model reduced wait times from 35.9 to 15 minutes/patient. This optimized schedule was implemented (2 half-day clinic sessions, 23 patients), and decreased mean wait time to 25 17 minutes/ patient (P 5 0.03).
Journal of AAPOS
Volume 20 Number 4 / August 2016 Discussion: EHR timestamp data, coupled with computer simulation modeling, can produce tools for managing clinical workflow. Additionally, we have used simulations to determine optimal number of ancillary staff and examination rooms. Conclusions: EHR timestamp data may be used to develop computer simulation models for testing alternative clinic configuration and scheduling policies, which have potential to improve efficiency of care delivery. 082 Strabismus measurements in adults before and after pupil dilation. Sean Rivera, Kim Merrill, Anna Schweigert, Andrea Kramer, Jill Anderson, Mike Lee, Erick Bothun Introduction: The goal of the study is to determine if pupil dilation affects strabismus measurements in adults, as this currently influences the examination sequence of standard clinical practice. Methods: Adult patients with strabismus were enrolled in the study and had a standard strabismus examination (visual acuity, motility, stereopsis, ocular alignment with alternate prism cover test) by a certified orthoptist. Pupils were then dilated with phenylephrine 2.5% and tropicamide 1%. Next, ocular alignment was measured at distance in primary gaze, 1/3 m and 1/3 m with a +3.00 add by a different orthoptist, masked to the initial measurements. To determine if the change was significant, the measurements were compared to published values of test–retest variability. Results: A total of 56 were enrolled, 12 with an exodeviation, 19 with an esodeviation, 19 with a hyperdeviation, 13 with a trochlear palsy, 4 with an abduscens palsy, and 11 with a mixed vertical/horizontal deviation. For horizontal measurements the mean change in prism diopters after dilation was 1.65 at distance (95% CI 0.77, P 5 0.99), 4.33 at near (95% CI 1.47, P 5 0.77), and 3.51 at near with +3.00 (95% CI 1.17, P 5 0.95). For vertical measurements the change was less with 0.76 at distance (95% CI 0.31, P 5 0.99), 1.33 at near (95% CI 0.53, P 5 0.99), and 1.16 at near with +3.00 (95% CI 0.67, P 5 0.99). Discussion: Pupil dilation does not seem to affect strabismus measurements in adults and age and presbyopia likely play a role. Conclusions: Pupil dilation does not need to influence the strabismus examination sequence in adults. 083 Bilateral multilayered retinal haemorrhages after a short distance accidental fall in an infant. Rehana Sadia, Jane L. Ashworth Introduction: A witnessed accidental short-distance fall in a 3 month old infant resulting in bilateral multilayered retinal hemorrhages. Methods: Case note review and RetCam images. Results: A 3-month-old infant accidentally fell from his mothers arms in a nursery group, which was witnessed by several other adults. CT and MR scan showed subdural hemorrhage and parietal bone fracture. Fundal examination and Retcam imaging showed multiple bilateral intraretinal and preretinal hemorrhages involving the posterior pole and midperiphery. Skeletal survey and coagulation profile was normal. Discussion: It is reported that retinal hemorrhages are virtually never seen in short distance falls; those that do occur are usually unilateral, located in the posterior pole and within a single retinal layer. Conclusions: This case adds to a small series of witnessed shortdistance falls associated with subdural and retinal hemorrhages. It highlights the diagnostic dilemma between accidental and nonaccidental head injury in infants and that multiple multilayered
Journal of AAPOS
e23 retinal hemorrhages can occur even in accidental short distance falls. 084 A population-based study of congenital nasolacrimal duct obstruction. Saraniya Sathiamoorthi, Brian Mohney, Ryan D. Frank Introduction: The purpose of this study was to describe the incidence, clinical characteristics and natural history of congenital nasolacrimal duct obstruction (CNLDO) in a population-based cohort of children. Methods: The medical records of all pediatric patients (\5 years) residing in a defined population who were diagnosed with CNLDO from January 1, 1995, through December 31, 2000, were retrospectively reviewed. Results: A total of 1,015 children were diagnosed with CNLDO during the 6-year period, yielding a birth prevalence of 9.8% or 1 in 11 births. The mean age at diagnosis was 15.3 weeks (range, birth to 60 months) and 520 (51.2%) were male. By a mean age of 5.0 months (range, 1 week to 65 months), 867 (85.4%) spontaneously resolved; 8 were lost to follow-up. Among the remaining 140 (13.8%) patients who were examined by an ophthalmologist, the cycloplegic refractive error was measured in 107 (76.4%), of which 8 (7.5%) had anisometropia of $1.00 D. Discussion: The incidence of CNLDO in this cohort was less than most prior reports, none of which were population-based. However, the rates of spontaneous resolution and anisometropia are similar to recent published findings. Conclusions: In this population-based cohort of children, CNLDO occurred in 1 in 11 live births with no gender predilection. Approximately 4 of 5 patients experienced a resolution of their symptoms by one year of age. Anisometropia was observed in 7.5% of those that underwent a cycloplegic refraction.
085 Rectus muscle plication for the treatment of anomalous head position and nystagmus. Theodor C. Sauer, Federico G. Velez, Stacy L. Pineles Introduction: Patients with nystagmus and head turn are traditionally treated by recession and resection of the rectus muscles as described by Kestenbaum and Anderson. Rectus muscle plication is a less invasive surgical option that minimizes the risk of anterior segment ischemia. Methods:A retrospective chart review of all patients with nystagmus and anomalous head position (AHP) who underwent plication of two horizontal rectus muscles as a treatment for AHP. Results: Six patients (4 males) met inclusion criteria and none were excluded. Age at the time of surgery ranged from 2 to 23 years. Plication amounts ranged from 3–8.5 mm on the medial rectus and 4.5–12 mm on the lateral rectus. Average preoperative horizontal AHP was 23.3 degrees and postoperative 5.0 degrees (P 5 0.007). Visual acuity improved from preoperative mean logMAR 0.58 (approximately 20/80) to postoperative 0.45 (20/60). One patient required an additional surgery for a residual exotropia despite full correction of the anomalous head posture. Discussion: We report 6 cases in which multiple rectus muscle plications were used for the treatment of AHP associated with nystagmus. To our knowledge, this is the first report detailing the use of variable amounts of plication and plication-only surgery in the treatment of AHP and nystagmus. Plication is a safer alternative to resection particularly in patients with previously operated rectus muscles at risk for anterior segment ischemia.